Enhancing Cognitive Restructuring with Concurrent Repetitive Transcranial Magnetic Stimulation for Transdiagnostic Psychopathology: A Proof of Concept Randomized Controlled Trial

Background: Emotional dysregulation constitutes a serious public health problem in need of novel transdiagnostic treatments. To this aim, we developed and tested a one-time intervention that integrates behavioral skills training with concurrent repetitive transcranial magnetic stimulation (rTMS). Methods: Forty-seven adults who met criteria for at least one DSM-5 disorder and self-reported low use of cognitive restructuring (CR) were enrolled in a randomized, double-blind, placebo-controlled trial. Participants were taught CR and underwent active or sham rTMS applied at 10 Hz over the right or left dorsolateral prefrontal cortex (dlPFC) while practicing reframing and emotional distancing in response to autobiographical stressors. Results: Those who received active as opposed to sham rTMS exhibited enhanced regulation (ds = 0.20 - 0.67) and reduced distress (ds = 0.32 - 0.35), as measured by self-report and psychophysiological indices during the intervention (higher high-frequency heart rate variability, lower regulation duration) and ambulatory self-report measures during the week following the intervention. All participants improved in their use of reappraisal (d = 2.25), psychopathology (d = 0.48) and emotional dysregulation (d = 0.81) and maintained their gains at the one month follow up. The procedures were acceptable and feasible with few side effects. A secondary analysis suggested that participants with stress disorders may respond particularly well to active right rTMS. Conclusion: These findings show that engaging frontal circuits simultaneously with cognitive skills training and rTMS is clinically feasible, well-tolerated and shows promise as the next generation of treatments for transdiagnostic emotional dysregulation.