Background: Bulimia nervosa (BN) is a severe psychiatric disorder characterized by recurrent binge eating episodes followed by inappropriate compensatory behavior such as purging or excessive exercise. Frank proposed in his model of eating disorders that BN is associated with a desensitized dopamine system (Frank, 2016). However, direct investigations on the causal effect of a hypofunction of the dopamine system on neural activity, bulimic and depressive symptoms, and on the course of the illness are still missing. Catecholamine depletion induced by alpha-methyl-paratyrosine (AMPT) is an instructive paradigm to investigate directly the relationship between dopaminergic neurotransmission and the symptoms and course of BN. In our previous behavioral study, experimental catecholamine depletion provoked mild eating disorder symptoms in fully remitted BN (Grob et al, 2015). The purpose of this study was to examine the effect of catecholamine depletion on neural activity in BN. Furthermore, we were interested in the relationship between this effect and the risk for relapse.
Methods: In a randomized, double-blind, crossover design, catecholamine depletion was achieved using the oral administration of AMPT over 24 hours in 18 remitted bulimic (rBN) and 22 healthy (HC) female participants. Cerebral blood flow (CBF) was measured using a pseudo continuous arterial spin labeling (pCASL) sequence. AMPT-induced mood and eating disorder symptoms were examined using the Montgomery-Åsberg Depression Scale (MADRS) (Schmidtke et al, 1988), the Eating Disorder Examination-Questionnaire (EDE-Q) (Hilbert and Tuschen-Caffier, 2006), and the vigor subscale of the Profile of Mood States (POMS) (McNair et al, 1981). Bulimic relapse was assessed in a follow-up telephone interview (latency varied between 18 and 42 months) after study participation.
Results: RBN participants revealed no increases of eating disorder symptoms following AMPT administration. However, AMPT reduced POMS vigor in both groups, and this effect was stronger in rBN participants. Furthermore, in rBN participants, AMPT decreased CBF in the pallidum and posterior midcingulate cortex (pMCC), whereas in HC participants, we did not find AMPT-induced alterations in CBF in these brain regions.
AMPT-induced depressive symptoms and reductions in CBF in the hippocampus/ parahippocampal gyrus predicted relapse in rBN participants. In contrast, AMPT-induced CBF increase in the hippocampus/ parahippocampal gyrus predicted remission.
Conclusions: We demonstrated that AMPT decreased CBF in the pallidum and pMCC in rBN participants. In the context of the Frank model (Frank, 2016), these regions can be considered as neural correlates of the desensitized dopamine system in BN.
In contrast to our previous study (Grob et al, 2015), we did not observe an AMPT-induced increase of eating disorder symptoms. However, our earlier investigation was carried out in a controlled environment, without food cues and with regular, standardized meals (Grob et al, 2015). The uncontrolled environment in which this study was conducted might have overridden the effect of AMPT on eating disorder symptoms. In rBN participants, AMPT reduced vigor more strongly than in healthy individuals. This vigor reduction might trigger eating disorder symptoms to counteract dopamine deficiency and the related depression-like mental state.
AMPT-induced depressive symptoms and CBF reduction in the hippocampus predicted bulimic relapse. Binge eating was reported to have an anti-depressive and dopamine elevating effect (Jahng et al, 2012). Therefore, dopamine deficiency and a dysfunctional hippocampus activity might trigger inappropriate behavior, such as binge eating to reduce negative emotions and anhedonia. Our findings expand Frank’s model of eating disorders (Frank, 2016), and emphasize the importance of depressive symptoms and the stress system in the course of bulimia nervosa.
