# Development of more advanced rTMS equipment.



## 35467 (Dec 31, 2010)

So, some of you might know that i am very interested in rTMS. It is an intervention the former "Depersonalization research unit" had high hopes for and a German DTI brain imaging study from 2019 also point towards rTMS as the intervention in the disorder.

rtms was developed 25.years ago but only approved to treatment for depression in Europe and the US around 2007. The technology has been very limited to two locations in the brain called the left and right DLPFC. These are very easy to find and stimulate as they are on the surface on the prefrontal cortex.

Around 50% with depression respond to stimulation at these locations. RTMS clinics will often in their material claim a response rate of 70%. But, the reality is that significant number sees a reduction of only 20% of their symptoms- that is very close to placebo. Because these clinics runs a business they will take those who "feels a little better" as respondent. They run a business and it is easy to sell a product by saying it works in 70% and not 50%.

That rTMS only works in 50% with depression is one reason why most psychiatrists have been very skeptical of the intervention. In Denmark and in Europe it is offered as a eksperimental treatment at limited numbers of hospitals for depression.

The reason why only 50% with depression respond is related to current technology used in rTMS. In many with depression (and also in depersonalization) the cognitive regulation of emotions is not done in the left or right DLPFC but other locations and networks in the prefrontal cortex. In depression the two other locations are the dorsomedial prefrontal and the right orbito frontal cortex. If you try these locations with a deep coil in depressed at a research facility the response rate for depression is closer to 90%. The reason why it is not a 100% is likely partly because the emotional regulation is done to deep in the brain for a deep coil used today to stimulate.

The problems is that rTMS as it is approved and used today uses coil that can only stimulate 1.cm into the brain. So, it can not treat at deep locations and networks. This is a problem in depersonalization as the over regulation of emotions making a state of numbing is too deep in the brain. This goes for the right VLPFC that can only be partly stimulated with a normal coil-like 30%. Other locations found active in depersonalization and under suspicion like the anterior cingulate/dorsomedial prefrontal cortex and the ventromedial prefrontal is to deep in the brain to stimulate with a normal rTMS. So, one can say that with the current rTMS technology used depersonalization will have a very low response rate due to the areas in the brain where the regulation likely is done. Magventure makes a deep coil that is only used for research that might reasch these areas. But, has just been approved in the US for treatment of obsessive compulsive disorder. It might also be approved in Europe.

I read an interview with a danish professor in psychiatry who I have talked to and written when he was chairman of the danish psychiatrists association around 2004. My complaint back then was that they where not aware of the existence of depersonalization disorder. But, in a recent interview he addresses that 15-20% of people might have a depression in their lifetime and of 20% of those no medication will work. They will end up on social programs ect as they are resident to current treatments. He pointed towards rTMS as a treatment and a research program he was a part of for the development of more advanced rTMS equipment.

it is as I can see from the danish innovation fund site who have given 2.mio euros to the project and money from two companies will also go into it . It is a danish-German program divided into two sections.

The danish producer of rTMS equipment, Magventure will with researchers from danish technical university( engineers) and a danish center for magnetic resonance and a research center in psychiatry develop a new coil, likely for a deeper and more selective stimulation in the brain that currently can not be stimulated.

The German part of the project is the neuronavigation company "Localite" who shall develop more advanced software for more individual brain stimulation. It looks like they try to develop a navigation system that is not dependent on a MRI scan of individuals. University in Munich is also in the program.

It is a very broad and vague description they come with and I think it is for the protection of the project. We will know more when it a patented.

But, the ambitions is to develop rTMS equipment that can be used in refractory depression, other psychiatric conditions and to reduce neurological symptoms in neurological disorders. So, rTMS might end up being much more commonly used in the future if the project succeeds.

So, they are developing coils for more deeper stimulation and likely equipment that is more precise and easy to use. The program should run until 2023. They will likely start testing some of it in the coming years. So, equipment that can make a deeper stimulation and treat more conditions is under development. The project in danish is here.Try a autotranslate.

https://innovationsfonden.dk/da/investeringer/investeringshistorier/nyt-hab-patienter-med-behandlingsresistent-depression

english version of the project: https://www.drcmr.dk/news-events/news/item/1026-new-hope-for-patients-with-treatment-resistant-depression


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## WithYourSigh (Nov 25, 2012)

Thank you for sharing the information. You may like to know that, since a coil for dTMS is manufactured by an Israeli company, the majority of TMS clinics in the country, be they research units or private-practice units, perform dTMS.

As for the high response rate reported in the literature and by TMS clinics in the context of DP, I searched DPSH extensively in the past for testimonials of DP sufferers treated with TMS to either the TPJ or VLPFC and found a lack of correlation between the reported response rate and the first-hand experience of those who received the treatment.


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## 35467 (Dec 31, 2010)

The Israeli " Brainsway" deep TMS is not the same as deep rTMS. "Brainsway" designs a H-coil or a helmet like coil for stimulation of one specific area only to one condition only. They have two coils approved and the first is for depression and stimulates the left and right DLPFC. The other is for OCD and stimulates the anterior cingulate and the dorsomedial prefrontal. It could likely also be used in some with depression. " Brainsway" machines are not widely used in Europe. I think there are around 30 providers for the depression coil and less than 5. With the OCD coil. In the US there are 120.who have the OCD coil. The OCD coil could be interesting to try in depersonalization. " Brainsway" have a business model where they have to be paid a fee pr. Session where there machine is used. So, a session is more expensive than normal rTMS. If the right VLPFC is right in depersonalization and deep tms coil for " Brainsway" will have no effect. They do not have a coil for depersonalization. Because the term "deep" is used does mean it works. It is about locations too. What locations are you trying? The problem with those who have tried to replicate the rTMS studies done is the you need neuronavigation for location for both the right VLPFC and the right TPJ. 95% of clinics do not have that. So, the setting for these reports is a business man with a rTMS clinic and a One with depersonalization who do not understand this interventiontion. The word "rTMS" is what is understood who goes into a clinic not equipped to replicate these studies and tries rTMS for a few sessions based on this business man to make a location on his "intuition". I have read many experiences from people with depersonalization who thinks they have tried rTMS. Most of them have tried the left or right DLPFC and there are only a few case reports of people having a benefit on the symptoms. Likely people with depression and secondary symptoms of depersonalization. Not, depersonalization disorder in its primary form. The rest is often "treatments" where the locations is likely wrong as no neuronavigation was used and the number of session to few. So, in reality nobody knows what have been tried.


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## WithYourSigh (Nov 25, 2012)

I was treated in the past with TMS to the left DLPFC with no significant results. I no longer remember the particular details of the various testimonials found on DPSH, except that the patients themselves did the utmost to ensure that treatment is performed on either the TPJ or VLPFC, although this naturally does not provide any guarantee.

In light of this discussion, I located a correspondence between myself and a head researcher who conducted at the time dTMS research within an Israeli public mental-health center. She confirmed that the Brainsway deep coil is unable to reach the TPJ, but added that she had conducted several clinical studies using dTMS to the VLPFC with no significant results.


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## leminaseri (Jul 1, 2020)

WithYourSigh said:


> I was treated in the past with TMS to the left DLPFC with no significant results. I no longer remember the particular details of the various testimonials found on DPSH, except that the patients themselves did the utmost to ensure that treatment is performed on either the TPJ or VLPFC, although this naturally does not provide any guarantee.
> 
> In light of this discussion, I located a correspondence between myself and a head researcher who conducted at the time dTMS research within an Israeli public mental-health center. She confirmed that the Brainsway deep coil is unable to reach the TPJ, but added that she had conducted several clinical studies using dTMS to the VLPFC with no significant results.


so this means it doesnt matter how much or deep of the vlpfc you do stimulate. if someone with dpd doesnt respond to any stimulation, then he seems to be refractory to any treatment.

another thing is, if they would develop a coil or a machine whats able to stimulate very deep areas in the brain, then they should be able to treat any psychoneurogical illness. but im sure, the reality is not like this. the pure psychological aspects are very important.

for example, if someone has the dpd due to huge anxiety and panic, and the brain triggered the depersonalization to suppress those horrendous feelings, then if you trick the brain to come out of the dissociation, you should get those horrible anxiety and panic again, what would end in an endless cycle.


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## 35467 (Dec 31, 2010)

WithYourSigh said:


> I was treated in the past with TMS to the left DLPFC with no significant results. I no longer remember the particular details of the various testimonials found on DPSH, except that the patients themselves did the utmost to ensure that treatment is performed on either the TPJ or VLPFC, although this naturally does not provide any guarantee.
> 
> In light of this discussion, I located a correspondence between myself and a head researcher who conducted at the time dTMS research within an Israeli public mental-health center. She confirmed that the Brainsway deep coil is unable to reach the TPJ, but added that she had conducted several clinical studies using dTMS to the VLPFC with no significant results.


On this site most of them who have tried rTMS have been without neuronavigation. Having read much brain imagening into depersonalisation and rTMS is general i would say that it is impossible to find these location without neuronavigation. I have had some correspondence with one in the UK who might come out with a book about depersonalization and he says that he have traced about 21.people who have tried rTMS at the "smart TMS" in the UK without effect. But, "smart tms" is a very expensive and ill equipped rTMS chain in the UK who do not have neuronavigation. So, I will consider all these attempts totally worthless due to the locations only.

The right VLPFC might not have any role in depression. "Brainsway" have tried other locations for different conditions without effect they have published them and if she claims she have done several trail without effect and not made a publication I would say something is wrong. You can not use such a claim to anything. Why have she not made a publication? Have she tried in depersonalization or depression? If is in depression then this information is also worthless as the emotional regulation in depersonalization and depression is not the same. The left and right DLPFC works in 50% with depression and allmost none in depersonalization because the emotional regulation are not related.

The right VLPFC might be wrong but you can say it as so few have tried this location with neuronavigation and a normal butterfly coil can only stimulate 30% of this location. I have tried for 12.session and I don't know if the location is wrong as it is only 30% that have been stimulated. It could also be the anterior cingulate and the dorsomedial prefrontal cortex. Again you need a deep coil for this locations.


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## 35467 (Dec 31, 2010)

WithYourSigh

if you live in Israel and is it easy to come to a Brainsway with a OCD coil that can stimulate the anterior cingulate and the dorsomedial prefrontal cortex I think you should consider it. There are some indication in some brain imaging studies of a overactivity in the anterior cingulate and the dorsomedial prefrontal cortex in depersonalization that is very OCD like. A brain imaging picture can be seen here, https://www.frontiersin.org/files/Articles/173530/fpsyg-07-00432-HTML-r2/image_m/fpsyg-07-00432-g002.jpg

it is from this study. https://www.frontiersin.org/articles/10.3389/fpsyg.2016.00432/full


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## WithYourSigh (Nov 25, 2012)

leminaseri said:


> so this means it doesnt matter how much or deep of the vlpfc you do stimulate. if someone with dpd doesnt respond to any stimulation, then he seems to be refractory to any treatment.
> 
> another thing is, if they would develop a coil or a machine whats able to stimulate very deep areas in the brain, then they should be able to treat any psychoneurogical illness. but im sure, the reality is not like this. the pure psychological aspects are very important.
> 
> for example, if someone has the dpd due to huge anxiety and panic, and the brain triggered the depersonalization to suppress those horrendous feelings, then if you trick the brain to come out of the dissociation, you should get those horrible anxiety and panic again, what would end in an endless cycle.


Please note that the region of my brain which received dTMS is the DLPFC, implicated in depression, as opposed to the VLPFC, implicated in DP, therefore no conclusion could be drawn as to the nature of my disorder. I responded partially to Lamictal, with which I am no longer treated, and to various supplements. As for the rest of your comment, when TMS is considered successful in a patient, they may still develop the same symptoms after a period of time; it is surely not considered to be permanent cure.



Mayer-Gross said:


> On this site most of them who have tried rTMS have been without neuronavigation. Having read much brain imagening into depersonalisation and rTMS is general i would say that it is impossible to find these location without neuronavigation. I have had some correspondence with one in the UK who might come out with a book about depersonalization and he says that he have traced about 21.people who have tried rTMS at the "smart TMS" in the UK without effect. But, "smart tms" is a very expensive and ill equipped rTMS chain in the UK who do not have neuronavigation. So, I will consider all these attempts totally worthless due to the locations only.
> 
> The right VLPFC might not have any role in depression. "Brainsway" have tried other locations for different conditions without effect they have published them and if she claims she have done several trail without effect and not made a publication I would say something is wrong. You can not use such a claim to anything. Why have she not made a publication? Have she tried in depersonalization or depression? If is in depression then this information is also worthless as the emotional regulation in depersonalization and depression is not the same. The left and right DLPFC works in 50% with depression and allmost none in depersonalization because the emotional regulation are not related.
> 
> The right VLPFC might be wrong but you can say it as so few have tried this location with neuronavigation and a normal butterfly coil can only stimulate 30% of this location. I have tried for 12.session and I don't know if the location is wrong as it is only 30% that have been stimulated. It could also be the anterior cingulate and the dorsomedial prefrontal cortex. Again you need a deep coil for this locations.


As I said previously, admittedly, the particular details of the various studies of TMS for DP patients are no longer fresh in my mind. Naturally, it seems that you are well read in this topic, but several questions come to mind. If am not mistaken, neuronavigation was used in those studies where TMS was given to either the TPJ to VLPFC (Mantovani et al., etc.), and the results were impressive. As for the author you mentioned, while those 21 individuals were treated unsuccessfully, do we know how many were treated successfully? Were they all suffering from DP? You may be familiar with Elliott (alias Elliott King), who was active in the DP community several years ago and seems to have vanished. I remember vaguely that, as a person trained in neuroscience, he collaborated with Smart Clinic and conducted a study with them on TMS to either the TPJ or VLPFC. He said that a person who was treated as part of the study achieved complete remission and maintained it a year later, and also that the study should be published soon. Then, he vanished. I believe Elliott was a believer in TMS to these regions for DP patients as much as the research allows us to be, and wanted to promote further research. Naturally, I regard his opinion more than my own.

I do not know the specifics of said researcher, nor do I know whether it was published or not. I was not in a position to inquire. I would say that she seemed to insinuate that various disorders were at the center of her research, but DP was likely not one of them. It is mostly DP experts who research the disorder, and the researcher with which I spoke is certainly not one.

I am sorry to hear that your experience with TMS was unsuccessful, quite as mine was.



Mayer-Gross said:


> WithYourSigh
> 
> if you live in Israel and is it easy to come to a Brainsway with a OCD coil that can stimulate the anterior cingulate and the dorsomedial prefrontal cortex I think you should consider it. There are some indication in some brain imaging studies of a overactivity in the anterior cingulate and the dorsomedial prefrontal cortex in depersonalization that is very OCD like. A brain imaging picture can be seen here, https://www.frontiersin.org/files/Articles/173530/fpsyg-07-00432-HTML-r2/image_m/fpsyg-07-00432-g002.jpg
> 
> it is from this study. https://www.frontiersin.org/articles/10.3389/fpsyg.2016.00432/full


Thank you for the information. There are several TMS clinics in Israel, at least one is private but run by a psychiatrist who conducts research, and is therefore knowledgeable. At this time, this information looks too preliminary to me. I would only consider TMS to either the TPJ or VLPFC; and, as you say, it may only be worthwhile with neuronavigation, which is not offered by private clinics. To me, It seems worthwhile only in the exact same conditions of the TPJ/VLPFC studies, although I certainly need to re-read them. It is possible only some of them used neuronavigation.


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## 35467 (Dec 31, 2010)

All rTMS clinics in UK the are pure money operations. The cost of one session is close to 250-300. pounds some are even more expensive . You need neuronavigation for all locations except the left and right DLPFC. Even there the locations can be missed in 20% of the cases. These locations are not depersonalization locations so people with depersonalization who have tried these locations I do not count as something tried. Like counting people who had the left leg amputated for a tumor in the head, who comes back and says; " they said an operation would work and I had my left leg removed but the tumor in my brain is still there". You can not do rTMS at the right VLPFC, right TPJ without neuronavigation and no clinics in the UK have neuronavigation. So, they do not have the equipment to do it. I have a rTMS clinic one hour drive from where I live. Never contacted them and never will as they do not have the equipment for location. It is a insult to human intelligence to contact a place who do not have the equipment to do it. On this site there are some posts of people who have tried in the Uk "smart tms". I do not count them as people who have tried rTMS for the locations only and very few session they had. I only know of two who have tried the right VLPLC with neuronavigation. One tried in a clinic in Texas and there was response after one session. I know of one from Switzerland who have tried both the right VLPFC and the right TPJ. It worked on his depersonalization, emotional numbing but not his derealisation. I count these people as the locations are right as neuronavigation was used. So, in reality very few have tried rTMS for depersonalization. I am aware that you need re treatments like half the sessions you had first time once a year or one session every 1-2.month in many cases and this need might be reduced over time. That is the case for depression.

There are two texts which addresses doing rTMS at the right VLPFC, one of them by depression researcher, Jonathan Downar. They both write that do to the placement or the right VLPFC where a small part of it is one the surface of the cortex (you need neuronavigation to find this small area) it expands into the cortex and much of it is covered by other areas in the brain and you need a deep coil to do a proper stimulation. Some of it might even not be stimulated by a deep coil as it to deep. So, it is not regarded as an area from stimulation with a normal coil. So, the response rate could be higher in those who had a partial response if a deep Coil was used. There are no other trails done at the right VLPFC other than those related to depersonalization. There are done experiments in normal people to find the role the right VLPFC plays in emotional regulation.

i have a hope that a rTMS clinic might open in Eastern Europe when all this Covid is over that have Magventure with a deep coil and neuronavigation from localite. The sessions might be close to 50.euros if the current prices for Eastern Europe is used. Then I have to try the right VLPFC again for 10.session and if that doesn't work go to dorsomedial prefrontal cortex that also is regarded as a prime suspect from brain imaging studies done.


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## WithYourSigh (Nov 25, 2012)

Thank you for the wealth of information. Please keep updating with new information in case you are treated with rTMS again. Treatment of any kind is irrelevant for me at the moment, but I may look into it again in the future.


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## Numb_1993 (Jul 22, 2020)

Dear Mayer-Gross i'm sorry to bother you with another rtms question again..i have the possibility to do neuronavigated rtms on the right Vlpfc in Lüneburg Germany ..i wanted to speak to the doctor about the possibility to try other locations if the treatment of the vlpfc would not be successful. Above you mentioned the dorsomedial prefrontal cortex ..is it possible to reach this area with a normal coil or do you need a deep coil ? Is this area overactive in dp ..so should it be inhibited with rtms then ? Best regards


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## 35467 (Dec 31, 2010)

I know about the clinic in Lüneburg and their rTMS equipment is from the rTMS maker "Magstrim". In general deep coils are not approved for clinical use yet. Magventure have just have their deep coil approved for OCD in the US. You are still restricted to a conventional rTMS machine with a stimulation dept of 1.cm. So, you can likely have stimulation of 30-% of the right VLPFC with a conventional coil. You can try the right TPJ that is also done with a conventional coil. You can wait for the publication of the French angular gyrus trial as it might also give some more information we do not have today. The angular gyrus can be stimulate with a conventional coil.

In depression rTMS with a normal coil can stimulate the left and right DPLFC. So, 50-60% with see some strong benefits from these locations. But, with a deep coil you could stimulate the dorsomedial prefrontal cortex and/or the right ventromedial prefrontal cortex and many with have a response to that. These locations can currently not be done a conventional rTMS as it is not approved yet. Magventure makes the coil used in research not "Magstrim".


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## Numb_1993 (Jul 22, 2020)

So i just had a phone call with Dr Tamme and thats what he told me: He is now using EKG-guided Repetitive Transcranial Magnetic Stimulation (rTMS) mostly instead of neuronavigation..with this technique he is able to find the vagus nerve ..by treating the vagus nerve via rtms the magnetic impulses are supposed to be able to go till 9 cm deep even if the coil is only able to normally go 1-2 cm deep ..the vagus nerve is thus used as kind of an electric forwarding. By gaining this information i'm now a little bit confused as it sounds a little bit like a charlatan to me.


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## 35467 (Dec 31, 2010)

Yes, it really sounds very odd. A normal flat 8.coil that is those approved only have a stimulation dept of 1.cm. Yes, the stimulation of one area might have affect to deeper structures the location is in network with. The vagus nerve (parasympatic tone) sounds like of something smart.

You shall remember that these trials that we try to replicate are very small in size. 12-15.patients for the right TPJ and 8. for the right VPLFC. They might not be replicated if people try in the effect size. Nobody will say that trails in that size are "scientific". So, it is in many ways an experiment and you shall be able to afford it might not work. There is two to my knowledge who have had some benefits for it. Very few have tried were neuronagation is used and you are sure that the location is correct.So, their experiences does not really count as any attempt to replicate the trial.

The angular gyrus trail should be with 100.patients and placebo controlled and if the follow their design they should also makes some fMRI before and after. The scanning part might give some more information about the emotional regulation done by the brain and networks. It is the core problem in depersonalization that the brain scans done is in size around 12-15.patients and in many areas they are in conflict where the regulation is done in the prefrontal cortex after what types of scanners used. You need some core locations for where this regulations starts and where to intervene to brake it up. Many of these locations are in reality to deep for intervention with convention rTMS. So, the technology to intervene in depersonalization might be the one that is under development.

A publication from last year recommended a research program to combine rTMS and fMRI to try to isolate the prime locations and get some ideas of the network at work. So, have 50.patients or much more. Make a fMRI one them and choose a locations and see if there are some reduction in some. Scan them all again and see where those who respond differs form those who didn't. There might be difference in regulations in patient as we see in depression. Then choose another location that comes up as abnormal. So, lots of rTMS and scanning until you have some ideas about locations that works and networks at play.

So, there is a risk due to the knowledge we have now and the technology available that rTMS might not work yet in most.

I would wait until the French angular gyrus trail is published. You likely cannot travel until midsummer anyway until doing anything. There is a rTMS clinic in Hungary that can replicate the small trials done to date and you can also gets a MRI scan done for 80.euros there that is likely 1/10 of the prize in Germany. It can be used later when more advanced and better equipment rTMS clinic comes in another place in Eastern Europe.


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## Numb_1993 (Jul 22, 2020)

Thanks a lot for your answer ! It's just so devastating to not really know what to do..but i think as in every mental illness patience is the key. The recommendation of this publication you mentioned sounds like an good approach to get more information about the context of the different brain areas.I will definitely check out the clinic in hungary and also Dr. Tamme suggested a clinic in Hamburg .. they have deep TMS and a brainsway helmet but they don't have dp listed on their website but i will try to contact them. Regarding the MRI i already got one done some months ago so i'm safe with that.


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## 35467 (Dec 31, 2010)

There is a testing site in Miami that is very closely related to "Brainsway" that have written that they have tried to treat depersonalization disorder with either deep TMS or deep rTMS. They have not specified if there was a response, witch machines or locations tried.They might have tried locations that is not available to conventional rTMS. I might write to them and ask about their experiences.

I am waiting for the French trail to come out so there also could be something relative new to related to and have a conversation about. There was a small case report from Munich last year with 4. patients given rTMS either at the right VLPFC or at the right TPJ in a combination with CBT and physical exercises. The response was very wage and you could not say if the response was primary related to rTMS or the other interventions. It could be that the response rate is very low and these trails do not replicate. I might write to the prof. behind this case and express my concerns about locations and see if he agrees. It can be start to think of alternative locations if that is this case.

A recent study point to a structure deep in the brain that changes frequency to many dissociative drugs and turns off to anesthesia. It is called retrospenial cortex and is in reality two structures: The posterior cingulate and precuneus cortex. The Precuneus have been found very active in some PET studies and larger in MRI scans in dictating that it is more active. It is related to both the right TPJ and angular Gyrus. So, they might indirectly affect this area. The retrospenial goes 4-5.cm into the brain and in all rTMS experiments related to it a deep coil have been used. A strong candidate of a central location. See if the French trail address it. But, I think that it might be very limited what conventional can offer to depersonalization and the use of deep coils to treat depression in those who do not respond to conventional rTMS could be what intervention in depersonalization is dependent on.


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## Numb_1993 (Jul 22, 2020)

It would be very interesting to hear about the report of the testing site in Miami. As i live in munich i have been to the clinic where this trial was done ..i tried to get rtms/dtms there on the vlpfc and they told me they tried it with dp patients before and it was not successful so they didn't want to do it with me. Well that's a lot of information i first have to reread all of this i guess ????


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## 35467 (Dec 31, 2010)

The German small trial was done by people with relation to this clinic.http://www.klinikum.uni-muenchen.de/Klinik-und-Poliklinik-fuer-Psychiatrie-und-Psychotherapie/en/forschung/forschungsbereiche/hirnstimulation/Brain-stimulation/index.html

I had the impression that the rTMS part did not replicate. Likely to small in size to write it directly. They wrote that they followed same procedure as the DP units trial,- so no deep coil at the right VLPFC. So, just 30% stimulation of it. It could be a wrong location. A recently German scan points towards the dorsomedial prefrontal cortex and anterior cingulate and it also comes out as active in some of the DP units trials. The right orbitofrontal cortex also comes out as larger in some structural scans indicating overactivity. This locations have been found central in the dissociative subtype of PTSD. It is a location that years back was though central in depersonalization and regulation of anxiety. It is also a location that is central in depression with anhedonia. I tried to get "Runtome" to a clinic in Italy that is the only place in Europe with a deep coil. But, it seems to me that formal approval for clinical use in Europe of deep coils is needed before we can more on with rTMS.


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## Numb_1993 (Jul 22, 2020)

So a little update of information i got by talking to the doctor of the rtms clinic in milano: She offered me a bilateral stimulation protocol of the prefrontal cortex.. so she told me not only the dlpfc but also further close areas would be targeted by it. So that's probably including the orbitofrontal cortex and ventromedial prefrontal cortex mentioned by you (MG). I wouldn't hesitate to try it right away if it would be close to my hometown but as i would have to travel and as i'm really not doing well atm i think i'm too scared to try it and to take the effort of traveling and i'm also scared of getting worse than i already am if that's even possible at this point. Best regards.


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## 35467 (Dec 31, 2010)

You have tried 20.sessions at the right DLPFC and what she is offering you is likely a combination of the left and right DLPFC with a conventional coil. I really do not know if that will work. This is a treatment you likely can have done in Germany close to you. There is no way that a conventional coil can stimulate other areas like the right VLPFC or the right orbitofrontal cortex while stimulating at the DLPFC. A conventional coil stimulation dept is 1.cm and the area that stimulated is around 2.cm in diameter. A deep coil will stimulate deeper but also in a restricted area.

If they can not offer you stimulation of the right orbitofrontal cortex then drop it. Is is rTMS italia head office you have been in contact with.


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## 35467 (Dec 31, 2010)

There is the possibility that she have offered you deep TMS that is a helmet that stimulates at these locations but also have a small effect on other locations. It should be more effective that normal rTMS and will effect more of the brain. It could be the case. They have "Brainsway" in Milano.https://www.brainsway.com/treatments/major-depressive-disorder/


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## 35467 (Dec 31, 2010)

if it is "rtmsitalia" then it is likely she have offered you the depression protocol from "Brainsway". I think that they have that is Milano. It is slightly more expensive as "Brainsway" want a fee for every session a machine is used. I think is 120.euros pr.session. They might have a low profile on using a deep coil as it is no approved yet and it might only be at their location on Sardinia. The clinics origin is from people around two universities there who have done research into the use of rTMS.

So, you likely have to go to Sardinia if you want to try the right orbitofrontal cortex. Very difficult to say with of the two is your best chances.


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