Cerebral blood flow changes in schizophrenia patients with auditory verbal hallucinations during low-frequency rTMS treatment

Low-frequency rTMS modulates small-world network properties in an AVH-related brain network in schizophrenia

Background

Auditory verbal hallucinations (AVH) are a core symptom of schizophrenia, often persisting despite pharmacological treatment. Repetitive transcranial magnetic stimulation (rTMS), particularly low-frequency rTMS targeting the left temporoparietal junction (TPJ), has shown promise in alleviating AVH symptoms by modulating dysfunctional brain connectivity. However, the network-level effects of rTMS remain incompletely understood, particularly in terms of small-world network properties, which provide insights into local and global network efficiency. Furthermore, most previous studies have analyzed whole-brain networks, lacking specificity regarding disease-relevant circuits.

Objective

This study aimed to investigate how low-frequency rTMS modulates the small-world network properties of a refined AVH-related network composed of 35 brain regions specifically implicated in hallucination generation and rTMS treatment effects, thereby providing a more targeted perspective on network reorganization. Healthy controls (HCs) were included as a reference to determine whether rTMS normalizes network alterations in schizophrenia. Additionally, a responder vs. non-responder analysis was conducted to assess individual variability in treatment response.

Methods

A total of 50 schizophrenia patients with persistent AVH underwent 15 sessions of 1 Hz rTMS over the left TPJ. Resting-state fMRI data were collected before and after treatment to assess functional connectivity within the predefined 35-region AVH-related network. small-worldness (σ), normalized clustering coefficient (γ), and normalized characteristic path length (λ), as well as functional segregation (clustering coefficient [Cp], local efficiency [El]) and functional integration (global efficiency [Eg], characteristic path length [Lp])-were analyzed before and after rTMS. Clinical symptom severity was assessed using the Auditory Hallucination Rating Scale (AHRS).

Results

At baseline, schizophrenia patients exhibited disrupted small-world properties, with significantly lower σ, Cp, El, and Eg compared to healthy controls, reflecting impaired network organization, reduced local clustering, and inefficient global communication. Following rTMS, small-worldness (σ), local efficiency (El), and global efficiency (Eg) showed significant improvement, suggesting partial restoration of network efficiency. Functional connectivity analyses revealed significant reductions in hyperconnectivity between the right middle temporal gyrus (MTG) and superior putamen, as well as between the left TPJ and left lateral prefrontal cortex (LPFC). Notably, responders showed greater connectivity changes, which were correlated with AVH severity reduction, highlighting the role of network modulation in treatment response.

Conclusion

These findings support the network dysregulation model of AVH in schizophrenia and demonstrate that rTMS can modulate AVH-related connectivity, partially restoring network efficiency. The inclusion of HCs provides evidence that rTMS-induced changes align with normative network patterns, and the responder analysis suggests that connectivity modulation is linked to clinical improvement. This study offers new insights into the neurobiological mechanisms of rTMS treatment and underscores the need for biomarker-driven, individualized neuromodulation strategies for schizophrenia.

Vagus nerve stimulation and gut microbiota interactions: A novel therapeutic avenue for neuropsychiatric disorders

The rising prevalence of treatment-resistant neuropsychiatric disorders underscores the need for innovative and effective treatment strategies. The gut microbiota (GM) plays a pivotal role in the progression of these diseases, influencing the brain and mental health through the gut-brain axis (GBA). The vagus nerve plays a significant role in the GBA, making it a key area of focus for potential novel therapeutic interventions. Vagus nerve stimulation (VNS) was introduced and approved as a treatment for refractory forms of some neuropsychological disorders, such as depression and epilepsy. Considering its impact on several brain regions that play a vital part in mood, motivation, affection, and cognitive function, the VNS has shown significant therapeutic potential for treating a variety of neuropsychiatric disorders. Using VNS to target the bidirectional communication pathways linking the GM and the VN could present an exciting and novel approach to treating neuropsychological disorders. Imbalances in the GM, such as dysbiosis, can impair the communication pathways between the gut and the brain, contributing to the development of neuropsychological disorders. VNS shows potential for modulating these interconnected systems, helping to restore balance. Interestingly, the composition of the GM may also influence the effectiveness of VNS, as it has the potential to modify the brain's response to this therapeutic approach. This study provides a comprehensive analysis of a relatively unexplored but noteworthy interaction between VNS and GM in the treatment of neuropsychiatric disorders. In addition, we discussed the mechanisms, therapeutic potential, and clinical implications of VNS on the GBA across neuropsychiatric disorders.

Targeting auditory verbal hallucinations in schizophrenia: effective connectivity changes induced by low-frequency rTMS

Low-frequency repetitive transcranial magnetic stimulation (rTMS) has emerged as an effective intervention for alleviating symptoms of psychiatric disorders, particularly schizophrenia characterized by persistent auditory verbal hallucinations (AVH). However, the underlying mechanism of its action remain elusive. This study employed a randomized controlled design to investigate the impact of low-frequency rTMS on the neural connectivity at the stimulate site, specifically left temporoparietal junction (TPJ), in schizophrenia patients with suffering from AVH. Using Dynamic Causal Modeling (DCM), this study assessed changes in directed connectivity patterns and their correlations with clinical symptomatology. The results demonstrated significant improvements in AVH. Notably, significant changes in connectivity were observed, including both abnormal functional connectivity and effective connectivity among multiple brain regions. Particularly, the inhibition effects from the left precentral gyrus and left medial superior frontal gyrus to the left TPJ were closely associated with improvements in AVH. These findings underscore the potential of rTMS to effectively modulate neural pathways implicated in hallucinations in schizophrenia, thereby providing a neurobiological foundation for its therapeutic effects.

Low-frequency rTMS induces modifications in cortical structural connectivity - functional connectivity coupling in schizophrenia patients with auditory verbal hallucinations

Auditory verbal hallucinations (AVH) are distinctive clinical manifestations of schizophrenia. While low-frequency repetitive transcranial magnetic stimulation (rTMS) has demonstrated potential in mitigating AVH, the precise mechanisms by which it operates remain obscure. This study aimed to investigate alternations in structural connectivity and functional connectivity (SC-FC) coupling among schizophrenia patients with AVH prior to and following treatment with 1 Hz rTMS that specifically targets the left temporoparietal junction. Initially, patients exhibited significantly reduced macroscopic whole brain level SC-FC coupling compared to healthy controls. Notably, SC-FC coupling increased significantly across multiple networks, including the somatomotor, dorsal attention, ventral attention, frontoparietal control, and default mode networks, following rTMS treatment. Significant alternations in SC-FC coupling were noted in critical nodes comprising the somatomotor network and the default mode network, such as the precentral gyrus and the ventromedial prefrontal cortex, respectively. The alternations in SC-FC coupling exhibited a correlation with the amelioration of clinical symptom. The results of our study illuminate the intricate relationship between white matter structures and neuronal activity in patients who are receiving low-frequency rTMS. This advances our understanding of the foundational mechanisms underlying rTMS treatment for AVH.

Rich-club reorganization of white matter structural network in schizophrenia patients with auditory verbal hallucinations following 1 Hz rTMS treatment

The human brain comprises a large-scale structural network of regions and interregional pathways, including a selectively defined set of highly central and interconnected hub regions, often referred to as the "rich club", which may play a pivotal role in the integrative processes of the brain. A quintessential symptom of schizophrenia, auditory verbal hallucinations (AVH) have shown a decrease in severity following low-frequency repetitive transcranial magnetic stimulation (rTMS). However, the underlying mechanism of rTMS in treating AVH remains elusive. This study investigated the effect of low-frequency rTMS on the rich-club organization within the brain in patients diagnosed with schizophrenia who experience AVH using diffusion tensor imaging data. Through by constructing structural connectivity networks, we identified several critical rich hub nodes, which constituted a rich-club subnetwork, predominantly located in the prefrontal cortices. Notably, our findings revealed enhanced connection strength and density within the rich-club subnetwork following rTMS treatment. Furthermore, we found that the decreased connectivity within the subnetwork components, including the rich-club subnetwork, was notably enhanced in patients following rTMS treatment. In particular, the increased connectivity strength of the right median superior frontal gyrus, which functions as a critical local bridge, with the right postcentral gyrus exhibited a significant correlation with improvements in both positive symptoms and AVH. These findings provide valuable insights into the role of rTMS in inducing reorganizational changes within the rich-club structural network in schizophrenia and shed light on potential mechanisms through which rTMS may alleviate AVH.