Single session real-time fMRI neurofeedback has a lasting impact on cognitive behavioral therapy strategies

Abstract

To benefit from cognitive behavioral therapy (CBT), individuals must not only learn new skills but also strategically implement them outside of session. Here, we tested a novel technique for personalizing CBT skills and facilitating their generalization to daily life. We hypothesized that showing participants the impact of specific CBT strategies on their own brain function using real-time functional magnetic imaging (rt-fMRI) neurofeedback would increase their metacognitive awareness, help them identify effective strategies, and motivate real-world use. In a within-subjects design, participants who had completed a clinical trial of a standardized course of CBT created a personal repertoire of negative autobiographical stimuli and mood regulation strategies. From each participant's repertoire, a set of experimental and control strategies were identified; only experimental strategies were practiced in the scanner. During the rt-fMRI neurofeedback session, participants used negative stimuli and strategies from their repertoire to manipulate activation in the anterior cingulate cortex, a region implicated in emotional distress. The primary outcome measures were changes in participant ratings of strategy difficulty, efficacy, and frequency of use. As predicted, ratings for unscanned control strategies were stable across observations, whereas ratings for experimental strategies changed after neurofeedback. At follow-up one month after the session, efficacy and frequency ratings for scanned strategies were predicted by neurofeedback during the rt-fMRI session. These results suggest that rt-fMRI neurofeedback created a salient and durable learning experience for patients, extending beyond the scan session to guide and motivate CBT skill use weeks later. This metacognitive approach to neurofeedback offers a promising model for increasing clinical benefits from cognitive behavioral therapy by personalizing skills and facilitating generalization.

Keywords: Cognitive behavioral therapy; Metacognition; Neurofeedback; Personalized therapy; Real-time fMRI.

Figures

Fig. 1

Timeline of Study Events. Screening measures were administered at each timepoint for symptom and safety monitoring. At Week 1, the Pre-Scan Interview catalogued and codified each individual participant's repertoire of negative memories (or worries) and of CBT strategies for regulating negative emotion. At Week 1 (Baseline) and Week 6 (Follow-Up), all strategies were rated for frequency, efficacy, and difficulty of use. At Week 2, immediately following the rt-fMRI neurofeedback task runs (Scan Session), all scanned strategies were rated for efficacy and difficulty.

Fig. 2

Rt-fMRI Neurofeedback Task Design. The rt-fMRI neurofeedback trial structure is illustrated here. The localizer task was identical except it did not include feedback. Activation in the individualized region of interest (ROI) was presented as neurofeedback following negative memory retrieval or worry (Memory Phase) and regulation (Strategy Phase). Successive trials rotated through each participant's repertoire of memories or worries and strategies, using the personalized phrases generated in the Pre-Scan Interview.

Fig. 3

Location of Subject-Specific MNI-space ROIs. ROI selection used activation in the individual localizer runs intersected with anatomical priors. Anatomical boundaries reflected prior research implicating anterior cingulate cortex (ACC) in subjective distress. The center coordinate of each subject-specific ROI is listed along with its anatomical label derived from the Harvard-Oxford structural atlas.

Fig. 4

Strategy-Neurofeedback Correlations. Note that negative neurofeedback values indicate a reduction in activation from Memory to Strategy Phase (desired outcome). Neurofeedback was not associated with baseline ratings on any measure (first column). A) Efficacy ratings. Strategies associated with stronger neurofeedback (i.e., a larger reduction) were rated as significantly more effective during the scan session and at 1-month follow-up. B) Frequency ratings. Strategies associated with stronger neurofeedback showed a trend towards being rated as more frequently used at 1-month follow-up. C) Difficulty ratings. Strategies associated with stronger neurofeedback were rated as easier to use on the day of the scan session, but not at 1-month follow-up.