25 Is deep brain stimulation a treatment option for anorexia nervosa? DBS IN AN Considering 1) the clear neurobiological correlates of the disorder, 2) the homogeneity of the disorder, 3) the severity of AN, its complications and high mortality rates, 4) the fact that AN takes on a chronic course in a considerable percentage of patients and the fact that, up to date, evidence based treatment for AN is very limited, it is crucial to investigate new treatment options for AN that focus on influencing the underlying neurobiological mechanisms of the disease rather than focus on weight restoration alone. In this review article we want to propose DBS as a possible new treatment option for patients with chronic, treatment-resistant AN. For a long time, neurosurgery targeted at various brain areas (mostly leucotomy) has been considered a last resort treatment for AN. While reviewing the literature on neurosurgical procedures in AN, we found most articles reported weight gain and sometimes other symptomatic improvements. However, there was much heterogeneity as well as missing data on patient selection, follow-up and outcome measurements. Therefore, clinical outcome appears at least to us, somewhat inconclusive (95-103). In a case-report of Barbier et al. (2011) a successful anterior capsulotomy in comorbid AN and OCD is described, resulting in normalization of eating pattern and weight and a significant decrease of food-related obsessive compulsive symptoms after three months (104). To date, there are very limited data on the effect of DBS in the treatment of AN. There are two case reports, a case series of four patients and a pilot study published on DBS in AN (see Table 1). Israël et al. (2010) described a patient treated with DBS in the subgenual cingulate cortex, part of the ACC, for severe refractory depression, whose co-morbid eating disorder showed lasting remission, consisting of a normalisation of BMI (19,1 kg/m2) and Eating Attitudes Test-26 at 2-year follow-up. It must be noted that pre-surgery this patient also had periods of (partial) recovery from her eating disorder, and that her BMI pre-surgery was 20,9 kg/m2 (105). A more recent case report by McLaughlin (2012) described improvements in AN symptoms following DBS of the VC/ VS for intractable OCD (106). The first study (case series) on DBS in AN was conducted by Sun et al. from the Shanghai group. Preliminary results reported an average of 65% increase in body weight at 38-month follow-up in four adolescent patients with AN treated with DBS of the NAc, showing that DBS might be a valuable option for weight-restoration in AN (107). Very recently, Lipsman et al. (2013) published the results of a phase-1 pilot trial of subcallosal cingulate (ACC) DBS in six adult patients with treatment-refractory AN. They found that DBS was relatively safe in this population and found to result in improvements of mood, anxiety, affective regulation and anorexia-related obsessions and compulsions in four patients. Furthermore, at a 9 month follow up period improved BMI’s compared to the estimated historical baseline BMI’s in three patients were found (103, 108).
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