Transcranial Magnetic Stimulation (TMS) in Conjunction With Exposure Therapy for the Treatment of Spider Phobia
Phase: NA
Conditions: Arachnophobia, Phobia
Sponsor: University of California, Los Angeles

COVER PAGE 
 
Study protocol as of 8/7/19, last reviewed/approved 4/1/2020, current as of 2/2/21 
 
NCT04019054 
 

Transcranial Magnetic Stimulation (TMS) in Conjunction with Exposure Therapy for the 
Treatment of Spider Phobia 
 
Project Summary: 
Spider phobia is an exceedingly common phobia throughout the world. The current standard 
treatment involves exposure therapy, which consists of a series of brief exposures of an 
individual to the thing they fear, in this case spiders. This study aims to examine the use of a 
neuromodulatory technology, transcranial magnetic stimulation (TMS), as a possible treatment 
option for spider phobia. TMS uses low-intensity electromagnetic energy to stimulate the brain, 
introducing energy into critical hubs of brain networks to “reset” their function and alleviate 
symptoms with very few side-effects. 
 
This study will consist of four separate visits. After screening subjects for spider phobia, 
baseline testing of subjective distress measures and physiologic stress data (heart rate 
variability and sweat response) during a prolonged spider exposure test will be collected. 
Subjects will then be placed into one of two groups: one receiving exposure therapy and 
intermittent Theta Burst Stimulation (iTBS) TMS (active study group), and another receiving 
exposure therapy with iTBS to a circuit not involved in a phobic reaction (control study group). 
Subjects will undergo their first treatment session during the first visit following the baseline 
data collection; the second and third treatments will occur the following two days. The fourth 
visit will occur one week after the third and consist of the same testing as the first visit; the 
same data will be collected. Changes from pre- to post-treatment in both subjective and 
physiologic data will be compared between the treatment and sham groups to examine effects 
of TMS on spider phobia. 
 
 
Background and significance 
Transcranial Magnetic Stimulation (TMS) is a groundbreaking approach to treatment of 
neuropsychiatric disorders.  TMS uses low-intensity electromagnetic energy to stimulate the 
brain, introducing energy into critical hubs of brain networks to “reset” their function and 
alleviate symptoms with very few side-effects.(Leuchter, Hunter, Krantz, & Cook, 2015)  
Repetitive TMS (rTMS), a specific protocol for using TMS, currently is indicated for the 
treatment of Major Depressive Disorder (MDD) and Obsessive Compulsive Disorder (OCD) and 
is more effective than medication for drug treatment resistant illness.(Demitrack & Thase, 
2009)  There also is evidence that rTMS is effective for the treatment of Generalized Anxiety 
Disorder (GAD) with fewer side-effects and potentially greater efficacy than medications 
alone.(Diefenbach, Assaf, Goethe, Gueorguieva, & Tolin, 2016; Dilkov, Hawken, Kaludiev, & 
Milev, 2017)  Intermittent theta-burst stimulation (iTBS), another treatment protocol using 
TMS, has been shown to have similar benefits and utility as rTMS.(Bulteau et al., 2017; Chung, 
Hoy, & Fitzgerald, 2015; Mutz, Edgcumbe, Brunoni, & Fu, 2018) Some evidence has 
demonstrated that rTMS and iTBS may have clinical benefit in the treatment of phobias 
warranting further study.(Baeken et al., 2010; Deppermann et al., 2016; Guhn et al., 2012; 
Notzon et al., 2015; Paes, 2013) 
 

Treatment of specific phobias, a disproportionate conditioned fear to a specific stimulus, 
typically involves exposure therapy, an extinction-based behavioral technique employed in the 
context of cognitive behavioral therapy (CBT).(Loerinc et al., 2015; Pachana, Woodward, & 
Byrne, 2007; Wolitzky-Taylor, Horowitz, Powers, & Telch, 2008) It involves exposing an 
individual to his or her feared stimulus in an effort to generate new non-fear associations with 
that stimulus.  Treatment benefit with exposure therapy is observed in 70-75% of individuals 
compared to placebo.(Wolitzky-Taylor et al., 2008)  However, not only do 25-30% of individuals 
not respond to exposure therapy, but few studies examining exposure therapy report long-term 
outcomes.(Wolitzky-Taylor et al., 2008)  And these phobias are estimate to affect up to 15% of 
the world’s population.(Eaton, Bienvenu, & Miloyan, 2018; Wolitzky-Taylor et al., 2008)  In the 
cases where therapy fails or a patient would prefer medication, a low-dose benzodiazepine can 
be used, though it is not considered first-line.(Pachana et al., 2007; Wolitzky-Taylor et al., 2008)  
This project is designed to examine the feasibility of combining exposure therapy and iTBS 
treatment for phobia, and gather preliminary data to address the question of whether this 
combination might  lead to greater or more rapid symptom resolution than exposure alone.  
Should our hypothesis prove true, further study may yield a new effective treatment for 
phobias.  This would not only impact the treatment of phobias, but provide the first evidence 
for the usefulness of iTBS in an integrated treatment approach for 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 undergraduate students recruited through the UCLA Psychology 
Department Subject Pool (i.e., SONA).  At this time, this small pilot study is not equipped to 
recruit from the population at-large, and therefore is currently limited to recruitment through 
SONA.  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, aneursym 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 after participating in the study.  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).  At this time, 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. 
 
DAY 1 
On Day 1, participants will first provide informed consent after the nature of the study has been 
fully explained and the participant has had time to ask questions. After obtaining informed 

consent, participants will complete a demographics and eligibility questionnaire (see Section 
10.1, Item 1.0) or hand in their already-completed forms, which will be reviewed by the 
researcher upon completion. Ineligible participants (i.e., participants with bee, insect, or spider 
allergies, with scores below 17 on the SPQ, who do not speak English, are taking medications 
that lower the seizure threshold, or other exclusion criteria as listed in section 11.1) will be 
informed that they do not meet criteria and the research session will be terminated at this 
time. Participants found to be ineligible will still receive 1 credit for their time.  All to-be-
administered questionnaires are listed below and uploaded in Section 10.1, Item 1.0 of this IRB 
submission.   
 
Spider Phobia Questionnaire (SPQ; Klorman et al, 1974) 
Demographics & Eligibility Questionnaire 
Fear of Spiders Questionnaire (FSQ; Szymanski & O’Donohue, 1995) 
PHQ2 
PHQ9 
Hamilton Rating Scale for Depression (specifically the suicidality item) 
GAD7 
 
All participants will complete a BAT with a live tarantula. This phase of the experiment consists 
of 9 steps, lasting 30 seconds each with a 30 second pause between each step. During the BAT, 
self-reported and physiological data will be collected at each step. Skin conductance response 
(SCR) and heart-rate variability (HRV) will be utilized as physiologic measures of fearful arousal 
using BIOPAC MP150 hardware and AcqKnowledge version 4.2 software (BIOPAC Systems, 
Inc.).(Appelhans & Luecken, 2006; Choi et al., 2017; Christopoulos, Uy, & Yap, 2016; Laine, 
Spitler, Mosher, & Gothard, 2009; Thayer, Åhs, Fredrikson, Sollers, & Wager, 2012; Williams et 
al., 2001)  Baseline SCR and HRV will be measured during a 3-minute prior to initiation of a BAT.  
SCR will be recorded from electrodes attached to the subjects’ second and third fingers.  
Average SCRs and peak SCRs at each step will be measured and compared to individual 
baselines.  HRV will be calculated from R-R intervals in a lead II electrode configuration 
recording; average HRVs from each step will be compared to individual baselines.  The steps are 
as follows: 
1. Stand 5 feet away from tarantula in closed terrarium 
2. Stand 1 foot away from tarantula in terrarium with top removed 
3. Place both hands on the side of terrarium with top removed 
4. Touch nose against the glass of terrarium while looking at the tarantula 
5. Place gloved hand halfway inside terrarium 
6. Place gloved hand inside terrarium with all fingertips touching base of terrarium 
7. Place bare hand inside terrarium with all fingertips touching base of terrarium 
8. Touch the back of the tarantula’s leg continuously with a Q-tip 
9. Touch the back of the tarantula’s leg continuously with the tip of the index finger 
 
Prior to beginning the BAT, all participants will be read the following instructions (from BAT 
Admin Script): "This part of the experiment consists of 9 steps, each lasting 30 seconds. 
Instructions for each step will be read aloud before you proceed to the next step. Each step 

must be completed before moving on to the next step, and steps much be completed in 
sequential order. During each step, your heart rate and sweating will be recorded via the 
electrodes on your chest and finger. After the experimenter reads the instructions for the next 
step and prior to completing the step, you will also be asked to rate your confidence level to 
complete the step on a scale from 0 to 100 (0= no confidence, 25= mild confidence, 50= 
moderate confidence, 75= high confidence, 100 = complete confidence) and your anticipatory 
distress on a scale from 0 to 100 (0=no distress, 25=mild distress, 50=moderate distress, 75= 
high distress, 100= severe distress). After completion of each step, you will be asked to rate 
your maximum level of distress during the step on a scale from 0 to 100. You are entitled to 
withdraw at any step if you do not wish to continue. Do you have any questions before we 
begin? The first step of the experiment is to stand 5 feet away from the tarantula while it is in 
its closed container for 30 seconds. The final step of the experiment is to touch the back of the 
tarantula’s leg with the tip of your index finger continuously for 30 seconds." 
Before beginning the BAT and after ensuring comprehension of the above instructions, the 
experimenter will ask the participant to rate his/her overall confidence and overall anticipatory 
distress with respect to his/her ability to complete all nine steps (see rating scales in above 
instructions). Before each subsequent step, the participant will be asked to rate his/her 
confidence and anticipatory distress regarding his/her ability to complete that particular step. 
During each step, the experimenter will record the spider’s movement on a categorical scale (0 
= no movement, 1 = a little movement, 2 = a lot of movement). After each step, the participant 
will be asked to rate his/her maximum level of distress while completing that particular step. 
Finally, the experimenter will record the number of steps willingly completed for a given 
participant. 
 
Next, all participants will engage in a series of exposure practices with a different live tarantula 
from the one they saw during the BAT.  Exposure therapy will consist of a series of 10 identical 
exposure trials of a 30-second duration with a 30-second pause between trials.  Participants will 
be asked to place an ungloved hand in the terrarium (with all fingertips touching the base of the 
terrarium) on the opposite end of the terrarium as the tarantula during the trial.  Prior to 
completing the series of exposures, participants will be asked about their feared outcome 
concerning approaching the tarantula (e.g., being bitten). Participants are entitled to withdraw 
at any step during exposures and will not be prevented from further continuation in the study. 
 
Following the series of exposures, participants will undergo TMS treatments using an iTBS 
protocol.  Before the first iTBS treatment, the TMS coil will be calibrated to the subject’s 
individual resting motor threshold (RMT), or the minimum stimulus intensity necessary to elicit 
a motor response in the right abductor pollicis brevis (APB) or first dorsal interosseus (FDI) 
muscles for ≥ 50% of stimuli applied to the motor cortex.  After initial calibration, the TMS coil 
will be placed over the subject’s ventral medial prefrontal cortex (vmPFC; as determined using 
position Fpz of the international 10-20 EEG electrode system), a TMS target shown to affect 
phobic response.(Baeken et al., 2010; Guhn et al., 2012, 2014; Suarez-Jimenez et al., 2018)  
Stimulation intensity of 100% of the individual RMT in bursts of three pulses at a frequency of 50 Hz 
every 200 ms on top of a 5Hz carrier wave.  Pulse delivery is over 2 s and repeated every 10 s, 20 times 
in succession, for a total of 600 pulses delivered in 3.33 minutes.(Baeken et al., 2010; Bulteau et al., 

2017; Guhn et al., 2014)  This specific protocol was selected based on the assumption that it 
should impact fear circuitry top-down from prefrontal to subcortical networks (particularly the 
amygdala) as seen in prior work.(Baeken et al., 2010; Bulteau et al., 2017; Guhn et al., 2014)  
Control iTBS will consist of the same stimulation parameters over the subject’s midline central 
sulcus or vertex (as determined using position Cz, of the international 10-20 EEG electrode 
system).  This placement was chosen for control as its position over the vertex will minimize 
amount of cortex stimulated and the stimulated area is not associated with the circuitry 
examined in this experiment.(Duecker & Sack, 2015)  It is a commonly-used control site in TMS 
studies because it is associated with no known effects and has a similar risk profile to other TMS 
sites.  (Foltys et al., 2001; Jung, Bungert, Bowtell, & Jackson, 2016; Rossi et al., 2009; Weiss, 
Sparing, Fink, Tomasino, & Dafotakis, 2008)  It is generally associated with lower rates of scalp 
discomfort and no clinically-observed behavioral or mood effects.(Jung et al., 2016; Rossi et al., 
2009)  Some work has demonstrated a possible decrease in activation of the default mode 
network though this has not been found to be clinically-significant.(Jung et al., 2016)  
 
 
DAY 2 
As described above, this visit will occur one to two days after Day 1.  All participants will return 
to the laboratory to engage in a second series of exposure practices with the same tarantula 
from exposures at the first visit. They will undergo 10 identical exposure trials for durations of 
30 seconds each, with a 30-second pause between trials. During each exposure trial, they will 
again be asked to place an ungloved hand in the terrarium (with all fingertips touching the base 
of the terrarium) on the opposite end of the terrarium as the tarantula during the trial. Prior to 
completing the series of exposures, participants will be asked about their feared outcome 
concerning approaching the tarantula (e.g., being bitten). Participants are entitled to withdraw 
at any step during exposures and will not be prevented from further continuation in the study. 
 
Following the series of exposure practices, participants will undergo a TMS treatment using an 
iTBS treatment protocol in the same location that they received stimulation on Day 1 (vmPFC 
vs. vertex). 
 
DAY 3 
This visit will be identical to Day 2, and will occur one to two days after Day 2. 
 
DAY 4 
This visit will occur five to seven days after Day 3.  All participants will complete the Spider 
Phobia Questionnaire (SPQ; Klorman et al, 1974) and Fear of Spiders Questionnaire (FSQ; 
Szymanski & O’Donohue, 1995), uploaded in Section 10.1, Item 1.0, to test for change in 
arachnophobia fear/avoidance symptoms as a function of TMS treatment received.  Next, all 
participants will complete an identical BAT to that completed at their first visit with the same 
tarantula (see DAY 1 above).  Self-report and physiological (i.e., SCR) data will again be 
collected.  After completion of these forms, participants will be debriefed by an un-blinded 
member of the study team and informed to which group they are assigned.  They will be 

encouraged to discuss whatever questions or concerns they have regarding the study at that 
time.  
 
After completion of Day 4, participants will be compensated for their time with one credit per 
hour of study participation. 
 
Dependent variables (DVs) will be quantitative self-reports and behavioral symptoms of fear 
and avoidance of spiders both pre- and post-treatment, including SCR (difference between 
baseline and average level during BAT anticipation period, and number of peaks during BAT), 
total number of steps completed during the BAT, self-reported distress, anticipatory distress, 
and maximum distress per BAT step, and total score on the SPQ. BAT measures will be collected 
for each step and therefore minima, maxima, and means will be compared between the two 
groups. Primary outcomes examined will be number of steps completed during BAT, self-
reported distress during BAT, number of SCR peaks during BAT, SPQ score, and FOS score.  All 
other variables examined will be secondary outcomes.  Additionally, for feasibility and 
tolerability assessment, attendance to TMS treatment sessions and early termination of TMS 
treatment sessions will be recorded.  The primary independent variable examined will be the 
treatment group (iTBS vs. control iTBS).  The sample size will be 40 participants (20 per group).  
Pre-comparison ANOVA will be performed to limit type 1 error due to multiplicity of 
comparisons. 
 
Hypotheses will be tested using between-group two-tailed t-tests given that we are testing not 
only for magnitude of an effect, but also direction of an effect.  We expect that comparisons of 
efficacy will demonstrate increased confidence during BAT approach, decreased endorsed fear 
of spiders as measured by SPQ and FSQ, and reduced physiologic response to stimulus (reduced 
HRV and SCR) with active iTBS and exposure when compared to control iTBS and exposure.  We 
expect that comparisons of feasibility and tolerability will show no significant difference 
between attendance to, early termination of, or subjective tolerability ratings of TMS treatment 
sessions between treatment groups. 
 
NOTE 2/2/21: the above reported statistical analysis plan was modified given the small sample 
size, technical limitations, and distributions of the data observed.  The number of statistical 
tests performed was minimized and multi-level mixed-effects models (MLMs) and 
nonparametric tests were utilized as appropriate based on the sample size of the experiment.  
Behavioral measures acquired during the BATs (anticipatory distress, maximum distress, mean 
skin conductance at each step) were examined using MLMs in Stata version 16.1 as functions of 
BAT step, group assignment, and timepoint (pre or post-treatment).  All other analyses were 
performed in SPSS (version 26.0.0.0).  Demographics and experimental parameters were 
analyzed for between-group differences using 2-sided Mann-Whitney U Tests. Changes in self-
reported fear of spiders (SPQ and FOS) were analyzed using a repeated-measures MANOVA 
(Greenhouse Geisser correction was applied in case of non-sphericity).  A pair of chi-square 
analyses were performed to validate blinding of the study (based on questionnaires completed 
by subjects and raters), and no significant deviation from 50/50 chance was observed.  A p-
value of <0.05 was considered significant for all testing. 

 
 
ADVERSE EVENT MANAGEMENT 
Study personnel administering the BAT and exposure treatments will be bachelors-level trained 
or current UCLA students.  These personnel have not been identified at this time, but will be 
added to the IRB and protocols as they are identified.  They will be trained by personnel from 
Anxiety and Depression Research Center (ADRC; personnel under the supervision of Dr. 
Michelle Craske) in both how to properly administer the BAT and exposure treatments, as well 
as how to address any questions, concerns, or unexpected events that arise from these 
treatments (including acute episodes of psychological distress, escape of spiders, etc.).  These 
personnel have ample experience in training others how to administer these treatments.   
 
Three Chilean Rose Tarantulas (Grammostola rosea) will be stored in individual terrariums with 
weighted lids in a locked room within the ADRC (Life Sciences 5347), under the supervision of 
Dr. Michelle Craske and her laboratory personnel.  All BATs and exposure treatments will take 
place in a controlled closed room without windows, open vents, or other large openings, to 
minimize the likelihood of a tarantula escape.  At the beginning and end of every study session, 
study personnel will confirm the presence of the tarantula within the terrarium and confirm 
complete closure of the terrarium.  After termination of testing for the day, study personnel will 
again confirm of the presence of the spider and the terrarium closure before departing. 
 
In the event that a spider should escape from its terrarium, the participant will be removed 
from the room and study personnel will immediately re-close the room, search for the 
tarantula, and transfer it back to the terrarium in a manner safe for both the personnel and the 
spider when found.  This will involve coaxing the spider to a sealable pre-dampened carrier, 
temporarily sealing it, and opening it inside the spider’s terrarium.  Though the risk posed by a 
tarantula bite or hair projection is low and the risk of occurrence is low, study personnel will 
don gloves, eye protection, and a long-sleeved labcoat (all three of which will be provided) 
before attempting transfer to minimize this risk.  If not found after a thorough search, the room 
will remain closed, and other laboratory personnel and the PI will be notified, and further 
action will be taken to locate the spider. 
 
Any injury sustained in the process of a spider escape or containment, such as a spider bite, will 
be reported as an adverse event.  Should such an event emerge, study personnel present at the 
time of the event will be asked to contact the PI or a study clinician, who will assess the severity 
of the event.  If the PI is not contacted in real-time, personnel will contact the PI within 24 
hours of the event, and the PI will then report the adverse event within 24 hours of being 
informed. 
 
We will employ the following strategy to manage suicidality and other serious adverse events 
(SAEs).  All exposure and TMS procedures will be performed during normal working hours while 
there is a psychiatrist on duty at the Clinical TMS Service.  Should participants become acutely 
distressed during a study visit, the attending psychiatrist on duty will take any steps necessary 
to address any clinical issues that emerge. The PI will follow up with all participants by phone 

12-24 hours after all exposure treatments to ensure that they are not suffering from ongoing 
distress, and participants will be given contact information for the PI to reach out sooner should 
they desire.  The PI will involve licensed clinicians as appropriate.  At the initial study visit, 
subjects will complete the PHQ2 (reflex to PHQ9), GAD7, and HamD suicidality item and review 
their responses with a research assistant and clinician. All subjects also will be reminded at each 
visit about the availability of a clinician should the subject develop any event of concern, 
including suicidality or adverse events. Should such an event emerge, the subject will be 
instructed to contact the PI or a study clinician, who will assess the presentation as per their 
standard clinical protocol. This assessment will categorize the SAE as emergent or 
nonemergent. For non-emergent events, the clinicians will manage as they see fit. Rapid 
consultation with the Principal Investigator is available; should the clinician contact the PI, he or 
she will then be responsible for reporting the event as an SAE. If a consultation with the PI is 
not pursued in real-time, the clinician will inform the PI of the event within 24 hours of having 
identified the event.  For emergent events, such as the worsening of suicidality or self-injurious 
behavior, the clinician will instruct the subject to go to the nearest emergency room possible. 
Should the clinician be concerned about the subject’s imminent safety, he or she may contact 
the individual named by the subject in the consent form as the emergency contact, so that the 
contact person may help the subject get to an emergency room. If such an action is not 
feasible, the clinician may petition the subject to be brought involuntarily to the nearest 
emergency room possible, as provided for under state mental health laws in California where 
the study is being conducted. Consultation at any time is available by contacting the PI or a 
study clinician. Should the PI be contacted in real-time, he will then be responsible for initiating 
the SAE reporting. If the PI is not contacted in real-time, the clinician will contact the PI within 
24 hours of the event, and the PI will then complete SAE reporting within 24 hours of being 
informed.  All reports of adverse events will be reviewed by the PI and reported to the UCLA 
Institutional Review Board in accordance with its policies. 
 
 
 
Figure 1: Flow diagram for proposed study 
 

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List of Abbreviations 
• rTMS: Repetitive Transcranial Magnetic Stimulation 
• iTBS: Intermittent Theta Burst Stimulation 
• MDD: Major Depressive Disorder 
• OCD: Obsessive Compulsive Disorder 
• GAD: Generalized Anxiety Disorder 
• CBT: Cognitive Behavioral Therapy 
• SPQ: Spider Phobia Questionnaire 
• FSQ: Fear of Spiders Questionnaire 
• BAT: Behavioral Approach Test 
• SCR: Skin Conductance Response 
• HRV: Heart-rate Variability 
• RMT: Resting Motor Threshold 
• APB: Abductor Pollicis Brevis 
• FDI: First Dorsal Interosseus 
• vmPFC: Ventral Medial Prefrontal Cortex