TMS is a safe, effective treatment for post-traumatic stress disorder.
Post-traumatic stress disorder (PTSD) is a psychiatric condition that can develop after a person experiences an event that involves intense shock, helplessness, horror, injury, or the threat of injury or death. The disorder can also occur among people who witnessed such an event, such as bystanders or first responders. Symptoms of PTSD vary by individual and may include flashbacks or nightmares, avoidance of places or objects that evoke memories of the trauma, difficulty sleeping, being easily startled, feelings of guilt and shame, depression and anxiety, and substance use. These symptoms may appear weeks, months, or even years after a trauma, and they are severe enough to interfere with a person’s ability to engage in relationships, work, school, and other important domains of daily life.1
During a traumatic event, the brain activates a fear response (sometimes known as “fight or flight”) that prepares a person’s body to survive a dangerous or scary situation, such as an accident, a physical assault, military combat, or any life-or-death scenario. In most cases, the fear response subsides after the danger ends. However, in a person with PTSD, the traumatic event causes long-term changes in the brain’s fear circuitry that can cause fight-or-flight behaviors (such as hyper-vigilance or an excessive startle response) to occur in response to harmless everyday situations. This overactivation of the fear circuitry can persist for months or even years, and in some cases may become chronic.2
Early recognition and treatment of PTSD may prevent the condition from becoming chronic and can alleviate the massive emotional, psychological, and social burdens associated with the disorder. However, treatment science for PTSD lags far behind that of other psychological disorders. Only two medications (both antidepressants) are approved to treat PTSD, and other medications can only mitigate the side effects of PTSD (such as insomnia) but do not address the underlying neuropsychiatric causes of the disorder. Unfortunately, only 60% of PTSD patients see improvements with antidepressant drugs, and fewer than one in three will experience remission.3
A cutting-edge technology known as transcranial magnetic stimulation (TMS) may offer an answer where antidepressant medications have failed to improve quality of life in individuals living with PTSD. The therapy works by generating a magnetic field that stimulates electrical activity in the brain, which modifies the malfunctioning pathways of neuronal communication that cause symptoms associated with mental illness. TMS has already received FDA approval to treat conditions such as major depressive disorder, obsessive-compulsive disorder (OCD), and nicotine addiction. Although TMS has not yet been approved as a treatment for PTSD, the over-activated fear pathways that cause the disorder are optimal targets for TMS modification—and a growing body of clinical evidence agrees.
Currently, neuroscientists are working to develop a specific TMS protocol for PTSD, which will eventually inform a standard protocol for FDA approval. Through these efforts, researchers have identified that the right dorsolateral prefrontal cortex, an area of the brain that has been implicated in anxiety and fear arousal,4 may be the best target region for TMS modulation.5,6 During a TMS session, a small wire coil is positioned above a certain area of the patient’s head, corresponding with the region of the brain that is targeted for stimulation. In a patient with PTSD, TMS can best modify fear circuitry by targeting regions that regulate fear response. Because the right dorsolateral prefrontal cortex of the brain plays an important role in regulating fear and anxiety, researchers believe that TMS stimulation of this region may yield optimal results for PTSD and other anxiety disorders.
A strong evidence base supports the use of TMS as a safe, effective treatment for PTSD. One study found that 30 participants who received daily TMS for two weeks showed significant improvements in their PTSD symptoms after only 5 days of treatment, and by the tenth day of treatment, these improvements were more significant in those who were stimulated in the right dorsolateral prefrontal cortex compared to the left.7 Another study found that TMS is particularly effective among individuals whose PTSD is treatment-resistant, meaning that their symptoms did not improve with one or more medications in combination with psychotherapy. Thirty participants with treatment-resistant PTSD who received TMS three times weekly for four weeks showed significant improvements in their symptoms compared to participants who received a placebo treatment. Critically, these improvements were maintained for at least two months after the treatment course ended, indicating that TMS can induce long-term changes in brain function.8
Researchers have also found that TMS is effective in a particular vulnerable population: veterans with combat-related PTSD.9 Evidence suggests that up to 30% of veterans return from combat with PTSD,10,11 yet a high proportion never receive treatment due to underdiagnosis, stigma, or financial instability. Consequently, there remains an urgent need to develop novel therapies that increase intervention access among this under-treated group. A study of 50 veterans found that those who received 20 TMS sessions over two weeks showed long-lasting improvements not only in PTSD symptoms, but in their ability to function in social and occupational settings.12 Another study found that TMS is a useful complement to psychotherapy for reducing the impact of PTSD among veterans aged 18 to 60.13 Additionally, researchers have found that TMS can simultaneously improve co-occurring PTSD and depression in veterans,14 indicating that the therapy is a valuable tool for quickly relieving the burden of comorbid mental illness among this high-risk group.
PTSD places immense emotional and psychological strain on sufferers and their loved ones, placing them at increased risk for poor long-term outcomes such as depression, substance abuse, and suicide. Fortunately, neuroscientists who are committed to advancing human health and happiness have optimized cutting-edge therapies like TMS to alleviate the burden of PTSD among the millions of people living with the condition. Although TMS for PTSD has yet to obtain FDA approval, experts expect that the evidence-based treatment will receive increased consideration in the coming years. In the meantime, Depression Doctors offers TMS for our patient seeking to alleviate the burden of PTSD and progress towards a fuller, happier quality of life.
1 NIMH. Post-Traumatic Stress Disorder. (2020). Retrieved from: https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml
2 Bremner JD. (2008). Traumatic stress: effects on the brain. Dialogues in Clinical Neuroscience, 8(4):445-461.
3 Alexander W. (2012). Pharmacotherapy for post-traumatic stress disorder in combat veterans: Focus on antidepressants and atypical antipsychotic agents. P T, 37(1):32-38.
4 Balderston NL, Beydler EM, Roberts C, et al. (2020). Mechanistic link between right prefrontal cortical activity and anxious arousal revealed using transcranial magnetic stimulation in healthy subjects. Neuropsychopharmacology,. 45:694–702.
5 Clark C, Cole J, Winter C, et al. (2015). A review of transcranial magnetic stimulation as a treatment for post-traumatic stress disorder. Current Psychiatry Reports, 17(10):83.
6 Cirillo P, Gold AK, Nardi AE, et al. (2019). Transcranial magnetic stimulation in anxiety and trauma-related disorders: A systematic review and meta-analysis. Brain and Behavior, 9(6):e01284.
7 Boggio PS, Rocha M, Oliveira MO, et al. (2010). Noninvasive brain stimulation with high-frequency and low-intensity repetitive transcranial magnetic stimulation treatment for posttraumatic stress disorder. Journal of Clinical Psychiatry, 71(8):992-999.
8 Isserles M, Shalev AY, Roth Y, et al. (2013). Effectiveness of deep transcranial magnetic stimulation combined with a brief exposure procedure in post-traumatic stress disorder: A pilot study. Brain Stimulation, 6(3):377–383.
9 Oznur T, Akarsu S, Celik C, et al. (2014). Is transcranial magnetic stimulation effective in treatment-resistant combat related posttraumatic stress disorder?. Neurosciences (Riyadh), 19(1):29-32.
10 Crocq MA & Crocq L. (2000). From shell shock and war neurosis to posttraumatic stress disorder: A history of psychotraumatology.Dialogues in Clinical Neuroscience, 2(1):47-55.
11 U.S. Department of Veterans Affairs. PTSD in Iraq and Afghanistan veterans. (2015). Retrieved from: www.publichealth.va.gov/epidemiology/studies/new-generation/ptsd.asp.
12 Philip NS, Barredo J, Aiken E, et al. (2019). Theta-burst transcranial magnetic stimulation for posttraumatic stress disorder. American Journal of Psychiatry, 176(11).
13 Kozel FA, Motes MA, Didehbani N, et al. (2018). Repetitive TMS to augment cognitive processing therapy in combat veterans of recent conflicts with PTSD: A randomized clinical trial. Journal of Affective Disorders, 229:506-514.
14 Kozel FA, Van Trees K, Larson V, et al. (2019). One hertz versus ten hertz repetitive TMS treatment of PTSD: A randomized clinical trial. Psychiatry Research, 273:153-162.
Original Article was published at our sister site TMSProgram.com.