Real-time fMRI neurofeedback to down-regulate superior temporal gyrus activity in patients with schizophrenia and auditory hallucinations: a proof-of-concept study

Brain Structural and Functional Neuroimaging Features are Associated With Improved Auditory Hallucinations in Patients With Schizophrenia After Real-Time fMRI Neurofeedback

Auditory hallucinations (AHs) are debilitating and often treatment-resistant symptoms of schizophrenia (SZ). Real-time functional magnetic resonance imaging (fMRI) neurofeedback (NFB) is emerging as a flexible brain circuit-based tool for targeting AH via self-modulation of brain activity. A better understanding of what baseline characteristics predict NFB success will enhance its clinical utility. Previous work suggests that AH symptomology implicates measures across multiple modalities, including T1 structural MRI (sMRI), diffusion-weighted MRI (dMRI), and resting-state fMRI (rsfMRI). Specifically, AH severity and treatment response are associated with thinner superior temporal gyrus (STG), thinner dorsolateral prefrontal cortex (DLPFC), reduced white matter integrity in tracts connecting brain regions implicated in SZ symptomatology, increased within-default mode network (DMN) connectivity, and reduced DMN-DLPFC anticorrelation. In this study, we tested the individual and combined contributions of multimodal brain features for the prediction of AH change after NFB in adults (N = 25, 36.1 ± 10.0 years, 24% females) with SZ spectrum disorders (SZ or schizoaffective disorder) and frequent medication-resistant AH. Participants underwent a baseline MRI scan (including sMRI, dMRI, and rsfMRI) and were randomly assigned to receive NFB from their STG (n = 12, real condition) or NFB from their motor cortex (MC) (n = 13, sham condition). NFB success was operationalized as the improvement in AH severity after NFB. We found that higher baseline AH severity, greater STG thickness, decreased dorsal cingulum integrity, increased within-DMN resting-state functional connectivity, and increased DMN-DLPFC anticorrelation were each individually correlated with reduction in AH severity. However, in a combined regression model, DMN-DLPFC connectivity emerged as the only independent variable that explained the unique variance in AH change. These results suggest that a specific rsfMRI measure, namely DMN-DLPFC connectivity, may be a promising predictor of NFB success in reducing AH and support the precision medicine approach. Trial Registration: ClinicalTrials.gov identifier: NCT03504579.

Integrating Virtual Reality, Neurofeedback, and Cognitive Behavioral Therapy for Auditory Verbal Hallucinations (Hybrid): Protocol of a Pilot, Unblinded, Single-Arm Interventional Study

BACKGROUND

Current treatments for schizophrenia and other psychotic disorders have limited efficacy, with high rates of nonresponse to "gold standard" treatments. New approaches are therefore urgently required.

OBJECTIVE

The aims of this pilot study are to investigate the feasibility, acceptability, safety, and usability of Hybrid treatment (primary aim); and to explore Hybrid's treatment efficacy and engagement of treatment targets (secondary aim). The primary aim will be assessed via face-to-face user experience surveys on a (self-assessed) 5-point Likert scale (and qualitative open-ended questions) examining: (1) acceptability, (2) helpfulness, (3) engagement, and (4) perceived safety. We will also examine consent and completion rates, and the number of sessions attended. Our threshold for moving on to efficacy trials will be at least 70% of our participants to rate 3 and above (which corresponds to agree or strongly agree) that the intervention package was acceptable, feasible, and safe. The secondary aims will be assessed by observing whether individuals achieve self-directed modulation of high-β neurophysiological activity (neural target) and progression upwards through the VR-based exposure hierarchy (psychological target), and by assessing symptom change scores. This study developed a new treatment approach for auditory verbal hallucinations, a major symptom of psychotic disorders, that integrates advances in psychological therapy (cognitive behavioral therapy for psychosis), technology (virtual reality, VR), and neuroscience (electroencephalography-based neurofeedback).

METHODS

Hybrid takes a "symptom capture" approach using individually tailored VR-based exposure exercises. Participants (N=10) will receive the intervention package weekly over 12 face-to-face sessions. Here, participants will be progressively exposed to symptom triggers and develop methods of downregulating neural activity associated with these symptoms (neurofeedback component) while concurrently receiving clinician-delivered cognitive behavioral therapy for psychosis.

RESULTS

As of February 2025, Hybrid has commenced (unblinded) recruitment activities from Orygen clinical services in Northwestern Melbourne, Australia. A total of 75 individuals have been approached and 64 individuals have been prescreened (41 individuals were deemed eligible, 15 individuals were ineligible, and 8 individuals declined or did not respond to contact attempts) and 5 individuals have been included in the study. Of the 5 individuals who have commenced the Hybrid treatment, 4 are actively engaged in the program and 1 individual has withdrawn. We expect recruitment to conclude in July 2025 and for the results to be published in 2026.

CONCLUSIONS

The Hybrid study is piloting a novel approach that has the potential to address the shortcomings of current treatments for psychotic symptoms. If there is favorable evidence for the acceptability, feasibility, safety and usability of Hybrid, the study team will move on to efficacy trials.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12624000357550; https://tinyurl.com/24ey8hpy.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/63405.

Polygenic Risk, Psychopathology, and Personalized Functional Brain Network Topography in Adolescence

Importance

Functional brain networks are associated with both behavior and genetic factors. To uncover biological mechanisms of psychopathology, it is critical to define how the spatial organization of these networks relates to genetic risk during development.

Objective

To determine the relationships among transdiagnostic polygenic risk scores (PRSs), personalized functional brain networks (PFNs), and overall psychopathology (p-factor) during early adolescence.

Design

The Adolescent Brain Cognitive Development (ABCD) Study ⍰ is an ongoing longitudinal cohort study of 21 collection sites across the United States. Here, we conduct a cross-sectional analysis of ABCD baseline data, collected 2017-2018.

Setting

The ABCD Study ® is a multi-site community-based study.

Participants

The sample is largely recruited through school systems. Exclusion criteria included severe sensory, intellectual, medical, or neurological issues that interfere with protocol and scanner contraindications. Split-half subsets were used for cross-validation, matched on age, ethnicity, family structure, handedness, parental education, site, sex, and anesthesia exposure.

Exposures

Polygenic risk scores of transdiagnostic genetic factors F1 (PRS-F1) and F2 (PRS-F2) derived from adults in Psychiatric Genomic Consortium and UK Biobanks datasets. PRS-F1 indexes liability for common psychiatric symptoms and disorders related to mood disturbance; PRS-F2 indexes liability for rarer forms of mental illness characterized by mania and psychosis.

Main Outcomes and Measures

(1) P-factor derived from bifactor models of youth- and parent-reported mental health assessments. (2) Person-specific functional brain network topography derived from functional magnetic resonance imaging (fMRI) scans.

Results

Total participants included 11,873 youths ages 9-10 years old; 5,678 (47.8%) were female, and the mean (SD) age was 9.92 (0.62) years. PFN topography was found to be heritable ( N =7,459, 57.1% of vertices h 2 p FDR <0.05, mean h 2 =0.35). PRS-F1 was associated with p-factor ( N =5,815, r =0.12, 95% CI [0.09-0.15], p<0.001). Interindividual differences in functional network topography were associated with p-factor ( N =7,459, mean r =0.12), PRS-F1 ( N =3,982, mean r =0.05), and PRS-F2 ( N =3,982, mean r =0.08). Cortical maps of p-factor and PRS-F1 regression coefficients were highly correlated ( r =0.7, p =0.003).

Conclusions and Relevance

Polygenic risk for transdiagnostic adulthood psychopathology is associated with both p-factor and heritable PFN topography during early adolescence. These results advance our understanding of the developmental drivers of psychopathology.

Key Points

Question: What are the relationships among transdiagnostic polygenic risk scores (PRSs), personalized functional brain networks (PFNs), and overall psychopathology (p-factor) during early adolescence?Findings: In this cross-sectional analysis of the Adolescent Brain Cognitive Development (ABCD) Study ⍰ ( N =11,873, ages 9-10), we found that a PRS of common mood-related psychopathology in adulthood (PRS-F1) was associated with p-factor during early adolescence. Interindividual differences in p-factor, PRS-F1, and PRS-F2 (capturing more severe psychotic disorders in adulthood) were all robustly associated with PFN topography. Meaning: Polygenic risk for transdiagnostic adulthood psychopathology is associated with both p-factor and PFN topography during early adolescence.

Brain Markers of Resilience to Psychosis in High-Risk Individuals: A Systematic Review and Label-Based Meta-Analysis of Multimodal MRI Studies

Background/Objectives: Most individuals who have a familial or clinical risk of developing psychosis remain free from psychopathology. Identifying neural markers of resilience in these at-risk individuals may help clarify underlying mechanisms and yield novel targets for early intervention. However, in contrast to studies on risk biomarkers, studies on neural markers of resilience to psychosis are scarce. The current study aimed to identify potential brain markers of resilience to psychosis. Methods: A systematic review of the literature yielded a total of 43 MRI studies that reported resilience-associated brain changes in individuals with an elevated risk for psychosis. Label-based meta-analysis was used to synthesize findings across MRI modalities. Results: Resilience-associated brain changes were significantly overreported in the default mode and language network, and among highly connected and central brain regions. Conclusions: These findings suggest that the DMN and language-associated areas and central brain hubs may be hotspots for resilience-associated brain changes. These neural systems are thus of key interest as targets of inquiry and, possibly, intervention in at-risk populations.

Real-time fMRI neurofeedback modulates auditory cortex activity and connectivity in schizophrenia patients with auditory hallucinations: A controlled study

Background and Hypothesis

We have reported previously a reduction in superior temporal gyrus (STG) activation and in auditory verbal hallucinations (AHs) after real-time fMRI neurofeedback (NFB) in schizophrenia patients with AHs.

Study Design

With this randomized, participant-blinded, sham-controlled trial, we expanded our previous results. Specifically, we examined neurofeedback effects from the STG, an area associated with auditory hallucinations. The effects were compared to Sham-NFB from the motor cortex, a region unrelated to hallucinations. Twenty-three adults with schizophrenia or schizoaffective disorder and frequent medication-resistant hallucinations performed mindfulness meditation to ignore pre-recorded stranger's voices while receiving neurofeedback either from the STG (n=10, Real-NFB) or motor cortex (n=13 Sham-NFB). Individuals randomized to Sham-NFB received Real-NFB in a subsequent visit, providing a within-subject 'Real-after-Sham-NFB' comparison.

Study Results

Both groups showed reduced AHs after NFB, with no group differences. Compared to the Sham-NFB group, the Real-NFB group showed more reduced activation in secondary auditory cortex (AC) and more reduced connectivity between AC and cognitive control regions including dorsolateral prefrontal cortex (DLPFC) and anterior cingulate. The connectivity reduction was also observed in the Real-after-Sham-NFB condition. Secondary AC-DLPFC connectivity reduction correlated with hallucination reduction in the Real-NFB group. Replicating prior results, both groups showed reduced primary auditory cortex activation, suggesting mindfulness meditation may regulate bottom-up processes involved in hallucinations.

Conclusions

Our findings emphasize delivering NFB from brain regions involved in medication-resistant AHs. They provide insights into auditory cortex and cognitive control network interactions, highlighting complex processing dynamics and top-down modulation of sensory information.

From lab to life: challenges and perspectives of fNIRS for haemodynamic-based neurofeedback in real-world environments

Neurofeedback allows individuals to monitor and self-regulate their brain activity, potentially improving human brain function. Beyond the traditional electrophysiological approach using primarily electroencephalography, brain haemodynamics measured with functional magnetic resonance imaging (fMRI) and more recently, functional near-infrared spectroscopy (fNIRS) have been used (haemodynamic-based neurofeedback), particularly to improve the spatial specificity of neurofeedback. Over recent years, especially fNIRS has attracted great attention because it offers several advantages over fMRI such as increased user accessibility, cost-effectiveness and mobility-the latter being the most distinct feature of fNIRS. The next logical step would be to transfer haemodynamic-based neurofeedback protocols that have already been proven and validated by fMRI to mobile fNIRS. However, this undertaking is not always easy, especially since fNIRS novices may miss important fNIRS-specific methodological challenges. This review is aimed at researchers from different fields who seek to exploit the unique capabilities of fNIRS for neurofeedback. It carefully addresses fNIRS-specific challenges and offers suggestions for possible solutions. If the challenges raised are addressed and further developed, fNIRS could emerge as a useful neurofeedback technique with its own unique application potential-the targeted training of brain activity in real-world environments, thereby significantly expanding the scope and scalability of haemodynamic-based neurofeedback applications.This article is part of the theme issue 'Neurofeedback: new territories and neurocognitive mechanisms of endogenous neuromodulation'.

Online self-evaluation of fMRI-based neurofeedback performance

This study explores the subjective evaluation of supplementary motor area (SMA) regulation performance in a real-time functional magnetic resonance imaging neurofeedback (fMRI-NF) task. In fMRI-NF, people learn how to self-regulate their brain activity by performing mental actions to achieve a certain target level (TL) of blood-oxygen-level-dependent (BOLD) activation. Here, we studied two types of self-evaluation: performance predictions and perceived confidence in the prediction judgement. Participants completed three sessions of SMA regulation in a 7 T fMRI scanner, performing a mental drawing task. During each trial, they modulated their imagery strategy to achieve one of two different levels of SMA activation and reported a performance prediction and their confidence in the prediction before receiving delayed BOLD-activation feedback. Results show that participants' performance predictions improved with learning throughout the three sessions, and that these improvements were not driven exclusively by their knowledge of previous performance. Confidence reports on the other hand showed no change throughout training and did not correlate with better and worse predictions. In addition to shedding light on mechanisms of internal self-evaluation during neurofeedback training, these results also point to a dissociation between predictions of performance and confidence reports in the presence of feedback. This article is part of the theme issue 'Neurofeedback: new territories and neurocognitive mechanisms of endogenous neuromodulation'.

Training individuals with schizophrenia to gain volitional control of the theory of mind network with real-time fMRI: A pilot study

Individuals diagnosed with schizophrenia spectrum disorders (SSDs) often demonstrate alterations in the Theory of Mind Network (ToM-N). Here, in this proof-of-concept, single-arm pilot study, we investigate whether participants with an SSD (N = 7) were able to learn to volitionally control regions of the ToM-N (dorso/middle/ventromedial prefrontal cortex [D/M/VMPFC], left temporoparietal junction [LTPJ], precuneus [PC], right superior temporal sulcus [RSTS], and right temporoparietal junction [RTPJ]) using real-time fMRI neurofeedback (rtfMRI-NF). Region-of-interest analyses demonstrate that after neurofeedback training, participants were able to gain volitional control in the following ToM-N brain regions during the transfer task, where no active feedback was given: right temporoparietal junction, precuneus, and dorso/ventromedial prefrontal cortex (neurofeedback effect Fs > 6.17, ps < .05). These findings suggest that trained volitional control over the ToM-N is tentatively feasible with rtfMRI neurofeedback in SSD, although findings need to be replicated with more robust designs that include a control group and larger samples.

Bridging the gap: Prenatal nutrition, myelination, and schizophrenia etiopathogenesis

Schizophrenia (SZ) is a complex mental illness characterized by disturbances in thinking, emotionality, and behavior, significantly impacting the quality of life for individuals affected and those around them. The etiology of SZ involves intricate interactions between genetic and environmental factors, although the precise mechanisms remain incompletely understood. Genetic predisposition, neurotransmitter dysregulation (particularly involving dopamine and serotonin), and structural brain abnormalities, including impaired prefrontal cortex function, have been implicated in SZ development. However, increasing evidence reveals the role of environmental factors, such as nutrition, during critical periods like pregnancy and lactation. Epidemiological studies suggest that early malnutrition significantly increases the risk of SZ symptoms manifesting in late adolescence, a crucial period coinciding with peak myelination and brain maturation. Prenatal undernutrition may disrupt myelin formation, rendering individuals more susceptible to SZ pathology. This review explores the potential relationship between prenatal undernutrition, myelin alterations, and susceptibility to SZ. By delineating the etiopathogenesis, examining genetic and environmental factors associated with SZ, and reviewing the relationship between SZ and myelination disorders, alongside the impact of malnutrition on myelination, we aim to examine how malnutrition might be linked to SZ by altering myelination processes, which contribute to increasing the understanding of SZ etiology and help identify targets for intervention and management.

Real-time fMRI neurofeedback modulates induced hallucinations and underlying brain mechanisms

Hallucinations can occur in the healthy population, are clinically relevant and frequent symptoms in many neuropsychiatric conditions, and have been shown to mark disease progression in patients with neurodegenerative disorders where antipsychotic treatment remains challenging. Here, we combine MR-robotics capable of inducing a clinically-relevant hallucination, with real-time fMRI neurofeedback (fMRI-NF) to train healthy individuals to up-regulate a fronto-parietal brain network associated with the robotically-induced hallucination. Over three days, participants learned to modulate occurrences of and transition probabilities to this network, leading to heightened sensitivity to induced hallucinations after training. Moreover, participants who became sensitive and succeeded in fMRI-NF training, showed sustained and specific neural changes after training, characterized by increased hallucination network occurrences during induction and decreased hallucination network occurrences during a matched control condition. These data demonstrate that fMRI-NF modulates specific hallucination network dynamics and highlights the potential of fMRI-NF as a novel antipsychotic treatment in neurodegenerative disorders and schizophrenia.

Cognitive effects of brief and intensive neurofeedback treatment in schizophrenia: a single center pilot study

Background

Schizophrenia is characterized by significant cognitive impairments and affects up to 98% of patients. Neurofeedback (NF) offers a means to modulate neural network function through cognitive processes such as learning and memorization, with documented structural changes in the brain, most notably an increase in grey matter volume in targeted regions.

Methods

The present 2-week, open-label, preliminary study aims to evaluate the efficacy on cognition of an adjunctive short and intensive (8 daily sessions lasting 30 minutes) alpha/theta NF training in a sample of subjects affected by schizophrenia on stabilized treatment with atypical antipsychotic drugs. The efficacy was measured at baseline and at the end of the study by the Brief Neuropsychological Examination 2 (ENB 2), the Mini Mental State Examination (MMSE), and the Stroop color-word interference test; the clinical symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS).

Results

A final sample of nine patients completed the study. Regarding the cognitive performance, at the final assessment (week 2), the NF treatment significantly improved the performance in the "Story Recall Immediate" (p = 0.024), "Story Recall Delayed" (p = 0.007), "Interference Memory 30 s" (p = 0.024), "Clock Test" (p = 0.014) sub-tests, and the ENB2 Total Score (p = 0.007). Concerning the clinical symptoms, no significant changes were observed in the PANSS subscales and the PANSS Total score.

Conclusions

NF could represent an adjunctive treatment strategy in the therapeutic toolbox for schizophrenia cognitive symptoms.

Targeting the superior temporal gyrus with real-time fMRI neurofeedback: A pilot study of the indirect effects on self-referential processes in schizophrenia

BACKGROUND

Individuals with schizophrenia (SZ) and auditory hallucinations (AHs) display a distorted sense of self and self-other boundaries. Alterations of activity in midline cortical structures such as the prefrontal cortex (mPFC) and anterior cingulate cortex (ACC) during self-reference as well as in the superior temporal gyrus (STG) have been proposed as neuromarkers of SZ and AHs.

METHODS

In this randomized, participant-blinded, sham-controlled trial, 22 adults (18 males) with SZ spectrum disorders (SZ or schizoaffective disorder) and frequent medication-resistant AHs received one session of real-time fMRI neurofeedback (NFB) either from the STG (n = 11; experimental group) or motor cortex (n = 11; control group). During NFB, participants were instructed to upregulate their STG activity by attending to pre-recorded sentences spoken in their own voice and downregulate it by ignoring unfamiliar voices. Before and after NFB, participants completed a self-reference task where they evaluated if trait adjectives referred to themselves (self condition), Abraham Lincoln (other condition), or whether adjectives had a positive valence (semantic condition). FMRI activation analyses of self-reference task data tested between-group changes after NFB (self>semantic, post>pre-NFB, experimental>control). Analyses were pre-masked within a self-reference network.

RESULTS

Activation analyses revealed significantly (p < 0.001) greater activation increase in the experimental, compared to the control group, after NFB within anterior regions of the self-reference network (mPFC, ACC, superior frontal cortex).

CONCLUSIONS

STG-NFB was associated with activity increase in the mPFC, ACC, and superior frontal cortex during self-reference. Modulating the STG is associated with activation changes in other, not-directly targeted, regions subserving higher-level cognitive processes associated with self-referential processes and AHs psychopathology in SZ.

CLINICALTRIALS

GOV: Rt-fMRI Neurofeedback and AH in Schizophrenia; https://clinicaltrials.gov/study/NCT03504579.

The hidden link: Investigating functional connectivity of rarely explored sub-regions of thalamus and superior temporal gyrus in Schizophrenia

Functional magnetic resonance imaging (fMRI) stands as a pivotal tool in advancing our comprehension of Schizophrenia, offering insights into functional segregations and integrations. Previous investigations employing either task-based or resting-state fMRI primarily focused on large main regions of interest (ROI), revealing the thalamus and superior temporal gyrus (STG) as prominently affected areas. Recent studies, however, unveiled the cytoarchitectural intricacies within these regions, prompting a more nuanced exploration. In this study, resting-state fMRI was conducted on 72 schizophrenic patients and 74 healthy controls to discern whether distinct thalamic nuclei and STG sub-regions exhibit varied functional integrational connectivity to main networks and to identify the most affected sub-regions in Schizophrenia. Employing seed-based analysis, six sub-ROIs - four in the thalamus and two in the STG - were selected. Our findings unveiled heightened positive functional connectivity in Schizophrenic patients, particularly toward the anterior STG (aSTG) and posterior STG (pSTG). Notably, positive connectivity emerged between the medial division of mediodorsal thalamic nuclei (MDm) and the visual network, while increased functional connectivity linked the ventral lateral nucleus of the thalamus with aSTG. This accentuated functional connectivity potentially influences these sub-regions, contributing to dysfunctions and manifesting symptoms such as language and learning difficulties alongside hallucinations. This study underscores the importance of delineating sub-regional dynamics to enhance our understanding of the nuanced neural alterations in Schizophrenia, paving the way for more targeted interventions and therapeutic approaches.

fMRI-based neurofeedback strategies and the way forward to treating phasic psychiatric symptoms

Auditory verbal hallucinations (AVH) are the perfect illustration of phasic symptoms in psychiatric disorders. For some patients and in some situations, AVH cannot be relieved by standard therapeutic approaches. More advanced treatments are needed, among which neurofeedback, and more specifically fMRI-based neurofeedback, has been considered. This paper discusses the different possibilities to approach neurofeedback in the specific context of phasic symptoms, by highlighting the strengths and weaknesses of the available neurofeedback options. It concludes with the added value of the recently introduced information-based neurofeedback. Although requiring an online fMRI signal classifier, which can be quite complex to implement, this neurofeedback strategy opens a door toward an alternative treatment option for complex phasic symptomatology.

Multiple genes encoding mitochondrial ribosomes are downregulated in brain and blood samples of individuals with schizophrenia

OBJECTIVES

Schizophrenia is a chronic, debilitating mental disorder whose pathophysiology is complex and not fully understood. Numerous studies suggest mitochondrial dysfunction may contribute to the development of schizophrenia. While mitochondrial ribosomes (mitoribosomes) are essential for proper mitochondrial functioning, their gene expression levels have not been studied yet in schizophrenia.

METHODS

We performed a systematic meta-analysis of the expression of 81 mitoribosomes subunits encoding genes, integrating ten brain samples datasets of patients with schizophrenia compared to healthy controls (overall 422 samples, 211 schizophrenia, and 211 controls). We also performed a meta-analysis of their expression in blood, integrating two blood sample datasets (overall 90 samples, 53 schizophrenia, and 37 controls).

RESULTS

Multiple mitoribosomes subunits were significantly downregulated in brain samples (18 genes) and in blood samples (11 genes) of individuals with schizophrenia, where two showed significant downregulation in both brain and blood, MRPL4 and MRPS7.

CONCLUSIONS

Our results support the accumulating evidence of impaired mitochondrial activity in schizophrenia. While further research is needed to validate mitoribosomes' role as biomarkers, this direction has the potential to promote patients' stratification and personalised treatment for schizophrenia.

Altered Functional Connectivity Strength in Distinct Brain Networks of Children With Early-Onset Schizophrenia

BACKGROUND

Schizophrenia is regarded as a brain network or connectome disorder that is associated with neurodevelopment. Children with early-onset schizophrenia (EOS) provide an opportunity to evaluate the neuropathology of schizophrenia at a very early stage without potential confounding factors. But dysfunction in brain networks of schizophrenia is inconsistent.

PURPOSE

To identify abnormal functional connectivity (FC) in EOS patients and relationships with clinical symptoms, we aimed to reveal neuroimaging phenotypes of EOS.

STUDY TYPE

Prospective, cross-sectional.

POPULATION

Twenty-six female/22 male patients (age:14.3 ± 3.45 years) with first-episode EOS, 27 female/22 male age- and gender-matched healthy controls (HC) (age:14.1 ± 4.32).

FIELD STRENGTH/SEQUENCE

3-T, resting-state (rs) gradient-echo echo-planar imaging and three-dimensional magnetization-prepared rapid gradient-echo imaging.

ASSESSMENT

Intelligence quotient (IQ) was measured by the Wechsler Intelligence Scale-Fourth edition for Children (WISC-IV). The clinical symptoms were evaluated by the Positive and Negative Syndrome Scale (PANSS). FC strength (FCS) from rs functional MRI (rsfMRI) was used to investigate functional integrity of global brain regions. In addition, associations between regionally altered FCS and clinical symptoms in EOS patients were examined.

STATISTICAL TESTS

Two-sample t-test controlling for sample size, diagnostic method, brain volume algorithm, and age of the subjects, Bonferroni correction, Pearson's correlation analysis. A P-value <0.05 with a minimum cluster size of 50 voxels was considered statistically significant.

RESULTS

Compared with HC, EOS patients had significantly lower total IQ scores (IQ:91.5 ± 16.1), increased FCS in the bilateral precuneus, left dorsolateral prefrontal cortex, left thalamus, and left parahippocampus (paraHIP), and decreased FCS in the right cerebellum posterior lobe and right superior temporal gyrus. The PANSS total score of EOS patients (PANSS total score:74.30 ± 7.23) was found to be positively correlated to FCS in the left paraHIP (r = 0.45).

DATA CONCLUSION

Our study revealed that disrupted FC of brain hubs illustrate multiple abnormalities in brain networks in EOS patients.

EVIDENCE LEVEL

1 TECHNICAL EFFICACY STAGE: 2.

Effects of polygenic risk of schizophrenia on interhemispheric callosal white matter integrity and frontotemporal functional connectivity in first-episode schizophrenia

BACKGROUND

Schizophrenia is a severely debilitating psychiatric disorder with high heritability and polygenic architecture. A higher polygenic risk score for schizophrenia (SzPRS) has been associated with smaller gray matter volume, lower activation, and decreased functional connectivity (FC). However, the effect of polygenic inheritance on the brain white matter microstructure has only been sparsely reported.

METHODS

Eighty-four patients with first-episode schizophrenia (FES) patients and ninety-three healthy controls (HC) with genetics, diffusion tensor imaging (DTI), and resting-state functional magnetic resonance imaging (rs-fMRI) data were included in our study. We investigated impaired white matter integrity as measured by fractional anisotropy (FA) in the FES group, further examined the effect of SzPRS on white matter FA and FC in the regions connected by SzPRS-related white matter tracts.

RESULTS

Decreased FA was observed in FES in many commonly identified regions. Among these regions, we observed that in the FES group, but not the HC group, SzPRS was negatively associated with the mean FA in the genu and body of corpus callosum, right anterior corona radiata, and right superior corona radiata. Higher SzPRS was also associated with lower FCs between the left inferior frontal gyrus (IFG)-left inferior temporal gyrus (ITG), right IFG-left ITG, right IFG-left middle frontal gyrus (MFG), and right IFG-right MFG in the FES group.

CONCLUSION

Higher polygenic risks are linked with disrupted white matter integrity and FC in patients with schizophrenia. These correlations are strongly driven by the interhemispheric callosal fibers and the connections between frontotemporal regions.

Impact of low-frequency repetitive transcranial magnetic stimulation on functional network connectivity in schizophrenia patients with auditory verbal hallucinations

Auditory verbal hallucinations (AVH) are a key symptom of schizophrenia. Low-frequency repetitive transcranial magnetic stimulation (rTMS) has shown potential in the treatment of AVH. However, the underlying neural mechanismof rTMS in the treatment of AVH remains largely unknown. In this study, we used a static and dynamic functional network connectivity approach to investigate the connectivity changes among the brain functional networks in schizophrenia patients with AVH receiving 1 Hz rTMS treatment. The static functional network connectivity (sFNC) analysis revealed that patients at baseline had significantly decreased connectivity between the default mode network (DMN) and language network (LAN), and within the executive control network (ECN) as well as within the auditory network (AUD) compared to controls. However, the abnormal network connectivity patterns were normalized or restored after rTMS treatment in patients, instead of increased connectivity between the ECN and LAN, as well as within the AUD. Moreover, the dynamic functional network connectivity (dFNC) analysis showed that the patients at baseline spent more time in this state that was characterized by strongly negative connectivity between the ENC and AUD, as well as within the AUD relative to controls. While after rTMS treatment, the patients showed a higher occurrence rate in this state that was characterized by strongly positive connectivity among the LAN, DMN, and ENC, as well as within the ECN. In addition, the altered static and dynamic connectivity properties were associated with reduced severity of clinical symptoms. Both sFNC and dFNC analyses provided complementary information and suggested that low-frequency rTMS treatment could induce intrinsic functional network alternations and contribute to improvements in clinical symptoms in patients with AVH.

Real-time fMRI neurofeedback as a new treatment for psychiatric disorders: A meta-analysis

Neurofeedback using real-time functional MRI (RT-fMRI-NF) is an innovative technique that allows to voluntarily modulate a targeted brain response and its associated behavior. Despite promising results in the current literature, its effectiveness on symptoms management in psychiatric disorders is not yet clearly demonstrated. Here, we provide 1) a state-of-art qualitative review of RT-fMRI-NF studies aiming at alleviating clinical symptoms in a psychiatric population; 2) a quantitative evaluation (meta-analysis) of RT-fMRI-NF effectiveness on various psychiatric disorders and 3) methodological suggestions for future studies. Thirty-one clinical trials focusing on psychiatric disorders were included and categorized according to standard diagnostic categories. Among the 31 identified studies, 22 consisted of controlled trials, of which only eight showed significant clinical improvement in the experimental vs. control group after the training. Nine studies found an effect at follow-up on ADHD symptoms, emotion dysregulation, facial emotion processing, depressive symptoms, hallucinations, psychotic symptoms, and specific phobia. Within-group meta-analysis revealed large effects of the NF training on depressive symptoms right after the training (g = 0.81, p < 0.01) and at follow-up (g = 1.19, p < 0.01), as well as medium effects on anxiety (g = 0.44, p = 0.01) and emotion regulation (g = 0.48, p < 0.01). Between-group meta-analysis showed a medium effect on depressive symptoms (g = 0.49, p < 0.01) and a large effect on anxiety (g = 0.77, p = 0.01). However, the between-studies heterogeneity is very high. The use of RT-fMRI-NF as a treatment for psychiatric symptoms is promising, however, further double-blind, multicentric, randomized-controlled trials are warranted.

Correlations Between the DMN and the Smoking Cessation Outcome of a Real-Time fMRI Neurofeedback Supported Exploratory Therapy Approach: Descriptive Statistics on Tobacco-Dependent Patients

The aim of this study was to explore the potential of default mode network (DMN) functional connectivity for predicting the success of smoking cessation in patients with tobacco dependence in the context of a real-time function al MRI (RT-fMRI) neurofeedback (NF) supported therapy.Fifty-four tobacco-dependent patients underwent three RT-fMRI-NF sessions including resting-state functional connectivity (RSFC) runs over a period of 4 weeks during professionally assisted smoking cessation. Patients were randomized into two groups that performed either active NF of an addiction-related brain region or sham NF. After preprocessing, the RSFC baseline data were statistically evaluated using seed-based ROI (SBA) approaches taking into account the smoking status of patients after 3 months (abstinence/relapse).The results of the real study group showed a widespread functional connectivity in the relapse subgroup (n = 10) exceeding the DMN template and mainly low correlations and anticorrelations in the within-seed analysis. In contrast, the connectivity pattern of the abstinence subgroup (n = 8) primarily contained the core DMN in the seed-to-whole-brain analysis and a left lateralized correlation pattern in the within-seed analysis. Calculated Multi-Subject Dictionary Learning (MSDL) matrices showed anticorrelations between DMN regions and salience regions in the abstinence group. Concerning the sham group, results of the relapse subgroup (n = 4) and the abstinence subgroup (n = 6) showed similar trends only in the within-seed analysis.In the setting of a RT-fMRI-NF-assisted therapy, a widespread intrinsic DMN connectivity and a low negative coupling between the DMN and the salience network (SN) in patients with tobacco dependency during early withdrawal may be useful as an early indicator of later therapy nonresponse.

Can neurofeedback provide evidence of direct brain-behavior causality?

Neurofeedback is a procedure that measures brain activity in real-time and presents it as feedback to an individual, thus allowing them to self-regulate brain activity with effects on cognitive processes inferred from behavior. One common argument is that neurofeedback studies can reveal how the measured brain activity causes a particular cognitive process. The causal claim is often made regarding the measured brain activity being manipulated as an independent variable, similar to brain stimulation studies. However, this causal inference is vulnerable to the argument that other upstream brain activities change concurrently and cause changes in the brain activity from which feedback is derived. In this paper, we outline the inference that neurofeedback may causally affect cognition by indirect means. We further argue that researchers should remain open to the idea that the trained brain activity could be part of a "causal network" that collectively affects cognition rather than being necessarily causally primary. This particular inference may provide a better translation of evidence from neurofeedback studies to the rest of neuroscience. We argue that the recent advent of multivariate pattern analysis, when combined with implicit neurofeedback, currently comprises the strongest case for causality. Our perspective is that although the burden of inferring direct causality is difficult, it may be triangulated using a collection of various methods in neuroscience. Finally, we argue that the neurofeedback methodology provides unique advantages compared to other methods for revealing changes in the brain and cognitive processes but that researchers should remain mindful of indirect causal effects.

Measuring Voluntary Control Over Hallucinations: The Yale Control Over Perceptual Experiences (COPE) Scales

Auditory verbal hallucinations (AVH) frequently cause significant distress and dysfunction, and may be unresponsive to conventional treatments. Some voice-hearers report an ability to fully control the onset and offset of their AVH, making them significantly less disruptive. Measuring and understanding these abilities may lead to novel interventions to enhance control over AVH. Fifty-two voice-hearers participated in the pilot study. 318 participants with frequent AVH participated in the validation study. A pool of 59 items was developed by a diverse team including voice-hearers and clinicians. After the pilot study, 35 items were retained. Factorial structure was assessed with exploratory (EFA, n = 148) and confirmatory (CFA, n = 170) factor analyses. Reliability and convergent validity were assessed using a comprehensive battery of validated phenomenological and clinical scales. CFA on the final 18 items supported two factors for a Methods of Control Scale (5 items each, average ω = .87), and one factor for a Degree of Control Scale (8 items, average ω = .95). Correlation with clinical measures supported convergent validity. Degree of control was associated with positive clinical outcomes in voice-hearers both with and without a psychosis-spectrum diagnosis. Degree of control also varied with quality of life independently of symptom severity and AVH content. The Yale control over perceptual experiences (COPE) Scales robustly measure voice-hearers' control over AVH and exhibit sound psychometric properties. Results demonstrate that the capacity to voluntarily control AVH is independently associated with positive clinical outcomes. Reliable measurement of control over AVH will enable future development of interventions meant to bolster that control.

Real-Time Functional MRI in the Treatment of Mental Health Disorders

Multiple mental disorders have been associated with dysregulation of precise brain processes. However, few therapeutic approaches can correct such specific patterns of brain activity. Since the late 1960s and early 1970s, many researchers have hoped that this feat could be achieved by closed-loop brain imaging approaches, such as neurofeedback, that aim to modulate brain activity directly. However, neurofeedback never gained mainstream acceptance in mental health, in part due to methodological considerations. In this review, we argue that, when contemporary methodological guidelines are followed, neurofeedback is one of the few intervention methods in psychology that can be assessed in double-blind placebo-controlled trials. Furthermore, using new advances in machine learning and statistics, it is now possible to target very precise patterns of brain activity for therapeutic purposes. We review the recent literature in functional magnetic resonance imaging neurofeedback and discuss current and future applications to mental health.

Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Decoding Activity in Broca's Area Predicts the Occurrence of Auditory Hallucinations Across Subjects

BACKGROUND

Functional magnetic resonance imaging (fMRI) capture aims at detecting auditory-verbal hallucinations (AVHs) from continuously recorded brain activity. Establishing efficient capture methods with low computational cost that easily generalize between patients remains a key objective in precision psychiatry. To address this issue, we developed a novel automatized fMRI-capture procedure for AVHs in patients with schizophrenia (SCZ).

METHODS

We used a previously validated but labor-intensive personalized fMRI-capture method to train a linear classifier using machine learning techniques. We benchmarked the performances of this classifier on 2320 AVH periods versus resting-state periods obtained from SCZ patients with frequent symptoms (n = 23). We characterized patterns of blood oxygen level-dependent activity that were predictive of AVH both within and between subjects. Generalizability was assessed with a second independent sample gathering 2000 AVH labels (n = 34 patients with SCZ), while specificity was tested with a nonclinical control sample performing an auditory imagery task (840 labels, n = 20).

RESULTS

Our between-subject classifier achieved high decoding accuracy (area under the curve = 0.85) and discriminated AVH from rest and verbal imagery. Optimizing the parameters on the first schizophrenia dataset and testing its performance on the second dataset led to an out-of-sample area under the curve of 0.85 (0.88 for the converse test). We showed that AVH detection critically depends on local blood oxygen level-dependent activity patterns within Broca's area.

CONCLUSIONS

Our results demonstrate that it is possible to reliably detect AVH states from fMRI blood oxygen level-dependent signals in patients with SCZ using a multivariate decoder without performing complex preprocessing steps. These findings constitute a crucial step toward brain-based treatments for severe drug-resistant hallucinations.

Dynamic Functional Connectivity Alterations and Their Associated Gene Expression Pattern in Autism Spectrum Disorders

Autism spectrum disorders (ASDs) are a group of heterogeneous neurodevelopmental disorders that are highly heritable and are associated with impaired dynamic functional connectivity (DFC). However, the molecular mechanisms behind DFC alterations remain largely unknown. Eighty-eight patients with ASDs and 87 demographically matched typical controls (TCs) from the Autism Brain Imaging Data Exchange II database were included in this study. A seed-based sliding window approach was then performed to investigate the DFC changes in each of the 29 seeds in 10 classic resting-state functional networks and the whole brain. Subsequently, the relationships between DFC alterations in patients with ASDs and their symptom severity were assessed. Finally, transcription-neuroimaging association analyses were conducted to explore the molecular mechanisms of DFC disruptions in patients with ASDs. Compared with TCs, patients with ASDs showed significantly increased DFC between the right dorsolateral prefrontal cortex (DLPFC) and left fusiform/lingual gyrus, between the DLPFC and the superior temporal gyrus, between the right frontal eye field (FEF) and left middle frontal gyrus, between the FEF and the right angular gyrus, and between the left intraparietal sulcus and the right middle temporal gyrus. Moreover, significant relationships between DFC alterations and symptom severity were observed. Furthermore, the genes associated with DFC changes in ASDs were identified by performing gene-wise across-sample spatial correlation analysis between gene expression extracted from six donors’ brain of the Allen Human Brain Atlas and case-control DFC difference. In enrichment analysis, these genes were enriched for processes associated with synaptic signaling and voltage-gated ion channels and calcium pathways; also, these genes were highly expressed in autistic disorder, chronic alcoholic intoxication and several disorders related to depression. These results not only demonstrated higher DFC in patients with ASDs but also provided novel insight into the molecular mechanisms underlying these alterations.

Voice Hearing in Borderline Personality Disorder Across Perceptual, Subjective, and Neural Dimensions

BACKGROUND

Auditory verbal hallucinations (AVH) commonly occur in the context of borderline personality disorder (BPD) yet remain poorly understood. AVH are often perceived by patients with BPD as originating from inside the head and hence viewed clinically as "pseudohallucinations," but they nevertheless have a detrimental impact on well-being.

METHODS

The current study characterized perceptual, subjective, and neural expressions of AVH by using an auditory detection task, experience sampling and questionnaires, and functional neuroimaging, respectively.

RESULTS

Perceptually, reported AVH correlated with a bias for reporting the presence of a voice in white noise. Subjectively, questionnaire measures indicated that AVH were significantly distressing and persecutory. In addition, AVH intensity, but not perceived origin (i.e., inside vs outside the head), was associated with greater concurrent anxiety. Neurally, fMRI of BPD participants demonstrated that, relative to imagining or listening to voices, periods of reported AVH induced greater blood oxygenation level-dependent activity in anterior cingulate and bilateral temporal cortices (regional substrates for language processing). AVH symptom severity was associated with weaker functional connectivity between anterior cingulate and bilateral insular cortices.

CONCLUSION

In summary, our results indicate that AVH in participants with BPD are (1) underpinned by aberrant perceptual-cognitive mechanisms for signal detection, (2) experienced subjectively as persecutory and distressing, and (3) associated with distinct patterns of neural activity that inform proximal mechanistic understanding. Our findings are like analogous observations in patients with schizophrenia and validate the clinical significance of the AVH experience in BPD, often dismissed as "pseudohallucinations." These highlight a need to reconsider this experience as a treatment priority.

Cerebellar involvement in hallucinations may transcend clinical conditions and perceptual modalities

Our recent neuroimaging study identified structural differences in cerebellar subfields linked to cortical attentional networks in patients with eye disease or Parkinson's disease who experience visual hallucinations and a commentary on the study by Zorzi et al. provided additional evidence of functional cerebellar changes in Dementia with Lewy bodies. Here, we review evidence for cerebellar involvement in hallucinations across multiple clinical conditions and sensory modalities as well as examine its wider clinical and mechanistic implications. The combined structural and functional evidence is consistent with two models of cerebellar contribution to hallucination which differ in their implied direction of cause, effect and temporal sequence. Additionally, we contend that the relatively neuroanatomically localised nature of the cerebellum makes it particularly suited to identifying changes affecting distributed cortical networks using imaging techniques. As such, cerebellar subfield differences may offer value as candidate prognostic and predictive biomarkers as well as targets for neuromodulatory treatment across a range of clinical conditions.

A proof-of-concept sub-study exploring feasibility and preliminary evidence for the role of physical activity on neural activity during executive functioning tasks among young adults after cancer treatment

Background

Executive functioning (EF) deficits are troubling for adolescents and young adults (AYAs) after cancer treatment. Physical activity (PA) may enhance neural activity underlying EF among older adults affected by cancer. Establishing whether PA enhances neural activity among AYAs is warranted. As part of a two-arm, mixed-methods pilot randomized controlled trial (RCT), this proof-of-concept sub-study sought to answer the following questions: (1) is it feasible to use neuroimaging with EF tasks to assess neural activity changes following a 12-week PA intervention? And (2) is there preliminary evidence that a 12-week PA intervention enhances neural activity among AYAs after cancer treatment?

Methods

AYAs in the pilot RCT were approached for enrollment into this sub-study. Those who were eligible and enrolled, completed functional magnetic resonance imaging (fMRI) with EF tasks (letter n-back, Go/No Go) pre- and post-PA intervention. Sub-study enrollment, adherence to scheduled fMRI scans, outliers, missing data, and EF task performance data were collected. Data were analyzed with descriptive statistics, blood oxygen level dependent (BOLD) analyses, and paired sample t-tests.

Results

Nine eligible participants enrolled into this sub-study; six attended scheduled fMRI scans. One outlier was identified and was subsequently removed from the analytical sample. Participants showed no differences in EF task performance from pre- to post-PA intervention. Increases in neural activity in brain regions responsible for motor control, information encoding and processing, and decision-making were observed post-PA intervention (p < 0.05; n = 5).

Conclusions

Findings  show that fMRI scans during EF tasks detected neural activity changes (as assessed by the BOLD signal) from pre- to post-PA intervention. Results thus suggest future trials confirming that PA enhances neural activity underlying EF are needed, though feasibility issues require careful consideration to ensure trial success.

Trial registration

clinicaltrials.gov, NCT03016728. Registered January 11, 2017, clinicaltrials.gov/ct2/show/NCT03016728.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02280-y.

Recent findings on neurofeedback training for auditory hallucinations in schizophrenia

PURPOSE OF REVIEW

To provide recent evidence on real-time neurofeedback (NFB) training for auditory verbal hallucinations (AVH) in schizophrenia patients.

RECENT FINDINGS

NFB is a promising technique that allows patients to gain control over their AVH by modulating their own speech-related/language-related networks including superior temporal gyrus (STG) and anterior cingulate cortex (ACC) using fMRI, fNIRS and EEG/MEG. A recent limited number of studies showed that while an EEG-based NFB study failed to regulate auditory-evoked potentials and reduce AVH, downregulation of STG hyperactivity and upregulation of ACC activity with fMRI-based NFB appear to alleviate treatment-resistant AVH in schizophrenia patients. A deeper understanding of AVH and development of more effective methodologies are still needed.

SUMMARY

Despite recent innovations in antipsychotics, many schizophrenia patients continue to suffer from treatment-resistant AVH and social dysfunctions. Recent studies suggested that real-time NFB shows promise in enabling patients to gain control over AVH by regulating their own speech-related/language-related networks. Although fMRI-NFB is suitable for regulating localized activity, EEG/MEG-NFB are ideal for regulating the ever-changing AVH. Although there are still many challenges including logistic complexity and burden on patients, we hope that such innovative real-time NFB trainings will help patients to alleviate severe symptoms and improve social functioning.

Lesions causing hallucinations localize to one common brain network

The brain regions responsible for hallucinations remain unclear. We studied 89 brain lesions causing hallucinations using a recently validated technique termed lesion network mapping. We found that hallucinations occurred following lesions to a variety of different brain regions, but these lesion locations fell within a single functionally connected brain network. This network was defined by connectivity to the cerebellar vermis, inferior cerebellum (bilateral lobule X), and the right superior temporal sulcus. Within this single hallucination network, additional connections with the lesion location dictated the sensory modality of the hallucination: lesions causing visual hallucinations were connected to the lateral geniculate nucleus in the thalamus while lesions causing auditory hallucinations were connected to the dentate nucleus in the cerebellum. Our results suggest that lesions causing hallucinations localize to a single common brain network, but additional connections within this network dictate the sensory modality, lending insight into the causal neuroanatomical substrate of hallucinations.

Towards semantic fMRI neurofeedback: navigating among mental states using real-time representational similarity analysis

Objective. Real-time functional magnetic resonance imaging neurofeedback (rt-fMRI-NF) is a non-invasive MRI procedure allowing examined participants to learn to self-regulate brain activity by performing mental tasks. A novel two-step rt-fMRI-NF procedure is proposed whereby the feedback display is updated in real-time based on high-level representations of experimental stimuli (e.g. objects to imagine) via real-time representational similarity analysis of multi-voxel patterns of brain activity.Approach. In a localizer session, the stimuli become associated with anchored points on a two-dimensional representational space where distances approximate between-pattern (dis)similarities. In the NF session, participants modulate their brain response, displayed as a movable point, to engage in a specific neural representation. The developed method pipeline is verified in a proof-of-concept rt-fMRI-NF study at 7 T involving a single healthy participant imagining concrete objects. Based on this data and artificial data sets with similar (simulated) spatio-temporal structure and variable (injected) signal and noise, the dependence on noise is systematically assessed.Main results. The participant in the proof-of-concept study exhibited robust activation patterns in the localizer session and managed to control the neural representation of a stimulus towards the selected target in the NF session. The offline analyses validated the rt-fMRI-NF results, showing that the rapid convergence to the target representation is noise-dependent.Significance. Our proof-of-concept study introduces a new NF method allowing the participant to navigate among different mental states. Compared to traditional NF designs (e.g. using a thermometer display to set the level of the neural signal), the proposed approach provides content-specific feedback to the participant and extra degrees of freedom to the experimenter enabling real-time control of the neural activity towards a target brain state without suggesting a specific mental strategy to the subject.

The efficacy of real-time functional magnetic resonance imaging neurofeedback for psychiatric illness: A meta-analysis of brain and behavioral outcomes

Real-time functional magnetic resonance imaging neurofeedback (rtfMRI-NF) has gained popularity as an experimental treatment for a variety of psychiatric illnesses. However, there has yet to be a quantitative review regarding its efficacy. Here, we present the first meta-analysis of rtfMRI-NF for psychiatric disorders, evaluating its impact on brain and behavioral outcomes. Our literature review identified 17 studies and 105 effect sizes across brain and behavioral outcomes. We find that rtfMRI-NF produces a medium-sized effect on neural activity during training (g = .59, 95 % CI [.44, .75], p < .0001), a large-sized effect after training when no neurofeedback is provided (g = .84, 95 % CI [.37, 1.31], p = .005), and small-sized effects for behavioral outcomes (symptoms g = .37, 95 % CI [.16, .58], p = .002; cognition g = .23, 95 % CI [-.33, .78], p = .288). Mixed-effects analyses revealed few moderators. Together, these data suggest a positive impact of rtfMRI-NF on brain and behavioral outcomes, although more research is needed to determine how rtfMRI-NF works, for whom, and under what circumstances.

N-methyl-D-aspartate Receptor Antibody and White Matter Deficits in Schizophrenia Treatment-Resistance

Insufficient or lack of response to antipsychotic medications in some patients with schizophrenia is a major challenge in psychiatry, but the underlying mechanisms remain unclear. Two seemingly unrelated observations, cerebral white matter and N-methyl-D-aspartate receptor (NMDAR) hypofunction, have been linked to treatment-resistant schizophrenia (TRS). As NMDARs are critical to axonal myelination and signal transduction, we hypothesized that NMDAR antibody (Ab), when present in schizophrenia, may impair NMDAR functions and white matter microstructures, contributing to TRS. In this study, 50 patients with TRS, 45 patients with nontreatment-resistant schizophrenia (NTRS), 53 patients with schizophrenia at treatment initiation schizophrenia (TIS), and 90 healthy controls were enrolled. Serum NMDAR Ab levels and white matter diffusion tensor imaging fractional anisotropy (FA) were assessed. The white matter specificity effects by NMDAR Ab were assessed by comparing with effects on cortical and subcortical gray matter. Serum NMDAR Ab levels of the TRS were significantly higher than those of the NTRS (P = .035). In patients with TRS, higher NMDAR Ab levels were significantly associated with reduced whole-brain average FA (r = -.37; P = .026), with the strongest effect at the genu of corpus callosum (r = -.50; P = .0021, significant after correction for multiple comparisons). Conversely, there was no significant correlation between whole-brain or regional cortical thickness or any subcortical gray matter structural volume and NMDAR Ab levels in TRS. Our finding highlights a potential NMDAR mechanism on white matter microstructure impairment in schizophrenia that may contribute to their treatment resistance to antipsychotic medications.

A Novel Brain-Computer Interface Virtual Environment for Neurofeedback During Functional MRI

Virtual environments (VEs), in the recent years, have become more prevalent in neuroscience. These VEs can offer great flexibility, replicability, and control over the presented stimuli in an immersive setting. With recent developments, it has become feasible to achieve higher-quality visuals and VEs at a reasonable investment. Our aim in this project was to develop and implement a novel real-time functional magnetic resonance imaging (rt-fMRI)-based neurofeedback (NF) training paradigm, taking into account new technological advances that allow us to integrate complex stimuli into a visually updated and engaging VE. We built upon and developed a first-person shooter in which the dynamic change of the VE was the feedback variable in the brain-computer interface (BCI). We designed a study to assess the feasibility of the BCI in creating an immersive VE for NF training. In a randomized single-blinded fMRI-based NF-training session, 24 participants were randomly allocated into one of two groups: active and reduced contingency NF. All participants completed three runs of the shooter-game VE lasting 10 min each. Brain activity in a supplementary motor area region of interest regulated the possible movement speed of the player's avatar and thus increased the reward probability. The gaming performance revealed that the participants were able to actively engage in game tasks and improve across sessions. All 24 participants reported being able to successfully employ NF strategies during the training while performing in-game tasks with significantly higher perceived NF control ratings in the NF group. Spectral analysis showed significant differential effects on brain activity between the groups. Connectivity analysis revealed significant differences, showing a lowered connectivity in the NF group compared to the reduced contingency-NF group. The self-assessment manikin ratings showed an increase in arousal in both groups but failed significance. Arousal has been linked to presence, or feelings of immersion, supporting the VE's objective. Long paradigms, such as NF in MRI settings, can lead to mental fatigue; therefore, VEs can help overcome such limitations. The rewarding achievements from gaming targets can lead to implicit learning of self-regulation and may broaden the scope of NF applications.

Putamen volume predicts real-time fMRI neurofeedback learning success across paradigms and neurofeedback target regions

Real-time fMRI guided neurofeedback training has gained increasing interest as a noninvasive brain regulation technique with the potential to modulate functional brain alterations in therapeutic contexts. Individual variations in learning success and treatment response have been observed, yet the neural substrates underlying the learning of self-regulation remain unclear. Against this background, we explored potential brain structural predictors for learning success with pooled data from three real-time fMRI data sets. Our analysis revealed that gray matter volume of the right putamen could predict neurofeedback learning success across the three data sets (n = 66 in total). Importantly, the original studies employed different neurofeedback paradigms during which different brain regions were trained pointing to a general association with learning success independent of specific aspects of the experimental design. Given the role of the putamen in associative learning this finding may reflect an important role of instrumental learning processes and brain structural variations in associated brain regions for successful acquisition of fMRI neurofeedback-guided self-regulation.

A systematic review of fMRI neurofeedback reporting and effects in clinical populations

Real-time fMRI-based neurofeedback is a relatively young field with a potential to impact the currently available treatments of various disorders. In order to evaluate the evidence of clinical benefits and investigate how consistently studies report their methods and results, an exhaustive search of fMRI neurofeedback studies in clinical populations was performed. Reporting was evaluated using a limited number of Consensus on the reporting and experimental design of clinical and cognitive-behavioral neurofeedback studies (CRED-NF checklist) items, which was, together with a statistical power and sensitivity calculation, used to also evaluate the existing evidence of the neurofeedback benefits on clinical measures. The 62 found studies investigated regulation abilities and/or clinical benefits in a wide range of disorders, but with small sample sizes and were therefore unable to detect small effects. Most points from the CRED-NF checklist were adequately reported by the majority of the studies, but some improvements are suggested for the reporting of group comparisons and relations between regulation success and clinical benefits. To establish fMRI neurofeedback as a clinical tool, more emphasis should be placed in the future on using larger sample sizes determined through a priori power calculations and standardization of procedures and reporting.

Gray Matter Alterations in Parkinson's Disease With Rapid Eye Movement Sleep Behavior Disorder: A Meta-Analysis of Voxel-Based Morphometry Studies

Background: Gray matter (GM) alterations in Parkinson's disease (PD) patients with rapid eye movement sleep behavior disorder (RBD) have been demonstrated in many neuroimaging studies using voxel-based morphometry (VBM). However, the inconsistent findings between studies cannot be applied to clinical practice as a neuroimaging biomarker. We performed a meta-analysis of VBM studies at a whole-brain level to investigate GM differences between PD patients with and without RBD. Methods: A systematic search was conducted in PubMed, Embase, and Web of Science from inception to November 2019 to identify eligible VBM studies. We adopted the latest Seed-based d Mapping with Permutation of Subject Images technique to quantitatively estimate the difference of regional GM volume between PD patients with and without RBD. Results: We included five studies comprising 105 PD patients with RBD and 140 PD patients without RBD. The pooled meta-analysis revealed that PD patients with RBD showed a significant reduction of GM volume in the right superior temporal gyrus (STG) compared with those without RBD. This result was confirmed to be robust by the jackknife sensitivity analysis. Conclusion: Our finding shows significantly and robustly reduced GM volume in the right STG in PD patients with RBD, preliminarily suggesting the association of GM atrophy in this brain region with the occurrence of RBD in PD patients.

Voluntary control of auditory hallucinations: phenomenology to therapeutic implications

Auditory verbal hallucinations (AVH) have traditionally been thought to be outside the influence of conscious control. However, recent work with voice hearers makes clear that both treatment-seeking and non-treatment-seeking voice hearers may exert varying degrees of control over their voices. Evidence suggests that this ability may be a key factor in determining health status, but little systematic examination of control in AVH has been carried out. This review provides an overview of the research examining control over AVH in both treatment-seeking and non-treatment-seeking populations. We first examine the relationship between control over AVH and health status as well as the psychosocial factors that may influence control and functioning. We then link control to various cognitive constructs that appear to be important for voice hearing. Finally, we reconcile the possibility of control with the field’s current understanding of the proposed cognitive, computational, and neural underpinnings of hallucinations and perception more broadly. Established relationships between control, health status, and functioning suggest that the development of control over AVH could increase functioning and reduce distress. A more detailed understanding of the discrete types of control, their development, and their neural underpinnings is essential for translating this knowledge into new therapeutic approaches.

Real-Time Functional Magnetic Resonance Imaging Neurofeedback for the Relief of Distressing Auditory-Verbal Hallucinations: Methodological and Empirical Advances

Auditory-verbal hallucinations (AVH) are often associated with high levels of distress and disability in individuals with schizophrenia-spectrum disorders. In around 30% of individuals with distressing AVH and diagnosed with schizophrenia, traditional antipsychotic drugs have little or no effect. Thus, it is important to develop mechanistic models of AVH to inform new treatments. Recently a small number of studies have begun to explore the use of real-time functional magnetic resonance imaging neurofeedback (rtfMRI-NF) for the treatment of AVH in individuals with schizophrenia. rtfMRI-NF protocols have been developed to provide feedback about brain activation in real time to enable participants to progressively achieve voluntary control over their brain activity. We offer a conceptual review of the background and general features of neurofeedback procedures before summarizing and evaluating existing mechanistic models of AVH to identify feasible neural targets for the application of rtfMRI-NF as a potential treatment. We consider methodological issues, including the choice of localizers and practicalities in logistics when setting up neurofeedback procedures in a clinical setting. We discuss clinical considerations relating to the use of rtfMRI-NF for AVH in individuals distressed by their experiences and put forward a number of questions and recommendations about best practice. Lastly, we conclude by offering suggestions for new avenues for neurofeedback methodology and mechanistic targets in relation to the research and treatment of AVH.

On the phenomenology of auditory verbal hallucinations in affective and non-affective psychosis

Phenomenological comparisons of auditory verbal hallucinations (AVHs) in affective versus non-affective psychosis have not been adequately documented. The current study aimed to: a) comprehensively describe AVH phenomenology by diagnosis and mood state, b) investigate significant predictors of voice-related distress and functional impairment, and c) conduct qualitative thematic analysis of participants' experiences. Participants were diagnosed with: a) bipolar disorder (n = 31), b) major depressive disorder (n = 34), c) schizophrenia (n = 50), or d) schizoaffective disorder (n = 26). Current voice-hearers were also subdivided into prevailing mood states: a) euthymic (n = 23), b) depressed (n = 51), or c) mania-mixed (n = 12). An in-depth, semi-structured interview was conducted, accompanied by mixed-methods analyses. Of the 34 AVH characteristics, significant group differences across diagnoses were identified only for frequency, number of voices, form of address, perceived location, level of conviction, beliefs regarding origin, and functional interference. Random forests modelling (RFM) showed experienced distress and functional interference were best predicted by discrete AVH variables. Qualitative thematic analysis revealed first-order themes: a) content, b) form, c) function, and d) non-voice. There were more similarities than differences in the phenomenology of AVHs across diagnoses, yet significant predictors of voice-related distress and functional impairment differed across affective and non-affective psychosis. This has important nosological and therapeutic applications.

Identification of a brain fingerprint for overweight and obesity

The brain plays a central role in the pathophysiology of overweight and obesity. Connectome-based Predictive Modeling (CPM) is a newly developed, data-driven approach that exploits whole-brain functional connectivity to predict a behavior or trait that varies across individuals. We used CPM to determine whether brain "fingerprints" evoked during milkshake consumption could be isolated for common measures of adiposity in 67 adults with overweight and obesity. We found that CPM captures more variance in waist circumference than either percent body fat or BMI, the most frequently used measures to assess brain correlates of obesity. In a post-hoc analysis, we were also able to derive a largely separable functional connectivity network predicting fasting blood insulin. These findings suggest that, in individuals with overweight and obesity, brain network patterns may be more tightly coupled to waist circumference than BMI or percent body fat and that adiposity and glucose tolerance are associated with distinct maps, pointing to dissociable central pathophysiological phenotypes for obesity and diabetes.

Improving treatments for psychotic disorders: beyond cognitive behaviour therapy for psychosis

More effective treatments for people with psychotic disorders are urgently required. Here, we make three suggestions for progress: 1. Targeting the disorders' core phenomenological features ('phenomenological phenotype'), 2. Addressing social disconnection, isolation and loneliness, and 3. Leveraging 'hot' cognitions and using symptom capture approaches that combine psychotherapy with advances in technology and neuroscience.

A Guide to Literature Informed Decisions in the Design of Real Time fMRI Neurofeedback Studies: A Systematic Review

Background: Although biofeedback using electrophysiology has been explored extensively, the approach of using neurofeedback corresponding to hemodynamic response is a relatively young field. Real time functional magnetic resonance imaging-based neurofeedback (rt-fMRI-NF) uses sensory feedback to operantly reinforce patterns of neural response. It can be used, for example, to alter visual perception, increase brain connectivity, and reduce depression symptoms. Within recent years, interest in rt-fMRI-NF in both research and clinical contexts has expanded considerably. As such, building a consensus regarding best practices is of great value. Objective: This systematic review is designed to describe and evaluate the variations in methodology used in previous rt-fMRI-NF studies to provide recommendations for rt-fMRI-NF study designs that are mostly likely to elicit reproducible and consistent effects of neurofeedback. Methods: We conducted a database search for fMRI neurofeedback papers published prior to September 26th, 2019. Of 558 studies identified, 146 met criteria for inclusion. The following information was collected from each study: sample size and type, task used, neurofeedback calculation, regulation procedure, feedback, whether feedback was explicitly related to changing brain activity, feedback timing, control group for active neurofeedback, how many runs and sessions of neurofeedback, if a follow-up was conducted, and the results of neurofeedback training. Results: rt-fMRI-NF is typically upregulation practice based on hemodynamic response from a specific region of the brain presented using a continually updating thermometer display. Most rt-fMRI-NF studies are conducted in healthy samples and half evaluate its effect on immediate changes in behavior or affect. The most popular control group method is to provide sham signal from another region; however, many studies do not compare use a comparison group. Conclusions: We make several suggestions for designs of future rt-fMRI-NF studies. Researchers should use feedback calculation methods that consider neural response across regions (i.e., SVM or connectivity), which should be conveyed as intermittent, auditory feedback. Participants should be given explicit instructions and should be assessed on individual differences. Future rt-fMRI-NF studies should use clinical samples; effectiveness of rt-fMRI-NF should be evaluated on clinical/behavioral outcomes at follow-up time points in comparison to both a sham and no feedback control group.

Real-time fMRI feedback impacts brain activation, results in auditory hallucinations reduction: Part 1: Superior temporal gyrus -Preliminary evidence

Auditory hallucinations (AH) are one of the core symptoms of schizophrenia (SZ) and constitute a significant source of suffering and disability. One third of SZ patients experience pharmacology-resistant AH, so an alternative/complementary treatment strategy is needed to alleviate this debilitating condition. In this study, real-time functional Magnetic Resonance Imaging neurofeedback (rt-fMRI NFB), a non-invasive technique, was used to teach 10 SZ patients with pharmacology-resistant AH to modulate their brain activity in the superior temporal gyrus (STG), a key area in the neurophysiology of AH. A functional task was designed in order to provide patients with a specific strategy to help them modify their brain activity in the desired direction. Specifically, they received neurofeedback from their own STG and were trained to upregulate it while listening to their own voice recording and downregulate it while ignoring a stranger's voice recording. This guided performance neurofeedback training resulted in a) a significant reduction in STG activation while ignoring a stranger's voice, and b) reductions in AH scores after the neurofeedback session. A single, 21-minute session of rt-fMRI NFB was enough to produce these effects, suggesting that this approach may be an efficient and clinically viable alternative for the treatment of pharmacology-resistant AH.

Real-time fMRI neurofeedback reduces auditory hallucinations and modulates resting state connectivity of involved brain regions: Part 2: Default mode network -preliminary evidence

Auditory hallucinations (AHs) are one of the most distressing symptoms of schizophrenia (SZ) and are often resistant to medication. Imaging studies of individuals with SZ show hyperactivation of the default mode network (DMN) and the superior temporal gyrus (STG). Studies in SZ show DMN hyperconnectivity and reduced anticorrelation between DMN and the central executive network (CEN). DMN hyperconnectivity has been associated with positive symptoms such as AHs while reduced DMN anticorrelations with cognitive impairment. Using real-time fMRI neurofeedback (rt-fMRI-NFB) we trained SZ patients to modulate DMN and CEN networks. Meditation is effective in reducing AHs in SZ and to modulate brain network integration and increase DMN anticorrelations. Consequently, patients were provided with meditation strategies to enhance their abilities to modulate DMN/CEN. Results show a reduction of DMN hyperconnectivity and increase in DMNCEN anticorrelation. Furthermore, the change in individual DMN connectivity significantly correlated with reductions in AHs. This is the first time that meditation enhanced through rt-fMRI-NFB is used to reduce AHs in SZ. Moreover, it provides the first empirical evidence for a direct causal relation between meditation enhanced rt-fMRI-NFB modulation of DMNCEN activity and post-intervention modulation of resting state networks ensuing in reductions in frequency and severity of AHs.

A Systematic Review of the Potential Use of Neurofeedback in Patients With Schizophrenia

Schizophrenia (SCZ) is a neurodevelopmental disorder characterized by positive symptoms (hallucinations and delusions), negative symptoms (anhedonia, social withdrawal) and marked cognitive deficits (memory, executive function, and attention). Current mainstays of treatment, including medications and psychotherapy, do not adequately address cognitive symptoms, which are essential for everyday functioning. However, recent advances in computational neurobiology have rekindled interest in neurofeedback (NF), a form of self-regulation or neuromodulation, in potentially alleviating cognitive symptoms in patients with SCZ. Therefore, we conducted a systematic review of the literature for NF studies in SCZ to identify lessons learned and to identify steps to move the field forward. Our findings reveal that NF studies to date consist mostly of case studies and small sample, single-group studies. Despite few randomized clinical trials, the results suggest that NF is feasible and that it leads to measurable changes in brain function. These findings indicate early proof-of-concept data that needs to be followed up by larger, randomized clinical trials, testing the efficacy of NF compared to well thought out placebos. We hope that such an undertaking by the field will lead to innovative solutions that address refractory symptoms and improve everyday functioning in patients with SCZ.

Altered Effective Connectivity in Schizophrenic Patients With Auditory Verbal Hallucinations: A Resting-State fMRI Study With Granger Causality Analysis

PURPOSE

Auditory verbal hallucinations (AVH) are among the most common and prominent symptoms of schizophrenia. Although abnormal functional connectivity associated with AVH has been reported in multiple regions, the changes in information flow remain unclear. In this study, we aimed to elucidate causal influences related to AVH in key regions of auditory, language, and memory networks, by using Granger causality analysis (GCA).

PATIENTS AND METHODS

Eighteen patients with schizophrenia with AVH and eighteen matched patients without AVH who received resting-state fMRI scans were enrolled in the study. The bilateral superior temporal gyrus (STG), Broca's area, Wernicke's area, putamen, and hippocampus were selected as regions of interest.

RESULTS

Granger causality (GC) increased from Broca's area to the left STG, and decreased from the right homolog of Wernicke's area to the right homolog of Broca's area, and from the right STG to the right hippocampus in the AVH group compared with the non-AVH group. Correlation analysis showed that the normalized GC ratios from the left STG to Broca's area, from the left STG to the right homolog of Broca's area, and from the right STG to the right homolog of Broca's area were negatively correlated with severity of AVH, and the normalized GC ratios from Broca's area to the left hippocampus and from Broca's area to the right STG were positively correlated with severity of AVH.

CONCLUSION

Our findings indicate a causal influence of pivotal regions involving the auditory, language, and memory networks in schizophrenia with AVH, which provide a deeper understanding of the neural mechanisms underlying AVH.

Association Between Connectivity of Hippocampal Sub-Regions and Auditory Verbal Hallucinations in Schizophrenia

Background: Hippocampal dysconnectivity has been detected in schizophrenia patients with auditory verbal hallucinations (AVHs). Neuroanatomical evidence has indicated distinct sub-regions in the hippocampus, but which sub-regions within the hippocampus may emerge dysfunction in the brain network, and the relationship between connection strength and the severity of this debilitating disorder have yet to be revealed. Masked independent component analysis (mICA), i.e., ICA restricted to a defined region of interest, can provide insight into observing local functional connectivity in a particular brain region. We aim to map out the sub-regions in the hippocampus with dysconnectivity linked to AVHs in schizophrenia.

Methods: In this functional magnetic resonance imaging study of schizophrenia patients with (n = 57) and without (n = 83) AVHs, and 71 healthy controls, we first examined hippocampal connectivity using mICA, and then the correlation between connection metric and clinical severity was generated.

Results: As compared with patients without AVHs, mICA showed a group of hyper-connections for the left middle part, as well as another group of hypo-connections for the bilateral antero-lateral and right antero-medial parts in patients with AVHs. Connectivity was linked to the clinical symptoms scores in the sample of patients with AVHs.

Conclusion: These findings demonstrate that the left middle part is more densely connected, but the bilateral antero-lateral and right antero-medial parts are more sparsely connected in schizophrenia patients with AVHs. The findings in the present study show proof of precious location in the hippocampus mediating the neural mechanism behind AVHs in schizophrenia.