Transcranial Magnetic Stimulation (TMS) for Anxiety: Is it Effective?

What Is Anxiety?

Anxiety involves anticipatory thoughts about future threats. Experiencing some anxiety or fear is normal because these emotions protect us from potential harm. However, prolonged and excessive anxiety can lead to avoidance, panic, or other maladaptive behaviors.

Anxiety disorders afflict nearly 20% of the population in the United States and are diagnosed twice as likely in women than in men.^1,2 Individuals at risk for an anxiety disorder often have a genetic predisposition, significant life stress, or a history of trauma (e.g., sexual assault, combat, severe illness, etc.).

The different types of anxiety disorders include:

• Generalized anxiety disorder (GAD): GAD results in excessive worry about events, social interactions, work, school, health, and sometimes nothing in particular. Symptoms can include restlessness, agitation, fatigue, brain fog, muscle tension, gastrointestinal upset, and sleep disturbance.
• Social anxiety disorder: Social anxiety disorder includes intense fear or worry about social situations, such as speaking with, being observed by, or performing in front of others. Social avoidance can interfere with one’s job, relationships, and daily activities.¹ Social phobia can beget isolation, meaning depressive symptoms often occur comorbidly.
• Panic disorder: A panic attack is a sudden surge of intense fear accompanied by physical and cognitive symptoms, such as palpitations, shaking, shortness of breath, dizziness, and nausea. Those with panic disorder experience recurrent panic attacks and persistent concern about having another.
• Specific phobias: Specific phobias are intense fears about particular situations or things, such as air travel, heights, insects, or needles. Phobias often begin in childhood and involve more than one phobic stimulus.¹
• Post-traumatic stress disorder (PTSD): PTSD is a trauma disorder characterized by intrusive thoughts (e.g., PTSD flashbacks) and emotions (e.g., fear). These experiences often arise unexpectedly long after a trauma has occurred.
• Obsessive-compulsive disorder (OCD): OCD results in intrusive, distressing, and fixating thoughts (obsessions). Those with OCD use repetitive behaviors (compulsions) to ease anxiety from these obsessions.

What Is Transcranial Magnetic Stimulation (TMS)?

Transcranial magnetic stimulation (TMS) is a relatively safe, non-invasive procedure. Providers place an electric current against the head to produce a magnetic field. This current travels through the scalp, skull, and cerebrospinal fluid (CSF) to stimulate and activate neurons in the brain.

Activating groups of neurons in specific brain areas–like the insular and pre-frontal cortex–may help stimulate underperforming brain regions and inhibit overactive regions that underlie anxiety symptoms.

Possible side effects of a TMS session include:³

• Headaches
• Seizures
• Dizziness/Lightheadedness
• Syncope (passing out)
• Tingling sensations
• Scalp discomfort and mild pain
• Muscle twitching
• Fatigue
• Anxiety
• Insomnia
• Jaw pain
• Back and neck pain
• Damage to implanted devices (e.g., pacemaker)
• Hearing loss (patients wear earplugs to prevent this)
• Manic episodes (in individuals with bipolar disorder)

Does TMS for Anxiety Work?

Underactivity in certain areas of the brain (e.g., intraparietal sulcus, right dorsolateral prefrontal cortex, insula, amygdala) and overactivity in other regions (e.g., left dorsolateral prefrontal cortex, ventromedial prefrontal cortex) contribute to anxiety.^3,4,5,6 Variations in TMS stimulation parameters (such as pulse frequency) can either activate or inhibit a targeted brain area to reduce symptoms.

Clinical research is still determining optimal parameters and target locations to relieve symptoms associated with anxiety. While TMS may help treat these symptoms, the FDA has not yet approved the treatment for conditions other than co-occurring major depressive disorder and anxiety due to a lack of evidence.³

How Long Will It Take to See Results From TMS for Anxiety?

TMS takes time to work and is time-intensive, requiring daily sessions for weeks to months. On average, symptom improvement can take about one month, with continued improvement extending out to 40 sessions.^7,8 There is a high degree of variability between individuals, with some first feeling relief in as little as nine sessions and others taking up to two months.^9,10 Symptom relief often lasts at least one month. However, some individuals may require maintenance treatment.

Is TMS an FDA-Approved Anxiety Treatment?

The FDA has not approved TMS to treat anxiety disorders. The treatment can help treat “anxious depression” or MDD with the specifier “anxious distress.” Studies suggest that symptom relief lasts four to six months in medication-resistant patients with anxious depression.^3,10,11

How Effective Is TMS for Anxiety?

TMS is an add-on therapy to traditional pharmacotherapy or psychotherapy for anxious depression. TMS aims to enhance therapeutic effects in those who experience symptoms despite medication or psychotherapy alone. According to one study, TMS is effective for 25-30% of people with anxious depression.⁸ However, deep TMS, which sends signals deeper and broader, may be even more effective.¹²

Results are mixed on the efficacy of TMS for anxiety without depression. Some studies show initial symptom improvement. However, relief did not last for a worthwhile amount of time. Other studies showed no improvement at all.¹⁰

TMS can expedite symptom relief for phobias when combined with virtual reality exposure therapy. One study showed that symptoms were relieved faster with TMS. Still, those participating in exposure therapy alone eventually achieved the same results.⁵

TMS Vs. Deep TMS for Anxiety

Transcranial magnetic stimulation is the general term for using electricity and the magnetic field to activate groups of neurons in the brain. Repetitive TMS (rTMS) refers to the delivery of TMS in repeating pulses, the pattern and timing of which have different effects (e.g., stimulating vs. inhibiting). Conventional rTMS devices can generate a magnetic field that typically only sends messages to a shallow and focal cortex area.

Deep TMS devices can generate magnetic fields that reach a deeper and broader area of brain tissue, such as the anterior cingulate cortex (ACC) implicated in OCD. Technically, dTMS can use a single pulse or repetitive pulses (specifically called “deep rTMS”), just like conventional rTMS. However, the unique coil design allows for broader reach and fewer targeting errors.¹³

Theta burst stimulation is another protocol variation of TMS not yet approved for clinical use. Research shows this method can reduce treatment time because patients can receive more than one daily session.¹⁴

Who Should Avoid TMS for Anxiety?

Before receiving TMS, professionals must screen individuals to ensure eligibility and safety. While specific contraindications may vary depending on the condition being treated (e.g., history of frequent headaches), other contraindications are prohibitive (e.g., seizure history, pacemaker). The healthcare professional will ask a series of questions before treatment. Some individuals must receive clearance from their medical team to determine if TMS is viable.

Populations who should avoid TMS treatment for anxiety include those who:

• Have a history of epilepsy
• Have a history of severe headaches
• Do not meet diagnostic criteria for MDD with anxiety
• Have not already tried and shown resistance to traditional treatments
• Are pregnant or nursing
• Have implanted medical and electronic devices (stents, stimulators, pacemakers, cardioverter defibrillators, cochlear implants, etc.)
• Have metal devices or objects in the body (bullet fragments, metal plate, etc.)
• Have another medical condition that may put you at risk for a seizure
• Have brain damage from illness or injury

Can TMS Make Anxiety Worse?

TMS providers often trigger anxiety symptoms before simulation to optimize effectiveness. Such symptom provocation can temporarily exacerbate symptoms (e.g., panic, fear) during the treatment period. Other transient side effects are common to TMS in general. While anxiety symptoms generally do not worsen with TMS, not all people find improvement.

What to Expect From TMS for Anxiety

TMS treatment for anxious depression is an intensive daily treatment that can be time-consuming. Treatment courses may vary slightly, depending on targeted symptoms. However, patients attend daily, 20-minute sessions, four to five days per week, for up to six weeks. They then taper treatment to fewer weekly sessions for about a month. The initial session is usually longer to establish treatment parameters.

The following is what to expect from a typical TMS for anxiety session:

• Arrival: TMS usually occurs in an outpatient office, clinic, or hospital setting (as is the case for clinical research trials).
• Evaluation: Before treatment, clinicians will ask you a series of questions to help determine if TMS is a safe treatment for you.
• Procedure preparation: TMS for anxiety is non-invasive and does not require any surgery, needles, or anesthesia. You will be awake for the entire procedure. Clinicians may measure your head to help identify your personal target location for stimulation.
• Setting: You will be seated in a comfortable chair. As the procedure involves a magnetic field, you cannot bring any ferrous metal (jewelry, keys, glasses) into the room. You will also wear earplugs because the treatment can be loud.
• Symptom provocation: In some cases, a symptom provocation protocol may intentionally trigger anxiety symptoms before or during stimulation to enhance treatment efficacy. This usually involves eliciting patient-specific thoughts through verbal suggestion or visual imagery.
• Device placement: The TMS coil is a cushioned helmet or panel that clinicians place against your scalp at a location specified to treat your symptom(s). Staying still is crucial once the coil is in place, but you may be allowed to talk or read if your head doesn’t move.
• Personalized target: Because brain shape and size vary between individuals, the clinician may use several methods to determine a target to stimulate. Some methods require head measurements, while others require prior neuroimaging.
• Determining intensity: The clinician will stimulate your motor cortex to identify your “motor threshold” (i.e., the pulse intensity that will cause your hand to contract). Your treatment intensity will be relative to this value. This threshold can change with sleep deprivation, medication, alcohol, or drug use. Notify the clinician before a session if these factors change between sessions.¹⁵
• Sensations: As the treatment begins, you will hear loud repetitive noises. You may experience tapping or clicking sensations against your scalp. Some individuals have described this as a light, repetitive tapping or knocking on the head.
• Daily activity: You can resume your daily activities immediately after each session. Typically, there is no recovery period or restrictions unless a seizure occurs as a side effect.
• Subsequent sessions: The stimulation parameters do not change unless you report sleep disturbances or substance use (including medications) that may impact the motor threshold.¹⁵ Subsequent daily sessions are usually briefer than the first session.
• Monitoring effects of treatment: Clinicians may adjust parameters throughout treatment. You will likely not experience improvement within the first few weeks. After the final session, symptom relief may last weeks to months. In some cases, you may receive brush-up sessions when treatment effects wane.

How Much Will TMS for Anxiety Cost?

Typically, each TMS for anxiety session can cost at least $250. The total cost can vary depending on how quickly symptoms resolve, which can vary greatly between people. As a rough estimate, the total cost can range from $3,000 to $15,000.^16,17

Will Insurance Cover TMS for Anxiety?

Most major insurance companies will cover TMS treatment if you are eligible and have not benefited from traditional treatment options like medication or psychotherapy. If you have anxiety without depression, your insurance will likely not cover treatment because the FDA has not approved TMS specifically for anxiety. Consider contacting your insurance company to learn what mental and behavioral health treatments your plan covers and your deductible, copay, or coinsurance costs.

How to Find a TMS Therapist for Anxiety

BrainsWay is the primary company providing dTMS devices (which have shown greater efficacy than conventional TMS). You can also consult a psychiatrist to determine if TMS is a viable option for you. If you have trouble finding a local or online psychiatrist near you, you can search online directories or ask your healthcare provider.

Alternative Treatments for Anxiety

Psychotherapy or medication for anxiety are often the first lines of treatment (e.g., serotonin reuptake inhibitors, dopamine agonists, neuroleptics). However, 40% of patients do not respond to these treatments.¹⁸ TMS is a potential add-on treatment for some but not everyone.

Other alternative treatments can supplement medication and therapy for anxiety. These alternatives range from invasive techniques like deep brain stimulation (DBS) to psychedelic-assisted therapy, depending on the severity of anxiety symptoms, contraindications, exhausted options, and feasibility.¹⁹

Alternative treatment options for anxiety include:

• Deep brain stimulation (DBS): DBS is an invasive neuromodulation technique (requiring surgery) whereby stimulating electrodes target specific brain areas. This approach is an FDA-approved treatment for OCD. DBS is effective in approximately 60% of treatment-resistant OCD cases.²⁰
• Transcranial direct current stimulation (tDCS): tDCS is a non-invasive neuromodulation technique that delivers weak electric current to specific brain areas through electrodes placed on the scalp surface. Ongoing research to fine-tune parameters (e.g., stimulation intensity, brain area targeted) may improve response rates in the future.²¹
• Cognitive behavioral therapy (CBT): CBT focuses on modifying one’s thought pattern, behavior, and physiological response to triggering stimuli. Professionals may provide CBT for anxiety alongside pharmaceutical or neuromodulation treatments.
• Exposure-response therapy (ERP): Exposure therapy is a CBT technique that involves presenting an individual with realistic scenario for their fear, paired with relaxation and cognitive restructuring. This psychotherapeutic method is highly effective for anxiety.
• Acceptance and commitment therapy (ACT): ACT is an offshoot of CBT that integrates aspects of transcendental meditation awareness into treatment. ACT for anxiety approaches anxiety symptoms as uncomfortable but normal thoughts and fears. People learn to accept their presence and learn to live without being disrupted by them.
• Psychedelic-assisted therapy: Psychedelics like ketamine and psilocybin have recently received attention for their potential efficacy in treating certain types of anxiety.²² This therapy may not benefit people with phobias or panic disorder because an anxious mindset during treatment can trigger or exacerbate intense fear. Still, psychedelic-assisted therapy is relatively safe and well-tolerated when administered in a controlled setting and for approved diagnoses.
• Medications: Several medications are available for anxiety, with selective serotonin reuptake inhibitors (SSRIs) being the frontline choice. Other pharmaceuticals, like off-label antidepressants, benzodiazepines, and antipsychotics, may help severe, resistant cases.

In My Experience

TMS may be an alternative for individuals with treatment-resistant anxiety. Given that it requires a large time commitment, people with full-time jobs and other responsibilities may find adhering to the full treatment regimen difficult. However, since TMS usually has fewer side effects than many drug treatments for anxiety, the lower risk profile may outweigh the temporary schedule inconvenience. I typically approach its viability on a case-by-case basis.

If you or someone you care about is considering TMS to relieve symptoms of an anxiety disorder, talk to your mental healthcare provider about whether TMS is a realistic option for you and what other alternatives are available.