Self-Regulation of Anterior Insula with Real-Time fMRI and Its Behavioral Effects in Obsessive-Compulsive Disorder: A Feasibility Study

Abstract

IntroductionObsessive-compulsive disorder (OCD) is a common and chronic condition that can have disabling effects throughout the patient's lifespan. Frequent symptoms among OCD patients include fear of contamination and washing compulsions. Several studies have shown a link between contamination fears, disgust over-reactivity, and insula activation in OCD. In concordance with the role of insula in disgust processing, new neural models based on neuroimaging studies suggest that abnormally high activations of insula could be implicated in OCD psychopathology, at least in the subgroup of patients with contamination fears and washing compulsions.MethodsIn the current study, we used a Brain Computer Interface (BCI) based on real-time functional magnetic resonance imaging (rtfMRI) to aid OCD patients to achieve down-regulation of the Blood Oxygenation Level Dependent (BOLD) signal in anterior insula. Our first aim was to investigate whether patients with contamination obsessions and washing compulsions can learn to volitionally decrease (down-regulate) activity in the insula in the presence of disgust/anxiety provoking stimuli. Our second aim was to evaluate the effect of down-regulation on clinical, behavioural and physiological changes pertaining to OCD symptoms. Hence, several pre- and post-training measures were performed, i.e., confronting the patient with a disgust/anxiety inducing real-world object (Ecological Disgust Test), and subjective rating and physiological responses (heart rate, skin conductance level) of disgust towards provoking pictures.ResultsResults of this pilot study, performed in 3 patients (2 females), show that OCD patients can gain self-control of the BOLD activity of insula, albeit to different degrees. In two patients positive changes in behaviour in the EDT were observed following the rtfMRI trainings. Behavioural changes were also confirmed by reductions in the negative valence and in the subjective perception of disgust towards symptom provoking images.ConclusionAlthough preliminary, results of this study confirmed that insula down-regulation is possible in patients suffering from OCD, and that volitional decreases of insula activation could be used for symptom alleviation in this disorder.

OCD: obsessive–compulsive … disgust? The role of

“…Positive behavioural changes in disgust responses were also observed outside of the scanner, post training, using BAT and picture rating tasks. 75 However, the sample size of this pilot study was very small (n = 3), and the effects were not assessed in the long term. Findings of in creased insular activity also extend to other symptom dimen sions of OCD.…”

Can we predict real-time fMRI neurofeedback learning success from pre-training brain activity?

“…Real-time fMRI-based neurofeedback enables subjects to learn control over brain activity in localized regions of interest (ROIs). Brain areas that have been investigated in fMRI-based neurofeedback studies include the anterior cingulate cortex (deCharms et al, 2005;Emmert et al, 2014;Gröne et al, 2015;Guan et al, 2014;Li et al, 2013), anterior insula (Yao et al, 2016), amygdala (Brühl et al, 2014;Gerin et al, 2016;Keynan et al, 2016;Nicholson et al, 2017;Paret et al, 2014;Young et al, 2014), auditory cortex Haller, Birbaumer, & Veit, 2010), default mode network (DMN;McDonald et al, 2017), dorsolateral prefrontal cortex (Sherwood, Kane, Weisend, & Parker, 2016), hippocampus , insula (Korhan Buyukturkoglu et al, 2015;Caria et al, 2007;Emmert et al, 2014;Frank et al, 2012;Zilverstand, Sorger, Sarkheil, & Goebel, 2015), motor cortex (Auer, Schweizer, & Frahm, 2015;Blefari, Sulzer, Hepp-Reymond, Kollias, & Gassert, 2015;Buyukturkoglu et al, 2013;Marins et al, 2015;Scharnowski et al, 2015;Yoo, Lee, O'Leary, Panych, & Jolesz, 2008), nucleus accumbens (Greer, Trujillo, Glover, & Knutson, 2014), parahippocampal gyrus , ventral tegmental area (MacInnes, Dickerson, Chen, & Adcock, 2016;Sulzer et al, 2013), and the visual cortex (Scharnowski, Hutton, Josephs, Weiskopf, & Rees, 2012;Shibata, Watanabe, Sasaki, & Kawato, 2011). More recently, functional brain networks have also been successfully trained employing connectivity-informed neurofeedback in networks sub-serving emotion...…”

“…Real-time fMRI neurofeedback has been shown to improve behavioral and cognitive functions in healthy participants (e.g. Rota et al, 2009;Scharnowski et al, 2015Scharnowski et al, , 2012Sherwood et al, 2016;Shibata et al, 2011), and to reduce clinical symptoms in neurological and psychiatric patient populations, such as patients suffering from adipositas (Frank et al, 2012), alcohol and nicotine addiction Hanlon et al, 2013;Hartwell et al, 2016;Karch et al, 2015;Kim et al, 2015;Li et al, 2013), borderline personality disorder (Paret et al, 2016), chronic pain (deCharms et al, 2005;Guan et al, 2014), depression (Linden et al, 2012;Young et al, 2017Young et al, , 2014, Huntington's disease (Papoutsi et al, 2018), obsessive compulsory disorder (Buyukturkoglu et al, 2015), Parkinson's disease (Buyukturkoglu et al, 2013;Subramanian et al, 2011), phobia (Zilverstand et al, 2015), post-traumatic stress disorder (Gerin et al, 2016;Nicholson et al, 2017), and tinnitus Haller et al, 2010).…”

The efficacy of biofeedback approaches for obsessive-compulsive and related disorders: A systematic review and meta-analysis

“…All studies included in the systematic review (n = 10) involved OCD patients and were published between 1974 and 2015. Two multicentric studies were conducted in Germany, Italy, USA, and Chile (Buyukturkoglu et al, 2015), and the Czech Republic and France Table 1 Summary of demographic and clinical information of the studies included for systematic reviewing. ( Koprivová et al, 2013).…”

“…All studies applied an intervention based on neurofeedback with fMRI (n = 2 (Buyukturkoglu et al, 2015;Scheinost et al, 2014)) or EEG (n = 7), except one publication that used thermal biofeedback (LeVine, 1983). Two studies combined the neurofeedback effects with CBT (Koprivová et al, 2013) or medication and CBT (Deng et al, 2014).…”