Becoming more oneself? Changes in personality following DBS treatment for psychiatric disorders: Experiences of OCD patients and general considerations

Qualitative studies involving users of clinical neurotechnology: a scoping review

BACKGROUND

The rise of a new generation of intelligent neuroprostheses, brain-computer interfaces (BCI) and adaptive closed-loop brain stimulation devices hastens the clinical deployment of neurotechnologies to treat neurological and neuropsychiatric disorders. However, it remains unclear how these nascent technologies may impact the subjective experience of their users. To inform this debate, it is crucial to have a solid understanding how more established current technologies already affect their users. In recent years, researchers have used qualitative research methods to explore the subjective experience of individuals who become users of clinical neurotechnology. Yet, a synthesis of these more recent findings focusing on qualitative methods is still lacking.

METHODS

To address this gap in the literature, we systematically searched five databases for original research articles that investigated subjective experiences of persons using or receiving neuroprosthetics, BCIs or neuromodulation with qualitative interviews and raised normative questions.

RESULTS

36 research articles were included and analysed using qualitative content analysis. Our findings synthesise the current scientific literature and reveal a pronounced focus on usability and other technical aspects of user experience. In parallel, they highlight a relative neglect of considerations regarding agency, self-perception, personal identity and subjective experience.

CONCLUSIONS

Our synthesis of the existing qualitative literature on clinical neurotechnology highlights the need to expand the current methodological focus as to investigate also non-technical aspects of user experience. Given the critical role considerations of agency, self-perception and personal identity play in assessing the ethical and legal significance of these technologies, our findings reveal a critical gap in the existing literature. This review provides a comprehensive synthesis of the current qualitative research landscape on neurotechnology and the limitations thereof. These findings can inform researchers on how to study the subjective experience of neurotechnology users more holistically and build patient-centred neurotechnology.

The Nested States Model: A Phenomenologically-Grounded Model of the Mind

BACKGROUND

Subjective experience is central to the nature of mental illness, yet it has not played a central role in most empirical approaches to psychopathology. While phenomenological perspectives in psychiatry have seen a recent resurgence, there remains a need for more detailed models of psychopathological processes based on explicit phenomenological and enactive foundations.

SUMMARY

We present a framework derived from the Nested States Model (NSM) through which such phenomenologically-grounded models might be constructed. The NSM describes the dynamic structure of subjective experience as a system of nested states that reciprocally influence one another across hierarchical layers. Here, we show how the NSM provides a scheme for characterizing patterns of experience that comprise various psychopathological processes. We demonstrate the utility of this scheme both for clinical practice and for building our knowledge of psychopathological processes more broadly.

KEY MESSAGES

The NSM can advance three aims that we see as critical for the lasting integration of phenomenological approaches to psychopathology within psychiatry. First, we show that the NSM provides a means for constructing clinical formulations and treatment considerations that center squarely on an individual's subjective experiences. Second, the NSM supplies a framework for organizing findings from clinical-phenomenological research that can guide the construction of broader phenomenologically-grounded models of psychopathological processes. Lastly, the NSM aligns our perspective on subjective experience with emerging perspectives on brain dynamics, helping to bridge phenomenological work with ongoing neurophysiological research.

Examination of self patterns: framing an alternative phenomenological interview for use in mental health research and clinical practice

Mental disorders are increasingly understood as involving complex alterations of self that emerge from dynamical interactions of constituent elements, including cognitive, bodily, affective, social, narrative, cultural and normative aspects and processes. An account of self that supports this view is the pattern theory of self (PTS). The PTS is a non-reductive account of the self, consistent with both embodied-enactive cognition and phenomenological psychopathology; it foregrounds the multi-dimensionality of subjects, stressing situated embodiment and intersubjective processes in the formation of the self-pattern. Indications in the literature already demonstrate the viability of the PTS for formulating an alternative methodology to better understand the lived experience of those suffering mental disorders and to guide mental health research more generally. This article develops a flexible methodological framework that front-loads the self-pattern into a minimally structured phenomenological interview. We call this framework 'Examination of Self Patterns' (ESP). The ESP is unconstrained by internalist or externalist assumptions about mind and is flexibly guided by person-specific interpretations rather than pre-determined diagnostic categories. We suggest this approach is advantageous for tackling the inherent complexity of mental health, the clinical protocols and the requirements of research.

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.

Neuroablative Intervention for Refractory Obsessive-Compulsive Disorder

OBJECTIVE

This review aims to investigate the progression of neuroablation, along with documented clinical efficacy and safety, in the management of treatment-resistant obsessive-compulsive disorder (OCD).

METHODS

We searched and compiled clinical research results of neuroablation therapy reported to date. We extracted outcomes related to clinical efficacy, side effects, and surgical complications. Additionally, we summarized key claims and findings.

RESULTS

Neuroablative intervention is a potential treatment approach for refractory OCD. Recent advancements, such as real-time magnetic resonance monitoring and minimally invasive techniques employing ultrasound and laser, offer distinct advantages in terms of safety and comparative efficacy when compared to conventional methods. However, the absence of randomized controlled trials and long-term outcome data underscores the need for cautious consideration when selecting neuroablation.

CONCLUSION

Neuroablative intervention shows promise for refractory OCD, but vigilant consideration is essential in both patient selection and surgical method choices due to the potential for rare yet serious complications.

Phenomenological Changes Associated with Deep Brain Stimulation for Obsessive Compulsive Disorder: A Cognitive Appraisal Model of Recovery

The current scientific enquiry of deep brain stimulation (DBS) does not capture the breadth of DBS-induced changes to an individual's life. Considering that DBS is applied in severe and complex cases, it is ethically and clinically necessary to consider the patient perspective and personally relevant outcomes. This lived experience investigation of people with obsessive compulsive disorder (OCD) undergoing DBS aims to provide a comprehensive evaluation of DBS-induced effects associated with OCD psychopathology. Six patients and six carers completed semi-structured open-ended interviews. A blended approach of interpretative phenomenological, inductive, and thematic analysis techniques was employed. Profound psychopathological changes were expressed; individuals felt more alive, had improved cognitive affective control, greater engagement in the world, and were able to manage their OCD. Through suppression of the condition, self-constructs were able to re-emerge and develop. A framework describing the progression of phenomenological changes, and a theoretical model describing changes in the cognitive appraisal of intrusions influencing recovery are proposed. This is the first identified qualitative investigation of DBS-induced changes in psychiatric patients and carers. Findings have implications for patient education and recovery models of OCD, and scientific understanding of DBS effects.

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.

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.

The Role of Family Members in Psychiatric Deep Brain Stimulation Trials: More Than Psychosocial Support

Family members can provide crucial support to individuals participating in clinical trials. In research on the "newest frontier" of Deep Brain Stimulation (DBS)-the use of DBS for psychiatric conditions-family member support is frequently listed as a criterion for trial enrollment. Despite the significance of family members, qualitative ethics research on DBS for psychiatric conditions has focused almost exclusively on the perspectives and experiences of DBS recipients. This qualitative study is one of the first to include both DBS recipients and their family members as interview participants. Using dyadic thematic analysis-an approach that takes both the individuals and the relationship as units of analyses-this study analyzes the complex ways in which family relationships can affect DBS trial participation, and how DBS trial participation in turn influences family relationships. Based on these findings, we propose ways to improve study designs to better take family relationships into account, and better support family members in taking on the complex, essential roles that they play in DBS trials for psychiatric conditions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12152-023-09520-7.

'Deep brain stimulation is no ON/OFF-switch': an ethnography of clinical expertise in psychiatric practice

Despite technological innovations, clinical expertise remains the cornerstone of psychiatry. A clinical expert does not only have general textbook knowledge, but is sensitive to what is demanded for the individual patient in a particular situation. A method that can do justice to the subjective and situation-specific nature of clinical expertise is ethnography. Effective deep brain stimulation (DBS) for obsessive-compulsive disorder (OCD) involves an interpretive, evaluative process of optimizing stimulation parameters, which makes it an interesting case to study clinical expertise. The aim of this study is to explore the role of clinical expertise through an ethnography of the particular case of DBS optimization in OCD. In line with the topic of the special issue this article is a part of, we will also use our findings to reflect on ethnography as a method to study complex phenomena like clinical expertise. This ethnography of DBS optimization is based on 18 months of participant observation and nine in-depth interviews with a team of expert clinicians who have been treating over 80 OCD patients since 2005. By repeatedly observing particular situations for an extended period of time, we found that there are recurrent patterns in the ways clinicians interact with patients. These patterns of clinical practice shape the possibilities clinicians have for making sense of DBS-induced changes in patients' lived experience and behavior. Collective established patterns of clinical practice are dynamic and change under the influence of individual learning experiences in particular situations, opening up new possibilities and challenges. We conclude that patterns of clinical practice and particular situations are mutually constitutive. Ethnography is ideally suited to bring this relation into view thanks to its broad temporal scope and focus on the life-world. Based on our findings, we argue that clinical expertise not only implies skillful engagement with a concrete situation but also with the patterns of clinical practice that shape what is possible in this specific situation. Given this constraining and enabling role of practices, it is important to investigate them in order to find ways to improve diagnostic and therapeutic possibilities.

Jumping through the hoops: Barriers and other ethical concerns regarding the use of psychiatric electroceutical interventions

Stakeholders' perceptions of barriers to and other ethical concerns about using psychiatric electroceutical interventions (PEIs), interventions that use electrical or magnetic stimuli to treat psychiatric conditions like treatment-resistant depression (TRD), may influence the uptake of these interventions. This study examined such perceptions among psychiatrists, patients with depression, and members of the public. We conducted semi-structured qualitative interviews with 16 members of each group to examine their views on practical barriers and ethical concerns. We used qualitative content analysis to identify relevant themes, and compared findings across stakeholder groups. Access limitations to the interventions, including cost and availability of the interventions, cut across all PEIs-including those that are still experimental, and were raised by all groups. Most participants across all groups raised concerns about informed consent, in terms of receiving adequate, appropriate, and understandable information. Our results suggest that these three stakeholder groups perceive similar structural and attitudinal barriers to, and have similar ethical concerns about, using PEIs for TRD. These results identify key issues that must be addressed for the full potential of PEIs to be realized. Future research with larger samples will help to better understand how to address these barriers to treatment for individuals with TRD.

Lived experiences of children and adolescents with obsessive-compulsive disorder: interpretative phenomenological analysis

BACKGROUND

Childhood obsessive-compulsive disorder (OCD) is distinct from OCD in adults. It can be severely disabling and there is little qualitative research on OCD in children. The present study aims to explore the subjective experiences of diagnosis, treatment processes and meaning of recovery in children and adolescents suffering from OCD and provide a conceptual model of the illness.

METHODS

It is a qualitative study of ten children and adolescents selected by purposive sampling. MINI KID 6.0, Children's Yale-Brown Obsessive-Compulsive Scale and Clinical Global Impression-Severity Scale were administered at the time of recruitment of subjects into the study. Interviews were conducted using an in-depth semi-structured interview guide and audio-recorded. The transcribed interviews were analyzed using Interpretative Phenomenological Analysis (IPA). The study sought to explore participants' sense-making of their world, their thoughts, feelings and perceptions through interpretative enquiry. The findings were confirmed by a process called investigator triangulation, member check and peer validation.

RESULTS

IPA yielded five major themes-'illness perception changes over time', 'disclosure on a spectrum', 'cascading effects of OCD', 'treatment infuses hope and helps', and 'navigating through OCD'. A summary of these themes and their subthemes is presented as a conceptual model. The essence of this model is to show the inter-relationship between themes and provide a comprehensive understanding of the phenomenon of OCD.

CONCLUSIONS

To the best of our knowledge, this is the first study to explore lived experiences of children and adolescents with OCD using interpretative phenomenological analysis (IPA). It was noted that perception of illness and treatment processes evolves over time, and recovery is viewed as a process. Future qualitative research can be carried out with a focus on 'therapist-related barriers' or 'student-teacher dyads' that can inform clinical practice and school policies respectively. Trial registration NIMH/DO/IEC (BEH. Sc. DIV)/2018, l1 April 2018.

Deep Brain Stimulation of the Nucleus Accumbens in Severe Enduring Anorexia Nervosa: A Pilot Study

Introduction

Anorexia nervosa (AN) is one of the most debilitating psychiatric disorders, becoming severe and enduring in a third of cases; with few effective treatments. Deep brain stimulation is a reversible, adjustable neurosurgical procedure that has been gaining ground in psychiatry as a treatment for depression and obsessive-compulsive disorder, yet few studies have investigated AN. Abnormal eating behavior and the compulsive pursuit of thinness in AN is, in part, a consequence of dysfunction in reward circuitry and the nucleus accumbens (NAcc) is central to reward processing.

Methods

Phase 1 prospective open-label pilot study of seven individuals with severe enduring AN. Electrodes were implanted bilaterally into the NAcc with stimulation at the anterior limb of the internal capsule using rechargeable implantable pulse generators. The protocol of 15 months included 12 months of deep brain stimulation incorporating two consecutive, randomized blind on-off fortnights 9 months after stimulation onset. The primary objectives were to investigate safety and feasibility, together with changes in eating disorder psychopathology.

Results

Feasibility and safety was demonstrated with no serious adverse events due to deep brain stimulation. Three patients responded to treatment [defined as > 35% reduction in Eating Disorders Examination (EDE) score at 12 months] and four patients were non-responders. Responders had a statistically significant mean reduction in EDE scores (50.3% reduction; 95% CI 2.6-98.2%), Clinical Impairment Assessment (45.6% reduction; 95% CI 7.4-83.7%). Responders also had a statistically significant mean reduction in Hamilton Depression Scale, Hamilton Anxiety Scale and Snaith-Hamilton pleasure scale. There were no statistically significant changes in Body Mass Index, Yale-Brown-Cornell Eating Disorder Scale, Yale-Brown Obsessive-Compulsive Scale and World Health Organization Quality of Life Psychological subscale.

Conclusion

This study provides some preliminary indication that deep brain stimulation to the NAcc. Might potentially improve some key features of enduring AN. In this small study, the three responders had comorbid obsessive-compulsive disorder which predated AN diagnosis. Future studies should aim to further elucidate predictors of outcome.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier [Project ID 128658].

Concerns About Psychiatric Neurosurgery and How They Can Be Overcome: Recommendations for Responsible Research

Background

Psychiatric neurosurgery is experiencing a revival. Beside deep brain stimulation (DBS), several ablative neurosurgical procedures are currently in use. Each approach has a different profile of advantages and disadvantages. However, many psychiatrists, ethicists, and laypeople are sceptical about psychiatric neurosurgery.

Methods

We identify the main concerns against psychiatric neurosurgery, and discuss the extent to which they are justified and how they might be overcome. We review the evidence for the effectiveness, efficacy and safety of each approach, and discuss how this could be improved. We analyse whether and, if so, how randomised controlled trials (RCTs) can be used in the different approaches, and what alternatives are available if conducting RCTs is impossible for practical or ethical reasons. Specifically, we analyse the problem of failed RCTs after promising open-label studies.

Results

The main concerns are: (i) reservations based on historical psychosurgery, (ii) concerns about personality changes, (iii) concerns regarding localised interventions, and (iv) scepticism due to the lack of scientific evidence. Given the need for effective therapies for treatment-refractory psychiatric disorders and preliminary evidence for the effectiveness of psychiatric neurosurgery, further research is warranted and necessary. Since psychiatric neurosurgery has the potential to modify personality traits, it should be held to the highest ethical and scientific standards.

Conclusions

Psychiatric neurosurgery procedures with preliminary evidence for efficacy and an acceptable risk–benefit profile include DBS and micro- or radiosurgical anterior capsulotomy for intractable obsessive–compulsive disorder. These methods may be considered for individual treatment attempts, but multi-centre RCTs are necessary to provide reliable evidence.

Integration and Causality in Enactive Approaches to Psychiatry

In this paper I address what has been called the integration problem in psychiatry. This problem is tied to conceptions of causality and explanatory levels in our understanding of mind. I take an interdisciplinary enactive perspective to develop a 3-fold method for exploring the dynamics of integration, based on a concept of dynamical causation and a non-hierarchical (level-free) notion of gestalt. I also consider Autism Spectrum Disorder (ASD) as a test case.

The prefrontal cortex and neurosurgical treatment for intractable OCD

Over the past two decades, circuit-based neurosurgical procedures have gained increasing acceptance as a safe and efficacious approach to the treatment of the intractable obsessive-compulsive disorder (OCD). Lesions and deep brain stimulation (DBS) of the longitudinal corticofugal white matter tracts connecting the prefrontal cortex with the striatum, thalamus, subthalamic nucleus (STN), and brainstem implicate orbitofrontal, medial prefrontal, frontopolar, and ventrolateral cortical networks in the symptoms underlying OCD. The highly parallel distributed nature of these networks may explain the relative lack of adverse effects observed following surgery. Additional pre-post studies of cognitive tasks in more surgical patients are needed to confirm the role of these networks in OCD and to define therapeutic responses to surgical intervention.

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.

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.

Recommendations for Responsible Development and Application of Neurotechnologies

Advancements in novel neurotechnologies, such as brain computer interfaces (BCI) and neuromodulatory devices such as deep brain stimulators (DBS), will have profound implications for society and human rights. While these technologies are improving the diagnosis and treatment of mental and neurological diseases, they can also alter individual agency and estrange those using neurotechnologies from their sense of self, challenging basic notions of what it means to be human. As an international coalition of interdisciplinary scholars and practitioners, we examine these challenges and make recommendations to mitigate negative consequences that could arise from the unregulated development or application of novel neurotechnologies. We explore potential ethical challenges in four key areas: identity and agency, privacy, bias, and enhancement. To address them, we propose (1) democratic and inclusive summits to establish globally-coordinated ethical and societal guidelines for neurotechnology development and application, (2) new measures, including "Neurorights," for data privacy, security, and consent to empower neurotechnology users' control over their data, (3) new methods of identifying and preventing bias, and (4) the adoption of public guidelines for safe and equitable distribution of neurotechnological devices.

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.

The Decline of Deep Brain Stimulation for Obsessive-Compulsive Disorder Following FDA Humanitarian Device Exemption Approval

Background: In February 2009, the US Food and Drug Administration (FDA) granted Humanitarian Device Exemption (HDE) for deep brain stimulation (DBS) in the anterior limb of the internal capsule (ALIC) for the treatment of severely debilitating, treatment refractory obsessive–compulsive disorder (OCD). Despite its promise as a life altering treatment for patients with otherwise refractory, severely debilitating OCD, the use of DBS for the treatment of OCD has diminished since the FDA HDE endorsement and is now rarely performed even at busy referral centers. We sought to identify factors hindering OCD patients from receiving DBS therapy.

Materials and Methods: University of Florida (UF) clinical research databases were queried to identify patients evaluated as potential candidates for OCD DBS from January 1, 2002 to July 30, 2020. A retrospective review of these patients' medical records was performed to obtain demographic information, data related to their OCD, and details relevant to payment such as third-party payer, study participation, evaluation prior to or after HDE approval, and any stated factors prohibiting surgical intervention.

Results: Out of 25 patients with severe OCD identified as candidates for DBS surgery during the past 18 years, 15 underwent surgery. Prior to FDA HDE approval, 6 out of 7 identified candidates were treated. After the HDE, only 9 out of 18 identified candidates were treated. Seven of the 9 were funded by Medicare, 1 paid out of pocket, and 1 had “pre-authorization” from her private insurer who ultimately refused to pay after the procedure. Among the 10 identified OCD DBS candidates who were ultimately not treated, 7 patients—all with private health insurance—were approved for surgery by the interdisciplinary team but were unable to proceed with surgery due to lack of insurance coverage, 1 decided against surgical intervention, 1 was excluded due to medical comorbidities and excessive perceived surgical risk, and no clear reason was identified for 1 patient evaluated in 2004 during our initial NIH OCD DBS trial.

Conclusion: Based on compelling evidence that DBS provides substantial improvement of OCD symptoms and markedly improved functional capacity in 2 out of 3 patients with severely debilitating, treatment refractory OCD, the FDA approved this procedure under a Humanitarian Device Exemption in 2009, offering new hope to this unfortunate patient population. A careful review of our experience with OCD DBS at the University of Florida shows that since the HDE approval, only 50% of the severe OCD patients (9 of 18) identified as candidates for this potentially life altering treatment have been able to access the therapy. We found the most common limiting factor to be failure of private insurance policies to cover DBS for OCD, despite readily covering DBS for Parkinson's disease, essential tremor, and even dystonia—another HDE approved indication for DBS. We have identified an inherent discrimination in the US healthcare system against patients with medication-refractory OCD who are economically challenged and do not qualify for Medicare. We urge policy makers, insurance companies, and hospital administrations to recognize this health care disparity and seek to rectify it.

Authentic Self and Last Resort: International Perceptions of Psychiatric Neurosurgery

Psychiatric neurosurgery has resurfaced over the past two decades for the treatment of severe mental health disorders, with improved precision and safety over older interventions alongside the development of novel ones. Little is known, however, about current public opinions, expectations, hopes, and concerns over this evolution in neurotechnology, particularly given the controversial history of psychosurgery. To fill this knowledge gap, we conducted a study with eight focus groups in Vancouver and Montreal (Canada; n = 14), Berlin (Germany; n = 22), and Madrid (Spain; n = 12). Focus group texts were transcribed and analyzed using qualitative content analysis in the language local to each city, guided by the theoretical framework of pragmatic neuroethics. Findings indicate that participants across all cities hold concerns about the last resort nature of psychiatric neurosurgery and the potential impact on the authentic self of patients who undergo these procedures. The views captured serve to advance discussion on the appropriate timing for psychiatric neurosurgery, promote sound health policy for the allocation of this resource, and foster scientific literacy about advances for mental health internationally.

Optimizing Deep Brain Stimulation Parameters in Obsessive-Compulsive Disorder

OBJECTIVES

Deep brain stimulation (DBS) is an innovative and effective treatment for patients with therapy-refractory obsessive-compulsive disorder (OCD). DBS offers unique opportunities for personalized care, but no guidelines on how to choose effective and safe stimulation parameters in patients with OCD are available. Our group gained relevant practical knowledge on DBS optimization by treating more than 80 OCD patients since 2005, the world's largest cohort. The article's objective is to share this experience.

MATERIALS AND METHODS

We provide guiding principles for optimizing DBS stimulation parameters in OCD and discuss the neurobiological and clinical basis.

RESULTS

Adjustments in stimulation parameters are performed in a fixed order. First, electrode contact activation is determined by the position of the electrodes on postoperative imaging. Second, voltage and pulse width are increased stepwise, enlarging both the chance of symptom reduction and of inducing side effects. Clinical evaluation of adjustments in stimulation parameters needs to take into account: 1) the particular temporal sequence in which the various OCD symptoms and DBS side-effects change; 2) the lack of robust response predictors; 3) the limited sensitivity of the Yale-Brown Obsessive-Compulsive Scale to assess DBS-induced changes in OCD symptoms; and 4) a patient's fitness for additional cognitive-behavioral therapy (CBT).

CONCLUSIONS

Decision-making in stimulation parameter optimization needs to be sensitive to the particular time-courses on which various symptoms and side effects change.

Researcher Perspectives on Ethical Considerations in Adaptive Deep Brain Stimulation Trials

Interest and investment in closed-loop or adaptive deep brain stimulation (aDBS) systems have quickly expanded due to this neurotechnology's potential to more safely and effectively treat refractory movement and psychiatric disorders compared to conventional DBS. A large neuroethics literature outlines potential ethical concerns about conventional DBS and aDBS systems. Few studies, however, have examined stakeholder perspectives about ethical issues in aDBS research and other next-generation DBS devices. To help fill this gap, we conducted semi-structured interviews with researchers involved in aDBS trials (n = 23) to gain insight into the most pressing ethical questions in aDBS research and any concerns about specific features of aDBS devices, including devices' ability to measure brain activity, automatically adjust stimulation, and store neural data. Using thematic content analysis, we identified 8 central themes in researcher responses. The need to measure and store neural data for aDBS raised concerns among researchers about data privacy and security issues (noted by 91% of researchers), including the avoidance of unintended or unwanted third-party access to data. Researchers reflected on the risks and safety (83%) of aDBS due to the experimental nature of automatically modulating then observing stimulation effects outside a controlled clinical setting and in relation to need for surgical battery changes. Researchers also stressed the importance of ensuring informed consent and adequate patient understanding (74%). Concerns related to automaticity and device programming (65%) were discussed, including current uncertainties about biomarker validity. Additionally, researchers discussed the potential impacts of automatic stimulation on patients' autonomy and control over stimulation (57%). Lastly, researchers discussed concerns related to patient selection (defining criteria for candidacy) (39%), challenges of ensuring post-trial access to care and device maintenance (39%), and potential effects on personality and identity (30%). To help address researcher concerns, we discuss the need to minimize cybersecurity vulnerabilities, advance biomarker validity, promote the balance of device control between patients and clinicians, and enhance ongoing informed consent. The findings from this study will help inform policies that will maximize the benefits and minimize potential harms of aDBS and other next-generation DBS devices.

Out of our heads: Addiction and psychiatric externalism

In addiction, apparently causally significant phenomena occur at a huge number of levels; addiction is affected by biomedical, neurological, pharmacological, clinical, social, and politico-legal factors, among many others. In such a complex, multifaceted field of inquiry, it seems very unlikely that all the many layers of explanation will prove amenable to any simple or straightforward, reductive analysis; if we are to unify the many different sciences of addiction while respecting their causal autonomy, then, what we are likely to need is an integrative framework. In this paper, we propose the theory of "Externalist" or "4E" - for extended, embodied, embedded, and enactive - cognition, which focuses on the empirical and conceptual centrality of the wider extra-neural environment to cognitive and mental processes, as a candidate for such a framework. We begin in Section 2 by outlining how such a perspective might apply to psychiatry more generally, before turning to some of the ways it can illuminate addiction in particular: Section 3 points to a way of dissolving the classic dichotomy between the "choice model" and "disease model" in the addiction literature; Section 4 shows how 4E concepts can clarify the interplay between the addict's brain and her environment; and Section 5 considers how these insights help to explain the success of some recovery strategies, and may help to inform the development of new ones.

Neuroethics for Fantasyland or for the Clinic? The Limitations of Speculative Ethics

What purpose can be served by empirically unsubstantiated speculation in ethics? In answering that question, we need to distinguish between the major branches of ethics. In foundational moral philosophy, the use of speculative examples is warranted to the extent that ethical principles and theories are assumed to be applicable even under the extreme circumstances referred to in these examples. Such an assumption is in need of justification, and it cannot just be taken for granted. In applied ethics, the use of unrealistic scenarios is more difficult to justify. It can be positively harmful if it diverts our attention from more urgent issues. Neuroethics is one of the areas of applied ethics where speculative scenarios have taken up much of the attention that could instead have been devoted to problems that are relevant for the treatment and care of patients. Speculative ethics has often been defended with mere possibility arguments that may at first hand seem difficult to refute. It is shown with examples how such claims can be defeated with a combination of science and argumentation analysis.

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.

Narrative Devices: Neurotechnologies, Information, and Self-Constitution

This article provides a conceptual and normative framework through which we may understand the potentially ethically significant roles that information generated by neurotechnologies about our brains and minds may play in our construction of our identities. Neuroethics debates currently focus disproportionately on the ways that third parties may (ab)use these kinds of information. These debates occlude interests we may have in whether and how we ourselves encounter information about our own brains and minds. This gap is not yet adequately addressed by most allusions in the literature to potential identity impacts. These lack the requisite conceptual or normative foundations to explain why we should be concerned about such effects or how they might be addressed. This article seeks to fill this gap by presenting a normative account of identity as constituted by embodied self-narratives. It proposes that information generated by neurotechnologies can play significant content-supplying and interpretive roles in our construction of our self-narratives. It argues, to the extent that these roles support and detract from the coherence and inhabitability of these narratives, access to information about our brains and minds engages non-trivial identity-related interests. These claims are illustrated using examples drawn from empirical literature reporting reactions to information generated by implantable predictive BCIs and psychiatric neuroimaging. The article concludes by highlighting ways in which information generated by neurotechnologies might be governed so as to protect information subjects' interests in developing and inhabiting their own identities.

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.

Neurotechnologies, Relational Autonomy, and Authenticity

The ethical debate about neurotechnologies has been largely framed around their effects on authenticity. In this paper, we investigate the concept of authenticity and associated conceptions of the self. We develop a conception of authenticity that eschews problematic essentialist or existentialist views of the self and the assumption that the authentic self transcends socialization. In our view, authenticity is a condition for self-governance and can involve either endorsement or acknowledgment. Revisiting the debate about neurotechnologies, we show why framing the ethical debate in terms of authenticity is unhelpful and argue that these ethical concerns are better understood as concerns about autonomy.

Building Intricate Partnerships with Neurotechnology: Deep Brain Stimulation and Relational Agency

Deep Brain Stimulation (DBS) is an FDA-approved treatment for symptoms of motor disorders—with experimental use for psychiatric disorders. DBS, however, causes a variety of side effects. Moral philosophers question DBS’s influence on users’ experiences of authenticity, identity, and/or autonomy. These characterizations of DBS, however, may not make sense of how DBS complicates, rather than simply impedes or bolsters, users’ abilities to exercise agency. Empirical work exploring DBS users’ lived-experiences and feminist accounts of relational autonomy demonstrate that the issues users face are better characterized in terms of the user’s relationship to their stimulator, that is, in terms of “relational agency.”

Effective Deep Brain Stimulation for Obsessive-Compulsive Disorder Requires Clinical Expertise

BACKGROUND

Deep brain stimulation (DBS) is an innovative treatment for severe obsessive-compulsive disorder (OCD). Electrodes implanted in specific brain areas allow clinicians to directly modulate neural activity. DBS affects symptomatology in a completely different way than established forms of treatment for OCD, such as psychotherapy or medication.

OBJECTIVE

To understand the process of improvement with DBS in patients with severe OCD.

METHODS

By means of open-ended interviews and participant observation we explore how expert clinicians involved in the post-operative process of DBS optimization evaluate DBS effects.

RESULTS

Evaluating DBS effect is an interactive and context-sensitive process that gradually unfolds over time and requires integration of different sources of knowledge. Clinicians direct DBS optimization toward a critical point where they sense that patients are being moved with regard to behavior, emotion, and active engagement, opening up possibilities for additional cognitive behavioral therapy (CBT).

DISCUSSION

Based on the theoretical framework of radical embodied cognitive science (RECS), we assume that clinical expertise manifests itself in the pattern of interaction between patient and clinician. To the expert clinician, this pattern reflects the patient's openness to possibilities for action ("affordances") offered by their environment. OCD patients' improvement with DBS can be understood as a change in openness to their environment. The threshold for patients to engage in activities is decreased and a broader range of daily life and therapeutic activities becomes attractive. Movement is improvement.

Open-label trial of anterior limb of internal capsule-nucleus accumbens deep brain stimulation for obsessive-compulsive disorder: insights gained

BACKGROUND

For more than 15 years, deep brain stimulation (DBS) has served as a last-resort treatment for severe treatment-resistant obsessive-compulsive disorder (OCD).

METHODS

From 2010 to 2016, 20 patients with OCD (10 men/10 women) were included in a single-centre trial with a naturalistic open-label design over 1 year to evaluate the effects of DBS in the anterior limb of the internal capsule and nucleus accumbens region (ALIC-NAcc) on OCD symptoms, executive functions, and personality traits.

RESULTS

ALIC-NAcc-DBS significantly decreased OCD symptoms (mean Yale-Brown Obsessive Compulsive Scale reduction 33%, 40% full responders) and improves global functioning without loss of efficacy over 1 year. No significant changes were found in depressive or anxiety symptoms. Our study did not show any effect of ALIC-NAcc-DBS on personality traits or executive functions, and no potential outcome predictors were identified in a post hoc analysis. Other than several individual minor adverse events, ALIC-NAcc-DBS has been shown to be safe, but 35% of patients reported a sudden increase in anxiety and anhedonia after acute cessation of stimulation.

CONCLUSIONS

We conclude that ALIC-NAcc-DBS is a well-tolerated and promising last-resort treatment option for OCD. The cause of variability in the outcome remains unclear, and the aspect of reversibility must be examined critically. The present data from one of the largest samples of patients with OCD treated with DBS thus far support the results of previous studies with smaller samples.

Deep brain stimulation and revising the Mental Health Act: the case for intervention-specific safeguards

Under the current Mental Health Act of England and Wales, it is lawful to perform deep brain stimulation in the absence of consent and independent approval. We argue against the Care Quality Commission's preferred strategy of addressing this problematic issue, and offer recommendations for deep brain stimulation-specific provisions in a revised Mental Health Act.Declaration of interestT.A. is a paid consultant for Boston Scientific, Medtronic and St. Jude Medical. He has received honoraria from Abbott, Boston and Medtronics and served as consultant to all three.

Ablative neurosurgery and deep brain stimulation for obsessive-compulsive disorder

Despite advancements in pharmacotherapeutic and behavioral interventions, a substantial proportion of patients with obsessive-compulsive disorder (OCD) continue to have disabling and treatment-refractory illness. Neurosurgical interventions, including ablative procedures and deep brain stimulation (DBS), have emerged as potential treatment options in this population. We review the recent literature on contemporary surgical options for OCD, focusing on clinical aspects such as patient selection, presurgical assessment, and safety and effectiveness of these procedures. Given the invasiveness and limited evidence, these procedures have been performed in carefully selected patients with severe, chronic, and treatment-refractory illness. Along with informed consent, an independent review by a multidisciplinary team is mandated in many centers. Both ablative procedures and DBS have been found to be helpful in around half the patients, with improvement observed months after the procedure. Various targets have been proposed for either procedure, based on the dominant corticostriatal model of OCD. There is no strong evidence to recommend one procedure over the other. Hence, the choice of procedure is often based on the factors such as affordability, expertise, and reversibility of adverse effects. Surgery is not recommended as a standalone treatment but should be provided as part of a comprehensive package including medications and psychotherapeutic interventions. Available evidence suggest that the benefits of the procedure outweigh the risks in a treatment-refractory population. Advances in neurosurgical techniques and increasing knowledge of neurobiology are likely to bring about further progress in the efficacy, safety, and acceptability of the procedures.

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.