Randomized Clinical Trial of Real-Time fMRI Amygdala Neurofeedback for Major Depressive Disorder: Effects on Symptoms and Autobiographical Memory Recall

Self-navigating the "Island of Reil": a systematic review of real-time fMRI neurofeedback training of insula activity

Real-time fMRI (rtfMRI) neurofeedback (NF) is a novel noninvasive technique that permits individuals to voluntarily control brain activity. The crucial role of the insula in emotional and salience processing makes it one of the most commonly targeted regions in previous rtfMRI studies. To provide an overview of progress in the field, the present review identified 25 rtfMRI insula studies and systematically reviewed key characteristics and findings in these studies. We found that rtfMRI-based NF training is efficient for modulating insula activity and its associated behavioral/symptom-related and neural changes. Furthermore, we also observed a maintenance effect of self-regulation ability and sustained symptom improvement, which is of importance for clinical application. However, training success of insula regulation was not consistently paralleled by behavioral/symptom-related changes, suggesting a need for optimizing the NF training protocol enabling more robust training effects. Principles including inclusion of a well-designed control group/condition, statistical analyses and reporting results following common criteria and a priori determination of sample and effect sizes as well as pre-registration are also highly recommended. In summary, we believe our review will inspire and inform both basic research and therapeutic translation of rtfMRI NF training as an intervention in mental disorders particularly those with insula dysfunction.

Attenuation processes in positive social emotion upregulation: Disentangling functional role of ventrolateral prefrontal cortex

Positive emotions determine individual well-being and sustainable social relationships. Here, we examined the neural processes mediating upregulation of positive social emotions using functional magnetic resonance imaging in healthy female volunteers. We identified brain regions engaged in upregulation of positive social emotions and applied a parametric empirical Bayes approach to isolate modulated network connectivity patterns and assess how these effects relate to individual measures of social perception. Our findings indicate that upregulation of positive social emotions shapes the functional interplay between affective valuation and cognitive control functions. We revealed a selective increase of bilateral posterior ventrolateral prefrontal cortex (vlPFC) activity and attenuation of activity in right anterior vlPFC under control influences from more superior prefrontal regions. We also found that individual perception of sociality modulates connectivity between affective and social networks. This study expands our understanding of neural circuits required to balance positive emotions in social situations and their rehabilitative potential.

Semantic fMRI neurofeedback of emotions: from basic principles to clinical applications

During fMRI neurofeedback participants learn to self-regulate activity in relevant brain areas and networks based on ongoing feedback extracted from measured responses in those regions. This closed-loop approach has been successfully applied to reduce symptoms in mood disorders such as depression by showing participants a thermometer-like display indicating the strength of activity in emotion-related brain areas. The hitherto employed conventional neurofeedback is, however, 'blind' with respect to emotional content, i.e. patients instructed to engage in a specific positive emotion could drive the neurofeedback signal by engaging in a different (positive or negative) emotion. In this future perspective, we present a new form of neurofeedback that displays semantic information of emotions to the participant. Semantic information is extracted online using real-time representational similarity analysis of emotion-specific activity patterns. The extracted semantic information can be provided to participants in a two-dimensional semantic map depicting the current mental state as a point reflecting its distance to pre-measured emotional mental states (e.g. 'happy', 'content', 'sad', 'angry'). This new approach provides transparent feedback during self-regulation training, and it has the potential to enable more specific training effects for future therapeutic applications such as clinical interventions in mood disorders.This article is part of the theme issue 'Neurofeedback: new territories and neurocognitive mechanisms of endogenous neuromodulation'.

Neurofeedback: potential for abuse and regulatory frameworks in the United States

Neurofeedback is a brain-training technique that continues to develop via ongoing innovations, and that has broadening potential impact. Once confined primarily to clinical and research settings, it is increasingly being used in the general population. Such development raises concerns about the current regulatory mechanisms and their adequacy in protecting patterns of economic and political decision-making from the novel technology. As studies have found neurofeedback to change subjects' preferences and mental associations covertly, there is a possibility it will be abused for political and commercial gains. Current regulatory practices (including disclaimer requirements, unfair and deceptive trade practice statutes and undue influence law) may be avenues from which to regulate neurofeedback influence. They are, however, limited. Regulating neurofeedback will face the line-drawing problem of determining when it induces an unacceptable level of influence. We suggest experiments that will clarify how the parameters of neurofeedback training affect its level of influence. In addition, we assert that the reactive nature of the traditional models of regulation will be inadequate against this and other rapidly transforming technologies. An integrated and proactive regulatory system designed for flexibility must be adopted to protect society in this era of modern technological advancement. This article is part of the theme issue 'Neurofeedback: new territories and neurocognitive mechanisms of endogenous neuromodulation'.

Inducing representational change in the hippocampus through real-time neurofeedback

When you perceive or remember something, other related things come to mind, affecting how these competing items are subsequently perceived and remembered. Such behavioural consequences are believed to result from changes in the overlap of neural representations of these items, especially in the hippocampus. According to multiple theories, hippocampal overlap should increase (integration) when there is high coactivation between cortical representations. However, prior studies used indirect proxies for coactivation by manipulating stimulus similarity or task demands. Here, we induce coactivation in visual cortex more directly using closed-loop neurofeedback from real-time functional magnetic resonance imaging (fMRI). While viewing one object, participants were rewarded for activating the representation of another object as strongly as possible. Across multiple real-time fMRI sessions, participants succeeded in using this neurofeedback to increase coactivation. Compared with a baseline of untrained objects, this protocol led to memory integration in behaviour and the brain: the trained objects became harder for participants to discriminate behaviourally in a categorical perception task and harder to discriminate neurally from patterns of fMRI activity in their hippocampus as a result of losing unique features. These findings demonstrate that neurofeedback can be used to alter and combine memories.This article is part of the theme issue 'Neurofeedback: new territories and neurocognitive mechanisms of endogenous neuromodulation'.

Regulation of craving for real-time fMRI neurofeedback based on individual classification

In previous real-time functional magnetic resonance imaging neurofeedback (rtfMRI-NF) studies on smoking craving, the focus has been on within-region activity or between-region connectivity, neglecting the potential predictive utility of broader network activity. Moreover, there is debate over the use and relative predictive power of individual-specific and group-level classifiers. This study aims to further advance rtfMRI-NF for substance use disorders by using whole-brain rtfMRI-NF to assess smoking craving-related brain patterns, evaluate the performance of group-level or individual-level classification (n = 31) and evaluate the performance of an optimized classifier across repeated NF runs. Using real-time individual-level classifiers derived from whole-brain support vector machines, we found that classification accuracy between crave and no-crave conditions and between repeated NF runs increased across repeated runs at both individual and group levels. In addition, individual-level accuracy was significantly greater than group-level accuracy, highlighting the potential increased utility of an individually trained whole-brain classifier for volitional control over brain patterns to regulate smoking craving. This study provides evidence supporting the feasibility of using whole-brain rtfMRI-NF to modulate smoking craving-related brain responses and the potential for learning individual strategies through optimization across repeated feedback runs. 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'.

fMRI neurofeedback for the modulation of the neural networks associated with depression

OBJECTIVES

Functional magnetic resonance imaging (fMRI) neurofeedback has emerged as a potential treatment modality for depression, but little is known about its mechanism of action. This study aims to investigate the efficacy of fMRI neurofeedback in modulating neural networks in depression.

METHODS

Following PRISMA guidelines, a systematic review was conducted focusing on fMRI neurofeedback interventions in depression. A comprehensive search across multiple databases yielded 16 eligible studies for review.

RESULTS

The review demonstrated that fMRI neurofeedback can modulate BOLD activity even in strategy-free protocols and within a single session, with a significant learning effect evident over sessions. Neurofeedback targeting specific regions led to changes in connectivity across broad neural networks, including the default-mode and executive control networks, with effects being region-specific. However, methodological diversity and the absence of standardized protocols in the reviewed studies highlighted the need for more uniform research approaches.

CONCLUSIONS

fMRI neurofeedback shows promise as a modulatory technique for depression, with the potential to induce significant changes in neural activity and connectivity of networks implicated in depression.

SIGNIFICANCE

The review underscores the necessity for standardized, reproducible neurofeedback protocols with control groups to enhance research comparability and generalizability.

A double-blind trial of decoded neurofeedback intervention for specific phobias

AIM

A new closed-loop functional magnetic resonance imaging method called multivoxel neuroreinforcement has the potential to alleviate the subjective aversiveness of exposure-based interventions by directly inducing phobic representations in the brain, outside of conscious awareness. The current study seeks to test this method as an intervention for specific phobia.

METHODS

In a randomized, double-blind, controlled single-university trial, individuals diagnosed with at least two (one target, one control) animal subtype-specific phobias were randomly assigned (1:1:1) to receive one, three, or five sessions of multivoxel neuroreinforcement in which they were rewarded for implicit activation of a target animal representation. Amygdala response to phobic stimuli was assessed by study staff blind to target and control animal assignments. Pretreatment to posttreatment differences were analyzed with a two-way repeated-measures anova.

RESULTS

A total of 23 participants (69.6% female) were randomized to receive one (n = 8), three (n = 7), or five (n = 7) sessions of multivoxel neuroreinforcement. Eighteen (n = 6 each group) participants were analyzed for our primary outcome. After neuroreinforcement, we observed an interaction indicating a significant decrease in amygdala response for the target phobia but not the control phobia. No adverse events or dropouts were reported as a result of the intervention.

CONCLUSION

Results suggest that multivoxel neuroreinforcement can specifically reduce threat signatures in specific phobia. Consequently, this intervention may complement conventional psychotherapy approaches with a nondistressing experience for patients seeking treatment. This trial sets the stage for a larger randomized clinical trial to replicate these results and examine the effects on real-life exposure.

CLINICAL TRIAL REGISTRATION

The now-closed trial was prospectively registered at ClinicalTrials.gov with ID NCT03655262.

Translation of monosynaptic circuits underlying amygdala fMRI neurofeedback training

fMRI neurofeedback using autobiographical memory recall to upregulate the amygdala is associated with resting-state functional connectivity (rsFC) changes between the amygdala and the salience and default mode networks (SN and DMN, respectively). We hypothesize the existence of anatomical circuits underlying these rsFC changes. Using a cross-species brain parcellation, we identified in non-human primates locations homologous to the regions of interest (ROIs) from studies showing pre-to-post-neurofeedback changes in rsFC with the left amygdala. We injected bidirectional tracers in the basolateral, lateral, and central amygdala nuclei of adult macaques and used bright- and dark-field microscopy to identify cells and axon terminals in each ROI (SN: anterior cingulate, ventrolateral, and insular cortices; DMN: temporal pole, middle frontal gyrus, angular gyrus, precuneus, posterior cingulate cortex, parahippocampal gyrus, hippocampus, and thalamus). We also performed additional injections in specific ROIs to validate the results following amygdala injections and delineate potential disynaptic pathways. Finally, we used high-resolution diffusion MRI data from four post-mortem macaque brains and one in vivo human brain to translate our findings to the neuroimaging domain. Different amygdala nuclei had significant monosynaptic connections with all the SN and DMN ipsilateral ROIs. Amygdala connections with the DMN contralateral ROIs are disynaptic through the hippocampus and parahippocampal gyrus. Diffusion MRI in both species benefitted from using the ground-truth tracer data to validate its findings, as we identified false-negative ipsilateral and false-positive contralateral connectivity results. This study provides the foundation for future causal investigations of amygdala neurofeedback modulation of the SN and DMN through these anatomic connections.

High-precision neurofeedback-guided meditation training optimises real-world self-guided meditation practice for well-being

Meditation can benefit well-being and mental health, but novices often struggle to effectively recognize and disengage from mental processes during meditation due to limited awareness, potentially diminishing meditation's benefits. We investigated whether personalised high-precision neurofeedback (NF) can improve disengagement from mental activity during meditation and enhance meditation's outcomes. In a single-blind, controlled, longitudinal paradigm, 40 novice meditators underwent two consecutive days of meditation training with intermittent visual feedback from either their own (N=20) or a matched participant's (N=20; control group) posterior cingulate cortex (PCC) activity measured using 7 Tesla functional magnetic resonance imaging. During training, the experimental group showed stronger functional decoupling of PCC from dorsolateral prefrontal cortex, indicating better control over disengagement from mental processes during meditation. This led to greater improvements in emotional well-being and mindful awareness of mental processes during a week of real-world self-guided meditation. We provide compelling evidence supporting the utility of high-precision NF-guided meditation training to optimise real-world meditation practice for well-being.

Neural signatures of emotional biases predict clinical outcomes in difficult-to-treat depression

Background

Neural predictors underlying variability in depression outcomes are poorly understood. Functional MRI measures of subgenual cortex connectivity, self-blaming and negative perceptual biases have shown prognostic potential in treatment-naïve, medication-free and fully remitting forms of major depressive disorder (MDD). However, their role in more chronic, difficult-to-treat forms of MDD is unknown.

Methods

Forty-five participants (n = 38 meeting minimum data quality thresholds) fulfilled criteria for difficult-to-treat MDD. Clinical outcome was determined by computing percentage change at follow-up from baseline (four months) on the self-reported Quick Inventory of Depressive Symptomatology (16-item). Baseline measures included self-blame-selective connectivity of the right superior anterior temporal lobe with an a priori Brodmann Area 25 region-of-interest, blood-oxygen-level-dependent a priori bilateral amygdala activation for subliminal sad vs happy faces, and resting-state connectivity of the subgenual cortex with an a priori defined ventrolateral prefrontal cortex/insula region-of-interest.

Findings

A linear regression model showed that baseline severity of depressive symptoms explained 3% of the variance in outcomes at follow-up (F[3,34] = .33, p = .81). In contrast, our three pre-registered neural measures combined, explained 32% of the variance in clinical outcomes (F[4,33] = 3.86, p = .01).

Conclusion

These findings corroborate the pathophysiological relevance of neural signatures of emotional biases and their potential as predictors of outcomes in difficult-to-treat depression.

Mu-Suppression Neurofeedback Training Targeting the Mirror Neuron System: A Pilot Study

Neurofeedback training (NFT) is a promising adjuvant intervention method. The desynchronization of mu rhythm (8-13 Hz) in the electroencephalogram (EEG) over centro-parietal areas is known as a valid indicator of mirror neuron system (MNS) activation, which has been associated with social skills. Still, the effect of neurofeedback training on the MNS requires to be well investigated. The present study examined the possible impact of NFT with a mu suppression training protocol encompassing 15 NFT sessions (45 min each) on 16 healthy neurotypical participants. In separate pre- and post-training sessions, 64-channel EEG was recorded while participants (1) observed videos with various types of movements (including complex goal-directed hand movements and social interaction scenes) and (2) performed the "Reading the Mind in the Eyes Test" (RMET). EEG source reconstruction analysis revealed statistically significant mu suppression during hand movement observation across MNS-attributed fronto-parietal areas after NFT. The frequency analysis showed no significant mu suppression after NFT, despite the fact that numerical mu suppression appeared to be visible in a majority of participants during goal-directed hand movement observation. At the behavioral level, RMET accuracy scores did not suggest an effect of NFT on the ability to interpret subtle emotional expressions, although RMET response times were reduced after NFT. In conclusion, the present study exhibited preliminary and partial evidence that mu suppression NFT can induce mu suppression in MNS-attributed areas. More powerful experimental designs and longer training may be necessary to induce substantial and consistent mu suppression, particularly while observing social scenarios.

Hooking the Self Onto the Past: How Positive Autobiographical Memory Retrieval Benefits People With Social Anxiety

Do people with social anxiety (SA) benefit from positive memory retrieval that heightens self-relevant meaning? In this preregistered study, an analog sample of 255 participants with self-reported clinically significant symptoms of SA were randomly assigned to retrieve and process a positive social-autobiographical memory by focusing on either its self-relevant meaning (deep processing) or its perceptual features (superficial processing). Participants were then socially excluded and instructed to reimagine their positive memory. Analyses revealed that participants assigned to the deep processing condition experienced significantly greater improvements than participants in the superficial processing condition in positive affect, social safeness, and positive beliefs about others during initial memory retrieval and in negative and positive beliefs about the self following memory reactivation during recovery from exclusion. These novel findings highlight the potential utility of memory-based interventions for SA that work by "hooking" self-meaning onto recollections of positive interpersonal experiences that elicit feelings of social acceptance.

Amygdala fMRI-A Critical Appraisal of the Extant Literature

Even before the advent of fMRI, the amygdala occupied a central space in the affective neurosciences. Yet this amygdala-centred view on emotion processing gained even wider acceptance after the inception of fMRI in the early 1990s, a landmark that triggered a goldrush of fMRI studies targeting the amygdala in vivo. Initially, this amygdala fMRI research was mostly confined to task-activation studies measuring the magnitude of the amygdala's response to emotional stimuli. Later, interest began to shift more towards the study of the amygdala's resting-state functional connectivity and task-based psychophysiological interactions. Later still, the test-retest reliability of amygdala fMRI came under closer scrutiny, while at the same time, amygdala-based real-time fMRI neurofeedback gained widespread popularity. Each of these major subdomains of amygdala fMRI research has left its marks on the field of affective neuroscience at large. The purpose of this review is to provide a critical assessment of this literature. By integrating the insights garnered by these research branches, we aim to answer the question: What part (if any) can amygdala fMRI still play within the current landscape of affective neuroscience? Our findings show that serious questions can be raised with regard to both the reliability and validity of amygdala fMRI. These conclusions force us to cast doubt on the continued viability of amygdala fMRI as a core pilar of the affective neurosciences.

Effects and neural mechanisms of different physical activity on major depressive disorder based on cerebral multimodality monitoring: a narrative review

Major depressive disorder (MDD) is currently the most common psychiatric disorder in the world. It characterized by a high incidence of disease with the symptoms like depressed mood, slowed thinking, and reduced cognitive function. Without timely intervention, there is a 20-30% risk of conversion to treatment-resistant depression (TRD) and a high burden for the patient, family and society. Numerous studies have shown that physical activity (PA) is a non-pharmacological treatment that can significantly improve the mental status of patients with MDD and has positive effects on cognitive function, sleep status, and brain plasticity. However, the physiological and psychological effects of different types of PA on individuals vary, and the dosage profile of PA in improving symptoms in patients with MDD has not been elucidated. In most current studies of MDD, PA can be categorized as continuous endurance training (ECT), explosive interval training (EIT), resistance strength training (RST), and mind-body training (MBT), and the effects on patients' depressive symptoms, cognitive function, and sleep varied. Therefore, the present study was based on a narrative review and included a large number of existing studies to investigate the characteristics and differences in the effects of different PA interventions on MDD. The study also investigated the characteristics and differences of different PA interventions in MDD, and explained the neural mechanisms through the results of multimodal brain function monitoring, including the intracranial environment and brain structure. It aims to provide exercise prescription and theoretical reference for future research in neuroscience and clinical intervention in MDD.

A double-blind trial of decoded neurofeedback intervention for specific phobias

Aim

A new closed-loop fMRI method called multi-voxel neuro-reinforcement has the potential to alleviate the subjective aversiveness of exposure-based interventions by directly inducing phobic representations in the brain, outside of conscious awareness. The current study seeks to test this method as an intervention for specific phobia.

Methods

In a randomized, double-blind, controlled single-university trial, individuals diagnosed with at least two (1 target, 1 control) animal subtype specific phobias were randomly assigned (1:1:1) to receive 1, 3, or 5 sessions of multi-voxel neuro-reinforcement in which they were rewarded for implicit activation of a target animal representation. Amygdala response to phobic stimuli was assessed by study staff blind to target and control animal assignments. Pre-treatment to post-treatment differences were analyzed with a 2-way repeated-measures ANOVA.

Results

A total of 23 participants (69.6% female) were randomized to receive 1 (n=8), 3 (n=7), or 5 (n=7) sessions of multi-voxel neuro-reinforcement. Eighteen (n=6 each group) participants were analyzed for our primary outcome. After neuro-reinforcement, we observed an interaction indicating a significant decrease in amygdala response for the target phobia but not the control phobia. No adverse events or dropouts were reported as a result of the intervention.

Conclusion

Results suggest multi-voxel neuro-reinforcement can specifically reduce threat signatures in specific phobia. Consequently, this intervention may complement conventional psychotherapy approaches with a non-distressing experience for patients seeking treatment. This trial sets the stage for a larger randomized clinical trial to replicate these results and examine the effects on real-life exposure.

Clinical Trial Registration

The now-closed trial was prospectively registered at ClinicalTrials.gov with ID NCT03655262.

Neural responses to facial emotions and subsequent clinical outcomes in difficult-to-treat depression

BACKGROUND

Amygdala and dorsal anterior cingulate cortex responses to facial emotions have shown promise in predicting treatment response in medication-free major depressive disorder (MDD). Here, we examined their role in the pathophysiology of clinical outcomes in more chronic, difficult-to-treat forms of MDD.

METHODS

Forty-five people with current MDD who had not responded to ⩾2 serotonergic antidepressants (n = 42, meeting pre-defined fMRI minimum quality thresholds) were enrolled and followed up over four months of standard primary care. Prior to medication review, subliminal facial emotion fMRI was used to extract blood-oxygen level-dependent effects for sad v. happy faces from two pre-registered a priori defined regions: bilateral amygdala and dorsal/pregenual anterior cingulate cortex. Clinical outcome was the percentage change on the self-reported Quick Inventory of Depressive Symptomatology (16-item).

RESULTS

We corroborated our pre-registered hypothesis (NCT04342299) that lower bilateral amygdala activation for sad v. happy faces predicted favorable clinical outcomes (rs[38] = 0.40, p = 0.01). In contrast, there was no effect for dorsal/pregenual anterior cingulate cortex activation (rs[38] = 0.18, p = 0.29), nor when using voxel-based whole-brain analyses (voxel-based Family-Wise Error-corrected p < 0.05). Predictive effects were mainly driven by the right amygdala whose response to happy faces was reduced in patients with higher anxiety levels.

CONCLUSIONS

We confirmed the prediction that a lower amygdala response to negative v. positive facial expressions might be an adaptive neural signature, which predicts subsequent symptom improvement also in difficult-to-treat MDD. Anxiety reduced adaptive amygdala responses.

Psychometric Properties of a Novel Affective Bias Task and Its Application in Clinical and Nonclinical Populations

To mitigate limitations of self-reported mood assessments, we introduce a novel affective bias task. The task quantifies instantaneous emotional state by leveraging the phenomenon of affective bias, in which people interpret external emotional stimuli in a manner consistent with their current emotional state. This study establishes task stability in measuring and tracking depressive symptoms in clinical and nonclinical populations. Initial assessment in a large nonclinical sample established normative ratings. Depressive symptoms were measured and compared with task performance in a nonclinical sample, as well as in a clinical cohort of individuals who were undergoing surgical evaluation for severe epilepsy. In both cohorts, a stronger negative affective bias was associated with a higher Beck Depression Inventory-II score. The affective bias task exhibited high stability and interrater reliability as well as construct validity in predicting depression levels in both cohorts, suggesting that the task is a reliable proxy for mood and a diagnostic tool for detecting depressive symptoms.

The Clinical Impact of Real-Time fMRI Neurofeedback on Emotion Regulation: A Systematic Review

Emotion dysregulation has long been considered a key symptom in multiple psychiatric disorders. Difficulties in emotion regulation have been associated with neural dysregulation in fronto-limbic circuits. Real-time fMRI-based neurofeedback (rt-fMRI-NFB) has become increasingly popular as a potential treatment for emotional dysregulation in psychiatric disorders, as it is able to directly target the impaired neural circuits. However, the clinical impact of these rt-fMRI-NFB protocols in psychiatric populations is still largely unknown. Here we provide a comprehensive overview of primary studies from 2010 to 2023 that used rt-fMRI-NFB to target emotion regulation. We assessed 41 out of 4001 original studies for methodological quality and risk of bias and synthesised concerning the frequency of significant rt-fMRI-NFB-related effects on the neural and behaviour level. Successful modulation of brain activity was reported in between 25 and 50 percent of study samples, while neural effects in clinical samples were more diverse than in healthy samples. Interestingly, the frequency of rt-fMRI-NFB-related behavioural improvement was over 75 percent in clinical samples, while healthy samples showed behavioural improvements between 0 and 25 percent. Concerning clinical subsamples, rt-fMRI-NFB-related behavioural improvement was observed in up to 100 percent of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) samples. Substance use samples showed behavioural benefits ranging between 50 and 75 percent. Neural effects appeared to be less frequent than behavioural improvements: most neural outcomes ranged between 25 and 50 percent for MDD and substance use and between 0 and 25 percent for PTSD. Using multiple individualised regions of interest (ROIs) for rt-fMRI-NFB training resulted in more frequent behavioural benefits than rt-fMRI-NFB solely based on the amygdala or the prefrontal cortex. While a significant improvement in behavioural outcomes was reported in most clinical studies, the study protocols were heterogeneous, which limits the current evaluation of rt-fMRI-NFB as a putative treatment for emotional dysregulation.

Uncovering the power of neurofeedback: a meta-analysis of its effectiveness in treating major depressive disorders

Neurofeedback, a non-invasive intervention, has been increasingly used as a potential treatment for major depressive disorders. However, the effectiveness of neurofeedback in alleviating depressive symptoms remains uncertain. To address this gap, we conducted a comprehensive meta-analysis to evaluate the efficacy of neurofeedback as a treatment for major depressive disorders. We conducted a comprehensive meta-analysis of 22 studies investigating the effects of neurofeedback interventions on depression symptoms, neurophysiological outcomes, and neuropsychological function. Our analysis included the calculation of Hedges' g effect sizes and explored various moderators like intervention settings, study designs, and demographics. Our findings revealed that neurofeedback intervention had a significant impact on depression symptoms (Hedges' g = -0.600) and neurophysiological outcomes (Hedges' g = -0.726). We also observed a moderate effect size for neurofeedback intervention on neuropsychological function (Hedges' g = -0.418). As expected, we observed that longer intervention length was associated with better outcomes for depressive symptoms (β = -4.36, P < 0.001) and neuropsychological function (β = -2.89, P = 0.003). Surprisingly, we found that shorter neurofeedback sessions were associated with improvements in neurophysiological outcomes (β = 3.34, P < 0.001). Our meta-analysis provides compelling evidence that neurofeedback holds promising potential as a non-pharmacological intervention option for effectively improving depressive symptoms, neurophysiological outcomes, and neuropsychological function in individuals with major depressive disorders.

Could neurofeedback improve therapist-patient communication? Considering the potential for neuroscience informed examinations of the psychotherapeutic relationship

Empathic communication between a patient and therapist is an essential component of psychotherapy. However, finding objective neural markers of the quality of the psychotherapeutic relationship have been elusive. Here we conceptualize how a neuroscience-informed approach involving real-time neurofeedback, facilitated via existing functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) technologies, could provide objective information for facilitating therapeutic rapport. We propose several neurofeedback-assisted psychotherapy (NF-AP) approaches that could be studied as a way to optimize the experience of the individual patient and therapist across the spectrum of psychotherapeutic treatment. Finally, we consider how the possible strengths of these approaches are balanced by their current limitations and discuss the future prospects of NF-AP.

Mapping the evolution of neurofeedback research: a bibliometric analysis of trends and future directions

Introduction

This study conducts a bibliometric analysis on neurofeedback research to assess its current state and potential future developments.

Methods

It examined 3,626 journal articles from the Web of Science (WoS) using co-citation and co-word methods.

Results

The co-citation analysis identified three major clusters: "Real-Time fMRI Neurofeedback and Self-Regulation of Brain Activity," "EEG Neurofeedback and Cognitive Performance Enhancement," and "Treatment of ADHD Using Neurofeedback." The co-word analysis highlighted four key clusters: "Neurofeedback in Mental Health Research," "Brain-Computer Interfaces for Stroke Rehabilitation," "Neurofeedback for ADHD in Youth," and "Neural Mechanisms of Emotion and Self-Regulation with Advanced Neuroimaging.

Discussion

This in-depth bibliometric study significantly enhances our understanding of the dynamic field of neurofeedback, indicating its potential in treating ADHD and improving performance. It offers non-invasive, ethical alternatives to conventional psychopharmacology and aligns with the trend toward personalized medicine, suggesting specialized solutions for mental health and rehabilitation as a growing focus in medical practice.

Neuroimaging features of cognitive impairments in schizophrenia and major depressive disorder

Cognitive dysfunctions are one of the key symptoms of schizophrenia (SZ) and major depressive disorder (MDD), which exist not only during the onset of diseases but also before the onset, even after the remission of psychiatric symptoms. With the development of neuroimaging techniques, these non-invasive approaches provide valuable insights into the underlying pathogenesis of psychiatric disorders and information of cognitive remediation interventions. This review synthesizes existing neuroimaging studies to examine domains of cognitive impairment, particularly processing speed, memory, attention, and executive function in SZ and MDD patients. First, white matter (WM) abnormalities are observed in processing speed deficits in both SZ and MDD, with distinct neuroimaging findings highlighting WM connectivity abnormalities in SZ and WM hyperintensity caused by small vessel disease in MDD. Additionally, the abnormal functions of prefrontal cortex and medial temporal lobe are found in both SZ and MDD patients during various memory tasks, while aberrant amygdala activity potentially contributes to a preference to negative memories in MDD. Furthermore, impaired large-scale networks including frontoparietal network, dorsal attention network, and ventral attention network are related to attention deficits, both in SZ and MDD patients. Finally, abnormal activity and volume of the dorsolateral prefrontal cortex (DLPFC) and abnormal functional connections between the DLPFC and the cerebellum are associated with executive dysfunction in both SZ and MDD. Despite these insights, longitudinal neuroimaging studies are lacking, impeding a comprehensive understanding of cognitive changes and the development of early intervention strategies for SZ and MDD. Addressing this gap is critical for advancing our knowledge and improving patient prognosis.

Ventromedial prefrontal cortex activation and neurofeedback modulation during episodic future thinking for individuals with suicidal thoughts and behaviors

Individuals experiencing suicidal thoughts and behaviors (STBs) show less specificity and positivity during episodic future thinking (EFT). Here, we present findings from two studies aiming to (1) further our understanding of how STBs may relate to neural responsivity during EFT and (2) examine the feasibility of modulating EFT-related activation using real-time fMRI neurofeedback (rtfMRI-nf). Study 1 involved 30 individuals with major depressive disorder (MDD; half with STBs) who performed an EFT task during fMRI, for which they imagined personally-relevant future positive, negative, or neutral events. Positive EFT elicited greater ventromedial prefrontal cortex (vmPFC) activation compared to negative EFT. Importantly, the MDD + STB group exhibited reduced vmPFC activation across all EFT conditions compared to MDD-STB; although EFT fluency and subjective experience remained consistent across groups. Study 2 included rtfMRI-nf focused on vmPFC modulation during positive EFT for six participants with MDD + STBs. Results support the feasibility and acceptability of the rtfMRI-nf protocol and quantitative and qualitative observations are provided to help inform future, larger studies aiming to examine similar neurofeedback protocols. Results implicate vmPFC blunting as a promising treatment target for MDD + STBs and suggest rtfMRI-nf as one potential technique to explore for enhancing vmPFC engagement.

Amygdala real-time fMRI neurofeedback upregulation in treatment resistant depression: Proof of concept and dose determination

Previous work has shown that adults suffering from major depressive disorder (MDD) can increase their amygdala reactivity while recalling positive memories via real-time neurofeedback (rt-fMRI-nf) training, which is associated with reduction in depressive symptoms. This study investigated if this intervention could also be considered for patients suffering from MDD who do not respond to standard psychological and pharmacological interventions, i.e., treatment resistant (TR-MDD). 15 participants received 5 neurofeedback sessions. Outcome measures were depressive symptoms assessed by BDI scores up to 12 weeks following acute intervention, and amygdala activity changes from initial baseline to final transfer run during neurofeedback sessions (neurofeedback success). Participants succeeded in increasing their amygdala activity. A main effect of visit on BDI scores indicated a significant reduction in depressive symptomatology. Percent signal change in the amygdala showed a learning curve during the first session only. Neurofeedback success computed by session was significantly positive only during the second session. When examining the baseline amygdala response, baseline activity stabilized/asymptoted by session 3. This proof-of-concept study suggests that only two neurofeedback sessions are necessary to enable those patients to upregulate their amygdala activity, warranting a future RCT. Over the course of the rtfMRI-nf intervention, participants also reported reduced depressive symptomatology. Clinical trial registration number: NCT03428828 on ClinicalTrials.gov.

Enhanced attention-related alertness following right anterior insular cortex neurofeedback training

The anterior insular cortex, a central node of the salience network, plays a critical role in cognitive control and attention. Here, we investigated the feasibility of enhancing attention using real-time fMRI neurofeedback training that targets the right anterior insular cortex (rAIC). 56 healthy adults underwent two neurofeedback training sessions. The experimental group received feedback from neural responses in the rAIC, while control groups received sham feedback from the primary visual cortex or no feedback. Cognitive functioning was evaluated before, immediately after, and three months post-training. Our results showed that only the rAIC neurofeedback group successfully increased activity in the rAIC. Furthermore, this group showed enhanced attention-related alertness up to three months after the training. Our findings provide evidence for the potential of rAIC neurofeedback as a viable approach for enhancing attention-related alertness, which could pave the way for non-invasive therapeutic strategies to address conditions characterized by attention deficits.

Recall of Autobiographical Memories Following Odor vs Verbal Cues Among Adults With Major Depressive Disorder

Importance

Major depressive disorder (MDD) is associated with deficits in autobiographical memory (AM) recall, which is thought to stem from disruptions in effortful recall. Understanding whether these deficits are mitigated when recall is stimulated more directly, such as by odor cues, could inform therapeutic interventions for MDD.

Objective

To evaluate whether deficits in specific AM recall in MDD are mitigated when odor cues vs word cues are used to prompt memory.

Design, Setting, and Participants

This cross-sectional study assessed recall of specific AMs in response to both odor cues and word cues (in a randomized, counterbalanced order) in a repeated measures design. Data were collected between September 2021 and November 2022. The study took place at the University of Pittsburgh School of Medicine in Pennsylvania and included adults with a primary diagnosis of MDD, according to the Mini International Neuropsychiatric Interview. Data were analyzed from January to June 2023.

Main Outcomes and Measures

The primary outcome measure was the percentage of specific AMs recalled in response to odor-cued memories vs word-cued memories. Additional outcome measures included ratings of arousal, vividness, repetition, and recall response time for odor-cued memories vs word-cued memories.

Results

Thirty-two adults (mean [SD] age, 30.0 [10.1] years; 26 [81.3%] female; 6 [18.8%] male) with a primary diagnosis of MDD completed the study. Participants recalled more specific AMs for odor cues than word cues (mean [SD], 68.4% [20.4%] vs 52.1% [23.3%]; Cohen d, 0.78; P < .001). Additionally, odor-cued recall was rated more arousing (mean [SD], 3.0 [0.8] vs 2.6 [0.7]; Cohen d, 1.28; P < .001) and vivid (mean [SD], 3.3 [0.7] vs 3.0 [0.7]; Cohen d, 0.67; P < .001), and was slower than word-cued recall (mean [SD], 14.5 [3.6] vs 8.9 [3.4] seconds; Cohen d, 1.18; P < .001). When compared with the population mean for word cues in healthy controls (80%), participants recalled fewer specific memories in response to words (Cohen d, 1.18; P < .001), supporting the presence of overgenerality. Notably, the percentage of specific memories recalled in response to odor cues did not differ from the healthy control population mean (Cohen d, 0.26; P = .15).

Conclusions and Relevance

In this cross-sectional study, adults with MDD recalled more specific AMs in response to odor cues compared with word cues. This study suggests that AM deficits may only be observed when verbal cues are used and provides a potential new method for increasing specific AM recall in patients with MDD.

Facing emotions: real-time fMRI-based neurofeedback using dynamic emotional faces to modulate amygdala activity

Introduction

Maladaptive functioning of the amygdala has been associated with impaired emotion regulation in affective disorders. Recent advances in real-time fMRI neurofeedback have successfully demonstrated the modulation of amygdala activity in healthy and psychiatric populations. In contrast to an abstract feedback representation applied in standard neurofeedback designs, we proposed a novel neurofeedback paradigm using naturalistic stimuli like human emotional faces as the feedback display where change in the facial expression intensity (from neutral to happy or from fearful to neutral) was coupled with the participant's ongoing bilateral amygdala activity.

Methods

The feasibility of this experimental approach was tested on 64 healthy participants who completed a single training session with four neurofeedback runs. Participants were assigned to one of the four experimental groups (n = 16 per group), i.e., happy-up, happy-down, fear-up, fear-down. Depending on the group assignment, they were either instructed to "try to make the face happier" by upregulating (happy-up) or downregulating (happy-down) the amygdala or to "try to make the face less fearful" by upregulating (fear-up) or downregulating (fear-down) the amygdala feedback signal.

Results

Linear mixed effect analyses revealed significant amygdala activity changes in the fear condition, specifically in the fear-down group with significant amygdala downregulation in the last two neurofeedback runs as compared to the first run. The happy-up and happy-down groups did not show significant amygdala activity changes over four runs. We did not observe significant improvement in the questionnaire scores and subsequent behavior. Furthermore, task-dependent effective connectivity changes between the amygdala, fusiform face area (FFA), and the medial orbitofrontal cortex (mOFC) were examined using dynamic causal modeling. The effective connectivity between FFA and the amygdala was significantly increased in the happy-up group (facilitatory effect) and decreased in the fear-down group. Notably, the amygdala was downregulated through an inhibitory mechanism mediated by mOFC during the first training run.

Discussion

In this feasibility study, we intended to address key neurofeedback processes like naturalistic facial stimuli, participant engagement in the task, bidirectional regulation, task congruence, and their influence on learning success. It demonstrated that such a versatile emotional face feedback paradigm can be tailored to target biased emotion processing in affective disorders.

Effects of Cortisol Administration on Resting-State Functional Connectivity in Women with Depression

Previous resting-state functional connectivity (rsFC) research has identified several brain networks impacted by depression and cortisol, including default mode (DMN), frontoparietal (FPN), and salience networks (SN). In the present study, we examined the effects of cortisol administration on rsFC of these networks in individuals varying in depression history and severity. We collected resting-state fMRI scans and self-reported depression symptom severity for 74 women with and without a history of depression after cortisol and placebo administration using a double-blind, crossover design. We conducted seed-based rsFC analyses for DMN, FPN, and SN seeds to examine rsFC changes after cortisol vs. placebo administration in relation to depression history group and severity. Results revealed a main effect of depression group, with lower left amygdala (SN)-middle temporal gyrus connectivity in women with a history of depression. Cortisol administration increased insula (SN)-inferior frontal gyrus and superior temporal gyrus connectivity. We also found that greater depression severity was associated with increased PCC (DMN)-cerebellum connectivity after cortisol. These results did not survive Bonferroni correction for seed ROIs and should be interpreted with caution. Our findings indicate that acute cortisol elevation may normalize aberrant connectivity of DMN and SN regions, which could help inform clinical treatments for depression.

A feasibility study of goal-directed network-based real-time fMRI neurofeedback for anhedonic depression

Anhedonia is a hallmark symptom of depression that often lacks adequate interventions. The translational gap remains in clinical treatments based on neural substrates of anhedonia. Our pilot study found that depressed individuals depended less on goal-directed (GD) reward learning (RL), with reduced reward prediction error (RPE) BOLD signal. Previous studies have found that anhedonia is related to abnormal activities and/or functional connectivities of the central executive network (CEN) and salience network (SN), both of which belong to the goal-directed system. In addition, it was found that real-time functional magnetic resonance imaging (rt-fMRI) neurofeedback (NF) could improve the balance between CEN and SN in healthy individuals. Therefore, we speculate that rt-fMRI NF of the CEN and SN associated with the GD system may improve depressive and/or anhedonic symptoms. Therefore, this study (1) will examine individuals with anhedonic depression using GD-RL behavioral task, combined with functional magnetic resonance imaging and computational modeling to explore the role of CEN/SN deficits in anhedonic depression; and (2) will utilize network-based rt-fMRI NF to investigate whether it is feasible to regulate the differential signals of brain CEN/SN of GD system through rt-fMRI NF to alleviate depressive and/or anhedonic symptoms. This study highlights the need to elucidate the intervention effects of rt-fMRI NF and the underlying computational network neural mechanisms.

INDUCING REPRESENTATIONAL CHANGE IN THE HIPPOCAMPUS THROUGH REAL-TIME NEUROFEEDBACK

When you perceive or remember one thing, other related things come to mind. This competition has consequences for how these items are later perceived, attended, or remembered. Such behavioral consequences result from changes in how much the neural representations of the items overlap, especially in the hippocampus. These changes can reflect increased (integration) or decreased (differentiation) overlap; previous studies have posited that the amount of coactivation between competing representations in cortex determines which will occur: high coactivation leads to hippocampal integration, medium coactivation leads to differentiation, and low coactivation is inert. However, those studies used indirect proxies for coactivation, by manipulating stimulus similarity or task demands. Here we induce coactivation of competing memories in visual cortex more directly using closed-loop neurofeedback from real-time fMRI. While viewing one object, participants were rewarded for implicitly activating the representation of another object as strongly as possible. Across multiple real-time fMRI training sessions, they succeeded in using the neurofeedback to induce coactivation. Compared with untrained objects, this coactivation led to behavioral and neural integration: The trained objects became harder for participants to discriminate in a categorical perception task and harder to decode from patterns of fMRI activity in the hippocampus.

Evidence of a large current of transcranial alternating current stimulation directly to deep brain regions

Deep brain regions such as hippocampus, insula, and amygdala are involved in neuropsychiatric disorders, including chronic insomnia and depression. Our recent reports showed that transcranial alternating current stimulation (tACS) with a current of 15 mA and a frequency of 77.5 Hz, delivered through a montage of the forehead and both mastoids was safe and effective in intervening chronic insomnia and depression over 8 weeks. However, there is no physical evidence to support whether a large alternating current of 15 mA in tACS can send electrical currents to deep brain tissue in awake humans. Here, we directly recorded local field potentials (LFPs) in the hippocampus, insula and amygdala at different current strengths (1 to 15 mA) in 11 adult patients with drug-resistant epilepsy implanted with stereoelectroencephalography (SEEG) electrodes who received tACS at 77.5 Hz from 1 mA to 15 mA at 77.5 Hz for five minutes at each current for a total of 40 min. For the current of 15 mA at 77.5 Hz, additional 55 min were applied to add up a total of 60 min. Linear regression analysis revealed that the average LFPs for the remaining contacts on both sides of the hippocampus, insula, and amygdala of each patient were statistically associated with the given currents in each patient (p < 0.05-0.01), except for the left insula of one subject (p = 0.053). Alternating currents greater than 7 mA were required to produce significant differences in LFPs in the three brain regions compared to LFPs at 0 mA (p < 0.05). The differences remained significant after adjusting for multiple comparisons (p < 0.05). Our study provides direct evidence that the specific tACS procedures are capable of delivering electrical currents to deep brain tissues, opening a realistic avenue for modulating or treating neuropsychiatric disorders associated with hippocampus, insula, and amygdala.

Protocol description for a randomized controlled trial of fMRI neurofeedback for tics in adolescents with Tourette Syndrome

This article describes the protocol for a randomized, controlled clinical trial of a neurofeedback (NF) intervention for Tourette Syndrome (TS) and chronic tic disorder. The intervention involves using functional magnetic resonance imaging (fMRI) to provide feedback regarding activity in the supplementary motor area: participants practice controlling this brain area while using the feedback as a training signal. The previous version of this NF protocol was tested in a small study (n = 21) training adolescents with TS that yielded clinically promising results. Therefore, we plan a larger trial. Here we describe the background literature that motivated this work, the design of our original neurofeedback study protocol, and adaptations of the research study protocol for the new trial. We focus on those ideas incorporated into our protocol that may be of interest to others designing and running NF studies. For example, we highlight our approach for defining an unrelated brain region to be trained in the control group that is based on identifying a region with low functional connectivity to the target area. Consistent with a desire for transparency and open science, the new protocol is described in detail here prior to conducting the trial.

Neurofeedback and Affect Regulation Circuitry in Depressed and Healthy Adolescents

Neurodevelopmental psychopathology seeks to understand higher-order emotion regulation circuitry to develop new therapies for adolescents with depression. Depressed (N = 34) and healthy youth (N = 19) completed neurofeedback (NF) training and exhibited increased bilateral amygdala and hippocampus activity in the region of interest (ROI) analyses by recalling positive autobiographical memories. We tested factors supportive of the engagement of emotion regulation's neural areas during NF (i.e., parental support, medication, and gender effects upon anterior cingulate cortex (ACC) engagement). Whole-brain analyses yielded effects of NF vs. control condition and effects of diagnosis. Youth showed higher amygdala and hippocampus (AMYHIPPO) activity during the NF vs. control condition, particularly in the left hippocampus. ACC's activity was also higher during NF vs. control. Higher average ACC activity was linked to better parental support, absent depression, female gender, and absent medication. Control youth showed higher average AMYHIPPO and ACC activity throughout the task and a faster decline in activity vs. depressed youths. Whole-brain level analyses showed higher activity in the frontotemporal network during the NF vs. control conditions, suggesting targeting their connectivity in future neurofeedback trials.

Mood-congruent memory revisited

Affective experiences are commonly represented by either transient emotional reactions to discrete events or longer term, sustained mood states that are characterized by a more diffuse and global nature. While both have considerable influence in shaping memory, their interaction can produce mood-congruent memory (MCM), a psychological phenomenon where emotional memory is biased toward content affectively congruent with a past or current mood. The study of MCM has direct implications for understanding how memory biases form in daily life, as well as debilitating negative memory schemas that contribute to mood disorders such as depression. To elucidate the factors that influence the presence and strength of MCM, here we systematically review the literature for studies that assessed MCM by inducing mood in healthy participants. We observe that MCM is often reported as enhanced accuracy for previously encoded mood-congruent content or preferential recall for mood-congruent autobiographical events, but may also manifest as false memory for mood-congruent lures. We discuss the relevant conditions that shape these effects, as well as instances of mood-incongruent recall that facilitate mood repair. Further, we provide guiding methodological and theoretical considerations, emphasizing the limited neuroimaging research in this area and the need for a renewed focus on memory consolidation. Accordingly, we propose a theoretical framework for studying the neural basis of MCM based on the neurobiological underpinnings of mood and emotion. In doing so, we review evidence for associative network models of spreading activation, while also considering alternative models informed by the cognitive neuroscience literature of emotional memory bias. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Selecting an optimal real-time fMRI neurofeedback method for alcohol craving control training

Real-time fMRI neurofeedback (rt-fMRI-NF) is a technique in which information about an individual's neural state is given back to them, typically to enable and reinforce neuromodulation. Its clinical potential has been demonstrated in several applications, but lack of evidence on optimal parameters limits clinical utility of the technique. This study aimed to identify optimal parameters for rt-fMRI-NF-aided craving regulation training in alcohol use disorder (AUD). Adults with AUD (n = 30) participated in a single-session study of four runs of rt-fMRI-NF where they downregulated "craving-related" brain activity. They received one of three types of neurofeedback: multi-region of interest (ROI), support vector machine with continuous feedback (cSVM), and support vector machine with intermittent feedback (iSVM). Performance was assessed on the success rate, change in neural downregulation, and change in self-reported craving for alcohol. Participants had more successful trials in run 4 versus 1, as well as improved downregulation of the insula, anterior cingulate, and dorsolateral prefrontal cortex (dlPFC). Greater downregulation of the latter two regions predicted greater reduction in craving. iSVM performed significantly worse than the other two methods. Downregulation of the striatum and dlPFC, enabled by ROI but not cSVM neurofeedback, was correlated with a greater reduction in craving. rt-fMRI-NF training for downregulation of alcohol craving in individuals with AUD shows potential for clinical use, though this pilot study should be followed with a larger randomized-control trial before clinical meaningfulness can be established. Preliminary results suggest an advantage of multi-ROI over SVM and intermittent feedback approaches.

Enhanced efficacy of CBT following augmentation with amygdala rtfMRI neurofeedback in depression

BACKGROUND

Despite cognitive behavioral therapy (CBT) being a standard treatment in major depressive disorder (MDD), nearly half of patients do not respond. As one of the predictors of CBT's efficacy is amygdala reactivity to positive information, which is often decreased in MDD, we explored whether real-time fMRI neurofeedback (rtfMRI-nf) training to increase amygdala responses during positive memory recall prior CBT would enhance its efficacy.

METHODS

In a double-blind, placebo controlled, randomized clinical trial, 35 adults with MDD received two sessions of rtfMRI-nf training to increase their amygdala (experimental group, n = 16) or parietal (control group, n = 19) responses during positive memory neurofeedback prior to receiving 10 CBT sessions. Depressive symptomatology was monitored between the rtfMRI sessions, the first three, 9th and 10th sessions of CBT and at 6 months and 1 year follow-up.

RESULTS

Participants in the experimental group showed decreased depressive symptomatology and higher remission rates at 6 months and 1 year follow-up than the control group. Analysis of CBT content highlighted that participants in the experimental group focused more on positive thinking and behaviors than the control group.

LIMITATIONS

The study was relatively small and not sufficiently powered to detect small effects.

CONCLUSIONS

CBT, when combined with amygdala neurofeedback, results in sustained clinical changes and leads to long-lasting clinical improvement, potentially by increasing focus on positive memories and cognitions.

Neurofeedback for obsessive compulsive disorder: A randomized, double-blind trial

We aim to develop fMRI neurofeedback as a treatment for obsessive compulsive disorder (OCD). In prior work, we found that providing neurofeedback of activity in the anterior prefrontal cortex (aPFC) improved control over contamination anxiety in a subclinical population. Here, we present the results of a randomized, double-blind clinical trial (NCT02206945) testing this intervention in patients with OCD. We recruited patients with primary symptoms in the fear-of-harm/checking or contamination/washing domains. During neurofeedback, they viewed symptom provocative images and attempted to up- and down-regulate the aPFC during different blocks of time. The active group received two sessions of neurofeedback and the control group received yoked sham feedback. The primary outcome measure was the Yale-Brown Obsessive-Compulsive Symptom scale. The secondary outcome was control over aPFC. Thirty-six participants completed feedback training (18 active, 18 control). The active group had a slightly but significantly greater reduction of obsessive-compulsive symptoms after neurofeedback compared to the control group (p<.05) but no significant differences in control over the aPFC. These data demonstrate that neurofeedback targeting the aPFC can reduce symptoms in OCD. Future investigations should seek to optimize the training protocol to yield larger effects and to clarify the mechanism of action.

Brain mechanisms underlying the emotion processing bias in treatment-resistant depression

Depression is associated with a cognitive bias towards negative information and away from positive information. This biased emotion processing may underlie core depression symptoms, including persistent feelings of sadness or low mood and a reduced capacity to experience pleasure. The neural mechanisms responsible for this biased emotion processing remain unknown. Here, we had a unique opportunity to record stereotactic electroencephalography (sEEG) signals in the amygdala and prefrontal cortex (PFC) from 5 treatment-resistant depression (TRD) patients and 12 epilepsy patients (as control) while they participated in an affective bias task in which happy and sad faces were rated. First, compared with the control group, patients with TRD showed increased amygdala responses to sad faces in the early stage (around 300 ms) and decreased amygdala responses to happy faces in the late stage (around 600 ms) following the onset of faces. Further, during the late stage of happy face processing, alpha-band activity in PFC as well as alpha-phase locking between the amygdala and PFC were significantly greater in TRD patients compared to the controls. Second, after deep brain stimulation (DBS) delivered to bilateral subcallosal cingulate (SCC) and ventral capsule/ventral striatum (VC/VS), atypical amygdala and PFC processing of happy faces in TRD patients remitted toward the normative pattern. The increased amygdala activation during the early stage of sad face processing suggests an overactive bottom-up processing system in TRD. Meanwhile, the reduced amygdala response during the late stage of happy face processing could be attributed to inhibition by PFC through alpha-band oscillation, which can be released by DBS in SCC and VC/VS.

Altered amygdala functional connectivity after real-time functional MRI emotion self-regulation training

Real-time functional MRI neurofeedback (rtfMRI-NF) is a noninvasive technique that extracts concurrent brain states and provides feedback to subjects in an online method. Our study aims to investigate the effect of rtfMRI-NF on amygdala-based emotion self-regulation by analyzing resting-state functional connectivity. We conducted a task experiment to train subjects in self-regulating amygdala activity in response to emotional stimuli. Twenty subjects were divided into two groups. The up-regulate group (URG) viewed positive stimulus, while the down-regulate group (DRG) viewed negative stimulus. The rtfMRI-NF experiment paradigm consisted of three conditions. The URG's percent amplitude fluctuation (PerAF) scores are significant, indicating that positive emotions may be a partial side effect, with increased activity in the left hemisphere. Resting-state functional connectivity was analyzed via a paired-sample t-test before and after neurofeedback training. Brain network properties and functional connectivity analysis showed a significant difference between the default mode network (DMN) and the brain region associated with the limbic system. These results reveal to some extent the mechanism of neurofeedback training to improve individuals' emotional regulate regulation ability. Our study has shown that rtfMRI-neurofeedback training can effectively enhance the ability to voluntarily control brain responses. Furthermore, the results of the functional analysis have revealed distinct changes in the amygdala functional connectivity circuits following rtfMRI-neurofeedback training. These findings may suggest the potential clinical applications of rtfMRI-neurofeedback as a new therapy for emotionally related mental disorders.

Cingulate prediction of response to antidepressant and cognitive behavioral therapies for depression: Meta-analysis and empirical application

We sought to identify baseline (pre-treatment) neural markers associated with treatment response in major depressive disorder (MDD), specific to treatment type, Cognitive Behavioral Therapy (CBT) or pharmacotherapy (selective serotonin reuptake inhibitors; SSRI). We conducted a meta-analysis of functional magnetic resonance imaging (fMRI) studies to identify neural prognostic indicators of response to CBT or SSRI. To verify the regions derived from literature, the meta-analytic regions were used to predict clinical change in a verification sample of participants with MDD who received either CBT (n = 60) or an SSRI (n = 19) as part of prior clinical trials. The meta-analysis consisted of 21 fMRI studies that used emotion-related tasks. It yielded prognostic regions of the perigenual (meta pgACC) and subgenual anterior cingulate cortex (meta sgACC), associated with SSRI and CBT response, respectively. When applying the meta-analytic regions to predict treatment response in the verification sample, reactivity of the meta pgACC was prognostic for SSRI response, yet the effect direction was opposite of most prior studies. Meta sgACC reactivity failed to be prognostic for CBT response. Results confirm the prognostic potential of neural reactivity of ACC subregions in MDD but further research is necessary for clinical translation.

Effects of neurofeedback on major depressive disorder: a systematic review

BACKGROUND

Major depressive disorder is a difficult-to-treat psychological disorder. Approximately 30% of patients with major depressive disorder do not respond to conventional therapies; thus, the efficacy of alternative therapies for treating major depressive disorder, such as neurofeedback, a non-invasive neuromodulation method used in the treatment of psychiatric diseases, must be investigated.

OBJECTIVE

We aimed to evaluate the efficacy of neurofeedback in minimizing and treating major depressive disorder and its application as a substitute to or an adjuvant with conventional therapies.

METHODS

We searched for experimental studies published between 1962-2021 in Scopus, PubMed, Web of Science, and Embase databases and identified 1,487 studies, among which 13 met the inclusion exclusion criteria.

RESULTS

We noted that not all patients responded to neurofeedback. Based on depression scales, major depressive disorder significantly improved in response to neurofeedback only in a few individuals. Additionally, the number of training sessions did not influence the results.

CONCLUSION

Neurofeedback can reduce depression symptoms in patients; however, not all patients respond to the treatment. Therefore, further studies must be conducted to validate the effectiveness of neurofeedback in treating major depressive disorder.

Self-regulation of visual word form area activation with real-time fMRI neurofeedback

The Visual Word Form Area (VWFA) is a key region of the brain's reading network and its activation has been shown to be strongly associated with reading skills. Here, for the first time, we investigated whether voluntary regulation of VWFA activation is feasible using real-time fMRI neurofeedback. 40 adults with typical reading skills were instructed to either upregulate (UP group, N = 20) or downregulate (DOWN group, N = 20) their own VWFA activation during six neurofeedback training runs. The VWFA target region was individually defined based on a functional localizer task. Before and after training, also regulation runs without feedback ("no-feedback runs") were performed. When comparing the two groups, we found stronger activation across the reading network for the UP than the DOWN group. Further, activation in the VWFA was significantly stronger in the UP group than the DOWN group. Crucially, we observed a significant interaction of group and time (pre, post) for the no-feedback runs: The two groups did not differ significantly in their VWFA activation before neurofeedback training, but the UP group showed significantly stronger activation than the DOWN group after neurofeedback training. Our results indicate that upregulation of VWFA activation is feasible and that, once learned, successful upregulation can even be performed in the absence of feedback. These results are a crucial first step toward the development of a potential therapeutic support to improve reading skills in individuals with reading impairments.

Amygdala downregulation training using fMRI neurofeedback in post-traumatic stress disorder: a randomized, double-blind trial

Hyperactivation of amygdala is a neural marker for post-traumatic stress disorder (PTSD) and improvement in control over amygdala activity has been associated with treatment success in PTSD. In this randomized, double-blind clinical trial we evaluated the efficacy of a real-time fMRI neurofeedback intervention designed to train control over amygdala activity following trauma recall. Twenty-five patients with PTSD completed three sessions of neurofeedback training in which they attempted to downregulate the feedback signal after exposure to personalized trauma scripts. For subjects in the active experimental group (N = 14), the feedback signal was from a functionally localized region of their amygdala associated with trauma recall. For subjects in the control group (N = 11), yoked-sham feedback was provided. Changes in control over the amygdala and PTSD symptoms served as the primary and secondary outcome measurements, respectively. We found significantly greater improvements in control over amygdala activity in the active group than in the control group 30-days following the intervention. Both groups showed improvements in symptom scores, however the symptom reduction in the active group was not significantly greater than in the control group. Our finding of greater improvement in amygdala control suggests potential clinical application of neurofeedback in PTSD treatment. Thus, further development of amygdala neurofeedback training in PTSD treatment, including evaluation in larger samples, is warranted.

Real-time functional magnetic resonance imaging neurofeedback training of amygdala upregulation increases affective flexibility in depression

BACKGROUND

Decreased affective flexibility is associated with depression symptoms, and it has been suggested that common interventions may target this mechanism. To explore this hypothesis, we evaluated whether real-time functional magnetic resonance imaging neurofeedback (rtfMRI-nf) training to increase the amygdala responses during positive memory recall resulted in both symptom improvements, as has been observed previously, and flexibility to decrease amygdala reactivity in response to a cognitive task among patients with major depressive disorder (MDD).

METHODS

In a double-blind, placebo-controlled, randomized clinical trial, adults with MDD received 2 sessions of rtfMRI-nf training to increase their amygdala (experimental group) or parietal (control group) responses during positive autobiographical memory recall. We evaluated signal changes in the amygdala during both the positive memory neurofeedback and a subsequent counting condition.

RESULTS

We included 38 adults with MDD, including 16 in the experimental group and 22 in the control group. In the experimental group, amygdala activity increased (t > 2.01, df < 27, p < 0.05, d > 0.5) and depressive symptoms decreased (-8.57, 95 % confidence interval [CI] -15.12 to -2.59; t 13 = -3.06, p = 0.009, d = 1). Amygdala activity during the count condition decreased after rtfMRI-nf (-0.16, 95 % CI -0.23 to -0.09; t 396 = 4.73, p < 0.001, d = 0.48) and was correlated with decreased depression scores (r = 0.46, p = 0.01). We replicated previous results and extended them to show decreased amygdala reactivity to a cognitive task during which no neurofeedback was provided.

LIMITATIONS

The count condition was reported by participants as negative, but emotionality or accuracy during this condition was not assessed.

CONCLUSION

These results suggest that nominally targeting unidimensional change in neural mechanisms could have implications for bidirectional control, increasing the likely reach and explanatory framework for how common depression interventions work.Trial registration: ClinicalTrials.gov NCT02709161.

Self-blame in major depression: a randomised pilot trial comparing fMRI neurofeedback with self-guided psychological strategies

BACKGROUND

Overgeneralised self-blame and worthlessness are key symptoms of major depressive disorder (MDD) and have previously been associated with self-blame-selective changes in connectivity between right superior anterior temporal lobe (rSATL) and subgenual frontal cortices. Another study showed that remitted MDD patients were able to modulate this neural signature using functional magnetic resonance imaging (fMRI) neurofeedback training, thereby increasing their self-esteem. The feasibility and potential of using this approach in symptomatic MDD were unknown.

METHOD

This single-blind pre-registered randomised controlled pilot trial probed a novel self-guided psychological intervention with and without additional rSATL-posterior subgenual cortex (BA25) fMRI neurofeedback, targeting self-blaming emotions in people with insufficiently recovered MDD and early treatment-resistance (n = 43, n = 35 completers). Participants completed three weekly self-guided sessions to rebalance self-blaming biases.

RESULTS

As predicted, neurofeedback led to a training-induced reduction in rSATL-BA25 connectivity for self-blame v. other-blame. Both interventions were safe and resulted in a 46% reduction on the Beck Depression Inventory-II, our primary outcome, with no group differences. Secondary analyses, however, revealed that patients without DSM-5-defined anxious distress showed a superior response to neurofeedback compared with the psychological intervention, and the opposite pattern in anxious MDD. As predicted, symptom remission was associated with increases in self-esteem and this correlated with the frequency with which participants employed the psychological strategies in daily life.

CONCLUSIONS

These findings suggest that self-blame-rebalance neurofeedback may be superior over a solely psychological intervention in non-anxious MDD, although further confirmatory studies are needed. Simple self-guided strategies tackling self-blame were beneficial, but need to be compared against treatment-as-usual in further trials. https://doi.org/10.1186/ISRCTN10526888.

Social anxiety inhibits needs repair following exclusion in both relational and non-relational reward contexts: The mediating role of positive affect

The pain of social exclusion can motivate people to capitalize on opportunities to reconnect with others and repair their self-esteem and feelings of belongingness. This effect is often diminished for those with high social anxiety (HSA). Prior research suggests this may be due to their diminished capacity for recognizing and emotionally responding to relational reward cues. We investigated whether non-relational success experiences in the aftermath of exclusion may be an alternative means of repairing threatened self-esteem and belongingness in HSA individuals. In a preregistered, online study, we threatened belongingness and self-esteem in 422 participants by excluding them in a Cyberball game and then assigned them to one of three conditions: Relational Repair, Non-Relational Repair, or a No-Repair control condition. Results showed that both repair contexts facilitated needs repair relative to the no-repair control condition, and mediation analyses suggested this effect was driven by increased positive affect (PA). HSA individuals were less likely to restore needs regardless of condition and this effect appeared to be driven by low PA. Findings emphasize the critical role of PA for restoring threatened needs in the aftermath of exclusion and suggest that HSA inhibits needs repair processes across both relational and non-relational reward contexts.

Posterior cingulate cortex targeted real-time fMRI neurofeedback recalibrates functional connectivity with the amygdala, posterior insula, and default-mode network in PTSD

BACKGROUND

Alterations within large-scale brain networks-namely, the default mode (DMN) and salience networks (SN)-are present among individuals with posttraumatic stress disorder (PTSD). Previous real-time functional magnetic resonance imaging (fMRI) and electroencephalography neurofeedback studies suggest that regulating posterior cingulate cortex (PCC; the primary hub of the posterior DMN) activity may reduce PTSD symptoms and recalibrate altered network dynamics. However, PCC connectivity to the DMN and SN during PCC-targeted fMRI neurofeedback remains unexamined and may help to elucidate neurophysiological mechanisms through which these symptom improvements may occur.

METHODS

Using a trauma/emotion provocation paradigm, we investigated psychophysiological interactions over a single session of neurofeedback among PTSD (n = 14) and healthy control (n = 15) participants. We compared PCC functional connectivity between regulate (in which participants downregulated PCC activity) and view (in which participants did not exert regulatory control) conditions across the whole-brain as well as in a priori specified regions-of-interest.

RESULTS

During regulate as compared to view conditions, only the PTSD group showed significant PCC connectivity with anterior DMN (dmPFC, vmPFC) and SN (posterior insula) regions, whereas both groups displayed PCC connectivity with other posterior DMN areas (precuneus/cuneus). Additionally, as compared with controls, the PTSD group showed significantly greater PCC connectivity with the SN (amygdala) during regulate as compared to view conditions. Moreover, linear regression analyses revealed that during regulate as compared to view conditions, PCC connectivity to DMN and SN regions was positively correlated to psychiatric symptoms across all participants.

CONCLUSION

In summary, observations of PCC connectivity to the DMN and SN provide emerging evidence of neural mechanisms underlying PCC-targeted fMRI neurofeedback among individuals with PTSD. This supports the use of PCC-targeted neurofeedback as a means by which to recalibrate PTSD-associated alterations in neural connectivity within the DMN and SN, which together, may help to facilitate improved emotion regulation abilities in PTSD.

Testing the efficacy of real-time fMRI neurofeedback for training people who smoke daily to upregulate neural responses to nondrug rewards

Although the use of nondrug rewards (e.g., money) to facilitate smoking cessation is widespread, recent research has found that such rewards may be least effective when people who smoke cigarettes are tempted to do so. Specifically, among people who smoke, the neural response to nondrug rewards appears blunted when access to cigarettes is anticipated, and this blunting is linked to a decrease in willingness to refrain from smoking to earn a monetary incentive. Accordingly, methods to enhance the value of nondrug rewards may be theoretically and clinically important. The current proof-of-concept study tested if real-time fMRI neurofeedback training augments the ability to upregulate responses in reward-related brain areas relative to a no-feedback control condition in people who smoke. Adults (n = 44, age range = 20-44) who reported smoking >5 cigarettes per day completed the study. Those in the intervention group (n = 22, 5 females) were trained to upregulate brain responses using feedback of ongoing striatal activity (i.e., a dynamic "thermometer" that reflected ongoing changes of fMRI signal intensity in the striatum) in a single neurofeedback session with three training runs. The control group (n = 22, 5 females) underwent a nearly identical procedure but received no neurofeedback. Those who received neurofeedback training demonstrated significantly greater increases in striatal BOLD activation while attempting to think about something rewarding compared to controls, but this effect was present only during the first training run. Future neurofeedback research with those who smoke should explore how to make neurofeedback training more effective for the self-regulation of reward-related brain activities.