Mind Matters of South Florida

06/28/2023

The disorders most commonly assessed and treated using biofeedback based interventions which have been shown to be reasonably efficacious through research studies are included in this section:

Efficacy is rated on a scale of 1 - 5 with 5 being the best. All disorders listed have been rated as having at least level 3 evidence supporting their efficacy.

ADD & ADHD

Alcoholism

Anxiety

Arthritis

Asthma

Breathing Problems

Chest Pain

Chronic Pain

Constipation

Drug Addiction

Epilepsy/Seizure

F***l Elimination Disorder

Headaches

Hypertension

Hyperventilation

Incontinence

Insomnia

Irritable Bowel Syndrome

Jaw Area Pain

Knee Pain

Low Back Pain

Non-Cardiac Chest Pain

Pain

Phantom Limb Pain

Posture Related Pain

Raynaud's Syndrome

Stump Pain

Subluxication of the Patella

Substance Abuse

Temporomandibular Disorder

Traumatic Brain Injury

TMJ/TMD

Urinary Elimination Disorders

Vulvar Vestibulitis

06/28/2023

Biofeedback has evolved from a fascination in the 1960s and 70s to a mainstream methodology today for treating certain medical conditions and improving human performance. This evolution has been driven by years of scientific research demonstrating that the mind and body are connected, and that people can be taught to harness the power of this connection to change physical activity and improve health and function. Public interest in biofeedback is growing, and with it the need for a clear answer to the question, “what is biofeedback?” The leading professional organizations representing the field have answered with the following standard definition.

“Biofeedback is a process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance. Precise instruments measure physiological activity such as brainwaves, heart function, breathing, muscle activity, and skin temperature. These instruments rapidly and accurately "feed back" information to the user. The presentation of this information — often in conjunction with changes in thinking, emotions, and behavior — supports desired physiological changes. Over time, these changes can endure without continued use of an instrument."

The Association for Applied Psychophysiology and Biofeedback (AAPB), the Biofeedback Certification International Alliance (BCIA), and International Society for Neurofeedback and Research (ISNR) convened a task force of renowned scientists and clinicians in late 2007 who worked together to craft the standard definition. “It is important for people to have good information from sources they can trust when making decisions about what health care and performance improving methods to choose,” commented AAPB President, Aubrey Ewing, Ph.D. “We felt strongly that with more about biofeedback and its efficacy appearing in the media, and the potential for confusion arising from inaccurate use of the term, that a standard definition was necessary,” he added.

Biofeedback and has been shown to be an effective treatment for migraine and tension type headache, urinary incontinence, high blood pressure, anxiety, and a number of other conditions. A growing body of research indicates that neurofeedback, (also known as EEG biofeedback) is an effective treatment for attention deficit hyperactivity disorder and can help manage the symptoms of autistic spectrum disorders, brain injury, posttraumatic stress, seizures, and depression. Corporate executives, musicians, artists, and athletes, including some of the medal winners in this year’s Beijing Olympics, use biofeedback and neurofeedback to reach their peaks in competition and performance.

The mainstream of biofeedback and neurofeedback practitioners, as represented by AAPB, BCIA, and ISNR, follow a standard of care based on scientific evidence that supports the use of particular biofeedback and neurofeedback methods, instruments, and claims of efficacy. The standard definition is intended to help consumers and the media in recognizing legitimate practitioners and methods, and insurance companies and government agencies in making decisions about biofeedback and neurofeedback coverage and regulation.

To learn more about the efficacy of biofeedback and neurofeedback in the treatment of certain disorders and their usefulness in promoting health and optimum performance, explore our website at https://www.mindmatterssouthflorida.com

06/28/2023

What is qEEG / Brain Mapping?

Electroencephalography (EEG) is the measurement of electrical patterns at the surface of the scalp which reflect cortical activity, and are commonly referred to as “brainwaves”. Quantitative EEG (qEEG) is the analysis of the digitized EEG, and in lay terms this sometimes is also called “Brain Mapping”. The qEEG is an extension of the analysis of the visual EEG interpretation which may assist and even augment our understanding of the EEG and brain function.

Quantitative Electroencephalography (qEEG) is a procedure that processes the recorded EEG activity from a multi-electrode recording using a computer. This multi-channel EEG data is processed with various algorithms, such as the “Fourier” classically, or in more modern applications “Wavelet” analysis). The digital data is statistically analyzed, sometimes comparing values with “normative” database reference values. The processed EEG is commonly converted into color maps of brain functioning called “Brain maps”.

The EEG and the derived qEEG information can be interpreted and used by experts as a clinical tool to evaluate brain function, and to track the changes in brain function due to various interventions such as neurofeedback or medication.

Quantitative Electroencephalography (qEEG) processing techniques and the use of modern analytic software to processes the EEG/qEEG gives us the ability to view the dynamic changes taking place throughout the brain during cognitive processing tasks, and this novel approach can be used to assist us in determining which areas of the brain are engaged and processing efficiently.

Various analytic approaches exist, from commercial databases to database free approaches, such as EEG phenotype analysis or the more classic European Vigilance model of Bente (1964) are used in modern clinical application of the EEG/qEEG. The use of advanced techniques such as Independent Component Analysis (ICA) and neuro-imaging techniques such as Low Resolution Electromagnetic Tomography (LORETA) can map the actual sources of the cortical rhythms. These advanced approaches are changing our understanding of the dynamics and function of the human brain.

Introduction to qEEG based Neurofeedback
It is presumptuous to think that the fields of qEEG and neuro-feedback (NF) are advanced far enough to have a scientifically qEEG based protocol that is a hard and fast rule. The field is scientific, but it is a scientific art at this time to use a qEEG to design an intervention. It is entirely foolhardy to make rules for this artistic task, so that is undoubtedly why I was approached for this task.

How does neurofeedback work?
An effective intervention into any system is to introduce feedback of the signal to be changed into the system This allows the system to self regulate, like the heating or cooling system in a house as a simple analogy. The models of how this works vary from systems theory, to anatomical/structural models, learning theory, even non-linear dynamics or “chaos theory”.

The organic models have some measurable validity, with the observed expansion of cortical areas dedicated to the structures utilized in tasks. Another observation supporting this model is the dendritic density increase in the cortex utilized in learned tasks. There are even reports recently of memory or ‘long term potentiation’ being predicted by the electrophysiologic brain state measured at the time of the perception to be recalled (Wagner et al., Science, August 1988)

The learning theory models have learning curve data to show the stages of the acquisition of the skill of volitional control over the autonomic activity with NT. They also predict the effect on efficacy of the sessions’ scheduling to shorten the total treatment times; massing the initial sessions and stretching out the later session’s intervals.

The systems theorists suggest the mere introduction of feedback may initiate self regulation. This is seen with the audible heart beat normalizing the inter-beat interval, without any instructions to the subject.

The most controversial systems theory being the “chaos” theoreticians, who vary in opinion. Some chaos theoreticians in this field will say the anatomically specific electrode site selection in NF is irrelevant ( Brown et al., 1998 SSNR), with others saying the site selection is critical for optimizing the training in NF (Thatcher, personal communication 1998). Some theoretical discussions even state that the purturbation of the system from feedback acts to chaotically restabilize the system independent of the need to follow out a learning curve of further treatment,
just expose the system to the chaos of feedback and that is all that is needed (Schore, 1997).

The bottom line is they all are theories, or perspectives with testable hypotheses associated with them. Many theories are not mutually exclusive of others, so the research proceeds with various, sometimes mutiple perspectives. The complexity and diversity of the models and opinions attests to the interdisciplinary nature of this field.

The most conservative critics would suggest placebo effect and experimenter effects as the sole forces at work in NF. This too is a testable hypothesis, one which is having an increasing difficulty explaining the observed results of the research found in peer reviewed publications.

Why do a qEEG for Neurotherapy?
There are many in the field of Neurotherapy who do not perform qEEGs prior to designing a clinical intervention. These people are currently practicing well within the standard of practice for this rapidly evolving field. Many within this group have standard protocols which are used on all clients, with various alterations to respond to the client’s reported experiences during the treatment.

I see the field of NF gradually moving more toward the use of qEEG, but it is not required by any stretch of the imagination, much less a standard of practice. I am sometimes misquoted as having said it is unethical to do neurofeedback without a qEEG. It may be less than optimal, in my estimation, but it is certainly not unethical.

The argument has been raised that the qEEG is only a way to bill the client additional charges, draining the vital cash reserves of the clients, with no scientific evidence of a benefit for the use of the qEEG. I agree there is an expense for a qEEG. To routinely perform a qEEG without a demonstrable treatment benefit would be difficult to justify.

There is an increasing body of evidence that there is a positive treatment impact from the use of a qEEG and the resultant customized NF intervention. The initial information coming from those using the technique “feeling” they got some clinical utility from qEEG data. The more persuasive evidence to date is a retrospective evaluation of outcomes in a single practice.

The retrospective research compared 3 years of NF data using a commonly used standard treatment approach to 2 years using the qEEG based customized intervention. A gross summarizing of the paper shows a doubling of the consevatively estimated clinical success, from 30 to 60%. Further, the total treatment benefit (both ‘some benefit’ and ‘full’ benefit groups added together) increased from the commonly previously reported 80% increased to 90% now receiving perceived benefit (C. Wright et al., SSNR, Austin 1998).

The cost effectiveness is seen easily if there are a few sessions spent “getting it right” using the clinical guesses to select sites. It only takes a few wasted sessions, not to mention possible adverse reactions, to pay for the proper selection using the qEEG.

I believe the strongest argument for the use of qEEG stems from the reported incidence of non-convulsive frontal and temporal lobe epilepsy comorbid with diagnosis of ADD/ADHD. When I saw 10% quoted in the literature, I was shocked and had some doubts about the reliability of the observation. Following nearly 3 years doing the screening for one ADD/ADHD practice, I saw a similar percentage of undiagnosed or “occult epilepsy”. I now have more faith in the figure.

To use a standard ADD/ADHD intervention with an undiagnosed epileptic may be problematic. The lack of awareness being no excuse (read ‘defense’) if legalities are invoked. The qEEG has a clinical EEG read during its evaluation, allowing for the proper referal or diagnosis of epilepsy (or any other occult condition such as tumor, metabolic or toxic encephalopathy or early dementia).

How do the maps tell you where to intervene?
I once heard qEEG referred to as “electro-phrenology”, a term that conjures up images of ancient times and archaic beliefs about brain function. I sort of like the term, as I think the term speaks to the potential to make simplistic assumptions about intervention, based on colored map “hot” spots, the ‘bumps’ of electro-phrenology.

QEEGers without an appropriately sophisticated model of how the brain works will be tempted to stick the intervening electrodes on areas that ‘light up’ with some color in a map. The area is likely to be an artifact, a normal finding, a normal variant or even the proper area for intervention. It may also be an effect of a distant cause or change in brain regulation.

The time consuming study of the brain’s function, EEG and the quantitative analysis techniques, including artifacts is needed to understand the colorful and informative mappings, tables of values and database comparisons. The careful study of the database selected is also needed to understand its strengths and weaknesses (Thatcher, 1998).

One of the earliest NF clinicians to use the qEEG to intervene in the 1970’s was Pourier, a Canadian clinician/researcher. He used the Fourier analysis derived compressed spectral array (CSA) to select the ‘deficient’ bands and those in ‘excess’, setting his protocol to act like a bull dozer, chopping off peaks and filling in valleys. His clinical judgements were based on experience, not database comparisons, but he did report positive results clinically.

Hopefully qEEG based NF has advanced since these early days of simplistic assumptions and electro-phrenology. For now, the study of the digital manipulations of the data needs to be put in place.

Regulatory and certification issues
Entering into the field of qEEG, one should expect to have a huge continuing education opportunity and responsibility ahead. I would advise the initial study of EEG to anyone entering this field, as it is the basis of the technique. Studying EEG allows for a solid foundation for the later study of qEEG methods and clinical applications.

Some certification in the field of EEG, or basic course completion in EEG should precede any entry into qEEG. The field of qEEG does not have any legislated requirements in California, though certification exists for various levels of practice in this area. Certification or licensure is regulated on a state-by-state basis.

The medical professional should proceed to board certification in EEG, then the qEEG specialization. This has been available from both the American Board of Electroencephalography and Neurophysiology (ABEN, AMEEGA’s associated testing board) and American Academy of Neurologies (AAN) affiliated testing bodies for EEG, but only ABEN for the quantitative EEG specialization.

Psychologists have had the American Psychiatric Electrophysiology Association (APEA) for education in the field, however, now the APEA and AMEEGA merged in 1998 to form the EEG and Clinical Neurosciences Society (ECNS).

This combined body will offer the board certification previously available to medical doctors through an associated testing board, ABEN.

I must disclose an association with technologist educational and testing groups, the AAQEEG and ABCQEEG boards, offering training seminars in EEG and qEEG and certification as a QEEGT. This certification is not required to practice anywhere, but does show a demonstrated competence in the technique of qEEG. Testing should not be attempted without substantial investment in studying the details of the technique, as the low pass rate would attest.

There is also the issue of regulatory approval for equipment, both in EEG/qEEG and in NT. The FDA has regulatory authority over NF and EEG devices that are sold or marketed, including NF devices, qEEG hardware and software… even databases. The FDA does not approve devices, it registers them, after they have gone through an arduous regulatory review for the validity of the claims and the safety and efficacy of the device.

The FDA registration has been cleared by many manufacturers, though there are some who continue to try flying beneath the regulatory ‘radar’. The equipment purchased by an end user that is not federally approved may be ‘taken’ without compensation by the FDA. As you can see, there is a benefit to looking for the FDA 510K number before purchasing any hardware or software.

Individuals interested in workshops and conventions in the field of NF and qEEG should look at AAPB (www.aapb.org) and ISNR (www.isnr.org) and local organizations and interest groups are often available as well.

Clinical applications of qEEG
The qEEG is used by those currently in a professional practice for the following clinical applications: evaluating effects of medications and predicting medication response, evaluating head traumas, assessment of cognitive and psychiatric changes, in NF and in peak performance assessment and training as well as others.

The use of qEEG ‘dipole location’ in surgical candidate assessment befor brain surgery in epilepsy is one of it’s most solidly accepted areas, with AAN approval. In other areas of qEEG application there are various levels of support or lack thereof from the various professional groups.

In the hands of those familiar with the field, qEEG can be used well in all these areas. In the hands of someone unfamiliar with the details of the technique, it can be a waste of time, a source of distraction or difficulty or even a liability.

04/07/2023

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02/21/2023

Is it really a disorder or all in your head? Neurofeedback shows otherwise.

Imagine a world where issues like autism, anxiety, post-traumatic stress disorder, insomnia, and addiction are a thing of the past, a world in which people no longer suffer from these ailments and their minds function properly. Neurofeedback treatment is bringing the world closer to that goal every day. “This requires an entire paradigm shift in the way you think about mental illness,” Mind Matters of South Florida Executive Director Martin Ludwig said. “Depression is not a condition to us, it’s a symptom of dysregulated brainwave activity.”

The dysregulated brain needs to be trained, reconditioned and remolded. Using state-of-the-art technology, the Mind Matters of South Florida Neurofeedback Center addresses a multitude of neurological symptoms, ranging from depression to Parkinson’s disease (view full list below), and the process is much simpler than you might think.

“As with anything that’s amazing, it’s simple, it’s elegant and it’s effective,” Martin said.

First, patients receive an evaluation that assesses their brain wave patterns and pinpoints the abnormalities. Then comes the fun part: All that is required of them at this point, is to kick back in a recliner and watch one of their favorite movies. That’s it.

Noninvasive sensors are attached to the patient to monitor brain activity. When brain waves operate less than ideally, the image on the screen will dim. The brain recognizes that and alters itself. This reconditioning allows the brain to regulate itself and create new connections. The more that patients use this brain training, the more permanent the connections become.

“We are training the brain wavelengths to get to a point where the symptoms disappear,” Martin said. “And it’s not something that you have to try to figure out. That’s the beauty of it.”

The research on neurofeedback, once referred to as biofeedback, is extensive and widely accredited. Neurofeedback treatment for attention deficit hyperactivity disorder is considered a Level 1 best treatment, on par with medication, except neurofeedback is drug-free, painless and noninvasive.

“But the difference here is that when you’re done, you’re done,” Martin said, “while if you stop taking medications, the symptoms come back.”

The U.S. Naval Combat Stress Center has recently adopted neurofeedback treatment as a way to treat soldiers with PTSD, and NASA has been using it for almost 60 years for peak performance training with their astronauts.

Special operations teams, Olympians, and professional athletes are also among the collection of elite groups utilizing the treatment to achieve peak intellectual and athletic performance.

Brain wave dysregularities occur based on environmental signaling. For example, when traumatic events occur such as abuse or r**e, the way our brains process the event is what causes irregular brain activity.

“What we have found is that our thoughts can create tons of brain wave dysregulation,” Martin said. “And that mostly comes from the way a person thinks about themselves; how they perceive things, the way they judge things.”

A symptom like addiction is associated with impulsive and compulsive tendencies both of which can be accredited to unbalanced brain waves caused by our perception of things that we encounter in our lives. Physical trauma that damaged the brain also causes irregularities that result in seizures and inability to function normally. Through neurofeedback treatment, our brains can be given the chance to operate at optimum levels.

“I’ve witnessed complete personality transformations,” Martin said. “People become who they’ve always meant to be before their brains started misfiring.”

02/10/2023

02/10/2023

Addiction

Neurofeedback helps stop the “revolving door” of addiction.
With relapse rates sky-high in the majority of addiction programs, people struggling with addiction can find themselves in and out of treatment and rehabilitation programs for years. Often, people with addiction even leave a treatment program before completion.

Neurofeedback helps bring increased success to the treatment of addiction. Combining neurofeedback with other addiction treatments can help a person finally escape the cycle of addiction.
Addiction Neurofeedback helps stop the “revolving door” of addiction.

With relapse rates sky-high in the majority of addiction programs, people struggling with addiction can find themselves in and out of treatment and rehabilitation programs for years. Often, people with addiction even leave a treatment program before completion.

Neurofeedback helps bring increased success to the treatment of addiction. Combining neurofeedback with other addiction treatments can help a person finally escape the cycle of addiction.

Addiction Is Physiological.
alcohol addiction and neurofeedback. Many people think addiction is due to a lack of self-discipline, but addiction is a physiological condition, and it’s extremely difficult to change. Addicts struggle with emotions such as guilt, shame, anger, and frustration, which further hinder their recovery.

Addiction is a brain disease, a mental health disorder that severely debilitates a person in all aspects of his or her life. In addition, people with addiction frequently suffer from other mental health disorders such as depression, bipolar disorder, and anxiety.

The current model of 30-day, inpatient treatment has a high relapse rate and often doesn’t work. Yet, at this time, insurance doesn’t usually pay for longer, more helpful alternatives, and people are stuck with the medical model of a 30-day treatment program that doesn’t address all their needs or help them acclimate back into everyday living.

Why Is Neurofeedback So Effective?
Neurofeedback treats the brain disorder of addiction by retraining a person’s brain. Teaching the brain how to be calm, focused, and relaxed helps a person think more clearly and rationally. As stressful incidents are a major cause of relapse, neurofeedback training helps build a solid base on which to build recovery. It helps teach the tools one needs to cope over the long term.

Medications may be helpful to begin change in the short-term, but recovery from addiction is a long-term process. Neurofeedback retrains the brain patterns causing dysfunction, giving a person with addiction the ability to succeed past the typical 30-day treatment cycle. In addition, for a person who has relied on a substance to manage daily life, medication may be just another substance.

How Does Neurofeedback Help End Addiction?
During times of stress, a person with addiction needs to be able to remain calm, reasonable, and rational in order to make important choices needed to stay clean and sober.

Neurofeedback teaches a person’s brain to operate in a calm, rational state, even in stressful situations.
It’s respectful, non-invasive therapy with no side effects.
According to a number of research studies, integrating neurofeedback training into one’s treatment program yields higher rates of success and lower rates of relapse than treatment programs without neurofeedback, for all age groups.
Neurofeedback clinicians report that more than 85% of their clients who train with neurofeedback improve their ability to focus, regulate behavior, and reduce impulsivity.
Since neurofeedback helps a person manage emotions and mood and improve sleep, adding neurofeedback to an addiction treatment program gives people the necessary tools to help them be more in control, achieve success, and avoid relapse.
neurofeedback software. How Does Neurofeedback Work?
Neurofeedback helps to correct dysfunctional brain patterns that contribute to addiction.

By using brain maps to determine the specific areas that are malfunctioning, a customized brain training plan targets and trains the regions with under- or over-arousal and connectivity. This helps correct some of the physiological aspects of the disease.

Neurofeedback helps replace maladaptive behaviors with more healthy patterns. People with addiction want to be free of this disease, and they want to learn new ways to manage it. Neurofeedback can help a person learn to be aware of triggers that lead to numbing and destructive behavior patterns, and eventual relapse.

With neurofeedback, a person receives real, physiological help, and the tools necessary to free themselves from the destructive cycles of addiction.

If you’re interested in learning more about how neurofeedback can help with addiction of prevent the chances of relapse, please contact us at Mind Matters of South Florida at 954-644-2884.

02/10/2023

EXPERIENCE THE CLARITY AND FOCUS OF YOUR BRAIN AT IT'S PEAK PERFORMANCE! In today’s fast paced world, many people have lost their ability to function at their peak potential.

Unfocused thinking, poor concentration, and lack of mental endurance can really hold you back. Neurofeedback can improve this. It can also help insomnia, anxiety, headaches, and other related conditions.

At Mind Matters of South Florida, we can help you regain control by optimizing your brain’s function. Neurofeedback training will sharpen your focus and maximize your potential so you can live your life at its fullest. How would your life change if you could improve and maintain clarity of mind at all times.

Neurofeedback is...​

Non-invasive​
​Results are long-lasting
May reduce or eliminate
the need for medication
Personalized for each client

Schedule your free consultation. Call Mind Matters of South Florida.

01/22/2023

Neurofeedback, also called electroencephalogram (EEG) biofeedback or neurotherapy, is an adjunctive treatment used for psychiatric conditions such as attention-deficit/hyperactivity disorder, generalized anxiety disorder, posttraumatic stress disorder, phobic disorder, obsessive-compulsive disorder, bipolar disorder, depression and affective disorders, autism, and addictive disorders (Moore, 2000; Rosenfeld, 2000; Trudeau, 2000).

In an interview with Psychiatric Times, Siegfried Othmer, Ph.D., chief scientist at EEG Spectrum International Inc., described neurofeedback as neuroregulation in the time and frequency domains through the use of bioelectrical operant conditioning. Like repetitive transcranial magnetic stimulation (rTMS), neurofeedback is an innovative form of electrother**eutics that complements neurochemical interventions for mood disorders. "With the use of anticonvulsants as mood stabilizers," Othmer said, "we have seen a convergence of psychiatry and neurology in the field of pharmacology. Similarly, neurofeedback signals a convergence of psychiatry and neurology in bioelectrical approaches to treating affective disorders. By stabilizing the brain and rewarding it for holding particular states, neurofeedback acts as a natural anticonvulsant." The rationale for using neurofeedback ther**eutically is that it corrects deficits in brain cerebral regulatory function related to arousal, attention, vigilance and affect (Othmer et al., 1999).

During neurofeedback sessions, patients learn to produce desirable brain wave patterns displayed on a computer screen by controlling the activity of a computerized game or task seen on a second screen. Increases in the amplitude of slow spindle activity are instantaneously rewarded. The reward corresponds to the earned score, similar to scores accumulated in a computer game (Othmer, 1999).

Neurofeedback represents a window of opportunity for assessing and shifting any given brain state (Manchester et al., 1998). The designated frequency band determines which brain state is rewarded (Othmer, 1999). Beta (15 Hz to 18 Hz) training usually produces a slightly upward shift in arousal levels, leading to increased wakefulness and attentiveness or to decreased depression. The sensorimotor rhythm (SMR) (12 Hz to 15 Hz) elicits a slightly downward shift in arousal. The SMR is associated with subjective feelings of relaxation, emotional calm and centeredness (Othmer, 1999). Combined left-side, ß-SMR and right-side

-

neurofeedback is often used to treat brain wave dysregulation associated with traumatic memories. Right-side training is also employed for social and emotional deficits such as conduct disorder, autism and reactive attachment disorder (Othmer, 2000; Othmer et al., 1999).

Assessment of Clinical Evidence

The efficacy of neurofeedback in the treatment of seizure and pseudoseizure disorders has been well documented in peer-reviewed literature for over 25 years (Lubar, 1997; Swingle, 1998). On the whole, however, clinical support for the effects of neurotherapy is limited and based primarily on case studies, rather than randomized, controlled, blinded studies. While Joel Lubar, Ph.D., professor of psychology at University of Tennessee in Knoxville, recognizes the shortage of randomized trials on neurofeedback, he told PT that matched-group studies conducted in accordance with the Declaration of Helsinki are more appropriate than controlled trials for studying hyperactivity. He noted that 1,500 groups worldwide currently use neurofeedback for psychiatric applications, including attention-deficit/hyperactivity disorder (ADHD) and comorbidities. Since the 1970s, his team has investigated various interventions for treating hyperactivity in children and found EEG to be superior.

Lubar and his colleagues (1995) evaluated the effects of neurofeedback treatment on ADHD in 19 youth, ages 8 years to 19 years, under relatively controlled conditions. The subjects received one-hour sessions of ß brain wave training daily for up to 40 hours over a two- to three-month period. The goal of the therapy was to increase 16 Hz to 20 Hz (ß) activity while reducing the amplitude of

brain waves (4 Hz to 8 Hz). Compared to pre-training results, post-training changes showed improvements in Test of Variables of Attention (TOVA) scores, Attention Deficit Disorders Evaluation Scale (ADDES) behavior ratings and Weschler Intelligence Scale for Children-Revised (WISC-R) performance. Twelve out of 18 subjects with pre-/post-TOVA scores had EEG-responsive improvements on an average of three of four possible scales. This change was comparable to pre-/post-medication differences in TOVA scores in youth with ADHD.

While TOVA scores typically return to baseline when the effects of pharmacotherapy wear off, the TOVA scores of the EEG-responsive subjects remained at the improved level. Significant post-test increases in IQ scores were observed in 10 EEG-responsive subjects who had been tested on the WISC-R two years earlier. Parental and teacher ratings of the children's behavior also improved following neurofeedback training. Thus, in the EEG-responsive youth, behavioral improvements corresponded with increased scores on TOVA and WISC-R. Lubar and his associates cautiously concluded that EEG neurofeedback training is a powerful adjunctive technique for treating ADHD when used as part of a multi-component ther**eutic approach.

Additional research suggests that EEG neurofeedback may be an effective alternative to psychostimulants in the treatment of ADHD if medication is ineffective or has adverse effects or if patients are noncompliant (Rossiter and La Vaque, 1995). In one case study, a 36-year-old female diagnosed with ADHD, temporal seizure disorder and borderline personality disorder received 30 weekly sessions of SMR neurofeedback training and carbamazepine (Tegretol) (Hansen et al., 1996). The patient initially was reluctant to take carbamazepine but became compliant after starting neurofeedback training. However, because of the drug's side effects, she stopped, restarted and then again discontinued her medication. Following 17 sessions of neurofeedback, her quantitative EEG (QEEG) showed relative powers within normal ranges. Carbamazepine increased the favorable effect of neurofeedback on TOVA performance in the early phase of treatment. Although the subject's TOVA scores fluctuated as she went on and off carbamazepine, all four scales were normal months after she ceased taking carbamazepine. At that time, her TOVA performance showed no evidence of attentional deficit.

In a survey, 36 children, ages 6 years to 17 years, receiving EEG neurofeedback as a treatment for attention-deficit disorder (ADD)/ADHD were evaluated for changes in both subjective and objective clinical parameters (Alhambra et al., 1995). After 20 sessions, subjective improvement based on parental observations was 86%. In objective assessments, the overall improvement was 74% for TOVA score and 78% for favorable changes in QEEG parameters. Over a 12-month period, neurofeedback was associated with either a decrease or termination of pharmacotherapy in 16 of 24 patients receiving medication for ADD/ADHD.

In a retrospective study, 11 females, ages 12 years to 21 years, diagnosed with dissociative identity disorder (DID) received 30 neurofeedback and 10 group sessions (Manchester et al., 1998). The treatment was designed to increase prefrontal ß activity for alertness and simultaneously enhance

activity associated with a reverie state. The combined increase of ß and

brain waves allowed patients to re-experience their traumatic memories while in a hypnagogic reverie state but free of the distortions that arise during dreaming or hypnosis. The ratio of

to ß activity is crucial in this type of training. If

activity becomes too high, patients may sink into an unconscious state and not remember their past experiences. Three to 27 months following neurofeedback training, the post-treatment score for the DID group was 82, falling within the range of normal values. By bringing dissociated information, affect and sensation into consciousness, neurofeedback training helped subjects to resolve conflicts that contributed to their dissociative defense symptoms.

Neurofeedback resulted in favorable changes between pre- and post-treatment scores on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) in a 65-year-old woman diagnosed with a major depressive disorder and in a 42-year-old woman with chronic psychological maladjustment (Baehr et al., 1997). The researchers concluded that even though EEG asymmetry training is not an efficacious stand-alone therapy for depression, it is an effective adjunct to psychotherapy for treating certain mood disorders.

Certain neurofeedback protocols may be beneficial for treating anxiety disorders (Moore, 2000), but the success of particular neurofeedback protocols for anxiety may depend on which diagnostic categories are used (Thomas and Sattlberger, 1997). Case studies on the effects of neurofeedback on bipolar disorder (BD) have produced mixed results. Although Rosenfeld (2000) was unsuccessful in treating two patients with BD using a neurofeedback protocol, Othmer (2001) found neurofeedback to be effective in managing mood swings in pediatric patients with BD when combined with pharmacotherapy and psychotherapy. In the Othmer case studies, neurofeedback protocols that directly affect inter-hemispheric communication were most efficacious for children diagnosed with BD.

In addition, EEG neurofeedback may have limited applicability for treating psychotic symptoms. Researchers successfully used neurofeedback to modulate slow potentials in schizophrenic and schizotypal subjects in the subacute phase (Gruzelier, 2000). And several studies show that neurofeedback is efficacious for long-term recovery in substance abusers (Kaiser et al., 1999; Trudeau, 2000).

Future Directions

Despite positive evidence from case studies, Russell A. Barkley, Ph.D., professor of psychiatry and neurology at University of Massachusetts Medical School, disputes claims that EEG neurofeedback has an effect on ADHD. Barkley told PT that EEG neurofeedback is not supported by evidence-based medicine. "One chief problem," he warned, "is that pre- and post-changes occur in subjects with ADHD regardless of whether or not they receive neurofeedback." Barkley attributed reported improvements in objective measures of ADHD symptoms (such as parent and teacher rating scales of disruptive behavior) to the practice effect. "Because of the lack of adequately designed studies, any effects associated with EEG neurofeedback may be due to the placebo response," Barkley said.

However, Lubar et al's. 1995 study provided comparative pre- and post-treatment measurements of several parameters in subjects with ADHD who improved and in those who did not. As noted, the pre-/post-changes observed in the neurofeedback-responsive treatment group were nearly equivalent to changes reported for pre-/post-medication in subjects with ADHD. Other studies comparing the effects of EEG neurofeedback and psychostimulants reveal that neurofeedback produces post-treatment changes equal to those associated with pharmacotherapy (Nash, 2000). Based on these findings, supporters argue that neurofeedback achieves its ther**eutic effects by acting on electrophysiological substrates of the brain and not via a placebo response (Othmer et al., 1999).

"Critics of EEG neurofeedback hold this treatment to more rigid standards than many of the drug treatments," David F. Velkoff, M.D., medical director of the Drake Institute of Behavioral Medicine in Los Angeles, who has treated over 1,000 patients with neurotherapy, told the press. "Yet unlike drugs, neurofeedback is benign." According to Frank H. Duffy, M.D., associate editor for Clinical Electroencephalography, any pharmaceutical drug that had as wide a range of effectiveness as neurofeedback would be universally accepted and widely used (Duffy, 2000).

Although neurofeedback remains an investigational therapy (Baydala and Wikman, 2001), the growing number of case studies on this therapy are compelling enough to warrant controlled clinical trials with adequate sample sizes that can generate replicable data. "Alternative research designs involving sham neurofeedback are already in use as well as comparative investigations of neurofeedback with both conventional treatments and with combined treatments consisting of neurofeedback and psychostimulants," according to Lubar. "The Association for Applied Psychophysiology and Biofeedback [AAPB] is currently developing application standards for ethical controlled studies of neurofeedback that simultaneously protect patients and the integrity of research investigations."

In summary, preliminary evidence suggests that psychopharmacological and electrophysiological approaches to the treatment of mood and behavioral disorders are not intrinsically contradictory. Neurofeedback is perhaps best viewed not as an alternative to conventional psychopharmacological agents, but rather as one component of a multimodal approach. When used as an adjunctive treatment in combination with standard medication, neurofeedback may improve certain clinical outcomes in some psychiatric patients.