Neuromodulation: Technology at the Neural Interface Received: July 31, 2013
Revised: September 4, 2013
Accepted: September 19, 2013
(onlinelibrary.wiley.com) DOI: 10.1111/ner.12129
LETTER TO THE EDITOR
Transcranial Direct Current Stimulation in a Patient With Schizoaffective Disorder Manic Episode To the Editor: Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique in which a weak current is applied through the scalp to produce changes in neuronal excitability in the underlying cerebral tissue (1). tDCS attracted the attention of clinicians and scientists due to its powerful effect on cortical function. This technique is based on the application of weak direct electrical currents (1–2 mA) to the scalp via surface electrodes. This results in an increase or decrease of the excitability of the cortical area underlying the electrodes. tDCS has shown to exert its effects by modulating membrane neuronal threshold and spontaneous neuronal activity, therefore leading to hyperpolarization or depolarization according to the polarity of stimulation (2,3). Recent clinical trials have shown promising results with left anodal prefrontal tDCS in treating depression (4). In their recent research, Brunoni et al. reported that in major depressive disorder, the combination of tDCS and sertraline increases the efficacy of each treatment. The efficacy and safety of tDCS and sertraline did not differ (5). Shiozawa et al. reported tDCS modulation of visual hallucinations in schizophrenia and a case report of using tDCS for catotonia (6,7). In a recent report, Schestatsky et al. reported that with five sessions of anodal tDCS over the right dorsolateral prefrontal cortex, there were some improvements in both agitation and manic symptoms in a patient with an episode of mania with sexual hyperactivity (8). This report investigates the answer for the question of whether tDCS can be a treatment option in manic episodes.
PATIENT AND METHOD
www.neuromodulationjournal.com
Address conrepondence to: Gökben Hızlı Sayar, MD, NP Istanbul Hospital, Alemdag Cad. Sitolu sk No: 27 Umraniye, Istanbul 34768, Turkey. Email: [email protected] All persons who meet authorship criteria are listed as authors, and all authors certify that they have participated sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revision of the manuscript. Furthermore, each author certifies that this material or similar material has not been and will not be submitted to orpublished in any other publication before its appearance in the Neuromodulation: Technology at the Neural Interface. Conflict of Interest: The authors declare no competing interest. • No financial support was received for this paper.
© 2013 International Neuromodulation Society
Neuromodulation 2014; 17: 743–745
743
The case is a 68-year-old female Caucasian patient suffering from schizoaffective disorder manic episode, diagnosed by the structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders IV. She was diagnosed with schizoaffective disorder at the age of 28. The affective episodes were predominantly manic, with episodes occurring one to two times a year. She described persecutional delusions and auditory hallucinations between the affective episodes. She was on antipsychotic medication continuously for 28 years. On her manic episodes, she was experiencing days to weeks of elevated and expansive mood, increased activity, decreased need for sleep, and increased talkativeness and socializing. Her auditory hallucinations also increased in manic episodes. She had used almost every known mood stabilizers and antipsychotic with poor clinical response. From the age of 28, she needed hospitalization on nine occasions owing to worsen-
ing manic symptoms. Three, six, and 12 years ago, the patient participated in three clinical trials of electroconvulsive treatment for the treatment of manic episodes. One year ago, ten sessions of repetitive transcranial magnetic stimulation (rTMS) was administered at 1 Hz (inhibitory frequency) at 120% motor threshold, 1500 pulses on each session over the right prefrontal cortex. Clinical response was partial to electroconvulsive treatment and poor to rTMS. A therapeutic regimen of lithium 900 mg/d (blood concentration, 0.78 mmol/L) and risperidone 4 mg/d was given with a diagnosis of schizoaffective disorder manic episode. She did not respond to treatment. Despite further reasonable mood stabilizer trials (lamotrigine, valproate, olanzapine), her clinical response was incomplete and not sustained. The patient participated in a clinical trial of tDCS for the treatment of manic episode after being assessed by her own treating psychiatrist as being capable of giving informed consent. She gave written informed consent for both trials and the publication of this case report. She underwent cathodal stimulation of the right dorsolateral prefrontal cortex and anodal stimulation of contralateral deltoid muscle more than three weeks as an add-on treatment to a stable antipsychotic and mood stabilizer medication. Direct current was transferred by a saline-soaked pair of surface sponge electrodes (35 cm2) and delivered by tDCS equipment (Medelec Ltd, Surrey, UK). The cathodal electrode was over F4. Patient received 2 mA tDCS for 15 min each day with a total of 20 sessions. The patient was assessed at baseline, after ten and 20 sessions of tDCS, and one month after the end of treatment. There was a significant improvement in manic symptoms and mania scores after treatment. Her clinical scale scores are given in Table 1. Her clinical outcome was satisfactory, and her mood returned to euthymia within a month. One month after ceasing tDCS, her mood
HIZLI SAYAR ET AL.
Table 1. YMRS, BPRS, and MMSE scores change over time.
BPRS YMRS MMSE
Baseline
Tenth session
20th session
After four weeks
65 40 23
48 24 27
30 18 27
28 18 26
BPRS, Brief Psychiatric Rating Scale; MMSE, Minimental State Examination; YMRS, Young Mania Rating Scale.
remained euthymic, but her psychotic symptoms (persecutional delusions and auditory hallucinations) did not respond to tDCS treatment and remained same throughout the tDCS trial. Her medications at that stage and for the last three months were lithium 900 mg/day and risperidone 4 mg/day. Patient tolerated tDCS well, and there were no adverse effects related to the application of this therapy. tDCS more than three weeks did exert clinically significant antimanic effects in this case. The cathodal montage to right prefrontal area and anodal montage to left deltoid muscle appeared to be the main contributory factor in the remission of manic symptoms. Brunoni et al. reported a 62-year-old woman who developed psychotic mania after five sessions of tDCS. On that case, electrode positioning was as anode over the left and cathode over the right dorsolateral prefrontal cortex (DLPFC); however, she was using sertraline 50 mg/day (9).
DISCUSSION
744
Various forms of brain stimulation appear to be effective in the treatment of mania. Electroconvulsive therapy is the most effective treatment of mania, but it is associated with anesthetic risks, adverse cognitive effects, and social burden. tDCS offers a noninvasive option for mania treatment. Previous animal studies suggest that cathodal tDCS reduces spontaneous firing of cortical neurons, most likely by depolarization of cell body, whereas anodal stimulation results in an opposite effect. Therefore, we speculate that the antimanic effect in this case was due to neuronal depolarization and subsequent prolonged decreased excitability of the right dorsolateral prefrontal cortex. Evidence indicates that mainly right-sided lesions are associated with manic-like behavior symptoms (10). In the Hausmann et al. study, manic symptoms occurred during 20 Hz, 2000 pulses rTMS treatment of a patient with bipolar depression (11). When the protocol was changed to 1 Hz, 1200 pulses, right DLPFC, and antidepressants were replaced by clozapine, manic symptoms disappeared. Ozten et al. observed hypomanic symptoms in four patients with recurrent major depressive disorder treated with 25 Hz, 1200 pulses, and left DLPFC rTMS. In each case, antidepressants were replaced by valproic acid, and the protocol was changed to 1 Hz, 250 pulses right DLPFC. In all cases, hypomanic symptoms disappeared following the protocol changes (12). Initial evidence suggesting that low-frequency rTMS over the right DLPFC may reduce manic symptoms, so we applied the tDCS cathode positioned over the right DLPFC as to hypothetically reduce manic symptoms, and anode over the contralateral deltoid muscle. Anodal stimulation of any cortical area results in enhanced excitability of that area. So, in order to prevent any enhancement of brain activity in any cortical area, we explored the efficacy of using extracephalic anodal electrode position. However, no studies have www.neuromodulationjournal.com
been conducted to compare the clinical efficacy of the cephalic and extracephalic electrode positioning. A problem with extracephalic electrode position might be the activation of brainstem structures (13). However, problematic vegetative effects have not been present in Vandermeeren et al. study (14). We did not observe any effect on psychotic symptoms and auditory hallucinations. One reason for this might be that we used extracephalic anodal electrode placement. For improvement of negative symptoms in schizophrenia, enhancement of left DLPFC activity, which is dysfunctional in schizophrenia, is a common approach. In a case report, cathodal tDCS over left DLPFC reduced auditory hallucinations (15). We can speculate that inhibiting the activity of left temporoparietal cortex would reduce, and enhancing activity of left temporoparietal cortex could worsen auditory hallucinations. In our case, electrodes were placed on right DLPFC and contralateral deltoid muscle. Limitation of this case is whether antimanic effects can be attributable to tDCS. It is difficult to determine if the patient improved because of the natural tendency to enter a remission state in manic symptoms. Pharmacological agents also were given to this patient. The rapid response after TDCS trial and the stability of her drug regimen for three months prior to tDCS trial provide evidence to support the impact of tDCS.
CONCLUSION These findings suggest that 2 mA cathodal stimulation of right prefrontal cortex promoted the decrease in manic symptoms without a change on psychotic symptoms. However, without a placebo control, these assumptions are merely speculative at this point. Our findings encourage further prospective studies to explore the effect of tDCS on mania.
Acknowledgement We would like to thank Dr. Nevzat Tarhan for his editorial support during preparation of this manuscript.
Authorship Statement Drs. Hızlı Sayar and Salcini designed and conducted the study, including patient recruitment. Dr. Özten prepared the manuscript draft with important intellectual input from Drs. Gül and Eryılmaz. All authors approved the final manuscript. All authors had complete access to the study data. Gökben Hızlı Sayar, MD*; Celal Salcini, MD†; Eylem Özten, MD*; Işıl Göğcegöz Gül, MD*; Gül Eryılmaz, MD* *Psychiatry Department, Uskudar University, Neuropsychiatry Istanbul Hospital, Istanbul, Turkey; and †Neurology Department, Uskudar University, Neuropsychiatry Istanbul Hospital, Istanbul, Turkey
REFERENCES 1. Paulus W. Transcranial electrical stimulation (tES– tDCS; tRNS, tACS) methods. Neuropsychol Rehabil 2011;21:602–617. 2. Nitsche MA, Paulus W. Excitability changes induced in the human motor cortex by weak transcranial direct current stimulation. J Physiol 2000;527 (Pt 3):633–639. 3. Nitsche MA. Transcranial direct current stimulation: a new treatment for depression. Bipolar Disord 2002;4 (Suppl. 1):98–99. 4. Fregni F, Boggio PS, Nitsche MA, Marcolin MA, Rigonatti SP, Pascual- Leone A. Treatment of major depression with transcranial direct current stimulation. Bipolar Disord 2006;8:203–204.
© 2013 International Neuromodulation Society
Neuromodulation 2014; 17: 743–745
LETTER TO THE EDITOR 5. Brunoni AR, Valiengo L, Baccaro A et al. The sertraline vs electrical current therapy for treating depression clinical study: results from a factorial, randomized, controlled trial. JAMA Psychiatry 2013;70:383–391. 6. Shiozawa P, Fregni F, Brunoni AR. Transcranial direct current stimulation (tDCS) fort he treatment of persistent visual and auditory hallucinations in schizophrenia: a case study. Brain Stimul 2013;6(5):831–833. 7. Shiozawa P, Da Silva ME, Fregni F, Brunoni A. Transcranial direct current stimulation (tDCS) for catatonic schizohrenia: a case study. Schizophr Res 2013;146:374– 375. 8. Schestatsky P, Janovik N, Lobato MI, Belmonte-de-Abreu P, Schestatsky S, Shiozawa P. Rapid therapeutic response to anodal tDCS of right dorsolateral prefrontal cortex in acute mania. Brain Stimul 2013;6:701–711. 9. Brunoni AR, Valiengo L, Zanao T, de Oliveira JF, Bensenor IM, Fregni F. Manic psychosis after sertraline and transcranial direct-current stimulation. J Neuropsychiatry Clin Neurosci 2011;23:E4–E5. 10. Cummings JL, Mega MS. Neuropsychiatry and Behavioral Neuroscience. New York: Oxford University Press, 2003.
11. Hausmann A, Kramer-Reinstadler K, Lechner-Schoner T et al. Can bilateral prefrontal repetitive transcranial magnetic stimulation induce mania? A case report. J Clin Psychiatry 2004;12:1575–1576. doi: 10.4088/JCP.v65n1122a. 12. Ozten E, Hizli Sayar G, Karamustafalioglu O. Hypomanic shift observed during rTMS treatment of patients with unipolar depressive disorder: four case reports. Ann Gen Psychiatry 2013;12:12. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3639843/ pdf/1744-859X-12-12.pdf. 13. Kuo MF, Paulus W, Nitsche MA. Therapeutic effects of non-invasive brain stimulation with direct currents (tDCS) in neuropsychiatric diseases. Neuroimage 2013 Jun 4. pii: S1053-8119(13)00627-7. doi: 10.1016/j.neuroimage.2013.05.117. [Epub ahead of print]. 14. Vandermeeren Y, Jamart J, Ossemann M. Effect of tDCS with an extracephalic reference electrode on cardio-respiratory and autonomic functions. BMC Neurosci 2010;11:38. 15. Homan P, Kindler J, Federspiel A et al. Muting the voice: a case of arterial spin labeling-monitored transcranial direct current stimulation treatment of auditory verbal hallucinations. Am J Psychiatry 2011;168:853–854.
745
www.neuromodulationjournal.com
© 2013 International Neuromodulation Society
Neuromodulation 2014; 17: 743–745
Copyright of Neuromodulation is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Revised: September 4, 2013
Accepted: September 19, 2013
(onlinelibrary.wiley.com) DOI: 10.1111/ner.12129
LETTER TO THE EDITOR
Transcranial Direct Current Stimulation in a Patient With Schizoaffective Disorder Manic Episode To the Editor: Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique in which a weak current is applied through the scalp to produce changes in neuronal excitability in the underlying cerebral tissue (1). tDCS attracted the attention of clinicians and scientists due to its powerful effect on cortical function. This technique is based on the application of weak direct electrical currents (1–2 mA) to the scalp via surface electrodes. This results in an increase or decrease of the excitability of the cortical area underlying the electrodes. tDCS has shown to exert its effects by modulating membrane neuronal threshold and spontaneous neuronal activity, therefore leading to hyperpolarization or depolarization according to the polarity of stimulation (2,3). Recent clinical trials have shown promising results with left anodal prefrontal tDCS in treating depression (4). In their recent research, Brunoni et al. reported that in major depressive disorder, the combination of tDCS and sertraline increases the efficacy of each treatment. The efficacy and safety of tDCS and sertraline did not differ (5). Shiozawa et al. reported tDCS modulation of visual hallucinations in schizophrenia and a case report of using tDCS for catotonia (6,7). In a recent report, Schestatsky et al. reported that with five sessions of anodal tDCS over the right dorsolateral prefrontal cortex, there were some improvements in both agitation and manic symptoms in a patient with an episode of mania with sexual hyperactivity (8). This report investigates the answer for the question of whether tDCS can be a treatment option in manic episodes.
PATIENT AND METHOD
www.neuromodulationjournal.com
Address conrepondence to: Gökben Hızlı Sayar, MD, NP Istanbul Hospital, Alemdag Cad. Sitolu sk No: 27 Umraniye, Istanbul 34768, Turkey. Email: [email protected] All persons who meet authorship criteria are listed as authors, and all authors certify that they have participated sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revision of the manuscript. Furthermore, each author certifies that this material or similar material has not been and will not be submitted to orpublished in any other publication before its appearance in the Neuromodulation: Technology at the Neural Interface. Conflict of Interest: The authors declare no competing interest. • No financial support was received for this paper.
© 2013 International Neuromodulation Society
Neuromodulation 2014; 17: 743–745
743
The case is a 68-year-old female Caucasian patient suffering from schizoaffective disorder manic episode, diagnosed by the structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders IV. She was diagnosed with schizoaffective disorder at the age of 28. The affective episodes were predominantly manic, with episodes occurring one to two times a year. She described persecutional delusions and auditory hallucinations between the affective episodes. She was on antipsychotic medication continuously for 28 years. On her manic episodes, she was experiencing days to weeks of elevated and expansive mood, increased activity, decreased need for sleep, and increased talkativeness and socializing. Her auditory hallucinations also increased in manic episodes. She had used almost every known mood stabilizers and antipsychotic with poor clinical response. From the age of 28, she needed hospitalization on nine occasions owing to worsen-
ing manic symptoms. Three, six, and 12 years ago, the patient participated in three clinical trials of electroconvulsive treatment for the treatment of manic episodes. One year ago, ten sessions of repetitive transcranial magnetic stimulation (rTMS) was administered at 1 Hz (inhibitory frequency) at 120% motor threshold, 1500 pulses on each session over the right prefrontal cortex. Clinical response was partial to electroconvulsive treatment and poor to rTMS. A therapeutic regimen of lithium 900 mg/d (blood concentration, 0.78 mmol/L) and risperidone 4 mg/d was given with a diagnosis of schizoaffective disorder manic episode. She did not respond to treatment. Despite further reasonable mood stabilizer trials (lamotrigine, valproate, olanzapine), her clinical response was incomplete and not sustained. The patient participated in a clinical trial of tDCS for the treatment of manic episode after being assessed by her own treating psychiatrist as being capable of giving informed consent. She gave written informed consent for both trials and the publication of this case report. She underwent cathodal stimulation of the right dorsolateral prefrontal cortex and anodal stimulation of contralateral deltoid muscle more than three weeks as an add-on treatment to a stable antipsychotic and mood stabilizer medication. Direct current was transferred by a saline-soaked pair of surface sponge electrodes (35 cm2) and delivered by tDCS equipment (Medelec Ltd, Surrey, UK). The cathodal electrode was over F4. Patient received 2 mA tDCS for 15 min each day with a total of 20 sessions. The patient was assessed at baseline, after ten and 20 sessions of tDCS, and one month after the end of treatment. There was a significant improvement in manic symptoms and mania scores after treatment. Her clinical scale scores are given in Table 1. Her clinical outcome was satisfactory, and her mood returned to euthymia within a month. One month after ceasing tDCS, her mood
HIZLI SAYAR ET AL.
Table 1. YMRS, BPRS, and MMSE scores change over time.
BPRS YMRS MMSE
Baseline
Tenth session
20th session
After four weeks
65 40 23
48 24 27
30 18 27
28 18 26
BPRS, Brief Psychiatric Rating Scale; MMSE, Minimental State Examination; YMRS, Young Mania Rating Scale.
remained euthymic, but her psychotic symptoms (persecutional delusions and auditory hallucinations) did not respond to tDCS treatment and remained same throughout the tDCS trial. Her medications at that stage and for the last three months were lithium 900 mg/day and risperidone 4 mg/day. Patient tolerated tDCS well, and there were no adverse effects related to the application of this therapy. tDCS more than three weeks did exert clinically significant antimanic effects in this case. The cathodal montage to right prefrontal area and anodal montage to left deltoid muscle appeared to be the main contributory factor in the remission of manic symptoms. Brunoni et al. reported a 62-year-old woman who developed psychotic mania after five sessions of tDCS. On that case, electrode positioning was as anode over the left and cathode over the right dorsolateral prefrontal cortex (DLPFC); however, she was using sertraline 50 mg/day (9).
DISCUSSION
744
Various forms of brain stimulation appear to be effective in the treatment of mania. Electroconvulsive therapy is the most effective treatment of mania, but it is associated with anesthetic risks, adverse cognitive effects, and social burden. tDCS offers a noninvasive option for mania treatment. Previous animal studies suggest that cathodal tDCS reduces spontaneous firing of cortical neurons, most likely by depolarization of cell body, whereas anodal stimulation results in an opposite effect. Therefore, we speculate that the antimanic effect in this case was due to neuronal depolarization and subsequent prolonged decreased excitability of the right dorsolateral prefrontal cortex. Evidence indicates that mainly right-sided lesions are associated with manic-like behavior symptoms (10). In the Hausmann et al. study, manic symptoms occurred during 20 Hz, 2000 pulses rTMS treatment of a patient with bipolar depression (11). When the protocol was changed to 1 Hz, 1200 pulses, right DLPFC, and antidepressants were replaced by clozapine, manic symptoms disappeared. Ozten et al. observed hypomanic symptoms in four patients with recurrent major depressive disorder treated with 25 Hz, 1200 pulses, and left DLPFC rTMS. In each case, antidepressants were replaced by valproic acid, and the protocol was changed to 1 Hz, 250 pulses right DLPFC. In all cases, hypomanic symptoms disappeared following the protocol changes (12). Initial evidence suggesting that low-frequency rTMS over the right DLPFC may reduce manic symptoms, so we applied the tDCS cathode positioned over the right DLPFC as to hypothetically reduce manic symptoms, and anode over the contralateral deltoid muscle. Anodal stimulation of any cortical area results in enhanced excitability of that area. So, in order to prevent any enhancement of brain activity in any cortical area, we explored the efficacy of using extracephalic anodal electrode position. However, no studies have www.neuromodulationjournal.com
been conducted to compare the clinical efficacy of the cephalic and extracephalic electrode positioning. A problem with extracephalic electrode position might be the activation of brainstem structures (13). However, problematic vegetative effects have not been present in Vandermeeren et al. study (14). We did not observe any effect on psychotic symptoms and auditory hallucinations. One reason for this might be that we used extracephalic anodal electrode placement. For improvement of negative symptoms in schizophrenia, enhancement of left DLPFC activity, which is dysfunctional in schizophrenia, is a common approach. In a case report, cathodal tDCS over left DLPFC reduced auditory hallucinations (15). We can speculate that inhibiting the activity of left temporoparietal cortex would reduce, and enhancing activity of left temporoparietal cortex could worsen auditory hallucinations. In our case, electrodes were placed on right DLPFC and contralateral deltoid muscle. Limitation of this case is whether antimanic effects can be attributable to tDCS. It is difficult to determine if the patient improved because of the natural tendency to enter a remission state in manic symptoms. Pharmacological agents also were given to this patient. The rapid response after TDCS trial and the stability of her drug regimen for three months prior to tDCS trial provide evidence to support the impact of tDCS.
CONCLUSION These findings suggest that 2 mA cathodal stimulation of right prefrontal cortex promoted the decrease in manic symptoms without a change on psychotic symptoms. However, without a placebo control, these assumptions are merely speculative at this point. Our findings encourage further prospective studies to explore the effect of tDCS on mania.
Acknowledgement We would like to thank Dr. Nevzat Tarhan for his editorial support during preparation of this manuscript.
Authorship Statement Drs. Hızlı Sayar and Salcini designed and conducted the study, including patient recruitment. Dr. Özten prepared the manuscript draft with important intellectual input from Drs. Gül and Eryılmaz. All authors approved the final manuscript. All authors had complete access to the study data. Gökben Hızlı Sayar, MD*; Celal Salcini, MD†; Eylem Özten, MD*; Işıl Göğcegöz Gül, MD*; Gül Eryılmaz, MD* *Psychiatry Department, Uskudar University, Neuropsychiatry Istanbul Hospital, Istanbul, Turkey; and †Neurology Department, Uskudar University, Neuropsychiatry Istanbul Hospital, Istanbul, Turkey
REFERENCES 1. Paulus W. Transcranial electrical stimulation (tES– tDCS; tRNS, tACS) methods. Neuropsychol Rehabil 2011;21:602–617. 2. Nitsche MA, Paulus W. Excitability changes induced in the human motor cortex by weak transcranial direct current stimulation. J Physiol 2000;527 (Pt 3):633–639. 3. Nitsche MA. Transcranial direct current stimulation: a new treatment for depression. Bipolar Disord 2002;4 (Suppl. 1):98–99. 4. Fregni F, Boggio PS, Nitsche MA, Marcolin MA, Rigonatti SP, Pascual- Leone A. Treatment of major depression with transcranial direct current stimulation. Bipolar Disord 2006;8:203–204.
© 2013 International Neuromodulation Society
Neuromodulation 2014; 17: 743–745
LETTER TO THE EDITOR 5. Brunoni AR, Valiengo L, Baccaro A et al. The sertraline vs electrical current therapy for treating depression clinical study: results from a factorial, randomized, controlled trial. JAMA Psychiatry 2013;70:383–391. 6. Shiozawa P, Fregni F, Brunoni AR. Transcranial direct current stimulation (tDCS) fort he treatment of persistent visual and auditory hallucinations in schizophrenia: a case study. Brain Stimul 2013;6(5):831–833. 7. Shiozawa P, Da Silva ME, Fregni F, Brunoni A. Transcranial direct current stimulation (tDCS) for catatonic schizohrenia: a case study. Schizophr Res 2013;146:374– 375. 8. Schestatsky P, Janovik N, Lobato MI, Belmonte-de-Abreu P, Schestatsky S, Shiozawa P. Rapid therapeutic response to anodal tDCS of right dorsolateral prefrontal cortex in acute mania. Brain Stimul 2013;6:701–711. 9. Brunoni AR, Valiengo L, Zanao T, de Oliveira JF, Bensenor IM, Fregni F. Manic psychosis after sertraline and transcranial direct-current stimulation. J Neuropsychiatry Clin Neurosci 2011;23:E4–E5. 10. Cummings JL, Mega MS. Neuropsychiatry and Behavioral Neuroscience. New York: Oxford University Press, 2003.
11. Hausmann A, Kramer-Reinstadler K, Lechner-Schoner T et al. Can bilateral prefrontal repetitive transcranial magnetic stimulation induce mania? A case report. J Clin Psychiatry 2004;12:1575–1576. doi: 10.4088/JCP.v65n1122a. 12. Ozten E, Hizli Sayar G, Karamustafalioglu O. Hypomanic shift observed during rTMS treatment of patients with unipolar depressive disorder: four case reports. Ann Gen Psychiatry 2013;12:12. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3639843/ pdf/1744-859X-12-12.pdf. 13. Kuo MF, Paulus W, Nitsche MA. Therapeutic effects of non-invasive brain stimulation with direct currents (tDCS) in neuropsychiatric diseases. Neuroimage 2013 Jun 4. pii: S1053-8119(13)00627-7. doi: 10.1016/j.neuroimage.2013.05.117. [Epub ahead of print]. 14. Vandermeeren Y, Jamart J, Ossemann M. Effect of tDCS with an extracephalic reference electrode on cardio-respiratory and autonomic functions. BMC Neurosci 2010;11:38. 15. Homan P, Kindler J, Federspiel A et al. Muting the voice: a case of arterial spin labeling-monitored transcranial direct current stimulation treatment of auditory verbal hallucinations. Am J Psychiatry 2011;168:853–854.
745
www.neuromodulationjournal.com
© 2013 International Neuromodulation Society
Neuromodulation 2014; 17: 743–745
Copyright of Neuromodulation is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
