Neurosurgery in Parkinson disease: A distressed mind in a repaired body?

Parkinson's Disease: Coping Strategies, Cognitive Restructuring and Deep Brain Stimulation

OBJECTIVE

Less is known concerning the evolution of coping strategies before and after deep brain stimulation (DBS) in Parkinson's disease (PD) patients.

METHODS

In a randomized controlled trial, coping was measured with the neurological version of the CHIP (Coping with Health Injuries and Problem) and the BriefCOPE in PD patients before ( T1: DBS - 2 months) and after (T2: + 3 months, T3: + 6 months) DBS. Patients (N = 50, age 59 ± 5.7 years, disease duration 9.54 ± 3.7 years) were randomised in 3 groups: CRTG (preoperative psychological preparation with cognitive restructuring), PIG (preoperative non structured interviews), and CG (no psychological preparation).

RESULTS

Coping strategies are modulated by the time of evaluation. Some strategies are significantly more used preoperatively than postoperatively, as strategies about the research for information (CHIP: F = 16.14; P = .000; η2 = .095; BriefCOPE F = 5.71; P = .005; η2 = .066), emotional regulation (F = 3.29; P = .042; η2 = .029), and well-being searching (F = 4.59; P = .013; η2 = .043). Some other strategies appear more used post than preoperatively, as palliative coping (F = 5.57; P = .005; η2 = .064), humour (F = 3.35; P = .041; η2 = .0.35), and use of substance (F = 4.43; P = .015; η2 = .070). No other specific time, group or time per group interaction effect was found.

CONCLUSION

Coping strategies are crucial for PD patients to adapt to the evolution of their parkinsonian state. Their consideration should be more systematic in the neurosurgical process, particularly when neurological symptoms would remain after DBS. More insights are needed concerning the evolution of coping strategies through DBS and the impact of a preoperative psychotherapy over them in preoperative PD patients.

Possible improvement of social adjustment after subthalamic deep brain stimulation in people with Parkinson's disease? A systematic review and meta-analysis

Interactions with others need social adjustment (i.e., the constant accommodation to changing social situations). Mixed evidence indicates positive as well as negative changes in social adjustment after subthalamic nucleus deep brain stimulation (STN-DBS) in people with Parkinson's Disease (PwPD). To date, however, no meta-analysis of these changes exists. Thus, the study aim was to review evidence of the effects of STN-DBS on social adjustment in PwPD. For this purpose, a systematic literature search in MEDLINE was conducted. The meta-analysis was performed using a random effects model and standardized mean differences (SMDs) with 95% confidence intervals (CIs). The MINORS tool was used to assess the methodological quality of the studies. The initial literature search identified 13,124 articles, of which 1,550 full texts were assessed for eligibility. Eight studies were finally included; for seven articles sufficient data for a meta-analysis was available. Most studies found mild impairment in social adjustment impairment pre-surgery. The meta-analysis revealed no significant changes but a statistical trend towards improvement in social adjustment up to six months (SMD = 0.25; 95%CI=-0.03,0.53; P = 0.08) and over 12 months (SMD = 0.26; 95%CI=-0.03,0.55; P = 0.07) post-surgery. Methodological quality was moderate in 87.5% of the studies and good in 12.5%. While mild impairment in social adjustment pre-surgery was reported in most studies, the data indicate that STN-DBS might yield beneficial effects toward this outcome. However, not enough data yet exists to draw firm conclusions. As a crucial skill for everyday functioning, social adjustment should be more often defined as an outcome in STN-DBS trials in PwPD and should be considered in clinical routines.

Adolescent OCD Patient and Caregiver Perspectives on Identity, Authenticity, and Normalcy in Potential Deep Brain Stimulation Treatment

The ongoing debate within neuroethics concerning the degree to which neuromodulation such as deep brain stimulation (DBS) changes the personality, identity, and agency (PIA) of patients has paid relatively little attention to the perspectives of prospective patients. Even less attention has been given to pediatric populations. To understand patients' views about identity changes due to DBS in obsessive-compulsive disorder (OCD), the authors conducted and analyzed semistructured interviews with adolescent patients with OCD and their parents/caregivers. Patients were asked about projected impacts to PIA generally due to DBS. All patient respondents and half of caregivers reported that DBS would impact patient self-identity in significant ways. For example, many patients expressed how DBS could positively impact identity by allowing them to explore their identities free from OCD. Others voiced concerns that DBS-related resolution of OCD might negatively impact patient agency and authenticity. Half of patients expressed that DBS may positively facilitate social access through relieving symptoms, while half indicated that DBS could increase social stigma. These views give insights into how to approach decision-making and informed consent if DBS for OCD becomes available for adolescents. They also offer insights into adolescent experiences of disability identity and "normalcy" in the context of OCD.

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.

Normalized affective responsiveness following deep brain stimulation of the medial forebrain bundle in depression

Deep brain stimulation (DBS) of the supero-lateral medial forebrain bundle (slMFB) is associated with rapid and sustained antidepressant effects in treatment-resistant depression (TRD). Beyond that, improvements in social functioning have been reported. However, it is unclear whether social skills, the basis of successful social functioning, are systematically altered following slMFB DBS. Therefore, the current study investigated specific social skills (affective empathy, compassion, and theory of mind) in patients with TRD undergoing slMFB DBS in comparison to healthy subjects. 12 patients with TRD and 12 age- and gender-matched healthy subjects (5 females) performed the EmpaToM, a video-based naturalistic paradigm differentiating between affective empathy, compassion, and theory of mind. Patients were assessed before and three months after DBS onset and compared to an age- and gender-matched sample of healthy controls. All data were analyzed using non-parametric Mann-Whitney U tests. DBS treatment significantly affected patients' affective responsiveness towards emotional versus neutral situations (i.e. affective empathy): While their affective responsiveness was reduced compared to healthy subjects at baseline, they showed normalized affective responsiveness three months after slMFB DBS onset. No effects occurred in other domains with persisting deficits in compassion and intact socio-cognitive skills. Active slMFB DBS resulted in a normalized affective responsiveness in patients with TRD. This specific effect might represent one factor supporting the resumption of social activities after recovery from chronic depression. Considering the small size of this unique sample as well as the explorative nature of this study, future studies are needed to investigate the robustness of these effects.

[Pacemaker, organ or walking stick? Pre-op association with and post-op subjective perception of a deep brain stimulation device]

AIM OF THE STUDY

This study was conducted in a pre-post design with a survey of patients who had undergone deep brain stimulation (DBS) as treatment for a neurological movement disorder. The aim of the study was to compare patients' expectations and beliefs before a DBS intervention with patients' subjective experience of this intervention.

METHODOLOGY

The longitudinal study of patients (n=132) with an indication for DBS therapy was based on a written survey at the time points of preoperative screening (pre-op) and one-year follow-up (post-op).

RESULTS

Preoperatively, a clear majority of respondents believed DSB to be similar to a pacemaker intervention, but one year after the intervention less than one third did so, as they compared DBS to using a walking stick or glasses.

CONCLUSION

The experience of DBS in the patient's own body seems to be comparable by means of individually different associations, whereby the comparison with non-invasive aids predominates postoperatively. The discussion of these descriptions in the educational interview can contribute to a realistic horizon of patients' expectations before DBS.

Role of expectations in clinical outcomes after deep brain stimulation in patients with Parkinson's disease: a systematic review

Deep brain stimulation (DBS) is a well-established treatment that significantly improves the motor symptoms of patients with Parkinson's disease (PD); however, patients may experience post-operative psychological distress and social maladjustments. This phenomenon has been shown to be related to patients' pre-operative cognitive representations, such as expectations. In this systematic review, we discuss the findings on the role of the expectations of patients with PD regarding the clinical outcomes of DBS to identify areas of intervention to improve pre-operative patient education and promote successful post-operative psychosocial adjustment. PubMed was searched for relevant articles published up to 16 January 2023. Of the 84 identified records, 10 articles focusing on the treatment expectations of patients with PD undergoing DBS were included in this review. The selected studies were conducted among cohorts of patients with different DBS targets, among which the most common was the bilateral subthalamic nucleus. Overall, the data showed that patients' expectations contribute to treatment efficacy. Experiments investigating the placebo effect itself have shown clinical improvement after the induction of positive therapeutic expectations; conversely, unrealistic treatment expectations can affect patient satisfaction after surgery, clinical outcomes, and subjective well-being. This review highlights the need for routine clinical practice to better investigate and manage patients' pre-operative expectations, as well as multidisciplinary education to improve patient satisfaction and psychosocial adjustment after DBS.

Access to device-aided therapies in advanced Parkinson's disease: navigating clinician biases, patient preference, and prognostic uncertainty

Device-aided therapies (DAT), which include deep brain stimulation and pump-based continuous dopaminergic stimulation with either levodopa or apomorphine, are among the major advances in the clinical management of Parkinson's disease (PD). Although DAT are being increasingly offered earlier in the disease course, their classical indication remains advanced PD. Theoretically, every patient should be offered transition to DAT when faced with refractory motor and nonmotor fluctuations and functional decline. Worldwide clinical reality is far from these ideal, and, therefore, question the "real-world" equal opportunity of access to DAT for PD patients with advanced PD-even within a single health care system. Differences in access to care, referral pattern (timing and frequency), as well as physician biases (unconscious/implicit or conscious/explicit bias), and patients' preferences or health-seeking behaviour are to be considered. Compared to DBS, little information is available concerning infusion therapies, as well as neurologists' and patients' attitudes towards them. This viewpoint aims to be thought-provoking and to assist clinicians in moving through the process of DAT selection, by including in their decision algorithm their own biases, patient perspective, ethical concerns as well as the current unknowns surrounding PD prognosis and DAT-related long-term side effects for a given patient.

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.

Caregiver Burden and Quality of Life of Caregivers for Patients with Parkinson's Disease Treated with Deep Brain Stimulation

Objective

This study aimed to identify caregiver burden (CB) and contributing factors to CB for Parkinson's disease (PD) patients under Subthalamic Nucleus Deep Brain Stimulation (STN-DBS) treatment, and investigation the factors, affecting the caregivers' quality of life (QoL).

Methods

Twenty-four PD patients under STN-DBS treatment and their caregivers participated in this study. Unified Parkinson's Disease Rating Scale (UPDRS) was applied for the clinical assessment of the patients. Beck Depression Inventory-II (BDI), Hospital Anxiety and Depression Scale (HADS), and Minnesota Impulse Control Disorders Interview (MIDI) were used to screen for neuropsychiatric symptoms of the patients. CB was evaluated with the Caregivers Burden Inventory (CBI) and the Burden Scale for Family Caregivers (BSFC-s). The health-related QoL of caregivers was assessed with the Short Form Survey-36 (SF-36).

Results

Mean total CBI and BSFC-s scores of caregivers were 32.53 ± 19.71 and 11.66 ± 8.86, respectively. Nineteen caregivers defined moderate or severe caregiver burden according to BSFC-s. Both CBI and BSFC-s scores were significantly associated with UPDRS-part-1 scores, but not with the age and gender of both the patients and their caregivers, disease duration, PDQ39, BDI, HADS, LARS scores, and scores of patients for other UPDRS parts. The presence of impulse control behaviors (ICBs) significantly increased the total CBI score and total BSFC-s (P < 0.01). The caregivers' total and all domain scores of SF-36 were significantly affected by higher CBI and BSFC-s scores.

Conclusions

The CB of the patients under STN-DBS treatment was severe. Non-motor symptoms, particularly impulsivity, significantly increased CB and worsened the caregivers' mental and physical health.

Weak transhumanism: moderate enhancement as a non-radical path to radical enhancement

Transhumanism aims to bring about radical human enhancement. In 'Truly Human Enhancement' Agar (2014) provides a strong argument against producing radically enhancing effects in agents. This leaves the transhumanist in a quandary-how to achieve radical enhancement whilst avoiding the problem of radically enhancing effects? This paper aims to show that transhumanism can overcome the worries of radically enhancing effects by instead pursuing radical human enhancement via incremental moderate human enhancements (Weak Transhumanism). In this sense, weak transhumanism is much like traditional transhumanism in its aims, but starkly different in its execution. This version of transhumanism is weaker given the limitations brought about by having to avoid radically enhancing effects. I consider numerous objections to weak transhumanism and conclude that the account survives each one. This paper's proposal of 'weak transhumanism' has the upshot of providing a way out of the 'problem of radically enhancing effects' for the transhumanist, but this comes at a cost-the restrictive process involved in applying multiple moderate enhancements in order to achieve radical enhancement will most likely be dissatisfying for the transhumanist, however, it is, I contend, the best option available.

Illness perceptions in pre-operative Parkinson's disease patients

Parkinson's disease (PD) is a neurodegenerative disease, that combines motor and non-motor disorders, and alters patients' autonomy. Even if subthalamic nucleus deep brain stimulation (STN-DBS) induces undisputable motor improvement, a post-operative social maladjustment was described by some patients. Our aim was to describe pre-operative illness perceptions in parkinsonian patients, and to determine the possible impact of cognitive restructuration over them. We analyzed 27 parkinsonian patient's candidates to DBS. The mean age was 59 ± 5.94 years, and mean disease duration was 9.89 ± 4.15 years. The patients had two pre-operative psychological interviews (DBS-45 days, DBS-25 days) and completed the Illness Perception Questionnaire-Revised (IPQ-R) before the first interview and at DBS-1 day. The CRTG group (n = 13) had cognitive restructuration during second interview, on dysfunctional cognitions about their perception of post-DBS life which emerged from the first interview. The PIG group (n = 14) benefited of two non-structured interviews. No significant differences were found between the visits (DBS-45 days, DBS-1 day) for IPQ-R dimensions, except for the perception of "personal control" over PD which appears significantly higher for CRTG than PIG group (p = .039) at DBS-1 day, whereas the scores were quite similar at DBS-45 days. Illness perceptions seem to be stable over time and mostly influenced by disease experience of PD. However, the perception of personal control over PD seemed to be modulated through cognitive restructuration, giving patients' control back over disease. Before DBS, illness perceptions investigation and restructuration constitute an interesting point to work on, to enhance perceived benefits of neurosurgery.Trial registration: Clinical Research Program, N°IDRCB 2008-A00655-50, approved by the local ethics committee (CPP EST III, N° CPP: 08.07.03, first version date: 04/01/2008), registered on the ClinicalTrials.gov website (NCT02893449).

Therapies for obsessive-compulsive disorder: Current state of the art and perspectives for approaching treatment-resistant patients

Even though obsessive compulsive disorder (OCD) is one of the ten most disabling diseases according to the WHO, only 30-40% of patients suffering from OCD seek specialized treatment. The currently available psychotherapeutic and pharmacological approaches, when properly applied, prove ineffective in about 10% of cases. The use of neuromodulation techniques, especially Deep Brain Stimulation, is highly promising for these clinical pictures and knowledge in this domain is constantly evolving. The aim of this paper is to provide a summary of the current knowledge about OCD treatment, while also discussing the more recent proposals for defining resistance.

Energy Delivered by Subthalamic Deep Brain Stimulation for Parkinson Disease Correlates With Depressive Personality Trait Shift

OBJECTIVES

Despite the large amount of literature examining the potential influence of subthalamic nucleus deep brain stimulation (STN-DBS) on psychiatric symptoms and cognitive disorders, only a few studies have focused on its effect on personality. We investigated the correlation between total electrical energy delivered (TEED) and the occurrence of depressive traits in patients with Parkinson disease (PD) after one year of DBS.

MATERIALS AND METHODS

Our study involved 20 patients with PD (12 women, mean [±SD] age 57.60 ± 7.63 years) who underwent bilateral STN-DBS, whose personality characteristics were assessed using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), according to the core assessment program for surgical interventional therapies in Parkinson's disease (CAPSIT-PD) procedure.

RESULTS

We found that despite a marked improvement in motor functions and quality of life after 12 months, patients showed a significant increase in MMPI-2 subscales for depression (D scale and Depression scale) and in other content component scales (low self-esteem, work interference, and negative treatment indicators). Interestingly, only the TEED on the right side was inversely correlated with the changes in scale D (r_s = -0.681, p = 0.007), whereas depressive traits did not correlate with disease duration, levodopa equivalent daily dose (LEDD) reduction, patient's age, or severity of motor symptoms.

CONCLUSIONS

Our preliminary observations indicate that despite the excellent motor outcome and general improvement in quality of life, DBS treatment can result in patients poorly adjusting to their personal, familiar, and socio-professional life. Different influences and multiple factors (such as TEED, intra/postsurgical procedure, coping mechanisms, and outcome expectations) may affect depressive traits. Further advances are expected to improve stimulation methods.

Perceived social support declines after deep brain stimulation surgery in patients with Parkinson's disease

INTRODUCTION

The Social Provisions Scale (SPS) measures a person's perceived social support. We evaluated the perceived social support in Parkinson's disease (PD) patients before and after subthalamic nucleus (STN) deep brain stimulation (DBS) and its impact on clinical outcomes following DBS.

METHODS

We analyzed 55 PD patients who underwent STN DBS surgery and completed the SPS, PDQ-39, and MDS-UPDRS Parts I-IV before and 6-12 months after surgery. Some patients also completed global cognitive, mood and apathy scales. Caregivers completed the CBI at each visit. Linear regression models and linear mixed models evaluated the association between the SPS baseline score, MDS-UPDRS and PDQ-39 scores, the association between MDS-UPDRS, CBI and the SPS follow-up score, and the association between SPS, global cognition and other psychological variables.

RESULTS

DBS implantation improved MDS-UPDRS I-IV and PDQ-39 scores. Perceived social support declined after DBS (baseline SPS total 82.55 ± 7.52 vs. follow-up SPS total 78.83 ± 9.02, p = 0.0001). Baseline SPS total score was not significantly associated with the MDS-UPDRS or PDQ-39 scores at follow-up. MDS-UPDRS scores and the CBI at follow-up had no significant association with SPS total score at follow-up. Measures of global cognition, mood and apathy were associated with the SPS before and after DBS, and the association was independent of STN DBS.

CONCLUSION

After STN DBS, PD patients experienced a decrease in perceived social support, but baseline perceived social support did not impact clinical outcomes. It is important to further identify factors that may contribute to this perception of worsened social support.

Neuropalliative care for the neurosurgeon: a primer

Many neurosurgical conditions are incurable, leading to disability or severe symptoms, poor quality of life, and distress for patients and families. The field of neuropalliative care (NPC) addresses the palliative care (PC) needs of individuals living with neurological conditions. Neurosurgeons play an important role within multidisciplinary NPC teams because of their understanding of the natural history of and treatment strategies for neurosurgical conditions, longitudinal patient-physician relationships, and responsibility for neurosurgical emergencies. Moreover, patients with neurosurgical conditions have unique PC needs given the trajectories of neurosurgical diseases, the realities of prognostication, psychosocial factors, communication strategies, and human behavior. PC improves outcomes among neurosurgical patients. Despite the importance of NPC, neurosurgeons often lack formal training in PC skills, which include identifying patients who require PC, assessing a patient's understanding and preferences regarding illness, educating patients, building trust, managing symptoms, addressing family and caregiver needs, discussing end-of-life care, and recognizing when to refer patients to specialists. The future of NPC involves increasing awareness of the approach's importance, delineating priorities for neurosurgeons with regard to NPC, increasing emphasis on PC skills during training and practice, expanding research efforts, and adjusting reimbursement structures to incentivize the provision of NPC by neurosurgeons.

Asking questions that matter – Question prompt lists as tools for improving the consent process for neurotechnology clinical trials

Implantable neurotechnology devices such as Brain Computer Interfaces (BCIs) and Deep Brain Stimulators (DBS) are an increasing part of treating or exploring potential treatments for neurological and psychiatric disorders. While only a few devices are approved, many promising prospects for future devices are under investigation. The decision to participate in a clinical trial can be challenging, given a variety of risks to be taken into consideration. During the consent process, prospective participants might lack the language to consider those risks, feel unprepared, or simply not know what questions to ask. One tool to help empower participants to play a more active role during the consent process is a Question Prompt List (QPL). QPLs are communication tools that can prompt participants and patients to articulate potential concerns. They offer a structured list of disease, treatment, or research intervention-specific questions that research participants can use as support for question asking. While QPLs have been studied as tools for improving the consent process during cancer treatment, in this paper, we suggest they would be helpful in neurotechnology research, and offer an example of a QPL as a template for an informed consent tool in neurotechnology device trials.

Cognitive Impact of Deep Brain Stimulation in Parkinson’s Disease Patients: A Systematic Review

Introduction

Parkinson’s disease (PD) patients have a significantly higher risk of developing dementia in later disease stages, leading to severe impairments in quality of life and self-functioning. Questions remain on how deep brain stimulation (DBS) affects cognition, and whether we can individualize therapy and reduce the risk for adverse cognitive effects. Our aim in this systematic review is to assess the current knowledge in the field and determine if the findings could influence clinical practice.

Methods

We have conducted a systematic review according to PRISMA guidelines through MEDLINE and Embase databases, with studies being selected for inclusion via a set inclusion and exclusion criteria.

Results

Sixty-seven studies were included in this systematic review according to the selected criteria. This includes 6 meta-analyses, 18 randomized controlled trials, 17 controlled clinical trials, and 26 observational studies with no control arms. The total number of PD patients encompassed in the studies cited in this review is 3677, not including the meta-analyses.

Conclusion

Cognitive function in PD patients can deteriorate, in most cases mildly, but still impactful to the quality of life. The strongest evidence is present for deterioration in verbal fluency, while inconclusive evidence is still present for executive function, memory, attention and processing speed. Global cognition does not appear to be significantly impacted by DBS, especially if cognitive screening is performed prior to the procedure, as lower baseline cognitive function is connected to poor outcomes. Further randomized controlled studies are required to increase the level of evidence, especially in the case of globus pallidus internus DBS, pedunculopontine nucleus DBS, and the ventral intermediate nucleus of thalamus DBS, and more long-term studies are required for all respective targets.

Assessing preoperative hope and expectations related to functional neurosurgery: a new questionnaire

BACKGROUND

Despite successful functional neurosurgery, patients suffering from epilepsy or Parkinson's disease may experience postoperative psychological distress and social maladjustments. Difficulties in coping with postoperative changes, even positive ones, have shown to be related to patients' presurgery cognitive representations (i.e., expectations, hope). The aim of this study was to develop an instrument assessing various key features of surgery outcomes' representations, namely the Preoperative Hope and Expectations Questionnaire (PHEQ).

METHODS

Participants were patients (n = 50) diagnosed with Parkinson's disease (n = 25) or epilepsy (n = 25), candidates for functional neurosurgery (i.e., Deep brain stimulation, anterior temporal lobectomy). Two to three weeks before the planned surgery, they were administrated items assessing their actual state, preoperative expectations, and hope regarding surgery outcomes. They also completed measures assessing optimism, quality of life and mood.

RESULTS

Exploratory analysis resulted in a 14-item version of the PHEQ composed of two factors (abstract representations, including psychological well-being and concrete representations, such as direct surgery outcomes). The PHEQ demonstrated high internal consistency and good convergent validity. Patients were more prone to express postoperative improvements in terms of hope rather than expectations. They generally focused on concrete rather than abstract features, although patients with Parkinson's disease had higher abstract future-oriented representations.

CONCLUSIONS

The PHEQ presents satisfactory psychometric properties and may be considered as a reliable instrument for research and clinical practice.

Memory Modification and Authenticity: A Narrative Approach

The potential of memory modification techniques (MMTs) has raised concerns and sparked a debate in neuroethics, particularly in the context of identity and authenticity. This paper addresses the question whether and how MMTs influence authenticity. I proceed by drawing two distinctions within the received views on authenticity. From this, I conclude that an analysis of MMTs based on a dual-basis, process view of authenticity is warranted, which implies that the influence of MMTs on authenticity crucially depends on the specifics of how memory modification would eventually work. Therefore, I continue with a systematic analysis of possible properties of MMTs in which I distinguish between the dimensions of memories and the kinds of experiences that can be modified as well as the properties of the process of memory modification. The impact of MMTs on authenticity is analyzed regarding the possible properties of MMTs and based on a narrative approach to authenticity which fulfills the requirements of a dual-basis, process view of authenticity. Lastly, I explore the potential of MMTs to shift the balance between self-discovery and self-creation within authenticity and thereby alter the concept itself as well as the value of authenticity.

Caregiver Burden in Partners of Parkinsonian Patients with Deep Brain Stimulation

In Parkinson’s disease (PD) patients, the progressive nature of the disease and the variability of disabling motor and non-motor symptoms contribute to the growing caregiver burden of PD partners and conflicts in their relationships. Deep brain stimulation (DBS) improves PD symptoms and patients’ quality of life but necessitates an intensified therapy optimization after DBS surgery. This review illuminates caregiver burden in the context of DBS, framing both pre- and postoperative aspects. We aim to provide an overview of perioperative factors influencing caregiver burden and wish to stimulate further recognition of caregiver burden of PD patients with DBS.

Prefrontal Physiomarkers of Anxiety and Depression in Parkinson's Disease

Objective: Anxiety and depression are prominent non-motor symptoms of Parkinson’s disease (PD), but their pathophysiology remains unclear. We sought to understand their neurophysiological correlates from chronic invasive recordings of the prefrontal cortex (PFC).

Methods: We studied four patients undergoing deep brain stimulation (DBS) for their motor signs, who had comorbid mild to moderate anxiety and/or depressive symptoms. In addition to their basal ganglia leads, we placed a permanent prefrontal subdural 4-contact lead. These electrodes were attached to an investigational pulse generator with the capability to sense and store field potential signals, as well as deliver therapeutic neurostimulation. At regular intervals over 3–5 months, participants paired brief invasive neural recordings with self-ratings of symptoms related to depression and anxiety.

Results: Mean age was 61 ± 7 years, mean disease duration was 11 ± 8 years and a mean Unified Parkinson’s Disease Rating Scale, with part III (UPDRS-III) off medication score of 37 ± 13. Mean Beck Depression Inventory (BDI) score was 14 ± 5 and Beck Anxiety Index was 16.5 ± 5. Prefrontal cortex spectral power in the beta band correlated with patient self-ratings of symptoms of depression and anxiety, with r-values between 0.31 and 0.48. Mood scores showed negative correlation with beta spectral power in lateral locations, and positive correlation with beta spectral power in a mesial recording location, consistent with the dichotomous organization of reward networks in PFC.

Interpretation: These findings suggest a physiological basis for anxiety and depression in PD, which may be useful in the development of neurostimulation paradigms for these non-motor disease features.

They Affect the Person, but for Better or Worse? Perceptions of Electroceutical Interventions for Depression Among Psychiatrists, Patients, and the Public

Responding to reports of cases of personality change following deep brain stimulation, neuroethicists have debated the nature and ethical implications of these changes. Recently, this literature has been challenged as being overblown and therefore potentially an impediment to patients accessing needed treatment. We interviewed 16 psychiatrists, 16 patients with depression, and 16 members of the public without depression, all from the Midwestern United States, about their views on how three electroceutical interventions (deep brain stimulation, electroconvulsive therapy, and transcranial magnetic stimulation) used to treat depression might affect the self. Participants were also asked to compare the electroceuticals' effects on the self with the effects of commonly used depression treatments (psychotherapy and pharmaceuticals). Using qualitative content analysis, we found that participants' views on electroceuticals' potential effects on the self mainly focused on treatment effectiveness and side effects. Our results have implications for both theoretical discussions in neuroethics and clinical practice in psychiatry.

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.

DBS-Edmonton App, a Tool to Manage Patient Expectations of DBS in Parkinson Disease

Objective

After deep brain stimulation (DBS) for Parkinson disease (PD), patients often do not report the level of satisfaction anticipated. This misalignment can relate to patients' expectations for an invasive treatment and insufficient knowledge of DBS's effectiveness in relieving motor and nonmotor symptoms (NMS). Patient satisfaction depends on expectations and goals for treatment. We hypothesized that improving patient education with a patient-centered shared decision-making tool emphasizing autonomy would improve patient satisfaction and clinical outcome.

Methods

We developed a computer application (DBS-Edmonton app), allowing patients with PD to input their symptoms and to learn how effective DBS addresses their prioritized symptoms. Sixty-two volunteers referred for DBS used the DBS-Edmonton app. DBS-related knowledge and patient perceptions of the DBS-Edmonton app were assessed with pre- and post-use questionnaires. Fourteen of 24 patients who proceeded to DBS achieved optimization at 6 months. Perceived functional improvement was assessed and compared with 12 control patients with DBS who did not use the DBS-Edmonton app.

Results

All 62 volunteers considered the DBS-Edmonton app helpful and would recommend it to others. There was improved knowledge about how NMS and axial symptoms respond to DBS. Postoperatively, there was no significant difference in symptoms improvement assessed by standard scales between the groups. Volunteers who used the DBS-Edmonton app had greater satisfaction (p = 0.014).

Conclusion

This interventional study showed that the DBS-Edmonton app improved DBS-related knowledge and patient satisfaction, independent of the objective motor outcome. It may assist patients in deciding to proceed to DBS and can be easily incorporated into practice to improve patient satisfaction post-DBS.

A Pilot Trial of Cognitive Behavioral Therapy for Caregivers After Deep Brain Stimulation for Parkinson's Disease

Subthalamic deep brain stimulation for Parkinson's disease may not ameliorate burden among caregivers. An 8-session, manualized program of cognitive-behavioral therapy (CBT) was delivered to a pilot sample of 10 caregivers (6 females, mean age: 60, age range: 34-79). Primary outcome measures were caregiver burden (Zarit Burden Interview) and caregiver quality of life (Parkinson's Disease Questionnaire-Carer). Secondary outcome measures comprised ratings of depression and anxiety in the caregiver, in addition to relationship quality. Caregiver burden (t = 2.91 P = .017) and caregiver anxiety (t = 2.82 P = .020) symptoms were significantly reduced at completion of the program, and these benefits were maintained 3 months later. Caregiver quality of life had significantly improved by the end of the intervention (t = 3.02 P = .015), but this effect was not sustained after 3 months. The longitudinal influence of participation in the program on caregiver burden was confirmed in a linear, mixed-effects model, χ² (3) = 15.1, P = .0017). The intervention was well received by participants, and qualitative feedback was obtained. These results indicate that caregiver burden is modifiable in this cohort with a short course of CBT, that benefits are maintained after termination of the program, and that psychological treatment is acceptable to participants. Larger, controlled trials are justified.

Personality changes with subcallosal cingulate deep brain stimulation in patients with treatment-resistant depression

BACKGROUND

Deep brain stimulation (DBS) is a promising investigational approach for treatment-resistant depression. However, reports suggesting changes in personality with DBS for movement disorders have raised clinical and ethical concerns. We prospectively examined changes in personality dimensions and antidepressant response to subcallosal cingulate (SCC)-DBS for treatment-resistant depression.

METHODS

Twenty-two patients with treatment-resistant depression underwent SCC-DBS. We used the NEO Five-Factor Inventory for personality assessment at baseline and every 3 months until 15 months post-DBS. We assessed depression severity monthly using the Hamilton Depression Rating Scale.

RESULTS

We found a significant decrease in neuroticism (p = 0.002) and an increase in extraversion (p = 0.001) over time, showing a change toward normative data. Improvement on the Hamilton Depression Rating Scale was correlated with decreases in neuroticism at 6 months (p = 0.001) and 12 months (p < 0.001), and with an increase in extraversion at 12 months (p = 0.01). Changes on the Hamilton Depression Rating Scale over time had a significant covariate effect on neuroticism (p < 0.001) and extraversion (p = 0.001). Baseline openness and agreeableness predicted response to DBS at 6 (p = 0.006) and 12 months (p = 0.004), respectively.

LIMITATIONS

Limitations included a small sample size, a lack of sham control and the use of subjective personality evaluation.

CONCLUSION

We observed positive personality changes following SCC-DBS, with reduced neuroticism and increased extraversion related to clinical improvement in depression, suggesting a state effect. As well, pretreatment levels of openness and agreeableness may have predicted subsequent response to DBS. The NEO Five-Factor Inventory assessment may have a role in clinical decision-making and prognostic evaluation in patients with treatment-resistant depression who undergo SCC-DBS.

The impact of subthalamic deep brain stimulation on belief revision and social validation

We investigated whether Deep Brain Stimulation (DBS) of the subthalamic nucleus (STN) influences social validation as measured by a Judge-Advisor task. In contrast to healthy controls and patients with their DBS OFF, patients with their stimulation switched on do not experience a gain of confidence after receiving competent advice.

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.

Neurotechnology ethics and relational agency

Novel neurotechnologies, like deep brain stimulation and brain-computer interface, offer great hope for treating, curing, and preventing disease, but raise important questions about effects these devices may have on human identity, authenticity, and autonomy. After briefly assessing recent narrative work in these areas, we show that agency is a phenomenon key to all three goods and highlight the ways in which neural devices can help to draw attention to the relational nature of our agency. Drawing on insights from disability theory, we argue that neural devices provide a kind of agential assistance, similar to that provided by caregivers, family, and others. As such, users and devices participate in a kind of co-agency. We conclude by suggesting the need for developing relational agency-competencies-skills for reflecting on the influence of devices on agency, for adapting to novel circumstances ushered in by devices, and for incorporating the feedback of loved ones and others about device effects on agency.

Mapping the Dimensions of Agency

Neural devices have the capacity to enable users to regain abilities lost due to disease or injury - for instance, a deep brain stimulator (DBS) that allows a person with Parkinson's disease to regain the ability to fluently perform movements or a Brain Computer Interface (BCI) that enables a person with spinal cord injury to control a robotic arm. While users recognize and appreciate the technologies' capacity to maintain or restore their capabilities, the neuroethics literature is replete with examples of concerns expressed about agentive capacities: A perceived lack of control over the movement of a robotic arm might result in an altered sense of feeling responsible for that movement. Clinicians or researchers being able to record and access detailed information of a person's brain might raise privacy concerns. A disconnect between previous, current, and future understandings of the self might result in a sense of alienation. The ability to receive and interpret sensory feedback might change whether someone trusts the implanted device or themselves. Inquiries into the nature of these concerns and how to mitigate them has produced scholarship that often emphasizes one issue - responsibility, privacy, authenticity, or trust - selectively. However, we believe that examining these ethical dimensions separately fails to capture a key aspect of the experience of living with a neural device. In exploring their interrelations, we argue that their mutual significance for neuroethical research can be adequately captured if they are described under a unified heading of agency. On these grounds, we propose an "Agency Map" which brings together the diverse neuroethical dimensions and their interrelations into a comprehensive framework. With this, we offer a theoretically-grounded approach to understanding how these various dimensions are interwoven in an individual's experience of agency.

Deep Brain Stimulation of the Subthalamic Nucleus in Parkinson's Disease: A Meta-Analysis of Mood Effects

This meta-analysis examines mood changes after bilateral subthalamic deep brain stimulation (STN-DBS) in patients with Parkinson's disease (PD). Deep brain stimulation improves motor outcomes in Parkinson's disease but there appears to be conflicting reports as to subsequent mood outcomes. Pubmed, PsychINFO and SCOPUS were searched for studies assessing mood outcomes in PD patients who had undergone STN-DBS published between January 2003 and the end of January 2019. Random effects meta-analyses were conducted for all outcome groups with at least two studies homogenous in design and measure. Forty-eight studies, providing data on negative moods (such as depression, anxiety, apathy, and anger) and positive moods (pleasure and euphoria) were assessed. Results of the meta-analysis suggest that post-DBS, depression and anxiety symptoms improve and there is a reduction in negative affect, an increase in apathy, and in energy level. Although there have been reported cases of mania post-DBS surgery, the meta-analysis suggested no significant changes in symptoms of mania in the broader DBS population. Considerable heterogeneity was found and partially addressed through meta-regression and qualitative assessment of the included STN-DBS controlled studies. The major strengths of this meta-analysis, include attention to outcome validity, heterogeneity, independence of samples, and clinical utility, with the potential to improve post-operative safety through comprehensive consideration of mood and psychological adjustment. It appears that STN-DBS is a relatively safe and, in the case of mood symptomatology, an advantageous treatment of Parkinson's disease.

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.

Effect of deep brain stimulation on caregivers of patients with Parkinson's disease: A systematic review

BACKGROUND

Caregivers of patients with Parkinson's Disease (PD) often provide important support in the pre- and postoperative phase of Deep Brain Stimulation (DBS). DBS-associated changes of patient-functioning may affect caregiver wellbeing and impact the support system. Factors influencing caregiver-wellbeing under these circumstances are incompletely known.

OBJECTIVE

to systematically review studies of sufficient methodological quality on the impact of DBS on caregivers of PD patients.

METHODS

using PRISMA guidelines, major databases were searched up to May 2020. Five subcategories were identified: Caregiver burden, Caregiver cognitive and psychiatric functioning, Caregiver Quality of Life (QoL), Marital Satisfaction/Conflicts, and Caregiver Satisfaction. Quality was assessed using an in-house checklist.

RESULTS

293 studies were identified; 12 were ultimately included. Caregiver burden, psychiatric and cognitive functioning and QoL remained relatively unchanged. Results on marital satisfaction/conflicts were contrasting: an increase in marital conflicts despite improved relationship quality scores DBS. Caregiver satisfaction with surgery was low with 50-58% of caregivers being disappointed with DBS outcomes. Concerning caregiver related factors: a higher preoperative caregiver QoL, younger age, lower scores on psychiatric rating scales, and more favourable preoperative relationship quality scores, were associated with better caregiver wellbeing. A favourable patient-profile includes younger age and age-at-onset, shorter disease duration, lower medication requirements, and lower scores on psychiatric rating scales.

CONCLUSION

Although most patient- and caregiver-related subdomains remained unchanged after DBS, dissatisfaction among caregivers and marital problems may constitute a large risk for a well-functioning patient-caregiver dyad. Early recognition of potential problem situations may improve post-DBS care for both patients and caregivers.

Intraoperative changes in the H-reflex pathway during deep brain stimulation surgery for Parkinson's disease: A potential biomarker for optimal electrode placement

BACKGROUND

Deep Brain Stimulation (DBS) targeting the subthalamic nucleus (STN) and globus pallidus interna (GPi) is an effective treatment for cardinal motor symptoms and motor complications in Parkinson's Disease (PD). However, malpositioned DBS electrodes can result in suboptimal therapeutic response.

OBJECTIVE

We explored whether recovery of the H-reflex-an easily measured electrophysiological analogue of the stretch reflex, known to be altered in PD-could serve as an adjunct biomarker of suboptimal versus optimal electrode position during STN- or GPi-DBS implantation.

METHODS

Changes in soleus H-reflex recovery were investigated intraoperatively throughout awake DBS target refinement across 26 nuclei (14 STN). H-reflex recovery was evaluated during microelectrode recording (MER) and macrostimulation at multiple locations within and outside target nuclei, at varying stimulus intensities.

RESULTS

Following MER, H-reflex recovery normalized (i.e., became less Parkinsonian) in 21/26 nuclei, and correlated with on-table motor improvement consistent with an insertional effect. During macrostimulation, H-reflex recovery was maximally normalized in 23/26 nuclei when current was applied at the location within the nucleus producing optimal motor benefit. At these optimal sites, H-reflex normalization was greatest at stimulation intensities generating maximum motor benefit free of stimulation-induced side effects, with subthreshold or suprathreshold intensities generating less dramatic normalization.

CONCLUSION

H-reflex recovery is modulated by stimulation of the STN or GPi in patients with PD and varies depending on the location and intensity of stimulation within the target nucleus. H-reflex recovery shows potential as an easily-measured, objective, patient-specific, adjunct biomarker of suboptimal versus optimal electrode position during DBS surgery for PD.

Parkinson's Disease and Bilateral Subthalamic Nuclei Deep Brain Stimulation: Beneficial Effects of Preoperative Cognitive Restructuration Therapy on Postoperative Social Adjustment

BACKGROUND

Bilateral subthalamic nucleus deep brain stimulation improves motor symptoms and treatment-related complications in patients with Parkinson's disease. However, some patients have trouble adjusting socially after successful neurosurgery, in part because of "unrealistic" expectations and psychiatric disorders. Preoperative psychological interventions focusing on these aspects could be beneficial for such patients.

METHODS

We compared the outcomes of 2 psychosocial approaches-1 based on cognitive restructuration and 1 consisting of 2 interviews-with those of a control group without preoperative preparation. All patients underwent a psychometric evaluation 2 months before surgery (M-2) and again at 3 (M+3) and 6 months (M+6) after surgery. The psychometric evaluation focused on social adjustment using the social adjustment scale-self-report. The psychiatric profile of the patients was also assessed.

RESULTS

Of 73 patients initially enrolled, 62 performed the initial inclusion visit (M-2) and the 2 postoperative visits (M+3, M+6). For these 62 patients (52% male), the overall mean age was 59 ± 6.13 years, and the mean disease duration was 9.44 ± 3.62 years. No specific differences were observed for social adjustment between the groups or visits (M-2, M+3, M+6); however, an interaction was found in the cognitive restructuration group at M+6 for the family dimension of the social adjustment scale-self-report.

CONCLUSION

Our results suggest that even if no overall increase in the social adjustment score was observed, patients with Parkinson's disease eligible for neurosurgery should undergo preoperative psychosocial therapy to define their expectations and help them in their psychological restructuration. This type of therapy, complementary to psychoeducation, could represent an opportunity to prevent postoperative deception and social maladjustment.

Sex Disparities in the Self-Evaluation of Subthalamic Deep Brain Stimulation Effects on Mood and Personality in Parkinson's Disease Patients

Changes in personality are one of the main concerns Parkinson's disease (PD) patients raise when facing the decision to undergo neurosurgery for deep brain stimulation (DBS) of the subthalamic nucleus (STN). While clinical instruments for monitoring functional changes following DBS surgery are well-established in the daily therapeutic routine, personality issues are far less systematically encompassed. Moreover, while sex disparities in the outcomes of STN-DBS therapy have been reported, little is known about the different effects that DBS treatment may have on mood and personality traits in female and male patients. To this aim, the effect of STN-DBS on personality traits was assessed in 46 PD patients (12 women and 34 men) by means of the Freiburg Personality Inventory. The Becks Depression Inventory (BDI-I) and the Parkinson's Disease Questionnaire were used to evaluate patients' level of depression and quality of life (QoL). Patients completed the questionnaires a few days before, within the first year, and 2 years after surgery. The 12 personality traits defined by the FPI-R questionnaire did not change significantly after STN-DBS surgery (p = 0.198). Women declared higher depression scores through all study stages (p = 0.009), but also showed a stronger QoL amelioration after surgery than male patients (p = 0.022). The BDI-I scores of female patients clearly correlated with their levodopa equivalent daily dose (LEDD; r = 0.621, p = 0.008). Remarkably, in both male and female patients, higher pre-operative LEDDs were related to worse post-operative QoL scores (p = 0.034). These results mitigate the concerns about systematic personality changes due to STN-DBS treatment in PD patients and encourage an early DBS approach, before severe levodopa-induced sequelae may irreparably compromise the patients' QoL. In the future, more focus should lie on sex-related effects, since female patients seem to profit more than male patients from STN-DBS, in terms of reduced depressive symptoms associated with a reduction of the LEDD and amelioration of QoL. These aspects may help to redress the sex imbalance in PD patients treated with DBS, given that women are still strongly under-represented.

Deep Brain Stimulation Impact on Social and Occupational Functioning in Parkinson's Disease with Early Motor Complications

Background

Deep brain stimulation (DBS) improves motor symptoms and quality of life in patients with Parkinson's disease (PD) and early motor complications, suggesting that DBS could be prescribed to the working‐age PD population.

Objectives

To investigate the effect of DBS compared with best medical therapy (BMT) on social, psychosocial, and occupational functioning in patients with PD ≤60 years of age with early motor complications, its correlates, and possible underlying rationale.

Methods

Methods included analyses of the Social and Occupational Functioning Assessment Scale, Scales for Outcomes for Parkinson's–Psychosocial, Professional Fitness, Starkstein Apathy Scale, and Schwab and England Activities of Daily Living Scale from the EARLYSTIM study.

Results

Compared with BMT, DBS resulted in significantly greater improvements from baseline through 24 months in social,occupational, and psychosocial functioning. Yet, work status in the 2 groups did not differ at baseline and 24 months. Physicians reported a significantly higher percentage of patients in the BMT group unable to work at 24 months relative to baseline compared with the DBS group. Apathy was significantly worse in patients for whom physicians overrated ability to work when compared with patients’ own ratings than in the group of patients who physicians' ability to work ratings were comparable to, or worse than, patients' self‐ratings of ability to work.

Conclusions

For patients aged ≤60 years with PD and early motor complications, DBS provided significant improvements in social, occupational, and psychosocial function, but not in the actual work engagement compared with BMT at 2 years. Apathy may impact ability to work.

Effects of Subthalamic Nucleus Deep Brain Stimulation on Facial Emotion Recognition in Parkinson's Disease: A Critical Literature Review

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an effective therapy for Parkinson's disease (PD). Nevertheless, DBS has been associated with certain nonmotor, neuropsychiatric effects such as worsening of emotion recognition from facial expressions. In order to investigate facial emotion recognition (FER) after STN DBS, we conducted a literature search of the electronic databases MEDLINE and Web of science. In this review, we analyze studies assessing FER after STN DBS in PD patients and summarize the current knowledge of the effects of STN DBS on FER. The majority of studies, which had clinical and methodological heterogeneity, showed that FER is worsening after STN DBS in PD patients, particularly for negative emotions (sadness, fear, anger, and tendency for disgust). FER worsening after STN DBS can be attributed to the functional role of the STN in limbic circuits and the interference of STN stimulation with neural networks involved in FER, including the connections of the STN with the limbic part of the basal ganglia and pre- and frontal areas. These outcomes improve our understanding of the role of the STN in the integration of motor, cognitive, and emotional aspects of behaviour in the growing field of affective neuroscience. Further studies using standardized neuropsychological measures of FER assessment and including larger cohorts are needed, in order to draw definite conclusions about the effect of STN DBS on emotional recognition and its impact on patients' quality of life.

Clarifying the Normative Significance of 'Personality Changes' Following Deep Brain Stimulation

There is evidence to suggest that some patients who undergo Deep Brain Stimulation can experience changes to dispositional, emotional and behavioural states that play a central role in conceptions of personality, identity, autonomy, authenticity, agency and/or self (PIAAAS). For example, some patients undergoing DBS for Parkinson's Disease have developed hypersexuality, and some have reported increased apathy. Moreover, experimental psychiatric applications of DBS may intentionally seek to elicit changes to the patient's dispositional, emotional and behavioural states, in so far as dysfunctions in these states may undergird the targeted disorder. Such changes following DBS have been of considerable interest to ethicists, but there is a considerable degree of conflict amongst different parties to this debate about whether DBS really does change PIAAAS, and whether this matters. This paper explores these conflicting views and suggests that we may be able to mediate this conflict by attending more closely to what parties to the debate mean when they invoke the concepts lumped together under the acronym PIAAAS. Drawing on empirical work on patient attitudes, this paper outlines how these different understandings of the concepts incorporated into PIAAAS have been understood in this debate, and how they may relate to other fundamental concepts in medical ethics such as well-being and autonomy. The paper clarifies some key areas of disagreement in this context, and develops proposals for how ethicists might fruitfully contribute to future empirical assessments of apparent changes to PIAAAS following DBS treatment.

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.

DBS: a compelling example for ethical and legal reflection-a French perspective on ethical and legal concerns about DBS

Deep brain stimulation (DBS) is an approved treatment for neurological diseases and a promising one for psychiatric conditions, which may produce spectacular results very quickly. It is also a powerful tool for brain research and exploration. Beyond an overview of the ethical and legal literature on this topic, this paper aims at showing that DBS is a compelling example for ethical-legal reflection, as it combines a highly technical surgical procedure, a complex active medical device and neuromodulation of the human brain to restore lost abilities caused by a chronic and evolving disease. Some of the ethical and legal issues raised by DBS are not specific, but shed new light on medical ethics and law. Others are more DBS-specific, as they are linked to the intricacies of research and treatment, to the need to tune the device, to the patients' control over the device and its effects and to the involvement of family caregivers.