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 Table of Contents  
PG CORNER
Year : 2019  |  Volume : 3  |  Issue : 1  |  Page : 71-73

Understanding biofeedback and its use in psychiatry


Department of Psychiatry, Seth GSMC and KEM Hospital, Mumbai, Maharashtra, India

Date of Web Publication24-May-2019

Correspondence Address:
Dr. Swati Balkrishna Shelke
104, Gayatri CHS, Nanabhai Paralkar Marg, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_13_19

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  Abstract 


Biofeedback is a technique which demonstrates the mind–body connection. It is training through which patients learn to exert voluntary control on involuntary body processes. Biofeedback can be helpful in the management of a wide variety of medical and psychiatric disorders. Among these are the anxiety-depression spectrum, psychosomatic disorders, chronic pain syndromes, as well as sleep disorders. Biofeedback is a good choice as main treatment and adjunct treatment in indicated disorders, if the patient prefers or when other treatment modalities are unsuccessful or contraindicated. The management of somatoform disorders is often a challenging task. Pharmacotherapy may not be effective or suitable in certain patients or situations, requiring different modes of interventions. In such cases, biofeedback can be effectively used. We, in this article, will review relevant research on the efficacy, mechanism of action, biofeedback training, planning of sessions, and clinical recommendations.

Keywords: Biofeedback, biofeedback training, somatoform disorders


How to cite this article:
Shelke SB, Singh RV. Understanding biofeedback and its use in psychiatry. Ann Indian Psychiatry 2019;3:71-3

How to cite this URL:
Shelke SB, Singh RV. Understanding biofeedback and its use in psychiatry. Ann Indian Psychiatry [serial online] 2019 [cited 2019 Dec 13];3:71-3. Available from: http://www.anip.co.in/text.asp?2019/3/1/71/259080




  Introduction Top


Biofeedback is a technique which demonstrates mind–body connection and trains individuals to modify their physiological parameters to improve the overall health. Although clinical biofeedback procedures are highly effective in ameliorating a variety of symptoms of medical and psychiatric disorders, it is scarcely used in India. There is a dearth of expertise and literature on biofeedback in India.

As postgraduate trainees, we often have limited knowledge and experience of biofeedback training either due to the unavailability of biofeedback equipment or a trained therapist. In our institute, we got the opportunity to use biofeedback training for patients suffering from a variety of psychiatric conditions. So far, we have found it to be effective in the management of variety of somatoform disorders and anxiety disorders. The management of somatoform disorders is often a challenging task. Pharmacotherapy may not be effective or suitable in certain patients or situations, requiring different modes of interventions. In such cases, biofeedback can be effectively used. We, in this article, will review relevant research on the efficacy, mechanism of action, biofeedback training, planning of sessions, and clinical recommendations.


  What is Biofeedback? Top


The term “Biofeedback - a real-time psychophysiological mirror” was first coined in 1969.[1] Neil Miller was one of the founding fathers behind the idea of biofeedback. Miller demonstrated that operant conditioning of various ANS functions could be achieved which means that involuntary processes in the body can be brought under voluntary control through training.[2]

Seeing is believing – The physiological feedback displayed on biofeedback machine monitor is important for providing the evidence to patients that thoughts and emotions affect their body. As biofeedback training progresses, patients understand that learning to control physiological functions also has an effect on their emotions and cognition. It is of utmost importance that skills acquired during training sessions are applied to everyday environment to achieve the goal of biofeedback therapy which is a long-term recovery of a patient.


  Who Can Benefit from Biofeedback? Top


Biofeedback can be helpful in the management of a wide variety of medical and psychiatric disorders. Among these are the anxiety-depression spectrum, psychosomatic disorders, chronic pain syndromes, as well as sleep disorders.

In 2008, Yucha and Montgomery rated various disorders into five levels of efficacy recommended by the joint task force of association for applied psychophysiology and biofeedback and the society for neuronal regulation.[3],[4]

Level 1: Not empirically supported for eating disorders as evidence is supported only by anecdotal reports and/or case which are not peer-reviewed.

Level 2: Possibly efficacious for depression,[5] erectile dysfunction, posttraumatic stress disorder, and fibromyalgia with at least one study of sufficient statistical power showing well-identified outcome measures.

Level 3: Probably efficacious for substance use disorder and insomnia as multiple observational, clinical, wait list controlled, within-subject, and intrasubject replication studies had demonstrated the efficacy of biofeedback in these disorders.

Level 4: Efficacious for anxiety,[6] chronic pain,[7] migraine,[8] attention deficit hyperactivity disorder, hypertension, and Raynaud's disease, i.e., in a comparison with a no-treatment control group, alternative treatment group, or sham (placebo) control utilizing randomized assignment with the biofeedback treatment being statistically significantly superior to the control condition or equivalent to a treatment of established efficacy in a study with sufficient power to detect moderate differences.

Level 5: Efficacious and specific for urinary incontinence in females as biofeedback treatment has been shown to be statistically superior to credible sham therapy, pill, or alternative bona fide treatment in at least two independent research settings.

Biofeedback equipment: Three components

  1. Transducer/detector – Can be a pair of electrodes or pressure or temperature transducer which detects physiological variables such as blood flow, heart rate, and respiratory rate
  2. Signal processor – Amplifies, filters transducer signal, and convert it into useful form which can be displayed
  3. Display – Demonstrates processed signals in visual, audible, or both forms.[9]


Modalities of biofeedback

  1. Surface electromyography: Uses sensor to represent muscle tension. It can be placed on, for example, the frontalis muscle (a placement which picks up activity from multiple muscles), trapezius or mastoid muscles.
  2. Galvanic skin response – Sensors on the fingers that monitor perspiration. Increased sympathetic activation = more moisture, thereby increasing the conductivity of the skin.
  3. Temperature – Sensor detects skin temperature with a thermistor usually attached to a finger or toe. Rise in hand temperature can indicate relaxation when there is increased blood flow to the skin.
  4. Heart rate or heart rate variability – Sensor attached to finger measures the heart rate.
  5. Pneumograph – It is a belt with a built-in strain gauge which provides feedback about the relative expansion/contraction of the chest and abdomen. It will allow us to determine the rate of breathing, pattern, and proportion of inhalation versus exhalation
  6. Electroencephalography (neurofeedback): Sensors are attached to the scalp that monitor the electrical activity of the brain.[9]


Biofeedback training

Biofeedback therapy is done with the help of a biofeedback therapist who selects the appropriate physiological modality, makes a training regimen, teaches awareness and relaxation skills, and follows up with the patient.

The first step of biofeedback therapy is the assessment of the patient followed by training sessions.[9]

Assessment

Every person has unique psychophysiological profile. The aim of the assessment is to determine the correction of which physiological changes will be helpful in symptoms reduction of the patient.

  1. Initial evaluation of patient – Detailed history of symptom duration, frequency, severity, triggering, and reliving factors is essential to plan the therapy and to decide the goal of therapy. It is also imperative to evaluate patient's acceptability and availability for therapy
  2. Psychophysiological stress profile – The stress profile consists of a 2-min baseline recording followed by 3-min exposure of several different stressors (arithmetic, loud noise, or emotional event recall). After exposure to each stressor, recovery break is given to evaluate the recovery from stressor. A therapist can decide the time duration for each stressor and type of stressor. This recording is done in different physiological modalities by application of sensors. This can take around 15 min. Stress assessment gives information about individual's unique physiological responses to different kinds of stressors. This is important since people are exposed to different kind of stressors in their lives, and their physiological responses to these stressors may be different. Their treatment will be optimized if it takes this pattern of response into consideration
  3. Psychophysiological relaxation profile – The relaxation profile consists of a 2-min baseline recording followed by 3-min trials of several different relaxation techniques (breathing, passive muscle relaxation, progressive muscle relaxation, autogenic training, and guided imagery). Before doing relaxation profile, one must ensure that the patient is well versed with different relaxation techniques; otherwise, one session should be exclusively done for teaching relaxation exercises.


The relaxation profile gives us information on whether the patient is able to reduce sympathetic arousal with relaxation and which areas of physiology respond to relaxation more easily than others.

The assessment will give us the physiological modalities to be addressed and also which relaxation techniques can be used in the training sessions.

Training sessions

During biofeedback training session, sensors for selected physiological modalities are applied, and the patient is asked to relax. The readings are analyzed by software and presented in the form of graphs, numbers, images, and sounds showing the patient whether he is relaxed or tense. This information can serve to reinforce and shape behavior and increase awareness for achieving self-regulation.

Each session: Approximately 45 min (10 min of reassessment, 20 min of training, and 15 min for giving homework assignments).

Homework assignments consist of keeping the log of symptoms and practicing relaxation. In the beginning, we can schedule weekly sessions while the patient is still in learning phase so that he/she can give frequent feedback on home practices. Once the patient has acquired skills, sessions can be spaced to once a fortnight and then once in a month till the patient shows static improvement. Follow-up sessions can be planned after every 6 months.[9]


  Conclusion Top


Thus, biofeedback is found to be efficacious in psychiatric disorders which we encounter in our daily practice. It has the potential to empower individuals and is a good choice as main treatment and adjunct treatment in indicated disorders, if the patient prefers or when other treatment modalities are unsuccessful or contraindicated. Treatment with biofeedback requires a trained therapist; hence, the integration of biofeedback therapist training in postgraduate curriculum is essential.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Charles S. Biofeedback and behavioural medicine. In: Kaplan HI. Sadock BJ, editors. Comprehensive Text Book of Psychiatry. 4th ed. Baltimore: Williams and Wilkins; 1985. p. 1466-72.  Back to cited text no. 1
    
2.
Blumenthal JA. Relaxation therapies and biofeedback: Applications in medical practice. In: Jesse OC Jr, editor. Consultation Liaison Psychiatry and Behavioural Medicine. Philadelphia: W. B. Saunders; 1988. p. 272-83.  Back to cited text no. 2
    
3.
Yucha C, Montgomery D. Evidence-based practice in biofeedback and neurofeedback. Evidence-based Practice in Biofeedback and Neurofeedback Association for Applied Psychophysiology and Biofeedback. Wheat ridge CO, USA; 2008.  Back to cited text no. 3
    
4.
Moss D, Gunkelman J. Task force report on methodology and empirically supported treatments: Introduction. Appl Psychophysiol Biofeedback 2002;27:271-2.  Back to cited text no. 4
    
5.
Karavidas MK, Lehrer PM, Vaschillo E, Vaschillo B, Marin H, Buyske S, et al. Preliminary results of an open label study of heart rate variability biofeedback for the treatment of major depression. Appl Psychophysiol Biofeedback 2007;32:19-30.  Back to cited text no. 5
    
6.
Rice KM, Blanchard EB, Purcell M. Biofeedback treatments of generalized anxiety disorder: Preliminary results. Biofeedback Self Regul 1993;18:93-105.  Back to cited text no. 6
    
7.
Corrado P, Gottlieb H, Abdelhamid MH. The effect of biofeedback and relaxation training on anxiety and somatic complaints in chronic pain patients. Am J Pain Manage 2003;13:133-9.  Back to cited text no. 7
    
8.
Arena JG, Bruno GM, Hannah SL, Meador KJ. A comparison of frontal electromyographic biofeedback training, trapezius electromyographic biofeedback training, and progressive muscle relaxation therapy in the treatment of tension headache. Headache 1995;35:411-9.  Back to cited text no. 8
    
9.
Inna Z, Khazan. The Clinical Handbook of Biofeedback a Step-by-Step Guide for Training and Practice with Mindfulness. Wiley Blackwell, John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, UK, 2013.  Back to cited text no. 9
    




 

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Abstract
Introduction
What is Biofeedback?
Who Can Benefit ...
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