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Take control! Towards novel training regimes enhancing inhibition and impulse control in health and psychiatric disease

Periodic Reporting for period 2 - Self-Control (Take control!Towards novel training regimes enhancing inhibition and impulse control in health and psychiatric disease)

Reporting period: 2018-02-01 to 2019-07-31

Imagine you are on a diet, and you are painfully aware that another piece of that delicious chocolate cake is waiting for you in the refrigerator. Do you go and get it, or not? Although our environment is full of temptations, we have mechanisms for resisting them. To reach your long-term goal of losing weight, you may be able to resist that mouth-watering temptation and keep from opening the refrigerator. The ability to postpone immediate gratification – also known as self-control, inhibition, self-regulation, or willpower – is extremely valuable. It is important in the context of addiction (e.g. to alcohol or nicotine), impaired emotion regulation (e.g. borderline personality disorder), and eating disorders (e.g. obesity), where the ability to control impulses is oftentimes disturbed. These disorders, which are highly debilitating for the individual, also impose considerable social and economic costs.

Research has shown that the prefrontal cortex, in particular the right inferior frontal gyrus, of the brain is the key to self-control. Later in life, the ability to inhibit responses wanes, accompanied by a natural decrease in the volume of the prefrontal cortex. The present research aims to show that there are ways to strengthen this part of the brain and therewith enhance the ability to resist the urge to go the refrigerator, light a cigarette, or open a bottle of whiskey.

In a first study on older adults we were able to demonstrate that a custom-made video game played on a day-to-day basis over a period of two months can increase self-control. We were able to show that the training that we developed increases the thickness of right inferior frontal gyrus, a subpart of the prefrontal cortex, and train the ability to inhibit prepotent responses in an untrained task (see Figure). This finding is remarkable in two ways, first that we find brain structural growth in a population above the age of 60 years, where neural plasticity has often been called into question and second that self-control can actually be trained, since this has frequently been doubted in the scientific community.

The overall goal of this ERC starting grant is to develop and optimize this promising self-control training and investigate its effectiveness in real-life self-regulation problems in the healthy population (dieting and quitting to smoke) as well as in patients suffering from alcohol addiction. To do so we will evaluate other training approaches and paradigms that have been proven successful in addiction such as trainings using the so-called approach-avoidance task. In this task addicted individuals have been shown to be faster in pulling pictures to themselves that relate to their addiction and slower in pushing them away. We will use this task in a training version where participants train to push the addiction-related pictures away from themselves. We will investigate the actual working mechanisms of these previously used interventions by conducting behavioural and neuroimaging studies. Our final goal is to integrate features of these training approaches that have proven successful into an extended self-control video game training that is not only scientifically validated but also fun and entertaining, so that individuals actually like to engage in it in their day-to-day life.

The final outcome of this project is going to be an app encompassing the optimized self-control training, adaptable to the temptations that the trainee wants to gain control about, and therewith enable the general population to counteract self-regulation problems. Since self-control has sparked the interest of multiple disciplines, that have unfortunately so far developed their concepts fairly independently, the results of this research proposal will pave the way to integrate the knowledge gained from experimental, clinical, and social psychology. The hope is that digital training, which is relatively easy to implement, might be used to augment common psychotherapeut
We have started several studies in different addicted populations (alcohol-dependent patients, smokers, and gamblers) but also in eating disorders testing assumed working mechanisms of the approach-avoidance based training. In typical approach-avoidance trainings participants are asked to push disease-related pictures away from themselves and pull non-disease-related pictures towards themselves. This has previously been shown to reduce relapse rates in alcohol dependent patients. We use neuroimaging methods, in particular structural and functional magnetic resonance imaging to show brain plasticity that is caused by the training intervention in order to better understand the neural substrate of the observed behavioural changes.

We have started to exchange with other researchers who focus on developing a self-control trainings for children and design interventions to change eating behavior and likewise use the approach avoidance task. We have made plans to collaborate more closely in the near future.
This research program may revise the view on the plasticity of self-control and inhibition and will potentially create a new field of research exploring training elements capable of altering the human ability to exert control. We have made a first step towards this goal by publishing first evidence showing that inhibition training in healthy older adults induced brain plasticity in the right inferior frontal gyrus and increases the ability to stop ongoing responses in an untrained transfer task (Kühn et al., 2017 NeuroImage).

Most importantly this research program will have considerable practical implications. A game-like self-control training can easily be integrated into and complement daily clinical practice on psychiatric wards, which is what we are experiencing already in the study on alcohol-dependent patients. At present we are planning to use our training app (in its work in progress version) in a rehabilitation clinic that already offers computer-based trainings in the day-to-day process of rehabilitation for all patients. This is an excellent opportunity to test hands-on in what way we need to adapt the training environment to make it feasible for routines in a clinical setting outside of clinical studies.

To make the research findings related to the present ERC grant useful for patients at need we generated an on-line version of an approach-avoidance training targeting gambling addiction for a website that has recently been launched by a collaborator at the University Clinic Hamburg-Eppendorf (http://www.neustart-spielerhilfe.de). The goal of this website is to inform individuals at risk of gambling addiction and provide online therapeutic tools.

At the end of the project phase our implementation of different versions of the approach-avoidance training and hopefully our optimized game will be distributed and therewith readily accessible all over the world. Moreover, if the tool proves successful in healthy participants it may make even more impact by allowing the general population to download the app and use it for the idiosyncratic temptations they wish to refrain from, e.g. chocolate chip cookies, smoking. Taken together this research program may enable us to enhance self-control a virtue that is at the heart of human nature and that humans have striven towards ever since Eve could not resist the apple from the forbidden tree.