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Rolnick's Chapter on Anxiety Disorders

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439
Anxiety disorders are among the most common
mental disorders, with the adult lifetime preva-
lence rate at 33.7% (Kess...
440	 VI.  CLINICAL APPLICATIONS: TRADITIONAL GENERAL BIOFEEDBACK PRACTICE
is made increasingly plausible with further disc...
26.  Anxiety Disorders	441
tion, dizzy, lightheaded, sweaty, hot flashes, chills,
nausea, upset stomach, diarrhea, trembli...
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Rolnick's Chapter on Anxiety Disorders

  1. 1. 439 Anxiety disorders are among the most common mental disorders, with the adult lifetime preva- lence rate at 33.7% (Kessler, Petukhova, Samp- son, Zaslavsky, & Wittchen, 2012). Symptoms of anxiety are regularly experienced by healthy indi- viduals and despite not reaching clinical levels, are found to be correlated with negative health consequences, work absenteeism, and lowered productivity (Borkovec & Sharpless, 2004). Clark and Beck (2010) remark: “Today, as never before, calamitous events brought about by natural disas- ters or callous acts of crime, violence, or terrorism have created a social climate of fear and anxiety in many countries around the world” (p. 3). Our aim in this chapter is to describe how biofeedback can help ameliorate this problem. Anxiety is both a physiologically based response, influenced by genetic predisposition, and one that is a result of learning processes. The physiologi- cal aspect is of central importance in treatment, because anxiety is at its core a physiological phe- nomenon. Indeed, the term “anxiety” typically refers to a collection of physiological symptoms, including shortness of breath, trembling, and nau- sea, for instance (Bourne, 2005). When a threatening situation arises, the sym- pathetic component of the nervous system is trig- gered in order to enable either defense against or escape from the threat, commonly known as the fight-or-flight response (Cannon, 1929). Internal changes such as increased alertness, rapid heart- beat, tensing of muscles, amplified sweating, hur- ried breathing rate, and increased oxygen in the body enable more effective preparation of the body to fight or flee the “enemy” and preserve safety (Sadock & Sadock, 2003). Therefore, those expe- riencing an anxiety disorder may be considered to have a an overreactive fight-or flight response, in that even the perception of a physical threat, and in some cases, a psychological threat, can act as triggers. Sympathetic nervous system response, such as elevated cardiovascular function, has indeed been correlated with worry (Pieper, Bross- chot, Van Der Leeden, & Thayer, 2010). An overproportional focus on danger and extreme sensitivity to potential threat, combined with inefficient functioning of physiological sys- tems, can result in the establishment of a sustained state of fear, either of the sensation of anxiety itself or the perceived risks this experience poses. The intensity of the physiological experience presum- ably makes it difficult for the person to consider and/or accept that their perception of external threat is not real, whereas the internal symptoms are. In concordance with this general understand- ing of anxiety, the preferred treatment for anxi- ety is cognitive-behavioral therapy (CBT) with or without medication (e.g., Smits, Berry, Tart & Powers, 2008; Stewart & Chambless, 2009). The proposition herein is that biofeedback can enhance CBT as it addresses certain shortcom- ings of cognitive aspects of therapy. This proposal C h a p t e r 2 6 Anxiety Disorders Arnon Rolnick, Dana Bassett, Udi Gal, and Anat Barnea Schwartz_Biofeedback4E.indb 439 11/12/2015 5:24:26 PM
  2. 2. 440 VI.  CLINICAL APPLICATIONS: TRADITIONAL GENERAL BIOFEEDBACK PRACTICE is made increasingly plausible with further discus- sion of the physiological aspects of clinical anxiety. Classical cognitive therapy is based on the ABC model, which purports a linear activa- tion from (A), the activating event, via (B), the beliefs of the patient, to (C), the inevitable con- sequences (Ellis, 1994). However, developments in the understanding of neural processes deem the ABC assumption’s validity to be questionable. LeDoux (2002) asserts that there exist two neu- ral information-processing pathways that contest the ABC assumption. One pathway, shorter and quicker acting, relays information about external stimuli to the amygdala directly from the thala- mus, while the second pathway, longer and slower acting, relays the information a short while later, from the thalamus through the cortex to the amygdala. These pathways differ in not only the speed of response but also their accuracy (LeDoux, 2002). The shorter, quicker path is highly valu- able in situations that demand a quick response for survival. However, this pathway is subject to inaccuracy, because it does not involve the cortex, which is responsible for the augmented analysis of information. Therefore, its activation may lead to a conditioned anxiety response before any cogni- tive processing has occurred. This conditioning process has a valuable aspect in that it enables one to learn the connection between situations/places where danger is truly present. However, this pro- cess is subject to fault in that it may also repeatedly err in its production of a response when the envi- ronment is devoid of any real danger. This auto- maticity, an inherent aspect of the conditioning process, produces anxiety and defensive responses as the quicker path acts on partial information. The work of CBT appears to be somewhat discor- dant with this pathway and may be a contribut- ing factor in the variable success rate of therapy, which is sometimes as low as 50% (e.g., Fisher & Wells, 2005; DiMauro, Domingues, Fernandez, & Tolin, 2013). It is in fact this pathway, according to LeDoux's (2002) model, that is responsible for the emotional response that occurs and is subjectively misunderstood, which sheds light on the maladap- tive pattern of functioning that is a main feature in pathology. On the other hand, LeDoux's model also notes the importance of cognitive interven- tion in that it explains the need for the cortical path to regulate the amygdala's response. The slower pathway has the potential either to amplify or to regulate the anxiety response. “However, because the direct [shorter] pathway bypasses the cortex, it is unable to benefit from cortical pro- cessing. As a result it can only provide the amyg- dala with a crude representation of the stimulus. The cortex's job is to prevent the inappropriate response rather than to produce the appropriate one” (pp.106–107, LeDoux, 2002). This is where CBT is focused. Anxiety Disorders The term “anxiety” is used to refer to a cluster of psychophysiological manifestations across the psychotherapeutic, learning-based, and neurobio- logical literature. In clinical psychopathology lit- erature the term also refers to a fear response that is both incongruous and exaggerated given the context in which it occurs (Pine, 2009). In this chapter we refer to anxiety in its vari- ous manifestations, such as that occurring within generalized anxiety disorder, social anxiety disor- der, phobias, panic disorder, obsessive–compulsive disorder, and trauma disorders. There is some dis- agreement about whether all of these syndromes are best considered anxiety disorders and in fact the Diagnostic and Statistical Manual of Mental Disorders modifed the classification of anxiety dis- orders between its fourth and fifth editions (DSM- IV and DSM-V, respectively) such that several of these syndromes are no longer regarded as anxiety disorders despite the fact that anxiety is a feature. The justification for this system of classifica- tion has been repeatedly subjected to criticism. Whereas some researchers emphasize the differ- ences between various kinds of anxiety, positing several distinct disorders, each with its own etiol- ogy, phenomenology, and treatment. Others focus on the similarities among the manifestations of anxiety and postulate the unity of all anxiety dis- orders (Barlow, 2002). Moreover, there has been a recent tendency in the psychotherapy literature for interventions to utilize a unified protocol for transdiagnostic treatment, designed to be appli- cable across the entire range of anxiety-related disorders (Barlow et al., 2011). Physiological Manifestation of Anxiety Disorders Clark and Beck (2010) in their review of the symptoms of anxiety, list the following as possible physiological manifestations of anxiety: increased heart rate, palpitations, shortness of breath, rapid breathing, chest pain or pressure choking sensa- Schwartz_Biofeedback4E.indb 440 11/12/2015 5:24:26 PM
  3. 3. 26.  Anxiety Disorders 441 tion, dizzy, lightheaded, sweaty, hot flashes, chills, nausea, upset stomach, diarrhea, trembling, shak- ing, tingling or numbness in arms, legs, weakness, unsteady, faintness, tense muscles, rigidity, and dry mouth. Many symptoms of anxiety are manifestations of autonomic nervous system (ANS) activity (Brad- ley, 2000). Activation of the sympathetic nervous system (SNS) is the most prominent physiologi- cal response in anxiety, inducing symptoms of hyperarousal such as constriction of the peripheral blood vessels, increased strength of the skeletal muscles, increased heart rate and force of contrac- tion, dilation of the lungs to increase oxygen sup- ply, dilation of the pupils for possible improvement of vision, cessation of digestive activity, increased basal metabolism, and increased secretion of epi- nephrine and norepinephrine from the adrenal medulla (Bradley, 2000). These SNS manifestations can be addressed via biofeedback. The goal is for patients to learn to influence each physiological incident of the entire cluster of symptoms to achieve symptom manage- ment and/or reduction. It was initially purported that the goal of biofeedback is to decrease sym- pathetic activity. However, recent research reveals that the picture is somewhat more complicated. The research on electrodermal activity (EDA) specifically sheds light on this issue. The electro- dermal system, primarily controlled by the SNS, has been studied extensively, yet the results are inconclusive. Certain models have linked anxiety with excessive autonomic lability and reactivity (e.g., Cruz & Larsen, 1995; Brenner, Beauchaine, & Sylvers, 2005). In support of these models, some research indicates that elevated electrodermal baseline levels and heightened responses are corre- lated with both PTSD and panic (Pole, 2007; Wil- helm, Gevirtz, & Roth, 2001). Electrodermal reac- tivity in anxious subjects has been demonstrated in a well-controlled study using virtual reality (Wilhelm et al., 2005). However, in his review, Crider (2008) argues that a substantial number of studies have failed to find any consistent relation- ship between electrodermal lability and self-report anxiety measures. Additionally, a diminished range of EDA responding has been found in panic, as well as GAD (Hoehn-Saric & McLeod, 1988; Hoehn-Saric, McLeod, Funderburk, & Kowalski, 2004). A broader view of anxiety disorders also considers the role of the PNS, which is involved in symptoms such as tonic immobility, drop in blood pressure, and fainting. The effects of PNS stimu- lation include decreased heart rate and force of contraction, constricted pupils, relaxed abdominal muscles, and constriction of the lungs (Bradley, 2000). HRV is a good indicator of both SNS and PNS activation, because the information provided by frequency analysis can differentiate between the two systems (Gevirtz, 2009; Gevirtz, Lehrer, & Schwartz, Chapter 13, this volume). It has been suggested that diminished HRV in patients with PTSD is a marker of autonomic dysregulation (Gevirtz, 2009). Other research has found both diminished HRV and reduced vagal tone to be associated with panic and GAD (Thayer, Fried- man, & Borkovec, 1996; Pittig, Arch, Lam, & Craske, 2012) as well as PTSD and SAD (Chalm- ers, Quintana, Abbott, & Kemp, 2014). The research on respiratory sinus arrythmia (RSA), a variation in heart rate that occurs dur- ing a breathing cycle, and on heart rate variability (HRV) indicates that there needs to be movement from a simplistic homeostatic view to a homeody- namic view of biological functioning (Friedman, 2007). Vascular constriction, as measured by skin tem- perature, is a known marker of stress, and skin temperature biofeedback provides training in stress reduction that has been widely accepted as efficacious (Shusterman & Barnea, 1995; Peper & Gibney, 2003). However, there appears to be a pau- city of research describing a correlation between skin temperature and anxiety disorders. Two instruments that measure patterns in respi- ration, the “pneuomograph,” a flexible rubber ves- sel that records the velocity and force of chest and abdominal movements during respiration and the “capnograpgh,” a device that monitors the concen- tration or partial pressure of carbon dioxide (Co2) in the respiratory gases, may be good indicators of anxiety because abnormalities in respiration have been postulated as a central component in anxiety disorders (e.g., Meuret, Wilhelm, & Roth, 2001) and exercises that regulate breathing have been shown to moderate ANS activity (e.g., Jerath, Crawford, Barnes, & Harden, 2015). One hypoth- esis of the etiology of panic attacks specifies hyper- ventilation as a key mechanism, proposing that panic attacks considered to be spontaneous are actually episodes of chronic or episodic hyperven- tilation of which the patient is unaware (Meuret et al., 2001; Meuret, Wilhelm, & Roth, 2008). The capnometric assessment is therefore considered a good tool for the assessment of panic disorder (Moss, 2003; Khazan, 2013). Additionally, it is imperative that the interconnectedness of emo- Schwartz_Biofeedback4E.indb 441 11/12/2015 5:24:26 PM
  4. 4. 442 VI.  CLINICAL APPLICATIONS: TRADITIONAL GENERAL BIOFEEDBACK PRACTICE tions and respiration be further deciphered if the treatment of stress, anxiety, and mood disorders is to be improved (Jerath et al., 2015). Electromyograph (EMG) has long been estab- lished as a measure of relaxation (Lehrer, 2007). In anxiety disorders elevated excessive muscle tension has been found in GAD, and inter- preted as reflecting generalized psychophysiologi- cal response rigidity to environmental stimuli (Hoehn-Saric & McLeod, 1988;,Yucha & Mont- gomery, 2008). The brain wave pattern (electroencephalo- graphic [EEG]) that is characteristic of most anxi- ety disorders shows abnormalities in basal levels of waking cortical arousal. This is indicative of some cerebral system instability, and sensory gating problems that suggest pathophysiology in brain- stem structures that are critical to the passage of exteroceptive information to cortical structures, and subsequent difficulties in the capacity for controlled information processing, indicating dys- function in working memory systems mediated by cortical network operations (Clark et al., 2009). It is generally agreed that anxiety is associated with increased activity in the beta range in con- junction with a decrease of activity in lower fre- quencies (Moss, 2003; Thompson & Thompson, 2007). Some discrepancy exists among reports regarding the specific range of beta activation, which is set to be elevated in anxiety, as well as the specific range of lower frequency activation, which is said to be reduced at the same time. Thompson and Thompson suggest that anxiety usually cor- responds to an increase in 19- to 22-Hz activity in conjunction with a decrease in 15- to 18-Hz activ- ity. Moss (2003) presents a different view, propos- ing that excessive fast wave activity (24–32 Hz) in combination with deficient amounts of slow wave activation is a cortical pattern of anxiety. This higher beta activation is often seen in conjunc- tion with a decrease in SMR, beta wave activity in the frequency of 12–15 Hz. Bursts of increased high beta activity in the low 20s seem to be a state marker, as the person reports feeling tense. Our own clinical experience suggests that anxi- ety of any kind is most often associated with an increase in frontal beta activation and occasion- ally with an increase in beta activation through- out the entire cortex. These observations suggest a general EEG biofeedback protocol for treating anxiety of any kind, essentially, reducing activa- tion in the beta range that seems excessive in an individual relative to the norm. Overall, it appears that important psychophysi- ological indices, such as elevated basal arousal level, slower habituation, and reduced autonomic flexibility, are associated with anxiety disorders. However, generalization of findings across the anxiety subtypes is not possible, because different physiological response patterns may distinguish phobia, panic disorder, and GAD. The homeody- namic model stresses the importance of physiolog- ical variability in maintaining organismic stability (Friedman, 2007). Despite the various manifes- tations that exist across the subtypes of anxiety and psychophysiological measures, there exist two commonalities. One relates to the subjective experience of the person so affected, an innate understanding that something is wrong. The sec- ond relates to the inherent inflexibility within the ANS. This accords with the proposal made by Borkovec and Sharpless (2004) that autonomic rigidity is a correlate of anxiety (GAD) that pre- vents healthy coping. Clark and Beck (2010) sug- gest that diminished autonomic flexibility might contribute to the misinterpretation of threat that is the core cognitive feature of anxiety. Similarly Craske (2003) has suggested that the likelihood of experiencing intense and acute autonomic sen- sations may heighten the salience of, and threat attributed to, bodily sensations. The clinician may train the patient to develop flexibility of responses so that physiological activ- ity can be reduced and/or increased in accordance with the situation, and simultaneously change the patient's interpretation of his or her physiologi- cal condition, such that perception of control is regained. The current discourse aims to outline the ways in which biofeedback can be used as a tool to assist in the regulation of physiological response, conditioned response, and cognitive pat- terns across the various subtypes of anxiety. The Use of Biofeedback in Anxiety Several theories of anxiety disorders propose that reports of fear and anxiety reflect an underlying state of physiological hyperarousal (Lang & McTe- ague, 2009). Yucha and Gilbert (2004) reported that reductions in both state and trait anxiety have been demonstrated with biofeedback (Hur- ley & Meminger, 1992; Wenck, Leu, & D'Amato, 1996). Yucha and Montgomery (2008) reviewed numerous controlled studies supporting the effi- cacious status of biofeedback (Bont, Castilla, & Maranon, 2004; Coy, Cardenas, Cabrera, Zirot, & Claros, 2005; Dong & Bao, 2005). Several other independent studies provide additional support for Schwartz_Biofeedback4E.indb 442 11/12/2015 5:24:27 PM
  5. 5. 26.  Anxiety Disorders 443 this finding (Hitanshu, Maman, & Jaspal, 2007; Reiner, 2008; Zucker, Samuelson, Greenberg, & Gevirtz, 2007; Gevirtz & Dalenberg, 2008; Agni- hotri, Paul, & Sandhu, 2007). Schoenberg and Anthony (2014) recently con- ducted a meta-analytic review of the use of bio- feedback in psychiatric disorders, in which they reported that anxiety disorders were the most commonly treated (68.3%). Overall, 80.9% of research reviewed reported some level of clinical amelioration resulting from biofeedback exposure, 65% of these to a statistically significant level of symptom reduction, as assessed via standard- ized clinical parameters. The authors admit that results must be interpreted with caution due to the heterogeneity of studies included; however, they also note the strong indication that biofeedback has the potential to unlock the channels of com- munication between mind and body with some proficiency, and that both therapeutic interaction and individual realizations can thus be augmented (Shoenberg & Anthony, 2014). Many of the research studies assessing biofeed- back have investigated it as a stand-alone inter- vention (Clough & Casey, 2011). For example, an early study of GAD demonstrated that both EEG and EMG biofeedback can reduce GAD (Rice, Blanchard, & Purcell, 1993). A later study sup- ported these findings, with results indicating that state and trait anxiety diminished significantly via EEG and EMG interventions (Agnihotri et al., 2007). Possibly, biofeedback might actually have the potential for even more promising results when integrated with interventions such as CBT (Reiner, 2008; See Hamiel and Rolnick, Chapter 11, this volume) and supportive intersubjective psychotherapy (Rolnick & Rickles, 2010). Indeed, some authors have investigated the combination of biofeedback with specific interventions (Kleen & Reitsma, 2011; Khazan, 2013). In this chapter we first attend to biofeedback as a stand-alone intervention and then explore the application of biofeedback in combination with other types of psychotherapeutic interventions. Biofeedback as a Stand‑Alone Intervention in Anxiety Disorders Arousal Reduction and Biofeedback as Tools for Alleviating Anxiety Biofeedback may be used effectively in the treat- ment of anxiety disorders as an arousal reduc- tion tool. The reason for this becomes clear when considering the need to regulate the ANS as an integral aspect of treating anxiety disorders. As discussed, some anxiety disorders involve over- activation of the SNS, while others involve an active avoidance of thoughts and behaviors that are likely to trigger this overactivity. Utilizing biofeedback to regulate the initial overarousal can be achieved in various ways: the reduction of muscle tension using EMG, regula- tion of the sympathetic response using EDA, bal- ance of the sympathetic–parasympathetic interac- tion using HRV or temperature, and control and prevention of hyperventilation with a breathing belt or capnometry (e.g., Lehrer, 2007). A meta-analysis of the treatment of anxiety dis- orders has shown that relaxation is highly effective whether the technique used is progressive muscle relaxation (PMR), autogenic training, breathing, applied relaxation, or meditation (Manzoni, Pag- nini, Castelnuovo, & Molinari, 2008). Biofeed- back may both enhance these relaxation methods or be used by people who are unable to use these other techniques (Rice et al., 1993). Indeed, Yucha and Montgomery’s (2008) review outlines studies that indicate the efficacy of biofeedback training that has not included relaxation techniques. Although research does not consistently show that biofeedback as a sole intervention provides superior results to relaxation, combining bio- feedback training in therapy may provide several advantages. For instance, motivation and belief in personal ability to gain control are established and strengthened as a function of the feedback, as objective immediate proof of technique efficacy is provided. Indeed, a study by Reiner (2008) indi- cated that participants found portable biofeedback devices to be more helpful than other relaxation techniques, such as yoga, meditation, and other unassisted breathing techniques. Relaxation-induced anxiety (RIA) is an occa- sionally reported difficulty that patients experi- ence with common relaxation techniques (Heide & Borkovec, 1983). Patients with RIA frequently report that relaxing may be harmful. Biofeed- back can address this challenge. For instance, if a heightened sense of lack of control is experienced when asked to keep their eyes closed, they may respond more positively to biofeedback, because they can keep their eyes open. Alternatively, even if patients close their eyes, auditory input can indi- cate to them that all is continuing as expected. Apart from the hypothesized motivational advantages, relaxation skills can be built via trial and error due to the feedback provided. Results achieved by Corrado, Gottlieb, and Abdelha- mid (2003) indicated that subjects receiving bio- Schwartz_Biofeedback4E.indb 443 11/12/2015 5:24:27 PM
  6. 6. 444 VI.  CLINICAL APPLICATIONS: TRADITIONAL GENERAL BIOFEEDBACK PRACTICE feedback and relaxation training had reductions on measures of both anxiety and somatization. When one begins to reduce arousal, the effects can be immediately observed. If the patient is not responding to a particular technique, therapist and patient can try other techniques, and both are immediately made aware of any reduction in arousal. In fact, the uniqueness of biofeedback lies within the inherent phenomenon that no tech- nique per se is actually needed to achieve arousal reduction. The act of receiving feedback, and the reinforcement provided each time there occurs a desired change, propels arousal reduction. This is of specific significance in cases in which patients have suffered continued tension and do not know what it feels like to be in a state of nonarousal. The moment they begin to reduce arousal, as the feedback shows, this awareness can be cultivated. Once this has been achieved, patients can begin to use arousal reduction skills in their everyday lives as they attend to their growing awareness of aroused versus nonaroused states. A review of early research that compared vari- ous biofeedback measures to one another or bio- feedback to relaxation techniques, such as PMR, autogenic training, and systematic desensitiza- tion, concluded that EMG biofeedback is superior to PMR in the specific achievement of muscle relaxation (Lehrer, Carr, Sargunaraj, & Woolfolk, 1994). To cultivate low arousal, various biofeedback sensors can be used. For PMR (Jacobson, 1938), the use of EMG, either from the frontalis or wrist flexor or wrist-to-wrist placement can be of bene- fit. Although Jacobson objected to the use of phys- iological measurements during PMR (Lehrer et al., 1994), using EMG provides patients with infor- mation about the tonus of their muscles, and it is the receipt of this information that helps to build self-awareness, ultimately leading to relaxation. In a similar vein, the other biofeedback sensors pro- vide information that also assist in developing self- awareness. To achieve relaxation through breath- ing techniques, a breathing belt, capnometry, or HRV can be used. Autogenic training and mind- fulness methods, as well as guided imagery relax- ation, also stand to be enhanced using feedback based on skin temperature and EDA. Neurofeedback The clearest illustration of biofeedback as a stand- alone intervention is provided by neurofeedback. Best understood within a learning paradigm of trial and error, neurofeedback relies more heavily on a patient's response to reinforcement and is less dependent on interpersonal or cognitive factors. Several studies suggest this technique is efficacious (e.g., Hammond, 2005; Walker, 2009). Anxiety disorders have brain biomarkers (EEG patterns) that can help with diagnosis and treat- ment prognosis (Clark et al., 2009). These EEG patterns may form the basis of the rationale for treating anxiety disorders not only psychothera- peutically but also with neurofeedback, which appears to offer specific benefits due to high sensi- tivity and high specificity. Neurofeedback has been researched and suc- cessfully applied in disorders of attention (Ams, Ridder, Strehl, Breteler, & Coenan, 2009; Barnea, Rassis, & Zaidel, 2005). Attention and anxiety have an interconnected nature, in that anxi- ety increases attention to threat-related stimuli (Eysenck, Derakshan, Santos, & Calvo, 2007) and in turn reduces the capacity for self-regulation. Anxiety is often considered in terms of attention deviation (e.g., Eysenck et al., 2007) and since it has central biomarkers in addition to peripheral ones, it is plausible to suggest that neurofeedback can be used as a primary, or complementary, treat- ment tool. Indeed, anxiety is a systemic phenom- enon that affects the individual on cognitive, emotional, and physical levels. Clark et al.’s (2009) seminal paper provides a systematic, evidence-based medicine (EBM) revi- sion of the field of electrophysiology with relation to anxiety disorders. Despite the fact that quan- titative EEG (QEEG) is not yet a diagnostic tool that can stand alone, research nevertheless sug- gests that QEEG is a tool that can efficiently guide neurofeedback training (Kropotov, 2009). Research indicates that the various anxiety syn- dromes disorders are characteristically different in their electrophysiological profile patterns, indicat- ing differences in underlying structural/functional pathology (Clark et al., 2009). Notwithstanding, there are some commonalities in the classes of measures characterizing dysfunction, all of which highlight difficulties with information processing. Thus, most of these disorders present with abnor- malities in basal levels of waking cortical arousal. This in turn suggests some cerebral system instabil- ity, accompanied by sensory gating problems that indicate pathophysiology in brainstem structures that are critical to the passage of exteroceptive information to cortical structures. Subsequently, there is a decrease in the capacity for controlled information processing (Ludewig et al., 2005). Schwartz_Biofeedback4E.indb 444 11/12/2015 5:24:27 PM
  7. 7. 26.  Anxiety Disorders 445 Based on EEG recordings, taken from the whole scalp, that have been quantitatively analyzed and compared to norms, the therapist can decide which protocol is most appropriate (e.g., which frequency should be enhanced, which should be decreased, and the site where electrodes should be placed). These two aspects of neurofeedback, frequency and electrode placement, are central to the successful use of neurofeedback (Walker & Kozlowski, 2005). Anxiety disorders tend to be characterized by a surplus of high-frequency waves (beta) and a defi- ciency in low-frequency waves (alpha) (Clark et al., 2009). In a limited number of cases, the reverse is true, in that anxiety is marked by excessive low- frequency waves and a paucity of high-frequency waves. Neurofeedback aims to reduce the power of high-frequency waves and increase that of low- frequency waves. Accordingly, the classic way to conduct neurofeedback is guided by the “bull- dozer” principle, which states that when one tries to normalize the pathological brain, the amplitude of the overactive brainwave frequency needs to be reduced, while the frequency that is less active requires enhancement (Moss, 2009). Given that the typical pattern of EEG in anxiety disorders is a surplus of beta waves, it is presumed that an increase of alpha waves is necessary. This increase is typically observed when one enters a meditative state (Travis, 2001). Thompson and Thompson (2007) suggest that raising high alpha (11–12 Hz) and semsorimo- tor rhythm (SMR; a beta wave in the frequency of 12–15 Hz), at the midline between Cz and Fz, and teaching diaphragmatic breathing at a rate of about six breaths per minute, produces relax- ation and improved motor control, and may cause a peaceful feeling. Davidson (1998) has proposed the existence of two motivation systems operating in separate hemispheres and subserving different forms of behavior and affect. The right hemisphere has been said to be especially active during process- ing of negative events, while the left hemisphere is more active in response to positive events. Thus, an additional direction that may be adopted in the use of neurofeedback is based on Davidson’s model, in that most anxiety disorders involve hemispheric asymmetry. It is possible that bipolar placement of the electrodes, one in each hemisphere, in F3 and F4 positions, forms part of the treatment in that it provides feedback about the different activity between the hemispheres, the purpose of which is to enhance or reduce the hemisphere's asymmetry, or to increase left-hemisphere activity by enhanc- ing beta frequencies. Walker (2009) reported successful results with 23 patients with PTSD whose QEEGs showed both high beta and a high anxiety rate (measured by self-report questionnaire). After several QEEG- guided neurofeedback sessions of reducing beta and enhancing alpha bands, a significant reduc- tion in anxiety was reported and remained stable throughout follow-up 1 month later. However, these results must be replicated before conclusions may be reached. Although studies assessing the use of neurofeedback for PTSD have been ongoing (Peniston & Kulkosky, 1991; Othmer, 2011), vali- dation studies remain sparse. This area is likely to benefit significantly from studies being conducted on the efficacy of neurofeedback for PTSD suffer- ers in more than 15 military and Veteran Admin- istration facilities, as reported by leading trauma researcher van der Kolk (2014). That neurofeedback may have the potential to be sensitive and specific is strongly suggested by results overall, but further research is required. Integrating Biofeedback with Psychotherapy The efficacy of biofeedback has been examined in several published studies; however, very few have used it as a technique to enhance current psycho- therapy practices (Clough & Casey 2011). As noted earlier, research has effectively estab- lished that biofeedback combines well with certain behavioral components of CBT such as breathing training and PMR (often referred to as “relax- ation exercises”), and leads to positive gains (e.g., Hawkins, Doell, Lindseth, Jeffers, & Skaggs, 1980; Reed & Saslow, 1980; Reiner, 2008). One case study, in which biofeedback, relax- ation, and CBT techniques of cognitive challeng- ing and exposure were combined, reported that panic attacks and agoraphobic avoidance ceased completely at the end of treatment (Goodwin & Montgomery, 2006). Reiner (2008) paired a por- table biofeedback device with CBT for a range of anxiety disorders and reported significant decreases in trait anxiety across subjects. Investigation of the potential efficacy of HRV biofeedback plus psychotherapy as a treatment for PTSD indicated that veterans receiving face-to- face treatment of HRV biofeedback with psycho- therapy showed significant reductions in PTSD symptoms, while those receiving only psycho- therapy did not (Tan, Dao, Farmer, Sutherland, & Gevirtz, 2011). Kleen and Reitsma (2011) suc- Schwartz_Biofeedback4E.indb 445 11/12/2015 5:24:27 PM
  8. 8. 446 VI.  CLINICAL APPLICATIONS: TRADITIONAL GENERAL BIOFEEDBACK PRACTICE cessfully integrated third-wave behavior therapies with HRV biofeedback and found that this was an effective method of training clients’ to increase both their HRV and mindfulness skills. Although these results are promising, demonstrating that the addition of biofeedback can enhance the ther- apeutic intervention, the general lack of empiri- cal research and, specifically, replication data, is a problem that must be rectified. A review of the rationale for its use in the treatment of anxiety dis- orders, primarily as a vehicle to enhance psycho- therapeutic processes, follows. Integrating Biofeedback with Desensitization and Exposure Most current CBT methods are based largely on exposure or desensitization as the major inter- vention. Biofeedback can be very easily paired with desensitization and prolonged exposure. In line with Wolpe's classical research (1958, 1973) desensitization of conditioned responses may be achieved by first training patients to utilize PMR during imaginal confrontation with the feared object. Biofeedback helps in the training of vari- ous relaxation techniques whose aim is to reduce arousal by providing detailed feedback in real-time about changes in level of arousal. The therapist is guided to provide better instructions during the desensitization process, because the feedback allows creation of a parallel in reaction to the patient’s responses. The arrangement of stimuli in a hierarchy is the second component of systematic desensitization. Biofeedback assists with the cre- ation of the hierarchy by providing an objective measure of response to imagined stimuli (Wood et al., 2008); that is, biofeedback reveals to therapist and patient the point at which a particular trigger activates the anxiety response. Prolonged or repeated exposure is based on the phenomenon of habituation of the CNS, an automatic process that brings about a reduction in the intensity of a response when exposed to an arousal-inducing stimulus for long periods (Foa et al., 2005). Biofeedback displays provide evi- dence of inherent ability to control a physiologi- cal response and as such can be used to manage anxiety, further reinforcing a belief in ability to cope with exposure overall. Wiederhold and Wie- derhold (2003) found that, compared to exposure alone, exposure with feedback was associated with better results. Whereas prolonged exposure requests that patients “grin and bear it” until such time that control is gained, biofeedback provides immediate reinforcement, in that it shows, objec- tively, the changes the patient has brought about, thus strengthening the patient's motivation and ability to persist. This result may be a function of the increase in one’s sense of control. When using biofeedback, there is a sense that balance in the arousal level of the PNS and SNS can be achieved while maintaining control, as opposed to relax- ation techniques that rely on closed eyes, which decreases the sense of control. Fostering Awareness and Acceptance A primary obstacle for anxious patients when attempting to relax is their very high level of arousal upon arrival, and their use of extreme effort to reduce this arousal. Therapists who use biofeedback can show patients that this goal may be achieved without exertion and in fact will only be completely achieved once the effort to control is released (i.e., once a patient “lets go.” The prin- ciple of effortless work and “letting go” is a primary principle in acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999). ACT is an example of a therapeutic approach that teaches patients to observe reality without judgment or criticism, and to cease efforts in the struggle against anxiety. Biofeedback can certainly assist with this aspect of change. The importance of developing a sense of self- awareness has been discussed by several psycholo- gists (e.g., Borkovek & Sharpless, 2004) and has been integrated as a principle aspect of various therapies, including Kabat-Zinn’s mindfulness- based stress reduction (MBSR; Kabat-Zinn, 1982), mindfulness-based cognitive therapy (MBCT; Teasdale, Segal, & Williams, 1995), and third- wave therapies such as ACT (Hayes et al., 1999). Originating from Eastern philosophy, the princi- ple of self-awareness is an essential prerequisite of change, because it reveals the function of behav- ior to therapist and patient, enables the patient to identify primary signals of change in internal state, and guides the patient toward a focus on the present (Borkovek & Sharpless, 2004). Some patients may object to mindfulness and meditation. People raised in a Western culture have tended to seek a scientifically based, fast- acting solution to their problems and, as such, may respond to mindfulness-based techniques with skepticism (Rolnick, 1999). On the other hand, this general attitude to mindfulness and meditation may have changed, as suggested by recent data that has put the number of free and Schwartz_Biofeedback4E.indb 446 11/12/2015 5:24:27 PM
  9. 9. 26.  Anxiety Disorders 447 paid meditation and mindfulness applications available to Smartphone users in the thousands (Plaza, Herrera-Mercadal, & Garcia-Campayo, 2013). Biofeedback meets the criteria of a scientific approach, elegantly combines knowledge from both Western and Eastern cultures, and is suitable for use by both medical practitioners and laypeople alike. Confidence about relaxation techniques can only be strengthened once people see with their own eyes how their body responds to the various exercises. In a case study that combined HRV biofeed- back with ACT principles, results indicated that the patient was helped to accept anxiety rather than attempt to suppress it (Gevirtz & Dalenberg, 2008). Kleen and Reitsma (2011) also studied the effects and processes of an integrative approach in which HRV biofeedback was combined with ACT. Their findings suggest that HRV training may be an effective way to train the client to be able to increase both HRV and mindfulness skills. Biofeedback, due to the feedback provided and the reinforcement attained, can lead to both arousal reduction and increased awareness, ulti- mately benefiting the patient in ways that are identical to the better known methods of relax- ation, such as mindfulness and applied relaxation, and guided imagery relaxation. Additionally, it can be paired with these techniques to increase their viability. The nature of the biofeedback para- digm is observation, generating distance between the patient and the physiological experience. Ulti- mately this demonstrates to the patient that when an attitude of acceptance is adopted and the effort to exact control is relinquished, change may be achieved. Biofeedback Enhances Cognitive Elements of Therapy All patients arrive with a set of beliefs and ideas regarding their anxiety (e.g., whether anxiety is learned or innate; whether it can be managed or eliminated; and whether it leads to loss of con- trol). The role of psychoeducation when combined with biofeedback is to address and alter beliefs that prevent the adoption of a more realistic and functional perspective. During biofeedback train- ing, patients observe feedback from the computer, leading to two types of learning: First, a specific understanding of the physiological measure taking place, and second, a more general understanding of their abilities to exert control. The use of biofeedback for treating disorders in which inaccurate interpretation of bodily symp- toms is a feature has been raised (Domschke, Ste- vens, Pfleiderer, & Gerlach, 2010). The plausibil- ity of biofeedback’s applicability is based on the fact that misinterpretation of bodily symptoms co- occurs with an excessive focus on the physiological condition of the body; biofeedback can be used to redirect attention, as well as introduce a new way of understanding the body’s signals. Sensors that monitor temperature and HRV may be valuable additions to the cognitive stage of therapy, because the patient can learn that con- trol over the physiological state (e.g., temperature or heartbeat) can be attained. Alternatively, the visual contact with evidence of the body’s inter- nal state may increase the patient’s willingness to attend to something else and in this way, reach the understanding that abandoning a focus on the body does not result in any disastrous con- sequences. The cognitive flexibility required to think about bodily sensations in a more realistic way is therefore facilitated. Psychoeducation continues throughout therapy. An example of how biofeedback can aid this pro- cess is seen in the demonstration of the fight-or- flight response. This idea is an aspect of many therapeutic approaches, yet sometimes patients may perceive the information as being uncon- nected to their own cases. Alternatively, when attached to biofeedback sensors, patients observe the body's rate of response in reaction to a stimu- lus and simultaneously connect the information provided to their own experience. Furthermore, patients learn that after the activation of the fight- or-flight response, additional time is needed for the body to regulate and regain a level of homeostasis. Additional examples, psychophysiological demon- stration of anticipatory anxiety, influences such as acceptance and distraction, the restricting effects of effort to control, and the thought–physiology– emotion connection are provided by Hamiel and Rolnick (Chapter 11, this volume). The Unique Contribution of Biofeedback in the Treatment of Anxiety Disorders Biofeedback, as has been discussed, can be eas- ily integrated with cognitive and behavioral concepts. In addition, biofeedback offers its own unique contributions in the treatment of anxiety disorders that relate to two characteristics inher- ent in biofeedback contingencies. The first of these pertains to the dialogue that occurs between clients and their physiology when exposed to their own physiological reactions; the second concerns Schwartz_Biofeedback4E.indb 447 11/12/2015 5:24:27 PM
  10. 10. 448 VI.  CLINICAL APPLICATIONS: TRADITIONAL GENERAL BIOFEEDBACK PRACTICE clients’ exposure to situations wherein their stress reaction is observed. Exposure to One’s Own Physiological Reaction The feedback of physiological information is usu- ally considered to be the core process of learning self-regulation; however, from a psychological per- spective, the fact that a client is introduced to his or her own physiology in an overt visual display can initiate some important psychological pro- cesses. Take, for instance, the case of health anxiety and hypochondriasis. “Hypochondriasis” is char- acterized by a focus on, and misinterpretation of, bodily symptoms. The client reacts to the experi- ence of all bodily sensations with fear due to the belief that these sensations are indicative of ill- ness. Biofeedback therapy involves direct exposure to this very frightening stimulus. In several cases, such exposure may produce sympathetic arousal that will attenuate over time and teach the client that his or her body is self-regulating. Moreover, this exposure can instigate significant cognitive change, such as the following: (1) The body’s reac- tions are usually adaptive and self-regulating; (2) there may be a significant discrepancy between subjective experience and actual physiological reaction; (3) one can learn to control his or her reactions; and (4) the best way to gain control over one’s physiology is by not trying too hard. Exposure to the Arousal and Stress Reaction Observed by the Therapist Several anxiety disorders feature a fear that other people will notice the existence of stress reactions. This is clearly the case in social anxiety disorder, in which the fear of embarrassment focuses on cer- tain aspects of self-presentation, such as exhibit- ing symptoms of anxiety. This sensitivity to the criticism of other people is also central in panic disorder, in which an aspect of the avoidance is related to the fear that bystanders will notice the panic attack. In fact, most of the avoidance behav- ior seen in anxiety disorders is associated with the fact that anxious people are afraid that their stress reactions will be noticed, and their avoidance is partly an attempt to prevent this exposure. Indeed, there are a variety of situations in which people feel shame at the idea that their stress reaction will be observed (e.g., the fear of blushing in front of others, that one’s trembling voice will be noticed, that one’s hands are shaking or one’s palms are wet), and there are several kinds of performance anxiety, especially in sexual activity. Self-focused attention is enhanced during anxious states, caus- ing individuals to become acutely aware of their own anxiety-related thoughts and behaviors. This heightened attention to the symptoms of anxiety serve to intensify one’s subjective apprehension. Furthermore, the presence of anxiety can impair performance in certain “threatening” situations, such as when a socially anxious person goes blank in the middle of a speech or begins to perspire profusely. Attending to these symptoms can eas- ily interfere with the person’s ability to deliver the speech. The anxious person is then left to interpret the presence of anxiety itself as a highly threatening event that must be managed immedi- ately in order to minimize or avoid its “catastrophic effects.” In this case, the person becomes anxious about being anxious. The case of blushing suggests that biofeedback can enhance the therapy of anxiety disorders in general, and social anxiety in particular, by acting as a tool for simulating a situation in which the client feels shame because another person can see their stress. In this case, if a client is connected to various peripheral physiological parameters (EDA EMG, skin temperature, heart rate), the moment he or she notices that the therapist has become aware of any minute change in his or her physiol- ogy, the client will experience an increase in stress. There is a strong parallel between blushing, which occurs primarily in social or interpersonal situa- tions, and the biofeedback situation, wherein the patient is aware that the therapist can observe his or her internal reaction. This is a unique type of exposure that CBT cannot create as easily, if at all. As in all types of exposure, this situation allows clients to face their fear that someone will notice their anxiety. This experience tends to attenuate the fear, and clients come to learn and accept that they can survive the “shame.” The Role of the Other in the Self‑Regulation Process The state of being observed by the therapist leads to a wider issue about the role of the other in the self-regulation process (Levit Binnun, Golland, Davidovitch, & Rolnick, 2010). Originally based on work by Winicott (1971), and later Bollas (1987), anxiety disorders are perceived as a func- tion of poor ability to self-regulate, a capacity that typically develops throughout infancy via interac- tion with parental figures. Schwartz_Biofeedback4E.indb 448 11/12/2015 5:24:27 PM
  11. 11. 26.  Anxiety Disorders 449 It has been argued that in order to attain a sense of safety, children typically react with fear in new situations, resulting in fear-based dependence on caregivers (Milrod, Busch, Cooper, & Shapiro, 1997). A parallel may be drawn within biofeed- back-assisted psychotherapy. The fearful, anxious patient is exposed as helpless and dependent before the therapist, which may incite feelings of shame, impotence, and hopelessness. In contrast to the patient’s developmental experience, the biofeed- backtherapistreactscalmly.Observingthepatient’s physiological makeup with him or her provides an opportunity for the therapist to validate this experi- ence, label it, and explain emotional arousal. The therapist also offers the patient an explanation of the process that produces their arousal. Then the therapist teaches self-regulation, fulfilling a role that was absent in the original parenting unit. This idea is also raised in the biosocial theory proposed by Linehan (1993), who asserts that individuals with emotional disorders are biologi- cally vulnerable to experiencing emotions more intensely than the average person, and also have more difficulty modulating their intensity. In psy- chophysiological terms, they are high reactors with a very limited ability to calm down. The second element in Linehan's theory states that emotional disorders develop during childhood, wherein an invalidating environment contributes to emotion dysregulation. More specifically, the issues are that parents fail to teach the child how to label and regulate arousal, how to tolerate emotional dis- tress, and when to trust his or her own emotional responses as reflections of valid interpretations of events. Therapy conducted with biofeedback calls for validation, empathy, and the acquisition of self- regulation ability. (Significant elements of the therapeutic alli- ance within biofeedback-assisted therapy are fur- ther discussed at www.marksschwartz.com.) Conclusion The value of biofeedback as a therapeutic tool in the management of anxiety disorders is cogent. The ease with which it can be integrated into existing therapeutic models, regardless of their theoretical and practical differences, is both impressive and encouraging. Assuming that the aim of clinicians, of all orientations, is to provide patients with useful tools and experiences of mas- tery, biofeedback has proved itself to be a suitable complement that merges smoothly and effectively into current modes of work. In the treatment of anxiety disorders, biofeedback contributes directly in three ways: (1) It provides a platform for direct modulation of autonomic arousal; (2) it enhances psychotherapuetic interventions; and (3) it cul- tivates the therapeutic alliance and presents the possibility for a unique reexperiencing of an early interaction with a primary caregiver. The degree to which the physiological aspect of anxiety is addressed by the biofeedback paradigm strength- ens the argument for its inclusion in treatment. The use of biofeedback to augment other critical aspects of treatment, such as the therapeutic alli- ance, increased self-awareness, and an attitude of acceptance, further warrants its utility. Further- more, biofeedback meets requests of evidence- based psychology standards, in that it provides an ongoing objective measure of progress. 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