Deep brain stimulation is a well-established therapy for the motor symptoms of Parkinson’s disease, but there remains an opportunity to improve symptom relief. The temporal pattern of stimulation is a new parameter to consider in DBS therapy, and we compared the effectiveness of Temporally Optimized Patterned Stimulation to standard DBS at reducing the motor symptoms of PD. Twenty-six subjects with DBS for PD received three different patterns of stimulation while on medication and using stimulation parameters optimized for standard DBS. Side (...) effects and motor symptoms were assessed after 30 min of stimulation with each pattern. Subjects experienced similar types of side effects with TOPS and standard DBS, and TOPS were well-tolerated by a majority of the subjects. On average, the most effective TOPS was as effective as standard DBS at reducing the motor symptoms of PD. In some subjects a TOPS pattern was the most effective pattern. Finally, the TOPS pattern with low average frequency was found to be as effective or more effective in about half the subjects while substantially reducing estimated stimulation energy use. TOPS DBS may provide a new programing option to improve DBS therapy for PD by improving symptom reduction and/or increasing energy efficiency. Optimizing stimulation parameters specifically for TOPS DBS may demonstrate further clinical benefit of TOPS DBS in treating the motor symptoms of Parkinson’s disease. (shrink)

IntroductionDeep brain stimulation has become a standard treatment option for select patients with Parkinson’s disease. The selection process and surgical procedures employed have, to date, not been standardized.MethodsA comprehensive 58-question web-based survey was developed with a focus on DBS referral practices and peri-operative management. The survey was distributed to the Parkinson’s Foundation Centers of Excellence, members of the International Parkinson’s Disease and Movement Disorders Society, and the Parkinson Study Group between December 2015 and May 2016.ResultsThere were 207 individual respondents drawn (...) from 59 countries and 6 continents, of whom 64% received formal training in DBS. Thirteen percent of centers reported that DBS could proceed despite a confidence level of < 50% for PD diagnosis. A case-based approach to DBS candidacy was applied in 51.3% of centers without a cut-off for levodopa-responsiveness. Surprisingly, 33% of centers regularly used imaging for diagnostic confirmation of idiopathic PD. Thirty-one percent of centers reported that neuropsychological evaluation did not affect DBS target selection. Approximately half of the respondents reported determination of DBS candidacy based on a multidisciplinary committee evaluation and 1/3rd reported that a committee was used for target selection. Eight percent of respondents felt that psychosocial factors should not impact DBS candidacy nor site selection. Involvement of allied health professionals in the preoperative process was sparse. There was high variability in preoperative education about DBS outcome expectations. Approximately half of the respondents did not utilize a “default brain target,” though STN was used more commonly than GPi. Specific DBS procedure techniques applied, as well as follow-up timelines, were highly variable.ConclusionResults revealed high variability on the best approaches for DBS candidate selection, brain target selection, procedure type, and postoperative practices. Cognitive and mood assessments were underutilized. There was low reliance on multidisciplinary teams or psychosocial factors to impact the decision-making process. There were small but significant differences in practice across global regions, especially regarding multidisciplinary teams. The wide variability of responses across multiple facets of DBS care highlights the need for prospective studies to inform evidence-based guidelines. (shrink)

Background: Treating medication-refractory freezing of gait in Parkinson’s disease remains challenging despite several trials reporting improvements in motor symptoms using subthalamic nucleus or globus pallidus internus deep brain stimulation. Pedunculopontine nucleus region DBS has been used for medication-refractory FoG, with mixed findings. FoG, as a paroxysmal phenomenon, provides an ideal framework for the possibility of closed-loop DBS.Methods: In this clinical trial, five subjects with medication-refractory FoG underwent bilateral GPi DBS implantation to address levodopa-responsive PD symptoms with open-loop stimulation. Additionally, PPN (...) DBS leads were implanted for CL-DBS to treat FoG. The primary outcome of the study was a 40% improvement in medication-refractory FoG in 60% of subjects at 6 months when “on” PPN CL-DBS. Secondary outcomes included device feasibility to gauge the recruitment potential of this four-lead DBS approach for a potentially larger clinical trial. Safety was judged based on adverse events and explantation rate.Findings: The feasibility of this approach was demonstrated as we recruited five subjects with both “on” and “off” medication freezing. The safety for this population of patients receiving four DBS leads was suboptimal and associated with a high explantation rate of 40%. The primary clinical outcome in three of the five subjects was achieved at 6 months. However, the group analysis of the primary clinical outcome did not reveal any benefit.Interpretation: This study of a human PPN CL-DBS trial in medication-refractory FoG showed feasibility in recruitment, suboptimal safety, and a heterogeneous clinical effect in FoG outcomes. (shrink)

Substantial discussion in the neuroethical literature has addressed the possibility that deep brain stimulation (DBS) and adaptive DBS (aDBS) could result in changes in personality, agency, and ide...

Background: Freezing of gait is a common symptom in Parkinson’s disease and can be difficult to treat with dopaminergic medications or with deep brain stimulation. Novel stimulation paradigms have been proposed to address suboptimal responses to conventional DBS programming methods. Burst-cycling deep brain stimulation delivers current in various frequencies of bursts, while maintaining an intra-burst frequency identical to conventional DBS.Objective: To evaluate the safety and tolerability of BCDBS in PD patients with FOG.Methods: Ten PD subjects with STN or GPi DBS (...) and complaints of FOG were recruited for this single center, single blinded within-subject crossover study. For each subject, we compared 4, 10, and 15 Hz BCDBS to conventional DBS during the PD medication-OFF state.Results: There were no serious adverse events with BCDBS. It was feasible and straightforward to program BCDBS in the clinic setting. The benefit was comparable to conventional DBS in measures of FOG, functional mobility and in PD motor symptoms. BCDBS had lower battery consumption when compared to conventional DBS.Conclusions: BCDBS was feasible, safe and well tolerated and it has potential to be a viable future DBS programming strategy. (shrink)

We estimate that 208,000 deep brain stimulation (DBS) devices have been implanted to address neurological and neuropsychiatric disorders worldwide. DBS Think Tank presenters pooled data and determined that DBS expanded in its scope and has been applied to multiple brain disorders in an effort to modulate neural circuitry. The DBS Think Tank was founded in 2012 providing a space where clinicians, engineers, researchers from industry and academia discuss current and emerging DBS technologies and logistical and ethical issues facing the field. (...) The emphasis is on cutting edge research and collaboration aimed to advance the DBS field. The Eighth Annual DBS Think Tank was held virtually on September 1 and 2, 2020 (Zoom Video Communications) due to restrictions related to the COVID-19 pandemic. The meeting focused on advances in: (1) optogenetics as a tool for comprehending neurobiology of diseases and on optogenetically-inspired DBS, (2) cutting edge of emerging DBS technologies, (3) ethical issues affecting DBS research and access to care, (4) neuromodulatory approaches for depression, (5) advancing novel hardware, software and imaging methodologies, (6) use of neurophysiological signals in adaptive neurostimulation, and (7) use of more advanced technologies to improve DBS clinical outcomes. There were 178 attendees who participated in a DBS Think Tank survey, which revealed the expansion of DBS into several indications such as obesity, post-traumatic stress disorder, addiction and Alzheimer’s disease. This proceedings summarizes the advances discussed at the Eighth Annual DBS Think Tank. (shrink)

DBS Think Tank IX was held on August 25–27, 2021 in Orlando FL with US based participants largely in person and overseas participants joining by video conferencing technology. The DBS Think Tank was founded in 2012 and provides an open platform where clinicians, engineers and researchers can freely discuss current and emerging deep brain stimulation technologies as well as the logistical and ethical issues facing the field. The consensus among the DBS Think Tank IX speakers was that DBS expanded in (...) its scope and has been applied to multiple brain disorders in an effort to modulate neural circuitry. After collectively sharing our experiences, it was estimated that globally more than 230,000 DBS devices have been implanted for neurological and neuropsychiatric disorders. As such, this year’s meeting was focused on advances in the following areas: neuromodulation in Europe, Asia and Australia; cutting-edge technologies, neuroethics, interventional psychiatry, adaptive DBS, neuromodulation for pain, network neuromodulation for epilepsy and neuromodulation for traumatic brain injury. (shrink)

Objective: Deep brain stimulation targeted to the ventral intermediate nucleus of the thalamus is effective for motor symptoms in essential tremor, but there is limited data on cognitive outcomes. We examined cognitive outcomes in a large cohort of ET DBS patients.Methods: In a retrospective analysis, we used repeated-measures ANOVA testing to examine whether the age of tremor onset, age at DBS surgery, hemisphere side implanted with lead, unilateral vs. bilateral implantations, and presence of surgical complications influenced the cognitive outcomes. Neuropsychological (...) outcomes of interest were verbal memory, executive functioning, working memory, language functioning, visuospatial functioning, and general cognitive function.Results: We identified 50 ET DBS patients; 29 males; the mean age of tremor onset was 35.84 years with a median age of 38 years. The mean age at DBS was 68.18 years. There were 37 unilateral 30 left, seven right, and 13 bilateral brain implantations. In the subgroup analysis, there was a significant interaction between assessment and age of tremor onset ; F = 4.47; p = 0.043 for working memory. The post hoc testing found improvements for younger onset ET. Similarly, there was a significant interaction between assessment and complications vs. no complications subgroups; F = 4.34; p = 0.043 for verbal memory with worsening scores seen for ET patients with complications. The remaining tests were not significant.Conclusion: In this large cohort of ET patients with, DBS was not accompanied by a significant decline in many cognitive domains. These outcomes were possibly related to the selection of patients with normal cognitive functioning before surgery, unilateral DBS implantations for the majority, and selection of patients with optimal response to DBS. (shrink)

IntroductionDeep brain stimulation (DBS) is increasingly used to treat the symptoms of various neurologic and psychiatric conditions. People can undergo the procedure during reproductive years but the safety of DBS in pregnancy remains relatively unknown given the paucity of published cases. We thus conducted a review of the literature to determine the state of current knowledge about DBS in pregnancy and to determine how eligibility criteria are approached in clinical trials with respect to pregnancy and the potential for pregnancy.MethodsA literature (...) review was conducted in EMBASE to identify articles involving DBS and pregnancy. Two reviewers independently analyzed the articles to confirm inclusion. Data extracted for analysis included conditions treated, complications at all stages of pregnancy, neonatal/pediatric outcomes, and DBS target. A second search was then conducted using www.clinicaltrials.gov. The same two reviewers then assessed whether each trial excluded pregnant individuals, lactating individuals, or persons of childbearing age planning to conceive. Also assessed was whether contraception had to be deemed adequate prior to enrollment.ResultsThe literature search returned 681 articles. Following independent analysis and agreement of two reviewers, 8 pregnancy related DBS articles were included for analysis. These articles described 27 subjects, 29 pregnancies (2 with subsequent pregnancies), and 31 infants (2 twin pregnancies). There was 1 preterm birth at 35 weeks, and 3 patients who experienced discomfort from the DBS battery (i.e., impulse generator) placement site. All 27 patients had a DBS device implanted before they became pregnant, which remained in use throughout their pregnancy. There was exclusion of pregnant individuals from 68% of 135 interventional trials involving DBS. Approximately 44% of these trials excluded persons of childbearing age not on “adequate contraception” or wishing to conceive in the coming years. Finally, 22% excluded breastfeeding persons.ConclusionThe data from 29 pregnancies receiving DBS treatment during pregnancy was not associated with unexpected pregnancy or post-partum complication patterns. Many clinical trials have excluded pregnant individuals. Documentation of outcomes in larger numbers of pregnancies will help clarify the safety profile and will help guide study designs that will safely include pregnant patients. (shrink)

John Martin Fischer's The Metaphysics of Free Will is devoted to two major projects. First, Fischer defends the thesis that determinism is incompatible with a person's control over alternatives to the actual future. Second, Fischer defends the striking thesis that such control is not necessary for moral responsibility. This review essay examines Fischer's arguments for each thesis. Fischer's defense of the incompatibilist thesis is the most innovative to date, and I argue that his formulation restructures the free will debate. To (...) defend his second thesis Fischer relies upon examples designed to show that an agent is responsible for an unavoidable action. I criticize Fischer's account of these examples, but I also maintain that my criticisms do not compromise his theory of responsibility. I raise several other difficulties for Fischer's theory of responsibility, and I close by offering some suggestions about how he might further defend it. (shrink)

The traditional desire view of painfulness maintains that pain sensations are painful because the subject desires that they not be occurring. A significant criticism of this view is that it apparently succumbs to a version of the Euthyphro Dilemma: the desire view, it is argued, is committed to an implausible answer to the question of why pain sensations are painful. In this paper, I explain and defend a new desire view, and one which can avoid the Euthyphro Dilemma. This new (...) view maintains that painfulness is a property, not of pain sensations, but of a pain experience, understood as a relational state constituted by a pain sensation and a desire that the sensation not be occurring. (shrink)

The central contention of The Implicit Mind is that understanding the two faces of spontaneity-its virtues and vices-requires understanding the "implicit mind." In turn, Michael Brownstein maintains that understanding the implicit mind requires the consideration of three sets of questions. First, what are implicit mental states? What kind of cognitive structure do they have? Second, how should we relate to our implicit attitudes? Are we responsible for them? Third, how can we improve the ethics of our implicit minds?

This article aims to highlight why R. S. Peters' conceptual analysis of ‘education’ was such an important contribution to the normative field of philosophy of education. In the article, I do the following: 1) explicate Peters' conception of philosophy of education as a field of philosophy and explain his approach to the philosophical analysis of concepts; 2) emphasize several (normative) features of Peters' conception of education, while pointing to a couple of oversights; and 3) suggest how Peters' analysis might be (...) used to reinvigorate a conversation on one central educational aim—that of how we might educate citizens for the 21st century. (shrink)

The emotions of guilt, shame, disappointment and grief, and the bodily states of pain and suffering, have something in common, at least phenomenologically: they are all unpleasant, they feel bad. But how might we explain what it is for some state to feel bad or unpleasant? What, in other words, is the nature of negative affect? In this paper I want to consider the prospects for evaluativist theories, which seek to explain unpleasantness by appeal to negative evaluations or appraisals. In (...) particular, I want to consider versions of evaluativism that seek to explain negative affect in terms of a kind of negative perceptual experience. These views thus attempt to explain feeling bad in terms of seeing bad. Now the most prominent evaluativist accounts of negative affect have been developed in the pain literature, and so my paper will primarily be focused on the question of whether evaluativism can provide a plausible account of the painfulness or unpleasantness of pain. I will argue that evaluativism faces serious objections on this score. Since my conclusions can be extended to cover negative affect more generally, however, we have good reason to reject evaluativist accounts of the negative affect involved in emotional experience. My arguments will thus have implications for those interested in the nature of emotional valence. I'll conclude with some brief remarks about the shape that a ‘relational’ account of painfulness in particular, and of negative affect in general, should take, in light of these criticisms of evaluativism. In my view, such views should appeal, not to negative evaluations to explain feeling bad, but to dislike. (shrink)

Yaffe's handling of two general questions is assessed in this review. The first question is why mere attempts (as opposed to successful wrongdoing) should be made punishable in a well-conceived criminal code. The second question is how attempt liability should be conceived in such a code. As to the first question, Yaffe's nonsubstantive mode of answering it (in terms of his ) is contrasted to answers based on some more substantive desert-bases; Yaffe's own more substantive kind of answer (in terms (...) of a desert-base of ) is examined in light of the implication that the traditional requirements of trying and intending are mere proxies for faulty reason recognition and response as the basis for blaming and punishing attempts. As to the second question, Yaffe's analysis of trying in terms of a is examined in some detail. Canvassed here are the subquestions of: (1) whether appropriate assessibility by certain norms of rationality can give the nature of intending and thus of trying; (2) whether the externally de dicto intent requirements of criminal law statutes can easily be interpreted and applied by standard, extensional methods; (3) whether the distinctions between various kinds of elements within the content of intentions, can be justified ontologically or only practically; (4) whether actors necessarily intend results of their actions that are to other results that clearly are intended, and if not, whether such actors are nonetheless just as blameworthy for those results as if they did intend them; and (5) whether intention with respect to circumstance-elements differ (in either their psychology or in their moral effect) from beliefs with respect to such circumstance-elements. (shrink)

In Consciousness and the Social Brain, Princeton neuroscientist Michael Graziano lays out an audacious new theory to account for the deepest mystery of them all.

This article explores the relationships between legal proof and fundamental epistemic concepts such as knowledge and justification. A survey of the legal literature reveals a confusing array of seemingly inconsistent proposals and presuppositions regarding these relationships. This article makes two contributions. First, it reconciles a number of apparent inconsistencies and tensions in accounts of the epistemology of legal proof. Second, it argues that there is a deeper connection between knowledge and legal proof than is typically argued for or presupposed in (...) the legal literature. This connection is illustrated through a discussion of the Gettier problem in epistemology. It is argued that the gap or disconnect between truth and justification that undermines knowledge in Gettier cases also potentially undermines the success of legal verdicts. (shrink)

This is the first scholarly study of Atlas Shrugged, covering in detail the historical, literary, and philosophical aspects of Ayn Rand's magnum opus. Topics explored in depth include the history behind the novel's creation, publication, and reception; its nature as a romantic novel; and its presentation of a radical new philosophy.

The second section contains chapters examining implicit bias and skepticism; the effects of implicit bias on scientific research; the accessibility of social stereotypes in epistemic environments; the effects of implicit bias on the self-perception of members of stigmatized social groups as rational agents; the role of gender stereotypes in philosophy; and the role of heuristics in biased reasoning. Volume 2: Moral Responsibility, Structural Injustice, and Ethics is comprised of three sections. 'Moral Responsibility for Implicit Bias' contains chapters examining the relationship (...) of implicit biases to concepts that are central to moral responsibility, including control, awareness, reasons-responsiveness, and alienation. The chapters in the second section--'Structural Injustice'--explore the connections between the implicit biases held by individuals and the structural injustices of the societies in which they are situated. (shrink)

Advaita Vedānta is one of the best-known schools of Indian philosophy, but much of its history-a history closely interwoven with that of medieval and modern Hinduism-remains surprisingly unexplored. This book focuses on a single remarkable work and its place within that history: The Ocean of Inquiry, a vernacular compendium of Advaita Vedānta by the North Indian monk Niścaldās (ca. 1791 - 1863). Though not well known today, Niścaldās's work was once referred to by Vivekananda (himself a key figure in the (...) shaping of modern Hinduism) as the most influential book in India. The present book situates The Ocean of Inquiry as a representative of both a neglected genre (vernacular Vedānta) and a neglected period (ca. 17th-19th centuries) in the history of Indian philosophy. It argues that the rise of Advaita Vedānta to a position of prestige began well before the period of British rule in India, and that vernacular texts like The Ocean of Inquiry played an important role in popularizing Vedāntic teachings. It also offers a new appraisal of the period of late Advaita Vedānta, arguing that it should not be seen as one of barren scholasticism. For thinkers like Niścaldās, intellectual "inquiry" (vicāra) was not an academic exercise but a spiritual practice-indeed, it was the central practice on the path to liberation. The book concludes by arguing that without understanding both vernacular Vedānta and the scholasticism of the period, one cannot fully understand the emergence of modern Hinduism. (shrink)

This article details how patent law works to create discrete, immutable biological ‘objects’. This socio-legal maneuver is necessary to distinguish these artifacts from the unwieldy realm of the natural world. The creation of ‘objects’ also serves the interests of capital, where a stable, unchanging, immutable object goes hand in hand with commodification. Yet this stabilization is incomplete. Pointing to a variety of different examples, this article illustrates how biotech patents do not speak to specific, immutable things. Biotech patents, rather, are (...) better understood as ontologically fluid, which is to say their identity cannot be ‘fixed’ — or, at least, not without undermining the very existence of today’s biotechnology regime. The article concludes by speaking briefly about how this mutability is perpetuating certain inequalities, particularly between holders of various property forms. (shrink)

In this article Christian ethicist Michael S. Jones introduces the work of Princeton University ethicist Thomas Pogge on the areas of global poverty and global justice. He then applies Pogge’s ideas to an ethical issue of continuing importance: racism. He discusses the history of racism in the United States and Romania, pointing out numerous parallels both historical and contemporary. He discusses the appropriate attitude for Christians to adopt on the issue, arguing that while Christian sources are not univocal on (...) the subject, there is an egalitarianism at the heart of Christianity that rules out racism as a Christian attitude. He concludes that Christians can contribute significantly to overcoming racism in the U.S. and Romania by addressing the underlying attitudinal problem from the podium and the pulpit, with the pen, and through their daily interactions with each other. (shrink)

This article explores the extent to which the I‐You relation should be applied to domains other than the human and the divine focusing particularly on artifacts and technology. Drawing first on the work of Martin Buber, Gabriel Marcel, and Martin Heidegger, I contend that the I‐You tradition has maintained I‐You relations with objects are possible even when these same figures level strong critiques of the I‐It relation. I extend these discussions and argue that some kind of You‐speaking for artifacts is (...) needed to combat rampant consumption and reduction of the world to pure utility. But, I equally suggest that there are limitations to applying the I‐You relation to artifacts precisely when doing so keeps us from having genuine relationships with other people as outlined by psychologist Sherry Turkle. Finally, I outline how this proposal impacts the doctrine of creation. In sum, it expands our intuitions of what is included in that doctrine creation. (shrink)

Ayn Rand's first novel, We the Living, offers an early form of the author's nascent philosophy—the philosophy Rand later called Objectivism. Robert Mayhew's collection of entirely new essays brings together pre-eminent scholars of Rand's writing. In part a history of We the Living, from its earliest drafts to the Italian film later based upon it, Mayhew's collection goes on to explore the enduring significance of Rand's first novel as a work both of philosophy and of literature.

We address two points in this commentary. First, we question the extent to which O'Brien & Opie have established that the classical approach is unable to support a viable vehicle theory of consciousness. Second, assuming that connectionism does have the resources to support a vehicle theory, we explore how the activity of the units of a PDP network might sum together to form phenomenal experience (PE).

In the 1950s, E.T. Gendlin developed a philosophical system, published as Experiencing and the Creation of Meaning, to explain the role of bodily feelings in cognition, and he then evolved a psychotherapy known as Focusing, based on this system. Focusing works primarily with bodily feelings and how they relate to the thinking processes. Gendlin’s work has had an important impact on the field of Psychology. An aspect of the historicity of E.T. Gendlin’s work is that it has intriguing similarities with (...) how the Vipassana meditation teacher S.N. Goenka, teaches, in line with the Pali Nikayas, that a correct understanding of affective bodily feelings can lead to the dissolution of destructive emotional tendencies. This article uses these similarities to begin a process, from a Western academic perspective, of conceptualizing the efficacy of Vipassana meditation, as taught by S.N. Goenka, in dissolving harmful emotional habits. This will be done by comparing how S.N. Goenka and E.T. Gendlin understand the operative factors in personality change. (shrink)

I had the pleasure of meeting Lawrence Kohlberg just two months before his tragic and untimely death. He told me that he had prepared some written comments on my article, "Reciprocity," which appeared in Analytic Teaching, Vol. 4, No. 2. I mentioned an article I had written about his work. We agreed to make an exchange. I jokingly said, "Stage 2. You scratch my back and I'll scratch yours." I sent him my paper, but he did not send his. At (...) first I amused myself with the thought that Lawrence Kohlberg, of all people, had failed to satisfy even stage 2 moral requirements. However, I then learned that he had suffered a recurrance of a debilitating and depressing disease, and I read the sad announcement of his presumed death in the New York Times, as well as its later confirmation. (shrink)

IntroductionDespite the fact that group fitness instructors serve as significant role models with potentially great impact on class participants' motivation for exercise, they are a very under-researched group. The aim of this study was therefore to examine group fitness instructors' motivational regulations for exercise, and how these motivational regulations can predict symptoms of exercise dependence and body image concerns.MethodsGroup fitness instructors from the largest fitness companies in Norway completed an online survey with reference to the Situational Motivation Scale, the Exercise (...) Dependence Scale, the Eating Disorders Inventory subscales drive for thinness and body dissatisfaction, and their weekly amount of exercise and instruction.ResultsThe instructors scored high on identified regulation and intrinsic regulation for exercise. EDS total score was positively correlated with all SIMS subscales and weekly instruction was positively correlated with Intrinsic regulation. Multiple hierarchical regression analyses found that both self-determined motivational regulations as well as external regulation positively predicted their EDS score. External regulation positively predicted EDI-DT, and EDI-BD.ConclusionGroup fitness instructors seem highly intrinsically motivated for exercise, which is hypothesized to have a positive impact on group fitness class participants. High self-determined exercise behavior does not seem to buffer against symptoms of exercise dependence within this specific population. There is a need for awareness of group fitness instructors who show high exercise dependency scores due to the link to body image concerns, amotivation and external regulated motivation. (shrink)