Non-invasive Vagal Nerve Stimulation Effects on Hyperarousal and Autonomic State in Patients with Posttraumatic Stress Disorder and History of Mild Traumatic Brain Injury: Preliminary Evidence

Damon G Lamb, Eric C Porges, Greg F Lewis, John B Williamson, Damon G Lamb, Eric C Porges, Greg F Lewis, John B Williamson

Abstract

Posttraumatic stress disorder (PTSD) is a reaction to trauma that results in a chronic perception of threat, precipitating mobilization of the autonomic nervous system, and may be reflected by chronic disinhibition of limbic structures. A common injury preceding PTSD in veterans is mild traumatic brain injury (mTBI). This may be due to the vulnerability of white matter in these networks and such damage may affect treatment response. We evaluated transcutaneous vagal nerve stimulation (tVNS), a non-invasive, low-risk approach that may alter the functions of the limbo-cortical and peripheral networks underlying the hyperarousal component of PTSD and thus improve patient health and well-being. In this single visit pilot study evaluating the impact of tVNS in 22 combat veterans, we used a between-subjects design in people with either PTSD with preceding mTBI or healthy controls. Participants were randomized into stimulation or sham groups and completed a posturally modulated autonomic assessment and emotionally modulated startle paradigm. The primary measures used were respiratory sinus arrhythmia (high-frequency heart rate variability) during a tilt-table procedure derived from an electrocardiogram, and skin conductance changes in response to acoustic startle while viewing emotional images (International Affective Picture System). The stimulation was well tolerated and resulted in improvements in vagal tone and moderation of autonomic response to startle, consistent with modulation of autonomic state and response to stress in this population. Our results suggest that tVNS affects systems underlying emotional dysregulation in this population and, therefore, should be further evaluated and developed as a potential treatment tool for these patients.

Keywords: autonomic; hyperarousal; posttraumatic stress disorder; sympathetic; transcutaneous; transcutaneous vagal nerve stimulation; traumatic brain injury; vagal.

Figures

Figure 1
Figure 1
Schematic of postural heart rate variability tilt table test. (A) Isometric perspective and (B) side view of the three positions (90°, 60°, 30°).
Figure 2
Figure 2
Impact of transcutaneous vagal nerve stimulation (tVNS) on heart rate variability (HRV) during tilt-table experiment. Analysis of pilot data shows a trend toward increased respiratory sinus arrhythmia (RSA) high frequency HRV, indicating increased parasympathetic activity, across all tilt angles in the tilt-table experiment. (A) Main effect of tVNS, (B) impact of tVNS within PTSD and mTBI group. Data presented are mean ± SEM.
Figure 3
Figure 3
Impact of transcutaneous vagal nerve stimulation (tVNS) on EDA measures. Box plots of phasic max, max deflection, and amplitude sum EDA measures showing a trend of reduced sympathetic activation in response to emotionally modulated startle with tVNS. Notches extend from the median ± 95% confidence interval (1.58/√n × interquartile range), whiskers extend from lower and upper quartile to 1.5 × interquartile range.

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