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Development of more advanced rTMS equipment.


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#13 Numb_1993

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Posted 09 January 2021 - 10:37 AM

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.

#14 Mayer-Gross

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Posted 09 January 2021 - 12:35 PM

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.



#15 Numb_1993

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Posted 09 January 2021 - 12:52 PM

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.

#16 Mayer-Gross

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Posted 09 January 2021 - 06:14 PM

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.   



#17 Numb_1993

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Posted 10 January 2021 - 11:01 AM

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 🙈

#18 Mayer-Gross

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Posted 10 January 2021 - 02:08 PM

The German small trial was done by people with relation to this clinic.http://www.klinikum....tion/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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