Real-Time-Monitoring in der Behandlung von Zwangsstörungen: Technologie und Fallbeispiel

Background: New methods of internet-based real-time monitoring of psychotherapy processes allow for the documentation, analysis, and data-driven control of behaviour therapy. Daily ratings of the patient result in highly resolved time series of the change dynamics. Method and Patient: The Synergetic Navigation System was used in the treatment setting of a day hospital. This method is specialized in the representation of critical instabilities and pattern transitions of the process. The patient of this case report had the combined diagnosis of obsessive-compulsive disorder and depressive episodes. Result: Quantitative time-series and qualitative data from the internet-assisted diaries mirror important features of the change process. Conclusion: The method could help optimise treatment effects of behavioural interventions by using the feedback on necessary conditions, appropriate timing, and short-term effects of these interventions. Patients' motivation for change can be enhanced and the navigation system realises the continuous documentation of treatment processes and effects

Individual- and Connectivity-Based Real-Time fMRI Neurofeedback to Modulate Emotion-Related Brain Responses in Patients with Depression: A Pilot Study

Introduction: Individual real-time functional magnetic resonance imaging neurofeedback (rtfMRI NF) might be a promising adjuvant in treating depressive symptoms. Further studies showed functional variations and connectivity-related changes in the dorsolateral prefrontal cortex (dlPFC) and the insular cortex. Objectives: The aim of this pilot study was to investigate whether individualized connectivity-based rtfMRI NF training can improve symptoms in depressed patients as an adjunct to a psychotherapeutic programme. The novel strategy chosen for this was to increase connectivity between individualized regions of interest, namely the insula and the dlPFC. Methods: Sixteen patients diagnosed with major depressive disorder (MDD, ICD-10) and 19 matched healthy controls (HC) participated in a rtfMRI NF training consisting of two sessions with three runs each, within an interval of one week. RtfMRI NF was applied during a sequence of negative emotional pictures to modulate the connectivity between the dlPFC and the insula. The MDD REAL group was divided into a Responder and a Non-Responder group. Patients with an increased connectivity during the second NF session or during both the first and the second NF session were identified as “MDD REAL Responder” (N = 6). Patients that did not show any increase in connectivity and/or a decreased connectivity were identified as “MDD REAL Non-Responder” (N = 7). Results: Before the rtfMRI sessions, patients with MDD showed higher neural activation levels in ventromedial PFC and the insula than HC; by contrast, HC revealed increased hemodynamic activity in visual processing areas (primary visual cortex and visual association cortex) compared to patients with MDD. The comparison of hemodynamic responses during the first compared to during the last NF session demonstrated significantly increased BOLD-activation in the medial orbitofrontal cortex (mOFC) in patients and HC, and additionally in the lateral OFC in patients with MDD. These findings were particularly due to the MDD Responder group, as the MDD Non-Responder group showed no increase in this region during the last NF run. There was a decrease of neural activation in emotional processing brain regions in both groups in the last NF run compared to the first: HC showed differences in the insula, parahippocampal gyrus, basal ganglia, and cingulate gyrus. Patients with MDD demonstrated deceased responses in the parahippocampal gyrus. There was no significant reduction of BDI scores after NF training in patients. Conclusions: Increased neural activation in the insula and vmPFC in MDD suggests an increased emotional reaction in patients with MDD. The activation of the mOFC could be associated with improved control-strategies and association-learning processes. The increased lOFC activation could indicate a stronger sensitivity to failed NF attempts in MDD. A stronger involvement of visual processing areas in HC may indicate better adaptation to negative emotional stimuli after repeated presentation. Overall, the rtfMRI NF had an impact on neurobiological mechanisms, but not on psychometric measures in patients with MDD

Discontinuous Patterns of Brain Activation in the Psychotherapy Process of Obsessive-Compulsive Disorder: Converging Results from Repeated fMRI and Daily Self-Reports

<div><p>This study investigates neuronal activation patterns during the psychotherapeutic process, assuming that change dynamics undergo critical instabilities and discontinuous transitions. An internet-based system was used to collect daily self-assessments during inpatient therapies. A dynamic complexity measure was applied to the resulting time series. Critical phases of the change process were indicated by the maxima of the varying complexity. Repeated functional magnetic resonance imaging (fMRI) measurements were conducted over the course of the therapy. The study was realized with 9 patients suffering from obsessive-compulsive disorder (subtype: washing/contamination fear) and 9 matched healthy controls. For symptom-provocative stimulation individualized pictures from patients’ personal environments were used. The neuronal responses to these disease-specific pictures were compared to the responses during standardized disgust-provoking and neutral pictures. Considerably larger neuronal changes in therapy-relevant brain areas (cingulate cortex/supplementary motor cortex, bilateral dorsolateral prefrontal cortex, bilateral insula, bilateral parietal cortex, cuneus) were observed during critical phases (order transitions), as compared to non-critical phases, and also compared to healthy controls. The data indicate that non-stationary changes play a crucial role in the psychotherapeutic process supporting self-organization and complexity models of therapeutic change.</p></div

Pre-post-comparisons of clinical measures, picture ratings, and brain activation.

<p>Comparison of total scores for Y-BOCS <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0071863#pone.0071863-Goodman1" target="_blank">[42]</a>, BDI <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0071863#pone.0071863-Beck1" target="_blank">[47]</a>, SCL 90-R <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0071863#pone.0071863-Franke1" target="_blank">[48]</a>, assessed at the beginning (pre) and at the end of inpatient treatment (post). The ratings for valence, arousal, and coping for individualized symptom provoking pictures, as well as the brain activation (voxel and weighted) were taken at the first (pre) and the third fMRI scan (post). The number of significant voxels (averaged across all 9 patients) of the first and last fMRI measurements were compared separately for eight brain areas (ROIs). Voxel numbers were also relativized for each patient for the brain areas with the largest voxel number, implying that brain areas with larger voxel numbers are weighted more.</p><p>Abbreviations: <i>t</i>: <i>t</i>-values of two-sided <i>t</i>-tests. ISPP: individualized symptom provoking pictures; CC/SMA: anterior cingulate cortex/supplementary motor area; DLPFC r: dorsolateral prefrontal cortex right; DLPFC l: dorsolateral prefrontal cortex left; Insula r: insula right; Insula l: insula left; Parietal r: parietal cortex right; Parietal l: parietal cortex left; cuneus.</p

Expanded model of OCD pathophysiology.

<p>A primary cognitive network (left) connects prefrontal and ventroanterior thalamic structures via dorsal striatal loops. A primary affective network (right) connects the posterior OFC and ventral parts of the ACC via ventral striatal loops and via limbic structures with the mediodorsal thalamus. The DLPFC interfaces with the parietal cortex and the cerebellum. (Modified according to <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0071863#pone.0071863-Kwon1" target="_blank">[14]</a>, p. 264; <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0071863#pone.0071863-Menzies1" target="_blank">[15]</a>, p. 541]).</p

Ratings of stimulus material.

<p>Ratings for individualized symptom provoking pictures [a], IAPS disgust pictures [b], and IAPS neutral pictures [c]. Left: patients, right: healthy controls. Rating according to valence, arousal, and coping. The three adjacent columns represent the ratings of three successive fMRI scans. The fourth measurement taken for 2 patients and one control is not represented. 95% confidence intervals of the means were bootstrapped with R’s boot.ci function using 10.000 resamples and the “bca” type of confidence intervals.</p

Descriptive results for the picture ratings after the first fMRI.

<p>Mean and standard deviation (mean ± <i>SD</i>) of ratings for the pictures presented (individualized symptom provoking pictures, disgust pictures, neutral pictures) immediately after the first fMRI measurement. Ratings according to valence, arousal, and coping. <i>t</i>: <i>t</i>-values of two-sided <i>t</i>-tests for paired samples.</p

Characterization of patients and healthy controls.

<p>Patients and controls did not differ with respect to age, <i>t</i>(16) = −0.25, <i>p</i> = .802. Length of hospital stay equals the number of daily ratings.</p

Changes in brain activity in eight regions of interest.

<p>Differences of brain activity in order transition intervals for patients (red), non order transitions for patients (yellow) and inter-scan-intervals for healthy controls (grey). Top: mean voxel number difference; below: relative percentage changes. Abbreviations: OT: order transitions; NOT: non order transitions; ISI: inter-scan-intervals for healthy controls. CC/SMA: anterior cingulate cortex/supplementary motor area; DLPFC r: dorsolateral prefrontal cortex right; DLPFC l: dorsolateral prefrontal cortex left; Insula r: insula right; Insula l: insula left; Parietal r: parietal cortex right; Parietal l: parietal cortex left; cuneus.</p

Activation patterns for each patient during fMRI scans in sagittal views.

<p>Talairach coordinate: <i>x</i> = 0. The order transitions within individual therapies are marked by arrows.</p