Depersonalization-derealization-syndrome (DDS) is generally associated with a state of self-alienation. The symptoms are experienced i-dystonically and consciously as a discrete and altered condition to the previous experience. There are hardly any well-researched explanatory models for pathogenesis or efficient treatment strategies. Newer approaches include cognitive-behavioral-therapy (CBT) and therapy with transcranial magnetic stimulation (rTMS). Against this background the idea arose to combine rTMS with CBT to find novel strategies in the treatment of DDS. Therefore the feasibility of a combination therapy, based on the concept of Donse et al. (2018) [1Donse L., Padberg F., Sack A.T., Rush A.J., Arns M. Simultaneous rTMS and psychotherapy in major depressive disorder: Clinical outcomes and predictors from a large naturalistic study Brain Stimul 2018 ;  11 (2) : 337-345 [cross-ref]

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Four patients with a leading DDS diagnosis were recruited and randomly assigned to a treatment protocol: right ventrolateral prefrontal cortex (rVLPFC) vs. temporoparietal junction (TPJ). All patients received 15 rTMS stimulation over three weeks. The stimulation parameters differed depending on the treatment protocol. Group 1 receives the so-called Mantovani-protocol: 1Hz, 30minutes (1800 pulses) with a 100% intensity of the MEP above the right TPJ. Group 2 received the so-called Jay-protocol: 1Hz, 15minutes (900 pulses) with a 110% intensity of the MEP above the right VLPFK. At the same time, all patients received CBT, which include exercises for mindfulness, confrontation, muscle relaxation and sport.

The rTMS treatment was tolerated well. In terms of psychotherapeutic intervention, they have benefited most from the confrontation exercises and from sport. The cut-off value for the DDS symptoms is a score of 40 and higher. The table shows a reduction in symptoms from pre to post rating for pat. 2 and for pat. 4 even under the cut-off in the Mantovani-protocol. As well as a reduction from post to FU for Pat. 1 and 3. using the Jay-protocol. Pat. 3 shows an increase of symptoms from pre to post measures but a decline to the baseline in 6-w-FU rating. The results suggest that a combination of rTMS and CBT is a promising approach in the treatment of DDS symptoms. Further placebo-controlled studies have to be conducted to investigate the efficacy of this treatment strategy.