Custom TMS
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At Brain Stimulation Clinic our mission is grounded in service, innovation, and transparency. We don’t just offer Transcranial Magnetic Stimulation (TMS)—we push its boundaries using customized, data-informed protocols, innovative psychiatry, and combined methodologies. For those of us who are clinicians and researchers this work is not just a treatment—it’s an ongoing study, aimed to help those who we serve and make the world a better place.
What is Custom TMS?
Traditional TMS targets a standardized location—typically the left dorsolateral prefrontal cortex—for every patient. While this has shown efficacy, it often treats only part of the picture. Mental health disorders are rarely isolated; they are frequently comorbid, overlapping in both symptoms and underlying neural circuits.
Custom TMS is our response to that complexity.
Rather than assuming a one-size-fits-all protocol, we personalize stimulation based on each patient’s unique neural patterns, symptom clusters, and clinical trajectory. This approach allows us to engage not only the right brain region—but the right network at the right time.
Our protocol development includes:
• Quantitative EEG (qEEG): Mapping brain activity to identify over- or underactive networks
• Structural and Functional Imaging (when available): Refining and verifying target areas
• Clinical phenotype matching: Aligning stimulation sites with symptom-specific evidence
• Real-time response monitoring: Weekly symptom scales, behavioral tracking, and EEG-guided adjustments
• Integration of current therapies: Leveraging psychotherapy or vagus nerve stimulation to reinforce plasticity-driven change
In short, Custom TMS is built for the real-world complexity of mental health care—where depression often comes with anxiety, trauma can affect attention, and healing is rarely linear.
Inferior Frontal Gyrus (IFG) – Broca’s Area
Targeted for: Autism Spectrum Conditions, Alexithymia, Expressive Aphasia
Stimulation Type: Excitatory (High-Frequency rTMS)
Brodmann Areas: 44, 45
The Inferior Frontal Gyrus (IFG), particularly on the left hemisphere, plays a central role in language production, social-emotional processing, and self-referential inner speech. It overlaps with Broca’s Area, a key hub in expressive language and internal narrative construction.
Why Target the IFG?
Autism & Alexithymia
In individuals with autism or high levels of alexithymia (difficulty identifying or verbalizing emotions), hypoactivity in the IFG is frequently observed. This underactivation may contribute to:
• Reduced social-emotional insight
• Difficulty putting feelings into words
• Impaired self-reflection or “mentalizing”
• Muted internal speech (reduced verbal mediation of thought)
Excitatory stimulation to the IFG has been proposed as a way to boost self-awareness and emotional labeling—core deficits in alexithymia and ASD.
Aphasia (Non-Fluent Type)
In post-stroke or neurodegenerative aphasia (particularly Broca’s aphasia), excitatory stimulation of the left IFG has shown promise in:
• Enhancing word retrieval and fluency
• Supporting re-engagement of language networks
• Promoting neuroplasticity and perilesional recruitment
Orbitofrontal Cortex (OFC)
Targeted for: Obsessive-Compulsive Disorder (OCD) & Addiction
Stimulation Type: Inhibitory
Brodmann Area: 11
The OrbitoFrontal Cortex (OFC) is central to how we assign value to stimuli, make decisions based on outcomes, and regulate urges. It acts as a neural evaluation hub, integrating sensory, emotional, and motivational information to guide adaptive behavior.
Why Target the OFC?
OCD – Right OFC
Patients with OCD often show hyperactivity in the right OFC, particularly in response to perceived threats or internal discomfort. This overactivity contributes to:
• Intrusive thoughts
• Repetitive checking/compulsions
• Rigid decision-making and threat overvaluation
Addiction – Left OFC
In contrast, left OFC hyperactivation is often seen in addiction, where reward valuation is distorted and cravings override rational control. Stimulation here aims to:
• Decrease craving and compulsive drug-seeking
• Normalize dysfunctional reward prediction error signals
• Rebalance impulsive vs. deliberative systems
Temporo-Parieto-Occipital Junction (TPO / TPJ)
Targeted for: Tinnitus, Auditory Hallucinations (e.g., Schizophrenia)
Stimulation Type: Inhibitory
Brodmann Areas: 41, 42 (Primary/Secondary Auditory Cortex)
The Temporo-Parieto-Occipital Junction (TPO)—also referred to as the Temporal Parietal Junction (TPJ)—is a multisensory integration zone critical for auditory perception, self-other processing, and spatial attention. Located at the crossroads of three major lobes, this area plays a key role in filtering internal vs. external stimuli.
Why Target the OFC?
Tinnitus
Tinnitus involves the persistent perception of sound (ringing, buzzing) in the absence of external input. It’s often linked to aberrant activity in the auditory cortex, particularly in the TPO region.
• TPO hyperactivity creates the phantom sound experience
• Inhibitory stimulation can reduce auditory cortex hyperexcitability
• Targeting this area helps “turn down the volume” of tinnitus perception
Auditory Hallucinations (Schizophrenia, Psychosis)
Patients with auditory hallucinations often exhibit spontaneous activation in the TPJ even in the absence of external sound, suggesting overactive internal voice monitoring systems.
• TPO/TPJ stimulation reduces hallucinatory episodes
• May enhance the discrimination between internal and external voices
• Often combined with antipsychotic therapy for synergistic effect
Inferior Parietal Lobule (IPL)
Targeted for: Autism Spectrum (Left – Excitatory), Depression (Right – Inhibitory)
Stimulation Type:
• Left IPL – Excitatory – Autism Spectrum
• Right IPL – Inhibitory – Depression
Brodmann Areas: 39, 40
The Inferior Parietal Lobule (IPL) sits at the intersection of the temporal, parietal, and occipital lobes. It plays a critical role in self-awareness, social cognition, perspective-taking, and semantic integration—making it a key region in both neurodevelopmental and affective disorders.
Why Target the IPL?
Autism – Left IPL (Excitatory)
Excitatory stimulation may help enhance self-other mapping, improve social insight, and support cognitive empathy. Studies have shown underactivation in the left IPL in individuals with autism spectrum conditions, particularly in tasks involving:
• Perspective-taking (theory of mind)
• Emotional understanding of others
• Imitation and mirror neuron systems
• Language and semantic processing
Depression – Right IPL (Inhibitory)
Inhibitory stimulation may help reduce maladaptive internal narratives, lessen emotional rigidity, and support DMN normalization. In depression, the right IPL often shows overactivity and is implicated in:
• Self-critical rumination
• Negative self-referential processing
• Default Mode Network (DMN) hyperconnectivity
Quick Reference
The following diagram offers a simplified scalp-based EEG map highlighting the most commonly targeted regions in our Custom TMS protocol library. Each location corresponds to an underlying brain region selected based on symptom cluster, network involvement, and qEEG findings.
🟢 Green markers indicate primary targets used for either excitatory or inhibitory stimulation, depending on the clinical presentation.
TMS Protocols
E X C I T A T O R Y
10 Hz – Left DLPFC
(Depression, ADD/ADHD, Pain, etc)
- 4 sec ON / 11 sec OFF
- Duration: ~20 minutes
20 Hz – Left DLPFC
(Depression, ADD/ADHD, Pain, etc)
- 3 sec ON / 12 sec OFF
- Duration: ~20 minutes
10 Hz - Left DLPFC
George–Stein Suicide Protocol
- 5 sec ON / 10 sec OFF
- 30 minutes, pause 60 minutes, then repeat
- 3 sessions/day for 3 consecutive days
iTBS (Intermittent Theta Burst Stimulation)
(Depression, ADD/ADHD, Pain, etc)
- 50 Hz bursts, delivered at 5 Hz
- 2 sec ON / 8 sec OFF
- Total session length: 3, 6, or 10 minutes
| Region | Use Case |
|---|---|
| Left DLPFC | Depression, Anxiety, Bipolar |
| Left & Right IFG | Autism, Aphasia |
| Left IPL | Autism |
| DMPFC (midline 30% nasion–inion) | Depression |
| SMA (midline 40% nasion–inion) | OCD, Tourette’s, Parkinson’s |
| M1 (midline 50% nasion–inion) | Pain, Parkinson’s |
| Precuneus (midline 70% nasion–inion) | Dissociation |
| Cerebellum (midline 100% = inion) | Parkinson’s |
I N H I B I T O R Y
1 Hz rTMS
(Anxiety, OCD, etc)
- Continuous: 1200 sec ON
- Duration: ~20 minutes
cTBS (Continuous Theta Burst Stimulation)
(Anxiety, OCD, etc)
- 50 Hz bursts at 5 Hz
- Standard: 40 seconds total
- Extended: 3 minutes total
Hanlon Protocol (cTBS)
(Addiction, Anxiety, OCD, etc)
- Standard cTBS frequencies (50hz burst at 5 hz)
- 2 min ON, 1 min OFF, 2 min ON
| Region | Use Case |
|---|---|
| Right DLPFC | Depression, Anxiety, Bipolar |
| Right OFC | Depression, Anxiety, OCD |
| Left OFC | Addiction, Alcohol |
| Left TPO | Tinnitus, Auditory Hallucinations |
| Right TPO | Tinnitus |
| Right IPL | Depression |
CustomTMS pocket reference
This quick-reference chart summarizes stimulation protocols used at American Brain Stimulation Clinic based on clinical indication, target location, stimulation type, and session parameters.
Technical Note
For the Curious, Skeptical, or Deeply Analytical
If you’re comfortable with the general TPO and IPL targeting explained above—feel free to move on. However, if you’re skeptical, confused, or just love anatomical detail, this section is for you.
Let’s Get Detailed
We often refer to TPO (Temporo-Parieto-Occipital Junction) and IPL (Inferior Parietal Lobule) as singular targets, but these regions are composite anatomical areas made up of multiple Brodmann areas and gyri.
MNI Coordinates and Brodmann Areas
| Location (MNI Coordinates) | Brodmann Area | Approx. Distance from Midline |
|---|---|---|
| -57, -20, 1 | BA 41 / 42 | 13 cm (Primary Auditory Cortex – Heschl’s Gyrus) |
| -53, -33, 33 | BA 40 | 8 cm (Supramarginal Gyrus) |
| -46, -60, 33 | BA 39 | 10 cm (Angular Gyrus) |
What Does This Mean for Targeting?
Using our NeuroNav software, we mapped these coordinates to scalp locations:
• 🟡 Yellow = TPO: Targeting the posterior superior temporal gyrus
• 🔵 Blue = Supramarginal Gyrus
• 🟢 Green = Angular Gyrus
These collectively inform our IPL targeting, as the Inferior Parietal Lobule encompasses both the Supramarginaland Angular Gyri.
A Note on Nomenclature
Strictly speaking, when we refer to “TPO” targeting, we are often stimulating the posterior superior temporal gyrus—which borders between:
• BA 41/42: Primary auditory cortex (Heschl’s gyrus)
• BA 22/39: Wernicke’s area and language processing zones
In practice, this area is involved in auditory hallucinations, tinnitus, and aberrant self-other processing, making it a clinically relevant (if not perfectly defined) target.
Final Note
The information presented on this page reflects our ongoing synthesis of research, clinical observation, neuroanatomical modeling, and EEG-informed practice. It is intended to spark curiosity, encourage collaboration, and offer insightful starting points for those seeking to improve patient care through precision neuromodulation.
That said, these protocols and targeting strategies should be used only by trained professionals and always adapted to individual cases. We encourage responsible interpretation, continued education, and ethical application of all techniques discussed. American Brain Stimulation Clinic is not responsible for how this information is used outside our practice.
Thank you for exploring this work with us. Whether you’re a clinician, researcher, technician, or student, we believe the path forward is one of shared learning, open dialogue, and compassionate care guided by science.