TMS is often used to treat anxiety when other types of treatments have failed. TMS therapy is an innovative treatment with promising results. TMS therapy may not eradicate your anxiety, but it can reduce your symptoms and allow you to a live a better quality of life. Jan 24, 2018 TMS Therapy for Anxiety Disorders. TMS is a noninvasive treatment that involves making incremental changes in brain chemistry using magnetic fields. A coil is placed over the scalp strategically, depending on which disorder is being treated, and repetitive magnetic pulses.
Why does rTMS work?
rTMS (repetitive transcranial magnetic stimulation) has been shown to produce changes in neuronal activity in regions of the brain implicated in mood regulation, such as the prefrontal cortex. As each magnetic pulse passes through the skull and into the brain, this induces brief activity of brain cells underlying the treatment coil.
The frequency of pulse delivery also influences whether brain activity is increased or decreased by a session of rTMS. Recent studies also suggest that stimulation over the left and right sides of the brain can have opposite effects on mood regulation.
When is rTMS used?
Antidepressant medications and psychotherapy are the first line treatments for major depression. These treatments, however, do not work for all patients. In these instances, rTMS might be used as an alternative treatment, or to augment antidepressant medications or psychotherapy. Patients who have failed to achieve an adequate response from antidepressants, or who are unable to tolerate medications, might consider rTMS therapy.
What happens during an rTMS procedure?
Because rTMS uses magnetic pulses, before beginning a treatment, patients are asked to remove any magnetic-sensitive objects (such as jewelry, credit cards). Patients are required to wear earplugs during treatment for their comfort and hearing protection, as rTMS produces a loud clicking sound with each pulse, much like an MRI machine. Patients are seated during each session of rTMS.
During the first rTMS session, several measurements are made to ensure that the TMS coil will be properly positioned over the patient’s head. Once this is done, the TMS coil is suspended over the patient’s scalp. The TMS physician then measures the patient’s motor threshold, by administering several brief pulses. The motor threshold is the minimum amount of power necessary to make the patient’s thumb twitch, and varies from individual to individual. Measuring the motor threshold helps the physician personalize the treatment settings and determine the amount of energy required to stimulate brain cells.
Once the motor threshold is determined, the coil is then brought forward so that it rests above the front region of the patient’s brain. Treatment is then commenced. During the treatment, patients will hear a series of clicking sounds and will feel a tapping sensation under the treatment coil.
Motor threshold is not checked at every treatment but may be reassessed if there is concern it may have changed, for example, because of a change in medication.
Who administers rTMS?
rTMS is always prescribed by a TMS physician. At Johns Hopkins, all TMS physicians are specifically TMS credentialed by the Hospital. The initial motor threshold is always determined by a TMS physician. The treatment itself is administered by an experienced TMS technician under the supervision of the TMS physician or by the TMS physician.
The TMS technician or physician will always be present to monitor the patient during the treatment. The patient can stop a treatment at any time by asking the staff member present.
How long is an rTMS procedure?
rTMS therapy involves a series of treatment sessions. Treatment sessions vary in length depending on the TMS coil used and the number of pulses delivered but typically last around 30 – 40 minutes. Patients receive TMS 5 days a week. A typical course of rTMS is 4 to 6 weeks. However, this can vary depending on an individual’s response to treatment.
Do I need to be hospitalized for a course of rTMS?
Unlike ECT, rTMS does not require any sedation or general anesthesia, so patients are fully awake and aware during the treatment. There is no “recovery time”, so patients can drive home afterwards and return to their usual activities.
What are the side-effects of rTMS?
rTMS is well-tolerated and associated with few side-effects and only a small percentage of patients discontinue treatment because of these. The most common side-effect, which is reported in about half of patients treated with rTMS, is headaches. These are mild and generally diminish over the course of the treatment. Over-the-counter pain medication can be used to treat these headaches.
About one third of patients may experience painful scalp sensations or facial twitching with rTMS pulses. These too tend to diminish over the course of treatment although adjustments can be made immediately in coil positioning and stimulation settings to reduce discomfort.
The rTMS machine produces a loud noise and because of this earplugs are given to the patient to use during the treatment. However, some patients may still complain of hearing problems immediately following treatment. No evidence suggests these effects are permanent if earplugs are worn during the treatment.
rTMS has not been associated with many of the side-effects caused by antidepressant medications, such as gastrointestinal upset, dry mouth, sexual dysfunction, weight gain, or sedation.
The most serious risk of rTMS is seizures. However, the risk of a seizure is exceedingly low. At Johns Hopkins, we follow up-to-date safety guidelines that are designed to minimize the risk of seizures. While rTMS is a safe procedure, it is important to point out that because it is a new treatment, there may be unforeseeable risks that are not currently recognized.
Who cannot get rTMS therapy?
Patients with any type of non-removable metal in their heads (with the exception of braces or dental fillings), should not receive rTMS. Failure to follow this rule could cause the object to heat up, move, or malfunction, and result in serious injury or death. The following is a list of metal implants that can prevent a patient from receiving rTMS:
- Aneurysm clips or coils
- Stents in the neck or brain
- Deep brain stimulators
- Electrodes to monitor brain activity
- Metallic implants in your ears and eyes
- Shrapnel or bullet fragments in or near the head
- Facial tattoos with metallic or magnetic-sensitive ink
- Other metal devices or object implanted in or near the head
Who will benefit the most?
Existing evidence to date suggests that patients who are less treatment-resistant respond better to rTMS than those who are highly treatment-resistant. However, there is much yet to be learned about particular variables that may impact response to rTMS. Researchers are presently conducting clinical studies to evaluate who will benefit most from rTMS therapy. For example, there is a lot of interest in evaluating whether rTMS with antidepressant medications is more effective than rTMS alone.
How can I get rTMS treatment?
rTMS is one of the brain stimulation treatments for depression offered at Johns Hopkins. Before scheduling you for treatment, you must first be evaluated by one of our TMS psychiatrists to determine if rTMS would be safe and appropriate for you.
If you reside locally and are interested in being evaluated for outpatient rTMS treatment, or to learn more about our program, please contact Michael Tibbs.
If you have anxiety, you how just how important relief is. You want to relieve the symptoms associated with it and not feel as though you’re worrying so much. TMS offers promise to those coping with anxiety disorders.
GAD is a psychiatric condition in which a person has excessive and uncontrollable worry, occurring more days than not, for at least 6 months. It’s also accompanied by at least 3 other symptoms, such as fatigue, irritability, and problems concentrating, among others. Generalized anxiety often occurs with other anxiety disorders, like panic disorder, social anxiety disorder, and OCD. Sixty percent of people with an anxiety disorder have or have had depression. Many people with depression, who never had anxiety before, develop anxiety in the setting of their depression.
When TMS is used with the standard protocol on the left side over the dorsolateral prefrontal cortex, the same pulses used to treat depression often lift the anxiety associated with it.
If anxiety is the primary symptom, and one or more anxiety disorders are present, TMS is used with a different position and pulse frequency protocol over the right sight of the brain. Many of our patients prefer right-sided lower frequency pulses and we have had excellent results in treating anxiety with these new off-label protocols.
We can even offer both left-sided and right-sided treatments in one treatment visit to target both depression and anxiety disorders simultaneously.
As with any treatment option, there are side effects, but they are minimal. Many patients report a slight headache during and after treatment for depression. However, when we treat patients with anxiety with low frequency protocols, headache is extremely rare.
If traditional medications haven’t been helpful, if you would rather not take medication, or if you’re pregnant or nursing, this is a great treatment option for you.
Anxiety can be debilitating and, while more research needs to be conducted, TMS is a viable treatment option. To learn more about how TMS can relieve your anxiety or to schedule an appointment, please contact us today.
To getting you back to your best self,
Lori Calabrese, MD
Lori Calabrese, MD