Abstract
The efficacy of deep repetitive transcranial magnetic stimulation (dTMS) for obsessive compulsive disorder (OCD) was recently confirmed in a Food and Drug Administration-regulated, multicenter, sham-controlled study. In this study, patients who failed pharmacotherapy underwent individually tailored provocations just prior to each stimulation session, in the attempt to activate the relevant circuitry and making it labile to change. The procedure that was developed reliably evoked moderate intensity symptoms, making it effective on the one hand and mild enough to allow the patient to continue with the dTMS session on the other. This methodology article describes in a detailed step wise fashion how to evaluate the patient’s specific symptoms and design the individualized provocations. Additionally, the article explains how to instruct relevant personnel to administer the provocations, gauge their efficacy, and overcome possible obstacles. This method, apart from its ongoing role in the clinical treatment of OCD by dTMS, may be used for provocation of symptoms in basic studies [e.g., imaging with Electroencephalogram (EEG) or Functional magnetic resonance imaging fMRI] as well as other treatments.
Highlights
In August of 2018, the Food and Drug Administration (FDA) cleared deep repetitive transcranial magnetic stimulation as a treatment for obsessive compulsive disorder (OCD) [1]
The authors of the smoking study suggested that rTMS interferes with the reactivated labile memory traces of cue-induced craving or inhibitory control circuitry [6], while the authors of the post-traumatic stress disorder (PTSD) study suggested that stimulation enhances the consolidation of traumatic memories extinguishing the fear response [7]
For OCD, the effects of provocation were not controlled, but because of the excellent results demonstrated in published studies [2, 3, 10, 11] as well as patient acceptability, it continues to be used clinically
Summary
In August of 2018, the Food and Drug Administration (FDA) cleared deep repetitive transcranial magnetic stimulation (dTMS) as a treatment for obsessive compulsive disorder (OCD) [1]. Activating obsessive-compulsive triggers may allow for the reconsolidation of fear or distress evoking memories, which are core to most forms of OCD, through dTMS. Patients should be aware that prior to treatment their obsessive-compulsive symptoms will be provoked by a trained technician, and the purpose of provocations is for the treatment to be most effective. It is imperative to explain to the technician each patient’s specific case, the nature of the obsessions and compulsions, the reasoning, and any pitfalls or notes that may help them provoke the patient or triggers that should be avoided (e.g., too distressing). If the technician understands the reasoning behind the patient’s thought process, they can provoke the symptom using internal and external provocations as their guide. As symptoms improve, provoking to the appropriate distress level becomes increasingly challenging During this time, using internal and external provocations simultaneously is beneficial. Some details were intentionally written in a vague and more general fashion both to protect anonymity and because they are characteristic of many OCD patients
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