Twiddler syndrome occurs when a patient intentionally or unintentionally manipulates an implantable generator (usually a pacemaker) and dislodges the pacing leads, causing malfunction of the device. Though the syndrome has been described in patients with pacemakers, to our knowledge only one spontaneous case has been described in patients undergoing deep brain stimulation for movement disorders. We report the clinical cases of two patients with Parkinson's disease who had subthalamic bilateral electrodes implanted and presented the twiddler syndrome 2 and 3 years after surgery. We analysed the possible mechanisms of this syndrome and note that twiddler syndrome should be suspected in patients undergoing deep brain stimulation and showing hardware dysfunction.

Introduction and development. Psychiatric symptoms in Parkinson's disease are relatively frequent, with a variation between 10 and 50%, according to different publications. They generally occur after several years of treatment. They may be symptoms derived from the disease itself or linked to the treatment used. These complications vary and include anxiety, affective and psychotic (hallucinations, delirium) disorders, as well as other alterations such as sexual, sleep and cognitive problems. Conclusions. Treatment must always be tailor-made to suit each individual and in many cases we have to resort to lowering or withdrawing the dopaminergic medication while, in others, treatment with benzodiazepines, antidepressants and atypical neuroleptic drugs is indicated.

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