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van ’t Wout-Frank M, Arulpragasam AR, Faucher C, Aiken E, Shea MT, Jones RN, Greenberg BD, Philip NS. Virtual Reality and Transcranial Direct Current Stimulation for Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2024; 81:437-446. [PMID: 38446471 PMCID: PMC10918574 DOI: 10.1001/jamapsychiatry.2023.5661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/19/2023] [Indexed: 03/07/2024]
Abstract
Importance Posttraumatic stress disorder (PTSD) is a common psychiatric disorder that is particularly difficult to treat in military veterans. Noninvasive brain stimulation has significant potential as a novel treatment to reduce PTSD symptoms. Objective To test whether active transcranial direct current stimulation (tDCS) plus virtual reality (VR) is superior to sham tDCS plus VR for warzone-related PTSD. Design, Setting, and Participants This double-blind randomized clinical trial was conducted among US military veterans enrolled from April 2018 to May 2023 at a secondary care Department of Veterans Affairs hospital and included 1- and 3-month follow-up visits. Participants included US military veterans with chronic PTSD and warzone-related exposure, recruited via referral and advertisement. Patients in psychiatric treatment had to be on a stable regimen for at least 6 weeks to be eligible for enrollment. Data were analyzed from May to September 2023. Intervention Participants were randomly assigned to receive 2-mA anodal tDCS or sham tDCS targeted to the ventromedial prefrontal cortex, during six 25-minute sessions of standardized warzone VR exposure, delivered over 2 to 3 weeks. Main Outcomes and Measures The co-primary outcomes were self-reported PTSD symptoms, measured via the PTSD checklist for DSM-5 (PCL-5), alongside quality of life. Other outcomes included psychophysiological arousal, clinician-assessed PTSD, depression, and social/occupational function. Results A total of 54 participants (mean [SD] age, 45.7 [10.5] years; 51 [94%] males) were assessed, including 26 in the active tDCS group and 28 in the sham tDCS group. Participants in the active tDCS group reported a superior reduction in self-reported PTSD symptom severity at 1 month (t = -2.27, P = .02; Cohen d = -0.82). There were no significant differences in quality of life between active and sham tDCS groups. Active tDCS significantly accelerated psychophysiological habituation to VR events between sessions compared with sham tDCS (F5,7689.8 = 4.65; P < .001). Adverse effects were consistent with the known safety profile of the corresponding interventions. Conclusions and Relevance These findings suggest that combined tDCS plus VR may be a promising strategy for PTSD reduction and underscore the innovative potential of these combined technologies. Trial Registration ClinicalTrials.gov Identifier: NCT03372460.
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Affiliation(s)
- Mascha van ’t Wout-Frank
- Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Amanda R. Arulpragasam
- Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Christiana Faucher
- Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, Rhode Island
| | - Emily Aiken
- Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, Rhode Island
| | - M. Tracie Shea
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Benjamin D. Greenberg
- Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Noah S. Philip
- Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
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Muacevic A, Adler JR. Application of Deep Brain Stimulation in Refractory Post-Traumatic Stress Disorder. Cureus 2023; 15:e33780. [PMID: 36819333 PMCID: PMC9928537 DOI: 10.7759/cureus.33780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/14/2023] [Indexed: 01/16/2023] Open
Abstract
Post-traumatic stress disorder (PTSD) is a mental disorder that produces crippling anxiety and occurs in response to an extreme, traumatic stressor. Compared to the prevalence of PTSD in the general population, the prevalence of PTSD in at-risk populations (e.g., army veterans, those affected by environmental calamities, and others) can reach up to threefold. The conventional treatment of PTSD involves using SSRIs (serotonin reuptake inhibitors) and other anti-depressants along with psychotherapy such as debriefing and CBT (cognitive behavioral therapy). Due to increasing resistance to conventional treatment, more novel treatment options, such as stellate ganglion block shots and neuromodulation, are being explored. These neuromodulation techniques include transcranial magnetic stimulation (TMS), transcranial direct current stimulation (TDS), and deep brain stimulation (DBS). The rationale behind employing these techniques in refractory PTSD is the altered neurocircuitry seen in PTSD patients, which can be visualized on imaging. Studies involving the use of DBS for PTSD primarily target specific areas in the brain: the amygdala, the prefrontal cortex, the hippocampus, and the hypothalamus. This article aims to provide a brief overview of the various neuromodulation techniques currently employed in the management of treatment-resistant PTSD and an in-depth review of the available literature on animal models in which DBS for PTSD has been researched. We also shed light on the human clinical trials conducted for the same.
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Omura J, Fuchikami M, Araki M, Miyagi T, Okamoto Y, Morinobu S. Chemogenetic activation of the mPFC alleviates impaired fear memory extinction in an animal model of PTSD. Prog Neuropsychopharmacol Biol Psychiatry 2021; 108:110090. [PMID: 32896603 DOI: 10.1016/j.pnpbp.2020.110090] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 08/19/2020] [Accepted: 08/30/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND AIM Although impaired extinction of fear memory (EFM) is a hallmark symptom of posttraumatic stress disorder (PTSD), the mechanisms underlying the impairment are unknown. Activation of the infralimbic cortex (IL) in the medial prefrontal cortex (mPFC) has been reported to predict successful fear extinction, whereas functionally disrupting this region impairs extinction. We examined whether chemogenetic activation of the IL could alleviate impaired EFM in a single prolonged stress (SPS) rat model of PTSD. METHODS Chemogenetic activation of IL and prelimbic (PL) excitatory neurons was undertaken to evaluate EFM using a contextual fear conditioning paradigm. Neuronal activity in the IL was recorded using a 32-multichannel silicon electrode. To examine histological changes in the mPFC, apoptosis was measured by TUNEL staining. RESULTS Chemogenetic activation of excitatory neurons in the IL, but not the PL, enhanced EFM in sham rats and resulted in alleviation of EFM impairment in SPS rats. The alleviation of impaired EFM in SPS rats was observed during the extinction test session. Neuronal activity in the IL of SPS rats was lower than that of sham rats after clozapine-n-oxide administration. Increased apoptosis was found in the IL of SPS rats. CONCLUSIONS These findings suggest that a decreased excitatory response in the IL due, at least in part, to an increase in apoptosis in SPS rats leads to impaired EFM, and that neuronal activation during extinction training could be useful for the treatment of impaired EFM in PTSD patients.
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Affiliation(s)
- Jun Omura
- Department of Psychiatry and Neuroscience, Division of Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Manabu Fuchikami
- Department of Psychiatry and Neuroscience, Division of Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Motoaki Araki
- Department of Psychiatry and Neuroscience, Division of Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tatsuhiro Miyagi
- Department of Psychiatry and Neuroscience, Division of Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yasumasa Okamoto
- Department of Psychiatry and Neuroscience, Division of Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shigeru Morinobu
- Department of Occupational Therapy, School of Health Science and Social Welfare, Kibi International University, Takahashi, Japan
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Lebois LAM, Seligowski AV, Wolff JD, Hill SB, Ressler KJ. Augmentation of Extinction and Inhibitory Learning in Anxiety and Trauma-Related Disorders. Annu Rev Clin Psychol 2019; 15:257-284. [PMID: 30698994 DOI: 10.1146/annurev-clinpsy-050718-095634] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Although the fear response is an adaptive response to threatening situations, a number of psychiatric disorders feature prominent fear-related symptoms caused, in part, by failures of extinction and inhibitory learning. The translational nature of fear conditioning paradigms has enabled us to develop a nuanced understanding of extinction and inhibitory learning based on the molecular substrates to systems neural circuitry and psychological mechanisms. This knowledge has facilitated the development of novel interventions that may augment extinction and inhibitory learning. These interventions include nonpharmacological techniques, such as behavioral methods to implement during psychotherapy, as well as device-based stimulation techniques that enhance or reduce activity in different regions of the brain. There is also emerging support for a number of psychopharmacological interventions that may augment extinction and inhibitory learning specifically if administered in conjunction with exposure-based psychotherapy. This growing body of research may offer promising novel techniques to address debilitating transdiagnostic fear-related symptoms.
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Affiliation(s)
- Lauren A M Lebois
- Division of Depression and Anxiety Disorders, Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, Massachusetts 02478, USA;
| | - Antonia V Seligowski
- Division of Depression and Anxiety Disorders, Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, Massachusetts 02478, USA;
| | - Jonathan D Wolff
- Division of Depression and Anxiety Disorders, Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, Massachusetts 02478, USA;
| | - Sarah B Hill
- Division of Depression and Anxiety Disorders, Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, Massachusetts 02478, USA;
| | - Kerry J Ressler
- Division of Depression and Anxiety Disorders, Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, Massachusetts 02478, USA;
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Van't Wout M, Longo SM, Reddy MK, Philip NS, Bowker MT, Greenberg BD. Transcranial direct current stimulation may modulate extinction memory in posttraumatic stress disorder. Brain Behav 2017; 7:e00681. [PMID: 28523223 PMCID: PMC5434186 DOI: 10.1002/brb3.681] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 02/13/2017] [Accepted: 02/16/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Abnormalities in fear extinction and recall are core components of posttraumatic stress disorder (PTSD). Data from animal and human studies point to a role of the ventromedial prefrontal cortex (vmPFC) in extinction learning and subsequent retention of extinction memories. Given the increasing interest in developing noninvasive brain stimulation protocols for psychopathology treatment, we piloted whether transcranial direct current stimulation (tDCS) during extinction learning, vs. during consolidation of extinction learning, might improve extinction recall in veterans with warzone-related PTSD. METHODS Twenty-eight veterans with PTSD completed a 2-day Pavlovian fear conditioning, extinction, and recall paradigm. Participants received one 10-min session of 2 mA anodal tDCS over AF3, intended to target the vmPFC. Fourteen received tDCS that started simultaneously with extinction learning onset, and the remaining 14 participants received tDCS during extinction consolidation. Normalized skin conductance reactivity (SCR) was the primary outcome measure. Linear mixed effects models were used to test for effects of tDCS on late extinction and early extinction recall 24 hr later. RESULTS During early recall, veterans who received tDCS during extinction consolidation showed slightly lower SCR in response to previously extinguished stimuli as compared to veterans who received tDCS simultaneous with extinction learning (p = .08), generating a medium effect size (Cohen's d = .38). There was no significant effect of tDCS on SCR during late extinction. CONCLUSIONS These preliminary findings suggest that testing the effects of tDCS during consolidation of fear extinction may have promise as a way of enhancing extinction recall.
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Affiliation(s)
- Mascha Van't Wout
- Department of Psychiatry and Human Behavior Alpert Brown Medical School Brown University Providence RI USA.,Center for Neurorestoration and Neurotechnology Providence VA Medical Center Providence RI USA
| | - Sharon M Longo
- Center for Neurorestoration and Neurotechnology Providence VA Medical Center Providence RI USA
| | - Madhavi K Reddy
- Department of Psychiatry and Human Behavior Alpert Brown Medical School Brown University Providence RI USA.,Center for Neurorestoration and Neurotechnology Providence VA Medical Center Providence RI USA.,Department of Psychiatry and Behavioral Sciences McGovern Medical School at The University of Texas Health Science Center at Houston Houston TX USA
| | - Noah S Philip
- Department of Psychiatry and Human Behavior Alpert Brown Medical School Brown University Providence RI USA.,Center for Neurorestoration and Neurotechnology Providence VA Medical Center Providence RI USA
| | - Marguerite T Bowker
- Center for Neurorestoration and Neurotechnology Providence VA Medical Center Providence RI USA
| | - Benjamin D Greenberg
- Department of Psychiatry and Human Behavior Alpert Brown Medical School Brown University Providence RI USA.,Center for Neurorestoration and Neurotechnology Providence VA Medical Center Providence RI USA
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van 't Wout M, Mariano TY, Garnaat SL, Reddy MK, Rasmussen SA, Greenberg BD. Can Transcranial Direct Current Stimulation Augment Extinction of Conditioned Fear? Brain Stimul 2016; 9:529-36. [PMID: 27037186 DOI: 10.1016/j.brs.2016.03.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 02/09/2016] [Accepted: 03/05/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Exposure-based therapy parallels extinction learning of conditioned fear. Prior research points to the ventromedial prefrontal cortex as a potential site for the consolidation of extinction learning and subsequent retention of extinction memory. OBJECTIVE/HYPOTHESIS The present study aimed to evaluate whether the application of non-invasive transcranial direct current stimulation (tDCS) during extinction learning enhances late extinction and early recall in human participants. METHODS Forty-four healthy volunteers completed a 2-day Pavlovian fear conditioning, extinction, and recall paradigm while skin conductance activity was continuously measured. Twenty-six participants received 2 mA anodal tDCS over EEG coordinate AF3 during extinction of a first conditioned stimulus. The remaining 18 participants received similar tDCS during extinction of a second conditioned stimulus. Sham stimulation was applied for the balance of extinction trials in both groups. Normalized skin conductance changes were analyzed using linear mixed models to evaluate effects of tDCS over late extinction and early recall trials. RESULTS We observed a significant interaction between timing of tDCS during extinction blocks and changes in skin conductance reactivity over late extinction trials. These data indicate that tDCS was associated with accelerated late extinction learning of a second conditioned stimulus after tDCS was combined with extinction learning of a previous conditioned stimulus. No significant effects of tDCS timing were observed on early extinction recall. CONCLUSIONS Results could be explained by an anxiolytic aftereffect of tDCS and extend previous studies on tDCS-induced modulation of fear and threat related learning processes. These findings support further exploration of the clinical use of tDCS.
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Affiliation(s)
- Mascha van 't Wout
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Butler Hospital, 345 Blackstone Boulevard, Providence, RI 02906, USA; Center of Excellence for Neurorestoration and Neurotechnology, Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI 02908, USA.
| | - Timothy Y Mariano
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Butler Hospital, 345 Blackstone Boulevard, Providence, RI 02906, USA; Center of Excellence for Neurorestoration and Neurotechnology, Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI 02908, USA
| | - Sarah L Garnaat
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Butler Hospital, 345 Blackstone Boulevard, Providence, RI 02906, USA
| | - Madhavi K Reddy
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Butler Hospital, 345 Blackstone Boulevard, Providence, RI 02906, USA
| | - Steven A Rasmussen
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Butler Hospital, 345 Blackstone Boulevard, Providence, RI 02906, USA; Center of Excellence for Neurorestoration and Neurotechnology, Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI 02908, USA
| | - Benjamin D Greenberg
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Butler Hospital, 345 Blackstone Boulevard, Providence, RI 02906, USA; Center of Excellence for Neurorestoration and Neurotechnology, Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI 02908, USA
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