Real-Time fMRI Neurofeedback in Patients With Tobacco Use Disorder During Smoking Cessation: Functional Differences and Implications of the First Training Session in Regard to Future Abstinence or Relapse

Abstract

One of the most prominent symptoms in addiction disorders is the strong desire to consume a particular substance or to show a certain behavior (craving). The strong association between craving and the probability of relapse emphasizes the importance of craving in the therapeutic process. Former studies have demonstrated that neuromodulation using real-time fMRI (rtfMRI) neurofeedback (NF) can be used as a treatment modality in patients with tobacco use disorder. The aim of the present project was to determine whether it is possible to predict the outcome of NF training plus group psychotherapy at the beginning of the treatment. For that purpose, neuronal responses during the first rtfMRI NF session of patients who remained abstinent for at least 3 months were compared to those of patients with relapse. All patients were included in a certified smoke-free course and took part in three NF sessions. During the rtfMRI NF sessions tobacco-associated and neutral pictures were presented. Subjects were instructed to reduce their neuronal responses during the presentation of smoking cues in an individualized region of interest for craving [anterior cingulate cortex (ACC), insula or dorsolateral prefrontal cortex]. Patients were stratified to different groups [abstinence (N = 10) vs. relapse (N = 12)] according to their individual smoking status 3 months after the rtfMRI NF training. A direct comparison of BOLD responses during the first NF-session of patients who had remained abstinent over 3 months after the NF training and patients who had relapsed after 3 months showed that patients of the relapse group demonstrated enhanced BOLD responses, especially in the ACC, the supplementary motor area as well as dorsolateral prefrontal areas, compared to abstinent patients. These results suggest that there is a probability of estimating a successful withdrawal in patients with tobacco use disorder by analyzing the first rtfMRI NF session: a pronounced reduction of frontal responses during NF training in patients might be the functional correlate of better therapeutic success. The results of the first NF sessions could be useful as predictor whether a patient will be able to achieve success after the behavioral group therapy and NF training in quitting smoking or not.

Keywords: craving; neurofeedback; real-time fMRI; therapy success; tobacco use disorder.

FIGURE 1

Experimental procedures: the patients participated in three rtfMRI NF sessions within 5 weeks; during the NF training presentation of neutral and tobacco-related pictures in blocks of 40 s with 10 pictures of the respective category; participants were instructed to reduce brain activity during the presentation of tobacco-associated information; during the presentation of neutral information, participants were instructed to simply gaze at the pictures. Before and after each NF training session, resting-state activity was acquired. NF, neurofeedback.

FIGURE 2

Neuronal responses during cue exposure task [tobacco-related pictures > neutral pictures; p(Bonf) < 0.05, T-score: 4.830–8]. (A,B) Smokers of both groups demonstrated neuronal responses to tobacco related pictures especially in the brain regions associated with visual information processing (x = 0; y = 0; z = 0). (C) The comparison of brain responses of the relapse group and the abstinent group showed only very small functional differences within the fusiform gyrus were detected (x = –1; y = –53; z = –18).

FIGURE 3

Neuronal responses of the first neurofeedback-session [tobacco-related pictures > neutral pictures; p(Bonf) < 0.05, T-score: 4.830–8]. (A) Smokers of the abstinent group demonstrated enhanced neuronal responses during the presentation of smoking related cues especially in frontal brain regions (e.g., superior/medial frontal gyrus, ACC), the pariatal cortex and the insula (x = 0; y = 4; z = 42). (B) Smokers of the relapse group demonstrated enhanced neuronal responses during the presentation of smoking related cues compared to neutral pictures especially in frontal brain regions (e.g., superior/medial/middle frontal gyrus, ACC), the insula, pariatal areas as well as temporal regions and the cuneus/precuneues (x = 0; y = 18; z = 27). (C) Neuronal responses of smokers who relapsed compared to smokers who remained abstinent: patients of the relapse group demonstrated enhanced BOLD responses especially in the medial/middle and superior frontal gyrus, the ACC, the caudate nucleus and the superior temporal gyrus compared to patients that remained abstinent. By contrast, the responses in the inferior occipital gyrus and the fusiform gyrus were decreased in the relapse group (x = 4; y = 3; z = 34).