Dr Natasza Orlov on neurofeedback games and auditory hallucinations

At the start of 2018, a study looking at the use of neurofeedback for the management of schizophrenia symptoms was published.¹ Part of the study involved participants controlling a video game featuring a rocket ship, which was reported to potentially help reduce the intensity of their auditory hallucinations. This led to a flurry of reports in the media, with the Daily Mail selling it as “The computer game that can control schizophrenia”. I was fortunate enough to speak with Dr Natasza Orlov, postdoctoral researcher at University of Roehampton and King's College London, and the primary author of this proof-of-concept study.

Feedback from your own brain

Dr Orlov explained how her research concept came about: “Previous neuroimaging has shown that increased activity in the brain's secondary auditory cortex is associated with auditory hallucinations. We wondered whether, with neurofeedback, reducing the activity in this brain region would also reduce the symptoms. The idea seems to be rational. When people hallucinate, the brain region is overactive, so why don’t we try to reduce activity in the brain region?”

Neurofeedback involves getting feedback from your own brain, usually by seeing a visual representation of your brain activity. This way, you can see when your brain is acting the way you want it to. This is a potential way to help someone regulate their own brain activity, by training them to reduce the kinds of brain activity that may cause them problems. Use of neurofeedback has been trialled in a wide range of conditions including ADHD, autism, schizophrenia and epilepsy. However, this is still a developing field that is being researched. An extensive review of evidence for neurofeedback in neurodevelopmental conditions is currently underway.²

Down to earth

The participants in Dr Orlov’s study were people with schizophrenia. Each had a functional magnetic resonance imaging (fMRI) brain scan to detect the level of activity in the secondary auditory cortex region of their brain. Each participant was shown a real-time depiction of that brain activity (the neurofeedback), but translated into a game. “We had a task that tapped into the secondary auditory cortex and connected to a game display,” Dr Orlov explained. “The game displayed a rocket floating in the sky and we asked the participants to move the rocket down to earth. A reduction in the participant's secondary auditory cortex activity would move the rocket down.”

The participant had to somehow reduce the activity in their own secondary auditory cortex to lower the rocket. Dr Orlov stressed that the team did not instruct the participants on how to do that. Instead, “they devised their own techniques.” The study found participants were able to reduce their levels of distress and were better able to internalise their auditory hallucinations. Of course, there remains further research to be done, for example with a control group.

“We told them to use the same techniques in the future, to help manage their symptoms,” Dr Orlov said. The team found that participants, having devised techniques to bring the rocket down, were indeed later able to use those techniques, even without the visual feedback of the rocket game, to reduce the level of activity in the secondary auditory cortex.

Using a visual representation of a rocket game is an innovative idea, but I wondered what specific benefit the use of a game was intended to have. Dr Orlov said that the rocket game was a visually appealing task, helping to motivate the participants. “The feedback from each participant was that by seeing a rocket, they found the study more engaging. The positive symptoms our patients have are often unpleasant and it is good for them to have something nice that they can enjoy. I think it is beneficial if it is engaging.”

Creating an engaging environment

This concept of engagement being a beneficial aspect of video games is not a new one. Michele Dickey, a Professor in Educational Psychology, has discussed how games are designed to engage players with choices (“hooks”), which allow player actions to have clear feedback.³ This aspect of choice helps to personalise the game experience for each individual player. Similarly, the game in this study gave limited instructions, but a clear aim (getting the rocket to land), which allowed the participants to “choose” how they achieved this goal. This may help create an engaging environment for them to learn how to manage their symptoms.

The concept of using game design in non-game settings was further discussed by Dicheva et al⁴, who noted that game aspects such as immediate feedback, clear goals and challenges, and freedom of choice showed the potential to improve participant learning. However, they recognised that this is still a developing field, with further research required into the underlying motivations of study participants that would influence their participation.

Overall, I feel that this study shows a novel and interesting method of empowering people who experience auditory hallucinations to find a means of alleviating some of the distress they may experience. I will be watching with interest for when Dr Orlov’s team continues on in the next stage of their research.

Authored by Sin Fai Lam

References

1. Orlov ND, Giampietro V, O’Daly O, Lam SL, Barker GJ, Rubia K, McGuire P, Shergill SS, Allen P. Real-time fMRI neurofeedback to down-regulate superior temporal gyrus activity in patients with schizophrenia and auditory hallucinations: a proof-of-concept study. Translational psychiatry. 2018 Feb 12;8(1):46.

2. Landes JK, Reid CL, Arns M, Badcock NA, Ros T, Enriquez‐Geppert S, Bulsara MK, Brini S, Rabipour S, Mason M, Birbaumer N, Gouldthorp B, Anderson M. EEG neurofeedback for executive functions in children with neurodevelopmental challenges. Cochrane Database of Systematic Reviews 2017, Issue 12. Art. No.: CD012890. DOI: 10.1002/14651858.CD012890.

3. Dickey MD. Engaging by design: How engagement strategies in popular computer and video games can inform instructional design. Educational Technology Research and Development. 2005 Jun 1;53(2):67-83.

4. Dicheva D, Dichev C, Agre G, Angelova G. Gamification in education: A systematic mapping study. Journal of Educational Technology & Society. 2015 Jul 1;18(3).