Clinical and resting-state EEG changes following neurofeedback in adult refugees with persistent trauma-related symptoms: a transdiagnostic pre-post observational study.

Abstract

Background: Neurofeedback has shown promise as an adjunctive intervention for persistent trauma-related psychopathology, but its electrophysiological effects in refugees following war, torture, and forced displacement remain poorly understood. This study investigated changes in resting-state alpha electrophysiology during trauma treatment incorporating individualised neurofeedback and whether these changes related to clinical improvement.

Methods: This retrospective pre-post observational study included 53 adult refugees with persistent trauma-related symptoms who completed resting-state electroencephalography (EEG) before and after multidisciplinary treatment incorporating neurofeedback, trauma-focused counselling and pharmacotherapy. Participants received a mean of 38.7 neurofeedback sessions after remaining symptomatic despite previous treatment. Clinical improvement was assessed retrospectively using the Clinical Global Impression-Improvement (CGI-I) scale. Resting-state EEG analyses examined changes in global alpha amplitude, alpha reactivity, peak alpha frequency (PAF), and alpha coherence. Neurofeedback protocol implementation was characterised across 2,361 protocol applications, and secondary analyses examined electrophysiological differences between responders and non-responders and associations between electrophysiological and clinical change.

Results: Thirty-three participants (62.3%) demonstrated clinically meaningful improvement following multidisciplinary treatment incorporating neurofeedback. Resting-state EEG demonstrated increased global alpha amplitude (FDR-adjusted p = .018) and reduced occipital alpha reactivity (FDR-adjusted p = .013), whereas peak alpha frequency and alpha coherence did not change significantly following correction for multiple comparisons. Exploratory analyses suggested different patterns of eyes-open and eyes-closed alpha change in responders and non-responders; however, the difference between groups was not statistically significant (t(51) = 0.88, p = .381, d = 0.24). Changes in electrophysiological measures were not significantly associated with clinical improvement. Protocol analysis demonstrated variability in electrode placement, whereas reward frequencies remained clustered within the alpha range throughout treatment.

Conclusions: Individualised neurofeedback delivered within routine multidisciplinary care was associated with clinically meaningful improvement in two-thirds of refugees with persistent trauma-related psychopathology, alongside selective changes in resting-state alpha electrophysiology. These findings extend current understanding of the electrophysiological changes observed during treatment incorporating neurofeedback in a clinically complex refugee population. Although the retrospective observational design limits conclusions regarding causality, the findings support investigation of neurofeedback as an adjunctive intervention for refugees who remain symptomatic despite previous treatment and identify resting-state alpha reactivity as a promising electrophysiological measure of treatment-associated change.