A Neurofeedback Case Report

by Siegfried Othmer | December 29th, 2017

Resolution of Attention Deficit, Impulsivity, and Anxiety in a 22-year-old male, using Infra-Low Frequency Neurofeedback By Priscilla Young

August 1, 2017

A mother brought her 22-year-old son M_ to me for neurofeedback, on the recommendation of a friend whose son I had also worked with. She reported that M_ had been identified as having ADD since elementary school, when he had taken medication for it. He had not been happy while on the medication, and did not eat well when taking it. In high school, he stopped taking it entirely. He had panic attacks in high school that responded positively to hypnotherapy. He had a concussion in the spring of his junior year. The panic attacks occurred during wrestling and predated the concussion. Fear-based anxiety was identified as a concern.

On the symptom inventory completed by his mother, the following symptoms were rated on a 0-10 scale: spaciness 4; day-dreaming 6; poor concentration 8; lack of motivation 8; impulsivity 6; distractibility 9; depression 5-6; irritability 5; passivity 5; agitation 6; impatience 5; grudge-holding 5; poor emotional expression 6; and compulsive behaviors 5. M_ also reported that his speech now gets slurred and his reading has gotten slower since getting out of high school. Utilizing the EEG Expert symptom tracking software in addition to some of the above listed symptoms, we tracked fifteen variables, including nightmares and vivid dreams, panic, anger, anxiety, mood swings, sinus headaches, poor sustained attention and pain up the right side of the back.

At this first session, we trained T4-P4 starting at .1 on the training variable, going down every 2-3 minutes in .02 intervals over the first 14 minutes, and settling at .01 for the rest of the session. I then moved to T3-T4 for 8 minutes and returned to T4-P4 for the last 8 minutes of the session, for a total training time of 30 minutes. In subsequent sessions, training was conducted for 40 minutes.

M_ reported that after his first session he was relaxed down to his toes, and the relaxed feeling lasted for several days; but there was also a loss of motivation, with too little get-up-and-go. Comparing .01 to .015 he felt more relaxed at .01, so we stayed there and also increased the time spent at T3-T4, hoping to help the motivation without adding the left pre-frontal placement yet. Based on the QIKtest that we had done that day, I was concerned about impulse control, so I added the right pre-frontal placement, T4-FP2. He reported that the outcome of this session was “awesome”; he noticed changes immediately, and was now better able to process emotions. I repeated those three sites for session #2 and he reported that he “felt amazing, mentally and physically. I am happy.” He was able to perform better at the gym and noted that he was now initiating conversations, which was unusual for him. He was pleased. There was a huge improvement in his ability to box, and he was thinking more clearly. Concerned about the potential for head injury from boxing, and wanting him to be fully informed about the risks, I suggested the movie Concussion for DVD-based feedback, and he agreed to my suggestion.

In session #4, he said everything was getting better, but he had had an anxiety attack during a boxing match. When I asked, he said he frequently has a busy stream of thoughts. I added T4-FP1, the placement we use in our practice for quieting the mind and improving the tone of self-talk. I stayed with these four sites for sessions 4-8. At session #6, he reported that his mind was clearer, and that he had been able to get back into drawing, which made him happy. He found that he was shooting baskets more skillfully, and that he was functioning with greater confidence. In session #7, he reported that he feels more motivation and concentration when drawing, and he is considering going back to school for it.

At five weeks into the training, following session #8, he did not schedule any neurofeedback sessions for ten days because he was planning a trip. When he came for his next session, his mother came also. M_’s anger outbursts, which had been moderating when he was coming to neurofeedback regularly, had regressed sufficiently over the ten days for her to be concerned. Both his mother and his girlfriend had noticed his symptoms increasing over the period. His mother also noted that while he talked about his future, there seemed to be some resistance around taking new steps.

I repeated the prior protocol for session #8 to get him back on track and he reported, “I can enjoy life again,” and there were no fights with his girlfriend. In session #9, responding to his mother’s comments and the return of his calmer state, I added T3-FP1 in place of the prior T4-FP1. He reported a nightmare, but also felt generally calm. Based on this report, I saw a reason to lower the training variable further, and went down to .009 on the right and .015 on the left. At his next session, #11, he said that it had been “awesome.” He reported increased curiosity; he was looking up new things.

At session #12, as we continued to move the right-side frequency down to .007, he reported that he now has the ability to control his anger, and was able to keep his mouth closed long enough to control what he chose to say. After session #13, he went on vacation, giving him twelve days without neurofeedback training. He reported staying steady over that time, getting along well with his girlfriend, and he was able to get right back into the swing of things upon his return.

At session #15, he reported that he is more tolerant now, and was able to talk to his Dad without fighting with him. In the past, he typically could not do this. At session #16, I received a symptom tracking report from his girlfriend (now fiancée). Some variability is introduced into the symptom-tracking report depending on who was doing the reporting: the client, his mother, or his girlfriend; but getting reports from multiple sources was very helpful. Based on her report of residual anger (she had assigned a 6), and oppositionality (she had assigned a 4), there was reason to continue to lower the training parameter. The left side was reduced from .015 to .01, and the right side from .007 down to .006. That resulted in greater calming, so at the following session a further step, to .005 on the right, was taken.

At session #18, M_ reported that he had a job interview at UPS and had no anxiety, a circumstance in which he would normally have been very anxious. (He was hired by UPS as a result of this interview; he had been working in landscaping.) At session #19, he reported that his ability to deal with disagreement had increased, and that it was easier to have a rational conversation. He is no longer subject to impulse-buying, and is playing music again.

At session #20, we had invited his mother to come in for the middle of his two-hour appointment, so we could go over the QIKtest results together. His commission error standard score in the high-demand section had risen from 55 to 105 (i.e., from the first percentile to above norms) and his omission error rate standard score for the first half of the high demand phase had risen from 70 to 103 (i.e., from the second percentile to above norms). The summary scores for the pre- and post-tests are shown in Table 1, and are shown graphically in Figure 1 in terms of standard scores. The total number of discrete errors declined from 34 to 3, as illustrated in Figure 2. M_ had moved from the 5th to the 82nd percentile in total discrete errors.

Figure 1. Standard scores for the pre- and post- QIKtest. Percentile scores are also indicated for the post-test results.

Figure 2. Total discrete errors are shown for before and after training. Percentile scores are indicated.

M_ had registered as very fast on the first test, but at the cost of a high number of impulsive errors. Consequently, his high initial score on reaction time comes with an asterisk (virtual in this case). On his second test he was still relatively fast, but now the standard score of 110 was legitimate, as the impulse control standard score was also above norms at 107. Consistency in reaction time had already been excellent at the outset, but was even better after the training, moving from 107 to 126, to an extraordinary 95th percentile rating.

With respect to symptom tracking results, severity scores were already cut in half by session 5, as shown in Figure 3. Symptom regression is shown in a waterfall plot in Figure 4. At the point of the 20-session review, symptom severity was down to 17% of the original value (last assessed at session #17). Given the reported status, the excellent test results, and the dramatic improvements in symptom severity, I offered two options at the 20-session review: Stopping the training, or tapering off slowly with five additional sessions, adding in T3-P3 for attention to detail and handwriting. His mother turned the choice over to her son, who opted for five more sessions with the additional site.

Figure 3. Symptom severity profiles for the fifteen items being tracked. Note that scores are cut in half by the fifth session, and nearly resolved at session 10. Subsequent regression shows that the learning had not yet fully consolidated, which is not surprising.

Figure 4. Waterfall display of the individual symptom trajectories.

The addition that day of T3-P3 led to the client feeling “almost anxious,” but everything else remained good. Given the choice of dropping that site or lowering the frequency further, the client opted to try a lower frequency, so his last four sessions were right side at .004 and left side at .008, and that fully resolved the hint of anxiety. He reported that he now felt that he had better control, and his work output, which is measured on his job, had improved dramatically. He also noted that he was very productive when it came to his art work, and his works of art are the best he has ever done. This implied better control of the dominant hand, which was quite possibly the result of the training at T3-P3.

At his 23rd session, his symptom-tracking showed 2% of original symptom severity remaining, and at his final session, #25, he rated every symptom at a 0, 100% reduction of symptoms from August 1st to December 19th, with the last two sessions spread two weeks apart, with no return of symptoms during that interval. A number of symptoms had fully resolved in the first 5-7 weeks; those quickly resolving symptoms were: nightmares and vivid dreams (5 to 0), sinus headaches (5 to 0), difficulty organizing personal time and space (8 to 0), panic attacks (8 to 0), and pain up the right side of the back (5 to 0).

Report by Priscilla Young, Certified Neurofeedback Coach


Commentary by Siegfried Othmer

Some additional discussion of this case report is in order. Impulsivity was a big issue initially, as reflected in the high commission error score. This is best illustrated in the time series of RT events for a high-demand segment of the test, as shown in Figure 5 for the pre- and post- tests. The distributions in reaction times for the total QIKtest are shown in Figure 6, along with the distributions for the commission errors, for before and after training. Observe that the commission errors nearly all occurred at short reaction time. With some significant probability, the client had reacted directly to the stimulus, without waiting to make the choice of Go/NoGo. A pure reaction time was being registered rather than a choice reaction time. This accounts for the bulge in the RT distribution at short RTs, which skewed the calculation of mean RT. Hence the (virtual) asterisk on the RT index for the pre-test. The bulge is entirely absent in the post-test, giving us a valid measure of the mean RT.

Figure 5. Time series for reaction time events during one of the high-demand segments of the QIKtest, for before and after the training.

Figure 6. Histogram of reaction times for the entire QIKtest, before and after training. Observe the large number of closely bunched commission errors at short reaction time, indicating a propensity toward pure reaction time events.

It is also worth observing that several distinct patterns of responding are discernible here. The rapidly responding symptoms are shown in Figure 7. Three of the four symptoms fall into the brain instability category, which responds to the T3-T4 placement. Some pain conditions do so as well, as in this case. By the fifth training session, all of the instability symptoms had become a non-issue.

Figure 7. Rapidly responding symptoms belonging to the category of brain instabilities.

Attention-related symptoms are shown in Figure 8. They are highly correlated with each other in terms of symptom trends. We are dealing here with a common underlying mechanism. The major part of symptom resolution had occurred by session ten.

Figure 8. Symptoms belonging to the attentional category.

The emotionally-grounded symptoms are shown in Figure 9. As in the case of the attentional symptoms, a high correlation is observed among the symptom profiles, again implying a common underlying mechanism. Note that lack of motivation clearly belongs among the attentional symptoms rather than the emotional, and that oppositionality clearly belongs in this category rather than with the attentional symptoms, even though it is so commonly seen in connection with ADHD.

Figure 9. Symptoms falling into the affective domain.

Symptom regression in the later stages was likely driven mainly by the emotional symptoms. We observe, however, that the client was in the throes of getting engaged, which can lead to emotional turmoil even in the best of circumstances. Attentional symptoms then also show some regression. This draws attention to the over-arching reality that the emotional symptomology is also highly correlated with the attentional, as evidenced by comparing Figures 8 and 9. This supports the view that both the attentional and affective domains are subject to a common underlying failure mode. At issue here is what we call a disorder of disregulation. The various symptom categories are then mere variations on the theme, as the core disregulation plays out differentially in various sub-domains. The fact that such a broad variety of symptoms resolves with such a simple set of tools testifies to the validity of the unitary model of disregulation.

This brings us then, finally, to a reflection on the earlier history of this client. Given his manifest responsiveness to ILF neurofeedback, one can safely judge that he did not really need stimulant medication back in elementary school. Neurofeedback training would have resolved his issues nicely—even with the methods available to us at the time–some fifteen years ago. Further, the stimulant medication offered no prospect of resolving the emotionally-rooted symptoms that undoubtedly also trace back to that earlier day. The medication regimen failed to resolve the issues, but did succeed in preventing the client’s family from finding their way to the proper remedy.

One might also observe that the client got no help for his concussion. The easiest way to read this history is to see it as a combination of a brain vulnerable to instabilities (likely genetically mediated) and a history of un-remediated concussion. Historically, infra-low frequency neurofeedback has done well with both. If a piece of advice may be offered to the client from this distance, it is that if his brain function is important to him, and to his fiancée, he should consider hanging up his boxing gloves.

If he does continue fighting, then the next best thing would be for him to train his brain both before and after every fight. He should confirm his skill level prior to a fight with both the QIKtest and Brain Check, and he should confirm his recovery from a fight using those same instruments. It is also advisable for him to schedule brain training sessions at regular intervals for optimum mental fitness with the full palette of protocols.

The focus in the above case has been on the remediation of manifest deficits, as it to be expected since that is what brought the client to the task in the first place. A lot of the benefit derived from the training is not captured by the symptom tracking data, however. The emphasis should more properly be based on optimum functioning. We get a hint of that from the QIKtest data, where the client is doing very well in all respects. In the optimum functioning perspective, there is yet more to be done, and there are yet more protocols to be evaluated. Optimum functioning has no headroom limit.

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