Dear Editor, Deep repetitive transcranial magnetic stimulation (dTMS) has emerged as a potential adjunctive intervention for medication and psychotherapy-resistant obsessive- compulsive disorder (OCD).[1] A case study involving a 19-year-old female with OCD exemplifies the promising outcomes of personalized neuromodulation strategies. The patient presented with excessive concern about dirt contamination, negative thoughts about her parents' health and her education, compulsive washing of her legs and hands (~30 times/day), and wetting her feet with saliva. Multiple blisters and callosities, and two nonbleeding, nontender ulcerations were seen on the feet. Her elder brother also had a history of OCD. Fluoxetine 80 mg/day, clomipramine 10 mg/day, buspirone hydrochloride 20 mg/day, and clonazepam 0.5 mg BD were started. As she did not improve after 1 month, dTMS was planned with an H7 coil of BrainsWay Deep TMS system that targets the medial prefrontal cortex (mPFC) and anterior cingulate cortex (ACC).[2] in November 2022. After applying the standard United States Food and Drug Administration (USFDA)-approved deep TMS protocol consisting of 30 sessions, each having 50 trains at 20 Hz frequency for 2s, there was only a mild reduction of the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) and Hamilton Anxiety Rating Scale (HAM-A) scores from 24 to 19 and 20 to 15, respectively. Distress continued and compulsive washing rose to 50 times/day by late January 2023. At this time, the Y-BOCS and HAM-A scores were 24 and 19, respectively. The prescription was changed to fluoxetine 80 mg/day, desvenlafaxine 50 mg/day, buspirone 20 mg/day, and aripiprazole 2 mg/day in two divided doses. In addition, 12 sessions of 1 Hz rTMS with a figure of 8 coils applied over the supplementary motor area (SMA) were started but the patient showed no signs of improvement. A personalized protocol was then developed, involving a novel combination of dTMS targeting mPFC and ACC and 1 Hz rTMS over SMA coupled with guided imagery. Each session comprised one H7 dTMS stimulation followed by 20 min of 1 Hz stimulation over SMA using a figure of 8 coils, after a gap of 10 min. This was combined with guided imagery, to help unlearn the compulsive act. During the process, she was asked to imagine applying saliva or pouring water over her feet, and at the same time saline water was poured on her feet. When one operator applied saline on the feet the other operator gave a tactile stimulus using a blunt object over the feet. Ten such sessions were planned, with a once-weekly frequency, over 10 weeks. The patient's response to this personalized regimen was substantial, with a reduction in compulsive washing first noticed at 4 weeks. Another significant event also occurred during the 4th week, when the patient revealed for the first time a pivotal traumatic event in her early childhood, around 7–8 years of age. She had developed a callosity in her right foot, which was surgically removed. Post surgery, she reported being bullied by peers about her limping and attending school with surgical dressing. She recollected it as the most disturbing event in her childhood. She was educated about the likelihood of this traumatic event precipitating her OC symptoms. By the 4th week, the frequency of compulsive washing of feet started reducing, and there was a progressive reduction in the same up to 8 weeks, after which the patient stopped washing her feet completely, and gradually, her ulcers healed. Y-BOCS and HAM-A scores dropped down to 10 and 5, respectively. She did not have any adverse effects during the treatment. She is still in remission after 5 months of completion of treatment. At present, she has been recommended only pharmacotherapy as maintenance treatment, and TMS as maintenance is not currently being considered as she is maintaining well on pharmacotherapy alone. The case underscores the potential of individualized neuromodulation strategies for intractable OCD. In this case, We theorize that the sequential process of ACC-amygdala circuit activation through the H7 coil, followed by SMA inhibition combined with guided imagery, led to synergistic effects triggering a transformative response. We advocate for further exploration of such personalized methods, positing that they could enhance treatment outcomes for refractory OCD. We hope that this report contributes to the evolving landscape of OCD management, highlighting the promise of combining neurostimulation and cognitive interventions to unlock remission in previously treatment-resistant patients Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
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Prabha et al. (2024) studied this question.