27 Is deep brain stimulation a treatment option for anorexia nervosa? but also significant and sustained improvement in AN core symptoms and associated comorbidities and complications. Possible targets for DBS in AN are the ACC, the ventral anterior limb of the capsula interna (vALIC) and the VS (consisting of the ventral caudate nucleus and the NAc). Suggestions for in- and exclusion criteria As DBS in AN is an experimental treatment whose efficacy still needs to be established, it would be logical to initially include only patients with a chronic course who are treatment-resistant and have a poor prognosis. As stated before, there has thus far been no agreement on the definitions of recovery and treatment-refractoriness in AN (37). We suggest to define treatment-refractoriness as a lack of response to two or more typical modes of treatment, including one hospital admission or inpatient treatment in a clinic specialized in the treatment of eating disorders, and an illness duration of five years or more. We suggest inclusion and exclusion criteria for studies investigating the efficacy of DBS in AN similar to those suggested by Wu et al. (2012) and Lipsman et al. (2013) (107, 108): Inclusion criteria • Primary diagnosis: Anorexia Nervosa (restricting or purging type) according to the DSM-IV criteria based on a psychiatric interview. • Chronicity, defined by an illness duration > 5 years. • Disabling severity with substantial functional impairment according to the DSM-IV criterion C and a Global Assessment of Function (GAF) score of 45 or less for at least two years. • Treatment refractoriness, defined as lack of response to two or more typical modes of treatment, including one hospital admission or inpatient treatment in a specialized clinic. • Weight <85% of ideal body weight (and/or BMI < 17,5). • Age: 21–65 years old. • Able to fully understand the consequences of the procedure capable to make his or her own choice without coercion and able to give written informed consent. Exclusion criteria • Unstable physical condition (severe electrolyte disturbances, cardiac failure, other physical contraindications for surgery/anesthesia). • A treatable underlying cause of anorexia/underweight. • An active neurological disease like Parkinson’s disease, dementia, tic disorder or epilepsy. • Schizophrenia/history of psychosis, bipolar disorder. • Alcohol or substance abuse (including benzodiazepines) during the last 6 months. • Antisocial personality disorder. • Standard MRI scan exclusion criteria (pregnancy, pacemaker and metals contraindicated for MRI except for the DBS implantation and stimulator itself).
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