Certain intense negative experiences may change the body's chemistry, increasing the stress hormone released from the adrenal cortex of the kidneys. This chemical, cortisol, is a healthy response to stress, though with chronic or overly intense stressors, the cortisol has deleterious effects on the brain, specifically attacking a temporal lobe structure, the hippocampus, which has immune receptors. This structure has important non-immune system functions as a memory comparator, required for both comprehension and recall. The implication for this latter process where stress deteriorates the brain's ability to comprehend and recall has large implications for education. A person with a stressful existence may never reach his or her true potential due to the damaging effects of the stress hormones. If the stress was experienced during pregnancy from the mother's hormonal balance, the newborn will have a disproportionately intense reaction to stress, causing inordinately large amounts of strain (and thus more cortisol) and ultimately more extensive deterioration of the brain's capacity.
The ability to teach a new response to the situational stressors can change the life course for these individuals, creating a much more favorable outcome. The operant conditioning technique, Neurotherapy, mentioned earlier is one such method of intervention. Similarly to the stress response, there is a relaxation response, which can be trained to counteract these deleterious effects.
The brain's electrical patterns are a form of behavior, which is subject to behavior modification through "operant conditioning, a fact discovered in research done in the late 1960s by Dr Barry Sterman, now a professor emeritus at UCLA. The operant conditioning of the EEG was first demonstrated in cats, where placebo effects are assumed to be absent. Sterman's original work with animals was replicated in humans starting in the 1970s (Sterman, 2000).
Recording and analysis of EEG has been shown to yield reliable results (Fein, Galin, Yingling, Johnstone, & Nelson, 1984). Further, those studies done with control groups have shown the neurotherapy technique to be a robust and valid intervention. Many more studies are of a case series variety, without control groups. Though this latter category is not held in high regard, perhaps this is changing. A recent issue of the New England Journal of Medicine reviews of research design have cast doubt on the need for placebo-controlled designs. Their review has shown that when there is a preponderance of case series reports, the concordance between those results and those of the "gold standard (double blind placebo-controlled studies) was very high. Many in the field are now arguing against doing a double blind study due to the lack of proper humane treatment of those in the control group (receiving no treatment), an approach which is also now considered unethical by the World Health Organization when known treatments exist. Interestingly, recent work with placebo effect has elucidated brain mechanisms underlying placebo response that were different than those mediating medication response (Leuchter, Cook, Morgan, Witte, & Abrams, 2002).
With the neurotherapy approach, the brain frequencies that are in excess are reduced, and those with a deficit are increased. The technique uses the EEG, amplified from the minute voltages and hooked up with special instruments to control a computer game. The person's EEG is the "joystick they use to operate the game. Over a series of sessions the person learns to use the EEG to control the game. The clinician slowly adjusts criteria for reward presented to the individual, and thereby "shapes the behavior of the participant's brain into a more normal pattern.
The neurotherapy technique requires time to learn, and varies depending on the initial condition the individual starts with. In general, the more severe the starting condition, the more learning has to occur to correct the state. Simple relaxation may take as few as 10 sessions to learn; although with more severe cases, a longer training course may be needed, such as with generalized anxiety disorder, or panic attacks. The important point is that the learning is internalized so that the benefit of the training persists, and does not require on-going training. This is unlike the use of medications where symptoms typically reappear after discontinuing medication.
The learning curve for EEG has been described in research done at Langley Porter Neuropsychiatric Institute, at the University of California, San Francisco. The research showed that the curve is a fifth-order curve, which contains an initial increase, followed by a dip, a second increase, followed by the exponential increase at the end of the training (Hardt, 1975). This corresponds to the subjective states reported in some individuals. They are initially presented in a slightly anxious state, which gets better when they habituate to the training situation, corresponding to the initial increase in the curve. The individuals then report that they "try hard to relax, a counterproductive attempt, which corresponds to the dip. They give up trying hard (active volitional attempts), corresponding to the second increase, which is then followed by the learning of the passive volitional state, which is the final exponential increase.
In some cases, the individuals may need more peripheral forms of
biofeedback-based intervention, such as muscle relaxation or training
of temperature or the electrodermal responses. These will depend upon
whether their individual response profile shows their stress in these
areas as well. The peripheral training often requires less training
time, though the source of the difficulty is universally central, as
these modalities are all under the control of the central nervous
system. Training peripherally may be all that is required in more mild
cases, but in many individuals, the central training is the only method
that will have a persistent result. In our clinical experience with
these more severe cases there may be symptom substitution without the
central intervention. In cases with mild stress, the peripheral
intervention is often a complete intervention, though when additional
complaints such as attentional problems, depression, or hyperactivity
are noted, the central intervention is usually the first choice, to
minimize the total number of sessions, by getting directly to the
common source
of the problem.
Prior to starting work with an individual, and in order to design an appropriate operant conditioning intervention, their existent brain function must be known. Optimally, this would entail a full recording of their EEG, with quantitative analysis and comparison of the individual's brain activity to an age matched database. These databases are commercially available from a number of sources, and are described in a recent Journal of Neurotherapy special edition (Vol. 7, No. 3 and 4, 2003). Following such a comparison, areas that deviate from normal may be identified, as well as the direction of the deviation from normal. This shows whether an excess or a deficit of any frequency pattern exists, as well as the location of the deviation. Specific individualized patterns of results are used to guide intervention with neurotherapy.
Following this evaluation, an appropriately customized operant training may be designed which optimizes the training time by focusing on the areas of deviation. The training will take time, with 30 to 40 sessions being quite common before a permanent result is established, and even more are required for more severe or complex cases such as Asperger's/Autism (Thompson & Thompson, 2003). There are commonly reported behavioral changes long before this end point of training is reached, with the early signs of change showing themselves at 5 "10 sessions for most individuals, though some have strong changes even after their initial session. It is also common for an individual to not notice the change, as they are occasionally not self-aware, though the changes are easily seen in objective testing and reported by those observing the individual's behavior.
Commonly reported success rates of 60 to 80% are seen in the scientific literature, with up to 90% reported in qEEG based intervention (Wright and Gunkelman, 1998). Using strict criteria (total remission of complaint) the percentage range from 50 to 60%, with those reporting positive results, though with less stringent measurements of success, such as "feeling like you got a positive benefit, ranging in the 80 to 90% rate.
Many therapists are not aware of neurofeedback as an application of operant conditioning, being familiar with more easily observable behavioral operant training than the operant training of "internal states. The neurofeedback literature is most well accepted in the area of operant training of EEG in epilepsy. Well-controlled studies show that the technique can assist in cases where medication alone was shown to be inadequate at controlling the electrical discharges associated with the epilepsy. A review of this application is published in a special edition of Clinical EEG, in the January 2000 issue (Sterman, 2000). Neurotherapy using slow cortical potentials also shows promise in the treatment of epilepsy (see, Kotchoubey et al., 2001; Birbaumer et al.,1981).
Since the EEG in epileptics can be taught to stop the abnormal discharges, leading to the elimination of the behavioral manifestations of the epilepsy, the neurotherapy technique has also been applied in less severe neurological disorders such as ADD/ADHD (Monastra et al., 2002) depression (Rosenfeld, 1997), anxiety (Vanathy et al., 1998), and fibromyalgia (Donaldson, 2002). Budzynski (2000) used neurofeedback to reverse cognitive decline in an elderly population (see also the work of Klimesch et al. for studies of EEG related to memory performance). For recent reviews of neurobehavioral disorders noted to respond to this emerging technologically based operant training technique see Yucha and Gilbert (2004), and Nelson, (2003).
There are two international professional organizations dedicated to the study of this technology and these applications: the Association of Applied Psychophysiology and Biofeedback (AAPB), and the International Society for Neuronal Regulation (ISNR). Both of these societies have annual conferences and often sponsor additional regional workshops. There are also many state and regional organizations, often affiliated with one of these international organizations. ISNR also has international chapters in other countries. Both organizations have web sites (www.aapb.org and www.isnr.org), and both sponsor a professionally published journal with material focused on Neurofeedback: The Journal of Neurotherapy (ISNR), and Applied Psychophysiology and Biofeedback (AAPB).
REFERENCES
Birbaumer, N., Elbert, T., Rockstroh, B., et al. (1981). Biofeedback
of event-related slow potentials of the brain. International Journal of Psychology, 16, 389 "415.
Budzynski, T. H. (2000). Reversing age-related cognitive decline:
Use of neurofeedback and audio-visual stimulation. Biofeedback, 28, 19 "21.
Chabot, R. J., & Serfontein, G. (1996). Biological Psychiatry, 40,
951 "963. Sensitivity and specificity of QEEG in children with attention
deficit or specific developmental learning disorders. Clinical EEG,
27, 26 "34.
Cook, I. A., O'Hara, R., Uijtdehaage, S. H., Mandelkern, M., &
Leuchter, A. F. (1998). Assessing the accuracy of topographic EEG
mapping for determining local brain function. Electroencephalography
and Clinical Neurophysiology, 107(6), 408 "414.
Donaldson, S. (2002). Society for Neuronal Regulation Annual Meeting, Scottsdale, AZ.
Fein, G., Galin, D., Yingling, C. D., Johnstone, J., & Nelson, M. A.
(1984). EEG spectra in 9 "13-year-old boys are stable over 1 "3
years. Electroencephalography and Clinical Neurophysiology,
58(6), 517 "518.
Gurnee, R. L. (2000). EEG Based Subtypes of Anxiety (GAD)
and Treatment Implications Society for Neuronal Regulation
Annual Meeting.
Hardt, J. V. (1975). The ups and downs of learning alpha feedback.
Proceedings, Biofeedback Research Society, Vol. 6,Monterey,
California, February.
Klimesch, W. (1999). EEG alpha and theta oscillations reflect
cognitive and memory performance: A review and analysis.
Brain Research and Brain Research Review, 29(2 "3), 169 "195.
Kotchoubey, B., Strehl, U., Uhlmann, C., Holzapfel, S., Konig,
M., Froscher, W., Blankenhorn, V., & Birbaumer, N. (2001).
Modification of slow cortical potentials in patients with refractory
epilepsy: A controlled outcome study. Epilepsia, 42(3),
406 "416.
Leuchter, A. F., Cook, I. A., Morgan, M. L., Witte, E. A., &
Abrams, M. (2002). Changes in brain function of depressed
subjects during treatment with placebo. American Journal of
Psychiatry, 159(1), 122 "129.
Monastra, V. J., Monastra, D.M., & George, S. (2002). The effects
of stimulant therapy, EEG biofeedback, and parenting style
on the primary symptoms of attention-deficit/hyperactivity
disorder. Applied Psychophysiology and Biofeedback, 27(4),
231 "249.
Nelson, L. A. (2003). Neurotherapy and the challenge of empirical
support: A call for a neurotherapy practice research network.
Journal of Neurotherapy, 7(2), 53 "67.
Niedermeyer, E., & Lopes Da Silva, F. (Eds). (1999). Electroencephalography:
Basic Principles, Clinical Applications, and
Related Fields (4th ed.). Baltimore: Lippincott, Williams &
Wilkins.
Prichep, L. S., & John, E. R. (1992). QEEG profiles of psychiatric
disorders. Brain Topography, 4(4), 249 "257.
Prichep, L. S., Mas, F., Hollander, E., Liebowitz, M., John,
E. R., Almas, M., DeCaria, C. M., & Levine, R. H. (1993).
Quantitative electroencephalographic subtyping of obsessivecompulsive
disorder. Psychiatry Research, 50(1), 25 "32.
Rosenfeld, J. P. (1997). EEG biofeedback of frontal alpha asymmetry
in affective disorders. Biofeedback, 25(1), 8 "25.
Sterman, M. B. (2000). Basic concepts and clinical findings in the
treatment of seizure disorders with EEG operant conditioning.
Clinical Electroencephalography, 31(1), 45 "55.
Suffin, S. C., & Emory, W. H. (1995). Neurometric subgroups in
attentional and affective disorders and their association with
pharmacotherapeutic outcome. Clinical Electroencephalography,
26, 76 "83.
Vanathy, S., Sharma, P. S. V. N., & Kumar, K. B. (1998). The efficacy
of alpha and theta neurofeedback training in treatment
of generalized anxiety disorder. Indian Journal of Clinical
Psychology, 25(2), 136 "143.
Wright, C., & Gunkelman, J. (1998). QEEG evaluation doubles
the rate of clinical success. Series data and case studies.
Abstracts 6th Annual Conference, Society for the Study of
Neuronal Regulation, September 10 "13, Austin, TX.
Yucha, C., & Gilbert, C. (2004). Evidence-based practice in
biofeedback and neurofeedback. Association of Applied Psychophysiology
and Biofeedback (http://www.aapb.org), 2004.
1Q-Metrx, Inc., Burbank, CA.
2Department of Psychology, University of California, Los
Angeles, CA.
3To whom correspondence should be addressed at Q-Metrx, Inc.,Burbank, CA
