Multiple Target Repetitive Transcranial Magnetic Stimulation (rTMS) Combined with Neurofeedback for Complete Resolution of Severe OCD, Bipolar Depression, and Anxiety

Abstract

anxiety, and depression following completing total of 41 sessions of rTMS and 15 sessions of ‘ Z-score neurofeedback’ . Patient is 33-year-old male diagnosed with over 15 years of OCD, generalized anxiety, and bipolar depression. Patient has undergone trials of Serotonin Reuptake Inhibitors (SSRIs), mood stabilizers including lithium and valproic acid, and benzodiazepines including lorazepam. At time of presentation to my clinic, patient’s self-guilt, with anxiety in environments, agoraphobia, self-worth, and extreme spells of depression, manic, and hypomanic episodes. In patient severe hypochondriasis with respect to various disorders including motor neuron disease, multiple sclerosis, and experienced various somatic symptoms including non-specific vibratory sensations of mouth, trunk, and extremities. At onset, Yale Brown Obsessive Compulsive Score (Y-BOCS) was 19, Burn’s anxiety score was 36, Burn’s depression score was 22, and PHQ-9 of Risks and benefits of rTMS including off-label use of rTMS parameters were discussed in detail with patient and written signed consent obtained. A brain MRI was obtained to include skin fiduciary markers for navigation software ( The Neural Navi gator, Brain Science Tools, Utrechet, Netherlands) 1mm sagittal and axial T1 MRI images were processed and segmented to identify several cortical targets including: left and right Dorsolateral Prefrontal Cortex (DLPFC), right OFC, left Dorsomedial the leading working model regarding the pathophysiology of OCD [4]. One randomized, sham-controlled study showed modest improvements in OCD (29% reduction on Y-BOCS) and depression (48% on HAM-D) symptoms after 14 sequential 1 Hz stimluation sessions targeting left DLPFC and SMA [11,12]. Additional randomized sham-controlled studies applying a multi-target approach and in combination with neurofeedback will be helpful and can potentially significanly increase the efficacy rate of treatment.