(PS9-95) The Power of Context: Enhancing Repetitive Transcranial Magnetic Stimulation Effects Through Skillful Behavior

Abstract Text:

Background: Emotional dysregulation is critical in the maintenance and development of many psychiatric disorders. Hyperactive limbic and paralimbic emotion generation regions (i.e., insula) may not be properly inhibited by cognitive control regions (i.e., dorsolateral prefrontal cortex[dlPFC]), giving rise to psychopathology. Neurostimulation has successfully altered emotional dysregulation in clinical and non-clinical samples.

Methods: In a secondary data analysis of 43 adults with high emotional dysregulation and at least one DSM-5 disorder, we examine whether engaging in skillful behavior during neurostimulation improves outcomes. Using a within-subjects design, participants received low-frequency neurostimulation (1Hz; 90% MT) over a personalized medial PFC (mPFC) target functionally connected to the left insula during an fMRI paradigm involving regulation of aversive and neutral sounds; high-frequency neurostimulation (10Hz; 5s trains, 15s-ITT, 120% MT) over a personalized dlPFC target functionally active during the same paradigm; and sham stimulation. Stimulations were applied while participants either listened to personalized aversive or neutral sounds (30s/sound) or downregulated emotions associated with these sounds using cognitive restructuring (CR). Subjective units of distress (SUDS) and psychophysiological measurements (skin conductance level [SCL], and high-frequency heart rate variability [HF-HRV]) were collected.

Results: Participants reported significantly less distress when receiving neurostimulation combined with CR, compared to receiving neurostimulation alone (∆SUDS_HF/LF-sham=1.23-1.31; ps <.001), especially when 10HZ rTMS was applied (∆SUDS_HF-LF=0.71, SE=0.23; p=.002). Furthermore, participants had significantly lower SCL under the HF rTMS+ CR condition versus sham (∆SCL=0.45, SE=0.19; p=.02). Only HF rTMS significantly increased HRV compared to sham (∆lg_HRV=0.12, SE=0.03; p<.001), with no significant differences observed whether CR was used (p=.15). Both types of neurostimulation were well tolerated and feasible to administer.

Discussion: HF-rTMS is a promising approach for enhancing emotion regulation in transdiagnostic clinical adults. Pairing HF-rTMS with CR increases its efficacy and leads to higher subjective and objective reductions in distress.