Late-Onset Mania With Psychotic Features Precipitated by Umrah Pilgrimage: A Place- and Culture-Associated Psychiatric Syndrome.

Alcohol impairs executive functioning, including inhibitory control, contributing to increased drinking and other adverse consequences (, , , , ). Laboratory studies consistently show that alcohol increases inhibition failures on cognitive-control tasks (, , , , , ). These impairments may reflect altered function within prefrontal networks, including the dorsolateral prefrontal cortex (DLPFC) and connected regions supporting executive control, working memory, and goal-directed behavior (, , , , , ). The DLPFC interacts with regions involved in conflict monitoring and action selection, including the dorsal anterior cingulate cortex, as part of a distributed cognitive-control network (, , , ). Transcranial magnetic stimulation (TMS) permits causal testing of cortical contributions to behavior (, ). Intermittent theta burst stimulation (iTBS) is often characterized as excitatory, although its effects vary by dose, spacing, and brain state, and higher pulse doses may produce effects opposite to standard protocols (Di Lazzaro and Pilato, 2008a; , , , ). Under sober conditions, prefrontal stimulation has been associated with improved executive control and working memory (, , ). Accelerated protocols deliver multiple stimulation blocks over a short interval and may produce more durable effects (, , , , ). For example, iTBS administrations separated by approximately 30 min produced more sustained motor-cortical excitability than a single administration (). Acute alcohol-related changes in cortical excitability and network dynamics may alter the behavioral effects of stimulation (, , , ). If alcohol-induced disinhibition reflects reduced prefrontal control, iTBS might counteract this effect; alternatively, the alcohol-altered brain state could modify the stimulation response. Despite growing interest in accelerated stimulation and neuromodulation for alcohol-related disorders (, , ), no published study has examined accelerated iTBS during controlled alcohol intoxication in humans.