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      Transcranial direct current stimulation (tDCS) as an intervention to improve empathic abilities and reduce violent behavior in forensic offenders: study protocol for a randomized controlled trial

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          Abstract

          Background

          Recent studies show that changes in one of the brain areas related to empathic abilities (i.e. the ventromedial prefrontal cortex (vmPFC)) plays an important role in violent behavior in abusers of alcohol and cocaine. According to the models of James Blair, empathy is a potential inhibitor of violent behavior. Individuals with less empathic abilities may be less susceptible and motivated to inhibit violent behavior, which causes a higher risk of violence. Recent neuroscientific research shows that modulating (stimulation or inhibition) certain brain areas could be a promising new intervention for substance abuse and to reduce violent behavior, such as the neurostimulation technique transcranial direct current stimulation (tDCS). This study aims to investigate tDCS as an intervention to increase empathic abilities and reduce violent behavior in forensic substance use offenders.

          Methods/design

          A total sample of 50 male forensic substance abuse patients (25 active and 25 sham stimulation) will be tested in a double-blind placebo-controlled study, from which half of the patients will receive an active stimulation plus treatment as usual (TAU) and the other half will receive sham stimulation (placebo) plus TAU. The patients in the active condition will receive multichannel tDCS targeting the bilateral vmPFC two times a day for 20 min for five consecutive days. Before and after the stimulation period, the patients will complete self-report measurements, perform the Point Subtraction Aggression Paradigm (PSAP) and a passive viewing empathy task. Resting state electroencephalography (rsEEG) will be performed before and after the treatment period. A follow up will be conducted after 6 months. The primary outcome is to investigate multichannel tDCS as a new intervention to increase empathic abilities and reduce violent behavior in offenders with substance abuse problems. In addition, we will determine whether electrophysiological responses in the brain are affected by the tDCS intervention. Finally, the effects of tDCS on reducing craving will be investigated.

          Discussion

          This study is one of the first studies using multichannel tDCS targeting the vmPFC in a forensic sample. This study will explore the opportunities to introduce a new intervention to improve empathic abilities and reduce violence in forensic substance use offenders. Specifically, this study may give insight into how to implement the tDCS intervention in the setting of daily clinical practice in this complex, multiple-problem target group and with that contribute to reduction of recidivism.

          Trial registration

          Dutch Trial Register, NTR7701. Registered on 12 January 2019. Prospectively registered before the recruitment phase. https://www.trialregister.nl/trial/7459.

          Recruitment started on the 1st of February 2019 and will be finished approximately in the winter of 2019. Protocol version 1. 22 May 2019.

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          Most cited references71

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          Deciding advantageously before knowing the advantageous strategy.

          Deciding advantageously in a complex situation is thought to require overt reasoning on declarative knowledge, namely, on facts pertaining to premises, options for action, and outcomes of actions that embody the pertinent previous experience. An alternative possibility was investigated: that overt reasoning is preceded by a nonconscious biasing step that uses neural systems other than those that support declarative knowledge. Normal participants and patients with prefrontal damage and decision-making defects performed a gambling task in which behavioral, psychophysiological, and self-account measures were obtained in parallel. Normals began to choose advantageously before they realized which strategy worked best, whereas prefrontal patients continued to choose disadvantageously even after they knew the correct strategy. Moreover, normals began to generate anticipatory skin conductance responses (SCRs) whenever they pondered a choice that turned out to be risky, before they knew explicitly that it was a risky choice, whereas patients never developed anticipatory SCRs, although some eventually realized which choices were risky. The results suggest that, in normal individuals, nonconscious biases guide behavior before conscious knowledge does. Without the help of such biases, overt knowledge may be insufficient to ensure advantageous behavior.
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            The neural basis of empathy.

            Empathy--the ability to share the feelings of others--is fundamental to our emotional and social lives. Previous human imaging studies focusing on empathy for others' pain have consistently shown activations in regions also involved in the direct pain experience, particularly anterior insula and anterior and midcingulate cortex. These findings suggest that empathy is, in part, based on shared representations for firsthand and vicarious experiences of affective states. Empathic responses are not static but can be modulated by person characteristics, such as degree of alexithymia. It has also been shown that contextual appraisal, including perceived fairness or group membership of others, may modulate empathic neuronal activations. Empathy often involves coactivations in further networks associated with social cognition, depending on the specific situation and information available in the environment. Empathy-related insular and cingulate activity may reflect domain-general computations representing and predicting feeling states in self and others, likely guiding adaptive homeostatic responses and goal-directed behavior in dynamic social contexts.
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              Resting-state networks link invasive and noninvasive brain stimulation across diverse psychiatric and neurological diseases.

              Brain stimulation, a therapy increasingly used for neurological and psychiatric disease, traditionally is divided into invasive approaches, such as deep brain stimulation (DBS), and noninvasive approaches, such as transcranial magnetic stimulation. The relationship between these approaches is unknown, therapeutic mechanisms remain unclear, and the ideal stimulation site for a given technique is often ambiguous, limiting optimization of the stimulation and its application in further disorders. In this article, we identify diseases treated with both types of stimulation, list the stimulation sites thought to be most effective in each disease, and test the hypothesis that these sites are different nodes within the same brain network as defined by resting-state functional-connectivity MRI. Sites where DBS was effective were functionally connected to sites where noninvasive brain stimulation was effective across diseases including depression, Parkinson's disease, obsessive-compulsive disorder, essential tremor, addiction, pain, minimally conscious states, and Alzheimer's disease. A lack of functional connectivity identified sites where stimulation was ineffective, and the sign of the correlation related to whether excitatory or inhibitory noninvasive stimulation was found clinically effective. These results suggest that resting-state functional connectivity may be useful for translating therapy between stimulation modalities, optimizing treatment, and identifying new stimulation targets. More broadly, this work supports a network perspective toward understanding and treating neuropsychiatric disease, highlighting the therapeutic potential of targeted brain network modulation.
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                Author and article information

                Contributors
                j.d.m.vandongen@essb.eur.nl
                Journal
                Trials
                Trials
                Trials
                BioMed Central (London )
                1745-6215
                13 March 2020
                13 March 2020
                2020
                : 21
                : 263
                Affiliations
                [1 ]GRID grid.6906.9, ISNI 0000000092621349, Department of Psychology, Education and Child Studies, , Erasmus University Rotterdam, ; P.O. Box 1738, 3000 DR Rotterdam, the Netherlands
                [2 ]GRID grid.15276.37, ISNI 0000 0004 1936 8091, Center for Cognitive Aging and Memory, McKnight Brain Institute, Department of Clinical and Health Psychology, College of Public Health and Health Professions, , University of Florida, ; Gainesville, FL USA
                Article
                4074
                10.1186/s13063-020-4074-0
                7069186
                32169111
                840818e5-2202-486d-bb55-29b023d6a0a0
                © The Author(s). 2020

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 29 May 2019
                : 13 January 2020
                Funding
                Funded by: Kwaliteit Forensische Zorg (KFZ)
                Funded by: Stichting Volksbond Rotterdam
                Funded by: Stichting Koningsheide
                Categories
                Study Protocol
                Custom metadata
                © The Author(s) 2020

                Medicine
                transcranial direct current stimulation (tdcs),empathy,violent behavior,substance use,forensic offenders,recidivism,effectiveness,ventromedial prefrontal cortex (vmpfc)

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