Amygdala-related electroencephalogram neurofeedback as add-on therapy for treatment-resistant childhood sexual abuse posttraumatic stress disorder: feasibility study

AIM

Childhood sexual abuse (CSA) among women is an alarmingly prevalent traumatic experience that often leads to debilitating and treatment-refractory posttraumatic stress disorder (PTSD), raising the need for novel adjunctive therapies. Neuroimaging investigations systematically report that amygdala hyperactivity is the most consistent and reliable neural abnormality in PTSD and following childhood abuse, raising the potential of implementing volitional neural modulation using neurofeedback (NF) aimed at down-regulating amygdala activity. This study aimed to reliably probe limbic activity but overcome the limited applicability of functional magnetic resonance imaging (fMRI) NF by using a scalable electroencephalogram NF probe of amygdala-related activity, termed amygdala electrical-finger-print (amyg-EFP) in a randomized controlled trial.

METHOD

Fifty-five women with CSA-PTSD who were in ongoing intensive trauma-focused psychotherapy for a minimum of 1 year but still met Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) PTSD criteria were randomized to either 10 add-on sessions of amyg-EFP-NF training (test group) or continuing psychotherapy (control group). Participants were blindly assessed for PTSD symptoms before and after the NF training period, followed by self-reported clinical follow-up at 1, 3, and 6 months, as well as one session of amygdala real-time fMRI-NF before and after NF training period.

RESULTS

Participants in the test group compared with the control group demonstrated a marginally significant immediate reduction in PTSD symptoms, which progressively improved during the follow-up period. In addition, successful neuromodulation during NF training was demonstrated.

CONCLUSION

This feasibility study for patients with treatment-resistant CSA-PTSD indicates that amyg-EFP-NF is a viable and efficient intervention.

Limbic self-neuromodulation as a novel treatment option for emotional dysregulation in premenstrual dysphoric disorder (PMDD); a proof-of-concept study

AIM

To assess the efficacy of a novel neurofeedback (NF) method, targeting limbic activity, to treat emotional dysregulation related to premenstrual dysphoric disorder (PMDD).

METHODS

We applied a NF probe targeting limbic activity using a functional magnetic resonance imaging-inspired electroencephalogram model (termed Amyg-EFP-NF) in a double-blind randomized controlled trial. A frontal alpha asymmetry probe (AAS-NF), served as active control. Twenty-seven participants diagnosed with PMDD (mean age = 33.57 years, SD = 5.67) were randomly assigned to Amyg-EFP-NF or AAS-NF interventions with a 2:1 ratio, respectively. The treatment protocol consisted of 11 NF sessions through three menstrual cycles, and a follow-up assessment 3 months thereafter. The primary outcome measure was improvement in the Revised Observer Version of the Premenstrual Tension Syndrome Rating Scale (PMTS-OR).

RESULTS

A significant group by time effect was observed for the core symptom subscale of the PMTS-OR, with significant improvement observed at follow-up for the Amyg-EFP group compared with the AAS group [F(1, 15)=4.968, P = 0.042]. This finding was specifically robust for reduction in anger [F(1, 15) = 22.254, P < 0.001]. A significant correlation was found between learning scores and overall improvement in core symptoms (r = 0.514, P = 0.042) suggesting an association between mechanism of change and clinical improvement.

CONCLUSION

Our preliminary findings suggest that Amyg-EFP-NF may serve as an affordable and accessible non-invasive treatment option for emotional dysregulation in women suffering from PMDD. Our main limitations were the relatively small number of participants and the lack of a sham-NF placebo arm.

Frontal alpha asymmetry interaction with an experimental story EEG brain-computer interface

Although interest in brain-computer interfaces (BCIs) from researchers and consumers continues to increase, many BCIs lack the complexity and imaginative properties thought to guide users toward successful brain activity modulation. We investigate the possibility of using a complex BCI by developing an experimental story environment with which users interact through cognitive thought strategies. In our system, the user's frontal alpha asymmetry (FAA) measured with electroencephalography (EEG) is linearly mapped to the color saturation of the main character in the story. We implemented a user-friendly experimental design using a comfortable EEG device and short neurofeedback (NF) training protocol. In our system, seven out of 19 participants successfully increased FAA during the course of the study, for a total of ten successful blocks out of 152. We detail our results concerning left and right prefrontal cortical activity contributions to FAA in both successful and unsuccessful story blocks. Additionally, we examine inter-subject correlations of EEG data, and self-reported questionnaire data to understand the user experience of BCI interaction. Results suggest the potential of imaginative story BCI environments for engaging users and allowing for FAA modulation. Our data suggests new research directions for BCIs investigating emotion and motivation through FAA.

Closed-loop neuromodulation for studying spontaneous activity and causality

Having established that spontaneous brain activity follows meaningful coactivation patterns and correlates with behavior, researchers have turned their attention to understanding its function and behavioral significance. We suggest closed-loop neuromodulation as a neural perturbation tool uniquely well suited for this task. Closed-loop neuromodulation has primarily been viewed as an interventionist tool to teach subjects to directly control their own brain activity. We examine an alternative operant conditioning model of closed-loop neuromodulation which, through implicit feedback, can manipulate spontaneous activity at the network level, without violating the spontaneous or endogenous nature of the signal, thereby providing a direct test of network causality.

A Two-Person Neuroscience Approach for Social Anxiety: A Paradigm With Interbrain Synchrony and Neurofeedback

Social anxiety disorder has been widely recognised as one of the most commonly diagnosed mental disorders. Individuals with social anxiety disorder experience difficulties during social interactions that are essential in the regular functioning of daily routines; perpetually motivating research into the aetiology, maintenance and treatment methods. Traditionally, social and clinical neuroscience studies incorporated protocols testing one participant at a time. However, it has been recently suggested that such protocols are unable to directly assess social interaction performance, which can be revealed by testing multiple individuals simultaneously. The principle of two-person neuroscience highlights the interpersonal aspect of social interactions that observes behaviour and brain activity from both (or all) constituents of the interaction, rather than analysing on an individual level or an individual observation of a social situation. Therefore, two-person neuroscience could be a promising direction for assessment and intervention of the social anxiety disorder. In this paper, we propose a novel paradigm which integrates two-person neuroscience in a neurofeedback protocol. Neurofeedback and interbrain synchrony, a branch of two-person neuroscience, are discussed in their own capacities for their relationship with social anxiety disorder and relevance to the paradigm. The newly proposed paradigm sets out to assess the social interaction performance using interbrain synchrony between interacting individuals, and to employ a multi-user neurofeedback protocol for intervention of the social anxiety.

The prefrontal cortex, pathological anxiety, and anxiety disorders

Anxiety is experienced in response to threats that are distal or uncertain, involving changes in one's subjective state, autonomic responses, and behavior. Defensive and physiologic responses to threats that involve the amygdala and brainstem are conserved across species. While anxiety responses typically serve an adaptive purpose, when excessive, unregulated, and generalized, they can become maladaptive, leading to distress and avoidance of potentially threatening situations. In primates, anxiety can be regulated by the prefrontal cortex (PFC), which has expanded in evolution. This prefrontal expansion is thought to underlie primates' increased capacity to engage high-level regulatory strategies aimed at coping with and modifying the experience of anxiety. The specialized primate lateral, medial, and orbital PFC sectors are connected with association and limbic cortices, the latter of which are connected with the amygdala and brainstem autonomic structures that underlie emotional and physiological arousal. PFC pathways that interface with distinct inhibitory systems within the cortex, the amygdala, or the thalamus can regulate responses by modulating neuronal output. Within the PFC, pathways connecting cortical regions are poised to reduce noise and enhance signals for cognitive operations that regulate anxiety processing and autonomic drive. Specialized PFC pathways to the inhibitory thalamic reticular nucleus suggest a mechanism to allow passage of relevant signals from thalamus to cortex, and in the amygdala to modulate the output to autonomic structures. Disruption of specific nodes within the PFC that interface with inhibitory systems can affect the negative bias, failure to regulate autonomic arousal, and avoidance that characterize anxiety disorders.

Amygdala electrical-finger-print (AmygEFP) NeuroFeedback guided by individually-tailored Trauma script for post-traumatic stress disorder: Proof-of-concept

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Randomized clinical trial with a novel self-neuromodulation training in PTSD.

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Demonstration of feasibility of an fMRI-informed EEG model of Amygdala modulation (AmygEFP).

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Individually-tailored trauma-related content as the training feedback interface.

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Results showed reduction of PTSD symptoms following AmygEFP trauma-related feedback training.

Background

Amygdala activity dysregulation plays a central role in post-traumatic stress disorder (PTSD). Hence learning to self-regulate one's amygdala activity may facilitate recovery. PTSD is further characterized by abnormal contextual processing related to the traumatic memory. Therefore, provoking the personal traumatic narrative while training amygdala down-regulation could enhance clinical efficacy. We report the results of a randomized controlled trial (NCT02544971) of a novel self-neuromodulation procedure (i.e. NeuroFeedback) for PTSD, aimed at down-regulating limbic activity while receiving feedback from an auditory script of a personal traumatic narrative. To scale-up applicability, neural activity was probed by an fMRI-informed EEG model of amygdala activity, termed Amygdala Electrical Finger-Print (AmygEFP).

Methods

Fifty-nine adults meeting DSM-5 criteria for PTSD were randomized between three groups: Trauma-script feedback interface (Trauma-NF) or Neutral feedback interface (Neutral-NF), and a control group of No-NF (to control for spontaneous recovery). Before and immediately after 15 NF training sessions patients were blindly assessed for PTSD symptoms and underwent one session of amygdala fMRI-NF for transferability testing. Follow-up clinical assessment was performed at 3- and 6-months following NF treatment.

Results

Patients in both NF groups learned to volitionally down-regulate AmygEFP signal and demonstrated a greater reduction in PTSD symptoms and improved down-regulation of the amygdala during fMRI-NF, compared to the No-NF group. The Trauma-NF group presented the largest immediate clinical improvement.

Conclusions

This proof-of-concept study indicates the feasibility of the AmygEFP-NF process-driven as a scalable intervention for PTSD and illustrates its clinical potential. Further investigation is warranted to elucidate the contribution of AmygEFP-NF beyond exposure and placebo effects.

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.

Prefrontal Asymmetry BCI Neurofeedback Datasets

Prefrontal cortex (PFC) asymmetry is an important marker in affective neuroscience and has attracted significant interest, having been associated with studies of motivation, eating behavior, empathy, risk propensity, and clinical depression. The data presented in this paper are the result of three different experiments using PFC asymmetry neurofeedback (NF) as a Brain-Computer Interface (BCI) paradigm, rather than a therapeutic mechanism aiming at long-term effects, using functional near-infrared spectroscopy (fNIRS) which is known to be particularly well-suited to the study of PFC asymmetry and is less sensitive to artifacts. From an experimental perspective the BCI context brings more emphasis on individual subjects' baselines, successful and sustained activation during epochs, and minimal training. The subject pool is also drawn from the general population, with less bias toward specific behavioral patterns, and no inclusion of any patient data. We accompany our datasets with a detailed description of data formats, experiment and protocol designs, as well as analysis of the individualized metrics for definitions of success scores based on baseline thresholds as well as reference tasks. The work presented in this paper is the result of several experiments in the domain of BCI where participants are interacting with continuous visual feedback following a real-time NF paradigm, arising from our long-standing research in the field of affective computing. We offer the community access to our fNIRS datasets from these experiments. We specifically provide data drawn from our empirical studies in the field of affective interactions with computer-generated narratives as well as interfacing with algorithms, such as heuristic search, which all provide a mechanism to improve the ability of the participants to engage in active BCI due to their realistic visual feedback. Beyond providing details of the methodologies used where participants received real-time NF of left-asymmetric increase in activation in their dorsolateral prefrontal cortex (DLPFC), we re-establish the need for carefully designing protocols to ensure the benefits of NF paradigm in BCI are enhanced by the ability of the real-time visual feedback to adapt to the individual responses of the participants. Individualized feedback is paramount to the success of NF in BCIs.

The Potential of Functional Near-Infrared Spectroscopy-Based Neurofeedback-A Systematic Review and Recommendations for Best Practice

Background: The effects of electroencephalography (EEG) and functional magnetic resonance imaging (fMRI)-neurofeedback on brain activation and behaviors have been studied extensively in the past. More recently, researchers have begun to investigate the effects of functional near-infrared spectroscopy-based neurofeedback (fNIRS-neurofeedback). FNIRS is a functional neuroimaging technique based on brain hemodynamics, which is easy to use, portable, inexpensive, and has reduced sensitivity to movement artifacts.

Method: We provide the first systematic review and database of fNIRS-neurofeedback studies, synthesizing findings from 22 peer-reviewed studies (including a total of N = 441 participants; 337 healthy, 104 patients). We (1) give a comprehensive overview of how fNIRS-neurofeedback training protocols were implemented, (2) review the online signal-processing methods used, (3) evaluate the quality of studies using pre-set methodological and reporting quality criteria and also present statistical sensitivity/power analyses, (4) investigate the effectiveness of fNIRS-neurofeedback in modulating brain activation, and (5) review its effectiveness in changing behavior in healthy and pathological populations.

Results and discussion: (1–2) Published studies are heterogeneous (e.g., neurofeedback targets, investigated populations, applied training protocols, and methods). (3) Large randomized controlled trials are still lacking. In view of the novelty of the field, the quality of the published studies is moderate. We identified room for improvement in reporting important information and statistical power to detect realistic effects. (4) Several studies show that people can regulate hemodynamic signals from cortical brain regions with fNIRS-neurofeedback and (5) these studies indicate the feasibility of modulating motor control and prefrontal brain functioning in healthy participants and ameliorating symptoms in clinical populations (stroke, ADHD, autism, and social anxiety). However, valid conclusions about specificity or potential clinical utility are premature.

Conclusion: Due to the advantages of practicability and relatively low cost, fNIRS-neurofeedback might provide a suitable and powerful alternative to EEG and fMRI neurofeedback and has great potential for clinical translation of neurofeedback. Together with more rigorous research and reporting practices, further methodological improvements may lead to a more solid understanding of fNIRS-neurofeedback. Future research will benefit from exploiting the advantages of fNIRS, which offers unique opportunities for neurofeedback research.

How Much Do Strategy Reports Tell About the Outcomes of Neurofeedback Training? A Study on the Voluntary Up-Regulation of the Sensorimotor Rhythm

The core learning mechanisms of neurofeedback (NF) training are associative, implicit, and, consequently, largely impervious to consciousness. Many other aspects of training that determine training outcomes, however, are accessible to conscious processing. The outcomes of sensorimotor rhythm (SMR) up-regulation training are related to the strategies reported by participants. The classification methods of individual strategies employed hitherto were possibly under influence of the idiosyncratic interpretation of the rater. To measure and possibly overcome this limitation, we employed independent raters to analyze strategies reported during SMR up-regulation training. Sixty-two healthy young participants took part in a single session of SMR up-regulation training. After completing six blocks of training, in which they received either simple visual feedback or a gamified version thereof, participants were required to report the strategies employed. Their individual learning outcomes were computed as well. Results point out that individual strategies as well as NF learning outcomes were not particularly sensitive to the presence of gamified elements in training the SMR up-regulation. A high degree of consistency across independent raters classifying strategy reports was observed. Some strategies were more typical of responders while other ones were more common among non-responders. In summary, we demonstrate a more objective and transparent way to analyze individual mental strategies to shed more light on the differences between NF responders and non-responders.

Multipurpose Virtual Reality Environment for Biomedical and Health Applications

Virtual reality is a trending, widely accessible, and contemporary technology of increasing utility to biomedical and health applications. However, most implementations of virtual reality environments are tailored to specific applications. We describe the complete development of a novel, open-source virtual reality environment that is suitable for multipurpose biomedical and healthcare applications. This environment can be interfaced with different hardware and data sources, ranging from gyroscopes to fMRI scanners. The developed environment simulates an immersive (first-person perspective) run in the countryside, in a virtual landscape with various salient features. The utility of the developed VR environment has been validated via two test applications: an application in the context of motor rehabilitation following injury of the lower limbs and an application in the context of real-time functional magnetic resonance imaging neurofeedback, to regulate brain function in specific brain regions of interest. Both applications were tested by pilot subjects that unanimously provided very positive feedback, suggesting that appropriately designed VR environments can indeed be robustly and efficiently used for multiple biomedical purposes. We attribute the versatility of our approach on three principles implicit in the design: selectivity, immersiveness, and adaptability. The software, including both applications, is publicly available free of charge, via a GitHub repository, in support of the Open Science Initiative. Although using this software requires specialized hardware and engineering know-how, we anticipate our contribution to catalyze further progress, interdisciplinary collaborations and replicability, with regards to the usage of virtual reality in biomedical and health applications.

Electrical fingerprint of the amygdala guides neurofeedback training for stress resilience

Real-time functional magnetic resonance imaging (rt-fMRI) has revived the translational perspective of neurofeedback (NF)¹. Particularly for stress management, targeting deeply located limbic areas involved in stress processing² has paved new paths for brain-guided interventions. However, the high cost and immobility of fMRI constitute a challenging drawback for the scalability (accessibility and cost-effectiveness) of the approach, particularly for clinical purposes³. The current study aimed to overcome the limited applicability of rt-fMRI by using an electroencephalography (EEG) model endowed with improved spatial resolution, derived from simultaneous EEG-fMRI, to target amygdala activity (termed amygdala electrical fingerprint (Amyg-EFP))^4-6. Healthy individuals (n = 180) undergoing a stressful military training programme were randomly assigned to six Amyg-EFP-NF sessions or one of two controls (control-EEG-NF or NoNF), taking place at the military training base. The results demonstrated specificity of NF learning to the targeted Amyg-EFP signal, which led to reduced alexithymia and faster emotional Stroop, indicating better stress coping following Amyg-EFP-NF relative to controls. Neural target engagement was demonstrated in a follow-up fMRI-NF, showing greater amygdala blood-oxygen-level-dependent downregulation and amygdala-ventromedial prefrontal cortex functional connectivity following Amyg-EFP-NF relative to NoNF. Together, these results demonstrate limbic specificity and efficacy of Amyg-EFP-NF during a stressful period, pointing to a scalable non-pharmacological yet neuroscience-based training to prevent stress-induced psychopathology.

A Motivational Model of BCI-Controlled Heuristic Search

Several researchers have proposed a new application for human augmentation, which is to provide human supervision to autonomous artificial intelligence (AI) systems. In this paper, we introduce a framework to implement this proposal, which consists of using Brain⁻Computer Interfaces (BCI) to influence AI computation via some of their core algorithmic components, such as heuristic search. Our framework is based on a joint analysis of philosophical proposals characterising the behaviour of autonomous AI systems and recent research in cognitive neuroscience that support the design of appropriate BCI. Our framework is defined as a motivational approach, which, on the AI side, influences the shape of the solution produced by heuristic search using a BCI motivational signal reflecting the user's disposition towards the anticipated result. The actual mapping is based on a measure of prefrontal asymmetry, which is translated into a non-admissible variant of the heuristic function. Finally, we discuss results from a proof-of-concept experiment using functional near-infrared spectroscopy (fNIRS) to capture prefrontal asymmetry and control the progression of AI computation of traditional heuristic search problems.

Unimodal Versus Bimodal EEG-fMRI Neurofeedback of a Motor Imagery Task

Neurofeedback is a promising tool for brain rehabilitation and peak performance training. Neurofeedback approaches usually rely on a single brain imaging modality such as EEG or fMRI. Combining these modalities for neurofeedback training could allow to provide richer information to the subject and could thus enable him/her to achieve faster and more specific self-regulation. Yet unimodal and multimodal neurofeedback have never been compared before. In the present work, we introduce a simultaneous EEG-fMRI experimental protocol in which participants performed a motor-imagery task in unimodal and bimodal NF conditions. With this protocol we were able to compare for the first time the effects of unimodal EEG-neurofeedback and fMRI-neurofeedback versus bimodal EEG-fMRI-neurofeedback by looking both at EEG and fMRI activations. We also propose a new feedback metaphor for bimodal EEG-fMRI-neurofeedback that integrates both EEG and fMRI signal in a single bi-dimensional feedback (a ball moving in 2D). Such a feedback is intended to relieve the cognitive load of the subject by presenting the bimodal neurofeedback task as a single regulation task instead of two. Additionally, this integrated feedback metaphor gives flexibility on defining a bimodal neurofeedback target. Participants were able to regulate activity in their motor regions in all NF conditions. Moreover, motor activations as revealed by offline fMRI analysis were stronger during EEG-fMRI-neurofeedback than during EEG-neurofeedback. This result suggests that EEG-fMRI-neurofeedback could be more specific or more engaging than EEG-neurofeedback. Our results also suggest that during EEG-fMRI-neurofeedback, participants tended to regulate more the modality that was harder to control. Taken together our results shed first light on the specific mechanisms of bimodal EEG-fMRI-neurofeedback and on its added-value as compared to unimodal EEG-neurofeedback and fMRI-neurofeedback.