A Guide To The Use Of TMS In The Treatment Of OCD

Transcranial magnetic stimulation,¹ or TMS, is an effective add-on treatment for managing OCD symptoms. In this article, we'll discuss TMS for OCD — what it is, how it works, and what you can expect from a treatment session.

What is TMS?

TMS uses an electromagnet made of wire. The wire coil produces a strong magnetic field, which activates neurons in the brain near the magnet. The activation is strong enough that when used to stimulate the motor cortex (the part of the brain that controls muscle movements), TMS can cause targeted muscles to twitch.  

In addition to stimulating neural activity, TMS can also inhibit it. Because the effects can extend beyond the treatment session, TMS can improve various brain conditions that benefit from neural inhibition or stimulation.

Is TMS effective for OCD?

TMS won’t work for everyone, but it’s effective enough that it has gained FDA approval² as an OCD treatment. The federal agency made its decision after examining a study³ of 99 patients with OCD, in which 38% of patients saw a significant reduction in their OCD symptoms after using the TMS device, compared to only 11% who used a placebo device that didn’t deliver TMS treatment.

The FDA approval builds on approvals in 2008 for the use of TMS in treating clinical depression and in 2013 for treating certain types of migraine pain.

How does TMS help OCD?

Studies of brain activity in people with OCD have shown that some brain regions become hyperactive in those patients. TCM inhibits neural activity in targeted parts of the brain, and by targeting specific locations, doctors can combat the overactivity associated with OCD. 

What parts of the brain are affected by OCD?

Three parts of the brain consistently show abnormal activity levels in people with OCD. One is the orbitofrontal cortex. This part of the brain is related to decision-making, and specific circuits in this region are activated when you make a mistake.

Unfortunately, in people with OCD, the orbitofrontal cortex is overly active, so they constantly feel like something has gone wrong.

Another brain region affected by OCD is the anterior cingulate cortex. This area plays a role in motivation and emotional responses to behavior. When it receives a signal from the orbitofrontal cortex that you’ve made a mistake, the anterior cingulate cortex triggers anxiety.

In people with OCD, this part of the brain is overly active, so they experience anxiety in response to the feeling that something has gone wrong.

The last of the three brain regions showing abnormal activity levels in OCD is the caudate nucleus. This area is involved in the control of behaviors, including inhibiting behavioral responses that are inappropriate or don’t make sense.

In people with OCD, the caudate nucleus is less active than in other people, making it difficult for them to resist impulses to perform certain actions, even though they may know that these actions make no sense.

How many TMS treatments are needed for OCD?

In most cases, TMS treatment for OCD is performed according to the same protocol used in the original study that demonstrated the effectiveness of the treatment (and on which the FDA based its approval decision).

In this study, sessions were performed every weekday for six weeks, for a total of 30 sessions. However, your doctor may recommend a different treatment schedule to suit your unique needs.

Not all patients see a significant benefit from TMS treatments. In the cited study, 38% of patients saw success by the end of the treatment period. The definition of “success” in the study was a reduction of at least 30% in the severity of OCD symptoms. TMS doesn’t work for everyone, but it helps a substantial number of OCD sufferers.

There is no situation where TMS will cure OCD. Instead, it reduces the severity of symptoms and improves a person’s quality of life.

How long does a TMS session last?

There are two FDA-approved TMS device manufacturers for treating OCD; Brainsway⁴ and MagVenture.⁵ For OCD, both manufacturers recommend a treatment time of 18 minutes. During the session, you’ll wear a special helmet that activates electromagnets in particular areas.

Keep in mind that 18 minutes is the treatment time, not the session duration. The entire session will take between 30–40 minutes. Before treatment starts, a trained medical professional will guide you through a provocation session designed to activate the parts of your brain being targeted by the treatment.

Brainsway’s newer model, Deep TMS,⁶ shortens the session time from 30–40 minutes to around 20 minutes.

How long do the effects of TMS treatment last?

Participants in the cited study were examined again one month after the treatments ended. At the check-in, 45% of patients reported improvement in their symptoms. Perhaps surprisingly, more participants saw improvement at the one-month mark (45%) than immediately after treatment (38%).

While the study protocol didn’t include follow-up treatments, TMS device manufacturer Brainsway notes that patients can receive maintenance treatments as needed, up to twice a week for up to 12 weeks.

What are the side effects of TMS therapy?

According to the FDA, TMS devices carry a low-to-moderate level of risk. However, nearly every medical procedure has some risk of side effects. While there were no serious adverse effects in those who participated in the study, just over a third of the participants experienced headaches during the initial weeks of the treatment.

Other side effects included pain in the neck, jaw, face, or muscles and spasms or twitching. These side effects were mild or moderate and resolved shortly after the treatment.

Can TMS cause permanent damage?

When appropriately used on patients who are pre-screened and approved by a medical professional, TMS is safe. However, not everyone can safely undergo TMS treatment. Therefore, it's essential to be honest with your doctor when they ask you questions regarding your eligibility. 

Who is not a candidate for TMS?

Because of the magnetic nature of the treatment, patients with metallic objects or implanted stimulator devices in the head or in any area that will get close enough to the machine to be affected should not undergo TMS treatment. This includes implants such as cochlear implants, deep brain stimulators, vagus nerve stimulators, or other implanted medical devices, as well as non-medical metallic objects such as bullet fragments.

However, metal fillings or other dental work will not prevent you from having TMS.

Inform your doctor if you have a history of seizures, as TMS can trigger seizures in people who are susceptible to them.

What are the other treatment options for OCD?

TMS is often used in OCD sufferers when other treatment methods have failed. However, rather than replacing them, TMS is generally used in conjunction with other treatments. Patients continue their previous therapies and add TMS.

The standard treatments for OCD are medication and therapy. The main type of therapy used for OCD is a type of cognitive behavioral therapy known as exposure and response prevention. 

Medication

Doctors commonly prescribe selective serotonin reuptake inhibitors (SSRIs) for OCD. SSRIs are widely used to treat depression and anxiety but are usually prescribed at higher doses for OCD. People who don’t respond well to SSRIs may see improvements with antipsychotic drugs. 

Therapy

Exposure and response prevention (ERP) is a cognitive behavior therapy (CBT) technique that helps patients to recognize harmful thought patterns (also called cognitive distortions) and replace them with healthier thoughts. ERP therapy works by exposing the person to a stimulus that triggers their obsession and training the brain to respond differently. ERP therapy can help people break the cycles leading to their compulsive behavior. 

Lifestyle changes

Your doctor or therapist may recommend lifestyle changes to help you better cope with your OCD. This could include practicing meditation or other mindfulness exercises and minimizing exposure to OCD triggers.

People with OCD often have trouble sleeping, and a lack of sleep profoundly affects brain function. If you aren’t sleeping well, your therapist may recommend adjusting your diet, exercise habits, and sleep routine to enhance your sleep quality.

The lowdown

OCD can be debilitating. In addition to the time wasted engaging in your compulsions, the anxiety that comes with OCD can drastically affect your quality of life. While there are pharmaceutical and psychotherapy options for treating OCD, some people may benefit from adding adjunct therapies, such as TMS.

TMS is a promising treatment option for people who hope to boost the efficacy of their current OCD treatment protocol. It’s not painful and has very few side effects. It’s essential to note that TMS is not a standalone therapy for OCD, and you won’t be able to quit your medications or psychotherapy program.

However, if your OCD treatment isn't going as well as you'd like, your doctor may decide that TMS is a suitable addition to your treatment plan.