 
Clinical results that have been obtained for schizophrenia with biofeedback and Neurofeedback / EEG Biofeedback techniques have been quite impressive, but this observation has essentially been lost to science and to medical practice. Typically, people diagnosed with schizophrenia are ushered immediately into a regimen of care that utilizes the latest offerings out of the pharmacological cornucopia. There is no opportunity to give self-regulation strategies a chance.
Schizophrenia is one of those conditions characterized by discontinuity in mental states on various time scales. Simply training the nervous system for enhanced stability is profoundly helpful. Neurofeedback does that well; and the medications by and large do not. The very simplest and one of the oldest biofeedback techniques has been shown to be profoundly helpful even with long-term hospitalized schizophrenia patients. The vast majority who underwent the training ended up being released from the hospital to their families.
One cannot help but wonder why such a finding did not have an immediate, huge impact on care. One reason could be that the trial did not occur in the United States, and another reason could be that the work was conducted by clinical psychologists rather than MDs. As clinicians, they never sought to publish the work.
Now that we have neurofeedback techniques to complement the more traditional biofeedback, we have even more ways to train the brain toward stability. A significant advance in therapeutic efficacy lies in store for schizophrenia once the importance of self-regulation methods is recognized.
A study of neurofeedback in application to schizophrenia has just been published by a psychiatrist in Turkey, Tanju Surmeli, MD (2011). He designs his training for each person according to features observed in the QEEG. The vast majority of clients responded strongly to the training and substantially reduced both their positive and negative symptoms.
Meanwhile there has also been progress in the application to schizophrenia of the infra-low frequency neurofeedback that we have developed over the last six years. One feature of this training is that clients typically respond quite quickly, so that one can get an early sense of how significant the training is likely to be for the person.
One report we have received makes this point rather clearly: A veteran of the Vietnam era was court-referred to a neurofeedback therapist for training. He had suffered many years with schizophrenia. At the end of the very first session, he declared that he did not feel like smoking. This is significant, because nicotine is like medication for a person with schizophrenia. It calms and stabilizes the brain. When he came in for his fifth session he declared that he had not had a cigarette since his fourth session----some 19 days. There was no intention to stop smoking in this case. The sudden lack of a desire to smoke indicates a significant improvement in physiological regulation. The training had clearly impacted the schizophrenia, and it had done so quickly.
Just as neurofeedback can be helpful for a variety of chronic pain conditions, it appears
to be helpful for sciatica as well. We have had numerous reports of a single session of
neurofeedback bringing substantial relief for sciatica pain, which then suggests that longer
term training should be worthwhile in order to sustain the gains.
- Seasonal Affective Disorder
Seasonal affective disorder probably affects many more of us than have been diagnosed with this disorder. Perhaps we are dealing with a mere exaggeration of what is in fact a normal response. After all, our species got its start in equatorial Africa, where seasonal variations in length of day were not an issue. We observe other species such as insects and birds being exquisitely sensitive to variations in length of day. Perhaps it should not be surprising that once we moved out of our comfort zone to Hamburg, London, and Alberta, there might be consequences for our biological rhythms.
In any event, neurofeedback can be very helpful here, although more mundane methods should be brought to bear as well, such as the use of white bright lights.
It was a fortuitous discovery in research that launched the field of neurofeedback some decades ago. It was discovered accidentally that the reinforcement of a particular kind of EEG rhythm in cats would make them resistant to chemically induced seizures. Since the cats were otherwise normal, the chemical induction of seizures was the kind of highly reproducible phenomenon not ordinarily encountered in the clinical world of seizure management. Such reproducibility made for a highly significant finding even with only a small number of cats.
The downside was that the result of this experiment could not be appreciated in the science of the day. So the results, stunning as they were, did not have the impact that they should have had. It has taken the neurosciences another several decades to reach the point where those early results can be fully appreciated. The fact that the results did not take root within neurology at the time is therefore not an indictment of the data, but rather is a reflection of the immaturity of the neurosciences back in the mid-sixties. It is also a commentary on the divisions among the health professions, as the early work was conducted entirely by psychologists rather than by MDs. The work did not have a real home within psychology, being concerned with a medical condition, nor did it find a home within medicine as it involved a psychological technique, namely operant conditioning.
The upshot has been that the technique, as it has matured over the years, can now be very helpful in the management of seizure disorder. Neurofeedback / EEG Biofeedback can be helpful in a variety of ways. Successful training can mean the reduction in the amount of anti-convulsant medication that is required to maintain control. It can mean a reduction in the severity and incidence of breakthrough seizures in seizure patients who remain uncontrolled. It can mean reduced severity of medication side effects for improved quality of life. And it may mean that brain surgery to eliminate seizures can be avoided.
Clinical effectiveness of neurofeedback for seizure management has been seen across the board with absence seizures, with motor seizures, and with complex partial seizures. It can be helpful if the seizures are seen as a consequence of head trauma, or of any other kind of brain insult such as chemical injury, ischemia or anoxia. Neurofeedback has also been helpful in cases of Landau-Kleffner syndrome, a subtype of autism in which seizure-like brain activity is observed.
By reciting these different categories we are not implying that neurofeedback represents any kind of specific treatment for these conditions. It should still be thought of as a general technique of brain “conditioning” that enhances its internal resources for maintaining stability. We train the neuronal networks toward stability; whereas the medications either move the membrane chemistry toward reduced excitability or else enhance inhibitory function neurochemically.
This is actually not too different from what is in fact being done with the medications, which also represent a general more than a specific treatment. That is to say, the medications typically do not target the seizure focus specifically, but rather the brain as a whole. The one medical technique that does treat the seizure focus directly is surgery. But that actually supports our point as well. Let us ask the question, “How can the removal of part of the brain make things better?” When it comes to the part of the brain that is being removed, surely that has to be making things worse in the neighborhood. When seizure surgery is effective, one can argue in retrospect that the seizure focus had to have been disrupting normal brain activity elsewhere in healthy brain tissue. By the same token, any technique that promotes stable function in the healthy brain tissue might be helpful with seizure management.
- Siegfried Othmer, PhD
For related information see Therapeutic Applications: Epilepsy
Sleep apnea has been categorized traditionally into a central sleep apnea, where the system “forgets to breathe” and an obstructive sleep apnea where the airway collapses at night when the musculature relaxes during certain phases of sleep. When it was first suggested that neurofeedback could be helpful for sleep apnea there was great skepticism about the observation that we did not see a great distinction between central and obstructive sleep apnea. Both seemed to respond to the training.
One could understand a favorable impact on centrally mediated apnea more easily than an effect on a collapsed airway. The answer of course lies in the fact that even in obstructive sleep apnea we are involved in the central regulation of the muscle system. Obstructive sleep apnea is associated with obesity, but not all obese people have obstructive sleep apnea. With training, the unfortunate ones can perhaps join the fortunate ones.
The outcome of neurofeedback for sleep apnea is highly variable, and there is at this point no way to predict outcome. The training simply needs to be tried. Even with success in training, the client may have to be alert for the reappearance of symptoms, and occasional booster sessions may be indicated.
Neurofeedback / EEG Biofeedback is significantly helpful for a variety of sleep disorders: difficulty with sleep onset; frequent waking; bed-wetting in childhood; nocturnal myoclonus; restless leg syndrome; nightmares; night terrors; central and obstructive sleep apnea; nocturnal bruxism; snoring; sleep paralysis; sleep walking and sleep talking; nocturnal seizures; circadian rhythm disregulation.
The breadth of impact of neurofeedback on sleep disorders is evidence, if any more were needed, that neurofeedback targets very basic regulatory functions in the brain, such as the management of physiological arousal. The complex organization of our sleep takes us through a variety of states of arousal. Any deficiency in basic arousal regulation is therefore likely to show up in sleep. And it is in sleep that we are witness to the process absent any conscious control of our arousal states. So any improvement we are able to achieve with neurofeedback should show up readily in sleep behavior.
Just was we look to sleep disregulation as an index to the quality of self-regulation generally, readers may wish to do the same. A particular sleep issue may not seem all that momentous in itself, but if it is seen more as an indication of a more pervasive problem of brain disregulation it could be the spur for further investigation into a course of action. The payoff for better sleep could indeed be multi-faceted.
A few years ago there was a serious effort to get people to quit smoking with aversive techniques. After a while even the promoters realized, “there has to be something more.” Aversive techniques by themselves are not enough. There clearly needs to be something more in the discussion of the problem as well. No one seems to be willing to confront the obvious reality that smokers often derive a functional benefit from smoking. They are not simply feeding their nicotine addiction. One college professor was on a 90-minute clock. He needed a cigarette every ninety minutes or so to keep up his mental function. One ex-smoker’s wife pleaded with him to start smoking again because she found him difficult to live with off cigarettes. The case of a famous bridge player in New York City was cited in the book “Licit and Illicit Drugs” many years ago. The lady gave up cigarettes and her bridge game deteriorated. She had to be aware of the connection, but in this case she decided that her interest was better served by tending to her health concerns.
There is a high incidence of smoking among schizophrenics and among prison occupants. For many of these people, cigarettes meet a real need and they are not better off in the short term for quitting. The idea of preventing prisoners from smoking is ludicrous. Interestingly, cigarettes seem to play a regulatory role that is in some ways reminiscent of neurofeedback itself. That is to say, where activation is needed, smoking may fill the bill; where calming is required, smoking may fill the bill as well.
Where neurofeedback comes in is in terms of training brain function to the point where the effect of nicotine is not particularly additive. The brain can now self-regulate without additional nicotine supplementation. This prepares the ground for smoking cessation, which really comes into the picture only later in the training. Just as it has been our experience that users of medical marijuana will quite readily give it up when they no longer need it, we have actually had the same experience with cigarette smoking. People have reported simply abandoning cigarettes at some point. That is to say, they were not making the effort to stop, and they were themselves surprised at the observation that they were losing interest in cigarettes.
Now we should hasten to say that such observations are rare. Most smokers are dealing with a rather treatment-resistant nicotine addiction, and there is no quick answer for that even with neurofeedback. The point we are making is that one should not even be having that discussion until the person no longer derives an immediate functional benefit from smoking.
We would prefer to put minimum reliance on the force of will in this endeavor. The brain should simply be trained in the best fashion we know how. Cigarette utilization is likely to decline progressively, and in time an opportunity may emerge in which the client will consider stopping smoking as a realistic option.
- Siegfried Othmer, PhD
Snoring is a very common problem, particularly among men past middle age. It can often be helped with neurofeedback to restore proper muscle tone to the airway during sleep. Wives will be grateful. Solving the problem of snoring in this fashion may have multiple benefits. The quality of sleep may be improved, and with it daytime functioning. The neurofeedback training will also affect other functions such as the regulation of vigilance, attention, and of executive function, etc.
Social anxiety was not a very visible issue in our society until a pharmacological remedy became available, at which point it became the disorder du jour. Social anxiety requires little more than a few neurofeedback sessions to calm the brain and settle it in to a more comfortable operating zone. This is far preferable to the medication route because essentially all anxiolytics are dependency-promoting. Whereas Neurofeedback / EEG Biofeedack training offers long-term benefit, undertaking the short-term solution of medications may involve one in long-term costs.
It took quite some time to get used to the idea that neurofeedback could actually be helpful with the personality disorders, including sociopathy. Even if this is believed to be true, how could we be sure? Sociopaths don’t come into mental health practices complaining, “Doc help me, I’m a sociopath.” These people famously do not think they have a problem. It’s the rest of the world that has a problem.
What first gave us permission to think along these lines were the observations with Conduct Disorder among children, and the children with Reactive Attachment Disorder that sometimes came our way. With neurofeedback we were able to take these children to the point where these issues were no longer clinically relevant. Emotional regulation could clearly be trained. Empathy could be evoked where none was evident before. The pathway to relationship could be paved with neurofeedback. Emotional regulation was a brain software issue subject to alteration, construction, and reconstruction.
If these things could be accomplished with children who were about as challenging to work with as anyone we get to see, perhaps the adult form of these emotional disregulations can yield to training as well. The opportunity to test this out only became available obliquely, as people come in for other conditions. In the course of work with their primary complaint, it was observed that the sociopathic tendencies were impacted by the training as well. One man stated at one point, “I have no idea why my wife has stuck with me for so many years….I am only now beginning to understand what love is.” No talk therapy was involved. There was, after all, no clay to mold. Only neurofeedback could accomplish this.
On another occasion, a rather dictatorial boss had taken up neurofeedback for a while. When he started skipping sessions because of his busy schedule, his office staff nudged him to continue the work. It was clear to them more than to the man himself that the training was humanizing him.
- Speech and Language Problems
Neurofeedback / EEG Biofeedback can be profoundly helpful in speech and language issues, although we are still at the beginning of determining the best training approaches for some of these conditions. Articulation problems may yield quite readily to training at Broca’s area. But many of these conditions are less straight-forward. If speech loss follows from a stroke, for example, the best strategy of remediation is not immediately apparent. And language deficits in the autistic spectrum require a number of avenues of approach.
The intimate relationship between speech output and what we are able to process through the auditory pathway was originally established by the French researcher and ENT physician Tomatis. The training of auditory processing may therefore need to be in the picture as well. In this domain, neurofeedback may need to share the stage with direct auditory training with music-based auditory challenges such as the Tomatis method, Somonas, and The Listening Program. Neurofeedback can also challenge our coordination of sensory input with speech output. This is an issue that may be centrally involved in stuttering, which is discussed separately.
The adverse response to stress is one of the central issues in the American way of illness. It is estimated that some 85% of medical conditions are either triggered by stress or adversely affected by unremediated stress reactions. Another estimate has it that the economic impact of unmanaged stress is at the level of $300B/year. That’s a three percent impact upon the entire private economy. These essential realities, taken together, mean that the management of our stress response should be at the heart of health care. It is, in fact, at the heart of biofeedback, which is all about giving the body-mind more resilience in meeting its challenges. Unfortunately, the way health care delivery is organized medical conditions will get the appropriate medical care, and the “self-care” model may get little more than lip service. Medical care has become a crisis-response system because crisis carries an ethical burden. Cost-cutting in health care strips away anything else. Moreove, training in self-regulation is not typically available at the medical clinic, where “real” medicine is practiced. Lamentably, good health status is largely a matter of self-care, but the skill still needs to be taught.
The result is that the American health care model is completely backwards, which accounts for the fact that we pay twice as much for health care as anyone else in the world, and we get lower health status and lower life expectancy than most of the developed world in the bargain. Since the actual care being delivered is second to none in the world, the problem must lie elsewhere. It must lie in what is not being done. And that is the management of stress in particular, and the self-care model in general.
There is no way to get there except by improved brain self-regulation, and that is unlikely to happen by itself given what we are up against in the Western lifestyle. Greater nervous system resilience in the face of stress must be trained explicitly to counter the adverse influences coming at us through our complex existence. Unfortunately, this whole realm of health care has been somewhat trivialized by the use of colloquial terms such as “relaxation training.” The fact is that relaxation training is not about relaxation per se at all, but rather about control, about enhanced regulatory capacity for our system.
One of the common consequences of stress is the anxiety response, and in that event we do wish to train people to live in calmer states. But the training does not constrain them in any way, but rather allows the nervous system to match its level of excitability to the demands of the moment. When the crisis disappears or is surmounted, the system should ratchet down to a lower level of engagement.
The message seems so mundane that the sophistication behind it is obscured: Stress management should be at the heart of care, not at the margins. The essential task in health care in general, and mental health in particular, must be to train our central nervous system toward greater tolerance of the stresses it encounters. This is an entirely non-trivial undertaking. The cost-benefit ratio is immensely favorable, both for the individual at risk and for the community at large.
The essential need here is already being appreciated by many competent individuals in our society who are trying to rise above their own limitations. Answers are being sought in physical exercise programs, in yoga routines, in meditation practice, and in massage. Indeed, all these regimens do train the central nervous system in the right direction, but they do so rather inefficiently. The advantage they offer is that the participant does not expect the insurance to cover these, even though they have health implications.
Biofeedback and neurofeedback should be seen in the same way. It is in our personal interest quite independently of whether an insurance company considers the expenditure essential. Unfortunately, by virtue of being seen as ‘medical’ simply because it has medical procedure codes, biofeedback and neurofeedback tend to fall into that category where individuals allow the insurance companies to make their decisions for them. That is unfortunate.
- Siegfried Othmer, PhD
Recovery from stroke needs to be discussed in several aspects. The obvious inclination is to focus on the functional loss that is directly traceable to the organic injury—be that language, or limb movement, or gait. At the same time, the person has had a brain injury that has broader implications for function. This can be seen by analogy to minor head trauma, where we see many symptoms despite the absence of any organic injury. Thirdly, if the person has lost significant function in the event, then we are also looking at the possibility of psychological trauma.
A Neurofeedback / EEG Biofeedback strategy is available for each of these categories. There is also a natural hierarchy here. The first order of business is not, in fact, the “specific” deficits that the person suffered in the stroke. Rather, it is the more diffuse symptoms and any psychological trauma. What we are able to do rather quickly with neurofeedback is to deal with any irritability, pain, sleep problems, mood swings, effort fatigue, or cognitive fog that may have emerged after the stroke, or after any associated surgical procedure. Secondly, we can address the psychological effect of the major loss of function that now has to be accepted. The person may have lost his career; his wife may no longer be thrilled to be living with him; friends fall away; etc.
The specific loss that attended the stroke is actually our last concern. This is because there is no quick remedy here in any event. Recovery from the specific loss is going to be a process with a long time horizon whatever we do. Even here, however, we are dealing with a two-stage process. The first stage involves the functional reintegration of neuronal resources that remained structurally sound after the stroke but are no longer functionally integrated. This process is similar to what takes place in other recovery conditions such as Parkinson’s, dementia, and chemical injury. One should see progress in a modest number of sessions, and such progress may start to plateau in the range of twenty to forty sessions.
Over the longer term, dendritic regrowth may present a further opportunity for functional recovery. One can sample this process by training at some interval, like once a month, and that process may continue for years. Also, the gradual reassignment of function that can occur in the brain may also be reinforced by neurofeedback.
Case Vignettes
A Neurofeedback clinician reports:
We had a middle-aged stroke patient who started Neurofeedback about eighteen months ago. She had had three strokes over a period of about one year and could not speak coherently, could barely walk unassisted, was depressed, and for the above reasons was on permanent disability.
Her doctors said this was the best it would get. Today she trots up three flights of stairs to our office, speaks very clearly, is off disability and is back to work full-time. Needless to say she is thrilled. Her doctor has been amazed to observe this recovery, and he is now very open to Neurofeedback. Honestly, I was a bit blown away as well.
A Neurofeedback clinician reports the following:
Recently more and more of my clients have gone back to ask their doctors why they weren't told about Neurofeedback. Often the response is that "most people couldn't afford Neurofeedback." That was the comeback given by a medical doctor (who specializes in pediatric brain injury at a local hospital) to a mom whose infant had a stroke at birth, suffered many developmental delays and had never spoken a word. After the child began training at age six, I imagined his first words might be something simple, like "da da or ma ma", but instead he let out a whole string of words for his first utterance, which was "Grandpa get out of the way! I can't see the TV!" He now talks and walks and tested out of special ed class, to the delight of his parents. His insurance company denied payment for the Neurofeedback on the grounds that there was "no medical necessity"!
We have seen a number of cases of stuttering recover nicely with neurofeedback, to the point where effective procedures have been worked out. There is an obvious connection with anxiety, so one order of business is to train the brain to live out of calmer states. But that merely addresses the context in which stuttering occurs. There is also a connection with Tourette Syndrome, with perhaps a third of Touretters also having a history of stuttering. We have clue here to a problem of high activation and arousal, again a matter of context. Finally, there may also be a connection with trauma, just as we have with selective mutism. In these situations, the neurofeedback training needs to take into account the larger context rather than focusing on the specific symptom.
Then there is the issue of stuttering itself, which presumably relates to our smooth integration of output function with sensory input function. The importance of brain timing in this matter can be illustrated by simply delaying the hearing of one’s own voice with headphones. Installing a delay of a few hundred milliseconds can turn any one of us into a stutterer instantaneously. With neurofeedback the above integration task can be accomplished more smoothly. With increased fluency in speech, the person can then also de-escalate further out of performance anxiety.
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