March 23, 2000 (Atlanta) -- The voices sound real, and they won't go away. From deep within a schizophrenic patient's head, they relentlessly repeat their awful messages, which can urge suicide or even murder. Now help may be on the way: A report in the journal Lancet suggests that an electromagnetic device can zap the voices out of the head without hurting the brain.
The technique, rTMS, which stands for repetitive transcranial magnetic stimulation, uses a handheld device to deliver a low-voltage electromagnetic pulse to a specific area of the brain. TMS pulses -- experienced as a tingling sensation -- do not damage the brain, although some patients report a minor headache due to muscle contractions of the face and scalp. The experimental devices have been able to help some patients with severe depression. Now Yale researcher Ralph E. Hoffman, MD, reports that rTMS can hush the voices haunting some schizophrenic patients -- one of the most difficult-to-treat symptoms known to psychiatry.
"I thought it was pretty remarkable," Hoffman, medical director of the Yale Psychiatric Institute, tells WebMD. "For a couple of patients, it seems to have had some lasting benefits. We are seeing a response rate now of up to 75%. For most of the patients who have a response, it seems to endure for months. It's frequently not a total response, but there is at least a 50% decrease in [auditory] hallucinations."
The voices technically are hallucinations, but this doesn't mean that they aren't real. "It is not in their imagination," Hoffman says. "They are having [the perception of hearing] in the same way we hear people around us. ... We compared the loudness of the hallucinations with [a recording of a person reading played at various volumes]. Some of these range up to 60 or 70 decibels -- really a loud sound."
During puberty, normal brain development goes through a process of fine-tuning by getting rid of unnecessary connections between areas of the brain. Hoffman's theory is that for some reason this process goes terribly wrong in some people, and too many brain connections are lost. One result can be a loss of proper function in the part of the brain that controls the way sounds are translated into speech, and in schizophrenic patients this leads to hearing voices in the head. If this is so, Hoffman says, then calming this part of the brain should quiet the voices. The rTMS device appears to do just that.
In an interview with WebMD, rTMS developer Alvaro Pascual-Leone, MD, PhD, says that the device originally was created as a way to map the language areas of the brain without surgery. While testing the device, he found that it had long-lasting effects on the brain. Depending on how, when, and where in the brain it was used, the rTMS had either a stimulating or calming effect. Taking advantage of these effects, he and other researchers began exploring whether rTMS could be used as an alternative to electroconvulsive therapy (ECT), sometimes called "shock therapy," in patients with severe depression. They have since expanded their studies to try the technique in patients with other psychiatric conditions, and Pascual-Leone finds the Hoffman results intriguing.
"Suppression of hallucination for months is fabulous and very interesting," Pascual-Leone says. "It is a very hard problem -- patients generally do not get very good responses even after long-term medication. To help with that aspect of the disease would be very helpful indeed."
Pascual-Leone, director of the Harvard laboratory of magnetic brain stimulation, notes that his group also is experimenting with rTMS as a treatment for schizophrenia. He says that one problem he has encountered is that when the effects of treatment wear off, some patients have worse symptoms than they did before undergoing the experimental therapy.
This rebound effect has not occurred in patients treated with rTMS for depression in studies under way at Emory University, according to William McDonald, MD, director of the Fuqua center for late-life depression. "The biggest concern is that it can cause seizures, so people are excluded from our studies if they have a history of seizures," he tells WebMD. "There is no apparent downside. There are no memory deficits, which gives rTMS an advantage over ECT."
Hoffman says he has undergone rTMS so that he could personally evaluate the effects. "It doesn't exactly feel like a shock but it feels weird, like a tingling sensation, kind of like a woodpecker tapping on the skull," he says. "It also causes a contraction of the scalp or face, and may produce other contractions. It feels odd, but by and large the patients tolerate it very well. But we have a selected group of patients who volunteer for this. They are pretty desperate, and their families are desperate."
One fear Hoffman was worried about was whether paranoid patients with a delusional fear that people were trying to control their brains would object to the use of electromagnetic waves to -- well, to control their brains. "It's something we are concerned about, but the patients have actually been reasonable," he says. "It is more acceptable to deal with someone actually trying to control their brain than their fears about it."