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BCIA Case ConferenceClinical Issues in Alpha-Theta Neurofeedback for Addiction

Genie Davis, PhD, BCN Psychologist, Professor Emerita,

University of North Texas

Richard E. Davis, MS, BCNLPC, Private Practice, Denton, Texas

EEG PATTERNS IN ADDICTIONSEEG PATTERNS IN ADDICTIONSEEG PATTERNS IN ADDICTIONSEEG PATTERNS IN ADDICTIONS::::

When is alpha-theta training appropriate for a client?

Addiction Predisposition EEG Patterns1. Cortical Excitability Pattern

This pattern associated with CNS hyperarousal

Low voltage/fast EEG consists of (in frontal and occipital areas):

Slowed alpha frequency

Reduced power in alpha and theta

Excessive fast (>20 Hz) beta power

(Frequently the hi beta is seen primarily over vertex sites, combined with slow wave activity)

EEG pattern noted in raw EEG of alcoholics (Neidermeyer & Lopez de Silva, 1982;

often a familial EEG pattern

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Low Voltage/Fast EEG Pattern

Cortical excitability → predisposition to addiction to alcohol/CNS

depressants (e.g. heroin) as well as other disorders

A transdiagnostic pattern with common symptoms

anxiety

insomnia

compulsivity & obsessiveness

rumination

depression

Seen in many clinical disorders: anxiety, OCD, addiction disorders, RAD, Trauma disorders and others

Low Voltage Fast EEG

The Peniston Protocol

• Based on EEG studies showing alpha, theta and beta abnormalities in alcoholism

• Influenced by early work with alcoholics and PTSD done at Menninger Foundation in Topeka (by Green & Green, Fahrion, Walters, Norris)

• Developed with V.A. alcoholics, mostly Viet Nam vets with PTSD/Substance Abuse

• Focused on increasing alpha & theta power

• Multi-modal protocol, using both peripheral and EEG biofeedback, guided imagery, supportive counseling

• Very successful with this population. Peniston obtained 80% total abstinance after 1 year; 90% after 5 years (Peniston & Kulkosky, 1989)

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Peniston Protocol Replications

Saxby & Peniston, 1995: outpt. alcoholics

Fahrion, 1995 Kansas Prison System group training; not effective for cocaine

Kelly, 1997 Navajo: 16 % relapse at 3 yrs.

Burkett, et al (2003) 65% success rate with homeless crack cocaine users (modified Peniston protocol)

Callaway & Bodenhamer-Davis 2005

High risk probationers; 81% abstinent or near abstinent at 74 – 98 month follow-up (mix of Peniston and modified Peniston protocols)

Studies also replicated changes in personality reported by Peniston.

Studies also consistently report subjects remain in treatment longer and complete treatment at a higher rate than controls

Components of the Original Peniston Protocol

1. 8 - 10 pre-training sessions to learn relaxation through breathing, temp biofeedback w/autogenic instructions

2. Sessions began with reading of a ““““script”””” that contained autogenic relaxation instructions and personalized guided imagery for cognitive rehearsal of alternative responses to problematic behaviors , e.g. alcohol/drug rejection scenes, ““““ideal self”””” behaviors

3. Minimum of 30 alpha-theta ↑ biofeedback sessions (5 X/wk, 30 min. of eyes-closed auditory fdbk, separate tones for alpha (75-80%) & theta (20 – 25%) at O1

4. Each session followed by discussion of reactions to feedback, any imagery or insights acquired during session/crossovers, and supportive counseling

Clinical Session Example of a

Theta/Alpha Crossover on BrainMaster screen

bBBB (BrainMaster)

Therapeutic Crossover Amplitude Difference = 1+mv; min; Beta= 3.75+mv

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Content of Imagery Related to Spectral Band Configuration in Crossover Event

Peniston considered crossover events important to alpha-theta therapeutic outcome

Reports of imagery or memory recall depend on which

frequencies are dominant at time of crossover as well as their relative amplitudes

Alpha and higher frequency theta: hypnogogic imagery; colors,

geometric shapes, not personally meaningful

5 – 10 Hz ranges can produce biographical memories; productive material for psychotherapy

Lower frequencies of theta and delta associated with more ““““dream-like”””” images: images around birth, symbolism, archetypal material, transpersonal imagery such as mystical

experiences, religious figures, etc.

Conducting Alpha-Theta Sessions

Clinical Considerations

Steps We Follow in Conducting

An

Alpha-Theta SessionAfter all assessments completed and protocol is considered appropriate:

1.Use reclining chair, with head and body resting comfortably, room

darkened. Client will do training with eyes closed.

2.Begin with 3 – 5 pre-training sessions in abdominal breathing and relaxation (HRV biofeedback is recommended). If client has not

mastered relaxation and breathing criteria in 5 sessions, begin alpha-theta training anyway but continue few minutes of HRV at

beginning of subsequent sessions until breathing improves.

3.Develop visualization script with client.

4.Begin alpha-theta: single channel training at O1/A1.

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Conducting individual sessions, cont. 5. Begin session by reading imagery script. This can be done either before or just after starting feedback recording.

6. Adjust initial thresholds as needed and begin feedback . Observe client and recording graph during 30 minute session (for a minimum of 30 sessions total).

We recommend using software that produces a continuous line graph recording throughout the session so that therapist can observe for crossovers and frequency changes during session.

7, After session completed, turn off feedback and save session record in desired manner. If graph shows a crossover is still in progress at end of 30 minutes, continue until crossover ends.

8. Ask client to describe his/her experience during session; any images or experiences that might have occurred. Make notes of client’’’’s reports. Allow client time to process any experiences they desire. Take care not to state or imply that client should be having imagery or memory experiences of any kind during sessions and do not interpret any experiences for client.

9. Check on client’’’’s alertness level prior to allowing them to leave the treatment room, especially if they are driving. Including some 15-18 Hz beta in the protocol can help reduce occurrence of ““““theta eyes”””” (continued fogginess due to elevated theta levels from the training session as well as reduce any abreactions.

Limitations of Original PenistonProtocol

Because early NF equipment could treat only 2 frequencies at a time, Peniston’s first protocol did not address high beta excess

High central beta has been found to be the best predictor of relapse among treated alcoholics (Bauer & Hesselbrock, 1992)

Peniston’s research subjects were primarily Viet Nam vets with chronic alcoholism and PTSD (thus more emotional abreactions reported in this study group)

Polysubstance and stimulant abusers usually have a different EEG pattern than alcoholics and marijuana users, therefore original Peniston Protocol not adequate with this group that is seen more commonly today.

Case Case Case Case Example Example Example Example Relapse following Relapse following Relapse following Relapse following ooooriginal riginal riginal riginal PenistonPenistonPenistonPeniston protocol for protocol for protocol for protocol for alcoholismalcoholismalcoholismalcoholism

52-year-old white male, Ph.D. medical school professor; self-

referred

Family history of alcoholism; using alcohol since age 14 ; daily

use, mainly in evening to sleep

Highly anxious, ““““driven””””, obsessive, depressed, no history of

trauma

Low amplitude fast pattern; excessive high central beta

Sessions conducted over a two week period, between semesters

Traditional Peniston Protocol rewarding posterior alpha & theta

Treatment done in 1990’’’’s using equipment capable of training

only 2 frequencies at a time

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Pre-Treatment Beta NXLink database

Early Alpha-Theta Session RecordFocus 1000 Equipment

Mid-Treatment Session Showing Alpha-Theta Crossovers

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Near Final Session Showing Alpha & Theta Amplitude Increases & Crossovers

Post TX QEEG Showing Excessive High Beta RemainingPost TX QEEG Showing Excessive High Beta RemainingPost TX QEEG Showing Excessive High Beta RemainingPost TX QEEG Showing Excessive High Beta Remaining(This EEG pattern predicted client(This EEG pattern predicted client(This EEG pattern predicted client(This EEG pattern predicted client’’’’s relapse s relapse s relapse s relapse -------- within 3 mo.)within 3 mo.)within 3 mo.)within 3 mo.)

2. CNS Underarousal Patterns Seen in Stimulant Abuse

Slowing, often with high beta as well, along vertex, over anterior and posterior cingulate

Excess slow waves fronto-centrally

Often accompany ADHD, Depression

Likely a CNS underarousal pattern, but genetic predisposition not well researched

Chronic stimulant abuse = excess alpha + delta deficit (Alperet al. 1990; Noldy et al. 1994; Prichep et al.; Roemer et al. 1995; Trudeau et al. 1999)

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Summary of Two Abnormal EEG Patterns

Related to Addiction Disorders

• Patterns associated with CNS hyper- or hypo-arousal may predict addiction to specific class of substances

1. low amplitude/fast: alcohol, other CNS depressants

2. frontal/central slowing w/hi beta: CNS stimulants

• More often seen are mixtures of more than one pattern, especially in cases of polysubstance abuse

First Researched Modification of Peniston Protocol for Polysubstance Abuse

Scott, W., Kaiser, D., Othmer, S. & Sideroff, S. (2005).

Pre-assessment with TOVA to determine if inattentive (hypo-aroused)

or impulsive (hyper-aroused)

Started with older Othmer bipolar protocol based on TOVA findings

(10 – 20 sessions):

Either Fpz-C3 15-18↑ & 2-7 ↓; 22-30↓ or C4-Pz 12-15↑ & 2-7↓; 22-30↓

Reassessed with TOVA after 10 sessions; if normal switched to alpha-

theta protocol at Pz for 30 sessions (alpha 8 – 11 Hz; theta 5 – 8 Hz)

Used relaxation induction & imagery scripts

Achieved 77% abstinence rate at 12-months, plus significant clinical improvements in TOVA & MMPI

3rd Wave of Alpha-Theta NF:QEEG-Based Alpha-Theta Approaches

Treat abnormalities seen in individual QEEG’’’’s

deBeus et al. 2002 compared Peniston Protocol to QEEG-based approach and found the Q-based approach more effective.

Treat EEG patterns typically seen in persons with addictions:(1) low amplitude/fast, and (2) vertex excesses related to compulsivity

(Cripes & Gunkelman, 2010, reported significant improvement in cognition, attention & personality

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QEEGQEEGQEEGQEEG----Based AlphaBased AlphaBased AlphaBased Alpha----Theta Protocol Theta Protocol Theta Protocol Theta Protocol

Approach Used by Davis & Davis for Approach Used by Davis & Davis for Approach Used by Davis & Davis for Approach Used by Davis & Davis for

PolysubstancePolysubstancePolysubstancePolysubstance AbuseAbuseAbuseAbuse

Protocols based on EEG pattern research & individualized to clients’’’’ specific QEEG patterns

Clinical Application Using QEEG-Based Approach(Protocol used in Case Summary that follows)

The QEEG patterns usually seen in this population require a modified Peniston approach, such as the following:

1. vertex fast/slow activity, starting at Fz and moving to Cz and Pz

2. reduce parietal/temporal slow/fast activity

3. increase posterior alpha-theta following Peniston protocol unless QEEG shows excessive theta or alpha (include imagery scripts recommended by Peniston)

(After frontocentral training completed first, fewer alpha-theta sessions needed to reduce cravings, anxiety, depression, compulsivity, insomnia, emotional trauma, and thus reduce risk of relapse.)

We recommend supplementing above protocol with pre-treatment HRV & breathing training to provide a stress/coping mechanism to client should emotional abreactions occur during alpha-theta (though these reactions are relatively rare unless severe trauma in client’s history).

Rationale for Treating Vertex Activity First

Starting frontally (Fz) engages frontal inhibitory,

cognitive and executive functions of cortex,

giving client capability for greater self-regulation

and cognitive participation in the therapeutic

process

Fz taps anterior cingulate gyrus, gateway to

limbic areas of brain that regulate emotions,

emotional memory, affect regulation, reducing

client anxiety & irritability and stabilizing mood

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Central Training

Fz and Cz to address obsessive-compulsive traits and

compulsion/craving aspects of addictive disorders

Reducing high beta at Cz addresses the hyperarousal

and anxiety that predispose to relapse

C4 for calming if overtraining (may present as

agitation) occurs or continues with frontal training

Parietal Training

Reduce Pz alpha seen in drug abuse: cocaine,

meth, prescription drug abuse & often in sex

addiction

P4 for calming if vertex sites or C4 not

sufficient

Temporal & Occipital Training

Decrease any excess alpha at T6 to address social

anxiety, limits/boundaries issues, interpersonal

communication & social integration problems

Move last to O1 for 10 – 15 sessions of alpha-theta

training using Peniston Protocol

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Case Summary:

OutpatientTreatment Using QEEG-Based Modification of Alpha-

Theta Neurofeedback for Substance Abuse/Dual Diagnosis

Third generation of alpha-theta protocols

suitable for polysubstance/dual diagnosis populations commonly seen today

Combines features of Peniston Protocol, Modified Peniston Protocol and QEEG-based Protocols

Client Background Information

White male, age 24, college student; drinking & using various drugs since age of 12

First presented for severe attention disorder and chronic depression interfering with completion of undergraduate degree

ADHD, depression, insomnia, alcoholism confirmed by pre-treatment assessments: TOVA, Beck Depression Inventory, MMPI, Pittsburgh Sleep Index

QEEG showed combined frontal/posterior slowing, with underlying low amp/fast pattern

Client denied severity of his drinking and refused to do NF for chronic alcohol problem

Description of First Round of Treatment

Successfully completed NF for ADHD

Targeted frontocentral slowing at Fz and Cz

Started reporting greater mental clarity and reduced depression at 10 sessions

Completed 20 sessions before discontinuing due to graduation and relocation

Did not complete post assessments

Client reported his reading concentration & grades improved significantly (from academic probation to B’’’’s and A’’’’s); completed undergraduate degree

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Second Round of Treatment

Client returned after a year for treatment of severe depression (suicidal) and chemical dependency

Facing trial for repeated alcohol-related arrests

Precautions done to prevent self-injury & resumed neurofeedback

Second QEEG showed frontal & vertex slowing was reduced from previous pre-treatment map, but significant slow and fast activity remained on vertex

Application Exercise:Application Exercise:Application Exercise:Application Exercise:

Based on information you have obtained so far in this presentation and about this case, what sites and frequencies would you target at this point in treatment to address this client’’’’s substance abuse and depression?

Starting at site _______

Frequencies and protocol:

inhibit ______ reward _______

Additional site(s) ______

inhibit _____ reward _______

Protocol Used in Second Round and Results of Treatment

Inhibited frontal/vertex (Fz, Cz) slowing and hi beta 20-30) to reduce depression, anxiety, rumination

4 sessions per week, included psychotherapy

Added CES (Alpha-Stim) to assist withdrawal (increases alpha and hi beta)

Client then agreed to alpha-theta (O1); crossover/mild abreaction 1st session – childhood memory related to overbearing older sister

Completed 20 sessions of alpha-theta using PenistonProtocol with 20 – 30 Hz inhibit added

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Case Outcome

Depression significantly reduced on post-treatment Beck and MMPI 2

Following second phase of treatment, client completed a grad program & internship working for a member of the state legislature

Currently employed full time

Maintains abstinence @ 5+ years post-treatment

Additional Ethical & Clinical Considerations

Clearly state possible risks and side effects of treatment (e.g., ““““Peniston flu””””, possible abreactions)

Be licensed in your state to treat mental health disorders or have on-site direct supervisor who is appropriately licensed as well as experienced and certified in neurofeedback

Have training and experience with substance abuse issues and populations, co-occurring diagnoses, psychotherapy, trauma and crisis intervention, handling unconscious material and possible reports of transpersonal experiences

Consider monitoring or including 10% reward for “cognitive beta” (15-18 Hz) during alpha-theta sessions if strong emotional abreactions possible

Be ready to implement calming protocol should strong emotional responses occur during alpha-theta states. Pre-training with HRV will help provide a coping mechanism for deep breathing and self-calming.

Thanks for attending. Thanks for attending. Thanks for attending. Thanks for attending.

To contact us:

Richard Davis: richard@ntatx.com

Genie Davis: genie@unt.edu