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Mayer-Gross

Member Since 31 Dec 2010
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#628254 i will try next week neuronavigated tms

Posted by Mayer-Gross on 09 January 2021 - 02:52 PM

no, i dont have those symptoms. Those are not symptoms related to depersonalization disorder. I sounds to me that you might have some DP/DR secondary to another condition. I thought that it might be related to "Chronic fatigue syndrome"/CFS. There are several posts on this site with people with CFS who have DP/DR secondary to it. https://www.dpselfhe...2-cfsme/?hl=cfs




#628048 i will try next week neuronavigated tms

Posted by Mayer-Gross on 01 January 2021 - 07:13 AM

a conventional rTMS 8.coil that can stimulate at 1.cm depth that is the one approved with look flat like this. 

 

https://www.magventu...coils/c-b70-2-2

 

 coil for deeper stimulation at a depth of 2.cm will look like this. It has been used for research in 5-6.years but is not approved for clinical used in Europe yet. Just been in the US. Magventure rTMS machines only. 

 

https://www.magventu...oils/cool-d-b80




#628046 i will try next week neuronavigated tms

Posted by Mayer-Gross on 01 January 2021 - 06:54 AM

in SPECT and PET scans you used a radioactive tracer that have a brief short life that is out of the body with some hours. This tracer has to be made prior to the scan. This tracer is given as a infusion or a tablet. In a fMRI you don't need that. It can measure the use of oxygen in the brain. 




#628044 i will try next week neuronavigated tms

Posted by Mayer-Gross on 01 January 2021 - 06:48 AM

as it stands and from what we know about depersonalization a scan will likely not be of any use like it could be in depression. The problem is that many locations show up as active. You do not know with is the "core" location among them. That is also why a review of brain imaging studies from this year recommended a study where a combination of fMRI with rTMS was done. You could then pick some of these locations a make a stimulation and see if it makes a difference in symptoms and in a new brain scan. That knowledge about depression comes form a decade of research where a combination of rTMS and fMRI was done in many hundreds of patients . In depression there are 3-4.networks affected and locations. So, you can scan a depressed and see what kind they are as you know what to look for. That we do not know in depersonalization. A SPECT is almost not used in psychiatry but neurology as it is not sensitive enough. Psychiatric symptoms are much "softer" than neurological symptoms. But, the problem is also can you intervene in these locations. Conventional rTMS have the limitation of stimulation depth of 1.cm and that rules out many areas for stimulation that are central in many states. Many with depression can not be treated with conventional rTMS as the emotional regulation in the prefrontal cortex is too deep. Many locations showing up in depersonalization as active is too deep for conventional rTMS. 




#628030 i will try next week neuronavigated tms

Posted by Mayer-Gross on 31 December 2020 - 11:16 AM

There are no coils that can go 5.cm into the brain. There are several scientific articles about locations for stimulation, other about coil design for deeper stimulation. The coil used for the rTMS approved in Europe,  USA and elsewhere have a stimulation depth of 1.cm. Coils that can go deeper was not developed until 5.years ago and are yet not approved for clinical use. They have been used for research until now and one have just been approved in the USA for OCD. The response rate for depression with normal rims is around 50% at two locations with the coil used. Research have shown that other with depression have regulation of emotions in structures deeper in the prefrontal cortex and when they are given rTMS at these two other locations with a deep coil they have a response. So, you might cure 85% of depressions if you also use a deep coil at other locations. There is only one place in Europe where they use such a coil. Because it is not approved for clinical use they are breaking the law in a way by using it. I think they  might have said that the size of the trials in depression where such a coil is used makes it sufficient for them to use. It has been approved in the US to use this year for OCD. I have seen videos by a psychiatrist in New York from 2017 with such a coil used on a patient. It was not legal then. I think they have got these coil though connections to research facilities at universities. So, it is a research facility that have ordered from the producer and not a rTMS clinic. It might explain why the are almost absent elsewhere. 

 

The rTMS researcher who works with depression, Jonathan Downar have addressed this problem about stimulation depth, locations and coils years ago. He writes this about the right VLPFC;

 

"The VLPFC also presents a challenging target for conventional rTMS, as much of it lies deep within the frontal operculum, or along the orbital surface of the prefrontal cortex. However, even for superficial VLPFC regions, tolerability remains a problematic issue, due to the proximity of the extraocular and temporalis muscles. There are several alleviating measures that may be effective in improving the tolerability of stimulation at this region, as reviewed in detail below. With appropriate measures to alleviate discomfort, conventional figure-8 coils may be suitable for stimulating some VLPFC regions, and newer coil designs should be able to address the depth-of-target issue in future. Hence, the VLPFC could also serve as a practical target in future studies of rTMS for depression, with appropriate refinements to technique."

 

https://dribrahimyil...emik-Makale.pdf

 

You psychiatrist might mean that the effects of stimulation might go as deep as 5.cm. There he is right. When you stimulate an area it will have affects on areas It is in networks with that is much deeper into the brain. But, a direct stimulation might that can go 5.cm might never be possible to develop as it will diffuse from the areas it shall pass (it will affect them too) and the stimulation will also spread over a larger area and become weak. Around 2-2,5.cm for a coil for deep rTMS is likely maximum and H-coils design for a specific locations might go close into 3,5-4.cm the brain.

 

In Western Europe a rTMS session can very in price between 100.euros to 300.euros. In the UK it close to 300.euros. In Eastern Europe from 50-55. euros. 

 

He is right to call out a placebo effect. But, the TPJ trial was much larger is size than the right VLPFC. In depersonalization the placebo effect is much smaller than in depression. To see reductions of 20-50% in depression trials relate to placebo is normal. That is also why many says that SSRIs don't work for depression because the response rate in placebo group is very high in in many trials. But, the placebo effect in other conditions is much smaller. In obsessive conplusive disorder the placebo effect is much less and a response of 25% is regarded as valid. It is not the case in depression trials. Depersonalization placebo effect is similar to obsessive compulsive disorder. It is there but low and likely not sustainable over time. You can see it on the posts of this forum. Some tries a drug and makes a post here a day after about feeling better. It is often drug that are normally many weeks to work and in larger doses than tried. But, people feel better. Here on the forum they can not understand a week or two later that is stopped working. It is the placebo effect that stopped working. Many posts about feeling better on something also changes within weeks. So, the placebo effect is there but it do not last for a very long time. Never take posts from anyone who have taken a drug for a very few weeks seriously. 

 

But, the reductions in a TPJ trial is much larger in those who respond. The problem with all trials in depersonalization is they are very small and not placebo controlled. Likely due to lack of funding into research into depersonalization. That is a problem. A bias from the researcher can also play a role. They hope their patients gets better and want to see a response. So, their perceptions can color the trail. 

 

I think that that the right TPJ might play a role but is not the "core" location. It is likely in network with it and it might have some effect in some. The angular gyrus trial is with a 100. patients and half of them will get placebo. So, it the first real trial in depersonalization ever.  If the rumor holds that the response rate is 50% it might again be related to networks connections. There is a locations that turns up in many studies with drugs that can make depersonalization and that is also found larger in people with symptoms with depersonalization. It is also connected to and close to angular gyrus and the TPJ. That is a location called "Precuneus". In a PET study from 2000 it came out as active along with the angular gyrus and TPJ. It is found larger in in MRI study at the depersonalization research unit. In people with borderline disorder with dissociation it is also affected. When people are given  sedation and lose consciousness, it is turn off. Drugs like ketamine and cannabis that can make depersonalization highly effects this location. But almost all drugs that have affect the the consciousness affect the precuneus. It plays a centrai role in consciousness and self-awareness.

 

There was a publications in "Nature" this year about a experiment where mouse was given ketamine and immobilized into dissociative state. They found an area changes the frequencies in the brain called "Retrosplenial" in mouse. The same area in humans are called "posteromedial cortex" and coveres two locations; precuneus and posterior cingulate cortex. In publication about the effect of cannabis those who experienceed a bad trip with depersonalization, anxiety, ego death found to have changes in frequencies in the precuneus and prosterior cingulate/posteromedial cortex. 

https://www.ecnp.eu/...8/P.1.b.009.pdf

 

I hope that angular gyrus trial might go into the role that the precuneus might play. You need a deep coil to stimulation of this area. 




#627938 Relapse, medications

Posted by Mayer-Gross on 26 December 2020 - 05:40 PM

There is no medicine formally approved for depersonalization. The trails done with medicine have been very small and not placebo controlled. However there are some who have a benefit of a combination of a antidepressant with lamotrigine. As antidepressants SSRIs or SNRIs are typically used and the dose of lamotrigine is typically within the rage of 200-300.mg. It will take months to reach a dose of 200-300.mg as it is normally increased with 25.mg pr.week to avoid a skin reaction. You can give that a try. 




#627794 Blank mind recovery story.

Posted by Mayer-Gross on 18 December 2020 - 06:57 PM

Another problem could be that these locations might not be right in the first place. Emotional numbing and depersonalization is thought to be related to over regulation of emotions done by the prefrontal cortex. Overactivity makes a suppression of emotions. The  right VLPFC is a location choosen by the then depersonalization research unit and only tested in a small trial with 8.patiants -too small. But, in their fMRI the anterior cingulate and the medial prefrontal cortex also came out as over active. So, this location could play a role. In their structual mri study they found that the right ventromedial prefrontal was larger and implying it could be over active too. A recent German DTI scan found a indication of a network involving the anterior cingulate cortex the dorsomedial with connection to the right ventromedial cortex. So, the locations might not be right or they could differentiate from person as seen in depression. 
 

The angular gyrus is more related to derealisation and perhaps anxiety. There are some indication that a location called the Precuneus  with is close to angular gyrus plays a role in depersonalization to. It could be an alternative location for those that do not respond at the angular gyrus. See,what the French trial have Anything to say about that. 




#627792 Blank mind recovery story.

Posted by Mayer-Gross on 18 December 2020 - 06:31 PM

mg it seems like youre very bored man. you said multiple times „i dont want lose time for such questions“ but despite you let trigger yourself from desperate people who seek here for any hope. its very non-productive. if you want anything to do, explain the differences between people with dpd who responds to rtms (vlpfc, tpj, angular gyrus) and who do not. use your intelligence for some productive stuff.

I am responding to a new person on this forum who likely is aware that people are not active anymore.

 

Nobody can give an answer to your question as all trials have been very small and there have not been any fMRI done prior to rTMS and after so one could have an idea about the differences in emotional regulation in those who respond and those who didn’t. There is simply no information in the trials to give an answer to that. That is also why the ideal research facility would employ a combination of rTMS and fMRI like the research done in depression done by Jonathan Downar research clinic in Canada. http://rtmslab.com/




#627750 Question about brain scan and Rtms (especially to Mayer-Gross)

Posted by Mayer-Gross on 17 December 2020 - 05:32 AM

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

https://clinicaltria...how/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.




#627590 Development of more advanced rTMS equipment.

Posted by Mayer-Gross on 10 December 2020 - 11:53 AM

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. 




#627528 Development of more advanced rTMS equipment.

Posted by Mayer-Gross on 08 December 2020 - 05:09 PM

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://innovationsf...tent-depression

 

english version of the project: https://www.drcmr.dk...tant-depression




#627522 Hi, Im new. I want to know if this sounds like DP

Posted by Mayer-Gross on 08 December 2020 - 10:55 AM

“I dont feel like I'm in a dream or fog or my body isn't real.i have a fear this is schizophrenia but have been told it isn't. I feel like I'm going to go crazy.”

There is a subgroup within depersonalization who primarily have derealisation but not depersonalization with emotional numbing. You say that you don’t derealisation but only emotional numbing and that likely do not qualify you the condition. I can not understand that you are given the diagnosis of dissociative identity disorder with the symptoms you say you have. You are suffering from a anxiety condition and the emotional numbing is likely a result of your brain trying to suppress anxiety, - the cost is all emotions are suppressed. You have have a fear of developing schizophrenia and the mental hypochondritis is normal in many with a anxiety condition and also at the outset at depersonalization. It seems to me that you are suffering from a anxiety condition but the absence of derealisation likely is against that you have depersonalization disorder. 




#627350 Question about brain scan and Rtms (especially to Mayer-Gross)

Posted by Mayer-Gross on 03 December 2020 - 05:43 PM

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/




#627046 Did you have seperation anxiety as a child?

Posted by Mayer-Gross on 22 November 2020 - 10:16 PM

The reason I ask about separation anxiety is because it seems to be related to the development of panic anxiety later in adolescence. Many who gets a negative trip on cannabis very often have a history of panic attacks. So, it was just out of interest to see if this element in development of panic attacks was present in some.




#627032 Did you have seperation anxiety as a child?

Posted by Mayer-Gross on 22 November 2020 - 06:28 PM

With seperation anxiety it could be anxiety for being away from you parents, sleeping at places without your parents ect. I had seperation anxiety as a child and there are some research pointing towards the risk of developing panic anxiety is 3.times higher if one had separation anxiety as a child. Panic anxiety has been seen as a component in development  depersonalization.