David L. Trudeau

EEG Biofeedback as a Treatment for Substance Use Disorders: Review, Rating of Efficacy and Recommendations for Further Research

Electroencephalographic (EEG) biofeedback has been employed in substance use disorder (SUD) over the last three decades. The SUD is a complex series of disorders with frequent comorbidities and EEG abnormalities of several types. EEG biofeedback has been employed in conjunction with other therapies and may be useful in enhancing certain outcomes of therapy. Based on published clinical studies and employing efficacy criteria adapted by the Association for Applied Psychophysiology and Biofeedback and the International Society for Neurofeedback and Research, alpha theta training—either alone for alcoholism or in combination with beta training for stimulant and mixed substance abuse and combined with residential treatment programs, is probably efficacious. Considerations of further research design taking these factors into account are discussed and descriptions of contemporary research are given.

Template for Developing Guidelines for the Evaluation of the Clinical Efficacy of Psychophysiological Interventions

An essential function of both the Association for Applied Psychophysiology and Biofeedback (AAPB) and the Society for Neuronal Regulation (SNR) is the systematic evaluation of psychophysiological interventions that have been developed for the treatment of medical and psychiatric disorders. In order to address scientific concerns regarding the efficacy of specific clinical applications of biofeedback, these two societies formed and Efficacy Task Force. The process to be used in the assessment of treatment efficacy, specificity and clinical utility is presented in the form of a template that will serve as the foundation for a series of scientific reviews and practice guidlines to be published by both societies.

The treatment of addictive disorders by brain wave biofeedback: a review and suggestions for future research.

INTRODUCTION This paper is presented as one of a series of papers in a focal issue of Clinical EEG describing and reviewing clinical brain wave biofeedback. The objective of this paper is to review the reported work on EEG biofeedback in Psychoactive Substance Use Disorder (PSUD) to date, the critical studies that have been undertaken. and to suggest further research directions. In the latter, the paper does not purport to offer the last word on possibilities for future research of EEG biofeedback and PSUD, but will make some contributions to that ongoing dialogue. This paper will give some mention of two other disorders featured in this issue, attention deficit hyperactivity disorder (ADHD) and traumatic brain injury (TBI), as important comorbidities in terms of their confounding impact on brain wave biofeedback of PSUD. No attempt will be made to review the field of biofeedback or of addictive disorders generally, although references will be made to specifics that are pertinent to a discussion of some emerging concepts of EEG biofeedback as a treatment for PSUD. In reviewing the findings reported to date on the use and effectiveness of EEG biofeedback in the treatment of PSUD, one is hampered by the paucity of published studies. Unfortunately, large controlled multi-center studies have yet to be reported, and a review of the existing literature is limited to case studies, open clinical trials and a few small controlled and randomized studies mainly focused on alpha-theta feedback. This paper will summarize those reports, as well as reports from several controlled placebo condition studies that have focused on assessing the specificity of alpha-theta to therapeutic effect. Before there is wide acceptance of brain wave biofeedback clinically, much more research is needed. In research design, the existing broad literature on outcome assessment of PSUD and PSUD psychiatric comorbidity needs to be taken into account. This paper will not attempt to review the literature generally related to outcome design and comorbidity, but will focus on specifics from these areas related to brain wave biofeedback study design. As discussed in the following sections, brain wave biofeedback was originally conceptualized as a way to augment insight and motivation through guided imagery in alcoholics, and the focus of initial implementation was on achieving very relaxed hypnagogic states using occipital slow wave feedback. However, much information has come to the fore regarding specific EEG aberrations in PSUD. It is beyond the scope of this paper to review the voluminous literature on EEG and QEEG in PSUD. However, several QEEG studies point to very specific abnormalities likely associated with drug neurotoxicity, suggesting that specific EEG biofeedback protocols may be studied for effect on these conditions. This is especially so in light of the potential for EEG biofeedback to address neurologically based problems such as TBI and ADHD that also may be associated with specific EEG abnormalities. This paper will selectively discuss some of these findings that may be pertinent to study design.

Standards of Practice for Neurofeedback and Neurotherapy: A Position Paper of the International Society for Neurofeedback & Research

This position paper of the International Society for Neurofeedback and Research (ISNR) sets forth standards and guidelines for the practice of neurofeedback and neurotherapy. Issues discussed include competency, qualifications of practitioners, scope of practice, informed consent, pretreatment assessment, standards for remote training, record keeping and billing, accountability, standards for practitioner training and qualifications to be trained, adequate supervision and coaching of training sessions, ethical advertising, standards for professional societies, and standards for those who sell and manufacture neurofeedback equipment.

Review of Rationale for Neurofeedback Application in Adolescent Substance Abusers with Comorbid Disruptive Behavioral Disorders

Neurofeedback is a type of operant conditioning in which an individual modifies the frequency, amplitude, or other characteristic of his or her own brain activity as measured by EEG. Neurofeedback-training-based neurotherapy is one of the potentially efficacious nonpharmacological treatment options for substance use disorders (SUD) in adults, but it is also a very promising as a treatment modality for adolescents, especially those with stimulant abuse and attention and conduct problems. There is practically no literature on the use of neurofeedback in adolescent drug abusers. Treatment of attention-deficit/hyperactivity disorder (ADHD) with neurofeedback has already gained substantial empirical support in recent years. Short-term effects were shown to be comparable to those of stimulant medication at the behavioral and neuropsychological level, leading to significant decreases of inattention, hyperactivity, and impulsivity. In addition, neurofeedback results in concomitant improvement and normalizations o...

Quantitative EEG Findings Associated with Chronic Stimulant and Cannabis Abuse and ADHD in an Adult Male Substance Use Disorder Population

QEEG was studied in a population of chronic male PSUD/ADHD (psychoactive substance use disorder/attention deficit hyperactivity disorder) subjects vs. a matched sample of non-ADHD subjects with PSUD. Our first interest in conducting this study was to determine if the Thatcher University of Maryland database and complex demodulation method could replicate the specific QEEG findings reported for cocaine and cannabis using the John-NYU database and Fourier Transform method. The effects of cannabis and stimulants were also studied both separately and together to see if there were interactions and to see if the QEEG changes associated with chronic stimulant dependence were predicted by childhood ADHD status. Eyes-closed QEEGs were obtained and two independent artifacted 60 second samples were compared for reliability. The Thatcher database was used to analyze QEEG data from 56 subjects with mixed substance use disorder. Results showed that the Thatcher database replicates the John database for chronic stimulant dependence findings. Because of confounding variables of alcohol and polysubstance abuse, the findings related to cannabis and stimulant interaction were difficult to assess. Cannabis and stimulant dependence together produced more QEEG changes than either alone. More right temporal abnormalities were observed with stimulant dependence. In the absence of stimulant use, the QEEG effects of cannabis were relatively small; however, sample selection and methods used precluded comparison to previous studies. The persistent QEEG abnormalities associated with chronic stimulant dependence were independent of ADHD status in this sample using the methods of this study. Further research is needed to clarify the relationship of stimulant dependence with QEEG changes and ADHD status, and to clarify the interactions of chronic stimulant and cannabis abuse on QEEG.

Treating Addiction Disorders

Substance use disorders (SUDs) are among the most common psychiatric conditions, resulting in serious behavioral impairments and cognition decline. Acute and chronic drug abuse, drug dependency and drug withdrawal result in significant alteration of the electroencephalogram (EEG). EEG biofeedback has been used in the treatment of alcohol and mixed substance abuse in residential inpatient populations. More recent outpatient approaches have used quantitative EEG (qEEG) guided neurofeedback, neurofeedback (NFB) integrated with motivational interviewing and LORETA neurofeedback. A recent review of the state-of-art of qEEG and NFB in SUD and earlier reviews have detailed the efficacy ratings and clinical uses of NFB for SUD. In these reviews NFB is rated “probably efficacious” as an add-on (adjunct) treatment to other therapies, namely 12-step programs and/or cognitive behavioral therapies, or other types of psychotherapies or residential programs. Neurofeedback is not yet validated as a stand-alone therapy for addictive disorders and cannot yet be considered a mainstream therapy for addiction. Many persons with SUD have comorbid conditions that need to be considered in designing a treatment plan that incorporates neurofeedback. These include mental conditions such as depression, posttraumatic stress disorder, and attention deficit hyperactivity disorder that may require separate neurofeedback treatment for those specific conditions either preceding neurofeedback treatment for addiction, or incorporated into it. This approach may require separate assessments during the course of therapy to determine response and the need to change protocols or seek other treatments, i.e., medication or psychotherapy, to integrate into the treatment plan update.