April 14, 2004

Report on the 35th AAPB Meeting, Colorado Springs, CO

Author: Siegfried Othmer

This was the second year in which I presented an all-day seminar on our approach to neurofeedback. The audience grew this year to fill the room, and many others apparently picked up the handout. I presented a lot of theory, but most were waiting for the goods on how we actually do things, which I saved until the end and covered only cursorily. Sue and I are somewhat ambivalent about putting the material out there in this fashion, since the use of the inter-hemispheric protocol is a two-edged sword. The one-day seminar is supposed to be the “appetizer” for the clinical course, but most will probably just take the material I presented and run with it.

My other major pre-occupation at the conference was our Symposium on Migraine. This was preceded the day before by another such symposium, where the emphasis was on conventional biofeedback therapies and pharmacology for migraine. Deb Stokes was attending the AAPB Conference for the first time and was shocked that this conference would be a vehicle for such a preoccupation with drug treatment. The title of the Symposium was “New Frontiers in Migraine Headache,” and appeared to offer nothing new at all. That symposium was led by the incoming president of the AAPB, Steve Baskin. I have talked with him over the years about our migraine work, and never was able to make an impression. Over most of that time, he was of course still tethered to the vascular model of migraines. Over the last few years he has also been drawn into pharmacological studies, and when you get paid $3000 per patient for a drug study, it’s hard to make room for biofeedback. One could even say that his professional well-being is more dependent on drug company success than biofeedback success.

The new frontiers in migraine were really covered in our Symposium. We had only an hour, and we were one part of a three-ring circus in that time-slot. The room was over-flowing into the hallway. Frank Andrasik laid the groundwork by summarizing the body of existing biofeedback research on migraine, which solidly establishes BF as an effective treatment by all the relevant criteria. Moreover, specific data shows BF to match medications in efficacy, with one study showing it to have the greatest effect size. Over the longer term, moreover, meds do worse, and biofeedback stands out even more strongly. Incidentally, insurance companies used the statement of equivalence between BF and meds over the first year to deny BF reimbursement! They conveniently ignored the next paragraph, which stated that over a three-year period BF is superior.

Frank was followed by Jeff Carmen, who has single-handedly developed an approach using the reinforcement of infrared emissions from cortex to remediate migraines. Initially he had expected that down-training of the thermal emissions would be effective. But he could not touch migraines with that. Partly in frustration, one time he went the other way, he found the person’s migraines to reduce, and the rest is history. Significantly, the training to increase cortical infrared emissions in a migraine patient does not address a known deficit. This is one reason that Jeff for many years remained his own most severe critic. What he saw happening did not have a good explanation.

His brief talk was followed by Deb Stokes, who has drawn the pIR HEG modality into her practice along with neurofeedback. Deb reported on 15 challenging cases out of her practice. She found that either the training was very helpful or it was not. There was no middle ground. Jeff found that if people stayed for as long as six sessions they would be likely to see significant benefit, and among that cohort he did in fact have 100% favorable outcome. However, there were some in his practice who did not follow through with the training.

I played two roles at the Symposium. Firstly I presented some of our own data on migraines, and then I changed hats to the role of Discussant. In my technical talk I showed a variety of case histories in which the reward frequency was all over the map. In contrast to Jeff’s technique, which is essentially the same for everybody, the EEG technique demands great specificity in application. Nevertheless, I commented at the end that this specificity reflected “the person who has the migraine” more than any aspect of migraines. Significantly, the inter-hemispheric training also does not work against any known deficit.

Our results differ from both Jeff’s and Deb’s in terms of the likelihood of good outcome. With respect to Jeff, we tend not to have the problem of early dropouts. And with respect to Deb, we tend not to have the problem of people responding only weakly to the training. I suspect the differences are due to the way in which Sue proceeds. First she offers people a free consultation, at which point a conditional commitment to the training is obtained. Then during the long intake session, they experience the first training.

In contrast to HEG, which may move people rather gently, this first exposure to inter-hemispheric training tends to leave no doubt in people’s minds that their brain is being state-shifted. This is so compelling that it either draws them further into commitment or causes them to abandon the training. Fortunately we tend not to see abandonment of the training at that time—although we have seen that in times past. This may have to do with the kind of client we tend to see---those who have a long-term history of unrelieved migraines and they are just tired of it. We really do not see the garden-variety migraineur who has an occasional migraine and pops meds for them.

Now Deb Stokes tends to see the same kind of “end-stage” migraineurs as we do. Deb is quite deliberately cautious at this stage with the inter-hemispheric training, and I suspect that perhaps Sue is more aggressive in that regard, pushing people to the point where they clearly respond. We believe that we now satisfy what might be called the “90-90 rule,” namely that at least 90% of clients obtain at least 90% relief for their migraines with our neurofeedback. And this is with the most difficult migraine population in treatment anywhere (outside of those who are in migraine status).

In my role as Discussant I suggested that we needed to go to a level of description that could be inclusive of both modalities. This was quite a challenge, since the two techniques have essentially nothing in common. The only common language is that of self-regulation itself, that both techniques simply represent a relatively minor provocation to the brain, to which it responds, and as a result of which the brain strengthens its self-regulatory capacity. At this level of a common language no one can claim exclusive turf. It is a commons. There are many ways to cue the brain toward self-regulation. We just happen to have found two that are particularly efficacious. There will be more.

At the end of our brief foray into this new terrain, Frank Andrasik threw the floor open for questions and discussion. Three people came up to criticize our presentation, and these included the President-Elect and the incoming President of the AAPB, Richard Sherman and Steve Baskin, respectively. Both are experienced pain researchers, and they had clearly been blind-sided. We should have prepared them in advance for what was going to happen. In any event, they salvaged their self-respect by lobbing minor critiques at our work, and ended up not asking a single question. It is indeed a heavy burden to be such an expert that no questions need asking.

One psychiatrist from Greece said that we were falling into the same shortcomings that had characterized prior thermal feedback research on migraines. There was no evidence of learning. Until there is evidence that learning is taking place, we are vulnerable to the placebo hypothesis, or any number of other interpretations.

Oh, no, we’re not. We are able to predict outcome, given the above 90-90 rule. No apostle of the placebo hypothesis would dare make such a prediction. Baskin lamely suggested that simply removing Imitrex from those who overuse it can help significantly. Yes, but why would the pattern of Imitrex utilization change in the first place? After all, we are not as biofeedback therapists making any recommendations in that regard. Imitrex intake is reduced not by virtue of willpower but because it is no longer needed. Baskin confuses cause and effect.

At any rate, the arguments were tedious and marginal. I was sorry we had opened the door to the ubiquitous critics, and in the bargain missed out on an opportunity to have the panel members discuss the findings first among themselves.

I do want to go back to the argument of the Greek psychiatrist about demonstrating learning. We cannot allow ourselves to be painted into that corner. The independent evidence that relevant learning has occurred will not be easily come by. First of all, matters are made difficult when science does not yet agree on what the problem is in the first place. We now model migraines at the top level as an instability, and things just don’t look very different when such an instability no longer exists.

The same problem is cropping up in peripheral biofeedback. “We” are finding out that Heart Rate Variability training is the best approach to such disparate conditions as asthma susceptibility and myofascial pain. With HRV so exquisitely state-dependent, how does one prove that a significant change has in fact occurred? Consider the following dilemma: It is known that one of the best predictors of cardiac mortality is anger. In the physiological realm, the best predictor is HRV. Yet when you do Heartmath, you are coached to tune into your emotions more than to the mechanics of the HRV. If change occurs in the HRV, one could say that it is simply because the person is no longer living life angry and on edge. Or one could say that the person’s HRV was responding to training. The two may not be separable! They probably aren’t separable. The attempt to separate them is a throw-back to the mechanistic thinking that still plagues this field of biofeedback.

The field is looking for the kind of proof that shall elude us because it truncates the complexity of the reality within which we live. I suspect that we do not deserve as a community to make the breakthrough into public consciousness until we have ourselves absorbed the message of mind-body integration, and perhaps not before we can forthrightly incorporate the reality of the essential spiritual nature of our sojourn on this earth into our discourse about health.

This brings me back to the great hope that I had for this Symposium, that by virtue of featuring two different techniques of remediation, one right out of the heart of biofeedback, we could set the objective of the conceptual reunification of the field of biofeedback and neurofeedback. Our internal divisions are entirely artificial. They are historical, and grounded in very limited perspectives on our methods. It was therefore particularly disquieting to be drawn right back into the trenches of hand-to-hand combat about the details of what we were saying. Things went from the ethereal to mud-wrestling within the blinking of an eye. And at the hands of the highest priesthood of the AAPB, no less. We should feel honored for all that attention. But disgust trumps it.

Somehow Lynda Kirk, the immediate past president, managed to maintain her energy and enthusiasm to bring this conference into being by sheer force of will. Only afterwards did I find out that the press releases going out about the conference were coming out of her pocket. Frank still feels hopeful that things can be turned around. I am torn between thinking that the field cannot go forward divided as we are, and thinking that these people are hopelessly mired in archaic perspectives. I would love nothing more than to see some carry-over of Lynda’s unifying spirit into the future, rather than having her presidency merely be a temporary break in the clouds over a barren wasteland. Until the old perspectives are out of office, there may only be the ISNR with which to make headway.

There were highlights. Scott Shannon spoke on “Child Psychiatry and the Paradigm of Holism.” He is a child psychiatrist from Loveland CO who is also the former president of the American Holistic Medical Association. In his presentation he made the assumption that in this community we would all be on board with respect to mind-body integration. It was a nice thought. He quoted Norman Shealy to the effect that “if it can be fed back, it can be changed.” Indeed, it should not be necessary to prove every manifestation of that generality all over again from first principles as if self-regulation were a novelty.

The marquee presentation of the conference was by Richard Davidson. Since unpublished material was being presented, Davidson did not allow his talk to be taped. During the lecture, he revealed himself to be rather more than a left-brained researcher, revealing an interest in meditation going back to his college days, and even quoting the Dalai Lama at length (with whom he had met in India at the Dalai Lama’s invitation): “The systematic training of the mind—the cultivation of happiness, the genuine inner transformation by deliberately selecting and focusing on the positive mental states and challenging negative mental states is possible because of the very structure and function of the brain…. The wiring of our brains is not static, not irrevocably fixed. Our brains also also adaptable.”

Davidson proclaimed: “Behavioral interventions are biological. They have to be changing the brain! The notion of a schism between behavioral and medical interventions is an absurd anachronism that will be regarded as a historical curiosity fifty years from now.”

Interestingly, he sees no bias in favor of the right amygdala being associated with negative affect. Most of his findings show bilateral effects in both amygdalas. But then he is studying normals. In that regard, Davidson found high variability both in terms of trait and state-related emotional reactivity. Yet in one study, his group was forced to report only group means! The most interesting findings were not allowed to see the light of day.

Davidson reported that the highest correlation of magnetic resonance data from the amygdala was with the ventro-medial prefrontal cortex, which we may take as supporting our use of the “lower tier” for the preferential training of fear and emotional regulation in general, particularly in the pre-frontal region.

Later in the day, Bud Craig presented an anatomical view of “The Sense of the Physiological Condition of the Body,” one that starts with William James, continues with Antonio Damasio’s “The Feeling of What Happens,” and emerges as a comprehensive physiological model of homeostasis that encompasses pain as a “homeostatic emotion.” Since Craig had the actual neural circuitry of pain and temperature regulation under his particular microscope, he was somewhat contemptuous of Davidson’s imagery, referring to it as “blobology.” Both, however, get us closer to the dynamics of regulation, and thus prepare the ground for acceptance of our work.

Closer to home there were discussions of recovery from severe trauma (gunshots) with neurofeedback by Steve Larsen and Lynda Kirk, as well as related discussions of the intimate relationship between anomalous experience and trauma, a discussion which also drew in Nancy White and Carol Schneider.

And closer to home still, Scott Makeig presented on his work of Principal Component Analysis, with a few minutes on neurofeedback for Parkinsonism thrown in at the end. So how is it that Scott gets an hour Symposium and the field has yet to hear from Lisa Tataryn, who put Parkinsonism on the agenda of neurofeedback over the years? Perhaps next year.

I find Scott’s approach to PCA much more satisfying than LORETA. LORETA is also a formulation for PCA, but it is not quite so honest. By restricting the source distribution to those parts of cortex that could in principle be the locus of current dipoles, LORETA gives the impression of a physical reality that is at least partly fictional. Makeig’s approach simply aims for the simplest description of the EEG spatial distribution that is possible, letting the sources fall where they may. They are virtual anyway. No physical reality is implied. But if the analysis shows up two different source distributions to describe the alpha band, this is still a meaningful result even if the source loci are not physically meaningful. They still point to two independent generators of some kind.

Consider the following analogy. If you bring an electron up to a metallic plate, the electron will repel the surface electrons in the metal to the point where things will appear as if there were a mirror image charge within the metal, a positive charge equal to the electron charge, and located within the metal at a depth which exactly matches the distance of our electron from the metal surface. The most elegant description of the field distribution is simply in terms of the mirror image charge. In reality, of course, there is no positive electron sitting within the metal at that depth. We are just looking for the simplest description of the field distribution. The same is the case with the EEG. The EEG largely arises from surface dipoles within the gray matter, and could in principle be described by a huge set of surface dipoles arrayed across the cortical surface. Such a description has in fact been given, but it is not of much use.

If, on the other hand, some simplifying assumptions can give us a description of the EEG based on just a handful of principal components, then we may conjecture that such principal components are the real phenomena that nature must be trying to organize. The filtering that we do can be thought of as our first primitive attempt at distilling a more fundamental description of the EEG. If we now adduce spatial information as well, we can begin to get to the real “cortical events” that the brain is organizing. The ebb and flow of spindles we see on our filtered reward waveform finds its complement in the spatial domain. Surely it will be a help to us to pull out of the muck the entire “event,” rather than just its temporal representation.

Once the orderly cortical “events” are better characterized, we may do better in terms of discerning the descent into disregulation and thus inform our inhibit strategy. We may also be able to effect a better reward strategy.

The very last talk at the conference was by Eran Zaidel. After a review of the issue of hemispheric differentiation and coordination, Eran discussed his early findings with EEG training at F3 and F4. We are collaborating with him on this work, and NeuroCybernetics even lent him instrumentation for a few months. The work confirmed that the NF protocols had specific effects, although these were not at all what had been expected. The effects on attentional networks are specific, but not localized to the hemisphere being trained. We knew that already, didn’t we? But at another level of detail, the results were surprising. There were even some gender differences that we never noticed before. The plot thickens.

Eran’s presentation raised the issue in more than one attendee about the ethics of working with naïve college students using these techniques. There is, after all, no therapeutic intent here. Moreover, the student researchers have only the barest acquaintance with this technique and may not know to look for adverse consequences of the training. Of course there has been IRB approval of the research, but how informed is such an approval? We certainly did everything we could to alert those involved to the possible negative consequences of training in students who may be volatile, unstable, etc. And we did arrange to serve as a backup in the event anything untoward happened. But some of the work is going on with young children in Israel, where we cannot readily step in.

The highlight of the conference was the exhibit area. The density of creative energy collected in that room was awesome for our small community. Exhibits were over-subscribed. There is inevitable delay in giving birth to the new generation of software. Tom Allen was there with the new version of BioTrace, but it is not quite ready for release. We are still talking to Thought Tech about implementing some changes in the Infinity package. BioExplorer is making inroads in various domains—HEG, ROSHI, along with conventional feedback. The plan is to support the C-2 from J&J along with BrainMaster. BrainMaster in turn is making some evolutionary changes in hardware and software.

I am sure this conference was many things to many people. It was a question of which sessions one managed to attend. One more activity I was involved in was the meeting of the Allied Health Professionals. A small group got together at lunch to see where the organization should put its energies. The problem is that the interests of the group participants are so disparate. I was asked to address these issues at the lunch, but find myself facing the same questions. I will be writing up my thoughts for possible publication in the Biofeedback magazine.

Finally, when everyone had cleared out at the end of the conference I had a chance to sit down with David Joffe, the creative mind behind Lexicor. David had just received an award for all his technical contributions (he was also involved in the development of Heartmath) at the meeting the Neurofeedback Division, and he was feeling footloose about a commitment for the future. We tossed around a number of ideas, but also voiced regret about the fact that Lexicor never made an overture to us years ago, and did not respond to our initial overture to them. Now Lexicor has essentially abandoned the field of neurofeedback.

We value competition so much in our society that the importance of collaboration and cooperation is neither recognized nor cultivated. Historically in our field the forces of competition so dominated that it was almost impossible to talk across the chasm. Something similar is happening to our national politics now also. I have wondered whether this may not be an appropriate place to insert our newly acquired knowledge about networks. If one imagines all our interactions with others, draws them as links and paints them either red or blue---red for competitive and blue for cooperative---how would things turn out? And how have things changed over the years?

There would certainly be a varied mix of red and blue, and many relationships where both are in play, where we might have difficulty deciding on red or blue. Maybe red and blue would have to be allowed to switch over time, as appropriate, from one to the other. I don’t know how things would sort out, but I do know that whenever I go to an AAPB meeting my whole physiology ends up on red alert by the end of the meeting. This cannot be my observation alone, and it cannot be healthy for the organization. And to see the incoming president and president-elect down in the trenches, intimidating a first presenter, is truly dispiriting. The last time the organization met in Colorado Springs, back around 1992, it conspired to gang up on Eugene Peniston, who came to report on three-year follow-up to his study, and the other speakers on alpha-theta, Nancy White, Tom Allen, and Ellen Saxby. What an inglorious history.

P.S. The American Holistic Medical Association is meeting in Albuquerque April 28-May 1. That is where we should find kindred spirits among the MDs. I’ll be in Sydney at that time, or I would be there.

The AAPB has audio tapes available for nearly all the presentations, and will have DVDs available shortly for many of them. I would particularly recommend the DVDs over the audio tapes for Scott Makeig’s, Eran Zaidel’s, and Bud Craig’s presentation, and perhaps for the Migraine Symposium as well.