Depersonalisation / Derealisation and TMS therapy

The brain underpins our sense of personal identity and the recognition of ourselves as individuals, as well as in relation to our surroundings. At times, contact with reality may deteriorate and the unity of body and mind may fragment, giving rise to feelings of unreality, emotional numbness, observing oneself from the outside, or a sense of estrangement from the self or from one’s immediate environment.

This may occur as a result of highly stressful events, exhaustion, the use of psychoactive substances, or the co-occurrence of other mental health disorders - depersonalisation/derealisation disorder (DPD), but also it can arise independently of these factors. In psychiatry, derealisation and depersonalisation are classified as dissociative disorders, involving a disruption of self-awareness, memories, and knowledge about oneself and the surrounding world, as well as disturbances in the perception of bodily sensations.

Transcranial magnetic stimulation (TMS), a non-invasive method for the treatment of mental health disorders, has been trialled in the therapy of DPD. In 2004, a case study has shown the effects of six sessions of repetitive TMS (rTMS), delivered at a frequency of 20 Hz and targeting the left dorsolateral prefrontal cortex (L-DLPFC), in a 25-year-old person suffering from chronic DPD. Single-photon emission computed tomography (SPECT) findings indicated abnormal in both temporal lobes and in the left frontotemporal region.

To test the persistence of the TMS effects, four months after completion of the rTMS series, a follow-up assessmen has been conducted. SPECT scan revealed improvement in the brain areas which were shown before to be abnormal. Following six rTMS sessions, a 28% reduction was observed in the patient’s score on the Cambridge Depersonalisation Scale (CDS), indicating a decrease in the severity of DPD symptoms experienced by the participant.

Another research team examined the effectiveness of two different TMS protocols in DPD. Twenty-four low-frequency (1 Hz) stimulations targeting the right dorsolateral prefrontal cortex (R-DLPFC), and thirty-two high-frequency (10 Hz) sessions targeting the L-DLPFC, were administered to a 30-year-old participant. Initial symptoms severity (measured by CDS scores) indicated a 51% severity level. Following completion of the 1 Hz stimulation series, this was reduced to 29%, and after an additional thirty-two 10 Hz rTMS sessions, symptom severity on the CDS fell to 17%, indicating a marked reduction in derealisation and depersonalisation symptoms.

A further therapeutic attempt involved low-frequency (1 Hz) stimulation of the right temporoparietal junction (TPJ). After three weeks of rTMS treatment, six out of twelve participants achieved a 50% remission of symptoms. After six weeks, CDS scores were assessed as 68% lower than a baseline.

Subsequently, a research team in London analysed the effects of rTMS targeting the right TPJ and the right ventrolateral prefrontal cortex (VLPFC). In both cases, lower CDS scores were observed following rTMS sessions. However, statistical analysis demonstrated that only stimulation of the right VLPFC was significantly associated with a reduction in DPD symptom severity. This led to the design of a procedure involving seven patients, who underwent a series of twenty 1 Hz rTMS sessions. As a result, two participants achieved complete remission of DPD symptoms, while four experienced partial remission.

In summary, the available findings suggest that transcranial magnetic stimulation (TMS) may present a promising therapeutic option for depersonalisation/derealisation disorder (DPD). Across the studies described, rTMS was associated with clinically meaningful reductions in symptom severity, as measured by the Cambridge Depersonalisation Scale (CDS), with some patients achieving partial and even complete remission. While the studies to date have involved small samples and, in some cases, single-case designs, the consistency of symptom reduction across different protocols suggests that TMS can effectively modulate neural circuits implicated in depersonalisation and derealisation. These preliminary results support the continued investigation of TMS as a potentially effective and clinically valuable intervention for DPD, particularly for patients who do not respond to conventional treatments.

References:

• Simeon, D. (2004). Depersonalisation disorder. CNS drugs, 18(6), 343-354.
• Jiménez-Genchi, A. M. (2004). Repetitive transcranial magnetic stimulation improves depersonalization: a case report. CNS spectrums, 9(5), 375-376.
• Karris, B. C., Capobianco, M., Wei, X., & Ross, L. (2017). Treatment of depersonalization disorder with repetitive transcranial magnetic stimulation. Journal of Psychiatric Practice®, 23(2), 141-144.
• Mantovani, A., Simeon, D., Urban, N., Bulow, P., Allart, A., & Lisanby, S. (2011). Temporo-parietal junction stimulation in the treatment of depersonalization disorder. Psychiatry Research, 186(1), 138-140.
• Jay, E. L., Sierra, M., Van den Eynde, F., Rothwell, J. C., & David, A. S. (2014). Testing a neurobiological model of depersonalization disorder using repetitive transcranial magnetic stimulation. Brain stimulation, 7(2), 252-259.
• Jay, E. L., Nestler, S., Sierra, M., McClelland, J., Kekic, M., & David, A. S. (2016). Ventrolateral prefrontal cortex repetitive transcranial magnetic stimulation in the treatment of depersonalization disorder: A consecutive case series. Psychiatry research, 240, 118-122.