Doctor Tjardo Postma demonstrates a TMS treatment at the Amsterdam UMC on an employee. Tim, the patient in the article, is not in the photos. Image Lina Selg
‘Are you ready for it?’ Doctor Tjardo Postma looks at his patient. About ten minutes ago, 33-year-old Tim – who is willing to give the newspaper an insight into his mind, but not under his full name – sat down in a kind of dentist’s chair with neck and calf support.
First Postma measured his skull. He then placed the coil – a round, black device – in exactly the right place on his head. Tim himself has already put in a set of bright yellow noise stoppers.
“Yes,” he then says. He’s ready. Postma: ‘Then we’ll start in three, two, one.’
Over by author
Kaya Bouma writes for de Volkskrant about psyche, brain and behavior. She also writes about mental health care.
Tap, tap, tap. A loud, rhythmic clicking fills the treatment room of the Amsterdam UMC. With each tap, an electric current passes through Tim’s head. More precisely: through the ‘pre-supplementary motor area’, the part of the brain that is important in inhibiting automated behavior, such as thoughtless habits.
This futuristic-looking treatment is called transcranial magnetic stimulation (TMS). ‘A kind of bodybuilding for the brain,’ says Odile van den Heuvel. As professor of neuropsychiatry at the Vrije Universiteit Amsterdam, she leads the research in which Tim participates.
It feels, Tim will say afterwards, as if someone is tightening a small rubber band and releasing it against his head. It’s not painful, nor is it fun.
The brain stimulation, in combination with the behavioral therapy that he subsequently receives, should help against the obsessive thoughts and actions that paralyze his life. The unemployed bus driver suffers from obsessive-compulsive disorder. His thoughts run in circles around Satan and hell. On bad days there is hardly any time left for anything else.
Because therapy and medication have had insufficient effect so far, he is participating in this study into the efficacy and affordability (‘cost-efficiency’) of this new treatment method. With each pulse, the hope is, the part of the brain that can curb his compulsion becomes stronger. Therapy must do the rest.
The new treatment method should offer perspective to the estimated 1 to 3 percent of Dutch people with an obsessive-compulsive disorder. For about half of the patients, existing treatments (behavioral therapy and pills) do not work sufficiently, says Van den Heuvel.
TMS is not really futuristic. Experiments have been going on with the technology since the 1980s. TMS is considered a lot less invasive and provides much less relief side effects then the more severe variant: electroconvulsive therapy. This treatment, better known as electroshock therapy, is intended for people with severe depression for whom therapy and pills do not work.
Demonstration of a TMS treatment in the Amsterdam UMC. The head is measured and the correct position for the coil is calculated. Image Lina Selg
Research is being conducted into numerous applications of TMS: from migraines to Parkinson’s disease, from autism to addictions.
The best-researched application is for people with major depression. Since 2017, Dutch health insurers have reimbursed TMS for this target group for whom therapy or medication does not provide sufficient relief. The figures vary per study, but roughly Two to three out of ten patients with depression who complete treatment recover.
Something similar applies to people with compulsive disorders for whom behavioral therapy and medication do not work, says Van den Heuvel. It is scientifically established that TMS can help some of them, she says.
The hard part
The point is that health insurers do not yet reimburse treatment for an obsessive-compulsive disorder. Private clinics already offer brain stimulation for a fee, ranging from about 50 to 100 euros per session (a treatment program consists of 20 to 40 sessions, depending on the provider).
For people like Tim, who currently lives on benefits, this is far out of reach. The research he is participating in could change that.
But that’s the future. It research, which also involves Radboud UMC and Maastricht UMC, will run until 2027. Tim hopes for improvements in the here and now. And so he travels from the Leiden area to Amsterdam for seven weeks, four times a week.
“There,” says Postma, when he turns off the device and the tapping stops. After 25 minutes the TMS is finished. Now the hard part begins, Tim says, as he walks out of the hospital and into the adjacent psychiatric clinic of GGZ InGeest. Exposure therapy.
Doctor Tjardo Postma places the coil on the head. Image Lina Selg
In the waiting room he has just filled his cardboard cup with coffee when the elevator doors slide open and cognitive behavioral therapy worker Elsbeth Zuiker briskly steps into the waiting room. “You know what to do,” she says, handing Tim a red highlighter.
Tim places the marker against the paper cup and starts writing. “Satan,” he writes in bright red block letters. In his eyes, the coffee is now poisoned by evil. Still, he will try to drink the cup for the next hour.
Exposure therapy is a form of cognitive behavioral therapy that is often used for anxiety and obsessive-compulsive disorders. Patients are exposed to their fears step by step in a safe setting.
‘Some people find exposure therapy very intense,’ says research leader Van den Heuvel. ‘They feel like they can’t cope. That may be why it doesn’t work equally well for everyone.’
The hope is that TMS will warm up patients’ brains prior to exposure therapy, so that they get more out of the therapy.
After Zuiker has taken him to a spacious, bright treatment room, Tim carefully takes a sip of his coffee. A few weeks ago that was a huge step for him, but now he’s used to it. “But I remain aware of every sip.”
Fear of evil
Since childhood, Tim has had anxiety and obsessive thoughts about various themes. Ultimately he got stuck in the fear of ‘evil’, the devil and hell. He thinks about it hundreds, sometimes thousands of times a day. When he sees an advertisement for beer brand Duvel, for example, or a license plate with the number 66. The obsessive thoughts also come ‘for free’, says Tim. For no reason.
Typical of his obsessive-compulsive disorder is that he then tries to exorcise thoughts of hell by thinking about what symbolizes ‘good’ for him: God, angels, the church.
For a long time, this was also accompanied by compulsive actions: opening and closing a door over and over again, for example, rubbing his leg with his thumb, or putting clothes on and taking them off again and again. He has achieved reasonable control over these compulsions during previous therapy.
But even without compulsions his life comes to a standstill. Until recently, he preferred to be alone, Tim says. Too busy with his mind for social contacts. He was also ashamed of his secluded existence. That has changed in recent weeks. His mind is calmer. Sometimes he even gets bored: a new sensation. This weekend he is going to a drink with neighbors, he says during therapy. He also arranged to meet a girlfriend. His life gets going again.
Whether it is due to the intensive therapy, the TMS, or a placebo effect (as a check, one in three participants in the study does not receive real current pulses through the head): Tim is happy with the progress.
Demonstration of a TMS treatment in the Amsterdam UMC. Image Lina Selg
The question is how permanent those improvements are. As with medication and cognitive behavioral therapy, the effects of brain stimulation can easily fade away afterwards. ‘Compare it with physiotherapy,’ says Van den Heuvel. ‘If you continue to do your exercises, you can get rid of your complaints permanently. If you don’t do them, the back pain will come back.’
Don’t expect miracles from brain stimulation, says Groningen professor of neuropsychology André Aleman, who is not involved in this study. He also does a lot of research into TMS himself, with varying results. ‘We looked at whether TMS helps people with schizophrenia who have hallucinations. That turned out to work no better than placebo.’ The technique turned out to improve apathy (listlessness), which many schizophrenia patients suffer from.
‘More impact with therapy’
The effect of TMS is relatively modest, says Aleman (‘comparable to antidepressants in depression’). And the long-term effects are limited. But the potential of the treatment method is great, he thinks. ‘There are indications that the combination with therapy has a greater impact. That makes research into coercion interesting.’
In the case of depression, it is known that people who relapse after TMS treatment can benefit from periodic maintenance treatments, says Van den Heuvel. ‘That possibility has not yet been investigated for obsessive-compulsive disorders.’
When Tim has almost finished his ‘contaminated’ coffee and has discussed the homework for the coming week with his therapist (including: visiting a church and looking at pictures of the devil on his phone), Zuiker says goodbye. She has to go to the next appointment.
As she closes the door behind her, the clock falls off the wall with a bang. The floor is littered with shards. “This makes me nervous,” Tim says. Had this happened a few weeks ago, before his treatments, the rest of his day would have been focused on the fallen clock and the question of whether that is a sign from the devil.
Now he expects to be able to let it go. But when Tim gets up a little later and walks to the door, he can’t resist. He carefully lifts the clock to see if the hands are still moving. They stop at exactly twelve o’clock.
Tim says nothing about it and leaves for home. He will be here again after the weekend for the next session. There is still a lot of work to be done.
Get rid of your obsessive thoughts with magnetic pulses, how does that work?
A device with a magnetic coil is placed against a patient’s head and induces short currents in the brain through the skull. That, in short, is TMS: Transcranial Magnetic Stimulation, also known as rTMS where the ‘r’ stands for ‘repetitive’ (repetition).
It is certain that people with, for example, a compulsive disorder of depression who have not been helped (enough) with therapy or medication can recover. But how does that work? What do those currents do to the brain?
Scientists don’t know exactly, says professor of neuropsychology André Aleman. Just as it is still not possible to say with certainty exactly how antidepressants work. ‘We actually know quite well how it works,’ says professor of neuropsychiatry Odile van den Heuvel.
In the brain, nerve cells ‘talk’ to each other by transmitting electricity. Van den Heuvel: ‘TMS can improve communication between certain brain areas.’ It is, she says, as if traffic flows better on the highways in the brain.
In the case of compulsion research, TMS improves the brain circuits involved in inhibiting habitual behavior (such as compulsions). ‘It also improves the brain circuits involved in adjusting unrealistic fears and thoughts.’
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2023-11-24 09:30:48
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