Cerebral implants and Parkinson's disease: a unique form of biographical disruption?

Caregivers' burden and deep brain stimulation for Parkinson disease: A systematic review of qualitative studies

BACKGROUND AND PURPOSE

The impact of subthalamic nucleus deep brain stimulation (STN-DBS) on caregivers' burden is understudied. We perform a systematic review and meta-synthesis aggregating qualitative studies involving partners of people with Parkinson disease (PwP) to explore their experiences and unmet needs.

METHODS

A systematic review for retrieving qualitative studies included six databases: MEDLINE, Embase, CINAHL, Cochrane, PsycInfo, and Scopus. Inclusion criteria were as follows: (i) studies on the experience of caregivers of PwP in the context of STN-DBS, (ii) English peer-reviewed articles, and (iii) qualitative or mixed methods studies reporting caregivers' quotations. After the appraisal of included studies, we performed meta-synthesis of qualitative findings. Descriptive themes and conceptual elements related to PwP partners' experiences and unmet needs were generated.

RESULTS

A total of 1108 articles were screened, and nine articles were included. Three categories were identified: (i) dealing with Parkinson disease (PD) every day (the starting situation characterized by the impact of PD on ordinary life; the limitations to partners' socialization; partners' efforts in stepping aside for love and care activities), (ii) facing life changes with STN-DBS (the feeling of being unprepared for changes; the fear and concern due to loved ones' behavioral changes; struggling to find an explanation for those changes), and (iii) rebuilding the role of caregiver and partner after STN-DBS.

CONCLUSIONS

This meta-synthesis elucidates concerns, challenges, and unmet needs of partners of PwP who underwent STN-DBS. It is important to provide them with information, education, and adequate support to face these challenges. Professionals need to involve partners in the care and decision process, because STN-DBS-related outcomes do not depend solely on the well-being of PwP but also on the well-being of individuals surrounding them.

Researcher Views on Changes in Personality, Mood, and Behavior in Next-Generation Deep Brain Stimulation

The literature on deep brain stimulation (DBS) and adaptive DBS (aDBS) raises concerns that these technologies may affect personality, mood, and behavior. We conducted semi-structured interviews with researchers (n = 23) involved in developing next-generation DBS systems, exploring their perspectives on ethics and policy topics including whether DBS/aDBS can cause such changes. The majority of researchers reported being aware of personality, mood, or behavioral (PMB) changes in recipients of DBS/aDBS. Researchers offered varying estimates of the frequency of PMB changes. A smaller majority reported changes in personality specifically. Some expressed reservations about the scientific status of the term 'personality,' while others used it freely. Most researchers discussed negative PMB changes, but a majority said that DBS/aDBS can also result in positive changes. Several researchers viewed positive PMB changes as part of the therapeutic goal in psychiatric applications of DBS/aDBS. Finally, several discussed potential causes of PMB changes other than the device itself.

Participant perceptions of changes in psychosocial domains following participation in an adaptive deep brain stimulation trial

BACKGROUND

There has been substantial controversy in the neuroethics literature regarding the extent to which deep brain stimulation (DBS) impacts dimensions of personality, mood, and behavior.

OBJECTIVE/HYPOTHESIS

Despite extensive debate in the theoretical literature, there remains a paucity of empirical data available to support or refute claims related to the psychosocial changes following DBS.

METHODS

A mixed-methods approach was used to examine the perspectives of patients who underwent DBS regarding changes to their personality, authenticity, autonomy, risk-taking, and overall quality of life.

RESULTS

Patients (n = 21) who were enrolled in adaptive DBS trials for Parkinson's disease, essential tremor, obsessive-compulsive disorder, Tourette's syndrome, or dystonia participated. Qualitative data revealed that participants, in general, reported positive experiences with alterations in what was described as 'personality, mood, and behavior changes.' The majority of participants reported increases in quality of life. No participants reported 'regretting the decision to undergo DBS.'

CONCLUSION(S)

The findings from this patient sample do not support the narrative that DBS results in substantial adverse changes to dimensions of personality, mood, and behavior. Changes reported as "negative" or "undesired" were few in number, and transient in nature.

Exploring the Caregiver Role after Deep Brain Stimulation Surgery for Parkinson’s Disease: A Qualitative Analysis

This pilot study aimed to explore how caregiver spouses make sense of themselves one and five years after their partner’s deep brain stimulation (DBS) surgery for Parkinson’s disease. 16 spouse (8 husbands and 8 wives) caregivers were recruited for the interview. Eight struggled to reflect on their own lived experience and primarily focused on the impact of PD on their partners, such that their transcripts were no longer viable for interpretative phenomenological analysis (IPA). A content analysis showed (1) how these 8 caregivers shared less than half as many self-reflections than the other caregivers, (2) that there was a bias to reflect on their partner’s experience answering the opening question, (3) the bias continued when answering subsequent questions, and (4) there was a lack of awareness of this bias. No other patterns of behaviour or themes were able to be extracted. The remaining 8 interviews were transcribed and analysed using IPA. This analysis discovered 3 inter-related themes: (1) DBS allows carers to question and shift the caregiver role, (2) Parkinson’s unites and DBS divides, and (3) seeing myself and my needs, DBS enhances visibility. How these caregivers interacted with these themes depended on when their partners were operated. The results suggested that spouses maintained the role of caregiver one year post DBS because they struggle to identify themselves in any other way but were more comfortable reassociating into the role of spouse 5 years post surgery. Further inquiry into caregiver and patient identity roles post DBS is recommended as a means of supporting their psychosocial adjustment after surgery.

Views about neuromodulation interventions for depression by stakeholder group, treatment modality, and depression severity

BACKGROUND

The past few decades have seen the emergence both of new neuromodulation treatment protocols and novel applications of standard neuromodulation interventions in psychiatry. Yet little is known about different stakeholders' views about these interventions.

METHODS

We administered an online survey with an embedded video vignette experiment to four national samples: the general public (N = 1022), caregivers for people with depression (N = 1026), patients living with depression (N = 1050), and board-certified psychiatrists (N = 505). We randomly assigned subjects to one of eight conditions in our full factorial design: four neuromodulation interventions [electroconvulsive therapy, repetitive transcranial magnetic stimulation, deep brain stimulation, or adaptive brain implants] by two depression severity levels [moderate or severe]. In this paper we present results from ANOVA and linear regression models explaining how views about these four neuromodulation interventions-as measured in five attitudinal scales (general affect, perceived influence on self, perceived benefit, perceived risk, and perceived invasiveness)-vary by (1) intervention, (2) depression severity, and/or (3) stakeholder group.

RESULTS

Our results provide evidence that psychiatrists views differ significantly in important ways from other stakeholder groups. Type of intervention also shaped participants' attitudes, including perceptions of invasiveness, effectiveness, and safety.

CONCLUSIONS

Given the differing affective valence among stakeholders and the differences found by modality and stakeholder groups across the different scales, future targeted educational initiatives could be developed to help address key misunderstandings and misinformed perceptions.

Parkinson's Disease and Deep Brain Stimulation Have an Impact on My Life: A Multimodal Study on the Experiences of Patients and Family Caregivers

Parkinson’s disease (PD) has a large impact on patients’ physical and mental health, which also greatly affects their family caregivers. Deep brain stimulation (DBS) has emerged as an effective treatment for PD, but different authors have expressed their concerns about the potential impact of DBS on personality and identity. Our study aims at better understanding how patients and family caregivers experience life with PD and DBS, the impact of both on their personal and social lives, and their perception of the changes that have occurred as a result of the disease and the treatment. Our study applies a multimodal approach by means of narrative semi-structured interviews and drawings. Seven principal themes have been identified: “everyone’s Parkinson’s is different”, “changing as a person during the disease”, “going through Parkinson’s together”, “DBS improved my life”, “I am treated with DBS but I have Parkinson’s still”, “DBS is not perfect”, and “being different after DBS”. PD is perceived as an unpredictable and heterogeneous disease that changes from person to person, as does the effect of DBS. While DBS side-effects may have an impact on patients’ personality, behavior, and self-perception, PD symptoms and drug side-effects also have a great impact on these aspects.

Why a Virtual Assistant for Moral Enhancement When We Could have a Socrates?

Can Artificial Intelligence (AI) be more effective than human instruction for the moral enhancement of people? The author argues that it only would be if the use of this technology were aimed at increasing the individual's capacity to reflectively decide for themselves, rather than at directly influencing behaviour. To support this, it is shown how a disregard for personal autonomy, in particular, invalidates the main proposals for applying new technologies, both biomedical and AI-based, to moral enhancement. As an alternative to these proposals, this article proposes a virtual assistant that, through dialogue, neutrality and virtual reality technologies, can teach users to make better moral decisions on their own. The author concludes that, as long as certain precautions are taken in its design, such an assistant could do this better than a human instructor adopting the same educational methodology.

Losing Meaning: Philosophical Reflections on Neural Interventions and their Influence on Narrative Identity

The profound changes in personality, mood, and other features of the self that neural interventions can induce can be disconcerting to patients, their families, and caregivers. In the neuroethical debate, these concerns are often addressed in the context of possible threats to the narrative self. In this paper, I argue that it is necessary to consider a dimension of impacts on the narrative self which has so far been neglected: neural interventions can lead to a loss of meaning of actions, feelings, beliefs, and other intentional elements of our self-narratives. To uphold the coherence of the self-narrative, the changes induced by neural interventions need to be accounted for through explanations in intentional or biochemical terms. However, only an explanation including intentional states delivers the content to directly ascribe personal meaning, i.e., subjective value to events. Neural interventions can deprive events of meaning because they may favor a predominantly biochemical account. A loss of meaning is not inherently negative but it can be problematic, particularly if events are affected one was not prepared or willing to have stripped of meaning. The paper further examines what it is about neural interventions that impacts meaning by analyzing different methods. To which degree the pull towards a biochemical view occurs depends on the characteristics of the neural intervention. By comparing Deep Brain Stimulation, Prozac, Ritalin, psychedelics, and psychotherapy, the paper identifies some main factors: the rate of change, the transparency of the causal chain, the involvement of the patient, and the presence of an acute phenomenological experience.

Frailty as biographical disruption

Biographical disruption positions the onset of chronic illness as a major life disruption in which changes to body, self and resources occur (Sociology of Health & Illness, 4, 1982, 167-182). The concept has been used widely in medical sociology. It has also been subject to critique and development by numerous scholars. In this paper, we build on recent developments of the concept, particularly those taking a phenomenological approach, to argue that it can also help in understanding other disruptive health-related experiences across the life course, in this case the onset of frailty. We draw on the findings of 30 situated interviews with frail older people, relating their experiences of frailty to the concept of biographical disruption. We show that frailty shares many similarities with the experience of chronic illness. Using the lens of biographical disruption to understand frailty also offers insights relevant to recent debates around both concepts, and on the continued relevance of the idea of biographical disruption given changing experiences of health and illness, including the circumstances in which biographical disruption is more and less likely to be experienced. Finally, we reflect on the potentials and limitations of applying the concept to a health-related condition that cannot be categorised as a disease.

Changes in Patients' Desired Control of Their Deep Brain Stimulation and Subjective Global Control Over the Course of Deep Brain Stimulation

Objective: To examine changes in patients’ desired control of the deep brain stimulator (DBS) and perception of global life control throughout DBS.

Methods: A consecutive cohort of 52 patients with Parkinson’s disease (PD) was recruited to participate in a prospective longitudinal study over three assessment points (pre-surgery, post-surgery months 3 and 6). Semi-structured interviews assessing participants’ desire for stimulation control and perception of global control were conducted at all three points. Qualitative data were coded using content analysis. Visual analog scales were embedded in the interviews to quantify participants’ perceptions of control over time.

Results: Participants reported significant increases in their perception of global control over time and significant declines in their desired control of the stimulation. These changes were unrelated to improvements in motor symptoms. Improvements in global control were negatively correlated with a decline in desired stimulation control. Qualitative data indicate that participants have changed, nuanced levels of desired control over their stimulators. Increased global life control following DBS may be attributed to increased control over PD symptoms, increased ability to engage in valued activities, and increased overall self-regulation, while other domains related to global control remained unaffected by DBS.

Conclusions: There are few empirical data documenting patients’ desire for stimulation control throughout neuromodulation and how stimulation control is related to other aspects of control despite the growing application of neuromodulation devices to treat a variety of disorders. Our data highlight distinctions in different types of control and have implications for the development of patient-controlled neurostimulation devices.

Beyond Technologies of Electroencephalography-Based Brain-Computer Interfaces: A Systematic Review From Commercial and Ethical Aspects

The deployment of electroencephalographic techniques for commercial applications has undergone a rapid growth in recent decades. As they continue to expand in the consumer markets as suitable techniques for monitoring the brain activity, their transformative potential necessitates equally significant ethical inquiries. One of the main questions, which arises then when evaluating these kinds of applications, is whether they should be aligned or not with the main ethical concerns reported by scholars and experts. Thus, the present work attempts to unify these disciplines of knowledge by performing a comprehensive scan of the major electroencephalographic market applications as well as their most relevant ethical concerns arising from the existing literature. In this literature review, different databases were consulted, which presented conceptual and empirical discussions and findings about commercial and ethical aspects of electroencephalography. Subsequently, the content was extracted from the articles and the main conclusions were presented. Finally, an external assessment of the outcomes was conducted in consultation with an expert panel in some of the topic areas such as biomedical engineering, biomechatronics, and neuroscience. The ultimate purpose of this review is to provide a genuine insight into the cutting-edge practical attempts at electroencephalography. By the same token, it seeks to highlight the overlap between the market needs and the ethical standards that should govern the deployment of electroencephalographic consumer-grade solutions, providing a practical approach that overcomes the engineering myopia of certain ethical discussions.

Long term perceptions of illness and self after Deep Brain Stimulation in pediatric dystonia: A narrative research

BACKGROUND

Deep Brain Stimulation (DBS) is increasingly used in pediatric patients affected by isolated dystonia, with excellent results. Despite well documented long-term effects on motor functioning, information on quality of life and social adaptation is almost lacking.

OBJECTIVES

The present study aims to explore the experience of illness and the relation with the device in adult patients suffering from dystonia who underwent DBS surgery in pediatric age.

METHODS

A narrative inquiry approach was used to collect patients' narratives of their experience with dystonia and DBS stimulator. A written interview was administered to 8 patients over 18 years old with generalized isolated dystonia who had undergone pallidal DBS implantation in childhood. A thematic analysis was realized to examine the narratives collected.

RESULTS

Five main themes emerged: "relationship with the disease", "experience related to DBS procedure", "relationship with one's own body", "fears", "thoughts about future". Despite a general satisfaction in relation to DBS intervention, some patients expressed difficulties, such as the acceptance of changes in one's own body, concerns and fears regarding the device and the future, also considering the critical phase of transition from childhood to adulthood.

CONCLUSIONS

These results suggest that further research is needed to understand the contribution of psychological, as much as medical, aspects to the overall outcome of the intervention. The present explorative study encourages a deeper investigations of psychological aspects of patients, in order to plan a tailored care path and to decide whether to suggest a psychological support, both before and after the intervention.

Illness Representations and Coping Strategies in Patients Treated with Deep Brain Stimulation for Parkinson's Disease

There is a debate on possible alterations of self-identity following deep brain stimulation for neurological disorders including Parkinson's disease. Among the psychological variables likely to undergo changes throughout such a medical procedure, illness representations and coping strategies have not been the target of much research to this day. In order to remedy this, we investigated the dynamics of illness representations and coping strategies in an 18-month longitudinal study involving 45 patients undergoing deep brain stimulation for idiopathic Parkinson's disease. Two research hypotheses were formulated and investigated through repeated measures of ANOVAs and structural equation modelling with full information maximum likelihood and Bayesian estimations. Representations of Parkinson's disease as a cyclical condition and perception of control over the disease diminished after surgery. Use of instrumental coping strategies was not modified after deep brain stimulation. These changes were identified by SEM but not ANOVAs; their magnitude was nevertheless relatively small, implying general stability in representations. These findings suggest that psychological variables do not undergo major changes after deep brain stimulation for Parkinson's disease.

Proceedings of the Seventh Annual Deep Brain Stimulation Think Tank: Advances in Neurophysiology, Adaptive DBS, Virtual Reality, Neuroethics and Technology

The Seventh Annual Deep Brain Stimulation (DBS) Think Tank held on September 8th of 2019 addressed the most current: (1) use and utility of complex neurophysiological signals for development of adaptive neurostimulation to improve clinical outcomes; (2) Advancements in recent neuromodulation techniques to treat neuropsychiatric disorders; (3) New developments in optogenetics and DBS; (4) The use of augmented Virtual reality (VR) and neuromodulation; (5) commercially available technologies; and (6) ethical issues arising in and from research and use of DBS. These advances serve as both "markers of progress" and challenges and opportunities for ongoing address, engagement, and deliberation as we move to improve the functional capabilities and translational value of DBS. It is in this light that these proceedings are presented to inform the field and initiate ongoing discourse. As consistent with the intent, and spirit of this, and prior DBS Think Tanks, the overarching goal is to continue to develop multidisciplinary collaborations to rapidly advance the field and ultimately improve patient outcomes.

Boy Interrupted - Biographical disruption during the transition to adulthood

Most studies on the gendered aspects of biographical disruption are predicated on adult experiences of chronic illness, often based on heterogeneous samples. This paper goes beyond typologies by analysing the life-history case study of 'Sam', a 23-year-old Australian man raised in a refugee family, who developed a disabling chronic health condition at 15 years of age. The analysis illustrates how critical contextual factors like life-phase, combine with powerful social structures like ethnicity and gender to shape Sam's experiences of, and responses to, biographical disruption. Even before the onset of any symptoms, Sam was railing against the marginal position he occupied in the Australian gender order as a young Asian man. With little guidance on how to adapt his biography to integrate his new differently functioning body, Sam's transition to adulthood stalls, and he becomes in effect, a boy interrupted.

Learning from deep brain stimulation: the fallacy of techno-solutionism and the need for 'regimes of care'

Deep brain stimulation (DBS) is an effective treatment for the debilitating motor symptoms of Parkinson's disease and other neurological disorders. However, clinicians and commentators have noted that DBS recipients have not necessarily experienced the improvements in quality of life that would be expected, due in large part to what have been described as the 'psychosocial' impacts of DBS. The premise of this paper is that, in order to realise the full potential of DBS and similar interventions, clinical services need to be arranged in such a way that these psychosocial dimensions are recognised and managed. Our starting point is that the psychosocial effects of DBS 'in the field' present us with analytically-useful disruptions: they disturb and foreground deeply held assumptions relating to the individual, health and its treatment, and which in a crude form manifest as the myth of technological solutionism within health care. Drawing on scholarship in medical sociology and science and technology studies (STS), we argue that DBS brings to the fore the relational dimensions of personhood, and demonstrates the emotional and social turmoil that can result if the relational dimensions of personhood are ignored by clinical services. In light of this, we argue that DBS should be implemented within a regime of care. Drawing on ethnographic research of a paediatric DBS clinical service, we provide an example of a regime of care, and conclude by reflecting on what other DBS services might learn from this paediatric service.

Τhe multiple temporalities of deep brain stimulation (DBS) in Greece

This contribution intends to explore patients' lived experience, with a focus on the temporal dimension. On the basis of a qualitative study that led me to interview persons with Parkinson's disease (PD), caregivers, and medical professionals, I develop an empirical and philosophical investigation of the temporalities surrounding the implementation of deep brain stimulation (DBS) in Greece. I raise the issue of access to DBS medical care, and show how distinct temporalities are implied when the patients face such a matter: that of linear time, linked with the medical discourse, the bureaucratic time linked to administrative and financial hurdles in the implementation and maintenance of DBS, and the technological time of the body/technology fusion. I consider initially the impact of technology and health care settings on the lived experience of patients and the enactment of multiple bodies which are interrelated with the social world. I then expand my analysis in order to show that this experience cannot be a solipsistic one, or specific to one physician/patient relationship. It is fully socially shaped.

Deep Brain Stimulation (DBS) experiences: an ethnographic approach to their expression on the Internet forums

This contribution aims at describing the experiences of Deep Brain Stimulation (DBS) as discussed on Internet forums. Since the 2000s, increasing attention has been paid to health practices associated with the use of the Internet, whether by medical professionals, public authorities or researchers in the social sciences. We know that Internet is used by patients with Parkinson's disease, in order to discuss about their lived experiences. This contribution will present how these Internet users address the specific theme of DBS. We will examine how their use and the information sharing associated to it participate in the "shaping" of the lived experience of deep cerebral stimulation. This contribution will be introduced by an analysis of the state-of-the-art in sociological and anthropological international research on the topic of "Internet health". On the basis of this analysis, it will propose a framework to describe and understand the various uses of the web that are made to give an account of the experience of stimulation. The existence of collective mobilizations in Parkinson's disease, an old Internet experience and media oppositions concerning certain antiparkinsonian drugs, are conditions which push us to question these themes concerning DBS. This paper is a description, for the first time, of roles played by the users of these Internet forums and the different online activities produced about DBS subject. In an ethnographic perspective, we had to imagine that we were an Internet user seeking patient experiences with this surgical procedure to understand these interactions about DBS. The main goal of this contribution is to describe the attention paid by users for medical information about DBS in the identity and self-help process. The interest of such an approach is to open an anthropological reflection on the place and the role of the medical representations in the testimonies of experience of the disease or the treatments.

Pragmatism and the Importance of Interdisciplinary Teams in Investigating Personality Changes following DBS

Gilbert and colleagues (2018) point out the discrepancy between the limited empirical data illustrating changes in personality (and related concepts of identity, agency, authenticity, autonomy, and self, i.e., PIAAAS) following implantation of deep brain stimulating (DBS) electrodes and the vast number of conceptual neuroethics papers implying that these changes are widespread, deleterious, and clinically significant. Their findings are reminiscent of C. P. Snow’s essay on the divide between the two cultures of the humanities (representing the conceptual publications) and the sciences (representing the empirical work). This division in the literature raises significant ethical concerns surrounding unjustified fear of personality changes in the context of DBS and negative perceptions of clinician-scientists engaged in DBS. These concerns have real world implications for funding future innovative, DBS trials aimed to reduce suffering as well as hampering true interdisciplinary scholarship. We argue that the philosophical tradition of pragmatism and the value it places on empirical inquiry, experiential knowledge, and inter-disciplinary scholarship – reflecting diverse ways of knowing – provides a framework to start to address the important questions Gilbert and colleagues raise. In particular, we highlight the importance of expert clinician knowledge in contributing to the neuroethical questions raised by Gilbert and colleagues. Finally, we provide illustrative examples of some of our interdisciplinary empirical research that demonstrate the iterative cycle of inquiry characteristic of pragmatism in which conceptual neuroethics questions have led to empirical studies whose results then raise additional conceptual questions that give rise to new empirical studies in a way that highlights the contributions of the humanities and the sciences.

The Lived Experiences of Deep Brain Stimulation in Parkinson's Disease: An Interpretative Phenomenological Analysis

Deep brain stimulation of the subthalamic nucleus (STN-DBS) is an effective treatment for Parkinson's disease (PD). In this study, we used an interpretative phenomenological analysis to explore how 10 male people with PD experienced life after STN-DBS surgery. Two themes emerged. The first, "Healed and relieved: all that glitters is not gold," highlights the benefits and the personal "costs" of surgery. The second, "The change within: new interpretations of the present and future unfold," explores how patients reinterpreted their lives as individuals and members of society in the present and as they face their future. Relief, gratitude, disappointment, and the need for social support are expressed as well as a new appraisal of values and the future. STN-DBS alters the life course of people with PD, and this study provides new insight into psychological and social issues that surgery raises for the patient and their family system. These psychosocial issues should be taken into account when preparing the patient and their family for surgery or supporting them postoperatively.

Changes in self-perception in patients treated with neurostimulating devices

BACKGROUND

In recent years, qualitative changes in self-perception have been reported in individual patients undergoing brain stimulation to treat their neurological disease. We here report a first systematic study addressing these unwanted treatment effects in a semiquantitative way.

HYPOTHESES

Hypothesis 1 (H1): Changes in self-perception can be detected and documented in patients following interventions with various neurostimulating devices using standardized assessment tools. Hypothesis 2 (H2): Central nervous-implanted neurostimulating devices (deep brain stimulation [DBS]) will have a greater impact on the patient's self-perception than "peripheral" implanted devices (implanted vagus nerve stimulation [iVNS]) and external devices (transcutaneous vagus nerve stimulation [tVNS] or transcutaneous electrical trigeminal nerve stimulation [eTNS]).

METHODS

Application of a newly developed semiquantitative questionnaire (FST-questionnaire [Fragebogen zur Veränderung der Selbstwahrnehmung unter tiefer Hirnstimulation]: Questionnaire regarding changes in self-perception while treated with DBS) to systematically assess changes in self-perception in a single-center, cross-sectional pilot-study at the University Hospital Freiburg, Germany on 50 patients (44% male; age 50 years [range: 27-73 years]), undergoing neurostimulation (DBS, iVNS, tVNS, or eTNS) to treat Parkinson's disease or epilepsy.

RESULTS

Standardized assessment detected alterations in self-perception in all treatment groups (H1 approved). This included rare self-alienating changes in self-perception. Unexpectedly, peripheral neurostimulation had similar effects as central stimulation techniques.

CONCLUSIONS

Properly designed questionnaires - like the FST-questionnaire as standardized assessment tool - can detect changes in self-perception in patients during neurostimulatory treatment in a wide spectrum of brain stimulation techniques. This may provide a strategy to systematically identify the subgroup of patients liable to experience such problems during treatment already prior to treatment decisions.

Persuasive bodies: Testimonies of deep brain stimulation and Parkinson's on YouTube

Contemporary publics actively engage with diverse forms of media when seeking health-related information. The hugely popular digital media platform YouTube has become one means by which people share their experiences of healthcare. In this paper, we examine amateur YouTube videos featuring people receiving Deep Brain Stimulation (DBS) for the treatment of Parkinson's disease. DBS has become a widely implemented treatment, and it is surrounded by high expectations that can create difficulty for clinicians, patients and their families. We examine how DBS, Parkinson's disease, and DBS recipients themselves, are delineated within these YouTube videos. The videos, we demonstrate, contain common compositional and stylistic elements that collectively represent DBS as a technological fix, and which accentuate the autonomy of the DBS recipient. The relational, interpersonal dimensions of chronic illness, and the complex impact of DBS on family dynamics, are elided. We therefore shed light on the means by which high expectations regarding DBS are sustained and circulated, and more generally, we illustrate how potentially powerful representations of medical technologies can emerge from the intersection of social media platforms, afflicted bodies and patient narratives.

Role of clinical neuropsychology in deep brain stimulation: Review of the literature and considerations for clinicians

Deep Brain Stimulation (DBS) is an effective surgical therapy for several neurological movement disorders. The clinical neuropsychologist has a well-established role in the neuropsychological evaluation and selection of surgical candidates. In this article, we argue that the clinical neuropsychologist's role is much broader, when considered in relation to applied psychologists' core competencies. We consider the role of the clinical neuropsychologist in DBS in relation to: assessment, formulation, evaluation and research, intervention or implementation, and communication. For each competence the relevant evidence-base was reviewed. Clinical neuropsychology has a vital role in presurgical assessment of cognitive functioning and psychological, and emotional and behavioral difficulties. Formulation is central to the selection of surgical candidates and crucial to intervention planning. Clinical neuropsychology has a well-established role in postsurgical assessment of cognitive functioning and psychological, emotional, and behavioral outcomes, which is fundamental to evaluation on an individual and service level. The unique contribution clinical neuropsychology makes to pre- and postsurgical interventions is also highlighted. Finally, we discuss how clinical neuropsychology can promote clear and effective communication with patients and between professionals.

Implantable Smart Technologies (IST): Defining the 'Sting' in Data and Device

In a world surrounded by smart objects from sensors to automated medical devices, the ubiquity of ‘smart’ seems matched only by its lack of clarity. In this article, we use our discussions with expert stakeholders working in areas of implantable medical devices such as cochlear implants, implantable cardiac defibrillators, deep brain stimulators and in vivo biosensors to interrogate the difference facets of smart in ‘implantable smart technologies’, considering also whether regulation needs to respond to the autonomy that such artefacts carry within them. We discover that when smart technology is deconstructed it is a slippery and multi-layered concept. A device’s ability to sense and transmit data and automate medicine can be associated with the ‘sting’ of autonomy being disassociated from human control as well as affecting individual, group, and social environments.

Patients' experiences of deep brain stimulation for Parkinson's disease: a qualitative systematic review and synthesis

OBJECTIVE

To review and synthesise qualitative research studies that have explored patients' experience of deep brain stimulation (DBS) in advanced Parkinson's disease (PD).

DESIGN

Systematic review and meta-synthesis of 7 original papers, using metaethnography.

SETTING

Studies conducted in Denmark, France and Sweden.

PARTICIPANTS

116 patients who had undergone DBS and 9 spouses of patients.

RESULTS

Prior to surgery, the experience of advancing PD is one of considerable loss and a feeling of loss of control. There are significant hopes for what DBS can bring. Following surgery, a sense of euphoria is described by many, although this does not persist and there is a need for significant transitions following this. We suggest that normality as a concept is core to the experience of DBS and that a sense of control may be a key condition for normality. Experience of DBS for patients and spouses, and of the transitions that they must undertake, is influenced by their hopes of what surgery will enable them to achieve, or regain (ie, a new normality).

CONCLUSIONS

There is a need for further qualitative research to understand the nature of these transitions to inform how best patients and their spouses can be supported by healthcare professionals before, during and after DBS. In assessing the outcomes of DBS and other treatments in advanced PD, we should consider how to capture holistic concepts such as normality and control. Studies that examine the outcomes of DBS require longer term follow-up.

Update on Neuromodulation for Treatment-Resistant Depression

About 30% of patients suffering from a major depressive disorder do not respond sufficiently to established pharmacological, psychotherapeutic, or somatic treatments. Advances in technology and emerging knowledge about the dysfunctional brain circuits underlying depression have led to the development of different neuromodulation techniques. The aim of the present review is to give an update on noninvasive techniques, such as electroconvulsive therapy (ECT), magnetic seizure therapy (MST), transcranial magnetic stimulation (TMS), and invasive techniques requiring brain surgery, such as vagus nerve stimulation (VNS) and deep brain stimulation (DBS). First, the clinical relevance for therapy-resistant depression, including the current level of evidence, are presented. Neuroethics is concerned with the ethical, legal and social policy implications of neuroscience. A second focus of the review is the application of fundamental ethical principles, such as patient autonomy, patient well-being and justice to neuromodulation therapies. Due to reduced availability and lacking long-term efficacy data, most patients with treatment-resistant depression face a trial-and-error approach to therapeutics. This contravenes the ethical criteria of patient autonomy and justice. In order to raise the level of evidence, financial support of long-term studies, including large samples and randomized control trials, are necessary.

Narratives reflecting the lived experiences of people with brain disorders: common psychosocial difficulties and determinants

BACKGROUND

People with brain disorders - defined as both, mental disorders and neurological disorders experience a wide range of psychosocial difficulties (PSDs) (e.g., concentrating, maintaining energy levels, and maintaining relationships). Research evidence is required to show that these PSDs are common across brain disorders.

OBJECTIVES

To explore and gain deeper understanding of the experiences of people with seven brain disorders (alcohol dependency, depression, epilepsy, multiple sclerosis, Parkinson's disease, schizophrenia, stroke). It examines the common PSDs and their influencing factors.

METHODS

Seventy seven qualitative studies identified in a systematic literature review and qualitative data derived from six focus groups are used to generate first-person narratives representing seven brain disorders. A theory-driven thematic analysis of these narratives identifies the PSDs and their influencing factors for comparison between the seven disorders.

RESULTS

First-person narratives illustrate realities for people with brain disorders facilitating a deeper understanding of their every-day life experiences. Thematic analysis serves to highlight the commonalities, both of PSDs, such as loneliness, anger, uncertainty about the future and problems with work activities, and their determinants, such as work opportunities, trusting relationships and access to self-help groups.

CONCLUSIONS

The strength of the methodology and the narratives is that they provide the opportunity for the reader to empathise with people with brain disorders and facilitate deeper levels of understanding of the complexity of the relationship of PSDs, determinants and facilitators. The latter reflect positive aspects of the lives of people with brain disorders. The result that many PSDs and their influencing factors are common to people with different brain disorders opens up the door to the possibility of using cross-cutting interventions involving different sectors. This strengthens the message that 'a great deal can be done' to improve the lived experience of persons with brain disorders when medical interventions are exhausted.

When benefitting a patient increases the risk for harm for third persons - the case of treating pedophilic Parkinsonian patients with deep brain stimulation

This paper investigates the question whether it is ethically justified to treat Parkinsonian patients with known or suspected pedophilia with deep brain stimulation - given increasing evidence that this treatment might cause impulse control disorders, disinhibition, and hypersexuality. This specific question is not as exotic as it looks at a first glance. First, the same issue is raised for all other types of sexual orientation or behavior which imply a high risk for harming other persons, e.g. sexual sadism. Second, there are also several (psychotropic) drugs as well as legal and illegal leisure drugs which bear severe risks for other persons. We show that Beauchamp and Childress' biomedical ethics fails to derive a veto against medical interventions which produce risks for third persons by making the patients dangerous to others. Therefore, our case discussion reveals a blind spot of the ethics of principles. Although the first intuition might be to forbid the application of deep brain stimulation to pedophilic patients, we argue against such a simple way out, since in some patients the reduction of dopaminergic drugs allowed by deep brain stimulation of the nucleus subthalamicus improves impulsive control disorders, including hypersexuality. Therefore, we propose a strategy consisting of three steps: (1) risk assessment, (2) shared decision-making, and (3) risk management and safeguards.

Acceptance and decision making in amyotrophic lateral sclerosis from a life-course perspective

Researchers have explored perceptions of health care services among people with amyotrophic lateral sclerosis (ALS), but little is known about how and why people with ALS engage with services. We undertook a grounded theory study to identify key psychosocial processes that underpin how and why people with ALS engage with health care services. We conducted in-depth interviews with 34 participants sampled from the Irish ALS population-based register. We found that age and life stage shaped participants' decision making about care. Participants in later life were more accepting of ALS and of death than young and middle-aged participants. Family was the primary context to how participants engaged with services, and their decisions about care were shaped by parenthood at different life stages. Health care professionals need to be attuned to the impact of life-course trajectories and family relations on the decisions people with ALS make about their care.

'You learn to live with all the things that are wrong with you': gender and the experience of multiple chronic conditions in later life

This article examines how older adults experience the physical and social realities of having multiple chronic conditions in later life. Drawing on data from in-depth interviews with 16 men and 19 women aged 73+ who had between three and 14 chronic conditions, we address the following research questions: (a) What is it like to have multiple chronic conditions in later life? (b) How do older men and women 'learn to live' with the physical and social realities of multiple morbidities? (c) How are older adults' experiences of illness influenced by age and gender norms? Our participants experienced their physical symptoms and the concomitant limitations to their activities to be a source of personal disruption. However, they normalised their illnesses and made social comparisons in order to achieve a sense of biographical flow in distinctly gendered ways. Forthright in their frustration over their loss of autonomy and physicality but resigned and stoic, the men's stories reflected masculine norms of control, invulnerability, physical prowess, self-reliance and toughness. The women were dismayed by their bodies' altered appearances and concerned about how their illnesses might affect their significant others, thereby responding to feminine norms of selflessness, sensitivity to others and nurturance. We discuss the findings in relation to the competing concepts of biographical disruption and biographical flow, as well as successful ageing discourses.

"I Am Who I Am": On the Perceived Threats to Personal Identity from Deep Brain Stimulation

This article explores the notion of the dislocated self following deep brain stimulation (DBS) and concludes that when personal identity is understood in dynamic, narrative, and relational terms, the claim that DBS is a threat to personal identity is deeply problematic. While DBS may result in profound changes in behaviour, mood and cognition (characteristics closely linked to personality), it is not helpful to characterize DBS as threatening to personal identity insofar as this claim is either false, misdirected or trivially true. The claim is false insofar as it misunderstands the dynamic nature of identity formation. The claim is misdirected at DBS insofar as the real threat to personal identity is the discriminatory attitudes of others towards persons with motor and other disabilities. The claim is trivially true insofar as any dramatic event or experience integrated into one’s identity-constituting narrative could then potentially be described as threatening. From the perspective of relational personal identity, when DBS dramatically disrupts the narrative flow, this disruption is best examined through the lens of agency. For illustrative purposes, the focus is on DBS for the treatment of Parkinson’s disease.

Aging and the Body: A Review

In this article, we examine the existing sociocultural research and theory concerned with the aging body. In particular, we review the body image and embodiment literatures and discuss what is known about how older adults perceive and experience their aging bodies. We analyse how body image is shaped by age, culture, ethnicity, gender, health status, sexual preference, and social class. Additionally, we critically elucidate the embodiment literature as it pertains to illness experiences, sexuality, the everyday management of the aging body, appearance work, and embodied identity. By outlining the key findings, theoretical debates, and substantive discrepancies within the body image and embodiment research and theory, we identify gaps in the literature and forecast future, much-needed avenues of investigation.

Ethical issues in deep brain stimulation

Deep brain stimulation (DBS) is currently used to treat neurological disorders like Parkinson's disease, essential tremor, and dystonia, and is explored as an experimental treatment for psychiatric disorders like major depression and obsessive compulsive disorder. This mini review discusses ethical issues in DBS treatment and research, as they have been discussed in the medical and ethical literature. With regard to DBS treatment, the most important issues are balancing risks and benefits and ensuring respect for the autonomous wish of the patient. This implies special attention to patient selection, psycho-social impact of treatment, effects on personal identity, and treatment of children. Moreover, it implies a careful informed consent process in which unrealistic expectations of patients and their families are addressed and in which special attention is given to competence. In the context of research, the fundamental ethical challenge is to promote high-quality scientific research in the interest of future patients, while at the same time safeguarding the rights and interests of vulnerable research subjects. Several guidelines have been proposed to ensure this. One of the preconditions to further development of responsible and transparent research practices is the establishment of a comprehensive registry.