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(Corydon Hammond) Investigations in Neuromodulatio
(Corydon Hammond) Investigations in Neuromodulatio
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To cite this article: D. Corydon Hammond (2011): What is Neurofeedback: An Update, Journal of Neurotherapy: Investigations
in Neuromodulation, Neurofeedback and Applied Neuroscience, 15:4, 305-336
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Journal of Neurotherapy, 15:305–336, 2011
Copyright # Taylor & Francis Group, LLC
ISSN: 1087-4208 print=1530-017X online
DOI: 10.1080/10874208.2011.623090
D. Corydon Hammond
Physical Medicine & Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
Written to educate both professionals and the general public, this article provides an update
and overview of the field of neurofeedback (EEG biofeedback). The process of assessment
and neurofeedback training is explained. Then, areas in which neurofeedback is being used
as a treatment are identified and a survey of research findings is presented. Potential risks,
side effects, and adverse reactions are cited and guidelines provided for selecting a legiti-
mately qualified practitioner.
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305
306 D. C. HAMMOND
in deep, restorative sleep. In general, different problems present, and not simply ADD=ADHD
levels of awareness are associated with domi- alone. Therefore, appropriate assessment is
nant brainwave states. important prior to beginning to do neurofeed-
It should be noted, however, that each of us back to determine what EEG frequencies are
always has some degree of each of these various excessive or deficient, or if there are problems
brainwave frequencies present in different parts in processing speed or coherence, and in what
of our brain. Delta brainwaves will also occur, parts of the brain. Proper assessment allows the
for instance, when areas of the brain go ‘‘off treatment to be individualized and tailored to
line’’ to take up nourishment, and delta is also the patient.
associated with learning disabilities. If someone Neurofeedback training is EEG (brainwave)
is becoming drowsy, there are more delta and biofeedback. During typical training, one or
slower theta brainwaves creeping in, and if more electrodes are placed on the scalp and
people are somewhat inattentive to external one or two are usually put on the earlobes.
things and their minds are wandering, there is Then, high-tech electronic equipment provides
more theta present. If someone is exceptionally real-time, instantaneous feedback (usually audi-
anxious and tense, an excessively high fre- tory and visual) about your brainwave activity.
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quency of beta brainwaves may be present in The electrodes allow us to measure the electri-
different parts of the brain, but in other cases cal patterns coming from the brain—much like
this may be associated with an excess of inef- a physician listens to your heart from the surface
ficient alpha activity in frontal areas that are of your skin. No electrical current is put into
associated with emotional control. Persons your brain. Your brain’s electrical activity is
with Attention-Deficit=Hyperactivity Disorder relayed to the computer and recorded.
(ADD, ADHD), head injuries, stroke, epilepsy, Ordinarily, patients cannot reliably influ-
developmental disabilities, and often chronic ence their brainwave patterns because they lack
fatigue syndrome and fibromyalgia tend to have awareness of them. However, when they can
excessive slow waves (usually theta and some- see their brainwaves on a computer screen a
times excess alpha) present. When an excessive few thousandths of a second after they occur,
amount of slow waves are present in the execu- it gives them the ability to influence and gradu-
tive (frontal) parts of the brain, it becomes ally change them. The mechanism of action is
difficult to control attention, behavior, and=or generally considered to be operant condition-
emotions. Such persons generally have prob- ing. We are literally reconditioning and retrain-
lems with concentration, memory, controlling ing the brain. At first, the changes are
their impulses and moods, or hyperactivity. short-lived, but the changes gradually become
They have problems focusing and exhibit more enduring. With continuing feedback,
diminished intellectual efficiency. coaching, and practice, healthier brainwave
As the reader can see, there can be com- patterns can usually be retrained in most
plexity involved in how the brain is operating. people. As is reviewed later in the article, most
Research (Hammond, 2010b) has found that research suggests that significant improvements
there is heterogeneity in the EEG patterns seem to occur 75 to 80% of the time. The pro-
associated with different diagnostic conditions cess is a little like exercising or doing physical
such as ADD=ADHD, anxiety, or obsessive- therapy with the brain, enhancing cognitive
compulsive disorder. For example, scientific flexibility and control. Thus, whether symptoms
research has identified a minimum of three stem from ADD=ADHD, a learning disability, a
major subtypes of ADD=ADHD, none of which stroke, head injury, deficits following neurosur-
can be diagnosed from only observing the gery, uncontrolled epilepsy, cognitive dysfunc-
person’s behavior and each of which requires tion associated with aging, depression,
a different treatment protocol. The picture anxiety, obsessive-compulsive disorder, autism,
can become even more complicated by the or other brain-related conditions, neurofeed-
fact that sometimes there are other comorbid back training offers additional opportunities
WHAT IS NEUROFEEDBACK 307
for rehabilitation through directly retraining the to doing neurofeedback training, legitimate
electrical activity patterns in the brain. The licensed clinicians will want to ask questions
exciting thing is that even when a problem is about the clinical history of the client or
biological in nature, there is now another treat- patient. Occasionally in more serious cases
ment alternative to simply relying on medi- they may suggest doing neuropsychological or
cation. Neurofeedback is also being used psychological testing. Competent clinicians
increasingly to facilitate peak performance in (Hammond et al., 2011) will also do a careful
‘‘normal’’ individuals, executives, and athletes. assessment and examine brainwave patterns.
More than a decade ago, Frank H. Duffy, Some practitioners may do an assessment by
MD, a professor and pediatric neurologist at placing one or two electrodes on the scalp
Harvard Medical School, stated in the journal and measuring brainwave patterns in a limited
Clinical Electroencephalography that scholarly number of areas. Other clinicians perform a
literature had already suggested that neurofeed- more comprehensive evaluation by doing a
back ‘‘should play a major therapeutic role in quantitative electroencephalogram (QEEG)
many difficult areas. In my opinion, if any medi- brain map where 19 or more electrodes are
cation had demonstrated such a wide spectrum placed on the scalp.
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involves a very tiny electromagnetic field, which that usually utilizes two, four, or more electrodes
only has a field strength of 1018 watts=cm2. on the head. Continuous calculations are being
This feedback is so small that it is the equivalent computed comparing the way that the brain is
1
of only 400 th of the strength of the input we functioning on different variables (e.g., power,
receive from simply holding an ordinary cell asymmetries, phase-lag, coherence) to a scien-
phone to the ear and only about the intensity tifically developed normative database. Feed-
of the output coming from a watch battery. It back is then based on these moment-to-
is delivered in 1-s intervals down electrode wires moment statistical comparisons to norms for
while the patient remains relatively motionless, the patient’s approximate age group. As with
usually eyes closed. This feedback is adjusted other methods of neurofeedback, the feedback
16 times a second to remain a certain number that is provided is designed to guide the brain
of cycles per second faster than the dominant toward normalized function. This feedback
brainwave frequency. Most preliminary often consists of observing a DVD where the pic-
research and clinical experience are encour- ture dims and flickers when the person is not
aging with articles published on LENS treatment doing as well and becomes more clear and
of conditions such as TBI (Hammond, 2010c; bright when his or her brain is functioning closer
Schoenberger, Shiflett, Esdy, Ochs, & Matheis, to norms. At this point, most of what has been
2001), fibromyalgia (C. C. S. Donaldson, Sella, published on this approach are case series data
& Mueller, 1998; Mueller, Donaldson, Nelson, (Collura, 2008a, 2008b, 2009; Collura, Guan,
& Layman, 2001), anger (Hammond, 2010a), Tarrant, Bailey, & Starr, 2010; Collura, Thatcher,
restless legs syndrome (Hammond, in press), Smith, Lambos, & Stark, 2009), with the excep-
ADD=ADHD, anxiety, depression, insomnia tion of a new controlled study showing positive
and other conditions (Larsen, 2006; Larsen, results with insomnia (Hammer, Colbert, Brown,
Harrington, & Hicks, 2006). LENS has even & Ilioi, 2011), but these preliminary results,
been used to modify behavioral problems in ani- which include pre- and posttreatment QEEGs,
mals (Larsen, Larsen, et al., 2006). Advantages of are very encouraging. As this is being written,
the LENS approach include that it commonly an expansion of this approach has become avail-
seems to produce results faster than traditional able wherein an entire electrode cap with 19
neurofeedback, and it can be used with very electrodes can also be used for training.
young children and with individuals who are less
motivated and who do not have the impulse LORETA Neurofeedback Training
control or stamina required with other neuro- LORETA refers to low resolution electromag-
feedback approaches. netic tomography. This is a kind of QEEG
310 D. C. HAMMOND
analysis that provides an estimation of the ADHD and learning disabilities. Clinical work
location of the underlying brain generators by Dr. Joel Lubar and his colleagues (e.g., Lubar,
(e.g., the anterior cingulate, insula, fusiform 1995) at the University of Tennessee as well as
gyrus) of the patient’s EEG activity within a many others has repeatedly demonstrated that
frequency band. Very preliminary research it is possible to retrain the brain. In fact, one
(Cannon & Lubar, 2007; Cannon et al., randomized controlled study (Levesque,
2007; Cannon et al., 2006; Congedo, Lubar, Beauregard, & Mensour, 2006) documented
& Joffe, 2004) has been published about this with fMRI neuroimaging the positive changes
approach. It does require more labor-intensive in brain function in ADHD children that mir-
preparation where an entire electrode cap with rored their behavioral changes following neuro-
19 electrodes must be applied in every session. feedback treatment. This and the research cited
It is believed that this approach may have next all provide strong support that demon-
potential to improve outcomes in difficult cases strate the effectiveness of neurofeedback in
and=or shorten the length of treatment, and a treating ADD=ADHD. Whereas the average
preliminary report (Cannon & Lubar, 2011) stimulant medication treatment study follow-up
suggests that changes may be enduring. is only 3 weeks long, with only four long-term
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compared with computerized attention skills efficacious and specific treatment—the highest
training (which would have placebo control level of scientific validation (La Vaque et al.,
characteristics). Behavioral and attentional 2002). In comparison to neurofeedback,
improvements were found to be stable on a meta-analysis (Schachter, Pham, King,
6-month follow-up in research studies reported Langford, & Hoher, 2001) of randomized con-
by Strehl et al. (2006) and Gevensleben et al. trolled studies of medication treatment for
(2010), and the latter found that neurofeedback ADD=ADHD concluded that the studies were
training produced superior results to computer- of poor quality, had a strong publication bias
ized attention skills training, as did Holtmann (meaning that drug company funded studies
et al. (2009). that failed to support the effectiveness of their
Two randomized, double-blind placebo product tended to never be submitted for pub-
controlled studies (deBeus & Kaiser, 2011; lication), and often produced side effects. They
deNiet, 2011) have documented the effective- further indicated that long-term effects (beyond
ness of neurofeedback with ADHD. Other placebo effects) for longer than a 4-week
recent, large randomized controlled studies follow-up period were not demonstrated.
(Gevensleben et al., 2009a; Wrangler et al., A recent comprehensive review (Drug
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2010) should also do much to dispel concerns Effectiveness Review Project, 2005) of medi-
that improvements from neurofeedback training cation treatment for ADD=ADHD concluded
simply reflect nonspecific placebo factors. These that there was no evidence on the long-term
studies demonstrated protocol-specific changes safety of the medications used in ADD=ADHD
in electrophysiological brain function using treatment and that good quality evidence is
EEG and sophisticated event-related potential lacking that drug treatment improves academic
measures, replicating some earlier findings performance or risky behaviors on a long-term
(Heinrich, Gevensleben, Freisleder, Moll, & basis, or in adolescents or adults. The latter con-
Rothenberger, 2004) and showing distinct clusions were also reached by Joughin and Zwi
neuronal mechanisms involved with different (1999). The largest randomized controlled mul-
training techniques. A 2-year follow-up (Gani, tisite study compared medication treatment,
Birbaumer, & Strehl, 2008) of the Heinrich ‘‘routine community care,’’ and behavior ther-
research found that not only were improve- apy. Outcome raters were not blinded, introdu-
ments in attention and behavior stable but that cing a bias, and most subjects in community
some parent ratings had shown continued care were also on medications. At 14-month
improvement during the 2 years. Continuing follow-up (MTA Cooperative Group, 1999), all
improvement on 6-week and 12-week follow- groups showed improvements, and medication
ups were also found after the completion of produced better improvements in attention
LENS treatment of adult ADD=ADHD by deNiet and hyperactivity (the latter only on parent rat-
(2011) in a randomized, double-blind placebo ings), but not in aggression, social skills, grades,
controlled study. Thus follow-up evaluations or parent–child relations. The ratings provided
ranging from 3 months to 10 years after treat- by the only blinded rater (a classroom observer),
ment (Gani et al., 2008; Heinrich et al., 2004; however, showed no difference between
Lubar, 1995; Monastra et al., 2002; Strehl groups, and on 3-year follow-up (Swanson
et al., 2006) provide strong support that et al., 2007) there was no difference on any
improvements from neurofeedback with ADD= outcome measures between groups, findings
ADHD should be enduring, unless of course that were confirmed on 8 year follow-up
something such as a head injury or drug abuse (Molina et al., 2009). Studies (e.g., Swanson
were to occur to negative alter brain function. et al., 2007) have confirmed loss of appetite
A recent meta-analysis (Arns, de Ridder, and growth suppression as a side effect of medi-
Strehl, Breteler, & Coenen, 2009) concluded cation treatment, along with other side effects
that neurofeedback treatment of ADD=ADHD such as increased heart rate and blood pressure,
meets criteria for being classified as an insomnia, loss of emotional responsiveness,
312 D. C. HAMMOND
costs associated with medication treatment et al., 2006). An additional report by Fernandez
are actually quite sizable. For instance, a study (Fernandez et al., 2007) on 16 children with
(Marchetti et al., 2001) of six different medica- learning disabilities documented significant
tions for ADD=ADHD treatment found that the EEG changes 2 months after neurofeedback
average cost per school-aged patient was compared to a placebo-control group where
$1,678 each year. Another study (Swensen there were no EEG changes, and 10 of 11 chil-
et al., 2003) examined the health care costs in dren in the neurofeedback treatment group
more than 100,000 families where ADHD showed objective changes in academic perfor-
was either present or not present. They found mance compared with one in five children in
that in families where a member had ADHD, the placebo group. Other articles have also
the direct costs of health care expenditures plus been published on the value of neurofeedback
indirect costs (such as work loss) averaged with learning disabilities (Orlando & Rivera,
$1,288 per year higher for the other family 2004; Tansey, 1991a; Thornton & Carmody,
members (who had not been diagnosed as hav- 2005). A randomized controlled study with
ing ADD=ADHD) in comparison with members children with dyslexia (Breteler, Arns, Peters,
of families where ADHD was not present. This Giepmans, & Verhoeven, 2010) documented
would mean that the cost of medication just significant improvement in spelling, and Walker
cited, combined with indirect costs each year (2010a; Walker & Norman, 2006) found signifi-
for a family with two children, one of whom cant improvements in reading ability in 41
had ADHD, would be $5,542. dyslexia cases. In the first 12 cases reported
Neurofeedback training for ADD=ADHD by Walker (Walker & Norman, 2006) after 30
is commonly found to be associated to 35 sessions, all the children had improved
with decreased impulsiveness=hyperactivity, at least two grade levels in reading ability.
increased mood stability, improved sleep pat- Barnea, Rassis, and Zaidel (2005) identified
terns, increased attention span and concen- improvements in reading ability in learning
tration, improved academic performance, and disability children after 20 sessions.
increased retention and memory, and with a Although controlled research has not been
much lower rate of side effects. It is fascinating done, Surmeli and Ertem (2007) evaluated
to note that ADD=ADHD or learning disability whether QEEG-guided neurofeedback could
studies that have evaluated IQ pre- and be helpful with Down Syndrome children. All
posttreatment have commonly found IQ eight children who completed up to 60 treat-
increases following neurofeedback training. ment sessions (one child dropped out after only
These improvements ranged from an average eight sessions) showed significant improvement
WHAT IS NEUROFEEDBACK 313
Sarnacki, Wolpaw, & McFarland, 2011; training on average produces a 70% reduction
Egner & Gruzelier, 2003; Egner, Strawson, & in seizures. In these harsh cases of medically
Gruzelier, 2002; Fritson, Wadkins, Gerdes, & intractable epilepsy, neurofeedback has been
Hof, 2007; Gruzelier, Egner, & Vernon, 2006; able to facilitate greater control of seizures in
Hanslmayer, Sauseng, Doppelmayr, Schabus, 82% of patients, often reducing the level of
& Klimesch, 2005; Hoedlmoser et al., 2008; medication required, which can be very posi-
Keizer, Verment, & Hommel, 2010; Rasey, tive given the long-term negative effects of
Lubar, McIntyre, Zoffuto & Abbott, 1996; some medications. Many patients, however,
Vernon et al., 2003; Zoefel, Huster, & may still need to remain on some level of
Herrmann, 2010). Neurofeedback to enhance medication following neurofeedback.
cognitive functioning and to counter the effects More recently Walker and Kozlowski
of aging has been referred to as ‘‘brain brighten- (2005) reported on 10 consecutive cases, and
ing’’ (Budzynski, 1996). Ros, Munneke, Ruge, 90% were seizure free after neurofeedback,
Gruzelier, and Rothwell (2010) produced although only 20% were able to cease taking
evidence that neurofeedback training with medication. In another group of 25 uncon-
normal persons may enhance neuroplasticity. trolled epilepsy patients (Walker, 2008),
100% became seizure free following QEEG-
Uncontrolled Epilepsy guided neurofeedback, with 76% no longer
Medication treatment of epilepsy is successful requiring an anticonvulsant for seizure control
only in completely controlling seizures in two on follow-up, which averaged 5.1 years.
thirds of patients (Iasemidis, 2003), and the Walker (2010b) reported on still an additional
long-term use of many antiseizure medications 20 patients with intractable seizures, 18 of
can have health risks. When medication treat- which were seizure free following neurofeed-
ment is not successful, neurosurgery is often back training, whereas two continued to report
recommended, but it has limited success occasional seizures. Two of the 18 patients
(Witte, Iasemidis, & Litt, 2003). In addition, remained on a single anticonvulsant medi-
many epilepsy patients are also women of cation. The average length of follow-up in
child-bearing age who wish to have children these cases was 4 years. In this same report,
but fear the effects of medications on the fetus. Walker indicated that he had seen nine
Therefore, a treatment option other than or in women who wished to stop taking anticonvul-
addition to medication and surgery would be sants to become pregnant, and all nine
desired. Research has shown that when medi- have remained seizure free for an average of
cation is insufficient to control the occurrence 6 years.
314 D. C. HAMMOND
TBI and Stroke many years after a head injury. The accumulat-
Concussions and head injuries that cause ing evidence indicates that neurofeedback
emotional, cognitive, and behavioral problems offers a valuable additional treatment in the
occur as a result of many things such as motor rehabilitation of head injuries and with athletes
vehicle accidents, war (Trudeau et al., 1998), who have suffered concussions.
and sports (McCrea, Prichep, Powell, Chabor,
& Barr, 2010; McKee et al., 2009), including Alcoholism and Substance Abuse
football (Amen et al., 2011), doing headers in EEG investigations of alcoholics (and the chil-
soccer (Tysvaer, Stroll, & Bachen, 1989), and dren of alcoholics) have documented that even
boxing (Ross, Cole, Thompson, & Kim, 1983). after prolonged periods of abstinence, they fre-
Neurofeedback treatment outcome studies quently have lower levels of alpha and theta
of closed and open head injuries have been brainwaves and an excess of fast beta activity.
published (Ayers, 1987, 1991, 1999; Bounias, This suggests that alcoholics and their children
Laibow, Bonaly, & Stubbelbine, 2001; Bounais, tend to be hardwired differently from other
Laibow, Stubbelbine, Sandground, & Bonaly, people, making it difficult for them to relax.
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2002; Byers, 1995; Hammond, 2007a, Following the intake of alcohol, however, the
2007b, 2010c; Hoffman, Stockdale, Hicks, & levels of alpha and theta brainwaves increase.
Schwaninger, 1995; Hoffman, Stockdale, & Thus individuals with a biological predis-
Van Egren, 1996a, 1996b; Keller, 2001; position to develop alcoholism (and their chil-
Laibow, Stubbelbine, Sandground, & Bounais, dren) are particularly vulnerable to the effects
2001; Schoenberger et al., 2001; Thornton, of alcohol because, without realizing it, alco-
2000; Tinius & Tinius, 2001), as well as with holics seem to be trying to self-medicate in an
stroke (Ayers, 1981, 1995a, 1995b, 1999; effort to treat their own brain pathology. The
Bearden, Cassisi, & Pineda, 2003; Cannon, relaxing mental state that occurs following alco-
Sherlin, & Lyle, 2010; Doppelmayr, Nosko, hol use is highly reinforcing to them because of
Pecherstorfer, & Fink, 2007; Putnam, 2001; their underlying brain activity pattern. Several
Rozelle & Budzynski, 1995; Walker, 2007; research studies now show that the best predic-
Wing, 2001), but further high-quality research tor of relapse is the amount of excessive beta
needs to be done. One article (Hammond, brainwave activity that is present in both
2007b) reported a case of moderate severity alcoholics and cocaine addicts (Bauer, 1993,
TBI treated with the LENS, which resulted in 2001; Prichep, Alper, Kowalik, John, et al.,
the complete reversal of posttraumatic anosmia 1996; Prichep, Alper, Kowalik, & Rosenthal,
(complete loss of sense of smell) of 912 years’ 1996; Winterer et al., 1998).
duration, which was previously unheard of, Recently, neurofeedback training to teach
as well as significant clinical improvement in alcoholics how to achieve stress reduction and
postconcussion symptoms. profoundly relaxed states through increasing
A recent research review (Thornton & alpha and theta brainwaves and reducing fast
Carmody, 2008) particularly suggests that beta brainwaves has demonstrated promising
QEEG-guided neurofeedback is superior to neu- potential as an adjunct to alcoholism treatment.
rocognitive rehabilitation strategies and medi- Peniston and Kulkosky (1989) used such training
cation treatment in the rehabilitation of TBI. in a study with chronic alcoholics compared to a
Traditionally physical medicine and rehabili- nonalcoholic control group and a control group
tation physicians tell head injury patients that of alcoholics receiving traditional treatment.
112 years after a TBI they cannot expect further Alcoholics receiving 30 sessions of neurofeed-
improvement and must simply adjust to their back training demonstrated significant increases
deficits. Clinical experience and research thus in the percentages of their EEG that was in the
far clearly indicate that neurofeedback may alpha and theta frequencies, and increased
often produce significant improvements even alpha rhythm amplitudes. The neurofeedback
WHAT IS NEUROFEEDBACK 315
treatment group also demonstrated sharp more than tripled the length of stay in the
reductions in depression when compared to recovery center. On 1-year follow-up of the
controls. Alcoholics in standard (traditional) 94 patients who completed treatment, 95.7%
treatment showed a significant elevation in were now maintaining a residence, 93.6% were
serum beta-endorphin levels (an index of stress employed or in schooling, 88.3% had no
and a stimulant of caloric [e.g., ethanol] intake), further arrests, and 53.2% had been alcohol
whereas those with neurofeedback training and drug free 1 year, whereas another 23.4%
added to their treatment did not demonstrate had used alcohol or dugs only one to three
this increase in beta-endorphin levels. On times, corroborated by urinalysis.
4-year follow-up checks (Peniston & Kulkosky, Arani, Rostami, and Nostratabadi (2010)
1990), only 20% of the traditionally treated compared results from 30 sessions of neuro-
group of alcoholics remained sober, compared feedback being provided to opioid dependent
with 80% of the experimental group who had patients undergoing outpatient treatment
received neurofeedback training. Furthermore, (methadone or Buprenorpine maintenance),
the experimental group showed improvement compared with a control group that received
in psychological adjustment on 13 scales of the outpatient treatment alone. Patients receiving
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tial for the use of neurofeedback, particularly & Thompson, 2010; Kouijzer, de Moor, Gerrits,
given the high recidivism rates that attest to Buitelaar, & van Schie, 2009; Kouijzer, de Moor,
the limited effectiveness of traditional psy- Gerrits, Congedo, & van Schie, 2009; Kouijzer,
chotherapies and pharmacology treatment. This van Schie, de Moor, Gerrits, & Buitelaar, 2010;
will be another fruitful area for further research. Pineda et al., 2007; Pineda et al., 2008;
Scolnick, 2005; Sichel, Fehmi, & Goldstein,
Posttraumatic Stress Disorder 1995).
Peniston and Kulkosky (1991) added thirty L. Thompson, Thompson, and Reid (2010)
30-minute sessions of alpha=theta neurofeed- reported on a case series of 150 Asperger’s Syn-
back training to the traditional VA hospital drome patients and nine autism spectrum dis-
treatment provided to a group of posttraumatic order patients who received 40 to 60 sessions,
stress disorder Vietnam combat veterans, and commonly with some supplementary peripheral
then compared them at 30-months posttreat- biofeedback. They found very statistically sig-
ment with a contrast group who received only nificant improvements in measures of attention,
traditional treatment. On follow-up, all 14 tra- impulsivity, auditory and visual attention, read-
ditional treatment patients had relapsed and ing, spelling, arithmetic, EEG measures, and an
been rehospitalized, whereas only three of 15 average full scale IQ score gain of 9 points.
neurofeedback training patients had relapsed. Some of the studies just cited were control
Although all 14 patients who were on medi- group studies. There has also been a placebo-
cation and were treated with neurofeedback controlled study (Pineda et al., 2008), and there
had decreased their medication requirements have been 6-month (Kouijzer et al., 2010) and
by follow-up, among the patients receiving tra- 1-year follow-ups (Kouijzer et al., 2009) docu-
ditional treatment, only one patient decreased menting maintenance of positive results. A
medication needs, two reported no change, review of neurofeedback with autism spectrum
and 10 required an increase in psychiatric med- problems, which includes a review of unpub-
ications. On the Minnesota Multiphasic Person- lished papers presented as scientific meetings,
ality Inventory, neurofeedback training patients has been published by Coben, Linden, and
improved significantly on all 10 clinical scales— Myers (2010). In an as-yet-unpublished study
dramatically on many of them—whereas there cited by those authors using neurofeedback
were no significant improvements on any scales and HEG training, Coben found a 42%
in the traditional treatment group. One study reduction in overall autistic symptoms, including
(Huang-Storms, Bodenhamer-Davis, Davis, & a 55% decrease in social interaction deficits and
Dunn, 2006) has also reported positive improvements in communication and social
WHAT IS NEUROFEEDBACK 317
interaction deficits of 55% and 52%, respect- Holmes, Hirst, & Gruzelier, 2008). In a rando-
ively. Overall, neurofeedback has positive mized, placebo-controlled study with medical
research support as a beneficial treatment with students (Raymond, Varney, Parkinson, & Gru-
autism spectrum problems, with findings of zelier, 2005) neurofeedback enhanced mood,
positive changes in brain function, attention, confidence, feeling energetic and composed.
IQ, impulsivity, and parental assessments of Neurofeedback has also been shown with
other problem behaviors such as communi- objective measures to improve depression
cation, stereotyped and repetitive behavior, (Baehr, Rosenfeld, & Baehr, 2001; Hammond,
reciprocal social interactions, and sociability. 2001a, 2005b; Hammond & Baehr, 2009). The
Although neurofeedback is certainly not a cure degree to which depressed patients were able
for these conditions, it appears to usually pro- to normalize their EEG activity during neuro-
duce significant improvements in these chronic feedback has been found to significantly corre-
conditions. late with improvement in depressive symptoms
(Paquette, Beauregard, & Beaulieu-Prevost,
Anxiety and Depression 2009). A blinded, placebo-controlled study
Encouraging preliminary research has been (Choi et al., 2011) demonstrated the superiority
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periodic limb movement disorder (Hammond, controlled outcome research is still needed in
in press); physical and emotional symptoms the application of neurofeedback to various
associated with Type I diabetes mellitus problems. Placebo-controlled studies are often
(Monjezi & Lyle, 2006); essential tremor; and regarded as the very highest level of scientific
for ‘‘chemo fog’’ (Raffa & Tallarida, 2010; validation. It can be assumed that positive
Schagen, Hamburger, Muller, Boogerd, & van results from neurofeedback are due to a com-
Dam, 2001) following chemotherapy or radi- bination of expectancy (placebo) effects and
ation treatments. effects specific to the neurofeedback treatment
Mixed results have been found with neuro- (Hammond, 2011; Perreau-Linck, Lessard,
feedback treatment of fibromyalgia. An uncon- Levesque, & Beauregard, 2010), because pla-
trolled trial (Mueller et al., 2001) with 30 cebo effects appear to be an active ingredient
patients with fibromyalgia (using an early version in virtually every therapeutic modality. We
of LENS) found significant improvements in know, however, that there are improvements
mood, clarity, and sleep. C. C. S. Donaldson very specific to neurofeedback because there
et al. (1998) used an earlier version of LENS are several placebo-controlled studies that
(and a small amount of EMG biofeedback) and have demonstrated significant efficacious and
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have expressed the view that requiring 2011; Ochs, 2007). Many of these feelings pass
placebo-controlled studies in conditions where within a short time after a training session. If
there is a known effective treatment already clients make their therapists aware of such
available is considered unethical. The primary feelings, they can alter training protocols and
benefit of placebo-controlled studies is that usually quickly eliminate such mild side effects.
they clarify the mechanism of action by which
a treatment works, but they are not necessary Selecting a Qualified Practitioner
to determine the effectiveness of a treatment It is possible, however, for more significant
(e.g., the degree of improvement in attention negative effects to occur (Hammond & Kirk,
and behavior in ADD=ADHD, and in compari- 2008; Hammond, Stockdale, Hoffman, Ayres,
son with stimulant drugs). & Nash et al., 2001; Todder, Levine, Dwolatzky,
When considering how well validated com- & Kaplan, 2010), particularly if training is not
mon medical and psychiatric treatments actually being conducted or supervised by a knowl-
are, it is enlightening to learn that only 11% of edgeable, certified (http://www.bcia.org) pro-
2,711 cardiac medical treatment recommenda- fessional who will individualize the training. A
tions are based on multiple randomized con- ‘‘one-size-fits-all’’ approach that is not tailored
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trolled studies (Tricoci, Allen, Kramer, Califf, & to the individual will undoubtedly pose a greater
Smith, 2009) and only 41% are based on evi- risk of either being ineffective or of producing an
dence from a single randomized trial or nonran- adverse reaction. Due to the heterogeneity in
domized studies, whereas 48% are simply based the brainwave activity (e.g., Clarke et al.,
on ‘‘expert opinion’’ or only case studies. As yet a 2001; Hammond, 2010b; Prichep et al.,
further example, the public is generally unaware 1993) within broad diagnostic categories (e.g.,
of the fact that studies (summarized in Kirsch, ADD=ADHD, head injuries, depression, autism,
2010, and Moncrieff, 2009) of psychiatric medi- or obsessive-compulsive disorder) the treatment
cation treatment of depression have concluded requires individualization, and research is
that they are only mildly (18%) more effective increasingly showing that different treatment
than a placebo (and yet frequently associated protocols have differential effects (e.g.,
with side effects and a withdrawal syndrome). Angelakis et al., 2007; Egner & Gruzelier,
Despite these facts, insurance companies accept 2004; Gevensleben et al., 2009a, 2009b;
medication treatment for depression and a large Gruzelier & Egner, 2005; Hauri, 1981; Hauri
proportion of medical treatments as being well et al., 1982; Heinrich et al., 2004; Ros et al.,
established and effective. These facts do not 2010; Wrangler et al., 2010) on the brain.
mean that more neurofeedback outcomes stu- Thus, it is emphasized once again that
dies are desirable and needed, but it creates an everyone does not need the same treatment
important perspective that much of current and that if training is not tailored to the person,
medical and psychiatric treatment practice does the risk is greater of it being ineffective or very
not rest on as much sound scientific evidence infrequently even detrimental. For instance,
as is commonly assumed. Lubar et al. (1981) published a reversal double-
blind controlled study with epilepsy which
documented that problems with seizure dis-
ADVERSE EFFECTS, SIDE EFFECTS, AND
order could be improved with neurofeedback,
HOME TRAINING
but they could also be made worse if the wrong
Mild side effects can sometimes occur during kind of training was done. Similarly, Lubar and
neurofeedback training. For example, occasion- Shouse (1976, 1977) documented that ADD=
ally someone may feel fatigued, spacey, or ADHD symptoms could improve but also be
anxious; experience a headache; have difficulty worsened if inappropriate training was done.
falling asleep; or feel agitated or irritable. Some- As yet another example in the treatment of
times such side effects may occur because the ADD=ADHD, it was found that when a nonin-
training session is too long (Matthews, 2007, dividualized approach was used (Steiner,
WHAT IS NEUROFEEDBACK 321
Sheldrick, Gotthelf, & Perrin, 2011) with one most of the research on neurofeedback is
electrode embedded in a helmet compared based on work conducted by qualified profes-
with computerized attention training, only sionals, following individualized assessment,
modest equivalent results were found. In con- and with training sessions that are supervised
trast, when individualized neurofeedback was by a knowledgeable therapist rather than with
compared with computerized attention train- unsupervised sessions taking place in an office
ing (Gevensleben et al., 2010; Gevensleben or at home. Supervised training sessions where
et al., 2009a, 2009b; Holtmann et al., 2009), the patient is coached have been found to
neurofeedback was significantly more effective produce significantly better outcomes than
than the skills training. unsupervised sessions (Hammond, 2000).
Therefore, seeking out a qualified and cer-
tified professional who will do a comprehen-
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