Brain imaging: on the way toward a therapeutic discipline

Real-time fMRI neurofeedback compared to cognitive behavioral therapy in a pilot study for the treatment of mild and moderate depression

Real-time functional magnetic resonance imaging (rt-fMRI) neurofeedback was found to reduce depressive symptoms. However, no direct comparison of drug-free patients with an active psychotherapy control group is available. The present study compared rt-fMRI neurofeedback with cognitive behavioral therapy, as the standard treatment in patients declining anti-depressants. Twenty adult, drug-free patients with mild or moderate depression were non-randomly assigned either to a course of eight half-hour sessions of neurofeedback targeting the left medial prefrontal cortex (N = 12) or to a 16-session course of cognitive behavioral therapy (N = 8). Montgomery-Asberg Depression Rating Scale was introduced at baseline, mid-treatment, and end-treatment points. In each group, 8 patients each remained in the study to a mid-treatment evaluation and 6 patients each to the study end-point. ANOVA revealed a depression reduction with a significant effect of Time (F(3,6) = 19.0, p < 0.001, η² = 0.76). A trend to greater improvement in the cognitive behavioral therapy group compared to neurofeedback emerged (Group × Time; p = 0.078). Percent signal change in the region of interest between up- and down-regulation conditions was significantly correlated with session number (Pearson's r = 0.85, p < 0.001) indicating a learning effect. As limitations, small sample size could lead to insufficient power and non-random allocation to selection bias. Both neurofeedback and cognitive behavioral therapy improved mild and moderate depression. Neurofeedback was not superior to cognitive behavioral therapy. Noteworthy, the neurofeedback training course was associated with continuous improvement in the self-regulation skill, without plateau. This study delivers data to plan clinical trials comparing neurofeedback with cognitive behavioral interventions.

Electroencephalographic neurofeedback: Level of evidence in mental and brain disorders and suggestions for good clinical practice

The technique of electroencephalographic neurofeedback (EEG NF) emerged in the 1970s and is a technique that measures a subject's EEG signal, processes it in real time, extracts a parameter of interest and presents this information in visual or auditory form. The goal is to effectuate a behavioural modification by modulating brain activity. The EEG NF opens new therapeutic possibilities in the fields of psychiatry and neurology. However, the development of EEG NF in clinical practice requires (i) a good level of evidence of therapeutic efficacy of this technique, (ii) a good practice guide for this technique. Firstly, this article investigates selected trials with the following criteria: study design with controlled, randomized, and open or blind protocol, primary endpoint related to the mental and brain disorders treated and assessed with standardized measurement tools, identifiable EEG neurophysiological targets, underpinned by pathophysiological relevance. Trials were found for: epilepsies, migraine, stroke, chronic insomnia, attentional-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, major depressive disorder, anxiety disorders, addictive disorders, psychotic disorders. Secondly, this article investigates the principles of neurofeedback therapy in line with learning theory. Different underlying therapeutic models are presented didactically between two continua: a continuum between implicit and explicit learning and a continuum between the biomedical model (centred on "the disease") and integrative biopsychosocial model of health (centred on "the illness"). The main relevant learning model is to link neurofeedback therapy with the field of cognitive remediation techniques. The methodological specificity of neurofeedback is to be guided by biologically relevant neurophysiological parameters. Guidelines for good clinical practice of EEG NF concerning technical issues of electrophysiology and of learning are suggested. These require validation by institutional structures for the clinical practice of EEG NF.

Upregulation of the rostral anterior cingulate cortex can alter the perception of emotions: fMRI-based neurofeedback at 3 and 7 T

Recent advances in real-time functional magnetic resonance imaging (rt-fMRI) techniques enable online feedback about momentary brain activity from a localized region of interest. The anterior cingulate cortex (ACC) as a central hub for cognitive and emotional networks and its modulation has been suggested to elicit mood changes. In the presented real-time fMRI neurofeedback experiment at a 3 and a 7 T scanner we enabled participants to regulate ACC activity within one training session. The session consisted of three training runs of 8.5 min where subjects received online feedback about their current ACC activity. Before and after each run we presented emotional prosody. Subjects rated these stimuli according to their emotional valence and arousal, which served as an implicit mood measure. We found increases in ACC activation at 3 T (n = 15) and at 7 T (n = 9) with a higher activation success for the 3 T group. FMRI signal control of the rostral ACC depended on signal quality and predicted a valence bias in the rating of emotional prosody. Real-time fMRI neurofeedback of the ACC is feasible at different magnetic field strengths and can modulate localized ACC activity and emotion perception. It promises non-invasive therapeutic approaches for different psychiatric disorders characterized by impaired self-regulation.

The covariation of independent and dependant variables in neurofeedback: a proposal framework to identify cognitive processes and brain activity variables

This methodological article proposes a framework for analysing the relationship between cognitive processes and brain activity using variables measured by neurofeedback (NF) carried out by functional Magnetic Resonance Imagery (fMRI NF). Cognitive processes and brain activity variables can be analysed as either the dependant variable or the independent variable. Firstly, we propose two traditional approaches, defined in the article as the "neuropsychological" approach (NP) and the "psychophysiology" approach (PP), to extract dependent and independent variables in NF protocols. Secondly, we suggest that NF can be inspired by the style of inquiry used in neurophenomenology. fMRI NF allows participants to experiment with his or her own cognitive processes and their effects on brain region of interest (ROI) activations simultaneously. Thus, we suggest that fMRI NF could be improved by implementing "the elicitation interview method", which allows the investigator to gather relevant verbatim from participants' introspection on subjective experiences.

Cyborg psychiatry to ensure agency and autonomy in mental disorders. A proposal for neuromodulation therapeutics

Neuromodulation therapeutics—as repeated Transcranial Magnetic Stimulation (rTMS) and neurofeedback—are valuable tools for psychiatry. Nevertheless, they currently face some limitations: rTMS has confounding effects on neural activation patterns, and neurofeedback fails to change neural dynamics in some cases. Here we propose how coupling rTMS and neurofeedback can tackle both issues by adapting neural activations during rTMS and actively guiding individuals during neurofeedback. An algorithmic challenge then consists in designing the proper recording, processing, feedback, and control of unwanted effects. But this new neuromodulation technique also poses an ethical challenge: ensuring treatment occurs within a biopsychosocial model of medicine, while considering both the interaction between the patients and the psychiatrist, and the maintenance of individuals' autonomy. Our solution is the concept of Cyborg psychiatry, which embodies the technique and includes a self-engaged interaction between patients and the neuromodulation device.

[Towards a new approach of neurophysiology in clinical psychiatry: functional magnetic resonance imaging neurofeedback applied to emotional dysfunctions]

Emotions color in a singular way our everyday life and constitute important determinants of human cognition and behavior. Emotional regulation is an essential process involved in neuropathophysiology and therapeutic efficacy in many psychiatric disorders. Yet, traditional psychiatric therapeutic has focused on symptomatic rather than neurophysiological criteria. Therefore, it was proposed to teach patients to modify their own brain activity directly, in order to obtain a therapeutic effect. These techniques, which are named neurofeedback, were originally developed using electroencephalography. Recent technical advances in fMRI enable real-time acquisition, and open opportunities to its utilization in neurofeedback. This seems particularly interesting in emotion regulation, which, at a neurofunctional level, lies on cortico-limbic pathways that, in great parts, were previously identified by traditional fMRI paradigms. This emotion regulation plays a central role in the etiopathogeny psychiatric, especially depressive and anxious, disorders. It is possible to devise new therapeutic strategies and research approach for addressing directly the neurophysiological processes of emotion regulation by integrating the neurofunctional activities of a subject. These prospects seem to be in line with the neurophenomenology project, which proposes to establish a link between subjective experiences and objective neurophysiological measures.

Dysfunctional pain modulation in somatoform pain disorder patients

To date, pain perception is thought to be a creative process of modulation carried out by an interplay of pro- and anti-nociceptive mechanisms. Recent research demonstrates that pain experience constitutes the result of top-down processes represented in cortical descending pain modulation. Cortical, mainly medial and frontal areas, as well as subcortical structures such as the brain stem, medulla and thalamus seem to be key players in pain modulation. An imbalance of pro- and anti-nociceptive mechanisms are assumed to cause chronic pain disorders, which are associated with spontaneous pain perception without physiologic scaffolding or exaggerated cortical activation in response to pain exposure. In contrast to recent investigations, the aim of the present study was to elucidate cortical activation of somatoform pain disorder patients during baseline condition. Scalp EEG, quantitative Fourier-spectral analyses and LORETA were employed to compare patient group (N = 15) to age- and sex-matched controls (N = 15) at rest. SI, SII, ACC, SMA, PFC, PPC, insular, amygdale and hippocampus displayed significant spectral power reductions within the beta band range (12-30 Hz). These results suggest decreased cortical baseline arousal in somatoform pain disorder patients. We finally conclude that obtained results may point to an altered baseline activity, maybe characteristic for chronic somatoform pain disorder.

State of psychiatry in Germany

Psychiatry in Germany is characterized by high relevance both individually and socioeconomically, and by the burden caused by mental disorders as lifelong diseases. This is comparable to most industrialized countries in the world. For Germany, the role of psychiatry in Nazi-Germany has to be critically discussed and still remains incompletely researched. Another more current focus has to be directed to attracting the most promising young students to the discipline. Psychiatry promises to profit especially from new approaches that combine scientific and clinical expertise in education and professional career.