Clinical Neurotherapy

Neurotherapy, sometimes called EEG biofeedback and/or neurobiofeedback involves techniques designed to manipulate brain waves through non-invasive means and are used as treatment for a variety of psychological and medical disorders. The disorders covered include ADHD, mood regulation, addiction, pain, sleep disorders, and traumatic brain injury. This book introduces specific techniques, related equipment and necessary training for the clinical practitioner. Sections focus on treatment for specific disorders and which individual techniques can be used to treat the same disorder and examples of application and the evidence base for use are described. An introduction for clinical practitioners and psychologists investigating neurotherapy techniques and application Includes coverage of common disorders such as ADHD, mood regulation, addiction, pain, sleep disorders, and traumatic brain injury Includes evidence base for use Includes training methods for new users

Substance use disorders (SUDs) are among the most common psychiatric conditions, resulting in serious behavioral impairments and cognition decline. Acute and chronic drug abuse, drug dependency and drug withdrawal result in significant alteration of the electroencephalogram (EEG). EEG biofeedback has been used in the treatment of alcohol and mixed substance abuse in residential inpatient populations. More recent outpatient approaches have used quantitative EEG (qEEG) guided neurofeedback, neurofeedback (NFB) integrated with motivational interviewing and LORETA neurofeedback. A recent review of the state-of-art of qEEG and NFB in SUD and earlier reviews have detailed the efficacy ratings and clinical uses of NFB for SUD. In these reviews NFB is rated “probably efficacious” as an add-on (adjunct) treatment to other therapies, namely 12-step programs and/or cognitive behavioral therapies, or other types of psychotherapies or residential programs. Neurofeedback is not yet validated as a stand-alone therapy for addictive disorders and cannot yet be considered a mainstream therapy for addiction. Many persons with SUD have comorbid conditions that need to be considered in designing a treatment plan that incorporates neurofeedback. These include mental conditions such as depression, posttraumatic stress disorder, and attention deficit hyperactivity disorder that may require separate neurofeedback treatment for those specific conditions either preceding neurofeedback treatment for addiction, or incorporated into it. This approach may require separate assessments during the course of therapy to determine response and the need to change protocols or seek other treatments, i.e., medication or psychotherapy, to integrate into the treatment plan update.

Nonpharmacological methods of therapeutically influencing the brain have become widely used by clinical practitioners, and there is an accumulating body of outcome research. This chapter introduces readers to existing neurofeedback (EEG biofeedback) methodologies, as well as different modalities of neurotherapy for brain stimulation. Neurofeedback methods include symptom-based neurofeedback, neurofeedback guided by quantitative electroencephalography data, neurofeedback based on normative database Z-score and LORETA data, the Low Energy Neurofeedback System, slow cortical potentials training, fMRI neurofeedback, hemoencephalography training and infra-low frequency training. Brain stimulation technologies include electroconvulsive therapy, transcranial magnetic stimulation, deep brain stimulation, vagal nerve stimulation, cranial electrotherapy stimulation, transcranial direct current stimulation, a pulsed electromagnetic stimulation device, and audiovisual stimulation. Ethical and standard of care issues and considerations for liability protection are then reviewed.

Quantitative EEG (qEEG) has become an increasingly common method of assessment in the field of neurofeedback. The International Society for Neurofeedback and Research (ISNR) has issued a position paper advocating its widespread use within the field, and many entering the field gravitate toward its use because of its empirical value in the assessment and determination of protocols for intervention with neurofeedback. At the same time, the neuroimaging field has also increasingly taken an interest in qEEG and begun to employ it extensively in research alongside fMRI, because of its high temporal resolution and increasing spatial resolution resulting from recent enhancements such as low-resolution brain electromagnetic tomography (LORETA) imaging. This growing common use has provided a valuable new information source for the field of neurofeedback that can be applied at the research and clinical levels for an enriched analysis of client disorders. This chapter, on the one hand, is intended as an example of how those already engaged in qEEG might synthesize the emerging neuroimaging research with their own clinical experience, and is also an effort to present this topic in a generally understandable fashion. Those clinicians who are new to the field of neurofeedback or who are considering the use of qEEG at the clinical level are often intimidated by the complexity of the technology, and by the lack of basic guides to its implementation. Psychologists, counselors and medical professionals do not typically receive the technical training to prepare them for this new and powerful technology, which may come to play an important role in their respective professions. This chapter therefore is also meant to examine qEEG in a basic and comprehensive schema to help inform and initially guide such an audience in further exploration of the topic.

This review provides an updated overview of both basic and clinical research literature, neurophysiological rationale and current methods of practice pertaining to clinical neurofeedback. While considering general issues of physiology, epilepsy and learning principles, it focuses on the treatment of epilepsy with sensorimotor rhythm (SMR) training, arguably the best established clinical application of EEG operant conditioning. The basic research literature provides ample data to support a very detailed model of the neural generation of SMR, as well as the most likely candidate mechanism underlying its efficacy in clinical treatment. Further, although more controlled clinical trials would be desirable, a respectable literature supports the clinical utility of this alternative treatment for epilepsy. The skilled application of clinical neurofeedback with epilepsy requires a solid understanding of the disorder, as well as the neurophysiology underlying EEG oscillations and operant learning principles. The best clinical practice includes a systematic quantitative mapping of multi-electrode EEG measures against a normative database before and after treatment to assess outcomes, as well as documented measurement of progress towards EEG normalization during training.

Neurofeedback involves EEG frequencies that are unique to each patient and influenced by the introduction of psychotropic medication. This requires the neurofeedback provider to understand the behavioral correlates of EEG frequencies and the effects introduced by psychotropics. This chapter is designed to provide an overview of broad classes of medications related to cognitive and EEG effects, as well as to offer implications for the neurofeedback provider in incorporating these effects to optimize treatment design. The chapter provides an overview of the acute and long-term impact of medication classes on cognitive function and EEG patterns. Medication-related EEG shifts in absolute frequency bands (delta, theta, alpha beta) are explored across anxiolytics, stimulants, antidepressants and antipsychotics. It is intended to highlight major trends in medication-related changes affecting cognition and EEG relevant to neurofeedback design. Each section contains summaries of potential cognitive/behavioral and EEG effects and recommendations for neurofeedback providers, with emphasis on individualized, repeated assessment.

The purpose of this chapter is to examine hidden factors affecting neurofeedback treatment. It proposes a sociotechnical systems field theory of the neurofeedback treatment setting to help the therapist think about these factors beyond the specifics of this article. A typology of therapist styles in this model is proposed – Buddy, Technocrat, Integrated Practitioner and Withdrawn – to help the therapist identify his or her impact on the field of treatment. Case vignettes are presented as illustrations, along with one case with qEEG data. Genetics, illicit and prescribed drugs, patient variables, therapist variables, historical factors, suggestions for clinical hygiene and guides for treatment are presented.

This chapter provides a brief introduction to neurofeedback as practiced by the author, followed by a rather detailed description of vision therapy, which he has found to be an excellent supplement, especially with many cases of attention deficit hyperactivity disorder and traumatic brain injury. The chapter provides basic information about the problems created by impaired control of binocular eye movement, and the use of orthoptic vision therapy to correct functional visual problems such as poor convergence and divergence. Poor binocular control creates problems such as headaches, slowed and inaccurate reading and poor depth perception. Poor depth perception in turn leads to poor sports performance and a self-perception of being “clumsy.” Combining challenging and activating tasks, including active listening and vision therapy methods, with neurofeedback during a course of neurotherapy is also addressed, as is how and when to refer to a developmental/behavioral vision specialist (orthoptist).