Reflecting on JMVFH’s most popular article of 2020: ‘Regulating posttraumatic stress disorder symptoms with neurofeedback: Regaining control of the mind’
Publication: Journal of Military, Veteran and Family Health
Volume 10, Number 4-EN
Posttraumatic stress disorder (PTSD) is a debilitating mental health condition with complex symptomatology and a high degree of comorbidity.1 In both the Canadian and global military and Veteran communities, treating PTSD proves challenging. Indeed, a considerable proportion of clients are treatment resistant to currently available first-line interventions, whereby high dropout rates remain of critical concern.2–8 In our 2020 Nicholson et al.9 Journal of Military, Veteran and Family Health (JMVFH) article, we discussed the use of neurofeedback as an emerging, novel intervention for the treatment of PTSD. Neurofeedback involves self-regulationachieved through the real-time feedback of neural states. This method is non-invasive and helps individuals to directly regulate brain activity associated with their symptoms. Importantly, given the heterogeneity in PTSD symptom presentation and treatment responses, personalized medicine approaches like neurofeedback are essential for improving treatment gains.
Our JMVFH article critically examined the neural mechanisms underlying the therapeutic effects associated with neurofeedback in the context of PTSD and explored the implementation of both real-time functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) modalities of neurofeedback. Further, our article discussed the use of this treatment intervention within military and Veteran communities affected by PTSD. Notably, since our 2020 neurofeedback publication in the JMVFH, our international team has championed several research and clinical efforts in the neurofeedback space.
Critically, one of the most challenging decisions that clinicians and researchers currently face is choosing an optimal brain region by which to generate the neurofeedback signal. Accordingly, we aimed to enrich the current knowledge base through scientific explorations of different neurofeedback brain region targets for PTSD. Previously, the majority of real-time fMRI neurofeedback studies targeted the regulation of the amygdala. During both rest and exposure to trauma triggers, activity in the amygdala (an area associated with emotion generation and fear/anxiety processing) has been robustly linked to PTSD symptoms. Hyperactivity within the amygdala is believed to stem from reduced top-down inhibition from emotion regulation regions in the prefrontal cortex.10
However, it is becoming increasingly apparent that the fronto-limbic model, as previously described, does not explain the full range of symptoms experienced by individuals with PTSD.11 Instead, the posterior cingulate cortex (PCC) is gaining recognition as another central brain region that is involved in PTSD psychopathology. The PCC is thought to represent the point of intersection between trauma and the sense-of-self and is involved in altered self-referential processing and social cognition in the aftermath of trauma, whereby hyperactivity within the PCC has been observed during the reliving and re-experiencing of trauma-related autobiographical memories in PTSD.11–13 Critically, however, no studies to date had conducted a direct comparison between multiple neurofeedback brain region targets (i.e., the amygdala and the PCC) among individuals with PTSD. To address this gap, we conducted a real-time fMRI neurofeedback study in 2023 comparing the differential effects of targeting the amygdala as compared to the PCC within a single neurofeedback session. We found that only regulation of the PCC led to significantly reduced symptoms of reliving and distress during one session of neurofeedback.11 Furthermore, although both participant groups were able to downregulate activity within their respective target brain regions to a similar extent, only the PCC group — as compared with the amygdala group — showed widespread whole brain decreases in activity within several brain regions involved in PTSD. Conversely, for the amygdala group, as compared with the PCC group, there were no significant unique (i.e., over and above that of the PCC group) regulatory decreases in neural activity. On balance, emerging evidence from network-level neuroscience studies suggests the PCC — because of its heterogeneous functionality, highly connected nature, and involvement in regulating both regional and global neural dynamics — may be a particularly fruitful target for regulation using neurofeedback.11
Taken together, this research may help to inform or optimize neurofeedback brain targets for the treatment of PTSD. Moreover, these findings also align with emerging paradigm shifts in the field of psychiatry that are moving away from fear- and anxiety-based theoretical models of PTSD.12 Future clinical trials investigating the use of real-time fMRI neurofeedback as a neuroscientifically guided treatment intervention are urgently needed to reduce illness burden. As an extension of this important pillar of research, we are currently conducting a Canadian Institutes of Health Research double-blind, randomized, sham-controlled trial (RCT) investigating amygdala versus PCC-targeted neurofeedback with fMRI over multiple sessions of training (NCT05456958).
Furthermore, our group recently conducted a 20-session, double-blind RCT of alpha-desynchronizing EEG neurofeedback for the treatment of PTSD.14–16 This is a recent milestone in our team’s 10-year neurofeedback research program that aims to build the evidence base regarding the effectiveness of EEG-based neurofeedback therapy. In this RCT, we observed significant decreases in PTSD symptom severity in the active neurofeedback group, with over 60% of trial participants no longer meeting diagnostic criteria for PTSD by the end of the trial. Importantly, no study participants left the trial, suggesting this form of neurofeedback therapy is highly tolerable and effective for the treatment of trauma-related symptoms. Findings from this RCT also demonstrate that neurofeedback brain training resulted in a rebound of alpha waves within the same areas of the brain that showed decreased alpha before treatment among individuals with PTSD as compared with healthy controls. Enhancing alpha waves in this context is crucial, as numerous studies consistently demonstrated a strong correlation between reduced alpha waves and symptoms of PTSD (whereby decreased alpha waves have been hypothesized to reflect chronic states of hyperarousal and hypervigilance in PTSD).15 In the same trial, fMRI data collected before and after the EEG neurofeedback intervention showed that disrupted brain networks associated with PTSD symptoms shifted toward normalization after treatment,14 supporting evidence of neurofeedback’s ability to heal the brain in the aftermath of trauma. We also found neurofeedback brain training improved engagement of emotional control regions during cognitive tasks that involved exposure to trauma reminders.16 Extending our 20-session RCT, we are currently conducting experiments to determine the optimal treatment dosage for alpha-based neurofeedback aimed at alleviating PTSD symptoms. Additionally, we are exploring potential variations in treatment efficacy across diverse presentations of the disorder.
Notably, whereas most evidence-based therapies for PTSD focus on the processing of traumatic memories, the target of neurofeedback is neural regulation, stabilization, homeostasis, and restoration of balance in the brain. Accordingly, neurofeedback may be especially beneficial for individuals with PTSD who may be too dysregulated, anxious, or dissociative to tolerate other forms of exposure-based treatments.14 Importantly, neurofeedback can be used in combination with other treatments, such as prolonged exposure therapy and trauma-focused psychotherapy, and may be tailored to fit individual needs. While our recent clinical trial examined the effectiveness of neurofeedback as a treatment on its own, we are currently conducting research examining the use of neurofeedback as a complementary adjunctive intervention to psychotherapy. Within a virtual, at-home environment, individuals taking part in this trial self-regulate brain waves using a portable and cost-effective form of neurofeedback for 30 minutes before participating in virtual group-based psychotherapy over 9 weeks. This work holds significance, as more research is currently needed to fully uncover the benefits of neurofeedback, particularly with respect to how it can be used in virtual environments and in combination with other treatment modalities to improve outcomes.
To mobilize and translate findings from our single-session mechanistic studies of real-time fMRI neurofeedback, and our 20-session EEG neurofeedback clinical trial, our team of researchers (Drs. Andrew Nicholson, Ruth Lanius, and Tomas Ros) partnered with the Atlas Institute for Veterans and Families to organize a Canada-wide neurofeedback webinar in 2023 entitled “Neurofeedback: A Promising New Treatment for PTSD.” This webinar included a panel discussion of clinicians/service providers, researchers, and individuals from the Veteran community with lived experience using neurofeedback to address their PTSD symptoms. Currently, the authors of this article are also working with the Atlas Institute for Veterans and Families to facilitate neurofeedback training/clinical implementation in several Canadian clinics serving military members and Veterans.
Overall, our collective efforts represent a significant step forward in understanding the potential of neurofeedback as a viable treatment option for PTSD. This body of research also highlights the importance of exploring additional innovative mind-body treatments for PTSD, such as deep brain reorienting17 and 3MDR.18,19 Moving forward, it will be important for policy makers to enhance the availability of emerging evidence-based mind-body treatments to improve clinical outcomes for individuals affected by PTSD. Facilitating access to these treatments offers hope not only to military members and Veterans, but also to their families. Indeed, future treatment outcome studies are also needed to evaluate improvements in the overall well-being of the entire family unit.
In conclusion, we envision this program of research will stimulate future inquiries, thereby catalyzing a deeper exploration of the neural pathways underlying the therapeutic effects of neurofeedback. Through continued investigation, we aim to refine and further validate the efficacy of novel treatment interventions for PTSD, ultimately enhancing their utility in addressing the complex manifestations of this debilitating mental health disorder.
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Journal of Military, Veteran and Family Health
Volume 10 • Number 4-EN • September 2024
Pages: 79 - 82
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Published in print: September 2024
Published online: 16 September 2024
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Journal of Military, Veteran and Family Health 2024 10:4-EN, 79-82
Journal of Military, Veteran and Family Health 2024 10:4-EN, 79-82