Public Information on Neurofeedback - ISNR

In the late 1960's and 1970's we learned that it was possible to recondition and retrain

brainwave patterns. Some of this work began with the training of alpha brainwave activity for

relaxation, while other work originating at UCLA focused on uncontrolled epilepsy. This

training is called EEG biofeedback or neurofeedback. Before discussing this in more detail, let

me provide you with some preliminary information about brainwaves. Brainwaves occur at

various frequencies. Some are fast and some are quite slow. The classic names of these EEG

bands are delta, theta, alpha, and beta. They are measured in cycles per second or hertz

(Hz).

mental, intellectual activity and outwardly focused concentration. This is basically a “brighteyed,

bushy-tailed” state of alertness.

relaxation and basically represent the brain shifting into an idling gear, relaxed and a bit

disengaged, waiting to respond when needed. If we merely close our eyes and begin picturing

something peaceful, in less than half a minute there begins to be an increase in alpha

brainwaves. These brainwaves are especially large in the back third of the head.

with mental inefficiency. At very slow levels, theta brainwave activity is a very relaxed state,

representing the twilight zone between waking and sleep.

experience when we are asleep. In general, different levels of awareness are associated with

dominant brainwave states.

Each of us, however, always has some degree of each of these brainwave bands present in

different parts of our brain. Delta brainwaves will also occur, for instance, when areas of the

brain go “off line” to take up nourishment. If we are becoming drowsy, there are more delta

and slow theta brainwaves creeping in, and if we are inattentive to external things and our

mind is wandering, there is more theta present. If we are exceptionally anxious and tense, an

excessively high frequency of beta brainwaves is often present. Persons with ADD, ADHD,

learning disabilities, head injuries, stroke, Tourette’s syndrome, epilepsy, and often chronic

fatigue syndrome and fibromyalgia tend to have excessive slow waves (usually theta and

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sometimes excess alpha) present. When an excessive amount of slow waves are present in the

executive (frontal) parts of the brain, it becomes difficult to control attention, behavior, and/

or emotions. Such persons generally have problems with concentration, memory, controlling

their impulses and moods, or with hyperactivity. They can’t focus very well and exhibit

diminished intellectual efficiency.

Neurofeedback training is brainwave biofeedback. During typical training, a couple of

electrodes are placed on the scalp and one or two are usually put on the ear lobe. Then, hightech

electronic equipment provides you with real-time, instantaneous audio and visual

feedback about your brainwave activity. The electrodes measure the electrical patterns

coming from the brain--much like a physician listens to your heart from the surface of your

skin. No electrical current is put into your brain. Your brainwave patterns are relayed to the

computer and recorded.

Ordinarily, we cannot influence our brainwave patterns because we lack awareness of them.

However, when you can see your brainwaves on a computer screen a few thousandths of a

second after they occur, it gives you the ability to influence and change them. The

mechanism of action is operant conditioning. We are literally reconditioning and retraining

the brain. At first, the changes are short-lived, but the changes gradually become more

enduring. With continuing feedback, coaching, and practice, we can usually retrain healthier

brainwave patterns in most people. It is a little like exercising or doing physical therapy with

the brain, enhancing cognitive flexibility and control. Thus, whether the problem stems from

ADD/ADHD, a learning disability, a stroke, head injury, deficits following neurosurgery,

uncontrolled epilepsy, cognitive dysfunction associated with aging, depression, anxiety,

obsessive-compulsive disorder, or other brain-related conditions, neurofeedback training

offers additional opportunities for rehabilitation through directly retraining the brain. The

exciting thing is that even when a problem is biological in nature, we now have another

treatment alternative than just medication. Neurofeedback is also being used increasingly to

facilitate peak performance in “normal” individuals and athletes.

Frank H. Duffy, M.D., a Professor and Pediatric Neurologist at Harvard Medical School, stated

in an editorial in the January 2000 issue of the journal Clinical Electroencephalography that

scholarly literature now suggests that neurofeedback “should play a major therapeutic role in

many difficult areas. In my opinion, if any medication had demonstrated such a wide

spectrum of efficacy it would be universally accepted and widely used” (p. v). “It is a field to

be taken seriously by all” (p. vii).

Prior to doing neurofeedback training, clinicians usually want to ask questions about the

symptom history of the patient. In some cases they may do neuropsychological or

psychological testing. Competent clinicians will also examine brainwave patterns. Some

practitioners may do this by placing one or two electrodes on the scalp and measuring

brainwave patterns in a few limited areas. Other clinicians perform more comprehensive

testing called a quantitative electroencephalogram (QEEG) or brain map where 19 or more

electrodes are placed on the scalp.

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A QEEG is an assessment tool to objectively and scientifically evaluate a person’s brainwave

function. The procedure may take about 1½ hours. It generally consists of placing a snug cap

on the head which contains small electrodes to measure the electrical patterns coming from

the brain. This is done while the patient is resting quietly with his or her eyes closed, and

sometimes also with eyes open or during a task such as reading. Afterwards, we then go

through a tedious and lengthy procedure to remove any artifacts that occurred when the eyes

moved or blinked, when patients moved slightly in the chair, or tightened their jaw or

forehead a little bit. The brainwave data we gathered is then compared to a sophisticated

normative database of how the brain should be functioning at the same age. Over a thousand

statistical analyses are then performed. This assessment procedure allows us to then

determine in a highly scientific, objective manner whether and how a patient’s brainwave

patterns are significantly different from normal.

Beginning during the 1970's and 1980's there began to be a great deal of experimentation with

QEEG. The American Medical EEG Association Ad Hoc Committee on QEEG has stated that

QEEG “is of clinical value now and developments suggest it will be of even greater use in the

future.” QEEG has scientifically documented ability to aid in the evaluation of conditions such

as mild traumatic brain injury, ADD/ADHD, learning disabilities, depression, obsessivecompulsive

disorder, anxiety and panic disorder, and a variety of other conditions (including

autism, schizophrenia, stroke, epilepsy, and dementia). QEEG has even been able to predict

outcomes from treating conditions such as ADD/ADHD, alcoholism, and drug abuse. The

American Psychological Association has also endorsed QEEG as being within the scope of

practice of psychologists who are appropriately trained, and ISNR has similarly endorsed its

use by legitimate health care professionals who are appropriately trained.

The EEG and QEEG evaluations assist us in knowing if there are abnormalities in brain

function that EEG neurofeedback might be helpful in treating, and it allows us to know how

we can individualize neurofeedback to the unique problems of each patient. For example,

scientific research has identified a minimum of three major subtypes of ADD/ADHD, none of

which can be diagnosed from observing the person’s behavior, and each of which requires a

different treatment protocol.

Once the assessment is complete and treatment goals have been established, we usually

place two electrodes on the scalp and one or more on the earlobes during neurotherapy

training sessions. The trainee then watches a display on the computer screen and listens to

audio tones, sometimes while doing a task such as reading. These training sessions are

designed to teach the person to slowly change and retrain their brainwave pattern. With

continuing feedback, coaching, and practice, the healthier brainwave patterns are

maintained. Some persons may need to learn to increase the speed or size of brainwaves in

some parts of the brain. Other individuals need training to decrease the speed of brainwaves

in certain areas of the brain. In a sense, it is like exercising or doing physical therapy with the

brain, enhancing cognitive flexibility and control. Neurofeedback training usually requires at

least 25, and most commonly 40-50 sessions of about 40 minutes in length.

ADD/ADHD & Learning Disabilities: Since the late 1970's, neurofeedback has been researched,

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Deficit/Hyperactivity Disorder and learning disorders by Dr. Lubar and his colleagues at the

University of Tennessee and others has demonstrated that it is possible to retrain the brain.

This neurofeedback research is quite strong in demonstrating its effectiveness in treating

ADD/ADHD. Whereas the average stimulation medication study follow-up is only three weeks

long and the longest medication study is only 14 months long with ADD/ADHD, Dr. Lubar

(1995) has published 10 year follow-ups on cases and found that in about 80% of patients

neurofeedback can substantially improve the symptoms of ADD and ADHD, and these changes

are maintained. Rossiter and LaVaque (1995) found that 20 sessions of neurofeedback

produced comparable improvements in attention and concentration to taking Ritalin, and

Fuchs et al. (2003) likewise demonstrated that neurofeedback produced comparable

improvements to ritalin. In a one year follow-up, control group study, Monastra et al. (2002)

found that neurofeedback produced superior improvements to ritalin, without needing to

remain on drugs. Neurofeedback training for ADD/ADHD is commonly found to be associated

with decreased impulsiveness/hyperactivity, increased mood stability, improved sleep

patterns, increased attention span and concentration, improved academic performance,

increased retention and memory, and increased IQ scores (often averaging 10 IQ points in

published studies).

treated using neurofeedback. Research in this area began in the early 1970's, and is very

extensive and rigorous, including blinded, placebo-controlled, cross-over studies (reviewed in

Sterman, 2000). Neurofeedback has been found to be helpful with all kinds of epilepsy,

including grand mal, complex partial, and petit mal (absence) seizures. Although the larger

proportion of seizure patients are adequately controlled by medication, most of the

individuals who have been treated with neurofeedback in research studies are among the

most severe epilepsy patients, where anticonvulsant drug therapy was unable to control their

seizures. However, even in this most severe group of patients, research found that

neurofeedback training on average produces a 70% reduction in seizures. In these severe

cases of medically intractable epilepsy, neurofeedback has been able to facilitate greater

control of seizures in 82% of patients, often reducing the level of medication required, which

can be very positive given the long-term negative effects of some medications. Many

patients, however, will need to remain on some level of medication following neurofeedback.

Training often requires 50 sessions or more. Treatment outcome studies of closed and open

head brain injuries are also now beginning to be seen, as well as with stroke, but better

research still needs to be done in these latter areas.

Alcoholism & Drug Abuse. EEG investigations of alcoholics (and the children of alcoholics)

have documented that even after prolonged periods of abstinence, they have lower levels of

alpha and theta waves and an excess of fast beta brainwaves in their EEG's. This means that

alcoholics and the children of alcoholics tend to be hard-wired differently from other people,

and in a way that makes it difficult for them to relax. However, following the use of alcohol,

the levels of alpha and theta brainwaves increase. Thus, individuals with a biological

predisposition to develop alcoholism (and their children) are particularly vulnerable to the

effects of alcohol. Without realizing it, alcoholics seem to be trying to self-medicate and

treat their own brain pathology. The relaxing mental state that occurs following alcohol use is

highly reinforcing to them because of the manner in which their brain is functioning. Several

research studies now show that the best predictor of relapse is how excessive the beta

brainwave activity is in alcoholics and cocaine addicts (Bauer, 1993, 2001; Prichep et al.,

1996; Winterer, 1998).

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Recently, EEG biofeedback training to teach alcoholics how to achieve stress reduction and

profoundly relaxed states through increasing alpha and theta brainwaves and reducing fast

beta brainwaves have demonstrated promising potential as an adjunct to alcoholism

treatment. Peniston and Kulkosky (1989) used such training with chronic alcoholics compared

to a nonalcoholic control group and a traditional alcoholism treatment control group.

Alcoholics receiving 30 sessions of brainwave training demonstrated significant increases in

percentages of their EEG record in alpha and theta rhythms, and increased alpha rhythm

amplitudes. The brainwave treatment group also demonstrated sharp reductions in depression

compared to controls. Alcoholics in standard (traditional) treatment showed a significant

elevation in serum beta-endorphin levels (an index of stress and a stimulant of caloric [e.g.,

ethanol] intake), while those with brainwave training added to their treatment did not

demonstrate an increase in beta-endorphin levels. On four-year follow-ups (Peniston &

Kulkosky, 1990), only 20% of the traditionally treated group of alcoholics remained sober,

compared with 80% of the experimental group who received neurofeedback training.

Furthermore, the experimental group showed improvement in psychological adjustment on 13

scales of the Millon Clinical Multiaxial Inventory compared to traditionally treated alcoholics

who improved on only two scales and became worse on one scale. On 16-PF personality

inventory, the neurofeedback training group demonstrated improvement on 7 scales,

compared to only one scale among the traditional treatment group. Thus, neurofeedback

training appears to hold encouraging promise as an adjunctive module in the treatment of

alcoholism, and in remediating damage done through drug abuse.

Posttraumatic Stress Disorder. Peniston and Kulkosky (1991) added thirty 30-minute sessions

of alpha/theta EEG biofeedback training to the traditional VA hospital treatment provided to

a group of PTSD Vietnam combat veterans, and compared them at 30 month follow-up with a

contrast group who only received traditional treatment. On follow-up, all 14 traditional

treatment patients had relapsed and been rehospitalized, while only 3 of 15 neurofeedback

training patients had relapsed. While all 14 patients treated with neurofeedback had

decreased their medication requirements by follow-up, among traditionally treated patients,

only one patient decreased medication needs, two reported no change, and 10 required more

psychiatric medications. On the MMPI, neurofeedback training patients improved significantly

on all 10 clinical scales--dramatically on many of them--while there were no significant

improvements on any scales in the traditional treatment group.

Other Clinical Applications of Neurofeedback Training. Neurofeedback has good research

support for its effectiveness in treating anxiety (Moore, 2000). It is also being used to work

with other clinical problems such as depression (Baehr, Rosenfeld & Baehr, 2001; Hammond,

2001), chronic fatigue syndrome (Hammond, 2001), fibromyalgia (Donaldson et al., 1998;

Meuller et al., 2001), sleep disorders, Tourette’s, obsessive-compulsive disorder (Hammond,

2003), autism (Jarusiuwicz, 2002), Parkinson’s tremors (Thompson & Thompson, 2002), and

essential tremor. Neurofeedback is being utilized in peak performance training, for instance

in enhancing musical (Egner & Gruzelier, 2003), with athletes, business executives, for

cognitive enhancement in normal college students (Rasey, Lubar, McIntyre, Zoffuto & Abbott,

1996), for memory enhancement in normal individuals (Vernon et al., 2003), and for “brain

brightening” to counter effects of normal aging. However, these areas of application do not

yet have strong research validation.

Although there are many health care practitioners who are convinced of the effectiveness

and value of this cutting-edge technology (and an estimated 2,000 clinicians are using

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neurofeedback), you should be aware that some insurance company personnel (whose job is

to save their company money), and even some professionals (many of whom may not be

aware of the latest published research), may regard all EEG neurofeedback as experimental.

all biofeedback as experimental and, thus, may not reimburse for these services.

Only rarely have significant side effects from neurofeedback training been noted. However,

occasionally someone may feel tired, spacey, anxious, experience a headache, have difficulty

falling asleep, or feel agitated or irritable. Many of these feelings pass within a short time

after a training session. If you make your therapist aware of such feelings, they can alter

training protocols and usually quickly eliminate such mild adverse effects. It has come to our

attention, however, that some individuals are now renting and leasing home training

equipment. It is our strong recommendation that training with equipment at home should

only be done under the regular consultation and supervision of a legitimately trained and

licensed professional, preferably following closely supervised training in the office for a

period of time. Otherwise, more serious negative effects could possibly occur with

unsupervised self-training. It is important to remember that the impressive success

documented in research is based on work with qualified professionals, following careful

assessment, and with training sessions that are supervised by the therapist rather than with

unsupervised sessions taking place in an office or at home.

You may identify individuals who are doing neurofeedback training by consulting the web site

listed below for the International Society for Neuronal Regulation (ISNR) and looking at the

membership directory. Below you will find a few references to the literature I have cited,

and a few web sites that provide further useful information. ISNR has listed on our web site a

comprehensive bibliography that I have compiled of scientific publications on neurofeedback.

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