Mayer-Gross

Just a follow up to this story. I have tried rTMS at the right VLPFC for 12.session without effect. So, I have looked into the research in depersonalization and also rTMS. A general problem is that allmost all locations found overactive in the prefrontal cortex in depersonalization are too deep in the prefrontal cortex for a normal coil to stimulate. The rTMS used and approved is called a 8.coil and can go 1.cm deep into the prefrontal cortex. In depersonalization both sides of the medial prefrontal cortex have been found active in brain scans but this location is too deep to stimulate. The depersonalization research unit likely chose the right VLPFC because parts of it can be stimulated by a normal 8.coil. Like 20% of the right VLPFC. They do not address this problem in their publications and it is in many ways a huge error. The rTMS researcher, Jonathan Downar wrote a text about stimulation of different locations in the prefrontal cortex in 2013 that the VLPFC only can be superficially stimulated by a normal coil. A deep coil is needed for this location. A more recent publication about doing rTMS at the right VLPFC says that the location is to deep for normal coil and a deep coil is needed. Deep coils for rTMS is only in process for being approved in clinical use. So, rTMS right now as it stands might not be optimal for depersonalization. Too many limitations.

Here are some brain images from fMRI scans done in depersonalization and the first picture on the top shows the activity of the right VLPFC. Actually one can see that the active part of the right VLPFC is not the part that is on the surface of the cortex. The active part is deeper than one cm. It might explain the problems with this location. Both sides of the dorsomedial prefrontal cortex is also very active and can be seen in the center Of the brain. https://www.frontier...-00432-g002.jpg

The French angular gyrus trail will if they follow their design do a follow up in the 50.pataints given the active rTMS with a fMRI scanner. They might be able so see why some have had full response, a partial and none, i think that locations in the prefrontal cortex might play a central role for it, it is much more of value than a personal fMRI scan that might be close to useless. Such a large trail also brings awareness about depersonalization among psychiatrists working with rTMS. It can open some doors.

where can i make a brain scan to figure out which parts of my brain are responsible to the symptoms?

No, you can not. The dream of a brain scan and doctor looking at the scanning and saying “there is depersonalization” is naive. All brain scans done in depersonalization are almost free for all to read. There is nowhere despite they have both a patient and normal group to compare with where they can say that this is the location. There are simply to many differences in activity. There is also conflicting data between studies about these activities. You will never as a private person or a patient have access to scannings equipment more advanced than the one they use. You can get a SPECT scan that have not been used in psychiatric research for 30. Year with a charlatan saying that there is the location and give me your money. Fact is that fMRI scanner is 20.times or more sensitive than a SPECT. If systematic brain studies can not give answers when studying groups it can not do it either in single persons. 
 

Some have said that the best research that could be done in depersonalization was an open trail that was explorative where rTMS with deep coil was used combined with fMRI scanners. You could try to stimulate some locations that shows up as active and stimulate them with rTMS and see if there was a reduction in some symptoms and what is still there. Then try other locations . You would find productive locations and also get some insight into emotional regulation in depersonalization. It would isolate and exclude many things.

In the UK there is the first depersonalization charity called “Unreal UK”. Two central persons around this charity have said that rTMS do not work in depersonalization. They really do not know anything about rTMS. Their statements are based on experiences from who have consulted a very expensive and poorly equipped rTMS chain in the UK called “Smart TMS”. It operates from 10.locations in the the UK and are charging prices 2-3.times higher that Western Europe. They are poorly equipped and do not have neuronavigation. They claim on their site that they treat depersonalization but can in reality not make the locations for depersonalization. The other aspect is that there could potentially be other locations in depersonalization that are the “core” in the disorder like the dorsomedial prefrontal cortex or the ventromedial prefrontal cortex. So, we need more brain scannings. So, their claim that rTMS doesn’t work in depersonalization is correct with the equipment the average rTMS clinic have. But, to claim that rTMS have been tried and is not a potential treatment is wrong. There are so many locations that have never been tried.

thanks for your reply.

im being afraid of my symptoms going worse. i did wanted to make any treatment as early as possible.. but youre right. i live in germany, maybe one day that deep coil comes to germany.

Very few have neuronavigation in Germany and not a deep coil. I think if Magventure gets their deep coil approved in Europe those who acquire it will likely also get neuronavigation. This clinic have neuronavigation and uses a normal coil. You could contact them. More than a year ago a wrote to them because they wrote they have neuronavigation and also on their site they mentioned depersonalization and had tree references, primarily to the right TPJ trail. I can not find it. They might have dropped working with depersonalization. I was also in contact a year ago with an Italian rTMS clinic in Europe that have both a deep coil and neuronavigation from Magventure. A professor  replied that they would look into into and answer me shortly. They never did and did not reply me when I contacted that. I think the problem is the many locations coming up and small trails. If you then look into brain scannings done then there are many possibilities of locations. I think they do not like such insecurities into a disorder. https://www.wege-aus...ession.de/rtms/

The area making dissociation will like shift to a normal state when locations it is in network with becomes stimulated. So, you are affecting it indirectly.

so if i understand your theory right, if they are able to figure out exactly which areas in our brain are responsible for dpdr, and if they found a coil whats able to go that deep, then we can treat our symptoms?

it sounds too easy for me, i dont know.

The area that is found abnormal and making dissociation is a central hub, -likely the most central in the default mode network. Other areas related to the default mode network is also found affected and overactive in depersonalization like the medial prefrontal, anterior cingulate, angular gyrus, right TPJ. I think the medial prefrontal cortex is the second potent location in the network. The medial prefrontal is central in some depression, OCD and many with depersonalization had their outset with depression or had OCD like symptoms prior to the outset. There are many OCD like symptoms in depersonalization like constant checking and self monitoring. So, I think this location is central. But, it not easy to treat right now. You need a coil for deep rTMS to affect the medial prefrontal and you also need neuronavigation to find locations like angular gyrus and the medial prefrontal cortex. There are almost none in Europe that have both a deep coil and neuronavigation. You also need a location for some prices that is fair and can be paid.

It partly looks like that the “default mode network” is central in depersonalisation with areas that are active at rest/Sleep as very active. I will wait to the french “angular gyrus” trail is published. It is related to the area via the default mode network and might be affected by inhibition angular gyrus. The French trail should do some scannings after the trail and might look for differences in non-responders, partial and full responders. I think it will point towards locations in the prefrontal cortex that is related to the default mode network as the main reason for no or partial response. In no or partial responders the activity might be high in the prefrontal cortex to normalize the network.  So, it might settle what location in the prefrontal cortex is central. It has been very confusing until now. 

I have just read it and read an article about the location.i think it correct. Areas around this location have been found to be larger in MRI scans and overactive in fMRI studies in depersonalisation. The location is a part of the “default mode network” or the network the brain is in when it is at rest and self reflective. The location is to deep in the brain to affect with rTMS but it like to be in several networks with locations you can affect with rTMS. The current french rTMS trail on “angular gyrus” is a central hub in the default mode network might have some affect on it in some. The medial prefrontal cortex and anterior cingulate are also overactive in depersonalization. They are also central hubs in the default mode network. So, the response from this location could likely be turned off by working with these locations in the default mode network. You need neuronavigation to find these location and a deep coil for the medial prefrontal cortex/dorsal nexus. A coil just approved for OCD in the US and likely later in Europa can work on this location also called the “dorsal nexus”. It is a depression, OCD, PTSD location.
 

To this article is a 8.min video where stimulation at the dorso medial prefrontal cortex/dorsal Nexus is done with neuronavigation and the coil that just have been approved in the US that go stimulate deep enough. 

https://www.ncbi.nlm...les/PMC4692428/

Hey, i find you to be very resourceful and some what intelligent. Do you mind if we get to know each other for a bit, because i want to ask your opinion about some matter. Possibly DR/DP related. Cheers!

I had my messenger open until a few months ago. I have closed it. I had some serious considerations of totally leaving this forum and have my profile deleted. The reason is being contacted by many people several times a day. In many cases using a lot of time on reply’s and explanations only to be asked the same question several times again up til 3-4.times. It stops becuase I stop, not because the other part stops. One gets the feeling of using time one people that in reality do not read or understand one’s reply . References in reply is often not read. A conversation can be up to 6.pages long where I felt it have been totally waste of time. So, I have had interactions with people 20-30% of the time that have been deeply frustrating I can not block them as individuals and have to close the messenger system totally. 

A French rTMS trial should be published later this year or beginning of the next of stimulation of the right angular gyrus. They should do some fMRI scans prior to the trail and after. So, it might also give some ideas of the networks at play in depersonalization. I might try the angular gyrus too if it gives some interesting results. But, the scanning part of the trial is very interesting too. 

Sarcosine will likely not work. It is a drug that works on the glycine sensitive site of the NMDA receptor. The theory behinds this is the ketamine witch blocks the NMDA receptor can make a state with dissociation or schizophrenia like symptoms. A co-agonist at the glycine sensitive site could in trails partly reverse it. So, in the late nineties they started in trails to give drugs like l-glycine, d-serine, d-cycloserine and sarcosine to negative symptoms in schizoprenia. It had some effect on these symptoms . I didn’t know at that time that I had depersonalization but had been given the diagnosis “pure negative symptoms” related schizophrenia and told they could do nothing. But, these trials showed effect on these symptoms and my symptoms was like being constant on ketamine. So, I imported 4.kg of l-glycine and tried. I took 90-120.grams of l-glycine every morning in water solution on a empty stomach every morning for 6.weeks. It was to make some the l-glycine cross the blood brain barrier. I felt nothing. That was in 2002. After depersonalization was diagnosed I became aware that a ketamine model also was used in depersonalization. In the book “Feeling Unreal” Daphne Simeon writes that she did a  placebo controlled trail on Mount 

Sinai in New York with d-cycloserine in depersonalization and there was no difference between the groups. The trail was for some reason never published. So, drugs that work similar to sarcosine have been tried in depersonalization without effect.

Yeah mahn why to be negative he talks like it can't get better, like new people on forums will think by seeing his comments that one can't get better which is totally untrue, in 10 months I am tremendously better and feel way in control but if I am new and look up to his comments I will think there is no end to it. We don't need more negativity mahn, we have enough and personally for me his comments doesn't impact me but it can harm new or fragile people.

Why are you lying? I have always recommended especially to people with a early outset to try cognitive and acceptance based therapies as they are the most productive in most ( like the “anxiety no more” site. I have always said to people they should try a combination of a antidepressant and lamotrigine as it benefits some. Benzodiazepines are also of some effect many when combined with a antidepressant but people developed rapid tolerance to this combination and they return to the state they where in. I had significant benefits form a combination of clonazepam and duloxitine for 6.months ,- then tolerance sat in.
 

There is no formel pharmacological treatment for depersonalization disorder. This is not because I that “know nothing” and am negative says it. That is a statement you find researchers into the disorder come with in publications. This is formally a pharmaceutical refractory disorder and that is also why I am very interested in rTMS. This was a intervention the depersonalization research unit believed in until they closed in 2015. 
 

you have made a endless list with medical examinations people should have done. Many of them pointless and expensive. You have recommended very many medicine and alternative remedies that had no effect on many of those who tried them. So, I am negative to pointing that out. If I am addressing the highly problematic in that antipsychotics is recommended on this site because I personally have had a major depression due to high doses of olanzapine and I had significantly worsening of my symptoms on abilify. This experience is not by a “negative” who ought to be banned. This is formal pharmacology in publications for the depersonalization research unit (p.95) https://pdfs.semanti...6cc61c43d27.pdf

you have in your post made the claim that “ECT” works and is a treatment. A publication form 1947 a case study with more than 40.patients who tried ECT. 1. Felt much better 2..slightly better and 10.much worse, - rest nothing. A more recent publication of 9.patients with DP from Singapore 3.where given ECT with no effect. If depersonalization is a secondary symptom to major depression studies shows that there is indication of that neither ECT or sleep deprivations works as well as in major depression.

https://journals.sag...591574603901206

To mayer-gros My advice .. You submit yourself to the study because the cooperation of intelligent sufferers seems needed rather than passive sufferers

Thanks.

I tried rTMS in march at the right VLPFC/ventrolateral prefrontal cortex and the right TPJ. 12.session and i felt nothing. The right ventrolateral prefrontal cortex was the area that the “Depersonalization research Unit” found to be an area for rTMS intervention though they expressed interest for some other location but likely dropped them as they where to deep for a rTMS intervention then(2014).You can not do rTMS at the right ventrolateral prefrontal cortex without neuronavigation from a MRI scan - that excludes almost 90% of all rTMS providers as they do not have neuronavigation . They would not be able to find a location. So, I have thought about why I did not respond and one reason could be I am left handed some much of my emotional regulation could be in the other brain hemisphere. Left handed are almost excluded from brain imaging studies or rTMS trail because they can cause errrors for the study. Other reason is that the location that they found might not be the right one. Other studies point towards the ventromedial prefrontal cortex - again a location too deep in the brain. I re-read a text by rTMS researcher, Jonathan Downar about different locations in the prefrontal cortex and he writes that ventrolateral prefrontal cortex have some surface that can be stimulated by a normal coil but it expands into the brain where a normal coil cannot go. To him it is a location for a coil for deep rTMS. When I looked at some of the images taken in the studies by the depersonalization research unit I could see that large parts of the ventrolateral prefrontal cortex active it likely to deep to be inhibited by a normal coil. So a reason for the lack of response could be the only 1/3 to 1/2 of the ventrolateral prefrontal cortex was stimulated. So, you likely need both neuronavigation and a coil for deep rTMS to give this area a fair trail. There are some who have benefited partly at this location but if it is only 50% a normal coil can cover of the location it might explain that. 

thanks for the very valuable informations. i hope in the next 15-20 years there will be accurate methods to threat this mental state.

I expect there could be a treatment within the coming years. There are some locations found active in depersonalization you have not been able to intervene in until recently. This is also the case for depression. The locations have been to deep in the prefrontal cortex to do it. But, there are coils that can go deeper and they will likely be available for the many with depression who do not respond to normal rTMS. Many of these locations found in depression are often very active in depersonalization too. So, when these coils that can go deeper are available then other locations can be tried. The medial prefrontal cortex along with anterior cingulate is found active in some states of depression and obsessive compulsive disorder. This area is also found active in depersonalization. It is very deep in the brain to reach but a deep coil can. There is a lot of obsessive self monitoring in depersonalization and it might be related to this activity.