Case Report: Unexpected Remission From Extreme and Enduring Bulimia Nervosa With Repeated Ketamine Assisted Psychotherapy

Abstract

Background: Bulimia nervosa is a disabling psychiatric disorder that considerably impairs physical health, disrupts psychosocial functioning, and reduces overall quality of life. Despite available treatment, less than half of sufferers achieve recovery and approximately a third become chronically ill. Extreme and enduring cases are particularly resistant to first-line treatment, namely antidepressants and cognitive behavioral therapy, and have the highest rate of premature mortality. Here, we demonstrate that in such cases, repeated sessions of ketamine assisted psychotherapy (KAP) is an effective treatment alternative for improving symptoms.Case Presentation: A 21-year-old woman presented with extreme and enduring bulimia nervosa. She reported recurrent binge-eating and purging by self-induced vomiting 40 episodes per day, which proved refractory to both pharmacological and behavioral treatment at the outpatient, residential, and inpatient level. Provided this, her physician recommended repeated KAP as an exploratory and off-label intervention for her eating disorder. The patient underwent three courses of KAP over 3 months, with each course consisting of six sessions scheduled twice weekly. She showed dramatic reductions in binge-eating and purging following the first course of treatment that continued with the second and third. Complete cessation of behavioral symptoms was achieved 3 months post-treatment. Her remission has sustained for over 1 year to date.Conclusions: To our knowledge, this is the first report of repeated KAP used to treat bulimia nervosa that led to complete and sustained remission, a rare outcome for severe and enduring cases, let alone extreme ones. Additionally, it highlights the degree to which KAP can be tailored at the individual level based on symptom severity and treatment response. While its mechanism of action is unclear, repeated KAP is a promising intervention for bulimia nervosa that warrants future research and clinical practice consideration.

Ketamine as a Novel Psychopharmacotherapy for Eating Disorders: Evidence and Future Directions

“…To date, few studies have examined the therapeutic use of ketamine for EDs, which are limited to case series [117,118] and reports [119][120][121] (Table 1); and are focused on AN over other primary (BN and BED) and secondary (pica, RD, and ARFID) subgroups. Mills et al first introduced the dissociative anesthetic as a novel treatment for compulsive EDs in 1998, where 15 patients with atypical, chronic refractory AN of 11.3 years ± 5.0 were treated with intermittent ketamine infusions combined with oral nalmefene, an opiate receptor antagonist [117].…”

“…While treatment efficacy was limited by ketamine's short duration of effect, initial symptom improvement was significant and achieved faster than with prior ECT. Most recently, Ragnhildstveit et al evaluated the use of ketamine assisted psychotherapy (KAP) in treating a 21-year-old woman with extreme and enduring BN-BP of nine years [121]. This was the first ED report to administer ketamine with a psychotherapeutic component, and additionally for an 'extreme' BN severity specifier, according to DSM-5 criterion (≥ 14 episodes/week) [128].…”

“…Interest in transdiagnostic applications has since grown, with more than 140 clinical trials in the National Institute of Health database (ClinicalTrials.gov) registered to investigate ketamine's therapeutic potential, comprising major depression (98; 70%), suicidal ideation (21; 15%), post-traumatic stress disorder (7; 5%), obsessive compulsive disorder (5; 3.6%), autism spectrum disorder (2; 1.4%), generalized anxiety disorder (1; 0.7%), borderline personality disorder (1; 0.7%), cognitive impairment (1; 0.7%) and schizophrenia (1; 0.7%) [111]. While data concerning ketamine and EDs is preliminary and principally limited to AN [117][118][119][120][121], results are nonetheless encouraging. A recent mixedmethods study (N = 200), examining patient attitudes towards complementary and emerging treatments for EDs, also provides evidence of support for psychedelics, including ketamine.…”

“…A growing body of literature has subsequently identified strategies to prolong its antidepressant effect, including KAP [142,143]. Ragnhildstveit et al were the first to report on serial KAP used to treat extreme and enduring BN, which utilized a person-centered, humanistic approach to psychotherapy, and resulted in complete and sustained remission [121]. The authors postulated that ketamine and psychotherapy act synergistically, with therapy augmenting the response to treatment, and repeated sessions accounting for the durability of effect.…”

“…Discussing patients' motives, intentions, and expectations for treatment, evaluating their current psychophysiological status, and providing a therapeutic environment conducive to the ketamine experience (i.e., "set and setting") are essential factors to consider prior to treatment. Examining different psychotherapeutic approaches in this context is additionally recommended, which has progressively diversified over the years to include cognitive-behavioral [147], humanistic [121,148], functional-analytic [149], and somatic-based interactional [150] therapy.…”