qEEG & Neurofeedback Brain Training

Karen Dodge, PhD, MSPH, MSW

Course Outline Handouts!
Definition of NFB
Introduction to qEEG guided Neurofeedback
Explanation of qEEG evaluation/Measures
Explanation of the Neurofeedback Intervention or Brain Training TX
The business end of qEEG NFB

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Neurofeedback Defined


Like other forms of biofeedback, NFT uses monitoring devices to provide







moment-to-moment information to an individual on the state of their physiological functioning The characteristic that distinguishes NFT from other biofeedback is a focus on the Central Nervous System NFT has its foundations in basic and applied neuroscience as well as databased clinical practice. It takes into account behavioral, cognitive and subjective aspects as well as brain activity (ISNR, 2014) It works on Operant Conditioning

1 D.Corydon Hammond, “What is Neurofeedback” Journal of Neurotherapy, Investigations in Neuromodulation, Neurofeedback and applied Neuroscience” 10.4 (2007) : 25-36. DOI 1300/J184v10n04_04

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Neurofeedback is considered an integrative approach and works well with other modalities; it provides more complete TX













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Group therapy Individual Therapy Family Reconstruction Psychiatry/Medication Psychology/testing and roll out of talk therapy Hypnosis EMDR Exposure Breath/Body work/DBT 12-Step

Coburn et al., “The Value of Quantitative Electroencephalography in Clinical Psychiatry: A Report by the Committee on Research of the American Neuropsychiatric Association” The Journal of Neuropsychiatry and Clinical Neurosciences 18 (2006):460-500

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A step-wise explanation of qEEGguided neurofeedback









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Orientation/SCL Acquire EEG, convert into qEEG; set up SCL Set up file Structure; add Excel capacity Brain Mapping Surface Z scores; LORETA & 3-D Develop Protocols (guided by symptoms and metrics 3 format) for a custom TX. in a hybrid Report Creation sent to therapists to mull over Select issues to be addressed working w/ primary DX., first First 10 sessions of NFB Brain Training Brain Mapping again to indicate progress and changes Second 10 sessions of NFB Brain Training for another symptom using custom protocol

John N. Demos, Getting Started with Neurofeedback , New York: W.W. Norton & Company Inc (2005)

Current Problems or Symptoms Denial of a problem Attention Deficits- Easily distractible, etc Auditory sequencing (listening & putting things in correct order) Balance Problems Blurred Vision Chronic Pain Compulsive behaviors and/or thoughts Decreased tactile (touch) or skin sensitivity Delusional (distorted or fixed idea(s)) Depression (sad or blue) Difficulty understanding social cues Difficulty calculating e.g., math Dyslexia- letter reversal Executive Function problems (judgment, decision making, self monitoring, organizing, etc.) Face Recognition Problems Failure to initiate action Generalized Anxiety Hyperactive and/or agitation Impulsive Behaviors

SEVERITY

Age Started

Optional Comment

(1 to 10)

If severity >3

Use back if necessary

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What is a qEEG?

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A qEEG (quantitative Electroencephalography) is a computer generated analysis of EEG data, providing information about cortical timing.




The analysis provided identifies variations from the norm/average as compared to a normative database.

4 Robert W. Thatcher Ph.D, “LORETA Z Score Biofeedback” Neuroconnections (2010) 5 John R. Hughes,MD, Ph.D and E. Roy John, Ph.D, “Conventional and Quantitative Electroencephalography in Psychiatry” The Journal of Neuropsychiatry and Clinical Neurosciences 11 (1999):190-208

qEEG Measures

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Fig. 1 – Example of conventional digital EEG (left) and qEEG (right) on the same screen at the same time. The conventional EEG includes examination and marking of EEG traces and events. The qEEG (right) includes the Fast Fourier Transform (Top right) and normative database Z scores (Bottom right). 6 Thatcher Ph.D et al, “Z-Score EEG Biofeedback: Technical Foundations” www.appliedneuroscience.com

Brain Mapping Measures Used

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Thatcher Ph.D et al, “Z-Score EEG Biofeedback: Technical Foundations” www.appliedneuroscience.com

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Robert W. Thatcher Ph.D, “LORETA Z Score Biofeedback” Neuroconnections (2010)

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Brodmann Areas

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Location

Functions

Right Hemisphere

Left Hemisphere

Supramarginal Gyrus/ Somatosensory

Economic decisions, (bilateral) goals, pain, conscious awareness of visual spatial events (bilateral), activation at rest- default mode network (bilateral)

Personal space, estimate, metaemotions, mental rotation, stereopsis, Line bisection judgments, Visuospatial attention Retrieval of words

Recall episodes, tool use, handwriting, spelling, shift attention, language, literalness, imageability

Structure and Function

Robert W. Thatcher, Ph.D and E.Roy John. Foundations of Cognitive Processes. New Jersey: Lawrence Erlbaum Associates, Inc. Publishers: 1997, 1-5.

NFB Treatment

10


Operant Conditioning


The Mechanism of rewards lies within each

individual and is different for everyone Biological Correlates of Operant conditioning: The highlight neurochemicals


Acetylcholine




Norepinephrine Dopamine Serotonin



10

Robert W. Thatcher Ph.D, “LORETA Z Score Biofeedback” Neuroconnections (2010)

How does it work, again?
Looney Tunes

Simply put, Neurofeedback,

Exercises your brain! And addresses resistance

How long is a typical session?

11

Robert W. Thatcher Ph.D, “LORETA Z Score Biofeedback” Neuroconnections (2010)

Reward Network

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Makris et al., “Decreased Volume of the Brain Reward System in Alcoholism” Biological Psychiatry 64.3 (2008) 192-202, doi10.1016/j.biopsych.2008.01.018

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Robert W. Thatcher, Ph.D and E.Roy John. Foundations of Cognitive Processes. 26-30.

Decision making

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Kenji Doya, “Modulators of Decision Making” Nature Neuroscience 11 (2008) 410-416. doi 10.1038/nn2077

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Eric J. Nestler and Robert C. Malenka. “The Addicted Brain” Scientific American 290 (2004) 78-85, doi 10.1038/scientificamerican0304-78

Neuroplasticity

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Refers to the brain’s ability to change
The brain’s plasticity is strongest during childhood
Neuroplasticity impacts our ability to learn and

change behaviors
qEEG-guided NFB changes neuroplasticity

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Jordan Grafman, “Conceptualizing Functional Neuroplasticity” Journal of Communication Disorder 33.4 (2004)345-356, doi 10.1016/s00219924(00)00030-7

Neurons and Axons

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Robert W. Thatcher, Ph.D and E.Roy John. Foundations of Cognitive Processes. 1-10.

Neurotransmitter

Distribution in the Central Nervous System

Drugs That Affect It

Functions Affected

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Dopamine

Midbrain, Ventral tegmental area (VTA), Cerebral cortex, Hypothalamus

Serotonin

Midbrain, VTA, Cerebral cortex, Mood, Sleep, Sexual desire, Hypothalamus Appetite

MDMA (ecstasy), LSD, Cocaine

Norepinephrine

Midbrain, VTA, Cerebral cortex, Sensory processing, Hypothalamus Movement, Sleep, Mood, Memory, Anxiety

Cocaine, Methamphetamine, Amphetamine

Endogenous opioids

Widely distributed in brain but Analgesia, Sedation, Rate of bodily functions, Mood regions vary in type of receptors, Spinal cord

Heroin, Morphine, Prescription painkillers (Oxycodone)

Hippocampus, Cerebral cortex, Memory, Arousal, Attention, Mood Thalamus, Basal ganglia, Cerebellum

Nicotine

(endorphin and enkephalin)

Acetylcholine

Pleasure and reward Cocaine, Methamphetamine, Movement, Attention, Memory Amphetamine. In addition, virtually all drugs of abuse directly or indirectly augment dopamine in the reward pathway

Endogenous cannabinoids Cerebral cortex, Hippocampus, Movement, Cognition and

Marijuana

(anandamide)

Thalamus, Basal ganglia

memory

Glutamate

Widely distributed in brain

Neuron activity (increased rate), Learning, Cognition, Memory

Ketamine, Phencyclidine, Alcohol

Gamma-aminobutyric acid (GABA)

Widely distributed in brain

Neuron activity (slowed rate),

Sedatives, Tranquilizers, Alcohol

22Anxiety, Memory, Anesthesia

Efficacy of qEEG NFB for SUDs

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18 Robert W. Thatcher, Ph.D and E.Roy John. Foundations of Cognitive Processes. 26-30. 19 Scott et al., “Effects of an EEG Biofeedback Protocol on a Mixed Substance Abusing Population” The American Journal of Drug and Alcohol Abuse 31.3 (2005): 455-469

How Important is combining qEEG with neurofeedback?

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 A qEEG report provides information that can help a professional target neurofeedback training.  Combining the qEEG and analyzing the EEG can display information about a person’s brain problem and can speed the efficacy of neurofeedback training.

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Robert W. Thatcher, Ph.D. “Neuropsychiatry and Quantitative Electroencephalography (qEEG) in the 21St Centruy” Neuropsychiatry (2011)

Can a clinician use a qEEG without specific training or experience?

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 There is a big learning curve when learning to apply information from a qEEG.  Some decide to learn the qEEG and neurofeedback at once or to rely on experts who can provide an analysis of the qEEG and how to combine it with neurofeedback.

21 Thatcher Ph.D et al, “Z-Score EEG Biofeedback: Technical Foundations” www.appliedneuroscience.com

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Do I need to buy special qEEG equipment?

 Yes- one can buy special equipment or one can send a client to a location that can record the EEG for you, although not all equipment is compatible with neurofeedback-oriented qEEG’s. CR has the equipment in-house. It is called a NeuroField amplifier and we use NeuroGuide as our statistical program. Both are FDA registered!

22 Thatcher Ph.D et al, “Z-Score EEG Biofeedback: Technical Foundations” www.appliedneuroscience.com

Can a clinician attempt to learn neurofeedback training and qEEG at the same time?

 One can do this, but the learning curve for both concepts is very steep, so it is recommended that a clinician learn the basics of neurofeedback first, followed by learning the qEEG.

23

Thatcher Ph.D et al, “Z-Score EEG Biofeedback: Technical Foundations” www.appliedneuroscience.com

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Is there insurance reimbursement?

 There are two main billing codes: 95816 for the

EEG and 95957 for the analysis of the EEG. Professional interpretations are billed with the same codes but with the trailer “-26.”

24

“New Guidelines for Third Party Reimbursement for Biofeedback”, Applied Psychophysiology and Biofeedback, accessed September 2014 http://www.aapb.org/i4a/pages/index.cfm?pageid=3387

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Do qEEG’s improve client compliance?

 According to several clinicians, the qEEG adds credibility and has improved client motivation to stick with the neurofeedback program. Neurofeedback training enhances patient’s longevity in most intervention modalities particularly with our pt. population as was documented in a RCT performed in 2005 at UCLA with a primary SUD sample of approx. 200 pts (Scott, 2005)

25 E. Roy John Ph.D and Leslie S. Prichep, “The Relevance of qEEG to the Evaluation of Behavioral Disorders and Pharmacological Interventions” Clinical EEG Neuroscience 37.2 (2006) 135-143 doi10.1177/155005940603700210

Who should qEEG NFB be recommended to? This should be based on judgment, but some recommendations of situations to be considered are:  SUDs TBI/Stroke/Head injury Rage disorders Depression Anxiety  Seizures  Long, difficult psychiatric/medical history with little response to many medications  Suicidal depression  Existing neurofeedback client who is making little or no progress within 8-15 sessions 26

John R. Hughes,MD, Ph.D and E. Roy John, Ph.D, “Conventional and Quantitative Electroencephalography in Psychiatry” The Journal of Neuropsychiatry and Clinical Neurosciences 11 (1999):190-208

26

References Apkarian, A. V. Functional magnetic resonance imaging of pain consciousness: cortical networks of pain critically depend on what is implied by “pain”. Curr. Rev. Pain 3, 308– 315 (1999). Buzsaki, G. (2006). Rhythms of the Brain, Oxford Univ. Press, New York. Cannon, R., Lubar, J., Thornton, K., Wilson, S., & Congedo, M. (2005) Limbic beta activation and LORETA: Can hippocampal and related limbic activity be recorded and changes visualized using LORETA in an affective memory condition? Journal of Neurotherapy, 8 (4), 5-24. Cannon, R., & Lubar, J. (2007). EEG spectral power and coherence: Differentiating effects of Spatial–Specific Neuro–Operant Learning (SSNOL) utilizing LORETA Neurofeedback training in the anterior cingulate and bilateral dorsolateral prefrontal cortices. Journal of Neurotherapy, 11(3): 25-44. Cannon, R., Lubar, J., Sokhadze, E. and Baldwin, D.
















References




























E. R., Prichep, L. S. & Easton, P. (1987). Normative data banks and neurometrics: Basic concepts, methods and results of norm construction. In A. Remond (Ed.), Handbook of electroencephalography and clinical neurophysiology: Vol. III. Computer analysis of the EEG and other neurophysiological signals (pp. 449-495). Amsterdam: Elsevier. Lubar, J., Congedo, M. and Askew, J.H. (2003). Low-resolution electromagnetic tomography (LORETA) of cerebral activity in chronic depressive disorder. Int J Psychophysiol. 49(3):175-185. Luria, A. The Working Brain. Penguin Press, London ISBN 0 14 080654 7 Thatcher, R.W., North, D., and Biver, C. Evaluation and Validity of a LORETA normative EEG database. Clin. EEG and Neuroscience, 2005b, 36(2): 116-122. Thatcher, R.W. and Collura, T. Z Score Biofeedback and New Technology. International Society of Neuronal Regulation Annual Meeting, Atlanta, GA, September 16-21, 2006. Thatcher, R.W., North, D., and Biver, C. Self organized criticality and the development of EEG phase reset. Human Brain Mapp., Jan 24, 2008a. Thatcher, R.W., North, D., and Biver, C. Intelligence and EEG phase reset: A twocompartmental model of phase shift and lock, NeuroImage, 42(4): 1639-1653, 2008b. Thatcher, R.W. and Lubar, J.F. History of the scientific standards of QEEG normative databases. In: Introduction to QEEG and Neurofeedback: Advanced Theory and Applications, T. Budzinsky, H. Budzinsky, J. Evans and A. Abarbanel (eds)., Academic Press, San Diego, CA, 2008. Thatcher, R.W., North, D., Neurbrander, J., Biver, C.J., Cutler, S. and DeFina, P. Autism and EEG phase reset: Deficient GABA mediated inhibition in thalamo-cortical circuits. Dev. Neuropsych. (In press, 2009). John,

References




















D.Corydon Hammond, “What is Neurofeedback” Journal of Neurotherapy, Investigations in Neuromodulation, Neurofeedback and Applied Neuroscience 10.4 (2007)25-36 doi.10.1300/J184v10n04_04 Kerry L.Coburn Ph.D, Edward C.Lauterbach MD, Nash N. Boutros MD, Kevin J. Black MD, David B. Arciniegos MD and C. Edward Coffey MD, “The Value of Quantitative Electroencephalography in Clinical Psychiatry: A Report by the Committee on Research of the American Neuropsychiatric Association” The Journal of Neuropsychiatry and Clinical Neurosciences 18 (2006):460-500 John N. Demos, Getting Started with Neurofeedback , New York: W.W. Norton & Company Inc (2005) Robert W. Thatcher Ph.D, “LORETA Z Score Biofeedback” Neuroconnections (2010) John R. Hughes,MD, Ph.D and E. Roy John, Ph.D, “Conventional and Quantitative Electroencephalography in Psychiatry” The Journal of Neuropsychiatry and Clinical Neurosciences 11 (1999):190-208 Robert W. Thatcher Ph.D, Carl J. Biven Ph.D and Duane M. North, MA, “Z-Score EEG Biofeedback: Technical Foundations” www.appliedneuroscience.com Robert W. Thatcher, Ph.D and E.Roy John. Foundations of Cognitive Processes. New Jersey: Lawrence Erlbaum Associates, Inc. Publishers: 1997. Nikos Makris, Marlene Oscar- Berman, Sharon Kim Jaffin, Steven M. Hodge, David N. Kennedy, Verne S. Caviness, Ksenija Marinkovic, Hans C. Breiter, Gregory P. Gasic and Gordon J. Harris, “Decreased Volume of the Brain Reward System in Alcoholism” Biological Psychiatry 64.3 (2008) 192-202, doi10.1016/j.biopsych.2008.01.018 Eric J. Nestler and Robert C. Malenka. “The Addicted Brain” Scientific American 290 (2004) 78-85, doi 10.1038/scientificamerican0304-78 Jordan Grafman, “Conceptualizing Functional Neuroplasticity” Journal of Communication Disorder 33.4 (2004)345-356, doi 10.1016/s00219924(00)00030-7 Robert W. Thatcher, Ph.D. “Neuropsychiatry and Quantitative Electroencephalography (qEEG) in the 21St Centruy” Neuropsychiatry (2011) “New Guidelines for Third Party Reimbursement for Biofeedback”, Applied Psychophysiology and Biofeedback, accessed September 2014 http://www.aapb.org/i4a/pages/index.cfm?pageid=3387 E. Roy John Ph.D and Leslie S. Prichep, “The Relevance of qEEG to the Evaluation of Behavioral Disorders and Pharmacological Interventions” Clinical EEG Neuroscience 37.2 (2006) 135-143 doi10.1177/155005940603700210 Kenji Doya, “Modulators of Decision Making” Nature Neuroscience 11 (2008) 410-416. doi 10.1038/nn2077 William c. Scott, David Kaiser, Siegfried Othmer and Stephen I. Sideroff. “Effects on an EEG Biofeedback Protocol on a Mixed Substance Abusing Population” The American Journal of Drug and Alcohol Abuse 31.3 (2005):455-469