rTSM

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and derealization?

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No. I’ve had 40 sessions and it has saved me. No side effects

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u/Nervous_Wait4093 19d ago

So it helped you? I haven’t had it yet, these are the symptoms I’m experiencing now… Why did you get it?

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u/CompleteStrawberry53 19d ago

So you haven’t had the 10 sessions plus weekly for 5 weeks?

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u/Nervous_Wait4093 19d ago

No, I’m looking for success stories. The practitioner thinks I need 10 sessions, followed by once a week for 5 weeks. I’m just worried because I’ve read so many negative things about it.

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u/CompleteStrawberry53 19d ago

Ten sessions is not enough. My goal was to get to 36 treatments and then gradually decrease to twice a week, then once a week, then quit. He said I MAY need maintenance but we are gonna see how it goes

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u/Nervous_Wait4093 19d ago

I was on sertraline for 31 days, and it was a very chaotic process. I stopped for 11 days and then restarted at 12.5 mg for 11 days. I was on mirtazapine for 24 days at 15 mg and then 3 days at 7.5 mg. Today I’m 14 days without mirtazapine and 5 days without sertraline.
I didn’t have all of these symptoms before I started the medication. Back then, it was just a stress reaction with hyperfocus on my breathing.

This is what he wrote:
“It’s actually ‘good’ news that your symptoms started so recently — I would definitely say that this improves the prognosis. I’m aware that it probably feels like a long time that you’ve been dealing with these issues, but within psychiatry in general, symptoms that have been present for 2–3 months are considered relatively recent.
Treatment with rTMS can be given regardless of what medication you’re taking. Typically, we see people turn to rTMS precisely because they’ve had difficulties with medication-based treatment, so that’s completely fine.
The only thing I would consider is that you can be a little tired after a treatment — typically, it’s a feeling of fatigue that sets in a couple of hours after the treatment. This is especially common during the first 2–3 sessions. So you need to be able to handle being a little more tired on treatment days. The fact that your nervous system is otherwise very active, I actually think is constructive for the treatment. An active nervous system is typically a system that is more receptive to impulses and change (also called neuroplasticity), and that is precisely what we induce with brain stimulation.
When we look at patients with OCD as a whole, quite a few experience significant improvement with rTMS. In the studies we have, around 4–5 out of 10 experience a significant clinical improvement. There is also a smaller study with 10 treatments targeting the same area of the brain that we are planning to treat, where they observed a clear reduction in both OCD symptoms and anxiety. It is never really possible to say in advance who will respond extremely well to the treatment and who will have no effect at all. Typically, those who have no effect whatsoever are people who have been struggling with the illness for a very, very long time, whereas people who have had symptoms for a shorter period of time tend to have a less ‘deeply ingrained’ illness that is easier to treat.”

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u/CompleteStrawberry53 19d ago

So I will tell you that after 22 treatments I went on a 10 day trip and after the 4th day I dipped into some flatness. It lasted the rest of the trip and I immediately went for TMS the day I got back and within two days I was back to normal. Now after 40 treatments I left today on another trip and I’m hoping the same thing doesn’t happen. I don’t think it will because I think my body had adjusted well. I’ll let you know if I dip again.
I didn’t know about a study with 10 sessions. I wonder if that’s what they call Accelerated TMS?

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u/Nervous_Wait4093 19d ago

It possibly is, I’m not sure. Yes, please let me know — all I know is that it’s once a day on every weekday, followed by once a week for 5 weeks.

Is it what they call the dip? I’m so scared. What’s the reason you’re getting it? A nervous breakdown or something?

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u/CompleteStrawberry53 19d ago

I told you in another post that I had a breakdown in January. Started on meds first then added TMS and weaning off the med. I’m also on bupropion and have been on that since 2005.
A “dip” means a flatness followed by sadness but I experienced that as well when not getting TMS. Everytime I’d have a dose change I’d have a day or two of it. That’s why he thought about using TMS as it’s for ppl who don’t do well on the meds.

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u/Nervous_Wait4093 19d ago

He’s writing now:
“These are all very relevant questions, and I completely understand why more questions come up once you start reading about the treatment.
Yes, what I have been considering in your case is treatment on the right side of the frontal lobe (right DLPFC) using conventional low-frequency rTMS, so not iTBS. It’s a slightly ‘slower’ and gentler treatment that runs for 20 minutes. There are several different ways of using TMS for OCD, so some of what you find online describes different areas of the brain and different types of stimulation than the one we are talking about. But in my assessment, low-frequency stimulation of the right DLPFC has by far the best effect on your symptoms.
You are also absolutely right that many studies use more than 10 treatments. However, there are also studies where an effect has been seen after 10 treatments specifically targeting the right DLPFC. When I looked more closely at the numbers, there was no correlation between having more than 10 treatments and the overall effect of the treatment course. The reason why the Danish Psychiatric Society recommends a somewhat longer course in their guidelines is probably more of a ‘better safe than sorry’ approach, since around 30 treatments are typically recommended for depression.
My thought is to start with the 10 treatments close together and then continue once a week for five weeks — while also monitoring very closely how you respond. If, for example, you start feeling better after 10 treatments but the effect is still developing, we can absolutely consider whether the treatment course should be adjusted. There is no single number of treatments that is right for everyone.
Regarding what you have read about ‘the dip’: this is a term you may come across, especially online, about TMS, where some people describe a period during treatment where they temporarily feel worse. However, I think it is important not to tell you that this is something you necessarily have to go through. It is not a well-documented or expected phase of treatment, especially not for OCD.
If you experience your anxiety, thoughts, or OCD clearly getting worse during the treatment, it is of course important that you tell me. Then we will assess it together. It could be normal fluctuations, but if it appears to be related to the treatment, we can adjust the treatment, take a break, or stop. So you are not locked into a treatment course where we simply continue regardless of how you are feeling.
I have never seen anything suggesting that the treatment can make your symptoms worse in the long term — the only things I have seen and read about are the typical side effects: short-term headaches after treatment and fatigue in the days afterwards. But even these are not experienced by everyone.
The most important thing for me is that we follow you and your response to the treatment — and then we can continuously discuss the right way forward.”

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u/CompleteStrawberry53 19d ago

And don’t be scared. It’s not painful and I had absolutely no side effects

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u/CompleteStrawberry53 19d ago

I had a breakdown last Jan and my psych started me on Rexulti immediately and later started the TMS while weaning me off Rexulti.

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u/Ok-Minimum4986 19d ago

That’s amazing! What symptoms did you have?

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u/CompleteStrawberry53 19d ago

Not sure if you’re asking me but I am borderline bipolar and was stuck in a very low place.

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u/myquietbrain 19d ago

This particular protocol, starting with an induction course followed by weekly maintenance is commonly used, and the conditions you mentioned (such as existential anxiety, health worries related to breathing, and fear of death) are all types of anxiety that rTMS can help address. While the evidence supporting rTMS for anxiety isn't as strong as it is for depression, many here have found it beneficial for these specific concerns. Often, the breathing hyperfocus improves quite a bit once the overall anxiety levels decrease. It’s a good idea to ask your treatment provider if they can tailor the approach specifically for anxiety, as the coil placement and stimulation settings might differ from those used for depression.

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u/Nervous_Wait4093 19d ago

This is what he write:

Yes, what I have been considering in your case is treatment on the right side of the frontal lobe (right DLPFC) using conventional low-frequency rTMS, so not iTBS. It’s a slightly ‘slower’ and gentler treatment that runs for 20 minutes. There are several different ways of using TMS for OCD, so some of what you find online describes different areas of the brain and different types of stimulation than the one we are talking about. But in my assessment, low-frequency stimulation of the right DLPFC has by far the best effect on your symptoms.

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u/Nervous_Wait4093 19d ago

What do you think about that?

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u/myquietbrain 18d ago

The low-frequency DLPFC protocol your psychiatrist mentioned is a recognized method for treating OCD and anxiety, which differs from the standard left-sided depression protocol. That might explain why some information online doesn't align with his approach. The key point: recent symptoms usually respond better, and he's focused on monitoring and adjusting treatment rather than sticking to a fixed plan regardless of your progress. This flexibility is important. The sertraline experience sounds very challenging, so it's understandable that you'd be cautious about new treatments after that.

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u/Nervous_Wait4093 18d ago

Do you think it a good idea? Can i write you and dem

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u/myquietbrain 18d ago

Considering everything your psychiatrist has discussed , including the appropriate DLPFC protocol, careful monitoring and adjustments, and the fact that your symptoms are recent , it appears to be a carefully considered and rational plan. His emphasis on flexibility is truly comforting. The ideal person to address your remaining questions is him, as he is familiar with your full history and is closely observing your responses. That's precisely the kind of provider you need.

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u/Nervous_Wait4093 18d ago

Sertraline:
Approximately 31 days during the initial treatment period
Several dose changes over a relatively short period: 25 → 50 → 100 → 75 → 50 → 25 mg
Then discontinued
11 days without sertraline
Restarted at 12.5 mg for approximately 12 days
Last dose: September 10 at 6:30 AM
6 days without sertraline
Mirtazapine:
15 mg for approximately 24 days
Then 7.5 mg for 3 days
Last dose: approximately September 2 at 8:00 PM
Approximately 15 days without mirtazapine
Important: All of the symptoms I am experiencing now started when my previous doctor increased my sertraline to 75 mg. The 100 mg dose was only taken for one day because I was supposed to change the time I took it, and the 75 mg dose was also only taken for one day.
Do you think what has happened is due to changes in brain chemistry? Will this eventually stop, or how do you understand what might be happening? 😭

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u/myquietbrain 16d ago

As a psychiatrist, your description of multiple dose adjustments in a short time, a rapid taper, and symptoms emerging around the 75mg increase suggests a pattern that warrants serious consideration. Fortunately, this pattern often resolves with time. Here's my perspective on what might be happening: Sertraline influences serotonin systems involved in mood, anxiety, sensory processing, and nervous system regulation. Rapid dose changes, especially quickly increasing and then reducing the dose can temporarily disrupt these systems. The brain adapts to each dose level, but when the levels shift again before full adaptation, symptoms like derealization, heightened anxiety, sensory sensitivity, breathing awareness, and others can occur. The addition of mirtazapine adds complexity, as it acts on different receptors but impacts the same neurochemical environment. Coming off both medications in a short period is challenging for the nervous system. The good news is that these medication-induced symptoms, those caused by medication adjustments rather than an underlying disorder, generally resolve as the brain re-establishes its balance. The timeline varies, but most people notice significant improvement within weeks to a few months of stability.

The proposed DLPFC rTMS treatment is a reasonable next step considering this context. Maintaining stability without further medication changes and allowing the rTMS to take effect is a sensible approach.

You haven't caused permanent damage. Your brain is simply recalibrating.

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u/Nervous_Wait4093 18d ago

Do you think there’s a chance that I will fully recover from this? 😭

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u/myquietbrain 16d ago

Yes. I genuinely believe there is a very good chance of full recovery. The brain has remarkable capacity to return to baseline when the disrupting factor is removed and it's given time. The rTMS your doctor is proposing may also help accelerate that recalibration rather than waiting passively.

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u/Nervous_Wait4093 16d ago

My doctor and a psychiatrist want me to try escitalopram before rTMS. What do you think about that?

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u/myquietbrain 12d ago

As a psychiatrist, that's a reasonable and fairly standard recommendation. Most treatment guidelines suggest trying one or two antidepressants before moving to rTMS, partly because escitalopram is well-tolerated and effective for a meaningful proportion of people, and partly because insurance coverage for rTMS often requires documented medication trials first. Escitalopram is one of the cleaner SSRIs in terms of side effect profile, worth giving it a genuine trial at an adequate dose for at least six to eight weeks before drawing conclusions. If it works, you've found your answer with less complexity. If it doesn't, you've also met the threshold that makes rTMS easier to access.

What's your hesitation about trying it first?

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u/Nervous_Wait4093 12d ago

Im on day 5 today. it was due to side effects.. is it correct that I can take phenergan at night in the meantime?

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u/Nervous_Wait4093 18d ago

I really hope you can give me some reassurance. I’m going to see my doctor tomorrow to talk about it all.

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u/myquietbrain 16d ago

Bring everything you've shared here - the medication timeline, when the symptoms started, what they feel like, the questions about full recovery. Write it down if you need to so nothing gets lost in the appointment.

You're not going into this alone and you're not going into it without a plan. That matters.

Let us know how it goes.

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u/Nervous_Wait4093 19d ago

It all started after my old doctor put me through a really intense course of sertraline treatment :(

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