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Europe is currently in lockdown and you can not travel. it might last to the beginning of the summer. However you write that you have tried rTMS at the left and right DLPFC for 20.sessions. There is a subtype within depression witch is marked by anhedonia and they do not respond well to these locations.

The location for this subgroup with anhedonia is the right ventromedial/orbito prefrontal cortex. It is a locations that also comes out as active in some depersonalization studies and in the dissociative subtype of PTSD. There is only one place in Europe where they have the equipment to do rTMS at this location. They rejected me in 2019 for depersonalization properly because of very small trials, ,many confusing locations they likely thought that depersonalization is purely understood and would not work with the disorder. So, they will likely reject people with depersonalization disorder. But, you also have depression, a journal form Germany that also states it, it might be possible for you to be accepted by them as one with depression.

The price is 100.euros pr. session. two sessions a day with theta burst the first week and one session a day the second week. If it do not work they might have some alternatives for you. I will not write the address here but contact you later when there is an end to the lockdown.

https://www.sciencedirect.com/science/article/pii/S0924977X17320023

https://www.dcs.warwick.ac.uk/~feng/papers/rtms-and-depression.pdf

The critical aspect in your case is that you have tried both imipramine and Parnate-a TCA and A MAOI. These are very old drugs that is much more effective than the newer drug. The newer anti-depressant are not so effective,- they just have fewer side-effects and can be tolerated by more people. So, you either have to be seen by one who are into more advanced psychopharmacology to look at your case or rTMS at other locations.

I would likely stay away from being a part of a rTMS trial. You might be in the placebo group or the tried a location that do not respond well to anhedonia like the dorsomedial prefrontal cortex.

The problem with rTMS is that there is likely 3.locations and networks know and the approved rTMS locations only treats on one of them. The clinic I refer to uses a coil that is not approved but widely used in research in depression. The risk are small and they likely think there is sufficient trials done to work with these two other locations. So, it is not very likely they can offer these locations in Germany unless it is a part of a trial. These locations are not formally approved yet and therefor not offered in the health systems that have rTMS. You also need some more advanced rTMS equipment to take these locations. Most rTMS clinics and in the health service is only conventional rTMS.

Runtome. We do not suffer from the same condition. I have depersonalization disorder in its primary form while you have according to a professor who have seen you and written two books and done research into depersonalization, have major depression with secondary symptoms of depersonalization/anhedonia. You are also too old to get depersonalization with such a late outset of your state.

Major depression is far more serious condition but also much better to treat than depersonalization . So, by insisting or thinking you have depersonalization you are put you life in danger because you will try highly experimental treatments for a condition you do not have and likely have no benefits from. I tried to get you to a rTMS clinic in Italy that is the only one in Europe that have the equipment to do rTMS on a location for that is responsive for depressions with anhedonia. But, you wanted to go to Hungary for experimental rTMS for depersonalization. So, your delusion of having depersonalization is standing in the way of you getting the right treatment.

I have tried a drug, Marplan similar to Parnate approved in Denmark and I have mentioned it is a thread where you are also active and asking into it.

https://www.dpselfhelp.com/forum/index.php?/topic/83818-how-did-jeffrey-abugel-recover/page-2?hl=marplan

Very difficult to say. Parnate/tranylcypromine formal max. dose is 60.mg. You might only have been in a dose of 60.mg for 4-5.weeks as you likely have increased to dose with 10.mg pr week. There have been trials where doses as high as 200.mg a day has been used with patients being depressed for more than a decade and refractory to electro convulsive therapy. The response rate was close to 60%. If your doctor is ok with it and you can tolerate it, it can be tried to increase the dose to 90-120.mg pr. day.If you are fine with it I would try to increase the dose and see if it works. The side.effects should not increase compared to what you have. This text from 1989 says this about doses;

"More recently, several case reports have sugge- sted that higher than conventional doses of the MAO inhibitor tranylcypromine, may be a safe and effective treatment for re- fractory depression (Shopsin and Kline. 1976; Robinson. 1983; Guze and Baxter. 1987; Pearlman. 1987). Robinson (1983) described a patient with refractory depression who finally responded at 90 mg of tranylcypromine, while Guze and Baxter (\ 987) and Pearlman (\ 987) described 3 patients with resistant depression who required tranylcypromine doses ranging from 100 mg to 200 mg daily. Furthermore, side effects appeared to be uncommon in these reports, and blood pressures remained in the normotensive range even though several of the patients were receiving concomitant psychotro-

pic medication."

https://sci-hub.se/https://doi.org/10.1055/s-2007-1014572

But, you could try rTMS at the right orbitofrontal cortex that is a location that many with depression with anhedonia who have failed other rTMS locations respond to. It can not be done in Germany, Hungary or elsewhere. Only one place in Italy. It is a research location in the brain and there is not yet a formal approval yet for this location. It will likely come. I tried to get you there in the summer but you did not take me or yourself serious,- you have "depersonalization" and wanted to go to Hungary.

Your friend "Didi" did this post about anhedonia.

https://ingcen.wordpress.com/2018/12/09/anhedonia/

Numb_1993 said:

Dear MG in other posts you wrote about two people who had a response to rtms on the vlpfc ..do you know where they had it done?

Click to expand...

One on this site claimed he had a response after one session with neuronavigation done in Texas. He stopped posting and replying to post after on this site,- it could have been placebo.

The other one was a video post done by guy from Lucerne Switzerland (see video) who had it done there at a price of 300-400.euros. pr session. I know their site and they do not have as advance equipment as those in Italy. They can not do deep brain stimulation and their prices are 4.times higher. He did not get cured and some of his symptoms was still there. He says in the video that emotional numbing was not his central problem and the symptoms was not profound it was most derealisation. There was no effect there. So, one can put in to question if it worked on him or it was placebo.

Both You and "Runtome" have major depression with anhedonia. Your both have this obsessive idea that a highly experimental location for depersonalization will work for depression. It likely do not work for depersonalization and if you have depression it will with 100% certainty not work. There was last year a small trail done on Munich with 4.with depersonalization where they go rTMS at either the right TPJ or the right VLPFC. They are very wage but says directly that one who had rTMS did not benefit at all. No, placebo either. To one the professor have said that the locations did not replicate. None had any benefits. A German brain scan form 2019 they put the right VLPFC into question and points towards other networks including the location I want you and "Runtome" to try in Italy.

There is only one location for depression with anhedonia and only place they can do it. If two with major depression form Germany do not want a treatment for major depression with anhedonia but a experimental treatment for depersonalization they do not suffer from, then what can I do?

"runtome" have been seen by a German prof. who have done research into depersonalization and written two books about it. He says that he don't have depersonalization disorder. He has major depression with secondary symptoms of depersonalization or anhedonia. This is also something that makes a major depression more difficult to treat.

To cry a lot is not normal affect. To have vegetative symptoms like changes in appetite, sleep are core symptoms of major depression.

The locations I want you to try in Italy is for major depression with anhedonia. The locations is called the right orbitofrontal cortex or the right ventromedial prefrontal cortex. This locations have for 4.decades thought to be central in suppressing anxiety to threat and making a numbing state. There is much more reseach done into PTSD and 15% with PTSD have the dissociative subtype with symptoms of derealization and depersonalization. In brains scans of people with the dissociative subtype DP/DR this area have been found overactive. In some studies of depersonalization it is also the case. So, you can likely get rTMS at this location it you have major depression with anhedonia but not if you say you have depersonalization. They will likely not take people with depersonalisation as it is purely understood. But, the location also plays a role in many states that have depersonalization symptoms. I could try this location I would do it.

Ok. That was also my impression but I became a little nervous about that it could be depersonalization with a secondary depression. The absence of derealisation and it is only related to being numb/having anhedonia very likely makes it is a major depression. You shall know that we really do not know much about depersonalization compered to depression. That your and "Runtome" treatment options are far better with major depression than with depersonalization that you most likely do not have. If you do not qualify for the criteria for depersonalization you are making you way to a correct treatment much worse and prolonging it by relating your symptoms to depersonalization disorder.

There is a subtype in depression that do not respond to normal rTMS locations and they are also marked by anhedonia,- feeling no emotions. 60% of them respond to rTMS at the right orbitofrontal cortex despite they have failed at other locations.Major depression is much worser than depersonalization but much easier to treat.

Fine. I do not know if the equipment they shall use like a deep coil is at their location in Milano or Cagliari, Sardinia. It could be both places. Milano is the closest to you but Cagliari is likely much cheaper to live in.

Write that you have depression with anhedonia and what rTMS locations you have tried and how many sessions. Also the medicines tried. I would likely leave naltrexone and the depersonalization story out of it. You have been told that they have equipment to do rTMS at other locations for depression. I think that have open 6.days a week for 12.hours a day and they might do 2.sessions a day with some hours spacing between sessions. There have been done some trails with 5.rTMS sessions a day in extremely depressed with reductions in symptoms of 80% after 5.days in one experiment recently.

The trail and location is this one. There is another location you have not tried called the dorsomedial prefrontal cortex. They have found out that people responding at that location have intact hedonic tone and those who did not, did not respond had anhedonia. The right orbitofrontal cortex is for depression with anhedonia. Some, with commodities like OCD and anxiety also see these symptoms significantly reduced with depression at this location. They do not need a MRI scan to find the location but if you have one it is likely ok.https://www.sciencedirect.com/science/article/pii/S0924977X17320023