- Department of Medical Education, School of Medicine, California University of Science and Medicine, Colton, California, United States.
- Department of Clinical Education, Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania, United States.
- Department of Basic Sciences, Touro University Nevada College of Osteopathic Medicine, Henderson, Nevada, United States.
Mark Immanuel Potes
Department of Basic Sciences, Touro University Nevada College of Osteopathic Medicine, Henderson, Nevada, United States.
DOI:10.25259/SNI_730_2020Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Mark Immanuel Potes1, Christian Joaquin2, Nicole Wiecks3, Sheshanna Phan3, Omron Hassan3. The utility of deep brain stimulation surgery for treating eating disorders: A systematic review. 19-Apr-2021;12:169
How to cite this URL: Mark Immanuel Potes1, Christian Joaquin2, Nicole Wiecks3, Sheshanna Phan3, Omron Hassan3. The utility of deep brain stimulation surgery for treating eating disorders: A systematic review. 19-Apr-2021;12:169. Available from: https://surgicalneurologyint.com/?post_type=surgicalint_articles&p=10738
Background: Deep brain stimulation (DBS) has demonstrated preliminary success as a treatment for neuropsychological disorders including obsessive-compulsive disorder and substance use disorder. This systematic review aims to assess the use of DBS in treating eating disorders (EDs) to determine its utility and the extent of adverse effects.
Methods: A PubMed search following PRISMA guidelines was executed to find studies encompassing DBS as a treatment of ED. Outcomes were extracted from the literature and summarized while a review of quality was also performed.
Results: From a search yielding 299 publications, 11 studies published between 2010 and 2020 were found to fit the inclusion criteria. Out of 53 patients who began with an abnormal BMI before treatment, 22 patients (41.5%) achieved normal BMI on follow-up. Significant neuropsychological improvement was seen in most patients as measured by neuropsychiatric testing and questionnaires.
Conclusion: DBS as a treatment for ED may result in significant objective and psychological benefits. Further studies should aim to increase the sample size, standardize follow-up protocol, and standardize the neuropsychiatric tests used to determine psychological and physiological benefits.
Keywords: Anorexia nervosa, Deep brain stimulation, Neuromodulation, Obesity, Systematic review
Eating disorders (EDs) encompass psychiatric illnesses which manifest as disruptions or severe alterations in a person’s eating behavior. Incidence is more common in women between the age of 15 and 35 years old and end complications may lead to long-term comorbidities such as high cholesterol, heart disease, and diabetes.[
DBS is a neurosurgical procedure in which electrodes stimulate targeted brain regions to alter or modulate neural circuitry.[
The literature remains unclear as to which circuits and brain regions should be stimulated with DBS. The nucleus accumbens (NAc) has been linked to obesity[
This study aims to systematically review and assess the current literature regarding the use of DBS to treat ED when typical noninvasive therapies fail. These findings further describe the utility of DBS as a treatment in refractory ED patients and identify adverse effects to consider when deciding on treatment options. A meta-analysis construct was not pursued because of limitations including small sample size, heterogeneity of outcome measures, and case report/series comprising the majority of the found literature.
PRISMA guidelines were followed to conduct the systematic review. A literature search of the PubMed database included all publications in English that use human subjects from earliest records to June 2020 using the search formula: (“deep brain stimulation” OR DBS) AND (“eating disorder*” OR bulimi* OR anorex* OR obese OR obesity OR binge OR “food intake disorder” OR “feeding disorder”).
Inclusion and exclusion criteria
Two independent reviewers performed an initial screening protocol and removed any publications that were duplicates, not in English, not published in a peer-reviewed journal, abstracts-only, or did not use human subjects. Afterward, the reviewers screened the remaining publications for eligibility based on the inclusion criteria: DBS must be the primary intervention; main findings pertain to an ED; study is a clinical trial, case report, or case series. In the case of disagreement, a third reviewer made the decision after reviewing the study. The process of study selection is summarized in [
Two independent reviewers assessed the quality of each publication in accordance with the MINORS quality assessment tool [
Measure of patient outcome
For the purpose of this study and to present data with more homogeneity, treatment success was determined based on CDC suggested guidelines of a healthy BMI range, in which patients in studies were assessed for the reported BMI’s before and after surgery. Therapeutic outcomes were determined based on reports of successful treatment of AN symptoms, attenuation of a normal menstrual cycle, decrease in binge behavior, performance on neuropsychological tests, and metabolic rate changes. Adverse effects were identified and recorded when available.
Summary of findings and patient demographics
The EDs treated with DBS reported in the literature include AN and obesity.[
Reports of treatment success
The CDC suggests that a healthy BMI ranges from 18.5 to 24.9.[
All therapeutic outcomes and adverse effects are outlined in [
About 87.5% (7/8)[
Significant decrease in BMI was seen in all obesity-related studies[
Of the 11 included studies, only one study did not use any neuropsychological testing or questionnaires.[
Three studies reported improvement of mood, anxiety, depression, and social functioning as represented by a mean decrease in Y-BOCS, HAMA, HAMD, and SDSS scores, respectively.[
The most common adverse effects were nausea, pain, and infection at the incision site.[
Coordinates and stimulation parameters
Coordinates and stimulation parameters are summarized in [
Neurosurgical treatment of ED is a recent development with potential to benefit patients who are refractory to other current treatment options. Furthermore, combined treatment plans may enhance treatment efficacy and potentially reduce morbidity. Larger studies investigating the influence of the patient population, neurobiological mechanisms, and limitations are necessary for transition to standard clinical application of DBS to treat ED.
OCD was a common concomitant neuropsychiatric disorder among patients with AN. OCD is characterized by obsession and compulsions that are either time consuming or cause significant psychological distress.[
The most common concurrent condition in patients with obesity who underwent DBS treatment was hypertension (HTN).[
Only one male was represented across studies, which is a potential limitation to the current literature on DBS for ED.[
Therapeutic potential of DBS to treat ED
The three essential diagnostic criteria for AN as described in the DSM-V should be considered when treatment plans are being generated for patients. These include the restriction of energy intake relative to requirements, intense fear of gaining weight or of becoming fat, and persistent behavior that interferes with weight gain even at a significantly low weight.[
Current treatment of AN relies on a multimodal approach that combines pharmacotherapy, psychotherapy, and surgical treatments.[
Neuropsychological testing was not consistently used among studies, so a direct comparison of their results was not possible. A more standardized approach to assess the diagnostic criteria of AN postoperatively should be determined in future studies. The use of clinician based tests such as the ED Examination and Yale-Brown-Cornell ED Scale may also be considered in future studies, as these are considered the “gold standard” for determining clinical diagnoses by the American Psychiatric Association.[
Obesity is not included in the DSM-V because of its exclusion of being a mental disorder.[
Current treatment of obesity encompasses a multimodal approach which includes pharmacotherapy, weight loss programs, and surgical treatment. Success of these treatments is limited, and many patients fail to achieve their weight loss goals. For example, a 3-year follow-up study of bariatric surgery patients found weight loss of 15.9% following gastric banding and 31.5% after gastric bypass surgery.[
The typical cost of DBS surgery ranges from $33,700 to $38,600 when utilizing a standard or rechargeable implantable pulse generator, respectively.[
Neurobiological basis behind therapeutic efficacy
The mechanisms of DBS are not fully understood, and literature generally agrees on the principle of electrical current modulating neural pathways. For example, the cortical-basal ganglia-thalamo-cortical loop is a model comprised of direct and indirect pathways all of which contribute to the initiation, inhibition, and regulation of voluntary movement.[
Choice of electrode design adds further complexity as different designs result in different stimulation fields. A monopolar electrode produces a spherical shape as the cathode is remotely located in the body while a bipolar configuration focuses the stimulation between the anode and cathode.[
DBS of the NAc (DBS-Nac) is the most common stimulation area in all the studies. This has shown efficacy in the treatment of other neurological syndromes, including SUD and OCD.[
Disparity in quality in current literature
Although the overall quality of the studies in this systematic review was adequate, many studies did not establish a protocol for data collection and suffered from a lack of blind evaluation of both objective and subjective endpoints [
Furthermore, there was wide variability in follow-up time ranging from 6 to 50 months. Three of the studies had follow-up times of less than 1 year and most studies only had a single follow-up time point. This may influence the accuracy of reported outcomes because follow-up times under 1 year have been associated with lower reported relapse rates as compared to follow-up times greater than 1 year.[
A current study hopes to explore the efficacy of DBS treatment for AN.[
Combining measurements of brain activity, computerized tasks, and neuropsychological status evaluation may allow for better understanding of the pathophysiology of AN and the role of the NAc. On/off stimulation was seen in a single case study and showed that the patient’s symptoms worsened during “off ” periods; however, this was only done during DBS treatment for obesity in a single patient.[
Current literature supports the use of DBS for AN and obesity through preliminary success. Although the percentage of patients achieving a healthy weight was less than half and none of the patients achieved a normal BMI in the obesity studies, the benefits of DBS in treating EDs appear to be lasting in most patients and warrant further studies. Studies should aim to increase their sample sizes, determine a follow-up protocol, and standardize the neuropsychiatric tests used to determine psychological and physiological benefits.
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