Increased Amygdala Activation during Symptom Provocation Predicts Response to Combined Repetitive Transcranial Magnetic Stimulation and Exposure Therapy in Obsessive-Compulsive Disorder in a Randomized Controlled Trial.

Abstract

Background: Repetitive transcranial magnetic stimulation (rTMS), combined with exposure and response prevention (ERP), is a promising treatment modality for treatment-refractory obsessive-compulsive disorder (OCD). Yet, not all patients respond sufficiently to this treatment. We investigated whether brain activation during a symptom provocation task could predict treatment response.

Methods: Sixty-one adults with OCD (22 male/ 39 female) underwent symptom provocation with OCD- and fear-related visual stimuli during fMRI prior to an 8-week combined rTMS and ERP treatment regimen. Participants received one of the three following rTMS treatments as part of a randomized controlled trial: (1) 10Hz rTMS (110% resting motor threshold (RMT)) to the left dorsolateral prefrontal cortex (DLPFC); (2) 10Hz rTMS (110% RMT) to the left pre-supplementary motor area (preSMA); or (3) 10Hz control rTMS (60% RMT) to the vertex. Multiple regression and correlation were used to examine the predictive value of task-related brain activation for treatment response in the following ROIs: dorsomedial prefrontal cortex, amygdala, DLPFC, and preSMA.

Results: The different treatment groups responded equally to treatment. Higher pre-treatment task-related activation of the right amygdala to OCD-related stimuli showed a positive association with treatment response in all groups. Exploratory whole-brain analyses showed positive associations between activation in multiple task-relevant regions and treatment response. Only dorsal anterior cingulate cortex activation to fear-related stimuli showed a negative association with treatment outcome.

Conclusions: Higher pre-treatment right amygdala activation during symptom provocation predicts better treatment response to combined rTMS and ERP in OCD.