Behavioural Brain Research 439 (2023) 114247

Contents lists available at ScienceDirect

Behavioural Brain Research

journal homepage: www.elsevier.com/locate/bbr

Transcutaneous auricular vagus stimulation (taVNS) improves human

working memory performance under sleep deprivation stress
Rui Zhao a, 1, Meng-Ying Chang a, 1, Chen Cheng b, 1, Qian-Qian Tian b, c, Xue-Juan Yang b, c, d, *,
Meng-Yu Du b, c, Ya-Peng Cui b, c, Zhao-Yang He a, Fu-Min Wang a, Yao Kong a, Hui Deng b, c, d,
Li-Ming Lu e, Chun-Zhi Tang e, Neng-Gui Xu e, Jin-Bo Sun b, c, d, *, Wei Qin b, c, d
a
School of Electronics and Information, Xi’an Polytechnic University, Xi’an, China
b
Intelligent Non-Invasive Neuromodulation Technology and Transformation Joint Laboratory, Xidian University, Xi’an, Shaanxi 710126, China
c
Engineering Research Center of Molecular and Neuro Imaging of the Ministry of Education, School of Life Science and Technology, Xidian University, Xi’an, Shaanxi
710126, China
d
Guangzhou Institute of Technology, Xidian University, Xi’an, Shaanxi 710126, China
e
South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine,
Guangzhou, China

A R T I C L E I N F O A B S T R A C T

Keywords: Many human activities require high cognitive performance over long periods, while impairments induced by
TaVNS sleep deprivation influence various aspects of cognitive abilities, including working memory (WM), attention,
Working memory and processing speed. Based on previous research, vagal nerve stimulation can modulate cognitive abilities,
Sleep deprivation
attention, and arousal. Two experiments were conducted to assess the efficacy of transcutaneous auricular vagus
Fatigue countermeasure
nerve stimulation (taVNS) to relieve the deleterious effects of sleep deprivation. In the first experiment, 35
Non-invasive neuromodulation
participants completed N-back tasks at 8:00 a.m. for two consecutive days in a within-subject study. Then, the
participants received either taVNS or earlobe stimulation (active control) intervention in two sessions at random
orders after 24 h of sustained wakefulness. Then, they completed the N-back tasks again. In the second exper­
iment, 30 participants completed the psychomotor vigilance task (PVT), and 32 completed the N-back tasks at
8:00 a.m. on the first and second days. Then, they received either taVNS or earlobe stimulation at random orders
and finished the N-back and PVT tasks immediately after one hour. In Experiment 1, taVNS could significantly
improve the accuracy rate of participants in spatial 3-back tasks compared to active control, which was
consistent with experiment 2. However, taVNS did not specifically enhance PVT performance. Therefore, taVNS
could be a powerful intervention for acute sleep deprivation as it can improve performance on high cognitive
load tasks and is easy to administer.

1. Introduction
Fatigue caused by acute or chronic sleep deprivation (SD) impairs
cognition and its various aspects, such as working memory (WM),
attention, reaction time, processing speed, multi-task, and verbal
learning [1-5]. Sleep deprivation is a severe problem for people working
long hours, including those in the military, medicine, or transportation
industry. As a result, damaging the psychological and physiological re­
activities may lead to serious somatic illness. Moreover, individuals with
long-term SD are also at risk of making errors due to sleepiness and
fatigue, leading to dangerous consequences. For instance, numerous
studies indicated that long nurses’ shifts caused increased procedural
and medical incidents [6]. The many errors of pilots are associated with
sleep loss, and up to 20 % of motor vehicle incidents are due to drowsy
driving [7]. Furthermore, Dawson et al. inferred that high operational
tempo led to performance changes similar to those induced by 0.05–0.08
% blood alcohol concentrations [8]. SD-induced fatigue has seriously
threatened public health, and investigating possible anti-fatigue

* Corresponding authors at: Intelligent Non-Invasive Neuromodulation Technology and Transformation Joint Laboratory, Xidian University, Xi’an, Shaanxi
710126, China
E-mail addresses: xjyang@xidian.edu.cn (X.-J. Yang), sunjb@xidian.edu.cn (J.-B. Sun).
1
Co-first author, equal contribution

https://doi.org/10.1016/j.bbr.2022.114247
Received 6 August 2022; Received in revised form 23 November 2022; Accepted 1 December 2022
Available online 5 December 2022
0166-4328/© 2022 Elsevier B.V. All rights reserved.
R. Zhao et al.
measures is necessary.
Some fatigue countermeasures exist, including stimulant medicines,
such as caffeine, theophylline, and amphetamine, etc [9–12]. However,
some stimulants, like amphetamine, are unsuitable for people working
long night shifts considering their pharmacological nature and side ef­
fects. Caffeine and tea are commonly used fatigue countermeasures,
which could improve visual vigilance, choice reaction time and
self-reported fatigue after long SD. They are even involved in hippo­
campal antioxidant defense [10,13,14]. However, they have varying
benefits among individuals, which decline over long-time usage. Be­
sides, some studies revealed that though caffeine could improve sus­
tained attention impaired by SD, it did not elevate behavioral
performance with a high cognitive load which is essential for occupa­
tional settings [12,15]. Therefore, some non-pharmacological methods,
including transcranial direct current stimulation (tDCS), transcranial
alternating current stimulation (tACS), and transcranial magnetic
stimulation (TMS) are promising [16–20]. These non-invasive elec­
trical/magnetic neuromodulation devices can modulate the excitability
of a range of cortical and subcortical regions and demonstrate significant
potential in controlling cognition and regulating sleep [16,17]. How­
ever, the underlying mechanisms of these technologies behind fatigue
control are unknown, and several recent meta-analyses cast doubt on the
effects of tDCS on cognitive performance [21,22]. Thus, the research of
innovative therapeutic approaches has turned into a "cutting-edge"
topic.
Alternatively, transcutaneous auricular vagus nerve stimulation
(taVNS) is a noninvasive stimulation of peripheral nerves under the
surface of the ear skin. Recently, it has gained ever-increasing scientific
interest for a bottom-up direction of sleep control from subcortical to
cortical structures. The vagus nerve projects to the nucleus tractus sol­
itarii (NTS) in the medulla, and associates with other brainstem nuclei
and higher-order structures, such as the thalamus, hippocampus,
amygdala, and insula [23,24]. Several brain imaging studies revealed
that various cortex and sub-cortex regions highly associated with
cognitive performance, including the contralateral postcentral gyrus,
bilateral insula, frontal cortex, right operculum, left cerebellum, insula,
hippocampus, amygdala, and thalamus, were regulated by taVNS [25,
26]. Additionally, the afferent nerves of the vagus connect to the NTS
and activate the noradrenergic neurons in the locus coeruleus (LC) and
cholinergic neurons within the nucleus basalis. Thus, it innervates the
central nervous system and is the primary source of norepinephrine (NE)
and acetylcholine for the neocortex [27–29]. Both the locus
coeruleus-norepinephrine (LC-NE) system and acetylcholine help regu­
late many behaviors impacted by SD, such as memory retention and
formation, attention, wakefulness, and arousal level [28,30,31].
Therefore, LC is recognized as a significant wakefulness-promoting nu­
cleus [32]. Stimulating vagus nerves activating LC could be a powerful
countermeasure for fatigue.
There is a solid theoretical foundation supporting vagal nerve stim­
ulation. It has been an FDA-approved medical treatment for epilepsy and
major depressive disorder (MDD) for over two decades. However,
studies investigating the effects of taVNS on fatigue control are limited.
For instance, Lindsey et al. (2021) observed that cervical transcutaneous
vagal nerve stimulation (ctVNS) could significantly improve the per­
formance on arousal and multi-tasks of participants, and induce lower
fatigue ratings than a sham condition after 34 h SD [33]. Nevertheless, it
is still unclear if taVNS has similar anti-fatigue effects after SD. Previous
studies suggested that taVNS could significantly improve the cognitive
performances of healthy volunteers, such as divergent thinking [34],
inhibitory control processes [35], emotion recognition [36], attentional
processes [37] and working motivation [38]. Our team had previously
identified that taVNS could effectively ameliorate WM performance,
which is a core component of cognitive functions in healthy teenagers
[39]. However, these results specific to the high load WM task (spatial
3-back WM) may be because taVNS mainly plays a role in high cognitive
functions modulation. Thus, in the present study we used WM tasks with
2
Behavioural Brain Research 439 (2023) 114247
both high and low cognitive load, and psychomotor vigilance task (PVT)
to investigate the effect of taVNS on relieving SD-related cognitive
deficits. Furthermore, it was examined whether the relief effects of
taVNS were universal for all cognition or specific to the high-load
cognitive functions.
2. Material and methods
2.1. Experiment 1
We focused on the facilitation of taVNS on the WM performance of
the subjects after 24 h of SD in the first experiment to illustrate the
positive modulation effects of taVNS on WM performance [39].
2.1.1. Participants
Forty healthy students from Xidian University were recruited in this
experiment from February to April in 2021. All participants were right-
handed, without any smoking history, neurological disease (e.g., epi­
lepsy), psychiatric disorders (e.g., schizophrenia, depression), brain
damage, or regular use of drug or medicine affecting heart rates (e.g.,
anti-anxiety drug). Besides, we excluded participants with a score higher
than 11 on the Epworth sleeping scale (ESS) [40], higher than 15 on the
Insomnia severity index (ISI) [41], higher than 12 on the Pittsburgh
sleep quality index (PSQI) [42], or a body mass index (BMI) higher than
30, to reduce heterogeneity between individuals and the influence of
various sleep disorders. None of the participants had ear injuries, drank,
or took medicines 48 h before the experiment. The participants signed
the informed consent after briefed about the stimulation procedure and
experimental protocols. Participants who successfully completed the
investigation received the corresponding remuneration and could
choose to withdraw from the experiment at any time. Four students
could not complete the entire experiment, and one student was excluded
because the baseline matching accuracy rate of the spatial 3-back task
was less than 50 %. Finally, the statistical analysis was performed among
35 students (mean age 21.26 ± 1.90 years, range from 18 to 26 years;
mean BMI 21.73 ± 2.80; 16 females). The research was conducted in
accordance with the Declaration of Helsinki and was approved by the
institutional research ethics committee of the Xijing Hospital of the Air
Force Medical University. Written informed consent was obtained from
all subjects prior to the study.
2.1.2. Experiment protocol
We employed a within-subject design with two sessions to determine
the facilitation effect of taVNS on WM performance after SD. Each
participant underwent a different type of stimulation in each session, i.
e., taVNS or earlobe stimulation (an active stimulation control). The
time interval was longer than one week between the two sessions. For
each participant, the first one used was randomly selected from the two
types of stimulation, and then the one used second was determined.
Participants were familiarized with the experimental procedure and
kept practicing the behavioral tasks (see the "Behavioral task paradigm"
section below for details) until the accuracy rate was higher than 75%
before the formal experiment sessions, which lasted about one to three
hours. In the formal sessions, participants were required to arrive at the
laboratory at about 8:00 a.m. and complete N-back tasks (T1). Then,
they could leave the laboratory and return at 9:00 p.m., but having a nap
or drink with caffeine was not allowed during daytime. They were kept
awake under the supervision of the experimenter during the night. At
8:00 a.m. the next day, participants completed the second version of N-
back tasks (T2). At about 8:30 a.m., participants sat in a chair and
received a 30-minute taVNS or earlobe stimulation intervention. All the
subjects were kept awake throughout the 30-minute stimulation.
Finally, they completed the N-back task again at 9:00 a.m. (T3) (see
Fig. 1A).
R. Zhao et al.
Fig. 1. Overview of this study. PVT represents psychomotor vigilance task, N-back refers to spatial 1 and 3-back tasks, and stimulation including taVNS and earlobe
stimulation (active control) which counterbalanced between participants.
2.1.3. Behavioral tasks paradigm
We employed the spatial N-back tasks with two cognitive loads (1-
back and 3-back) for this experiment. It is one of the most frequently
used paradigms to assess WM capacity [43]. The psychology experiment
computer program E-Prime version 3.0 was employed to administer this
task and record the response accuracy and reaction time for all the
participants.
The spatial 1-back and 3-back tasks were organized based on a block-
design paradigm where participants were asked to watch the 72 stimuli
in the task repeated in four blocks (1-back, 3-back, 1-back, 3-back). Each
block had the same number of "matching" (n = 24) and "non-matching"
(n = 48) responses. Before the formal tasks, there was a small practice
(16 trials). Participants were not allowed to start formal experiments
unless the accuracy rate was over 75 % and the average reaction time
was less than 800 ms. Each stimulus was present for 400 ms, followed by
an interstimulus interval of 1600 ms. Moreover, there was a half-minute
resting time between each block. The stimuli in the spatial N-task had
nine square areas, with one of the squares marked with an "*". Each trial
was inserted in picture format with 257 × 257 width and height pixels.
Stimuli were presented in a pseudorandom order to prevent the same
stimuli from appearing more than three times consecutively. Partici­
pants were required to answer whether "*" was in the same stimulus
location as in previous (1 or 3) trials. Later, it was impulsive for the
participants to make a choice, which was done using a keyboard. "J"
represented ’match,’, while "F" represented ’mismatch.’.
2.1.4. taVNS stimulation equipment and parameters
XD-Kerfun Intelligent Non-invasive Neuromodulation Technology
and Transformation Joint Laboratory, Xidian University, Xi’an, China
(BS-VNS-001), helped make the electrical stimulation equipment used in
this study. This version has been used in previous studies [39]. The
taVNS channel was connected to the two silver chloride electrodes
(outer diameter 7 mm). The anode and cathode of taVNS were placed at
the left cymba conchae using the outside anode and 0.5 cm apart from
the cathode. The electrical stimulation waveform was a single-phase
rectangular pulse with a pulse width of 500 microseconds and a 25 Hz
frequency. The current intensity was set based on the sensory threshold
of each subject. To avoid habituation, the current was delivered with a
cycle of 30 s on and 30 s off. Except for the anode and cathode of taVNS
were placed in the left earlobe with the anode front side and cathode
back side. The current parameters of the active control condition were
3
Behavioural Brain Research 439 (2023) 114247
the same as taVNS. Based on previous studies [38,39], the stimulation
strength was assessed individually with VAS pain ratings (i.e., "How
strongly do you perceive pain induced by the stimulation?" ranging from
0, "no sensation," to 10, "strongest sensation imaginable") for both taVNS
and active sham stimulation condition. The stimulation started with a
0.1 mA intensity, which intensified by 0.1 mA until the subject reported
slight pain (corresponding to 7 or higher on the subjective sensation
rating). The intensity was lowered by 0.1 mA until it reached the
baseline 0.1 mA below the light tingling threshold (corresponding to 3
or lower). The protocol was repeated twice, and the average of the in­
tensities was the stimulation threshold with a 5 rating (mild tingling).
2.1.5. Data analysis
We used the primary WM outcome measures on the N-back tasks for
determining the accuracy in matching (mACC) and mismatching (mis­
mACC) trials and reaction time in accurate trials (aRT). First, paired T-
tests were used to conform that WM performance was not different be­
tween two conditions (taVNS and control) at baseline test (T1) and SD
impairments after 24 h (the impairments were defined by T2 divided by
T1, i.e., T2/T1). Additionally, paired T-tests were utilized to assess the
impairments due to 24 h SD in both taVNS and sham conditions. The
intraclass correlation coefficient (ICC) was employed to compare the
reliability of individual changes (i.e., T2 divided by T1, T2/T1) after
24 h SD in the taVNS and sham condition. Permutation-test-based two-
way ANOVAs with 100,000 random samplings were employed to assess
the main effects of Conditions (2 levels, taVNS, and control) and Time (2
levels, T2 divided by T1 and T3 divided by T1, i.e., T2/T1 and T3/T1) for
the WM performance changes, and their interactions. Permutation-test-
based post hoc effect analysis of performance changes (T2/T1 and T3/
T1) were used in significant interaction effects through paired T-test for
conditions (taVNS vs. control). Moreover, Bonferroni correction was
employed to account for multiple comparisons.
2.2. Experiment 2
This experiment aimed to verify experiment 1 and investigate the
facilitation of taVNS on alertness in the psychomotor vigilance task
(PVT). It is somewhat similar to the 1-back task and sensitive to SD-
induced fatigue. In addition, the persistence of taVNS intervention on
behavioral performance was further investigated by testing behavioral
performance after one hour of stimulation. The research was conducted
R. Zhao et al.
in accordance with the Declaration of Helsinki and was approved by the
institutional research ethics committee of the Xijing Hospital of the Air
Force Medical University, too. Written informed consent was obtained
from all subjects prior to the study.
2.2.1. Participants
From June to August in 2021, thirty-six healthy students at Xidian
University were recruited and inclusion criteria was the same as
Experiment 1. Four students could not complete the entire experiment
and 32 students were included in the statistical analysis (mean age
19.65 ± 1.34 years, range from 18 to 23 years; 13 females; mean BMI
20.93 ± 2.71). However, two students were excluded in PVT analysis
because of data missing caused by subjects’ number code error. There­
fore, in total 30 subjects were included in the PVT statistical analysis.
2.2.2. Experiment protocol
This was a within-subject design similar to experiment 1. Partici­
pants first came to the lab to familiarize themselves with the experi­
mental procedure and practice the behavioral tasks. Before the formal
experiment, they were required to get enough sleep. On the formal
experiment day, participants had to be at the lab at about 8:00 a.m. and
complete behavioral tasks (T1). Then, they could leave and come back at
9:00 p.m. However, no nap and drinking caffeine was allowed during
the daytime. They would stay awake under the supervision of experi­
menters until 8:00 a.m., and then finish the behavioral tasks (T2). Later,
they would sit on a chair and receive 30-min taVNS or earlobe stimu­
lation at 8:30 a.m. The subjects were asked to stay awake during the 30-
minute stimulation. Later, participants completed the behavioral tasks
at 9:00 a.m. (T3), and the tasks again after one hour of stimulation at
10:00 a.m. (T4) (see Fig. 1B).
2.2.3. Behavioral tasks paradigm
Two cognitive tasks were employed in this experiment, i.e., spatial N-
back tasks and psychomotor vigilance task (PVT). PVT is a sustained
attention task with a reliable index for objective drowsiness [44,45]. The
psychology experiment computer program E-Prime version 3.0 was
employed to administer the tasks and record the response accuracy and
reaction time of all participants. Spatial N-back tasks with two cognitive
loads (1-back and 3-back) were similar to experiment 1. We employed
the paradigm used in our previous studies [46,47] for PVT task. Briefly,
the participants placed their dominant finger on the response button,
responding as quickly as possible to a red target circle (PVT stimulus) in
the center of a black background screen that remained for 2 s. When
participants responded, the red target circle disappeared and the reac­
tion time (RT) was displayed for feedback. Random inter-stimulus in­
tervals ranged from 2 to 10 s, with an approximate task duration of
7 min
2.2.4. taVNS stimulation equipment and parameters
All the stimulation parameters were the same as experiment 1.
2.2.5. Data analysis
The data analysis processes were similar to Experiment 1. We used
the accuracy in matching trials (mACC), accuracy in mismatching trials
(mismACC), and reaction time in accurate trials (aRT) on the N-back
tasks as the primary WM outcome measures. The mean reaction time
(mRT), the standard deviation of mean reaction time, the coefficient of
variation, the mean reaction time of 10% of the fastest trials (fast RT),
and the reciprocal of the mean reaction time of the slowest 10% trials
(slow 1/RT) were utilized as the primary PVT outcome measures. Paired
T-tests compared the difference between two conditions (taVNS and
control) at baseline and after 24 h SD (T2/T1). The intraclass correlation
coefficient (ICC) was used to test the reliability of individuals changes
(T2/T1) after 24 h SD between the taVNS and sham sessions. Then,
permutation-test-based two-way ANOVAs with 100,000 random sam­
plings were employed to assess the main effects of Conditions (2 levels,
4
Behavioural Brain Research 439 (2023) 114247
taVNS, and control) and Time (3 levels, T2/T1, T3/T1 and T4/T1) for
the behavioral changes, and their interaction effects (Time­
×Conditions). Permutation-test-based post-hoc effect analysis of per­
formance changes (T2/T1, T3/T1 and T4/T1) was utilized in significant
interaction effects through paired T-test for two conditions (taVNS vs.
control). Bonferroni correction was employed to account for multiple
comparisons.
3. Results
3.1. Experiment 1
In this experiment, we tested the cognitive impairments caused by
24 h sleep deprivation and the immediate improvement of taVNS
intervention on WM performance under this sleep deprivation stress.
3.1.1. Comparison of baseline
No significant difference was observed between taVNS and control
conditions at baseline (p > .05) and after SD impairments (p > .05) (see
Table S1 in supplementary materials). No significant difference between
taVNS first and sham first group (p > .05) at T1 (baseline performance),
T2 (performance after 24-hour sleep deprivation) and T3 (performance
after taVNS intervention), which indicated that there was no significant
order effect of taVNS intervention. Results were presented in Table 1.
3.1.2. Impairments caused by sleep deprivation
The impairments caused by SD were substantial on the accuracy rate
of matching trials (mACC, p < .001) and mismatching trials (mismACC,
p = .01) in spatial 1-back task. In the spatial 3-back task, the SD effects
were significant in reaction time (aRT, p = .002), the accuracy rate of
matching trials (mACC, p < .001), and mismatching trials (mismACC,
p = .01) (see Table 2). Except for aRT in spatial 1-back task (p = .07)
and spatial 3-back task (p = .79), the intraclass correlation coefficient
(ICC) of performance changes were significantly caused by 24-hour SD
(T2 divided by T1, i.e., T2/T1) in accuracy rate (mACC and mismACC) in
both spatial 1-back and 3-back tasks (p < .001). This indicated that the
individuals had stable impairments caused by 24 h SD on the accuracy
rate of spatial n-back tasks performance (see Table 3).
3.1.3. Spatial 1-back task
The main effects of time were significant in aRT (F(1,34) = 15.65,
p = .002), but not in mACC (F(1,34) = 6.78, p = .058) and mismACC (F
(1,34) = 2.33, p = 1.00), which suggested that only reaction time
significantly changed with time in both taVNS and sham condition. At
the same time, the main effects of conditions were insignificant in aRT (F
(1,34) = .69, p = 1.00), mACC (F(1,34) = 1.42, p = 1.00), and mis­
mACC (F(1,34) = .24, p = 1.00), indicating that the participants per­
formed similarly in the two conditions. The interaction between time
and conditions was insignificant in all three indexes, i.e., aRT (F(1,34)
= 4.17, p = .29), mACC (F(1,34) = 2.22, p = .87), and mismACC (F
(1,34) = .47, p = 1.00, see Table 4). These results suggested a limited
immediate effect of taVNS on spatial 1-back performance.
3.1.4. Spatial 3-back task
The main effects of time were significant in aRT (F(1,34) = 18.47,
p < .001), but not in mACC (F(1,34) = 2.15, p = .91) and mismACC (F
(1,34) = 1.95, p = 1.00), depicting that reaction time changed signifi­
cantly at different time point. Simultaneously, the accuracy rate was
relatively stable. The main effects of conditions were insignificant in aRT
(F(1,34) = 1.12, p = 1.00), mACC (F(1,34) = 1.11, p = 1.00), and mis­
mACC (F(1,34) = .08, p = 1.00), demonstrating that the average per­
formance was similar in taVNS and control conditions. The interaction
between time and conditions was insignificant in aRT (F(1,34) = .90,
p = 1.00), but significant in mACC (F(1,34) = 12.11, p = .006) and
mismACC (F(1,34) = 8.29, p = .02) (see Table 4). Post-hoc analysis on
accuracy rate in both mACC and mismACC suggested that stimulation
R. Zhao et al. Behavioural Brain Research 439 (2023) 114247

Table 1
The order effect of taVNS first vs sham first in Experiment 1.
Tasks Outcome measures Time 1 Time 2 Time 3

t-test p value t-test p value t-test p value

Spatial 1-back aRT t(33) = .48 .64 t(33) = − .55 .59 t(33) = − .07 .95
mACC t(33) = − 1.10 .28 t(33) = − .29 .77 t(33) = .04 .97
mismACC t(33) = − .31 .76 t(33) = .85 .40 t(33) = − .05 .97
Spatial 3-back aRT t(33) = .44 .66 t(33) = .46 .65 t(33) = .69 .50
mACC t(33) = − .98 .34 t(33) = − .66 .51 t(33) = − .97 .34
mismACC t(33) = − .15 .88 t(33) = .17 .87 t(33) = 1.32 .20

Note: Results showed the performance difference between two groups (taVNS first vs sham first) in taVNS condition. The aRT is the reaction time in accurate trials;
mACC is the accuracy rate in matching trials; mismACC is the accuracy rate in mismatching trials. For PVT, mRT is the mean reaction time; Fast RT is the reaction time
of 10% of the fastest trials; Slow 1/RT is the inverse of mean reaction time of the 10 % of the slowest trials. Time 1 showed performance at baseline, Time 2 showed
performance after 24 h sleep deprivation, and Time 3 showed performance after taVNS intervention. All the p values were raw results without Bonferroni correction.

effects (T3/T1 vs. T2/T1) due to taVNS (t(34) = 3.28, p = .009 for
Table 2 mACC; t(34) = 2.63, p = .034 for mismACC) were significantly larger
Impairments caused by 24 h sleep deprivation in each outcome measure.
than earlobe stimulation (t(34) = − 1.16, p = 1.00 for mACC; t(34) = −
Tasks Outcome measures Experiment 1 Experiment 2 1.61, p = .467 for mismACC) (see Table 5). These results indicated that
t-test p value t-test p value taVNS could significantly improve the accuracy rate of WM performance
Spatial 1- aRT t(34) = .72 t(31) = < .001 after 24 h of SD than earlobe stimulation (control) (see Fig. 2).
back 1.57 5.20
mACC t(34) = − < .001 t(31) = − .03
7.37 4.48 3.2. Experiment 2
mismACC t(34) = − .01 t(31) = − < .001
3.19 6.03
Spatial 3- aRT t(34) = .002 t(31) = < .001
In the first experiment, we discovered an immediate improvement of
back 3.73 6.04 taVNS on spatial WM performance after 24-hour sleep deprivation. In
mACC t(34) = − < .001 t(31) = − < .001 this experiment, we aimed to replicate these results and further inves­
4.74 7.88 tigate the duration of taVNS effect.
mismACC t(34) = − .01 t(31) = − < .001
3.14 5.18
PVT mRT t(31) = < .001 3.2.1. Comparison of baseline
4.71 In all the behavioral tasks, no significant difference was observed
standard deviation t(31) = .03 between taVNS and active control conditions before (T1) and after SD
of mRT 2.93 impairments (T2/T1) (p > .05) (see Table S1 in supplementary mate­
coefficient of t(31) = .02
variation 2.99
rials). No significant difference between taVNS first and sham first group
Fast RT t(31) = < .001 (p > .05) at T1 (baseline performance), T2 (performance after 24-hour
5.18 sleep deprivation), T3 (performance after taVNS intervention) and T4
Slow 1/RT t(31) = − < .001 (performance at one hour after taVNS intervention), which indicated
4.96
that there was no significant order effect of taVNS intervention (see
Note: Results showed performance impairments in T2 compared with baseline Table 6).
(T1). For the spatial 1-back and 3-back tasks, aRT is the reaction time in accurate
trials; mACC is the accuracy rate in matching trials; mismACC is the accuracy 3.2.2. Impairments caused by sleep deprivation
rate in mismatching trials. For PVT, mRT is the mean reaction time; Fast RT is The impairments caused by 24 h SD were significant across all
the reaction time of 10 % of the fastest trials; Slow 1/RT is the inverse of mean outcome measures (p < .05) (see Table 2). Except for mismACC in
reaction time of the 10 % of the slowest trials.
spatial 1-back task, aRT in spatial 3-back task and fast RT in PVT task
(p > .05), the intraclass correlation coefficient (ICC) of performance
Table 3 changes due to 24-hour SD (T2/T1) were significant (p < .05). This
The intraclass correlation coefficient (ICC) of performance changes caused by suggested that the impairments caused by SD on spatial n-back and PVT
24 h sleep deprivation (T2 divided by T1) in each outcome measures. performance were stable among individuals (see Table 3).
Tasks Outcome measures Experiment 1 Experiment 2
3.2.3. Psychomotor vigilance task (PVT)
ICC p value ICC p value
The main effects of time were significant in both mean reaction time
Spatial 1-back aRT .25 .07 .41 .01
mACC .57 < .001 .35 .02 (mRT) (F(2,58) = 7.61, p = .004) and standard deviation of mRT (F
mismACC .67 < .001 .07 .36 (2,58) = 5.41, p = .02). However, it was not significant in the coefficient
Spatial 3-back aRT -.14 .79 .22 .11 of variation (F(2,58) = 4.19, p = .10), fast RT (F(2,58) = .97, p = 1.00),
mACC .80 < .001 .61 < .001 and slow 1/RT (F(2,58) = 3.62, p = .16). This suggested that mRT and
mismACC .64 < .001 .61 < .001
PVT mRT .71 < .001
the standard deviation of mRT increased with time while the changes
standard deviation of mRT .39 .01 were insignificant in coefficient of variation, fast RT, and slow 1/RT (see
coefficient of variation .36 .02 Table 7). The main effects of conditions were insignificant in mRT (F
Fast RT .16 .20 (1,29) = .04, p = 1.00), the standard deviation of mRT (F(1,29) = .24,
Slow 1/RT .50 .002
p = 1.00), coefficient of variation (F(1,29) = .23, p = 1.00), fast RT (F
Note: Results showed the stability of impairments induced by 24 h sleep (1,29) = .19, p = 1.00), and slow 1/RT (F(1,29) = .04, p = 1.00), and
deprivation within individuals. For the spatial 1-back and 3-back tasks, aRT is the interaction of time and conditions were also insignificant in all the
the reaction time in accurate trials; mACC is the accuracy rate in matching trials; five indexes, i.e., mRT (F(2,58) = .18, p = 1.00), the standard deviation
mismACC is the accuracy rate in mismatching trials. For PVT, mRT is the mean of mRT (F(2,58) = 1.11, p = .10), coefficient of variation (F(2,58) = .63,
reaction time; Fast RT is the reaction time of 10% of the fastest trials; Slow 1/RT p = 1.00), fast RT (F(2,58) = 1.54, p = 1.00), and slow 1/RT (F(2,58)
is the inverse of mean reaction time of the 10 % of the slowest trials.
= .60, p = 1.00) (see Table 7). These results suggested that although the

5
R. Zhao et al. Behavioural Brain Research 439 (2023) 114247

Table 4
Means, Standard Deviations and two-way ANOVAs results of spatial N-back tasks in Experiment 1.
Spatial 1-back Spatial 3-back

Descriptive statistics aRT mACC mismACC aRT mACC mismACC

Conditions Time Mean±SD Mean±SD Mean±SD Mean±SD Mean±SD Mean±SD

taVNS T1 595.03 ± 114.98 .910 ± .061 .976 ± .023 700.09 ± 161.10 .823 ± .103 .943 ± .059
T2 606.69 ± 120.62 .797 ± .096 .949 ± .056 722.89 ± 155.10 .726 ± .146 .902 ± .094
T3 547.74 ± 102.43 .850 ± .128 .933 ± .094 669.91 ± 150.67 .801 ± .147 .933 ± .112
Control T1 579.54 ± 113.48 .891 ± .067 .976 ± .024 664.54 ± 152.66 .823 ± .114 .949 ± .053
T2 581.49 ± 100.55 .820 ± .119 .956 ± .079 708.77 ± 148.12 .761 ± .157 .925 ± .104
T3 568.34 ± 108.01 .848 ± .117 .943 ± .041 670.54 ± 139.62 .728 ± .202 .916 ± .124
Permutation-based RM ANOVA test
Time F(1,34) ¼ 15.65** F(1,34) = 6.78 F(1,34) = 2.33 F(1,34) = 18.47*** F(1,34) = 2.15 F(1,34) = 1.95
Conditions F(1,34) = .69 F(1,34) = 1.42 F(1,34) = .24 F(1,34) = 1.12 F(1,34) = 1.11 F(1,34) = .08
Time×Conditions F(1,34) = 4.17 F(1,34) = 2.22 F(1,34) = .47 F(1,34) = .90 F(1,34) = 12.11* * F(1,34) = 8.29*

Note: One asterisk indicates a corrected p-value smaller than 0.05, two asterisks indicate a corrected p-value smaller than 0.01, and three asterisks indicate a corrected
p-value smaller than 0.001. Bonferroni correction was used to account for multiple comparisons Control means earlobe stimulation condition; SD means standard
deviation; RM ANOVA means repeated measures analysis of variance. aRT is the reaction time in accurate trials; mACC is the accuracy rate in matching trials;
mismACC is the accuracy rate in mismatching trials.

Table 5
Post hoc of significant Time × Conditions interactions in Experiment 1.
Task Comparison Conditions Spatial 3-back task

estimate SD t test p value* Cohen’d

mACC T3/T1 taVNS .093 .144 t(34) = 3.28 .009 1.125

VS Control -.038 .139 t(34) = − 1.16 1.000 -.400
T2/T1
mismACC T3/T1 taVNS .035 .106 t(34) = 2.63 .034 .902
VS Control -.010 .060 t(34) = − 1.61 .467 -.552
T2/T1

Note: *Bonferroni correction was used to account for multiple comparisons. mACC is the accuracy rate in matching trials, mismACC is the accuracy rate in mismatching
trials; SD means standard deviation; Control is the earlobe stimulation condition. T2/T1 means T2 divided by T1 and T3/T1 means T3 divided by T1

current stimulation could effectively restrain and delay the impairments
induced by SD on mRT and standard deviation of mRT (see Fig. 3), there
were limited immediate effects of taVNS on PVT performance.
3.2.4. Spatial 1-back task
The main effects of time were significant in mACC (F(2,62) = 4.00,
p = .02), but not significant in aRT (F(2,62) = .17, p = .85) and mis­
mACC (F(2,62) = 2.34, p = .10). Thus, except for the accuracy rate in
matching trials, the reaction time and accuracy rate in mismatching
trials remained unchanged with time. The main effects of conditions
were significant in mACC (F(1,31) = 14.41, p < .001) and mismACC (F
(1,31) = 5.74, p = .02), but not significant in aRT (F(1,31) = 1.82,
p = .18), indicating that the average accuracy rate in the taVNS condi­
tion was larger than the control. At the same time, there was no sig­
nificant difference in reaction time between the two conditions.
However, the interactions between time and conditions were insignifi­
cant on aRT (F(2,62) = .91, p = .40), mACC (F(2,62) = 2.68, p = .08),
and mismACC (F(2,62) = 2.37, p = .10, see Table 8). These results were
similar to experiment 1, demonstrating that taVNS induced minimal
improvements on spatial 1-back task.
3.2.5. Spatial 3-back task
The main effects of time and conditions, and their interaction were
significant in mACC (Time: F(2,62) = 6.95, p = .002; Conditions: F
(1,31) = 7.28, p = .01; Time×Conditions: F(2,62) = 5.68, p = .005) and
mismACC (Time: F(2,62) = 3.54, p = .04; Conditions: F(1,31) = 12.76,
p = .001; Time×Conditions: F(2,62) = 5.45, p = .006), but were not
significant in aRT (Time: F(2,62) = .73, p = .48; Conditions: F(1,31)
= .06, p = .81; Time×Conditions: F(2,62) = 1.16, p = .32) (see Table 8).
These results suggested that taVNS effects were significant in accuracy
rate but not reaction time. The post-hoc analysis demonstrated a sig­
nificant impairment after one hour of stimulation than in 24 h SD (T4/
T1 vs. T2/T1) (t(31) = − 4.04, p = .001) in control but not in the taVNS
condition (t(31) = − 1.19, p = 1.00) for mACC. Additionally, the per­
formance at T4 was significantly worse than T3 (T4/T1 vs. T3/T1)
within the taVNS condition (t(31) = − 5.04, p < .001), but not in control
(t(31) = 1.21, p = 1.00, see Table 9). The results indicated a continuous
decline in WM performance after 24 h SD, while this tendency was
restrained and delayed by taVNS. For mismACC, the difference between
T3 and T2 (T3/T1 vs. T2/T1) was significant in control (t(31) = − 2.93,
p = .025) but not in taVNS condition (t(31) = 1.31, p = 1.00). More­
over, there was a significant difference between T4 and T2 (T4/T1 vs.
T2/T1) in the control (t(31) = − 3.27, p = .012) but not in the taVNS
condition (t(31) = − .42, p = 1.00, see Table 9). These results also
indicated that WM performance would continually decline after 24 h SD
while this tendency was effectively restrained and delayed by taVNS(see
Fig. 4).
4. Discussion
The present study employed two independent experiments to assess
the immediate effects of taVNS on WM performance and alertness levels
under 24 h of SD stress, considering the great potential of taVNS in
controlling fatigue, promoting wake, and improving cognitive perfor­
mance. Both experiments found that 24 h of SD significantly impaired
the cognitive abilities of individuals, whether on WM performance or
alertness levels (see Table 3). Therefore, the stress and fatigue induced
by 24 h of SD [2,16,48] were confirmed, consistent with our previous
studies [49–56]. Besides, the behavioral performance impairments were
stable within individuals between two sessions of SD, consistent with
previous studies [57–59]. They indicated that these two tasks could
reflect the impairments in trait rather than a state change. Under this SD
stress, the current study observed that a 30-minute taVNS intervention
could effectively improve the WM accuracy of participants compared

6
R. Zhao et al. Behavioural Brain Research 439 (2023) 114247

Fig. 2. The accuracy rate of matching trials (mACC) and mismatching trials (mismACC) in spatial 3-back trials of Experiment 1. (A) The performance of mACC at
different times in two conditions. (B) The post-hoc results of mACC. (C) The performance of mismACC at different times in two conditions. (D) The post-hoc results of
mismACC. Bonferroni correction was used to account for multiple comparisons. One asterisk indicates a corrected p-value smaller than 0.05, two asterisk indicate a
corrected p-value smaller than 0.01, and three asterisks indicate a corrected p-value smaller than 0.001. Error bars represent standard error.

Table 6
The order effect of taVNS first vs sham first in Experiment 2.
Tasks Outcome measures Time 1 Time 2 Time 3 Time 4

t-test p value t-test p value t-test p value t-test p value

Spatial 1-back aRT t(30) = − .19 .85 t(30) = − .40 .69 t(30) = − .13 .89 t(30) = .62 .54
mACC t(30) = − .62 .54 t(30) = − .83 .41 t(30) = − 2.10 .05 t(30) = − 1.77 .09
mismACC t(30) = 1.62 .12 t(30) = − 1.07 .30 t(30) = − 1.54 .14 t(30) = − 2.06 .05
Spatial 3-back aRT t(30) = − .10 .99 t(30) = − .90 .38 t(30) = .55 .59 t(30) = .86 .40
mACC t(30) = − .48 .63 t(30) = − .76 .45 t(30) = − 1.93 .06 t(30) = − 1.76 .09
mismACC t(30) = − .56 .58 t(30) = − .31 .76 t(30) = − 1.37 .18 t(30) = − 1.56 .13
PVT mRT t(28) = − .01 .99 t(28) = .08 .94 t(28) = .52 .61 t(28) = .23 .82
standard deviation of mRT t(28) = .95 .35 t(28) = .06 .96 t(28) = − .36 .72 t(28) = .46 .65
coefficient of variation t(28) = .85 .40 t(28) = .18 .86 t(28) = − .08 .94 t(28) = .97 .34
Fast RT t(28) = − .24 .81 t(28) = .49 .63 t(28) = .24 .82 t(28) = − .37 .71
Slow 1/RT t(28) = .86 .40 t(28) = − .16 .88 t(28) = − .07 .94 t(28) = − 1.56 .13

Note: Results showed the performance difference between two groups (taVNS first vs sham first) in taVNS condition. For spatial 1, 3-back task, aRT is the reaction time
in accurate trials; mACC is the accuracy rate in matching trials; mismACC is the accuracy rate in mismatching trials. For PVT, mRT is the mean reaction time; Fast RT is
the reaction time of 10 % of the fastest trials; Slow 1/RT is the inverse of mean reaction time of the 10 % of the slowest trials. Time 1 showed performance at baseline,
Time2 showed performance after 24 h sleep deprivation, Time3 showed performance after taVNS intervention, and Time 4 showed performance one hour after taVNS
intervention. All the p values were raw results without Bonferroni correction.

with active control (earlobe stimulation) condition. These results were
replicated in Experiment 2 in an independent cohort. Different aspects,
including circadian rhythmicity and homeostatic sleep pressure, could
have led to these changes. They also impair the performance, varying
from alertness level to high cognitive function, such as WM perfor­
mance. The present study found that taVNS intervention could signifi­
cantly elevate WM performance under SD stress with a high cognitive
load but not PVT task or WM performance with a low cognitive load.
Therefore, taVNS may depict a specific improvement in high cognitive
function rather than general fatigue control. To the best of our knowl­
edge, we were the first to investigate the immediate enhancement of
taVNS on WM performance after 24 h of SD. Moreover, we identified the
potential of taVNS on cognition modulation.
WM capacity combines attentional control with temporary storage
and information manipulation [60], traditionally divided into three
distinct components. These include processing and storing phonologic
information, spatial information, and an executive system allocating
attentional resources [61]. This ability is essential for air traffic con­
trollers, security screeners, cyber operators, etc. Thus, a method to
enhance WM performance is necessary for people with long night shifts.
However, the improvements of taVNS on WM memory performance
were only found in 3-back tasks but not in 1-back tasks, similar to our
previous study [39]. Several studies indicated that SD did not impact all
cognitive tasks, but more specifically, on tasks that were not

7
R. Zhao et al. Behavioural Brain Research 439 (2023) 114247

Table 7
Means, Standard Deviations and two-way ANOVAs results of PVT task in Experiment 2.
Descriptive statistics mRT standard deviation of mRT coefficient of variation Fast RT Slow 1/RT

Conditions Time Mean±SD Mean±SD Mean±SD Mean±SD Mean±SD

taVNS T1 308.27 ± 43.21 90.79 ± 131.27 26.69 ± 29.31 239.64 ± 22.43 2.39 ± .42
T2 353.05 ± 66.51 171.94 ± 267.06 41.3 ± 48.78 256.28 ± 27.76 2.07 ± .49
T3 358.16 ± 67.09 173.70 ± 257.69 39.76 ± 36.74 255.95 ± 30.07 1.91 ± .59
T4 393.60 ± 139.37 271.41 ± 399.02 54.73 ± 60.17 251.13 ± 23.98 1.85 ± .69
Control T1 307.33 ± 50.34 68.65 ± 50.28 20.96 ± 10.96 235.95 ± 24.44 2.40 ± .60
T2 350.77 ± 70.73 130.32 ± 130.60 33.11 ± 25.29 250.96 ± 21.36 2.01 ± .61
T3 353.87 ± 74.39 168.25 ± 219.83 41.22 ± 41.65 241.29 ± 31.89 1.93 ± .48
T4 403.93 ± 163.64 299.19 ± 394.74 57.66 ± 59.76 249.51 ± 29.36 1.80 ± .75
Permutation-based RM ANOVA test
Time F(2,58) = 7.61** F(2,58) = 5.41* F(2,58) = 4.19 F(2,58) = .97 F(2,58) = 3.62
Conditions F(1,29) = .04 F(1,29) = .24 F(1,29) = .23 F(1,29) = .19 F(1,29) = .04
Time×Conditions F(2,58) = .18 F(2,58) = 1.11 F(2,58) = .63 F(2,58) = 1.54 F(2,58) = .60

Note: mRT is the mean reaction time; Fast RT is the reaction time of 10% of the fastest trials; Slow 1/RT is the inverse of mean reaction time of the 10 % of the slowest
trials; Control means earlobe stimulation condition; SD means standard deviation; RM ANOVA means repeated measures analysis of variance. One asterisk indicates a
corrected p-value smaller than 0.05 and two asterisks indicate a corrected p-value smaller than 0.01. Bonferroni correction was used to account for multiple
comparisons

Fig. 3. The mean reaction time and standard deviation of mean RT in PVT task of Experiment 2. (A) The performance of mean reaction time (mean RT) at different
times in two conditions. (B) The performance of standard deviation of mean RT (mean SD) at different times in two conditions. Bonferroni correction was used to
account for multiple comparisons. One asterisk indicates a corrected p-value smaller than 0.05 and three asterisks indicate a corrected p-value smaller than 0.001.
Error bars represent standard error.

Table 8
Means, Standard Deviations and two-way ANOVAs results of spatial N-back tasks in Experiment 2.
Spatial 1-back Spatial 3-back

Descriptive statistics aRT mACC mismACC aRT mACC mismACC

Conditions Time Mean±SD Mean±SD Mean±SD Mean±SD Mean±SD Mean±SD

taVNS T1 460.53 ± 95.02 .834 ± .123 .982 ± .015 498. 88 ± 116.39 .865 ± .106 .965 ± .051
T2 501.63 ± 102.98 .772 ± .165 .911 ± .097 547.28 ± 109.42 .681 ± .211 .909 ± .102
T3 492.38 ± 94.51 .786 ± .142 .951 ± .041 555.78 ± 126.96 .746 ± .163 .929 ± .080
T4 498.88 ± 90.78 .727 ± .179 .913 ± .082 560.19 ± 123.59 .644 ± .206 .902 ± .102
Control T1 448.44 ± 92.28 837 ± .101 .975 ± .022 498.16 ± 120.54 .861 ± .094 .964 ± .050
T2 500.81 ± 106.22 .733 ± .191 .903 ± .090 556.31 ± 123.78 .702 ± .206 .917 ± .091
T3 501.75 ± 88.34 .670 ± .226 .883 ± .118 560.06 ± 102.36 .619 ± .231 .845 ± .148
T4 494.37 ± 108.93 .663 ± .216 .867 ± .122 541.91 ± 121.27 .581 ± .244 .848 ± .145
Permutation-based RM ANOVA test
Time F(2,62) = .17 F(2,62) = 4.00* F(2,62) = 2.34 F(2,62) = .73 F(2,62) = 6.95** F(2,62) = 3.54*
Conditions F(1,31) = 1.82 F(1,31) = 14.41*** F(1,31) = 5.74* F(1,31) = .06 F(1,31) = 7.28** F(1,31) = 12.76***
Time×Conditions F(2,62) = .91 F(2,62) = 2.68 F(2,62) = 2.37 F(2,62) = 1.16 F(2,62) = 5.68** F(2,62) = 5.45**

Note: One asterisk indicates a corrected p-value smaller than 0.05, two asterisks indicate a corrected p-value smaller than 0.01, and three asterisks indicate a corrected
p-value smaller than 0.001. Control means earlobe stimulation condition; SD means standard deviation; RM ANOVA means repeated measures analysis of variance.
Bonferroni correction was used to account for multiple comparisons. aRT is the reaction time in accurate trials; mACC is the accuracy rate in matching trials; mismACC
is the accuracy rate in mismatching trials.

well-learned, not executed automatically, needed deliberate action and there was no significant improvement in the previous ctVNS study that
thought, and were more mentally demanding. Thus, 1-back tasks may be used 2-back tasks [33], which could be due to the difficulty of the tasks.
too simple to benefit from the increasing attention, arousal and wake­ Moreover, taVNS from our previous studies [39,62], only showed
fulness induced by taVNS compared with 3-back tasks. Simultaneously, facilitation on accuracy in matching trials. In this study, taVNS could

8
R. Zhao et al. Behavioural Brain Research 439 (2023) 114247

Table 9
Post hoc of significant Time × Conditions interactions in Experiment 2.
Comparison Conditions mACC mismACC

estimate SD t test p value* Cohen’d estimate SD t test p value* Cohen’d

T3/T1 taVNS .077 .224 t(31) = 1.93 .376 .693 .021 .089 t(31) = 1.31 1.000 .470
vs Control -.092 .242 t(31) = − 2.14 .229 -.769 -.073 .142 t(31) = − 2.93 .025 -1.052
T2/T1
T4/T1 taVNS -.047 .225 t(31) = − 1.19 1.000 -.427 -.007 .090 t(31) = − .42 1.000 .151
vs Control -.142 .199 t(31) = − 4.04 .001 -1.451 -.074 .127 t(31) = − 3.27 .012 1.175
T2/T1
T4/T1 taVNS -.124 .139 t(31) = − 5.04 < .001 -1.810 -.028 .074 t(31) = − 2.10 .256 .754
vs Control -.050 .234 t(31) = 1.21 1.000 .435 < − .001 .169 t(31) = − .01 1.000 .004
T3/T1

Note: *Bonferroni correction was used to account for multiple comparisons. mACC is the accuracy rate in matching trials, mismACC is the accuracy rate in mismatching
trials; SD means standard deviation; Control is the earlobe stimulation condition. T2/T1 means T2 divided by T1, T3/T1 means T3 divided by T1, and T4/T1 means T4
divided by T1.

Fig. 4. The accuracy rate of matching (mACC) and mismatching trials (mismACC) in spatial 3-back trials of Experiment 2. (A) The performance of mACC at different
times in two conditions. (B) The post-hoc results of mACC. (C) The performance of mismACC at different times in two conditions. (D) The post-hoc results of
mismACC. Bonferroni correction was used to account for multiple comparisons. One asterisk indicates a corrected p-value smaller than 0.05, two asterisk indicate a
corrected p-value smaller than 0.01, and three asterisks indicate a corrected p-value smaller than 0.001. Error bars represent standard error.

elevate WM accuracy in matching and mismatching trials. This may be
because that SD increased the difficulty of mismatching trials and cir­
cumvented the ceiling effects.
Besides, a study by McIntire [33] delivered ctVNS before sleep
deprivation at 7:00–8:30 p.m. However, no immediate difference was
observed between the experimental and control groups in both behav­
ioral performance and subjective mood rating. Thus, the ctVNS im­
provements in PVT performance and subjective mood rating came at
7:00 a.m. and 4:00 a.m., respectively, nearly 12 h after stimulation.
However, the present study applied taVNS intervention after 24 h sleep
deprivation and observed immediate improvements in WM perfor­
mance, which disappeared one hour after stimulation. Our previous
studies [39,62] had reported the facilitation of taVNS on WM
performance without SD stress in healthy adults. Therefore, in this
study, the underlying mechanism of taVNS on WM did not work through
increasing wakefulness and arousal levels. In contrast, the facilitation of
taVNS could depend on its modulation effects during high cognitive
functions. However, the arousal levels of participants would decline and
gradually offset the promotive effects of taVNS with the prolonging of
wakefulness time. Although more neurophysiological or biological evi­
dence is needed to elaborate the mechanisms of the improvements in
WM performance, our study provides a potential choice for temporarily
improving cognitive performance post-acute sleep deprivation.
Except for using taVNS to control the adverse effects of sleep
deprivation on behavioral performance in the present study, many
studies reported the facilitation of other brain stimulation techniques,

9
R. Zhao et al.
including tDCS and TMS, on fatigue and cognition decline due to SD [16,
18–20]. Some studies showed that tDCS over left DLPFC did not influ­
ence WM performance of participants [19], even though several studies
reported that TMS over the left dorsolateral prefrontal cortex (DLPFC)
could improve WM performance after 24 h SD. However, some other
tDCS research without sleep deprivation stress improved the reaction
time in WM tasks, which participants were similar to the present study
[63–65]. These findings are different from the current study, and our
previous research found an improvement in the accuracy rate [39,46]. It
suggests that though both vagal nerve stimulation and tDCS could be
effective cognitive modulatory treatments [19,33,66], they may have
different mechanisms and effects on WM performance. Besides, the
primary effects of tDCS modulate the central nervous system with a
"top-down" influence on the cerebral cortex and cognitive functions
[67–69], even though the stimulation on LC may be one of the mecha­
nisms of tDCS on fatigue controlling [19]. On the contrary, vagus nerves
belong to the peripheral nervous, and taVNS displays "bottom-up"
functions in cognition and clinical disorders [70]. Moreover, the vagus
nerves project the nucleus tractus solitarii (NTS) and influence other
brainstem nuclei before affecting higher-order structures [23,24]. The
stimulation of vagus nerves could have a more direct influence on
wakefulness promotion and sleepiness controlling since NTS and other
brainstem nuclei are important for homeostatic and circadian sleep
regulation [71,72]. Thus, the combined stimulation of taVNS and tDCS
could influence sleep deprivation intervention [73], which requires
future study. Though tDCS and caffeine could be powerful fatigue
countermeasures, they had few effects on WM performance under sleep
loss stress [19]. This indicates that taVNS could be another effective
fatigue countermeasure compensating for the current treatments.
An interesting result in the current study is that both taVNS and
earlobe stimulation could restrain and delay the decline of PVT perfor­
mance. In other words, there was no stimulation specificity on PVT
performance. Compared with the study by McIntire [33], there were
specific effects of ctVNS on PVT performance due to three possible
reasons, i.e., stimulation site and time difference. First, the sham con­
ditions were different in the two studies. No electrical stimulation was
delivered in McIntire’s study. However, we used an active sham con­
dition with earlobe electrical stimulation in the present study. The PVT
task is a sample reaction time test that requires the ability to sustain
attention for long periods in an environment with targets appearing
infrequently and randomly in the background. Thus, it is a "simple" that
reflects overall arousal or fatigue levels. Transcutaneous electrical
stimulation could vastly influence this basic cognitive process. Second,
the stimulation sites are different between taVNS and ctVNS. All the
stimulation of taVNS would travel to NTS and then be integrated into the
ascending reticular activating system (ARAS) system since auricular
vagus nerves are made of sensory afferents. They are essential in high
cognitive functions, like WM performance, through different nucleus
[61]. However, cervical vagus nerves are consistent with afferent and
efferent nerves. They innervate numerous visceral organs and muscles,
such as the pharynx, larynx, heart, lungs, bronchi and gut muscles [74,
75]. Besides, participants from McIntire’s study received 2-minute
stimulation for the right and left cervical vagal branches. The cardiac
branch of the right cervical vagus projects to the sinoatrial node, the
primary pacemaker of the heart. In contrast, the left cervical vagus
branch projects to the atrioventricular node, the secondary controller of
the heart [70,76]. Thus, the right ctVNS intervention may substantially
affect visceral organs more than the left ctVNS and taVNS. Therefore,
ctVNS would impact visceral organs and increase the basic arousal level
reflected in the PVT task, except for ascending a part of influence to NTS
and ARAS system. Although positive effects on fatigue control were
found in both taVNS and ctVNS [27] intervention, the underlying
mechanism could lead to varied facilitation of cognitive tasks. Third, the
stimulation time is different from the previous study. McIntire et al. [33]
observed that ctVNS was delivered before SD. The improvements on the
PVT test occurred after about 12 h at 7:00 a.m, directly reflecting the
10
Behavioural Brain Research 439 (2023) 114247
effects of ctVNS on fatigue and drowsiness due to SD. On the contrary,
taVNS was delivered after 24 h SD. Its immediate effect was tested on
behavioral performance, indicating the cognitive modulation effect
rather than the anti-fatigue effect of taVNS. However, both our study
and the one by McIntire [33] failed to examine the mechanisms of the
improvements of taVNS and ctVNS on the arousal levels (PVT perfor­
mance). Therefore, the difference between them and the specific effect
of taVNS on arousal modulation needs further research.
Our study did not examine the mechanisms underlying the effect of
taVNS on WM performance after SD. Several theories could explain
observed behaviors. Firstly, it is known that afferent fibers from vagus
nerves travel to the brainstem, projecting to the NTS [77], and is inte­
grated into the reticular formation (i.e., an extensive network of nerves
with nuclei clusters throughout the brainstem). It further participates in
ARAS, a system with a set of nuclei that release neurotransmitters
directly and through thalamic relays in the cortex [78]. Simultaneously,
the sleep-regulating circadian and homeostatic signals are integrated
within the ARAS system [79]. From the ARAS system, the ascending
monoaminergic projections activate wake-promoting cholinergic basal
forebrain and histaminergic cells a route to the cerebral cortex. At the
same time, the sleep-promoting ventrolateral preoptic area and the
median preoptic area neurons are inhibited, which could help in­
dividuals awake [78]. Secondly, brain imaging studies have indicated
that LC, one of the nuclei of the ARAS system, and the areas innervated
by this region, such as the thalamus, hippocampus, insula, and amyg­
dala, could be activated by taVNS intervention [25]. LC interacts with
cortical and subcortical sensory and attention networks. Moreover, it is
essential in regulating attention, arousal, wakefulness, collecting sen­
sory information, and memory retention [80]. Further, LC can activate
noradrenergic activity, enabling increased forebrain activation and
inducing the waking state with enhanced arousal [80]. LC released NE,
which improves behavioral and cognitive processes [81,82]. Besides,
NTS can activate the noradrenergic neurons in cholinergic neurons
within the nucleus basalis. It innervates the entire central nervous sys­
tem and is the primary source of acetylcholine. Acetylcholine can also
increase wakefulness and arouse levels as an essential neurotransmitter
for most cognitive activities. Thirdly, some of the improvements could
be due to direct influence since this study focused on the immediate
effects of taVNS on behaviors. Previous studies have observed that
taVNS could modulate the activities in various cortical and subcortical
regions. These include the contralateral postcentral gyrus, bilateral
insula, frontal cortex, right operculum, left cerebellum, LC, insula,
hippocampus, amygdala, and thalamus [25,26]. Like the frontal cortex
and hippocampus, these areas are essential for high cognitive functions,
and their activation could directly enhance WM performance.
Nevertheless, the current study has some limitations. Firstly, we
focused on the immediate effects of taVNS on behaviors after acute SD.
However, we did not investigate its prevention roles against acute SD
and facilitation of keeping wakefulness during the night shift. Secondly,
the current stimulation of McIntire et al. [33] was 6-minute, which was
much shorter than ours. Therefore, the effects of other taVNS parame­
ters, such as stimulation duration, current intensity, and frequency,
should be investigated. Thirdly, the present study could not provide
clear evidence to demonstrate the improvements in WM performance,
even though there are several theories to explain the effects of taVNS on
fatigue control and cognitive modulation. Thus, more research is needed
to obtain brain imaging, neurophysiological or biological evidence for
identifying the underlying mechanisms. Fourth, the specific effects of
taVNS may vary significantly, and its benefits may decline over time due
to chronic use. The WM performance task is also based on the standard
lab paradigm, restricting the taVNS application. Thus, more research
with various participant cohorts, including the elderly, sleep disorder
patients, or people with long night shift or new WM paradigms, such as
tasks with virtual reality, is essential for increasing the external validity
of taVNS. Lastly, we did not record the subjective feeling concerning
arousal, sleepiness, and fatigue, even though this study explored the
R. Zhao et al.
effects of taVNS on cognition and fatigue levels under acute SD.
Therefore, this problem may restrict the reliability of taVNS effects on
fatigue countermeasures. These questions need to be investigated in
future research.
5. Conclusion
The evidence suggested that taVNS might have the potential to
mitigate the deleterious effects of SD on cognitive functions, particularly
on WM performance with high cognitive load. In the same time, taVNS
might be an feasible intervention against sleep deprivation as compen­
sation for pharmaceuticals, TMS, or tDCS since it is convenient, easy to
administer, and has fewer side effects. However, the current study had
limited types of tasks and a single stimulation time. Future research
should investigate alternative cognitive resources, stimulation time, and
repeated/chronic stimulation and include other participants cohorts,
like pilots, nurses, long-distance drivers, etc. More research could
confirm these findings in both laboratory and operational setting.
Funding
This study was funded by the Innovation Team and Talents Culti­
vation Program of National Administration of Traditional Chinese
Medicine (Grand No. ZYYCXTD-C-202004), the National Key R&D
Program of China (Grand No. 2021YFF0306500), the National Science
Foundation of China (Grant No. 81901827), Natural Science Basic
Research Program of Shaanxi (Grand Nos. 2021JQ-211, 2022JQ-649
and 2021JQ-656), the Fundamental Research Funds for the Central
Universities (Grand No. XJS201209) and the Ph.D. start-up fund of Xi’an
Polytechnic University (Grand No. BS201914).
CRediT authorship contribution statement
Rui Zhao: Conceptualization; Formal analysis; Funding acquisition;
Project administration; Software; Validation; Visualization; Writing –
original draft; Writing-review & editing; Meng-Ying Chang: Formal
analysis; Investigation; Software; Validation; Visualization; Writing –
review & editing; Chen Cheng: Formal analysis; Software; Validation;
Visualization; Writing – original draft; Writing – review & editing; Qian-
Qian Tian: Formal analysis; Investigation; Software; Validation; Visu­
alization; Writing – original draft; Xue-Juan Yang: Conceptualization;
Formal analysis; Funding acquisition; Project administration; Supervi­
sion; Validation; Writing-original draft; Meng-Yu Du: Formal analysis;
Investigation; Software; Ya-Peng Cui: Formal analysis; Investigation;
Software; Zhao-Yang He: Formal analysis; Investigation; Software; Fu-
Min Wang: Formal analysis; Investigation; Software; Yao Kong:
Funding acquisition; Resources; Software; Hui Deng: Conceptualiza­
tion; Funding acquisition; Li-Ming Lu: Conceptualization; Resources;
Chun-Zhi Tang: Conceptualization; Resources; Neng-Gui Xu: Concep­
tualization; Resources; Jin-Bo Sun: Conceptualization; Formal analysis;
Project administration; Resources; Supervision; Validation; Writing –
original draft; Writing – review & editing; Wei Qin: Funding acquisition;
Project administration; Resources; Supervision.
Declarations of interest
None.
Data availability
Data will be made available on request.
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at doi:10.1016/j.bbr.2022.114247.
11
Behavioural Brain Research 439 (2023) 114247
References
[1] A. Kusztor, L. Raud, B.E. Juel, A.S. Nilsen, J.F. Storm, R.J. Huster, Sleep
deprivation differentially affects subcomponents of cognitive control, Sleep 42 (4)
(2019), https://doi.org/10.1093/sleep/zsz016.
[2] J. Lim, D.F. Dinges, A meta-analysis of the impact of short-term sleep deprivation
on cognitive variables, Psychol. Bull. 136 (3) (2010) 375–389, https://doi.org/
10.1037/a0018883.
[3] M. Basner, H. Rao, N. Goel, D.F. Dinges, Sleep deprivation and neurobehavioral
dynamics, Curr. Opin. Neurobiol. 23 (5) (2013) 854–863, https://doi.org/
10.1016/j.conb.2013.02.008.
[4] S.P. Drummond, G.G. Brown, J.C. Gillin, J.L. Stricker, E.C. Wong, R.B. Buxton,
Altered brain response to verbal learning following sleep deprivation, Nature 403
(6770) (2000) 655–657, https://doi.org/10.1038/35001068.
[5] W.D. Killgore, Effects of sleep deprivation on cognition, Prog. Brain Res. 185
(2010) 105–129, https://doi.org/10.1016/B978-0-444-53702-7.00007-5.
[6] D.F. Dinges, An overview of sleepiness and accidents, J. Sleep. Res. 4 (S2) (1995)
4–14, https://doi.org/10.1111/j.1365-2869.1995.tb00220.x.
[7] M.L. Lee, M.E. Howard, W.J. Horrey, et al., High risk of near-crash driving events
following night-shift work, Proc. Natl. Acad. Sci. USA 113 (1) (2016) 176–181,
https://doi.org/10.1073/pnas.1510383112.
[8] D. Dawson, K. Reid, Fatigue, alcohol and performance impairment, Nature 388
(6639) (1997) 235, https://doi.org/10.1038/40775 ([published Online First: Epub
Date]|).
[9] W.D. Killgore, A.E. Muckle, N.L. Grugle, D.B. Killgore, T.J. Balkin, Sex differences
in cognitive estimation during sleep deprivation: effects of stimulant
countermeasures, Int J. Neurosci. 118 (11) (2008) 1547–1557, https://doi.org/
10.1080/00207450802323970.
[10] F. Forouzanfar, J. Gholami, M. Foroughnia, et al., The beneficial effects of green
tea on sleep deprivation-induced cognitive deficits in rats: the involvement of
hippocampal antioxidant defense, Heliyon 7 (11) (2021), e08336, https://doi.org/
10.1016/j.heliyon.2021.e08336.
[11] H. Yang, J. Xie, W. Mu, et al., Tea polyphenols protect learning and memory in
sleep-deprived mice by promoting AMPA receptor internalization, Neuroreport 31
(12) (2020) 857–864, https://doi.org/10.1097/WNR.0000000000001462.
[12] M. Quiquempoix, F. Sauvet, M. Erblang, et al., Effects of caffeine intake on
cognitive performance related to total sleep deprivation and time on task: a
randomized cross-over double-blind study, Nat. Sci. Sleep. 14 (2022) 457–473,
https://doi.org/10.2147/NSS.S342922.
[13] T.M. McLellan, G.H. Kamimori, D.M. Voss, D.G. Bell, K.G. Cole, D. Johnson,
Caffeine maintains vigilance and improves run times during night operations for
special forces, Aviat. Space Environ. Med. 76 (7) (2005) 647–654.
[14] W.J. Tharion, B. Shukitt-Hale, H.R. Lieberman, Caffeine effects on marksmanship
during high-stress military training with 72 h sleep deprivation, Aviat. Space
Environ. Med. 74 (4) (2003) 309–314.
[15] M.E. Stepan, E.M. Altmann, K.M. Fenn, Caffeine selectively mitigates cognitive
deficits caused by sleep deprivation, J. Exp. Psychol. Learn Mem. Cogn. 47 (9)
(2021) 1371–1382, https://doi.org/10.1037/xlm0001023.
[16] L. Annarumma, A. D’Atri, V. Alfonsi, L. De Gennaro, The efficacy of transcranial
current stimulation techniques to modulate resting-state EEG, to affect vigilance
and to promote sleepiness, Brain Sci. 8 (7) (2018), https://doi.org/10.3390/
brainsci8070137.
[17] G. Lanza, Repetitive TMS for the "cognitive tsunami" of sleep deprivation, Sleep
Med. 77 (2021) 279–280, https://doi.org/10.1016/j.sleep.2020.11.010.
[18] Z. Guo, Z. Jiang, B. Jiang, M.A. McClure, Q. Mu, High-frequency repetitive
transcranial magnetic stimulation could improve impaired working memory
induced by sleep deprivation, Neural Plast. 2019 (2019), 7030286, https://doi.
org/10.1155/2019/7030286.
[19] L.K. McIntire, R.A. McKinley, J.M. Nelson, C. Goodyear, Transcranial direct current
stimulation versus caffeine as a fatigue countermeasure, Brain Stimul. 10 (6)
(2017) 1070–1078, https://doi.org/10.1016/j.brs.2017.08.005.
[20] S. Li, H. Zhou, Y. Yu, et al., Effect of repetitive transcranial magnetic stimulation on
the cognitive impairment induced by sleep deprivation: a randomized trial, Sleep
Med. 77 (2021) 270–278, https://doi.org/10.1016/j.sleep.2020.06.019.
[21] A.T. Hill, P.B. Fitzgerald, K.E. Hoy, Effects of anodal transcranial direct current
stimulation on working memory: a systematic review and meta-analysis of findings
from healthy and neuropsychiatric populations, Brain Stimul. 9 (2) (2016)
197–208, https://doi.org/10.1016/j.brs.2015.10.006.
[22] N.P. Sloan, L.K. Byrne, P.G. Enticott, J.A.G. Lum, Non-invasive brain stimulation
does not improve working memory in Schizophrenia: a meta-analysis of
randomised controlled trials, Neuropsychol. Rev. 31 (1) (2021) 115–138, https://
doi.org/10.1007/s11065-020-09454-4.
[23] L.E. Goehler, R.P. Gaykema, M.K. Hansen, K. Anderson, S.F. Maier, L.R. Watkins,
Vagal immune-to-brain communication: a visceral chemosensory pathway, Auton.
Neurosci. 85 (1–3) (2000) 49–59, https://doi.org/10.1016/S1566-0702(00)
00219-8.
[24] C.B. Saper, The central autonomic nervous system: conscious visceral perception
and autonomic pattern generation, Annu Rev. Neurosci. 25 (2002) 433–469,
https://doi.org/10.1146/annurev.neuro.25.032502.111311.
[25] N. Yakunina, S.S. Kim, E.C. Nam, Optimization of transcutaneous vagus nerve
stimulation using functional MRI, Neuromodulation 20 (3) (2017) 290–300,
https://doi.org/10.1111/ner.12541.
[26] B.W. Badran, L.T. Dowdle, O.J. Mithoefer, et al., Neurophysiologic effects of
transcutaneous auricular vagus nerve stimulation (taVNS) via electrical stimulation
of the tragus: a concurrent taVNS/fMRI study and review, Brain Stimul. 11 (3)
(2018) 492–500, https://doi.org/10.1016/j.brs.2017.12.009.
R. Zhao et al.
[27] L.A. Schwarz, L. Luo, Organization of the locus coeruleus-norepinephrine system,
Curr. Biol. 25 (21) (2015) R1051–R1056, https://doi.org/10.1016/j.
cub.2015.09.039.
[28] D.J. Chandler, Evidence for a specialized role of the locus coeruleus noradrenergic
system in cortical circuitries and behavioral operations, Brain Res. 1641 (Pt B)
(2016) 197–206, https://doi.org/10.1016/j.brainres.2015.11.022.
[29] J. Nichols, A. Nichols, S. Smirnakis, N. Engineer, M. Kilgard, M. Atzori, Vagus
nerve stimulation modulates cortical synchrony and excitability through the
activation of muscarinic receptors, Neuroscience 189 (2011) 207–214, https://doi.
org/10.1016/j.neuroscience.2011.05.024.
[30] S.L. Foote, C.W. Berridge, New developments and future directions in
understanding locus coeruleus – norepinephrine (LC-NE) function, Brain Res. 1709
(2019) 81–84, https://doi.org/10.1016/j.brainres.2018.09.033.
[31] Q. Gu, Neuromodulatory transmitter systems in the cortex and their role in cortical
plasticity, Neuroscience 111 (4) (2002) 815–835, https://doi.org/10.1016/s0306-
4522(02)00026-x.
[32] E.R. Samuels, E. Szabadi, Functional neuroanatomy of the noradrenergic locus
coeruleus: its roles in the regulation of arousal and autonomic function part II:
physiological and pharmacological manipulations and pathological alterations of
locus coeruleus activity in humans, Curr. Neuropharmacol. 6 (3) (2008) 254–285,
https://doi.org/10.2174/157015908785777193.
[33] L.K. McIntire, R.A. McKinley, C. Goodyear, J.P. McIntire, R.D. Brown, Cervical
transcutaneous vagal nerve stimulation (ctVNS) improves human cognitive
performance under sleep deprivation stress, Commun. Biol. 4 (1) (2021) 634,
https://doi.org/10.1038/s42003-021-02145-7.
[34] L.S. Colzato, S.M. Ritter, L. Steenbergen, Transcutaneous vagus nerve stimulation
(tVNS) enhances divergent thinking, Neuropsychologia 111 (2018) 72–76, https://
doi.org/10.1016/j.neuropsychologia.2018.01.003.
[35] C. Beste, L. Steenbergen, R. Sellaro, et al., Effects of concomitant stimulation of the
GABAergic and norepinephrine system on inhibitory control – a study using
transcutaneous vagus nerve stimulation, Brain Stimul. 9 (6) (2016) 811–818,
https://doi.org/10.1016/j.brs.2016.07.004.
[36] L.S. Colzato, R. Sellaro, C. Beste, Darwin revisited: the vagus nerve is a causal
element in controlling recognition of other’s emotions, Cortex 92 (2017) 95–102,
https://doi.org/10.1016/j.cortex.2017.03.017.
[37] C. Ventura-Bort, J. Wirkner, H. Genheimer, J. Wendt, A.O. Hamm, M. Weymar,
Effects of transcutaneous vagus nerve stimulation (tVNS) on the P300 and alpha-
amylase level: a pilot study, Front. Hum. Neurosci. 12 (2018) 202, https://doi.org/
10.3389/fnhum.2018.00202.
[38] M.P. Neuser, V. Teckentrup, A. Kuhnel, M. Hallschmid, M. Walter, N.B. Kroemer,
Vagus nerve stimulation boosts the drive to work for rewards, Nat. Commun. 11 (1)
(2020) 3555, https://doi.org/10.1038/s41467-020-17344-9.
[39] J.B. Sun, C. Cheng, Q.Q. Tian, et al., Transcutaneous Auricular Vagus nerve
stimulation improves spatial working memory in healthy young adults, Front
Neurosci. 15 (2021), 790793, https://doi.org/10.3389/fnins.2021.790793.
[40] B. Anderson, A. Storfer-Isser, H.G. Taylor, C.L. Rosen, S. Redline, Associations of
executive function with sleepiness and sleep duration in adolescents, Pediatrics
123 (4) (2009) e701–e707, https://doi.org/10.1542/peds.2008-1182.
[41] C.H. Bastien, A. Vallieres, C.M. Morin, Validation of the insomnia severity index as
an outcome measure for insomnia research, Sleep Med. 2 (4) (2001) 297–307,
https://doi.org/10.1016/s1389-9457(00)00065-4.
[42] D.J. Buysse, C.F. Reynolds 3rd, T.H. Monk, S.R. Berman, D.J. Kupfer, The
Pittsburgh sleep quality index: a new instrument for psychiatric practice and
research, Psychiatry Res 28 (2) (1989) 193–213, https://doi.org/10.1016/0165-
1781(89)90047-4.
[43] C. Jarrold, J.N. Towse, Individual differences in working memory, Neuroscience
139 (1) (2006) 39–50, https://doi.org/10.1016/j.neuroscience.2005.07.002.
[44] J. Lim, D.F. Dinges, Sleep deprivation and vigilant attention, Ann. N. Y Acad. Sci.
1129 (2008) 305–322, https://doi.org/10.1196/annals.1417.002.
[45] S. Banks, D.F. Dinges, Behavioral and physiological consequences of sleep
restriction, J. Clin. Sleep Med. 3 (5) (2007) 519–528.
[46] J. Sun, R. Zhao, Z. He, et al., Abnormal dynamic functional connectivity after sleep
deprivation from temporal variability perspective, Hum. Brain Mapp. (2022),
https://doi.org/10.1002/hbm.25886.
[47] J. Sun, R. Zhao, X. Yang, et al., Alteration of brain gray matter density after 24h of
sleep deprivation in healthy adults, Front. Neurosci. 14 (2020) 754, https://doi.
org/10.3389/fnins.2020.00754.
[48] L. Riontino, C. Cavallero, Individual differences in working memory efficiency
modulate proactive interference after sleep deprivation, Psychol. Res. 85 (2)
(2021) 480–490, https://doi.org/10.1007/s00426-020-01292-6.
[49] R. Zhao, X. Zhang, Y. Zhu, et al., Prediction of the effect of sleep deprivation on
response inhibition via machine learning on structural magnetic resonance
imaging data, Front. Hum. Neurosci. 12 (2018) 276, https://doi.org/10.3389/
fnhum.2018.00276.
[50] R. Zhao, X. Zhang, N. Fei, et al., Decreased cortical and subcortical response to
inhibition control after sleep deprivation, Brain Imaging Behav. 13 (3) (2019)
638–650, https://doi.org/10.1007/s11682-018-9868-2.
[51] Y. Zhu, Y. Xi, J. Sun, et al., Neural correlates of dynamic changes in working
memory performance during one night of sleep deprivation, Hum. Brain Mapp. 40
(11) (2019) 3265–3278, https://doi.org/10.1002/hbm.24596.
[52] R. Zhao, X. Zhang, Y. Zhu, et al., Disrupted resting-state functional connectivity in
hippocampal subregions after sleep deprivation, Neuroscience 398 (2019) 37–54,
https://doi.org/10.1016/j.neuroscience.2018.11.049.
[53] Y. Zhu, Z. Feng, J. Xu, et al., Increased interhemispheric resting-state functional
connectivity after sleep deprivation: a resting-state fMRI study, Brain Imaging
Behav. 10 (3) (2016) 911–919, https://doi.org/10.1007/s11682-015-9490-5.
12
Behavioural Brain Research 439 (2023) 114247
[54] J. Xu, Y. Zhu, C. Fu, et al., Frontal metabolic activity contributes to individual
differences in vulnerability toward total sleep deprivation-induced changes in
cognitive function, J. Sleep Res. 25 (2) (2016) 169–180, https://doi.org/10.1111/
jsr.12354.
[55] Y. Zhu, Y. Xi, N. Fei, et al., Dynamics of cerebral responses to sustained attention
performance during one night of sleep deprivation, J. Sleep Res. 27 (2) (2018)
184–196, https://doi.org/10.1111/jsr.12582.
[56] Y. Zhu, L. Wang, Y. Xi, et al., White matter microstructural properties are related to
inter-individual differences in cognitive instability after sleep deprivation,
Neuroscience 365 (2017) 206–216, https://doi.org/10.1016/j.
neuroscience.2017.09.047.
[57] J. Lim, W.C. Choo, M.W. Chee, Reproducibility of changes in behaviour and fMRI
activation associated with sleep deprivation in a working memory task, Sleep 30
(1) (2007) 61–70, https://doi.org/10.1093/sleep/30.1.61.
[58] S.T. Kuna, G. Maislin, F.M. Pack, et al., Heritability of performance deficit
accumulation during acute sleep deprivation in twins, Sleep 35 (9) (2012)
1223–1233, https://doi.org/10.5665/sleep.2074.
[59] E.C. Chua, S.C. Yeo, I.T. Lee, et al., Individual differences in physiologic measures
are stable across repeated exposures to total sleep deprivation, Physiol. Rep. 2 (9)
(2014), https://doi.org/10.14814/phy2.12129.
[60] A. Chiesa, R. Calati, A. Serretti, Does mindfulness training improve cognitive
abilities? A systematic review of neuropsychological findings, Clin. Psychol. Rev.
31 (3) (2011) 449–464, https://doi.org/10.1016/j.cpr.2010.11.003.
[61] A. Baddeley, Recent developments in working memory, Curr. Opin. Neurobiol. 8
(2) (1998) 234–238, https://doi.org/10.1016/S0959-4388(98)80145-1
([published Online First: Epub Date]|).
[62] R. Zhao, Z.Y. He, C. Cheng, et al., Assessing the effect of simultaneous combining of
transcranial direct current stimulation and transcutaneous auricular vagus nerve
stimulation on the improvement of working memory performance in healthy
individuals, Front. Neurosci. 16 (2022), 947236, https://doi.org/10.3389/
fnins.2022.947236.
[63] S.H. Ohn, C.I. Park, W.K. Yoo, et al., Time-dependent effect of transcranial direct
current stimulation on the enhancement of working memory, Neuroreport 19 (1)
(2008) 43–47, https://doi.org/10.1097/WNR.0b013e3282f2adfd.
[64] S.Y. Jeon, S.J. Han, Improvement of the working memory and naming by
transcranial direct current stimulation, Ann. Rehabil. Med. 36 (5) (2012) 585–595,
https://doi.org/10.5535/arm.2012.36.5.585.
[65] F. Fregni, P.S. Boggio, M. Nitsche, et al., Anodal transcranial direct current
stimulation of prefrontal cortex enhances working memory, Exp. Brain Res. 166 (1)
(2005) 23–30, https://doi.org/10.1007/s00221-005-2334-6.
[66] D. San-Juan, R.N.M. Mas, C. Gutierrez, et al., Effect of the anodal transcranial
direct current electrical stimulation on cognition of medical residents with acute
sleep deprivation, Sleep Sci. 15 (Spec 1) (2022) 89–96, https://doi.org/10.5935/
1984-0063.20220007.
[67] H.W. Chase, M.A. Boudewyn, C.S. Carter, M.L. Phillips, Transcranial direct current
stimulation: a roadmap for research, from mechanism of action to clinical
implementation, Mol. Psychiatry 25 (2) (2020) 397–407, https://doi.org/10.1038/
s41380-019-0499-9.
[68] A. Liu, M. Voroslakos, G. Kronberg, et al., Immediate neurophysiological effects of
transcranial electrical stimulation, Nat. Commun. 9 (1) (2018) 5092, https://doi.
org/10.1038/s41467-018-07233-7.
[69] G. Kronberg, M. Bridi, T. Abel, M. Bikson, L.C. Parra, Direct current stimulation
modulates LTP and LTD: activity dependence and dendritic effects, Brain Stimul.
10 (1) (2017) 51–58, https://doi.org/10.1016/j.brs.2016.10.001.
[70] D. Adair, D. Truong, Z. Esmaeilpour, et al., Electrical stimulation of cranial nerves
in cognition and disease, Brain Stimul. 13 (3) (2020) 717–750, https://doi.org/
10.1016/j.brs.2020.02.019.
[71] K. Eguchi, T. Satoh, Characterization of the neurons in the region of solitary tract
nucleus during sleep, Physiol. Behav. 24 (1) (1980) 99–102, https://doi.org/
10.1016/0031-9384(80)90020-7.
[72] F. Weber, Y. Dan, Circuit-based interrogation of sleep control, Nature 538 (7623)
(2016) 51–59, https://doi.org/10.1038/nature19773.
[73] J.B. Sun, Q.Q. Tian, X.J. Yang, et al., Synergistic effects of simultaneous
transcranial direct current stimulation (tDCS) and transcutaneous auricular vagus
nerve stimulation (taVNS) on the brain responses, Brain Stimul. 14 (2) (2021)
417–419, https://doi.org/10.1016/j.brs.2021.02.010.
[74] N. Thompson, S. Mastitskaya, D. Holder, Avoiding off-target effects in electrical
stimulation of the cervical vagus nerve: neuroanatomical tracing techniques to
study fascicular anatomy of the vagus nerve, J. Neurosci. Methods 325 (2019),
108325, https://doi.org/10.1016/j.jneumeth.2019.108325.
[75] T.J. Verlinden, K. Rijkers, G. Hoogland, A. Herrler, Morphology of the human
cervical vagus nerve: implications for vagus nerve stimulation treatment, Acta
Neurol. Scand. 133 (3) (2016) 173–182, https://doi.org/10.1111/ane.12462.
[76] H. Yuan, S.D. Silberstein, Vagus nerve and vagus nerve stimulation, a
comprehensive review: part I, Headache 56 (1) (2016) 71–78, https://doi.org/
10.1111/head.12647.
[77] D. Adair, D. Truong, Z. Esmaeilpour, et al., Electrical stimulation of cranial nerves
in cognition and disease, Brain Stimul. 13 (3) (2020) 717–750, https://doi.org/
10.1016/j.brs.2020.02.019.
[78] M.D. Schwartz, T.S. Kilduff, The neurobiology of sleep and wakefulness, Psychiatr.
Clin. North Am. 38 (4) (2015) 615–644, https://doi.org/10.1016/j.
psc.2015.07.002.
[79] L. Krone, L. Frase, H. Piosczyk, et al., Top-down control of arousal and sleep:
fundamentals and clinical implications, Sleep Med. Rev. 31 (2017) 17–24, https://
doi.org/10.1016/j.smrv.2015.12.005.
R. Zhao et al.
[80] C.W. Berridge, B.D. Waterhouse, The locus coeruleus-noradrenergic system:
modulation of behavioral state and state-dependent cognitive processes, Brain Res.
Rev. 42 (1) (2003) 33–84, https://doi.org/10.1016/s0165-0173(03)00143-7.
[81] D. Mueller, J.T. Porter, G.J. Quirk, Noradrenergic signaling in infralimbic cortex
increases cell excitability and strengthens memory for fear extinction, J. Neurosci.
28 (2) (2008) 369–375, https://doi.org/10.1523/Jneurosci.3248-07.2008.
13
Behavioural Brain Research 439 (2023) 114247
[82] Harley C.W. Norepinephrine and the dentate gyrus. Dentate Gyrus: A
Comphrehensive Guide to Structure, Function, and Clinical Implications 2007;163:
299–318 doi: 10.1016/S0079–6123(07)63018–0[published Online First: Epub
Date]|.