Notes From Clinical Practice: An MD’s Perspective on 9 Years of Neurofeedback Practice

Abstract

Neurofeedback is a form of biofeedback in which electroencephalogram (EEG) activity is made apparent to a patient, who is “persuaded” to alter that activity via rewards and inhibitions that are manipulated by the EEG feedback therapist. The most popular forms of feedback presentation to a patient are via videos or simple video games. The operating parameters of the chosen feedback are altered according to selected EEG frequencies. The closer the EEG activity comes to optimal, the more the patient is rewarded by feedback that runs well. When the EEG deviates from the desired objectives, the feedback runs poorly in several ways that inform the brain how it has changed (eg, an increase in delta or theta causes the picture on the computer screen to fog over, and an increase in beta causes the sound volume to decrease). Conversely, as the patient'sEEGbecomesmoreoptimal,thevideoorgamebegins to run better. Some neurofeedback systems also include a tactile object that vibrates with greater intensity as the patient produces more EEG in the desirable frequency range. Neurofeedback appeals to the innate desire to earn rewards, and the brain's ability to detect liminal events and to relate these changes to its own internal state. The brain's activity is made obvious to itself just as one can monitor facial expressions in a mirror. Via trial and error, the brain is operantly conditioned to manipulate feedback and change the relative quantity of EEG produced in various frequency bands. In a typical 30-minute session, a patient may receive up to 2000 discrete data points about the function of his or her brain. With repeated practice, the patient slips easily and naturally into prescribed EEG patterns. It appears that improved brain functioning becomes self-reinforcing as the patient applies their newly learned EEG patterns in their everyday life and meets with positive consequences. At a certain point, usually in 40-60 sessions, the patient is able to reliably replicate the desired EEG without the use of neurofeedback equipment. The neurofeedback-trained EEG is translated into better-regulated brain states that are in turn reflected in improved brain functioning and patient symptoms. 2 The most frequent medical diagnoses for which I