EEG Neurofeedback as Adjunct to Psychotherapy for Complex Developmental Trauma-Related Disorders: Case Study and Treatment Rationale

Fisher, S. F., Lanius, R. A., & Frewen, P. A. (2016). EEG neurofeedback as adjunct to psychotherapy for complex developmental trauma-related disorders: Case study and treatment rationale. Traumatology (Tallahassee, Fla.), 22(4), 255-260. https://doi.org/10.1037/trm0000073

Abstract: The present clinical case study describes the long-term treatment of “Bea”, a survivor of repeated and complex developmental trauma, via trauma-focused psychotherapy combined with electroencephalography (EEG) neurofeedback. Bea’s case is described alongside a brief introduction to a rationale for including EEG neurofeedback as an intervention for complex developmental trauma-related disorders. Future research directions are discussed.

Keywords: neurofeedback, electroencephalography (EEG), complex posttraumatic stress disorder

(PTSD), dissociation

Conclusion: Because of a history of treatment failure with medications and both cognitive-behavioral and psychodynamic therapies, Bea was considered by many previous mental health providers to be an untreatable patient. However, with the introduction of EEG NFB and the apparent improved regulation of her nervous system, her once crippling trauma-related symptoms slowly remitted. Her case suggests that a dysregulated nervous system may have been at the core of her symptom formation, and that resolution of these symptoms depended on her brain relearning how to regulate itself (Fisher, 2014). Research since the late 1960s demonstrates that both animals and humans can learn NFB (Kamiya, 1968, 2011; Sterman, 2000; Wyrwicka & Sterman, 1968). To date, however, despite increasing acknowledgment of the effects of early trauma and neglect on the development and function of the human brain, little systematic research has examined the potential efficacy of NFB in the treatment of complex developmental trauma-related disorders in a methodologically strong, double-blinded randomized controlled trial. Cases like Bea’s, however, suggest that such research is long overdue.

Restoring Large-Scale Brain Networks in the Aftermath of Trauma: Implications For Neuroscientifically-Informed Treatments

Lanius, R. A., Frewen, P. A., Nicholson, A. N., & McKinnon, M. C. (2021). Restoring large-scale brain networks in the aftermath of trauma: Implications for neuroscientifically-informed treatments. European Journal of Psychotraumatology, 12(sup1) https://doi.org/10.1080/20008198.2020.1866410

Increasing evidence for impaired functioning of the default mode network, the salience network, the central executive network, and the dorsal/ventral attention networks in PTSD has been described. Each network has been proposed to be associated with specific clinical symptoms observed in PTSD, including an altered sense of self (default mode network), increased or decreased arousal/interoception (salience network), and cognitive dysfunction (central executive network; attentional networks). Specific neuroscientifically-informed treatments designed to restore each of these brain networks and the related clinical symptomatology will be discussed.

The Sense of Self in the Aftermath of Trauma: Lessons from the Default Mode Network in Posttraumatic Stress Disorder

Lanius, R. A., Terpou, B. A., & McKinnon, M. C. (2020). The sense of self in the aftermath of trauma: Lessons from the default mode network in posttraumatic stress disorder. European Journal of Psychotraumatology, 11(1), 1807703. https://doi.org/10.1080/20008198.2020.1807703

Trauma can profoundly affect the sense of self, where both cognitive and somatic disturbances to the sense of self are reported clinically by individuals with posttraumatic stress disorder (PTSD). These disturbances are captured eloquently by clinical accounts, such as ‘I do not know myself anymore,’ ‘I will never be able to experience normal emotions again,’ and ‘I feel dead inside.’ Self-related thoughts and experiences are represented neurobiologically by a large-scale, cortical network located along the brain’s midline and referred to as the default mode network (DMN). Recruited predominantly during rest in healthy participants, the DMN is also active during self-referential and autobiographical memory processing – processes which, collectively, are thought to provide the foundation for a stable sense of self that persists across time and may be available for conscious access. In participants with PTSD, however, the DMN shows substantially reduced resting-state functional connectivity as compared to healthy individuals, with greater reductions associated with heightened PTSD symptom severity. Critically, individuals with PTSD describe frequently that their traumatic experiences have become intimately linked to their perceived sense of self, a perception which may be mediated, in part, by alterations in the DMN. Accordingly, identification of alterations in the functional connectivity of the DMN during rest, and during subliminal, trauma-related stimulus conditions, has the potential to offer critical insight into the dynamic interplay between trauma- and self-related processing in PTSD. Here, we discuss DMN-related alterations during these conditions, pointing further towards the clinical significance of these findings in relation to past-and present-centred therapies for the treatment of PTSD.

Posterior cingulate cortex targeted real-time fMRI neurofeedback recalibrates functional connectivity with the amygdala, posterior insula, and default-mode network in PTSD

Lieberman, J. M., Rabellino, D., Densmore, M., Frewen, P. A., Steyrl, D., Scharnowski, F.,   Théberge, J., Neufeld, R. W. J., Schmahl, C., Jetly, R., Narikuzhy, S., Lanius, R. A., & Nicholson, A. A. (2023). Posterior cingulate cortex targeted real‐time fMRI neurofeedback recalibrates functional connectivity with the amygdala, posterior insula, and default‐mode network in PTSD. Brain and Behavior, 13(3), e2883-n/a. https://doi.org/10.1002/brb3.2883

Observations of PCC connectivity to the DMN and SN provide emerging evidence of neural mechanisms underlying PCC-targeted fMRI neurofeedback among individuals with PTSD. This supports the use of PCC-targeted neurofeedback as a means by which to recalibrate PTSD-associated alterations in neural connectivity within the DMN and SN, which together, may help to facilitate improved emotion regulation abilities in PTSD.

Electroencephalographic Biofeedback in the Treatment of Attention-Deficit/Hyperactivity Disorder

Monastra, V. J., Lynn, S., Linden, M., Lubar, J. F., Gruzelier, J., & LaVaque, T. J. (2005). Electroencephalographic biofeedback in the treatment of attention-deficit/hyperactivity disorder. Applied psychophysiology and biofeedback, 30(2), 95–114. https://doi.org/10.1007/s10484-005-4305-x

Historically, pharmacological treatments for attention-deficit/hyperactivity disorder (ADHD) have been considered to be the only type of interventions effective for reducing the core symptoms of this condition. However, during the past three decades, a series of case and controlled group studies examining the effects of EEG biofeedback have reported improved attention and behavioral control, increased cortical activation on quantitative electroencephalographic examination, and gains on tests of intelligence and academic achievement in response to this type of treatment.

The Neurobiology of Emotion Regulation in Posttraumatic Stress Disorder: Amygdala Downregulation Via Real-Time fMRI Neurofeedback

Nicholson, A. A., Rabellino, D., Densmore, M., Frewen, P. A., Paret, C., Kluetsch, R., Schmahl, C., Théberge, J., Neufeld, R. W., McKinnon, M. C., Reiss, J., Jetly, R., & Lanius, R. A. (2017). The neurobiology of emotion regulation in posttraumatic stress disorder: Amygdala downregulation via real-time fMRI neurofeedback. Human Brain Mapping, 38(1), 541–560. https://doi.org/10.1002/hbm.23402

Here, we describe the first study to examine cortical and subcortical biomarkers of directed connectivity in PTSD and its dissociative subtype, as well as in healthy controls. We found that PTSD patients were characterized predominantly by bottom–up connections from the PAG to the vmPFC and amygdala, and from the amygdala to vmPFC. By contrast, PTSD 1 DS was characterized predominantly by top–down connections from the vmPFC to amygdala and PAG, and from the amygdala to PAG. These results suggest that the contrasting symptom profiles of PTSD and its dissociative subtype (hyper- vs. hypo-emotionality, respectively) may be related to their opposing patterns of directional connectivity.

Intrinsic Connectivity Network Dynamics in PTSD During Amygdala Downregulation Using Real‐Time fMRI Neurofeedback

Nicholson, A. A., Rabellino, D., Densmore, M., Frewen, P. A., Paret, C., Kluetsch, R., Schmahl, C., Théberge, J., Ros, T., Neufeld, R. W. J., McKinnon, M. C., Reiss, J. P., Jetly, R., & Lanius, R. A. (2018). Intrinsic connectivity network dynamics in PTSD during amygdala downregulation using real‐time fMRI neurofeedback: A preliminary analysis. Human Brain Mapping, 39(11), 4258-4275. https://doi.org/10.1002/hbm.24244

In conclusion, this study provides provocative, preliminary evidence that downregulation of the amygdala using rt-fMRI-NFB in PTSD is associated with dynamic changes in ICN, an effect similar to those observed using EEG modalities of neurofeedback.

A Randomized, Controlled Trial of Alpha-Rhythm EEG Neurofeedback in Posttraumatic Stress Disorder

Nicholson, A. A., Ros, T., Densmore, M., Frewen, P. A., Neufeld, R. W. J., Théberge, J., Jetly, R., & Lanius, R. A. (2020). A randomized, controlled trial of alpha-rhythm EEG neurofeedback in posttraumatic stress disorder: A preliminary investigation showing evidence of decreased PTSD symptoms and restored default mode and salience network connectivity using fMRI. NeuroImage Clinical, 28, 102490-102490. https://doi.org/10.1016/j.nicl.2020.102490

With regard to the primary outcome measure of PTSD severity, we found a significant main effect of time in the absence of a group ×time interaction. Nevertheless, we found significantly decreased PTSD severity scores in the experimental NFB group only, when comparing post-NFB (dz =0.71) and 3-month follow-up scores (dz =0.77) to baseline measures. Interestingly, we found evidence to suggest a shift towards normalization of DMN and SN connectivity post-NFB in the experimental group only. Both decreases in PTSD severity and NFB performance were correlated to DMN and SN connectivity post-NFB in the experimental group. Critically, remission rates of PTSD were significantly higher in the experimental group (61.1%) as compared to the sham-control group (33.3%). Conclusion: The current study shows mechanistic evidence for therapeutic changes in DMN and SN connectivity that are known to be associated with PTSD psychopathology, with no patient dropouts. This preliminary investigation merits further research to demonstrate fully the clinical efficacy of EEG-NFB as an adjunctive therapy for PTSD.