Effectiveness of Neurofeedback Training for Patients with Personality Disorders: A Systematic Review
,
Abstract
Objective: Personality disorders are serious psychiatric conditions, and some studies have examined neurofeedback training as a potential alternative treatment to improve cognitive and clinical symptoms in patients with such disorders. Here, we aimed to provide a first systematic review of such trials and present existing evidence regarding this treatment for individuals with personality disorders.
Method: A systematic search of peer-reviewed English journal articles was conducted for this study to identify original studies on fMRI and EEG neurofeedback treatment protocols in patients with personality disorders up to January 2023. PubMed, Web of Science, ProQuest, Cochrane Library, and Google Scholar databases were queried through the keywords "neurofeedback," "biofeedback," and "personality disorder," as well as their related Mesh synonyms.
Results: Totally, five studies were included in our systematic review. Two studies utilized EEG neurofeedback protocols, while three articles used real-time fMRI neurofeedback protocols. The types of studies were non-randomized, not-blinded case reports, case series, and single-arm trials with a high risk of bias. EEG neurofeedback protocols applied more training sessions and reported improvements in patients' neuropsychological and behavioral functions after treatment. Furthermore, fMRI-based neurofeedback studies reported neurophysiological changes, such as a shift in vmPFC-amygdala connectivity, towards healthy states following treatment. Moreover, behavioral symptoms of patients were reported to be improved after fMRI neurofeedback.
Conclusion: Neurofeedback studies investigating this therapeutic technique for personality disorders are still very preliminary, and no strict conclusions can be drawn at this time. Therefore, further basic and clinical investigations are required to address several open methodological and technical questions and establish consensus and standardization, which will eventually lead to translational works.
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2. Volkert J, Gablonski TC, Rabung S. Prevalence of personality disorders in the general adult population in Western countries: systematic review and meta-analysis. Br J Psychiatry. 2018;213(6):709-15.
3. Winsper C, Bilgin A, Thompson A, Marwaha S, Chanen AM, Singh SP, et al. The prevalence of personality disorders in the community: a global systematic review and meta-analysis. Br J Psychiatry. 2020;216(2):69-78.
4. Perrotta G. Borderline personality disorder: Definition, differential diagnosis, clinical contexts, and therapeutic approaches. Annals of Psychiatry and Treatment. 2020;4(1):043-56.
5. Gazzillo F, Dazzi N, Kealy D, Cuomo R. Personalizing psychotherapy for personality disorders: Perspectives from control-mastery theory. Psychoanalytic Psychology. 2021;38(4):266.
6. Ronningstam EF, Keng SL, Ridolfi ME, Arbabi M, Grenyer BFS. Cultural Aspects in Symptomatology, Assessment, and Treatment of Personality Disorders. Curr Psychiatry Rep. 2018;20(4):22.
7. Kramer U, Eubanks CF, Bertsch K, Herpertz SC, McMain S, Mehlum L, et al. Future Challenges in Psychotherapy Research for Personality Disorders. Curr Psychiatry Rep. 2022;24(11):613-22.
8. Schulze L, Schmahl C, Niedtfeld I. Neural Correlates of Disturbed Emotion Processing in Borderline Personality Disorder: A Multimodal Meta-Analysis. Biol Psychiatry. 2016;79(2):97-106.
9. Mier D, Lis S, Esslinger C, Sauer C, Hagenhoff M, Ulferts J, et al. Neuronal correlates of social cognition in borderline personality disorder. Soc Cogn Affect Neurosci. 2013;8(5):531-7.
10. Davidson RJ, Jackson DC, Kalin NH. Emotion, plasticity, context, and regulation: perspectives from affective neuroscience. Psychol Bull. 2000;126(6):890-909.
11. Janak PH, Tye KM. From circuits to behaviour in the amygdala. Nature. 2015;517(7534):284-92.
12. Buhle JT, Silvers JA, Wager TD, Lopez R, Onyemekwu C, Kober H, et al. Cognitive reappraisal of emotion: a meta-analysis of human neuroimaging studies. Cereb Cortex. 2014;24(11):2981-90.
13. Ochsner KN, Silvers JA, Buhle JT. Functional imaging studies of emotion regulation: a synthetic review and evolving model of the cognitive control of emotion. Ann N Y Acad Sci. 2012;1251:E1-24.
14. Viviani R. Neural correlates of emotion regulation in the ventral prefrontal cortex and the encoding of subjective value and economic utility. Front Psychiatry. 2014;5:123.
15. Kamphausen S, Schröder P, Maier S, Bader K, Feige B, Kaller CP, et al. Medial prefrontal dysfunction and prolonged amygdala response during instructed fear processing in borderline personality disorder. World J Biol Psychiatry. 2013;14(4):307-18, s1-4.
16. New AS, Hazlett EA, Buchsbaum MS, Goodman M, Mitelman SA, Newmark R, et al. Amygdala-prefrontal disconnection in borderline personality disorder. Neuropsychopharmacology. 2007;32(7):1629-40.
17. Mohammadi MR, Malmir N, Khaleghi A, Aminiorani M. Comparison of Sensorimotor Rhythm (SMR) and Beta Training on Selective Attention and Symptoms in Children with Attention Deficit/Hyperactivity Disorder (ADHD): A Trend Report. Iran J Psychiatry. 2015;10(3):165-74.
18. Sitaram R, Ros T, Stoeckel L, Haller S, Scharnowski F, Lewis-Peacock J, et al. Closed-loop brain training: the science of neurofeedback. Nat Rev Neurosci. 2017;18(2):86-100.
19. Paret C, Ende G, Zähringer J, Ruf M, Schmahl C. 387. Training Amygdala-Prefrontal Networks with Neurofeedback in Borderline Personality Disorder. Biological Psychiatry. 2017;81(10):S158.
20. Thibault RT, Lifshitz M, Raz A. The self-regulating brain and neurofeedback: Experimental science and clinical promise. Cortex. 2016;74:247-61.
21. Paret C, Goldway N, Zich C, Keynan JN, Hendler T, Linden D, et al. Current progress in real-time functional magnetic resonance-based neurofeedback: Methodological challenges and achievements. Neuroimage. 2019;202:116107.
22. Birbaumer N, Ruiz S, Sitaram R. Learned regulation of brain metabolism. Trends Cogn Sci. 2013;17(6):295-302.
23. Micoulaud-Franchi JA, Batail JM, Fovet T, Philip P, Cermolacce M, Jaumard-Hakoun A, et al. Towards a Pragmatic Approach to a Psychophysiological Unit of Analysis for Mental and Brain Disorders: An EEG-Copeia for Neurofeedback. Appl Psychophysiol Biofeedback. 2019;44(3):151-72.
24. Trambaiolli LR, Kohl SH, Linden DEJ, Mehler DMA. Neurofeedback training in major depressive disorder: A systematic review of clinical efficacy, study quality and reporting practices. Neurosci Biobehav Rev. 2021;125:33-56.
25. Ros T, Enriquez-Geppert S, Zotev V, Young KD, Wood G, Whitfield-Gabrieli S, et al. Consensus on the reporting and experimental design of clinical and cognitive-behavioural neurofeedback studies (CRED-nf checklist). Brain. 2020;143(6):1674-85.
26. Sitaram R, Caria A, Veit R, Gaber T, Ruiz S, Birbaumer N. Volitional control of the anterior insula in criminal psychopaths using real-time fMRI neurofeedback: a pilot study. Front Behav Neurosci. 2014;8:344.
27. Surmeli T, Ertem A. QEEG guided neurofeedback therapy in personality disorders: 13 case studies. Clin EEG Neurosci. 2009;40(1):5-10.
28. Zaehringer J, Ende G, Santangelo P, Kleindienst N, Ruf M, Bertsch K, et al. Improved emotion regulation after neurofeedback: A single-arm trial in patients with borderline personality disorder. Neuroimage Clin. 2019;24:102032.
29. Paret C, Kluetsch R, Zaehringer J, Ruf M, Demirakca T, Bohus M, et al. Alterations of amygdala-prefrontal connectivity with real-time fMRI neurofeedback in BPD patients. Soc Cogn Affect Neurosci. 2016;11(6):952-60.
30. Howard R, Schellhorn K, Lumsden J. A biofeedback intervention to control impulsiveness in a severely personality disordered forensic patient. Personal Ment Health. 2013;7(2):168-73.
31. Sulzer J, Haller S, Scharnowski F, Weiskopf N, Birbaumer N, Blefari ML, et al. Real-time fMRI neurofeedback: progress and challenges. Neuroimage. 2013;76:386-99.
32. Weiskopf N. Real-time fMRI and its application to neurofeedback. Neuroimage. 2012;62(2):682-92.
33. Khaleghi A, Mohammadi MR, Shahi K, Motie Nasrabadi A. A neuronal population model based on cellular automata to simulate the electrical waves of the brain. Waves Random Complex Media. 2021:1-20.
34. Mohammadi MR, Khaleghi A, Nasrabadi AM, Rafieivand S, Begol M, Zarafshan H. EEG classification of ADHD and normal children using non-linear features and neural network. Biomed Eng Lett. 2016;6:66-73.
35. Khaleghi A, Birgani PM, Fooladi MF, Mohammadi MR. Applicable features of electroencephalogram for ADHD diagnosis. Biomed Eng Res. 2020;36:1-11.
36. Ries AJ, Touryan J, Vettel J, McDowell K, Hairston WD. A comparison of electroencephalography signals acquired from conventional and mobile systems. JNSNE. 2014;3(1):10-20.
37. Khaleghi A, Zarafshan H, Mohammadi MR. Visual and auditory steady-state responses in attention-deficit/hyperactivity disorder. Eur Arch Psychiatry Clin Neurosci. 2019;269(6):645-55.
38. Koenigsberg HW. Affective instability: toward an integration of neuroscience and psychological perspectives. J Pers Disord. 2010;24(1):60-82.
39. Putnam KM, Silk KR. Emotion dysregulation and the development of borderline personality disorder. Dev Psychopathol. 2005;17(4):899-925.
40. Dillon DG, Pizzagalli DA. Inhibition of Action, Thought, and Emotion: A Selective Neurobiological Review. Appl Prev Psychol. 2007;12(3):99-114.
41. Herpertz SC, Schneider I, Schmahl C, Bertsch K. Neurobiological Mechanisms Mediating Emotion Dysregulation as Targets of Change in Borderline Personality Disorder. Psychopathology. 2018;51(2):96-104.
42. Phillips ML, Drevets WC, Rauch SL, Lane R. Neurobiology of emotion perception II: Implications for major psychiatric disorders. Biol Psychiatry. 2003;54(5):515-28.
43. Adolphs R. Cognitive neuroscience of human social behaviour. Nat Rev Neurosci. 2003;4(3):165-78.
44. Stein MB, Simmons AN, Feinstein JS, Paulus MP. Increased amygdala and insula activation during emotion processing in anxiety-prone subjects. Am J Psychiatry. 2007;164(2):318-27.
45. Simmons A, Matthews SC, Stein MB, Paulus MP. Anticipation of emotionally aversive visual stimuli activates right insula. Neuroreport. 2004;15(14):2261-5.
46. Blair RJ, Peschardt KS, Budhani S, Mitchell DG, Pine DS. The development of psychopathy. J Child Psychol Psychiatry. 2006;47(3-4):262-76.
47. de Oliveira-Souza R, Hare RD, Bramati IE, Garrido GJ, Azevedo Ignácio F, Tovar-Moll F, et al. Psychopathy as a disorder of the moral brain: fronto-temporo-limbic grey matter reductions demonstrated by voxel-based morphometry. Neuroimage. 2008;40(3):1202-13.
48. Fernández-Alvarez J, Grassi M, Colombo D, Botella C, Cipresso P, Perna G, et al. Efficacy of bio- and neurofeedback for depression: a meta-analysis. Psychol Med. 2022;52(2):201-16.
49. Schönenberg M, Wiedemann E, Schneidt A, Scheeff J, Logemann A, Keune PM, et al. Neurofeedback, sham neurofeedback, and cognitive-behavioural group therapy in adults with attention-deficit hyperactivity disorder: a triple-blind, randomised, controlled trial. Lancet Psychiatry. 2017;4(9):673-84.
50. Khaleghi A, Mohammadi MR, Shahi K, Nasrabadi AM. Computational Neuroscience Approach to Psychiatry: A Review on Theory-driven Approaches. Clin Psychopharmacol Neurosci. 2022;20(1):26-36.
51. Campos-Ugaz WA, Garay JPP, Rivera-Lozada O, Diaz MAA, Fuster-Guillén D, Arana AAT. An Overview of Bipolar Disorder Diagnosis Using Machine Learning Approaches: Clinical Opportunities and Challenges. Iran J Psychiatry. 2023:1-11.
52. Schoeller F, Bertrand P, Gerry LJ, Jain A, Horowitz AH, Zenasni F. Combining Virtual Reality and Biofeedback to Foster Empathic Abilities in Humans. Front Psychol. 2018;9:2741.
2. Volkert J, Gablonski TC, Rabung S. Prevalence of personality disorders in the general adult population in Western countries: systematic review and meta-analysis. Br J Psychiatry. 2018;213(6):709-15.
3. Winsper C, Bilgin A, Thompson A, Marwaha S, Chanen AM, Singh SP, et al. The prevalence of personality disorders in the community: a global systematic review and meta-analysis. Br J Psychiatry. 2020;216(2):69-78.
4. Perrotta G. Borderline personality disorder: Definition, differential diagnosis, clinical contexts, and therapeutic approaches. Annals of Psychiatry and Treatment. 2020;4(1):043-56.
5. Gazzillo F, Dazzi N, Kealy D, Cuomo R. Personalizing psychotherapy for personality disorders: Perspectives from control-mastery theory. Psychoanalytic Psychology. 2021;38(4):266.
6. Ronningstam EF, Keng SL, Ridolfi ME, Arbabi M, Grenyer BFS. Cultural Aspects in Symptomatology, Assessment, and Treatment of Personality Disorders. Curr Psychiatry Rep. 2018;20(4):22.
7. Kramer U, Eubanks CF, Bertsch K, Herpertz SC, McMain S, Mehlum L, et al. Future Challenges in Psychotherapy Research for Personality Disorders. Curr Psychiatry Rep. 2022;24(11):613-22.
8. Schulze L, Schmahl C, Niedtfeld I. Neural Correlates of Disturbed Emotion Processing in Borderline Personality Disorder: A Multimodal Meta-Analysis. Biol Psychiatry. 2016;79(2):97-106.
9. Mier D, Lis S, Esslinger C, Sauer C, Hagenhoff M, Ulferts J, et al. Neuronal correlates of social cognition in borderline personality disorder. Soc Cogn Affect Neurosci. 2013;8(5):531-7.
10. Davidson RJ, Jackson DC, Kalin NH. Emotion, plasticity, context, and regulation: perspectives from affective neuroscience. Psychol Bull. 2000;126(6):890-909.
11. Janak PH, Tye KM. From circuits to behaviour in the amygdala. Nature. 2015;517(7534):284-92.
12. Buhle JT, Silvers JA, Wager TD, Lopez R, Onyemekwu C, Kober H, et al. Cognitive reappraisal of emotion: a meta-analysis of human neuroimaging studies. Cereb Cortex. 2014;24(11):2981-90.
13. Ochsner KN, Silvers JA, Buhle JT. Functional imaging studies of emotion regulation: a synthetic review and evolving model of the cognitive control of emotion. Ann N Y Acad Sci. 2012;1251:E1-24.
14. Viviani R. Neural correlates of emotion regulation in the ventral prefrontal cortex and the encoding of subjective value and economic utility. Front Psychiatry. 2014;5:123.
15. Kamphausen S, Schröder P, Maier S, Bader K, Feige B, Kaller CP, et al. Medial prefrontal dysfunction and prolonged amygdala response during instructed fear processing in borderline personality disorder. World J Biol Psychiatry. 2013;14(4):307-18, s1-4.
16. New AS, Hazlett EA, Buchsbaum MS, Goodman M, Mitelman SA, Newmark R, et al. Amygdala-prefrontal disconnection in borderline personality disorder. Neuropsychopharmacology. 2007;32(7):1629-40.
17. Mohammadi MR, Malmir N, Khaleghi A, Aminiorani M. Comparison of Sensorimotor Rhythm (SMR) and Beta Training on Selective Attention and Symptoms in Children with Attention Deficit/Hyperactivity Disorder (ADHD): A Trend Report. Iran J Psychiatry. 2015;10(3):165-74.
18. Sitaram R, Ros T, Stoeckel L, Haller S, Scharnowski F, Lewis-Peacock J, et al. Closed-loop brain training: the science of neurofeedback. Nat Rev Neurosci. 2017;18(2):86-100.
19. Paret C, Ende G, Zähringer J, Ruf M, Schmahl C. 387. Training Amygdala-Prefrontal Networks with Neurofeedback in Borderline Personality Disorder. Biological Psychiatry. 2017;81(10):S158.
20. Thibault RT, Lifshitz M, Raz A. The self-regulating brain and neurofeedback: Experimental science and clinical promise. Cortex. 2016;74:247-61.
21. Paret C, Goldway N, Zich C, Keynan JN, Hendler T, Linden D, et al. Current progress in real-time functional magnetic resonance-based neurofeedback: Methodological challenges and achievements. Neuroimage. 2019;202:116107.
22. Birbaumer N, Ruiz S, Sitaram R. Learned regulation of brain metabolism. Trends Cogn Sci. 2013;17(6):295-302.
23. Micoulaud-Franchi JA, Batail JM, Fovet T, Philip P, Cermolacce M, Jaumard-Hakoun A, et al. Towards a Pragmatic Approach to a Psychophysiological Unit of Analysis for Mental and Brain Disorders: An EEG-Copeia for Neurofeedback. Appl Psychophysiol Biofeedback. 2019;44(3):151-72.
24. Trambaiolli LR, Kohl SH, Linden DEJ, Mehler DMA. Neurofeedback training in major depressive disorder: A systematic review of clinical efficacy, study quality and reporting practices. Neurosci Biobehav Rev. 2021;125:33-56.
25. Ros T, Enriquez-Geppert S, Zotev V, Young KD, Wood G, Whitfield-Gabrieli S, et al. Consensus on the reporting and experimental design of clinical and cognitive-behavioural neurofeedback studies (CRED-nf checklist). Brain. 2020;143(6):1674-85.
26. Sitaram R, Caria A, Veit R, Gaber T, Ruiz S, Birbaumer N. Volitional control of the anterior insula in criminal psychopaths using real-time fMRI neurofeedback: a pilot study. Front Behav Neurosci. 2014;8:344.
27. Surmeli T, Ertem A. QEEG guided neurofeedback therapy in personality disorders: 13 case studies. Clin EEG Neurosci. 2009;40(1):5-10.
28. Zaehringer J, Ende G, Santangelo P, Kleindienst N, Ruf M, Bertsch K, et al. Improved emotion regulation after neurofeedback: A single-arm trial in patients with borderline personality disorder. Neuroimage Clin. 2019;24:102032.
29. Paret C, Kluetsch R, Zaehringer J, Ruf M, Demirakca T, Bohus M, et al. Alterations of amygdala-prefrontal connectivity with real-time fMRI neurofeedback in BPD patients. Soc Cogn Affect Neurosci. 2016;11(6):952-60.
30. Howard R, Schellhorn K, Lumsden J. A biofeedback intervention to control impulsiveness in a severely personality disordered forensic patient. Personal Ment Health. 2013;7(2):168-73.
31. Sulzer J, Haller S, Scharnowski F, Weiskopf N, Birbaumer N, Blefari ML, et al. Real-time fMRI neurofeedback: progress and challenges. Neuroimage. 2013;76:386-99.
32. Weiskopf N. Real-time fMRI and its application to neurofeedback. Neuroimage. 2012;62(2):682-92.
33. Khaleghi A, Mohammadi MR, Shahi K, Motie Nasrabadi A. A neuronal population model based on cellular automata to simulate the electrical waves of the brain. Waves Random Complex Media. 2021:1-20.
34. Mohammadi MR, Khaleghi A, Nasrabadi AM, Rafieivand S, Begol M, Zarafshan H. EEG classification of ADHD and normal children using non-linear features and neural network. Biomed Eng Lett. 2016;6:66-73.
35. Khaleghi A, Birgani PM, Fooladi MF, Mohammadi MR. Applicable features of electroencephalogram for ADHD diagnosis. Biomed Eng Res. 2020;36:1-11.
36. Ries AJ, Touryan J, Vettel J, McDowell K, Hairston WD. A comparison of electroencephalography signals acquired from conventional and mobile systems. JNSNE. 2014;3(1):10-20.
37. Khaleghi A, Zarafshan H, Mohammadi MR. Visual and auditory steady-state responses in attention-deficit/hyperactivity disorder. Eur Arch Psychiatry Clin Neurosci. 2019;269(6):645-55.
38. Koenigsberg HW. Affective instability: toward an integration of neuroscience and psychological perspectives. J Pers Disord. 2010;24(1):60-82.
39. Putnam KM, Silk KR. Emotion dysregulation and the development of borderline personality disorder. Dev Psychopathol. 2005;17(4):899-925.
40. Dillon DG, Pizzagalli DA. Inhibition of Action, Thought, and Emotion: A Selective Neurobiological Review. Appl Prev Psychol. 2007;12(3):99-114.
41. Herpertz SC, Schneider I, Schmahl C, Bertsch K. Neurobiological Mechanisms Mediating Emotion Dysregulation as Targets of Change in Borderline Personality Disorder. Psychopathology. 2018;51(2):96-104.
42. Phillips ML, Drevets WC, Rauch SL, Lane R. Neurobiology of emotion perception II: Implications for major psychiatric disorders. Biol Psychiatry. 2003;54(5):515-28.
43. Adolphs R. Cognitive neuroscience of human social behaviour. Nat Rev Neurosci. 2003;4(3):165-78.
44. Stein MB, Simmons AN, Feinstein JS, Paulus MP. Increased amygdala and insula activation during emotion processing in anxiety-prone subjects. Am J Psychiatry. 2007;164(2):318-27.
45. Simmons A, Matthews SC, Stein MB, Paulus MP. Anticipation of emotionally aversive visual stimuli activates right insula. Neuroreport. 2004;15(14):2261-5.
46. Blair RJ, Peschardt KS, Budhani S, Mitchell DG, Pine DS. The development of psychopathy. J Child Psychol Psychiatry. 2006;47(3-4):262-76.
47. de Oliveira-Souza R, Hare RD, Bramati IE, Garrido GJ, Azevedo Ignácio F, Tovar-Moll F, et al. Psychopathy as a disorder of the moral brain: fronto-temporo-limbic grey matter reductions demonstrated by voxel-based morphometry. Neuroimage. 2008;40(3):1202-13.
48. Fernández-Alvarez J, Grassi M, Colombo D, Botella C, Cipresso P, Perna G, et al. Efficacy of bio- and neurofeedback for depression: a meta-analysis. Psychol Med. 2022;52(2):201-16.
49. Schönenberg M, Wiedemann E, Schneidt A, Scheeff J, Logemann A, Keune PM, et al. Neurofeedback, sham neurofeedback, and cognitive-behavioural group therapy in adults with attention-deficit hyperactivity disorder: a triple-blind, randomised, controlled trial. Lancet Psychiatry. 2017;4(9):673-84.
50. Khaleghi A, Mohammadi MR, Shahi K, Nasrabadi AM. Computational Neuroscience Approach to Psychiatry: A Review on Theory-driven Approaches. Clin Psychopharmacol Neurosci. 2022;20(1):26-36.
51. Campos-Ugaz WA, Garay JPP, Rivera-Lozada O, Diaz MAA, Fuster-Guillén D, Arana AAT. An Overview of Bipolar Disorder Diagnosis Using Machine Learning Approaches: Clinical Opportunities and Challenges. Iran J Psychiatry. 2023:1-11.
52. Schoeller F, Bertrand P, Gerry LJ, Jain A, Horowitz AH, Zenasni F. Combining Virtual Reality and Biofeedback to Foster Empathic Abilities in Humans. Front Psychol. 2018;9:2741.
| Files | ||
| Issue | Vol 18 No 3 (2023) | |
| Section | Review Article(s) | |
| DOI | https://doi.org/10.18502/ijps.v18i3.13014 | |
| Keywords | ||
| Neurofeedback Personality Disorders Self-Regulation Systematic Review | ||
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How to Cite
1.
Babaskina L, Afanasyeva N, Semyonkina1M, Myasnyankina O, Sushko N. Effectiveness of Neurofeedback Training for Patients with Personality Disorders: A Systematic Review. Iran J Psychiatry. 2023;18(3):352-361.
