Infra-Low Frequency Neurofeedback in the Treatment of Patients With Chronic Eating Disorder and Comorbid Post-Traumatic Stress Disorder

Abstract

The treatment of patients suffering from an eating disorder and a comorbid post-traumatic stress disorder is challenging and often leads to poor outcomes. In a randomized control trial, we evaluated to what extent adding Infra-Low Frequency (ILF) neurofeedback could improve symptom reduction within an established inpatient treatment program. In a randomized two-group design, patients suffering from an eating disorder (anorexia nervosa, bulimia nervosa, or binge eating disorder) and comorbid post-traumatic stress disorder (N = 36) were examined while attending an inpatient treatment program in a clinic for psychosomatic disorders. The intervention group received ILF neurofeedback in addition to regular therapy, while the control group received “media-supported relaxation” as a placebo intervention. At the beginning and at the end of their treatment, all participants completed the Eating Disorder Examination-Questionnaire (EDE-Q) as a measure of eating disorder psychopathology and the Impact of Event Scale-Revised (IES-R) in order to assess symptoms of post-traumatic stress. Changes in EDE-Q and IES-R scores over time served as primary outcomes as well as an increase in body mass index in underweight patients. Secondary outcomes were the perceived benefit of the received intervention, global assessment of psychological treatment success, and complications in the course of treatment. Statistical evaluation was carried out with repeated measurement analysis of variance for the primary outcomes and with t-tests and Fisher’s exact test for the secondary outcomes. Our results indicate better treatment outcomes in the ILF neurofeedback group with regard to trauma-associated avoidance as well as with regard to restraint eating and increase in body weight. Furthermore, patients who had received ILF neurofeedback rated the intervention they received and, in tendency, their overall treatment more positively and they experienced fewer complications in the course of treatment. ILF neurofeedback is very well accepted by patients and seems to provide a relevant additional benefit in some aspects of symptom reduction. Findings confirm the feasibility of embedding this treatment approach in an inpatient setting and support the case for a larger study for greater statistical power.Clinical Trial Registration: “Infra-Low Frequency Neurofeedback training in the treatment of patients with eating disorder and comorbid post-traumatic stress disorder”; German Clinical Trials Registry (https://www.drks.de; Identifier: DRKS00027826).

Systematic review and meta-analysis of neurofeedback and its effect on posttraumatic stress disorder

“…After duplicates were removed ( 21 – 24 ), 17 randomized controlled trials, involving 628 patients (55% men), met the inclusion criteria and were included in the review ( 16 , 25 – 40 ). The studies took place from 1991 to 2023, with eight in the United States ( 25 – 28 , 30 , 31 , 34 , 35 ), one in Canada ( 32 ), two in Iran ( 29 , 36 ), two in Israel ( 16 , 38 ), and one each in Germany ( 37 ), South Korea ( 33 ), the Netherlands ( 39 ), and Nepal ( 40 ). All but three of the studies were on adults ( 31 , 39 , 40 ).…”

“…All but three of the studies were on adults ( 31 , 39 , 40 ). Of the 17 studies, three compared NF with yoked feedback ( 27 , 32 , 34 ), four compared NF with waitlist (the waitlist group received the same NF after the trial was completed) ( 28 , 31 , 33 , 40 ), five compared NF with the standard of care/treatment as usual the patient was presently on ( 16 , 25 , 36 , 38 , 39 ), two compared NF with no treatment ( 26 , 29 ), one compared NF with a form of biofeedback (HRV biofeedback) ( 35 ), one compared NF with a form of relaxation ( 37 ), and one compared NF with sham neurofeedback ( 30 ).…”

“…There were 13 of 17 studies that used EGG NF ( 25 – 29 , 31 – 33 , 35 – 37 , 39 , 40 ). Two studies used fMRI NF ( 30 , 34 ), and two studies utilized fMRI informed EEG-NF ( 16 , 38 ). Additionally, one study used fMRI scans as an assessment tool for the mechanism of the NF training ( 32 ).…”

“…Effects of NF on PTSD symptoms were assessed via meta-analyses in 10 of the 17 studies ( 16 , 28 – 30 , 32 – 36 , 38 ,).…”

Inpatient treatments for adults with anorexia nervosa: a systematic review of literature

“…Out of the initial 846 studies identified, 105 were chosen for full-text review. Among these, 49 were excluded due to their predominant focus on pediatric populations [ 23 , 24 ], 21 were omitted because they also pertained to non-hospitalization settings [ 25 , 26 ] and 8 were disregarded for their inclusion of a significant number of patients with various EDs [ 27 , 28 ]. Consequently, the final 27 studies were selected for this review (see Flow Diagram in Supplementary Materials).…”