What is the “Anxiety Protocol”

May 18, 2018

In 2008, use of repetitive TMS for the treatment of major depressive disorder was approved by the FDA. The “standard” MDD protocol involves 36 sessions, treating at the left dorsolateral prefrontal cortex daily. What has not been discussed as much is what is known as the “Anxiety Protocol,” which often is used either alone or as an augmentation to the Standard MDD protocol for TMS. Though the Anxiety Protocol has not yet received official FDA approval, it is widely used as an off label treatment in the TMS psychiatric community for anxiety and OCD symptoms that frequently accompany depression. Furthermore, its efficacy is supported by many clinical studies.


So what has been the literature on the Anxiety Protocol thus far?


Beginning in 1997, Brian Greenberg, M.D., Ph.D. and colleagues found that stimulating any part of the neural circuitry involved in reward processing and salience detection, including cortex, striatum, globus pallidus and thalamus, could produce modulatory effects on symptoms of obsessive-compulsive disorder (OCD). Repetitive TMS at the prefrontal cortex can alter activity in that region of the brain, which can in turn have modulatory effects on the rest of the circuitry. It was also found that a certain protocol of rTMS against the left and right dorsolateral prefrontal cortex (DLPFC) resulted in a statistically significant reduction in obsessive-compulsive-like behavior. The study used stimulation of the right Prefrontal Cortex, which is the treatment location for the Anxiety Protocol.


It is thought that the Anxiety Protocol works by activating GABA-releasing interneurons in the prefrontal cortex, which have an inhibitory effect on the rest of the circuitry. The Anxiety Protocol uses a pulse of 1 Hz, which is an inhibitory pulse that activates these GABA-releasing interneurons and in turn can “deactivate” the deeper areas of the brain responsible for inducing that “fight-or-flight” response to stress or perceived threat, most notably the amygdala.


In 2004, researchers showed that repetitive TMS applied over the right dorsolateral prefrontal cortex (DLPFC) led to reduced symptoms of post-traumatic stress disorder (PTSD). Following 30 sessions of TMS over 6 weeks using the Anxiety Protocol, participants suffering from PTSD showed significantly reduced frequency and intensity of symptoms including re-experiencing visual flashbacks, avoidance, and hyperarousal or anxiety. Neuroimaging via PET scans also confirmed lowered metabolic rate in regions of the brain correlated with reduced anxiety symptoms among participants.


What have the clinical outcomes been at Principium Psychiatry?


At Principium Psychiatry, patients will be thoroughly evaluated and an appropriate treatment protocol determined based on individual needs. We prescribe the Standard MDD protocol for treatment of depressive symptoms. We also offer the Anxiety Protocol as an augmentation to the depression treatment, as well as a treatment for symptoms of anxiety comorbid with depression. Clinical outcomes of the Anxiety Protocol have been excellent, with nearly all patients reporting accelerated improvement of both depression and anxiety symptoms since starting the Anxiety Protocol. It is safe and well-tolerated, with no reports of negative outcomes.

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