What are indications of TMS?
In our private practice setting, we offer rTMS for the following indications:
For Resistant Depression:
In what disorders is rTMS being researched or is being offered on an “off-Label” basis?
Besides Treatment-Resistant Depression (TRD) and Obsessive-Compulsive disorder (OCD) that are FDA approved treatments, rTMS has shown promising efficacy results and can be used as an "off-label" treatment for:
For any of these treatment indications, we do a complete evaluation with all patients to ensure there are no safety contraindications, and we acquire informed consent from them to ensure that all patients are aware that the treatments are considered off-label.
Depression, Including Severe Burn Out
Many recent studies have particularly shown the therapeutic efficacy of rTMS in treatment-resistant depression i.e., depression that does not respond to conventional therapeutic approaches (medications, psychotherapy). It can also be an alternative treatment for people who cannot tolerate the side-effects of antidepressant medications.
In the case of treatment-resistant depression, the majority of these studies showed a response rate of at least 50% after a minimum of 21 days of treatment. In our clinic, the rates of response and remission to date were 60% and 45.5% respectively, in unipolar and bipolar depressed patients treated for four to eight weeks (see Publications for more information).
Auditory Hallucinations
Refractory hallucinations in schizophrenia ("voices"), the majority of studies showed a reduction of at least 50% of these symptoms in 50% of the cases
Your psychiatrist or your treating physician has diagnosed you with a psychotic disorder (schizophrenia, schizoaffective disorder or other psychotic disorders) and you have auditory hallucinations.
The auditory hallucinations that you present with are severe and have not responded to at least one antipsychotic treatment which you have been taking regularly for a period of at least 2 months.
Severe Anxiety or Panic Disorder
Symptoms: Panic disorder is characterized by recurrent panic attacks that typically begin suddenly, without warning even when there is no real danger. They can can be ooccasional, or may occur frequently. Panic attacks have many variations, but symptoms usually peak within minutes. Panic attacks while intensely uncomfortable, are not dangerous and typically include a sense of impending doom or danger, fear of loss of control or death, rapid, pounding heart rate, sweating, shaking, shortness of breath or tightness in the throat, chill, hot flashes, nausea, abdominal cramping, chest pain, headache, dizziness, lightheadedness or faintness, numbness or tingling sensation, feeling of unreality or detachment. People may fear having panic attacks so much that they avoid certain situations where they may occur.
Causes: It's not known what causes Severe anxiety and panic disorder, but some factors may play a role: genetics, major stress, temperament that is more sensitive to stress or prone to negative emotions
Symptoms of panic disorder often start in the late teens or early adulthood and affect more women than men. Complications that panic attacks may cause include the development of specific phobias, such as fear of driving or leaving home, frequent medical care for health concerns and other medical conditions, avoidance of social situations among others.
Treatments: Panic attacks are hard to manage on your own, and they may get worse without treatment. rTMS may offer hope in the treatment of this condition.
Post Traumatic Stress Disorder (PTSD)
Causes of PTSD
PTSD can develop in the aftermath of experiencing an extremely traumatic event.
Symptoms of PTSD
Trauma survivors often have symptoms that may or may not have a delayed onset, including:
People with PTSD produce more stress hormones even at times when it is not needed by the brain. It has also been shown through brain imagery that people with PTSD have altered brain regions that are responsible for controlling emotion and memory.
Certain persons, places or activities can trigger emotionally distressing memories, which lead to intense psychological and physiological distress. This causes the patient suffering from PTSD to avoid contact with certain individuals or to avoid certain places or activities that might trigger a PTSD event.
PTSD is a "trauma and stressor-related disorder" in the DSM-5.
Treatments of PTSD
Psychotherapy & Pharmacotherapy:
Some patients who do not respond adequately to psychotherapy, specifically to cognitive behavioral therapy (CBT) alone may benefit from a combination of medication and psychotherapy. In these cases, antidepressants are recommended as a first-line approach for PTSD.
Caution on Benzodiazepines: Caution against any use of benzodiazepines to manage core PTSD symptoms because evidence not only suggests that they are not effective, they may even be harmful in worsening the symptoms.
rTMS for Treatment resistant PTSD:
The VA Guideline provides a B level recommendation for rTMS as treatments for patients with “chronic, severe, medication- and psychotherapy-resistant PTSD.”
Depersonalization / Derealization Disorder (DPD)
Depersonalization / Derealization disorder (DPD) is a mental illness that is a subcategory in the Dissociative disorders’ spectrum.
People who suffer from depersonalization / derealization disorder (DPD) feel isolated, anxious and depressed. Statistics have shown that depersonalization / derealization disorder is one of the most common mental health issues, it is the third most common psychological disorder, after anxiety and depression, the rate of dissociative disorders is around 2% of the population. Although DPD has been medically documented since decades, it still remains relatively unknown by the public. The disorder is difficult to recognize and those who suffer from it are often misdiagnosed with depression or anxiety.
Causes of DPD
Symptoms of DPD
Symptoms of DPD may start gradually or suddenly. Episodes can last for only a very short period or, in severe cases, symptoms may be present and remain at the same intensity for years and may become intolerable. Episodes can involve depersonalization, derealization, or both.
Depersonalization/derealization disorder involves a persistent or recurring feeling of being:
People are always aware (have the insight) that their experiences of detachment are not real but rather a perception. This awareness is what separates depersonalization/derealization disorder from a psychotic disorder. People with a psychotic disorder always lack such insight.
Treatments of DPD
Conventional Treatments, both pharmacological and psychotherapy may relieve the symptoms of DPD (such as anxiety, depression and obsessions) and patients may experience some relief from their symptoms. Antidepressants and Cognitive Behavioral Therapy (CBT) have shown some success.
However, treatment for depersonalization disorder remains difficult because there is no approved or proven treatment for the disorder itself, and there is limited clinical research into the best methods to use.
Certain studies with Repetitive Transcranial Magnetic Stimulation (rTMS) have shown reductions in DPD symptoms by 44-68% and rTMS potentially provides treatment for those suffering from the severe condition with no significant side-effect. TMS is not yet FDA approved for the treatment of DPD, it is offered only as an off-label treatment for PTSD or DPD.
Addiction
Causes of Addiction
Addiction is a disorder of the brain’s reward system, associated with the prefrontal cortex and other cortical and sub-cortical regions. Dopamine is a neurotransmitter, a chemical released by neurons that acts on the reward system in the brain. It plays a role in regulating emotion, motivation and feelings of pleasure among others. Natural rewards like eating cause a release of dopamine and almost all addictive drugs directly or indirectly affect dopamine neurotransmission in the brain.
Most addictive drugs act on the brain’s reward system by overflowing the reward system with dopamine (cocaine for instance can release 2-10 times the amount of dopamine as in a natural response such as food) and potentially damage the reward system with over-activation of the brain regions concerned, creating a permanent craving that results in addiction which is in part genetically determined.
Symptoms of Addiction
Characteristics of addiction include impulsivity in decision-making, self-control, poor risk assessment and judgment, cognitive evaluation of consequences and errors and goal identification. Habits and patterns associated with addiction are typically characterized by immediate gratification coupled with long term destructive effects.
Examples of drug and behavioral addictions include: alcoholism, amphetamine or methamphetamine addiction, cocaine addiction, nicotine addiction, addiction to opioids, food addiction, gambling addiction, and sexual addiction. The only behavioral addiction recognized so far by the DSM-5 is gambling addiction or “gambling disorder”. Internet or video-game addiction will potentially be recognized as gaming disorder under "Disorders Due to Addictive Behaviors" by ICD-11.
rTMS in TREATING ADDICTION disorders:
Although various treatment programs including cognitive therapy, and other psychotherapeutic approaches are very helpful for many people, they don’t work for everyone, and relapse rates are high.
Many brain imaging techniques, including functional magnetic resonance imaging (fMRI), have demonstrated that rTMS over the prefrontal cortex in healthy subjects resulted in increased levels of extracellular dopamine and dopamine release in the caudate nucleus (deeper structure of the brain) and a reduction in dopaminergic activity during substance withdrawal.
In recent years, rTMS has been also researched for treating addictions. The device creates a magnetic pulse that alters (activates or inhibits) electrical activity in the brain circuitry. In the case of addictions, studies demonstrate that rTMS alters cortical excitability through the modulation of different neurotransmitters involved in addiction-related processing, including dopamine and gamma-aminobutyric acid (an inhibitory brain chemical). In the case of cocaine, for instance, it reduces cravings and the desire for using the drug.
How does rTMS help overcome addiction disorders
rTMS helps overcome addiction by:
rTMS demonstrated decreases in drug craving and consumption in the following cases:
Conclusion
rTMS is an emerging therapeutic option for addiction disorders. For people who did not respond to conventional treatment approaches alone, rTMS may be offered as an off-label treatment and may be accompanied with psychosocial or psychotherapeutic approaches to give the best chance and the least painstaking way to overcome drug and behavioral addictions.
Fibromyalgia and Chronic Pain
Causes of Fibromyalgia
Fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. The exact cause of fibromyalgia is unknown, but it is thought to be related to abnormal levels of certain chemicals in the brain and changes in the way the central nervous system (the brain, spinal cord and nerves) processes pain messages carried around the body. It also has genetic factors. Fibromyalgia typically develops in women between the ages of 30 and 50.
Symptoms of Fibromyalgia
For Fibromyalgia to be diagnosed:
rTMS Treatment for Fibromyalgia
In the most recent large-scale researches average pain ratings and associated symptoms showed significant improvement post rTMS and the beneficial effects of rTMS lasted up to 6 months in the follow-up phase. Furthermore, research has shown rTMS to be effective in treating chronic pain.