A Perspective on the Beginnings of Transcranial Magnetic Stimulation, diluted by four weeks

"Magnets magnets on my brain,

Magnets magnets cause me pain,

Oh please magnets keep me sane"

-TMS Theme Song, by my friend Jess

I'm not going to say anything about the fact that this post about starting TMS comes four weeks after I actually started.  Except that. And the title.  Clearly my fatigue hasn't really improved.  And that.

Photo credit: Google Images

Anyway, as I left off before, with the financial decisions and emotional investments planned and set, I just had to start.  The week prior to my beginning the treatment I spent in Ocean City, MD at the beach, and expected it to be relaxing and preparatory for the move I was undergoing. However, as is the case whenever I go to OC, my mood was unpredictable and one day as I was driving to pick up sushi for my sister and I, I had a depressive crash.  I thought my sobbing might be from that I was about to eat raw fish for dinner, but of course these shrinks read much more into it. Most of the week went by fine, but it helped cement my belief that undergoing TMS was the right decision.  I started my treatment at 15:00 on August 12th, and have continued every weekday since.

Going into the first day I was understandably nervous.  Not because of the potential for pain or discomfort, really, but more for the possibility that it would not work.  Emotionally, on the surface, I had nothing to lose but a lot to gain, but the real anxiety came from that possibility of being out six weeks from my job search, with the same crappy mood disorder, and with my parents out six-thousand dollars with nothing to show for it.  They are so convinced that this is going to work, and I spent the weeks leading up to the start of my treatment trying to manage expectations.  Some part of me always felt that this procedure would be fruitless, and for all I know that feeling is a product of the negativity that is spawned by my disease. But once more into the breech, dear friends, and after all this is just another stab at that ghost.

When I arrived, I had to wait awhile, which was just fantastic for someone wrestling with anxiety.  What's worse, and while I am deeply appreciative of Dr. Sussal for his candor, wit, expertise, and in perhaps the most important way his true appreciation that mood disorder patients are at constant war with their insurance companies to offset the immense cost of mental health medicine, his waiting room sucks.  Probably because he and his office are so willing to work directly with insurance, he and his practice colleagues have a lot of patients.  The small waiting room is constantly packed to the gills, and I'm not sure if this is a mental health thing or people are just generally assholes, but the people in his waiting room are rude.  Talking loudly on a cell phone, snapping their gum, letting their kids run around unchecked; one guy I saw there was actually singing, loudly, to himself.  Or maybe his wife.  I don't want to hear "Old Man River" before I go in to see a shrink.  I deal with this kind of thing everyday, but most of the time its tolerable and my wait is brief.  Other times I have had to leave the room.

Anyway, when the time came, I was escorted into a room in the back of his practice where I saw, for the first time, "Old Shocky".

The Neurostar Transcranial Magnetic Stimulation device.  Note the magnetic coil, which is hanging from the apparatus slightly right of center with the cord running out of it down to the base of the chair.  This is the part of the machine that actually delivers the pulses to the prefrontal cortex of the brain.

I was told to sit in the chair, and we began the calibration process.  Understandably, the machine requires a pretty precise placement on the noggin in order to be effective.  Using, and I admit I have an extremely slight understanding of this process, some kind of laser mounted on the coil, they find the correct location on the skull to place the coil, and then attempt to find each patient's individualized "motor threshold", or essentially, how much juice is required in a pulse to get your right thumb to twitch.  This is sort of funny: due to my anxiety and general constitution, I am a very "shaky" person and at first it caused some ambiguity because my hands were moving so much.  Apparently, I have one of the lowest motor thresholds of any of the patients that the doctor and technician had encountered, but once again I have no idea what that means, other than that it supposedly makes the machine not be as loud during the treatment.  I am still forced to wear ear plugs, which I despise. To sum this up, and in full layman's terms, they stick the coil on the head, line it up using some sort of laser system, then use single pulses in increasing magnitude in order to determine the correct setting for the machine, using a twitch in the thumb as a guide.  I wish I had been more inquisitive as to this whole process, but as I mentioned I was quite nervous and I didn't feel up to asking very many questions, even though (perhaps this is arrogant) I think I could have understood most of the technical descriptions of the goings on.

After this process, they turned it on for real for the first time, and I did not expect what was coming.  The calibration process kind of led me into a false sense of security regarding the discomfort I would experience during this first treatment.  Since they used single pulses at the beginning, all I felt was a very slight tap on my head with each pulse.  I thought, "Oh, this isn't that bad at all."  For at least that first treatment, I was wrong. The treatment consists of an "on" and "off" phase, and alternates between the two of them for the 37 minutes. The on phase lasts about four seconds, and produces what I would guess would be about 15 pulses in that period, in rapid succession.  The machine then "rests" for about 30 seconds, before the pulses begin again.

Part of the machine's side effect
profile is the distinct expression
of the "double chin."

That first time they turned it on: yowza.  The way I described to my folks and friends the pain that the machine caused at first was "as if someone was chipping away at your skull with an ice-pick."  15 times in four seconds.  The doctor asked if it was painful, and me being the stoic dope that I am replied in euphemism by saying "well, it is not comfortable."  He replied, "is it unbearable?" Hrmm...  It is why I came up with the name "brain shockies", even though electricity is never applied to the brain.

And so I went through the rest of the first treatment thinking I would have six weeks of pretty intense pain to look forward to.  However, as I quickly found out, by the end of the first week, the immediate pain had pretty much dulled to the point of being inconsequential.  Occasionally I do get headaches immediately following the treatments, but they quickly go away with the help of some ibuprofen and rest.  So, discounting those two minor irritants, the only other discomforts, which are far more annoying, are the neck crick, and the sheer boredom.  Although I didn't really notice these two effects until the 2nd week or so, they are much more uncomfortable than the direct pain from the procedure.  I'm not sure, but I believe that part of my trouble is my size, which requires me to place my head correctly on the headrest while keeping my neck bent awkwardly, which some days makes my neck ache immensely towards the end of and following the procedure.  A direct product of the required placement of the head is that it precludes one from performing any productive activity.  I tried reading the first week, but as you're looking upwards it forces one to hold a book, or in my case a Kindle above the head, and after about ten minutes of that one realizes it is not feasible to keep it up for long.  Most days I just sit quietly in the chair, although recently I have started to take advantage of the TV and DVD player that they have for patients.  I'm watching Jurassic Park II at the moment, in 37 minute intervals.

I intend to follow with at least two more posts in the immediate future: one as a sort of progress report at the beginning of next week, and another at the conclusion of my treatment.  Hopes are still high that the brain shockies will come through in the end.

-Benjamin