Repetitive Transcranial Magnetic Stimulation (rTMS) to Treat Social Anxiety Disorder: Case Reports and a Review of the Literature

Flávia Paes1, 2, Tathiana Baczynski1, Felipe Novaes1, Tamires Marinho1, Oscar Arias-Carrión3, Henning Budde4, Alexander T. Sack5, Joseph P. Huston7, Leonardo Ferreira Almada8, Mauro Carta9, Adriana Cardoso Silva1, 2, Antonio E. Nardi1, 2, Sergio Machado1, 2, 6, 8, *
1 Laboratory of Panic and Respiration, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ), Rio de Janeiro, RJ, Brazil
2 National Institute for Translational Medicine (INCT-TM), Brazil
3 Movement Disorders and Transcranial Magnetic Stimulation Unit, Hospital General Dr. Manuel Gea Gonzalez, Secretaria de Salud México DF, México
4 Department of Sport Science and Physical Education, School of Science and Engineering, Reykjavik University, Iceland
5 Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Netherlands
6 Quiropraxia Program, Central University, Santiago, Chile
7 Institute of Physiological Psychology, University of Düsseldorf, Germany
8 Institute of Philosophy, Federal University of Uberlandia, Minas Gerais, Brazil
9 Department of Public Health and Clinical and Molecular Medicine, University of Cagliari, Italy

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© Paes et al.; Licensee Bentham Open.

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

* Address correspondence to this author at the Laboratory of Panic and Respiration, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ), Brazil; Tel: +5521-91567006; Fax: +5521-25112254; E-mail:


Objectives: Social anxiety disorder (SAD) is a common and debilitating anxiety disorders. However, few studies had been dedicated to the neurobiology underlying SAD until the last decade. Rates of non-responders to standard methods of treatment remain unsatisfactorily high of approximately 25%, including SAD. Advances in our understanding of SAD could lead to new treatment strategies. A potential non invasive therapeutic option is repetitive transcranial magnetic stimulation (rTMS). Thus, we reported two cases of SAD treated with rTMS Methods: The bibliographical search used Pubmed/Medline, ISI Web of Knowledge and Scielo databases. The terms chosen for the search were: anxiety disorders, neuroimaging, repetitive transcranial magnetic stimulation. Results: In most of the studies conducted on anxiety disorders, except SAD, the right prefrontal cortex (PFC), more specifically dorsolateral PFC was stimulated, with marked results when applying high-rTMS compared with studies stimulating the opposite side. However, according to the “valence hypothesis”, anxiety disorders might be characterized by an interhemispheric imbalance associated with increased right-hemispheric activity. With regard to the two cases treated with rTMS, we found a decrease in BDI, BAI and LSAS scores from baseline to follow-up. Conclusion: We hypothesize that the application of low-rTMS over the right medial PFC (mPFC; the main structure involved in SAD circuitry) combined with high-rTMS over the left mPFC, for at least 4 weeks on consecutive weekdays, may induce a balance in brain activity, opening an attractive therapeutic option for the treatment of SAD.

Keywords: : Dorsolateral prefrontal cortex, medial prefrontal cortex, repetitive transcranial magnetic stimulation, social anxiety disorders, valence hypothesis.