Negative Effects and the Need for Standards of Practice in Neurofeedback

Biofeedback ©Association for Applied Psychophysiology & Biofeedback Volume 35, Issue 4, pp. 139–145 www.aapb.org SPECIAL ISSUE Negative Effects and the Need for Standards of Practice in Neurofeedback D. Corydon Hammond, PhD, ECNS, QEEG-D, BCIA-EEG,1 and Lynda Kirk, MA, LPC, QEEG-D, BCIA-EEG2 1University of Utah School of Medicine, Salt Lake City, UT; 2Austin Biofeedback & EEG Neurofeedback Center, Austin, TX Keywords: neurofeedback, EEG biofeedback, iatrogenic effects, standards, FDA Negative effects associated with psychotherapy have associated with various symptom complexes, whether it is been documented for more than 40 years. In the field of something relatively more common such as attention deficit electroencephalography biofeedback, controlled research disorder/attention deficit hyperactivity disorder (ADD/ has likewise demonstrated that negative effects can occur ADHD; e.g., Monastra, 2005) or a more complex condition from inappropriate neurofeedback training. New evidence such as obsessive-compulsive disorder (OCD; Prichep et al., is presented from acknowledgments by practitioners 1993), schizophrenia (e.g., John, Prichep, & Alper, 1994), of both transient side effects and more serious adverse or autism (Sutton et al., 2005). Thus, treatment that is not reactions that have occurred in response to neurofeedback individualized following careful assessment of not only training. Issues of consumer protection and the future of the symptoms but also electrophysiological brain functioning profession are discussed. It is imperative that professionals can pose a greater risk of either producing an adverse and professional societies emphasize standards of practice reaction or of simply being ineffective. Everyone does not and that individuals not use neurofeedback to work with need the same thing. conditions for which they are not trained and licensed to Because of the ethical problems inherent in seeking work. to induce iatrogenic harm, formal research with regard to neurofeedback and harmful effects is of course limited. Introduction Nonetheless, some hard research evidence does exist. Lubar As early as 1971, Bergin reported 30 psychotherapy studies et al. (1981) published a reversal, double-blind, controlled that documented deterioration in a proportion of patients study with epilepsy. They demonstrated that problems who underwent treatment. By 1977, there were more than with uncontrolled epilepsy could either be improved with 40 studies that had been found detailing negative effects neurofeedback or be made worse if the wrong kind of from therapy (Lambert, Bergin, & Collins, 1977). Bergin and training was done. Lubar and Shouse (1976, 1977) likewise Lambert (1978) defined this phenomenon as follows documented that both ADD and ADHD symptoms could improve but also could be worsened if inappropriate Deterioration implies an impairment of vigor, resilience, or neurofeedback was done. This study used an A-B-A reversal usefulness from a previously higher state. Generally, it has been design and found that when theta (4–7 Hz) was inhibited regarded as a worsening of the patient’s symptomatic picture, and the sensorimotor rhythm reinforced, there were the exaggeration of existing symptoms, or the development of improvements in ADHD symptoms. However, when theta new symptoms, as assessed before and after treatment. (p. 152) was reinforced, there was a deterioration and reversal of the positive improvements. Although clinical experience and research (briefly summa- Whitsett, Lubar, Holder, Pamplin, and Shabsin (1982) rized in Hammond, 2006) have found that neurofeedback similarly performed a double-blind, A-B-A crossover design has great therapeutic value, it has also been pointed out study with uncontrolled epilepsy patients. This was one of the Biofeedback (Hammond, Stockdale, Hoffman, Ayers, & Nash, 2001) that studies that documented that neurofeedback is not teaching side effects and adverse reactions can occur in association voluntary self-regulation of brainwave activity but is actually with neurofeedback treatment of various conditions. reconditioning how the brain is functioning. Anyone familiar There is an abundance of evidence that there is a with epilepsy knows that there is more epileptiform activity Ô Winter 2007 heterogeneity in the electroencephalograph (EEG) patterns found in the sleep EEG than in a waking EEG. In this study, 139 Standards of Practice in Neurofeedback sleep EEGs were evaluated, and it was found that training to reduce theta activity and to enhance sensorimotor rhythm resulted in an 18% decrease in paroxysmal activity from a baseline of 72%. However, when the reward contingencies were reversed, there was an increase of 29% in epileptiform activity (which the authors concluded was detrimental to the patients); following subsequent appropriate treatment, there was a decrease of more than 60% in paroxysmal activity. These findings reinforce, once again, that if inappropriate neurofeedback training is done, negative effects can occur. Incorrect assumptions are sometimes made by less educated neurofeedback practitioners. We have heard a few of these practitioners express to the public that neurofeedback never results in adverse effects. As we have documented, this simply cannot be said. We have also seen it assumed that because quantitative EEG (QEEG) research has found that, overall, alcoholics tend to have an excess of beta activity and a deficit in alpha and theta activity (e.g., John, Prichep, Figure. “Z”-values of electroencephalography features referenced to norms. Fridman, & Easton, 1988) neurofeedback training that inhibits beta activity and reinforces alpha and theta is the competency to work with serious medical, psychiatric, and treatment of choice for this population. Such an assumption psychological problems such as depression, bipolar disorder, rests on generalities and group averages that do not always uncontrolled epilepsy, obsessive-compulsive disorder, apply to individual cases. In the real world of clinical traumatic brain injuries, stroke, autism, alcoholism, and practice, comorbidities are common, and individual patients drug abuse, as well as ADD/ADHD and learning disabilities. can be unique. For example, the Figure displays the QEEG Some equipment and software manufacturers are seeking to map from the Nx Link database for a 25-year-old chronic fly under the radar of the Food and Drug Administration alcoholic patient. As can be seen, there is an extreme excess (FDA) and are evading registration of their equipment, of theta, not beta, activity. This patient fits a subtype of 24% whereas others are violating FDA regulations against the of alcoholics who have a diagnosis of ADHD (Schubiner et sale of biofeedback equipment to unlicensed individuals (or al., 2000). A lack of individualization and use of an alpha/ without the written prescription of a licensed practitioner). theta protocol in such a case could be anticipated to have the Second, we have been impressed with the number of potential to seriously compromise cognitive function and reports on public and professional Internet list groups result in even greater problems with impulse and emotional about side effects and adverse reactions. These effects range control. Similarly, a patient with excess beta activity from very mild, transient symptoms such as fatigue or and cortical irritability who was being trained to further headache to very serious conditions such as exacerbation of reinforce beta activity might become more vulnerable to depression, manic episodes, emotional lability, seizures, and seizure or tic activity, as might a patient with excess theta and deterioration in cognitive functioning. Consequently, we epileptiform activity for which a neurofeedback practitioner believe that it is vitally important for legitimate and legally inappropriately reinforced theta activity. licensed practitioners to be aware of potential risks and for practitioners as well as professional societies to emphasize The Need for More Vigorous Standards of standards of practice. We also believe that it is important Practice that future neurofeedback research not only monitor rates The authors have become increasingly alarmed about the of improvement and lack of change but also report the risks of adverse reactions and iatrogenic harm for two reasons. frequency of side effects, adverse reactions, and deterioration First, there have come to be an increasing number of dealers, in functioning. manufacturers, and trainers who have been supplying EEG biofeedback equipment directly to lay persons. These New Data About Adverse Reactions From Biofeedback individuals have no advanced degrees or health care licenses Neurofeedback Training Ô for independent practice, yet many of them are opening Because research on negative effects of neurofeedback is practices and advertising to the public that they have difficult to conduct, the authors have compiled information Winter 2007 140 Hammond, Kirk from at least seven Internet list groups from which there Regression have been reports of side effects and adverse reactions. In A home-training mother of an autistic child acknowledged, the material that follows, we will describe, and in some “Adverse events happen from neurofeedback—at least in cases directly quote, from these reports. In every case, my home. My son regressed dramatically from the wrong the identity of the list groups, equipment being used, and training when we started four years ago.” This smart individual making the report have been left anonymous.

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