Instituciones Educativas en Reestructuración

The current chapter investigated whether patients suffering from depression were able to voluntarily increase the activation in emotion processing areas (experimental EMO group) or in a scene processing region (control PPA group). We found that patients in both groups were able to significantly up- regulate their target area. Already during the first session patients in the PPA group showed relatively high physiological self-regulation abilities, yet these did not improve any further over time. It seemed that patients performed relatively better when the up-regulation task had not been executed recently, such as during the first and last neurofeedback session. Relatively long term

habituation effects might underlie this observation. In contrast, the up- regulation of emotion processing areas seemed more difficult without any practise. Moreover, once successful up-regulation had been achieved in the EMO group, it seemed that continued training was required to maintain this ability. Booster sessions might thus be necessary for keeping patients’ self- regulation ability of emotion networks at optimal performance. As patients did not succeed in up-regulating their target area during the transfer session, it seemed that after two training sessions patients still required feedback to execute the up-regulation task properly. Any booster sessions would thus have to be scheduled after an initial training consisting of more than two neurofeedback sessions.

Since there are no objective measures of what constitutes a positive mood or a non-depressed state of being, it was of especial importance for the currently ongoing clinical trial that any changes in depression in the experimental group were benchmarked against those in an apt control group. The findings in the control group of the pilot study suggested that the mere repetition of positive emotion imagery did not improve depression severity (Linden et al., 2012). The design of that study could however not rule out that clinical improvement in the experimental group was due to the specialist MRI environment or rewarding feedback. Therefore, the current control group also received neurofeedback training. Given the nature of the current sample, we opted for accurate feedback to minimise distress that could have been caused by a perceived inability to perform the task. We therefore selected a control area that was relatively unrelated to depression and emotion regulation.

A disadvantage of the current control group is that it cannot establish the importance of self-induced opposed to externally induced activation increases. Therefore it cannot validate Bandura’s self-efficacy theory. Sulzer, Haller, et al. (2013) recently stressed the importance of control conditions that compare outcomes resulting from neurofeedback training with the best-known alternative method to excite the region-of-interest. To some extent, transcranial magnetic stimulation (TMS) could shed more light on the importance of playing an active role in establishing heightened brain activity. It must be noted

however that TMS cannot target subcortical areas and is a relatively invasive method which imposes other drawbacks on such a control group.

Given this limitation of the current control group, one could argue that for instance providing yoked feedback to the control group would be more suitable. This is unlikely to be the case as patients may realise that the feedback is not contingent on their mental strategies, especially if one particular strategy results in contradictory thermometer feedback at different moments in time. As the frustration that may be experienced as a result of this is likely to have a negative effect on depression severity, this control group comes with weaknesses of its own. In addition, it is unlikely that patients would be able to exercise physiological self-regulation over emotion areas when provided with yoked feedback as previous studies have shown the importance of valid feedback to master this task (see for instance DeCharms et al., 2005; Hamilton et al., 2011; Young et al., 2014).

Given the emotion regulation problems that depressed patients experience, it is noteworthy that patients in the EMO group managed to learn the self-regulation of their target area. Nevertheless, it did seem that continuous practise was required to maintain this ability. The inclusion of booster sessions might ensure getting the most out of neurofeedback as an add-on treatment for depression.

In terms of the overarching clinical trial, it is hypothesised that both groups will show an improvement in depression severity because both groups acquired up- regulation abilities. (The mediating role of perceived self-efficacy is examined in Chapter 7.) It is expected that the EMO group will show a larger improvement than the PPA group as the former group also targets abnormal brain activation levels associated with depression. Such an outcome would suggest that merely exposing patients to an MRI environment, providing rewarding feedback and expectancies generated by clinical trial participation do not induce improvements in depression. Because the dataset employed in the current chapter forms part of a currently ongoing clinical trial, the accuracy of these speculations will have to be awaited.

Chapter 6 - Neural networks mediating self-regulation via