Transcranial Magnetic Stimulation (TMS) in Conjunction With Exposure Therapy for the Treatment of Spider Phobia

OVERVIEW The experiment will consist of four days. Day 1 will include informed consent, questionnaires, a behavioral approach test with a spider, a series of short exposures with a spider, and the first TMS treatment (for a total of approximately 75-90 minutes). Day 2 will occur one to two days after Day 1 and will consist of a second series of short exposures with a spider and the second TMS treatment (30 minutes). Day 3 will occur one to two days after Day 2 and will also consist of a series of short exposures and a TMS treatment (30 minutes). Day 4 will occur five to seven days after Day 3 and will consist of post-study questionnaires and an identical behavioral approach test as is conducted on the first visit (30 minutes). Participants will be randomized to either an active TMS treatment group (using an iTBS stimulation protocol over the participant's ventro-medial prefrontal cortex, an area involved in phobic response) or a control TMS treatment group (using the same iTBS stimulation protocol over the central sulcus and between hemispheres, a site not associated with memory or fear response).

Prospective participants will be recruited from two groups: 1) undergraduate students recruited through the UCLA Psychology Department Subject Pool (i.e., SONA) and 2) general population over the age of 18 recruited via flyers. All prospective participants will be screened with the 31-question Spider Phobia Questionnaire (SPQ) to ensure eligibility for participation, with a minimum total score equal to or greater than 17 required for participation.(Klorman, Weerts, Hastings, Melamed, & Lang, 1974) Participants will be enrolled for the study only if they are able to complete all four visits of the experiment. Exclusion criteria will include:

1. Subject is mentally or legally incapacitated, unable to give informed consent.
2. Subjects with psychosis (psychotic depression, schizophrenia, or schizoaffective diagnoses (lifetime)); bipolar disorder (lifetime); dementia (lifetime); delirium within the past 6 months; eating disorder within the past year; obsessive-compulsive disorder (lifetime); post-traumatic stress disorder within the past year; acute risk for suicide or self-injurious behavior. Patients with diagnostic uncertainty or ambiguity (e.g. rule-out pseudodementia of depression) will be excluded.
3. Subjects with a HamD suicidality item score of '3' or '4,' corresponding to "suicidal ideas or gestures" or "attempts at suicide," will be excluded.
4. Subjects with exposure to ECT within the past 6 months, previous TMS treatment for any condition, or VNS treatment (lifetime).
5. Past history of skull fracture; cranial surgery entering the calvarium; space occupying intracranial lesion; stroke, CVA, or TIAs; cerebral aneurysm; Parkinson's or Huntington's disease; or Multiple Sclerosis.
6. Any history of intracranial implant including cochlear implant, implanted electrodes/stimulators, aneurysm clips or coils, stents, bullet fragments; implanted cardiac pacemaker, defibrillator, vagus nerve stimulator, deep brain stimulator; or other implanted devices or objects contraindicated by product labeling.
7. Neurological conditions including epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, history of repetitive or severe head trauma, or with primary or secondary tumors in the CNS.
8. current pregnancy or breast feeding.
9. Infection or loss of integrity of skin over the forehead, where the device will be positioned.
10. Increased risk of seizure as indicated by: a) history (or family history) of seizure or epilepsy; b) history of stroke, head injury, or unexplained seizures; c) concurrent medication use such as tricyclic antidepressants, neuroleptic medications, or other drugs that are known to lower the seizure threshold; d) secondary conditions that may significantly alter electrolyte balance or lower seizure threshold; e) no quantifiable motor threshold such that TMS dosage cannot be accurately determined.
11. Known bee, insect, or arachnid allergy
12. Other medical contraindications to any of the study procedures.

Participants will be assigned course credit or receive financial compensation after participating in the study. Those who participate through SONA recruitment will receive course credit. Participants will sign up for the study only if they are able to make all four visits of the experiment. If a participant does not attend all three visits, course credit will still be given for the amount of time the participant spent doing the experiment (i.e., 1 credit for 1 hour).

After screening, participants will be emailed blank copies of the forms, questionnaires, and screening tools that will be completed during the first visit, and they will be informed that they may complete the forms in advance and bring the completed forms with them to save time, should they desire. They will be asked to not return their forms via email, and to only bring them to the first visit.