The 5 Pillars in Tourette Syndrome Deep Brain Stimulation Patient Selection: Present and Future

The selection of patients with Tourette syndrome (TS) for deep brain stimulation (DBS) surgery rests on 5 fundamental pillars. However, the operationalization of the multidisciplinary screening process to evaluate these pillars remains highly diverse, especially across sites. High tic severity and tic-related impact on quality of life (first 2 pillars) require confirmation from objective, validated measures, but malignant features of TS should per se suffice to fulfill this pillar. Failure of behavioral and pharmacologic therapies (third pillar) should be assessed taking into account refractoriness through objective and subjective measures supporting lack of efficacy of all interventions of proven efficacy, as well as true lack of tolerability, adherence, or access. Educational interventions and use of remote delivery formats (for behavioral therapies) play a role in preventing misjudgment of treatment failure. Stability of comorbid psychiatric disorders for 6 months (fourth pillar) is needed to confirm the predominant impact of tics on quality of life, to prevent pseudo-refractoriness, and to maximize the future DBS response. The 18-year age limit (fifth pillar) is currently under reappraisal, considering the potential impact of severe tics in adolescence and the predictive effect of tic severity in childhood on tic severity when transitioning into adulthood. Future advances should aim at a consensus-based definition of failure of specific, noninvasive treatment strategies for tics and of the minimum clinical observation period before considering DBS treatment, the stability of behavioral comorbidities, and the use of a prospective international registry data to identify predictors of positive response to DBS, especially in younger patients.

Pediatric Deep Brain Stimulation for Dystonia: Current State and Ethical Considerations

Dystonia is a movement disorder that can have a debilitating impact on motor functions and quality of life. There are 250,000 cases in the United States, most with childhood onset. Due to the limited effectiveness and side effects of available treatments, pediatric deep brain stimulation (pDBS) has emerged as an intervention for refractory dystonia. However, there is limited clinical and neuroethics research in this area of clinical practice. This paper examines whether it is ethically justified to offer pDBS to children with refractory dystonia. Given the favorable risk-benefit profile, it is concluded that offering pDBS is ethically justified for certain etiologies of dystonia, but it is less clear for others. In addition, various ethical and policy concerns are discussed, which need to be addressed to optimize the practice of offering pDBS for dystonia. Strategies are proposed to help address these concerns as pDBS continues to expand.

Deep transcranial magnetic stimulation for obsessive compulsive disorder

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a common psychiatric disorder that can be chronic and debilitating if not properly treated. Current first-line treatments for OCD include cognitive-behavioral therapy with exposure and response prevention and serotonin uptake inhibitor medications; however, these therapies are not effective for all individuals.

AREAS COVERED

Deep transcranial magnetic stimulation (dTMS) has been hypothesized to be an effective alternative for individuals with treatment-resistant OCD. dTMS has thought to be favorable due to its low side effect profile and its minimally invasive nature.

EXPERT OPINION

This review evaluates the current research on effectiveness of dTMS therapy for individuals with treatment-resistant OCD. This review also investigates shortcomings in current dTMS research and the hypothesized future of dTMS therapy.

Parental Attitudes Toward Deep Brain Stimulation in Adolescents with Treatment-Resistant Conditions

Objective: To examine parent's perceptions of deep brain stimulation (DBS) and whether DBS is perceived to be a viable and safe treatment for their adolescent child presenting with a severe, treatment-resistant neurological or psychiatric condition. Method: Two hundred and seventy-nine parents completed an online survey using Amazon Mechanical Turk (MTurk). Participants were presented with five vignette scenarios involving adolescents with severe, treatment-resistant neurological or psychiatric conditions: Rett syndrome, autism spectrum disorder, epilepsy, obsessive-compulsive disorder, and Tourette syndrome. Parents were then asked to evaluate each scenario and rate overall acceptability of using DBS to improve their child's core symptoms. Data were collected over a period of 2 weeks in the month of October 2018. Results: We found that parents reported favorable impressions of DBS regardless of the target condition, especially when greater improvement could be assured and when their child had the capacity to assist in the treatment decision-making. Parents indicated some reluctance to use DBS when possible safety concerns were present. Familiarity with DBS was directly associated with attitudes. Conclusions: The findings highlight an overall parental willingness to consider DBS as a treatment option for key symptoms of neurological and psychiatric conditions in adolescents.

Deep Brain Stimulation for Tourette Syndrome: Potential Role in the Pediatric Population

Tourette syndrome (TS) is a complex neuropsychiatric disorder. Despite an expected natural history of improvement with age, many individuals continue to have severe tics and remain refractory to the current best pharmacologic and nonpharmacologic treatments. Deep brain stimulation (DBS) has emerged as a potential treatment option. This article reviews the published reports on the use of deep brain stimulation in Tourette syndrome revealing that 2 anatomical targets have been most commonly used: the centromedian thalamus and the globus pallidus internus. The evidence supports a significant clinical improvement of tics with deep brain stimulation, though the data are limited by the small number of patients and variable methodology employed. To bridge these limitations, the international Tourette syndrome deep brain stimulation database and registry have been created, fostering collaboration among multiple centers from 10 countries. By standardizing data collection, the database and registry are providing valuable insights into deep brain stimulation for Tourette syndrome. In conclusion, deep brain stimulation offers significant promise for the management of tics.

Neuroethics of Neuromodulation: An Update

This article reviews neuroethics issues that arise with the development, translation, and use of technologies for neuromodulation. Three electronic databases (PubMed, Embase, and PhilPapers) were searched for relevant articles published between 1/1/16 - 6/26/18. We focus on pressing ethical issues related to the use of deep brain stimulation (DBS), adaptive DBS (aDBS), transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), and associated technologies. The neuroethics issues we address include privacy, continued access to devices, device removal, do-it-yourself neurostimulation, neuroenhancement, media coverage, changes in personal identity and agency, informed consent, and neuromodulation in minors. This review should be of assistance to a variety of stakeholders, including neurotechnology developers, as they make important decisions that will drive these neurotechnologies.