Non-invasive brain stimulation to improve psychotherapy of anxiety disorders

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With a lifetime prevalence of more than 15% (Jacobi et al., 2014), anxiety disorders are a very common mental disorder, occurring even more frequently than affective, and the associated burden expressed in "Disability adjusted life years" (dalys) is the second highest rate after depressive disorders (Whiteford et al., 2013). In general, patients with anxiety disorders show a high level of psychological distress and impairment of daily functioning (Whiteford et al., 2013). Effective therapy is of particular relevance for reducing anxiety symptoms and improving the quality of life. With the help of cognitive behavioral therapy (CBT) for anxiety disorders, great progress can already be made (Carpenter et al., 2018), but not all patients benefit sufficiently. Non-invasive brain stimulation methods are increasingly considered (Bajbouj and Padberg, 2014, Zwanzger et al., 2016) and described as an effective new method (Herrmann et al., 2019) for optimizing psychotherapy and psychopharmacotherapy for anxiety disorders. Based on our own previous work (Herrmann et al., 2017) the aim of the applied feasibility study is to transfer the new and promising laboratory results of Raij et al. (2018) into a therapy study. As the vmPFC cannot be reached directly with non-invasive brain stimulation due to its location Raij et al (2018) activated the vmPFC indirectly by stimulating the left PFC, which is functionally linked to vmPFC. They revealed with a fear learning paradigm that this left PFC brain stimulation improves extinction of fear and reduces return of fear. In this project we will examine with a placebo-controlled double-blind design for the first time whether an activation of the left PFC induced by rTMS and thus indirectly of the coupled vmPFC significantly improves a subsequent exposure therapy for specific phobia All study patients will receive two exposure treatments in virtual reality. A five-sided Cave Automatic Virtual Environment (psyCAVE) is available for this purpose, which visually displays the virtual environment on four walls and the floor. The primary parameter for the evaluation of treatment efficacy is the psychometric assessment of acrophobic fear (AQ questionnaire), with the hypothesis that the verum-stimulated group compared to the placebo-stimulated group exhibits a greater decrease of symptoms immediately after therapy. The secondary outcome parameters are the approach behaviour (BAT) immediately after therapy and the changes in both acrophobic fear and approach behaviour at 6 months follow-up.