ALTERNATIVAS

Neurofeedback Clinics

*Scientific evidence of successful ADD evaluations & training* 

Many psychiatric illnesses may turn out to be clusters of diseases that have similar symptoms but require different treatments. Functional neuroimaging tools as QEEG-LORETA may eventually play an important role in diagnosis and in monitoring the effectiveness of treatment.  They are completely safe (non invasive) and now use reliable data of normal brains as references for helping the psychiatrist or neurologist to detect specific areas and patterns of brain deregulation.  The use of scientific evidence of neuro-images, medical-psychiatric, neurological and neuropsychological testing to guide Neurofeedback have increased  the potential applications as part of a psychiatric treatment. of these promising and non invasive tools.

 

 

Quantitative Electroencephalography (QEEG), 

Low Resolution Electromagnetic Tomography (LORETA), 

Z scores-evidence based 1to19 channels NF, 

3D-LORETA NF, 

Infra-low Frequency NF, 

Low energy NF (LENS), 

Neuro-acustic NF (BAUD), 

Audio-visual entrainment

 

What is QEEG ? 

 

Major psychiatric diseases (e.g. Major Depression, Schizophrenia, Bipolar disorder), Alzheimer’s disease, substance intoxication or dependence, toxic injury, seizure disorder,  brain infection (e.g., encephalitis) and anoxia  alter brainwave activity. Similarly, metabolic changes (hormonal changes), damage or physical injury to the brain, such as concussion, even changes in normal sleep patterns, disrupts normal flow of electrical impulses in the brain tissue.  ADD, anxiety, OCD, depression and learning disability have distinct brainwave “signatures.”  This means different abnormal patterns of brainwaves in specific "3D" areas of the brain.

 

EEG (or electroencephalogram) is a recording of brainwave electrical activity. QEEG (Quantitative EEG), popularly known as brain mapping, refers to a comprehensive analysis of brainwave frequency bandwidths that make up the raw EEG using sophisticated computer technology. QEEG is recorded the same way as EEG, but the data acquired in the recording are used to create topographic color-coded maps that show electrical activity of the cerebral cortex.   

 

While other brain imaging techniques (e.g., PET, CT, SPECT,MRI) measure such properties as cerebral blood flow, metabolism or structural integrity, QEEG measures electrical activity of the brain. It provides complex analysis of such brainwave characteristics as symmetry, phase, coherence, amplitude, power and dominant frequency. In fact, subtle disruptions of electrical connectivity and flow in the brain sometimes may be the only or the early signs of a problem.  The QEEG findings are then compared to a normative database. This database consists of brain map recordings of several hundred healthy individuals. Comparisons are displayed as Z scores, which represent standard deviations from the norm.  

 

 What is LORETA ?

 

LORETA means low resolution electromagnetic tomography.  After a QEEG is done it shows only the electrical activity of the surface of the head that present the electrical activity of the neurons of the cortex near that surface of the head.  By using complex mathematical calculations the computer constructs a visual image of the 3D electrical activity of deep parts of the brain from this surface electrical measures.  In that way specialized software like LORETA and VARETA ( Variable resolution electromagnetic tomography) have being developed with success.  Several scientific studies have found amazing correlation between these neuroimages and more invasive, complex and expensive studies like Functional Magnetic Resonance Images and PET scan.  What is more promising is the integration of all these technologies for the detailed study of the brain functioning.  Is evident the powerful influence in the development of psychiatry that such windows to the living brain could bring today and in the near future.

 

Several scientific studies had found good correlation between LORETA images and a much more expensive and complex study of fMRI as seen bellow: Integration of fMRI and simultaneous EEG: towards a comprehensive understanding of localization and time-course of brain activity in target detection (NeuroImage; 22 (2004) 83– 94

 

The function of any specific functional neuro-images system are not to substitute others but to eventually integrate one to each other for the benefit of the patients.  The growing use of QEEG in neuropsychiatry is mostly experimental but is expanding each day with worldwide studies in this field.  The primary uses of QEEG is to examine patterns of brainwaves and help determine whether a person is an appropriate candidate for Neurofeedback, a treatment that normalizes brainwaves and indirectly may help to restore brains capacity for auto- regulation.  These changes may result in a stable improvement of symptoms of many psychiatric and even neurological diseases.    

 

It is important to remember that QEEG is just one part of the overall assessment. QEEG, along with MRI, SPECT, PET or CT scans is an imaging technique and, as such, it does not describe cognitive or emotional problems in functional terms. QEEG does not render a diagnosis, but is designed to help the clinician to make a diagnosis. For an accurate diagnosis we have to do and integrate a complete medical-psychiatric evaluation than may include neuropsychological tests (we use Neuropsy test for Hispanics), personality tests (we use Minnesota personality Inventory-2), blood-urine, toxicology laboratory, continuous performance tests (we use Qik test).   For example, QEEG may show reduced electrical activity in the Hippocampus area, which is associated with memory storage and retrieval. Neuropsychological testing, on the other hand, may reveal that an individual’s short term auditory memory is at the 9th percentile of functioning.   

 

QEEG is not a substitute for EEG; it is a different process than that carried out by the neurologist when he or she performs an EEG assessment. Medical and psychiatric illness of the brain, such as seizure disorder, dementia, encephalopathy, brain tumor, lesion, haematoma and aneurysm should be diagnosed by a physician specialized in neurology or psychiatry.  

 

Dr. Cruz Igartua during his own QEEG study.

How is it Done?  An elastic cap with 19 sensors is placed on the head and the sensors are connected to the recording device. A special conductive gel is squeezed into each of the 19 sensors in the cap. At Alternativas, we test the conductivity of each electrode to assure excellent conduction (less than 5uk of resistance).  This preparation takes approximately 45 minutes.  The actual recording might take from 15 to 30 minutes.  A patient may be instructed to keep his eyes open or closed during parts of the recording, or asked to close them, stay still or perform a mental task, such as reading or simple math. It is important to sit very still during the recording.

 

Interpretation of the Maps 

 

QEEG results are presented as Z scores. Z scores represent Standard Deviations (SD) from the norm and span from -3 to +3. Thus a Z score of +2 means that the result is 2 Standard Deviations higher than the norm (+2SD) and exceeds 98% of the age-matched people in the normative sample. A Z score of 0 represents the norm and is white. Red and blue colors on the maps show brainwave activity that is 3 SDs above or below the norm.

 

 

 The following examples show different ways in which QEEG can be useful in clarifying diagnostics and treatment, as well as evaluation of treatment effectiveness. 

LORETA help to identify specific areas or patterns of problems in the brain (Brodmann areas) that are related to clinical disorders (psychiatric or neurological disorders).  The Brodman areas represent 50 different cortical areas that are divided because of different neuronal arrangements (cytoarchitecture) that correlate to different functioning.

 

 

 

 

 

LORETA images are 3D and also show multiple angles and cuts of images for easier visualization of the lesions or problems of functioning in cortical and sub- cortical brain regions.

 

Some samples of different kinds of 3D surface brain of maps

White - Normal    Red = Excessive    Blue = Diminished Activity

 

 

 

  Other Important Considerations 

 

Although QEEG may render lots of useful information it has its limitations. The QEEG and LORETA only detect the cortical functional activity; not subcortical nor anatomical as could be detected by other more invasive neuroimages.  The majority of mental illness manifest as changes in cortical regulation and functioning.  It is important that raw data that are digitized and analyzed by the computer are free from artifacts, which are electrical signals produced by something else than the brain, such as muscles or improper electrode placement. Therefore, the person that performs the recording and data analysis should be well trained in artifact recognition. There is also some debate about the several normative databases that are currently on the market. Some of them have larger sample size or age span than others. They also use somewhat different inclusion criteria for “normalcy” and different mathematical procedures for data analysis.

 

At Alternativas clinics we use  FDA approved software and: the new Neuropulse amplifier device. We found it to be a reliable and sensitive instrument that produces very clean recordings. For data analysis we use Neuroguide software with Dr. Robert Thatcher’s Lifespan normative database, which consists of 625 subjects from two months of age to 82.3 years of age. We also use LORETA (Low Resolution Electromagnetic Tomography) which allows for 3-dimentional electrical source localization analysis and Atlantis four channel machine with Z scores for neurotherapy. By live Z score training we means that during the therapy, the clinician and the patient could actually see and measure the live changes in brainwave activities as they approach the normal scores for patients age. The combination of four channel live Z scores with QEEG gives more reliability to the process of therapy than each one alone.

 

 

Important articles on QEEG in Psychiatry (Click to open in Adobe Acrobat)

Conventional andQuantitativeElectroencephalography in Psychiatry; John R. Hughes, M.D., Ph.D.E. Roy John, Ph.D.(The Journal of Neuropsychiatry and Clinical Neurosciences 1999; 11:190±208)

Emerging brain-based interventions for children and adolescents: overview and clinical perspective, Laurence M. Hirshberg, PhDa,b,*, Sufen Chiu, MD, PhDc, Jean A. Frazier, MD aThe NeuroDevelopment Center,Child Adolesc Psychiatric Clin; N Am 14 (2005) 1 – 19

The Value of Quantitative Electroencephalography in Clinical Psychiatry: A Report by the Committee on Research of the American Neuropsychiatric Association Kerry L. Coburn, Ph.D. Edward C. Lauterbach, M.D. et al; The Journal of Neuropsychiatry and Clinical Neurosciences 2006; 18:460–500)

 

 

 

What is Evidence Based Neurofeedback?

 

Neurofeedback is also known as EEG biofeedback is a non invasive non painful training process that measure actual brainwaves from the scalp surface and help the brain to improve its self-regulation process.  Originally it was done using only clinical symptoms as guidelines to a series of training protocols.  These training improved in effectiveness adding more specific and scientific evaluations (evidence) of the actual functioning of the brain before, during and after the training.  The QEEG- LORETA and the use of live Z scores correlated with the clinical findings were powerful improvements for these techniques giving objective evidence of actual functioning of brain.   It uses a audiovisual or tactile stimulation feedback to the brain to train it to gradually normalize the frequencies by a mechanism known as conditioned response.  This process is non painful and non voluntary one but automatic.  The amazing part of these changes resulting of the training are that they may produce long lasting results in reducing symptoms of many psychiatric disorders.  Most of the evidence of multiple studies that evidence great long lasting benefits are in Attention Deficit Hyperactivity (ADHD) patients.

 

Evidence based Neurofeedback (guided by QEEG- LORETA-Z scores, neuropsychological testing plus clinical evaluations) is now classified as effective treatment for ADD. Very few NF providers do EB practices.  The medicine doctor  with specialty in psychiatry is trained to evaluate more deeply the complex and multiple interaction between body and mind including the effects of other mental illness, metabolic changes, toxics, drugs or medicines in the clinical picture of the patient.  The scientific medical psychiatric and neuropsychological evaluations prior and after the treatment are important to verify and increment effectiveness in any NF training.  The new technology of  four channel EB neurofeedback of year 2009 had cut the number of necessary training trainings to 10 of 40-60 minutes long.  Before this  advances (year 2000) there were fixed standard protocols for each symptom and the raw waves of EEG with the clinical changes were the only available guidance.  We don't recommend the use of non EB "intuitive neurofeedback" .  The non evidence based NF is based mostly on clinical evaluations and is still done by many NF providers.  It may and take much more secions of training (about 30 to 60 or even more trainings) for a good effect due to a lot of trial and errors in the process.

 

We use the most advanced technology available; with a four channels live Z scores (from +3red to –3blue standard deviation of normal values) panel that measures multiples functions of the brain waves (delta,theta,alpha,beta1,beta2, beta3, gama) during the live treatment process and compare them to normality (in power, asymmetry, coherence, phase and others).  This new technology greatly increases the precision and safety of the neurotherapy; specially if guided by QEEG-LORETA mapping and other neuropsychiatry evaluations. We also use the NEUROPSI as a neuropsychological evaluation for Spanish speaking patients and correlate the results with clinical and LORETA findings and make definitive and precise diagnosis of neuropsychological disorders.  After Neurofeedback we do retesting to verify the improvement in a scientific way both in functional neuroimages (LORETA) and in neuropsychological testing.

 

 

 

 

 

Important articles on Neurofeedback and psychiatry (Click for opening Adobe Acrobat file)

 

EEG Neurofeedback for Treating Psychiatric Disorders; Psychiatric Times February 2002   Train Your Brain; Mental exercises with neurofeedback may ease symptoms of attention-deficit disorder, epilepsy and depression--and even boost cognition in healthy brains; SCIENTIFIC AMERICAN MIND February 2006 Issue   Electroencephalographic Biofeedback in the Treatment of Attention-Deficit/Hyperactivity Disorder, Vincent J. Monastra, Steven Lynn, Michael Linden, Joel F. Lubar, John Gruzelier,and Theodore J. LaVaque Applied Psychophysiology and Biofeedback, Vol. 30, No. 2, June 2005

 

Dr. Arnaldo Cruz Igartua has done neurofeedack as part of his interdisciplinary treatment of Substance Dependence patients for seven years.  He have being trained in Z score guided Neurofeedback and QEEG-LORETA by the actual pioneers in the field and developers of this new hardware-software technology; Dr Robert Thatcher (developer of Neuroguide) and Dr. Tomas Collura (developer of Brain Master).  Is member of the International Society for Neuronal Regulation www.insr.org.  This organization may be helpful in providing information or journal articles describing relative merits of various scientific studies in the field. 

 

At left is Dr. Cruz Igartua, in the center is Dr. Tomas Collura and in his right side is Dr. Robert Thatcher after a 2007 seminar.