Abstract

Objective-To evaluate the addition of an advanced EEG biofeedback protocol to a substance abuse residential treatment program.

Methods-Sixty one (61) control and 60 experimental volunteers undergoing an inpatient 12-step based program were randomly assigned to the EEG biofeedback or control group.  The experimental group received a 40-session biofeedback protocol in addition to the standard residential treatment. Abstinence rates as well as psychometric measures were compared at set intervals for both groups, with both tester and subject blind as to group.   The experimental group received beta/SMR training, followed by alpha training (divided into alpha suppression or augmentation training empirically based on initial alpha amplitudes).  UCLA's HSPC approved the study design.

Results-The experimental group demonstrated significant improvements on all psychometric tests, with subgroup differences noted in the alpha-attenuation and alpha-augmentation subgroups.  Experimental subjects stayed in treatment significantly longer compared to the control group (p< 0.005). At one-year post study 36 of the 47 completing experimental subjects were abstinent compared to 12 of 27 control subjects.

As many as 80 percent of recovered drug abusers resume drug use within a few months of leaving treatment (e.g., Peniston & Kulkosky, 1989; Alterman et al., 1998; Morral et al., 1997).  Among the many factors identified contributing to the poor expectable outcome is xbrain instability,x which derives from a new bio-psycho-social paradigm gaining currency in the field of brainwave biofeedback, based on neuro-electric complex self-regulation systems of the brain itself.  Beyond the important factors of psychiatric co-morbidity and social/therapeutic support systems, chronic substance abusers inevitably have created toxic encephalopathies with resultant compromised or dysfunctional central nervous system regulatory agencies (Pollock et al., 1992; Prichep & John, 1992;). Many of the stress management and coping strategies taught in traditional substance dependence treatment cannot xtake holdx immediately until the addicted person stabilizes neurologically and emotionally and continues working an ongoing program of recovery (Scott & Peniston 1998). In other words many drug users are simply not neuro-biologically available for treatment.

Our observations suggest that EEG biofeedback has a major contribution to make in the field of substance abuse recovery.

Historically, the field of EEG biofeedback has incorporated three waves of advances.  I. Alpha-theta EEG biofeedback (eyes closed).  (Peniston and Kulkosky, 1989; 1990) reported greater success in treating alcoholics with therapy that included an operant conditioning technique, alpha-theta EEG biofeedback, than with traditional treatment alone (e.g., abstinence, group therapy).  Alpha-theta EEG biofeedback helps to reduce the tension and negative self-efficacy associated with early stages of abstinence (Peniston & Kulkosky, 1989). Peniston adapted a trauma-reducing meditation-based protocol from Emer and Alyce Green which reactivates repressed anxiety-evoking imagery in a state of deep calm (Peniston et al., 1993). II. SMR-beta EEG biofeedback (eyes open).  SMR-beta was a serendipitous discovery (Shouse & Sterman, 1982), initially applied to epilepsy (Lantz & Sterman, 1988; Shouse & Sterman, 1982), and later found to be effective in treating the symptoms of ADHD (Lubar & Shouse, 1976; Lubar, 1991). SMR-beta EEG biofeedback normalizes the EEG power spectrum in children and adults (Lubar, Swartwood, Swartwood, & O'Donnell, 1995; Sterman, 1996; Brod, 1999).  III.  Phased EEG spectrum/location-specific feedback (eyes open phase, followed by eyes closed or mixed sessions.  Biofeedback protocols have been developed based on quantitative EEG (qEEG) studies (Gurnee, 2001) and empirical clinical observations.  This report addresses the advances provided by the later.

In 1999, members of this study group presented data on a large group of recovering substance abusers. (Scott et al, 1999)   In that study, we addressed the hypothesized neuropsychological, cognitive, and psychophysiological factors that hinder successful recovery from substance dependence by initially having subjects undergo 10 to 20 SMR-Beta EEG biofeedback followed by 30 sessions of alpha-theta training.

We conducted a large-scale randomized controlled design with two groups; one received standard Minnesota Model 12-step based residential treatment alone. (Stinchfield R, 1998), the other included a program of EEG biofeedback training in the context of Minnesota Model treatment.  Treatment success was evaluated one-year post-study for multiple domains of functioning including relapse, attentional and cognitive performance, and changes in personality.

Summary of the original report:

Design. The protocol was administered to the experimental group in addition to traditional treatment.  EEG biofeedback included training in Beta and SMR to address attentional variables.  This was followed by an alpha theta protocol.  Subjects received a total of 40 biofeedback sessions.   The control group received only the traditional treatment.  However, time in treatment was matched to the experimental subjects. Participants. One hundred and twenty-one (121) volunteers undergoing an inpatient 12-step Minnesota model based program were randomly assigned to the EEG biofeedback or control group.  U.C.L.A.xs Human Subject Protection Committee approved the studyxs design. Measurements. The Test of Variables of Attention (TOVA), MMPI, and Automated Neuropsychological Assessment Metrics (ANAM) test battery were administered with both tester and subject blind as to group placement to obtain unbiased baseline results. Abstinence rates as well as psychometric and cognitive measures were compared at set intervals for both groups.  Findings: The experimental group demonstrated significant improvements on the TOVA. (p< .005) after an average of 13 beta-SMR sessions. Following alpha-theta training, significant differences were noted on 5 of the 10 MMPI-2 scales at the p<.005 level. Experimental subjects stayed in treatment significantly longer compared to the control group (p< 0.005).  Finally, of the experimental subjects completing the protocol, 77% were abstinent at 12 months, compared to 44% for the controls.

Subjects were provided informed consent before participating in this experiment, approved by the UCLA Human Subjects Protection Committee.

Participants

One hundred and twenty-one volunteers from the Cri-Help, Inc. residential treatment program in the Los Angeles area participated in this study.

Ninety-four percent were multiple-drug users.

Days in Treatment

Length of stay in treatment averaged 135 days for experimental subjects and 97 days for controls. This difference was significant (p< 0.005). Median length of stay was 142 days for experimentals and 88 days for control subjects. As shown in Figure 1, after 12 weeks, 46% of control subjects had dropped out of treatment, compared to only 24% of those who received EEG biofeedback. A Chi-square analysis demonstrated a significant difference in drop-out rate between experimental and control groups over the 12 week period, X2 (n=121) = 6.29, p<. 05. There was no significant interaction between drug type used (stimulant versus sedating drugs) and treatment days, F(1,118)=.004, ns.

Figure 1. Effect of the EEG biofeedback protocol on patient retention for control (n=61) and experimental (n=60) subjects.}

Abstinence Rates

Figure 2 presents the data available for the 103 subjects who had reached their 12-months post-study status: 55 experimental and 48 control subjects. Of these subjects, there were 7 experimental and 17 control subjects who dropped out of treatment prior to completing the study (the initial 45 days), while there were four control subjects and one experimental subject who could not be contacted at the 12-month interval. -
Of the remaining experimental subjects who completed the study and were assessed at 12 months, 36 of 47, or 77% were abstinent. This included 8 subjects who had one brief relapse period of less than 30 days during the year. Of the control subjects who completed the study, there were 12 of 27 subjects, or 44% who were abstinent. This included one subject who had one brief relapse period of less than 30 days. A Chi square analysis demonstrated a significant difference between one year abstinence rates of the experimental group versus the control group, X2 2(74)=7.78 p<0.01. There was no significant interaction between drug type used (stimulant versus depressant) and abstinence rate, F(1,113)=.844, p>.05.

(Figure 2. Twelve month follow-up abstinence data for experimental (n=55) and control (n=48) groups.)

MMPI-2

Figure 3 A univariate mixed-design analysis of variance (ANOVA) was used to evaluate the effects of the experimental protocol compared to controls on the 10 clinical scales, and multiple subscales.
As shown in Figure 3, the experimental group exhibited significant improvement over the changes in the control subjects, at the p< .005 level on the Hs (Hypochondriasis), D (Depression), Hy (Conversion Hysteria), Sc (Schizophrenia) and Si (Social Introversion) scales. The experimental group also improved on the Pt (Psychasthenia) scale, although the difference between groups on this scale was not significant, p>.05. Both groups improved on Pd (Psychopathic Deviate) scale, p<. 05.

(Figure 3. Change in 10 MMPI clinical scales and three validity scales for the experimental group (n=50) and the controls (n=33). (+,  p<.05; *,  p<.005) )

TOVA

Mean TOVA standard scores are presented for both groups in Figure 4 (61 experimental, 45 controls). There was no significant difference between groups in initial baseline TOVA scores,
F(1,303)=1.333, p>.05. A univariate, mixed-design ANOVA was used to compare the two groups on four dependent measures of the TOVA: inattention (percent omission), impulsivity (percent commission), response time, and response variability. Low scores were truncated at four standard deviations below normal.

As can be seen in Figure 4, the experimental group exhibited significant improvement in impulsivity and variability measures in response to Beta-SMR training (p< .005) whereas no comparable change was found for the control group, (p> 0.05). Experimental subjects also demonstrated significant improvement in inattention; however the score only marginally differed from that of the control group (p<.05). TOVA scores were not further enhanced by either the Alpha-Theta training nor 30 additional days of treatment.

(Figure 4. TOVA standard scores for experimental and control groups for pre-training, post-SMR, and post-Alpha-Theta assessments. (+,  p<.05; *, p<.005) )

EEG TYPE-SPECIFIC TRAINING DIFFERENCES:
POST HOC ANALYSIS

We sought to explore the extent to which subjects would respond to two different alpha-theta EEG biofeedback protocols. We compared abstinence at one-year post treatment and as psychometric testing between two groups receiving two types of EEG biofeedback. Below is data from 32 subjects whose alpha was above 12 microvolts and were trained for alpha suppression. Fifteen (15) subjects whose baseline alpha was below 12 microvolts were trained to augment alpha amplitudes. Although previous studies had posited alcoholics had low alpha amplitudes (Cohen, Porjesz, & Begleiter, 1991; Enoch, Rohrbaugh, et al, 1995; Enoch, White, et al 1999; Enoch, White, et al 2001; Moore 2000; Plotkin & Rice 1981; Walters 1998) and were trained to augment alpha (Peniston & Kulkosky 1989; Saxby & Peniston 1995; Scott & Peniston 1998), our clinical experience with mixed substance abusers revealed that the majority of substance abusers of all types--although to a lesser extent alcoholics--demonstrated notably high alpha amplitudes. No group has previously studied training for EEG differences between "high alpha" and "low alpha" substance abusers.

We conclude that the highly successful outcomes of the main study result from differential treatment of these two groups.

Figure 5. Linear regression indicates a drop in amplitude of 7 microvolts during the course of the high alpha subjectxs final 30th session. (n=32) There was no significant difference in this trend when it was compared to their 1st and 15th session.  In other words, alpha down training occurred from the first session forward.

Figure 6. Linear regression indicates no change in amplitude during the course of the low alpha subjectxs final 30th alpha augmentation session. There was no significant difference in this above trend when it was compared to their 1st and 15th session. (n=15)

Figure 7. There were no significant differences between the alpha augmentation and alpha attenuation groups in terms of their baseline MMPI-2 results of the pretest. (p>.05)

Figure 8. Significant improvements from pre to post MMPI-2 results were found in the alpha suppression groups on scales F, D, Hy, Pt, Sc, and Si.

Figure 9. Significant MMPI-2 improvement was found in the alpha augmentation groups on scale Hy. (p<.05)

Figure 10. Post treatment improvements in MMPI-2 scales made by the alpha attenuation group surpassed changes made by the alpha augmentation group on scales D, Pa, and Sc.

Conclusion

The original study supported the efficacy of EEG biofeedback protocols as adjunctive therapy in an in-patient drug treatment program for several types of drug dependency. Success was determined by length of time in treatment as well as by abstinence one year after termination of treatment. Supportive data were provided through neuro-cognitive and psychological assessments. The findings extended the research employing alpha-theta EEG biofeedback with an alcoholic population to other drugs of choice.

There was no significant difference in abstinence rates between the alpha augmentation and alpha suppression groups.   The post-hoc analysis presented here highlights the importance of differentiating EEG-based subgroups, so that individuals get appropriate feedback.

ACKNOWLEDGEMENTS

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