Combination of Real-Time fMRI Neurofeedback and Mindfulness Instructions in Problematic Alcohol Use

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Abstract Submission 

Jingying Zhang¹, Falk Kiefer², Martin Gerchen^1,3, Peter Kirsch^1,3

¹Department of Clinical Psychology, Central Institute of Mental Health, Mannheim, Germany, ²Department of Addictive Behaviour and Addiction Medicine, Central Institute of Mental Health, Mannheim, Germany, ³Institute of Psychology, University of Heidelberg, Heidelberg, Germany

Jingying Zhang  
Department of Clinical Psychology, Central Institute of Mental Health
Mannheim, Germany

Falk Kiefer  
Department of Addictive Behaviour and Addiction Medicine, Central Institute of Mental Health
Mannheim, Germany

Martin Gerchen  
Department of Clinical Psychology, Central Institute of Mental Health|Institute of Psychology, University of Heidelberg
Mannheim, Germany|Heidelberg, Germany

Peter Kirsch  
Department of Clinical Psychology, Central Institute of Mental Health|Institute of Psychology, University of Heidelberg
Mannheim, Germany|Heidelberg, Germany

Hyperreactivity towards alcoholic cues is a key aspect in understanding and treating alcohol use disorders, particularly in the ventral striatum (VS) (Heinz et al. 2009). Real-time fMRI neurofeedback (rtfMRI NF) is a newly emerging non-invasive method to reduce ventral striatal alcohol-cue reactivity. Existing studies have found its capacity on decreasing cue-induced craving and empowering participants modulating their brain processes (Karch et al., 2015; Kirsch et al., 2016; Pindi et al., 2022). However, the efficacy of rtfMRI NF might be subject to effective strategies that participants can employ to regulate the brain process (Oblak et al., 2017). Mindfulness, which aims at building insight and non-reactive acceptance of one's own experience, might provide promising strategies to regulate brain activity elicited by alcohol triggers.
In our randomized, double-blind, sham-controlled study, we investigated the hypothesis that mindfulness-based instructions will increase the rtfMRI NF training efficiency in reducing VS alcohol-cue reactivity for participants with problematic alcohol use. The study was approved by the Ethics Committee of the Medical Faculty Mannheim at Heidelberg University (2020-632N) and pre-registered at the Open Science Foundation (OSF, NeuMinds https://osf.io/7bmqw/).

Participants with problematic alcohol use, as in our previous study (Kirsch et al., 2016) identified with the online version of the alcohol use disorder identification test (AUDIT), were enrolled and randomly assigned to one of three groups: group1: NF with mindfulness-based instruction, group2: NF without mindfulness-based instruction, and group3: sham NF without mindfulness-based instruction. Participants received a 2-session rtfMRI NF at a 3T Scanner (Biograph, Siemens Healthineers, Erlangen, Germany) at the Central Institute of Mental Health (CIMH). Before NF, participants received either a mindfulness-based instruction or a length-matched neutral message (an introduction to CIMH) for 5 min. During NF, an alcohol picture and a thermometer display reflecting the brain activation induced by alcohol pictures were presented on the screen. Participants were instructed to down-regulate the thermometer. Both real NF groups (groups 1 and 2) were presented with NF signals from VS, while the sham NF group (group 3) received signals from the auditory cortex (A1) which is not involved in cue reactivity or cognitive control. (see rtfMRI NF setup in Figure 1a, and training process in Figure 1b).

A total of 66 participants have been enrolled (age: 23.82±7.52, 37/29 male/female), group1: n=25, group2: n=19, group3: n=22. The randomized groups did not differ in gender, age, alcohol consume associated measures, or trait mindfulness. Craving was assessed before and after each session using a visual analog scale to track NF-related dynamics (Figure 2a). Group1 (real NF with mindfulness instruction) showed a decreasing tendency of craving after NF at the first NF session. The VS activity to alcohol cues is shown in Figure 2b, and group1 decreased VS activity from the 2nd run to the transfer run. To test whether mindfulness instruction has an impact on real NF, group1 and group2 (real NF with control instruction) were compared (Figure 2d). The negative effects across all NF runs reflect that VS activity of group1 was lower than that of group2 during all NF runs, but the differences were not significant. The negative effect size in the transfer run, although not significant, indicates a possible larger learning effect in group1.

These preliminary results suggest a possible supportive effect of mindfulness-based instruction on rtfMRI NF training on both clinical outcomes (reduction in self-reported cravings) and neurobiological outcomes (reduction in alcohol cue-induced VS activity) for people with problematic alcohol use. We will continue recruiting participants to reach our recruitment goals (N=111) and make solid conclusions with sufficient statistical power.

Non-Invasive Stimulation Methods Other ¹

Psychiatric (eg. Depression, Anxiety, Schizophrenia) ²

Reward and Punishment

Executive Function, Cognitive Control and Decision Making

Activation (eg. BOLD task-fMRI)

Addictions

FUNCTIONAL MRI

Psychiatric

Other - neurofeedback