Volume 3, Issue 21, June 9, 2005

An Apology…

Author: Dr. Siegfried Othmer

A couple of weeks ago, in the article “What does Psychology have to do with it?” I mentioned a new research program getting launched at Misericordia Hospital on ADHD. I had welcomed the study earlier as a beneficial fallout of our having taught our course there in September 2001.

I had a number of facts wrong in that little vignette which need correction.
First of all, the hospital did pay for the pediatricians to attend the course, and they did all come at their own initiative, i.e. because of their own interest in neurofeedback.
The hospital is sponsoring the study on ADHD, and the Principal Investigator did attend our course. Further, the psychologist who motivated our doing the course there in the first place is also involved in the research, but he did not wish to serve in the role of Principal Investigator.

More importantly, I am told that the Principal Investigator did not express herself to the effect that she favored the stimulant medication approach to ADHD over neurofeedback. It was suggested to us that that quotation might well have come from one of the pediatricians in the community at large, or even elsewhere in Canada, when the press first featured this study and obtained feedback from other physicians.

Indeed, the press was somewhat less than neutral on the matter. The CBC piece on April 22nd (http://www.cbc.ca/story/science/national/2005/04/22/ADHD-therapy050422.html) started out with:

EDMONTON - Children in Edmonton with Attention Deficit Hyperactivity Disorder are testing a controversial treatment that aims to improve their concentration.

Although many doctors consider the technique to be a waste of time and money, some researchers say it may be worth exploring.

And later in the piece we find:
Yet few Canadian children have access to biofeedback, because it is expensive, time-consuming and considered unproven. Treatment at a private clinic can cost several thousand dollars, paid directly out of parents' pockets.
The money is not well spent, according to Dr. Wendy Roberts, a specialist in ADHD at Toronto's Hospital for Sick Children. Roberts said she is not convinced that using biofeedback to teach a child strategies to focus their attention and fill in gaps in learning will help them pick up skills. Paying for tutors and counseling is better, she believes.

On top of everything else, my remarks apparently stirred up controversy in Edmonton, empowering those who think none too highly about this study in the first place, worrying other agencies who had contributed funds to the study, and not making it any easier to recruit kids for the study. For this I am of course truly sorry. A valid study should certainly go forward, and such initiative by an organization that is not in the food chain for research funds is to be welcomed.

How, then, did things come to such a place? Everything I said in the story had a single source, it turns out (though not all the same source), and I was simply not sufficiently skeptical all along to check things out. At least I am in the best of company now, with Newsweek and CBS, but that is small consolation. There is something else at work, however, and that bears more discussion.

When I was told at the Cleveland class by an attendee of the apparent motivation of the study (implicitly supporting the mainstream remedy of stimulant medication), I did not think to question this. It had immediate credibility with me because of our prior experience in this field. Matters were somewhat similar perhaps to Islamist militants hearing about the report of desecration of the Qu’ran. They weren’t inclined to wait around for confirmation. The Newsweek story was in line with earlier reports after all, so that was good enough for them.

I recall a conversation some years back with Alan Strohmayer in which he sought funding for a Tourette study using neurofeedback. He couched the proposal in terms that were largely negative, saying that neurofeedback was being offered variously for remediation of Tourette symptoms, and that it was a matter of “noblesse oblige” to show through rigorous study that neurofeedback had nothing to offer beyond an expensive placebo…. He got funded. He is persuaded that if he had shown the slightest indication in favor of neurofeedback in his proposal, as for example the suggestion that it might actually work, he would not have gotten funded. Of course we are not asking anyone to put his or her thumb on the scale.

More Parallel Universes

We’ve been looking into Deep Brain Stimulation (DBS) for Parkinson’s at the office, for the purposes of a proposal for neurofeedback for Parkinson’s that Vicki Pollock was writing (and not as an adjunctive technique!) It has been some years since I last looked into this.

Early on there had been some success in reducing Parkinson’s symptoms by ablation of a part of the ventral thalamus that communicates with the substantia nigra (SN) and other basal ganglia, thus compensating for the loss of dopaminergic efferent drive from the SN. DBS can be thought of in first instance as a kind of electronic lesion or ablation, with the stimulus of sufficient magnitude so as to disrupt the ongoing activity. It is now most commonly applied to the subthalamic nucleus (STN). But the electronic lesion model turned out not to be the whole story.

Application of stimulation at sufficiently high frequency appears not only to disrupt the pathological rhythms that get established in basal ganglia circuits, but impose a new rhythm that has beneficial consequences. When such stimulation is applied at low frequencies, it merely modulates the pathological firing patterns with an excitatory bias.
Just what do these pathological electrical activities consist of? First, there is a loss of specificity of receptive fields in cortex; secondly, there is irregular discharge with a tendency toward bursting activity, and third, there is abnormal synchronization of rhythms in different brain regions. This is all beginning to sound very familiar.

There are problems with the “silencing” or inhibitory hypothesis of high-frequency stimulation. This led then to the consideration of a positive or “reward-based” aspect to DBS, one in which the pathological firing patterns are entirely replaced by a stimulation-based pattern. The frequency range is 120-180 Hz, and the pulse duration some 60-200 microseconds. The pulse amplitude is huge: 1-5V. We are tough!

There are a number of commonalities and analogies here to our world of neurofeedback. First of all, there are similarities in terms of results. A candidate for DBS is someone who still shows a good response to dopamine agonists, but is starting to show adverse side effects of the drugs, such as dyskinesias. Significant symptom reduction can be hoped for, as well as a reduction in medication requirement. The outcomes we can achieve non-invasively with neurofeedback for Parkinson’s are entirely comparable to those obtained with DBS. And I understand that we can still be helpful even when the dopamine agonists poop out.

When I pointed this out in response to a paper on DBS presented at the ECNS Conference several years ago, the speaker did not go beyond the courteous reply that he found this “interesting.” The problem of course is that if a non-invasive procedure is available that is as potent, then DBS becomes ethically questionable. That is not good news for this researcher. Here is an opportunity to get at a look at neuronal firing streams that is not usually available in human subjects. These researchers need Parkinson’s people much like the split-brain researchers needed intractable epileptics.

There are further similarities to neurofeedback in terms of research design. Once the electrode is in there, one is going to do everything within reason to determine the optimum stimulation parameters. That’s how researchers migrated to high stimulation frequencies and to steady-state stimulation in first instance. No one is bothered by the fact that stimulation optimizes under slightly different conditions for different people. No one would object if “research” would ideally allow individuation of the stimulation parameters. More specifically, there is an analogy here to both the inhibit and reward component of neurofeedback. And there has been a migration over time from the inhibit-based to the reward-based model, just as the reverse has occurred in neurofeedback. Finally, there is the analogy to stimulation-based neurofeedback, where ensemble periodicity is entrained rather than neuronal firing sequences.

And what about the vaunted controlled studies? How would you simulate the surgery? You don’t. How would you simulate the stimulation? You can’t. The technique simply has to be studied on its own terms. This is not something that can be done blind, and nobody would insist upon it. There is no such thing as sham DBS. The technique requires observation to determine the optimum stimulation parameters to regulate behavioral responding. The means to this end is an A/B design, which is the same way that we discriminate between alternative protocols.

So why is it that while DBS is progressing naturally in expanding knowledge about how we can intervene productively with neuronal firing patterns in sub-cortical nuclei, neurofeedback researchers insist upon validation with a research design which would be as inappropriate to neurofeedback as it would be to DBS, as foreign to psychology as behavioral research is to Medicine?

Consider the paradigm set up by people like Russell Barkley. His model of ADHD is consonant with what EEG people are saying in all respects. People on all sides of the discipline of psychology believe that behavior and attention skills are largely learned, and they have some idea of the mechanisms of learning involved. They are also familiar with the literature on operant and classical conditioning, and that both voluntary motor and autonomic function can be altered thereby.

So just why is it that these very same people find it so astoundingly bizarre that a child who is clearly capable of paying attention and controlling his behavior at least to some degree could also enhance those capabilities through overt conditioning techniques? Indeed, large claims demand good evidence, but why is this claim treated as such a large claim, almost as if it were from off the planet, by psychologists themselves? This should not be considered a large claim at all, but should follow naturally from what is already known. It would be entirely bizarre if nature did not behave this way.

Why would psychologists not insist that a behavioral technique should be tested in a manner that brings all of psychology to bear? Why do these very people insist on a testing paradigm in which psychodynamic psychology is most carefully and explicitly excluded, thus handicapping the technique, on the one hand, and reducing human subjects to the equivalent of rats in a maze, on the other? Why would they not be the first to insist that the technique be tested whole, which would mean including the feedback loop of client and therapist, and allowing for an adaptive response on the part of the therapist as well as of the client? Why are these psychologists out in front on the proposition that the clinician-client dyad has no clinical import whatsoever bearing on the success of neurofeedback? And why do they go on to flog any researcher who falls short of a pristine research design that reduces feedback to a purely mechanistic enterprise?

The Barkley types are strident in their opposition, when the facts of the situation warrant nothing worse than prudent skepticism. Instead we get “buyer beware” messages, demeanor of foreboding, and cautioning parents sagely about taking this huge gamble on expensive and unproven techniques. Curiously, the more the evidence mounts against them, the more strident they get. Is that any way for a scientist to behave? Let us call this what it really is, namely hucksterism on behalf of Big PhRMA, and abject obsequiousness before Big Medicine. Jesse Unruh once said that money is the mother’s milk of politics. Comparable intelligence now discerns that Big PhRMA is the mother of all medical research. Oh, don’t mind us psychologists over here; we really do understand that it’s all just a chemical deficiency. It’s all just about drugs and sympathy...

Let us take a lesson from the DBS researchers. Confident of the fact that they are onto something, they simply follow their scientific noses into the future. Let us do the same. We do not even have to sell people on brain surgery ahead of a questionable enterprise. The worst we inflict on people is electrode paste in their scalp. Can we just stop beating up on ourselves, and on each other? In the same timeframe that DBS has developed modestly to the extent that it has, we have laid down a path for revolutionizing all of mental health, and with fewer resources, with lower costs, and with fewer side effects. On top of that, we are a $300M enterprise in this country before the NIH has even heard of neurofeedback.

Dr. Siegfried Othmer