Compiled for Beat by: Carla Dirmina, Ulrike Schmidt, and Amelia Hemmings
Anorexia nervosa is a complex and serious mental health disorder. It has the highest mortality rate out of any psychiatric disorder, yet treatments have changed very little for many years [1]. The most common approaches for treating anorexia are forms of talking therapies, including family therapy (FT-AN) for children and adolescents, and various individual therapies for adults, such as cognitive behavioural therapy for eating disorders (CBT-ED), specialist supportive clinical management (SSCM), and newer models such as the Maudsley Model of Anorexia Treatment for Adults (MANTRA) [2].
These therapies are helpful and can be life-changing for many people with anorexia. However, only around half achieve remission after two years, and even fewer fully recover [3]. With anorexia becoming more common, and especially since the COVID-19 pandemic [4], there is an increasing need to find new treatments which may improve outcomes for people.
Common symptoms of anorexia involve a strong desire to be thin or to lose weight, intense fear of weight gain, eating very little or skipping meals, and a distorted body image [5]. Some people also engage in behaviours to counter what they feel is overeating, such as intense exercise or purging (e.g., vomiting). These symptoms usually begin in the teenage years or early adulthood, and – if untreated – may worsen and become more ingrained over time, which makes it harder to treat [6].
Another challenge is that the person with anorexia may start to see their illness as a positive – for example, by seeing their ability to restrict food as a strength, or their weight loss as an achievement [7]. Such mixed feelings about recovering create another barrier to successful treatment [8].
Recent research has now shown that anorexia is about far more than just food, weight, and body image – it’s also linked to changes in how the brain processes reward, negative emotions (anxiety, depression) and self-control [9]. For instance, our brain’s reward system usually responds positively to eating a meal and releases dopamine (a ‘feel-good’ brain chemical), which makes the meal feel rewarding. In anorexia, this system’s activity is altered so that it responds positively to successful food restriction or over-exercise instead, encouraging these behaviours over time [10].
More than that, living with anorexia long-term has been linked to structural changes in the brain, such as thinning of the outer layer (cortex) and shrinking in deeper regions [11]. Researchers suggest that these changes further worsen symptoms in a vicious cycle: for example, changes in the frontal regions of the brain, which control planning and decision-making, have been linked to increased self-restraint over eating and greater rigidity around food choices [12]. Therefore, researchers are now investigating treatments which target these brain changes directly, such as neuromodulation.
Neuromodulation, also known as neurostimulation or brain stimulation, describes techniques which excite or calm activity in a specific area of the brain. All neuromodulation techniques work by taking advantage of the brain’s electrical transmission signals - they stimulate parts of the brain that may not be working properly, similar to recharging a battery in a circuit.
Some methods are non-invasive, meaning nothing is inserted into the body. This includes [13]:
There are also invasive methods, like deep brain stimulation (DBS), which works a bit like a pacemaker for the brain, though this is much less commonly used [13].
Because researchers have identified which brain areas are involved in anorexia, they have begun testing whether these techniques might help reduce symptoms and support recovery, and potentially become a new method of treatment.
So how well do these techniques actually work in anorexia? Though it’s difficult to say for certain, the research so far gives some early but promising answers.
Most studies so far have focused on individual people or small groups: while this is standard when investigating a new, unapproved potential treatment, it also means the evidence for how effective these methods are is somewhat limited. Still, many early studies have been encouraging – finding that both TMS and tDCS improved participants’ mood, their attitudes to eating and weight, and in some cases, also their BMI (a simple measure of weight relative to height) [14, 15, 16, 17].
Since then, larger trials have gone on to investigate tDCS – researchers in the Czech Republic found a positive effect of tDCS on body image and a reduced need to follow strict rules around eating [18], while a recent study from Poland discovered that the improvement in symptoms of anorexia following tDCS was maintained for several weeks after the stimulation [19].
As for TMS, so far there has only been one randomised controlled trial (RCT) testing its effects in anorexia – this is a type of study where participants are assigned by chance to receive either the active treatment, or a sham (placebo) version. The TIARA trial, carried out by researchers at King’s College London, suggested that TMS was effective and led to benefits in mood, weight, and eating disorder symptoms [20]. Many of the individuals who took part said they felt hopeful about the possibility of a new treatment which intervenes at a brain-based level, and this was a major theme in the interviews conducted about their experiences [21]. Importantly, TMS was also found to reduce activity in the amygdala, a small part of the brain associated with negative emotions and stress – this change was further linked to higher maintained weight gain over time, offering potential insights into how TMS might work to improve symptoms [22].
As a result of these encouraging findings, the same group at King’s College London have now turned their focus towards the use of a newer version of TMS called intermittent theta burst stimulation (iTBS), in a trial known as RaISE [23]. The trial is investigating its effects in young people specifically, with the hope of intervening before the illness becomes deeply entrenched. More information about this study is available at EDIFYresearch.co.uk.
Researchers around the world are now running more clinical trials to strengthen the evidence for neuromodulation and see if they would actually work for patients in practice.
Right now, neuromodulation for eating disorders is still mainly available in research settings. It requires daily sessions, usually spread over several weeks, as well as specialised equipment, making it difficult to offer widely.
But, researchers are working to make these treatments more accessible. For example:
While much more research is needed, neuromodulation represents one of the most exciting frontiers in the search for better, more effective, and more long-lasting treatments for anorexia. For people who have struggled with current therapies, these brain-based approaches may, one day, offer a new path to recovery.
We asked someone with lived experience what this research means to them. Read what they said below
"This is incredibly interesting! I'm not sure how I'd have felt about it when I was in the midst of my anorexia. On the one hand, new things can be really scary, but on the other, if I knew there was something potentially helpful alongside my therapy that was quite passive, I'd have been for it! Recovery is hard, so advancements like this provide me with hope for others. I'd definitely want to hear more about upcoming evidence before agreeing to it, but it sounds promising."
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