Closed-Loop Neuromodulation and Self-Perception in Clinical Treatment of Refractory Epilepsy

Abstract

Background: Newer "closed-loop" neurostimulation devices in development could, in theory, induce changes to patients' personalities and self-perceptions. Empirically, however, only limited data of patient and family experiences exist. Responsive neurostimulation (RNS) as a treatment for refractory epilepsy is the first approved and commercially available closed-loop brain stimulation system in clinical practice, presenting an opportunity to observe how conceptual neuroethical concerns manifest in clinical treatment. Methods: We conducted ethnographic research at a single academic medical center with an active RNS treatment program and collected data via direct observation of clinic visits and in-depth interviews with 12 patients and their caregivers. We used deductive and inductive analyses to identify the relationship between these devices and patient changes in personality and self-perception. Results: Participants generally did not attribute changes in patients' personalities or self-perception to implantation of or stimulation using RNS. They did report that RNS affected patients' experiences and conceptions of illness. In particular, the capacity to store and display electrophysiological data produced a common frame of reference and a shared vocabulary among patients and clinicians. Discussion: Empirical experiences of a clinical population being treated with closed-loop neuromodulation do not corroborate theoretical concerns about RNS devices described by neuroethicists and technology developers. However, closed-loop devices demonstrated an ability to change illness experiences. Even without altering identify and self-perception, they provided new cultural tools and metaphors for conceiving of epilepsy as an illness and of the process of diagnosis and treatment. These findings call attention to the need to situate neuroethical concerns in the broader contexts of patients' illness experiences and social circumstances.

Moral reasoning through the eyes of persons with behavioral variant frontotemporal dementia

“…The measure is an extension of the standard CDR and includes two additional domains that are predominantly affected in FTD: behavior and language. Each patient’s CDR plus NACC FTLD global score was calculated based on the scoring rules by Miyagawa and colleagues ( 32 ).…”

“…Five investigators coded the data independently and subsequently compared and discussed the codes until a consensus was reached. Lastly, divergences in theme categorization were discussed until a consensus was established ( 32 ).…”

Corticospinal circuit neuroplasticity may involve silent synapses: Implications for functional recovery facilitated by neuromodulation after spinal cord injury

“…Generally, a typical electrical stimulation protocol is applied in open-loop mode to deliver consistent pre-programmed stimulation to the target organs or physiological systems irrespective of their dynamic states. In contrast, closed-loop systems continuously monitor brain or physiological activity, decode relevant neural signals in real time, and modulate such activities by stimulation when certain physiological states or conditions are met ( Haeusermann et al, 2021 ). The stimulation parameters can also be adjusted dynamically in real time to acquire desired state-specific effects while minimizing the undesired side effects, therefore the closed-loop mode is thought to be more dynamic and efficient than the open-loop systems ( Haeusermann et al, 2021 , Zanos, 2019 ).…”

“…In contrast, closed-loop systems continuously monitor brain or physiological activity, decode relevant neural signals in real time, and modulate such activities by stimulation when certain physiological states or conditions are met ( Haeusermann et al, 2021 ). The stimulation parameters can also be adjusted dynamically in real time to acquire desired state-specific effects while minimizing the undesired side effects, therefore the closed-loop mode is thought to be more dynamic and efficient than the open-loop systems ( Haeusermann et al, 2021 , Zanos, 2019 ). The closed-loop neuromodulation systems have been used experimentally to facilitate the activity-dependent adaptive neuroplasticity leading to sensorimotor function restoration after SCI, and might have sustained therapeutic benefits in chronic applications ( Jackson and Zimmermann, 2012 , Zanos, 2019 ).…”

Delayed closed-loop neurostimulation for the treatment of pathological brain rhythms in mental disorders: a computational study

“…This non-optimal approach is inferior to so-called closed-loop techniques, which automatically adapt to the patients current brain/health state. Such an adaptive, or closed-loop, approach has been introduced for intracranial (Hartshorn and Jobst, 2018 ; Prosky et al, 2021 ; Stanslaski et al, 2022 ) and transcranial stimulation (Tervo et al, 2022 ) and has been shown to improve neurostimulation in major depression patients (Scangos et al, 2021 ), epilepsy (Haeusermann et al, 2023 ) and affective and anxiety disorders (Guerrero Moreno et al, 2021 ). These proposed closed-loop methods are adaptive in the sense that a pre-defined stimulation signal is applied when observed brain activity fulfills certain criteria, such as passing an amplitude or power threshold.…”