Non-Invasive, Medication free therapy for Improved Brain Function
An Introduction to Neurofeedback - Cory Hammond PhD
Dr. Corydon Hammond, PhD, ABEN, QEEG-D
Professor & Psychologist, Physical Medicine & Rehabilitation
University of Utah School of Medicine
Introduction
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).
Beta
mental, intellectual activity and outwardly focused concentration. This is basically a “brighteyed,
bushy-tailed” state of alertness.
Alpha
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.
Theta
with mental inefficiency. At very slow levels, theta brainwave activity is a very relaxed state,
representing the twilight zone between waking and sleep.
Delta
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
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.
What is Neurofeedback Training?
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).
Assessment Prior to Neurofeedback Training
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.
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.
Neurofeedback Training
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,
refined, and tested with ADD/ADHD and learning disabilities. Clinical work with Attention
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).
Epilepsy, Brain Injuries & Stroke 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).
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
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.
Even for well validated biofeedback treatments,
all biofeedback as experimental and, thus, may not reimburse for these services.
Training Side Effects & Home Training
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.
Referral Sources
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.
References
1) Protocol in the treatment of mood disorders: Follow-up study one to five years post therapy. Journal of
Neurotherapy, 4(4), 11-18.
2) Psychiatry Research, 47, 69-77.
3) Electroencephalography. Neuropsychopharmacology, 25(3), 332-240.
4) Consecutive referrals. Canadian Journal of Clinical Medicine, 5(6), 116-127.
5) EEG enhances musical performance. NeuroReport, 14(9), 1121-1224.
6) https://www.isnr.org/pubarea/intro-nfb.htm (6 of 8)1/22/2005 5:06:20 PM
Public Information on Neurofeedback - ISNR
7) Treatment for attention deficit/hyperactivity disorder in children: A comparison with methylphenidate.
Applied Psychophysiology & Biofeedback, 28, 1-12.
8) Neurotherapy, 4(2), 45-56.
9) NeuroRehabilitation, 16, 295-300.
10) Disorder. Journal of Neurotherapy, 7(2), 25-52.
11) Journal of Neurotherapy, 6(4), 39-49.
12) Chapter in M. S. Schwartz (Ed.), Biofeedback: A Practitioner's Guide. New York, Guilford, 493-522.
13) Incorporating EEG-driven stimulation: A clinical outcomes study. Journal of Clinical Psychology, 57(7),
933-952.
14) Biofeedback, and parenting style on the primary symptoms of attention-deficit/hyperactivity disorder.
Applied Psychophysiology & Biofeedback, 27(4), 231-249.
15) Electroencephalography, 31(1), 1-6.
16) Alcoholics. Alcohol: Clinical & Experimental Research, 13(2), 271-279.
17) Medical Psychotherapy, 2, 37-55.
18) Veterans with combat-related post-traumatic stress disorder. Medical Psychotherapy, 4, 47-60.
19) Cocaine dependence and treatment outcome. Journal of Addictive Diseases, 15(4), 39-53.
20) The enhancement of attentional processing in normal college students. Journal of Neurotherapy, 1(3), 15-
21) https://www.isnr.org/pubarea/intro-nfb.htm (7 of 8)1/22/2005 5:06:20 PM
Public Information on Neurofeedback - ISNR
22) Treating attention deficit/hyperactivity disorders. Journal of Neurotherapy, 1, 48-59.
23) EEG operant conditioning. Clinical Electroencephalography, 31(1), 45-55.
24) Disease: Theory and preliminary results. Journal of Neurotherapy, 6(4), 51-70.
25) Effect of training distinct neurofeedback protocols on aspects of cognitive performance. International
Journal of Psychophysiology, 47, 75-85.
Contact
Vita Centre
Integrative Medical Centre
136 New South Head Road
Edgecliff NSW 2027
Ph: (02) 9328 1066
Fax: (02) 9328 1561
Mobile: 0434 915 739
"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. It is a field to be taken seriously by all”
Dr. Frank Duffy
Director of Clinical Neurophysiology
Children’s Hospital Boston
Professor of Neurology
Harvard University.