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. 2025 Oct;25(5):1400-1418.
doi: 10.3758/s13415-025-01314-z. Epub 2025 Jun 23.

Cognitive appraisal modulates Theta Burst Stimulation effects on stress-reactive rumination and affect

Isabell Int-Veen #  1 , Stefanie De Smet #  2   3   4 , Matias M Pulopulos  5 , Gert Vanhollebeke  2   3   6   7 , Beatrix Barth  8   9 , Sarah Pasche  8   9 , Francesco Albasini  10   11   12 , Chris Baeken  2   3   13   14 , Hans-Christoph Nuerk  9   15 , Christian Plewnia  8   9 , Vanessa Nieratschker  8   9 , Andreas Jochen Fallgatter  8   9 , Ann-Christine Ehlis  8   9 , David Rosenbaum #  8 , Marie-Anne Vanderhasselt #  2   3
Affiliations

Cognitive appraisal modulates Theta Burst Stimulation effects on stress-reactive rumination and affect

Isabell Int-Veen et al. Cogn Affect Behav Neurosci. 2025 Oct.

Abstract

The DLPFC plays a central role in cognitive appraisal and stress regulation, as this process-particularly secondary appraisal, where individuals assess their ability to cope with a situation-significantly influences stress responses on both psychological and physiological levels. We conducted a study where we applied different types of Theta Burst Stimulation (intermittent (i)TBS vs. continuous (c)TBS vs. sham (s)TBS) to the left DLPFC to increase or decrease the cortical excitability of the prefrontal neural network. We then examined how participants responded psychologically and physiologically to a potent psychosocial stressor, the Trier Social Stress Test (TSST), and aimed to investigate the influence of secondary cognitive appraisal on the effects of TBS on the stress response. Depending on the stimulation, we discovered that the cognitive appraisal significantly influenced rumination, positive and negative affect specifically in stress recovery. More precisely, as expected, individuals who perceived greater control experienced a faster recovery of stress-reactive ruminative thinking following sTBS and lower rumination following the stressor. We found lower increases and faster recovery of negative affect in all stimulation conditions and faster decreases in positive affect after the TSST following cTBS and iTBS, suggesting beneficial effects of both stimulation conditions. Concerning the assessed physiological variables, namely heart rate, heart rate variability, and salivary cortisol, we did not observe any impact of appraisal. These findings suggest that the effect of secondary appraisal on psychological variables depends on the type of stimulation, and while it may be linked to increased DLPFC activity, further research is needed to clarify the neurostimulation mechanisms involved.

Keywords: Appraisal; Dorsolateral Prefrontal Cortex; Rumination; Stress; Theta Burst Stimulation; Trier Social Stress Test.

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Conflict of interest statement

Declarations. Ethics approval: This study was approved by the ethics committees at the University Hospital of Ghent (UZGent) and the University Hospital of Tübingen (UKT) (UZGent: B67Q2021000115, UKT: 673/2019BO1) and are in line with the Declaration of Helsinki in its latest version. Consent to participate: All participants gave written informed consent prior to study participation. Consent to publication: All participants consent to their data being published in the article. Conflicts of interest/Competing interests: The authors have no relevant financial or nonfinancial interests to disclose. Open Practices Statements: The data and materials for the experiment reported here is available; none of the experiments was preregistered.

Figures

Fig. 1
Fig. 1
Experimental procedure. cTBS = continuous Theta Burst Stimulation; ECG = electrocardiogram; iTBS = intermittent Theta Burst Stimulation; PANAS = Positive and Negative Affect Schedule; PASA = Primary Appraisal Secondary Appraisal Scale; SERI = State Emotion Regulation Inventory; state rum = state rumination questionnaire; sTBS = sham Theta Burst Stimulation; VAS = Visual Analogue Scale assessing current stress (0–100%)
Fig. 2
Fig. 2
Raincloud plots for subjective stress dependent on PASA secondary appraisal. Note that in terms of clearer visualization, we categorized continuous PASA secondary appraisal in low and high scores according to a median split. Individual jittered raw data are represented by dots. Data distributions are depicted by split-half violin plots (on the right side of each series of boxplots). Each boxplot displays the stimulation condition median alongside the interquartile ranges (horizontal lines). min = minutes; post speech = post job interview of the TSST; post math = post arithmetic task of the TSST; TSST = Trier Social Stress Test
Fig. 3
Fig. 3
Raincloud plots for state rumination dependent on stimulation condition (A = sTBS, B = iTBS, C = cTBS) and PASA secondary appraisal. Note that in terms of clearer visualization, we categorized continuous PASA secondary appraisal in low and high scores according to a median split. Individual jittered raw data are represented by dots. Data distributions are depicted by split-half violin plots (on the right side of each series of boxplots). Each boxplot displays the stimulation condition median alongside the interquartile ranges (horizontal lines). cTBS = continuous Theta Burst Stimulation; iTBS = intermittent Theta Burst Stimulation; min = minutes; sTBS = sham Theta Burst Stimulation; TSST = Trier Social Stress Test
Fig. 4
Fig. 4
Predicted values (marginal effects) for state rumination post 60 min TSST dependent on PASA secondary appraisal ratings for each stimulation condition (A = sTBS, B = iTBS, C = cTBS), respectively. cTBS = continuous Theta Burst Stimulation; iTBS = intermittent Theta Burst Stimulation; sTBS = sham Theta Burst Stimulation; PASA = Primary Appraisal Secondary Appraisal Scale
Fig. 5
Fig. 5
Raincloud plots for positive affect dependent on stimulation condition (A = sTBS, B = iTBS, C = cTBS) and PASA secondary appraisal. Note that in terms of clearer visualization, we categorized continuous PASA secondary appraisal in low and high scores according to a median split. Individual jittered raw data are represented by dots. Data distributions are depicted by split-half violin plots (on the right side of each series of boxplots). Each boxplot displays the stimulation condition median alongside the interquartile ranges (horizontal lines). cTBS = continuous Theta Burst Stimulation; iTBS = intermittent Theta Burst Stimulation; min = minutes; sTBS = sham Theta Burst Stimulation; TSST = Trier Social Stress Test
Fig. 6
Fig. 6
Predicted values (marginal effects) for positive affect 0 min post TSST dependent on PASA secondary appraisal ratings for each stimulation condition (A = sTBS, B = iTBS, C = cTBS), respectively. cTBS = continuous Theta Burst Stimulation; iTBS = intermittent Theta Burst Stimulation; sTBS = sham Theta Burst Stimulation; PASA = Primary Appraisal Secondary Appraisal Scale
Fig. 7
Fig. 7
Raincloud plots for negative affect dependent on stimulation condition (A = sTBS, B = iTBS, C = cTBS) and PASA secondary appraisal. Note that in terms of clearer visualization, we categorized continuous PASA secondary appraisal in low and high scores according to a median split. Individual jittered raw data are represented by dots. Data distributions are depicted by split-half violin plots (on the right side of each series of boxplots). Each boxplot displays the stimulation condition median alongside the interquartile ranges (horizontal lines). cTBS = continuous Theta Burst Stimulation; iTBS = intermittent Theta Burst Stimulation; min = minutes; sTBS = sham Theta Burst Stimulation; TSST = Trier Social Stress Test
Fig. 8
Fig. 8
Predicted values (marginal effects) for negative affect 60 min post TSST dependent on PASA secondary appraisal ratings for each stimulation condition (A = sTBS, B = iTBS, C = cTBS). cTBS = continuous Theta Burst Stimulation; iTBS = intermittent Theta Burst Stimulation; sTBS = sham Theta Burst Stimulation; PASA = Primary Appraisal Secondary Appraisal Scale
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