Conventional wisdom, and the guiding principle for virtually all cognitive and neuropsychological rehabilitation efforts, assumes that awareness of impairments is a necessary first step in the rehabilitation of such residual brain injury deficits as memory, problem solving, and self-control difficulties. While this assumption is intuitively appealing, facilitating increased self-awareness in some brain injured individuals may also restrict and block rehabilitation interventions. Improperly applied, it can even undermine the optimization of adaptive behavior, a higher level goal that transcends the development of self-awareness.

Unawareness of deficit, often referred to as anosagnosia, has been recognized in the neurological literature for over a century. Increasingly, the phenomenon of unawareness has resurfaced in brain injury literature because it can generate significant dilemmas for rehabilitation. In the treatment of acquired brain injury (ABI), unawareness of deficits is often considered by clinicians to be a core problem that impedes progress and greatly influences outcome. An accumulating body of research has confirmed the clinical view that unawareness is both prevalent in ABI and predictive of poor outcome. In fact, large sample studies of persons with ABI indicate that a high proportion present with some degree of unawareness of deficit (Prigatano, 1996). This unawareness can seriously impede participation in rehabilitation by persons with TBI, and cause problems with motivation, engagement in therapy tasks, compliance with suggestions for behavioral change, and the use of compensatory strategies (Fleming, Strong, & Ashton, 1998).

A number of factors have been identified as possibly influencing the development of self awareness, including severity of injury as measured by initial Glasgow Coma Scale (GCS), length of coma, or length of posttraumatic amnesia (PTA), and location of brain lesion. Lesion site may impact the degree of self-awareness possible, as damage to frontal systems could produce a general decrease in levels of self-awareness, for example. McGlynn and Schachter (1989) have theorized that generalized unawareness of deficits  and cognitive deficits in particular  is due to impaired executive cognitive abilities associated with anterior cerebral dysfunction. In an applied sense, individuals capable of increased self-awareness after ABI pose a significant challenge to any rehabilitation team. An individual’s ability to deny their deficits may be adaptive in the sense that this allows for the preservation of self-esteem and hope for the future. Therefore, treatment methods that highlight deficits in a confrontative way may trigger deeper depression and catastrophic reactions and be counterproductive in some individuals.

Denial of acquired disability has been proposed as a coping strategy for loss of previous life style in those with acquired injury and in those with major diseases such as stroke, lung cancer, and heart disease. It has also been suggested that both the prevalence and persistence of unawareness in those with ABI is more complicated in that it is brought about because of some mixture of organic impairment and psychological factors. Prigatano commented, "patients cannot maintain a productive lifestyle unless they have come to face the realities of their life and this means improving self-awareness and self-acceptance." (Fleming et al., 1998, p. 40). With respect to the hypothesis that self-awareness is necessary for successful ABI rehabilitation, however, the research findings have been mixed. In fact, a number of studies have failed to support the hypothesis that self-awareness of deficits positively impacts TBI outcome. Hence, the question remains whether or not self-awareness is necessary for ABI Rehabilitation.

The literature is more conclusive regarding the positive correlation between increased self-awareness and greater risk of experiencing emotional distress. Extreme emotional reactions (e.g., depression, anxiety, and catastrophic reactions) sometimes accompany the development of self-awareness and influence or compete with level of motivation. Several studies indicate a relationship between enhanced emotional reactions and increased self-awareness. For instance, Prigatano and Fordyce (1986) found a negative correlation between unrealistic self-appraisal and emotional distress. In this study, those patients who overestimated their abilities (relative to staff members) experienced less emotional distress. Ranseen, Bohaska, and Schmitt (1990), in their study of 32 TBI patients, found a modest correlation (r=-36; P=.041) between self-report of depression and the discrepancy between patient and staff ratings of competency. They observed relatively higher levels of depression in those patients with self-ratings closer to staff ratings. Linn, Allen, and Willer (1994), in a study of 60 TBI patients who were 6 years post injury, demonstrated that higher self-ratings of cognitive disability and social aggression were associated with higher depression. Godfrey, Partridge, Knight, and Bishara (1993), in a cross-sectional study of groups of TBI subjects at 6 months, 1 year, and 2 to 3 years post injury, demonstrated that greater self-awareness of behavioral deficits was associated with greater emotional distress at later stage post injury. The question remains as to whether the effects of emotional distress may impede involvement in rehabilitation and ultimately compromise outcome, or whether such distress serves as a motivator to rehabilitate for certain patients.

Fleming et al. (1998) found relatively greater motivation to change and more emotional distress among a high self-awareness group. This finding is consistent with the theories and anecdotal reports proposed by those who have observed a negative relationship between denial and depression, a positive relationship between motivational and emotional states, and complex interactions among denial and self-awareness, motivation, and emotion. Less clear is the relationship of self-awareness with outcome. Several researchers have reported better participation (Lam, McMahon, Priddy, & Gehred-Schultz, 1988) and better outcomes (e.g., Ezrachi, Ben-Yishay, Kay, Diller, & Rattok, 1991; Prigatano et al., 1994) for those postacute brain injury rehabilitation patients who demonstrated the most accurate self-awareness (Malec & Moessner, 2000). On the other hand, in their research, Fleming et al. (1998) hypothesized that persons with greater self-awareness of deficits would achieve better functional outcomes and community integration as a result of their enhanced motivation to comply with treatment, adopt compensatory strategies, and engage in behavioral change.

Findings failed to support this hypothesis, however, as no significant differences emerged in any of the outcome variables between the high self-awareness and low self-awareness groups. Explanations for this finding included the following:

1. In the high self-awareness group, depression formed a feedback loop influencing motivational state, which led to a reduction in positive coping behaviors.
2. No differences between high and low self-awareness groups may reflect measurements that were taken prematurely (1-year follow up). Perhaps given more time, the high self-awareness group may work through their emotional distress, and the high involvement in rehabilitation may begin to show results.

Other research (e.g., Fordyce & Roueche, 1986; Cavallo et al., 1992) has similarly failed to find a positive relationship between self-awareness and rehabilitation outcome (as measured by vocational or employment status) from traumatic brain injury.

The following is a striking example of overzealous attempts to increase awareness. A 23 year old severe brain injury survivor was unaware of the extent of his residual memory, mobility and behavior problems and seemed to cope with job and friend loss through excessive drinking. He initially was referred to a clinical psychologist who immediately proscribed drinking and enlisted family support to restrict purchase of alcohol. Within one week of forced sobriety, the survivor attempted to commit suicide and almost succeeded. Fortunately, his treatment provider consulted a rehabilitation neuropsychologist, and the new treatment plan called for specific assistance in coping with loss of job and friends, setting incremental goals for finding new friends, improving chances of sustaining reasonable employment through stepwise efforts, finding new, constructive activities to replace previous drinking, and education regarding drinking after brain injury. With simple encouragement and supportive counseling aimed at improving situational stress and general coping skills , drinking gradually reduced to infrequent.

In other cases, we have observed where significant improvements in behavior and coping are achieved without much or any increase in awareness. The following recent example is illustrative. A 47 year old New York executive who sustained a severe TBI almost 10 years ago had been treated at the best brain injury rehabilitation centers in the country. Despite this, and despite having received very specific, targeted, aggressive treatment for unawareness, he continued to interact with others in an insulting, impatient, aggressive, too frequently dictatorial and sometimes abusive manner. Initial treatment efforts with this clinician involved trying to identify his red flag situations (change in schedule, having to wait for a request, etc.), teaching him to recognize these, and respond with a strategic self corrective procedure. After a lot of practice and consistent staff intervention to help make it become a habit, this strategy showed some benefit. However, it was still a multiple-step procedure with room for error and misuse, it did not work on bad days or when he was already angry or for new situations that did not exactly fit with the red flag list> Further,, even though it was an easy procedure, he had trouble remembering, especially when angry, and the requirements for divided attention presented an additional obstacle. Subsequently, a much simpler and easier approach was tried. This approach did not require awareness, did not even involve confrontation with any unpleasant realizations about personal weaknesses. Instead, it emphasized an acceptable premorbid style relating to his being a New York native and instead even allowed jokes about his New York style. With practice, this strategy was soon adopted as a habit that worked pretty effectively in most situations. The strategy essentially involved instruction to increase smiling when talking with others..."the more important the communication, or the stronger you feel, the more you smile". Shaping to reinforce this habit was liberally provided and clearly assisted with acquisition.

In this second case example, a simple and intermittently present behavior, smiling, was increased as a habit. Importantly, smiling tends to produce pleasant interactions. It is incompatible with insult, aggression and an interpersonally abusive style. By it’s increased presence, it tended to produce noticeably mellowed responses that were more pleasant and less impatient, aggressive or dictatorial in style. As a result, he continues to receive more satisfactory responses from others, which removes reasons for anger and increases reasons to smile. As time passed, the positive responses from others and the more satisfactory responses to his requests reward his smiling, in a cyclic and self perpetuating fashion.

Finally, there are situations where limited cognitive abilities, including concrete thinking, may leave persons unable to adequately increase awareness of problem behaviors. A recent illustrative example is that of a fairly bright 40 year old severe TBI survivor who had some unusual residual "holes" in cognitive abilities. He was treated for three years at some of the better brain injury rehabilitation centers and was transferred between institutions without improvement in persistent childish behaviors and lack of self awareness and self control. Attempts to incrementally increase awareness as a prerequisite step to modifying behavior failed, as did simple behavioral modification programs aimed at rewarding more adaptive behaviors. After several months at his fourth treatment program, it was determined that a combination of an unusual and concrete thinking style, an Axis II premorbid personality style and significant hysterical and other psychiatric symptoms made increasing awareness a near impossibility. As a result, his treatment program was modified considerably. Rather than emphasizing awareness, which was apparently too complex, behavioral interpretations were simplified and paired with dichotomous "positive" or "negative" labels. Explanations and attempts to appreciate his behavior beyond this were curtailed. A list of "negative" behaviors along with alternatively desirable "positive" behaviors was devised and reviewed extensively. Rewards were assigned for increasing ratios of good to bad behaviors and staff provided encouragement and praise for increasing semblance of "positive" behavior. In a short period of time, a pattern of consistent increases in appropriate behavior, and decreases in inappropriate behaviors, was observed.

Because the development of increased self-awareness is helpful in rehabilitative efforts for some TBI patients (and potentially harmful to others), devising reliable ways to identify candidates who would benefit from insight-oriented interventions is of paramount importance. Prigatano (1999), in his 10^th Principle of neuropsychological rehabilitation, noted that "failure to identify which patients can and cannot be helped by different (neuropsychological) rehabilitation approaches creates a lack of credibility for the field" (p. 4). Facilitating self-awareness in certain TBI patients may have dire consequences if such persons are unable to cope with increased psychological insight. Individuals with relatively more severe organic deficits and/or psychologically fragile individuals might experience overwhelming distress when their customary defenses are disabled. In short, the increased knowledge of factors influencing self-awareness may assist rehabilitation professionals to determine which patients will benefit most from "insight-oriented" rehabilitation programs.

We argue that increasing awareness without first evaluating a person’s self-esteem, abstract or higher level reasoning, or general coping abilities, is a "beginner’s mistake" for any therapist. Inexperienced therapists, for example, might employ confrontational strategies without realizing that a patient’s unawareness may defend against powerful feelings of grief and/or helplessness. Stripping patients of primitive defense mechanisms without first offering new coping strategies may bring about overwhelming stress and/or emotional and behavioral deterioration that will hamper rehabilitation efforts. As such, approaching TBI rehabilitation from a stress/coping perspective, old and ineffective strategies should be replaced with newer, more effective ones. We believe that ineffective coping strategies are preferable to none at all, however, and that existing coping strategies (ineffective or not) should remain until another is offered in its place.

In summary, although increasing awareness about deficits and maladaptive coping that results from brain injury is often important, and although it is often a logical or necessary first step in modifying ineffective behavior, it is not always necessary. In fact, there are many situations in where efforts to increase awareness before new coping strategies are acquired will cause increased emotional distress and catastrophic fears to the point that more harm than good can occur. Further, there are situations where it is infinitely easier to change a behavior than change awareness. Finally, there are situations where limited cognitive abilities, including concrete thinking, may leave persons unable to increase awareness of problem behaviors. In these situations, simplifying expectations and rewarding desirable behaviors, in order to build desirable habits, is a more effective alternative to increasing awareness.

Cavallo, M. M., Kay, T., Ezrachi, O. (1992). Problems and changes after traumatic brain injury: Differing perceptions within and between families. Brain Injury, 6, 327-335.

Ezrachi, O., Ben-Yishay, Y., Kay, T., et al. (1991). Predicting employment in traumatic brain injury following neuropsychological rehabilitation. Journal of Head Trauma Rehabilitation, 6, 71-84.

Fleming, J. M., Strong, J., & Ashton, R. (1998). Cluster analysis of self-awareness levels in adults with traumatic brain injury and relationship to outcome. Journal of Head Trauma Rehabilitation, 13(5), 39-51.

Fordyce, D. J. & Roueche, J. R. (1986). Changes in perspective of disability among patients, staff, and relatives during rehabilitation of brain injury. Rehabilitation Psychology, 31, 217-229.

Godfrey, H. P. D., Partridge, F. M., Knight, R. G., Bishara, S. (1993). Course of insight disorder and emotional dysfunction following closed head injury: A controlled cross-sectional follow-up study. Journal of Clinical Experimental Neuropsychology, 15, 503-515.

Hart, T., Giovannetti, T., Montgomery, M. W., & Schwartz, M. F. (1998). Awareness of errors in naturalistic action after traumatic brain injury. Journal of head trauma rehabilitation, 13(5), 16-28.

Lam, C. S., McMahon, B. T., Priddy, P. A., Gehred-Schultz, A. (1988). Deficit awareness and treatment performance among traumatic head injured adults. Brain Injury, 2, 235-242.

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Prigatano, G. P. (1991). Disturbance of self-awareness of deficit after traumatic brain injury. In: Prigatano, G. P., Schachter, D. L., eds. Awareness of Deficit After Brain Injury. New York, NY: Oxford University Press.

Prigatano, G. P., Klonoff, P. S., O’Brien, K. P., Altman, I. M., Amin, K., Chiapello, D., Shepard, J., Cunningham, M., & Mora, M. (1994). Prductivity after neuropsychologically oriented milieu rehabilitation. Journal of Head Trauma Rehabilitation, 9(1), 91-102.

Prigatano, G. P. (1996). Behavioral limitations TBI patients tend to underestimate: A replication and extension to patients with lateralized cerebral dysfunction. Clinical Neuropsychology, 10, 191-201.

Prigatano, G. P. (1999). Principles of Neuropsychological Rehabilitation. New York, NY: Oxford University Press.

Ranseen, J. D., Bohaska, L. A., & Schmitt, F. A. (1990). An investigation of anosagnosia following traumatic head injury. International Journal of Neuropsychology, 12, 29-36.

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Response Bias Following ABI

Michael F. Martelli, PhD, Nathan D. Zasler, MD and Treven C. Pickett, ABD

Concussion Care Centre of Virginia, Pinnacle Rehabilitation and Tree of Life

Richmond-Glen Allen, Virginia

Medical College of Virginia and Virginia Commonwealth University

Abstract

With regard to neuropsychological assessment, response bias represents an especially important threat to validity. Neuropsychological assessment usually begins with interview about self-reported symptoms and subsequently relies heavily on standardized measures of performance on well-normed tests. Hence, its validity and utility requires the veracity, cooperation and motivation of the examinee for obtaining valid performance measures. Increasing evidence, however, clearly demonstrates that self-reported symptoms associated with neuropsychological deficits can be unreliable and non-descriminatory (e.g., Lees-Haley, Williams, Zasler and Margulies, in press). This is especially true with post-concussive deficits since these symptoms often appear with similar frequency in both non neurologic groups and even the general population (Lees-Haley and Brown, 1993). Further, the demonstrated ability of neuropsychologists to accurately detect malingering in test protocols has been less than impressive (e.g., Loring, 1995). Additionally, the common utilization of technicians to administer tests has been called into question in the 1996 Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology for reasons that include concerns about the adequacy to utilize behavioral observation information and appreciate qualitative aspects of test performance to maximize testing utility; detection and management of testing response bias issues are at least implied. Nonetheless, various instruments, techniques and strategies are available which have demonstrated at least some utility in detecting response bias, especially malingering, as a means of increasing confidence in motivation and effort during neuropsychological tests, and hence the validity of performance findings.

Importantly, examinee expectancy in independent examinations is a relevant topic that has been underappreciated with regard to effect on behavior during neuropsychological examinations. The first +author gathered survey data to evaluate examinee expectation against the backdrop of an adversarial legal and health system. Attitudinal data from professionals who work with injured Workers Compensation (WC) patients was collected. A summary of the preliminary data are quite compelling. Overall, approximately 25% of WC patients are believed to be exaggerating or malingering, which suggests a general skepticism and distrust faced by injured persons during evaluations. In contrast, the majority of professionals filling out the survey believed they would be treated unfairly by the WC system if they were injured, suggesting the corrolary of a general skepticism and perhaps greater distrust of the extant systems that evaluate and treat injury and disability.Although preliminary and from small samples, and although generalizability across situations cannot be assumed, these data seem nonetheless compatible with the levels of diffuse distrust observed by the authors in medicolegal situations. These data highlight the importance of considering the presumably different set of motivational factors that operate on examinees who present to independent evaluations. They also argue strongly for assessment of response bias during medicolegal examinations. Finally, the suggest that consideration should be given to thorough preparation of examinees prior to the examination in order to reduce response bias.

Finally, in the case of most neuropsychological evaluations, additional medical examinations are also conducted. Although many medical tests are considered objective, and hence less prone to motivation or effort effects, the fact remains that significant portions of most medical examinations still rely on examinee complaints and history as well as physical exam procedures that are susceptible to response bias.

A multiaxial conceptual model and associated procedure for completing a profile of motivation and response bias which incorporates a wide array of findings from common instruments during ABI evaluation, including multiple medical fields as well as neuropsychology. Finally, explicit and comprehensive recommendations for enhancing motivation, assessing response bias, and increasing efficiency, utility and ecological validity of ABI assessment are offered.

In the included table, an illustrative summary of some specific response bias detection strategies is presented, in an integrated format. Importantly, these strategies are presented as illustrations of indicators of important information for interpreting neuropsychological test data within a larger context of multidisciplinary evaluation for ABI. This approach integrates contextual information, history, behavioral observation, interview data, collaborative data, personality data, with measures of effort or performance (or symptom exaggeration or malingering) and neuropsychological and medical examination performance data. This approach potentially offers increased reliability with regard to estimating the degree to which an examinee is exerting full effort or withholding or distorting effort or performance, and the degree to which specific and general test results from multiple assessment areas are reliable and valid and reflect true abilities.

This multiaxial conceptual model is presented with a methodology and procedural instrument for completing a profile of motivation and response bias which incorporates a wide array of findings from common instruments during ABI evaluation. Empirical support exists indicating that each of these indicators has some utility in detecting suboptimal effort. Examining the pitfalls and limitations of each of these procedures, both conceptual and methodological, is well beyond the scope of this poster. However, increasing evidence exists for improved discrimination and increased reliability when multiple measures are employed. The conceptual approach offered by the proposed Motivation Assessment Profiling (MAPing) is one where behavioral observation, interview, collaborative, historical and personality and contextual data with neuropsychological and medical performance data and measures of effort or performance (or response bias) are integrated as an optimal method for estimating the degree of effort or performance and the degree to which test results are reliable and valid and reflect actual abilities. This conceptual model and a procedure (MAP) for estimating motivation economically incorporates currently available instruments and methods and, and the available published research, for direct and indirect measurement of motivation and response bias.

Notably, these strategies are not offered individually and are not intended to support a simple dualistic model that assumes examinees either try hard or malinger, or that evidence of less than full effort on any one test necessarily implies absence of impairment in other areas of testing or in real world abilities. Although they are also not offered with specific guidelines (e.g., failure on any one, or any two, or any three, etc., represents inadequate performance, or symptom exaggeration or malingering), they are offered with the suggestion that:

• a) test performance can be influenced by multiple factors that include desire to perform with full effort; b) the degree of effort exerted on testing exists on a continuum (versus a dichotomy) and can be estimated by the /extent to which indicators of poor effort are present or absent;
• c) reliability and validity of neuropsychological and neuromedical examination findings is dependent on relative assurances of full test effort; and
• d) interpretation and diagnostic inferences and impressions are dependent upon reliable and valid test results.

Notably, a significant disparity exists between the adversarial legal process and responsibility of attorneys as client advocates versus the more dispassionate and objective scientific ethics expected of psychologists and physicians, especially in the independent examiner role. The danger of attorney "coaching" based on utilization of this material cannot be underestimated. This, of course, would then represent a form of "stealth" threat to the validity of examination data. This threat, or expected consequence of collision between the disparate legal and scientific ethics, has recently been documented in a national publication, noting a case of attorney client coaching (Youngjohn, 1996). However, compared to simpler models where only a couple of isolated response bias measures are used, it seems extremely unlikely that the multiple measures employed in the MAP approach could be understood and manipulated.

Finally, enhancing response bias detection as a means of optimizing interpretability of neuropsychological test and neuromedical examination results, critical as it is, should not be considered the final step. Decreasing response bias must certainly be considered a more efficacious and economic approach to enhancing utility of neuropsychological and neuromedical assessment.

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Presentation at the National Academy of Neuropsychology

Annual Meeting, Orlando, FL 2000

• 80% effective in more than 1000 children
• Average increase in grade level on standardized tests is 2.5 years
• Typical increase in IQ test scores of 8-19 points
• Average Grade Point Average improves 1.5 levels (C to B+)
• Neurofeedback Helps Adults With Problems Paying Attention, Standard scores on 104 Tests of Variables of Attention were improved after 20 sessions:

THATCHER QEEG MILD TBI ASSESSMENT PROCEDURE

• Discriminant Analysis for Mechanical Head Injury and Diffuse Axonal Injury for mild TBI population - As many as 50% of subtle injuries are not picked up through neuropsychological testing (Posthuma, 1988).
• Thatcher Procedure: QEEG digitized signal:
• Two Z scores comparing patient’s EEG with reference database, with anatomical location pattern, and correlated clinical history and presentation. Pathology is assumed.
• Multi-variant regression analysis for discrimination for mechanical head injury and, in part, diffuse axonal injury (identifies pattern of pathology EEG power spectral analysis on 608 mild head trauma patients and108 age matched normal subjects)
• Three neurophysiologic abnormalities: variables.
• Increased coherence and decreased phase in the frontal and frontal-temporal regions
• Decreased power differences between anterior and posterior cortical re-ions, and
• Reduced alpha power in posterior cortical regions

• Inhibit Theta & Enhance Beta - 12 sessions to enhance SMR (12-15 Hz), while suppressing theta (4-7 Hz).
• 19 sessions of beta (15-18 Hz) enhancement while suppressing theta.
• Cz scalp location used as active lead with linked both ear reference with forehead ground
• Findings often seen in sensory motor strip, but training is at most prominent damage site, & where neuroanatomy fits the deficits.
• Most TBI treatment approaches share element of reduction or inhibition of 4-7 hertz theta.
• Based on typically observed abnormal TBI patterns: high amplitudes in the slow wave frequencies and relatively low amplitudes in faster frequencies
• Compare QEEG with reference database of Thatcher (1989).
• Train the patient to enhance the EEG frequency band in the 12-20 Hz range, while
• Suppressing slower frequency 4-8Hz band.
• Permanent "normalization" of the’ EEG pattern is reported.

• Monitors and analyzes EEG signals for Abnormality
• EEG information guides feedback (photic / Electromagnetic stimulation or entrainment)
• Feedback changes the EEG pattern
• Disrupts the EEG activity that is entrained on dysfunction.
• Typically results is lower amplitude slow waves, and more flexible functioning
• Shift in amplitude is accompanied by a reduction of symptoms
• NIH studies for TBI, Fibromyalgia Traumatic Brain Injury patients have been seen to easily recover ability to take in information, improve in short-term memory, organization, sequencing, prioritizing, sensory discrimination, initiation, confidence, assertiveness, and sense of humor. Depression, irritability, and explosiveness
• Mean treatment time of 6-20 sessions
• As with All Neurofeedback, non-invasive, non-pharmacological, and non-psychotherapeutic
• Effects have persisted at three year follow up

• Combat - Related PTSD - Vietnam Vets
• 80% success at 26 months follow-up
• Medical Psychotherapy 1991, Volume 4, pp.47-60

• Enhance (12-15 Hz) around C3 at sensorimotor cortex
• Use C3 irrespective of any seizure focus elsewhere on the cortex, nature of the seizure
• Training has been effective (60% reduction in intractible cases).

• Train by placing the electrodes at C-3 and C-4 (standard 10/20 chart of the human head) which are 1/3 of the way up from the left ear (C-3) and 1/3 of the way up from the right ear (C-4). The ground may go anywhere.
• Train 10-16 Hz, 11-15, 12-14, to increase amplitude - the "Reward".
• Train 2-7 Hz to decrease amplitude - the "Inhibit".
• "Inhibit" is a misnomer - instrument is inhibited to not signal "success" if the amplitude is high in 2-7 (typically). Do not tell brain it is successful if making high amplitude in 2-7 Hz.
• Same Training reportedly works on almost all EEG abnormalities
• Lots of individual case study support, including many year post severe TBI
• Published data of 200+ felons by D. Quirk showing 15 -20% (vs. 65 - 5%) Recidivism for EEG - SMR Treated (vs. Matched Controls)
• Unpublished data from 1000+ felons with similar results
• Claim No evidence of any harm to humans or animals by EEG biofeedback

• Depression (current & remitted) associated with CZ-Referenced Frontal Asymmetry
• Left Frontal Hypoactivation (high Left Frontal Alpha (Low Beta) vs. Low Right Frontal Alpha (High Beta)).
• Training: Reverse EEG Asymmetry
• Initial relaxation training for 15-30 min: diaphragmatic breathing & fingertip temperature warming
• EEG Biofeedback sessions X 2/week:
• 50% biofeedback; 50% psychotherapy
• F3 and F4 referenced to Cz: A(symmetry) Score = (F4-F3)/(F4+F3).
• Tonal feedback when A > 0. 30 - 60 sessions
• Numerous Replications Showing Clinical Efficacy
• Some question of Phase vs. Amplitude asymmetry

• CAPACITY FOR LOW AMPLITUDE IS FUNDAMENTAL TO OPTIMAL FUNCTION
• At any given time, the EEG signal is receiving contributions from cells involved in any of the following:
• Rest
• Excitatory postsynaptic potential
• Inhibitory postsynaptic potential
• Action potential
• Oscillations of EEG generally reflect pools of neurons acting in synchrony. The larger the pooling, the greater the "amplitude"
• Neurons active in pools are less available for other activity. Less pooling means greater availability for action.
• Optimally functioning brain is characterized by to quickly and efficiently pool neurons to organize a specific task, then release when no longer needed, maintaining optimal availability to respond to new demand / stimuli.
• Many "disorders" can be characterized by stereotypical response to demands, possibly reflected in the EEG as persistent dominant and/or high amplitude frequencies.
• Brains ability to disengage the pooling mechanisms and leave neurons available for activation is fundamental to cortical flexibility

• EQUIPMENT SETUP:
• Biocomp 2010, Linked ear reference.
• One channel per hemisphere, using "Wide" (4-32Hz analog filters), adding channels for single feedback from combined
• Lexicor NRS-2D
• Digital Filters  set a 3.0 to 32 Hz. band (also 0.5-32 Hz.)
• LCC montage
• Opposite ear reference
• One channel for each hemisphere to opposite ear, with feedback from "TWO" (a 50% weighting from each channel)

PEAK ACHIEVEMENT TRAINING FOR CONCENTRATION AND NEW LEARNING (J.Cowan)

• Based on Air Force and NASA Research Showing a Concentration and Relaxation Cycle
• Sterman’s EEG studies of Air Force pilots in B2 simulators: Focus on aviation task = alpha suppression, particularly midline central & parietal. Task /focus ending = alpha burst, and then suppression as next task began.
• More difficult tasks = greater the alpha suppression. Alpha burst between tasks. Better pilots needed shorter alpha/rest before focusing again

• Even best-trained brain cannot concentrate forever.
• Consistent, intense concentration has its costs in stress, emotional tension, and disease.
• Healthy individual cycles between concentration and relaxation by focussing on (part of) a task until it is done, and then taking a brief rest.
• There are also cycles within each task.

• Thalamus tells cortex to turn off / save energy (blood flow). Cortex then turns off cortical-cortical processing. Through effort or interest, we can overcome idling rhythms and focus.

• This network directs the sequence of activation of other areas by priming them, initially by cortical-cortical connections w/o rhythmic EEG.
• Activating it will enhance the ability to attend to and learn new material.
• It is activated by drive states from the mammillary bodies in the hypothalamus, which cause us to concentrate on tasks that are important.

• Many people have trouble shifting between concentrating and taking brief, relaxing microbreaks:
• Microbreaks periodically to recharge the brain and release stress
• Some don’t know how to relax
• Some don’t remember to relax frequently enough
• Many people can’t adjust their degree of focus to be appropriate to the task.

Training Concentration - Relaxation Cycle: Relaxation II via breathing as cue for relaxed microbreaks

• Alternate short periods of concentration and microbreaks. Home practice

• Identify concentration- microbreak in the particular task or sport. Train to focus and relax in a similar sequence. Introduce elements of the task during EEG training. Train to perform the sequence despite realistic distraction

• Ayres, M (1987). Electroencelphalographic neurofeedback and closed head injury of 250 individuals. In National Head Injury Syllabus, Head Injury Frontiers. National Head Injury Foundation Annual Conference, Los Angeles.
• Ayres, M (1991). A controlled study of EEG neurofeedback training and clinical psychotherapy for right hemispheric closed head injury. Paper presented at the annual meeting of the National Head Injury Foundation, Los Angeles.
• Bruner, R (1989). Treatment of post-concussion syndrome with alpha EEG biofeedback training: tree case studies. Paper presented at the Pennsylvania Society of Behavioral Medicine and Biofeedback, King of Prussia, Pa.
• Byers, AP (1995). Neurofeedback for a mild head injury. Journal of Neurotherapy, 1(1), 22-37.
• Forscher, W, Birbaumer,N. (1977). Self-Regulation of slow cortical potentials in epilepsy - a retrial with analysis of influencing factors. Epilepsy Research. 25(3):269-276, Nov.
• Hoffman, DA, Stockdale, S, Hicks, LL and Schwaninger, BA (1995). Diagnosis and Treatment of Head Injury. Journal of Neurotherapy, 1(1), 14-21.
• Kotchoubey, B., Schneider D.,Schleichert, H., Strehl, U. Uhlmann, C., Blankenhorn, V.,
• Lantz, D and Sterman, B (1988). Neuropsychological assessment of subjects with uncontrolled epilepsy: Effects of EEG feedback training. Epilepsia, 29(2), 163-171.
• Lubar, J (1991). Discourse on the development of EEG diagnostics and biofeedback for attention-deficit/ hyperactivity disorders. Biofeedback and Self Regulation, 16, 201-222.
• Rumpl, E (1993). Craniocerebral trauma. In F. Niedermeyer, L Da Silva (Eds.), Electroencephalography, pp 383-403. Baltimore: Williams & Wilkins.
• Salerno, J. (1996). Multiple case study of neurofeedback in closed head injury. Doctoral Dissertation, Saybrook Institute.
• Thatcher, RW, Walker, RA, Gerson, I & Geisler, FH (1989). EEG discriminant analyses of mild head trauma. Electroencephalography and Clinical Neurophysiology, 73, 94-106.

• Lubar, J.F., "Discourse on the Development of EEG Diagnostics and Biofeedback for Attention-Deficit/Hyperactivity Disorders." Biofeedback and Self-Regulation, 16(3), 1991: 201-225.
• Lubar, J.F., Bianchini, K.J., Calhoun, W.H., Lambert, E.W., Brody, Z.H., and H.S. Shabsin, "Spectral Analysis of EEG Differences Between Children With and Without Learning Disabilities." Journal of Learning Disabilities, 18(7), 1985: 403-408.
• Lubar, J.O., and and J.F. Lubar, "Electroencephalographic Biofeedback of SMR and Beta for Treatment of Attention Deficit Disorders in a Clinical Setting, Biofeedback and Self-Regulation, 9(1), 1984: 1-23.
• Lubar, J.F., Mann, C.A., Gross, D.M., and M.S. Shively, "Differences in Semantic Event-Related Potentials in Learning-Disabled, Normal, and Gifted Children." Biofeedback and Self-Regulation, 17(1), 1992: 41-57.
• Lubar, J.F., and M.N. Shouse, "EEG and Behavioral Changes in a Hyperkinetic Child Concurrent with Training of the Sensorimotor Rhythm (SMR)," Biofeedback and Self-Regulation, 1(3), 1976: 293-306.
• Lubar, J.F., Swartwood, M.O., Swartwood, J.N, and P.H. O’Donnel, "Evaluation of the Effectiveness of EEG Neurofeedback Training or ADHD in a Clinical Setting as Measured by Changes in T.O.V.A. Scores, Behavioral Ratings, and WISC-R Performance." Biofeedback and Self-Regulation, 20(1), 1995: 83-99.
• Mann, C.A., Lubar, J.F., Zimmerman, A.W., Miller, C.A., and R.A. Muenchen, "Quantitative Analysis of EEG in Boys with Attention-deficit-hyperactivity Disorder: Controlled Study with Clinical Implications," Pediatric Neurology, 8(1), 1992: 30-36.
• References on EEG Biofeedback & Epilepsy
• Cabral, R.J., and D.F. Scott, "Effects of two desensitization techniques, biofeedback and relaxation, on intractable epilepsy: follow-up study," Jour. Neurology, Neurosurg., and Psychiatry 39(1976) 504-507.
• Chase, M.H., and R.M. Harper, "Somatomotor and Visceromotor Correlates of Operantly Conditioned 12-14 c/sec Sensorimotor Cortical Activity," Electroenceph. Clin. Neurophysiol., 31(1971), 85-92.
• Finley, W.W., "Effects of Sham Feedback following Successful SMR Training in an Epileptic Follow-Up Study," Biofeedback and Self-Regulation 1:2(1976) 227-235.
• Finley, W.W., Smith H.A., and M.D. Etherton, "Reduction of Seizures and Normalization of the EEG in a Sever Epileptic following Sensorimotor Biofeedback Training: Preliminary Study," Biological Psychology, 2(1975) 189-203.
• Lantz D., and M.B. Sterman, "Neuropsychological Assessment of Subjects with Uncontrolled Epilepsy: Effects of EEG Feedback Training," Epilepsia 29:2(1988) 163-171.
• Lubar, J.F. and W.W. Bahler, "Behavioral Management of Epileptic Seizures Following EEG Biofeedback Training of the Sensorimotor Rhythm," Biofeedback and Self-Regulation, 1:1(1976) 77-104.
• Lubar, J.F., Shabsin, H.S., Natelson, S.E., Holder, G.S., Whitsett, S.F., Pamplin, W.E., and D.I. Krulikowski, "EEG Operant Conditioning in Intractable Epileptics," Arch Neurol 38 (1981) 700-704.
• Sterman, M.B., "Physiological Origins and Functional Correlates of EEG Rhythmic ACtivities: Implications for Self-regulation,"
• Sterman, M.B., Macdonald, L.R., adn R.K. Stone, "Biofeedback Training of the Sensorimotor Electroencephalogram Rhythm in Man: Effects on Epilepsy," Epilepsia, 15(1974) 395-416.
• Sterman, M.B., Mann, C.A., Kaiser, D.A., and B.Y Suyenobu, "Multiband topographic EEG analysis of a simulated visuomoter aviation task," Int’l Jour. of Psychophysiology, 16(1994) 49-56.
• References, Michael Tansey’s work
• Tansey, Michael A. 1982. EEG sensorimotor biofeedback training and the treatmentof a six-year-old asthmatic child. American Journal of Clinical Biofeedback, , 5,145-149.
• Tansey, Michael A. & Bruner, Richard, L. 1983. EMG and EEG biofeedback trainingin thetreatment of a 10-year old hyperactive boy with a developmental readingdisorder. Biofeedback and Self-Regulation, 8, 25-37.
• Tansey, Michael A. 1984. EEG sensorimotor rhythm biofeedback training: Someeffects on the neurologic precursors of learning disabilities. InternationalJournal of Psychophysiology, 1,163-177.
• Tansey, Michael A. 1985. Brainwave signatures - An index reflective of the brain’sfunctional neuroanatomy: Further findings on the effect of EEG sensorimotorrhythm biofeedback training on the neurologic precursors of learningdisabilities.International Journal of Psychophysiology, 3, 85-89.
• Tansey, Michael A. 1985. The response of a case of petit mal epilepsy to EEG sensorimotor rhythm biofeedback training. International Journal ofPsychophysiology, 3, 81-84.
• Tansey, Michael A. 1986. A simple and a complex tic (Giles de la Tourette’sSyndrome):Their response to EEG sensorimotor rhythm biofeedbacktraining. InternationalJournal of Psychophysiology, 4, 91-97.
• Tansey, Michael A. 1990. Righting the rhythms of reason: EEG biofeedback trainingas a therapeutic modality in a clinical office setting. Medical Psychotherapy -An International Journal, 3, 57-68.
• Tansey, Michael A. 1990. EEG for a better BP. Biofeedback, 18, 25-28.
• Tansey, Michael A. 1991. Wechsler (WISC-R) changes following treatment of learningdisabilities via EEG biofeedback training in a private practice setting.Australian Journal of Psychology, 43,147-153.
• Tansey, Michael A. 1991b. A neurobiological treatment for migraine: The Response of four cases of migraine to EEG biofeedback training. Headache Quarterly:Current Treatment and Research, 90-96.
• Tansey, Michael A. 1993a. Ten year stability of EEG biofeedback results for a hyperactive boy who failed fourth grade perceptually impaired class.Biofeedback and Self-Regulation, 18, 33-44.
• Tansey, Michael A. 1993b. Neurofeedback and Chronic Fatigue Syndrome: Newfindings with respect to Diagnosis and treatment. The CFIDS Chronicle, 9, 30-32.
• Tansey, M. A., Tansey, J.A. & Tachiki, K. 1994a. Electroencephalographic Cartography of Conscious States. International Journal of Neuroscience. 77,89-98.
• Tansey, M. A. , Tachiki, K. & Tansey, J.A. 1994c . Cartography of Conscious States:A functional re-examination of theta, alpha, and Beta. Subtle Energies, 4, 135-150.
• Nahmias, J., Tansey, M.A., & Karetzky, M 1994b. The syndrome of asthmaticextrathroacic upper airway obstruction: Laryngeal dyskinesis, New JerseyMedicine, 91, 616-620..
• Tansey, M. A. 1994c. Boundary Conditions: The Surrounds of a State of Mind. Subtle Energies, 5, 180-194.