Unanticipated elimination of bulimia symptoms following a cervical sympathetic block for treating Post-Traumatic Stress Disorder (PTSD) : A Case Report

Unanticipated elimination of bulimia symptoms following a cervical sympathetic block for treating Post-Traumatic Stress Disorder (PTSD) : A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Unanticipated elimination of bulimia symptoms following a cervical sympathetic block for treating Post-Traumatic Stress Disorder (PTSD) : A Case Report Eugene G. Lipov, Hunter Rolain, Luke Lammers This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3970755/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective Report the efficacy of cervical sympathetic block (CSB) in treating PTSD as well as bulimia symptoms and discuss possible mechanisms of action to explain these findings. Background Successful treatment of PTSD with CSB has been reported previously in several publications. Bulimia has been associated with comorbid PTSD and is often comorbid with PTSD. Treatment of PTSD could be an effective approach to treat bulimia. Methods The patient received bilateral CSB at C6 and C4 levels on the right side followed 1 day later by the left side, as per clinic protocol. The patient’s PTSD symptoms were evaluated using the Post-Traumatic Stress Disorder Checklist (PCL-5). This checklist was administered one day before treatment and again 45 days later following treatment. Results CSB showed marked benefit for PTSD symptoms as demonstrated by significant reduction of PCL-5 scores following the bilateral CSB procedures. The patient spontaneously reported complete and persistent elimination of bulimia symptoms. Reduction of PTSD and bulimia symptoms were sustained at the 45-day follow-up. Conclusion CSB is a minimally invasive procedure with an excellent safety profile that may provide sustained relief of PTSD and bulimia symptoms. Considering the marked difficulties in treating bulimia, CSB may be a new ray of hope for the bulimia cohort. We believe CSB should be studied as a therapeutic approach for eating disorder patients with associated trauma in adequately powered studies. bulimia cervical sympathetic block PTSD SGB PLAIN ENGLISH SUMMARY Post-Traumatic Stress Disorder (PTSD) is commonly associated with eating disorders (ED), particularly the bulimia type. A possible cause of the condition is the over activation of the fight or flight system, known as the sympathetic nervous system. As the background efficacy of current ED and bulimia treatments is limited, more effective approaches would be welcomed. Multiple studies have demonstrated efficacy of cervical sympathetic blocks (CSB) for treating PTSD. CSB involves the use of local anesthetic injection next to sympathetic ganglion in the neck and it seems to work by resetting the sympathetic nervous system. Cervical sympathetic block seems to have rapid and persistent elimination of bulimia and PTSD symptoms and may be a new ray of hope for ED populations. 1. INTRODUCTION 1.1 Bulimia Prevalence of bulimia was estimated from a cross-sectional general population survey of 1498 adults, using the Diagnostic Interview Schedule (DIS). Lifetime prevalence has been reported as 1% of the US population in adults aged 18–64. 1 Trauma is commonly associated with Eating disorders (EDs), particularly among those with bulimic features. 2 , 3 EDs have been associated with posttraumatic stress disorder (PTSD). 2 – 4 Multiple traumas has been shown to lead to bulimia, classically childhood sexual abuse, but also bullying. 5 Treatment modality for ED currently is psychotherapy, as pharmaceutical modalities do not seem to be effective. 2 The hypothesis is that bulimic behaviors, such as vomiting, serve to facilitate numbing and avoidance of trauma-related memories, dreams, feelings, thoughts, and behaviors, as well as decrease associated hyperarousal. 6 , 7 However, the use of pharmaco- therapy without concomitant psychotherapy is generally ineffective in terms of producing complete and lasting abstinence in ED patients. 2 1.2 PTSD Post-traumatic stress disorder (PTSD) is a prevalent and potentially debilitating disorder typically occurring as a result of exposure to physical violence, natural disasters, or other severe stressors. The World Health Organization (WHO) World Mental Health Surveys determined the lifetime prevalence of PTSD to be approximately 3.9% in the general population and 5.6% among the trauma-exposed. 8 Higher percentages are seen in populations who have experienced one or more forms of trauma, such as war-related trauma, physical or sexual violence, and accidents. 9 Among veterans who begin PTSD treatment with psychotherapy or medication, drop-out rates are reported to be as high as 20%-40% in randomized clinical trials and considerably higher in routine practice. 10 While therapeutic efficacy is reported to be achieved in 60%-80% among patients compliant with medical treatment, intention-to-treat analysis shows efficacy decreases to approximately 40% when accounting for patients not completing treatment. 10 CSB has been shown to be successful in treating PTSD in multiple cohorts. In a 2022 publication, 21 types of self-reported trauma leading to PTSD were treated using CSB. 11 The average decrease in PCL scores for men and women was 28.59 and 29.2, respectively. Statistical analysis of the male population with a military background showed a significantly greater change in corresponding PCL scores than civilians (PCL-M change = -31.83 vs PCL-C change =-24.89). Likewise, women who had a military background had a significantly greater reduction in PCL scores than civilians (39.15 vs 28.23). Statistically significant improvements in PTSD symptoms were noted independent of the causative trauma type, gender, age greater than 20, previous suicide attempts, or use of prescription medications for PTSD. 11 Among the 21 types of reported trauma, 19 types reached statistical significance. 11 2. METHODS 2.1 Patient and Setting The patient was a 30-year-old male that was treated in our clinic for the diagnosis of PTSD. His trauma leading to PTSD was described as being bullied emotionally from the 2nd to 6th grade, with minimal physical abuse following. Patient received minimal psychiatric interventions since high school that included brief use of Prozac and was started on Adderall which he is currently taking. Patient denied psychiatric or medical admissions or suicide attempts. He further denied persistent GERD, as well as the history of Mallory-Weiss tears. 2.2 Cervical sympathetic block The patient was given information concerning the risk/benefits of the procedure and a consent form was completed. Patients received local anesthetic or sedation as desired by the patient. The patient was positioned comfortably in the supine position, with the head rotated slightly contralaterally, routine monitoring was applied as per clinic protocol. The skin over the anterior and right-side neck was widely cleaned with chlorhexidine-isopropyl alcohol preparation. Sterile ultrasound gel was applied. Appropriate ASA monitors where applied, and an intravenous line with a 22-Gauge IV was placed. The right-side anterior neck was scanned using a linear transducer (Mindray Ultrasound, China) from the level of the 7th to the 4th cervical vertebrae in transverse view. Power Doppler was utilized to identify vasculature in the planned needle track. The skin on the lateral neck was anesthetized with 1 mL of 1% lidocaine. Utilizing an in-plane approach, under real-time ultrasound guidance, a 22 Gauge echogenic needle was placed just dorsal to the ventral fascia of the longus coli, medial to the longus capitus, and approximated to the cervical sympathetic chain. After negative aspirations for blood or CSF, 0.5 mL of 0.5% bupivacaine was injected, and after observing the patient for 30 seconds, 7.5 cc of injectate was injected over 1 minute for a total injection volume at C6 level. The same procedure was performed at C4 level; the total volume use was 4 cc at this level. Due to the risk of serious airway compromise with inadvertent bilateral blockade of the recurrent laryngeal nerves, the left-sided SGB was performed 24 hours after the right-sided SGB to allow adequate time for local anesthetic effects to subside. Both before and after the procedure, the patient was specifically informed as to the potential for and signs of life-threatening adverse events, including worsening neck pain which may indicate hematoma formation, and shortness of breath. All procedures were well tolerated. The patient exhibited Horner’s syndrome (ptosis, miosis and anhidrosis) within 10 minutes of the injection. The patient was monitored for an additional 30 minutes before discharge. No hospital admissions occurred, or persistent complications were observed. 2.3 Psychometric Testing: The PTSD Checklist Version 5 (PCL-5) The PTSD Checklist Version 5 is a 20-item self-reported questionnaire designed to assess PTSD symptomatology including symptoms of re-experiencing, avoidance, and hyperarousal. The PCL-5 has demonstrated excellent reliability and validity in primary care settings. 12 Non-response to the treatment was defined in patients who had obvious Horner’s syndrome findings but failed to improve by at least 10 points on a PTSD Checklist Version 5 (PCL-5). 12 3. RESULTS One day prior to CSB, the patient’s PCL-5 score was 39. He experienced significant relief of symptoms after the procedures and had marked Horner’s syndrome demonstrating a dense sympathetic block following both procedures. At the 45-day follow-up, he acknowledged sustained benefit with a PCL-5 score of 6 (84.62% reduction). He reported complete resolution of bulimia symptoms one day following left CSB. 4. DISCUSSION Noradrenaline (NE) is a catecholamine acting as both a neurotransmitter and a hormone, with relevant effects in modulating feeding behavior and satiety. Several studies have assessed the relationship between the noradrenergic system and eating disorders (EDs). Preclinical studies demonstrated an involvement of the noradrenergic pathways in binge-like behaviors. Clinical studies have shown alterations in plasma NE values in patients with Anorexia Nervosa (AN) and Bulimia Nervosa (BN). Pharmacological studies have documented the efficacy of noradrenaline-modulating therapies in the treatment of BN and Binge Eating Disorder (BED). Venlafaxine, which is a selective norepinephrine reuptake inhibitor (SNRI), helps modulate the impulsiveness of eating. 13 Prior publications have reported NE as the main transmitter in PTSD pathophysiology. 14 Specifically, a persistent increase in the urine concentration of NE has been shown in patients with PTSD. 15 Thus, showing the common pathway for PTSD and BN. Brain scans further demonstrate similarity of EDs and PTSD. Increased insula and amygdala activity during selective attention for negatively valenced body parts in binge eating disorder. 16 Westerhaus and Loewy used pseudorabies virus injections to identify connections of the stellate ganglion. 17 Pseudorabies virus allows identification of neural pathway connections that are 2–3 synapses from the point of injection of the virus. In this manner, the use of pseudorabies virus injection is used to identify cortical areas connected to the stellate ganglion. Early labeling was found in the hypothalamus and central nucleus of the amygdala. 14 , 17 With slightly longer time labeling was found in lateral, basolateral, and medial amygdala. After 6–8 days, injections of the stellate ganglion produced extensive transneuronal labeling in the infralimbic, insular, and ventromedial temporal cortical regions. 14 , 17 The amygdala has been shown to be involved in the persistence of PTSD symptoms. CSB has been shown to deactivate the amygdala and reduce the symptoms of PTSD, 18 a likely mechanism of the effect seen. 5. CONCLUSION As found in prior studies, CSB is safe and effective in treating PTSD, with an unexpected benefit in reducing/ eliminating bulimia symptoms. Although the mechanism of effect is not known, the role of norepinephrine and amygdala seem to play a significant role in pathophysiology of PTSD and bulimia. Considering the difficulties in treating PTSD and comorbid bulimia, this case report can pave the way for effective treatments in this patient cohort. Abbreviations CSB Cervical Sympathetic Block ED Eating Disorder PCL 5-Post-Traumatic Stress Disorder Checklist − 5 PTSD Post Traumatic Stress Disorder DIS Diagnostic Interview Schedule WHO World Health Organization NE Noradrenaline AN Anorexia Nervosa BN Bulimia Nervosa BED Binge Eating Disorder SNRI Selective Norepinephrine Reuptake Inhibitor Declarations Human Ethics and Consent to Participate declarations: not applicable Consent for publication: Patient consented for this manuscript to be published. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request Competing Interests: The authors declare that they have no competing interests Funding: None Authors’ Contributions: E.L. conceived the study concept. H.R. and L.L. collected the data and assembled the manuscript. All authors read and approved the final manuscript. Acknowledgements: Not applicable References Bushnell JA, Wells JE, Hornblow AR, Oakley-Browne MA, Joyce P. Prevalence of three bulimia syndromes in the general population. Psychol Med . 1990;20(3):671-680. doi:10.1017/s0033291700017190 Brewerton, T.D. Eating disorders, victimization and comorbidity: Principles of treatment. In T. D. Brewerton (Ed.). Clinical handbook of eating disorders: An integrated approach. New York: Marcel Dekker, Inc; 2004:509-545. Brewerton TD. Eating disorders, trauma, and comorbidity: focus on PTSD. Eat Disord . 2007;15(4):285-304. doi:10.1080/10640260701454311 Brady KT, Killeen TK, Brewerton T, Lucerini S. Comorbidity of psychiatric disorders and posttraumatic stress disorder. J Clin Psychiatry . 2000;61 Suppl 7:22-32. Johnson JG, Cohen P, Kasen S, Brook JS. Childhood adversities associated with risk for eating disorders or weight problems during adolescence or early adulthood. Am J Psychiatry . 2002;159(3):394-400. doi:10.1176/appi.ajp.159.3.394 Root MP, Fallon P. Treating the victimized bulimic: The functions of binge-purge behavior. Journal of Interpersonal Violence. 1989 4(1):90–100 . https://doi.org/10.1177/088626089004001006 Vidaña AG, Forbush KT, Barnhart EL, et al. Impact of trauma in childhood and adulthood on eating-disorder symptoms. Eat Behav . 2020;39:101426. doi:10.1016/j.eatbeh.2020.101426 Koenen KC, Ratanatharathorn A, Ng L, et al. Posttraumatic stress disorder in the World Mental Health Surveys. Psychol Med . 2017;47(13):2260-2274. doi:10.1017/S0033291717000708 Kessler RC, Aguilar-Gaxiola S, Alonso J, et al. Trauma and PTSD in the WHO World Mental Health Surveys. Eur J Psychotraumatol . 2017;8(sup5):1353383. Published 2017 Oct 27. doi:10.1080/20008198.2017.1353383 Hoge CW. Interventions for war-related posttraumatic stress disorder: meeting veterans where they are. JAMA . 2011;306(5):549-551. doi:10.1001/jama.2011.1096 Lipov EG, Jacobs R, Springer S, Candido KD, Knezevic NN. Utility of cervical sympathetic block in treating post-traumatic stress disorder in multiple cohorts: a retrospective analysis. Pain physician. 2022; 25:77-85. Bovin MJ, Marx BP, Weathers FW, et al. Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5) in veterans. Psychol Assess . 2016;28(11):1379-1391. doi:10.1037/pas0000254 Pruccoli J, Parmeggiani A, Cordelli DM, Lanari M. The Role of the Noradrenergic System in Eating Disorders: A Systematic Review. Int J Mol Sci . 2021;22(20):11086. Published 2021 Oct 14. doi:10.3390/ijms222011086 Lipov EG, Joshi JR, Sanders S, Slavin KV. A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD). Med Hypotheses . 2009;72(6):657-661. doi:10.1016/j.mehy.2009.01.009 Kosten TR, Mason JW, Giller EL, Ostroff RB, Harkness L. Sustained urinary norepinephrine and epinephrine elevation in post-traumatic stress disorder. Psychoneuroendocrinology . 1987;12(1):13-20. doi:10.1016/0306-4530(87)90017-5 Press SA, Biehl SC, Domes G, Svaldi J. Increased insula and amygdala activity during selective attention for negatively valenced body parts in binge eating disorder. J Psychopathol Clin Sci. 2023;132(1):63-77. doi:10.1037/abn0000788 Westerhaus MJ, Loewy AD. Sympathetic-related neurons in the preoptic region of the rat identified by viral transneuronal labeling. J Comp Neurol . 1999;414(3):361-378. Alkire MT, Hollifield M, Khoshsar R, NguyenL, Alley SR. Neuroimaging Suggests that Stellate Ganglion Block Improves Post-Traumatic Stress Disorder (PTSD) Through an Amygda-la Mediated Mechanism. American Society of Anesthesiology Annual Meeting. 2005 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3970755","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":275488929,"identity":"1c5db1ee-b39b-4768-88bf-839cc3321758","order_by":0,"name":"Eugene G. Lipov","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYBACAxAhAcRs7A0grgWRWiyAFBvPARBXgkgtFSBKIgFmIQFgzt578MHNHX/s+SSfX93wo0CCgb+9OwGvFsuec8mGM88YJLZJ55Td7AE6TOLM2Q34HXYjx0xass0ggU06J+0GD1CLgUQuQS3mv/+2GdizSZ5Ju/mHSC1mDEBbGNsk2I/dJs6WM+eSJSTPGCe28eSw3ZYxkOAh7JfjvQc/SO6Qs5dvP/7s5ps/NnL87b34tTAw8DAwMDaAGQZQLkEA18L+gAjVo2AUjIJRMBIBAHCYRYnU/xemAAAAAElFTkSuQmCC","orcid":"","institution":"Stella Center","correspondingAuthor":true,"prefix":"","firstName":"Eugene","middleName":"G.","lastName":"Lipov","suffix":""},{"id":275488930,"identity":"158374ea-de0b-41d9-9bf9-736c7bf9a8bc","order_by":1,"name":"Hunter Rolain","email":"","orcid":"","institution":"Midwestern University - Chicago College of Osteopathic Medicine, Downers Grove","correspondingAuthor":false,"prefix":"","firstName":"Hunter","middleName":"","lastName":"Rolain","suffix":""},{"id":275488931,"identity":"5316bae2-272d-49f7-820b-e34c0b360ea4","order_by":2,"name":"Luke Lammers","email":"","orcid":"","institution":"Midwestern University - Chicago College of Osteopathic Medicine, Downers Grove","correspondingAuthor":false,"prefix":"","firstName":"Luke","middleName":"","lastName":"Lammers","suffix":""}],"badges":[],"createdAt":"2024-02-19 19:31:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3970755/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3970755/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":61749799,"identity":"545e1d26-15ea-442e-a782-4c9c7d6b2558","added_by":"auto","created_at":"2024-08-05 07:29:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":267178,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3970755/v1/c489c77c-8490-4134-940e-3074a6c19288.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Unanticipated elimination of bulimia symptoms following a cervical sympathetic block for treating Post-Traumatic Stress Disorder (PTSD) : A Case Report","fulltext":[{"header":"PLAIN ENGLISH SUMMARY","content":"\u003cp\u003ePost-Traumatic Stress Disorder (PTSD) is commonly associated with eating disorders (ED), particularly the bulimia type. A possible cause of the condition is the over activation of the fight or flight system, known as the sympathetic nervous system. As the background efficacy of current ED and bulimia treatments is limited, more effective approaches would be welcomed. Multiple studies have demonstrated efficacy of cervical sympathetic blocks (CSB) for treating PTSD. CSB involves the use of local anesthetic injection next to sympathetic ganglion in the neck and it seems to work by resetting the sympathetic nervous system. \u0026nbsp;Cervical sympathetic block seems to have rapid and persistent elimination of bulimia and PTSD symptoms and may be a new ray of hope for ED populations.\u003c/p\u003e"},{"header":"1. INTRODUCTION","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Bulimia\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003ePrevalence of bulimia was estimated from a cross-sectional general population survey of 1498 adults, using the Diagnostic Interview Schedule (DIS). Lifetime prevalence has been reported as 1% of the US population in adults aged 18\u0026ndash;64.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Trauma is commonly associated with Eating disorders (EDs), particularly among those with bulimic features.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e EDs have been associated with posttraumatic stress disorder (PTSD).\u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Multiple traumas has been shown to lead to bulimia, classically childhood sexual abuse, but also bullying.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Treatment modality for ED currently is psychotherapy, as pharmaceutical modalities do not seem to be effective.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe hypothesis is that bulimic behaviors, such as vomiting, serve to facilitate numbing and avoidance of trauma-related memories, dreams, feelings, thoughts, and behaviors, as well as decrease associated hyperarousal.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e However, the use of pharmaco- therapy without concomitant psychotherapy is generally ineffective in terms of producing complete and lasting abstinence in ED patients.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.2 PTSD\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003ePost-traumatic stress disorder (PTSD) is a prevalent and potentially debilitating disorder typically occurring as a result of exposure to physical violence, natural disasters, or other severe stressors. The World Health Organization (WHO) World Mental Health Surveys determined the lifetime prevalence of PTSD to be approximately 3.9% in the general population and 5.6% among the trauma-exposed.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Higher percentages are seen in populations who have experienced one or more forms of trauma, such as war-related trauma, physical or sexual violence, and accidents.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Among veterans who begin PTSD treatment with psychotherapy or medication, drop-out rates are reported to be as high as 20%-40% in randomized clinical trials and considerably higher in routine practice.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e While therapeutic efficacy is reported to be achieved in 60%-80% among patients compliant with medical treatment, intention-to-treat analysis shows efficacy decreases to approximately 40% when accounting for patients not completing treatment.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e CSB has been shown to be successful in treating PTSD in multiple cohorts. In a 2022 publication, 21 types of self-reported trauma leading to PTSD were treated using CSB.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e The average decrease in PCL scores for men and women was 28.59 and 29.2, respectively. Statistical analysis of the male population with a military background showed a significantly greater change in corresponding PCL scores than civilians (PCL-M change = -31.83 vs PCL-C change =-24.89). Likewise, women who had a military background had a significantly greater reduction in PCL scores than civilians (39.15 vs 28.23). Statistically significant improvements in PTSD symptoms were noted independent of the causative trauma type, gender, age greater than 20, previous suicide attempts, or use of prescription medications for PTSD.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Among the 21 types of reported trauma, 19 types reached statistical significance.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"2. METHODS","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Patient and Setting\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe patient was a 30-year-old male that was treated in our clinic for the diagnosis of PTSD. His trauma leading to PTSD was described as being bullied emotionally from the 2nd to 6th grade, with minimal physical abuse following. Patient received minimal psychiatric interventions since high school that included brief use of Prozac and was started on Adderall which he is currently taking. Patient denied psychiatric or medical admissions or suicide attempts. He further denied persistent GERD, as well as the history of Mallory-Weiss tears.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Cervical sympathetic block\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe patient was given information concerning the risk/benefits of the procedure and a consent form was completed. Patients received local anesthetic or sedation as desired by the patient. The patient was positioned comfortably in the supine position, with the head rotated slightly contralaterally, routine monitoring was applied as per clinic protocol.\u003c/p\u003e \u003cp\u003eThe skin over the anterior and right-side neck was widely cleaned with chlorhexidine-isopropyl alcohol preparation. Sterile ultrasound gel was applied. Appropriate ASA monitors where applied, and an intravenous line with a 22-Gauge IV was placed. The right-side anterior neck was scanned using a linear transducer (Mindray Ultrasound, China) from the level of the 7th to the 4th cervical vertebrae in transverse view. Power Doppler was utilized to identify vasculature in the planned needle track. The skin on the lateral neck was anesthetized with 1 mL of 1% lidocaine. Utilizing an in-plane approach, under real-time ultrasound guidance, a 22 Gauge echogenic needle was placed just dorsal to the ventral fascia of the longus coli, medial to the longus capitus, and approximated to the cervical sympathetic chain. After negative aspirations for blood or CSF, 0.5 mL of 0.5% bupivacaine was injected, and after observing the patient for 30 seconds, 7.5 cc of injectate was injected over 1 minute for a total injection volume at C6 level. The same procedure was performed at C4 level; the total volume use was 4 cc at this level. Due to the risk of serious airway compromise with inadvertent bilateral blockade of the recurrent laryngeal nerves, the left-sided SGB was performed 24 hours after the right-sided SGB to allow adequate time for local anesthetic effects to subside.\u003c/p\u003e \u003cp\u003eBoth before and after the procedure, the patient was specifically informed as to the potential for and signs of life-threatening adverse events, including worsening neck pain which may indicate hematoma formation, and shortness of breath. All procedures were well tolerated. The patient exhibited Horner\u0026rsquo;s syndrome (ptosis, miosis and anhidrosis) within 10 minutes of the injection. The patient was monitored for an additional 30 minutes before discharge. No hospital admissions occurred, or persistent complications were observed.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Psychometric Testing:\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eThe PTSD Checklist Version 5 (PCL-5)\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe PTSD Checklist Version 5 is a 20-item self-reported questionnaire designed to assess PTSD symptomatology including symptoms of re-experiencing, avoidance, and hyperarousal. The PCL-5 has demonstrated excellent reliability and validity in primary care settings.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Non-response to the treatment was defined in patients who had obvious Horner\u0026rsquo;s syndrome findings but failed to improve by at least 10 points on a PTSD Checklist Version 5 (PCL-5).\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eOne day prior to CSB, the patient\u0026rsquo;s PCL-5 score was 39. He experienced significant relief of symptoms after the procedures and had marked Horner\u0026rsquo;s syndrome demonstrating a dense sympathetic block following both procedures. At the 45-day follow-up, he acknowledged sustained benefit with a PCL-5 score of 6 (84.62% reduction). He reported complete resolution of bulimia symptoms one day following left CSB.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eNoradrenaline (NE) is a catecholamine acting as both a neurotransmitter and a hormone, with relevant effects in modulating feeding behavior and satiety. Several studies have assessed the relationship between the noradrenergic system and eating disorders (EDs). Preclinical studies demonstrated an involvement of the noradrenergic pathways in binge-like behaviors. Clinical studies have shown alterations in plasma NE values in patients with Anorexia Nervosa (AN) and Bulimia Nervosa (BN). Pharmacological studies have documented the efficacy of noradrenaline-modulating therapies in the treatment of BN and Binge Eating Disorder (BED). Venlafaxine, which is a selective norepinephrine reuptake inhibitor (SNRI), helps modulate the impulsiveness of eating.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Prior publications have reported NE as the main transmitter in PTSD pathophysiology.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Specifically, a persistent increase in the urine concentration of NE has been shown in patients with PTSD.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Thus, showing the common pathway for PTSD and BN.\u003c/p\u003e \u003cp\u003eBrain scans further demonstrate similarity of EDs and PTSD. Increased insula and amygdala activity during selective attention for negatively valenced body parts in binge eating disorder.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Westerhaus and Loewy used pseudorabies virus injections to identify connections of the stellate ganglion.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Pseudorabies virus allows identification of neural pathway connections that are 2\u0026ndash;3 synapses from the point of injection of the virus. In this manner, the use of pseudorabies virus injection is used to identify cortical areas connected to the stellate ganglion. Early labeling was found in the hypothalamus and central nucleus of the amygdala.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e With slightly longer time labeling was found in lateral, basolateral, and medial amygdala. After 6\u0026ndash;8 days, injections of the stellate ganglion produced extensive transneuronal labeling in the infralimbic, insular, and ventromedial temporal cortical regions.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e The amygdala has been shown to be involved in the persistence of PTSD symptoms. CSB has been shown to deactivate the amygdala and reduce the symptoms of PTSD,\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e a likely mechanism of the effect seen.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"5. CONCLUSION","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAs found in prior studies, CSB is safe and effective in treating PTSD, with an unexpected benefit in reducing/ eliminating bulimia symptoms. Although the mechanism of effect is not known, the role of norepinephrine and amygdala seem to play a significant role in pathophysiology of PTSD and bulimia. Considering the difficulties in treating PTSD and comorbid bulimia, this case report can pave the way for effective treatments in this patient cohort.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCSB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCervical Sympathetic Block\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eED\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEating Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e5-Post-Traumatic Stress Disorder Checklist \u0026minus;\u0026thinsp;5\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePTSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePost Traumatic Stress Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDIS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDiagnostic Interview Schedule\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNoradrenaline\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnorexia Nervosa\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBulimia Nervosa\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBED\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBinge Eating Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSNRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSelective Norepinephrine Reuptake Inhibitor\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eHuman Ethics and Consent to Participate declarations: not applicable\u003c/p\u003e\n\u003cp\u003eConsent for publication: Patient consented for this manuscript to be published.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003eCompeting Interests:\u0026nbsp;The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding: None\u003c/p\u003e\n\u003cp\u003eAuthors’ Contributions: E.L. conceived the study concept. H.R. and L.L. collected the data and assembled the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: Not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBushnell JA, Wells JE, Hornblow AR, Oakley-Browne MA, Joyce P. Prevalence of three bulimia syndromes in the general population. \u003cem\u003ePsychol Med\u003c/em\u003e. 1990;20(3):671-680. doi:10.1017/s0033291700017190\u003c/li\u003e\n \u003cli\u003eBrewerton, T.D. Eating disorders, victimization and comorbidity: Principles of treatment. In T. D. Brewerton (Ed.). \u003cem\u003eClinical handbook of eating disorders: An integrated approach.\u0026nbsp;\u003c/em\u003eNew York: Marcel Dekker, Inc; 2004:509-545.\u003c/li\u003e\n \u003cli\u003eBrewerton TD. Eating disorders, trauma, and comorbidity: focus on PTSD. \u003cem\u003eEat Disord\u003c/em\u003e. 2007;15(4):285-304. doi:10.1080/10640260701454311\u003c/li\u003e\n \u003cli\u003eBrady KT, Killeen TK, Brewerton T, Lucerini S. Comorbidity of psychiatric disorders and posttraumatic stress disorder. \u003cem\u003eJ Clin Psychiatry\u003c/em\u003e. 2000;61 Suppl 7:22-32.\u003c/li\u003e\n \u003cli\u003eJohnson JG, Cohen P, Kasen S, Brook JS. Childhood adversities associated with risk for eating disorders or weight problems during adolescence or early adulthood. \u003cem\u003eAm J Psychiatry\u003c/em\u003e. 2002;159(3):394-400. doi:10.1176/appi.ajp.159.3.394\u003c/li\u003e\n \u003cli\u003eRoot MP, Fallon P. Treating the victimized bulimic: The functions of binge-purge behavior. \u003cem\u003eJournal of Interpersonal Violence. 1989 4(1):90\u0026ndash;100\u003c/em\u003e. https://doi.org/10.1177/088626089004001006\u003c/li\u003e\n \u003cli\u003eVida\u0026ntilde;a AG, Forbush KT, Barnhart EL, et al. Impact of trauma in childhood and adulthood on eating-disorder symptoms. \u003cem\u003eEat Behav\u003c/em\u003e. 2020;39:101426. doi:10.1016/j.eatbeh.2020.101426\u003c/li\u003e\n \u003cli\u003eKoenen KC, Ratanatharathorn A, Ng L, et al. Posttraumatic stress disorder in the World Mental Health Surveys. \u003cem\u003ePsychol Med\u003c/em\u003e. 2017;47(13):2260-2274. doi:10.1017/S0033291717000708\u003c/li\u003e\n \u003cli\u003eKessler RC, Aguilar-Gaxiola S, Alonso J, et al. Trauma and PTSD in the WHO World Mental Health Surveys. \u003cem\u003eEur J Psychotraumatol\u003c/em\u003e. 2017;8(sup5):1353383. Published 2017 Oct 27. doi:10.1080/20008198.2017.1353383\u003c/li\u003e\n \u003cli\u003eHoge CW. Interventions for war-related posttraumatic stress disorder: meeting veterans where they are. \u003cem\u003eJAMA\u003c/em\u003e. 2011;306(5):549-551. doi:10.1001/jama.2011.1096\u003c/li\u003e\n \u003cli\u003eLipov EG, Jacobs R, Springer S, Candido KD, Knezevic NN. Utility of cervical sympathetic block in treating post-traumatic stress disorder in multiple cohorts: a retrospective analysis. \u003cem\u003ePain physician.\u0026nbsp;\u003c/em\u003e2022; 25:77-85.\u003c/li\u003e\n \u003cli\u003eBovin MJ, Marx BP, Weathers FW, et al. Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5) in veterans. \u003cem\u003ePsychol Assess\u003c/em\u003e. 2016;28(11):1379-1391. doi:10.1037/pas0000254\u003c/li\u003e\n \u003cli\u003ePruccoli J, Parmeggiani A, Cordelli DM, Lanari M. The Role of the Noradrenergic System in Eating Disorders: A Systematic Review. \u003cem\u003eInt J Mol Sci\u003c/em\u003e. 2021;22(20):11086. Published 2021 Oct 14. doi:10.3390/ijms222011086\u003c/li\u003e\n \u003cli\u003eLipov EG, Joshi JR, Sanders S, Slavin KV. A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD). \u003cem\u003eMed Hypotheses\u003c/em\u003e. 2009;72(6):657-661. doi:10.1016/j.mehy.2009.01.009\u003c/li\u003e\n \u003cli\u003eKosten TR, Mason JW, Giller EL, Ostroff RB, Harkness L. Sustained urinary norepinephrine and epinephrine elevation in post-traumatic stress disorder. \u003cem\u003ePsychoneuroendocrinology\u003c/em\u003e. 1987;12(1):13-20. doi:10.1016/0306-4530(87)90017-5\u003c/li\u003e\n \u003cli\u003ePress SA, Biehl SC, Domes G, Svaldi J. Increased insula and amygdala activity during selective attention for negatively valenced body parts in binge eating disorder. J Psychopathol Clin Sci. 2023;132(1):63-77. doi:10.1037/abn0000788\u003c/li\u003e\n \u003cli\u003eWesterhaus MJ, Loewy AD. Sympathetic-related neurons in the preoptic region of the rat identified by viral transneuronal labeling. \u003cem\u003eJ Comp Neurol\u003c/em\u003e. 1999;414(3):361-378.\u003c/li\u003e\n \u003cli\u003eAlkire MT, Hollifield M, Khoshsar R, NguyenL, Alley SR. Neuroimaging Suggests that Stellate Ganglion Block Improves Post-Traumatic Stress Disorder (PTSD) Through an Amygda-la Mediated Mechanism. \u003cem\u003eAmerican Society of Anesthesiology Annual Meeting.\u003c/em\u003e 2005\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"bulimia, cervical sympathetic block, PTSD, SGB","lastPublishedDoi":"10.21203/rs.3.rs-3970755/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3970755/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eReport the efficacy of cervical sympathetic block (CSB) in treating PTSD as well as bulimia symptoms and discuss possible mechanisms of action to explain these findings.\u003c/p\u003e\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSuccessful treatment of PTSD with CSB has been reported previously in several publications. Bulimia has been associated with comorbid PTSD and is often comorbid with PTSD. Treatment of PTSD could be an effective approach to treat bulimia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe patient received bilateral CSB at C6 and C4 levels on the right side followed 1 day later by the left side, as per clinic protocol. The patient\u0026rsquo;s PTSD symptoms were evaluated using the Post-Traumatic Stress Disorder Checklist (PCL-5). This checklist was administered one day before treatment and again 45 days later following treatment.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eCSB showed marked benefit for PTSD symptoms as demonstrated by significant reduction of PCL-5 scores following the bilateral CSB procedures. The patient spontaneously reported complete and persistent elimination of bulimia symptoms. Reduction of PTSD and bulimia symptoms were sustained at the 45-day follow-up.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCSB is a minimally invasive procedure with an excellent safety profile that may provide sustained relief of PTSD and bulimia symptoms. Considering the marked difficulties in treating bulimia, CSB may be a new ray of hope for the bulimia cohort. We believe CSB should be studied as a therapeutic approach for eating disorder patients with associated trauma in adequately powered studies.\u003c/p\u003e","manuscriptTitle":"Unanticipated elimination of bulimia symptoms following a cervical sympathetic block for treating Post-Traumatic Stress Disorder (PTSD) : A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-29 15:40:34","doi":"10.21203/rs.3.rs-3970755/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ea581a5f-a766-4a90-bd6b-a4eaf7e42892","owner":[],"postedDate":"February 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-05T07:21:08+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-29 15:40:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3970755","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3970755","identity":"rs-3970755","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}