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 electrotherapeutics 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
therapeutically 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, b-SMR and right-side a-q 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 b 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 (b) activity while reducing the amplitude of q 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 therapeutic 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
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 b activity for alertness
and simultaneously enhance q activity associated with a reverie state.
The combined increase of b and q 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 q to b activity is crucial in this type of
training. If q 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).
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 therapeutic 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.
Alhambra MA, Fowler TP, Alhambra AA (1995), EEG
biofeedback: a new treatment option for ADD/ADHD. Journal of
Baehr E, Rosenfeld JP, Baehr R (1997), The clinical
use of an alpha asymmetry protocol in the neurofeedback treatment of
depression: two case studies. Journal of Neurotherapy 2(2):12-27.
Baydala L, Wikman E (2001), The efficacy of
neurofeedback in the management of children with attention
deficit/hyperactivity disorder. Paediatrics and Child Health
Duffy FH (2000), The state of EEG biofeedback therapy
(EEG operant conditioning) in 2000: an editor's opinion. Clin