Provocation or State Dependent Deep rTMS for Resistant Obsessive-Compulsive-Disorder

Saturday, April 7: 3:30 PM  - 5:00 PM 
Mezzanine Level 
Room: Marriott Balcony B 
Credits: 1.5 
Introduction: Currently approved medications for OCD only result in a reduction of symptoms for 40-60% of patients, leaving most patients significantly affected. Symptom severity is correlated to the degree of hyperconnectivity in the cortico-striato-thalamic circuit and increased glucose metabolism in the anterior cingulate cortex during symptom provocation and at rest.

Methods: Ninety-four OCD patients who met inclusion/exclusion were randomized to receive active or sham treatment for twenty-nine sessions over six weeks. Deep transcranial magnetic stimulation(dTMS) was applied over the medial prefrontal(mPFC) and anterior cingulate cortices(ACC) using the H7 dTMS coil. Once the coil was in the treatment position, the patient's symptoms were provoked using an individualized script tailored to the patient's obsessions and compulsions. Subsequently, dTMS was administered for eighteen minutes at 100% resting motor threshold of the foot, 20HZ pulse frequency, in 2 second trains, with a 20 second inter-train interval totaling 2000 pulses. The sham coil was designed to have the same sound, scalp and facial sensation as the real coil without stimulating the brain directly.

Results: At the end of week 6 (the primary endpoint) the YBOCS decreased by 5.7 points (95% CI: [3.3;8.2]) in the dTMS arm and by 3.0 points (95% CI: [0.7;5.4]) in the control arm (p-value: 0.0157). Response rates were (≥30% decrease in the YBOCS) 38.10% in the dTMS arm and 11.11% in the sham arm (p-value:0.0033). Partial response rates were (≥20% decrease in the YBOCS) 54.76% in the dTMS arm and 26.67% in the sham arm (p-value: 0.0076). At week 10 (follow up) the YBOCS decreased by 6.2 points (95% CI: [3.6;8.7]) in the dTMS arm and by 3.8 points (95% CI: [1.4;6.2]) in the control arm (p-value: 0.0459). There were no serious adverse events related to the treatment. The most frequent adverse event, headache, did not differ in frequency between the two arms.

Conclusions: High frequency dTMS of the mPFC/ACC with the H7 coil is an effective and safe treatment for OCD.

Learning Objectives

1. Analyze the evidence for state dependent differences in the efficacy of TMS from PTSD and addiction

2. Create provocations for a patient with OCD from a detailed YBOCS interview

3. Summarize results from the double blinded multi center OCD dTMS study 


Aron Tendler, MD, Advanced Mental Health Care Inc. & Brainsway Ltd.
Prof. Joseph Zohar, MD, Chaim Sheba Medical Center

Audience Level





Diversity - No


90 minutes


Obsessive Compulsive Disorder

Treatment Approach