Taking a Better History for Behavioral Issues Pre- and Post-Deep Brain Stimulation: Issues Missed by Standardized Scales Oscar Bernal-Pacheco, MD*, Genko Oyama, MD, PhD*, Kelly D. Foote, MD † , Yunfeng E. Dai, MS ‡ , Samuel S. Wu, PhD ‡ , Charles E. Jacobson IV, BS*, Natlada Limotai, MD*, Pamela R. Zeilman, ARNP*, Janet Romrell, PA*, Nelson Hwynn, DO*, Ramon L. Rodriguez, MD*, Irene A. Malaty, MD*, Michael S. Okun, MD* Objectives: To screen for potentially underreported behavioral changes in patients with idiopathic Parkinson’s disease (PD) pre- and post-deep brain stimulation (DBS), a retrospective data base review was performed. Methods: In total, 113 patients who underwent unilateral or bilateral DBS at the University of Florida in either subthalamic nucleus or globus pallidus internus for PD were screened for behavioral issues by asking about the presence or absence of seven neuropsychiatric symptoms (panic, fear, paranoia, anger, suicidal flashes, crying, and laughing). Results: There was a high prevalence of fear (16.3%), panic (14.0%), and anger (11.6%) at baseline in this cohort. In the first six months following DBS implantation, anger (32.6%), fear (26.7%), and uncontrollable crying (26.7%) were the most frequent symptoms reported. Those symptoms also were present following six months of DBS surgery (30.2%, 29.1%, and 19.8%, respec- tively). New uncontrollable crying occurred more in the acute postoperative stage (less than or equal to six months) (p = 0.033), while new anger occurred more in the chronic postoperative stage (greater than six months) (p = 0.017). The frequency of uncontrollable laughing significantly increased with bilateral DBS (p = 0.033). Conclusions: Many of the neuropsychiatric issues were identified at preoperative baseline and their overall occurrence was more than expected. There was a potential for worsening of these issues post-DBS. There were subtle differences in time course, and in unilateral vs. bilateral implantations. Clinicians should be aware of these potential behavioral issues that may emerge following DBS therapy, and should consider including screening questions in preoperative and postoperative interviews. Standardized scales may miss the presence or absence of these clinically relevant issues. Keywords: Adverse events, complications, deep brain stimulation, monitoring, screening Conflicts of Interest: The authors reported no conflicts of interest. INTRODUCTION Deep brain stimulation (DBS) is a widely utilized treatment for well- selected patients with advanced fluctuating Parkinson’s disease (PD), as well as for medication-refractory tremor. Previous studies have revealed that patients with PD experience a high rate of mood and behavioral manifestations, including depression (1), anxiety (2), apathy (3), pseudobulbar affective changes, and psychosis (4), as well as worsening of other psychiatric comorbidities (5). Despite careful screening by experienced interdisciplinary DBS teams, as well as recent refinements in the surgical procedure (6,7), behavioral issues still pose potentially significant post-DBS prob- lems (8) and psychiatric complications such as depression, anxiety, and suicide, all of which have become potential concerns for implanting teams. Neuropsychiatric symptoms such as impulsivity (9), mania/ hypomania (10), apathy (11,12), fear recognition (13), panic, laughing/crying (14), punding (15), changes in appetite (16), sui- cidal thoughts (17,18), and paranoid ideas (19) have been less screened and less reported. Currently, there have not been vali- dated measures for these symptoms in DBS patients. Existing con- ventional assessments of mood disorders have not been sensitive for these specific symptoms in DBS patients, and the existing Address correspondence to: Michael S. Okun, MD, Department of Neurology, McKnight Brain Institute, 100 S Newell Dr, Room L3-101, Gainesville, FL 32610, USA. Email: okun@neurology.ufl.edu * Departments of Neurology Center for Movement Disorders and Neurorestora- tion, University of Florida, Gainesville, FL, USA; † Departments of Neurosurgery, Center for Movement Disorders and Neurores- toration, University of Florida, Gainesville, FL, USA; and ‡ Department of Biostatistics, University of Florida, Gainesville, FL, USA For more information on author guidelines, an explanation of our peer review process, and conflict of interest informed consent policies, please go to http:// www.wiley.com/bw/submit.asp?ref=1094-7159&site=1 Disclosure/Disclaimer: We would like to acknowledge the support of the National Parkinson Foundation Center of Excellence, UF inform data base and the Univer- sity of Florida Foundation. Neuromodulation: Technology at the Neural Interface Received: October 24, 2011 Revised: April 16, 2012 Accepted: May 26, 2012 (onlinelibrary.wiley.com) DOI: 10.1111/j.1525-1403.2012.00477.x 1 www.neuromodulationjournal.com Neuromodulation 2012; ••: ••–•• © 2012 International Neuromodulation Society