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Treatment-refractory anorexia nervosa: subcallosal cingulate deep brain stimulation seems to be generally safe


Anorexia nervosa is characterised by a chronic course that is refractory to treatment in many patients and has one of the highest mortality rates of any psychiatric disorder. Deep brain stimulation ( DBS ) has been applied to circuit-based neuropsychiatric diseases, such as Parkinson's disease and major depression, with promising results.
Researchers have assessed the safety of deep brain stimulation to modulate the activity of limbic circuits and to examine how this might affect the clinical features of anorexia nervosa.

They did a phase 1, prospective trial of subcallosal cingulate deep brain stimulation in six patients with chronic, severe, and treatment-refractory anorexia nervosa.
Eligible patients were aged 20-60 years, had been diagnosed with restricting or binge-purging anorexia nervosa, and showed evidence of chronicity or treatment resistance.
Patients underwent medical optimisation preoperatively and had baseline body-mass index ( BMI ), psychometric, and neuroimaging investigations, followed by implantation of electrodes and pulse generators for continuous delivery of electrical stimulation.

Patients were followed up for 9 months after deep brain stimulation activation, and the primary outcome of adverse events associated with surgery or stimulation was monitored at every follow-up visit.
Repeat psychometric assessments, BMI measurements, and neuroimaging investigations were also done at various intervals.

Deep brain stimulation was associated with several adverse events, only one of which ( seizure during programming, roughly 2 weeks after surgery ) was serious.
Other related adverse events were panic attack during surgery, nausea, air embolus, and pain.

After 9 months, three of the six patients had achieved and maintained a BMI greater than their historical baselines.

Deep brain stimulation was associated with improvements in mood, anxiety, affective regulation, and anorexia nervosa-related obsessions and compulsions in four patients and with improvements in quality of life in three patients after 6 months of stimulation.
These clinical benefits were accompanied by changes in cerebral glucose metabolism ( seen in a comparison of composite PET scans at baseline and 6 months ) that were consistent with a reversal of the abnormalities seen in the anterior cingulate, insula, and parietal lobe in the disorder.

Subcallosal cingulate deep brain stimulation seems to be generally safe in this sample of patients with chronic and treatment-refractory anorexia nervosa. ( Xagena )

Lipsman N et al, The Lancet 2013; 381: 1361-1370

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