TMS FOR OCD

Typically, The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Patients with mild OCD usually have good insight: meaning that the patient recognizes that obsessive-compulsive disorder beliefs are not true. Patients with severe OCD might have poor (limited) insight: meaning that the patient thinks obsessive-compulsive disorder beliefs are probably true. The most severe cases could be associated with delusional beliefs: meaning that the patient is completely convinced that obsessive-compulsive disorder beliefs are true.

How common is OCD?

The annual prevalence of OCD is about 1.2%. The lifetime prevalence of OCD is 2.3%. This means that about 1 in 44 Americans had, have, or will have OCD at some point. According to the National Institute of Mental Health, approximately one half (50.6%) of those with OCD had had a serious impairment. Obsessive compulsive disorder can also co-occur with anxiety disorders and depression.

What causes obsessive compulsive disorder?

The exact etiology of obsessive compulsive disorder is not fully understood. We have long thought that there is a biological abnormality in the brain that leads to OCD. A chemical imbalance of neurotransmitters used to be the most convincing explanation for the etiology of OCD. As neuropsychiatry is unfolding more about brain circuits, we are learning that imbalances in the cortical-striatal-thalamic-cortical (CSTC) pathway are present in patients with OCD.

This pathway consists of multiple parallel interconnected loops between cortical and subcortical areas whose role is to determine which actions are selected as important and which are ignored. These regions include the dorsolateral prefrontal cortex (DLPFC), orbitofrontal cortex (OFC), medial prefrontal cortex (mPFC), cingulate cortex, caudate nucleus, striatum, and thalamus.

What is the treatment for OCD?

The best first-line treatment for OCD is Cognitive Behavior Therapy (CBT). More specifically, the most effective cognitive behavioral therapy for OCD is a type of CBT called Exposure and Response Prevention (ERP). Exposure and Response Prevention is typically done by a mental health professional (psychiatrist, psychologist, social worker, or mental health counselor) in an outpatient setting. ERP is a type of behavioral therapy that exposes the patient to situations that provoke their obsessions and the resulting distress while helping them prevent their compulsive responses. Response prevention is the key to ERP. This process of getting used to the provocation of obsessions is what we call habituation.

In addition to psychotherapy, medication antidepressants are also considered first-line treatment, Usually, psychopharmacological treatment is done with ERP CBT mentioned above. Pharmacotherapy options include selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft) and fluvoxamine (Luvox) and the mostly serotonergic tricyclic antidepressant clomipramine (Anafranil). These treatments help some patients with OCD have some reduction of OCD symptoms, but they do not usually result in full remission. About 30% of OCD patients wouldn’t have satisfactory results from CBT +/- medications. Now, these patients have an alternative treatment option.

Learn more about the success rate of TMS

Does TMS work for OCD?

The answer is; Yes. A specific form of TMS called deep TMS is a safe, effective, and FDA-cleared treatment option for OCD. Let’s look at the details of TMS for OCD.

What is TMS for OCD?

Transcranial Magnetic Stimulation (TMS) utilizes an electromagnetic field on the skull and directing it to specific brain regions. This will activate certain circuits of the brain, returning the normal sync of the brain circuits. 

In a typical TMS session, patients are awake and sit in a comfortable treatment chair, while the operator places a magnetic coil over a given region of the head. Then, magnetic pulses will be applied that travel through hair, skin, muscle, and bone until they reach the brain. The magnet intensity is close to magnets uses in an MRI brain scanner but more focal. When magnetic pulses reach the targeted brain circuits, they turn into micro-electrical currents and activate neurons (brain cells), which then affects the related brain circuits. The magnetic pulses and location of stimulation are always specific for each patient according to an initial assessment of the person’s brain “brain mapping”. A typical TMS session takes about 20 minutes, and most treatments require daily sessions Monday to Friday for a few weeks (typically 6 weeks). Because there aren’t any systemic side effects, Patients drive to the TMS clinic on their own, receive the treatment, and then continue with regular daily activities.

In 2008, the FDA approved the use of TMS for the treatment of depression. In 2013, the FDA approved the use of “deep TMS” (using TMS H1-coil) also for depression. In 2017, the FDA approved the use of “deep TMS” (using TMS H7-coil) for OCD. In August 2020, the FDA approved MagVenture TMS therapy (using D-B80 coil) for the treatment of OCD.

OCD treatment with TMS delivers magnetic stimulation to the frontal brain structures and networks, targeting the dorsal medial Prefrontal Cortex (dmPFC) and the Anterior Cingulate Cortex (ACC) bilaterally. 

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A multicenter blinded randomized controlled trial published in the American Journal of Psychiatry in 2019 described the positive results. After six weeks of TMS treatment, the study showed significant improvement for the active treatment group when compared to sham (placebo). To be more specific, 38.1% of patients in the active group achieved a response of more than 30% reduction in symptom severity. Moreover, 54.8% of patients in the active group achieved a partial response of more than 20% reduction in symptom severity.