M.H.M. Breteler

Efficacy of Neurofeedback Treatment in ADHD: the Effects on Inattention, Impulsivity and Hyperactivity: a Meta-Analysis

Since the first reports of neurofeedback treatment in Attention Deficit Hyperactivity Disorder (ADHD) in 1976, many studies have investigated the effects of neurofeedback on different symptoms of ADHD such as inattention, impulsivity and hyperactivity. This technique is also used by many practitioners, but the question as to the evidence-based level of this treatment is still unclear. In this study selected research on neurofeedback treatment for ADHD was collected and a meta-analysis was performed. Both prospective controlled studies and studies employing a pre-and post-design found large effect sizes (ES) for neurofeedback on impulsivity and inattention and a medium ES for hyperactivity. Randomized studies demonstrated a lower ES for hyperactivity suggesting that hyperactivity is probably most sensitive to nonspecific treatment factors. Due to the inclusion of some very recent and sound methodological studies in this meta-analysis, potential confounding factors such as small studies, lack of randomization in previous studies and a lack of adequate control groups have been addressed, and the clinical effects of neurofeedback in the treatment of ADHD can be regarded as clinically meaningful. Three randomized studies have employed a semi-active control group which can be regarded as a credible sham control providing an equal level of cognitive training and client-therapist interaction. Therefore, in line with the AAPB and ISNR guidelines for rating clinical efficacy, we conclude that neurofeedback treatment for ADHD can be considered “Efficacious and Specific” (Level 5) with a large ES for inattention and impulsivity and a medium ES for hyperactivity.

EEG PHENOTYPES PREDICT TREATMENT OUTCOME TO STIMULANTS IN CHILDREN WITH ADHD

This study demonstrates that the EEG phenotypes as described by Johnstone, Gunkelman & Lunt are identifiable EEG patterns with good inter-rater reliability. Furthermore, it was also demonstrated that these EEG phenotypes occurred in both ADHD subjects as well as healthy control subjects. The Frontal Slow and Slowed Alpha Peak Frequency and the Low Voltage EEG phenotype discriminated ADHD subjects best from controls (however the difference was not significant). The Frontal Slow group responded to a stimulant with a clinically relevant decreased number of false negative errors on the CPT. The Frontal Slow and Slowed Alpha Peak Frequency phenotypes have different etiologies as evidenced by the treatment response to stimulants. In previous research Slowed Alpha Peak Frequency has most likely erroneously shown up as a frontal theta sub-group. This implies that future research employing EEG measures in ADHD should avoid using traditional frequency bands, but dissociate Slowed Alpha Peak Frequency from frontal theta by taking the individual alpha peak frequency into account. Furthermore, the divergence from normal of the frequency bands pertaining to the various phenotypes is greater in the clinical group than in the controls. Investigating EEG phenotypes provides a promising new way to approach EEG data, explaining much of the variance in EEGs and thereby potentially leading to more specific prospective treatment outcomes.

High prevalence of benzodiazepine dependence in out-patient users, based on the DSM-III-R and ICD-10 criteria

Despite the fact that there have been many reports on benzodiazepine (BZD) dependence, consensus about its definition has not been reached. Reliable prevalence data to estimate the dependence liability of BZDs are therefore lacking. This study is the first to assess the prevalence of BZD dependence in out‐patient BZD users (115 general practice (GP) patients, 124 psychiatric out‐patients and 33 self‐help patients) on the basis of the DSM‐III‐R and ICD‐10 substance dependence criteria. Past year and lifetime diagnoses of BZD dependence were made by means of the Schedules for Clinical Assessments in Neuropsychiatry (SCAN). High prevalence figures were found, ranging from 40% in the GP patients (DSM‐III‐R past year) to 97% in the self‐help patients (ICD‐10 lifetime), indicating that BZD users run a high risk of developing BZD dependence. The clinical management of BZD use could benefit from further development of diagnostic instruments such as a self‐report questionnaire which reflects the severity of BZD dependence.

Restraint Scale, its sub-scales concern for dieting and weight fluctuation

Abstract The Herman and Polivy Restraint Scale (RS) contains items which assess weight fluctuation (WF) and subjective concern for dieting (CD). A number of studies have determined relationships with the RS-sub-scales WF and CD, but these subscales are not factorially simple, and there is no agreement on their predictive power for weight suppression and overeating. In the present study RS sub-scales were constructed which are factorially unidimensional and their constructive and predictive validity was assessed. Two items were deleted from the original sub-scales, one item on splurging (from CD), and one item on weight history (from WF). RS-CD measures restrained eating, but RS-WF is not covered by other measures for eating behaviour or BMI. RS-WF had the greatest predictive power for ice cream consumption, but may have suppressed the preload × restraint interaction for the total RS. Use of the total RS should be discouraged.

Predictors of long-term benzodiazepine abstinence in participants of a randomized controlled benzodiazepine withdrawal program

Objective: To identify predictors of resumed benzodiazepine use after participation in a benzodiazepine discontinuation trial. Method: We performed multiple Cox regression analyses to predict the long-term outcome of a 3-condition, randomized, controlled benzodiazepine discontinuation trial in general practice. Results: Of 180 patients, we completed follow-up for 170 (94%). Of these, 50 (29%) achieved long-term success, defined as no use of benzodiazepines during follow-up. Independent predictors of success were as follows: offering a taper-off program with group therapy (hazard ratio [HR] 2.4; 95% confidence interval [CI], 1.5 to 3.9) or without group therapy (HR 2.9; 95%CI, 1.8 to 4.8); a lower daily benzodiazepine dosage at the start of tapering off (HR 1.5; 95%CI, 1.2 to 1.9); a substantial dosage reduction by patients themselves just before the start of tapering off (HR 2.1; 95%CI, 1.4 to 3.3); less severe benzodiazepine dependence, as measured by the Benzodiazepine Dependence Self-Report Questionnaire Lack of Compliance subscale (HR 2.4; 95%CI, 1.1 to 5.2); and no use of alcohol (HR 1.7; 95%CI, 1.2 to 2.5). Patients who used over 10 mg of diazepam equivalent, who had a score of 3 or more on the Lack of Compliance subscale, or who drank more than 2 units of alcohol daily failed to achieve long-term abstinence. Conclusions: Benzodiazepine dependence severity affects long-term taper outcome independent of treatment modality, benzodiazepine dosage, psychopathology, and personality characteristics. An identifiable subgroup needs referral to specialized care.

Scalability, reliability, and validity of the benzodiazepine dependence self-report questionnaire in outpatient benzodiazepine users

As there is no multidimensional instrument available that reflects the severity of benzodiazepine (BZD) dependence comprehensively, the Benzodiazepine Dependence Self-Report Questionnaire (Bendep-SRQ) was developed and investigated. The Bendep-SRQ, Symptom Checklist-90 (SCL-90), Schedules for Clinical Assessments in Neuropsychiatry (SCAN), and Addiction Severity Index-Revised (ASI-R) were administered to 115 general practice (GP) patients, 124 psychiatric outpatients, and 33 self-help patients who were using BZDs. Factor and Rasch analyses were applied to construct scales. Reliability assessments were made in terms of subject discriminability, item discriminability, and test-retest stability. To support the construct validity of the scales, theoretical rationales were required to explain the specific item order provided by the Rasch scale values. To assess the concurrent and discriminant validity, a matrix consisting of the above-mentioned measures was factor-analyzed. Four Rasch-homogeneous scales were delineated: problematic use, preoccupation, lack of compliance, and withdrawal. Nearly all subject discriminability, item discriminability, and test-retest results indicated good reliability. A BZD dependence factor was extracted with high loadings for the Bendep-SRQ scales and the concurrent measures. The discriminant measures had high loadings on other factors. The scalability, reliability, and validity of the Bendep-SRQ scales appeared to be good. The Bendep-SRQ shows great promise as a useful and easily manageable instrument for assessment of the severity of BZD dependence in clinical practice and scientific research.

Compulsive smoking: the development of a Rasch homogeneous scale of nicotine dependence

The unidimensionality of nicotine dependence has not been established firmly yet. The aim of this study was to assess the dimensionality of nicotine dependence, preferably meeting the strict assumptions of the Rasch model. First, we examined the validity of the Fagerström Test for Nicotine Dependence (FTND) [Br. J. Addict. 86 (1991) 1119.] in 1525 smokers who participated in a national survey considering smoking behavior. Two factors were found, suggesting that the FTND does not measure a unidimensional construct. Factor analysis of 19 other dependence items in 512 smokers resulted in four factors of which three were interpretable: compulsive smoking, social problems due to smoking, and physical dependence. We focused on smoking compulsivity. This factor turned out to consist of a four-item Rasch homogeneous scale. Two items of the FTND with face validity of smoking compulsivity were found to fit into the scale. The results of Rasch analysis were in support of a continuum of compulsivity. Difficulty refraining from smoking in places where it is forbidden was found to indicate highest compulsivity. Several correlates with smoking compulsivity were found. We conclude that compulsive smoking is one important dimension of nicotine dependence, which may account for the considerable relapse of this disorder.

No effect of negative mood on the alcohol cue reactivity of in-patient alcoholics

Forty in-patient alcoholics were exposed to an alcohol cue (holding and smelling an alcoholic drink) while in a negative mood, and while in a neutral mood. For the negative mood condition either a distressing or depressing Mood Induction Procedure (MIP) was used. In the control condition, a neutral MIP was used. In the negative mood condition, the subjects were found to be more distressed, more irritated, less calm, and less satisfied than in the neutral mood condition. In all conditions, following exposure to the alcohol cue, the desire to drink, systolic blood pressure, and heart rate variability increased, while self-efficacy beliefs to resist the urge to drink, and heart rate decreased. In sum, alcohol cue reactivity was observed, but not in response to a negative as opposed to a neutral mood or a distressed versus a depressed mood.

Withdrawal Symptoms and Previous Attempts to Quit Smoking: Associations with Self-Efficacy

This study examines the relationship between self-efficacy and sustained smoking cessation in Dutch quitters attending a group program for smoking cessation in 1991. Increase in self-efficacy during treatment was found to be a predictor of outcome after controlling for demographic characteristics and cessation history variables. Relapsers (n = 75) showed more negative relationships between self-efficacy and withdrawal symptoms than long-term abstainers (n = 58). Relapsers who were more depressed during the attempt under study were less self-efficacious at the end of treatment. In addition, the duration of the previous attempt to quit smoking proved to be differently associated with self-efficacy for quitters and relapsers.

General practice counseling for patients with chronic obstructive pulmonary disease to quit smoking: impact after 1 year of two complex interventions.

OBJECTIVE To evaluate two counseling programs in general practice to help smokers with chronic obstructive pulmonary disease (COPD) to quit smoking. METHODS Cluster randomized controlled trial including 68 general practices (667 patients) using a randomly assigned intervention program with counseling and advice about nicotine replacement therapy (and additional bupropion-SR in one of the programs) or usual care. Usual care consisted of periodic regular check-ups and COPD information. The main outcome measure was biochemically verified point prevalence at 12 months. RESULTS The two intervention groups were treated as one in the analysis because they were equally effective. The intervention resulted in a significantly self-reported higher success rate (14.5%) compared to usual care (7.4%); odds ratio=2.1, 95% confidence interval=1.1-4.1. Biochemically verified quit rates were 7.5% (intervention) and 3.4% (usual care); odds ratio=2.3, 95% confidence interval=0.9-6.0. CONCLUSION The program doubled the cessation rates (statistically nonsignificant). Too few participants used the additional bupropion-SR to prove its effectiveness. PRACTICE IMPLICATIONS The protocols can be used for COPD patients in general practice, but expectations should be modest. If quitting is unsuccessful, a stepped care approach should be considered.