29 Is deep brain stimulation a treatment option for anorexia nervosa? CONCLUSIONS AN is a serious psychiatric disorder with high rates of morbidity, comorbidity and mortality, that takes on a chronic course in a considerable percentage of patients. Since evidence-based treatments are scarce, it is crucial to investigate treatment options based on underlying neurobiological mechanisms of the disease. The fronto-striatal circuitry, in particular the insula, the VS and the prefrontal, orbitofrontal, temporal, parietal and anterior cingulate cortices, appear to be implicated in the etiopathogenesis of AN. Thus, the areas communicating between the limbic and the cortical systems, such as the NAc and the cingulate and insular cortices may be of interest as target areas for future neurosurgical interventions. DBS had the advantage over ablative neurosurgery in being reversible and adjustable and studies show that DBS is able to reduce maladaptive activity and connectivity of the stimulated region and to restore disease-related brain networks to a healthy state. Given the overlap in symptomatology and associated neurocircuits between reward-related disorders like OCD and AN, and the established efficacy of accumbal DBS in OCD, we hypothesize that DBS of the NAc and other areas associated with reward, e.g. the ACC, might be an effective treatment for patients with chronic, treatment refractory AN, providing not only weight restoration, 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 vALIC and the VS (consisting of the ventral caudate nucleus and the NAc). Larger studies with primary outcome aimed at sustained core symptom reduction and weight restoration are necessary. Preferably, studies should be conducted with a double blind cross-over design with active and sham stimulation. Furthermore, functional effects of DBS in AN should be explored by evaluating neuropsychological parameters and by using neuroimaging techniques. In our opinion, the seriousness of the disorder and the clear neurobiological substrates of AN justify considering an invasive procedure like DBS as a treatment-option for chronic, treatment-refractory AN. When carefully selecting the stimulation target, using clear in- and exclusion criteria and closely monitoring the safety aspects of DBS in this population, and in the meanwhile thoroughly investigating the clinical and functional effects, DBS could be promising in attacking the core symptoms of AN and contribute to the knowledge of the intriguing pathophysiological mechanisms of AN .
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