How TMS Treats OCD: Inside the Brain Circuit Behind Compulsions and How Deep TMS Targets It

If OCD makes you feel trapped in checking, cleaning, reassurance-seeking, mental reviewing, or other rituals, the problem is not a lack of willpower. Obsessive-Compulsive Disorder is a treatable neuropsychiatric condition involving brain circuits, learning patterns, anxiety, and behavior.

One useful way to understand OCD is to picture a smoke alarm that keeps re-triggering after the danger has passed. The alarm feels urgent, so you perform a compulsion to quiet it. Relief arrives briefly, but that relief teaches the brain to activate the alarm again the next time uncertainty appears.

Transcranial Magnetic Stimulation (TMS) uses magnetic pulses to influence specific neural networks. For adults with persistent OCD, BrainsWay Deep TMS using an H-coil is FDA-cleared as an adjunctive treatment when medication and/or therapy has not provided adequate benefit. It is not a cure and does not replace evidence-based OCD therapy, but it may help reduce symptom intensity for some people.

At Light-tunnel Behavioral Health Services Inc. in New Haven, OCD care may include therapy, medication management, psychiatric evaluation, and TMS assessment. Psychiatric providers include Dr. Omolola Aragbada, PMHNP-BC.

The brain circuit behind OCD

OCD symptoms are associated with communication among regions in the cortico-striato-thalamo-cortical (CSTC) circuit, including:

• The orbitofrontal and medial prefrontal cortex
• The anterior cingulate cortex
• The striatum
• The thalamus

This network helps evaluate potential threats, detect errors, assign importance, and decide whether an action should be repeated. In OCD, the system may behave like a stuck mechanical loop: “Something is wrong. Check again. Make sure. Repeat.”

The compulsion may temporarily reduce distress, but the brain can interpret that relief as evidence that the ritual was necessary. Over time, the alarm becomes easier to trigger.

Deep TMS is designed to influence the cortical entry points of this network, especially the dorsal medial prefrontal cortex (dmPFC) and nearby anterior cingulate cortex (ACC). These areas are connected with deeper structures involved in error monitoring, threat evaluation, and repetitive behavior.

How Deep TMS may interrupt the OCD loop

A conventional figure-8 TMS coil produces a relatively focal magnetic field near the surface of the brain. That approach can be useful for certain cortical targets, but the medial prefrontal and anterior cingulate regions involved in OCD can be more difficult to stimulate directly and broadly.

The BrainsWay H-coil is built into a helmet-like system and is designed to produce a broader, deeper field than a standard figure-8 coil. It does not “reach into the brain” like a surgical instrument. Instead, changing magnetic fields induce electrical activity in cortical tissue, which may influence connected networks.

A simplified mechanism looks like this:

1. The coil delivers carefully timed magnetic pulses.
2. The pulses influence neurons in the targeted medial prefrontal and cingulate regions.
3. Those cortical regions communicate with connected CSTC structures.
4. Repeated sessions may promote changes in network excitability and functional connectivity.
5. Reduced circuit overactivity may make it easier to resist compulsions and tolerate uncertainty.

The magnetic pulse is not erasing thoughts. It is more like using a tool to help reset a misfiring circuit so that every intrusive thought does not automatically become an emergency.

In the pivotal multicenter randomized, double-blind, sham-controlled trial, active Deep TMS produced greater OCD symptom reduction than sham treatment. Response occurred in 38.1% of active-treatment participants compared with 11.1% receiving sham treatment at the end of treatment (Carmi et al., 2019). This means meaningful improvement is possible, but response is not guaranteed.

Deep TMS for OCD compared with other treatment pathways

A 2023 meta-analysis of randomized sham-controlled TMS trials found a moderate overall benefit and a higher likelihood of response than sham treatment, while also noting differences among targets and protocols (Steuber & McGuire, 2023). Your clinician should therefore evaluate the specific device, indication, protocol, and evidence, not simply the word “TMS.”

TMS for OCD versus TMS for depression

TMS is not one universal treatment. The protocol changes according to the condition being treated.

• OCD: FDA-cleared Deep TMS with the BrainsWay H-coil targets medial prefrontal and anterior cingulate-related circuitry.
• Major depression: Common protocols target the left dorsolateral prefrontal cortex, although systems and treatment plans vary.
• Treatment schedule: Both commonly involve repeated weekday sessions, but session duration, frequency, intensity, and positioning differ.
• Clearance: FDA clearance is indication- and device-specific. A TMS system cleared for depression should not automatically be described as cleared for OCD.

BrainsWay is one of the most researched Deep TMS systems, and BrainsWay Deep TMS is the system associated with FDA clearance for adult OCD treatment. The FDA decision describes the treatment as adjunctive, meaning it is generally considered alongside appropriate psychiatric care rather than as a replacement for ERP or medication.

What treatment actually looks like, session by session

Before the first session

A psychiatric and medical evaluation reviews your OCD symptoms, previous ERP or medication trials, current medications, bipolar-spectrum symptoms, neurological history, seizure risk, hearing concerns, and metal or electronic implants.

An evaluation may begin through telehealth when clinically appropriate. However, TMS treatment itself is always provided in person because the device must be positioned and monitored directly.

Session 1: Mapping and positioning

The clinician measures your scalp and head position, identifies the appropriate treatment location, and establishes individualized stimulation settings. You may hear clicking and feel tapping as the system is tested.

Some OCD protocols include a brief, personalized symptom-provocation exercise before stimulation. In the pivotal Carmi trial, this was used to help engage the relevant OCD circuitry. Your provider will determine whether it is clinically appropriate.

Early sessions

You remain awake, alert, and able to communicate. The coil or helmet rests over the prescribed target. You may feel tapping, pressure, or mild scalp discomfort and hear repeated clicking. Facial or scalp muscle movement can occasionally occur.

TMS does not require anesthesia, and it is not the same as electroconvulsive therapy. Most people can drive themselves home afterward if they feel well and have no other reason not to drive.

Sessions commonly take about 20–40 minutes, depending on the system and settings. Some TMS protocols are substantially shorter. Treatment is typically delivered on weekdays for about 4–6 weeks; the BrainsWay OCD pivotal protocol ran 5 days a week for 6 weeks (about 30 sessions).

Later weeks and follow-up

Your team tracks OCD severity, compulsions, intrusive thoughts, functioning, side effects, and mood changes. Improvement may be gradual. TMS may make the alarm less intense, while ERP helps you practice not obeying it.

What to do and what to avoid

Do

• Attend sessions consistently whenever possible.
• Tell your clinician about every medication, supplement, substance, and recent medication change.
• Report headaches, scalp pain, hearing symptoms, unusual mood elevation, or worsening distress.
• Continue ERP, medication, and psychiatric follow-up as prescribed.
• Ask which device, coil, target, and protocol are being recommended.
• Bring questions about insurance authorization, treatment duration, and expected costs.

Avoid

• Stopping an SSRI, clomipramine, or another psychiatric medication without medical guidance.
• Assuming TMS will eliminate every intrusive thought.
• Beginning intense exposure exercises without an individualized ERP plan.
• Hiding a seizure history, implanted device, head injury, or symptoms of mania.
• Treating online testimonials as a substitute for clinical evaluation.
• Delaying emergency care because you are waiting for TMS to begin.

Care at Light-tunnel Behavioral Health Services Inc.

At Light-tunnel Behavioral Health Services Inc. in New Haven, treatment planning is personalized rather than based on a single diagnosis or device. Care may include psychiatric evaluation, psychotherapy, medication management, and evaluation for TMS or Spravato/esketamine when clinically appropriate.

Self-pay clients can benefit from transparent fees, direct access, and avoiding delays related to prior authorization. The practice can provide superbills and reimbursement documentation for patients who want to request out-of-network benefits. The team can also discuss evaluation, medication management, therapy, TMS, and Spravato/esketamine evaluation when appropriate. Light-tunnel accepts a wide range of major insurance plans, although coverage and eligibility vary.

Although this article focuses on OCD therapy and TMS treatment in New Haven, the practice also provides anxiety treatment, depression treatment options, and care for treatment-resistant depression.

Medical safety disclaimer and crisis resources

This article is for education only. It does not diagnose OCD or determine whether Deep TMS, medication, ERP, or another treatment is appropriate for you. TMS must be prescribed and administered after an individualized evaluation. Possible side effects include headache, scalp discomfort, facial twitching, lightheadedness, hearing-related symptoms, and, rarely, seizure or mood elevation.

If you may hurt yourself or someone else, cannot stay safe, or are experiencing an emergency:

• Call or text 988 to reach the Suicide & Crisis Lifeline.
• Call 911 or go to the nearest emergency department for immediate danger.
• Do not delay emergency care while waiting for a consultation or TMS appointment.

References

1. Carmi, L., Tendler, A., Bystritsky, A., et al. (2019). Efficacy and safety of deep transcranial magnetic stimulation for obsessive-compulsive disorder: A prospective multicenter randomized double-blind placebo-controlled trial. American Journal of Psychiatry, 176(11), 931–938. https://pubmed.ncbi.nlm.nih.gov/31109199/

2. U.S. Food and Drug Administration. BrainsWay Deep Transcranial Magnetic Stimulation System de novo decision summary and OCD clearance materials. https://www.accessdata.fda.gov/cdrh_docs/reviews/DEN170078.pdf

3. Foa, E. B., Liebowitz, M. R., Kozak, M. J., et al. (2005). Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. American Journal of Psychiatry, 162(1), 151–161. https://doi.org/10.1176/appi.ajp.162.1.151

4. Soomro, G. M., Altman, D., Rajagopal, S., et al. (2008). Selective serotonin re-uptake inhibitors for obsessive-compulsive disorder. Cochrane Database of Systematic Reviews. https://pubmed.ncbi.nlm.nih.gov/18253995/

5. Steuber, E. R., & McGuire, J. F. (2023). A meta-analysis of transcranial magnetic stimulation in obsessive-compulsive disorder. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 8(11), 1145-1155. https://pubmed.ncbi.nlm.nih.gov/37343662/

Continue the Series

For further reading, visit Breaking the Loop: How OCD Therapy and TMS Can Help You Regain Control.