Symptom provocation for treatment of obsessive-compulsive disorder using transcranial magnetic stimulation: A step-by-step guide for professional training

Abstract

Transcranial Magnetic Stimulation (TMS) is a non-invasive brain stimulation technique that was cleared by the Food and Drug Administration (FDA) for the treatment of Obsessive-Compulsive Disorder (OCD) in 2018. The approved protocol includes individualized symptom provocation before each stimulation session, to elicit a moderate level of obsessional distress. Although symptom provocation can be a delicate, demanding, and uncomfortable procedure, structured training methods for those who are going to apply it are not available. Here, we describe a model for training in symptom provocation for TMS technicians, developed at the Champalimaud Clinical Centre in Lisbon, Portugal. Our programme includes two-sessions dedicated to clinical communication and symptom provocation techniques from a theoretical and practical perspective. Additionally, supervision meetings are conducted during treatment of patients, allowing regular case discussion and redefinition of symptom provocation hierarchy, as needed. In addition to having a strong practical component, our training program is short and pragmatic, allowing for easy implementation and fluid transition to clinical practice. By sharing our experience, we hope to contribute to systematize training procedures required for symptom provocation in the context of TMS, and to qualitatively describe a methodology that can be used for implementation of TMS programmes for the treatment of OCD.

Toward personalized circuit-based closed-loop brain-interventions in psychiatry: using symptom provocation to extract EEG-markers of brain circuit activity

“…Instead of evaluating a specific psychiatric diagnosis, a more promising approach may be considering trans-diagnostic symptoms experienced across different psychiatric disorders. Considering the existing literature, it seems that symptoms such as anxiety ( Holt and Andrews, 1989 ), phobic fear ( Schienle et al, 2007 ), obsessive thinking and compulsive avoiding behavior ( Maia et al, 2022 ) and craving ( Milivojevic et al, 2020 ) (either for a substance or for food) may be more easily provoked and resolved more rapidly than other symptoms, such as worry, dysphoria/dysthymia and mania/hypomania. We will discuss insights from psychopharmacological interventions for symptom provocation and then focus our discussion on selected symptoms which we consider promising candidates for behavioral interventions for both symptom provocation and symptom reduction and for which physiological models exist that relate the severity of symptom expression to the degree of activity of a specific dysfunctional brain circuit.…”

“…The desired level of subjective self-reported distress is defined according to clinical experience with good acceptability and treatment efficacy in clinical trials ( Carmi et al, 2019 ). Symptom provocation aims to achieve a moderate self-reported level of obsessional distress (i.e., “4–7” on a “0–10” Visual Analog Scale) before each stimulation session ( Maia et al, 2022 ). In addition to provocation hierarchy approaches, virtual reality is also emerging as an option to provoke symptoms of OCD ( Dehghan et al, 2021 ).…”

Brain Stimulation Mechanisms and Therapeutic Effects in Neural Circuits

“…Instead of evaluating a specific psychiatric diagnosis, a more promising approach may be considering transdiagnostic symptoms experienced across different psychiatric disorders. Considering the existing literature, it seems that symptoms such as anxiety (Holt and Andrews, 1989), phobic fear (Schienle et al, 2007), obsessive thinking and compulsive avoiding behavior (Maia et al, 2022) and craving (Milivojevic et al, 2020) (either for a substance or for food) may be more easily provoked and resolved more rapidly than other symptoms, such as worry, dysphoria/dysthymia and mania/hypomania. We will discuss insights from psychopharmacological interventions for symptom provocation and then focus our discussion on selected symptoms which we consider promising candidates for behavioral interventions for both symptom provocation and symptom reduction and for which physiological models exist that relate the severity of symptom expression to the degree of activity of a specific dysfunctional brain circuit.…”

“…An individual-tailored symptom provocation hierarchy is designed with the patient prior to treatment with TMS, such as the seven-step process following a provocation hierarchy design proposed by Maia et al (2022). As described by Tendler et al (2019), symptom provocation should be administered using an 10.3389/fncir.2023.1208930 internal and external hierarchy provocation list to formulate questions that instill obsessive distress until the desired level of selfreported distress is achieved (Maia et al, 2022). The desired level of subjective self-reported distress is defined according to clinical experience with good acceptability and treatment efficacy in clinical trials .…”

“…The desired level of subjective self-reported distress is defined according to clinical experience with good acceptability and treatment efficacy in clinical trials . Symptom provocation aims to achieve a moderate self-reported level of obsessional distress (i.e., "4-7" on a "0-10" Visual Analog Scale) before each stimulation session (Maia et al, 2022). In addition to provocation hierarchy approaches, virtual reality is also emerging as an option to provoke symptoms of OCD (Dehghan et al, 2021).…”