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Discussion Starter · #1 ·
the onset is only 9 months ago for me and i want to make an early effective treatment. and rtms seems to be the best one at the moment. but where and how i can expect real results?

is a budget of 10.000 € enough?
 

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Yes, more than enough.
I have tried rTMS 6.months ago at the right VLPFC and the right TPJ. 12.sessions in total without any effect.

There are several problems related to rTMS and depersonalization. Some are related to what we know about emotional regulation In depersonalization from brain scans and others are related to technical issues what the average rTMS clinic can offer with the equipment they have. We are talking about 95% of them.

The locations found active in the prefrontal cortex in depersonalization are these:

1) The right dorsolateral prefrontal cortex. This location is a standard location for treatment for depression with rTMS. The location can be found with 90% accuracy without neuronavigation and is on the surface of the brain so it is easy to stimulate with a standard coil. I think that most with depersonalization who have tried rTMS have tried this location. The response rate is likely close to 10% with some reduction. So, from that you can say that this is not the location.

2) the other location is the right ventrolateral prefrontal cortex. This location was found by the depersonalization research unit in their very small series of brains scans, -between 8-12. patients in each study done over a decade. Other researcher have later said that the size of patients is likely to small with risks of errors. From these they made a trail of 7.patients with a 43% reduction. This is the location I have tried. There are two publications about doing rTMS at this location and they say the a substantial part of the VLPFC can not be stimulated with a normal 8-coil. It is too deep. A part of it is on the surface and can be stimulated. You need neuronavigation to find it and most rTMS clinics do not have it. In reality you need a deep coil for this location.

3) in some brain scans from the depersonalization research unit they also found that both sides of the dorsomedial prefrontal cortex and the anterior cingulate was active with the right VLPFC. These locations are also locations for depression, OCD and PTSD. They are to deep to stimulate with a normal coil. When the depersonalization research unit did their trails in 2014 deep coil was not available for research so they have likely excluded this location as it was to deep. Since then a deep coil have been developed and it can been done in theory. Some German DTI studies also point at this location.

4) there are also some data that point towards the ventromedial prefrontal cortex playing a role. This is also a very deep locations and 50% can like not be stimulated with a deep coil.

Then there are the right TPJ and angular gyrus. You can take them with a normal coil but you need neuronavigation for location. These are locations that might take the derealisation aspect of the condition and work in some. A large French trail on angular gyrus should be published by the end of the year or beginning of the next. They should scan people afterways and might clarify what location in the prefrontal cortex is central.

so, there are many potential locations and you need both neuronavigation and a deep coil to give them a fair tail. Most rTMS have either and I would stay away from them. A deep coil from Magventure have just been approved for OCD in the US and I hope that it might happen in Europe too within a year. To find a rTMS clinic in Eastern Europe that uses Magventure with neuronavigation would be cheap and ideal.

I am personally waiting for the publication of the French trail and hopefully the approval of Magventure deep coil in Europe. You can likely not travel in Europe before the spring due to COVID either. So, wait with rTMS as the limitations are many and the options are few as it stands.

To give you an idea of what neuronavigation is and a deep coil then see the 8.min video to this text. That is about the stimulation of the dorsomedial prefrontal cortex.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4692428/
 

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Discussion Starter · #3 ·
Yes, more than enough.
I have tried rTMS 6.months ago at the right VLPFC and the right TPJ. 12.sessions in total without any effect.
There are several problems related to rTMS and depersonalization. Some are related to what we know about emotional regulation In depersonalization from brain scans and others are related to technical issues what the average rTMS clinic can offer with the equipment they have. We are talking about 95% of them.

The locations found active in the prefrontal cortex in depersonalization are these:

1) The right dorsolateral prefrontal cortex. This location is a standard location for treatment for depression with rTMS. The location can be found with 90% accuracy with neuronavigation and is on the surface of the brain so it is easy to stimulate with a standard coil. I think that most with depersonalization who have tried rTMS have tried this location. The response rate is likely close to 10% with some reduction. So, from that you can say that this is not the location.
2) the other location is the right ventrolateral prefrontal cortex. This location was found by the depersonalization research unit in their very small series of brains scans, -between 8-12. patients done over a decade. Other researcher have later said that the size of patients is likely to small with risks of errors. From these they made a trail of 7.patients with a 43% reduction. This is the location I have tried. There are two publications about doing rTMS at this location and they say the a substantial part of the VLPFC can not be stimulated with a normal 8-coil. It is too deep. A part of it is on the surface and can be stimulated. You need neuronavigation to find it and most rTMS clinics do not have it.
3) in some brain scans from the depersonalization research unit they also found that both sides of the dorsomedial prefrontal cortex and the anterior cingulate was active with the right VLPFC. These locations are also locations for depression, OCD and PTSD. They are to deep to stimulate with a normal coil. When the depersonalization research unit did their trails in 2014 deep coil was not available for research so they have likely excluded this location as it was to deep. Since then a deep coil have been developed and it can been done in theory. Some German DTI studies also point at this location.
4) there are also some data that point towards the ventromedial prefrontal cortex playing a role. This is also a very deep locations and 50% can like not be stimulated with a deep coil.

Then there are the right TPJ and angular gyrus. You can take them with a normal coil but you need neuronavigation for location. These are locations that might take the derealisation aspect of the condition and work in some. A large French trail on angular gyrus should be published by the end of the year or beginning of the next. They should scan people afterways and might clarify what location in the prefrontal cortex is central.

so, there are many potential locations and you need both neuronavigation and a deep coil to give them a fair tail. Most rTMS have either and I would stay away from them. A deep coil from Magventure have just been approved for OCD in the US and I hope that it might happen in Europe too within a year. To find a rTMS clinic in Eastern Europe that uses Magventure with neuronavigation would be cheap and ideal.

I am personally waiting for the publication of the French trail and hopefully the approval of Magventure deep coil in Europe. You can likely not travel in Europe before the spring due to COVID either. So, wait with rTMS as the limitations are many and the options are few as it stands.

To give you an idea of what neuronavigation is and a deep coil then see the 8.min video to this text. That is about the stimulation of the dorsomedial prefrontal cortex.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4692428/
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.
 

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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-der-depression.de/rtms/
 

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Discussion Starter · #5 ·
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-der-depression.de/rtms/
where can i make a brain scan to figure out which parts of my brain are responsible to the symptoms?
 

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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.
 

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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.
 

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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.
 
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