People commonly ask the questions : "Why?", "How does a thing work?" and "How can I fix it?". I do not attempt to answer "Why?" because it is a metaphysical question. Much of this article answers the question of "How can I fix it?".
I shall mainly describe "How does the brain work?" which I freely acknowledge is an immodest goal.
The nervous system is built upon a living network of feedback, constantly adapting
::::::::
A chapter from
Textbook of
Neurofeedback, EEG Biofeedback, qEEG and Brain Self
Regulation
I. Introduction.
2. The brain functions as a communication
system.
3. The brain functions as a gland, with neurotransmitters
and neuropeptides.
4. The brain functions as a system of adaptation.
5.
The brain controls emotions. Mood related to patho-physiology.
6.
The brain controls activity and behavior. Hypo-activity and
hyper-activity.
7. The nervous system is built on stimulus-response
mechanisms.
8. Biofeedback as a treatment modality in
neuropsychiatry.
9. Biofeedback as a treatment modality in
restorative neurology.
1. INTRODUCTION
People commonly ask
the questions : "Why?", "How does a thing work?" and "How can I fix
it?". I do not attempt to answer "Why?" because it is a metaphysical
question. Much of this article answers the question of "How can I fix
it?".
I shall mainly describe "How does the brain work?" which I
freely acknowledge is an immodest goal.
The nervous system
is built upon a living network of feedback, constantly adapting to the
environment, both the internal and the external. The prefix"bio" in
biofeedback is semantically unnecessary since we are dealing with
systems during life. However, because of the historical use of
"biofeedback" as a treatment modality the term can be accepted.
Biofeedback is an important technique in the wide spectrum of
behavioral medicine. Behavior is the motor output of the nervous system
which depends upon the conscious and unconscious reception and
acceptance of stimuli by an individual. It is the response to a
continuous stream of stimuli in the waking and the sleeping state.
Biofeedback professionals learn the art of encouraging self-awareness
both of themselves and of their patients, in order for perception of
stimuli to be changed if desired.
Therefore we need to become
more self-aware of the physiology that generates our behavior. We need
to harness our feedback forces, and to use the inherent physiological
mechanisms of feedback to the best advantage of ourselves and of those
whom we contact.
Behavioral responses can be modified by the
way the individual perceives these incoming stimuli. Similar stimuli
are experienced differently by different people, and they also vary
according to the actual psycho-physiological state of the individual,
including their age and experiences.
A.R. Luria in his
classic book "Higher Cortical Function in Man" analysed "the reflex
mechanisms by means of which the organism maintains its equilibrium with
the environment" and "the problem of the cerebral mechanisms of mental
activity". Replace the word "reflex" by "biofeedback" and we see how
we are perpetually studying these mechanisms.
For an
excellent review of the central autonomic network (CAN), with its
functional organization and dysfunction, the reader is referred to the
article by Eduardo Benarroch (1993), (see Fig 1).
2. THE BRAIN
AS A COMMUNICATION SYSTEM
The brain functions as a system for
communication over the entire body. The nervous system consists of a
CENTRAL part (the brain and the spinal cord) and a PERIPHERAL part
which comprises the nerves that arises from the brain and spinal cord.
These nerves supply the special senses, the musculature and the
sensation of the trunk and the four limbs.
This chapter
deals with the central nervous system (CNS). It is a bilateral and in
many ways symmetrical group of structures consisting of 6 parts: (1)
the Spinal cord; (2) the Brain stem subdivided into 3 regions, the
midbrain, the pons and the medulla; (3) the Cerebellum, important for
modulating and co-ordinating motor movement together with (4) the Basal
ganglia, (the caudate nucleus, putamen and globus pallidus); (5) the
Diencephalon (the thalamus, hypothalamus, subthalamus, and epithalamus)
and (6) the Cerebral Hemispheres capped by the cerebral cortex or rind
with higher perceptual cognitive and motor functions, (Kandel). (see fig
2). The brain weighs 3 lbs. The spinal cord is like a tail arising
from the base of the brain and its thickness averages that of a human
finger.
Broadly speaking the tasks of the brain can be
divided into three categories:
(1) the RECEPTION OF STIMULI (this is
the sensory system);
(2) the association of stimuli and the analysis
or PERCEPTION OF INCOMING STIMULI; and (
3) the MOTOR RESPONSE to
those stimuli. These motor responses summate so as to constitute the
behavior of the individual. At the cellular level, sensory signals are
transformed into motor acts.
(1) The RECEPTION OF STIMULI by the
brain occurs via the AFFERENT PATHWAYS FOR SENSATION. (The
term"afferent" indicates travelling towards the brain, and "efferent"
travelling away from the brain.) The pathways for light touch,
(tickle), pain, pressure, heat, cold and vibration from the periphery to
the cerebral cortex are well-known and they do not vary significantly.
It is the conscious PERCEPTION by the individual of these stimuli
(when they reach the appropriate area of the cerebral cortex) which
varies constantly throughout life.
In order to prevent
overloading of the individual by a continous stream of stimuli, the
nervous system has developed a variety of methods of INHIBITION.
Inhibition is an important neurological concept for biofeedback
professionals since learning how to inhibit sensations, thoughts or
behavior is basic in biofeedback training. Inhibition as applied to
synaptic transmission refers to an active process by which excitatory
transmission is prevented. Inhibition occurs in the CNS both before and
after the synapse ("pre-synaptic" and "post-synaptic"). A major
pre-synaptic neurotransmitter, which is inhibitory in many processes, is
gamma-amino-butyric-acid (GABA). In the thalamus (its nucleus is the
main way-station for sensation) there is both pre- and post-synaptic
inhibition. At higher levels in the brain, both in the cerebellum and in
the cerebral cortex, inhibition is mainly post-synaptic.
Inhibition can be directed from the cerebral cortex. Efferent pathways
from the sensori-motor cortex excite thalamo-cortical relay cells. By
exerting inhibition the cerebral cortex is able to block the synapses
and thus to protect itself from being stimulated by cutaneous stimuli;
it can neglect these stimuli. This happens for example when one is deep
in thought, preoccupied with an experience or intensely involved in
carrying out an action. Counter-irritation to relieve pain acts in this
way. Discharges from the cerebral cortex down the pyramidal tracts and
other pathways may exert an inhibitory blockage at the relays in the
spino-cortical pathways. This can inhibit unwanted motor movements.
INHIBITORY
FUNCTIONS OF THE CEREBELLUM.
The cerebellum is the great
"smoother" of all motor activities. The Purkinje cells are large nerve
cells in the cerebellar cortex. The unique feature of the cerebellar
cortex is that its output is expressed entirely by the inhibitory
Purkinje cells.
Nowhere else in the brain is inhibition so dominant.
How can information be conveyed effectively in this negative manner?
Because this inhibitory action is exerted on nuclear cells that have a
strong background discharge.
Eccles gives the analogy of the
sculpture of stone. A sculptor has a block and achieves form by "taking
away" stone through chiselling. Similarly the Purkinje cells of the
cerebellum achieve form in the nuclear cell discharge by taking away
from the background discharges through the process of inhibition.
(2)
The association of stimuli and the analysis or PERCEPTION OF INCOMING
STIMULI is carried out in the cerebral hemispheres. Here memory,
judgement, thought association, verbal and non-verbal communication, the
emotional coloring of stimuli all combine to create the personal
interpretation of on-going stimuli. This is the meeting-ground which
regulates the psycho-physiology of the individual.
(3) THE MOTOR
RESPONSE TO THE STIMULI. This is the output of the brain, the efferent
system, via the pyramidal, extra-pyramidal and non-pyramidal pathways.
These
responses require exquisite MOTOR COORDINATION.
The CEREBELLUM is
concerned with the reliable and regulated control of movement. The
cerebellum is the part of the brain which through the process of
evolution has come to function as a special computer by handling all the
complex inputs from receptors or from other parts of the brain. The
articulation of speech is subserved by cerebellar mechanisms.
Let us visualize the neural events in the cerebro-cerebellar circuits
during a skilled action, such as running a machine at work or playing
the piano. There will be initially a motor command with a preprogramming
of the movements by circuits in the association cortex, cerebellum,
basal ganglia and thalamic nuclei. The learned skills are mobilized and
the discharge leads on to the action impulses in the pyramidal tract,
with the consequent report of the discharge to the part of the
cerebellar cortex receiving and projecting both to the cerebrum and the
spinal cord. Cerebral"willing" of a muscle movement sets in train
neural events that lead to the discharge of pyramidal cells.
There is a sequence of neuronal events, a chain reaction, such that one
part is called into operation (in the temporal or time sense) and this
leads other parts to go into action which generates further activity .
Since, however, all areas of the brain are constantly (and therefore
concurrently) active, many elements are carrying out their own intrinsic
activities (cross-talks between the cells) which are not apparent to an
outside observer; these do not impinge on the consciousness of the
individual concerned. It is clear, therefore, that a good deal of
cerebral activity goes unheeded by the originator and all observers.
Biofeedback treatment is based on learning. How does the brain as the
organ of communication bring about learning?
The process of
learning consists of excluding from consciousness all stimuli except the
one which the individual chooses to focus upon, and to which his
attention is directed. The acquisition of new data thus involves a
process of selective listening and consists mainly of rejection or
ignoring of stimuli which are nonrelevant at that time.
Biofeedback consists of acquiring a technique for selective "listening"
to a particular set of stimuli, which may come from the external
environment or from inside the individual's own body (internal
environment) . The purpose of the technique is for the student to have
the ability to regulate psycho-physical function himself. In order to
acquire and to teach this technique, we have to know, first, the
GEOGRAPHY OF SPECIALIZED FUNCTIONING, meaning the localization within
the brain of neurons with specialized function. These neurons in
different parts of the brain vary greatly one from another. For example
they vary in size as a petunia varies from an oak tree, (Stevens).
Second, we have to understand the interconnections (neural connections)
or microstructural changes in SYNAPSES, linkages or pathways of the
brain, because this gives a basis of the HOW of behavior, both of the
patient and of ourselves. Third, we have to understand the concept of
EXCITATION and INHIBITION. The neurons are either excitatory or
inhibitory and/or secretory. When two parts of the brain (two neuronal
populations) interact, they may each exert an excitatory or an
inhibitory effect.
A neuronal impulse may release a
neurotransmitter which excites or inhibits. If one part fails to act,
there is uncontrolled or deafferented functioning of neurones, because
they are lacking their accustomed stimulation or input.
NEURONAL
FUNCTION.
Neurons have four main functions: (1) they respond
to specific neurotransmitters by altering membrane permeability to
common ions (sodium, chloride, potassium, calcium); (2) they conduct
electrical impulses; (3) they secrete transmitters (see below in
"Neurotransmitter"); (4) they communicate with other post-synaptic
cells by the process of synaptic transmission.
Neurons are
able to respond and act as "receptors"; this is because their intrinsic
membranes (coverings) contain proteins which can receive messages and
are therefore called receptors. The membranes of different neurons
contain different receptors.. These receptors are protein-complexes
bound in the intrinsic membrane of the neuron.
3.
THE BRAIN AS A GLAND
When we add together the concepts of
the brain as the organ for communication and the brain as a gland,
secreting chemicals, we see that the sensory messages that arrive at the
brain from the periphery are being continuously changed, altered,
modified, censored, embellished, intensified or inhibited by
NEUROTRANSMITTERS. A transmitter is a chemical substance that is
released synaptically by one neuron and that affects another cell
(neuron or effector organ) in a specific manner. However, a given
transmitter does not always open the same ionic gates or bring about
the same biochemical change in the postsynaptic neuron; the receptor
determines whether the synapse will be excitatory or inhibitory.
These transmitters act at the neuro-muscular junctions, the
interneuronal junctions and the sensory way-stations, and they are
either repressed or further attended to and analysed according to the
state of the "receiving" cortex. The incoming sensations are matched
with previous experiences. The brain can discard anything "foreign" in
the same way that foreign substances like grafts, bacteria or other
non-self substances are rejected by the tissues which represent the
"self". Some nerve cell receptors have been found to be isomers of
immune cell receptors.
SYNAPTIC TRANSMISSION. There are four
biochemical steps in synaptic transmission: (1) synthesis of the
neurotransmitter substance; (2) release of transmitter into the
synaptic cleft; (3) binding of transmitter to the postsynaptic
receptor, and (4) removal or destruction of the transmitter substance,
(Schwartz).
There are eight substances which are the
original classical neurotransmitters: Acetylcholine, the 4 biogenic
amines: Dopamine, Histamine, Nor-epinephrine (the locus caeruleus is
rich in nor-epinephrine), and Serotonin (5-hydroxy-tryptamine) ; and 3
amino-acids: Gamma-amino-butyric acid (GABA), Glycine and Glutamate.
NEUROPEPTIDES. Some neurotransmitters are, chemically, neuropeptides.
Neuroactive peptides or neuropeptides have been found to be
localized in neurons. More than 50 neuropeptides have now been isolated
and arranged in a chemical sequence. They range is size from small
peptides (two amino acids joined by a single peptide bond) to a large
molecule such as corticotropin-releasing-factor (CRF) which is comprised
of 41 amino acids.(Nemeroff). The amino acids arranged in chains
include Glycine, Alanine, Leucine, Aspartine and Arginine.
These neuropeptides act as hormones in some tissues, (a hormone is a
chemical messenger, a substance released at considerable distance from
its intended site of action); and in other tissues these peptides act
as neurotransmitters
( a neurotransmitter is released directly onto
the site of the intended action).
Neuropeptides are
important in the field of biofeedback because their action is closely
related to the psycho-physical state of the individual.
Certain neuropeptides are involved in the perception of pain, pleasure,
fear, depression and other emotions. Others are involved in the
control of blood pressure, reproduction, and the mobilizing of energy.
Some can be termed neuromodulators because they are substances that
modulate the action of classical neurotransmitters, (the first 25 or so
neurotransmitters to be isolated), but the field is increasing so
rapidly that terms change their exact meaning.
The brain,
functioning as a gland secreting chemicals, regulates our
psycho-physical state through many systems, including the
gastro-intestinal, the cardio-vascular and the immune systems. Many
brain areas are particularly involved, including the hypothalamus. the
pituitary, and the amygdala. We shall discuss these biochemical factors
as they relate to mood and behavior.
First we review the brain
areas identified as specially important.
The HYPOTHALAMUS.
The
hypothalamus is a minute collection of nuclei situated just below the
thalamus. These nuclei are distinguished microscopically, and they
include the median eminence, the peri-and para-ventricular nuclei, the
preoptic nuclei, the arcuate nucleus and many others.
HYPOTHALAMIC-RELEASING
HORMONES include Thyrotropin-releasing hormone (TRH), Luteinizing
hormone (LH), and somatostatin (growth hormone release-inhibiting
factor, SRIF).
The PITUITARY. The pituitary is the pea-like body
sitting in the pituitary fossa at the base of the skull. PITUITARY
PEPTIDES include Adrenocorticotropin (ACTH), Beta-Endorphin,
Vasopressin and Oxytocin. The hypothalamic-pituitary-adrenal axis is
central to many aspects of the stress response.
The AMYGDALA.
(plural for amygdalum). The amygdalum is a nucleus the shape of an
almond situated deep in each temporal lobe. The two nuclei constitute
the amygdala and are part of the limbic system, the so-called affective
brain, associated with emotionally-based behavior. The amygdala within
the limbic system connects to the cerebral cortex, to the thalamus and
hypothalamus, and to the brainstem and spinal cord. The amygala is
important for the mediation of normal responses to fear-evoking or
anxiety-producing stimuli. Epileptic seizures where the abnormal
neuronal discharge involves the amygdalum can be manifested by severe
sensations of fear and memories of events full of fear. Autonomic
changes can accompany this fear with increases in heart rate and blood
pressure, dialation of the pupils and pallor. "A majority of the
peptides that have been localised with neurons of the brain are found
within either neuronal cells bodies or terminals of the amygdala"
(Gray). These include cortocotropin-releasing factor (CRF), neurotensin,
Enkephalin, Somatostatin and Substance P.
Next we review the
systems where neuropeptides are particularly involved.
THE
GASTR0-INTESTINAL SYSTEM.
GUT-BRAIN PEPTIDES give us the concept of
the MINIBRAIN in the intestinaltract. They include vasoactive intestinal
polypeptide (VIP), Cholecystokinin (CCK), Substance P, Neurotensin,
Methionine enkephalin, Leucine enkephalin, Insulin and Glucagon.
GASTRO-INTESTINAL
(GI) FUNCTION. The stomach and intestines have been known for a long
time to have a large nerve supply, mainly of non-medullated sympathetic
fibers and medullated preganglionic fibers of the parasympathetic.
Nerve fibers between two layers of smooth circular muscle form the
plexus of Auerbach. From there they pass to the submucosa of the gut to
form the plexus of Meissner.
Details of the enteric nervous
system are now described with brain peptides effecting GI transit
(motility), and this gives the concept ot the MINIBRAIN in the gut.
Many neuropeptides are involved: the Opioids, Bombesin, CRF,
Thyrotropin-releasing hormone (TRH), Somatostatin, Calcitonin,
Neurotensin and Substance P. Opium and opiates such as morphine have
been known since antiquity to inhibit gastro-intestinal transit.
Endogenous (naturally produced) opioid peptides like beta-Endorphin act
on gut motility, mainly inhibiting it. CRF is a critical mediator of
stress responses acting on the hypothalamus as described above. It has
been shown experimentally to inhibit transit in the small intestine
and to stimulate it in the colon. Biofeedback techniques can be helpful
in reducing stress, plus modulating neuropeptide activity, and thereby
regulating the motility of the gut, and altering patterns of motility.
The
CARDIO-VASCULAR SYSTEM.
CARDIO-VASCULAR REGULATION.
Adreno-cortico-trophic hormone (ACTH) has important effects on blood
pressure and sodium metabolism. Chronic treatment with ACTH can cause
hypertension and sodium retention. ACTH is primarily synthesized in
the anterior pituitary and its major role is the regulation of the
adrenal cortex, but its role within the CNS is unclear. (see below in
mood-regulation). Vasopressin can cause excitation of the sympathetic
system. Endogenous opioid peptides appear to confer protection against
the arrhythmias that arise during stress, (Verrier). Indeed, many
investigators have shown that these opioids play a role in modulating
the cardiovascular response to circulatory stressors, (Frantz and
Liang).
The IMMUNE SYSTEM.
IMMUNE FUNCTION. There is strong
evidence for a functional effect of opioids on the immune system.
Opioid peptides have an effect onreceptor sites of many subgroups of
leucocytes (white blood cells) including natural killers (NK) cells,
monocytes, macrophages, mast cells, lymphocytes and thymocytes which are
all involved in reactions to infections, and in auto-immune disease
processes, such as multiple sclerosis.
Natural killer (NK)
cells are thought to play an important role as tumor cell scavengers
and also in transplant rejection. NK cell activity has been shown in
humans to be enhanced by exercise (Brahmi et al.).
The COGNITIVE -
EMOTIONAL SYSTEM
Neuropeptides have effects which overlap several
systems and therefore repetition is inevitable when we review some of
the chemical control mechanisms of mood, behavior and reactions to
stressors.
The age-old drug from the poppy, opium, gives a
"pleasurable" or antidepressant effect. Substances produced in the body
which give"pleasure" are therefore called opioids. ENDOGENOUS OPIOID
PEPTIDES have been implicated as being either causative or curative
agents in a variety of mental disorders. Stress, opioid peptides
(endorphins) and cardiac arrhythymias are often inter-related, and this
aspect of the cardio-vascular system is well-known as suitable for
biofeedback treatment.
Stress stimulates the secretion of
corticopin-releasing- factor (CRF) from the hypothalamus. CRF is
carried down the pituitary stalk and stimulates secretion of ACTH and
beta-endorphin into the periphery. CRF produces activation of the
sympathetic nervous system resulting in secretion of epinephrine
(adrenaline) and nor-epinephrine from the adrenal medulla.
Leu-and
met-enkephalin are co-secreted along with epinephrine and
nor-epinephrine from the adrenal medulla into the bloodstream. Also,
inhibitory feedback pathways go from the pituitary to the adrenal and
cortisol in the blood stream can inhibit the hypothalamus as well as
ACTH and endophins in the pituitary.
ENDOCRINE
REGULATION for the prevention of stress and/or depression involves the
hypothalamic-pituitary-adrenal axis.
Corticotrophin-releasing
factor (CRF) is the hypothalamic releasing hormone that controls the
hypothalamic-pituitary-adrenal axis (HPA axis). Stress increases ACTH
and glucocortisol concentrations. Apparently the activation of the HPA
axis by stress is due to the release of several neuro-modulators
including CRF, Arginine, Vasopressin, Oxytocin, Angiotensin II,
Vasoactive intestinal peptide (VIP). Epinephrine, and Norepinephrine.
Corticotrophin-releasing
factor (CRF), however, is THE major regulator of ACTH.
Patients suffering from major depression, when not medicated, are as a
group hypercorticolemic (too much cortisol in the blood), and they may
therefore be chronically over (hyper) secreting CRF. The possible
mechanisms involving CRF and the pathogenesis of depression are numerous
and await detection. Biofeedfack as a treatment can help the symptom
by modifying the behavior.
4. THE BRAIN AS A SYSTEM OF
ADAPTATION
There is a plethora of data generated in the last decade
on the various physiological alterations that occur after exposure to
stressful stimuli. This shows how the brain functions for adaptation.
It is important for biofeedback professionals to have some understanding
of these alterations, because the technique of biofeedback teaches the
subject to modify his/her responses to stressors in order to maintain
psycho-physiological balance when battered by these stimuli.
The hypothalamic-pituitary-adrenal (HPA) axis has been the focus of
many investigations on the manifestations of the stress response ever
since Hans Selye described in 1936 the hypertrophy of the adrenal gland
and the atrophy of lymph glands in response to chronic stress. With
the discovery of corticotropin-releasing factor (CRF) by Vale and
co-workers in 1981, the hypothalamic component of this axis became
available for investigation.
The HPA axis is a multistep
integrated process involving several CNS sites (cerebral cortex,
amygdala, locus caeruleus, hippocampus, etc). In the hypothalamus these
signals are transduced to humoral-type messages, release and release-
inhibiting hormones. These travel a short distance to the anterior
pituitary where they are funneled into the general circulation and
travel to their appropriate target organs. The responses that these
signals engender have major influences on blood pressure, reproductive
function and energy mobilization. In addition the various neuroendocrine
axes are also influenced by a variety of feedback control loops. These
feedback controls can be of both a fast and a slow nature and involve
both central and peripheral sites (Ritchie and Nemeroff). In major
depression, corticotropin-releasing factor ( CRF) is most likely
hypersecreted (see above).
It is also possible that the precipitous
fall in CRF, in ACTH and in cortisol levels in maternal plasma at the
time of delivery leaves the HPA axis uncompensated, and postpartum
depression may develop because of sudden changes.
The locus
caeruleus is important in the process of adaptation to the environment
because it is rich in nor-epinephrine, (nor-adrenaline). The locus
caeruleus (literally the "blue spot") is so-called because of
melanin-pigment granules found in human infants and increasing with age.
It has a very rich blood supply enabling this nor-epinephrive to be
rapidly transported over the body. It is a microscopic nucleus in the
floor of the 4th ventricle in the upper pons, near structures that
regulate respiration with changes in the relative carbon dioxide and
oxygen content of the blood.
It is important to understand
something of the neuropeptide involvement in STRESS. Since stress is
the result of an individual's response to stressors, we can see that the
brain is the organ of adaptation, acting through its neuro-humoral
network. Neuropeptides are part of this network. They mediate the
regulation of the neuroendocrine and the autonomic responses to stress.
The neuropeptides identified in this network include :
(1)Corticotropin-releasing-factor (CRF); (2) thyrotropin-releasing
factor (TRF); (3) Bombesin and related peptides: and (4)
Somatostatin-related peptides. All 4 groups of these peptides effect
both the sympathetic and the parasympathetic systems. For example, CRF
increases the plasma concentration of glucose and glucagon, increases
cardiac output, heart rate and blood pressure, decreases kidney and
mesenteric blood flow, gastric motility and acid secretion, and inhibits
ovulation, (Brown). TRF and Somatostatin-related peptides have
cardiorespiratory, metabolic, gastrointestinal and pancreatic effects
demonstrated in animal experiments (Brown). "Bombesin acts within the
CNS to decrease regulatory heat production and oxygen consumption during
cold exposure" (Brown). Thus Bombesin slows an animal's metabolism.
The brain reacts in many ways to drinking behavior, drinking bouts
and signals that initiate or terminate drinking. For example,
Angiotensin II is a neuropeptide with three physiological mechanisms
appropriate to a response to water loss. (a) vasoconstriction (b)
increased release of aldosterone and (c) increased release of
antidiuretic hormone.
5. MOOD RELATED TO
PATHO-PHYSIOLOGY
Dr. Eliot Stellar, a physiological
psychologist, author of the well-known books "Physiological Psychology"
in 1950 and "The Neurobiology of Motivation and Reward" in 1985,
illuminated the interdependence of psychology and physiology. This
interdependence may seem self-evident but must be understood in
detail.
Mood and emotional reactions are sensitively related to
our physiological well-being or our pathological ill-state. Everyone is
aware that sleep and food intake effect mood. Thus a sleep deprived
person is "grumpy", irritable and lacks judgement. People are less
aware that sleep deprivation can cause seizures; that over-activity
(hyperfunction) of the thyroid gland can lead to thyrotoxic emotional
lability; and that under-activity (hypo-function) of the thyroid gland
(myxedema) can lead to "myxedema madness". With an insulin tumor, a
patient may develop bursts of irrational behavior. A phaeochromocytoma
is a tumor of certain cells of the adrenal medulla. The tumors secrete
an excess of adrenaline and noradrenaline but because the output may be
continuous or paroxysmal, the clinical features vary greatly. Apart
from hypertension, anxiety and fear can be severe in attacks, (Lishman,
1987). Depression is frequent after influenza and other viral
infections. Episodes of abnormal behavior may occur in patients with
epilepsy, unrelated in time to a seizure.
Other evidence of
mood related to pathology includes depression in Parkinson's disease,
the on-off drug effects in the treatment of Parkinson's disease;
chemical imbalance in manic-depression; pre-menstrual syndrome;
depression in cerebral arteriosclerosis; drug-related mood changes;
hallucinatory drugs; oxygen lack causes loss of judgement; sensory
deprivation illusions; vitamin deficiences cause lack of energy; and
toxic disorders like lead poisoning are associated with low IQ.
Changes in personality are frequently observed due to cerebral tumors
(mainly frontal), to head injury, to cerebrovascular disorders, to
senile dementia, and to presenile dementia (Alzheimer's disease). All
these disorders show that disfunction in any organ, including the
brain, changes mood, emotions and behavior.
For many people,
mood is associated with the "mind". However they can understand that
the brain is as much part of the body as all the other organs, such as
heart, lungs, thyroid. They can see that disfunction of any of these
organs can cause psychological disfunction. Because the brain regulates
the other organs through feedback mechanisms, it is pivotal in
psychology. The "mind"is a concept and from the physiological point of
view its workings are those of the brain.
Biofeedback treatment
is directed to the brain mechanisms that control all our physiological
functions. When this biofeedback treatment is inappropriate for
patients because of their significant cognitive deterioration,
biofeedback may be offered to their relatives suffering from
reactive anxiety and distress.
6. THE BRAIN
CONTROLS ACTIVITY.
Charles SHERRINGTON, the founder of modern
motor physiology, wrote that : "To move is all mankind can do and for
such, the sole executant is muscle, whether in whispering a syllable or
in felling a forest".
Here the CNS operates through the
peripheral nervous system. "Spinal interneurons constitute an important
set of networks for processing both peripheral inputs and commands
descending from higher brain centers" (Sherrington)
Both too
little (hypo) and too much (hyper) activity can be pathological.
HYPOACTIVITY is one of the hallmarks of clinical depression. The
patho-physiology of depression is described in detail in the
book:"Neuropeptides and Psychiatric disorders" edited by Charles B.
Nemeroff.
Inability to "get going" can be pathologically
based as in Parkinson's disease where patients have great difficulty in
initiating a movement, for example walking; here the dopamine metabolism
is disturbed. Many patients with Parkinsonism suffer from depression
because their musculature does not respond to their desires; actual
slowing of thinking processes may also be involved. On the other hand
inability to "get going" may be psychologically based through lack of
motivation or sensory deprivation on a socio-economic background.
HYPERACTIVITY with its corollary of defective attention in childhood is
in many cases a contemporary phenomenon caused by excessive
television-watching, an environment of "sound-bites" and methods of
education.
Hyperactivity associated with various forms of
neurological retardation is associated with lack of neuronal inhibition
and poor control of responses.
The LIMBIC CHILDREN is a concept
(Fischer-Williams ) that arose from the clinical observation of certain
patients with "retardation"on an organic neurological basis. These
subjects, children and young adults, have frequent mood changes with
outbursts of uncontrolled activity, disturbed behavior and abnormal
"drives". The limbic system regulates emotions and the activities of the
frontal cerebral cortex through many anatomo-physiological pathways.
When there is a lack of feedback control from the limbic system to the
frontal cortex (where judgement is formed and social activity is
analysed), these subjects show inappropriate hyperactivity. A more
correct term would be "a-limbic children" because the condition
indicates that the limbic structures never developed their functions or
were lost through early disease. Information on the neuropeptides
operating in the limbic system (particularly of the amygdala which are
part of the limbic system) is now detailed.
THE BRAIN NEEDS
FEEDING WITH BLOOD. Clearly, brain function depends on a healthy supply
of blood. This subject, however, will not be discussed in this
chapter. except to say that the heart can be likened to a pump, the
blood vessels to a garden hose, and the brain to a garden.
7. STIMULUS - RESPONSE MECHANISMS
In biofeedback, there is a
primary concern with two mechanisms: first, when the subject or patient
becomes continuously aware of the stimulus of certain physiological
activities, such as muscle tone or heart rate, and second when the
subject has incentives or rewards for changing or controlling the
feedback and therefore learns to control voluntarily the physiological
response associated with the feedback. The continuous information fed
back to the subject brings to consciouness something which has not
previously been registered at a conscious level. Consequently
information travels a different neuronal pathway.
It
is therefore important to understand the principle of divergence and
convergence of information, and some of the complex neuronal systems
that can modify or modulate behavior. For example a great deal of
information arrives (converges) at the retinal nerve cells. This
information is compacted (reduced) and then passed down the visual
pathways. At the occipital cortex it is received by cells with very
specialized functions, so that the information is sorted out (teased
out) and diverges to individual groups of cells. However the brain has
learned to converge vision and the "normal" individual sees one picture.
Psycho-physiological techniques can teach an individual to separate or
to converge sensations.
The "expectancy " wave of
Grey Walter. Another phenomenon may be relevant in this context. When
two stimuli are associated and the subject is instructed to terminate
the second one by pressing a button, a low voltage "intention" or
"expectancy " wave develops and can be recorded in normal subjects with
DC recording on the scalp. It is termed the negative contingent wave
(Walter), and this electrical cortical event is important because it
comes just before action. Grey Walter once suggested that a disturbance
of this "intention" wave was related to the indecision sometimes seen
in "neurotic" patients. It might be related to the "jitters" described
in some golf players just before the action of putting.
Other phenomena may exist similar to those seen in patients with "split
brains", where the two hemispheres have been disconnected after section
of the corpus callosum and the anterior commissure in the treatment of
intractable epilepsy. Division (separation) of information has been
demonstrated in regard to perception, cognition, volition, learning and
memory (Sperry). These phenomena allow one to speculate that during
biofeedback training, new linkage pathways may be established between
perception of the monitor measurements fed back and the unconcious
physical changes in whatever modality is being monitored at the time.
The patient's body makes physical changes in by-passing the ordinary
sequence of volitional motor activity, just as motor skills are acquired
by constant repetition.
8.Biofeedback as a treatment modality
in Neuropsychiatry
Neuropsychiatry is based on the "delicate
balance between our knowledge and understanding of the brain and our
knowledge and understanding of people", (Lishman). As a
neuropsychiatrist, Dr. Lishman wrote: "I tend to see patients with brain
disease- - - and the decision we must often try to make is on whether
the problems we see in the clinic are "organic" or "functional"--- more
precisely whether they derive from a primary brain malfunction or from
difficulties the patients are encountering in their lives," (Lishman).
He wisely comments that "we must sidestep the risk of becoming too far
seduced by one or other pole of this dual requirement". "Brain
biochemistry - - with increasing relevance to emotional and behavioral
disorder" (Lishman), pharmacotherapy, psycho-pharmacology, imaging of
many areas in the brain including the limbic system during cognitive
activities, all open up exciting vistas for health therapists to
explore.
For example, Lishman quoted Weinberger: "We can visualize
the increased blood flow to frontal regions when a normal subject
engages in a category sorting task and show that equivalent dynamic
shifts are defective in the schizophrenic brain". (Weinberger et al.)
We can ask other questions: is there a neurologic cause for
obsessive-compulsive disorder? (Insel). How much is pre-menstrual
tension a neurochemical dysfunction, and how much is it a psychological
reaction to feedback mechanisms in normal cyclical events? Similar
questions arise with sleep disorders when observed with the
electroencephalogram (EEG) in the study of wake-sleep behavioral
mechanisms.
9. Biofeedback as a treatment
modality in RESTORATIVE NEUROLOGY.
Biofeedback treatment is
useful as an adjunct in the therapy of neurological disorders.
Criteria for sucessful treatment include basic knowledge of brain
function, and honest motivation of both patient and therapist with
reasonable self-knowledge. Expectations both of the patients and the
therapist must be realistic.
The sad consequences of not keeping this
in mind are described in the book: The Bitter Pill: Doctors,
Patients and Failed Expectations, by Martin R. Lipp. They can
often be avoided by close co-ordination with other treatment modalities
and on-going co-operation with specialists in other fields.
Biofeedback is a technique to help reconnect the feedback systems. We
can"listen to our thalamus" (part of the limbic system, sometimes
designated as the emotional brain), we can use our dreams, our
sensations, whatever messages come from our "unconscious". Add to
this, we can "use our brain", meaning we can use our cerebral cortex to
analyse our 10 emotions. This control of thought and action (cognitive
and behavioral activities) can lead to synthesis and the acceptance of
paradox.
Biofeedback can play an interventory role at many
levels within the nervous system. It can facilitate re-inhibition,
activation, re-balancing , stabilization or re-assignment of function.
Once a patient is properly evaluated neurologically, biofeedback can be
an adjunct or primary treatment of neurological disorders. The criteria
for the use of biofeedback is discussed in A Textbook of
Biological Feedback (Fischer-Williams, Nigl and Sovine) and in many
chapters of this book. For cost-effective results, the expectations of
both the patient and the therapist must be realistic. For long-lasting
results, biofeedback effectiveness is often enhanced when co-ordinated
with other modalities (Fischer-Williams, 1993).
For a better future,
we trust that there will be expansion of methods of preventive
medicine. This, however, depends on the health of therapists and the
imaginative education of the public.
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Authors Bio:Dr. Fischer-Williams received her M.D. in Edinburgh, Scotland, and practiced Neurology in Oxford England, and at the London Hospital, London, England. She was Assistant Professor of Neurology at Wayne State Univ., Detroit, MI; Research Associate and on the teaching faculty at the Mayo Clinic, Rochester, MI; Consultant Neurologist at Marshfield Clinic; and practed neurology in Milwaukee Wisconsin and Director of the Department of Clinical Neurophysiology and Biofeedback at Trinity Memorial Hospital, Cudahy, Wisconsin. She is a Pst-President of both the Central Association of Electroencephalographers and the Biofeedback SOciety of Wisconsin.