QEEG abnormal

in Psychiatric Setting

Neurofeedback Clinical Training

Santi Yuliani
MD., M.Sc. Psychiatrist
Psychiatric Disorder

• growth
• function
Hardware

• electricity
• neurotransmitter
Software
NFB  Neuroplasticity
• neuroplasticity and neurogenesis (growth of
new neurons) can alter
the architectural connectivity between brain
regions  which directly impacts cognitive,
behavior and affective
Dysfunctional Brain Wave

May have
• too much of some
frequencies over others or
wrong place
• unstable frequencies
• an impaired ability to
shift from one
mental state to another.

4
During eyes closed
baseline rest, the theta
rhythm (4-8 Hz)
dominates the spectral
energies of a child’s brain
whereas the alpha rhythm
(8-12 Hz) dominates the
adult brain.
 DELTA
• Delta waves are produced during stages of deep
sleep and they are associated with the production
of Human Growth Hormone which is necessary for
growth, healing and tissue repair.

• If a person’s brain is unable to produce delta waves,

then a deficiency of Human growth hormone may
result.

• This can lead to conditions such as fibromyalgia,

tension headache, migraine headache, insomnia,
and chronic pain.
 THETA WAVES
• Over 25 different research studies have
demonstrated that children and adults with
ADHD produce unusually high levels of this
wave.

• It has been suggested that measuring Theta

wave levels is the most accurate method for
diagnosing ADHD.
 ALPHA WAVES

• Alpha waves are also known as the meditative

brain wave. This is because when a person
meditates the brain waves shift to alpha.
• Alpha is associated with relaxation, calmness
and a sense of wellbeing.
• Alpha is also associated with the ability of the
brain to enter deep sleep.
 ALPHA WAVES
• If a person’s brain produces unusually low levels
of alpha then it will be impossible to enter delta
sleep – a disorder known as insomnia.

• This finding has also been linked to conditions

such as hyperactivity, migraine headache,
tension headache, fibromyalgia.
 SENSORIMOTOR RHYTHM (SMR)
• These are the brain waves that are produced
when a person is completely still and focused on
one particular task.

• The Olympic high diver standing stop his diving

board just before the dive, or the golfer standing
perfectly still just before his swing are just two
examples of when the brain is producing SMR
waves.
 BETA WAVES
• The brain produces beta waves when the
individual is alert and externally focused.

• Established research studies have demonstrated

that children and adults suffering from ADHD
produce unusually low levels of beta waves.
 BETA WAVES
• This finding may help explain why these patients
are unable to stay focused on certain tasks.

• On the other hand, if the brain produces too

many of these beta waves the individual may
become hyperactive and anxious.
Brainwave Summary:
Name: Frequency: Function: Too much: Too little:

DELTA 1-4 Hz deep sleep lethargy, too diminished

much sleep capacity for
sleep

THETA 4-7 Hz sleep, “brain fog”, decreased

creativity, day emotionality
intuition, dreaming, & sense of
spontaneity inattention self

ALPHA 7-12 Hz inner calm, sluggish, anxiety &

meditation, idle, & reduced
inwardly anxiety ability to
focused relax
13
EEG bandwidths cont… :
Name: Frequency: Function: Too much: Too little:

SMR 12-15 body= heightened poor

relaxed IQ, but also sustained
Hz mind= anxiety attention
(ex: driving)
focused

BETA 15-20 alert & heightened inattention,

externally IQ, anxiety, lowered
Hz focused & over-focus external
focus

HIGH 20-40 logical, hyper- diminished

sequential, vigilance, ability for
BETA Hz & analytical attention vigilance,
thinking surplus emotionality
14
Neurophysiological and Psychophysiological
Approaches to Schizophrenia and Its Pathogenesis
Keith H. Nuechterlein, and Michael E. Dawson

EEG Findings in Schizophrenia

• Consistent with hyperactivation are quantitative results
showing that EEGs of schizophrenic subjects have lower alpha
power, increased variability of frequency, and higher wave
symmetry than comparison subjects .
• Given that excesses in both slow and fast EEG activity have
been reported, however, Shagass suggests that dysregulation
of brain activity in schizophrenia might be a more basic
problem than hyperactivation per second.
EEG Findings in Schizophrenia
• Several topographic EEG studies have found evidence
of excessive slow activity (delta) in frontal areas.
This is conceptually consistent with PET and regional
cerebral blood flow evidence of reduced frontal
activity in at least some schizophrenic patients and
was correlated within schizophrenic samples with PET
hypofrontal metabolic patterns.
 Schizophrenia
• Q EEG
• Aktivitas gel.beta meningkat
• Aktivitas gel.alfa menurun
• Aktivitas gel.delta meningkat
Neurophysiological and Psychophysiological Approaches to
Schizophrenia and Its Pathogenesis
Keith H. Nuechterlein, and Michael E. Dawson

EEG Findings in Schizophrenia

• Consistent with hyperactivation are quantitative results showing that EEGs of
schizophrenic subjects have lower alpha power, increased variability of
frequency, and higher wave symmetry than comparison subjects .
• Given that excesses in both slow and fast EEG activity have been reported,
however, Shagass suggests that dysregulation of brain activity in
schizophrenia might be a more basic problem than hyperactivation per se.
Neurophysiological and Psychophysiological Approaches to
Schizophrenia and Its Pathogenesis
Keith H. Nuechterlein, and Michael E. Dawson

EEG Findings in Schizophrenia

• Several topographic EEG studies have found evidence of excessive slow
activity (delta) in frontal areas. This is conceptually consistent with
PET and regional cerebral blood flow evidence of reduced frontal activity in at
least some schizophrenic patients and was correlated within schizophrenic
samples with PET hypofrontal metabolic patterns.
 Neuroleptic
“Tranquilizers” such as chlorpromazine, or it’s
equivalent, increase the coherence of the EEG and
decrease beta, however they increase temporal and
frontal sharp morphologic theta transients.

• Thioridazine also increases faster activity,

accounting for its commonly reported
antidepressant effects.

• Clozapine shows the typical neuroleptic pattern

 ADHD
• Aktivitas gelombang thetha meningkat
• Aktivitas gelombang beta menurun
Differentiating ADHD from Other Psychiatric Disorders via QEEG
Scan -2
Monastra,VJ.

Abstract
Recent quantitative electroencephalographic (QEEG) studies have revealed evidence of cortical
hypoarousal over frontal and central, midline regions in patients diagnosed with
attention-deficit/hyperactivity disorder (ADHD). In order to determine whether these QEEG
characteristics were specific for patients with ADHD, a power spectral analysis was conducted on the
QEEG recordings obtained from a total of 314 child/adolescent psychiatric patients (176 diagnosed
with ADHD, 138 diagnosed with an anxiety, mood or oppositional defiant disorder).
Power ratios were calculated comparing picoWatt (pW) output at 4-8 Hz (theta) with output at 13-21
Hz (beta), as recorded at the vertex (Cz), while the patients were involved in academic tasks.

Results of the study indicated that patients diagnosed with ADHD exhibited
significantly greater theta/beta power ratios than each of the comparison
psychiatric groups (p < .001), supporting a cortical underarousal model of
ADHD.
Examination of the classification accuracy of the QEEG procedure revealed a test sensitivity for ADHD
of 78% with test specificity of 95%, suggesting that cortical hypoarousal at the vertex is not a
neurophysiological characteristic of
oppositional, mood or anxiety disorders.
 Quantitative analysis of EEG in boys with attention-deficit-
hyperactivity disorder: controlled study with clinical
implications.
Mann CA, Lubar JF, Zimmerman AW, Miller CA, Muenchen RA.
Abstract
Sixteen-channel topographic brain mapping of electroencephalograms of 25 right-handedmales, 9-12 years of
age,

with attention-deficit-hyperactivity disorder revealed increased theta (4-7.75 Hz) and

decreased beta 1 (12.75-21 Hz)

when compared with 27 controls matched for age and grade level. The differences were greater when patients
were tested for reading and drawing skills, but were decreased when they were at rest during visual
fixation. Although the differences in patients with attention-deficit-hyperactivity disorder were generalized,

increased theta was more prominent in frontal regions, while beta 1 was
significantly decreased in temporal regions.

Principal component analysis was used to combine the variables into 2 components which accounted for 82% of
the total variance. A discriminant function analysis using these components was able to predict group
membership for attention-deficit-hyperactivity disorder patients 80% of the time and 74% for controls.
These findings support the use of topographic electroencephalography for further elucidation of the
neurophysiology of attention-deficit-hyperactivity disorder.
This information was retrieved, real-time, on your behalf from the public area
of the Pubmed website:
1. Dement Geriatr Cogn Disord. 2003 ;15(2):106-14

Quantitative EEG abnormalities and cognitive dysfunctions in

Frontotemporal Dementia and Alzheimer's Disease.

Lindau M, Jelic V, Johansson SE, Andersen C, Wahlund LO, Almkvist OKarolinska

Institutet, Department of Clinical Neuroscience, Occupational Therapy and
Elderly Care Research, Huddinge University Hospital, Stockholm, Sweden.
maria.lindau@telia.com

OBJECTIVE: To investigate the relationship between quantitative EEG (qEEG)

measurements in frontotemporaldementia (FTD), Alzheimer's disease (AD) and
healthy controls and to study to what extent qEEG in FTD and AD or
neuropsychological test results of FTD and AD patients or a combination of
both contribute to classification accuracy.
RESULTS: In comparison to controls FTD patients were marked by an absence of an
increase in slow qEEG activities and a decrease in fast activities, whereas
AD patients were marked by an increase in slow activities and
a smaller decrease in fast activities. According to the Mann-Whitney U
test the cognitive functions of attention, visuospatial thinking and episodic memory
were significantly better in FTD than in AD. Using logistic regression analysis the
best predictors of FTD and AD were in a model using the delta and theta activities,
and high levels of visuospatial ability and episodic memory. Classification accuracy
of the model was 93.3%.

PMID : 12566600 [PubMed - Indexed for MEDLINE]

 Demensia (Alzheimer type)
Q EEG
• Peningkatan aktivitas gel.delta (frontal,parietal)
• Penurunan aktivitas gel.alfa
• Penurunan aktivitas gel.beta

Protocol Neurofeedback
Promoted : Alpha / Beta
Supressed : Delta
This information was retrieved, real-time, on your behalf from the public area
of the Pubmed website:
1. Dement Geriatr Cogn Disord. 2003 ;15(2):106-14

Quantitative EEG abnormalities and cognitive dysfunctions in

Frontotemporal Dementia and Alzheimer's Disease.

Lindau M, Jelic V, Johansson SE, Andersen C, Wahlund LO, Almkvist OKarolinska

Institutet, Department of Clinical Neuroscience, Occupational Therapy and
Elderly Care Research, Huddinge University Hospital, Stockholm, Sweden.
maria.lindau@telia.com

OBJECTIVE: To investigate the relationship between quantitative EEG (qEEG)

measurements in frontotemporaldementia (FTD), Alzheimer's disease (AD) and
healthy controls and to study to what extent qEEG in FTD and AD or
neuropsychological test results of FTD and AD patients or a combination of
both contribute to classification accuracy.
RESULTS: In comparison to controls FTD patients were marked by an absence of an
increase in slow qEEG activities and a decrease in fast activities, whereas
AD patients were marked by an increase in slow activities and
a smaller decrease in fast activities. According to the Mann-Whitney U
test the cognitive functions of attention, visuospatial thinking and episodic memory
were significantly better in FTD than in AD. Using logistic regression analysis the
best predictors of FTD and AD were in a model using the delta and theta activities,
and high levels of visuospatial ability and episodic memory. Classification accuracy
of the model was 93.3%.

PMID : 12566600 [PubMed - Indexed for MEDLINE]

 Depresi
• Q EEG
• Aktivitas gel.delta meningkat (temporoparietal
kanan)
• Aktivitas gel.beta meningkat (bifrontal)
 Depression
Alpha asymmetry in the EEG:

Left Right

33
Raw EEG:

34
Raw EEG:

35
 Anxiety

 Left hemisphere is more dopaminergic

 Underactivation on the left = depression

 Right hemisphere is more noradrenergic

 Overactivation of the right = anxiety

36
 Neurofeedback & anxiety:

Normal EEG at CZ

EEG with excessive beta at CZ

37
 Neurofeedback Protocol:
• Depression protocols:

– address alpha asymmetry

– help to relieve underarousal / hypoactivation
– inhibit slower frequencies

• Anxiety protocols:

– Address beta asymmetry

– Help to relieve overarousal
– Inhibit higher frequencies
38
Anxiolytics
• Meprobamate  decreases alpha and
increases beta over 20 Hz, also slightly
increasing theta
• The benzodiazapines, like Valium or
Ativan also decrease alpha and increase the
20-30 Hz band
Antidepressant
Imipramine:
produces an increase in slow activity, a decrease in
alpha and high alpha, with an increase in the faster
beta frequencies in the mid to upper 20 Hz range and
up.
Amitriptyline:
produces more slowing than imipramine
Ipronazid:
produces a slight increase in slower activity, though it
produces a marked increase in faster activity.
Antidepressants
• MAO Inhibitors:
Isocarboxazide increases 30-20 Hz and
decreases slow waves
• SSRIs:
Fluoxetine have fewer changes in the slow
activity (associated with less
viscero/autonomic side-effect), with a mild
fronto-central beta increase in the range of
18-25 Hz
THC
• These studies found that THC produced a
transient dose-dependent rapid onset;
• decrease in alpha frequency, increase in theta
frequency

Protocol Neurofeedback?
Opiate
• The neurofeedback treatment consisted of
sensory motor rhythm training on, followed by
an alpha-theta protocol.
• The study supports the effectiveness of
neurofeedback training as a therapeutic
method in opiate dependence disorder, in
supplement to pharmacotherapy.
Alcoholism
• Increase Beta, decrease alpha and delta

• Protocol Neurofeedback?
DIAGNOSIS AND CHOOSING
PROTOCOL
Protocol
• SMR/Theta: promoted rhythm - SMR,
suppressed rhythms - Theta, Beta2
• Beta/Theta: promoted rhythm - Beta,
suppressed rhythm - Theta, Beta2
• SMR/Delta: promoted rhythm - SMR,
suppressed rhythm - Delta, Beta2
• Beta/Delta: promoted rhythm- Beta,
suppressed rhythms – Delta, Beta2
• Alpha/Theta: promoted rhythm- Alpha,
suppressed rhythm - Theta.
Protokol Neurofeedback
Case 1
• Laki-laki 45 tahun, datang dengan keluhan;
6 bulan terakhir mengalami gangguan dalam
bekerja, mudah khawatir, muncul perasaan
berdebar-debar, kehilangan konsentrasi tiba-
tiba.
Pasien juga mengalami kesulitan tidur,
terbangun di tengah malam karena mimpi
buruk dan sulit masuk tidur lagi
• Di gelombang apakah kemungkinan gangguan
pada pasien tersebut?
• Protocol apakah yang akan kita pilih pada
kondisi pasien kita tersebut?
Case 2
• Seorang anak umur 7 tahun datang dibawa
ibunya dengan keluhan tidak naik kelas karena
tidak bisa mengikuti beberapa mata pelajaran
dengan baik. Gurunya mengatakan bahwa si
anak sering bicara sendiri, mondar-mandir,
tidak memperhatikan pelajaran dan tidak
pernah selesai mengerjakan tugasnya.
• Di gelombang apakah kemungkinan gangguan
pada pasien tersebut?
• Protocol apakah yang akan kita pilih pada
kondisi pasien kita tersebut?
Case 3
• Seorang wanita 28 tahun datang di bawa
keluarganya dengan keluhan sudah 5 tahun
mengalami gangguan perilaku berupa bicara
sendiri, merasa dirinya adalah ratu di kerajaan
tanah jawa dan mampu membaca pikiran
orang lain.
• Pasien sudah mendapatkan pengobatan
farmakoterapi tetapi keluarga ingin
mendapatkan terapi yang lain
• Di area manakah gangguan yang terjadi pada
pasien tersebut
• Di titik manakah penempatan elektrode yang
akan di pilih pada pasien tersebut?
Review Brain Mapping
• Standart Deviasi
• Apakah yang disebut normal?
• Apakah yang disebut abnormal?
Case 4
• Jelaskan gambaran gelombang pada gambar
di atas
• Protocol apa yang akan kita pilih untuk terapi
kondisi tersebut
Case 5
• Sebutkan permasalahan gelombang pada
gambar diatas
• Kemungkinan diferensial diagnosisnya
• Tatalaksana protocol
doktersanti@gmail.com
THANK YOU