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According to the Association for Applied Psychophysiology and Biofeedback, the technique was developed in the early 1970s by psychologists and physicians. These techniques continue to be used by psychologists, physicians, nurses, and other health care professionals such as physical therapists. Prior to beginning any biofeedback training, individuals may need a comprehensive psychological, educational, and/or medical assessment. Biofeedback can be used in conjunction with nonmedical treatments, such as psychotherapy, cognitive-behavioral therapy, and behavioral treatment strategies.

How biofeedback works

Biofeedback utilizes electronic sensors, or electrodes, attached to various parts of the body to detect changes in physical responses. Signals then inform the individual of these changes by means of visual or auditory signals such as a light display or a series of beeps. While the individual views or listens to feedback, he or she begins to recognize thoughts, feelings, and mental images that influence his or her physical reactions. By monitoring this mind-body connection, the individual can use the same thoughts, feelings, and mental images as cues or reminders to become more relaxed, or to change heartbeat, brain wave patterns, body temperature, and other body functions. The individual uses trial-and-error to change the signals change in the desired direction. For example, individuals trying to control their blood pressure levels may see a light flash whenever the pressure drops below a certain level. They may then try to remember what their thoughts and feelings were at the moment and deliberately maintain them to keep the blood pressure level low.

Through training, the individual learns to control the targeted physical response and, over time, is able to recognize what is required to reduce problematic symptoms. Eventually, the external biofeedback becomes unnecessary as the individual learns to perceive internal physical responses and make the desired changes. The individual then has a powerful, portable, and self-administered treatment tool to deal with problematic symptoms.

Three stages of biofeedback training

• Awareness of the problematic physical response: Individuals may complete a psychophysiological stress profile (PSP) to identify how their bodies respond to a variety of stressors and determine their ability to overcome undesired physical reactions. This involves a period of rest, stress, and recovery. For example, various sensors are attached to various parts of the body, and a baseline measurement lasting from two to four minutes records physical responses. The individual then goes through a standard set of stressors (such as rapid math calculations or running in place) each lasting from two to four minutes. This is followed by another relaxation period to determine the length of the recovery period.

• Using signals from the biofeedback equipment to control physical responses: The individual is assisted in reaching certain goals related to managing a specific physical response.

• Transferring control from biofeedback equipment or the health care professional: Individuals learn to identify triggers that alert them to implement their new-found self-regulation skills.

Types of biofeedback equipment

• Electromyograph (EMG): Sensors (or electrodes) placed on the skin on pertinent parts of the body monitor electrical activity in muscles, specifically tension. This is the most frequently used biofeedback method in the treatment of various neurologic disorders such as stroke, cerebral palsy, traumatic brain injury, and multiple sclerosis. In children and adolescents, EMG may be used to treat tension headaches, enuresis, and encopre-sis. In treating TMJ or bruxism, EMG sensors are placed on jaw muscles. Chronic pain is treated by monitoring muscle tension in various places on the body.

• Galvanic skin response (GSR): Sensors on the fingers monitor perspiration or sweating. This is also referred to as obtaining a skin conductance level (SCL). GSR may be used in the treatment of anxiety, fears or phobias, stress, and sleep problems.

• Temperature or thermal sensors: Sensors monitor body temperature and changes in blood flow. Changes in hand temperature, for example, can indicate relaxation when there is increased blood flow to the skin. Temperature biofeedback may be useful for treating migraine headache, Raynaud's disorder, and anxiety disorders.

• Heart rate sensors: A pulse monitor placed on the fingertip monitors pulse rate. Increases in heart rate are associated with emotional arousal, such as being angry or fearful. Decreases in heart rate are associated with relaxation.

• Capnometry (CAP): Respiratory sensors monitor oxygen intake and carbon dioxide output. This differentiates correct breathing from problematic breathing practices. Breath control training may be used to treat

A patient undergoes biofeedback monitoring for stress.

(Photo by Will and Deni McIntyre. Photo Researchers, Inc. Reproduced by permission.)

A patient undergoes biofeedback monitoring for stress.

(Photo by Will and Deni McIntyre. Photo Researchers, Inc. Reproduced by permission.)

panic attacks, asthma, and a variety of stress-related conditions.

• Electroencephalographs (EEG) or neurofeedback: Sensors attached to the scalp monitor brain wave activity in different parts of the brain. It may be used to treat conditions with proven or suspected impact on brain wave patterns such as seizure disorders or epilepsy, ADHD, learning disabilities, migraine headaches, traumatic brain injury, and sleep disorders.

Biofeedback is geared toward whatever a person finds most appealing and understandable and provided in several formats such as auditory, visual, or multimedia. Audio feedback, that may take the form of changes in tone and pitch, is useful because visual attention is not necessary. Visual feedback can be provided in various forms such as bar or line graphs on a computer screen. Initially, it was thought that—over time—computer signals could become boring or visually unappealing. In response to this, Barry Bittman developed Mindscope in 1992 that displays video scenes with realistic sounds on a high-definition television set connected to a computer. Physical responses detected by the biofeedback equipment control an engaging audiovisual environment of beautiful and realistic scenes. Clarity, perspective,

-g motion, and sounds improve as the individual deepens Ja their relaxation. For children and adolescents, this may g be described as a "video game for the body." Visual displays for EMG biofeedback may include sports such as ^ basketball, baseball, and golf, where the individual plays against the computer.

The setting in which biofeedback training takes place can vary. Sometimes the clinician, client, and equipment are in the same room. Sometimes the client may sit in comfortable seating in a semi-dark, quiet room while the clinician is in another room with the equipment. In this arrangement, the clinician and client may communicate using an intercom.

In some cases, children and adolescents may reach the desired level of control in three to five sessions. Depending on the condition, biofeedback training may require a series of sessions for several days or weeks. In general, it may take 10 or 15 sessions at the lower end to 40 or 50 sessions at the higher end.

Preparation

Biofeedback is most successful when individuals are motivated to learn. It is useful for people who have difficulty relaxing, even when they make efforts to do so. A receptive and open attitude is important for attaining desired responses rather than actively focusing on attaining them. It is important that individuals are willing to practice regularly at home to apply the skill to everyday life. Establishing a foundation of trust and confidence in the health care professional is an important component of biofeedback training.

Before beginning biofeedback training, an initial consultation will be conducted to record medical history, treatment background, and biofeedback goals. The procedure will be explained to provide a clear understanding of how and why the training will be helpful. The individual may be shown the equipment and told where they will be placed and how they work.

Before electrodes are placed on the body, the skin surface must be adequately prepared by using alcohol preparation pads to remove oils, makeup, and dead skin cells that may interfere with the biofeedback signal. An electrode paste is then applied to the sensor, or a small adhesive pad is used to adhere the sensor to the skin. Heart rate, temperature, and GSR monitors may be placed on the fingertip with a Velcro or elastic band. With CAP, the tip of a small, flexible, plastic tube is positioned in the nostril using tape. An individual may be taught several forms of biofeedback initially, then the training may be tailored to the individual's preference.

The biofeedback trainer must have technical skill, an understanding of basic anatomy and physiology, knowledge of various conditions, and familiarity with computer hardware and software. The American Psychological Association views biofeedback as a proficiency area, master's and doctoral level training programs are available through a variety of sources, and certification is available through the Biofeedback Certification Institute of America.

Aftercare

One or two follow-up sessions may be arranged two to four months after the initial set of appointments. In this way, long-term progress can be assessed, support can be provided, and adjustments can be made, if needed.

Risks

There are no known side effects with properly administered biofeedback. Problems may occur if biofeedback is used to treat certain conditions where the use of biofeedback is not advised.

Normal results

A normal result may be indicated by achieving the desired changes in muscle tension, heart rate, sweat activity, respiration rate, temperate change, and brainwave activity. Health care professionals may use various criteria or normal values that have been developed for some biofeedback equipment. These values indicate levels that can be expected from normal physiological functioning or relaxation. Importantly, an individual learns to control their physical reactions, which may lead to feelings of empowerment and confidence.

Abnormal results

Unusual results may arise from a number of factors, including poor sensor or electrode contact with the skin and interference from other electrical signals or "noise." Some equipment may react to room temperature conditions, especially when the room is very hot or very cold. Although inexpensive monitoring equipment is available, such as watches that monitor heartbeat and handheld GSR devices, their results may not be accurate.

See also Anxiety and anxiety disorders; Substance abuse and related disorders

Resources books

Culbert, Timothy P. "Biofeedback with Children and

Adolescents." In Innovative Psychotherapy Techniques in

Child and Adolescent Therapy., edited by C. Schaefer. 2nd ed. New York: John Wiley and Sons, 1999. Di Franco, Joyce T. "Biofeedback." In Childbirth Education: Practice, Research and Theory, edited by F. H. Nichols and S. S. Humenick. 2nd ed. Philadelphia: W. B. Saunders, 2000. Schwartz, Mark S. and Associates. Biofeedback: A

Practitioner's Guide. New York: Guilford, 1987. Spencer, John W. and J. J. Jacobs. Complementary/Alternative Medicine: An Evidence-Based Approach. Baltimore: Mosby, 1999.

Stoyva, Johann M. and Thomas H. Budzynski. "Biofeedback Methods in the Treatment of Anxiety and Stress Disorders." In Principles and Practice of Stress Management. edited by P. M. Lehrer and R. L. Woolfolk. 2nd ed. New York: Guilford Press, 1993.

periodicals

American Psychological Association. "HCFA will cover biofeedback for incontinence." Monitor on Psychology 31, no.11 (December 2000). Burgio, Kathryn L., Julie L. Locher, Patricia S. Goode, M. Hardin, B. Joan McDowell, and Dorothy C. Dombrowski. "Behavioral vs. Drug Treatment for Urge Urinary Incontinence in Older Women: A Randomized Controlled Trial." JAMA, The Journal of the American Medical Association 280, no. 23 (December 1998): 1995-2000.

organizations

Association for Applied Psychotherapy and Biofeedback. 10200 W. 44th Avenue, Suite 304, Wheat Ridge, CO 80033-2840. (303) 422-8436. <http://www.aapb.org>. Biofeedback Certification Institute of America. 1022 W. 44th Avenue, Suite 310, Wheat Ridge, CO 80033. (303) 4202902. <http://www.bcia.org>.

Joneis Thomas, Ph.D.

KEY TERMS

Acetylcholine—A naturally occurring chemical in the body that transmits nerve impulses from cell to cell. Generally, it has opposite effects from dopamine and norepinephrine; it causes blood vessels to dilate, lowers blood pressure, and slows the heartbeat. Central nervous system well-being is dependent on a balance among acetylcholine, dopamine, serotonin, and norepinephrine.

Anticholinergic—Related to the ability of a drug to block the nervous system chemical acetylcholine. When acetylcholine is blocked, patients often experience dry mouth and skin, increased heart rate, blurred vision, and difficulty in urinating. In severe cases, blocking acetylcholine may cloud thinking and cause delirium.

Catheterization—Placing a tube in the bladder so that it can be emptied of urine.

Dopamine—A chemical in brain tissue that serves to transmit nerve impulses (is a neurotransmitter) and helps to regulate movement and emotions.

Neurotransmitter—A chemical in the brain that transmits messages between neurons, or nerve cells.

Parkinsonian—Related to symptoms associated with Parkinson's disease, a nervous system disorder characterized by abnormal muscle movement of the tongue, face, and neck, inability to walk or move quickly, walking in a shuffling manner, restlessness, and/or tremors.

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