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#13 Mayer-Gross

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Posted 12 April 2020 - 10:18 AM

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. 

 

#14 Markjones90

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Posted 12 April 2020 - 02:08 PM

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.

#15 Mayer-Gross

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Posted 12 April 2020 - 03:18 PM

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.research...a_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.  



#16 Markjones90

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Posted 14 April 2020 - 02:02 AM

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?

#17 Mayer-Gross

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Posted 14 April 2020 - 02:23 AM

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. 



#18 Mayer-Gross

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Posted 14 April 2020 - 02:29 AM

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.c...467-019-12486-x



#19 Mayer-Gross

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Posted 14 April 2020 - 03:46 AM


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 . 



#20 Markjones90

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Posted 29 April 2020 - 03:54 AM

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?

#21 Mayer-Gross

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Posted 29 April 2020 - 04:44 AM

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.magventu...oils/cool-d-b80



#22 Markjones90

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Posted 29 April 2020 - 09:45 AM

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.

#23 Markjones90

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Posted 29 April 2020 - 10:09 AM

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.

#24 Mayer-Gross

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Posted 29 April 2020 - 10:51 AM

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.https://www.youtube....onj_PEQ1g&t=33s






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