Treating Self Injurious Behavior: A Novel Brain Stimulation Approach

Study Overview
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Brief Summary
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The purpose of this study is to explore the tolerability and effectiveness of transcranial direct current stimulation (tDCS) as a potential treatment for non-suicidal self-injury (NSSI). NSSI is the deliberate attempt to harm oneself, most often through cutting or burning, without suicidal intent. NSSI is a maladaptive emotion-regulation strategy often triggered by negative emotions, especially those involving feelings of rejection. tDCS is a low-cost, portable, well-tolerated, non-invasive form of brain stimulation that delivers a low current to a specific area of the brain via electrodes. Several studies have demonstrated its effectiveness in treating an array of conditions, depending on electrode placement, including depression and chronic pain. tDCS may also facilitate adaptive emotion regulation; researchers have also successfully used tDCS to reduce negative emotions and aggressive responses to social rejection. The investigators therefore seek to explore tDCS as a potential treatment for NSSI. This pilot feasibility study seeks 1) to examine how at-home, self-administered tDCS is tolerated in a sample of individuals who engage in frequent NSSI; 2) to gather pilot data regarding changes in emotional and neural responses during a social task after a series of tDCS sessions in this clinical population of individuals who engage in NSSI; 3) to gather pilot data on the effects of tDCS on NSSI behaviors and urges. The investigators seek to recruit a sample of 22 individuals who engage in frequent NSSI to complete all study procedures. Individuals will be randomized to receive active- or sham-tDCS for two twenty-minute applications on each of six alternating days over approximately two weeks. Participants will be trained on tDCS self-administration, which will be supervised during each session over a videoconferencing platform by a researcher. Functional MRI (fMRI) may be performed at baseline and again after the completion of 12 sessions of tDCS. Subjects' NSSI and urges to engage in NSSI will be recorded for four weeks in real-time, using an iPod- based system that reminds subjects to stop at certain times during the day to record their thoughts, feelings, and behaviors. This will allow measurement of NSSI urges and behaviors for one week before, two weeks during, and one week after the tDCS intervention. The long-term goal of this study is to identify a novel form of treatment for NSSI and to better understand NSSI pathophysiology.

Official Title
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Treating Self Injurious Behavior: A Novel Brain Stimulation Approach

Conditions
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Cutting, Self-Injurious Behavior, Self Harm, Self-injury, Self-inflicted Injury, Self Injurious Behavior Without Suicidal Intent, Non-Suicidal Self Injury, Non Suicidal Self Inflicted Injury, Depression, Bipolar Disorder, Borderline Personality Disorder

Intervention / Treatment
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* Device: Transcranial direct current stimulation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 18-60 Frequent current NSSI (including cutting in which the skin is broken; self-hitting in which there is bruising; or burning in which there is evidence of a burn. Will not enroll if skin-picking or scratching is the only form of self-injury): has engaged in ≥2 episodes of NSSI in the two months prior to enrollment Capacity to provide informed consent If carries a diagnosis of bipolar I or II disorder, taking a therapeutic dose of a mood stabilizer. Normal hearing. Physical capacity (e.g., manual dexterity) to set-up and self-administer tDCS. - Exclusion Criteria: Unstable medical conditions based on medical history or physical examination Current psychotic disorder, mania, hypomania, intellectual disability Dermatologic condition resulting in non-intact skin on the scalp Significant suicidal ideation with a plan and intent that cannot be managed safely as an outpatient Pregnancy, currently lactating, or planning to conceive during the course of study participation. A neurological disease or prior head trauma with evidence of cognitive impairment. Subjects who endorse a history of prior head trauma and score ≥ 1.5 standard deviations below the mean on the Trailmaking A&B will be excluded from study participation. Current alcohol or substance use disorder that is moderate or severe Individuals who initiated or increased the dose of concurrent psychiatric medications (including antidepressants, anxiolytics, antipsychotic medications, mood stabilizers, and benzodiazepines) within two weeks prior to enrollment Individuals who initiated psychotherapy within two weeks prior to enrollment Metal implants or paramagnetic objects contained within the body (including heart pacemaker, shrapnel, or surgical prostheses) which may present a risk to the subject or interfere with the MRI scan, according to the guidelines set forth in the following reference book commonly used by neuroradiologists: Guide to MR procedures and metallic objects, F.G. Shellock, Lippincott Williams and Wilkins NY 2001. Additionally transdermal patches will be removed during the MR study at the discretion of the investigator. Claustrophobia significant enough to interfere with MRI scanning Weight that exceeds 325 lbs or inability to fit into MRI scanner Current seizure disorder. Use of anticonvulsant medications that target the GABA system (e.g., gabapentin). Individuals currently using benzodiazepines who are unwilling or unable to refrain from the use of benzodiazepine medications for at least 72 hours before the first tDCS session and throughout the duration of the 2-week tDCS intervention. -

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 60 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: active anodal tDCS to ventrolateral prefrontal cortex (VLPFC)<br>1.5 milliamp (mA) anodal tDCS over right ventrolateral prefrontal cortex; 20-minutes, 6-sessions | Device: Transcranial direct current stimulation<br>* tDCS is a low-cost, portable, well-tolerated, non-invasive form of brain stimulation that delivers a low current to a specific area of the brain via electrodes.<br>|
| Sham Comparator: sham anodal tDCS to VLPFC<br>Identical electrode montage, sham tDCS over 6 sessions. | Device: Transcranial direct current stimulation<br>* tDCS is a low-cost, portable, well-tolerated, non-invasive form of brain stimulation that delivers a low current to a specific area of the brain via electrodes.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| tDCS Adverse Effects Questionnaire | A questionnaire to evaluate side-effects related to tDCS administration. This questionnaire asks about the presence and severity of possible side-effects of tDCS procedures, and was recently published as a gold-standard tool for this purpose: Aparício LVM, Guarienti F, Razza LB, Carvalho AF, Fregni F, Brunoni AR. A Systematic Review on the Acceptability and Tolerability of Transcranial Direct Current Stimulation Treatment in Neuropsychiatry Trials. Brain Stimul. 2016 Oct;9(5):671-81. | Administered after each (12) tDCS session over 6 days | 
| social processing fMRI task: fMRI responses | Pre- and post-treatment fMRI scan to assess changes in brain responses during a social processing task following the tDCS intervention | One scan each pre- and post-treatment; approx. 10-days apart. | 
| Ecological Momentary Assessment (EMA): NSSI urges and behavior | EMA assessment of NSSI urges and behavior before, during, and after tDCS intervention. EMA is a tool through which participants can respond to a brief questionnaire on a smartphone device while going about their daily lives. Participants will be prompted to complete a brief questionnaire 6 times per day over a 3 week period, which asks questions about urges to engage in NSSI and in actual NSSI behavior. | 4-weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| social processing fMRI task: emotional responses | Ratings of affect (mood state) will be measured a total of 5 times during each social processing fMRI task, which will be performed before and after a course of tDCS. | One scan each pre- and post-treatment; approx. 10-days apart. | 
| Ecological Momentary Assessment (EMA): affect ratings | Assessment of daily changes in affect during and after tDCS intervention. Participants will be prompted to complete a brief questionnaire 6 times per day as described in Outcome 2. This questionnaire will also ask questions about mood/affect. | 4-weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Transcranial direct current stimulation, Transcranial electric stimulation, non-invasive brain stimulation, tDCS