The standard treatment regimen for OCD involves a high frequency stimulation (HFS) with 20 Hz. In addition, there is also a possibility of using a combination of 5 Hz and 50 Hz frequencies. This combination treatment is called Intermittent Theta Burst Stimulation (ITBS).
Case scenario:
A middle-aged female patient has been on medication for OCD since about 20 years. She had a flare up of symptoms and she sought medical help at our hospital. Deep TMS was advised to her in addiction to drugs.
Proceedings:
Deep TMS was started for OCD using BrainsWay’s H7 coil. Each session lasted for about 20 minutes with a brief 2–3-minute provocation before each session. She received 30 sessions in the 1st cycle and also 15 more sessions in the 2nd cycle a month later. Surprisingly, there is very little reduction in the symptoms. This happens rarely in a few patients who do not respond to the standard HFS with H7 coil. The team was committed to help the patient and bring her out of OC symptoms. Thanks to her, she understood our commitment to quality care, and she cooperated with us.
The idea:
Literature review was done. It was decided to study her EEG and find out if it could be of any help. Frequency component analysis of her 32-channel EEG showed that the frontal regions were dominated by a 3 Hz rhythm (see representative images below). Considering this, the idea was to customize a treatment protocol for her based on the frequency pattern.
(all the above images are only representative and have no relevance to the case discussed)
Re-initiation of dTMS after about 1 month:
Using the customised treatment protocol, the patient was treated with the same H7 coil but at a newer iTBS regimen. To everybody’s surprise, she was relieved from her OC symptoms after 6 such sessions.
The result:
The Yale-Brown Obsessive Compulsive Scale (YBOCS) showed a 50% reduction in the score on day 6 of administration of this new treatment. She later showed a decline in the severity of symptoms and is maintained at 80% – 85% reduction currently. As on today, 22 months follow-up has completed, and the patient is reportedly doing better and the YBOCS scale did not increase.
The reflections:
The patient was extremely happy that she got rid of the distressing obsessions. Few patients might not respond to the standard approved stimulation frequency of 20 Hz for OCD. In such cases, there are many different approaches tested by many scientists and clinicians across the world. Few of them tried sequential stimulation, few tried Cognitive Behavioural Therapy combined with brain stimulation, few more have tried TDCS. In the same lines of innovation, we used the EEG-based approach in our patient.