Biofeedback, self-control, and self-management

Mechanisms of brain self-regulation: psychological factors, mechanistic models and neural substrates

While neurofeedback represents a promising tool for neuroscience and a brain self-regulation approach to psychological rehabilitation, the field faces several problems and challenges. Current research has shown great variability and even failure among human participants in learning to self-regulate target features of brain activity with neurofeedback. A better understanding of cognitive mechanisms, psychological factors and neural substrates underlying self-regulation might help improve neurofeedback's scientific and clinical practices. This article reviews the current understanding of the neural mechanisms of brain self-regulation by drawing on findings from human and animal studies in neurofeedback, brain-computer/machine interfaces and neuroprosthetics. In this article, we look closer at the following topics: cognitive processes and psychophysiological factors affecting self-regulation, theoretical models and neural substrates underlying self-regulation, and finally, we provide an outlook on the outstanding gaps in knowledge and technical challenges. This article is part of the theme issue 'Neurofeedback: new territories and neurocognitive mechanisms of endogenous neuromodulation'.

The Influence of Physiological and Psychological Learning Mechanisms in Neurofeedback vs. Mental Imagery Against Binge Eating

In biofeedback research, the debate on physiological versus psychological learning has a long tradition and is still relevant today, regarding new developments of biofeedback for behavior modification. Analyzing the role of these learning mechanisms may help improving the protocols and answer the question, whether feedback of physiological functions is necessary to modify a target behavior. We explored the presence and impact of physiological (EEG changes) versus psychological learning (changes in somatic self-efficacy) in a recently developed EEG neurofeedback protocol for binge eating. The protocol targets a reduction of food-cue induced cortical arousal through regulation of EEG high beta activity. In an experimental study accompanying a randomized controlled trial, pre and post treatment EEG measurements were analyzed in a neurofeedback group (n = 18) and an active mental imagery control group without physiological feedback (n = 18). Physiological learning in terms of EEG high beta reduction only occurred in the neurofeedback group. Post treatment, participants with successfully reduced binge eating episodes (≥ 50% reduction) showed lower EEG high beta activity than unsuccessful participants (p = .02) after neurofeedback, but not after mental imagery. Further, lower EEG high beta activity at post-treatment predicted fewer binge eating episodes in neurofeedback only. In mental imagery, somatic self-efficacy predicted treatment success instead of EEG activity. Altogether, the results indicate that physiological changes serve as a specific treatment mechanism in neurofeedback against binge eating. Reducing cortical arousal may improve eating behaviors and corresponding neurofeedback techniques should therefore be considered in future treatments.

Learning to stand tall: Idiopathic scoliosis, behavioral electronics, and technologically-assisted patient participation in treatment, c. 1969-1992

Drawing on the archives of American learning psychologist Neal E. Miller, this article investigates the role of instrumentation in the expansion and diversification of the behavior therapy domain from the late 1960s to the early 1990s. Through the case of Miller's research on the use of biofeedback to treat idiopathic scoliosis, it argues that the post-World War II adoption of electronic technology by behavioral psychologists contributed to extending their subject matter to include physiological processes and somatic conditions. It also enabled a technologically-instrumented move outside the laboratory through the development of portable ambulatory treatment devices. Using the example of the Posture-Training Device that Miller and his collaborators invented for the behavioral treatment of idiopathic scoliosis, this paper considers how electromechanical psychological instrumentation illustrated a larger and ambiguous strategic shift in behavior therapy from an orientation toward external control to one of self-control.

Skin conductance biofeedback training in adults with drug-resistant temporal lobe epilepsy and stress-triggered seizures: a proof-of-concept study

The present proof-of-concept study investigated the feasibility of skin conductance biofeedback training in reducing seizures in adults with drug-resistant temporal lobe epilepsy (TLE), whose seizures are triggered by stress. Skin conductance biofeedback aims to increase levels of peripheral sympathetic arousal in order to reduce cortical excitability. This might seem somewhat counterintuitive, since such autonomic arousal may also be associated with increased stress and anxiety. Thus, this sought to verify that patients with TLE and stress-triggered seizures are not worsened in terms of stress, anxiety, and negative emotional response to this nonpharmacological treatment. Eleven patients with drug-resistant TLE with seizures triggered by stress were treated with 12 sessions of biofeedback. Patients did not worsen on cognitive evaluation of attentional biases towards negative emotional stimuli (P>.05) or on psychometric evaluation with state anxiety inventory (P = .059); in addition, a significant improvement was found in the Negative Affect Schedule (P = .014) and in the Beck Depression Inventory (P = .009). Biofeedback training significantly reduced seizure frequency with a mean reduction of -48.61% (SD = 27.79) (P = .005). There was a correlation between the mean change in skin conductance activity over the biofeedback treatment and the reduction of seizure frequency (r(11) = .62, P = .042). Thus, the skin conductance biofeedback used in the present study, which teaches patients to achieve an increased level of peripheral sympathetic arousal, was a well-tolerated nonpharmacological treatment. Further, well-controlled studies are needed to confirm the therapeutic value of this nonpharmacological treatment in reducing seizures in adults with drug-resistant TLE with seizures triggered by stress.

Impact of biofeedback on self-efficacy and stress reduction in obesity: a randomized controlled pilot study

Biofeedback application is an evidence-based technique to induce relaxation. A primary mechanism of action is the improvement of self-efficacy, which is needed to facilitate the translation of health behavioral intentions into action. Obesity is often associated with low self-efficacy and dysfunctional eating patterns, including comfort eating as an inexpedient relaxation technique. This is the first study investigating the effects of biofeedback on self-efficacy and relaxation in obesity. In the present experiment, 31 women, mean body mass index 35.5 kg/m², were randomized to a food-specific biofeedback paradigm, a non-specific relaxation biofeedback paradigm, or a waiting list control. Eight sessions of biofeedback of the electrodermal activity were performed while presenting either a challenging food stimulus or a non-specific landscape stimulus. Self-efficacy, stress, ability to relax, eating behavior, and electrodermal activity were assessed before, directly after, and 3 months after the intervention. The food-specific biofeedback predominantly showed effects on food-related self-efficacy and perceived stress. The non-specific relaxation biofeedback showed effects on the ability to relax. Self-reported improvements were confirmed by corresponding decrease in the electrodermal reaction to food stimuli. Biofeedback treatment is effective in improving self-efficacy in individuals with obesity and might therefore be a valuable additional intervention in obesity treatment.

Task-related stress and EEG alpha biofeedback

Establishing a contingency between stress and a physiological response is essential in biofeedback. The sensitivity of high alpha to contingent stress was investigated by manipulating conditions known to influence stress, such as the distribution, predictability, and controllability of stressful stimuli, and number of tasks performed. Forty subjects were divided into stress and non-stress groups. Within each group, one-half had the dual-task of anticipating and increasing alpha activity. The other half was initially instructed to only anticipate alpha and, later, had the dual task of anticipating and controlling alpha. No feedback training was included to distribute the task-related stressor and allowed the assessment of self-control. All of the stress manipulations significantly influenced the effects of stress on alpha production. The dual-task subjects produced less alpha and less self-control than did training with control phased in after subjects learned to anticipate alpha. Without stress, phased-in control produced highly significant increases in alpha production and self-control without feedback. The use of an alpha-contingent feedback paradigm and anticipation training was related to the therapeutic applications of alpha feedback to stress and anxiety.

Temperature-biofeedback treatment of migraine headache. Specific effects and the effects of "generalization training"

Digital skin temperature biofeedback was used in the treatment of migraine headache. The value of a "generalization-training" procedure as well as the relationship between temperature control and clinical effects were studied. In all, 24 migraine sufferers were randomly assigned to either "standard" or a "generalization-training" biofeedback procedure and were given eight treatment sessions. Headache activity was measured before, during, and after treatment; and digital skin temperature was continuously measured during training sessions. From the results the following tentative conclusions were drawn: (1) Those who acquire temperature control show greater decrease in headache, (2) pretreatment baseline finger temperatures might predict if temperature control will be achieved, and (3) "generalization-training" methods do not seem to result in a greater degree of temperature control.

Biofeedback-assisted control of peripheral skin temperature: a methodological study

To maximize the production and detection of training effects in biofeedback-assisted control of peripheral skin temperature, this study incorporated these methodological features: differential feedback between dominant and nondominant hands, monetary incentives, within-subjects manipulation of training direction and multiple-training sessions, graphic-based visual feedback, and no-feedback self-control periods. Eight male subjects participated in eight sessions each consisting of adaptation (22 min.), bidirectional self-control (10 min.), and bidirectional feedback training (35 min.). Mean differential temperature changes were significantly different for increase and decrease conditions, but the magnitude of control did not change over sessions. Differential feedback control was of small magnitude and tended to be accomplished by decreasing both hands at different rates; self-control did not develop during the course of training. This methodology did not produce large-magnitude feedback, or self-control, but differential feedback is recommended for further study as an experimental paradigm.

Muscle discrimination ability at three muscle sites in three headache groups

The present study examined the ability of three headache groups (migraine, mixed migraine/tension, and tension) to accurately discriminate subjective levels of muscle tension at the forearm flexor, frontalis, and trapezius muscle sites. Discrimination ability was assessed at pre- and posttreatment using a psychophysical method of magnitude production. Results show that the ability to discriminate muscle tension levels at pretreatment varied across the headache groups, with migraineurs being the most accurate (r = .854), followed by the mixed headache group (r = .785), and finally the tension headache group (r = .732). Discrimination ability significantly increased at the posttreatment assessment. A multiple regression analysis showed that pretreatment performance on the muscle discrimination task significantly predicted outcome (r = .75) from relaxation and biofeedback training for migraine patients but not for the mixed or tension headache groups.

The control issue in biofeedback training

Well-delineated models and procedural descriptions are noticeably missing from the clinical biofeedback literature dealing with the training of physiological self-control. As a consequence, optimal protocols for the assessment and training of self-control of physiological functions have not eventuated. The present article reviews evidence suggesting that researchers have (a) confused self-control training, assessment, and measurement of tonic response levels, (b) neglected to determine the degree of acquired physiological self-control, and (c) failed to report the relationship between level of acquired physiological control and clinical outcome. The article also proposes an assessment and training paradigm that may be useful in reducing these methodological problems in future biofeedback research.

Critical issues in the assessment of headache

In an earlier paper, Thompson (1982) made the point that "an adequate assessment and understanding of the relevant independent and dependent variables related to subjects' headache complaints will yield information pointing to the most logical choice for a treatment intervention" (p. 230). It is essential that researchers and clinicians adopt an idiographic approach if we are to fully realize the potential of biofeedback, behavior therapy, and other nonpharmacological approaches as primary or ancillary interventions in the management of head pain. Large group comparisons, composed of heterogeneous subject populations treated with standardized techniques, have failed to elucidate the optimal intervention for individualized headache complaints. Yates (1980) noted with reference to biofeedback. "The reason for the failure of biofeedback training to show any consistent superiority over other relaxation training techniques stems from its use as a blunderbuss rather than as a rapier or precision instrument" (p. 499). We would maintain that a similar situation has pervaded the headache literature with a "blunderbuss" approach characterizing assessment and client-treatment-matching strategies. The remediation of the current controversy regarding treatment efficacy in the area of head pain is dependent upon the careful and critical use of assessment strategies in future research and clinical activity.

Self-control procedures in biofeedback: a review of temperature biofeedback in the treatment of migraine

It is argued that in order to optimize the achievement of self-control and to evaluate the clinical effects of biofeedback three skills should be included in training and assessment, namely: (1) the ability of voluntary control with external feedback, (2) the ability of voluntary control without external feedback, and (3) the ability to apply the self-control skill in critical situations in everyday life. A review of the literature concerning temperature-biofeedback in the treatment of migraine headaches shows that the research from this point of view is in a rather poor state of affairs and that no definite conclusion can in fact be drawn about the degree of self-control which has been achieved and hence of the ultimate clinical value of biofeedback.

The relationship between muscle discrimination ability and response to relaxation training in three kinds of headaches

Accurate discrimination of changes in physiological response has been noted as an important element in learning to control that response. Using a magnitude production procedure involving forearm isometric contractions, it was found that the ability to discriminate muscle tension varied across headache groups, with the no-headache control group (r = .76) being most accurate, followed by the tension group (r = .68), the mixed tension and migraine group (r = .60), and finally the migraine group (r = .51). The most important result, however, was that muscle discrimination ability significantly predicted clinical outcome from treatment by relaxation training for tension headache subjects (r = .50) but did not predict outcome for migraine or mixed headache subjects.

An experimental analysis of discrimination of pulse transit time

The present study attempted to determine if individuals could be trained to discriminate changes in their own pulse transit time, an indirect estimate of relative (systolic) blood pressure. A single-subject ABAB reversal-reinstatement design was used in an experimental analysis of the effects of feedback on pulse transit time discrimination in a normotensive and essential hypertensive subject. Subjects engaged a response button on a free-operant schedule each time they felt pulse transit time was momentarily below a predetermined mean. After baseline, visual feedback was provided contingent on correct responses (feedback) and incorrect responses (reversal). Procedures also assessed the role of respiration as a possible discriminative stimulus. For both subjects discrimination improved during feedback, showed disruption when the reversal was implemented, and subsequently improved during the second feedback phase. Respiration did not appear to have served as the discriminative stimulus. Results are discussed in terms of the need for refining procedures, especially to ensure generalization to no-feedback conditions, and the potential applications and importance of training of pulse transit time.

Effectiveness of EMG biofeedback training for controlling arousal in subsequent stressful situations

Thirty-five subjects participated in (1) a pretreatment session during which arousal was measured while subjects anticipated and then viewed a stressful film; (2) four 20-min treatment sessions during which subjects received either contingent EMG biofeedback (biofeedback treatment), instructions to attend to a variable pitch tone (attention-placebo control), instructions to relax as much as possible (instructions-only control), or instructions to sit quietly (no-treatment control); and (3) a posttreatment session that was identical to the pretreatment session. Results indicate that when compared to the subjects in the control conditions, subjects who received EMG biofeedback were not effective in reducing frontalis EMG levels during treatment or while viewing the stressful film, but they were effective in reducing frontalis EMG levels while anticipating the stressful film. There was no evidence that EMG biofeedback influenced either skin conductance or self-reports of arousal.

The behavioral management of asthma and asthma-related problems in children: a critical review of the literature

This review focuses upon the behavioral approach to childhood asthma. Asthma is defined as intermittent, variable, and reversible airways obstruction with a complex multidimensional etiology. The major measures of asthma include physiological, symptomatic, and collateral measures. The behavioral management of childhood asthma has been restricted to relaxation training, systematic desensitization, assertive training, biofeedback, and deconditioning of exercise-induced asthma. The efficacy of such intervention strategies for asthmatic children is in doubt, although the management of asthma-related problems in children appears to be a more promising area of research. The author suggests that the power of intervention programs for asthmatic children may be strengthened by the development of multifaceted treatment programs contingent upon the antecedents and consequences of the individual case. Also, behavior therapy may be of assistance to mild asthmatic children.

A component analysis of biofeedback induced self-control of peripheral (finger) temperature

Most of the research on biofeedback induced peripheral temperature control is open to serious methodological and theoretical criticisms. In the present research investigation, increase in peripheral (finger) temperature was targeted because of the possible therapeutic implications for the treatment of migraine and Raynaud's disease. Two experiments are reported in which the pretest-posttest control group design was employed to test the power of the variables in biofeedback induced self-control of finger temperature, and the necessity for subjects to engage in somatic manoeuvres. Significant increases in within-session and absolute finger temperature occurred in a test for self-control only for those subjects who had undergoing contingent feedback-somatic activity training conditions. It is suggested that future research should examine the role of mediational strategies in biofeedback-temperature training.

The effectiveness of EMG biofeedback training in low back pain

Eighteen patients with chronic low back pain (lbp) of muscle tension origin were given an EMG biofeedback training. Compared to seven controls they showed a significant decrease during training in muscle tension and subsequently in pain. However, at follow-up EMG levels dropped to the initial (high) level. Pain scores of patients with high pain decrements during training showed further improvement during follow-up, which was not the case with patients showing less substantial improvement. The importance of cognitions was discussed.

The effects of feedback on blood pressure discrimination

Discrimination of blood pressure in the natural environment as a function of feedback was assessed. Seventeen normotensives screened for blood pressure lability were randomly assigned to two groups. These subjects were then asked to estimate their systolic and diastolic blood pressure values two times per day over a 4-week period. Feedback for accuracy of blood pressure discriminations was implemented across the two groups in a multiple baseline fashion, using a feedback withdrawal condition in Group I to assess maintenance effects over time. Results showed improvement in discrimination accuracy for subjects in both groups when feedback was used, and no decrement in performance over a 2-week period after feedback was removed for subjects in Group I. Discrimination of systolic pressures improved at a slightly faster rate than discrimination of diastolic pressures.

Effect of heart-rate control training on heart-rate discrimination

4 subjects were exposed to discrimination-testing procedures before and later biofeedback training to increase and decrease their heart rates. Results indicated significant increases and decreases in heart rate, as well as a significant improvement in accuracy of discrimination. The results suggest improvements in discrimination may occur as a function of feedback training.