Virtual reality plus electrical stimulation helps ease PTSD

Transcranial direct current stimulation (tDCS), when combined with virtual reality (VR), yields improvements in the severity of post-traumatic stress disorder (PTSD) symptoms, as shown in a study.

Compared with sham, active tDCS had superior effects on self-reported PTSD symptom severity at 1 month (t, −2.27; p=0.02). There were no significant between-group differences in quality of life. [JAMA Psychiatry 2024;doi:10.1001/jamapsychiatry.2023.5661]

While VR exposure reduced PTSD symptoms for all participants, active tDCS acted as a booster, the investigators pointed out. In other words, active tDCS helped the participants manage their psychological and physiological responses to the VR scenarios between sessions more quickly relative to sham tDCS (p<0.001).

Adverse effects were mild and consistent with the known safety profile of tDCS and VR. The frequency of adverse effects was similar in the active and sham tDCS groups. Four serious adverse events were reported, including exacerbations of chronic gastrointestinal illnesses in two participants in the active tDCS group and a syncopal episode in one participant in the sham tDCS group. One participant in the sham tDCS group had treatment-emergent suicidal ideation that was possibly related to study participation.

In the study, 54 US military veteran participants (mean age 45.7 years, 94 percent men) were randomly allocated to groups who received VR therapy in addition to either active tDCS (n=26) or sham tDCS (n=28). For active tDCS, a low amount of electricity (2 mA) was delivered to the ventromedial prefrontal cortex during six 25-minute sessions of standardized warzone VR exposure. Treatment was delivered over 2 to 3 weeks.

“This is a different and innovative way of approaching treatment where we’re combining the best aspects of psychotherapy, neuroscience, and brain stimulation to help people get better,” said senior study author Prof Noah Philip of Brown University’s Warren Alpert Medical School in Providence, Rhode Island, US.

In just 3 weeks, the combined electric stimulation and VR treatment achieved results that typically take 12 weeks with prolonged exposure therapy, Philip noted. Remarkably, the benefits continued to build over time, he added.

“What we found was that people continued to get better after they were done with the treatment, and we started seeing the biggest effects 1 month later,” he said.

Acknowledging the existing challenges in treating patients with PTSD, Philip described the findings as highly encouraging. He stressed that the results be placed in the context of an inexpensive and accessible technical setup and modest participant burden.

“[The tDCS plus VR treatment] intervention is amenable to wide implementation, and ongoing development of these technologies might enable home therapeutic use. These methods also demonstrate an approach to controlling the context of brain stimulation, which is among the most difficult of factors to address in brain stimulation studies,” Philip said. “There’s a lot of promise here, and that offers hope.”

Fear extinction

According to first study author Dr Mascha van ’t Wout-Frank of Brown University’s Warren Alpert Medical School, the study highlights the potential of noninvasive brain stimulation to accelerate ‘fear extinction’—the process of learning that feared stimuli are not actually dangerous and can be safe, leading to a reduced fear response.

“Through exposure therapy, the brain is reprocessing the trauma, and learning that even though the traumatic experience was dangerous, the memories of the traumatic experience, as well as the thoughts and feelings that are conjured up by those memories, are not dangerous—they are safe. This results in a decline in conditioned fear response,” van 't Wout-Frank explained.

A painless technique uses low electrical currents to stimulate brain regions, tDCS is well-suited to potentially augment trauma-focused exposure therapy, van 't Wout-Frank said. In PTSD, he added, tDCS might strengthen the connection between the prefrontal cortex and amygdala, enhancing safety learning and potentially boosting the effectiveness of exposure therapy.

Philip and van 't Wout-Frank, along with the rest of their team, called for additional studies to explore a larger group of study participants and a longer follow-up time, as well as examine the effects of retreatment with the combination of VR plus tDCS.