Specific effects and biofeedback versus biofeedback-assisted self-regulation training

In any field, clear and logical conceptualizations are the basis of accurate models → correct research design → correct results → correct conclusions → advancement in the field. Faulty conceptualizations → faulty models → faulty research design → faulty results → faulty conclusions → confusion. In analyzing the conceptualizations of “biofeedback” as expressed by John Furedy (1987) in, “Specific versus Placebo Effects in Biofeedback Training: A Critical Lay Perspective,” we focus on two issues: Does biofeedback have a treatment effect? Is biofeedback necessary for the training effect? In discussing issue (1) we describe the multiple meanings of “biofeedback” and raise the fundamental question: Is biofeedback a treatment? We argue that faulty conceptualizations of clinical biofeedback (1) assume that the treatment in clinical biofeedback is “biofeedback” with specific effects, (2) assume that the scientific basis of biofeedback is dependent upon demonstrations of these specific effects through double-blind designs that distinguish “specific” from “placebo effects,” and (3) trivialize clinical research by attempting to determine the usefulness of biofeedback information — usefulness that is already understood logically by professionals and consumers and demonstrated by clinical studies in the laboratory and in the clinic. We further argue that accurate conceptualizations of clinical biofeedback (1) identify self-regulation skills as the treatment with specific effects of physiological change and symptom reduction, and (2) describe the use of information from biofeedback instruments as scientific verification of self-regulation skills. Finally, the scientific basis of clinical biofeedback is based on (1) evidence from experimental and clinical control studies that have demonstrated the effectiveness of self-regulation skills for symptom alleviation, and (2) the use of biofeedback instruments to verify the acquisition of self-regulatory skills, thus fulfilling the scientific dictum of verifiability.     

Blood volume pulse biofeedback in the treatment of migraine headache: A controlled evaluation

In order to evaluate the specific effects of blood volume pulse (BVP) biofeedback in the treatment of migraine headaches, 21 female migraine patients were randomly assigned to one of three experimental conditions: temporal artery constriction feedback, temporal artery dilation feedback, or waiting list. Biofeedback training consisted of 15 sessions over an 8-week period. All patients completed 5 weeks of daily self-monitoring of headache activity and medication before and after treatment. Results showed that constriction and dilation biofeedback were equally effective in controlling migraines and produced greater benefits than the waiting-list condition. No significant relationships were found between therapeutic gains and BVP self-regulation skills. However, further analyses revealed that changes in headache activity and medication were associated with changes in vasomotor variability. The current rationale for the use of BVP biofeedback in the treatment of migraine is questioned and a new one is proposed.     

Self-regulation of slow cortical potentials in psychiatric patients: depression.

Findings on depressive patients indicate that depressives have electrophysiological characteristics similar to those of schizophrenics, in that they exhibit reduced Contingent Negative Variation (CNV) amplitudes and more distinct Postimperative Negative Variations (PINVs) than normal controls. In a biofeedback experiment, 8 medicated male inpatients with the DSM III-R diagnosis of "Bipolar Disorder, Depressive," and "Major Depression" demonstrated no impairment in the self-regulation of Slow Cortical Potentials (SCP) in comparison to schizophrenics in terms of increasing and suppressing negativity. Continuous visual SCP feedback is presented to the patient as a horizontally moving rocket in a video game format. The direction changes of the rocket represented SCP changes at each point in time, recorded by the central EEG (based on the pretrial baseline). Depressives demonstrated SCP self-regulation across 20 sessions, although with many between-and-within variations. The 8 male controls were unable to regulate their SCPs across 5 sessions. This result contradicts other findings of our laboratory on normal controls. Motivational factors and insufficient operant reinforcement (financial reward) may have facilitated this effect.     

Self-regulation of slow cortical potentials in psychiatric patients: depression.

Findings on depressive patients indicate that depressives have electrophysiological characteristics similar to those of schizophrenics, in that they exhibit reduced Contingent Negative Variation (CNV) amplitudes and more distinct Postimperative Negative Variations (PINVs) than normal controls. In a biofeedback experiment, 8 medicated male inpatients with the DSM III-R diagnosis of "Bipolar Disorder, Depressive," and "Major Depression" demonstrated no impairment in the self-regulation of Slow Cortical Potentials (SCP) in comparison to schizophrenics in terms of increasing and suppressing negativity. Continuous visual SCP feedback is presented to the patient as a horizontally moving rocket in a video game format. The direction changes of the rocket represented SCP changes at each point in time, recorded by the central EEG (based on the pretrial baseline). Depressives demonstrated SCP self-regulation across 20 sessions, although with many between-and-within variations. The 8 male controls were unable to regulate their SCPs across 5 sessions. This result contradicts other findings of our laboratory on normal controls. Motivational factors and insufficient operant reinforcement (financial reward) may have facilitated this effect.     

The Raynaud's Treatment Study: Biofeedback Protocols and Acquisition of Temperature Biofeedback Skills

The Raynaud's Treatment Study (RTS) compared temperature biofeedback training and a behavioral control procedure (frontalis EMG biofeedback) with nifedipine-XL and a medication placebo for treatment of primary Raynaud's phenomenon (RP) in a large (N = 313) multicenter trial. The present study describes the RTS biofeedback protocols and presents data on the acquisition of digital skin temperature and frontalis EMG responses in the RTS. The findings point to substantial problems with acquisition of physiological self-regulation skills in the RTS. Only 34.6% of the Temperature Biofeedback group (N = 81) and 55.4% of the EMG Biofeedback group (N = 74) successfully learned the desired physiological response. In contrast, 67.4% of a Normal Temperature Biofeedback group (N = 46) learned hand warming. Multivariate analysis found that coping strategies, anxiety, gender, and clinic site predicted acquisition of hand-warming skills whereas variables related to RP disease severity did not. Physiological data showed vasoconstriction in response to the onset of biofeedback and also found that performance in the initial sessions was critical for successful acquisition. These findings indicate that attention to the emotional and cognitive aspects of biofeedback training, and a degree of success in the initial biofeedback sessions, are important for acquisition.     

Regarding the Database for the Peniston Alpha-Theta EEG Biofeedback Protocol

Five papers by Peniston and colleagues, which constitute the basic literature for alpha-theta EEG biofeedback treatment for alcoholism and posttraumatic stress disorder, are reviewed. As a result, we raise three questions: (a) Are the samples studied independent? (b) What was the clinical status of the participants prior to treatment? (c) What treatment did the participants actually receive? In seeking answers to these questions we aim to strengthen the database for neurofeedback with specific procedural information so that claims of efficacy can be tested and accepted or rejected on an objective basis.     

A long-term, single-group follow-up study of biofeedback therapy with chronic medical and psychiatric patients

In a long-term follow-up study, 524 (93%) of 563 consecutive medical and psychiatric patients, who received an average of 8 sessions of biofeedback and relaxation training, provided follow-up evaluations of treatment outcome. Seventy-five percent reported maximum, significant, or moderate improvement. There was a significant positive association between the percent of patients improved and the number of treatment sessions up to 10 sessions, but not thereafter. Symptom frequency decreased by 54% and symptom severity by 30%. About 54% of the medicated patients reported a decrease in medication. No differential therapist effects were found. About twice as many patients rated relaxation training as most helpful compared with the audio/visual signals from biofeedback instruments.     

Spreading disease: a controversy concerning the metaphysics of disease.

This article concerns the metaphysics of disease. Is disease a fixed feature of the world or a social value or preference? I argue that disease is not a value-laden concept and thus debates concerning it differ fundamentally from debates concerning health, harm, or suffering where evaluative judgements are central. I show how the so-called social constructionist view of disease has been motivated both by ethical concerns with medical practices and general theoretical doubts about scientific naturalism. If I can show that ethical concerns about medical treatment can be answered without adopting social constructionism, that leaves only the broader theoretical question of naturalism. I cannot completely answer those theoretical doubts, but I show that the theoretical motivation is less convincing when it is separated from the moral challenge often accompanying it. I conclude that a convincing defense of the non-naturalistic conception of disease is rarely attempted and proves more difficult and counter-intuitive than its proponents assume.     

Self-regulation of response patterning

This paper develops the basic premise that learning to self-regulate a pattern of responses can have different consequences from those observed when controlling individual functions alone. It is suggested that the self-regulation of patterns of responses can be a particularly sensitive and effective procedure for(a) uncovering biological linkages and constraints between responses in the intact human,(b) investigating how multiphysiological systems combine to produce unique subjective experiences and effects on performance, and(c) enhancing the clinical effectiveness of biofeedback procedures by training patients to integrate and coordinate voluntarily specific patterns of cognitive, autonomic, and motor responses. These hypotheses are illustrated by basic research involving biofeedback training for patterns of blood pressure, heart rate and EEG activity, related experiments on the cognitive self-regulation of patterns of physiological responses using affective imagery and meditation procedures, and case studies of patients treated with biofeedback. The concept of electronic biofeedback as an unnatural act is presented with the goal of placing self-regulation within a more biobehavioral perspective emphasizing the natural patterning of physiological processes.Presidential address read at the Biofeedback Research Society meeting on February 18, 1974 at Colorado Springs, Colorado. I would like to express my gratitude to my former teachers and colleagues, whose thinking and data have helped shape the theme presented in this paper. They are, in alphabetical order: Professors Joseph Campos, Andrew Crider, Harold Johnson, Peter Lang, David Shapiro, and Bernard Tursky. I would also like to thank my graduate students, notably Terry Bergman, Richard Davidson, Paul Fair, Daniel Goleman, Jim Hassett, and Marilyn Neyers for their important contributions to the research program.A portion of the recent data reported here was supported by the Advanced Research Projects Agency of the Department of Defense and monitored by the Office of Naval Research under Contract N00011-70-C-0350 to the San Diego State University Foundation.     

Concordance among self-regulated responses: Is self-regulatory ability a psychophysiological “trait”?

The purposes of this study were to examine whether or not self-regulation of physiological responses demonstrates day-to-day reliability, to determine the degree of individual subject consistency (or concordance) in the ability to self-regulate across several different physiological responses, and, finally, to explore the impact of biofeedback training on interresponse concordance. Twenty normal subjects participated in six bidirectional self-regulation sessions—the first and last sessions involving instructions only, and the remainder, biofeedback. Self-regulation scores consisted of the absolute difference between increase and decrease trial means. The average test-retest reliability coefficients (r _s) for the self-regulation scores, across the four biofeedback sessions, were a highly significant .50, .68, .30, and .47 for EEG, EMG, HR, and SCL, respectively. By contrast, the average concordance among the self-regulation scores for the four feedback sessions, estimated by Kendall's coefficient of concordance, was a marginally significant 39% of the possible variance of the rank sums. This corresponds to an average between-responser _s value only of .19. The concordance level from the initial no-feedback (i.e., instructions only) session was not significant. Multivariate concordance levels did increase during the first three feedback sessions, but declined at the fourth, and again was nonsignificant during the final no-feedback session. Among the individual self-regulation response pairings, only the EEG/EMG combination was consistently associated during the no-feedback sessions. The present results suggest that self-regulatory ability is neither a highly unitary “trait”-like phenomenon nor an entirely response-specific event, but may vary considerably as a function of subject factors, or the situational circumstances, under which it is measured.     

Question 7: The Vesicle World: The Emergence of Cellular Life can be Related to Properties Specific to Vesicles

The question “What was the minimum number of genes necessary in the early cell” is rephrased as “Is it feasible to assume that early cells had no genes?” It is shown that a kind of primitive life process could exist on the basis only of properties specific to vesicles, and that it would have the potential to evolve into more complex cell-like processes.     

Biofeedback control of migraine headaches: a comparison of two approaches

In order to assess the relative effectiveness of finger warming and temporal blood volume pulse reduction biofeedback in the treatment of migraine, 22 female migraine patients were assigned to one of three experimental conditions: temporal artery constriction feedback, finger temperature feedback, or waiting list. Biofeedback training consisted of 12 sessions over a 6-week period. All patients completed 5 weeks of daily self-monitoring of headache activity (frequency, duration, and intensity) and medication before and after treatment. Treatment credibility was assessed at the end of Sessions 1, 6, and 12. Results showed that temporal constriction and finger temperature biofeedback were equally effective in controlling migraine headaches and produced greater benefits than the waiting list condition. Power analyses indicated that very large sample sizes would have been required to detect any significant differences between the two treatment groups. No significant relationships were found between levels of therapeutic gains and levels of thermal or blood volume pulse self-regulation skills. Likewise, treatment outcome was not found to be related to treatment credibility. Further analyses revealed that changes in headache activity and medication were associated with changes in vasomotor variability. Because blood volume pulse variability was not significantly affected by biofeedback training, questions about its role in the therapeutic mechanism are raised.     

Emotionally Triggered Asthma: A Review of Research Literature and Some Hypotheses for Self-Regulation Therapies

Asthma is a common disease whose morbidity and mortality are rapidly increasing. Panic disorder is common in asthma. Panic, other negative emotions, and a passive coping orientation may affect asthma by producing hyperventilation, increased general autonomic lability, a specific pattern of autonomic arousal that may cause bronchoconstriction, and/or detrimental effects on health care behaviors. Generalized panic is a risk factor for increased asthma morbidity. A repressive coping style also appears to be a risk factor for asthma morbidity because it is accompanied by an impaired ability to perceive symptoms, a necessary prerequisite for taking appropriate remediation. Several self-regulation strategies are hypothesized to be useful adjuncts to asthma treatment. Preliminary research has been done on relaxation therapy, EMG biofeedback, biofeedback for improved sensitivity in perceiving respiratory sensations, and biofeedback training for increasing respiratory sinus arrhythmia. It is hypothesized that finger temperature biofeedback also may be a promising treatment method, and that relaxation-oriented methods will have their greatest effect among asthmatics who experience panic symptoms, while improved perceptual sensitivity will be helpful both for patients who panic and those with repressive coping styles.     

Cognitive skills training versus EMG biofeedback in the treatment of tension headaches

In an effort to study the role of cognitive skills training in the treatment of psychosomatic disorders, two single-case design experiments were conducted to assess the relative effectiveness of biofeedback procedures and cognitive coping techniques in the alleviation of tension headaches. For both subjects, biofeedback training influenced mean frontalis EMG levels, although such changes were not associated with concomitant reductions in headache activity. It was the presence or absence of cognitive skills training, however, that determined whether each subject reported changes in headache levels. These results suggest that a more efficient treatment approach for tension headaches would involve an increased emphasis on the modification of maladaptive cognitive activity. The present findings support the general view that a comprehensive approach in the treatment of stress-related disorders requires a concomitant focus on the cognitive, behavioral, and affective dimensions of the symptom. It was also suggested that biofeedback technology may be a useful tool for studying the physiological consequences of particular cognitive processes and in identifying particular cognitions with anxiety-provoking properties.     

Urodynamic biofeedback treatment of urinary incontinence in children with myelomeningocele

Eight children with myelomeningocele and chronic neurogenic urinary incontinence were provided urodynamic biofeedback training. During urodynamic biofeedback, six of the eight children demonstrated improved self-regulation of detrusor and/or sphincter functioning. However, substantial improvements in clinical symptomatology (i.e., urinary incontinence) were clearly shown by only one child. Unexpectedly, chronic neurogenic fecal incontinence was reduced in four children. Several methodological modifications are discussed which may improve clinical symptomatology and which may facilitate further urodynamic biofeedback research for these children with congenital neurogenic urinary incontinence.     

Negative side effects of self-regulation training: Relaxation and the role of the professional in service delivery

Procedures used for relaxation training can resolve or precipitate dysfunction in patients undergoing self-regulation treatments. The present article discusses the role of the clinician in administering relaxation training via thermal biofeedback and coping with unforeseen negative effects of treatment. A case illustration involving the biobehavioral treatment of chest pain is presented and discussed to remind the reader of the significance of the therapist's role in helping tailor treatment programs to unique responses of the individual patient. The case highlights the value of thorough case management and clinical formulation in the successful resolution of relaxation-induced leg pain.     

Biofeedback-assisted relaxation training for the aging chronic pain patient.

The older segments of the U.S. population are expanding rapidly and account for a disproportionate amount of health care, including treatment for pain-related musculoskeletal disorders. In a prospective study with objective measures and one-year follow-up, Middaugh et al. (1988) found that older patients (55-78 yr; N = 17, 76% success) treated in a multidisciplinary chronic pain rehabilitation program enjoyed a success rate equal to that of younger patients (29-48 yr, N = 20, 70% success). The current study presents additional data on these two groups of patients to compare their ability to learn the physiological self-regulation skills taught in the biofeedback/relaxation component of the multimodal program. This component included progressive muscle relaxation training, diaphragmatic breathing instruction, and EMG biofeedback. Repeated measures ANOVA showed significant increases in digital skin temperature (peripheral vasodilation) and decreases in respiration rate both within and across training sessions (p values = .04 to .0001) with no differences between age groups (p greater than .05). EMG measures for the upper trapezius ms in patients with cervical pain showed similar deficits in muscle control at evaluation and similar improvements with biofeedback training for the two age groups. These findings indicate that older pain patients responded well to the biofeedback/relaxation training component of the multimodal pain program.     

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.     

Urodynamic biofeedback treatment of urinary incontinence in children with myelomeningocele

Eight children with myelomeningocele and chronic neurogenic urinary incontinence were provided urodynamic biofeedback training. During urodynamic biofeedback, six of the eight children demonstrated improved self-regulation of detrusor and/or sphincter functioning. However, substantial improvements in clinical symptomatology (i.e., urinary incontinence) were clearly shown by only one child. Unexpectedly, chronic neurogenic fecal incontinence was reduced in four children. Several methodological modifications are discussed which may improve clinical symptomatology and which may facilitate further urodynamic biofeedback research for these children with congenital neurogenic urinary incontinence.This work was supported by a grant from The Crippled Children's Guild through the Behavioral Pediatrics Program at Orthopaedic Hospital.