Impulse Control

by Siegfried Othmer | July 13th, 2006

If one leaves aside for a moment the horrors that are unfolding in the Gaza strip and in Iraq, the memorable image of the past week was the headbutt by Zinedine Zidane during the World Cup final between France and Italy. Until the moment of Zidane’s ejection from the game, France had to have been content with the way things were going for them in the overtime. One can only assume that in reflection on his loss of poise Zidane would very much have wanted to rewind the film and replay the scene.

From our perspective as neurofeedback practitioners, one can easily sympathize with the dilemma faced by Zidane. Players in his league are surely distinguished from their lower-ranked compatriots in their physiological reaction time, among other criteria. They compete in that zone where many of their reactions are almost reflexive. In our offices we get to measure this every day with our continuous performance tests, and we get to witness that domain of rapid decision-making that is just at the threshold of voluntary control. With neurofeedback training, we get to witness the emergence and consolidation of inhibitory control that makes even rapid responses subject to volition. The pure reaction time measured in an impulsive error becomes the choice reaction time that we had intended to measure.

What the data show us is that the imposition of voluntary control does not exact a time delay in the response to the go/no-go challenge. Impulsivity can simply vanish in the competent brain without reaction time getting any slower. That being the case, there need be no hesitancy on the part of top athletes, even those for whom fast reaction times are crucial, in undertaking neurofeedback to deal with any impulse control problems.

As it happens, a number of players on the Italian team had taken advantage of the chance to do biofeedback with Thought Tech equipment in the Mind Room.*1) So it is quite possible that the soccer final turned on the fact that members of one team had neurofeedback training while the other one didn’t.

Another factor that comes into play here is that heading the soccer ball puts stresses on the pre-frontal cortex, anterior temporal lobes, and on the brainstem that are sufficient to induce symptoms of mild traumatic brain injury. And those symptoms include impulse control problems. So Zidane, as one of the most active players, could be vulnerable here simply by virtue of his being so successful over his career. On the one hand, there is more opportunity to handle the ball, and on the other, he becomes a more obvious target for interference by other players who want to take him out of the game. Collectively this can take its toll. Zidane was already known for his “temper,” so his nervous system could have been vulnerable to further deterioration of impulse control.

There is one complication in this promising construction of the possibilities for neurofeedback among elite athletes where fast reaction time is involved. We also observe a small subset of trainees where the reaction time does slow as impulsivity resolves. The question we have been asking ourselves is whether this involves a necessary slowing of reaction time in some nervous systems, or whether it involves a more psychodynamic process, namely an altered tolerance of risk. There is evidence for both, and it may not be easy to tease them apart.

The fact that regulatory control of the reflexive motor act can take place without incurring time penalty may indicate that the process is accomplished via parallel rather than sequential processing in the intact brain. This could be seen in terms of bringing control circuitry on line that monitors the unfolding of the preliminaries to the motor act. If this mechanism is compromised in some brains, the task of inhibiting the impulsive act is unlikely to fail catastrophically. After all, commission errors are usually sparse in a CPT, even among those who score poorly. More likely, the process just becomes less efficient, possibly involving alternative pathways, and taking more time.

As for the psychodynamic hypothesis, it has been my own personal experience in doing neurofeedback over the years that I have become much less tolerant of time urgency. For example, when I still worked in aerospace I used to hold it out as an ideal to arrive for the Hughes corporate helicopter just in time for my pickup, and not a moment before. These days I would much rather get to the airport with plenty of time to spare. One has the impression that something similar is happening to some of our trainees. They become less tolerant of commission errors so they make a behavioral adjustment in their test-taking strategies despite our instructions to respond quickly.

Could something like this happen to our elite athletes, namely that they would become more deliberate and hence slower to act under a challenge? All we can say is that this has not been our experience. And the athletes themselves dismiss the concern out of hand. One can also argue that the challenge in soccer is different from a go/no-go challenge. No advantage at all is conferred by hesitation. Advantage in the game inevitably goes to the swift. So there is no positive reinforcement in the game for a more deliberate response if it imposes a delay.

This week’s Parade Magazine has a feature article by Isadore Rosenfeld, MD, on the state of acupuncture in the US. I take the appearance of such an article as an index of a certain level of mainstream acceptance—not as a source of technical information! Rosenfeld estimates that more than a million Americans may have tried acupuncture by this time; that thousands of practitioners have been trained in acupuncture; and that it is being used for a wide variety of conditions ranging from “migraines to nausea, menstrual cramps to tennis elbow, asthma to addiction.”

This sounds very much like the neurofeedback story. With more than 100,000 Americans getting neurofeedback every year (my estimate), surely the magic one million is within our sights. We are quite possibly no more than three years away from where acupuncture is now, both in terms of “penetration” and possibly also in terms of professional acceptance.

Rosenfeld takes a stab at describing a possible mechanism: acupuncture needles “cause the brain to release a variety of pain-killing neural chemicals.” This is hardly an adequate explanation. First of all, what do pain-killing chemicals have to do with asthma and addiction and nausea? Secondly, what mediates between the locus of the needling and those neural chemicals? And what sense does it make for the brain to make “pain-killing” chemicals when it is the brain that gives us the pain in the first place? (Fire extinguishers don’t set fires.)

A much better narrative is given within the language of our neural regulatory systems. The body is aware of the breach of its boundary, the skin, and it mounts its defenses. For a “deep wound” such as the acupuncture needle represents, the reaction lies in the direction of a parasympathetic-dominant response. The body-mind looks to its various defenses, which include the signaling of pain. But pain is not an absolute, and it is not a reality external to the brain. It is itself a signaling response by the brain, and it must be modulated, or modulatable. So mechanisms must exist within the brain both for the generation of pain, for its modulation in severity, and for its dissolution.

The mechanism of action must be that acupuncture alters the state of functioning of the neuronal networks, which in turn calls upon a variety of neurochemicals, not just those having a specific role in pain regulation. The communication from the site of “injury” to the brain is first of all bioelectrical in nature, as a volley of action potentials carries the information to the spinal column, and from thence back to central headquarters. The response of the “system” is bio-electrical as well. The neurochemicals are merely “demand-responsive.” They are not the actors in this drama but rather merely the stage lighting.

Matters are much the same as when a bee arrives at the hive with news of a discovered food source. The information rapidly spreads to the whole hive, affecting the state of agitation of the whole. Now some of this communication may indeed take place via chemical signaling. But the story isn’t really about the chemicals. The story of the response of the hive remains largely in the behavioral realm, and that is also the case for acupuncture. We just have to talk about our neuronal assemblies as the behaving entities.

Acupuncture, just as neurofeedback, re-regulates the system under some kinds of stress. The needling provokes a subtle change in the group properties of the neuronal assemblies, to which the brain is compelled to respond. The response lies in the direction of improved self-regulatory status, just as it does in the case of neurofeedback. We are simply dealing with a qualitatively different kind of challenge to our regulatory regime, eliciting a response of the system that is quite familiar to us from neurofeedback.

One obvious difference lies in the fact that acupuncture may not involve a learning component to the same degree as neurofeedback. A person may be liberated from pain with acupuncture in the event, but may also slip back into pain quite readily some time after the intervention. That happens to us with neurofeedback as well, but one may surmise that the active neurofeedback process may involve more of a learning component. Another obvious difference is that with neurofeedback we can tailor the challenge to the requirement, whereas with acupuncture we have to take what we are given.

There is another interesting analogy between acupuncture and neurofeedback, best illuminated with another anecdote. When we were working with David Comings, MD, on the potential application of neurofeedback to Tourette Syndrome during the early nineties, he announced quite triumphantly one day that he had just seen a study on acupuncture showing no significant benefit of using known acupuncture points in comparison with more random application of the treatment. This was enough to allow him to dismiss the whole thing in his own mind. The fact that both cohorts in the study showed substantial benefit of the intervention did not factor into his judgment. In neurofeedback we are up against the same mindset: protocol specificity has to be proved as a condition of acceptance.

One can argue, of course, that any such specificity is not really essential to the basic claim of efficacy–either for neurofeedback or for acupuncture. But in this regard both practitioners and spokesmen for the field become part of the problem in that they clearly “believe in” treatment specificity themselves. That being the case, they can hardly complain when they are judged on their own proclamations.

It seems to me quite possible that there is a generic response to acupuncture and that the specific acupuncture points offer only incremental benefit beyond that. Likewise in neurofeedback almost any of the standard protocols can be used to shape people toward improved self-regulation, at least for the conditions commonly treated with neurofeedback. Nevertheless nearly all of us see advantages in tailoring our intervention to the situation in various ways. Matters should not be allowed to stand or fall on the argument of specificity, but then our language also needs to adapt to that clinical reality.

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