# Question about brain scan and Rtms (especially to Mayer-Gross)



## Numb_1993 (Jul 22, 2020)

As i can not send any private message i would be very glad if Mayer-Gross would have a look at my question as you are the specialist in this field.
I'm now suffering from emotional numbness for 7 month and all other symptoms like seeing sunlight too bright or sitting behind a glasswall or thinking my voice sounds strange are gone also appetite and sleep is better. I already tried several meds and the classic Rtms protocol for depression without success in emotional numbness. I don't know if there exists a brain scan method to see which parts in my brain are causing the numbness so i could precisely target those areas with Rtms. Maybe a Pet-Ct? Or do you think the brainscan would not provide any helpful results? I'm very sorry bothering you about this as i know you deal with a lot of questions like this but i would be very thankful for an answer !


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## leminaseri (Jul 1, 2020)

you would need a fmri to see which parts of your brain are overactive i think.


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## leminaseri (Jul 1, 2020)

which kind of rtms you got? did they used neuronavigation for targeting?


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## Numb_1993 (Jul 22, 2020)

Yes i thought about fmri or pet ct  i did the normal 10 hz left Dlpvc and 1 hz right Dlpvc without neuronavigation but they don't need it for that.


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## Numb_1993 (Jul 22, 2020)

I contacted a practice in Lüneburg they do rtms especially for dp and they use neuronavigation to target the right Vlpfc with 1 hz


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## 35467 (Dec 31, 2010)

2.Problems with rTMS

1) We do not know exact locations where the emotional overregulation done in the prefrontal cortex making the emotional numbing and suppressing the emotional system. In scan the right DLPFC, the right VLPFC, the anterior cingulate and the dorsomedial prefrontal and in some the right orbito frontal cortex. This are extremely many and very confusing locations. The right DLPFC is a standard location for depression done by almost all rTMS clinics and very few respond to this location if you have depersonalization disorder in its primary form. If it's secondary to depression the response rate it likely much higher. The fact is we don't know the core locations. The brains scans done dates back between 2000-2015. The size of the patients groups have been around 12 and most studies say that you have to and a patient group of at least 20 and a control group of the same size to reduce errors. Newer scannings are also needed as the technology have evolved. fMRI scanners have become much faster as the computers supporting them have more power. These scanners are for research only. You can not as a private person get a fMRI and those on the private market do likely not have enough computer power as those used in research-simply too costly. fMRI and the older and less effective PET and the very, very old SPECT are functional scanners and are looking a brain metabolism- over and under active areas in the brain to stimuli. In a recent evolution of brain imaging studies done in depersonalization they said that they excluded PET, SPECT and QEEG studies as worthless as they are old and very imprecise. So, why as a patient use money on "mental horoscopes of the brain" that QEEG, PET and Spect are. I can tell you for free that it is pointless.

Scanners like MRI, CT are structural scanners that looks at the structure of the physical brain, for injuries, stroke lessons or tumors. In most with depersonalization such a scaning will come out as normal.

You use a MRI scan not for diagnosis with rTMS but for location of areas. Because our brain structures are slightly different from person to person it can be very difficult to locate an area in the brain. You might risk not stimulating the correct area in the brain without neuronavigation from MRI. So, it has nothing to do with understanding the disorder a MRI is taken but location of areas in the individual brain.

To sum up. We don't known exactly location where the emotional regulation is done. The recent evaluation I referred to point towards the anterior cingulate and the dorsomedial prefrontal cortex.

Here is a brain scaning picture of emotional regulation in depersonalization from 2015 and on the picture there is and overactivity in the right VLPFC and the anterior cingulate and the dorsomedial prefrontal cortex. The problem is that these locations are much deep into the brain for a normal rTMS coil to stimulate. https://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=4890597_fpsyg-07-00432-g0002.jpg

2) rTMS in Europe and the US are only approved for depression at the right or left DLPFC. These locations are easy to find without neuronavigation and easy to stimulate as they are on the frontal brain of cortex. There is no brain tissue above these areas. All rTMS it set up for the location and stimulation of the two locations only. In people with depression around 50% will respond at these locations and the rest will not. That is because in depression the emotional regulation likely comes from much deeper locations in the brain in many who don't respond. These people with depression can't get a treatment either with the equipment used in most places now. As there are some conflicting data about the locations in depersonalization we could say that it it likely that the anterior cingulate cortex and the dorsomedial prefrontal cortex plays a role along with right VLPFC. So, you want rTMS at these locations. But, most clinics can not locate these locations as they don't have neuronavigation. But, the coil they use is a normal butterfly 8.coil. It can stimulate 1.cm into the brain. If you look at the brain scan you can see that the activity of the right VLPFC is much deeper than 1.cm. You can likely stimulate 30% of the right VLPFC with a normal coil. The anterior cingulate and the dorsomedial prefrontal cortex can not be stimulated at all with a normal coil as they are too deep. There are coils developed that can stimulate these areas and they are used in research for depression, OCD and PTSD. They are not approved for clinical use in clinics yet. You have to work at approved research facility that have the right to use this equipment for research. A deep coil has just been approved in the US for OCD and that is for the stimulation of the anterior cingulate and the dorsomedial prefrontal cortex.

you can try the right VLPFC with the stimulation of 30% of it that a normal coil can do or you can wait until there are private providers that uses deep coil in Europe and that the French rTMS at the angular gyrus might also come up with some ideas for where the emotional regulation in done in the prefrontal cortex.


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## 35467 (Dec 31, 2010)

If i was you i would wait with rTMS until the french angular gyrus trail is published. It might say something about other location under consideration in depersonalisation. The angular gyrus is on the close to the back side of the head and is related to derealisation , out of body experience. There have been some recent small trails with rTMS at this location for anxiety. So, it might be a location affected by anxiety. Emotional numbing is more related to regulation in the prefrontal cortex. Angular gyrus is on the surface of the brain and can be stimulated by a normal coil. You could also try the right VLPFC. But you need a provider that have neuronavigation for these locations. So, neuronavigation system can make an artificial brain in a computer system that gives an estimated location so, a MRI might not be needed. For other locations and to stimulate the right VLPFC there is a need for coils with deeper stimulation. They likely will be approved in Europe for clinical use within the coming years. I expect the French trail to be published within the coming months. Likely on this site. https://www.brainstimjrnl.com/


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## Numb_1993 (Jul 22, 2020)

Thanks a lot for the information you have given ! I will try rtms on the right vlpfc next week but unfortunately without neuronavigation so i don't really think there will be any effect but lets see. It would just be too wonderful if there were an option to see what's wrong in the brain and then target those areas till everything works like it should again. Best regards


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## leminaseri (Jul 1, 2020)

Numb_1993 said:


> Thanks a lot for the information you have given ! I will try rtms on the right vlpfc next week but unfortunately without neuronavigation so i don't really think there will be any effect but lets see. It would just be too wonderful if there were an option to see what's wrong in the brain and then target those areas till everything works like it should again. Best regards


are you being from germany?


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## Numb_1993 (Jul 22, 2020)

Yes i am i know you are too ..as i read your posts in the german forum


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## chng (Oct 11, 2020)

Mayer-Gross said:


> If i was you i would wait with rTMS until the french angular gyrus trail is published. It might say something about other location under consideration in depersonalisation. The angular gyrus is on the close to the back side of the head and is related to derealisation , out of body experience. There have been some recent small trails with rTMS at this location for anxiety. So, it might be a location affected by anxiety. Emotional numbing is more related to regulation in the prefrontal cortex. Angular gyrus is on the surface of the brain and can be stimulated by a normal coil. You could also try the right VLPFC. But you need a provider that have neuronavigation for these locations. So, neuronavigation system can make an artificial brain in a computer system that gives an estimated location so, a MRI might not be needed. For other locations and to stimulate the right VLPFC there is a need for coils with deeper stimulation. They likely will be approved in Europe for clinical use within the coming years. I expect the French trail to be published within the coming months. Likely on this site. https://www.brainstimjrnl.com/


Mayer-Gross, without divulging too much info or compromising your anonymity, would you mind sharing how it is that you have such in-depth knowledge of all this stuff? Are you a some kind of science or neuroscience professional working in the field?


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## 35467 (Dec 31, 2010)

I have a BA in psychology and had the plan to read into neuropsychology. I have a cause in psychopharmacology that is the part neuropsychologist take and also psychiatrists. But that is 25.years ago. But I am very familiar with reading in medical research and literature. I have read everything published about depersonalization. rTMS is a relatively new area in psychiatry that is mostly based around cognitive relation of emotions in the brain. To me it is relative new and most psychiatrists are not trained in this way of thinking and treating disorders. You have to read many brain imaging studies, studies of networks in the brain. It is mostly in the understanding of depression this area develops. But, it is a intervention that might be promising for many conditions in the future. It will not work in psychotic conditions like schizophrenia though. Then there is the technological development in rTMS equipment that does you can go deeper into areas in the brain where networks are abnormal. In depersonalization the problem is partly related to conflicting data where the core relations is and where to intervene. In reality it could be in several locations in the same network. The problem is also that the areas in the brain that is under suspicion to play role is to deep for the rTMS coils that was available until recently. So, locations active in depersonalization have never been tried because coils to stimulate so deep was not developed.


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## chng (Oct 11, 2020)

Thank you very much. You are a boon to this community.


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## leminaseri (Jul 1, 2020)

Mayer-Gross said:


> I have a BA in psychology and had the plan to read into neuropsychology. I have a cause in psychopharmacology that is the part neuropsychologist take and also psychiatrists. But that is 25.years ago. But I am very familiar with reading in medical research and literature. I have read everything published about depersonalization. rTMS is a relatively new area in psychiatry that is mostly based around cognitive relation of emotions in the brain. To me it is relative new and most psychiatrists are not trained in this way of thinking and treating disorders. You have to read many brain imaging studies, studies of networks in the brain. It is mostly in the understanding of depression this area develops. But, it is a intervention that might be promising for many conditions in the future. It will not work in psychotic conditions like schizophrenia though. Then there is the technological development in rTMS equipment that does you can go deeper into areas in the brain where networks are abnormal. In depersonalization the problem is partly related to conflicting data where the core relations is and where to intervene. In reality it could be in several locations in the same network. The problem is also that the areas in the brain that is under suspicion to play role is to deep for the rTMS coils that was available until recently. So, locations active in depersonalization have never been tried because coils to stimulate so deep was not developed.


what about the ocd helmet from brainsway? is that not for anterior cingulate and dorsomedial pfc? what would be the difference between the ocd coil from magventure what you shown me?


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## DPFighter (Apr 8, 2013)

Hey Mayer-Gross do you know for sure that the French rTMS trial is even going to happen? I haven’t been able to find anything online about it currently happening. Just wondering because an rTMS depersonalization study that was going to take place in New York was cancelled a few years ago. I hope they didn’t cancel this one


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## 35467 (Dec 31, 2010)

The design of the French angular gyrus trail is from 2015 is here in this link.

https://clinicaltrials.gov/ct2/show/NCT02476435

The head researcher of the trail should have replied some in February that the analysis of data should be finished in September. But, the outbreak of COVID-19 might have delayed it. A French girl who have had depersonalization for 7.years have made some post in a Facebook group about her experiences of being part of the trail. The location worked on her but she also wrote that the response rate was around 50% at that location from what she knew.

I think that the trail might have difficulties in recruiting patients for the trail. In a German brain scan studies from 2019 they wrote that they had difficulties in finding sufficient numbers of patients closed to the area of the studies and it was likely due to that depersonalization in its primary form is highly under diagnosed. I don't think a research program will accept self-diagnosed patients. They want a formal diagnosis made by a psychiatrist with journals of a medical history, then they will likely do some testing and interviews themselves prior to a trail. If they do not have done that the empirical material for the trail ( patients used) can be put into question and then the validity of the whole trail is put into question. The referral to the trail is likely also have to come though a psychiatrist.

This could also have been the case in France and might explain the delay and it took several years. But, the French study in finished and it is the publication we are waiting for. It likely have to be in a peer-review process for 2-3.months prior to publication too. It will be published very soon I think.


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## Want2lifeagain (Jun 20, 2020)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6562708/

Is that ???? Gyrus tms??


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## 35467 (Dec 31, 2010)

Want2lifeagain said:


> https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6562708/
> 
> Is that ???? Gyrus tms??


This do not make any sense. The trail you are referring too is in coma patients who have a low self awareness and is give rTMS stimulation at 20.hz at the left angular gyrus to make it more active. In depersonalization you are inhibiting right angular gyrus with 1hz as it is too active. Totally different conditions, locations and treatments.


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