RESUMO A estimulação magnética transcraniana (TMS) foi recentemente proposta como um possível tratamento adjuvante para muitos distúrbios neuropsiquiátricos, e já foi aprovada para o tratamento de depressão fármaco-resistente nos Estados Unidos e no Brasil, entre outros países. Apesar do fato de que seu uso em outros transtornos neuropsiquiátricos ainda é em grande parte experimental, muitos médicos têm utilizado essas técnicas como uma terapia off-label em várias doenças. Mais recentemente, uma outra técnica, a estimulação transcraniana por corrente contínua (ETCC), tornou-se também disponível como uma alternativa muito mais barata e portátil do que a TMS, embora os seus mecanismos de ação sejam diferentes daqueles da TMS. O uso off-label de TMS ou ETCC tende a ocorrer no caso de doenças que são notoriamente resistentes a outras modalidades terapêuticas. Aqui nós discutimos o caso dos transtornos de ansiedade, ou seja, transtorno do pânico e estresse pós-traumático, destacando as incertezas, benefícios e problemas potenciais inerentes ao uso clínico dessas técnicas neuromoduladoras no atual estágio do conhecimento.

ABSTRACT Transcranial magnetic stimulation (TMS) has recently been investigated as a possible adjuvant treatment for many neuropsychiatric disorders, and has already been approved for the treatment of drug-resistant depression in the United States and in Brazil, among other countries. Although its use in other neuropsychiatric disorders is still largely experimental, many physicians have been using it as an off-label add-on therapy for various disorders. More recently, another technique, transcranial direct current stimulation (tDCS), has also become available as a much cheaper and portable alternative to TMS, although its mechanisms of action are different from those of TMS. The use of off-label therapeutic TMS or tDCS tends to occur in the setting of diseases that are notoriously resistant to other treatment modalities. Here we discuss the case of anxiety disorders, namely panic and post-traumatic stress disorders, highlighting the uncertainties and potential problems and benefits of the clinical use of these neuromodulatory techniques at the current stage of knowledge.

A ativação farmacológica dos receptores 5-HT2C induz comportamentos de defesa em modelos animais. O estudo busca investigar se o bloqueio seletivo de receptores 5-HT2C no hipocampo ventral (HV) previne comportamentos defensivos induzidos por um agonista de receptor 5-HT2C administrado perifericamente em ratos expostos ao labirinto em cruz elevado (LCE). Quinze minutos após injeções intraperitoniais (IP, 1ml/kg) do agonista 5-HT2C WAY-161503, ratos foram microinjetados bilateralmente no HV com o antagonista seletivo de receptores 5-HT2C SB-242084 (0, 0,1, 0,5 ou 1.5μg). Dez minutos após, cada animal foi exposto ao LCE para o registro de categorias de ansiedade. Injeções sistêmicas do WAY-161503 reduziram seletivamente as explorações nos braços abertos e aumentaram padrões de avaliação de risco. Esse efeito foi atenuado de maneira dose-dependente pela microinjeção de SB-242084 no HV, confirmando a ação ansiogênica de agonistas 5-HT2C e sugerindo que esse perfil comportamental seja mediado, pelo menos em parte, por receptores 5-HT2C do HV.

Pharmacological 5-HT2C receptor activation induces defensive behaviors in several animal models of anxiety. The present study investigated whether the selective blockade of 5-HT2C receptors in the ventral hippocampus (VH) prevents defensive behaviors induced by a 5-HT2C agonist administered systemically in rats exposed to the elevated plus-maze (EPM). Fifteen minutes after intraperitonial (IP, 1ml/kg) injections of the selective 5-HT2C receptor agonist WAY-161503 (3 mg/kg), rats were bilaterally microinjected with the selective 5-HT2C antagonist SB-242084 (0, 0.1, 0.5 or 1.5μg) into the VH. Ten minutes after, each animal was exposed to the EPM for measuring classical and ethological anxiety measures. IP WAY-161503 injections selectively decreased open-arm exploration while increasing risk-assessment. This anxiogenic-like action was dose-dependently attenuated by intra-VH SB-242084 microinjections. These results not only further confirm the anxiogenic-like action of 5-HT2C agonists, but also suggest that this behavioral profile might be mediated at least in part by VH 5-HT2C receptors.

O presente trabalho investigou experimentalmente os limiares nociceptivos e a percepção subjetiva de dor no transtorno de pânico (TP). Trinta e sete pacientes com TP foram voluntariamente submetidos a um Teste Pressor ao Frio (TPF), em que uma de suas mãos era mergulhada em um banho termostatizado de água fria (7ºC) por um período máximo de três minutos. A latência de retirada da mão da água foi utilizada como um índice de dor aguda, enquanto a experiência subjetiva de dor foi avaliada por meio do Questionário McGill de Dor e de uma escala visual analógica. Os resultados indicaram latências similares de retirada da mão em comparação a 37 sujeitos-controle sadios, mas uma experiência subjetiva de dor significantemente maior nos pacientes com TP. Esse padrão de resultados não apenas confirma a utilidade do teste de pressor ao frio para a indução e estudo experimental da dor aguda em laboratório, mas também sugere uma importante associação entre dor e ansiedade.

The present study experimentally investigated the nociceptive threshold and the subjective pain perception in panic disorder (PD). Thirty seven PD patients were voluntarily submitted to a cold pressor test (CPT) in which one of their hands was dipped into a thermostatized cold water bath (7ºC) for a maximum period of three minutes. Acute pain experience was assessed by measuring the hand retrieval latency, whereas the subjective pain experience was evaluated through McGill Pain Questionnaire and a pain visual analog scale. As compared to 37 healthy control-subjects, results indicated similar hand retrieval latencies but a significantly higher subjective pain experience in PD patients. Such pattern of results not only indicates the usefulness of the cold pressor test to induce and experimentally study pain in laboratory settings, but also suggests an important anxiety-pain association.

This study investigated the behavioral effects in the forced swim test (FST) and the elevated plus-maze (EPM) of acute administration of WAY 161503 ([4aR]-8,9-dichloro-2,3,4,4a-tetrahydro-1H-pyrazino[1,2-a]quinoxalin-5[6 H]-one), a selective 5-HT2C receptor agonist with putative antidepressant-like properties. Fifteen minutes after intraperitoneal (i.p.) injections of either WAY 161503 (1, 3 and 10 mg/kg) or saline, naive male Wistar rats were exposed to the EPM for 5 min to assess classical and ethological anxiety-like measures. Immediately after EPM exposure, each animal was exposed to the FST, and the latency to the first episode of immobility was recorded (trial session). Twenty-four hours later, the rats were reexposed to a second EPM-FST exposure sequence (test session for FST) under the effect of the same pharmacological treatment. The two lowest WAY 161503 doses selectively reduced open-arm exploration and increased risk-assessment without affecting locomotor activity. This selective anxiogenic-like effect was observed in both the first and second EPM exposures. The highest WAY 161503 dose produced robust locomotor impairment. In the FST, the same WAY 161503 doses significantly increased the latency to the first immobility in the test session, a behavioral profile that suggests an antidepressant-like action. These results further support the involvement of 5-HT2C receptors in the mediation of anxiety and suggest an intricate relationship between anxiogenic- and antidepressant-like actions.

Electrical or chemical stimulation of the dorsal periaqueductal gray (DPAG) has been accepted as an animal model of panic attacks. This study investigates the influence of anticipatory anxiety in the occurrence of panic-like behavior induced by N-methyl-D-aspartate (NMDA) microinjection into the DPAG of rats. Behavioral (i.e., contextual fear conditioning) and pharmacological (i.e., pentylenetetrazol) manipulations were employed as animal models of anticipatory anxiety. In the first experiment, animals exposed to contextual cues that had been previously associated with electric footshocks through contextual fear conditioning were less likely than non-conditioned control animals to display defensive reactions such as running and jumping in response to microinjection of NMDA (0.3 µl of 15.0 µg/µl) into the DPAG. In the second experiment, rats were injected intraperitoneally with the anxiogenic drug pentylenetetrazol (PTZ, 15 mg/kg) 5 minutes before receiving intra-DPAG microinfusion with the same dose of NMDA as in Experiment 1. Panic-related behaviors were registered in an experimental arena immediately after NMDA microinfusion. As compared with saline pre-treated animals, PTZ significantly attenuated NMDA-induced panic-like reactions. These results further demonstrate the usefulness of DPAG chemical stimulation as an animal model of panic attacks and suggest that behavioral and pharmacological activation of the brain mechanisms underlying anticipatory anxiety might exert an antipanic-like effect.

This study investigated the effects of two selective serotonin2C (5-hydroxytryptamine, 5-HT2C) receptor-acting compounds into the ventral hippocampus (VH) of rats exposed to the elevated plus-maze (EPM). In the first experiment, rats were exposed to the EPM 10 min following VH infusions of either vehicle or the selective 5-HT2C-receptor agonist RO-60-0175 (0.3, 1.0, 3.0 and 10.0µg). In addition to conventional parameters of open arm exploration (i.e. percentages of open arm entries and of time spent in these arms), risk assessmentrelated behaviors were recorded as anxiety-like measures in EPM scoring. RO-60-0175 selectively decreased open arm exploration at the dose of 1.0 µg, while inducing locomotor-suppressant effects at the two highest doses. In the second experiment, VH infusions of the selective 5-HT2C antagonist RS 102221 (0.75, 1.25 and 2.5 µg) did not affect open arm exploration, while reducing risk assessment in the closed ones. This behavioral profile of risk assessment is suggestive of an anxiolytic-like action. These results further corroborate our previous findings showing that VH 5-HT2C receptor activation elicits anxiogenic-like and locomotor-suppressant effects, and suggest that the selective blockade of this receptor is accompanied by an anxiolytic-like action as detected by ethologically derived measures in the EPM.

Embora os transtornos de ansiedade sejam tipicamente humanos, eles apresentam correlações com determinadas reações de defesa de animais em situações de perigo. Este trabalho apresenta algumas relações entre determinados padrões da resposta defensiva de congelamento e diferentes formas de transtornos de ansiedade. Em particular, destaca-se o isomorfismo entre a resposta de congelamento a estímulos contextuais associados a um estímulo aversivo e o transtorno de ansiedade generalizado. Evidências indicam também que a resposta de congelamento induzida pela estimulação elétrica da matéria cinzenta periaqueductal dorsal (MCPD) constitui um excelente modelo animal de ataque de pânico. A resposta de congelamento que surge imediatamente após estimulação da MCPD, capaz de produzir uma resposta de fuga, parece estar associada ao transtorno de pânico. Finalmente, é possível que a resposta de congelamento a estímulos previamente associados à estimulação elétrica da MCPD seja um modelo animal para o transtorno de pânico com agorafobia.

Although anxiety disorders are exclusive to humans, it is possible to find correlation between these disorders and defensive responses that animals present when facing dangerous situations. The present article presents a series of evidence that indicate that different freezing defensive patterns might be associated with specific anxiety disorders. Particularly, there is an excellent isomorphism between freeing response to contextual stimuli associated with electrical shocks and generalized anxiety disorder. Much evidence also shows that freezing response triggered directly through the electrical stimulation of the dorsal periaqueductal gray matter (dPAG) is an excellent animal model of panic attack. Moreover, freezing response observed after the interruption of the electrical stimulation of the dPAG which triggers an escape response seems to be associated with panic disorder. Finally, it is hypothesized that freezing to contextual stimuli previously associated with intense electrical stimulation of the dPAG might be related to panic disorder with agoraphobia.

Bien que les troubles anxieux soient propres aux humains, il est possible d'établir un parallèle entre ces troubles et les réponses défensives que les animaux présentent lorsqu'ils sont confrontés à des situations dangereuses. Dans cet article, une série d'arguments est présentée indiquant que différents patterns d'immobilisation défensive sont associés avec des troubles anxieux spécifiques. En particulier, il y a un excellent isomorphisme entre la réponse d'immobilisation aux stimuli contextuels aversives et le trouble d'anxiété généralisée. De plus, le comportement d'immobilisation déclenché directement par la stimulation de la substance grise périaqueducale dorsale (dPAG) est un excellent modèle animal d'attaque de panique. D'autre part, la réponse d'immobilisation observée après interruption de la stimulation électrique du dPAG semble associée avec le trouble panique. Finalement, l'hypothèse est proposée que l'immobilisation déclenchée par les stimuli contextuels précédemment associés avec la stimulation électrique du dPAG pourrait être mise en parallèle avec le trouble panique avec agoraphobie.

O efeito de microinjeções intra-amigdalóides do antagonista 5-HT2A/2C de receptores serotoninérgicos RP 62203 (1,0; 2,5; 5,0 mg) foi investigado em medidas tradicionais e etológicas (esquadrinhar, espreitar e explorações da extremidade) de ansiedade de ratos no labirinto em cruz elevado. A dose de 5,0 mg aumentou as porcentagens de entrada e de tempo nos braços abertos, sem alterar no número de entradas nos braços fechados. As categorias esquadrinhar, espreitar e explorações da extremidade também foram alteradas pela droga. As doses de 2,5 e 5,0 mg aumentaram o tempo gasto em esquadrinhar e diminuíram o tempo gasto em espreitar. O número de explorações da extremidade também foi aumentado pela injeção da droga na dose de 5,0 mg. Este padrão comportamental sugere um efeito ansiolítico do RP 62203. A participação dos receptores 5-HT2A/2C da amígdala na regulação desse efeito é discutida.

The effect of microinjections of the 5-HT2A/2C receptor antagonist RP62203 (1,0; 2,5; 5,0 mg) in the amygdala was investigated on traditional and ethological (scanning, risk-assessment, explorations of extremities) anxiety measures of rats in the elevated plus-maze test. The dose of 5,0 mg increased the percentages of entries and time spent in the open arms, without altering the number of closed arm entries. Scanning, risk-assessment and end exploration were also changed by the treatment, there being an increase of time spent in scanning (2,5 and 5,0 mg) and a reduction of time in risk-assessment (2,5 and 5,0 mg). The number of explorations of extremities was increased by the dose of 5,0 mg. This behavioral profile suggests an anxiolytic effect of the RP 62203. The participation of the 5-HT2A/2C receptors of the amygdala in the regulation of those effects is discussed.