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Deep Brain Stimulation for Patients With Chronic Anorexia is Safe and May Improve Symptoms

Summary: A small study suggests deep brain stimulation may be beneficial for improving mood and reducing anxiety while helping to increase weight in those with anorexia.

Source: The Lancet.

Small study in 16 people suggests technique is safe and might help improve mood, anxiety and wellbeing, while increasing weight.

Deep brain stimulation might alter the brain circuits that drive anorexia nervosa symptoms and help improve patients’ mental and physical health, according to a small study published in The Lancet Psychiatry.

Despite having the highest mortality rate of any psychiatric disorder, there are few effective ways to manage treatment-resistant anorexia. While the study only included 16 patients, it suggests that the intervention is safe and could help improve some symptoms of anorexia, but more research is needed.

Worldwide, 0.5% of people have anorexia, and teenage girls account for the majority of cases. The eating disorder is characterised by persistent concerns about bodyweight, shape and size, leading patients to maintain a low weight. Many patients experience mood and anxiety disorders, deny their illness and avoid seeking medical help for it.

Chronic anorexia causes severe health problems as a result of malnutrition, including weak bones and muscles, sexual problems, infertility, heart problems and seizures. The condition can be fatal and those who become acutely ill are admitted to specialised hospital units to receive nutritional support, medical stabilisation and behavioural therapy.

The small study followed 16 women aged between 21 and 57 years old who had had anorexia for an average of 18 years and were severely underweight (with an average body mass index (BMI) of 13.8). They were selected for the study as all other available treatments did not work for them and they were at risk of early death because of anorexia.

All patients underwent deep brain stimulation, which involves implanting electrodes and stimulating areas of the brain that control dysfunctional behaviours. The technique is currently used to target the brain circuits involved in Parkinson’s disease, dystonia, and tremors, where it has been shown to be highly effective in controlling symptoms.

The study looked at how safe deep brain stimulation was for patients with anorexia, and how it affected their BMI, mood, anxiety and wellbeing. Using PET scans, the researchers also looked at how brain activity changed after one year of stimulation.

Electrodes were placed into their subcallosal cingulate, an area located in the centre of the brain that has been shown to have altered serotonin binding in patients with anorexia. Once implanted, the electrodes stimulated the area for one year at a level of 5 – 6.5 volts every 90 micro-seconds.

The treatment had few serious adverse events; however, five patients had pain that persisted for longer than usual following the surgery (more than 3-4 days) and one had an infection at the site of the surgery which resulted in the electrodes needing to be removed and re-implanted. Most adverse events were a result of the patients’ chronic anorexia and included having very low sodium and potassium levels. One patient had an unexplained seizure several months after their electrodes were implanted.

During the study, two patients asked to have the electrodes removed, potentially a result of them being uncomfortable with their weight gain. This meant that there were only 14 patients included at follow-up.

For these patients, mental health symptoms improved over the study with mood and anxiety symptoms reducing in five patients and depression reducing in 10 out of 14 patients. They also reported better quality of life.

While psychological symptoms improved soon after the stimulation began, changes in weight started after three months, suggesting that improving mental health symptoms may precede or even enable changes in weight. Over the course of the study, average BMI of the group increased to 17.3 – an increase of 3.5 points – and six patients achieved a normal BMI (of 18.5 or more).

When comparing the scan results for brain activity before treatment and after a year of stimulation, the researchers found that there were changes in the regions linked to anorexia, suggesting that deep brain stimulation was able to directly affect the related brain circuits. This included less activity in the putamen, thalamus, cerebellum amongst other areas, and more activity in the peripheral cortical areas which are also linked to social perception and behaviour.

“Anorexia remains the psychiatric disorder with the highest mortality rate, and there is an urgent need to develop safe, effective, evidence-driven treatments that are informed by a growing understanding of brain circuitry,” said study author, Professor Andres Lozano, University of Toronto, Canada. “While our results show some early promise, more research will be needed before this becomes available for patients with anorexia. Our findings emphasise the need for continued research into novel neuromodulation strategies for anorexia nervosa, and for psychiatric disorders more broadly.”

Image shows brain scans.

This image shows brain activity differences. NeuroscienceNews.com image is credited to Reprinted from The Lancet, http://dx.doi.org/10.1016/S2215-0366(17)30076-7, Lipsman et al, Deep brain stimulation of the subcallosal cingulate for treatment-refractory anorexia nervosa: 1 year follow-up of an open-label trial, Copyright (2017), with permission from Elsevier.

“Our study suggests that a focal brain intervention, deep brain stimulation, may have an impact on the circuitry of symptoms that serve to maintain anorexia and make it so difficult to treat.” said lead author, Dr Nir Lipsman, Sunnybrook Health Sciences Centre, Canada.

The researchers note some limitations within their work, including that the group was small and there was no control group. In addition, all patients were aware they were being given treatment so the results seen could be affected by placebo effect. However, the authors note this is unlikely as the results lasted for a year and were confirmed with the brain activity scans.

Writing in a linked Comment Dr Carrie McAdams, University of Texas, USA, said: “Conventional treatment of anorexia nervosa includes behavioural modifications to improve feeding, combined with psychological therapy to address cognitive distortions related to self-esteem, eating, and body dissatisfaction. Nevertheless, after intensive treatment, nearly half of adult women with anorexia nervosa relapse within a year… This work shows how modern neuroscience can lead to a new treatment and simultaneously improve understanding of perpetuating factors in a complex, multifactorial disease… Both mood and social function warrant further examination as potential neural factors that might perpetuate anorexia nervosa in adults. Difficulty in changing these factors, which are not part of the diagnostic symptoms of anorexia nervosa, could contribute to the poor outcomes seen with conventional treatments.”

About this psychology research article

Funding: The study was funded by the Klarman Family Foundation Grants Program in Eating Disorders Research and Canadian Institutes of Health Research. It was conducted by scientists from University of Toronto, Sunnybrook Health Sciences Centre and Johns Hopkins University School of Medicine.

Source: Emily Head – The Lancet
Image Source: NeuroscienceNews.com image is credited to Reprinted from The Lancet, http://dx.doi.org/10.1016/S2215-0366(17)30076-7, Lipsman et al, Deep brain stimulation of the subcallosal cingulate for treatment-refractory anorexia nervosa: 1 year follow-up of an open-label trial, Copyright (2017), with permission from Elsevier.
Original Research: Abstract for “Deep brain stimulation of the subcallosal cingulate for treatment-refractory anorexia nervosa: 1 year follow-up of an open-label trial” by Nir Lipsman, MD, Eileen Lam, BPHE, Matthew Volpini, BSc, Kalam Sutandar, MD, Richelle Twose, MD, Peter Giacobbe, MD, Devin J Sodums, MSc, Prof Gwenn S Smith, PhD, Prof D Blake Woodside, MD, and Prof Andres M Lozano, MD in The Lancet Psychiatry. Published online February 23 2017 doi:10.1016/S2215-0366(17)30076-7

Cite This NeuroscienceNews.com Article
The Lancet “Deep Brain Stimulation for Patients With Chronic Anorexia is Safe and May Improve Symptoms.” NeuroscienceNews. NeuroscienceNews, 25 February 2017.
<http://neurosciencenews.com/dbs-anorexia-6159/>.
The Lancet (2017, February 25). Deep Brain Stimulation for Patients With Chronic Anorexia is Safe and May Improve Symptoms. NeuroscienceNew. Retrieved February 25, 2017 from http://neurosciencenews.com/dbs-anorexia-6159/
The Lancet “Deep Brain Stimulation for Patients With Chronic Anorexia is Safe and May Improve Symptoms.” http://neurosciencenews.com/dbs-anorexia-6159/ (accessed February 25, 2017).

Abstract

Deep brain stimulation of the subcallosal cingulate for treatment-refractory anorexia nervosa: 1 year follow-up of an open-label trial

Background

Anorexia nervosa is a life-threatening illness. Brain circuits believed to drive anorexia nervosa symptoms can be accessed with surgical techniques such as deep brain stimulation (DBS). Initial results suggest that DBS of the subcallosal cingulate is safe and associated with improvements in mood and anxiety. Here, we investigated the safety, clinical, and neuroimaging outcomes of DBS of the subcallosal cingulate in a group of patients during 12 months of active stimulation.

Methods
We did this prospective open-label trial at the Department of Surgery of the University of Toronto (Toronto, ON, Canada). Patients were eligible to participate if they were aged 20–60 years and had a diagnosis of anorexia nervosa (restricting or binge–purging subtype) and a demonstrated history of chronicity or treatment resistance. Following a period of medical stabilisation, patients underwent surgery for DBS and received open-label continuous stimulation for the entire 1 year study duration. The primary outcome was safety and acceptability of the procedure. The secondary outcomes were body-mass index (BMI), mood, anxiety, affective regulation, and anorexia nervosa-specific behaviours at 12 months after surgery, as well as changes in neural circuitry (measured with PET imaging of cerebral glucose metabolism at baseline and at 6 and 12 months after surgery). This trial was registered with ClinicalTrials.gov, number NCT01476540.

Findings

16 patients with treatment-refractory anorexia nervosa were enrolled between September, 2011, and January, 2014, and underwent DBS of the subcallosal cingulate between November, 2011, and April, 2014. Patients had a mean age of 34 years (SD 8) and average illness duration of 18 years (SD 6). Two patients requested that their devices be removed or deactivated during the study, although their reasons for doing so were poorly defined. The most common adverse event was pain related to surgical incision or positioning that required oral analgesics for longer than 3–4 days after surgery (five [31%] of 16 patients). Seven (44%) of 16 patients had serious adverse events, most of which were related to the underlying illness, including electrolyte disturbances. Average BMI at surgery was 13·83 (SD 1·49) and 14 (88%) of the 16 patients had comorbid mood disorders, anxiety disorders, or both. Mean BMI after 12 months of stimulation was 17·34 (SD 3·40; p=0·0009 vs baseline). DBS was associated with significant improvements in measures of depression (mean Hamilton Depression Rating Scale scores 19·40 [SD 6·76] at baseline vs 8·79 [7·64] at 12 months; p=0·00015), anxiety (mean Beck Anxiety Inventory score 38·00 [15·55] vs 27·14 [18·39]; p=0·035), and affective regulation (mean Dysfunction in Emotional Regulation Scale score 131·80 [22·04] vs 104·36 [31·27]; p=0·019). We detected significant changes in cerebral glucose metabolism in key anorexia nervosa-related structures at both 6 months and 12 months of ongoing brain stimulation.

Interpretation
In patients with chronic treatment-refractory anorexia nervosa, DBS is well tolerated and is associated with significant and sustained improvements in affective symptoms, BMI, and changes in neural circuitry at 12 months after surgery.

“Deep brain stimulation of the subcallosal cingulate for treatment-refractory anorexia nervosa: 1 year follow-up of an open-label trial” by Nir Lipsman, MD, Eileen Lam, BPHE, Matthew Volpini, BSc, Kalam Sutandar, MD, Richelle Twose, MD, Peter Giacobbe, MD, Devin J Sodums, MSc, Prof Gwenn S Smith, PhD, Prof D Blake Woodside, MD, and Prof Andres M Lozano, MD in The Lancet Psychiatry. Published online February 23 2017 doi:10.1016/S2215-0366(17)30076-7

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