68 Chapter 3 There were no intraoperative adverse events in any of four patients. Nevertheless, 28 severe adverse events (SAE’s) occurred, with two being probably and nine possibly related to the intervention. Probable related SAE’s were (hypo)manic symptoms. Possible related SAE’s consisted of self-destructive behavior (autointoxication, auto-mutilation and aggression). SAE’s were mostly related to the severity of AN and its somatic complications rather than DBS (n=11). The number of SAE’s reflects the challenging nature of this study. Transient hypomanic and impulsive symptoms may be caused by downregulation of reward and emotion regulation circuitries due to DBS (4, 10). We hypothesize that vALIC-DBS inhibits positive reinforcement of ritualistic AN behavior making them useless as a coping strategy. Patients develop alternative coping strategies such as self-destructive behavior, explaining some of our (S)AE’s. Three out of four patients showed improvement on coping and emotion regulation following psychotherapy. DBS was provided open-label, therefore results might be influenced by placebo or other non-specific effects. These were however minimized due to the one-year follow-up period. Though the small sample size of this vALIC DBS study limits its power, it is deemed sufficient to answer basic research questions. To the best of our knowledge, this is the first study of vALIC-DBS in AN. The results indicate that vALIC-DBS is a valid, safe and feasible last-resort intervention in treatment-refractory AN. Our findings pave the way for a follow-up study with a larger sample size.
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