Neurofeedback (NF) is one of the most exciting and promising applications of
biofeedback. Clinicians who use the Quantitative EEG (qEEG) monitor
multiple EEG channels for assessing and training of disorders as diverse
as addiction, ADHD, coma, and grand mal epilepsy. While NF training for disorders like ADHD and alcoholism is time-intensive and initially expensive, it promises long-term cost savings and reduces or eliminates patient dependence on medication. The NF
community has increasingly embraced heart rate variability biofeedback (HRVB) as a complementary intervention to treat anxiety and affective disorders.
BCIA Blueprint Coverage
Although BCIA addresses the anatomy and physiology of the EEG in its Neurofeedback Blueprint, we include this important topic to provide a comprehensive introduction to the field.
This unit covers
The Quantitative EEG, Neurofeedback Training Strategies, Attention Deficit Hyperactivity Disorder, Mild Closed Head Injuries and Traumatic Brain Injury, Substance Use Disorder, Epilepsy, Anxiety and Anxiety Disorders, Post-Traumatic Stress Disorder, Depression, and Tinnitus.
Please click on the podcast icon below to hear a full-length lecture.
EVIDENCE-BASED PRACTICE (4TH ED.)
We have updated the efficacy ratings for clinical applications covered in AAPB's Evidence-Based Practice in Biofeedback and Neurofeedback (4th ed.).
McGrady and Moss' Pathways Model
Although the BCIA Biofeedback Blueprint does not cover the Pathways Model, you may find it a useful framework for clinical and performance applications.
McGrady and Moss' (2013) Pathways Model rejects the concept of most illness as a discrete event: "Rather it is truly a pathway, a process involving a continuum from complete health to mild insufficiencies, to concerning deficiencies, and to diagnosed disease. Mainstream health care, which identifies a problem to address only when the individual's health is grossly impaired and diagnostic criteria are met, misses multiple opportunities to intervene in less expensive ways and to sustain optimal wellness" (p. 4).
"The aim of the Pathways Model is twofold: (1) to educate healthcare professionals and the general public to recognize earlier on the signs that one is on a pathway directed toward illness, allow one to correct that path earlier in the process, and (2) to assist those already in a state of disease to identify those past and present lifestyle choices and turning points, which have contributed to the onset and escalation of the disease, and to discover new choices and well behaviors to enable recovery of health" (p. 4).
The Pathways Model identifies three intervention levels. Each successive level builds on the preceding one. Level One interventions, which a client can develop and implement, restore disrupted biological rhythms.
Level Two interventions build on the platform provided by Level One interventions. They teach basic skills needed for psychological and physical health. They may be taught using educational (e.g., books and podcasts) and community resources (e.g., classes).
Level Three interventions build on the foundation provided by Level One and Level Two interventions. Most of these interventions will be directed by a professional.
The Pathways Model recognizes that mindfulness and motivation to change your "path" must develop progressively and that clients have self-care options (Level One and Two Interventions) that may restore health and promote optimal functioning without recourse to professional care (Level Three Interventions). Alternatively, they may provide a foundation that can make clinical interventions more effective. We invite the reader to read their excellent text, Pathways to Illness, Pathways to Health, and use their model when considering biofeedback treatment for the disorders reviewed in Biofeedback Tutor.
The Quantitative EEG (qEEG) measures and displays real-time brain activity with
considerably less delay than fMRI, PET, or SPECT. QEEG measurements are highly correlated with neuropsychological
tests. The qEEG provides clinicians with valuable information about the distribution of power in each frequency
band for all monitored sites and about the connectivity between sites, which is particularly important in
traumatic brain injury (TBI). The graphic below shows a Mind Media NeXus 32.
While clinicians can provide effective NF training without the use of qEEG assessment,
Sterman and Egner (2006) argued that qEEG maps could make NF twice as
effective when treating diverse symptoms.
The qEEG map shown below is courtesy of the Biofeedback Federation of Europe.
Neurofeedback Training Strategies
Three major NF strategies are performance-based, Z-score, and connectivity training. Performance-based protocols use
tasks and NF training to correct symptoms and improve performance. This approach compares clients to
themselves and not a clinical database.
Z-score training attempts to normalize brain function with respect to mean values in a
clinical database. EEG amplitudes that are 2 or more standard deviations above or below the database means are
down-trained or up-trained to treat symptoms and improve performance.
Connectivity training is designed to correct deficient or excessive communication between two brain sites as measured by indices like coherence and comodulation.
There are currently insufficient data to compare the efficacy of these training strategies for specific disorders or optimal performance applications.
The Centers for Disease Control and Prevention (Schwartz & Cohen, 2013) estimates that 11% of school-aged children and almost 20% of high school boys are medically diagnosed with ADHD in the US.
Boys are diagnosed with ADHD 4-5 times more often than girls (Costello et al., 2003). Their parents are more likely to pursue treatment due to their more severe symptoms or greater degree of impairment (Beidel et al., 2014). Girls are more likely to show inattention and are less likely to be diagnosed with a learning disability, comorbid depression, oppositional defiant disorder, or conduct disorder than their male classmates (Biederman et al., 2002; Spencer et al., 2007).
Almost half of the children diagnosed with ADHD exhibit difficulty learning, and communicating, and interacting with their classmates. Roughly 80% misbehave, frequently very seriously (Goldstein, 2011; Mash & Wolfe, 2010).
Neurofeedback Studies
Theta/beta ratio (TBR), SMR, and SCP interventions have been widely investigated using randomized controlled trials. The aim of theta/beta training is to down-train theta and up-train beta amplitude. SMR training attempts to increase SMR amplitude. SCP training seeks to increase the amplitude of positive SCPs. Click on the Read More button to review seminal neurofeedback studies.
Lubar, Swartwood, Swartwood, and O'Donnell
(1995) reported that training to reduce slow EEG activity
increased WISC-R and Test of Variables of Attention (TOVA) scores. Full-scale
WISC-R scores increased about 12 points. The increase in TOVA scores
correlated with decreased slow EEG activity.
Lubar (1995) followed 52 patients
treated with NF for as long as 10 years. Their improvement on the
Connors scale, used to measure attention, remained stable at follow-up.
Rossiter and La Vaque (1995) matched
and randomly assigned 46 subjects to either Ritalin or NF.
Both groups improved on TOVA measures of inattention, impulsivity,
information processing, and response variability.
Linden, Habib, and Radojevic's (1996)
controlled study of 18 children demonstrated that NF to
increase beta and suppress theta activity increased intelligence scores
and reduced inattention rated by their parents compared to a
wait-list control group.
Thompson and Thompson (1998) reported
the successful treatment of 98 children and 13 adults over 40 50-minute
sessions using Lubar's ADHD protocol. The percentage of children using
Ritalin declined from 30% at the start of the study to 6% post-treatment.
Theta/beta ratios significantly declined for children but not for
adults. Study participants achieved impressive pre-treatment to
post-treatment gains on intelligence, TOVA, and Wide Range Achievement
Test scores. Lynda and Michael Thompson are pictured below.
Case studies by Ramos (1998) and
Wadhwani, Radvanski, and Carmody (1998)
support the efficacy of NF for ADD and ADHD.
Camp (1999) reported that theta
suppression biofeedback training compared favorably with cognitive
behavior modification, based on pre-treatment to post-treatment changes in
48 children on TOVA, parent and teacher ratings, and ADHD scales.
The Kaiser and Othmer (2000)
multi-center study involved 1,089 patients ranging from 5-67 years. It
demonstrated that SMR-beta NF training produced significant
gains on TOVA measures of attentiveness, impulse control, and response
variability.
Carmody and colleagues (2001) randomly assigned 16 children (ages 8-10) to either EEG
biofeedback or a wait-list control condition. Eight of the 16 children were diagnosed with ADHD, and 8 had received
no diagnosis of any disorder. In the EEG biofeedback condition, participants received 3-4 weekly sessions of EEG
biofeedback (using a synthesis of Protocols 1 and 3) for 6 months and completed 36-48 sessions.
The children
diagnosed with ADHD who received EEG biofeedback decreased impulsivity as measured by the TOVA, and their
teachers' ratings of attentiveness on the School Version of the Attention Deficit Disorders Evaluation Scale (ADDES) improved. Selected qEEG measures did not
consistently validate improvement by participants in the EEG biofeedback condition.
Monastra, Monastra, and George (2002)
compared 49 children diagnosed with ADHD who participated in 1-year
multimodal program (Ritalin, parent counseling, and academic
consultation) with 51 children who participated in the multimodal program
combined with NF (weekly 30 to 40-min sessions using the Lubar
protocol with a cash reward for increased frontal cortical arousal).
Both
groups significantly improved performance on TOVA and the Attention
Deficit Disorders Evaluation Scale when medicated with Ritalin, but only
the group that received NF maintained performance gains when
unmedicated. A qEEG scan only showed reduced cortical slowing in children
who received NF. Parenting style moderated behavioral symptoms
at home but not in the classroom. Vincent Monastra is pictured below.
Fuchs, Birbaumer, Lutzenberger, Gruzelier, and
Kaiser (2003) compared the efficacy of 3 months of
sensorimotor rhythm (12-15 Hz) and beta1 (15-18 Hz) NF against
methylphenidate in 46 ADHD children. The children were assigned to the
NF (22) and medication (12) based on their parents' preference
(the assignment was nonrandom). Both treatment groups improved on all TOVA
subscales and speed and accuracy on the d2 Attention Endurance Test.
Teacher and parent ratings of ADHD behaviors on the IOWA-Conners Behavior
Rating Scale also improved for both groups.
Monastra and colleagues (2005) assigned a more conservative rating of probably
efficacious for
EEG biofeedback for ADHD in an AAPB White Paper. Despite significant
improvement in about 75% of patients in the published studies they
examined, the authors concluded that more randomized, controlled group
studies that control for therapist and patient characteristics are
needed to calculate the percentage of patients diagnosed with ADHD who
will achieve these gains in typical clinical settings.
NF appears to be superior to no treatment and equivalent to
stimulant medication. Patients require at least 20 sessions and as many
as 50 sessions to produce clinical improvement.
Gevensleben and colleagues (2009)
conducted a multisite randomized controlled study of 102 children diagnosed with ADHD using NF training that combined blocks of theta/beta and slow cortical potential NF, and computer-based attention skills training control. The combined NF group was superior to the control group on parent and teacher ratings, and both NF protocols produced comparable changes. These gains were maintained at a 6-month follow-up (Gevensleben et al., 2010).
Sherlin, Arns, Lubar, and Sokhadze (2010) argued that NF for
ADHD is safe, should be reclassified as level 5: efficacious and specific, produces long-term effects that last
from 3-6 months, and may produce clinical results like stimulant medications. While NF effectively
treats inattention and impulsivity, they suggested that medication may be more appropriate when the primary
symptom is hyperactivity and that NF may be successfully combined
with medication.
Duric and colleagues (2012) conducted a randomized
controlled trial of 91 children and adolescents diagnosed with ADHD who were assigned to 30 NF sessions, methylphenidate, or NF with methylphenidate. Parent ratings of core ADHD symptoms improved for all three groups, and there were no group differences. NF achieved equal efficacy to methylphenidate.
The American Academy of Pediatrics (2012)rated biofeedback
for child and adolescent attention and hyperactivity behaviors Level 1- Best support.
Pigott, De Biase, Bodenhamer-Davis, and Davis (2013)
provided a comprehensive review of NF efficacy for ADHD and persuasively argued that it should
receive a level-5 classification. The authors emphasized that compared with stimulant medication, only
NF has demonstrated effectiveness at 2-year follow-up.
Meisel and colleagues (2013) reported a randomized controlled trial of 23 children diagnosed with ADHD who either completed 40 theta/beta NF sessions or received methylphenidate.
While both groups improved on parent and teacher ratings of functioning and core ADHD symptoms, only the NF group improved on academic performance at 6-month follow-up.
Arns and Strehl (2013) concluded in their review of recent studies that in randomized controlled trials where theta/beta or slow cortical potential NF were active treatments and either cognitive training or EMG biofeedback were controls, NF produced significant improvements in teacher ratings.
Steiner and colleagues (2014) conducted a randomized controlled study of 104 children assigned to either NF, cognitive training (CT), or control conditions. At a 6-months follow-up, the NF group sustained greater gains on the Conners 3-P, Executive Functioning, Hyperactivity/Impulsivity, and Behavior Rating Inventory of Executive Function (BRIEF) subscales than the CT or control groups. Moreover, the NF group maintained their stimulant dosage while the CT and control groups increased their dosage.
Below is a NeXus-10 ® BioTrace+ caterpillar game. The three caterpillars represent the theta, SMR, and beta
frequency bands.
Clinical Efficacy
Based on six RCTs, Stefanie Enriquez-Geppert and colleagues rated NFB for ADHD level 5 - efficacious and specific in Evidence-Based Practice in
Biofeedback and Neurofeedback (4th ed.).
NFB interventions included training to decrease the theta/beta ratio and increase sensorimotor rhythm (SMR) activity or slow cortical potential (SCP) activity.
NFB training resulted in post-treatment gains in ADHD symptoms, including the Attention Deficit Disorders Evaluation Scale (ADDES). Participants also improved on intelligence, TOVA measures of attentiveness, impulse control, and response variability, and Wide Range Achievement Test scores.
Mild Closed Head Injuries and Traumatic Brain Injury (TBI)
Traumatic brain injury (TBI) results when an external force produces intracranial
injury through acceleration or direct impact. Mild TBI symptoms that NF may treat include deficits in memory, attention, and decision-making (National Institute of Neurological Disorders and Stroke, 2008). Check out Siddharthan Chandran's TED Talk Can the Damaged Brain Repair Itself?
Click on the Read More button to review seminal neurofeedback studies.
Ayers (1995) reported treating 32 level-two coma patients, who were
comatose for
more than 2 months, noninvasively with NF. There is a generalized response where patients move aimlessly and inconsistently in a level-two coma on the Rancho Los Amigos Cognitive Scale. If they open their
eyes, patients do not focus on objects.
Twenty-five of 32 patients emerged from their comas after 1-6 treatments.
NF for coma involved inhibiting 4-7 Hz activity and
reinforcing the replacement of 4-7 Hz with 15-18 Hz activity.
Ayers and colleagues started NF for open head trauma at the
somatosensory cortex. They trained these patients to decrease 4-7 Hz
activity and increase 15-18 Hz activity.
Thornton (2000) reported that NF improves the memory of
TBI patients. Tinius and Tinius (2000) found that it improves
attention, problem-solving, and task performance. Keller's (2001)
controlled study showed that beta training significantly improved attention compared to matched controls.
Another controlled study by Schoenberger, Shif, Esty, Ochs, and
Matheis (2001) showed that NF enhanced cognitive function and self-reported depression
and fatigue.
Walker, Norman, and Weber (2002) reported that 88% of mild TBI
patients achieved over 50% improvement in EEG coherence. All patients who had been previously employed resumed
work after completion of their training.
Thornton and Carmody (2013) reported auditory and visual memory gains in 15 TBI patients who received NF training for both qEEG power and connectivity in an uncontrolled pre-test/post-test study.
Clinical Efficacy
Anne Ward Stevens and Kori Trotter rated NFB for concussion as as level 3 - probably efficacious in Evidence-Based Practice in
Biofeedback and Neurofeedback (4th ed.).
HRV was the only BFB modality. NFB training involved operant conditioning utilizing real-time normative database comparisons (z-score training) and training several measures concurrently (e.g., inhibiting 4-7 Hz and rewarding 15-18 Hz activity). EEG tomography through Low-Resolution Electromagnetic Tomography Analysis (LORETA) offered greater training specificity and TBI treatment customization.
Participants reduced medication, the number of symptoms, symptom severity, and anxiety. They improved on attention, cognitive function, memory, and tandem gait time (walking in a straight line by placing one foot directly in front of the other, heel-to-toe).
Substance Use Disorders
Koob (2006) defined drug addiction as a: "Chronically relapsing disorder that is characterized by a compulsion to seek and take a drug, loss of control in limiting intake and the emergence of a negative emotional state (e.g., dysphoria, anxiety, irritability) when access to the drug is prevented (here, defined as the 'dark side' of addiction).""
In DSM-5, substance use disorders (SUDs) are seen as behavioral disorders consisting of three elements:
1. Loss of control (e.g., compulsive use)
2. Continued intake despite serious adverse consequences
3. Preoccupation with obtaining,
using, and recovering from the substance (Julien et al., 2023)
The U.S. National Longitudinal Alcohol Epidemiologic Study estimated that the lifetime prevalence for adult alcoholism ranges between 13.5-23.5%. In the past year, 7.5-9.5% of adults experienced alcohol abuse and dependency. Twenty percent of hospitalized adults are alcoholics. The CDC estimates that over 38 million adults engage in binge drinking four times a month (Thompson, 2014).
Neurofeedback Protocols
Researchers often observe deficient slow-wave activity (delta, theta, and
alpha) and excessive beta activity in alcoholics. Alcohol consumption
slows their alpha frequency and increases its amplitude (Peniston &
Kulkosky, 1990).
Click on the Read More button to review neurofeedback substance use disorder protocols.
Click on the Read More button to review seminal neurofeedback studies.
The Menninger Clinic ON-OFF-ON training and alpha-theta protocol provided components of the Peniston Protocol, which has been effectively used to treat alcoholism.
The Menninger ON-OFF-ON EEG protocol teaches a
patient to increase the
amplitude within a frequency band, reduce the amplitude, and then
increase the amplitude again during 100- or 200- second segments. For example, a
patient may increase 8-13 Hz alpha activity for 100 s, decrease it for
100 s, and then increase it for 100 seconds. This approach may produce superior
control compared to procedures that only train alpha or theta
increase (Norris, 1988).
The Menninger alpha-theta protocol places the active electrode 1 centimeter
above and left of the inion (the bony prominence located on the back of
the head) with a reference on the left earlobe. This protocol teaches EEG
control using 100- or 200-seconds "ON-OFF-ON" exercises.
Temperature and frontal SEMG biofeedback precede alpha-theta training.
Patients receive 3-4 weekly sessions of temperature biofeedback followed
by 3-4 weekly sessions of frontal SEMG biofeedback. Judy Green has
likened the temperature and SEMG biofeedback sessions to settling
elementary school students in their seats so they can pay attention
without distraction. These sessions also teach patients the strategy of passive
volition (allowing), which is critical to alpha-theta training.
The patient then receives 10-12 bi-weekly sessions of alpha-theta
biofeedback using ON-OFF-ON exercises. Training attempts to gradually
slow the EEG until the patient can increase alpha and theta amplitude
without falling asleep.
Egner, Strawson, and Gruzelier (2002) addressed whether the
effects of alpha-theta
NF depend on with-session EEG changes or are non-specific and
shared with other relaxation procedures. They compared the effect of
contingent and noncontingent alpha-theta NF on theta/alpha
ratios within and across sessions.
The contingent group achieved
increased within-session theta/alpha ratios, while the noncontingent
group did not. The contingent group also achieved higher theta/alpha
ratios than the noncontingent group during some training sessions.
There were no group differences in subjective reports of activation
since both groups reported significantly lower activation following
training. Both contingent and noncontingent NF were relaxing.
This study validated the assumption underlying alpha-theta NF
that accurate feedback results in higher within-session theta/alpha
ratios than does noncontingent NF.
The Peniston addiction protocol (1989) is a multimodal approach that
incorporates both biofeedback and non-biofeedback components. Patients
start with visualization training, receive 6 temperature biofeedback
sessions, learn rhythmic breathing techniques, participate in autogenic
training exercises, learn to construct personalized imagery, and
experience guided imagery (where the therapist directs the patient
visualization). This training prepares patients for 30 alpha-theta
sessions in which they learn to slow the EEG to increase alpha
and theta amplitude using the Menninger alpha-theta training procedure.
Following the alpha-theta biofeedback sessions, the supervising physician
may need to adjust medication.
Experimental patients who received Peniston and Kulkosky's alpha-theta
protocol for alcoholism and control patients were assessed over a
24-month follow-up period. Across this period, 8 of the 10 experimental
patients and none of the 10 controls maintained abstinence from alcohol.
Due to the Peniston-Kulkosky addiction protocol's multimodal nature, we cannot identify the components responsible for clinical improvement. Further clinical research that "dismantles" this protocol will be required to isolate the active treatment components.
Kaiser and Scott (Kaiser et al., 1999; Scott et al., 2002, 2005)
modified the Peniston protocol to increase its success with patients dependent on cannabis and stimulants. The Kaiser-Scott protocol, which starts with NF ADHD training and then progresses to the Peniston protocol, has improved retention and abstinence in these hard-to-treat populations.
This video takes the viewer through an alpha-theta training demonstration using the Nexus/Biotrace system (Mind Media, Roermond, The Netherlands) using the training approach developed by John Anderson. The demonstration uses saved session data to illustrate the functions and discuss the threshold settings and training concepts.
Neurofeedback Studies
Click on the Read More button to review influential neurofeedback substance use disorder studies.
Peniston and Kulkosky (1990) reported
that patients who received alpha-theta NF achieved
significantly greater decreases on Millon Clinical Multiaxial Inventory
factors than those who received conventional medical treatment.
Alcoholics who received alpha-theta NF improved on schizoid,
avoidant, passive-aggressive, schizotypal, borderline, paranoid, anxiety,
somatoform, dysthymic, alcohol abuse, psychotic thinking, psychotic
depression, and psychotic delusional factors.
Schneider et al. (1993) reported that
6 of 10 male alcoholics remained abstinent 4 months after completing
slow cortical potential NF.
Taub and colleagues (1994)
randomly assigned 118 chronic alcoholics to one of four treatments:
Alcoholics Anonymous and counseling (RTT), RTT combined with
Transcendental Meditation, RTT combined with SEMG biofeedback, or RTT plus
sham neurotherapy. The sham NF condition involved "electrocranial stimulation" and not alpha-theta biofeedback. Rates of
self-reported abstinence were 25%, 65%, 55%, and 28%, respectively. While
the addition of Transcendental Meditation and EMG biofeedback seemed to
increase abstinence, sham neurotherapy did not. The addition of
Transcendental Meditation or EMG biofeedback to RTT produced abstinence
rates comparable to those reported for the addition of alpha-theta
biofeedback.
Saxby and Peniston (1995) demonstrated in a controlled study that alpha-theta
NF could
reduce depression in alcoholics and increase the rate of abstinence
assessed over a 21-month follow-up period.
Kelley's (1997) 3-year
follow-up study of 20 Native American alcoholic inpatients reported the
following changes: increased EEG synchrony and alpha-theta amplitudes,
extinction of drinking behavior, less personally damaging behavior (81%),
and lower Beck Depression Inventory scores.
Burkett and colleagues (2003) conducted an open-label uncontrolled study of the Scott-Kaiser modification of the Peniston protocol with 270 male homeless patients addicted to crack cocaine
who also received faith-based interventions within a residential setting. At 1-year follow-up, data from 94 patients who completed treatment showed abstinence from alcohol or other drugs in 53.2% and drug use only 1-3 times in 23.4%, corroborated by urinalysis. A follow-up report on 87 patients who completed treatment documented improvement on urinalysis, length of residential stay, and self-reported depression (Burkett et al., 2005).
Bodenhamer-Davis and Calloway (2004) conducted an uncontrolled trial of 16 outpatients diagnosed with chemical dependency in which they administered alpha-theta NF. At 74- to 98-month follow-up,
81.3% were abstinent, and rates for re-arrest and loss of probation were lower than for a comparison group.
Scott, Kaiser, Othmer, and Sideroff (2005) randomly assigned patients with mixed
substance abuse to EEG biofeedback or a control group. The EEG biofeedback group stayed in treatment longer than
the control group. Seventy-seven percent of patients who completed EEG training remained abstinent at 12 months
compared with 44% of controls.
Sokhadze, Cannon, and Trudeau (2008) found that alpha-theta training for alcoholism
and a combination of alpha-theta training, beta training for polydrug abuse (including stimulants), and
residential treatment were probably effective.
Clinical Efficacy
Estate M. Sokhadze and David Trudeau rated NFB for SUD as probably efficacious based on an RCT (N = 121) using the Scott–Kaiser NFB protocol.
The five other RCTs incorporated alpha and high beta regulation, alpha/theta with TEMP and guided imagery, SMR and beta upregulation with 1-13 Hz and high beta (18-22 Hz) suppression, SMR/theta followed by alpha-theta, and the Scott–Kaiser NFB protocol.
The Scott-Kaiser protocol, which starts with NF ADHD training and then progresses to the Peniston protocol, has improved retention and abstinence in these hard-to-treat populations. Participants increased abstinence, quality of life, self-efficacy, time in the program, and TOVA (continuous attention), and reduced addiction severity and craving.
The Scott-Kaiser modification of the Peniston Protocol can be classified as probably efficacious with residential or office-based rehabilitation and opioid replacement for alcohol, opioid, mixed-substance, and stimulant abusers.
Alpha-theta NF received a level-2 rating of possibly efficacious.
Petit mal seizures feature loss of consciousness without
abnormal movement (patient appears to be daydreaming). The patient,
typically a child, may suffer hundreds of these seizures daily for
periods lasting up to 30 seconds.
Check out the Epilepsy Therapy Project video Understanding Partial Seizures.
The sensorimotor cortex is a central cortical area defined by the central
sulcus (fissure of Rolando) separating the frontal and parietal lobes.
Sterman (1977) recorded the EEG over the left sensorimotor cortex from
sites 10% and 30% lateral to the vertex (slightly medial to C3 and T3).
The sensorimotor rhythm (SMR) is an EEG rhythm from 12-14 Hz located over
the sensorimotor cortex (central sulcus). This rhythm is associated with
inhibition of movement and reduced muscle tone.
Demographics
In the United States, about 2% of adults experience a seizure, and two-thirds of these patients do not have additional episodes. Those who experience two or more seizures are diagnosed with epilepsy, which is frequently idiopathic (no identified cause) or symptomatic (identified cause like a brain tumor). Age of seizure onset provides a guide to its likely cause (Adamolekun, 2013).
Neurofeedback Protocols
The two main neurofeedback protocols to treat uncontrolled generalized seizures are sensorimotor rhythm (SMR) up-training and slow cortical potential (SCP) training.
SMR Up-training
SMR up-training, which may include inhibition of theta, beta, and epileptiform spikes, is the most frequently used protocol to manage generalized seizures (Tan et al., 2009). The graphic below shows a NeXus-10 SMR display.
For example, Sterman's protocol trains an epileptic patient to increase SMR (12-14 Hz)
amplitude
and duration while theta (4-7 Hz), beta (20+ Hz), epileptiform spikes,
and EMG artifact are suppressed during 36 sessions. The aim is to
normalize the waking and sleep EEG with elevated SMR and suppressed theta
and beta activity.
SCP Training
SCP training has emerged as an alternative to SMR training for generalized tonic-clonic
seizures, especially in Europe. SCPs consist of positive and negative event-related EEG waveforms that last several seconds (slower than 1 Hz). Positive SCPs are associated with cortical hyperpolarization and inhibited neuronal firing. Conversely, negative shifts reflect cortical depolarization and increased neuronal firing. SCP protocols involve bi-directional training. Clinicians use operant conditioning to teach patients to increase positive shifts and reduce negative shifts to raise neuron firing thresholds and reduce epileptiform activity. This
strategy has also been successfully applied to treat migraines. The graphic below shows a NeXus-10 SCP display.
Neurofeedback Studies
Click on the Read More button to review neurofeedback epilepsy studies.
Elbert et al. (1991)
conducted a double-blind, randomized controlled study of 14 patients with seizures not controlled by medication. They assigned patients to either 28 1-hour sessions of bi-directional SCP or alpha training. At 1-year follow-up, all patients in SCP group and only 1 in the alpha group reduced seizure frequency.
Rockstroh et al. (1993) reported a pre-test/post-test study of 28 1-hour sessions of bi-directional SCP training for 25 uncontrolled epilepsy patients. Follow-up data from 18 participants, who monitored their seizure frequency through training and 1-year follow-up, showed reduced seizure frequency.
Kotchoubey et al. (1996) reported that SCP
NF decreased the baseline seizure frequency in
drug-resistant epileptics and Kotchoubey et al. (1997) showed that this improvement was
maintained 6 months post-treatment.
Kotchoubey, Busch, Strehl, and Birbaumer (1999) concluded that
SMR and SCP protocols improve epilepsy control in about 66% of
patients. While the mechanism underlying SCP training remains unclear, it
may involve increased 6.0-7.9 Hz theta activity during training trials
without feedback.
Joy Andrews et al. (2000) found that a NF protocol
involving five consecutive days of
training enabled 79% of patients to control their seizures.
Sterman (2000) summarized 18
peer-reviewed studies in which 174 patients were trained using his SMR
protocol. The outcome data were impressive; 82% clinically improved,
reducing seizures by more than 30%. The average seizure reduction exceeded 50%. Many studies found decreased seizure severity. Five
percent of patients remained seizure-free for as long as one year. In those studies where researchers recorded
pre-treatment and
post-treatment EEG amplitudes, 66% normalized their EEG power spectra.
Kotchoubey et al. (2001) treated patients with refractory epilepsy
with an anti-epileptic drug and
psychosocial counseling, a breathing training control group, or SCP
NF in a non-randomized clinical study in which participants selected their treatment. Only the drug and SCP
groups significantly reduced seizure frequency.
La Vaque (2003) considers slow cortical potential
(SCP) training to be highly effective in controlling "drug-resistant" epilepsy.
Marson and Ramaratnam (2003) reviewed randomized controlled trial studies and
reported a significant reduction in median seizure activity in one study.
Sheth, Stafstrom, and Hsu (2005) examined 16 studies of biofeedback treatment of
refractory epilepsy, including contingent negative variation (CNV), slow cortical potential (SCP), and galvanic
skin response (GSR). While most studies involved 1-8 patients, one enrolled 83 patients. Epilepsy symptoms
improved in 82% of patients who received biofeedback training. Both the EEG and GSR treatments produced
significant gains.
Strehl and colleagues
(2005) reported that 70% of SCP training treatment success with drug-resistant patients could be predicted by initial cortical excitability (negative SCP amplitude), location of epileptic foci (sites that trigger seizures), and personality. Successful patients did not exhibit large negative SCP amplitudes at the start of training, did not have left temporal foci, and reported lower life satisfaction and high reactivity to stressors.
Ramaratnam, Baker, and Goldstein (2005),
in a Cochrane Database Systematic Review, challenged the efficacy of
NF for epilepsy due to methodological flaws and small sample
size.
A meta-analysis by Tan and colleagues (2009) reviewed
nine studies that used SMR and one that used SCP neurofeedback. They found consistent reductions in seizure frequency for drug-resistant patients and successful reduction in seizure frequency by 79% of patients who received SMR training.
Clinical Efficacy
Lauren Frey rated SMR-based and SCP-based NFB as efficacious for seizures, SMR-based NFB as probably efficacious for non-seizure manifestations of epilepsy, and connectivity-based NFB as not empirically supported for seizures. In a meta-analysis, SMR- and SCP-based treatments were associated with fewer seizures and improved quality of life in a RCT.
Anxiety and Anxiety Disorders
Generalized anxiety disorder (GAD) is defined by excessive anxiety and
worry most of the time for at least 6 months (Beidel, Bulik, & Stanley, 2014). Chronic overarousal
results in fatigue and insomnia, worsened by changes in their circadian rhythm due to their job or
travel (McGrady & Moss, 2013).
Patients perceive their worrying as outside their control. They present with physical (muscle tension) and
cognitive symptoms (the belief that worrying can prevent an adverse event). They are usually diagnosed with a second
disorder (Beidel, Bulik, & Stanley, 2014).
Specific phobia involves significant emotional distress, excessive anxiety,
or fear about an object or situation that disrupts everyday performance. DSM-5 lists five specifiers: animal
phobias, natural environment phobias, blood/injection/ injury phobias, situational phobias, and other phobias
(Beidel, Bulik, & Stanley, 2014).
DSM-5 classifies Post-traumatic stress disorder (PTSD) as one of the Trauma and Stress-Related Disorders. PTSD is a response to a traumatic event
like assault, military combat, or rape that may be experienced firsthand or observed (American Psychiatric Association, 2013).
Demographics
Estimated lifetime prevalence rates for anxiety disorders in the United States are panic disorder (2.3-2.7%),
generalized anxiety disorder (4.1-6.6%), OCD (2.3-2.6%), PTSD (1-9.3%), and social phobia (2.6-13.3%). The
male-to-female ratio for a lifetime anxiety disorder is 3 to 2 (Yates, 2014).
Overview
Most controlled, randomized experiments have found that
neurofeedback and biofeedback (electrodermal, SEMG, and temperature)
produce comparable anxiety reductions to relaxation procedures like
meditation and progressive relaxation. Biofeedback and relaxation
procedures may achieve equivalent results because anxiety involves
disordered attention and cognition in addition to abnormal physiological
arousal. In some cases, biofeedback may be superior to relaxation procedures and may produce additive effects
when combined with medication.
Neurofeedback and Biofeedback Studies
Click on the Read More Button to review seminal neurofeedback and biofeedback anxiety studies.
Neurofeedback Studies
Rice, Blanchard, and Purcell (1993)
studied 45 patients with generalized anxiety. Thirty-eight of these
patients satisfied the DSM-III criteria for Generalized Anxiety Disorder
(GAD) and 7 were subclinical for GAD and only met 2 of these criteria.
They randomly assigned patients to one of five conditions: frontal EMG
biofeedback, EEG biofeedback to increase alpha, EEG biofeedback to
decrease alpha, pseudomeditation, or a wait-list control. For the two
EEG biofeedback conditions, the electrodes were placed at OZ, the right
mastoid process, and the forehead. All four treatment groups received
eight 60-minute sessions and achieved significant reductions on
STAI-Trait Anxiety scores and Psychosomatic Symptom Checklist (PSC)
scores.
Only the alpha-increase condition decreased heart rate reactivity to
stressors. Subjects in the frontal EMG, alpha-increase, and alpha
suppression conditions maintained improvement in STAI-Trait Anxiety and
PSC scores at 6 weeks post-treatment. The alpha-increase and
alpha-suppression groups showed further improvement in
Psychosomatic Symptom Checklist scores at 6 weeks post-treatment.
Vanathy, Sharma, and Kumar (1998) randomly assigned subjects who met the diagnostic
criteria for Generalized Anxiety Disorder (GAD) to a wait-list control, alpha-increase biofeedback, or
theta-increase biofeedback. EEG biofeedback consisted of 15 sessions of training to enhance alpha or theta and
suppress beta.
Both the alpha-increase and theta-increase groups reduced self-reported (STAI-State Anxiety) and blind
observer-rated anxiety (Hamilton Anxiety Rating Scale) in comparison to the control group. These results may
have been due to Type 1 error caused by multiple t-tests without statistical correction. The
authors' failure to observe changes in EEG power in the alpha or theta bands following EEG training suggests
that non-specific treatment components, and not EEG training, may have produced clinical improvement, assuming
that the findings of symptom improvement were valid.
Agnihotry, Paul, and Sandhu (2007) conducted a randomized controlled study of 45 patients diagnosed with Generalized Anxiety Disorder, which compared frontalis SEMG relaxation, EEG training to increase alpha, and a control group. Both the SEMG and EEG groups reduced STAI-State Anxiety and Trait Anxiety scores. Galvanic skin resistance (more resistance means less SNS activation) increased for both groups, with more significant gains for the SEMG group. At a 2-week follow-up, the SEMG group maintained the largest gains on all three measures.
Biofeedback Studies
Corrado, Gottlieb, and Abdelhamid (2003) reported that chronic pain patients who
received a combination of finger temperature and SEMG biofeedback showed reduced anxiety and physical
complaints compared to those in a pain education control group.
Coy, Cardenas, Cabrera, Zirot, and Claros (2005) found that combining the
antidepressant imipramine and biofeedback resulted in more significant anxiety reduction than imipramine alone.
Reiner (2008) reported an uncontrolled pre-test/post-test study of 24 patients diagnosed with an anxiety disorder and receiving outpatient CBT who practiced at home using a portable HRVB device.
Nineteen participants who completed the study reduced Spielberger State-Trait Anger Expression Inventory (STAEI) and Spielberger State-Trait Anxiety Inventory (STAI-Y) scores and increased Pittsburgh Sleep Quality Index (PSQI) scores and sleep duration. Participants who practiced more frequently achieved more significant improvements on these measures.
Mikosch and colleagues (2010) conducted a randomized controlled study of 212 patients scheduled for elective coronary angiography (CA), which compared an intervention group that received psychological support, abdominal breathing instruction, and one session of HRVB with a control group that received TAU and information. While both groups reduced Spielberger State-Trait Anxiety Inventory (STAI) scores after the CA, the intervention group showed the largest decrease, and its scores were normal.
Ratanasiripong, Sverduk, Prince, and Havashino (2012) reported a randomized controlled study of 30 undergraduates, which compared counseling plus HRVB with a counseling comparison group. While both groups reduced Beck Anxiety Inventory scores, the HRVB group showed more significant improvement.
Clinical Efficacy
Generalized Anxiety Disorder(GAD)
Based on five RCTs, Donald Moss and Matthew Watkins rated BFB and NFB for GAD as efficacious. The BFB interventions included HR decrease, HRV increase, SCL decrease, SEMG decrease, and virtual reality (VRB). The NF interventions included alpha increase and alpha/theta increase.
Participants decreased HR, SCL, state and trait anxiety, and HR reactivity to stress. They increased HRV measures (HF and LF power) and theta power.
Panic Disorder(PD)
Based on five RCTs, Donald Moss and Matthew Watkins rated BFB for PD as efficacious and specific.
The BFB interventions included end-tidal CO2 increase, HRV increase, and SEMG decrease.
Participants reduced agoraphobic avoidance, anger, panic-related cognitions, PD frequency and severity, and state and trait anxiety. They increased end-tidal CO2 and sleep time.
Phobia
Donald Moss and Matthew Watkins rated BFB for PD as possibly efficacious for biofeedback and neurofeedback.
Post-Traumatic Stress Disorder
(PTSD)
Based on four RCTs, Donald Moss, Fred Shaffer, and Matthew Watkins rated BFB and NFB for PTSD as efficacious in Evidence-Based Practice in
Biofeedback and Neurofeedback (4th ed.).
The BFB interventions included HRV and TEMP increase, and respiration rate (RR) decrease. The NFB interventions included left amygdala fMRI decrease; 2-6 Hz and 22-36 Hz decrease, and 10-13 Hz increase; and theta and high-beta decrease and low-beta increase.
Participants reduced anxiety and depression scores and PTSD symptoms.
The National Survey on Drug Use and Health (NSDUH) defines a significant depressive episode as a minimum 2-week phase during which an individual encounters feelings of depression or
a lack of enjoyment in their usual activities.
During this period, a person must also exhibit a majority of symptoms, including sleep, diet, energy levels, focus, or self-esteem.
Multiple pathways to depression include polygenic, dysfunction involving the lateral and medial orbitofrontal cortex and limbic
system, and environmental factors (McGrady & Moss, 2013).
Depression is associated with activation of the lateral orbitofrontal cortex, which signals that our behavior has not been rewarded. This activation may be related to feelings of loss and disappointment. Since this region communicates with networks responsible for our self-concept, this may also lower self-esteem (Cheng et al., 2016).
Depression also involves reduced activation of reward circuitry in the medial orbitofrontal cortex and its communication with autobiographical memory systems. These changes may contribute to depressed patients' lack of enjoyment of daily activities and difficulty remembering happy experiences.
The 2020 National Survey on Drug Use and Health (NSDUH) found:
1. About 8.4% of U.S. adults experienced a MDD episode in the last year.
2. MDD was more prevalent in women (10.5%) than men (6.2%).
3. MDD prevalence was highest among those aged 18-25 (17.0%).
If untreated, 25-30% of adult depressive attempt or commit suicide. Most cases of major depression involve
another comorbid psychological disorder that is primary (Zimmerman et al., 2002). Only 21% of annual cases of
depression are adequately treated (Kessler et al., 2003).
Neurofeedback and Biofeedback Protocols
EEG and functional MRI (fMRI) are the primary NF interventions, and EMG and HRV are the central biofeedback interventions for depression. NF EEG protocols attempt to correct frontal alpha asymmetry or enhance parietal-occipital upper alpha. The rationale for alpha asymmetry neurofeedback for mood disorders is
that the left frontal cortex mediates approach behavior, while the right
mediates negative affect.
Clinical depression is associated
with less activation of the left frontal lobe than the right. Since alpha
is an "idling frequency," this asymmetry is seen when alpha amplitude is
greater in the left (F3) than the right frontal
lobe (F4). The goal of alpha asymmetry
NF for depression is to correct this imbalance, decreasing
left frontal alpha with respect to right frontal alpha.
Successful NF training increases the activation of the left hemisphere with respect to the right.
Before EEG asymmetry training, patients are trained using diaphragmatic
breathing and autogenic phrases to teach them to relax and warm their
hands. The hand-warming criterion is 95 degrees F.
Patients are seen once or twice a week for one-hour sessions, which
consist of 30 minutes of EEG training followed by 30 minutes of
psychotherapy. Scalp sites F3 and F4 are used and are referenced to
CZ. A bell or
clarinet tone reinforces behavior when the asymmetry score exceeds
0 (right alpha amplitude exceeds left).
Typically, it is desirable for 15-18 Hz amplitude to be higher and 8-11 Hz amplitude to be lower at F3 compared to F4.
fMRI protocols attempt to up-regulate the activity of targeted regions that mediate positive emotion.
Neurofeedback, Functional MRI, and Biofeedback Studies
Click on the Read More button to review neurofeedback, functional MRI, and Biofeedback depression studies.
EEG Studies
Baehr et al. (1999) reported that 3
of 6 patients discontinued antidepressant medication before the close of
the fourth treatment quarter and that their proportion of A (alpha
asymmetry) scores remained stable.
Case
studies reported by Kumano et al. (1996)
and Rosenfeld (2000), and a pilot
study by Waldkoetter and Sanders (1997)
support the Baehr et al. (1999)
finding that NF can reduce the symptoms of clinical
depression.
Corrado and Gottlieb (1999) compared
biofeedback-assisted relaxation with a wait-list control condition in
chronic pain patients. The biofeedback-assisted relaxation group
achieved improved Beck Depression Inventory scores.
Rosenfeld (2000) summarized a series of case studies involving patients diagnosed with depression. Before NF sessions, patients were trained to breathe diaphragmatically for 15-30 minutes and to warm their hands to a criterion of 95 degrees F. Active electrodes at F3 and F4 were both referenced to Cz. Training sessions conducted twice a week, were divided into 50% NF and 50% psychotherapy. As the alpha asymmetry score improved in four cases, Beck Depression Inventory (BDI) and Minnesota Multiphasic Personality Inventory (MMPI) depression scores declined.
Baehr, Rosenfeld, and Baehr (2001) reported follow-up data for three of six patients
diagnosed with unipolar depression who had completed 27 sessions of alpha asymmetry training. The authors compared
pre-treatment and follow-up alpha asymmetry and Beck Depression Inventory scores. All three patients had achieved
normal right hemisphere alpha asymmetry scores and Beck scores by the completion of their training and maintained
these gains at 1- to 5-year follow-up.
Choi et al. (2011) conducted a randomized controlled trial of 24 right-handed depressed patients who had not received psychoactive drugs within 2 months of the study. The researchers placed active electrodes at F3 and F4, referenced to Cz, and utilized Rosenfeld's asymmetry protocol. Training sessions comprised six 4-minute trials separated by 30-second rest periods. They trained participants twice a week for 5 weeks. Following NF training, participants received self-training to reproduce the mental state they experienced during NF without equipment twice a week for 1 month. The psychotherapy placebo sessions were also conducted for 5 weeks. After these sessions, they were referred to other therapists who provided traditional psychotherapy for depression as required.
Only the NF group increased right frontal alpha power and asymmetry scores and a significant improvement on the HAM-D and BDI-II scales. Six (50%) of the NF participants and none of the psychotherapy placebo participants achieved a clinical response.
Functional MRI Studies
Real-time functional MRI NF (rtfMRI-nf) interventions are designed to increase the metabolism of brain regions, like the ventromedial prefrontal cortex, that mediate positive affect.
Linden et al. (2012) reported an open-label pilot study of fMRI NF for 16 participants diagnosed with Recurrent Depressive Disorder. In the fMRI NF condition, the researchers trained 8 participants during four sessions to up-regulate brain regions responsive to positive emotions using a visual display updated every 2 seconds. Each session consisted of three 7-minute trials. In the control condition, the researchers instructed 8 participants to utilize positive imagery techniques employed by the fMRI NF subjects during four sessions conducted outside the scanner. The fMRI NF group successfully up-regulated the target areas (left or right ventromedial prefrontal cortex, insula, dorsolateral prefrontal cortex, medial temporal lobe, or the orbitofrontal cortex). While the fMRI NF group improved on the Hamilton Depression Rating Scale (HDRS), the control group did not change.
Young et al. (2014) randomly assigned unmedicated participants diagnosed with major depressive disorder to either receive rtfMRI-nf from the left amygdala (experimental; n = 14) or the left intraparietal sulcus (control; n = 7). Training sessions consisted of seven 8-minute 30-second runs. The experimental group increased left amygdala activation when recalling positive autobiographical memories within the first training session. This training effect was maintained during transfer runs in which participants did not receive NF. In contrast, the control group did not increase the activation of the intraparietal sulcus. While the experimental group decreased Profile of Mood States (POMS) depression scores, it was not superior to the control group. The experimental group decreased State-Trait Anxiety Inventory (STAI) state and trait scores, and the two groups only differed on state anxiety. Finally, the experimental group increased Visual Analog Scale (VAS) happiness ratings, and this gain was more significant than in the control group.
Biofeedback Studies
Surface EMG Biofeedback
Durmus, Alayli, and Canturk (2005)
randomly assigned 50 female patients diagnosed with knee osteoarthritis to biofeedback-assisted isometric exercise or electrical stimulation. For both groups, 20 minutes of therapy was applied 5 days a week for 4 weeks. Patients were evaluated before and after treatment. Both groups showed significant improvements in pain, measured by the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), and physical function scores. They demonstrated significant improvements in anxiety and depression scores on the Hospital Anxiety Depression (HAD).
Heart Rate Variability Biofeedback
HRVB is possibly efficacious for depression, and its effects may be mediated by the diaphragm's stimulation of vagal afferent nerves (Gevirtz, 2013). This hypothesis is supported by findings that vagal nerve stimulation in some studies improved intractable depression.
Karavidas and colleagues (2007) administered 10 weekly sessions of heart rate
variability (HRV) biofeedback to 11 patients diagnosed with major depressive disorder (MDD). By session 4, these
patients showed significant improvement on the Hamilton Depression Scale (HAM-D) and the Beck Depression Inventory
(BDI-II). They maintained these changes over the remaining 6 weeks of training.
Siepmann et al. (2008) conducted an open-label controlled pilot study with 38 participants. They placed 14 depressed individuals in the HRVB condition. Additionally, they randomly assigned 12 healthy individuals to HRVB and active control (watch the same HRVB display without instructions) conditions. The decision to assign all depressed individuals to the HRVB condition and none to the active control condition undermined the internal validity of this design for these subjects. All participants received three treatment sessions per week for 2 weeks. While depressed individuals significantly reduced Beck Depression Inventory (BDI) scores, decreased Spielberger State-Trait Anxiety Inventory (STAI) scores and heart rate, and increased HRV compared to baseline, healthy participants who received HRVB or the active control treatment did not change.
Zucker et al. (2009) conducted a controlled pilot study with 38 participants recruited from a residential therapeutic community for substance use disorder e diagnosed with PTSD symptoms. They randomly assigned individuals to either HRVB (StressEraser) or progressive muscle relaxation (PMR) recording. They instructed subjects to practice 20 minutes per day and complete weekly logs. The HRVB group achieved lower Beck Depression Inventory (BDI-II) scores and increased HRV (SDNN) compared to the PMR group. Both groups significantly reduced PTSD symptoms on the Posttraumatic Stress-Total (PTS-T) scale and PTSD Checklist-Civilian Version (PCL-C). Increased HRV predicted improvement, even when respiration rate was statistically controlled.
Patron et al. (2013) studied 26 individuals with depressive symptoms following cardiac surgery. They randomly assigned participants to either five 45-minute sessions of HRVB or treatment as usual (TAU). HRVB was superior to TAU in increasing respiratory sinus arrhythmia (RSA), heart rate speeding and slowing across the breathing cycle, and decreasing the Centre for Epidemiologic Studies of Depression (CES-D) values from pre- to post-treatment. Improvement was correlated with increased RSA.
Clinical Efficacy
Based on 10 RCTs, Zachary Meehan, Fred Shaffer, and Christopher Zerr rated BFB and NFB for MDD as efficacious and specific in Evidence-Based Practice in
Biofeedback and Neurofeedback (4th ed.).
BFB treatments included HRV increase. NFB interventions included alpha asymmetry reduction, alpha/theta increase, and real-time functional MRI (rtfMRI) to increase left or right ventromedial prefrontal cortex, insula, dorsolateral prefrontal cortex, medial temporal lobe, or orbitofrontal cortex activity.
Participants achieved decreased behavioral inhibition, depression symptoms and severity, and state and trait anxiety.
The biofeedback studies
(House, 1978; Walsh & Gerley, 1985; Weise et al., 2008) provided surface EMG and finger temperature biofeedback. The neurofeedback studies (Crocetti, Forti, & Del Bo, 2010; Dohrmann, Elbert, Schlee, & Weisz, 2007) provided feedback to modify power in the delta and tau bands of the EEG, and to down-regulate real-time functional MRI (rtfMRI) activity in cortical auditory processing regions.
Clinical Efficacy
Shaffer and Mannion (2016) rated biofeedback for tinnitus as probably efficacious and neurofeedback for tinnitus as possibly efficacious in Evidence-Based Practice in
Biofeedback and Neurofeedback (3rd ed.). These ratings were limited by the reliance of many of the reviewed studies on a single-group pre-test/post-test design, which precluded drawing causal conclusions.
Glossary
alpha asymmetry neurofeedback for mood disorders: a protocol that trains depressed clients to relax and warm their hands using diaphragmatic breathing and autogenic phrases and then decrease left frontal alpha with respect to the right frontal alpha.
amplitude control: a protocol that trains patients to increase EEG amplitude (signal strength) instead of
frequency. This strategy can raise the amplitude of both a target rhythm (beta) and an unwanted rhythm (alpha)
since it does not teach frequency discrimination.
connectivity training: a strategy designed to correct deficient or excessive communication between two brain sites measured by indices like coherence and comodulation.
frequency control: a protocol that trains patients toincrease the amplitude of one frequency (SMR) while suppressing another (theta). This procedure refines
EEG control and may result in better clinical outcomes than amplitude control.
Generalized Anxiety Disorder (GAD): a disorder characterized by excessive anxiety and worry, which
frequently interfere with daily functioning.
hyperactivity: excessive motor activity for a situation like a classroom, including fidgeting,
leaving a seat, and climbing or running.
impulsivity: failure to restrain behavior, including answering before a question is completed,
interrupting others' conversations or play, and an inability to wait for one's turn.
inattention: difficulty sustaining attention, including distractibility, insufficient attention to detail,
careless mistakes, forgetfulness, and loss of assignments and toys.
International 10-20 system: standardized procedure for placing 21 recording and 1 ground
electrode on adults.
Kaiser-Scott protocol (Scott-Kaiser modification): an intervention that starts with NF ADHD training and then progresses to the Peniston protocol.
Menninger alpha-theta protocol: a procedurethat helps clients increase their attention through temperature and frontal SEMG training and then
teaches clients to gradually slow the EEG until they can increase alpha and theta amplitude without falling
asleep. Menninger ON-OFF-ON EEG training: a procedure that teaches clients to increase the amplitude within a frequency
band, reduce the amplitude, and then increase the amplitude again during 100- or 200-second segments. For example,
clients may be instructed to increase 8-13 Hz alpha activity for 100 seconds, decrease it for 100 seconds, and then increase
it for 100 seconds.
passive volition: in autogenic training, visualizing the desired change and then allowing the body to
make the change at its own pace.
Peniston-Kulkosky addiction protocol: a multi-modal approach that incorporates visualization training,
temperature biofeedback, rhythmic breathing techniques, autogenic training exercises, construction of personalized
imagery, guided imagery, and 30 alpha-theta sessions.
performance-based protocols: use of tasks and neurofeedback training to correct symptoms and improve performance. This approach compares clients to themselves and not a clinical database.
petit mal seizures: type of epilepsy characterized bythe loss of consciousness without abnormal movement during which a client appears to be
daydreaming. A child may suffer hundreds of these seizures daily for periods lasting up to 30 seconds.
sensorimotor cortex: central cortical area defined by the central sulcus (fissure of Rolando)
separating the frontal and parietal lobes.
sensorimotor rhythm (SMR): EEG rhythm from 12-14 Hz located over the sensorimotor cortex (central
sulcus) that is associated with inhibition of movement and reduced muscle tone.
slow cortical potential (SCP) training: neurofeedback to increase the gradual negative changes in the
membrane potentials of cortical dendrites that last from 300 milliseconds to several seconds to reduce neuronal excitability
in conditions like grand mal epilepsy and migraines.
SMR training: a procedure that up-trains SMR activity and possibly down-trains theta, beta, and epileptiform activity.
Sterman's grand mal epilepsy protocol: a procedure that trains an epileptic
patient to increase SMR (12-14 Hz) amplitude and duration while theta (4-7 Hz), beta (20+ Hz), epileptiform
spikes, and EMG artifact are suppressed during 36 sessions. The aim is to normalize the waking and sleep EEG with
elevated SMR and suppressed theta and beta activity.
stroke: cerebrovascular accident (CVA), destruction of brain tissue (infarction) due to cerebral
hemorrhage, and cerebral ischemia affecting blood vessels that supply the brain. CVAs show abrupt onset and involve
temporary or permanent neurological symptoms like aphasia, paralysis, or loss of sensation.
theta/beta training: a procedure that down-trains theta and up-trains beta.
tinnitus: ringing in the ear when noise is absent.
tonic-clonic seizures (grand mal seizures): primary generalized seizures featuring a peculiar cry, loss
of consciousness, fall, tonic-clonic convulsions of all extremities, incontinence, and amnesia for the episode.
These seizures are diagnosed in fewer than 20% of adult epileptics.
traumatic brain injury: intracranial insult due to acceleration or direct impact that may cause
permanent or temporary cognitive, physical, and psychosocial deficits and impaired or altered consciousness.
Z-score training: a strategy that attempts to normalize brain function with respect to mean values in a clinical database. EEG amplitudes that are 2 or more standard deviations above or below the database means are down-trained or up-trained to treat symptoms and improve performance.
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Assignment
Now that you have completed this module, consider the elements that neurofeedback training shares with modalities
like EMG and temperature. How is neurofeedback training different?
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Graphic © Steve Buckley/Shutterstock.com shows a 2-year-old boy with 24-hour EEG electrodes to find the source of his seizures.
