在立体定向手术干预伏隔核治疗神经性厌食症
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摘要
神经性厌食症是有意节制饮食，导致体重明显低于正常标准的一种进食障碍。神经性厌食症的特征是拒绝将体重维持在高于或等于最低正常体重的水平（即根据年龄和身高所得到的预期体重的85％，或体重指数为17.5kg／m2），或者在生长发育阶段没有出现预期的体重增加。主要患病群体为青少年女性，女性神经性厌食症的平均发病率是19/100,000/year(约为男性发病率的10倍)。
精神科治疗(包括药物及心理-行为治疗)配合营养治疗是目前最为普及的治疗方案。然而仍有约20%的患者为难治性神经性厌食症，对上述治疗方案无任何效果，而这也是造成该疾病高病死率的主要原因之一。
伏隔核大脑边缘系统的重要组成部分，是奖赏环路的重要结构。基于以往我们对毁损伏隔核在治疗毒品依赖和酒精依赖方面的前期工作，以及毁损伏隔核在治疗强迫症方面的疗效。
本研究拟通过立体定向手术干预伏隔核以治疗AN。纳入的12名女性神经性厌食症患者，随机分为两组，分别为单靶点毁损组（伏隔核）和多靶点毁损组（伏隔核、内囊前肢、扣带回），每组6名患者。通过立体定向射频毁损术分别对两组患者进行毁损。术后两组患者术后BMI指数、HAMD、HAMA、Y-BOCS及SF-36得分均立即下降（P<0.05）。单靶点毁损组与多靶点毁损组的患者术后BMI指数、HAMD、HAMA、Y-BOCS及SF-36之间比较均无明显差异（P＞0.05）。单靶点毁损伏隔核与多靶点毁损伏隔核、内囊前肢及扣带回的手术疗效无明显差异。对纳入的5名接受伏隔核脑深部电极植入术的患者行手术治疗。术后HAMD、HAMA、Y-BOCS、SF-36的改变均显示逐步的改善效果（P<0.05）。NAc-DBS组与单靶点毁损组、多靶点毁损组的患者术后BMI指数、HAMD、HAMA、Y-BOCS及SF-36之间比较均无明显差异（P＞0.05）。NAc-DBS治疗AN是有效的。通过本研究发现，立体定向手术干预伏隔核单靶点治疗神经性厌食症是有效的。射频毁损术与脑深部电刺激术间疗效无明显差异。可通过患者实际病情选择手术方式。
AN is one kind of eating disorders. AN patients intentionally control their diet andhence have significantly lower weight than the normal standard. The characteristics of ANis refusal to maintain a body weight which is greater than or equal to the lowest level ofnormal body weight (i.e.,85%of the expected body weight according age and height, orBMI of17.5kg/m2), or lack of expected weight gain in certain growth and developmentstages. Majority of the patients are young women; the average rate of AN incidence inwomen is19/100,000/year, which is about10times of that in men.
Psychiatric treatment (including drugs and psycho-behavioral therapy) accompaniedby nutritional therapy is the most popular treatment for AN so far. However, about20%ofthe AN patients are refractory to above treatments, and this is one of the main reasonscausing high mortality of AN.
NAc is an important part of the limbic system of brain and a critical structure of brain’s reward loop. Based on the results from our previous works of treating drug abuseand alcoholism by NAc ablation and the adverse therapeutic effect of NAc ablation onobsessive-compulsive disorders, the present study aims to investigate the effect ofstereotactic surgical intervention of NAc on the treatment of AN.
The purpose of this experiment was to effectively treat AN through stereotacticsurgery and implantation of deep brain stimulation.12female patients were randomlyassigned into two groups.6patients underwent bilateral ablation of NAc.6patientsunderwent bilateral ablation of NAc, anterior limb of internal capsule and cingulate gyrus.The BMI、HAMD、HAMA、Y-BOCS and SF-36scoles of patients who received bilateralablation of NAc have shown immediate improvements（P<0.05）. And the such scolesshowed no significant difference （P＞0.05）between two groups. Other5patients whoreceived deep brain stimulation also shown immediate improvements in the BMI、HAMD、HAMA、Y-BOCS and SF-36scoles（P<0.05）. And the such scoles also showedno significant difference （P＞0.05）between patients who received stereotactic surgeryand implantation of deep brain stimulation. Taking together, the study indicates that NAcis an effective target for AN treatment. Stereotactic surgical intervention of NAc caneffectively improve the symptoms in AN patients.
精神科治疗(包括药物及心理-行为治疗)配合营养治疗是目前最为普及的治疗方案。然而仍有约20%的患者为难治性神经性厌食症，对上述治疗方案无任何效果，而这也是造成该疾病高病死率的主要原因之一。
伏隔核大脑边缘系统的重要组成部分，是奖赏环路的重要结构。基于以往我们对毁损伏隔核在治疗毒品依赖和酒精依赖方面的前期工作，以及毁损伏隔核在治疗强迫症方面的疗效。
本研究拟通过立体定向手术干预伏隔核以治疗AN。纳入的12名女性神经性厌食症患者，随机分为两组，分别为单靶点毁损组（伏隔核）和多靶点毁损组（伏隔核、内囊前肢、扣带回），每组6名患者。通过立体定向射频毁损术分别对两组患者进行毁损。术后两组患者术后BMI指数、HAMD、HAMA、Y-BOCS及SF-36得分均立即下降（P<0.05）。单靶点毁损组与多靶点毁损组的患者术后BMI指数、HAMD、HAMA、Y-BOCS及SF-36之间比较均无明显差异（P＞0.05）。单靶点毁损伏隔核与多靶点毁损伏隔核、内囊前肢及扣带回的手术疗效无明显差异。对纳入的5名接受伏隔核脑深部电极植入术的患者行手术治疗。术后HAMD、HAMA、Y-BOCS、SF-36的改变均显示逐步的改善效果（P<0.05）。NAc-DBS组与单靶点毁损组、多靶点毁损组的患者术后BMI指数、HAMD、HAMA、Y-BOCS及SF-36之间比较均无明显差异（P＞0.05）。NAc-DBS治疗AN是有效的。通过本研究发现，立体定向手术干预伏隔核单靶点治疗神经性厌食症是有效的。射频毁损术与脑深部电刺激术间疗效无明显差异。可通过患者实际病情选择手术方式。
AN is one kind of eating disorders. AN patients intentionally control their diet andhence have significantly lower weight than the normal standard. The characteristics of ANis refusal to maintain a body weight which is greater than or equal to the lowest level ofnormal body weight (i.e.,85%of the expected body weight according age and height, orBMI of17.5kg/m2), or lack of expected weight gain in certain growth and developmentstages. Majority of the patients are young women; the average rate of AN incidence inwomen is19/100,000/year, which is about10times of that in men.
Psychiatric treatment (including drugs and psycho-behavioral therapy) accompaniedby nutritional therapy is the most popular treatment for AN so far. However, about20%ofthe AN patients are refractory to above treatments, and this is one of the main reasonscausing high mortality of AN.
NAc is an important part of the limbic system of brain and a critical structure of brain’s reward loop. Based on the results from our previous works of treating drug abuseand alcoholism by NAc ablation and the adverse therapeutic effect of NAc ablation onobsessive-compulsive disorders, the present study aims to investigate the effect ofstereotactic surgical intervention of NAc on the treatment of AN.
The purpose of this experiment was to effectively treat AN through stereotacticsurgery and implantation of deep brain stimulation.12female patients were randomlyassigned into two groups.6patients underwent bilateral ablation of NAc.6patientsunderwent bilateral ablation of NAc, anterior limb of internal capsule and cingulate gyrus.The BMI、HAMD、HAMA、Y-BOCS and SF-36scoles of patients who received bilateralablation of NAc have shown immediate improvements（P<0.05）. And the such scolesshowed no significant difference （P＞0.05）between two groups. Other5patients whoreceived deep brain stimulation also shown immediate improvements in the BMI、HAMD、HAMA、Y-BOCS and SF-36scoles（P<0.05）. And the such scoles also showedno significant difference （P＞0.05）between patients who received stereotactic surgeryand implantation of deep brain stimulation. Taking together, the study indicates that NAcis an effective target for AN treatment. Stereotactic surgical intervention of NAc caneffectively improve the symptoms in AN patients.
引文
1. Pawluck DE, Gorey KM. Secular trends in the incidence of anorexia nervosa:integrative review of population-based studies. Int J Eat Disord1998;23:347–52.
2. Herzog DB, Nussbaum KM, Marmor AK．Comorbidity and outcome in eatingdisorders．Psychiatr Clin Noah Am．1996,19:843-859．
3. Tamburrino MB. Mcginnis RA. Anorexia nervosa．A review．Panminerva Med，2002,44:301-311.
4. Anderluh MB, Tchanturia K, Rabe-Hesketh S, et al. Childhood obsessive-compulsivepersonality traits in adult women with eating disorders: defining a broader eatingdisorder phenotype. Am J Psychiatry2003;160:242–7.
5. Lim SL, Sinaram S, Ung EK, et al. The pursuit of thinness: an outcome study ofanorexia nervosa. Singapore Med J,2007;48:222-226.
6. Morgan JF, Crisp AH. Use of leucotomy for intractable anorexia nervosa: a long-termfollow-up study. Int J Eat Disord,2000;27:249-258.
7. Steinhausen HC, Seidel R, Winkler-Metzke C. Evaluation of treatment andintermediate and long-term outcome of adolescent eating disorder. Psychol Med,2000;30:1089-1098.
8. Zipfel S, Lowe B, Reas DL, et al. Long-term prognosis in anorexia nervosa: lessonsfrom a21-year follow-up study. Lancent,2000,355:721-722.
9. G. Gao, X. Wang, S. He, et al. Clinical study for alleviating opiate drug psychologicaldependence by a method of ablating the nucleus accumbens with stereotactic surgery.Stereotactic and Functional Neurosurgery,2003;81:96–104.
10. He-Ming Wu, Xue-Lian Wang, Chong-Wang Chang, et al. Preliminary findings inablating the nucleus accumbens using stereotactic surgery for alleviatingpsychological dependence on alcohol. Neuroscience Letters,2010;473:77–81.
11. Pineles SL, Mineka S. Attentional biases to internal and external sources of potentialthreat in social anxiety. Journal of Abnormal Psychology,2005;114:314-318．
12.张大荣.进食障碍./沈渔邨，主编.精神病学.第4版.北京：人民卫生出版社，2005:503-506.
13. Ben-Dor DH, Laufer N, Apter A, et al. Heritability, genetics and association findingsin anorexia nervosa. Isr J Psychiatry Relat Sci,2002;39:262-270.
14.郭庆华.神经性厌食症综述.榆林学院学报，2006；6（16）：15-19.
15. Sing Lee. From diversity to unity. The classification of mental disorders in21st-century China. Psychiatr Clin North Am.2001;24(3):421-431.
16. Kaplan HI, Sadock BJ, Grebb JA, et a1. Kaplan and sadock’s synopsis of psychiatry.Behavioral sciences clinical psychiatry. Seventh edition. Maryland: Williams andWilkins,1994,689-695.
17. Salvador Minuchin著，刘琼英译．结构派家族治疗入门，第一版．台北市：心理出版社有限公司，1996，377-401.
18. Grice DE, Halmi KA, Fichter MM, et al. Evidence for a susceptibility gene foranorexia nervosa on chromosome1. Am J Hum Genet,2002;70:787–92.
19. Stice E. Risk and maintenance factors for eating pathology: a meta-analytic review.Psychol Bull,2002;128:825–848.
20. Jacobi C, Hayward C, Agras WS, et al. Coming to terms with risk factors for eatingdisorders: application of risk terminology and suggestions for a general taxonomy.Psychol Bull,2003; in press.
21. Klump K, McGue M, Iacono WG. Age differences in genetic and environmentalinfluences on eating attitudes and behaviors in preadolescent and adolescent femaletwins. J Abnorm Psycho1,2000;109:239-251.
22. Clark S. Treatment of anorexia nervosa. Nursing Times,2003;99:34.
23. Brewerton TD. Review：toward a unified theory of serotonin dysregulation in eatingand related disorders. Psychoneuroendocrinology,1995;20:561-590.
24. Halford JC, Harrold JA, Boyland EJ, et al. Serotonergic drugs: effects on appetiteexpression and use for the treatment of obesity. Drugs,2007;67:27-55.
25. Kaye W, Strober M. The neurobiology of eating disorders. In: Charney DS, Nestler EJ,Bunney BS. Neurobiology of mental illness. New York: Oxford University Press,1999:891-906.
26. Frank GK, Kaye WE, Mehzer CC, et al. Reduced5-HT2A receptor binding afterrecovery from anorexia nervosa. Biol Psychiatry,2002;52:896-906.
27. Powers PS. Initial assessment and early treatment options for anorexia nervosa andbulimia nervosa. Psychiatric Clinics of North America,1996;19:639-655.
28.28Carney CP, Anderson AE. Eating disorder: guide to medical evaluation andcomplications. Psychiatric Clinics of North America,1996;19:657-679.
29. Nobili L, Baglietto MG, De Carli F, et al. A quantified analysis of sleepelectroencephalography in anorectic adolescents. Biol Psychiatry,1999;45:771-775.
30. J Treaure. Eating disorder. Medcine,2004;32:63-66.
31. Agras WS, Robinson AH. Forty years of progress in the treatment of the eatingdisorders. Nord J Psychiatry,2008;47:19-24.
32.黄悦.神经性厌食症的药物治疗.临床心理卫生，2007；21（10）：724-726.
33. Attia E, Haiman C, Walsh BT, et a1. Does fluoxetine augment the inpatient treatmentof anorexia nervosa? Am J Psychiatry,1998;155:548-551.
34. Kaye WH, Nagata T, Weltzin TE, et a1. Double-blind placebo-controlledadministration of fluoxetine in restricting and restricting-purging-type anorexianervosa. Biol Psychiatry,2001;49:644-652.
35. Walsh BT, Kaplan AS, Atria E, et a1. Fluoxetine after weight restoration in anorexianervosa: a randomized controlled tria1.J Am Med Associat,2006;295:2605-2612.
36.陈玉龙，王霞．米氮平治疗神经性厌食症的疗效对照研究．中国心理卫生杂志，2005，19：640-642．
37. Halmi KA, Eckert E, LaDu TJ,et a1. Anorexia nervosa. Treatment efficacy ofcyproheptadine and amitriptyline. Arch Gen Psychiatry,1986;43:177-181.
38. Biederman J, Herzog DB, Rivinus TM, et a1. Amitriptyline in the treatment ofanorexia nervosa：a double-blind, placebo-controlled study. J Clin Psychopharmacol,1985;5:10-16.
39.39Hill K, Bucuvalas J, McClain C, et a1. Pilot study of growth hormoneadministration during the refeeding of malnourished anorexia nervosa patients. JChild Adolesc Psychopharmacol.2000;10:3-8.
40. Klibanski A, Biler BM, Scboenfeld DA, et a1. The effects of estrogen administrationon trabecular bone loss in young women with anorexia nervosa J Clin EndoerinolMetab,1995;80:898-904.
41. Miller KK, Grieco KA, Klibanski A. Testosterone administration in women withanorexia nervosa. J Clin Endocrinol Metab,2005;90:1428-1433.
42. Birmingham CL, Goldner EM, Bakan R. Controlled trial of zinc supplementation inanorexia nervosa. Int J Eal Disord,1994;15:251-255.
43. Powers PS. Initial assessment and early treatment options for anorexia nervosa andbulimia nervosa. Psychiar Clin North Am,1996;19:639-643.
44. Rock CL, Curran-Celentano J. Nutritional management of eating disorders. PsychiatClin North Am,1996;19:701-707.
45. Jimerson DC, Wolfe BE, Brotman AW, et al. Medications in the treatment of eatingdisorder. Psychiat Clin North Am,1996;19:739-745.
46. Gowers SG, Shore A. Development of weight and shape concerns the etiology ofeating disorders. British J Psychiatry,2001;179:236.
47.付翠.神经性厌食症的家庭治疗—西方关于神经性厌食症心理治疗的新进展.医学与哲学,2005;26:71-72.
48.48Minuchin S. Families and Family Therapy. Cambridge, MA: Harvard UniversityPress,1974:241-242.
49. Minuchin S, Roseman BL, Baker L. Psychosomatic Families: Anorexia nervosa incontext. Cambridge, MA: Harvard University Press,1978:246-250.
50. David M,Garner and Paul E. Garfinkel Handbook of treatment for eating disorders,New York: Guilford Press,1997:448.
51. Sevini-Palazzoli M. Towards a general model of psychotic family games. J MartalFam Ther,1986;12:339-349.
52.史靖宇,赵旭东,缪绍疆.青少年神经性厌食症的家庭治疗.上海精神医学,2008;20:106-109.
53. Steinglass P. Multiple family discussion group for patients with chronic medicalillness. Families, Systems and Health,1998;16:55-70.
54. Neumark-Sztainer D, Wall M, Story M, et al. Are family meal patterns associated withdisordered eating behavior among adolescents? J Adolescent Health,2004;35:350-359.
55. Birch LL, Fisher JO. Development of eating behaviors among children andadolescents. Paediatrician,1998;3:539-549.
56. Birch LL, Fisher JO, Grimm-Thomas K, et al. Confirmatory factor analysis of theChild Feeding Questionnaire: A measure of parental attitudes, beliefs and practicesabout child feeding and obesity proneness. Appetite,2001;36:201-210.
57. Ma JLC, Chow MLY, Lee S, et al. Family meaning of self-starvation: Themesdiscerned in family treatment in Hong Kong. J Fam Ther,2002;24:57-71.
58. Karwautz A, Nobis G, Haidvog M, et al. Perceptions of family relationships inadolescents with anorexia nervosa and their unaffected sisters. Eur Child Adoles Psy,2003;12:128-135.
59. Sifneos PE. A case of anorexia nervosa treated successfully by leucotomy. Am JPsychiatry,1952;109:356-360.
60. Carmody JT, Vibber FL. Anorexia nervosa treated by prefrontal lobotomy. AnnIntern Med,1952;36:647-652.
61. Mitchell-Heggs N, Kelly D, Richardson A. Stereotactic limbic leucotomy-afollow-up at16months.Br J Psychiatry,1976;128:226-240.
62. Crisp AH, Kalucy RS. The effect of leucotomy in intractable adolescent weightphobia (primary anorexia nervosa). Postgrad Med J,1973;49:883-893.
63. Vocks S, Herpertz S, Rosenberger C, et al. Effects of gustatory stimulation on brainactivity during hunger and satiety in females with restricting-type anorexia nervosa:An fMRI study. J Psychiatr Res,2010;13[Epub ahead of print]
64. Jean A, Conductier G, Manrique C, et al. Anorexia induced by activation of serotonin5-HT4receptors is mediated by increases in CART in the nucleus accumbens. ProcNatl Acad Sci USA,2007;104:16335-16340.
65. Fladung AK, Gr n G, Grammer K, et al. A neural signature of anorexia nervosa inthe ventral striatal reward system. Am J Psychiatry,2010;167:206-212.
66. Zamboni R, Larach V, Poblete M, et al. Dorsomedial thalamotomy as a treatment forterminal anorexia: a report of two cases. Acta Neurochir Suppl (Wien).1993;58:34-35.
67. Meredith GE, Pattiselanno A, Groenewegen HJ, et al. Shell and core in monkey andhuman nucleus accumbens identified with antibodies to cabindin-D28k. J CompNearol,1996;365:628-639.
68. Ikemoto S, Panksepp J. The role of nucleus accumbens dopamine in motivatedbehavior: a unifying interpretation with special reference to reward-seeking. BrainRes Brain Res Rev,1999;31:6-41.
69. Meredith GE. The synaptic framework for chemical signaling in nucleus accumbens.Ann N Y Acad Sei,1999;877:140-156.
70.王学廉.“3＋X”全息导航手术治疗难治性精神病.第四军医大学学报,2008;29:2017-2018.
71. Di Chiara G. Nucleus accumbens shell and core dopamine: differential role inbehavior and addiction. Behav Brain Res,2002;137:75-114.
72.赵继宗主编.微创神经外科学第一版.人民卫生出版社,2005:536-546.
73. Leyton ML, Young SN, Srivastava LK. The25th Annual Meeting of the CanadianCollege of Neuropsychopharmacology. J Psychiatry Neurosci,2002;27:438-450.
74. KayeW. Frank G. Gene-environment interactions: brain and behavior in anorexianervosa (lecture). Annual meeting of the Eating Disorder Research Society,2002:20-23.
75. Crisp AH, Kalucy RS. The effect of leucotomy in intractable adolescent weightphobia(primary anorexia nervosa). Postqrad Med J,1973;49:883-893.
76. Hemmings WU,潘宜新,李锋等.立体定向功能神经外科治疗神经性厌食症-从现在到未来.当代医学,2010;16:36-37.
2. Herzog DB, Nussbaum KM, Marmor AK．Comorbidity and outcome in eatingdisorders．Psychiatr Clin Noah Am．1996,19:843-859．
3. Tamburrino MB. Mcginnis RA. Anorexia nervosa．A review．Panminerva Med，2002,44:301-311.
4. Anderluh MB, Tchanturia K, Rabe-Hesketh S, et al. Childhood obsessive-compulsivepersonality traits in adult women with eating disorders: defining a broader eatingdisorder phenotype. Am J Psychiatry2003;160:242–7.
5. Lim SL, Sinaram S, Ung EK, et al. The pursuit of thinness: an outcome study ofanorexia nervosa. Singapore Med J,2007;48:222-226.
6. Morgan JF, Crisp AH. Use of leucotomy for intractable anorexia nervosa: a long-termfollow-up study. Int J Eat Disord,2000;27:249-258.
7. Steinhausen HC, Seidel R, Winkler-Metzke C. Evaluation of treatment andintermediate and long-term outcome of adolescent eating disorder. Psychol Med,2000;30:1089-1098.
8. Zipfel S, Lowe B, Reas DL, et al. Long-term prognosis in anorexia nervosa: lessonsfrom a21-year follow-up study. Lancent,2000,355:721-722.
9. G. Gao, X. Wang, S. He, et al. Clinical study for alleviating opiate drug psychologicaldependence by a method of ablating the nucleus accumbens with stereotactic surgery.Stereotactic and Functional Neurosurgery,2003;81:96–104.
10. He-Ming Wu, Xue-Lian Wang, Chong-Wang Chang, et al. Preliminary findings inablating the nucleus accumbens using stereotactic surgery for alleviatingpsychological dependence on alcohol. Neuroscience Letters,2010;473:77–81.
11. Pineles SL, Mineka S. Attentional biases to internal and external sources of potentialthreat in social anxiety. Journal of Abnormal Psychology,2005;114:314-318．
12.张大荣.进食障碍./沈渔邨，主编.精神病学.第4版.北京：人民卫生出版社，2005:503-506.
13. Ben-Dor DH, Laufer N, Apter A, et al. Heritability, genetics and association findingsin anorexia nervosa. Isr J Psychiatry Relat Sci,2002;39:262-270.
14.郭庆华.神经性厌食症综述.榆林学院学报，2006；6（16）：15-19.
15. Sing Lee. From diversity to unity. The classification of mental disorders in21st-century China. Psychiatr Clin North Am.2001;24(3):421-431.
16. Kaplan HI, Sadock BJ, Grebb JA, et a1. Kaplan and sadock’s synopsis of psychiatry.Behavioral sciences clinical psychiatry. Seventh edition. Maryland: Williams andWilkins,1994,689-695.
17. Salvador Minuchin著，刘琼英译．结构派家族治疗入门，第一版．台北市：心理出版社有限公司，1996，377-401.
18. Grice DE, Halmi KA, Fichter MM, et al. Evidence for a susceptibility gene foranorexia nervosa on chromosome1. Am J Hum Genet,2002;70:787–92.
19. Stice E. Risk and maintenance factors for eating pathology: a meta-analytic review.Psychol Bull,2002;128:825–848.
20. Jacobi C, Hayward C, Agras WS, et al. Coming to terms with risk factors for eatingdisorders: application of risk terminology and suggestions for a general taxonomy.Psychol Bull,2003; in press.
21. Klump K, McGue M, Iacono WG. Age differences in genetic and environmentalinfluences on eating attitudes and behaviors in preadolescent and adolescent femaletwins. J Abnorm Psycho1,2000;109:239-251.
22. Clark S. Treatment of anorexia nervosa. Nursing Times,2003;99:34.
23. Brewerton TD. Review：toward a unified theory of serotonin dysregulation in eatingand related disorders. Psychoneuroendocrinology,1995;20:561-590.
24. Halford JC, Harrold JA, Boyland EJ, et al. Serotonergic drugs: effects on appetiteexpression and use for the treatment of obesity. Drugs,2007;67:27-55.
25. Kaye W, Strober M. The neurobiology of eating disorders. In: Charney DS, Nestler EJ,Bunney BS. Neurobiology of mental illness. New York: Oxford University Press,1999:891-906.
26. Frank GK, Kaye WE, Mehzer CC, et al. Reduced5-HT2A receptor binding afterrecovery from anorexia nervosa. Biol Psychiatry,2002;52:896-906.
27. Powers PS. Initial assessment and early treatment options for anorexia nervosa andbulimia nervosa. Psychiatric Clinics of North America,1996;19:639-655.
28.28Carney CP, Anderson AE. Eating disorder: guide to medical evaluation andcomplications. Psychiatric Clinics of North America,1996;19:657-679.
29. Nobili L, Baglietto MG, De Carli F, et al. A quantified analysis of sleepelectroencephalography in anorectic adolescents. Biol Psychiatry,1999;45:771-775.
30. J Treaure. Eating disorder. Medcine,2004;32:63-66.
31. Agras WS, Robinson AH. Forty years of progress in the treatment of the eatingdisorders. Nord J Psychiatry,2008;47:19-24.
32.黄悦.神经性厌食症的药物治疗.临床心理卫生，2007；21（10）：724-726.
33. Attia E, Haiman C, Walsh BT, et a1. Does fluoxetine augment the inpatient treatmentof anorexia nervosa? Am J Psychiatry,1998;155:548-551.
34. Kaye WH, Nagata T, Weltzin TE, et a1. Double-blind placebo-controlledadministration of fluoxetine in restricting and restricting-purging-type anorexianervosa. Biol Psychiatry,2001;49:644-652.
35. Walsh BT, Kaplan AS, Atria E, et a1. Fluoxetine after weight restoration in anorexianervosa: a randomized controlled tria1.J Am Med Associat,2006;295:2605-2612.
36.陈玉龙，王霞．米氮平治疗神经性厌食症的疗效对照研究．中国心理卫生杂志，2005，19：640-642．
37. Halmi KA, Eckert E, LaDu TJ,et a1. Anorexia nervosa. Treatment efficacy ofcyproheptadine and amitriptyline. Arch Gen Psychiatry,1986;43:177-181.
38. Biederman J, Herzog DB, Rivinus TM, et a1. Amitriptyline in the treatment ofanorexia nervosa：a double-blind, placebo-controlled study. J Clin Psychopharmacol,1985;5:10-16.
39.39Hill K, Bucuvalas J, McClain C, et a1. Pilot study of growth hormoneadministration during the refeeding of malnourished anorexia nervosa patients. JChild Adolesc Psychopharmacol.2000;10:3-8.
40. Klibanski A, Biler BM, Scboenfeld DA, et a1. The effects of estrogen administrationon trabecular bone loss in young women with anorexia nervosa J Clin EndoerinolMetab,1995;80:898-904.
41. Miller KK, Grieco KA, Klibanski A. Testosterone administration in women withanorexia nervosa. J Clin Endocrinol Metab,2005;90:1428-1433.
42. Birmingham CL, Goldner EM, Bakan R. Controlled trial of zinc supplementation inanorexia nervosa. Int J Eal Disord,1994;15:251-255.
43. Powers PS. Initial assessment and early treatment options for anorexia nervosa andbulimia nervosa. Psychiar Clin North Am,1996;19:639-643.
44. Rock CL, Curran-Celentano J. Nutritional management of eating disorders. PsychiatClin North Am,1996;19:701-707.
45. Jimerson DC, Wolfe BE, Brotman AW, et al. Medications in the treatment of eatingdisorder. Psychiat Clin North Am,1996;19:739-745.
46. Gowers SG, Shore A. Development of weight and shape concerns the etiology ofeating disorders. British J Psychiatry,2001;179:236.
47.付翠.神经性厌食症的家庭治疗—西方关于神经性厌食症心理治疗的新进展.医学与哲学,2005;26:71-72.
48.48Minuchin S. Families and Family Therapy. Cambridge, MA: Harvard UniversityPress,1974:241-242.
49. Minuchin S, Roseman BL, Baker L. Psychosomatic Families: Anorexia nervosa incontext. Cambridge, MA: Harvard University Press,1978:246-250.
50. David M,Garner and Paul E. Garfinkel Handbook of treatment for eating disorders,New York: Guilford Press,1997:448.
51. Sevini-Palazzoli M. Towards a general model of psychotic family games. J MartalFam Ther,1986;12:339-349.
52.史靖宇,赵旭东,缪绍疆.青少年神经性厌食症的家庭治疗.上海精神医学,2008;20:106-109.
53. Steinglass P. Multiple family discussion group for patients with chronic medicalillness. Families, Systems and Health,1998;16:55-70.
54. Neumark-Sztainer D, Wall M, Story M, et al. Are family meal patterns associated withdisordered eating behavior among adolescents? J Adolescent Health,2004;35:350-359.
55. Birch LL, Fisher JO. Development of eating behaviors among children andadolescents. Paediatrician,1998;3:539-549.
56. Birch LL, Fisher JO, Grimm-Thomas K, et al. Confirmatory factor analysis of theChild Feeding Questionnaire: A measure of parental attitudes, beliefs and practicesabout child feeding and obesity proneness. Appetite,2001;36:201-210.
57. Ma JLC, Chow MLY, Lee S, et al. Family meaning of self-starvation: Themesdiscerned in family treatment in Hong Kong. J Fam Ther,2002;24:57-71.
58. Karwautz A, Nobis G, Haidvog M, et al. Perceptions of family relationships inadolescents with anorexia nervosa and their unaffected sisters. Eur Child Adoles Psy,2003;12:128-135.
59. Sifneos PE. A case of anorexia nervosa treated successfully by leucotomy. Am JPsychiatry,1952;109:356-360.
60. Carmody JT, Vibber FL. Anorexia nervosa treated by prefrontal lobotomy. AnnIntern Med,1952;36:647-652.
61. Mitchell-Heggs N, Kelly D, Richardson A. Stereotactic limbic leucotomy-afollow-up at16months.Br J Psychiatry,1976;128:226-240.
62. Crisp AH, Kalucy RS. The effect of leucotomy in intractable adolescent weightphobia (primary anorexia nervosa). Postgrad Med J,1973;49:883-893.
63. Vocks S, Herpertz S, Rosenberger C, et al. Effects of gustatory stimulation on brainactivity during hunger and satiety in females with restricting-type anorexia nervosa:An fMRI study. J Psychiatr Res,2010;13[Epub ahead of print]
64. Jean A, Conductier G, Manrique C, et al. Anorexia induced by activation of serotonin5-HT4receptors is mediated by increases in CART in the nucleus accumbens. ProcNatl Acad Sci USA,2007;104:16335-16340.
65. Fladung AK, Gr n G, Grammer K, et al. A neural signature of anorexia nervosa inthe ventral striatal reward system. Am J Psychiatry,2010;167:206-212.
66. Zamboni R, Larach V, Poblete M, et al. Dorsomedial thalamotomy as a treatment forterminal anorexia: a report of two cases. Acta Neurochir Suppl (Wien).1993;58:34-35.
67. Meredith GE, Pattiselanno A, Groenewegen HJ, et al. Shell and core in monkey andhuman nucleus accumbens identified with antibodies to cabindin-D28k. J CompNearol,1996;365:628-639.
68. Ikemoto S, Panksepp J. The role of nucleus accumbens dopamine in motivatedbehavior: a unifying interpretation with special reference to reward-seeking. BrainRes Brain Res Rev,1999;31:6-41.
69. Meredith GE. The synaptic framework for chemical signaling in nucleus accumbens.Ann N Y Acad Sei,1999;877:140-156.
70.王学廉.“3＋X”全息导航手术治疗难治性精神病.第四军医大学学报,2008;29:2017-2018.
71. Di Chiara G. Nucleus accumbens shell and core dopamine: differential role inbehavior and addiction. Behav Brain Res,2002;137:75-114.
72.赵继宗主编.微创神经外科学第一版.人民卫生出版社,2005:536-546.
73. Leyton ML, Young SN, Srivastava LK. The25th Annual Meeting of the CanadianCollege of Neuropsychopharmacology. J Psychiatry Neurosci,2002;27:438-450.
74. KayeW. Frank G. Gene-environment interactions: brain and behavior in anorexianervosa (lecture). Annual meeting of the Eating Disorder Research Society,2002:20-23.
75. Crisp AH, Kalucy RS. The effect of leucotomy in intractable adolescent weightphobia(primary anorexia nervosa). Postqrad Med J,1973;49:883-893.
76. Hemmings WU,潘宜新,李锋等.立体定向功能神经外科治疗神经性厌食症-从现在到未来.当代医学,2010;16:36-37.