Biofeedback Society of California Conference

by Siegfried Othmer | November 17th, 2005

The BSC is the strongest of the local biofeedback organizations, unsurprising perhaps in the birthplace of the national biofeedback organization. Nevertheless, it is a small organization, and for its size put on quite a conference. There were some 80 attendees.

I attended Naras Bhat’s workshop on reversing heart disease. Naras Bhat is one of the pioneering cardiologists who is looking at heart disease from a systems perspective. Known risk factors are associated with only half of cardiac events at best, so much of coronary artery disease must be due to dynamic factors. Beyond the plumbing preoccupation that just deals with the pumps and pipes, there is the world of body chemistry, and finally the realm of the emotions. All are manageable, and all should be managed before there is a crisis. Even after a crisis we are back into a steady-state management regime, so that a person may at worst die with heart disease rather than from it.

In any steady-state management program, the emotions are paramount. Anger is well-known to be a trigger of heart attacks, and a significant contributor to incidence of cardiac events in general. The heart apparently suffers many little ischemic insults in conjunction with anger episodes, many of these unobserved and unremarked. But the punctuation of anger episodes may arise out of a more steady-state condition of pervasive cynicism and hostility that does its own corrosive work. A “type D” of cardiac risk has been identified around negative affectivity and social isolation as being of the greatest import. Consequently, Bhat encourages the deliberate cultivation of altruism as the remedy available to Western man. In his heart of hearts, of course, he sees the remedy in a more encompassing spirituality, an inclusive mindfulness, and an openness to transcendence, from which altruism would be the natural issue. This goes beyond the usual language of mind-body medicine, which he refers to as “vertical intimacy,” to the “horizontal intimacy” of affiliation. Unfortunately, our culture militates against this, with its emphasis on individuality, mobility, and cultural heterogeneity, so one must swim against the prevailing current.

Bhat refers to a comprehensive program of reversing heart disease being promoted by Dr. Peter Nixon of Charing Cross Hospital in London. The program is based around stress management and controlling chronic hyperventilation of vigilance. The program runs under the acronym SABRES, where S stands for quality of Sleep; A for control of stress-induced Arousal; B for Breathing regulation; R for Rest; E for effort; and S for self-esteem. Bhat adds additional elements to this program: the uprooting of anger, with the aid of Heart Rate Variability (HRV) training; meditation and imagery; and self-disclosure.

If there is a flaw in this prescription, then it lies in the fact that one is being lectured to by someone for whom altruism is probably congenital, for whom a spiritual orientation to life is the natural state of being. What does the guy do who has been selected to be the enforcer on the hockey team, the guy who is being shot at in Falloujah? Neurofeedback, along with HRV, is the accessible remedy for those whose life tilts the wrong way. We enable the physiology, and the mind follows, rather than the other way around.

Carolyn Yucha (pronounced Yoo-Hah), nurse physiologist, opened the general program with a lecture on evidence for biofeedback efficacy. I nearly died in my chair. What a paragon of constricted thinking! After making the case for biofeedback efficacy studies, Yucha said that these must be followed by effectiveness studies, which typically exhibit somewhat lower success rates than the efficacy studies. “Normally there is a degradation from research to the clinical setting…,” said Yucha. What rubbish! We already have effectiveness studies in great abundance. There is no longer any mystery here. The real question is why anyone would still insist on efficacy studies under artificial, constrained circumstances when real-world trials are already being successful on a daily basis.

The history of biofeedback research is that the various trials in research settings have typically turned out worse than what clinicians accomplish in the real world. In practice, this serves merely to enhance skepticism about the clinical claims, and wonderful techniques end up side-lined. Consider the following dichotomy: We have often heard the criticism leveled at new clinicians that they simply take a weekend training course and then hang out their shingle as a neurofeedback practitioner. We are also routinely advised to be guided by what issues out of the formal research studies.

Over the years there have been many cases in which university-based researchers have inquired about how they might proceed with research on neurofeedback for Tourette Syndrome or some other condition. In every case, after answering their questions I urge the researchers to take a training course before they proceed to define their research study. Secondly, I urge them to do a pilot study before putting a formal study design in concrete. Only rarely is that advice followed. On the contrary; researchers prefer to design their research without reference to the particularities of neurofeedback, and most actually prefer to do their work uncontaminated by clinical input. And they call it science…

Most of those studies never see the light of day. No surprise here. We would not populate West Point with professors of military strategy who had never seen action on the battlefield, nor would the Pentagon hire military planners with no practical experience. We would not have professors of music from CCNY conduct at Carnegie Hall. But we are supposed to be respectful of research conducted by people who have never done neurofeedback, or even witnessed it, in the real world? Steve Sideroff said it well in a later part of the program: “Effective biofeedback involves many contextual issues.” Is it any surprise that outcomes should be worse when these are deliberately stripped away than when the context is overtly supportive? What most needs to happen is to have aspiring researchers do apprenticeships in the clinical world. Why does it remain for a physicist to make this point?

The highlight of the conference for me was the presentation by Peter Litchfield on breathing chemistry. Not that there was much new in his presentation. I was just more ready to hear it than before. It is always nice to be instructed by someone who lives his beliefs, and Peter Litchfield shares honors with Naras Bhat in that regard. I am in the hunt now for models that promote an integrative perspective on our body’s regulatory obligations, and none could serve better than an understanding of breathing physiology. Here we have a regulatory system that is subject to both voluntary control and autonomic regulation. Our breathing patterns can also be habit-forming, and such habits could eventuate in grievous physiological disregulation. Remedy for such disregulated breathing (hyper-ventilation, over-breathing) may be readily at hand, but without explicit guidance in the matter, the client is more likely to slip into worse disregulation than the alternative.

The importance of breathing chemistry was summarized by Fensterheim as follows:

“Given the high frequency of incorrect breathing patterns in the adult population, attention to the symptoms of hyperventilation [over-breathing] should be a routine part of every psychological evaluation, regardless of the specific presenting complaints. Faulty breathing patterns affect patients differently. They may be the central problem, directly bringing on the pathological symptoms; they may magnify, exacerbate, or maintain symptoms brought on by other causes; or they may be involved in peripheral problems that must be ameliorated before psychotherapeutic access is gained to the core treatment targets. Their manifestations may be direct and obvious, as when over-breathing leads to a panic attack, or they may initiate or maintain subtle symptoms that perpetuate an entire personality disorder. Diagnosis of hyperventilatory [over-breathing] conditions is crucial.” (Herbert Fensterheim, Behavioral and Psychological Approaches to Breathing Disorders, 1994)

A partial listing of symptoms that may be attributable to CO2 depletion (hypocapnia) resulting from over-breathing is as follows:

  • Neurological syndromes, epilepsy
  • Cognitive deficits: thinking, problem solving, memory
  • Attention deficit and learning disabilities
  • Psychomotor behavior disturbances, including coordination
  • Emotional reactivity, including anger and anxiety
  • Performance anxiety, e.g., public speaking, test taking, music recitals
  • Phobia and panic attack trigger
  • Personality changes, including self-esteem
  • Psychological defensiveness: denial, self-talk
  • Behavioral posturing: bracing vs. embracing
  • Dissociative behavior and disconnectedness
  • Stress and tension symptoms/syndromes
  • Angina, chest pain, heart attack, cardiac arrhythmias, irregular heart beat
  • Cardiac ECG abnormalities: T-wave flattening, marked ST depression, QT prolongation
  • Hypertension, migraine phenomena (headache, gut, heart), digital artery spasm, e.g., Raynaud’s Bronchial spasm and constriction, asthma symptoms and attack
  • Irritable bowel syndrome (IBS)
  • Birth complications, including fetal health and premature birth
  • Muscle spasm (carpopedal), hyperreflexia, pain, and tetany (anaerobic metabolism and lactic acid)
  • Muscle weakness, fatigue, and stiffness (effects of shifts in calcium, magnesium, potassium)
  • Neuromuscular dysfunctions, e.g., repetitive strain injury (RSI), exaggeration of tendon reflexes
  • Reduced physical endurance (loss of bicarbonates)
  • Sleep apnea, correlated with waking hypocapnia
  • Fatigue, exhaustion, effort syndrome, chronic fatigue, hypoglycemia
  • Altitude sickness

In our recent discussion of autism a systems perspective was needed, and the same goes for heart disease in this newsletter. Significantly, Dr. Peter Nixon appreciates the role of the breath in heart disease. I am often struck by the varied patterns of symptom improvement we observe in our clinical populations. Typically we see the patterns that we expect of a gradual improvement across the board. Yet other times the progress is much more precipitous, almost as if a switch had been thrown that rather quickly altered the regulatory milieu. Sometimes that switch gets thrown only at session 34, so we know that we are not simply dealing with one of the easier cases.

When we consider the involvement of breath chemistry in so many of the disregulations of interest to us, it is possible to consider that our training may have induced a simple change in breathing habits, followed by a substantial symptomatic improvement. If that is the case, then we should think about targeting breathing directly in our work, if for no other reason than we would like for the client to stop sabotaging the recovery process sooner rather than later. This might be particularly the case for anxiety, for the autism spectrum, and for Reactive Attachment Disorder.

Peter talked about the fact that the understandings of breath biochemistry are quite advanced within medicine, but that the discussion is always conducted strictly in medical terms. That is to say, the medical literature largely ignores the realm of behavior. Yet our behavioral control of breath chemistry is direct, immediate, and profound. It can even be lasting. One person’s persistent bad breathing habits were altered permanently within one session as the implications of her breathing pattern were demonstrated to her.

During a subsequent workshop, Peter demonstrated the system he developed for monitoring CO2 levels in the breath. It also monitors heart rate. The software builds on the J&J platform; the hardware is his own development. The volunteer manifested an almost ideal breathing pattern, and the undulations on the screen probably took all of us to a calmer state as we watched. But then she was asked to fill out a questionnaire about her health history, and the waveform began to reveal subtle disturbances and little hiccups. I am sure I was not the only one in the room who felt strongly that I was invading the person’s private emotional space by watching her breathing pattern.

We have been looking for physiological measures that might indicate to us when we have reached the optimum reward frequency in neurofeedback. Monitoring CO2 levels might well be the best candidate among the peripheral measures. Changes in breath chemistry would literally be observable from one breath to the next. We have often been mystified by how quickly some people can respond to a change in EEG reinforcement parameters. Again, the immediacy of changes in breath chemistry could be part of an explanation. We should find out. The subtlety of our assessment of state change should match the subtlety of our techniques in inducing state shifts. We should not be dependent on verbal report from those who have not a clue about how they feel. I came home with Peter’s CO2 monitor under my arm. We shall see…


A client at our office recently observed that she was drinking a whole lot of juice and coffee, and was having difficulty maintaining her energy level. Diabetes was suspected, so eventually her HMO got her an appointment with an endocrinologist. Said the doc: “You’ve probably lost 90% of your insulin-making capacity, and the other ten percent is on its way out.” She went home with a batch of insulin syringes and blood sugar monitors, plus some general dietary precautions.

Next day she was back in the Dr.’s office with the report that her blood sugar level was below 80. “Just eat a candy bar,” was the helpful suggestion of the receptionist, no doubt knowing already what the doc would say under that circumstance. “Bang-bang regulation”, one might call it. Hit the system with insulin, and balance with sugar. The body’s regulatory response is no longer involved. This is what happens when medicine encounters self-regulatory systems. We were aghast, and so was the lady in question.

She fled the office, and proceeded to get her own house in order dietarily, exercise-wise, and in terms of supplements to aid the restoration of balance. She has not had a single shot of insulin since, and blood sugar remains well-controlled. Further medical procedures will be diagnostic in nature, oriented toward teasing out more subtle aspects of the physiology that may have tipped things badly in the first place.

The lack of understanding of regulatory systems is unfortunately pervasive. When we teach our classes it is often the case that the hotel does not manage the room temperature well. When attendees have access to the machinery, someone quite often adjusts the thermostat by a lot rather than a little. A little later, someone else gets uncomfortable and reverses the process. Bang-bang regulation.

I recall a taxi ride from Kennedy airport to the city some number of decades ago in which the driver would episodically floor the accelerator and then come off of it entirely. This was intended to give us the impression that he was going as fast as conditions allowed. Acceleration was intended to simulate velocity. We were not fooled, and we were also miserable. But one does not argue with a taxi driver from Brooklyn. Another such example is the “Back to the Future” ride at Universal Studios. Acceleration is used to simulate velocity. (Chiropractors should be there handing out business cards at the exit.)

It occurs to me that this is relevant to how medication often works. One cannot help but get a strong hit from the insulin shot, so the message is “powerful medicine.” Whether this is actually helpful in the steady-state is an entirely different question. We may confuse acceleration with velocity, the sudden induction of change with steady-state improvement. Whatever the domain, jolts to the system give our strongest simulation of progress. If our young lady had continued with her initial kind of “bang-bang” regulation, no doubt the doc’s prediction would have been borne out, and complete insulin dependency would have eventuated sooner or later. Once ensnared, hooked for life.
As it is, there is at least some hope for a different outcome.

I recite this example for two reasons. The first reason is that Big Medicine still does not handle problems of regulation well. It is still only the isolated cardiologist that advises on the centrality of lifestyle issues. Breath chemistry is not treated as connected to the realm of behavior. And blood glucose regulation is still treated in the crudest fashion. Diabetes, common as it is, remains an exemplar of medical over-reach with respect to conditions of disregulation.

The discussion of autism and of breath chemistry, etc. makes it clear that problems of disregulation can be fully understood only at a systems level, and no one yet has that perspective. Broad efficacy of neurofeedback can be attributed to the fact that we address the head of the regulatory hierarchy, and perhaps as well to the fact that we target the regulatory systems subject to the greatest constraints. But much of our regulatory impact remains opaque.

The second reason for citing the diabetes vignette is that we are prepared to send people home with hypodermic needles to manage their own glucose level after a single office visit. How might this compare in terms of hazard to the self with neurofeedback undertaken at home under clinical supervision after the first twenty sessions are conducted in the office? It is time to un-ring the alarm bells on remote use.

– A 70% effective surgery in heart disease was compared with sham surgery.
The chest was opened and the ribs interrupted and then the wound was closed.
The patients who received the sham operation experienced the same 70% cure rate as measured by EKG, exercise tolerance and reduction in pain as measured by reduced pain medication. N=100.
o HK Beecher, JAMA Dec 29, 1955; 159(17) 1602-06

– “Heart massage was a medical scandal on a larger scale than frontal lobotomy.”
o Naras Bhat

– Surveys have found that up to 60 percent of all ambulance calls in major US cities are the result of over-breathing.

“How to Reverse and Prevent Heart Disease and Cancer,” by Naras Bhat

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