- Email: [email protected]
Persistent genital arousal disorder – Case report of symptomatic relief of symptoms with transcranial magnetic stimulation
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Abstracts / Brain Stimulation 9 (2016) e1–e9
Methods: This is a consecutive clinical case series (N = 6) of BDD patients who were treated with TMS in an outpatient TMS clinic. All the patients were on mood stabilizers with insufficient benefit for their mood symptoms. Primary outcome was the change in the MADRS scores. TMS was administered over the right DLPFC. All the patients were carefully monitored for any side effects or treatment emergent mania. The treatment regimen was 2000 pulses of 1 Hz at 120% of the MT (motor threshold). If this was uncomfortable, we lowered the treatment intensity as necessary. Results: All 6 patients reported benefit in their mood symptoms without any treatment emergent mania. The MADRS score decreased by 24 points, averaging across all patients. Conclusion: This study suggests that low frequency of right DLPFC TMS treatment may be beneficial in BDD patients. Further studies with more number of patients and a control arm are required to demonstrate its efficacy.
21 Persistent genital arousal disorder – Case report of symptomatic relief of symptoms with transcranial magnetic stimulation Robert McMullen a, Shashank Agarwal b a Psychiatrist, TMS Brain Care, New York, NY b Research Scientist, NYU Langone Medical Center, New York, NY Objective: To acknowledge the successful symptom relief of persistent genital arousal disorder (PGAD) with transcranial magnetic stimulation (TMS). Background: PGAD is a rare syndrome of excessive and unremitting sexual arousal in the absence of conscious feelings of sexual desire. Various treatment modalities including medications, regional nerve blocks with transcutaneous electrical nerve stimulation and electroconvulsive therapy have shown limited benefit. Case Report: A 29-year-old female presented with symptoms of persistent unwanted genital sensations and imminent orgasm without sexual desire. She also had chronic pelvic pain secondary to interstitial cystitis and bipolar depressive disorder (BDD). She received pudendal nerve blocks for the pelvic pain without benefit. After failing multiple different medications, we decided to treat her mood and pelvic pain symptoms with TMS. We treated her pelvic pain with inhibitory TMS (2000 pulses at 1 Hz at 90% MT) bilaterally on the motor strip in the area of the pelvis on the homunculus. For her BDD, we eschewed excitatory treatment of the left DLPFC (dorsolateral prefrontal cortex) and stimulated the right DLPFC (1200 pulses of 1 Hz at 100% MT). After 50 TMS sessions over 3 months, her Montgomery–Åsberg Depression Rating Scale (MADRS) score decreased from 32 to 16. Her pelvic pain and PGAD symptoms were virtually in remission. Spontaneous orgasms had completely ceased. Conclusion: To our knowledge, this is the first reported case of successful symptomatic relief of PGAD symptoms with TMS. The patient’s improvement suggests that TMS may be a promising intervention for the physical and psychological symptoms associated with PGAD.
22 Bilateral rTMS vs. unilateral rTMS: An analysis of comparative effectiveness Ryan Webler a,*, Brian Gallagher a, Makai McClintock b, Tarique Perera c a New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032 b University of Massachusetts Amherst, 300 Massachusetts Avenue, Amherst, MA 01003 c Columbia Medical School, 3960 Broadway, New York, NY 10032 *E-mail: [email protected].
Objective: To compare the effectiveness of bilateral high frequency left-side rTMS and low frequency right-side rTMS with unilateral high frequency left-side rTMS. Background: Research remains divided on whether unilateral (UL) rTMS treatment is more effective than bilateral (BL) rTMS. Methods: We conducted an observational analysis of 89 patients with MDD who received rTMS in five outpatient clinics over a 4-year period (January 2011 to November 2015) for a minimum of 9 weeks. Our BL group included 58 patients; our UL group included 31 patients. We performed one-way ANOVAs to determine whether the groups differed in terms of age, gender, or depression severity, and Hamilton Depression Scale (HamD) reduction and response rate at 3 weeks, 6 weeks, and 9 weeks. Results: Our groups do not differ significantly in terms of age (p = .41), gender (p = .68), or depression severity (p = .34). The protocols do not differ significantly in terms of response rate at 3 weeks (BL = 44.83%; UL = 32.26%, p = .25) or 9 weeks (BL = 70.69; UL = 58.07, p = .23), but do differ significantly at 6 weeks (BL = 68.97%; UL = 45.16%, p = .03). Conclusions: Our results indicate that patients respond more quickly to BL rTMS than UL rTMS, but that the two treatments are similarly effective after 9 weeks of treatment. Why low frequency rightside rTMS accelerates the benefits of high-frequency left-side rTMS and why this benefit reaches a point of diminishing returns by week 9 should be the focus of future study.
23 Timing of depressive symptom response to rTMS: An analysis of psychometric scales Ryan Webler a,*, Brian Gallagher a, Makai McClintock b, Tarique Perera c a New York State Psychiatric Institute, 175 Pinehurst Avenue, New York, NY 10033 b University of Massachusetts Amherst, 175 Pinehurst Avenue, New York, NY 10033 c Columbia University, Contemporary Care, 175 Pinehurst Avenue, New York, NY 10033 *E-mail: [email protected]. Objective: To evaluate the timing of specific depressive symptom response to rTMS. Background: The Beck Depression Inventory and Hamilton 24 Depression Scale measure different depressive symptoms. Comparing response rate between scales could illuminate the timing of specific depressive symptom response to rTMS. Design/Methods: Between 2011 and 2016, 64 of 89 patients achieved depression response (their depression scores were halved) to both the Beck Inventory and Hamilton Scale at 6 clinical offices by week 9 of treatment. Response time to each scale was compared through a paired t-test. Results: Patients responded to the Ham D Scale in 3.56 weeks and the Beck Scale in 4.21 weeks (p = .003). Age (p = .10) and gender (p = .78) were not predictive of responding first to a particular scale. One way ANOVAs suggest that first response to a particular scale was not associated with relapse rate (p = .59) or double response (response to both scales) at week 9 (p = .32). Conclusion: Research suggests that the Beck Scale is more sensitive to cognitive changes and the ‘feeling’ of being depressed, whereas the Ham D Scale is more sensitive to changes in somatic and behavioral symptoms. Our results suggest that somatic and behavioral symptoms respond more quickly to rTMS than cognitive depressive changes and subjective awareness of depression. rTMS is understood to dampen the activity of the default mode network. Understanding the timing of depressive symptom recovery could help illuminate the relationship between the default mode network, specific depressive symptoms, and depressive recovery.
Abstracts / Brain Stimulation 9 (2016) e1–e9
Methods: This is a consecutive clinical case series (N = 6) of BDD patients who were treated with TMS in an outpatient TMS clinic. All the patients were on mood stabilizers with insufficient benefit for their mood symptoms. Primary outcome was the change in the MADRS scores. TMS was administered over the right DLPFC. All the patients were carefully monitored for any side effects or treatment emergent mania. The treatment regimen was 2000 pulses of 1 Hz at 120% of the MT (motor threshold). If this was uncomfortable, we lowered the treatment intensity as necessary. Results: All 6 patients reported benefit in their mood symptoms without any treatment emergent mania. The MADRS score decreased by 24 points, averaging across all patients. Conclusion: This study suggests that low frequency of right DLPFC TMS treatment may be beneficial in BDD patients. Further studies with more number of patients and a control arm are required to demonstrate its efficacy.
21 Persistent genital arousal disorder – Case report of symptomatic relief of symptoms with transcranial magnetic stimulation Robert McMullen a, Shashank Agarwal b a Psychiatrist, TMS Brain Care, New York, NY b Research Scientist, NYU Langone Medical Center, New York, NY Objective: To acknowledge the successful symptom relief of persistent genital arousal disorder (PGAD) with transcranial magnetic stimulation (TMS). Background: PGAD is a rare syndrome of excessive and unremitting sexual arousal in the absence of conscious feelings of sexual desire. Various treatment modalities including medications, regional nerve blocks with transcutaneous electrical nerve stimulation and electroconvulsive therapy have shown limited benefit. Case Report: A 29-year-old female presented with symptoms of persistent unwanted genital sensations and imminent orgasm without sexual desire. She also had chronic pelvic pain secondary to interstitial cystitis and bipolar depressive disorder (BDD). She received pudendal nerve blocks for the pelvic pain without benefit. After failing multiple different medications, we decided to treat her mood and pelvic pain symptoms with TMS. We treated her pelvic pain with inhibitory TMS (2000 pulses at 1 Hz at 90% MT) bilaterally on the motor strip in the area of the pelvis on the homunculus. For her BDD, we eschewed excitatory treatment of the left DLPFC (dorsolateral prefrontal cortex) and stimulated the right DLPFC (1200 pulses of 1 Hz at 100% MT). After 50 TMS sessions over 3 months, her Montgomery–Åsberg Depression Rating Scale (MADRS) score decreased from 32 to 16. Her pelvic pain and PGAD symptoms were virtually in remission. Spontaneous orgasms had completely ceased. Conclusion: To our knowledge, this is the first reported case of successful symptomatic relief of PGAD symptoms with TMS. The patient’s improvement suggests that TMS may be a promising intervention for the physical and psychological symptoms associated with PGAD.
22 Bilateral rTMS vs. unilateral rTMS: An analysis of comparative effectiveness Ryan Webler a,*, Brian Gallagher a, Makai McClintock b, Tarique Perera c a New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032 b University of Massachusetts Amherst, 300 Massachusetts Avenue, Amherst, MA 01003 c Columbia Medical School, 3960 Broadway, New York, NY 10032 *E-mail: [email protected].
Objective: To compare the effectiveness of bilateral high frequency left-side rTMS and low frequency right-side rTMS with unilateral high frequency left-side rTMS. Background: Research remains divided on whether unilateral (UL) rTMS treatment is more effective than bilateral (BL) rTMS. Methods: We conducted an observational analysis of 89 patients with MDD who received rTMS in five outpatient clinics over a 4-year period (January 2011 to November 2015) for a minimum of 9 weeks. Our BL group included 58 patients; our UL group included 31 patients. We performed one-way ANOVAs to determine whether the groups differed in terms of age, gender, or depression severity, and Hamilton Depression Scale (HamD) reduction and response rate at 3 weeks, 6 weeks, and 9 weeks. Results: Our groups do not differ significantly in terms of age (p = .41), gender (p = .68), or depression severity (p = .34). The protocols do not differ significantly in terms of response rate at 3 weeks (BL = 44.83%; UL = 32.26%, p = .25) or 9 weeks (BL = 70.69; UL = 58.07, p = .23), but do differ significantly at 6 weeks (BL = 68.97%; UL = 45.16%, p = .03). Conclusions: Our results indicate that patients respond more quickly to BL rTMS than UL rTMS, but that the two treatments are similarly effective after 9 weeks of treatment. Why low frequency rightside rTMS accelerates the benefits of high-frequency left-side rTMS and why this benefit reaches a point of diminishing returns by week 9 should be the focus of future study.
23 Timing of depressive symptom response to rTMS: An analysis of psychometric scales Ryan Webler a,*, Brian Gallagher a, Makai McClintock b, Tarique Perera c a New York State Psychiatric Institute, 175 Pinehurst Avenue, New York, NY 10033 b University of Massachusetts Amherst, 175 Pinehurst Avenue, New York, NY 10033 c Columbia University, Contemporary Care, 175 Pinehurst Avenue, New York, NY 10033 *E-mail: [email protected]. Objective: To evaluate the timing of specific depressive symptom response to rTMS. Background: The Beck Depression Inventory and Hamilton 24 Depression Scale measure different depressive symptoms. Comparing response rate between scales could illuminate the timing of specific depressive symptom response to rTMS. Design/Methods: Between 2011 and 2016, 64 of 89 patients achieved depression response (their depression scores were halved) to both the Beck Inventory and Hamilton Scale at 6 clinical offices by week 9 of treatment. Response time to each scale was compared through a paired t-test. Results: Patients responded to the Ham D Scale in 3.56 weeks and the Beck Scale in 4.21 weeks (p = .003). Age (p = .10) and gender (p = .78) were not predictive of responding first to a particular scale. One way ANOVAs suggest that first response to a particular scale was not associated with relapse rate (p = .59) or double response (response to both scales) at week 9 (p = .32). Conclusion: Research suggests that the Beck Scale is more sensitive to cognitive changes and the ‘feeling’ of being depressed, whereas the Ham D Scale is more sensitive to changes in somatic and behavioral symptoms. Our results suggest that somatic and behavioral symptoms respond more quickly to rTMS than cognitive depressive changes and subjective awareness of depression. rTMS is understood to dampen the activity of the default mode network. Understanding the timing of depressive symptom recovery could help illuminate the relationship between the default mode network, specific depressive symptoms, and depressive recovery.