Multimodal smoking cessation treatment combining transcranial magnetic stimulation, cognitive behavioral therapy, and nicotine replacement therapy in veterans with posttraumatic stress disorder: A feasibility randomized controlled trial protocol.

Tobacco-related deaths exceed those resulting from homicides, suicides, motor vehicle accidence, alcohol consumption, illicit substance use, and acquired immunodeficiency syndrome (AIDS), combined. Amongst U.S. veterans, this trend is particularly concerning given that those suffering from posttraumatic stress disorder (PTSD)-about 11% of those receiving care from the Department of Veterans Affairs (VA)-have triple the risk of developing tobacco use disorder (TUD). The most efficacious strategies being used at the VA for smoking cessation only result in a 23% abstinence rate, and veterans with PTSD only achieve a 4.5% abstinence rate. Therefore, there is a critical need to develop more effective treatments for smoking cessation. Recent studies have revealed the insula as integrally involved in the neurocircuitry of TUD, specifically showing that individuals with brain lesions involving this region had drastically improved quit rates. Some of these studies show a probability of quitting up to 5 times greater compared to non-insula lesioned regions). Altered activity of the insula may be involved in the disruption of the salience network's (SN) connectivity to the executive control network (ECN), which compromises that patient's ability to switch between interoceptive states focused on cravings to executive and cognitive control. Thus, we propose a feasibility phase II randomized controlled trial (RCT) to study a patterned form of repetitive transcranial magnetic stimulation (rTMS), intermittent theta burst stimulation (iTBS), at 90% of the subject's resting motor threshold (rMT) applied over a region in the right post-central gyrus most functionally connected to the right posterior insula. We hypothesize that by increasing functional connectivity between the SN with the ECN to enhance executive control and by decreasing connectivity with the default mode network (DMN) to reduce interoceptive focus on withdrawal symptoms, we will improve smoking cessation outcomes. Fifty eligible veterans with comorbid TUD and PTSD will be randomly assigned to two conditions: active-iTBS + cognitive behavioral therapy (CBT) + nicotine replacement therapy (NRT) (n=25) or sham-iTBS + CBT + NRT (n=25). The primary outcome, feasibility, will be determined by achieving a recruitment of 50 participants and retention rate of 80%. The success of iTBS will be evaluated through self-reported nicotine use, cravings, withdrawal symptoms, and abstinence following quit date (confirmed by bioverification) along with evaluation for target engagement through neuroimaging changes, specifically connectivity differences between the insula and other regions of interest.

The neurobiology of misophonia and implications for novel, neuroscience-driven interventions.

Decreased tolerance in response to specific every-day sounds (misophonia) is a serious, debilitating disorder that is gaining rapid recognition within the mental health community. Emerging research findings suggest that misophonia may have a unique neural signature. Specifically, when examining responses to misophonic trigger sounds, differences emerge at a physiological and neural level from potentially overlapping psychopathologies. While these findings are preliminary and in need of replication, they support the hypothesis that misophonia is a unique disorder. In this theoretical paper, we begin by reviewing the candidate networks that may be at play in this complex disorder (e.g., regulatory, sensory, and auditory). We then summarize current neuroimaging findings in misophonia and present areas of overlap and divergence from other mental health disorders that are hypothesized to co-occur with misophonia (e.g., obsessive compulsive disorder). Future studies needed to further our understanding of the neuroscience of misophonia will also be discussed. Next, we introduce the potential of neurostimulation as a tool to treat neural dysfunction in misophonia. We describe how neurostimulation research has led to novel interventions in psychiatric disorders, targeting regions that may also be relevant to misophonia. The paper is concluded by presenting several options for how neurostimulation interventions for misophonia could be crafted.

Transcranial Magnetic Stimulation Treatment for Smoking Cessation: An Introduction for Primary Care Clinicians.

Tobacco use remains the number one preventable cause of death in the United States, resulting in significant public health and economic costs. Despite progress in reducing tobacco use through pharmacotherapy and psychotherapy smoking cessation interventions, additional treatment options are still needed to improve treatment effectiveness. As an adjunctive treatment, the US Food and Drug Administration recently cleared transcranial magnetic stimulation (TMS), a noninvasive brain stimulation technique, as an aid for smoking cessation in adults. Given that most smoking cessation interventions occur in the primary care setting, this article aims to introduce TMS, to provide an overview of the evidence of TMS for smoking cessation, and to outline the procedures for implementing TMS in the primary care setting when referral to an interventional psychiatrist is not possible. With growing scientific evidence and increasing regulatory approval of TMS for smoking cessation, this novel treatment option is now available for patients who want to quit smoking but have been unsuccessful with pharmacologic approaches.

The Effects of Functionally Guided, Connectivity-Based rTMS on Amygdala Activation.

While repetitive transcranial magnetic stimulation (rTMS) is widely used to treat psychiatric disorders, innovations are needed to improve its efficacy. An important limitation is that while psychiatric disorders are associated with fronto-limbic dysregulation, rTMS does not have sufficient depth penetration to modulate affected subcortical structures. Recent advances in task-related functional connectivity provide a means to better link superficial and deeper cortical sources with the possibility of increasing fronto-limbic modulation to induce stronger therapeutic effects. The objective of this pilot study was to test whether task-related, connectivity-based rTMS could modulate amygdala activation through its connectivity with the medial prefrontal cortex (mPFC). fMRI was collected to identify a node in the mPFC showing the strongest connectivity with the amygdala, as defined by psychophysiological interaction analysis. To promote Hebbian-like plasticity, and potentially stronger modulation, 5 Hz rTMS was applied while participants viewed frightening video-clips that engaged the fronto-limbic network. Significant increases in both the mPFC and amygdala were found for active rTMS compared to sham, offering promising preliminary evidence that functional connectivity-based targeting may provide a useful approach to treat network dysregulation. Further research is needed to better understand connectivity influences on rTMS effects to leverage this information to improve therapeutic applications.