Name: Protocol for Repetitive Transcranial Magnetic Stimulation with Symptom Provocation to Treat Obsessive-compulsive Disorder (Video) | JoVE Journal
Uploaded: 2025-11-25T13:30:00.000+00:00
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Description: Learn a standardized rTMS protocol for obsessive-compulsive disorder using individualized symptom provocation. This method enhances treatment efficacy and ensures safe, reproducible delivery across clinical settings.

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ND (2022.12871.BD), DRS (2023.05754.BD) and FFV (2024.00723.BD) are supported by doctoral fellowships from Funda&#231;&#227;o para a Ci&#234;ncia e Tecnologia (FCT, Portugal). GC is supported by a 2023 NARSAD Young Investigator Grant from the Brain &#38; Behavior Research Foundation. AJO-M is supported by a Starting Grant from the European Research Council (grant agreement no. 950357), and by the PsyPal project (grant agreement no. 875358), both funded by the European Union&#39;s Horizon 2020 Research and Innovation Programme. GC and AJO-M are supported by a Proof-of-Concept Grant from the European Research Council (grant agreement no. 101158262). The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of any of the funding agencies.

AJO-M was recipient of a grant from Schuhfried GmBH for norming and validation of cognitive tests, and national coordinator for Portugal of medication trials for treatment-resistant depression, sponsored by Compass Pathways, Ltd (EudraCT number 2017-003288-36 and 2020-001348-25) and Janssen-Cilag, Ltd (EudraCT NUMBER: 2019-002992-33). He has received payment, honoraria, or support for attending meetings and participating in advisory boards from MSD, Neurolite AG, Janssen Pharmaceuticals, Angelini Pharma, and the European Monitoring Centre for Drugs and Drug Addiction, and has received consultancy fees from Bioprojet Pharma and NaturalX Health Ventures (all outside the submitted work). He is Vice President of the Portuguese Society for Psychiatry and Mental Health, head of the Psychiatry Working Group for the National Board of Medical Examination at the Portuguese Medical Association and Portuguese Ministry of Health, President of the Ethics Committee for the&#160;Institute for Addictive Behaviors and Dependence and President of the Scientific Council of the Portuguese Obsessive Compulsive Disorder Foundation. The remaining authors declare that they have no potential conflicts of interest involving this work, including relevant financial activities outside the submitted work and any other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing what is written. None of these agencies had a role in the design and conduct of the study, in the collection, management, analysis, and interpretation of the data, in the preparation, review, or approval of the manuscript, nor in the decision to submit the manuscript.

This protocol provides a standardized and replicable approach to deliver rTMS for OCD, incorporating procedures consistent with current regulatory clearances and best-practice recommendations. Through a comprehensive, step-by-step guide, it addresses key procedural gaps in the clinical application of TMS for OCD.
First, it is important to discuss team composition, infrastructure, and emergency preparedness. The successful delivery of TMS for OCD depends on a coordinated multidisciplinary team. Core personnel should include a licensed psychiatrist responsible for clinical oversight, psychologists with experience in symptom provocation and exposure-based interventions, and TMS technicians trained in both the technical and interpersonal aspects of stimulation delivery. TMS technicians must undergo structured training covering device operation, safety monitoring, emergency protocols, and basic life support8,29,45. For OCD-specific protocols, additional training in symptom provocation is essential, including how to elicit moderate distress, maintain engagement, and manage patient responses sensitively27. Although psychologists may contribute to training and supervision, their systematic involvement in symptom provocation at every session is rarely feasible in most clinical settings, and was not included in the pivotal clinical trial that established efficacy and regulatory clearance12. Instead, published methods for technician training in provocation procedures have been developed to allow for consistent and reproducible delivery of symptom provocation27. This approach balances the need for standardized implementation with the practical demands of treatment scalability to better ensure access. Additionally, when TMS is delivered in clinical or research settings involving trainees or observers, patient consent in this regard must be obtained in advance. To ensure consistent treatment quality, regular supervision and adherence audits are recommended.
TMS treatment should be delivered in appropriately equipped clinical settings using cleared or approved stimulation devices46. Essential infrastructure includes a dedicated treatment room that accommodates comfortable patient positioning, typically involving a reclining chair or bed. The room should be maintained at an appropriate temperature to prevent the TMS device from overheating47. Sites offering TMS must also have protocols in place to manage acute and potentially serious adverse events, such as syncope or seizures. These protocols should follow the specific recommendations in Rossi et al (Clin Neurophysiol, 2009)8. Although comprehensive resuscitation equipment is not mandatory for standard outpatient treatments, facilities must maintain basic medical tools for airway management and efficient procedures to contact external emergency medical services8.
A critical aspect of implementation is troubleshooting during execution of the protocol. Common challenges include difficulties in reliably identifying the leg motor hotspot and determining the resting motor threshold, which are discussed in detail elsewhere48. Coil stability can also be problematic, as small deviations in angle or position reduce targeting accuracy. The use of mechanical arms and repeated verification of scalp markings are essential. During symptom provocation, insufficient distress induction can be an obstacle, especially in patients who minimize symptom disclosure or habituate quickly to stimuli. This may be addressed by expanding the provocation hierarchy, combining internal and external triggers, and maintaining close psychologist-technician communication throughout treatment16. Excessive anxiety or escalation to compulsive behaviors may also occur. These situations require technicians to de-escalate while preventing reinforcement of compulsions, for example, by redirecting conversation, pausing briefly, or switching to less distressing stimuli16. Finally, patient discomfort from stimulation (e.g., scalp pain or headaches) can usually be mitigated through ramping procedures, slight coil adjustments, or the use of over-the-counter analgesics. Anticipating these challenges in advance is crucial to ensure protocol fidelity and enhance&#160;patient tolerability.
The integration of symptom provocation in TMS for OCD is a defining feature, covered in detail here. Although randomized controlled trials specifically assessing its effect in TMS for OCD are lacking, a recent meta-analysis by Bello et al&#160;&#160;(JAMA Psychiatry, 2025)49 found that while the added benefit of symptom provocation was not statistically significant when compared to active TMS without provocation, the effect size was numerically stronger relative to sham stimulation, suggesting provocation might potentiate the clinical effects of TMS49. Additionally, indirect evidence from related neuropsychiatric conditions supports its clinical relevance18,19. Provoking obsessive-compulsive symptoms is thought to engage the cortico-striato-thalamo-cortical circuitry, particularly in the right hemisphere50,51. Activating these circuits immediately prior to stimulation may enhance the specificity of TMS-induced plasticity, preferentially modulating symptom-relevant neural populations. A recent study has demonstrated that greater pre-treatment right amygdala activation, as measured through functional magnetic resonance imaging (MRI) during symptom provocation, predicted better treatment response to combined rTMS and exposure and response prevention, lending support to a state-dependent neuromodulation model52. Taken together, these findings indicate that&#160;symptom provocation may&#160;potentiate rTMS effects, but&#160;current evidence does not establish a clear superiority over rTMS delivered without provocation.
The post-treatment medical assessment is critical to establish treatment response and define next steps. For patients classified as non-responders, treatment planning should shift toward alternative or adjunctive strategies, including optimization or escalation of pharmacotherapy, referral for structured CBT-ERP, or, in treatment-refractory cases, consideration of invasive neuromodulation approaches such as deep brain stimulation4. Since TMS for OCD is approved as an adjunctive treatment, the optimal combination with other available therapies must be assessed on a case-by-case basis within a multidisciplinary framework. Conversely, for patients classified as responders, the question becomes how to best sustain clinical benefit. Evidence regarding maintenance treatment in OCD is scarce. To date, only a single study has systematically examined durability: in a secondary analysis of the pivotal trial by Carmi et al. (Am J Psychiatry, 2019), 86.7% of responders who were followed longitudinally maintained benefit for at least one year53. While this suggests substantial durability, the absence of controlled data does not allow for a clear definition of the optimal approach to continuation, maintenance, or retreatment schedules.
While the protocol described here follows&#160;FDA-cleared parameters, the choice of stimulation hardware may vary. H-coils, designed for deep transcranial magnetic stimulation, deliver broad and diffuse fields that penetrate deeper cortical and subcortical structures. In contrast, double-cone coils may induce a more focal field geometry and higher intensity along the midline. Computational models and electric field measurements comparing these coils suggest that both can stimulate the cortical target for OCD (the dmPFC/ACC), although their E-field distributions differ in depth, intensity, and spatial specificity38. These physical differences may influence clinical response profiles, tolerability, and the capacity for individualized targeting. However, no direct comparative trials between coils have been conducted, and further research is necessary to determine the extent to which coil-specific properties affect treatment outcomes.
Ongoing research is exploring alternative cortical targets. A recent network meta-analysis reported that rTMS over the dorsolateral prefrontal cortex and supplementary motor area ranked among the highest in terms of efficacy25. Although small sample sizes&#160;limit&#160;generalizability, these regions may represent promising targets for TMS. Nonetheless, it is important to emphasize that the dmPFC/ACC targeted through dTMS remains the only site with regulatory clearance and is the focus of this protocol. Furthermore, although this protocol describes a scalp-based measurement approach to targeting, systems based on individual neuroimaging data are increasingly used to improve anatomical precision. Image-guided targeting has the potential to increase accuracy and reduce variability in coil positioning, though its widespread implementation remains limited due to cost, infrastructure, and training demands54. Regarding dosing, this protocol delivers high-frequency stimulation at 100% of the individual&#39;s motor threshold. However, motor threshold-based dosing does not necessarily reflect the actual induced dose at the cortical target, and recent work using E-field modeling has shown that electric-field guided dosing may provide a more accurate and individualized approach to TMS application55. Future iterations of this protocol may incorporate such updates on target and dosing as evidence grows.
In addition to the open questions regarding symptom provocation, targeting, dosing, and maintenance strategies discussed above, important practical challenges remain. Coordinating a multidisciplinary team, including physicians, psychologists, and TMS technicians, can be logistically complex and requires clear communication and structured workflows to ensure fidelity and patient safety. Furthermore, the optimal timing of rTMS prescription within a patient&#39;s treatment pathway is not yet well defined and likely varies according to prior treatment response, comorbidities, and access to care. Future research should clarify when this intervention is most effective and how best to streamline team coordination for wider implementation.
Alongside a detailed explanation of the FDA-cleared treatment protocol, this protocol offers a practical framework to facilitate team coordination in delivering complex interventions such as rTMS for OCD. By formally incorporating structured psychological assessments and team briefings into the symptom provocation workflow, this protocol aims to enhance homogeneity in care, ensure alignment across clinical roles, and enable systematic monitoring of treatment response56. In sum, the protocol described here is intended as a practical contribution to the ongoing clinical implementation of TMS for OCD. As the field moves forward, the continued refinement of targeting strategies, stimulation parameters, and team-based delivery models will be essential to improve outcomes and broaden access to care.

Obsessive-compulsive disorder (OCD) is a chronic neuropsychiatric disorder characterized by the presence of recurrent, intrusive thoughts or impulses (obsessions), and/or of repetitive behaviors or mental acts (compulsions) performed to alleviate distress, and frequently complicated by significant avoidance behaviors1. It affects an estimated 1.3% of the population over their lifetime, with a typical onset in childhood or early adulthood and a waxing-and-waning course2,3. First-line treatments for OCD consist of high-dose serotonin reuptake inhibitors (SRIs) and/or cognitive-behavioral therapy with exposure and response prevention (CBT-ERP)4. However, first-line treatments yield insufficient response in approximately 50% of patients, with a substantial proportion of patients experiencing persistent symptoms despite treatment5,6.
Transcranial magnetic stimulation (TMS) has emerged over the last decade as an effective non-invasive neuromodulation technique for OCD. TMS uses focused, time-varying magnetic fields to induce electrical currents in targeted brain regions, thereby modulating cortical excitability and activity within neural circuits7. It does not require anesthesia, and is generally safe and well-tolerated, with no significant systemic side effects8. Initially cleared for the treatment of treatment-resistant episodes of major depressive disorder, TMS has since gained further regulatory clearance and is used widely in various neuropsychiatric conditions9,10,11. In 2018, the United States Food and Drug Administration (FDA) cleared a repetitive TMS (rTMS) protocol for OCD as an adjunctive treatment for adults, following a pivotal multi-center randomized controlled trial, involving 100 patients, where those allocated to active stimulation had significant symptom improvement when compared to sham stimulation12.
The FDA-cleared rTMS protocol for OCD targets the dorsomedial prefrontal cortex (dmPFC) and anterior cingulate cortex (ACC), cortical regions consistently implicated in the neurobiology of obsessive-compulsive disorder3. This repetitive TMS protocol employs high-frequency stimulation (20 Hz) for 30 daily sessions (up to 6 weeks on weekdays), delivered through coils capable of reaching deeper cortical structures (this technique is also referred to as deep TMS, dTMS). Currently, there are three coils cleared for OCD, one H-coil, used in the clinical trial leading to clearance, and two double-cone coils13,14,15. A defining element of the protocol used in the original&#160;trial used for clearance of TMS for OCD is the incorporation of symptom provocation immediately prior to stimulation initiation12. This procedure&#160;was proposed as an approach to transiently activate symptom-relevant neural circuits, towards enhancing the efficacy of TMS through state-dependent plasticity mechanisms16. Importantly, greater levels of distress during symptom provocation have been associated with stronger treatment-related improvements in active, but not sham, protocols17. Similar state-dependent strategies have been incorporated into other FDA-cleared indications for TMS, such as major depressive disorder, and smoking cessation, and have also been explored in off-label applications, including alcohol use disorder, with interesting results18,19,20,21. Following clearance of TMS for OCD, additional studies have shown clinical utility and cost-efficiency of treatment in real-world settings22,23,24. Importantly, while there are increasing numbers of alternative protocols implemented in clinical research and off-label settings for the same indication25, the original protocol targeting the dmPFC/ACC remains the only one with regulatory clearance.
TMS is thus currently cleared as an adjunctive treatment in adult patients with OCD, to be used in combination with standard treatments, namely psychotropic medications and/or CBT-ERP26. Indeed, rather than a replacement for conventional therapies, TMS is an additional therapeutic modality, suitable for patients whose symptoms persist despite conventional care, or for those with limited tolerability and/or access to first-line treatments. Despite growing clinical adoption, detailed procedural descriptions of the FDA-cleared TMS protocol for OCD, including methods for individualized symptom provocation, remain limited in the literature. In an effort to reduce this literature gap, a guide for professional training in symptom provocation during TMS has been previously published27. Here, a comprehensive protocol aligned with current regulatory approvals is presented to guide the delivery of TMS for OCD in clinical settings. Compared to other TMS approaches for OCD that are experimental or off-label, the main advantage of this protocol is that it has regulatory clearance from the FDA for OCD, based on randomized controlled trial evidence. This protocol aims to provide clinicians with a standardized, reproducible method that has demonstrated efficacy and safety, facilitating broader clinical adoption.

<table><tbody><tr><td>&amp;nbsp;&amp;nbsp;&amp;nbsp;&amp;nbsp; BrainsWay H7 Coil and Helmet</td><td>BrainsWay</td><td>https://www.brainsway.com/products/</td><td>Deep TMS coil approved for OCD treatment</td></tr><tr><td>&amp;nbsp;&amp;nbsp;&amp;nbsp; CloudTMS DCC-03-125-C Coil</td><td>Neurosoft (CloudTMS)</td><td>https://neurosoft.com/en/catalog/accessory/1452</td><td>Double-cone coil for deep TMS</td></tr><tr><td>D-B80 Butterfly Coil, OR alternatively</td><td>MagVenture</td><td>9016E046</td><td>Double-cone coil approved for OCD treatment</td></tr><tr><td>Earplugs</td><td>Generic/irrelevant</td><td>N/A</td><td>Hearing protection for patients and technicians</td></tr><tr><td>Flexible Measuring Tape</td><td>Generic/irrelevant</td><td>N/A</td><td>Used to measure head landmarks for coil positioning</td></tr><tr><td>Lycra Cap</td><td>Generic/irrelevant</td><td>N/A</td><td>Head cap used for coil placement marking</td></tr><tr><td>Reclining Chair</td><td>Generic/irrelevant</td><td>N/A</td><td>Used for comfortable patient positioning during treatment</td></tr><tr><td>Transcranial Magnetic Stimulation (TMS) MagPro X100</td><td>MagVenture</td><td>9016D0041</td><td>TMS operating system for OCD treatment</td></tr></tbody></table>

protocol for repetitive transcranial magnetic stimulation with symptom provocation to treat obsessive-compulsive disorder

Protocol for Repetitive Transcranial Magnetic Stimulation with Symptom Provocation to Treat Obsessive-compulsive Disorder

Obsessive-compulsive disorder (OCD) is a chronic, debilitating neuropsychiatric disorder characterized by the presence of obsessions and/or compulsions that are time-consuming and cause significant functional impairment. Pharmacotherapy and cognitive-behavioral therapy are standard first-line treatments but often fail to provide satisfactory symptom relief, making treatment resistance a significant clinical challenge. Over the last decade, transcranial magnetic stimulation (TMS), a non-invasive brain stimulation technique that allows for focal cortical neuromodulation in humans, has emerged as a promising treatment for OCD. In 2018, the US Food and Drug Administration (FDA) cleared TMS as an adjunctive treatment for adults with OCD, based on procedures to target the anterior cingulate cortex and dorsomedial prefrontal cortex (ACC/dmPFC), while incorporating symptom provocation at the start of each session. Here, a step-by-step TMS protocol for OCD that adheres to the FDA-cleared protocol is detailed, namely an acute cycle of 30 repetitive TMS sessions over 6 weeks with high-frequency stimulation (20 Hz) at 100% of leg motor threshold over the ACC/dmPFC. Treatment consists of 50 trains of 2 s with 20 s of interval between trains, in a total of 2000 pulses per session. Additionally, since each session starts with an individualized symptom provocation task to elicit moderate obsessional distress, a structured description for this procedure is provided, as developed at the Champalimaud Clinical Centre, in Lisbon, Portugal. This article provides guidance on patient preparation, coil targeting, stimulation settings, and symptom provocation, offering a clear framework for clinicians and researchers to implement this neuromodulation approach for OCD.

The protocol described here is based on the randomized controlled trial conducted by Carmi et al. (Am J Psychiatry, 2019), which led to FDA clearance of rTMS for OCD. The study was conducted at multiple sites and approved by local institutional review boards.  All patients provided written informed consent. In this study, adult patients with treatment-resistant OCD received 29 sessions of high-frequency rTMS (20 Hz) over the dmPFC/ACC, preceded by individualized symptom provocation12. The results showed that 38.1% of participants in the active treatment group achieved a full response (defined as ≥ 30% reduction in Y-BOCS score), compared to 11.8% in the sham group (p = 0.003)43. To visualize these effects, a figure from Carmi et al.12 is reproduced, which summarizes response rates at week 6 of treatment.
<img alt="Bar chart comparing sham and active treatment responses; ** indicates statistical significance." class="xfigimg" src="/files/ftp_upload/68971/68971fig1.jpg" data-altupdatedat="1783396841000" data-alt="Figure 1"> 
Figure 1: Percentage of full and partial responders according to Y-BOCS score at week 6 in the active and sham TMS treatment groups. Criteria for full response was Y-BOCS score reduction of ≥ 30%, and partial response as a ≥ 20% reduction. **p &lt; 0.01. Y-BOCS: Yale-Brown Obsessive Compulsive Scale. Reprinted with permission from The American Journal of Psychiatry, Volume 176, Number 11, "Efficacy and Safety of Deep Transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: A Prospective Multicenter Randomized Double-Blind Placebo-Controlled Trial" by Carmi et al. (Copyright © 2019)12. American Psychiatric Association. All Rights Reserved.<a href="https://www.jove.com/files/ftp_upload/68971/68971fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
More recently, a meta-analysis aggregating results from multiple randomized trials applying the FDA-cleared parameters has confirmed the clinical benefit of this approach. Across a pooled sample of 252 patients with treatment-resistant OCD over 4 clinical trials, active rTMS significantly outperformed sham stimulation in terms of response rates, consolidating the protocol's efficacy across independent cohorts44.

This article presents a clinical protocol for repetitive transcranial magnetic stimulation (rTMS) with individualized symptom provocation in obsessive-compulsive disorder (OCD), following parameters from protocols cleared by the FDA.

Obsessive-compulsive disorder (OCD) is a chronic, debilitating neuropsychiatric disorder characterized by the presence of obsessions and/or compulsions ...

We developed a protocol to standardize the implementation of the only FDA-cleared treatment with transcranial magnetic stimulation for obsessive compulsive disorder. Main challenges include translating protocols using research for regulatory clearance into everyday clinical practice and ensuring reproducible and safe delivery across multiple centers. Before treatment, the psychologist assesses the patient to construct the symptom provocation list that will be used during TMS stimulation.When consulting the patient, first explain the rationale and procedure for symptom provocation and clarify any questions the patient may have. Administer the Yale Brown Obsessive Compulsive Scale Second Edition Symptom Checklist to identify active obsessions and compulsions. Next, create a draft list of primary symptoms including obsessions, compulsions, and avoidance behaviors.Ask the patient to rate each symptom using the visual analog scale and record the scores next to each item. Collaboratively discuss and revise any ratings that appear inconsistent. Complete the clinician-rated Yale Brown Obsessive Compulsive Scale Second Edition severity scale based on the previous week, using the symptom list and other relevant information regarding the patient's functioning.In collaboration with the patient, construct a symptom hierarchy from the primary symptoms list, selecting the most significant target symptoms for provocation that elicit moderate distress. Create a customized list of internal and external provocation stimuli based on the established hierarchy. Provide a concise summary of the patient's clinical history, highlighting the nature and severity of their obsessive compulsive symptoms.Review the individualized symptom provocation list, including the specific internal and external provocations that will be used. Highlight annotations that indicate which items are especially effective and which should be avoided due to their potential to cause excessive distress. Provide clinical notes or contextual strategies to facilitate the smooth and effective delivery of provocations.Ensure that the psychologist maintains communication with the technician throughout the treatment course. Instruct the technician to thoroughly review and become familiar with the content of the symptom provocation list before starting the first treatment session. Explain the treatment rationale for repetitive transcranial magnetic stimulation, or rTMS, expected sensations during stimulation, and possible side effects to ensure the patient feels comfortable and engaged.Using a single low-intensity pulse, demonstrate the tapping sensation on the forearm to help the patient anticipate the experience if necessary. Then, place a lycra cap on the patient's head, aligning it with the patient's eyebrows and the apex of the helix on each ear to establish consistent reference points for future sessions. Now, provide a pair of earplugs to the patient to reduce auditory discomfort during stimulation.To determine the motor hotspot, sit the patient comfortably with legs uncrossed and barefoot, with both feet either resting on a cushioned leg support or hanging freely. Then, using a measuring tape, trace the midsagittal line by measuring the distance from the nasion at the bridge of the nose to the inion at the raised area on the lower back of the skull. To identify the intertragal line, measure the distance between the left and right tragus, which are the small cartilage nubs in front of each ear canal.The intersection of this line with the midsagittal line defines the cranial vertex, Cz, which will serve as the reference point. Position the coil just posterior to the Cz along the midline with the handle oriented posteriorly. For motor threshold determination, with the stimulator in single-pulse mode, deliver initial stimulation pulses at a low intensity to help the patient get used to the tapping sensation and assess tolerability.Set the intensity to 50%of maximum stimulator output and deliver single pulses with an interstimulus interval of at least three seconds. Once a motor response is detected, deliver another pulse at the same location to confirm visible dorsiflexion of the foot. If foot dorsiflexion is confirmed, adjust the coil to identify the site that produces the strongest and most consistent visible contraction, defined as the leg motor hotspot.To determine the leg resting motor threshold, mark the anterior edge of the coil on the patient's cap without moving the coil from the identified location to ensure accurate coil placement in future sessions. Gradually decrease the stimulation intensity in small steps to determine the lowest intensity that elicits visible muscle contraction in at least three out of five consecutive single pulses. Record this value as the leg resting motor threshold in the patient's file.To identify the treatment site, using a flexible ruler or measuring tape, locate the treatment site by measuring four centimeters anterior to the motor hotspot along the sagittal midline. Mark the treatment site clearly on the patient's cap to serve as the coil placement reference for future sessions. For symptom provocation, start the symptom provocation procedure.This should start with general questions about the patient's day to build rapport and gather contextual cues for guiding the provocations. Intentionally activate obsessive symptoms to enhance treatment efficacy. Aim to provoke a moderate anxiety level rated between four and seven on a 0 to 10 visual analog scale.Instruct patients to refrain from engaging in compulsions or anxiety-reducing behaviors until the session concludes to maintain distress levels during the rTMS session. Use the symptom provocation hierarchy flexibly, starting with less anxiogenic items and gradually progressing toward more distressing provocations. As each provocation is delivered, ask the patient to rate their current anxiety on a visual analog scale from 0 to 10.If present in the hierarchy, use external provocations such as instructing the patient to start a washing compulsion and interrupt it midway. Record the item from the provocation hierarchy that triggered the desired distress level. Start the TMS treatment by setting the treatment protocol on the stimulator to high-frequency stimulation and 100%of the leg motor threshold with 50 trains totaling 2, 000 pulses over approximately 18 minute.Ensure the coil orientation aligns with the previously marked positioning, and hold the coil in place using either the mechanical arm of the TMS system or by manual positioning. Confirm with the patient that they are comfortable and that the earplugs are properly placed before beginning the session. Also verify that all technicians and individuals present in the room are also wearing hearing protection.Inform the patient that the session is about to start. If the patient is unfamiliar with TMS or sensitive to stimulation, use ramping to reduce discomfort during the initial sessions. After confirming the coil's precise alignment over the treatment site, initiate the treatment protocol in the stimulator while ensuring accurate coil placement throughout the procedure.Remind the patient to continue thinking about the provoking item to maintain an adequate level of obsessive compulsive distress during stimulation. Once stimulation concludes, carefully remove the coil, followed by the cap, and instruct the patient to take out their earplugs. Instruct the patient to stand up slowly, and observe them for any signs of dizziness or imbalance.This protocol is based on the results of the pivotal randomized clinical trial published by Carmi et al. American Journal of Psychiatry 2019, that led to regulatory clearance of TMS for OCD. In this clinical trial, at week six of treatment, 38.1%of patients in the active treatment group achieved a full response, compared to 11.8%in the sham group, and 55%of patients in the active group showed a partial response, compared to 28%in the sham group.This work fills the gap between regulation and daily clinical practice through a complete step-by-step protocol for delivering TMS for OCD. This protocol incorporates structured steps to develop and conduct individualized symptom provocation, as has been described in the research leading to clearance of TMS for OCD. Future research should focus on individualization of treatments, for example, through connectivity-based TMS targeting, expected to improve delivery precision and efficacy.

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Learn a standardized rTMS protocol for obsessive-compulsive disorder using individualized symptom provocation. This method enhances treatment efficacy and ensures safe, reproducible delivery across clinical settings.

Protocol for Repetitive Transcranial Magnetic Stimulation with Symptom Provocation to Treat Obsessive-compulsive Disorder

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