Building an Evidence Based Practice: Use of Brain Imaging in Clinical Assessment and Evaluation of Treatment Outcomes

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1 Building an Evidence Based Practice: Use of Brain Imaging in Clinical Assessment and Evaluation of Treatment Outcomes Mirjana Askovic, Anna Watters, Mariano Coello, Jorge Aroche, Anthony Harris Presented at the 1st Australia and New Zealand Refugee Trauma Recovery in Resettlement Conference, March 2017, Sydney NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS) Discipline of Psychiatry, Sydney Medical School, University of Sydney Brain Dynamics Centre, Westmead Institute for Medical Research, University of Sydney

2 STARTTS (Sydney, NSW, Australia) The NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS) opened its doors in 1988, and is one of Australia's leading organisations that helps refugees recover from their experiences and build a new life in Australia. Our clinical services include counselling, psychotherapy, psychiatric assessment and treatment, physiotherapy, acupuncture, behavioural activation, neurofeedback, family & group interventions and psychosocial approaches. We currently employ around 250 professionals from diverse ethnic and cultural backgrounds speaking at least 30 different languages. We utilise a culturally aware bio-psycho-social model in assessing the impact of trauma, planning treatment and framing interventions.

3 Neurofeedback/Biofeedback Clinic at STARTTS 2 EEG Technicians 6 Neurofeedback Clinicians 2 Peripheral Biofeedback Clinicians Neurofeedback Research Officer Neurofeedback/Biofeedback Program Engineer Assessment: EEG/ERP study Stress assessment Cognitive and psychophysiological measures Treatment: EEG Biofeedback Peripheral Biofeedback Research: Resting EEG in trauma ERP study (Go/NoGo) Controlled study pre and post Neurofeedback

4 Experiences reorganize neural pathways in the brain Controls (n=16) Reduced functional connectivity within the default network during the resting-state PTSD (n=18) Bluhm et al. J of Psychiatry & Neuroscience, 2009

5 Trauma destabilises brain (electrical) activity These can be manifested as patterns of increased or decreased activity in various areas of the brain Many of these changes can be detected by EEG data analysis This lack of stability in brainwave activity can lead to emotional problems such as: anxiety, stress, fear and aggression poor affect control problems with self-regulation

6 What is EEG? ElectroEncephaloGram Brain waves - rhythmic electrical activity of the brain - arises from the simultaneous firing of many neurons. Coordinated firing of pools of neurons represents the core of brain function The brain function is measured by placing multiple sensors on the scalp to record the electrical potentials on the surface. The test that records brainwave patterns is called Electroencephalogram (EEG). EEGs taken while the brain is performing a standard task are called Event Related Potentials (ERP)

7 EEG data collection at STARTTS The faster brain waves (Beta, High Beta) indicate high level of activity. The slower brain wave (Delta, Theta and Alpha) indicate low level of activity or idling. If part of the brain is idling or is over-active it cannot perform its function well. EEG readings can indicate which parts of the brain are functioning properly and which are not.

8 EEG data collection at STARTTS 10 min. eyes open 10 min. eyes closed 20 minutes under a task (GO/NOGO)

9 EEG analysis

10 ERP data Event Related Potentials (ERPs): Assess brain electrical activity during a task. The Visual Continuous Performance Task (VCPT) assesses working memory and sustained attention. In clinical practice, this provides useful information about cognitive functioning and to assess changes pre to post treatment.

11 Brain processing (ERPs) in refugee trauma: pilot study

12 Behavioural task Go/NoGo Press the button on the second animal The task consists of 400 trials sequentially presented to the subject every 3 seconds Duration of stimuli presentation 100 ms

13 Altered brain activation in PTSD

14 Altered brain activation in PTSD cont.

15 Can neurofeedback improve brain functioning?

16 What is Neurofeedback? A method of training the brain to produce better organised brainwaves This leads to better self-regulation of mood and emotions EEG sensors (passive) are placed on the client s head Clinician s view Client s view

17 How does Neurofeedback work?

18 Neurofeedback pilot study Data collected on 15 clients pre and post neurofeedback treatment The clients received an average of 25 sessions of neurofeedback

19 Neurofeedback training protocols Treatment geared to promote calming and relaxed states by enhancing client s ability to produce alpha rhythm (8-11hz) and/or sensory-motor rhythm (12-15hz) and suppressing both, slow and fast brain activity (theta and high beta).

20 Changes in symptoms pre to post neurofeedback treatment

21 Changes in ERPs in the GO/NOGO task pre to post neurofeedback treatment (a) Grand average ERPs at Cz for NOGO stimuli (b) Post-Pre difference wave with the confidence level of statistical significance at p<0.05. (c) Maps computed at maximums of P3 NOGO for Pre, Post and healthy control (HC) subjects. (d) LORETA images of the Post-Pre difference waves (Low Resolution Brain Electromagnetic Tomography)

22 Case study: Naval Demographics: 54 year-old male Diagnosis: PTSD, Major Depression Symptoms: depressed mood, headaches, back pain, insomnia, nightmares, intrusive thoughts Trauma History: torture and war trauma Neurofeedback: 36 sessions focusing on mood stabilization, tension reduction and sleep enhancement; included frontal downtraining and temporal enhancement of alpha

23 Case study: Naval assessment pre and post neurofeedback Symptoms Scales: PTSD (HTQ): 3.3 to 2.4; Depression (HSCL-D): 3.0 to 2.5; Anxiety (HSCL-D): 3.1 to 2.0 Observations: stable mood, improved sleep, a reduction in nightmares (from several per week to 1-2 per month) and only occasional headaches, reduction in pregabalin and tramadol. Table 1. Behavioural performance Pre and Post neurofeedback therapy Accuracy (% errors) Response Time (msec) Omission Commission Speed Variability Pre Post ERPs: normalization in CNV, P3 NOGO and P3 GO (b)) suggesting improved attention and cognitive control

24 Conclusion Benefits of using EEG in clinical practice To better understand presenting problems (such as dissociative symptoms, headaches, memory or attentional difficulties) To help with making decision related to the interventions that may be appropriate with complex cases As the basis for neurofeedback therapy To evaluate treatment progress and outcomes

25 STARTTS Neurofeedback/Biofeedback Team Acknowledgments Jay Gunkelman, QEEG Diplomat Brain Science International Sejla Murdoch NF Mentor Trix Harvey NF Team Leader Sue Stirling BF Counsellor Prof. Dr. Juri Kropotov Institute of the Human Brain (HBI), Russian Academy of Sciences, St. Petersburg Larisa Zilenkov NF Counsellor Shaheen Kohser NF Counsellor Carol Garabedian NF Counsellor Dr. Andreas Müller Research Clinic, Chur, Switzerland HBImed AG Tanami Sonter BF Counsellor Peter Farleigh EEG Technician Anna Watters NF Research Officer A/Prof. Anthony W. F. Harris Sydney Medical School University of Sydney David Parker NF Engineer STARTTS Direct Services Counsellors for referring to Neurofeedback Clinic and supporting. their clients while receiving neurofeedback treatment. Kimberley Collinson and Amir Hossain for preparing data for the analysis, and Russell Downham for ERP analysis We acknowledge the invaluable contribution of STARTTS clients to our studies.

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