Efficacy of Neuro-Feedback Training for PTSD Symptoms: A Systematic Review and Meta-Analysis

Getting stress-related disorders under control: the untapped potential of neurofeedback

Stress-related disorders are among the biggest global health challenges. Despite significant progress in understanding their neurocognitive basis, the promise of applying insights from fundamental research to prevention and treatment remains largely unfulfilled. We argue that neurofeedback - a method for training voluntary control over brain activity - has the potential to fill this translational gap. We provide a contemporary perspective on neurofeedback as endogenous neuromodulation that can target complex brain network dynamics, is transferable to real-world scenarios outside a laboratory or treatment facility, can be trained prospectively, and is individually adaptable. This makes neurofeedback a prime candidate for a personalized preventive neuroscience-based intervention strategy that focuses on the ecological momentary neuromodulation of stress-related brain networks in response to actual stressors in real life.

Neurofeedback and meditation technology in outpatient offender treatment: a feasibility and usability pilot study

Introduction

Although Cognitive Behavioral Therapy (CBT) is the most often used intervention in forensic treatment, its effectivity is not consistently supported. Interventions incorporating knowledge from neuroscience could provide for more successful intervention methods.

Methods

The current pilot study set out to assess the feasibility and usability of the study protocol of a 4-week neuromeditation training in adult forensic outpatients with impulse control problems. The neuromeditation training, which prompts awareness and control over brain states of restlessness with EEG neurofeedback, was offered in addition to treatment as usual (predominantly CBT).

Results

Eight patients completed the neuromeditation training under guidance of their therapists. Despite some emerging obstacles, overall, the training was rated sufficiently usable and feasible by patients and their therapists.

Discussion

The provided suggestions for improvement can be used to implement the intervention in treatment and set up future trials to study the effectiveness of neuromeditation in offender treatment.

Systematic review and meta-analysis of neurofeedback and its effect on posttraumatic stress disorder

Background

To date, only one systematic review and meta-analysis of randomized controlled trials (RCTs) has evaluated the effect of neurofeedback in PTSD, which included only four studies and found an uncertainty of the effect of EEG-NF on PTSD symptoms. This meta-analysis is an update considering that numerous studies have since been published. Additionally, more recent studies have included fMRI-NF as well as fMRI-guided or -inspired EEG NF.

Methods

Systematic literature searches for RCTs were conducted in three online databases. Additional hand searches of each study identified and of systematic reviews and meta-analyses published were also undertaken. Outcomes evaluated the effect of neurofeedback vs. a control (active, sham, and waiting list) on their effects in reducing PTSD symptoms using various health instruments. Meta-analytical methods used were inverse variance random-effects models measuring both mean and standardized mean differences. Quality and certainty of the evidence were assessed using GRADE. Adverse events were also evaluated.

Results

A total of 17 studies were identified evaluating a total of 628 patients. There were 10 studies used in the meta-analysis. Results from all studies identified favored neurofeedback's effect on reducing PTSD symptoms including BDI pretest-posttest [mean difference (MD): 8.30 (95% CI: 3.09 to 13.52; P = 0.002; I 2 = 0%)]; BDI pretest-follow-up (MD: 8.75 (95% CI: 3.53 to 13.97; P < 0.00001; I 2 = 0%); CAPS-5 pretest-posttest [MD: 7.01 (95% CI: 1.36 to 12.66; P = 0.02; I 2 = 86%)]; CAPS-5 pretest-follow-up (MD: 10 (95% CI: 1.29 to 21.29; P = 0.006; I 2 = 77%); PCL-5 pretest-posttest (MD: 7.14 (95% CI: 3.08 to 11.2; P = 0.0006; I 2 = 0%); PCL-5 pretest-follow-up (MD: 14.95 (95% CI: 7.95 to 21.96; P < 0.0001; I 2 = 0%). Other studies reported improvements using various other instruments. GRADE assessments of CAPS, PCL, and BDI demonstrated a moderate/high level in the quality of the evidence that NF has a positive clinical effect.

Conclusion

Based on newer published studies and the outcomes measured, NF has demonstrated a clinically meaningful effect size, with an increased effect size at follow-up. This clinically meaningful effect appears to be driven by newer fMRI-guided NF and deeper brain derivates of it.

Increasing Value and Reducing Waste of Research on Neurofeedback Effects in Post-traumatic Stress Disorder: A State-of-the-Art-Review

Post-Traumatic Stress Disorder (PTSD) is often considered challenging to treat due to factors that contribute to its complexity. In the last decade, more attention has been paid to non-pharmacological or non-psychological therapies for PTSD, including neurofeedback (NFB). NFB is a promising non-invasive technique targeting specific brainwave patterns associated with psychiatric symptomatology. By learning to regulate brain activity in a closed-loop paradigm, individuals can improve their functionality while reducing symptom severity. However, owing to its lax regulation and heterogeneous legal status across different countries, the degree to which it has scientific support as a psychiatric treatment remains controversial. In this state-of-the-art review, we searched PubMed, Cochrane Central, Web of Science, Scopus, and MEDLINE and identified meta-analyses and systematic reviews exploring the efficacy of NFB for PTSD. We included seven systematic reviews, out of which three included meta-analyses (32 studies and 669 participants) that targeted NFB as an intervention while addressing a single condition-PTSD. We used the MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 and the criteria described by Cristea and Naudet (Behav Res Therapy 123:103479, 2019, https://doi.org/10.1016/j.brat.2019.103479 ) to identify sources of research waste and increasing value in biomedical research. The seven assessed reviews had an overall extremely poor quality score (5 critically low, one low, one moderate, and none high) and multiple sources of waste while opening opportunities for increasing value in the NFB literature. Our research shows that it remains unclear whether NFB training is significantly beneficial in treating PTSD. The quality of the investigated literature is low and maintains a persistent uncertainty over numerous points, which are highly important for deciding whether an intervention has clinical efficacy. Just as importantly, none of the reviews we appraised explored the statistical power, referred to open data of the included studies, or adjusted their pooled effect sizes for publication bias and risk of bias. Based on the obtained results, we identified some recurrent sources of waste (such as a lack of research decisions based on sound questions or using an appropriate methodology in a fully transparent, unbiased, and useable manner) and proposed some directions for increasing value (homogeneity and consensus) in designing and reporting research on NFB interventions in PTSD.

Neurofeedback for post-traumatic stress disorder: systematic review and meta-analysis of clinical and neurophysiological outcomes

Background: Posttraumatic stress disorder (PTSD) is a debilitating condition affecting millions of people worldwide. Existing treatments often fail to address the complexity of its symptoms and functional impairments resulting from severe and prolonged trauma. Electroencephalographic Neurofeedback (NFB) has emerged as a promising treatment that aims to reduce the symptoms of PTSD by modulating brain activity.Objective: We conducted a systematic review and meta-analysis of ten clinical trials to answer the question: how effective is NFB in addressing PTSD and other associated symptoms across different trauma populations, and are these improvements related to neurophysiological changes?Method: The review followed the Preferred Reporting Items for Systematic Reviews and Meta analyses guidelines. We considered all published and unpublished randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs) involving adults with PTSD as a primary diagnosis without exclusion by type of trauma, co-morbid diagnosis, locality, or sex. Ten controlled studies were included; seven RCTs and three NRSIs with a total number of participants n = 293 (128 male). Only RCTs were included in the meta-analysis (215 participants; 88 male).Results: All included studies showed an advantage of NFB over control conditions in reducing symptoms of PTSD, with indications of improvement in symptoms of anxiety and depression and related neurophysiological changes. Meta-analysis of the pooled data shows a significant reduction in PTSD symptoms post-treatment SMD of -1.76 (95% CI -2.69, -0.83), and the mean remission rate was higher in the NFB group (79.3%) compared to the control group (24.4%). However, the studies reviewed were mostly small, with heterogeneous populations and varied quality.Conclusions: The effect of NFB on the symptoms of PTSD was moderate and mechanistic evidence suggested that NFB leads to therapeutic changes in brain functioning. Future research should focus on more rigorous methodological designs, expanded sample size and longer follow-up.