The training allows the patient to monitor and modify the activity of brain networks for critical functions facilitating attention and arousal, mood and emotion, learning and memory, and control of behaviour. The effects can be beneficial by directly affecting behaviour and performance and well as physical and emotional well-being. The intervention is non-invasive and evidence based.
It involves sensors being placed on on the scalp and referred to non-cephalic sites such as the ears or mastoids. During brain training (i.e. neurofeedback) computers are used to feedback information in real time to the client about brain activity, in the form of auditory cues and visual images. For children, this feedback is often in the form of games.
Neurofeedback is designed to help re-regulate the dysfunctional brain systems disturbing effective psychological function. These can include the extensive thalamocortical networks that induce both the idling rhythms of the brain (alpha 1 rhythms) as well as processes critical to attentional filtering (selection), involving parietal cortical regions, the superior colliculus, and the intralaminar and reticular nuclei of the thalamus; and that lead to the activation of semantic memories related to extant working memories (alpha 2 rhythms). They also include the limbic-cortical networks (theta), involving the hippocampi, enthorhinal cortex, anterior and posterior cingulates, the amygdalae, and the perirhinal and parahippocampal cortices, which drive critical function related to a self-preservating evaluation of the significance of stimuli, their relationship to ongoing plans and goals, the targeting of related events for attention, the monitoring and correction of subsequent behavioural response, the storage and activation of episodic memories related to extant working memory, and control of the flight and flight responses associated with stimulus-related affect. And they include intracortical and corticocortical activity reflecting the information analysis and preparatory activities of this structure (e.g. beta and gamma rhythms; and the slow cortical potentials such as the anticipatory, orienting and preparatory components of the Contingent Negative Variation, and the motor preparation and readiness components of the Bereitschaftspotential).
Dysregulation in any of these systems or their network components disrupts effective psychological function. Importantly, such dysregulation is not directly amenable to stabilisation through talking therapy (e.g. CBT and other psychotherapies), since the difficulties lie with the carrier systems rather than with system content, though the latter will obviously be affected as a consequence. Thus, a combination of cognitive/behavioural therapy and neurofeedback is often necessary for a more complete recovery.
Quantitative EEG and ERPs: Quantitative EEG (QEEG) and quantitative event-related potentials (QERP) are the key methods for identifying systemic dysregulation in the brain. Their effectiveness derives from a number of factors. Firstly, they have high temporal resolution,permitting measurement of network activity in real-time in the order of milliseconds, the time scale within which cognitive activity operates. They contrast with other functional imaging methods, such as functional MRI and SPECT, that are too slow to track such activity – the haemodynamic response measured by fMRI extends to 20 seconds or more and cannot characterise brain dynamics within the cognitive timescale.
Secondly, QEEG/QERPs are able to discriminate real time macroscopic activity associated with thalamo-cortical, limbic-cortical, intra-cortical and cortico-cortical function, across the 2D surface of the scalp. QEEG is able to characterise the activity of these networks by virtue of inherent differences in the length of the recurrent pathways subserving these systems and associated synaptic delays. The energetics of the systems correlate with the size of the activated cortical fields beneath the electrodes (Nunez, 1983, 1995). Thus, thalamocortical activity operates within a frequency range of 8-13 Hz (called alpha); limbic-cortical activity within the range 3-7 Hz (called theta); and intra-cortical activity within the range 14-40 Hz (called beta, and gamma). The modulatory influences of glial cells on network selection and de-selection is detected via slow cortical potentials (SCPs) detectable in frequency ranges below 1Hz – this glial action reflects white matter modulation that effects the selection of distributed associative networks for attentional processing; note, this is indirectly driven by conscious rather than subconscious operations – with SCPS only present when there is mental intention – thereby providing an index of the operations of consciousness on perception, mentation and behaviour. The modulatory influences of the monamine and related systems (noradrenaline, dopamine, serotonin, acetylcholine) on sensory, perceptual, motor, memory and executive function are also detected within this range.
Thirdly, QERPs provide information about the timing of cortical events during information processing – including early physical selection of information within the time range of 50-250 milliseconds post-stimulus, to the contextual evaluation of such information within the time range 250-1000ms post-event, to cortical activities that take many seconds. Anomalies in network function at any stage within the elaboration of information results in diminished psychological function.
Finally, the assessment of dysfunctional brain networks from QEEG and QERPs derives from the recent development of large international databases of brain and cognitive function. Our clinic uses, amongst others, the Brain Resource International Database (BRID; see also BrainNet), the largest and most comprehensive yet developed. It now houses data from over 16,000 healthy males and females across the age range (6-80+), drawing for normative comparison on regression statistics derived from the work of John Crawford, the respected Scottish neuropsychologist. The size of this database ensures that the error in the population statistic is well below 1% (see Galton)
The power of neurofeedback therapy derives from its capacity to exploit the information obtained from QEEG measurement using the brains intrinsic learning menchanisms (operant conditioning). Further, new neurotherapies have recently emerged to exploit the information available from QERPs. One of the best known is repetitive trans-cranial magnetic stimulation (rTMS) which has been tested as a treatment tool for various neurological and psychiatric disorders including migraines, strokes, Parkinson’s disease, dystonia, tinnitus, depression and auditory hallucinations. Another is transcranial Direct Current Stimulation (tDCS) that has been tested for treatment in a number of psychological disorders, though more evidence based work is still needed (see Kropotov, 2009).
Some useful reference papers on QEEG and brain mapping:
Below are some useful references for the use of QEEG and neurofeedback therapy in children, adolescents and adults.
The use of neurofeedback with ADHD is extensively discussed in the articles by Arns (2009), Cantor (2009), Chabot (2001) and Gevensleben (2009). Importantly, the Arns et al (2009) paper is a metareview of neurofeedback treatment studies on ADHD, leading to the recognition of the method as both efficacious and specific (see the associated Behavioural Medicine Report). Another Arns et al (2009) reports an RCT in the area of language dysfunction.
The recent review by Chabot et al (2009) refers to the use of quantitative EEG (QEEG) as a method for identifying abnormalities in brain function during development, as well as showing how QEEGs provide a basis for establishing treatment for the dysfunctions under the related brain disorders. There is also some reference to the underlying functional neuroanatomy. Note that whilst this paper focuses on children, the rationale extends to both adolescents and adults. The earlier review by Chabot et al (2001) also provides useful background.
The article by Hammon reviews the use of neurotherapy with anxiety disorders. The Sokhadze article examines the same with substance abuse.
The Hirschberg et al (2005) paper provides a more general overview of a range of brain-based interventions for psychological disorders, focusing in this case on children and adolescents. Their review includes neurofeedback therapy, which is also referred to as EEG biofeedback (EBF), as well as repetitive transcranial magnetic stimulation and vagal nerve stimulation which are less relevant. Hirschberg et al (2005) notes the utility of neurofeedback therapy in conditions such as attention, impulsivity, mood, anxiety, learning and memory, as well as providing improvements in addictive disorders and epilepsy. See also the editorial abstract (Emerging Interventions, Hirschberg et al 2009) from the same special edition of the Child and Adolescent Clinics of North America journal.
Note also that epilepsy was the first condition neurotherapy was successfully used for and is still used frequently in the USA for this purpose by neurologists (see paper by Tan et al, 2009).
The Peniston-Kulkosky web article discusses evidence for efficacy of the non-QEEG neurofeedback protocol (alpha-theta therapy) in PTSD and alcoholism. It provides the full list of useful and related list of their own and other journal references (see Peniston, 2009).
The Bretelier paper examines the utility of neurofeedback with dyslexia.
The paper by Nash et al (2005) is a simple outline of the method (there are many others), its use as a therapy or adjunctive therapy and its place with other techniques such as CBT.
The book by Yuri Kropotov is the seminal first text covering the field of QEEG and neurotherapy. It is easy to read and explains the functional anatomy underlying the QEEG measures obtainable from the scalp and the rationale of neurotherapy as treatment interventions. Note that Professor Kropotov is publishing another text in early 2012 on the new diagnostics of ADHD using spontaneous and event-related EEG endophenotypes – which will then impact more broadly on the way ADHD is assessed and treated, both pharmacologically (for temporary respite) and neurotherapeutically (for effecting permanent change during the respite).
Note in this regard, that QEEG based (also called assessment based) neurofeedback therapy targets dysregulated brain systems that cannot easily be treated by talk based therapies such as CBT, that target dysfunctional beliefs, associations and the like; and vice versa. But the two can work well conjunctively when appropriate, since dysregulated brain systems are very likely to result in dysfunctional memory content as a secondary outcome.
References (Check on Google scholar to see article abstracts. Search using authors names and key words from title. Some articles may be freely downloadable).
- Arns, M. yet al (2009) Efficacy of neurofeedback treatment in ADHD: the effects on inattention, impulsivity and hyperactivity: a meta-analysis. Clinical EEG and Neuroscience 40: 180-189.
- Breteler, MHM, Arns, M, Peter,S Giepmans, I, Verhoeven, L (2010) Improvements in Spelling after QEEG-based Neurofeedback in Dyslexia: A Randomized Controlled Treatment Study. Appl Psychophysiol Biofeedback (2010) 35:5–11
- Cantor DS and Chabot R (2009) QEEG studies in the assessment and treatment of childhood disorders. Clinical EEG and Neuroscience 40: 113-121.
- Chabot, RJ, di Michele, F, Prichep, L and John ER. (2001) The clinical role of computerized EEG in the evaluation and treatment of learning and attention disorders in children and adolescents. The Journal of Neuropsychiatry and Clinical Neurosciences; Spring 2001; 13, 2
- Gevensleben, H (2009) Is neurofeedback an efficacious treatment for ADHD? A randomised controlled clinical trial. Journal of Child Psychology and Psychiatry 50:780–789
- Hammond, DC (2005) Neurofeedback with anxiety and affective disorders. Child Adolesc Psychiatric Clin N Am 14: 105– 123
- Heinrich, H, Gevensleben, H and Strehl, U (2007) Annotation: Neurofeedback – train your brain to train behaviour. Journal of Child Psychology and Psychiatry 48:3–16 Link
- Hirshberg, H , Chu S et al (2005) Emerging Interventions. Child and Adolescent Clinics of North America. Volume 14, Issue 1, Pages xiii-xvii
- Hirshberg, LM, Chiu, S, Frazier, JA (2005) Emerging brain-based interventions for children and adolescents: overview and clinical perspective Child Adolesc Psychiatric Clin N Am 14: 1 – 19
- Klimesch, W., 1999. EEG alpha and theta oscillations reflect cognitive and memory performance: a review and analysis. Brain Research Review 29, 169-195.
- Kropotov, J, (2009) Quantitative EEG, event-related potentials and neurotherapy. Elsevier: Amsterdam.
- Nash, JK (2005) Neurotherapy with adults. Journal of Adult Development, 12: 105-112.
- Peniston, EO (2009) The Peniston-Kulkosky Brainwave Neurofeedback Therapeutic Protocol: see http://www.aaets.org/article47.htm
- Sokhadze, TM, Cannon, RL, Trudeau, DL (2008) EEG Biofeedback as a Treatment for Substance Use Disorders: Review, Rating of Efficacy, and Recommendations for Further Research. Appl Psychophysiol Biofeedback (2008) 33:1–28
- Tan, G, Thornby J et al (2009) meta-analysis of EEG biofeedback in Epilepsy. Clinical EEG and Neuroscience 40: 173-179.