# TMS



## Markjones90 (Apr 10, 2020)

I have engaged in many many binge drinking episodes over the last decade or so and began to suffer panic attacks during withdrawal as a result. Hypersensitive receptors? Maybe.

I developed HPPD with comorbid DP/DR in 2005 so have a feeling that all of the negative psychological symptoms are linked to this neurological disorder.

I have tried SSRIs which did naught to help my psychological problems whilst increasing my visual symptoms and am currently on lamictal (100mg) for five weeks which doesn't seem to be demonstrating much efficacy thus far.

I have been reading about the damage binge drinking can cause to our NMDA/R and am wondering if the NMDA/R might also be linked to my HPPD/DP/DR.

I also suffer from trichotillomania if that is relevant at all.

Would TMS be useful if the NMDA is implicated in what ails me? TMS on the PFC of perhaps another area of the brain?

I know positive thinking/acceptance/exercise etc. are very useful at helping on live with this conditions but really think I need the expertise of a neurologist/psychiatrist to truly make somewhat of a recovery from these disorders.

Thanks for all of your help and thank you for reading.


----------



## 35467 (Dec 31, 2010)

" TMS on the PFC of perhaps another area of the brain?"

That is a nonsense statement. The prefrontal cortex is a large area of the brain with many structures involved in cognitive regulation of emotions. rTMS is typically given to the left or right dorsolateral prefrontal cortex as it is the only locations approved for rTMS and 95% of private providers of rTMS have the tools to locate and the coil to stimulate. Other areas you often need a MRI scan to find, rTMS equipment to calibrate the location and sometimes a special coil to do deep rTMS as the structure is too deep in the brain for a normal coil to reach. 95% of rTMS providers cannot do that.

So almost all rTMS is done at the right or left dorsolateral prefrontal cortex (DLPFC)

There are other locations in the prefronal cortex of interest in various disorders like;

The left and right dorsomedial prefrontal cortex (DMPFC)

The left and right frontopolar cortex

The left and right ventromedial prefrontal cortex (VMPFC)

The left and right ventrolateral prefrontal cortex (VLPFC)

From brain scannings of depersonalisation the right DLPFC is found overactive, both the left and right medial prefrontal cortex is found overactive and the right ventrolateral prefrontal cortex in some studies. You need a special coil to go into the medial prefrontal cortex that can go 4-6.cm into the brain. It is has never been tried.

http://dribrahimyilmaz.com/site/wp-content/uploads/Depresyonda-TMS-Tedavisi-Akademik-Makale.pdf


----------



## RunToMe (May 30, 2019)

Hey Dino,

as you know i did rtms in utrecht. The psychologist made 10 seizures at one second at right dlpfc.Makes it the condition worser due to the researchers outcomes that right dlpfc is overactive.

And have you done anything yet in the field of rtms or you planning something right now ?


----------



## Markjones90 (Apr 10, 2020)

Thanks very much for clearing up my misconceptions Mayer-Gross. Demonstrating my ignorance for all to see seemingly.

I am very interested in pursuing TMS and just wanted to know as much info re. the procedure from an unbiased source as realistically, it's a one shot deal considering the cost of the procedures.

I did read about TMS being used on the TPJ as well. Is that viable?


----------



## RunToMe (May 30, 2019)

Hi Mark-Jones,

where you are from ?

I made it in Netherlands. They do it without neuronavigation. Its relative cheap there. i paid to each session 100 euro. i made daily 1 in 14 days. When you want i can give you further information.


----------



## 35467 (Dec 31, 2010)

To, "Runtome"

I have many difficulties given you advice. Here is my problem;

1)I suffer from depersonalisation disorder in it primary form. The outset for this disorder is typically between 15-25 of age for 90%. The majority of the 10% develop the disorder prior to that age. You are twice the age of the median age for the outset.

2) You have been seen by a prof. in your country who have written books and publications about depersonalisation disorder. He have said to you that you don´t suffer from depersonalisation disorder in its primary from but major depression with secondary symptoms of depersonalisation. When you suffer from that the symptoms of depersonalisation should subside with the depression.

3) your compliant on this site is symptoms like anhedonia, inability to sleep, lack of appetite. These are all symptoms of major depression. Not, depersonalisation disorder.

So, why are you insisting of getting a treatment for depersonalisation disorder when you likely do not suffer from the condition?

I have tried rTMS at the right VLPFC and the right TPJ from a MRI scan a month ago with another one. None of us have benefited from it. Some research from germany and also research into the dissociative subtype of PTSD that also sufferes from depersonalisation point towards the right medial prefrontal cortex as the site for making the emotional suppression in depersonalisation. It is also a location of interest in depression. The problem is that this site is very deep into the brain. There is a lot a cranial bone and tissue from a brain location in front of it that a normal rTMS cannot reach it. You need a special coil for deep rTMS that can go 5-6.cm deep. The coil is relatively new and i do not know of any private providers of rTMS who have it. The coil looks like this.https://www.magventure.com/tms-research/products-overview/research-coils/coils/cool-d-b80


----------



## 35467 (Dec 31, 2010)

This german diffusion tensor imaging study into depersonalisation from 2018 found indications that emotional numbing in depersonalisation came from the right ventromedial prefronal cortex overactivity.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6158023/


----------



## RunToMe (May 30, 2019)

Thanks you a lot !

Sorry, for insisting. its my despair owed.


----------



## 35467 (Dec 31, 2010)

RunToMe said:


> Thanks you a lot !
> 
> Sorry, for insisting. its my despair owed.


You could try other locations for major depression. The site that is active in in depersonalisation is also a depression site but need a special coil for rTMS. The location is used in depression with anhedonia and 50% that don´t respond to rTMS at the right or left DLPFC respond to this site. There is only one place in Europe that have such a coil. I know them and they where open to me at first but didn't reply me after. They likely will not go into depersonalisation disorder at all because research and trial are very small. So, if i gave you their address and you started with your hallmark idiocy -" i suffer from depersonalisation". They would likely turn you down. The prognosis for major depression and treatment options are many compared to depersonalisation and you are suffering from that but continue to claim you are suffering from depersonalisation. It is like you will not be normal and try the options you have by claiming you are suffering from depersonalisation with writing on this site about symptoms related to major depression.

You could also try deep rTMS for major depression with machines from "Brainwave". But, everything is closed down right now in Europe and there is no point in it right now. You can use that time to stop calling your state depersonalisation disorder when it is major depression. Here is a trail and the location i think might benefit you.https://www.ncbi.nlm.nih.gov/pubmed/29153927


----------



## RunToMe (May 30, 2019)

Thank you, you are so engaged in rtms and the best expert in this topic !


----------



## 35467 (Dec 31, 2010)

RunToMe said:


> Thank you, you are so engaged in rtms and the best expert in this topic !


Yes, i likely am. I read all brain imaging studies into depersonalisation, much research into rTMS in general.

PS. The depression trail with rTMS at the right orbital prefrontal cortex at 1.hz is the same as the right ventromedial prefrontal cortex. The right orbital prefrontal cortex and the right ventral medial prefrontal cortex are the same area,- just two diffrent terms. This area is also overactive in almost all brain imaging studies of emotional numbing in depersonalisation. It have connection to immobilisation when the body and brain can not mobilised a "fight and flight response"- it shot down.. The body becomes very parasympathetic by its overactivity. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2590602/


----------



## Markjones90 (Apr 10, 2020)

Hi Mayer Gross. Some excellent insights there. Thank you so much.

My DP/DR was prompted by a drug episode many moons ago with concurrent visual symptoms (trails, halos around objects etc.)

I have developed depressive episodes since then but I think the DP has promoted the depressive episodes rather than vice versa.

Based on your research and expertise, do you think I am wasting my time with TMS on the right VLPFC and TPJ or do you think if might still be worth a shot?

How useful is a MRI/QEEG/neuromodulating in investigating the area of the brain which gives the greatest prospect of success?

Thank you so much once again. I think this thread could turn out to be an invaluable source of info for people for years to come.


----------



## 35467 (Dec 31, 2010)

Difficult to say. Because until recently depersonalisation was very unknown and undiagnosed so the research into the disorder had little funding and was done at one location in the US and one in the UK. So, everything has small samples sizes. Different types of brain scans, drug trials and rTMS trial are all very small.It makes the risk of error of replication high. I only know of 2. who have tried the right VLPFC and felt some effect. I have never read a post of someone trying the right TPJ and had any benefit from it. In a very small german trial from last year they tried 4.persons with rTMS with a combination of CBT and rTMS.

2.was given rTMS at the right TPJ and 2. was given it at the right VLPFC. The case report said that those in the TPJ both had a reduction and only one at the right VLPFC. How big their reduction was i don´t know. It was a case report. But, in the TPJ trials those who responded had the lest reduction in emotional numbing. They where still symptomatic with emotional numbing. It was mostly derealisation that was reduced at this location among those who had a response.

These trials are based on brain scanning done between 2000-2012. So, in a way they are old. The right VLPFC was chosen because in some scans this location was active when people with DP saw aversive pictures. The right VLPFC is not a regulator of emotions by itself. It more delegates to other areas in the prefrontal cortex to regulate. So, doing inhibitory rTMS at this location they hoped it might normalise other areas like the right DLPFC, left and right medial prefrontal cortex.

If one looks at other studies also those done by the DP unit, the left and right medial prefrontal cortex is central. Some recent studies done in the dissociative subtype in PTSD they find the right medial prefrontal cortex is overactive and makes inhibition of the amygdala so you do not feel fear and anxiety, it also makes a inhibition of some of the reward system.So, the emotional numbing comes by this effect. It affect a structure deep in the brain called the ventral periaqueductal gray that is central in mobilising "fight and flight" responses and "freeze, immobilisation". The ventral part makes immobilization and a parasympathetic state. They says that sensory disintegration is related to this response from the periaqueductal gray. So, it becomes more integrated in the model. These studies are from 2015-2019.

So, the problem in DP with rTMS is that they might not have found the "core"location where is comes from.


----------



## Markjones90 (Apr 10, 2020)

Interesting. A lot of food for thought. I am not sure if you know of the rare condition HPPD which is usually comorbid with severe anxiety/DP and obviously involves some sort of occipital disorder.

Lamictal which has been vaunted as one of the most promising treatments has offered me little relief this far which has led me to investigate the efficacy or lack thereof of TMS in treating this condition.

I know it has a very high success rate in treating depression but the evidence is somewhat lacking in treating DP/anxiety.

Do you plan to do the treatment again?

I live in the UAE currently and the cost is prohibitive and it's not exactly a country where I would feel overly comfortable explaining what led me to this condition so am considering getting it done in Kazakhstan of all places as I will be moving to Central Asia soon.


----------



## 35467 (Dec 31, 2010)

No, i don´t know so much about HPPD. The emotional numbing in DP is related to anxiety. You suppress the anxiety by over activation of areas in the prefrontal cortex. You don´t feel anxiety nor nothing else. You are numb. So, with rTMS you are trying to inhibit this overregulation of emotions -in theory you would feel anxiety again with other feelings. So, if you feel anxiety it might be an indication that you symptoms is not related to overregulation, -more likely unregulation.

I looked it up. There are some overlaps in visual perception with depersonalisation disorder though the character might be different. I can find no other trials than this slightly related https://www.researchgate.net/publication/297673863_Repetitive_Trans_Cranial_Magnetic_Stimulation_in_Resistant_Visual_Hallucinations_in_a_Woman_With_Schizophrenia_A_Case_Report

But, much of rtms interventions are based on functional brain imaging studies. So, you have to have some ideas about networks and locations. The development with these scanning techniques is also very fast.


----------



## Markjones90 (Apr 10, 2020)

Thanks so much for your experise once again.

Do most TMS clinics run tests (QEEG, MRI etc..) in advance of treatment to try shed some light on what area of the brain to best target or do they generally have their own clinical bias as to which area should be targeted?

Like one clinic might favour targeting the TPJ whilst another clinic might favour the RMPFC?


----------



## 35467 (Dec 31, 2010)

No, that is my problem. They only run after diagnosis and trials, case reports related to the diagnosis. So, i what to try the right medial prefrontal cortex because the right VLPFC didn't work for me. In almost all functional brain imaging studies of depersonalisation and also depersonalisation in the dissociative subtype this area is active. So, there is a strong indication that this area might work. But, there has never been a trial or a case report in that area for depersonalisation. So, that makes it difficult.

Some might do a EEG to rule out the risk of epilepsy when rTMS is given not in relation to find a location for rTMS.

So, if you have a disorder with few brain imaging studies it can be a problem.


----------



## 35467 (Dec 31, 2010)

A new type of scanner with wearable helmet with quantum sensors is under development. It might make scanning much cheaper, make rTMS more individualistic in the future because it becomes cheaper and more easy to see areas and networks in the brain.https://www.nature.com/articles/s41467-019-12486-x


----------



## 35467 (Dec 31, 2010)

Markjones90 said:


> Like one clinic might favour targeting the TPJ whilst another clinic might favour the RMPFC?


None of it. Most clinics can only locate the right and left dorsolateral prefrontal cortex and stimulate them. rTMS in only approved for depression in Europe and the US at these locations. They might be able to find some locations close to it. To find other locations you need a MRI scan of the individual brain. You need a neuronavigation program and equipment on your rTMS like "Localite" to calibrate for the location. 95% do not have that. Some areas in the brain are to deep. A normal rTMS coil can go 1-2 cm into the brain. If you will try a location like the right orbito prefrontal cortex/medial prefrontal cortex you need a special coil for deep rTMS. I am only aware of one location in Europe that have such a coil.

rTMS in depression you see at the right and left dorsolateral prefrontal cortex a reduction of more than 50% in 40-50% and a reduction of less then 50-20% in 30%. 20-30% do not benefit at all and many only have a slight improvement. To do inhibitory rTMS at the right orbito prefrontal cortex might make those who didn't respond at the left or right DLPFC into respondents. The location should also be more "clear". If you respond at this location you reduction are more significant. In depression this location cannot be offered right now in Europe or the US because it is still experimental and not approved. You need a special coil to do it. So, rTMS in a way still new with many limitions .


----------



## Markjones90 (Apr 10, 2020)

https://mycloudtms.com/

Hi again. The clinic I am looking at pursuing treatment in in Russia. (It is a clinic in Russia where it is called Neurosoft but my understanding is that Cloud/Neurosoft is essentially the same technology).

My research indicates that it is capable of penetrating to a depth of over 5cm which as you stated offers the best chance of clinical efficiacy for DP/DR patients.

I also hear that these deep TMS options can't target specific brain areas as much as other options which use neuronavigation technology.

What do you think about this?


----------



## 35467 (Dec 31, 2010)

That is not clinic, but a maker of rtms equipment. Coils to make deep brain stimulation is almost made by all providers of rTMS equipment but rarely used as approved locations do not need such a coil that can go so deep.So, very few have such a coil. All deep rtms coils becomes very diffuse at the dept of more the 4-5.cm. Do, you have a location for your disorder from brain scans or rTMS trials?

A coil for deep rTMS is typically bowed in a angle of 80-120 degrees to go so deep. That coil is slightly bowed and can not go so deep.

Here er coils for deep rtms. The one called "120 BFV" here; "Butterfly V Cone Coil 120mm with controls

Typical use:
Deep cortical stimulation." https://deymed.com/duomag-xt

Or this one. https://www.magventure.com/tms-research/products-overview/research-coils/coils/cool-d-b80


----------



## Markjones90 (Apr 10, 2020)

No, not yet.

I am not sure if the clinic does this in advance. I would certainly like to have s deep brain scan to see if they can identify the region of my brain that is malfunctioning.

I wouldn't want them to just hone in on the DLPFC as seems to generally be the case with major depressive disorder.


----------



## Markjones90 (Apr 10, 2020)

So, I've been looking more at what the specific clinic offers and it only says Neurosoft.

I was under assumption that each of the various brands, Theta Burst/Briansway etc used their own particular coil: figure8 or the round coil.

So, do you recommended I ask the clinic which coil they use (I believe figure8 is the one that can reach deeper) before pursuing treatment.

As I said before, I really only have one shot at this and want to go in armed with as much info as possible before I commit.


----------



## 35467 (Dec 31, 2010)

Because there is no trails or brain scans related to your disorder there are no locations to go for. You can look for comorbidities to your state like depression, OCD ect and try treatment for that.

Jonathan Downar gave this lecture recently and adresses that one can make a general stimulation in larger areas as it will increase plasticity in the brain and brake with old networks ect. He mentions Brainways indirectly as some close to that concept. So, when you don´t have any location i would go for brainsway.


----------



## Markjones90 (Apr 10, 2020)

Thanks so much for your expertise.

I do think OCD plays a big part if what ails me (I suffer from trichotillomania or hair pulling disorder and earworms/stuck song syndrome) so I've already been thinking that TMS targeted at areas of the brain implicated in OCD might be worth a shot.

Thank you so much for your expertise once again and I will be sure to update you and the board how I get on when I am able to start the treatment.


----------



## Markjones90 (Apr 10, 2020)

Thanks so much for your expertise.

I do think OCD plays a big part if what ails me (I suffer from trichotillomania or hair pulling disorder and earworms/stuck song syndrome) so I've already been thinking that TMS targeted at areas of the brain implicated in OCD might be worth a shot.

Thank you so much for your expertise once again and I will be sure to update you and the board how I get on when I am able to start the treatment.


----------



## 35467 (Dec 31, 2010)

I suspected that OCD might be a problem. "Brainsway" helmets/coils are not the same for depression and OCD. If you will try them you have to find a provider with a OCD coil.https://www.brainsway.com/find-a-provider


----------



## Markjones90 (Apr 10, 2020)

"In the treatment anxiety using high intensity stimulation left prefrontal lobe or low intensive stimulation right prefrontal lobe or combination...I'm combinating this method with kinesiology and osteopathic technics - it's more effective"

This is what a TMS doctor I'm considering visiting in Ukraine has said to me. Does kinsieology and osepathic techniques demonstrate much efficacy in treating deperzonalisation/anxiety?

From what I have read, there is little evidence to back that up. Has anyone else heard of TMS being combined with the above treatments?


----------

