Benefits of EEG-Neurofeedback on the Modulation of Impulsivity in a Sample of Cocaine and Heroin Long-Term Abstinent Inmates: A Pilot Study
| Published date | 01 September 2020 |
| Date | 01 September 2020 |
| DOI | http://doi.org/10.1177/0306624X20904704 |
| Subject Matter | Articles |
research-article2020
Article
International Journal of
Offender Therapy and
Benefits of EEG-
Comparative Criminology
2020, Vol. 64(12) 1275 –1298
Neurofeedback on the
© The Author(s) 2020
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Modulation of Impulsivity
https://doi.org/10.1177/0306624X20904704
DOI: 10.1177/0306624X20904704
journals.sagepub.com/home/ijo
in a Sample of Cocaine and
Heroin Long-Term Abstinent
Inmates: A Pilot Study
M. Corominas-Roso1,2 , I. Ibern3, M. Capdevila3,
R. Ramon3, C. Roncero2,4 , and J. A. Ramos-Quiroga1,2
Abstract
The aim of this pilot study was to assess whether neurofeedback (NFB) can be useful
in the treatment of impulsive behavior in long-term abstinent cocaine and heroin
addicts. A single-blind sham-controlled NFB protocol was carried out to assess the
effects of NFB on impulsivity in 20 (10 + 10) cocaine and heroin long-term abstinent
addicts (Diagnostic and Statistical Manual of Mental Disorders [4th ed., text rev.; DSM-
IV-TR]). Psychotic and neurologic diseases were excluded. Participants underwent 40
NFB sessions based on the very slow cortical potential range. Inhibitory deficits were
specifically addressed through right and left prefrontal training. Clinical improvement
was measured with Likert-type scales, the Hamilton Depression Rating Scale, and
the State–Trait Anxiety Inventory, and impulsivity was assessed using the Barratt
Impulsiveness Scale and the Continuous Performance Test. Although the results are
preliminary due to the small sample size, the NFB-treated group showed a significant
clinical improvement, including symptoms of anxiety and depression, with two
differentiated time periods. No significant clinical improvement was found in the
control group. A significant decrease in the post- versus pre-treatment measures
1Psychiatry Department, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Spain
2Biomedical Network Research Center on Mental Health, Madrid, Spain
3Generalitat de Catalunya, Barcelona, Spain
4Universidad de Salamanca, Spain
Corresponding Author:
M. Corominas-Roso, Department of Psychiatry, Hospital Universitari Vall d’Hebron, Universitat
Autònoma de Barcelona, Escola d’Infermeria Building 5th Floor, Pg. Vall d’Hebron, 119-129, 08035
Barcelona, Spain.
Email: margarida.corominas@vhir.org
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International Journal of Offender Therapy and Comparative Criminology 64(12)
of global impulsivity, nonplanning impulsivity, and error commission measures was
found in the NFB-treated group; effect size (dKorr) in the pre–post control design
was moderate. No significant change was found in the control group. Despite the
limitations of this study, the results suggest that NFB is better than placebo in
improving impulsivity and clinical symptoms of anxiety and depression in long-term
abstinent cocaine- and heroin-dependent individuals.
Keywords
impulsivity, anxiety, depressive symptoms, arousal, opiates, cocaine, dependence,
neurofeedback
Introduction
Impulsivity plays a crucial role in cocaine and heroin dependence (Moeller et al., 2002;
Ortal et al., 2015; Rodríguez-Cintas et al., 2016; Roncero et al., 2013; Valero et al.,
2014), associated to poor treatment outcomes (Coffey et al., 2003; Poling et al., 2007)
and relapses even after long-term abstinence (Laudet, 2007; Winhusen et al., 2013).
Among substance-dependent individuals, poly-drug addicts are more impulsive than
those dependent on single substances (Bornovalova et al., 2005; Boyle, 1993; Clarke
et al., 2012; McCown, 1988; Verdejo-García et al., 2007). In drug-dependent individu-
als, impulsivity is usually both a premorbid characteristic that predisposes to addiction
and a consequence of the consumption. In this regard, siblings of stimulant-dependent
individuals also exhibit significantly decreased levels of inhibitory control, suggesting
that impulsivity may be a trait predisposing to addiction (Ersche et al., 2013), a view that
is also supported by animal models of cocaine addiction (Dalley et al., 2011) and neuro-
imaging studies in human beings (Makris et al., 2004). Impulsivity is also a risk factor
among opiate-dependent people (Kirby et al., 1999; Rodríguez-Cintas et al., 2016;
Tolomeo et al., 2016). On the contrary, impulsivity is a strong predictor of criminal
offending (Loeber et al., 2012).
Impulsivity (or impulsiveness) is a tendency to act with a swift action, displaying
behavior characterized by little or no forethought, reflection, or consideration of the
consequences (Moeller et al., 2002). Impulsivity is a complex and multidimensional
construct, which includes different trait and behavioral instruments. The majority of
research in this field at a clinical level rely on self-reported questionnaires such as the
Barratt Impulsiveness Scale (BIS), which is a measure of trait impulsivity that identi-
fies three different components: attentional impulsiveness which refers to the tendency
to make quick decisions and a diminished ability to focus on tasks, motor impulsive-
ness which refers to a tendency to act without thinking, and nonplanning impulsive-
ness referring to a lack of “futuring” or forethought (Barratt, 1967; Patton et al., 1995).
On the contrary, different instruments to measure behavioral impulsivity have been
developed, and these are thought to be better for neurobiological studies. Behavioral
instruments include two dimensions: those measuring impulsive actions or disinhibi-
tion, and those measuring impulsive choice associated to impulsive decision making
Corominas-Roso et al.
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(Winstanley et al., 2006, 2010). One of the most widely used behavioral tests of motor
impulsivity is the Continuous Performance Test (CPT), which is also a test of atten-
tional functions (Rosvold et al., 1956; Winstanley et al., 2010). It is not always possi-
ble to establish a direct relationship between the dimensions of trait impulsivity
obtained from the BIS-11 and the psychological processes measured in behavioral
paradigms. Despite that, there is agreement that the concept of impulsive action fits
well into the BIS-11 factor of motor impulsivity. In contrast, the concept of impulsive
choice appears to span both the cognitive/attentive and nonplanning domains of the
BIS-11 (Patton et al., 1995; Winstanley et al., 2006, 2010), and it is related to lack of
consideration of the consequences or “myopia for the future” (Damasio, 1994).
Emotional states such as anxiety, anger, sadness, or joy are associated with impul-
sivity (Chester et al., 2016) and linked to physiological arousal (Kreibig, 2010), both
enhancing impulsive reactions. The relationship between impulsivity, anxiety, and
depressive mood is complex and might be moderate by age (Moustafa et al., 2017). In
addition, there is evidence that anxious individuals with high impulsivity (but not low
impulsivity) experience strong craving after alcohol cue exposure (Adams et al.,
2019). In opioid-dependent individuals, anxiety mediated the relationship between
intolerance of uncertainty and impulsivity (Garami et al., 2017). From the neurobio-
logical point of view, higher depressive symptoms and impulsivity were significantly
associated with reduced cortical thickness in different regions of the prefrontal cortex
(PFC), including ventromedial PFC/medial OFC (orbitofrontal cortex), although there
was no significant association between anxiety symptoms and brain structures (Merz
et al., 2018).
In chronic cocaine-dependent individuals, there is consistent evidence of structural
(Tanabe et al., 2009) and functional abnormalities in prefrontal regions, especially in
orbitofrontal areas (London et al., 2000; Stapleton et al., 1995; Volkow et al., 1992;
Volkow & Fowler, 2000). Increased activity of the striatum and limbic regions relative
to prefrontal areas (Hu et al., 2015) has also been reported. Similar deficits have been
found in heroin-abstinent addicts (Tolomeo et al., 2016). These abnormalities are at
least partially neurophysiological in nature and involve changes in the electroencepha-
logram (EEG; Fingelkurts et al., 2006; Franken et al., 2004; Prichep et al., 1996;
Roemer et al., 1995) and evoked potentials (Cadaveira et al., 1994). As most of the
brain areas associated to drug addiction overlap with those related to impulsivity
(Bechara et al., 2000; Dalley et al., 2011; Winstanley et al., 2006), therapeutic
approaches addressed to improve brain function can be useful in ameliorating impul-
sivity in difficult populations, such as cocaine and heroin addicts.
One of these approaches is EEG-neurofeedback (NFB), a form of biofeedback
designed to learn how to enhance certain types of EEG activity and to decrease others,
aiming to improve brain activity and hence behavioral, cognitive, and emotional self-
regulation (Hammond, 2010; Johnstone et al., 2005). So far, different NFB approaches
have been used to improve impulsivity in distinct populations. In children and adults
with attention deficit hyperactivity disorder (ADHD), reinforcement of the sensorimotor
rhythm (SMR; Fuchs et al., 2003) and the theta/beta NFB protocol (Bluschke et al.,
2016) have shown to be useful in improving impulsive responses, with effects lasting
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International Journal of Offender Therapy and Comparative Criminology 64(12)
more than 6 months (Leins et al., 2007). Arns and coworkers used...
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