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EASY-TO-UNDERSTAND SUMMARY: NEUROFEEDBACK
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What is neurofeedback and how does it work?

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How does neurofeedback affect people without mental health diagnoses & do the benefits last?

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What are the benefits of neurofeedback for PTSD?

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How does neurofeedback impact the amygdala - a part of the brain that detects threats?

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How does one session of neurofeedback impact people with no mental health diagnoses compared to people with PTSD?

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How does neurofeedback impact key brain networks in people with PTSD?

What is neurofeedback?
What is neurofeedback and how does it work?

Neurofeedback is a type of brain training in which a person is given information (or feedback) from their own brain activity, with the idea that, with this information, they might be able to learn to change how their brain is working (i.e., to make their brain be healthier or more effective). 

In our studies, the feedback that people received was mostly visual – for example, a thermometer-like image showing them when their brain became more or less active, or a video-game character moving in response to their brain activity.  In some studies, however, there was also a beep sound that guided their brain activity.  Using the feedback as their guide, participants could try to alter what their brain was doing.  If the thermometer was too high, or if their character stopped moving, they could make a change in what their brain was doing.  Once the thermometer decreased or the character began moving again, the participant would know they were making a change in the right direction. 

In the studies below, you will see the term “EEG”, which stands for electroencephalogram - a method of recording brain activity using sensors placed on the scalp. EEG-based neurofeedback uses recordings of the individual’s brain activity to provide the feedback needed to guide the brain training.  It has been used to effectively treat many issues that arise from the brain working in less ideal ways, for example, attention deficit, anxiety, migraine, and sleep disorders.  The image below shows the basic setup for neurofeedback. 

neurofeedback_57461377 (1).png

Within our brains, there are different frequencies, or waves, of energy (e.g., alpha, beta, theta waves – see an image of these below), and these are what the scalp sensors are recording in neurofeedback.  Brain waves are similar to waves of light or sound.  For the following neurofeedback studies, we designed neurofeedback brain training to target alpha waves.  Alpha waves play a role in calm awareness, mind/body integration, learning, and general mental co-ordination. Alpha waves are most active when a person is relaxed but still aware of themselves and their surroundings. 

To better understand the brain’s alpha waves, think about a car idling at a stoplight – the motor is running and ready for use, but the car is still.  This could be compared to our brain’s alpha wave state – when our alpha waves are active, we’re awake and aware of our surroundings but we’re calm and relaxed.  Unfortunately, individuals with PTSD struggle to feel calm or relaxed, and they often feel overly alert, so we hoped that addressing alpha waves would be a helpful approach in treating PTSD.   

Ros et al 2013 - Neurofeedback
How does neurofeedback affect people without mental health diagnoses, and do the benefits last?

Ros, T., Théberge, J., Frewen, P.A., Kluetsch, R., Densmore, M., Calhoun, V.D., & Lanius, R.A. (2013). Mind over chatter: Plastic up-regulation of the fMRI salience network directly after EEG neurofeedback. NeuroImage, 65, 324–335.

Knowing how effective neurofeedback can be in treating certain mental health conditions, we wondered whether EEG neurofeedback could be helpful in treating PTSD (Post-traumatic Stress Disorder). To begin investigating this possibility, we wanted to better understand how neurofeedback might affect people without any mental health diagnoses.  In particular, we wanted to know if changes in brain function could be made with only one session of neurofeedback, and whether these changes would last beyond the session itself. 

For this study, we recruited both men and women without mental health diagnoses, and we designed the neurofeedback to impact alpha brain waves. To help us determine what kind of changes might arise in brain activity after one session of neurofeedback, we used fMRI scans (functional Magnetic Resonance Imaging) before and after neurofeedback. An fMRI scan takes many images of the brain to reveal which areas are being used while completing a mental activity – in this study, it was an attention task. 

To help us to be sure any changes in brain activity were due to neurofeedback, half of the participants received real neurofeedback (i.e., normal neurofeedback, where the feedback given was based on their own brain’s activity), while the other half received simulated neurofeedback (i.e., feedback based on someone else’s pre-recorded brain activity – not their own).  Participants did not know which type of neurofeedback they were receiving, as each person received authentic-looking feedback.  This allowed us to determine whether any results were due to neurofeedback, or perhaps to the effect of something else (e.g., having an fMRI scan, placebo effect). 

Results were quite exciting – they showed that one session of neurofeedback (targeting alpha waves) increased connections within parts of the brain referred to as the “salience network”.  A “network” refers to a group of brain areas that communicate with one another, and the salience network is thought to be involved in mental alertness and the ability to pay attention to our senses.  These are abilities often impacted by PTSD.

Consistent with the increased connections we saw in the fMRI scans, participants also showed and reported better focus during the attention task after neurofeedback.  Further, their improved focus lasted at least 30 minutes after neurofeedback had ended, suggesting neurofeedback can have a lasting impact on the brain. We also found increased connections in the “default mode network” which is thought to play an important role in processing information about ourselves, and social interactions. 

Increasing the connections in both of these networks could prove to be helpful in treating PTSD – perhaps by impacting focus, self-awareness, and social interaction, etc.  Overall, these results suggest that neurofeedback shows promise as a treatment for PTSD, and that it may have a lasting impact on brain function.

Kleutsch and others - EEG Neurofeedback for PTSD
What are the benefits of neurofeedback for people with PTSD?

Kluetsch RC, Ros T, Théberge J, Frewen PA, Calhoun VD, Schmahl C, Jetly R, Lanius RA. (2014). Plastic modulation of PTSD resting-state networks by EEG neurofeedback. Acta Psychiatr Scand, 130: 123–136.

Following up on our previous study on the effects of EEG Neurofeedback on brain function in individuals with no mental health diagnoses, we were interested in researching its impact on individuals diagnosed with PTSD (Post-traumatic Stress Disorder).  Once again, we targeted alpha brain waves (i.e., those active during relaxed focus).  For the current study, we enrolled adult women who had experienced chronic childhood abuse.  As we did before, we used fMRI brain scans (functional Magnetic Resonance Imaging) before and after neurofeedback to help us assess any changes in brain activity. 

Results showed that our participants were able to change their alpha brain waves after only one session of neurofeedback, and that this process was connected to positive changes in their brain function.  More specifically, as in our previous study, we could see increased connections within the “salience network” of the brain, which is thought to be involved in mental alertness and the ability to pay attention to one’s senses.  Previous research suggests that connections in this network are often weaker in those diagnosed with PTSD, so finding a way to potentially increase them is exciting. 

We also saw better connections within the “default mode network” - thought to play an important role in processing information about social interactions and thoughts/beliefs about oneself.  Increasing the connections in both of these brain networks are promising in terms of treatment for PTSD.  Seemingly connected to the changes in brain activity following neurofeedback, the women in our study reported an increased sense of calmness – which, arguably, might be one of the main goals of any PTSD treatment.  Overall, results of this study suggest that neurofeedback has promise as a treatment for PTSD.

Amygdala
How does neurofeedback impact the amygdala - a part of the brain that detects threats?

Nicholson AA, Ros T, Frewen PA, Densmore M, Théberge J, Kluetsch RC, Jetly R, & Lanius RA. (2016). Alpha oscillation neurofeedback modulates amygdala complex connectivity and arousal in posttraumatic stress disorder. NeuroImage: Clinical 12, 506–516.

The amygdala is a brain area that plays an important role in symptoms of PTSD.  It can be compared to a smoke alarm, in that its role is to quickly detect threat or danger.  Unfortunately, with PTSD, this “smoke alarm” can become oversensitive, often detecting danger when there is none.  While this hypersensitivity may have been helpful in keeping the person safe in the past, in the present (if they’re no longer in a threatening environment), it can interfere with regular life with false alarms. 

Our current study continued the investigation started in 2014 by Kluetsch and others (described above), exploring neurofeedback in women who had experienced chronic abuse as children.  As a reminder, these women completed one session of EEG neurofeedback that targeted alpha brain waves (i.e., brain activity involved in relaxed focus).  In order to track any changes in brain activity that might have resulted from neurofeedback, fMRI (functional Magnetic Resonance Imaging) brain scans were completed before and after neurofeedback training.  For this study, we were particularly interested in any changes that might have happened in the amygdala. 

Our analysis suggested that neurofeedback seemed to change the communication between the amygdala and other brain areas.  Before the neurofeedback session, there was strong communication between the amygdala and other brain areas that are involved in fear processing and fear memories.  This makes sense knowing the symptoms of PTSD (i.e., intrusive trauma memories, emotion dysregulation, etc.).  After neurofeedback, however, communication with the amygdala had shifted to different brain areas that help us manage emotions more effectively. 

Consistent with these changes in brain activity, after neurofeedback, participants reported reduced PTSD symptoms, and less arousal (e.g., feeling less overly alert).  Again, these results suggest that there is great promise in using alpha wave-targeted neurofeedback as a drug-free method of treating PTSD.

One session
How does one session of neurofeedback impact people with no mental health diagnoses compared to people with PTSD?

Ros T, Frewen P, Théberge J, Michela A, Kluetsch R, Mueller A, Candrian G, Jetly R, Vuilleumier P, Lanius RA. (2017). Neurofeedback tunes scale-free dynamics in spontaneous brain activity. Cerebral Cortex, 27(Oct): 4911–4922.

This study builds on two of our previous studies (see the summaries above of the research by Ros et al., 2013 and Kluetsch et al., 2014) and continues our investigation of the effects of a single session of neurofeedback on brain function and PTSD.  Once again, we designed neurofeedback to impact alpha brain waves (i.e., those active during relaxed focus) in two groups of adults – individuals diagnosed with PTSD related to childhood abuse (“PTSD group”), and individuals without any mental health diagnoses (“healthy control group”). 

For the current study, we were specifically interested in the EEG (electroencephalogram) recordings taken just before and right after one session of neurofeedback.  EEG is a way of recording brain activity, and we were interested to see if brain activity could be changed with neurofeedback. 

Results suggested that one session of neurofeedback did indeed help participants significantly change their alpha-wave brain activity – allowing them to almost “tune” their own brains.  This was true for both the healthy control participants receiving real neurofeedback (vs those who received simulated neurofeedback), and for the PTSD participants (all of whom received real neurofeedback).  In fact, we were excited to see that after neurofeedback, the alpha activity in the PTSD group had shifted so that it looked more like that of the healthy control group. 

Interestingly, along with this shift in alpha activity came a sense of less hyperarousal (i.e., a reduction in feeling overly watchful for danger, feeling less easily startled).  Overall, these results provide further support that neurofeedback may be an effective, drug-free treatment for certain mental health disorders like PTSD, but perhaps also for other disorders like depression, and schizophrenia.

Key brain networks - neurofeedback
How does neurofeedback impact key brain networks in people with PTSD?

Nicholson AA, Rabellino D, Densmore M, Frewen PA, Paret C, Kluetsch R, Schmahl C, Théberge J, Ros T, Neufeld RWJ, McKinnon MC, Reiss JP, Jetly R, & Lanius RA. (2018). Intrinsic connectivity network dynamics in PTSD during amygdala downregulation using real-time fMRI neurofeedback: A preliminary analysis. Hum Brain Mapp., 39:4258–4275.

In this study, we continued our investigation of the effects of neurofeedback on PTSD.  As mentioned in previous sections of our website, within the human brain, there are important “networks” (i.e., multiple brain areas that communicate with one another) called “intrinsic connectivity networks”, or ICNs.  Evidence shows that these networks play important roles in mental illness, and in many of our more complex brain functions (e.g., problem-solving, evaluating, paying attention). 

 

Previous research has shown that activity in these brain networks has been altered in people with PTSD, and that these alterations are related to the symptoms they experience.  With this in mind, we wanted to begin exploring whether neurofeedback might be able to change, and potentially correct, the activity of these networks in people diagnosed with PTSD. 

 

For this study involving both men and women, neurofeedback was conducted inside an fMRI (functional Magnetic Resonance Imaging) brain scanner to allow us to record any changes in brain activity that took place during neurofeedback (i.e., in “real time”).  In this case, neurofeedback was set up to provide participants with feedback from their own amygdala – a brain area that helps detect threat or danger in the environment (much like a smoke detector).  Individuals with PTSD tend to have a heightened sense of danger – their amygdala frequently signals danger, even when there is no threat. 

 

To see whether neurofeedback could change the function of their amygdala, while lying in the fMRI scanner, participants viewed a series of single words they had previously selected - either related to their personal trauma(s), or neutral words.  Viewing the trauma-related words was meant to trigger a strong (but manageable) emotional reaction so that we could record how it impacted brain activity using the fMRI scanner.  While looking at the words, participants were asked to do one of three things:  1) to “regulate” their emotions while viewing the trauma-related words (i.e., try to calm their emotional reaction); 2) to simply view the trauma-related words (i.e., look at the words without any attempt to regulate their emotions); or 3) to view their neutral words (i.e., simply look at words that were not meant to trigger strong emotion). 

 

For the “regulate” conditions, participants were shown a thermometer-like image that represented the activity in their amygdala.  As their amygdala became more active (e.g., as their feelings of distress rose while viewing trauma words), the “temperature” displayed by the thermometer also rose.  This was the “feedback” participants received regarding the activity in their amygdala in real time.  Using this feedback, participants were asked to try to calm their emotions and lower the activity in their amygdala – to try to make the “temperature” go down on the thermometer. 

 

Results of this study showed that neurofeedback was successful in helping people “quiet” their amygdala, by decreasing its activity and their emotional response to the trauma-triggering words.  Further, neurofeedback was associated with changes in three important ICNs – the central executive network (which helps us manage our thoughts, emotions, working memory, and behaviour), the default mode network (which helps us process information about ourselves and who we are), and the salience network (which helps us detect and process information from our environment and from within our bodies to help guide our behaviour).  Overall, these results suggest that neurofeedback targeting the amygdala could help create lasting changes in key ICNs, which may be helpful in treating PTSD (and other mental health issues) in a drug-free way.

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