59 Deep Brain Stimulation of the Ventral Anterior Limb of the Capsula Interna in Patients with Chronic Treatment-Refractory Anorexia Nervosa PTSD, substance use disorders, personality disorders or emotion dysregulation did not help due to the dominating consequences of AN. Because this is the first study of vALIC DBS in AN, we did not include additional outcome measures specifically regarding emotion regulation or self-destructive behavior. Based on our findings, future vALIC DBS studies can focus on these aspects in order to provide further insight in these interesting novel perspectives on the underlying pathophysiological mechanisms in chronic treatment-refractory AN. Based on this pilot-study, DBS for severely and chronically ill, treatment-refractory AN patient seems to be a relatively safe and feasible last-resort option. Ethics dictate that DBS should only be considered in a population with grim perspective in treatment options and mortality, and our population qualifies as such. Limitations As DBS was provided open-label, results might be influenced by placebo or other non-specific effects. For example, the increase in contact or the participation in this study might have caused an increase in the patient-involvement and with it a more positive outcome. We minimized these limitations by providing a one-year follow-up period, providing the possibility to investigate sustained effects. The type of patients in our study warrants some attention. Our subjects were extremely ill patients with chronic, treatment-refractory AN for whom pharmacological and psychotherapeutic treatments had failed for decades and who were completely functionally impaired in almost all aspects of life. Preoperatively their physical condition was very poor, all patients were severely underweight and suffered acute and long-term complications of severe and enduring malnutrition. The average illness duration was 21 years, classifying as chronic (38). The findings of our study can therefore be extrapolated to this specific, severely affected patient group, not to AN in general. The small sample size of this first vALIC DBS study limits the power. However, this sample size is similar to several DBS pilot trials for other novel indications, and -in consultation with the DSMB and MEC- sufficient to answer the research questions. The moral debate of applying an experimental and invasive procedure in a physically severely compromised patient group justifies the lack of a control group. CONCLUSION AND FUTURE PERSPECTIVES Results of this first study indicate that vALIC DBS seems a valid last-resort intervention in chronic, treatment-refractory AN. Our findings pave the way for a follow-up study with a larger sample size, to establish DBS as a standardized last resort treatment in this challenging patient group.
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