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出境医 / 临床实验 / Theta Burst Stimulation in Anorexia Nervosa: A Case Series (ANTS)

Theta Burst Stimulation in Anorexia Nervosa: A Case Series (ANTS)

Study Description
Brief Summary:

Anorexia Nervosa (AN) is a life-threatening eating disorder characterised by an intense fear of weight gain and disturbed body image, which motivates severe dietary restriction or other weight loss behaviours (e.g. purging). Treatment efficacy in adults with AN remains low: only a small percentage of individuals fully recover, and dropout rates are high. For adolescents with a relatively short term illness duration (under 3 years), family-based therapy has been associated with more favourable outcomes. However, for those adolescents with a longer illness duration (over 3 years), there are no specific treatments associated with positive long-term outcomes and these individuals are at risk of developing a severe and enduring form of the illness (SE-AN).

In part, treatment can be problematic due to ambivalence, which is reflected in poor take-up of certain treatments (e.g. pharmacological treatments that lead to weight gain) and high drop-out rates. Repetitive transcranial magnetic stimulation (rTMS) has demonstrated efficacy for treatment of AN in adults and improving treatment adherence. However, this has yet to be investigated in adolescents with AN.

This study will use a novel type of rTMS, called intermittent theta burst stimulation (iTBS). TBS takes as little as a few minutes duration compared to the classical rTMS protocol which takes approximately 37.5 minutes. In addition, TBS has been found to produce longer after-effects of the induced plastic changes and has a lower stimulation intensity, which may therefore be more practical and potentially safer to administer in people with AN. Thus, the aim of this feasibility case series is to obtain preliminary data on the longer-term (i.e. up to 6 months) effects of 20 sessions of iTBS on reducing core symptoms of AN.


Condition or disease Intervention/treatment Phase
Anorexia Nervosa Device: Intermittent Theta Burst Stimulation Not Applicable

Study Design
Layout table for study information
Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 15 participants
Allocation: N/A
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: A Feasibility Case Series of Theta Burst Stimulation in Anorexia Nervosa
Actual Study Start Date : February 18, 2020
Estimated Primary Completion Date : May 1, 2021
Estimated Study Completion Date : September 1, 2021
Arms and Interventions
Arm Intervention/treatment
Experimental: Active iTBS
iTBS will be delivered at 80% of resting motor threshold, consisting of a triplet of 50Hz bursts, repeated at 5Hz; 2 seconds on and 8 seconds off; 600 pulses per session; total duration of 3 minutes and 9 seconds, to the left dorsolateral prefrontal cortex.
Device: Intermittent Theta Burst Stimulation
The Magstim Rapid2 Magnetic Stimulator (Magstim ®, UK) will be used to administer active TBS.
Other Name: iTBS

Outcome Measures
Primary Outcome Measures :
  1. Changes in core symptoms of AN from baseline to post-treatment [ Time Frame: Throughout the study, lasting 7 months: baseline (before treatment), weekly throughout 4-weeks of treatment and 6 months after treatment (long-term follow-up) ]
    Core symptoms of AN are computed by summing scores on three 10cm visual analogue scales (maximum score of 30) that assess levels of "urge to restrict", "feeling full", and "feeling fat". Participants are requested to indicate on this line a degree or level of experiencing the specific emotion or behavioural urge from "not at all" to "severe".


Secondary Outcome Measures :
  1. Changes in performance on the Two-step Sequential Learning Task from baseline to post-treatment [ Time Frame: 1 month: baseline (before treatment) and post-treatment ]
    Neuropsychological task measuring model-based and model-free reinforcement learning

  2. Changes in performance on the Food Choice Task from baseline to post-treatment [ Time Frame: 1 month: baseline (before treatment) and post-treatment ]
    Neuropsychological task measuring decision making regarding food selection

  3. Changes in performance on the Face Affective Go No-Go Task from baseline to post-treatment [ Time Frame: 1 month: baseline (before treatment) and post-treatment ]
    Neuropsychological task measuring information processing biases for positive and negative facial expressions

  4. Changes in performance on the Visual Probe Task from baseline to post-treatment [ Time Frame: 1 month: baseline (before treatment) and post-treatment ]
    Neuropsychological task measuring information processing biases to high and low calorie foods

  5. Changes in performance on the Emotion Regulation Task from baseline to post-treatment [ Time Frame: 1 month: baseline (before treatment and post-treatment ]
    Neuropsychological task measuring heart rate variability (as an index of autonomic nervous system activity) during presentation of highly aversive pictures

  6. Changes in self-reported perception of low mood from baseline to post-treatment [ Time Frame: 7 months: baseline (before treatment), post-treatment and at 6-month follow-up (long-term follow-up) ]
    Low mood is measured on a 10cm visual analogue scale (maximum score 10). Participants are requested to indicate on this line a degree or level of experiencing "low mood" from "not at all" to "severe". Therefore a higher score reflects higher feelings of low mood.

  7. Changes in self-reported perception of anxiety from baseline to post-treatment [ Time Frame: 7 months: baseline (before treatment), post-treatment and at 6-month follow-up (long-term follow-up) ]
    Anxiety is measured on a 10cm visual analogue scale (maximum score 10). Participants are requested to indicate on this line a degree or level of experiencing "anxiety" from "not at all" to "severe". Therefore a higher score reflects higher feelings of anxiety.

  8. Changes in self-reported perception of urge to exercise from baseline to post-treatment [ Time Frame: 7 months: baseline (before treatment), post-treatment and at 6-month follow-up (long-term follow-up) ]
    Urge to exercise is measured on a 10cm visual analogue scale (maximum score 10). Participants are requested to indicate on this line a degree or level of experiencing "urge to exercise" from "not at all" to "severe". Therefore a higher score reflects a higher urge to exercise.

  9. Changes in self-reported perception of urge to be sick/purge from baseline to post-treatment [ Time Frame: 7 months: baseline (before treatment), post-treatment and at 6-month follow-up (long-term follow-up) ]
    Urge to be sick/purge is measured on a 10cm visual analogue scale (maximum score 10). Participants are requested to indicate on this line a degree or level of experiencing "urge to be sick/purge" from "not at all" to "severe". Therefore a higher score reflects a higher urge to be sick/purge.

  10. Changes in global scores on the Depression and Anxiety Stress Scale (DASS-21) from baseline to post-treatment [ Time Frame: 7 months: baseline (before treatment), post-treatment and at 6-month follow-up (long-term follow-up) ]
    The DASS-21 is a self-report questionnaire of 21 items, 7 items per sub-scale: depression, anxiety and stress. Participants are asked to score every item on a scale from 0 (did not apply to me at all) to 3 (applied to me very much) based on how much each statement applies to them over the past week. Global score is computed by adding up the scores on the items per sub-scale and multiplying them by a factor 2, therefore higher scores reflecting more severe depressive symptoms. Global scores for the DASS-21 range between 0 and 120.

  11. Changes in global scores on the Eating Disorder Examination Questionnaire (EDE-Q) from baseline to post-treatment [ Time Frame: 7 months: baseline (before treatment), post-treatment and at 6-month follow-up (long-term follow-up) ]
    The EDE-Q is a 28-item questionnaire that provides a measure of the range and severity of eating disorder features experienced over the past 28 days. The EDE-Q is scored using a 7-point, forced-choice rating scale (0-6) with higher scores reflecting a higher level of symptomatology. The EDE-Q yields a global score and four sub-scale scores: restraint, shape concern, weight concern, eating concern. The global score is calculated as the sum of the four sub-scale scores divided by the number of sub-scales (i.e. four). Global scores for the EDE-Q range between 0 and 6.

  12. Changes in body mass index (BMI; kg/m2) from baseline to post-treatment [ Time Frame: 7 months: baseline (before treatment), post-treatment and at 6-month follow-up (long-term follow-up) ]
    BMI is a simple calculation of a person's height (m2; metres squared) and weight (kilograms). It is widely used as a general indicator of whether a person has a healthy body weight for their height.


Eligibility Criteria
Layout table for eligibility information
Ages Eligible for Study:   13 Years to 70 Years   (Child, Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Male and female participants over the age of 13
  • BMI over 14 (for participants over the age of 18) or over 66% of the median BMI for age and gender (for participants under the age of 18)
  • Right-handed
  • Current Diagnostic and Statistical Manual-5 (DSM-5) diagnosis of AN-restricting type (AN-R) or AN-binge/purge type (AN-BP) and an illness duration of 3 years or more
  • Must have completed at least one adequate previous course of eating disorder treatment (e.g. one 6-month course of specialist outpatient therapy, specialist day-care or in-patient treatment for refeeding)
  • Participants under the age of 18 must have informed consent from parent(s)/carer(s)
  • Must have approval from treating eating disorders clinician or general practitioner (GP) to participate

Exclusion Criteria:

  • Having a history of head or eye injury
  • Having a history of a neurological disease including previous seizures of any kind
  • Having metallic implants anywhere in the head or body
  • Being on a dose of any psychotropic medication that has not been stable for at least 14 days prior to participation in the study
  • Taking antipsychotic medication
  • Taking anti-convulsive medication
  • Pregnancy or suspected pregnancy in female participants
  • Having a current other major psychiatric disorder (e.g. major depressive disorder, substance dependence, schizophrenia or bipolar) needing treatment in its own right
  • Excessive alcohol (>3 units per day, 5 days of the week) and/or cigarette consumption (>15 cigarettes per day)
  • Severe abnormalities in the screening clinical blood sample
  • An rTMS safety questionnaire and an MRI safety questionnaire will also be administered and if deemed not safe to deliver rTMS or undergo MRI scanning, people will be excluded on this basis.
Contacts and Locations

Contacts
Layout table for location contacts
Contact: Lucy J Gallop +44 (0)2078485977 lucy.gallop@kcl.ac.uk

Locations
Layout table for location information
United Kingdom
King's College London Recruiting
London, United Kingdom
Contact: Lucy Gallop         
Sponsors and Collaborators
King's College London
South London and Maudsley NHS Foundation Trust
Tracking Information
First Submitted Date  ICMJE June 4, 2019
First Posted Date  ICMJE June 7, 2019
Last Update Posted Date February 21, 2020
Actual Study Start Date  ICMJE February 18, 2020
Estimated Primary Completion Date May 1, 2021   (Final data collection date for primary outcome measure)
Current Primary Outcome Measures  ICMJE
 (submitted: June 6, 2019)
Changes in core symptoms of AN from baseline to post-treatment [ Time Frame: Throughout the study, lasting 7 months: baseline (before treatment), weekly throughout 4-weeks of treatment and 6 months after treatment (long-term follow-up) ]
Core symptoms of AN are computed by summing scores on three 10cm visual analogue scales (maximum score of 30) that assess levels of "urge to restrict", "feeling full", and "feeling fat". Participants are requested to indicate on this line a degree or level of experiencing the specific emotion or behavioural urge from "not at all" to "severe".
Original Primary Outcome Measures  ICMJE Same as current
Change History
Current Secondary Outcome Measures  ICMJE
 (submitted: June 6, 2019)
  • Changes in performance on the Two-step Sequential Learning Task from baseline to post-treatment [ Time Frame: 1 month: baseline (before treatment) and post-treatment ]
    Neuropsychological task measuring model-based and model-free reinforcement learning
  • Changes in performance on the Food Choice Task from baseline to post-treatment [ Time Frame: 1 month: baseline (before treatment) and post-treatment ]
    Neuropsychological task measuring decision making regarding food selection
  • Changes in performance on the Face Affective Go No-Go Task from baseline to post-treatment [ Time Frame: 1 month: baseline (before treatment) and post-treatment ]
    Neuropsychological task measuring information processing biases for positive and negative facial expressions
  • Changes in performance on the Visual Probe Task from baseline to post-treatment [ Time Frame: 1 month: baseline (before treatment) and post-treatment ]
    Neuropsychological task measuring information processing biases to high and low calorie foods
  • Changes in performance on the Emotion Regulation Task from baseline to post-treatment [ Time Frame: 1 month: baseline (before treatment and post-treatment ]
    Neuropsychological task measuring heart rate variability (as an index of autonomic nervous system activity) during presentation of highly aversive pictures
  • Changes in self-reported perception of low mood from baseline to post-treatment [ Time Frame: 7 months: baseline (before treatment), post-treatment and at 6-month follow-up (long-term follow-up) ]
    Low mood is measured on a 10cm visual analogue scale (maximum score 10). Participants are requested to indicate on this line a degree or level of experiencing "low mood" from "not at all" to "severe". Therefore a higher score reflects higher feelings of low mood.
  • Changes in self-reported perception of anxiety from baseline to post-treatment [ Time Frame: 7 months: baseline (before treatment), post-treatment and at 6-month follow-up (long-term follow-up) ]
    Anxiety is measured on a 10cm visual analogue scale (maximum score 10). Participants are requested to indicate on this line a degree or level of experiencing "anxiety" from "not at all" to "severe". Therefore a higher score reflects higher feelings of anxiety.
  • Changes in self-reported perception of urge to exercise from baseline to post-treatment [ Time Frame: 7 months: baseline (before treatment), post-treatment and at 6-month follow-up (long-term follow-up) ]
    Urge to exercise is measured on a 10cm visual analogue scale (maximum score 10). Participants are requested to indicate on this line a degree or level of experiencing "urge to exercise" from "not at all" to "severe". Therefore a higher score reflects a higher urge to exercise.
  • Changes in self-reported perception of urge to be sick/purge from baseline to post-treatment [ Time Frame: 7 months: baseline (before treatment), post-treatment and at 6-month follow-up (long-term follow-up) ]
    Urge to be sick/purge is measured on a 10cm visual analogue scale (maximum score 10). Participants are requested to indicate on this line a degree or level of experiencing "urge to be sick/purge" from "not at all" to "severe". Therefore a higher score reflects a higher urge to be sick/purge.
  • Changes in global scores on the Depression and Anxiety Stress Scale (DASS-21) from baseline to post-treatment [ Time Frame: 7 months: baseline (before treatment), post-treatment and at 6-month follow-up (long-term follow-up) ]
    The DASS-21 is a self-report questionnaire of 21 items, 7 items per sub-scale: depression, anxiety and stress. Participants are asked to score every item on a scale from 0 (did not apply to me at all) to 3 (applied to me very much) based on how much each statement applies to them over the past week. Global score is computed by adding up the scores on the items per sub-scale and multiplying them by a factor 2, therefore higher scores reflecting more severe depressive symptoms. Global scores for the DASS-21 range between 0 and 120.
  • Changes in global scores on the Eating Disorder Examination Questionnaire (EDE-Q) from baseline to post-treatment [ Time Frame: 7 months: baseline (before treatment), post-treatment and at 6-month follow-up (long-term follow-up) ]
    The EDE-Q is a 28-item questionnaire that provides a measure of the range and severity of eating disorder features experienced over the past 28 days. The EDE-Q is scored using a 7-point, forced-choice rating scale (0-6) with higher scores reflecting a higher level of symptomatology. The EDE-Q yields a global score and four sub-scale scores: restraint, shape concern, weight concern, eating concern. The global score is calculated as the sum of the four sub-scale scores divided by the number of sub-scales (i.e. four). Global scores for the EDE-Q range between 0 and 6.
  • Changes in body mass index (BMI; kg/m2) from baseline to post-treatment [ Time Frame: 7 months: baseline (before treatment), post-treatment and at 6-month follow-up (long-term follow-up) ]
    BMI is a simple calculation of a person's height (m2; metres squared) and weight (kilograms). It is widely used as a general indicator of whether a person has a healthy body weight for their height.
Original Secondary Outcome Measures  ICMJE Same as current
Current Other Pre-specified Outcome Measures Not Provided
Original Other Pre-specified Outcome Measures Not Provided
 
Descriptive Information
Brief Title  ICMJE Theta Burst Stimulation in Anorexia Nervosa: A Case Series
Official Title  ICMJE A Feasibility Case Series of Theta Burst Stimulation in Anorexia Nervosa
Brief Summary

Anorexia Nervosa (AN) is a life-threatening eating disorder characterised by an intense fear of weight gain and disturbed body image, which motivates severe dietary restriction or other weight loss behaviours (e.g. purging). Treatment efficacy in adults with AN remains low: only a small percentage of individuals fully recover, and dropout rates are high. For adolescents with a relatively short term illness duration (under 3 years), family-based therapy has been associated with more favourable outcomes. However, for those adolescents with a longer illness duration (over 3 years), there are no specific treatments associated with positive long-term outcomes and these individuals are at risk of developing a severe and enduring form of the illness (SE-AN).

In part, treatment can be problematic due to ambivalence, which is reflected in poor take-up of certain treatments (e.g. pharmacological treatments that lead to weight gain) and high drop-out rates. Repetitive transcranial magnetic stimulation (rTMS) has demonstrated efficacy for treatment of AN in adults and improving treatment adherence. However, this has yet to be investigated in adolescents with AN.

This study will use a novel type of rTMS, called intermittent theta burst stimulation (iTBS). TBS takes as little as a few minutes duration compared to the classical rTMS protocol which takes approximately 37.5 minutes. In addition, TBS has been found to produce longer after-effects of the induced plastic changes and has a lower stimulation intensity, which may therefore be more practical and potentially safer to administer in people with AN. Thus, the aim of this feasibility case series is to obtain preliminary data on the longer-term (i.e. up to 6 months) effects of 20 sessions of iTBS on reducing core symptoms of AN.

Detailed Description Not Provided
Study Type  ICMJE Interventional
Study Phase  ICMJE Not Applicable
Study Design  ICMJE Allocation: N/A
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Condition  ICMJE Anorexia Nervosa
Intervention  ICMJE Device: Intermittent Theta Burst Stimulation
The Magstim Rapid2 Magnetic Stimulator (Magstim ®, UK) will be used to administer active TBS.
Other Name: iTBS
Study Arms  ICMJE Experimental: Active iTBS
iTBS will be delivered at 80% of resting motor threshold, consisting of a triplet of 50Hz bursts, repeated at 5Hz; 2 seconds on and 8 seconds off; 600 pulses per session; total duration of 3 minutes and 9 seconds, to the left dorsolateral prefrontal cortex.
Intervention: Device: Intermittent Theta Burst Stimulation
Publications * Not Provided

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Recruitment Information
Recruitment Status  ICMJE Recruiting
Estimated Enrollment  ICMJE
 (submitted: June 6, 2019)
15
Original Estimated Enrollment  ICMJE Same as current
Estimated Study Completion Date  ICMJE September 1, 2021
Estimated Primary Completion Date May 1, 2021   (Final data collection date for primary outcome measure)
Eligibility Criteria  ICMJE

Inclusion Criteria:

  • Male and female participants over the age of 13
  • BMI over 14 (for participants over the age of 18) or over 66% of the median BMI for age and gender (for participants under the age of 18)
  • Right-handed
  • Current Diagnostic and Statistical Manual-5 (DSM-5) diagnosis of AN-restricting type (AN-R) or AN-binge/purge type (AN-BP) and an illness duration of 3 years or more
  • Must have completed at least one adequate previous course of eating disorder treatment (e.g. one 6-month course of specialist outpatient therapy, specialist day-care or in-patient treatment for refeeding)
  • Participants under the age of 18 must have informed consent from parent(s)/carer(s)
  • Must have approval from treating eating disorders clinician or general practitioner (GP) to participate

Exclusion Criteria:

  • Having a history of head or eye injury
  • Having a history of a neurological disease including previous seizures of any kind
  • Having metallic implants anywhere in the head or body
  • Being on a dose of any psychotropic medication that has not been stable for at least 14 days prior to participation in the study
  • Taking antipsychotic medication
  • Taking anti-convulsive medication
  • Pregnancy or suspected pregnancy in female participants
  • Having a current other major psychiatric disorder (e.g. major depressive disorder, substance dependence, schizophrenia or bipolar) needing treatment in its own right
  • Excessive alcohol (>3 units per day, 5 days of the week) and/or cigarette consumption (>15 cigarettes per day)
  • Severe abnormalities in the screening clinical blood sample
  • An rTMS safety questionnaire and an MRI safety questionnaire will also be administered and if deemed not safe to deliver rTMS or undergo MRI scanning, people will be excluded on this basis.
Sex/Gender  ICMJE
Sexes Eligible for Study: All
Ages  ICMJE 13 Years to 70 Years   (Child, Adult, Older Adult)
Accepts Healthy Volunteers  ICMJE No
Contacts  ICMJE
Contact: Lucy J Gallop +44 (0)2078485977 lucy.gallop@kcl.ac.uk
Listed Location Countries  ICMJE United Kingdom
Removed Location Countries  
 
Administrative Information
NCT Number  ICMJE NCT03979404
Other Study ID Numbers  ICMJE KCLANTSCASE19
Has Data Monitoring Committee Not Provided
U.S. FDA-regulated Product
Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
IPD Sharing Statement  ICMJE Not Provided
Responsible Party King's College London
Study Sponsor  ICMJE King's College London
Collaborators  ICMJE South London and Maudsley NHS Foundation Trust
Investigators  ICMJE Not Provided
PRS Account King's College London
Verification Date May 2019

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP