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Communications and Updates   |    
Muting the Voice: A Case of Arterial Spin Labeling-Monitored Transcranial Direct Current Stimulation Treatment of Auditory Verbal Hallucinations
Philipp Homan, M.D.; Jochen Kindler, M.D.; Andrea Federspiel, Ph.D.; Richard Flury, M.D.; Daniela Hubl, M.D.; Martinus Hauf, M.D.; Thomas Dierks, M.D.
Am J Psychiatry 2011;168:853-854. doi:10.1176/appi.ajp.2011.11030496
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Bern, Switzerland

Dr. Dierks has received honoraria from Eli Lilly and grants from the University of Bern, the Synapsis Foundation, and the Swiss Science Foundation. The remaining authors report no financial relationships with commercial interests. This study was supported in part by the Swiss Science Foundation (SNF#: 112578).

This letter was accepted for publication in May 2011.

Accepted May , 2011.

Copyright © American Psychiatric Association

To the Editor: In February 2011, a 44-year-old man with schizophrenia was referred to our hospital for the treatment of auditory verbal hallucinations. He had undergone outpatient treatment with adequate dosages of antipsychotic medications for several months, but he still heard a real-sounding voice that ordered him to commit suicide. We introduced transcranial direct current stimulation (tDCS) as a novel therapeutic approach. Cathodal stimulation diminishes cortical excitability at a circumscribed region (1), and Wernicke's area has been described as an appropriate target region for cathodal stimulation in previous transcranial magnetic stimulation (TMS) studies (24). The anodal electrode was placed over the right supraorbital area.

Transcranial direct current stimulation was applied for 15 minutes on 10 consecutive days by using a 1 mA current and 7 cm × 5 cm electrodes, resulting in a current density of 0.029 mA/cm2. The medication doses (5 mg of haloperidol and 20 mg of olanzapine) remained the same 4 weeks before and during the patient's intervention. Before and after tDCS, we measured arterial spin labeling, a noninvasive MR technique that provides a direct quantitative measure of cerebral blood flow (CBF). Arterial spin labeling has been successfully used to measure the difference and changes in regional CBF between healthy individuals and schizophrenia patients experiencing formal thought disorders (5). Clinical assessments showed improvements in our patient's scores on the Hallucination Change Scale (pre-tDCS score=10; post-tDCS score=4), the Positive and Negative Syndrome Scale (pre-tDCS score=61; post-tDCS score=50), and the Psychotic Symptom Rating Scale (pre-tDCS score=51; post-tDCS score=43). The decrease in regional CBF indicated that the intervention had a specific neurobiological effect (Figure 1). At follow-up investigation 6 weeks after the tDCS intervention, our patient's clinical improvement was maintained.

 
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FIGURE 1.

Cerebral Blood Flow (CBF) Before and After 10 Sessions of Transcranial Direct Current Stimulation (tDCS) as Measured by Arterial Spin Labelinga

a The target region for cathodal stimulation (blue electrode) lies halfway between T3 and P3 in the 10—20 electroencephalography system (panel A). The reduction of the auditory verbal hallucinations as measured by scores on the Hallucination Change Scale (HCS) is confirmed by activation maps with regions of interests obtained by a preintervention fMRI involving a listen-rehearse language paradigm before and after 10 sessions of tDCS. The x and z locations denote the sectional planes in the Talairach system (panels B and C). BA=Brodmann's area.

To our knowledge, this is the first case report suggesting the clinical and neurobiological efficacy of cathodal tDCS in the treatment of auditory verbal hallucinations in a patient with schizophrenia. Compared to TMS, a rather expensive and laborious technique, tDCS is convenient and inexpensive, and the equipment is highly portable. It could be an attractive treatment option for alleviating long-term hallucinations in the clinical setting. Although the findings are promising, further study of tDCS for this clinical indication is required.

Nitsche  MA;  Paulus  W:  Excitability changes induced in the human motor cortex by weak transcranial direct current stimulation.  J Physiol 2000; 527:633—639
[CrossRef] | [PubMed]
 
Hoffman  RE;  Hampson  M;  Wu  K;  Anderson  AW;  Gore  JC;  Buchanan  RJ;  Constable  RT;  Hawkins  KA;  Sahay  N;  Krystal  JH:  Probing the pathophysiology of auditory/verbal hallucinations by combining functional magnetic resonance imaging and transcranial magnetic stimulation.  Cereb Cortex 2007; 17:2733—2743
[CrossRef] | [PubMed]
 
Horacek  J;  Brunovsky  M;  Novak  T;  Skrdlantova  L;  Klirova  M;  Bubenikova-Valesova  V;  Krajca  V;  Tislerova  B;  Kopecek  M;  Spaniel  F;  Mohr  P;  Hoschl  C:  Effect of low-frequency rTMS on electromagnetic tomography (LORETA) and regional brain metabolism (PET) in schizophrenia patients with auditory hallucinations.  Neuropsychobiology 2007; 55:132—142
[CrossRef] | [PubMed]
 
Langguth  B;  Eichhammer  P;  Zowe  M;  Marienhagen  J;  Spiessl  H;  Hajak  G:  Neuronavigated transcranial magnetic stimulation and auditory hallucinations in a schizophrenic patient: monitoring of neurobiological effects.  Schizophr Res 2006; 84:185—186
[CrossRef] | [PubMed]
 
Horn  H;  Federspiel  A;  Wirth  M;  Muller  TJ;  Wiest  R;  Wang  JJ;  Strik  W:  Structural and metabolic changes in language areas linked to formal thought disorder.  Br J Psychiatry 2009; 194:130—138
[CrossRef] | [PubMed]
 
References Container

FIGURE 1. 

Cerebral Blood Flow (CBF) Before and After 10 Sessions of Transcranial Direct Current Stimulation (tDCS) as Measured by Arterial Spin Labelinga

a The target region for cathodal stimulation (blue electrode) lies halfway between T3 and P3 in the 10—20 electroencephalography system (panel A). The reduction of the auditory verbal hallucinations as measured by scores on the Hallucination Change Scale (HCS) is confirmed by activation maps with regions of interests obtained by a preintervention fMRI involving a listen-rehearse language paradigm before and after 10 sessions of tDCS. The x and z locations denote the sectional planes in the Talairach system (panels B and C). BA=Brodmann's area.

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References

Nitsche  MA;  Paulus  W:  Excitability changes induced in the human motor cortex by weak transcranial direct current stimulation.  J Physiol 2000; 527:633—639
[CrossRef] | [PubMed]
 
Hoffman  RE;  Hampson  M;  Wu  K;  Anderson  AW;  Gore  JC;  Buchanan  RJ;  Constable  RT;  Hawkins  KA;  Sahay  N;  Krystal  JH:  Probing the pathophysiology of auditory/verbal hallucinations by combining functional magnetic resonance imaging and transcranial magnetic stimulation.  Cereb Cortex 2007; 17:2733—2743
[CrossRef] | [PubMed]
 
Horacek  J;  Brunovsky  M;  Novak  T;  Skrdlantova  L;  Klirova  M;  Bubenikova-Valesova  V;  Krajca  V;  Tislerova  B;  Kopecek  M;  Spaniel  F;  Mohr  P;  Hoschl  C:  Effect of low-frequency rTMS on electromagnetic tomography (LORETA) and regional brain metabolism (PET) in schizophrenia patients with auditory hallucinations.  Neuropsychobiology 2007; 55:132—142
[CrossRef] | [PubMed]
 
Langguth  B;  Eichhammer  P;  Zowe  M;  Marienhagen  J;  Spiessl  H;  Hajak  G:  Neuronavigated transcranial magnetic stimulation and auditory hallucinations in a schizophrenic patient: monitoring of neurobiological effects.  Schizophr Res 2006; 84:185—186
[CrossRef] | [PubMed]
 
Horn  H;  Federspiel  A;  Wirth  M;  Muller  TJ;  Wiest  R;  Wang  JJ;  Strik  W:  Structural and metabolic changes in language areas linked to formal thought disorder.  Br J Psychiatry 2009; 194:130—138
[CrossRef] | [PubMed]
 
References Container
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