rTMS
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I have and some other too without any general succes.
Among the researchers working with depersonalization there was and still is high hopes for rTMS or brain stimulation.
But, rTMS is not just rTMS. If is about locations and frequencies. If you take depression there are today 4.locations you that is productive. The left and right DPLPC where you stimulate with inhibitory low frequency at the right DLPFC or high frequency at the left DLPFC. About 50% with major depression have a response at these two locations,- the rest do not. Most rTMS machines can only locate and stimulate these two locations. rTMS was until last year only approved at these two locations.
In depression you can then stimulate at the dorsomedial and the right orbifrontal cortex. Around 50% with depression with respond at the right orbitofrontal cortex that didn't respond at the left or right DLPFC.To take the right orbitofrontal cortex or the dorsomedial prefrontal cortex you need a deep coil that is recently been approved and can stimulate into deeper structures in the prefrontal cortex. 95% of private clinics and hospitals can only stimulate the right or left DLPFC. So, you can treat around 75% with depression with the right equipment. Many americans with depersonalization have tried rTMS at the right DLPFC without any benefits.,- so that locations do not give any benefits.
The "Depersonalization research unit" when active had a small trial in 2014 and they chose the right ventrolateral prefrontal cortex. This area is very difficult to locate and you need a navigation program and a MRI scan of the patient to make a location. 95% of clinics don´t have it and can not make the location. So, very few have tried this location. The right VLPFC can likely only be stimulated at around 30% as it expands into the brain and becomes to deep for a normal coil. The DP Unit trial then was only with 9. patients with no follow ups. So, placebo is likely high and it might not be the right locations. Other studies have later put the location into question and the own brain studies pointed towards the dorsomedial prefrontal cortex and anterior cingulate as overactive. This location could not be stimulated in 2014 with the coils available then. It can today. The problem with rTMS and depersonalization is the locations productive is not known. Studies is too old, too small to really have and idea what location to go to.
Another location is the right TPJ/angular gyrus and there are more trails been done at this location and one have been done in France and likely published soon. This location is likely the most promising until now. From the trials done today we know the 50% have a response. Those most recently symptomatic respond best and it is most symptoms related to derealisation and body that is significantly reduced. Not so much emotional numbing.
There is a need for studies with newer equipment and some researcher have talked about trials for a combination of brain scans and newer rTMS to also get an idea of the networks implicated in the condition. rTMS is not a "magic magnet". It is about locations and frequencies. If you can't come with studies that give you and idea about the locations and networks then you are closed to being lost.
There is this recent italian evaluation of the right TPJ and rTMS.
www.ncbi.nlm.nih.gov
Among the researchers working with depersonalization there was and still is high hopes for rTMS or brain stimulation.
But, rTMS is not just rTMS. If is about locations and frequencies. If you take depression there are today 4.locations you that is productive. The left and right DPLPC where you stimulate with inhibitory low frequency at the right DLPFC or high frequency at the left DLPFC. About 50% with major depression have a response at these two locations,- the rest do not. Most rTMS machines can only locate and stimulate these two locations. rTMS was until last year only approved at these two locations.
In depression you can then stimulate at the dorsomedial and the right orbifrontal cortex. Around 50% with depression with respond at the right orbitofrontal cortex that didn't respond at the left or right DLPFC.To take the right orbitofrontal cortex or the dorsomedial prefrontal cortex you need a deep coil that is recently been approved and can stimulate into deeper structures in the prefrontal cortex. 95% of private clinics and hospitals can only stimulate the right or left DLPFC. So, you can treat around 75% with depression with the right equipment. Many americans with depersonalization have tried rTMS at the right DLPFC without any benefits.,- so that locations do not give any benefits.
The "Depersonalization research unit" when active had a small trial in 2014 and they chose the right ventrolateral prefrontal cortex. This area is very difficult to locate and you need a navigation program and a MRI scan of the patient to make a location. 95% of clinics don´t have it and can not make the location. So, very few have tried this location. The right VLPFC can likely only be stimulated at around 30% as it expands into the brain and becomes to deep for a normal coil. The DP Unit trial then was only with 9. patients with no follow ups. So, placebo is likely high and it might not be the right locations. Other studies have later put the location into question and the own brain studies pointed towards the dorsomedial prefrontal cortex and anterior cingulate as overactive. This location could not be stimulated in 2014 with the coils available then. It can today. The problem with rTMS and depersonalization is the locations productive is not known. Studies is too old, too small to really have and idea what location to go to.
Another location is the right TPJ/angular gyrus and there are more trails been done at this location and one have been done in France and likely published soon. This location is likely the most promising until now. From the trials done today we know the 50% have a response. Those most recently symptomatic respond best and it is most symptoms related to derealisation and body that is significantly reduced. Not so much emotional numbing.
There is a need for studies with newer equipment and some researcher have talked about trials for a combination of brain scans and newer rTMS to also get an idea of the networks implicated in the condition. rTMS is not a "magic magnet". It is about locations and frequencies. If you can't come with studies that give you and idea about the locations and networks then you are closed to being lost.
There is this recent italian evaluation of the right TPJ and rTMS.
Targeting temporal parietal junction for assessing and treating disembodiment phenomena: a systematic review of TMS effect on depersonalization and derealization disorders (DPD) and body illusions
The temporal-parietal junction (TPJ) is a key structure for the embodiment, term referred to as the sense of being localized within one's physical body and is a fundamental aspect of the self. On the contrary, the sense of disembodiment, an alteration ...
www.ncbi.nlm.nih.gov
How do you know there Is a France trials?
Thank you very much, but has 2019 still not been published?
How do you know it is not effective on emotional numbing?
Likely delayed due to covid.
Prior rTMS trail at the right TPJ and evaluations of those who responded showed that it have no effect of emotional numbing. The angular gyrus/right TPJ is the hierarchy of the emotional regulation in the final last stages done by the brain related to embodiment of regulated emotions, putting them into action. So, it is stimulation at this final stange. If you want to address emotional numbing and and where it likely begins you have to stimulate at a location of the pre-frontal cortex. Emotional regulation of emotions is typically done in areas in the pre-frontal cortex. It is also seen in depression where over-activity in the pre-frontal cortex makes a state of overregulation of emotions or inhibition of emotions. Same mechanism in depersonalization is thought to be the case. In depression there are variations and differences in location this over regulation is done so in reality there are diffrent types of depressions,- some can be changed with rTMS at these diffrent locations and some can not as it is simply too deep in the prefrontal cortex for normal rTMS to change. This sub-group have found to benefit from a operation where a stimulator is operated into an area deep in the brain called the subcallosal cingulate and the over activity is inhibited by the stimulator - and the depression goes away. A connectomic approach for subcallosal cingulate deep brain stimulation surgery: prospective targeting in treatment-resistant depression - PubMed
In depression today in theory you can with a functional MRI scan make a prediction with 80% accuracy if people will respond to cognitive therapy, rTMS, medication or everything you do except operation will fail. The use of these scanning is not done in clinical practice yet as it is relatively recent it could be done. But, the use of functional brain scans in clinical settings will likely come in the coming decade.
The problem with depersonalization is that many locations shows up as over-active in the prefrontal cortex. Some of these locations have been tried by many without effect like the right DLPFC and parly the right VLPFC. So, these locations are likely not the right one.
The dorsomedial/anteterior cingulate also shows up as overactive and that is a pattern also seen in obsessive compulsive disorder. An area called the right ventromedial prefrontal cortex/orbitofrontal have also been found enlarged indicating overactivity. A network to an area called the ventral periaqueductal gray from the ventromedial prefrontal cortex is thought to play a role in the dissociative subtype of PTSD. It is an area involved in immobilization responds. The "play dead" reopens found in animals when the can not fight or flight to a danger,- then they immobilize. Depersonalization is thought to be such a related state of immobilisation/play dead. So, people feel dead inside, have lost the self because they are partly sedated by this response.
The problem with these location is they are to deep to be tested with conventional rTMS. You likely can do with technologies developed the last decade or in development. All rTMS trails is based on conventional rTMS and it is coils and technologies developed more 3-2.decades ago. So, there is a need for trails that explore these locations with newer equipment to treat and find the locations and networks making the disorder. The right TPJ/angular gyrus might take some symptoms in 50% and likely also to a degree in some that the state can go away totally for a period. But, it is not where the disorder starts. It have to be in the prefrontal cortex if one follows the hierarchy in the brain for regulation of emotions.
Prior rTMS trail at the right TPJ and evaluations of those who responded showed that it have no effect of emotional numbing. The angular gyrus/right TPJ is the hierarchy of the emotional regulation in the final last stages done by the brain related to embodiment of regulated emotions, putting them into action. So, it is stimulation at this final stange. If you want to address emotional numbing and and where it likely begins you have to stimulate at a location of the pre-frontal cortex. Emotional regulation of emotions is typically done in areas in the pre-frontal cortex. It is also seen in depression where over-activity in the pre-frontal cortex makes a state of overregulation of emotions or inhibition of emotions. Same mechanism in depersonalization is thought to be the case. In depression there are variations and differences in location this over regulation is done so in reality there are diffrent types of depressions,- some can be changed with rTMS at these diffrent locations and some can not as it is simply too deep in the prefrontal cortex for normal rTMS to change. This sub-group have found to benefit from a operation where a stimulator is operated into an area deep in the brain called the subcallosal cingulate and the over activity is inhibited by the stimulator - and the depression goes away. A connectomic approach for subcallosal cingulate deep brain stimulation surgery: prospective targeting in treatment-resistant depression - PubMed
In depression today in theory you can with a functional MRI scan make a prediction with 80% accuracy if people will respond to cognitive therapy, rTMS, medication or everything you do except operation will fail. The use of these scanning is not done in clinical practice yet as it is relatively recent it could be done. But, the use of functional brain scans in clinical settings will likely come in the coming decade.
The problem with depersonalization is that many locations shows up as over-active in the prefrontal cortex. Some of these locations have been tried by many without effect like the right DLPFC and parly the right VLPFC. So, these locations are likely not the right one.
The dorsomedial/anteterior cingulate also shows up as overactive and that is a pattern also seen in obsessive compulsive disorder. An area called the right ventromedial prefrontal cortex/orbitofrontal have also been found enlarged indicating overactivity. A network to an area called the ventral periaqueductal gray from the ventromedial prefrontal cortex is thought to play a role in the dissociative subtype of PTSD. It is an area involved in immobilization responds. The "play dead" reopens found in animals when the can not fight or flight to a danger,- then they immobilize. Depersonalization is thought to be such a related state of immobilisation/play dead. So, people feel dead inside, have lost the self because they are partly sedated by this response.
The problem with these location is they are to deep to be tested with conventional rTMS. You likely can do with technologies developed the last decade or in development. All rTMS trails is based on conventional rTMS and it is coils and technologies developed more 3-2.decades ago. So, there is a need for trails that explore these locations with newer equipment to treat and find the locations and networks making the disorder. The right TPJ/angular gyrus might take some symptoms in 50% and likely also to a degree in some that the state can go away totally for a period. But, it is not where the disorder starts. It have to be in the prefrontal cortex if one follows the hierarchy in the brain for regulation of emotions.
So there is no hope of recovering emotions... neither drugs nor rTMS nor anything else
Some have benefit from a combination of an antidepressant and lamotrigine 200-300.mg. If you have only had depersonalization for some years psychological approaches is likely also productive.
I have never said that rTMS didn't work. The locations tried and with conventional rTMS with the trails done nearly more than a decade ago it will likely not work. Brain stimulation is in development and is expected to develop for the next decades. So, more is known, new ways of interventions develop and new locations can be tried. Synchronized TMS will likely come out and be approved and that concept is very promising.
I have never said that rTMS didn't work. The locations tried and with conventional rTMS with the trails done nearly more than a decade ago it will likely not work. Brain stimulation is in development and is expected to develop for the next decades. So, more is known, new ways of interventions develop and new locations can be tried. Synchronized TMS will likely come out and be approved and that concept is very promising.
Thank you a lot
I'm italian physician...but now i'm in a black hole.
There is often a strong interaction between depersonalization and depression. Many gets depersonalization in a major depression episode and often you can get major depression from having depersonalization. So, if you have never tried an antidepressant combined with lamotrigine it might be worth a try. You could have a major depression running along with depersonalization. I was in contact in 2019 with rtmsitalia and they are likely the best equipped rTMS clinic in Europe with neuronavigation from Localite and deep coils like the magventure D-B80. They said they would look into depersonalization but they never replied me. I got the impression that the trails done to date was too small and the locations to conflicting indicating that the condition was not understood properly and the risk of non-response was to high for them to have anything to do with it. Depersonalization is not on their site and they have many conditions. But, it could be they have given it some considerations. They have coils to try the dorsomedial prefrontal cortex and the orbitofrontal cortex. You could ask them if they have any experience with it or given it any considerations. But, if you likely also have depression I would give the right orbitofrontal/ventromedial cortex a try. This network have been a suspected to play a role in dissociative subtype of PTSD and likely also in depersonalization. The regulation starts in the ventromedial prefrontal cortex. I am not aware of any with depersonalization who have tried this location and it is likely because deep coils have come out recently but only to Magventure machines. They have used for some years.
pubmed.ncbi.nlm.nih.gov
Free will versus survival: brain systems that underlie intrinsic constraints on behavior - PubMed
This article discusses the neuroanatomical systems involved in the related functions of fear and discernment of the consequences of one's actions, two internal constraints on free will and action. Both mechanisms are related to a system for control and modulation of visceral function stretching...
pubmed.ncbi.nlm.nih.gov
Lo
I don't have depression....only depersonalization...It would be interesting to know someone who participated in the France trial..There is often a strong interaction between depersonalization and depression. Many gets depersonalization in a major depression episode and often you can get major depression from having depersonalization. So, if you have never tried an antidepressant combined with lamotrigine it might be worth a try. You could have a major depression running along with depersonalization. I was in contact in 2019 with rtmsitalia and they are likely the best equipped rTMS clinic in Europe with neuronavigation from Localite and deep coils like the magventure D-B80. They said they would look into depersonalization but they never replied me. I got the impression that the trails done to date was too small and the locations to conflicting indicating that the condition was not understood properly and the risk of non-response was to high for them to have anything to do with it. Depersonalization is not on their site and they have many conditions. But, it could be they have given it some considerations. They have coils to try the dorsomedial prefrontal cortex and the orbitofrontal cortex. You could ask them if they have any experience with it or given it any considerations. But, if you likely also have depression I would give the right orbitofrontal/ventromedial cortex a try. This network have been a suspected to play a role in dissociative subtype of PTSD and likely also in depersonalization. The regulation starts in the ventromedial prefrontal cortex. I am not aware of any with depersonalization who have tried this location and it is likely because deep coils have come out recently but only to Magventure machines. They have used for some years.
Free will versus survival: brain systems that underlie intrinsic constraints on behavior - PubMed
This article discusses the neuroanatomical systems involved in the related functions of fear and discernment of the consequences of one's actions, two internal constraints on free will and action. Both mechanisms are related to a system for control and modulation of visceral function stretching...
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