MICHAEL GMcKEEPhDDepartment of Psychiatry and PsychologyCleveland ClinicClevelandOHBiofeedbackAn overview in the context of heartbrain medicine ABSTRACTspecific physiologic functionsCommon mod ID: 937767
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CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 SUPPLEMENT 2 MARCH 2008 MICHAEL G.McKEE,PhDDepartment of Psychiatry and Psychology,Cleveland Clinic,Cleveland,OHBiofeedback:An overview in the context of heart-brain medicine ABSTRACTspecific physiologic functions.Common modalities forbiofeedback include surface electromyography,respi-ration rate and depth,skin surface temperature,car-diovascular reactivity,and electrodermal response.tic/stress-management/biofeedback model,whichan individual.Biofeedback interventions have beena number of medical disorders,and are increasinglyproviders and payors.various modalities that it can serve to monitor, dis-cussing major models of biofeedback therapy, and out-BIOFEEDBACK:BOTH PROCESS AND INSTRUMENTATIONwhen it was coined to describe laboratory proceduresresearch subjects learned to modify heart rate, bloodflow, and other physiologic functions that were nothuman history, particularly through the use of mir-simple, direct, and immediate way. Biofeedback equip-individual and the disorder, ranging from a few to 50 orMULTIPLE MODALITIES FOR MONITORINGMultiple modalities can be monitored via biofeed-cular reactivity (particularly heart rate and bloodpressure), and electrodermal response.only by ones creativity and technological capabili- Dr.McKee reported that he has no financial relationships that pose a potentialconflict of interest with this article. by reaching a goal (such as a systolic blood pressurein with colors of the patients choosing as he or sheputer-generated figures and graphs.deficit disorder. A baseline electroencephalogram isMore recently, heart rate variability has come intolow-frequency (0.1-Hz) bands produced the highestfrequency-specific oscillations in heart rate variability,tality, teaching patients to increase heart rate variabil-related to optimal low-frequenc
y band power.LEARNING AND MODELS OF BIOFEEDBACKproblem, or controlling physiologic behavior. A mangood a score as he would with the blindfold off,Have the capacity to respondBe motivated to learnBe positively reinforced for learningBe given accurate information about the resultsDirect feedback learning modelThe direct feedback learning model assumes that addingphysiology being targeted. This model has been used inBiofeedback training in this model may involve athe coach teaches the patient how to use the mirror.tribute to excessive reactivity. The relationship ofgood at identifying the stressors in their lives. TheTherapeutic/stress-management/biofeedback modelstress-management/biofeedback model, it is essentialmodel, stress management and psychotherapeutictivity and then by a recovery period in which rate andnerability. Patients typically respond well to thissuggests that the notion of mind-body interaction res-Table 1BIOFEEDBACK OVERVIEW CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 SUPPLEMENT 2 MARCH 2008 CRITERIA FOR EVALUATING EFFICACY OF BIOFEEDBACK INTERVENTIONSdetailed below.Level 1:Not empirically supportedby anecdotal reports and/or case studies in non peer-Level 2:Possibly efficaciousassignment to a control condition internal to the study.Level 3:Probably efficaciousreplication studies that demonstrate efficacy.Level 4:Efficaciousa. In a comparison with a no-treatment control group,cacy in a study with sufficient power to detect mod-b. The studies have been conducted with a popula-tionally defined manner, c. The study used valid and clearly specified outcomed. The data were subjected to appropriate data analy-e. The diagnostic and treatment variables and proce-f. The superiority or equivalence of the interventionLevel 5:Efficacious and specificbeen shown to be superior to credible sham therapy,pill
therapy, or alternative bona fide treatment in atEfficacy ratings for specific disordersback, Yucha and Gilbert CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 SUPPLEMENT 2 MARCH 2008 TABLE 1Processes potentially at work during biofeedback- assisted psychotherapeutic stress management1.Operant conditioning,with success in changing physiology2.Feedback learning,with the biofeedback equipment repre-back loop upon already existing internal feedback loops.3.Feedback learning,with the biofeedback equipmentcontrol systems.4.Learning the relaxation response via imagery and cognitiveexercises.5.Modifying assumptions,attitudes,and expectations thatlead to psychophysiologic stress reactions.6.Enhancing self-awareness in general,including awarenessof bodily functioning,by getting specific informationrelationship of physiologic functioning to thought patterns.7.Resolving conflicts by discussing them with a therapist,psychophysiologic reactions.8.Responding to hypnotic suggestion of greater well-being9.Faith healing,with belief in the process being a curative10.Changing behavior to reduce stressors,in response to 11.Experiencing an increase in self-esteem secondary towarmth,genuineness,and empathy of the therapist,thereby reducing stress.12.Emulating a relaxed therapist who is not upset thinkingabout and discussing emotionally laden topics.13.Articulating values and shifting them to enable attitudinal,behavioral,and emotional change.14.A cathartic re-experiencing and emotional release thatreduces stress.15.Changing the locus of control so that the patient takes Adapted,with permission,from SLACK Incorporated:McKee MG (1978).Using biofeedback and self-control techniques to prevent heart attacks.Psychiatric Annals,8(10),92 99. Table 2Despite high standards,biofeedback thrivesMoreover, the effectiveness of training is perhapsmanual.
Baltimore, MD: Williams and Wilkins; 1977.Schwartz MS, Andrasik F.Biofeedback: a practitioners guide. 3rded. New York, NY: Guilford Press; 2003.Yucha C, Gilbert C.Lehrer PM, Vaschillo E, Lu SE, et al.biofeedback: effects of age on heart rate variability, baroreflex gain,diagnosis and treatment of chronic head pain: a case study.Task Force Report on methodology andempirically supported treatments: introduction. Appl PsychophysiolWeatherall M.fied in a systematic review. BJU Int 1999; 83:1015 1016.Wenck LS, Leu PW, DAmato RC.biofeedback intervention to reduce childrens anxiety. J ClinSilberstein SD, for the US Headache Consortium.American Academy of Neurology. Neurology 2000; 55:754 762.Yucha CB, Clark L, Smith M, Uris P, Lafleur B, Duval S.Van Kampen M, De Weerdt W, Van Poppel H, De Ridder D, FeysLavigne JV, Ross CK, Berry SL, Hayford JR, Pachman LM.juvenile rheumatoid arthritis. Arthritis Care Res 1992; 5:101 110.Humphreys PA, Gevirtz RN.Treatment of recurrent abdominalModification of slowoutcome study. Epilepsia 2001; 42:406 416.Chiarioni G, Bassotti G, Stanganini S, Vantini I, Whitehead WE.Treatment of childhood migraine with autogenic train-Academy of Sleep Medicine review. Sleep 1999; 22:1134 1156. with neurotherapy/QEEG biofeedback. J Head Trauma Rehabilof group cognitive behavioral therapy, surface electromyographic Correspondence:Psychiatry and Psychology, Cleveland Clinic, 9500 Euclid Avenue,BIOFEEDBACK OVERVIEW TABLE 2Efficacy ratings for biofeedback interventions in various medical conditions*Level 5:Efficacious and specificLevel 4:EfficaciousTemporomandibular disordersLevel 3:Probably efficaciousFecal elimination disordersTraumatic brain injuryVulvar vestibulitis *Ratings are by Yucha and Gilbertbased on data from the cited references. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 SUPPLEMENT 2 MARCH 2