Category
Applied
Description
This case report describes the use of deep transcranial magnetic stimulation (dTMS) for treatment-resistant major depressive disorder comorbid with dissociative identity disorder (DID) and chronic post-traumatic stress disorder (PTSD) in a 73-year-old veteran male with 59 years of marriage. Severe spousal distress influenced treatment selection toward neuromodulation rather than trauma-focused therapy requiring extensive caregiver involvement. The patient completed two 36-session courses of dTMS targeting the left dorsolateral prefrontal cortex 6-months apart. Baseline assessment employed clinician-administered scales (Hamilton Depression Rating Scale, HDRS-17; Clinician-Administered PTSD Scale for DSM-5, CAPS-5) and self-completed questionnaires. Significant discrepancies between self-reported and clinician-rated scores prompted a shift to weekly clinician-administered monitoring using the CAPS-5 (past week), HDRS-17, and brief Dissociative Symptoms Scale (DSS-B).
Over eight weeks, HDRS-17 scores improved from severe (24) to mild (11-12) by weeks 3-5, while PTSD symptoms showed modest fluctuation with slight overall reduction, and dissociative symptoms worsened. Treatment selection was influenced by severe spousal caregiver burden; the patient's wife could no longer sustain support for intensive trauma therapy. Quantitative burden indicators included maximum relationship strain scores (CAARS-2: 3/3) and elevated caregiver distress (BRIEF-A Negativity Index). However, longitudinal caregiver burden assessment was not conducted, precluding evaluation of systemic treatment effects.
Findings suggest that dTMS may meaningfully reduce depressive burden in DID, but it does not address dissociative pathology and may exacerbate dissociative symptoms. This case underscores three critical points: (1) self-completed questionnaires are invalid in DID, requiring clinician-administered tools; (2) TMS shows differential efficacy across symptom domains; and (3) caregiver burden profoundly influences treatment selection, yet remains unmeasured due to the lack of validated DID-specific instruments.
Transcranial Magnetic Stimulation for Treatment-Resistant Depression in Elderly Dissociative Identity Disorder: A Case Report on Differential Symptom Response, Assessment Challenges, and Long-Term Spousal Caregiver Burden
Applied
This case report describes the use of deep transcranial magnetic stimulation (dTMS) for treatment-resistant major depressive disorder comorbid with dissociative identity disorder (DID) and chronic post-traumatic stress disorder (PTSD) in a 73-year-old veteran male with 59 years of marriage. Severe spousal distress influenced treatment selection toward neuromodulation rather than trauma-focused therapy requiring extensive caregiver involvement. The patient completed two 36-session courses of dTMS targeting the left dorsolateral prefrontal cortex 6-months apart. Baseline assessment employed clinician-administered scales (Hamilton Depression Rating Scale, HDRS-17; Clinician-Administered PTSD Scale for DSM-5, CAPS-5) and self-completed questionnaires. Significant discrepancies between self-reported and clinician-rated scores prompted a shift to weekly clinician-administered monitoring using the CAPS-5 (past week), HDRS-17, and brief Dissociative Symptoms Scale (DSS-B).
Over eight weeks, HDRS-17 scores improved from severe (24) to mild (11-12) by weeks 3-5, while PTSD symptoms showed modest fluctuation with slight overall reduction, and dissociative symptoms worsened. Treatment selection was influenced by severe spousal caregiver burden; the patient's wife could no longer sustain support for intensive trauma therapy. Quantitative burden indicators included maximum relationship strain scores (CAARS-2: 3/3) and elevated caregiver distress (BRIEF-A Negativity Index). However, longitudinal caregiver burden assessment was not conducted, precluding evaluation of systemic treatment effects.
Findings suggest that dTMS may meaningfully reduce depressive burden in DID, but it does not address dissociative pathology and may exacerbate dissociative symptoms. This case underscores three critical points: (1) self-completed questionnaires are invalid in DID, requiring clinician-administered tools; (2) TMS shows differential efficacy across symptom domains; and (3) caregiver burden profoundly influences treatment selection, yet remains unmeasured due to the lack of validated DID-specific instruments.
