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Real-time functional magnetic resonance imaging (fMRI) neurofeedback is an experimental framework in which fMRI signals are presented to participants in a real-time manner to change their behaviors. Changes in behaviors after real-time fMRI neurofeedback are postulated to be caused by neural plasticity driven by the induction of specific targeted activities at the neuronal level (targeted neural plasticity model). However, some research groups argued that behavioral changes in conventional real-time fMRI neurofeedback studies are explained by alternative accounts, including the placebo effect and physiological artifacts. Recently, decoded neurofeedback (DecNef) has been developed as a result of adapting new technological advancements, including implicit neurofeedback and fMRI multivariate analyses. DecNef provides strong evidence for the targeted neural plasticity model while refuting the abovementioned alternative accounts. In this review, we first discuss how DecNef refutes the alternative accounts. Second, we propose a model that shows how targeted neural plasticity occurs at the neuronal level during DecNef training. Finally, we discuss computational and empirical evidence that supports the model. Clarification of the neural mechanisms of DecNef would lead to the development of more advanced fMRI neurofeedback methods that may serve as powerful tools for both basic and clinical research. •Decoded Neurofeedback (DecNef) leads to specific behavioral changes.•We propose a targeted neural plasticity model that accounts for results by DecNef.•Results of meta-analyses based on DecNef results and simulations support the model.

Post-traumatic stress disorder (PTSD) is a neuropsychiatric affective disorder that can develop after traumatic life-events. Exposure-based therapy is currently one of the most effective treatments for PTSD. However, exposure to traumatic stimuli is so aversive that a significant number of patients drop-out of therapy during the course of treatment. Among various attempts to develop novel therapies that bypass such aversiveness, neurofeedback appears promising. With neurofeedback, patients can unconsciously self-regulate brain activity via real-time monitoring and feedback of the EEG or fMRI signals. With conventional neurofeedback methods, however, it is difficult to induce neural representation related to specific trauma because the feedback is based on the neural signals averaged within specific brain areas. To overcome this difficulty, novel neurofeedback approaches such as Decoded Neurofeedback (DecNef) might prove helpful. Instead of the average BOLD signals, DecNef allows patients to implicitly regulate multivariate voxel patterns of the BOLD signals related with feared stimuli. As such, DecNef effects are postulated to derive either from exposure or counter-conditioning, or some combination of both. Although the exact mechanism is not yet fully understood. DecNef has been successfully applied to reduce fear responses induced either by fear-conditioned or phobic stimuli among non-clinical participants. Follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was conducted to compare DecNef effect with those of conventional EEG/fMRI-based neurofeedback on PTSD amelioration. To elucidate the possible mechanisms of DecNef on fear reduction, we mathematically modeled the effects of exposure-based and counter conditioning separately and applied it to the data obtained from past DecNef studies. Finally, we conducted DecNef on four PTSD patients. Here, we review recent advances in application of neurofeedback to PTSD treatments, including the DecNef. This review is intended to be informative for neuroscientists in general as well as practitioners planning to use neurofeedback as a therapeutic strategy for PTSD. Our mathematical model suggested that exposure is the key component for DecNef effects in the past studies. Following DecNef a significant reduction of PTSD severity was observed. This effect was comparable to those reported for conventional neurofeedback approach. Although a much larger number of participants will be needed in future, DecNef could be a promising therapy that bypasses the unpleasantness of conscious exposure associated with conventional therapies for fear related disorders, including PTSD.