EAPL-05 Audit — Combined TMS + Cognitive Modification → Additional Anxiety Reduction

Conference claim under audit

The EAPL 2026 keynote abstract states that combined Transcranial Magnetic Stimulation (TMS) and cognitive modification yielded additional decreases in anxiety.

Official source: https://eapl2026.com/keynote-lectures/

Best-matching peer-reviewed study

Sikki M, Konikkou K, Kostantinou N, Fanti KA. Testing the effectiveness of combined attention modification training with right dorso-lateral prefrontal cortex theta-burst stimulation on reducing levels of anxiety and attentional bias. Experimental Brain Research. 2025;243:137. DOI: 10.1007/s00221-025-07040-9.

Full text: https://link.springer.com/article/10.1007/s00221-025-07040-9

Design match

Intervention: active right-DLPFC cTBS + active Attention Modification Training (AMT)
Comparator 1: active cTBS + control AMT
Comparator 2: sham cTBS + active AMT
Dose: 8 sessions over 2 weeks
Population: 89 community young adults, age 18–25, differentiated on anxiety severity
Clinical status: not clinically diagnosed for anxiety; moderate/high symptom participants classified as at risk
Primary symptom endpoint relevant to the keynote: self-reported anxiety
Proximal endpoints: attentional bias and eye-gaze measures
Follow-up: immediate post-treatment; no durable follow-up reported

Direct anxiety result

The study found an overall time effect for self-reported anxiety, but the treatment-specific pattern does not demonstrate an incremental anxiety benefit from adding active cTBS to AMT.

Sham cTBS + active AMT: significant pre/post anxiety reduction, d = 1.15.
Active cTBS + active AMT: pre/post reduction was not significant; d = 0.42.
Active cTBS + control AMT: pre/post reduction was not significant; d = 0.41.
The authors explicitly state that AMT with sham stimulation produced the larger and significant symptom decrease and that active cTBS + AMT was not superior for anxiety reduction.

What the combined active treatment did show

The combined active cTBS + AMT condition produced evidence of proximal attentional change:

increased attention toward happy facial expressions;
increased gaze fixation in the mouth region of happy faces;
increased fixation duration to emotional stimuli among anxious participants.

These findings support a mechanism/attention claim, not an incremental symptom-efficacy claim.

Why this is a direct tension rather than merely incomplete evidence

The paper states that its design was intended to test the added benefit of cTBS to AMT by comparing active cTBS + AMT with sham cTBS + AMT. That comparison is the natural evidentiary test for the keynote phrase “additional decreases in anxiety.” The published result does not support such an incremental benefit on the anxiety endpoint.

Alternate-evidence search

A targeted search located:

the 2024 SSSP poster, Combining Attention Modification Training with right dorsolateral prefrontal cTBS alters emotional processing — title-level conference evidence consistent with a proximal emotional-processing claim, not evidence of superior anxiety reduction;
the December 2025 randomized cTBS study in 91 healthy young adults — this tested emotional attention after real versus sham cTBS and did not test anxiety reduction as a treatment endpoint;
GENAMAT project records confirming the project rationale and funding — project intent, not outcome evidence.

No separate peer-reviewed Fanti-led study was located that demonstrates an incremental anxiety reduction from combined active TMS/cTBS + cognitive/attention modification over an appropriate active/sham comparator.

Audit judgment

Status: tension

The strongest currently traceable peer-reviewed evidence supports this narrower formulation:

Combined cTBS + AMT altered positive/emotional attention and gaze behavior, while AMT was associated with anxiety reduction; the addition of active cTBS did not demonstrate superior self-reported anxiety reduction over sham cTBS + AMT in the 2025 feasibility trial.

The EAPL wording may reflect:

a broad conference-level synthesis;
within-group decreases rather than incremental superiority;
unpublished or subsequently analyzed data;
or imprecise compression of distinct findings.

Until such evidence is identified, the atlas should not encode “combined TMS + cognitive modification → additional anxiety reduction” as an established treatment effect.

Genealogy consequence

The neurostimulation branch should split at this node:

cTBS + AMT

→ proximal emotional-attention/gaze change — supported
→ incremental anxiety symptom reduction — constrained / not demonstrated

This becomes a high-value inference-boundary node in Evidence-Gated Genealogy v1.