BCIA Case Conference Clinical Issues in Alpha-Theta Neurofeedback for Addiction

Transcription

1 BCIA Case Conference Clinical Issues in Alpha-Theta Neurofeedback for Addiction Genie Davis, PhD, BCN Psychologist, Professor Emerita, University of North Texas Richard E. Davis, MS, BCN LPC, Private Practice, Denton, Texas EEG PATTERNS IN ADDICTIONS: When is alpha-theta training appropriate for a client? Addiction Predisposition EEG Patterns 1. 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 1

2 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) 2

3 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 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 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 3

4 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 Session After 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. 4

5 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 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 Peniston Protocol 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 Example Relapse following original Peniston protocol for alcoholism 52-year-old white male, Ph.D. medical school professor; selfreferred 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 5

6 Pre-Treatment Beta NXLinkdatabase Early Alpha-Theta Session Record Focus 1000 Equipment Mid-Treatment Session Showing Alpha-Theta Crossovers 6

7 Near Final Session Showing Alpha & Theta Amplitude Increases & Crossovers Post TX QEEG Showing Excessive High Beta Remaining (This EEG pattern predicted client s s relapse -- within 3 mo.) 2. CNS UnderarousalPatterns 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 (Alper et al. 1990; Noldy et al. 1994; Prichepet al.; Roemer et al. 1995; Trudeau et al. 1999) 7

8 Summary of Two Abnormal EEG Patterns Related to Addiction Disorders Patterns associated with CNS hyper- or hypoarousal 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 PenistonProtocol 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-C & 2-7 ; or C4-Pz & 2-7 ; Reassessed with TOVA after 10 sessions; if normal switched to alphatheta 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 3 rd Wave of Alpha-Theta NF: QEEG-Based Alpha-Theta Approaches Treat abnormalities seen in individual QEEG s debeus et al 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 8

9 QEEG-Based Alpha-Theta Protocol Approach Used by Davis & Davis for Polysubstance Abuse 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 frontocentraltraining 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 9

10 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 sessions of alpha-theta training using Peniston Protocol 10

11 Case Summary: OutpatientTreatment Using QEEG- Based Modification of Alpha- Theta Neurofeedbackfor 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 11

12 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: 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 1 st session childhood memory related to overbearing older sister Completed 20 sessions of alpha-theta using Peniston Protocol with Hz inhibit added 12

13 Case Outcome Depression significantly reduced on posttreatment 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 5+ years posttreatment 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 onsite 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. To contact us: Thanks for attending. Richard Davis: richard@ntatx.com Genie Davis: genie@unt.edu 13