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Nervenheilkunde 2015; 34(12): 965-975
DOI: 10.1055/s-0038-1627660
Hirnstimulation
Schattauer GmbH

rTMS in der Therapie psychiatrischer Erkrankungen

Grundlagen und Methodik[*] rTMs in depressive disorderbasics and methods
P. M. Kreuzer
1   Klinik und Poliklinik für Psychiatrie und Psychotherapie der Universität Regensburg am Bezirksklinikum, Regensburg
,
J. Höppner
2   Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsmedizin Rostock
,
T. Kammer
3   Klinik für Psychiatrie und Psychotherapie III, Universitätsklinikum Ulm
,
C. Schönfeldt-Lecuona
3   Klinik für Psychiatrie und Psychotherapie III, Universitätsklinikum Ulm
,
F. Padberg
4   Klinik für Psychiatrie und Psychotherapie, Klinikum der Universität München
,
M. Bajbouj
5   Klinik für Psychiatrie und Psychotherapie, Charité –Universitätsmedizin Berlin, Campus Benjamin Franklin
,
P. Zwanzger
6   kbo-Inn-Salzach-Klinikum gemeinnützige GmbH, Fachkrankenhaus für Psychiatrie, Psychotherapie, Psychosomatische Medizin, Geriatrie und Neurologie
,
C. Plewnia
7   Universitätsklinik für Psychiatrie und Psychotherapie, Universität Tübingen
,
A. Fallgatter
7   Universitätsklinik für Psychiatrie und Psychotherapie, Universität Tübingen
,
M. Landgrebe
8   kboLech-Mangfall-Klinik Agatharied, Psychiatrie – Psychotherapie – Psychosomatik
,
J. Cordes
9   LVR-Klinikum Düsseldorf, Kliniken der Heinrich-Heine-Universität Düsseldorf
,
T. Wobrock
10   Klinik für Psychiatrie und Psychotherapie, Georg-August-Universität Göttingen
11   Zentrum für Seelische Gesundheit, Kreiskliniken Darmstadt-Dieburg, Groß-Umstadt
,
A. Hasan
4   Klinik für Psychiatrie und Psychotherapie, Klinikum der Universität München
,
G. Hajak 13
12   Klinik für Psychiatrie und Psychotherapie, Sozialstiftung Bamberg, Bamberg
,
M. Schecklmann
1   Klinik und Poliklinik für Psychiatrie und Psychotherapie der Universität Regensburg am Bezirksklinikum, Regensburg
,
J.-P. Lefaucheur
13   Department of Physiology, Henri Mondor Hospital, Assistance Publique – Hôpitaux de Paris, Créteil, France
14   EA 4391, Nerve Excitability and Therapeutic team, Faculty of Medicine, Paris Est Créteil University, Créteil, France
,
B. Langguth
1   Klinik und Poliklinik für Psychiatrie und Psychotherapie der Universität Regensburg am Bezirksklinikum, Regensburg
› Institutsangaben
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Publikationsverlauf

eingegangen am: 01. Oktober 2015

angenommen am: 01. Oktober 2015

Publikationsdatum:
22. Januar 2018 (online)

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Zusammenfassung

Als transkranielle Magnetstimulation (TMS) wird ein Verfahren bezeichnet, bei dem ein Stimulator über eine Spule kurze elektromagnetische Pulse mit einer Flussdichte von bis zu 2 Tesla induziert, welche die Schädelkalotte mit wenig Abschwächung durchdringen und zu einer Depolarisierung neuronaler Zellverbände führen. Die Stromdichte am Stimulationsort wird von einer Vielzahl physikalischer und biologischer Parametern bestimmt: Spulengeometrie sowie -positionierung, der Abstand der Spule zum Kortex, die Pulsform, die Intensität, Frequenz und das Muster der Stimulation sowie die dreidimensionale Orientierung der stimulierten neuronalen Strukturen im Verhältnis zur Geometrie des Magnetfeldes. Bei der repetitiven transkraniellen Magnetstimulation (rTMS) werden mehrere elektromagnetische Einzelstimuli als Reizserien mit konstanter Wiederholungsrate appliziert. Mithilfe dieser repetitiven TMS können Veränderungen der neuronalen Aktivität induziert werden, die über die eigentliche Stimulationsdauer hinweg andauern. Im vorliegenden Themenheft wird die Datenlage zu etablierten und potenziellen therapeutischen Anwendungen der repetitiven transkraniellen Magnetstimulation in psychiatrischen Indikationsgebieten zusammengefasst. Eine Empfehlung mit Evidenzgrad A kann für die hochfrequente rTMS-Behandlung des linken dorsolateralen präfrontalen Kortex (DLPFC) bei depressiven Störungen ausgesprochen werden. Empfehlungen mit dem Evidenzgrad B bestehen für niederfrequente rTMS des rechten DLPFC bei der Behandlung depressiver Störungen und für hochfrequente rTMS des linken DLPFC bei depressiver Symptomatik von Patienten mit Parkinson-Syndrom. Wahrscheinlich besteht ein additiver Effekt von rTMS des DLPFC zu einer antidepressiven Pharmakotherapie. Eine Empfehlung mit dem Evidenzgrad C kann folgenden rTMS-Paradigmen zugesprochen werden: hochfrequente rTMS des linken DLPFC bei Patienten mit schizophrener Negativsymptomatik (trotz einer großen negativen Multicenterstudie), niederfrequente rTMS des linken TPC bei chronischem Tinnitus und akustischen Halluzinationen (trotz vieler Publikationen eher niedriges Evidenzniveau), hochfrequente rTMS des rechten DLPFC bei Patienten mit posttraumatischer Belastungsstörung und hochfrequente rTMS des linken DLPFC bei Nikotinabhängigkeit. Gerade bei der Behandlung von Patienten mit chronischem und therapieresistentem Erkrankungsverlauf ist zu erwarten, dass dem gesamten Bereich neurostimulatorischer Methoden eine steigende Bedeutung zukommen wird. Es bleibt zu hoffen, dass vor dem Hintergrund innovativer technischer Entwicklungen und verbesserter Studienmethodologie die transkranielle Magnetstimulation in der nahen Zukunft ihr volles therapeutisches Potenzial entfalten wird.

Summary

Transcranial magnetic stimulation (TMS) is a neuromodulatory technique consisting of short electromagnetic stimuli of approx. 2 Tesla produced by a stimulator connected to a coil. These magnetic fields penetrate the skull painlessly resulting in a depolarization of cortical neurons. The power of the magnetic field at the target area is mainly determined by a variety of physical and biological parameters such as coil geometry, coil position, coil distance to cortical target, pulse form, stimulation intensity, frequency, stimulation pattern, threedimensional orientation of cortical target in relation to the geometry of the applied magnetic field. Repetitive transcranial magnetic stimulation (rTMS) means the serial application of several electromagnetic stimuli at a given repetition rate. rTMS is able to evoke lasting changes in neuronal activity by induction of neuroplastic activity. The aim of the presented special issue is to provide a comprehensive overview regarding established and potential therapeutic applications of rTMS in the treatment of psychiatric disorders. A level-A-recommendation (“definitively effective”) is obtained for high-frequency stimulation of the left dorsolateral prefrontal cortex (DLPFC) in depressive disorders. Level-B-evidence (“probably effective”) is available for: (i) low-frequency rTMS of the right DLPFC in depressive disorders and (ii) high-frequency rTMS of the left DLPFC in case of depressive symptoms in patients suffering from Parkinson’s disease (probably additive effect of rTMS to antidepressant medication). Level-C-evidence (“possibly effective”) is available for: high-frequency rTMS of the left DLPFC in the treatment of negative symptoms in schizophrenic patients (despite a large multicenter- trial with negative findings), low-frequency rTMS of the left temporoparietal cortex in chronic tinnitus and acoustic halluzinations (low level of evidence despite a large number of publications), high-frequency stimulation of the right DLPFC in posttraumatic stress disorder (PTSD), and high-frequency rTMS of the left DLPFC in nicotine craving. It is very likely that – especially in the treatment of patients with chronic and treatment resistant conditions – the whole spectrum of neuromodulatory treatments will obtain increasing importance in the future. Innovative technical advances and improved study methodology may increase the potential of repetitive transcranial magnetic stimulation as an innovative and noninvasive treatment approach.

Schlüsselwörter

Transkranielle Magnetstimulation - TMS - Psychiatrie

Keywords

Transcranial magnetic stimulation - TMS - psychiatry

* Dieses Manuskript wurde als Positionspapier der Deutschen Gesellschaft für Hirnstimulation in der Psychiatrie (DGHP) erarbeitet.


 

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