Neurofeedback interventions for obsessive-compulsive and related disorders: Current evidence and future directions

Obsessive-compulsive and related disorders (OCRDs) are characterized by obsessions, compulsive or repetitive behaviors, hoarding and saving, or recurrent body-focused repetitive behaviors. Although pharmacological, cognitive-behavioral, or behavioral therapies provide relief for many for these conditions, a substantial proportion respond insufficiently or experience relapses. Neurofeedback (NF) enables individuals to self-modulate neural activity in real time and has been explored as a non-invasive neuromodulation strategy in obsessive-compulsive disorder (OCD), the only OCRD in which NF has been empirically tested to date. Conventional electroencephalogram-based (EEG-NF) and functional magnetic resonance imaging-based (fMRI-NF) protocols have demonstrated that patients can learn to regulate oscillatory activity or region-specific blood-oxygen-level-dependent signals, with some studies reporting symptom improvements. However, heterogeneity in targets, limited personalization, and modest clinical effects constrain conclusions regarding efficacy and scalability. This narrative review synthesizes the existing empirical evidence of NF studies to-date. In addition, it highlights the potential for decoded neurofeedback (DecNef) as a next-generation NF method. Unlike conventional NF, DecNef leverages multivoxel pattern analysis to reinforce distributed neural representations, in some cases without explicit awareness or symptom exposure, and may allow greater precision and personalization of circuit-level interventions. We discuss how DecNef can address limitations of traditional NF and outline its potential translational applications across the OCRD spectrum. By integrating current empirical findings with a forward-looking precision psychiatry framework, this review offers ideas for conceptual and methodological advances for targeting dysfunctional neural systems underlying OCRDs.