BIOFEEDBACK Overview in Psychiatry Today

Biofeedback

1. BIOFEEDBACK Presenter: Dr.S.Chandana , Junior Resident. Chairperson: Dr.D.Vijaya lakshmi , Assistant Professor, Government Hospital for Mental Care .

2. Scheme of Presentation: Introduction Instrumentation Mechanism Applications of biofeedback Psychiatric Implications References

3. Definition: Provision of information to a person regarding one or more physiological processes in an effort to enable the person to gain some element of voluntary control over bodily functions that normally operate outside consciousness is known as Biofeedback Biofeedback is a process that enables an individual to learn how to change physiological activity for the purpose of improving health and performance

4. Leading Professional Organizations Association for Applied Psychophysiology and Biofeedback(AAPB) Biofeedback Certification International Alliance(BCIA) International Society for Neurofeedback and Research(ISNR)

5. Neal Miller(1969) published his pioneering paper “learning of visceral and glandular responses” in which he reported that ,in animals ,various visceral responses regulated by autonomic nervous system could be modified through operant conditioning carried out in laboratory This led to humans being able to learn to control involuntary physiological responses By means of instruments ,patients acquire information about the status of involuntary biological functions and learn to regulate them through biofeedback

6. Involuntary biological functions include blood pressure heart rate skin temperature electrical conductivity Muscle tension Brain wave activity

7. Instrumentation:

8. The feedback instrument used depends on the patient and the specific problem Patients are attached to one of the instruments that measures the physiological function and small changes in the physiological levels of the feedback parameter are recorded and displayed The display can be visual such as big meter or a bar of lights or auditory Patients are instructed to use the feedback from the display as a guide to change the levels of the parameter

9. HOW BIOFEEDBACK WORKS Biofeedback is an instrumental conditioning procedure According to this view , feedback information rewards the learners for specific physiological responses. Other alternative explanations have been proposed by Raczynski et al,1982. Biofeedback teaches people skills in generalized relaxation which lowers overall sympathetic nervous system activity which inturn moves many physiological processes away from overactivity

10. 2.Meichenbaum proposed that biofeedback effects are mediated by Cognitions where people learn to control internal processes by using self-statements or specific mental images which in-turn trigger specific physiological reactions. e.g. One headache victim learned to control her temporal artery blood flow and stop her headache by picturing “a cameo lady from a soap advertisement” in her mind.

11. Biofeedback Applications: CONDITION METHOD OF FEEDBACK EFFECT Asthma Frontal EMG Airway Resistance biofeedback Relaxation from the panic associated with asthma Improvement of airflow rate Cardiac arrhythmias ECG biofeedback To lower the frequency of PVC Fecal incontinence Triple lumen rectal catheters in reestablishing normal bowel habits Grand mal epilepsy EEG Biofeedback Used experimentally to suppress seizure activity prophylactically in patients not responsive to anticonvulsant

12. CONDITION METHOD OF FEEDBACK EFFECT Migraine Thermal biofeedback from a digit accompanied by self suggestive phrases encouraging hand warming and head cooling Helps in preventing excess cerebral artery vasoconstriction Myofacial and TMJ pain EMG biofeedback Reduction of pain Tension headache EMG biofeedback Patient learns to relax the muscle Raynaud’s syndrome Thermal feedback To improve the temperature of hands and feet Idiopathic Hypertension and Orthostatic Hypotension Blood pressure feedback Galvanic skin response Foot-hand thermal feedback Decrease and increase of Blood pressure

13. Resperate is approved by U.S.FDA for reducing stress and lowering Blood pressure It is a portable electronic device that promotes slow, deep breathing It is intended to be used at least 15 minutes a day,3-4 days in a week Within a few weeks ,the device guided slow breathing exercises can help to lower both the systolic and diastolic BP. AHA says slow breathing is an effective add-on treatment for people with high Blood pressure

14. Other conditions include Vulvodynia Urinary incontinence Phantom limb pain Bruxism Constipation Chronic pain Fibromyalgia Cognitive Rehabilitation of Traumatic brain injury patient To improve athletic performance

15. Biofeedback in Psychiatric conditions Generalized anxiety disorder OCD Stress Insomnia Unipolar Depression ADHD Learning disorders

16. ADVANTAGES: Non-invasive It might enhance the benefits of medication DISADVANTAGES: Time consuming,takes months to show desired improvement Expensive

17. Neurofeedback A form of biofeedback using brain scanning devices to provide feedback about brain activity in an effort to modify behavior Through operant conditioning At first changes are short lived By reconditioning and retraining the brain with continuing feedback , coaching and practice ,healthier brainwave patterns can usually be retrained in most people

18. Each session lasts for 20-25 minutes once equipment is attached Number of sessions vary 15-20 sessions for anxiety or insomnia For ADHD or learning disabilities,30-50 sessions

19. EEG Frequency Bands Delta Theta Alpha Low beta beta High beta gamma 1-4 hz 4-8 hz 8-12 hz 12-15 hz 15-20 hz 20-35 hz 35-40 hz

20. Specialized types of Neurofeedback

21. Frequency/Power Neurofeedback This technique typically includes the use of 2 to 4 surface electrodes Also known as Surface Neurofeedback Most frequently used neurofeedback techniques It is used to change the amplitude or frequency of specific brain waves in particular brain locations

22. Slow Cortical Potentials Training These are the positive or negative polarizations of the EEG in the very slow frequency range 0.3Hz to 1.5Hz They maybe thought of as the direct current baseline on which the alternating current EEG activity rides There is generally a negative shift in direct current potentials that occur during cognitive processing and positive slow cortical potentials occur during inhibition of cortical networks

23. The Low Energy Neurofeedback System(LENS) Passive form of neurofeedback Produces its effects through feedback that involves a very tiny electromagnetic field which only has a field strength of 10 watts/cm It is delivered in 1 second intervals down the electrode wires The feedback is adjusted 16 times a second to remain certain number of cycles faster than dominant brainwave frequency

24. Advantages of LENS: It seems to produce results faster than traditional neurofeedback Can be used with very young children Can be used in individuals with poor motivation

25. Homoencephalography Two approaches-near infrared and passive infrared These are indirect measures of neural activity based on neurovascular coupling On the completion of the process patients learn to increase cerebral blood flow to a specified region of brain which helps in increasing the brain activity and performance on tasks involving specific regions of the brain

26. Z Score Neurofeedback Training It utilizes two , four or entire 19 electrodes Continuous calculations are being computed comparing the way that the brain is functioning on different variables(e.g. power, asymmetries, phase-lag, coherence) to a scientifically developed normative database Feedback is then based on these moment to moment statistical comparisons to norms for the patients approximate age group.

27. 10-20 system of electrode placement:

28. Neurometric brain mapping is a specialized QEEG approach that compares EEG characteristics of the individual being evaluated with normative database for same age It helps in clarifying functional brain correlates for cognitive impairment and yields info that is useful for planning EEG Biofeedback protocols addressing specific kinds of dysfunction

29. LORETA Neurofeedback training LORETA refers to low resolution electromagnetic tomography This is a kind of QEEG analysis that provides an estimation of the location of patients EEG activity within a frequency band

30. fMRI-Neurofeedback It is a rather recent development for providing feedback training based on blood oxygen concentration technique(BOLD) It overcomes some limitations of more traditional forms of neuro-feedback because of its better spatial resolution and can examine functioning at deep subcortical areas of brain. A promising technique for non-invasive psychiatric rehabilitation because it allows patients in self regulating the activity of relevant brain areas

31. Disadvantages of fMRI- Neurofeedback Incredibly expensive Cost of equipment is high as well as extreme expenses associated with day-to-day operation of such equipment

32. Relaxation therapy Muscle relaxation is used as a component of treatment programs (e.g., systematic desensitization) or as a treatment in its own right (relaxation therapy). Relaxation involves (1) immobility of the body, (2) control over the focus of attention, (3) low muscle tone, and (4) cultivation of a specific frame of mind, described as contemplative, nonjudgmental, detached or mindful

33. Psychiatric implications: HRV Biofeedback is a highly promising intervention for reducing anxiety and stress It can be tried as an adjunct intervention in combination with other emperically supported treatments(CBT) This intervention is becoming increasingly more attractive as a treatment aid with rapid improvements and affordability of wearable devices(fitness trackers and smart watches)

34. Neurofeedback has gained interest as a non pharmacological management option for individuals suffering from OCD. EEG studies in patients with OCD reported a widespread increase of slow waves with additional report of epileptiform activities over left temporal lobe Q-EEG studies more often involved anterior regions of scalp supporting hypothesis of frontal dysfunction in the pathogenesis of OCD Cingulate gyrus in particular has been implicated as a locus of dysfunction in Q-EEG studies

35. QEEG studies in psychiatric disorders Unipolar Depression Increase in alpha or theta power Generalised Anxiety Disorder Decrease in alpha OCD Increase in theta Panic attacks Paroxysmal activity

36. QEEG-guided biofeedback with ADHD and persons with learning disability focussed on increasing the amount of low beta microvolt activity and decreasing the amount of high beta & theta microvolt activity across the sensorimotor strip

37. Selecting a Qualified Practitioner Biofeedback training should be done under the supervision of a qualified and certified professional who will individualize the training. A “one-size-fits-all” approach that is not tailored to the individual will undoubtedly pose a greater risk of being ineffective and at times may be even detrimental

38. References: Introduction to Psychology by Morgan and king-Seventh edition Kaplan and Sadock’s Synopsis of Psychiatry-Eleventh edition Kaplan and Sadock’s Comprehensive Textbook of Psychiatry-Tenth edition Len Ochs PhD (2006) The Low Energy Neurofeedback System (LENS): Theory, Background, and Introduction, Journal of Neurotherapy: Investigations in Neuromodulation, Neurofeedback and Applied Neuroscience, 10:2- 3, 5-39 D. Corydon Hammond (2011): What is Neurofeedback: An Update, Journal of Neurotherapy: Investigations in Neuromodulation, Neurofeedback and Applied Neuroscience, 15:4, 305-336.

39. Marzbani , H., Marateb , H. R., & Mansourian , M. (2016). Neurofeedback: a comprehensive review on system design, methodology and clinical applications. Basic and Clinical Neuroscience, 7(2), 143-158. Strehl , Ute(2009) 'Slow Cortical Potentials Neurofeedback', Journal of Neurotherapy, 13: 2, 117 — 126

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