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Neurofeedback Effect on Symptoms of Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis

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Abstract

Posttraumatic stress disorder (PTSD) encompasses various psychological symptoms and a high early dropout rate due to treatment unresponsiveness. In recent years, neurofeedback has been implemented to control PTSD’s psychological symptoms through physiological brain regulation. However, a comprehensive analysis concerning its efficacy is lacking. Therefore, we conducted a systematic review and meta-analysis to determine neurofeedback’s effect on reducing PTSD symptoms. We analyzed randomized and non-randomized controlled trials (RCTs) from 1990 to July 2020, evaluating neurofeedback treatments for those diagnosed with PTSD and their symptoms. In addition, we calculated the standardized mean difference (SMD)using random-effects models to estimate effect sizes. We assessed ten articles comprising 276 participants, with a − 0.74 SMD (95% confidence interval = − 0.9230, − 0.5567), 42% I2, moderate effect size, and − 1.40 to -0.08 prediction intervals (PI). Neurofeedback was more effective for complex trauma PTSD patients than single trauma. Increasing and lengthening sessions are more effective than fewer, condensed ones. Neurofeedback positively affected arousal, anxiety, depression, and intrusive, numbing, and suicidal thoughts. Therefore, neurofeedback is a promising and effective treatment for complex PTSD.

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Data Availability

The datasets generated and analyzed during the current study are not publicly available.

References

  • Akbari, Y. Z., Dolatshahee, B., & REZAEE, D. E. (2016). The effectiveness of neurofeedback training on reducing symptoms of war veterans with posttraumatic stress disorder. Practice in Clinical Psychology, 4(1), 17–23.

  • Askovic, M., Watters, A. J., Aroche, J., & Harris, A. W. F. (2017). Neurofeedback as an adjunct therapy for treatment of chronic posttraumatic stress disorder related to refugee trauma and torture experiences: Two case studies. Australasian Psychiatry: bulletin of Royal Australian and New Zealand College of Psychiatrists, 25(4), 358–363. https://doi.org/10.1177/1039856217715988.

    Article  PubMed  Google Scholar 

  • Askovic, M., Watters, A. J., Coello, M., Aroche, J., Harris, A. W. F., & Kropotov, J. (2020). Evaluation of Neurofeedback for Posttraumatic Stress Disorder Related to Refugee Experiences Using Self-Report and Cognitive ERP Measures. Clinical EEG and neuroscience, 51(2), 79–86. https://doi.org/10.1177/1550059419849170

  • Beidel, D. C., Frueh, B. C., Neer, S. M., Bowers, C. A., Trachik, B., Uhde, T. W., & Grubaugh, A. (2019). Trauma management therapy with virtual-reality augmented exposure therapy for combat-related PTSD: A randomized controlled trial. Journal of Anxiety Disorders, 61, 64–74. https://doi.org/10.1016/j.janxdis.2017.08.005.

    Article  PubMed  Google Scholar 

  • Bell, A. N., Moss, D., & Kallmeyer, R. J. (2019). Healing the neurophysiological roots of trauma: A controlled study examining LORETA z-score neurofeedback and HRV biofeedback for chronic PTSD. NeuroRegulation, 6(2), 54–54. https://doi.org/10.15540/nr.6.2.54.

    Article  Google Scholar 

  • Bryant, R. A., Creamer, M., O’Donnell, M., Forbes, D., McFarlane, A. C., Silove, D., & Hadzi-Pavlovic, D. (2017). Acute and chronic posttraumatic stress symptoms in the emergence of posttraumatic stress disorder: A network analysis. JAMA Psychiatry, 74(2), 135–142. https://doi.org/10.1001/jamapsychiatry.2016.3470.

    Article  PubMed  Google Scholar 

  • Capone, C., Presseau, C., Saunders, E., Eaton, E., Hamblen, J., & McGovern, M. (2018). Is integrated CBT effective in reducing PTSD symptoms and substance use in Iraq and Afghanistan veterans? Results from a randomized clinical trial. Cognitive Therapy and Research, 42(6), 735–746. https://doi.org/10.1007/s10608-018-9931-8.

    Article  Google Scholar 

  • Chiba, T., Kanazawa, T., Koizumi, A., Ide, K., Taschereau-Dumouchel, V., Boku, S., Hishimoto, A., Shirakawa, M., Sora, I., Lau, H., Yoneda, H., & Kawato, M. (2019). Current status of neurofeedback for post-traumatic stress disorder: A systematic review and the possibility of decoded neurofeedback. Frontiers in Human Neuroscience, 13, 233. https://doi.org/10.3389/fnhum.2019.00233.

    Article  PubMed  PubMed Central  Google Scholar 

  • Cloitre, M. (2020). ICD-11 complex post-traumatic stress disorder: Simplifying diagnosis in trauma populations. The British Journal of Psychiatry, 216(3), 129–131. https://doi.org/10.1192/bjp.2020.43

  • Cohen, J. (1988). Statistical power analysis for the behavioral Sciences (2nd ed).). Routledge.

  • Egger, M., Smith, G. D., Schneider, M., & Minder, C. (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ (Clinical research ed), 315(7109), 629–634. https://doi.org/10.1136/bmj.315.7109.629.

    Article  PubMed  Google Scholar 

  • Elbogen, E. B., Dennis, P. A., Van Voorhees, E. E., Blakey, S. M., Johnson, J. L., Johnson, S. C., Wagner, H. R., Hamer, R. M., Beckham, J. C., Manly, T., & Belger, A. (2019). Cognitive rehabilitation with mobile technology and social support for veterans with TBI and PTSD: A randomized clinical trial. The Journal of head trauma rehabilitation, 34(1), 1–10. https://doi.org/10.1097/HTR.0000000000000435

  • Fisher, S. F. (2014). Neurofeedback in the treatment of developmental trauma: Calming the fear-driven brain. New York: WW Norton & Company.

    Google Scholar 

  • Gerge, A. (2020). A multifaceted case-vignette integrating neurofeedback and EMDR in the treatment of complex PTSD. European Journal of Trauma & Dissociation, 4(3), 100157. https://doi.org/10.1016/j.ejtd.2020.100157.

    Article  Google Scholar 

  • Hameed, S., Sadiq, A., & Din, A. U. (2018). The increased vulnerability of refugee population to mental health disorders. Kansas Journal of Medicine, 11(1), 20. https://doi.org/10.17161/kjm.v11i1.8680.

    Article  PubMed Central  Google Scholar 

  • Hansen, M., Armour, C., McGlinchey, E., Ross, J., Ravn, S. L., Andersen, T. E., Lindekilde, N., Elmose, M., Karsberg, S., & Fried, E. (2021). Investigating centrality in PTSD symptoms across diagnostic systems using network analysis. European Journal of Psychotraumatology, 12(Suppl. 1), 1866412. https://doi.org/10.1080/20008198.2020.1866412.

    Article  PubMed Central  Google Scholar 

  • Hedges, L. V., & Olkin, I. (1985). Statistical methods for meta-analysis. Academic Press.

  • Hembree, E. A., Foa, E. B., Dorfan, N. M., Street, G. P., Kowalski, J., & Tu, X. (2003). Do patients drop out prematurely from exposure therapy for PTSD? Journal of Traumatic Stress, 16(6), 555–562. https://doi.org/10.1023/B:JOTS.0000004078.93012.7d.

    Article  PubMed  Google Scholar 

  • Higgins, J. P. T., & Green, S. (2017). Cochrane Handbook for Systematic Reviews of Interventions version 5.1.0. (Online), [updated March 2011] retrieved. http://handbook.cochrane.org/

  • Higgins, J. P. T., Thompson, S. G., & Spiegelhalter, D. J. (2009). A re-evaluation of random‐effects meta‐analysis. Journal of the Royal Statistical Society Series A (Statistics in Society), 172(1), 137–159. https://doi.org/10.1111/j.1467-985X.2008.00552.x.

    Article  PubMed  Google Scholar 

  • Hundt, N. E., Helm, A., Smith, T. L., Lamkin, J., Cully, J. A., & Stanley, M. A. (2018). Failure to engage: A qualitative study of veterans who decline evidence-based psychotherapies for PTSD. Psychological Services, 15(4), 536–542. https://doi.org/10.1037/ser0000212.

    Article  PubMed  Google Scholar 

  • Hurley, E. C. (2018). Effective treatment of veterans with PTSD: Comparison between intensive daily and weekly EMDR approaches. Frontiers in Psychology, 9, 1458. https://doi.org/10.3389/fpsyg.2018.01458.

    Article  PubMed  PubMed Central  Google Scholar 

  • IntHout, J., Ioannidis, J. P., Rovers, M. M., & Goeman, J. J. (2016). Plea for routinely presenting prediction intervals in meta-analysis. BMJ open, 6(7), e010247. https://doi.org/10.1136/bmjoopen-2015-010247.

    Article  PubMed  PubMed Central  Google Scholar 

  • Kelson, C. Y. (2013). The impact of EEG biofeedback on veterans’ symptoms of posttraumatic stress disorder (PTSD) (Unpublished doctoral thesis). The Chicago School of Professional Psychology, Chicago.

  • Kim, S. Y., Park, H. J., Lee, H., & Lee, H. (2011). Acupuncture for premenstrual syndrome: a systematic review and meta-analysis of randomised controlled trials. BJOG: An International Journal of Obstetrics & Gynaecology, 118(8), 899–915.?https://doi.org/10.1111/j.1471-0528.2011.02994.x

  • Kluetsch, R. C., Ros, T., Théberge, J., Frewen, P. A., Calhoun, V. D., Schmahl, C., Jetly, R., & Lanius, R. A. (2014). Plastic modulation of PTSD resting-state networks and subjective wellbeing by EEG neurofeedback. Acta Psychiatrica Scandinavica, 130(2), 123–136. https://doi.org/10.1111/acps.12229.

    Article  PubMed  Google Scholar 

  • Loucks, L., Yasinski, C., Norrholm, S. D., Maples-Keller, J., Post, L., Zwiebach, L., Fiorillo, D., Goodlin, M., Jovanovic, T., Rizzo, A. A., & Rothbaum, B. O. (2019). You can do that?!: Feasibility of virtual reality exposure therapy in the treatment of PTSD due to military sexual trauma. Journal of Anxiety Disorders, 61, 55–63. https://doi.org/10.1016/j.janxdis.2018.06.004.

    Article  PubMed  Google Scholar 

  • Misaki, M., Phillips, R., Zotev, V., Wong, C. K., Wurfel, B. E., Krueger, F., Feldner, M., & Bodurka, J. (2018). Real-time fMRI amygdala neurofeedback positive emotional training normalized resting-state functional connectivity in combat veterans with and without PTSD: A connectome-wide investigation. NeuroImage: Clinical, 20, 543–555. https://doi.org/10.1016/j.ncl.2018.08.025.

    Article  PubMed  Google Scholar 

  • Misaki, M., Mulyana, B., Zotev, V., Wurfel, B. E., Krueger, F., Feldner, M., & Bodurka, J. (2021). Hippocampal volume recovery with real-time functional MRI amygdala neurofeedback emotional training for posttraumatic stress disorder. Journal of Affective Disorders, 283, 229–235. https://doi.org/10.1016/j.jad.2021.01.058.

    Article  PubMed  Google Scholar 

  • Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2010). Preferred reporting items for systematic reviews and Meta-analyses: The PRISMA statement. International Journal of Surgery, 8(5), 336–341. https://doi.org/10.1016/j.ijsu.2010.02.007.

    Article  PubMed  Google Scholar 

  • Najavits, L. M. (2015). The problem of dropout from “gold standard” PTSD therapies. F1000Prime Reports, 7, 43. https://doi.org/10.12703/P7-43.

    Article  PubMed  PubMed Central  Google Scholar 

  • Noohi, S., Miraghaie, A. M., Arabi, A., & Nooripour, R. (2017). Effectiveness of neuro-feedback treatment with alpha/theta method on PTSD symptoms and their executing function. Biomedical Research-Tokyo, 28, 2019–2027.

    Google Scholar 

  • Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., & Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., & McDonald, … Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ (Clinical research ed), 372, n71. https://doi.org/10.1136/bmj.n71

  • Peniston, E. G., & Kulkosky, P. J. (1991). Alpha-theta brainwave neurofeedback for Vietnam veterans with combat-related post-traumatic stress disorder. Medical Psychotherapy, 4(1), 47–60.

    Google Scholar 

  • 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. https://doi.org/10.1016/j.neuroimage.2012.09.046.

    Article  PubMed  Google Scholar 

  • Ros, T., Baars, J., Lanius, B., R. A., & Vuilleumier, P. (2014). Tuning pathological brain oscillations with neurofeedback: A systems neuroscience framework. Frontiers in Human Neuroscience, 8, 1008. https://doi.org/10.3389/fnhum.2014.01008.

    Article  PubMed  PubMed Central  Google Scholar 

  • Schottenbauer, M. A., Glass, C. R., Arnkoff, D. B., Tendick, V., & Gray, S. H. (2008). Nonresponse and dropout rates in outcome studies on PTSD: Review and methodological considerations. Psychiatry, 71(2), 134–168. https://doi.org/10.1521/psyc.2008.71.2.134.

    Article  PubMed  Google Scholar 

  • Simon, N., McGillivray, L., Roberts, N. P., Barawi, K., Lewis, C. E., & Bisson, J. I. (2019). Acceptability of internet-based cognitive behavioural therapy (i-CBT) for post-traumatic stress disorder (PTSD): A systematic review. European Journal of Psychotraumatology, 10(1), 1646092. https://doi.org/10.1080/20008198.2019.1646092.

    Article  PubMed  PubMed Central  Google Scholar 

  • Smith, W. D. (2008). The effect of neurofeedback training on PTSD symptoms of depression and attention problems among military veterans (Unpublished doctoral thesis). Capella University, Minnesota.

  • Steingrimsson, S., Bilonic, G., Ekelund, A. C., Larson, T., Stadig, I., Svensson, M., Vukovic, I. S., Wartenberg, C., Wrede, O., & Bernhardsson, S. (2020). Electroencephalography-based neurofeedback as treatment for post-traumatic stress disorder: A systematic review and meta-analysis. European Psychiatry: The Journal of the Association of European Psychiatrists, 63(1), e7. https://doi.org/10.1192/j.eurpsy.2019.7.

    Article  PubMed  Google Scholar 

  • Thibault, R. T., MacPherson, A., Lifshitz, M., Roth, R. R., & Raz, A. (2018). Neurofeedback with fMRI: a critical systematic review. NeuroImage 172, 786–807. https://doi.org/10.1016/j.neuroimage.2017.12.071

  • Tripp, J. C., Norman, S. B., Kim, H. M., Venners, M. R., Martis, B., Simon, N. M., Stein, M. B., Allard, C. B., Rauch, S. A. M., & PROGrESS Study Team. (2020). Residual symptoms of PTSD following Sertraline plus enhanced medication management, sertraline plus PE, and PE plus placebo. Psychiatry Research, 291, 113279. https://doi.org/10.1016/j.psychres.2020.113279.

    Article  PubMed  Google Scholar 

  • van der Kolk, B. A., Hodgdon, H., Gapen, M., Musicaro, R., Suvak, M. K., Hamlin, E., & Spinazzola, J. (2016). A randomized controlled study of neurofeedback for chronic PTSD. PloS One, 11(12), e0166752. https://doi.org/10.1371/journal.pone.0166752.

    Article  PubMed  PubMed Central  Google Scholar 

  • Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A review of evidence-based psychotherapy interventions. Frontiers in Behavioral Neuroscience, 12, 258. https://doi.org/10.3389/fnbeh.2018.00258.

    Article  PubMed  PubMed Central  Google Scholar 

  • World Health Organization (2018). International Classification of Diseases for Mortality and Morbidity Statistics (11th revision). (Online), https://icd.who.int/browse11/l-m/en

  • Zotev, V., Phillips, R., Misaki, M., Wong, C. K., Wurfel, B. E., Krueger, F., Feldner, M., & Bodurka, J. (2018). Real-time fMRI neurofeedback training of the amygdala activity with simultaneous EEG in veterans with combat-related PTSD. NeuroImage Clinical, 19, 106–121. https://doi.org/10.1016/j.ncl.2018.04.010.

    Article  PubMed  PubMed Central  Google Scholar 

  • Zweerings, J., Pflieger, E. M., Mathiak, K. A., Zvyagintsev, M., Kacela, A., Flatten, G., & Mathiak, K. (2018). Impaired voluntary control in PTSD: Probing self-regulation of the ACC with real-time fMRI. Frontiers in Psychiatry, 9, 219. https://doi.org/10.3389/fpsyt.2018.00219.

    Article  PubMed  PubMed Central  Google Scholar 

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Funding

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (NRF-2020R1A2B5B0100208). ※ MSIT: Ministry of Science and ICT.

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Choi, YJ., Choi, EJ. & Ko, E. Neurofeedback Effect on Symptoms of Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis. Appl Psychophysiol Biofeedback 48, 259–274 (2023). https://doi.org/10.1007/s10484-023-09593-3

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