I found out today that Amazon is now taking pre-orders on a book for which I wrote a chapter. My aim in the chapter to to look at each patient as a whole person who needs to functions well as possible in our society. I present a number of case studies to show how this is applied. In an ideal world, I would like to see all doctors and medical health providers follow similar approaches. In the long run I think we could decrease health care costs and increase satisfaction with health care delivery.
Author Archives: Doreen E McMahon, MD
Concussions and mental health
The Washington Post had an interesting article yesterday that nicely sums up some of the difficulties that those with head injuries can experience.
http://www.washingtonpost.com/sports/concussions-and-depression-questions-renewed-over-whether-theres-a-link/2014/12/06/1bbc8c3c-7c8e-11e4-8241-8cc0a3670239_story.html
Neurofeedback is a great way to treat concussions and other head injuries. It can begin as soon as the patient is medically stable enough to receive treatment. Of course, prevention is the best way to approach head injury, but once it has happened, neurofeedback usually provides an important element of rehabilitation and return to pre-injury function.
Causes of Depression
A couple of articles caught my eye over the last couple of days. The first one, http://mic.com/articles/104096/there-s-a-suicide-epidemic-in-utah-and-one-neuroscientist-thinks-he-knows-why?utm_source=Mic+Check&utm_campaign=02a28d3a4c-Mic_Report_11_17_2014&utm_medium=email&utm_term=0_51f2320b33-02a28d3a4c-285454177&mc_cid=02a28d3a4c&mc_eid=9a4e021687, looks at the correlation of living at high altitude and increased rate of suicide. This particular researcher seems to think that it all comes down to changes in the metabolism of the neurotransmitter, serotonin.
I would counter that this is an oversimplification of a complex issue. It like saying cancer has a single cause when the evidence is quite well established that most cancers are caused by a complex interaction between the individual’s genome and environmental influences.
So while high altitude needs to be examined as a risk factor for committing suicide, other contributing factors must be examined. We already know that high altitude results in a change in oxygen and carbon dioxide levels in the human body. This, in turn, changes the acid/base balance or pH of the body. Since many physiological processes are dependent on a narrow range of pH, it affects how the body operates and the person feels. Altitude sickness is a well known short to medium term manifestation of this. Might mood alterations be another?
The last few paragraphs of the article mention other possible causative factors to the suicide problem in Utah. Certainly these are important when assessing the situation and at risk individuals.
The other article, http://www.nature.com/nature/journal/vaop/ncurrent/full/nature13976.html, discusses the protein, beta-catenin, which seems to act as a factor in depression, anxiety, and resiliency of emotions. Once again, I think it would be short-sighted to think that some sort of beta-catenin therapy would solve the problems caused by anxiety or depression.
EEG neurofeedback is agnostic to these issues. It works by appealing to better function of brain systems by guiding the electrical activity of the brain. While it is true that a brain under extreme duress from physiological or environmental insults would have difficulties responding to neurofeedback, it has great utility for most cases of depression. Neurofeedback conveys an ability to treat something as complex as depression without having to know all the details of how that depression has come about.
It would be lovely if we could identify all the potential causes of depression and fix them. Until then we have the potentially powerful tool of EEG neurofeedback.
Environmental Factors Influence Brain Function
There is some more experimental validation for those who feel that adverse factors in their environment are affecting their brain function. This study on mice, https://www.sciencenews.org/article/mold-may-mean-bad-news-brain, found slowing of new cell growth in the hippocampus (memory center) in mice exposed regularly to the toxic mold Stachybotrys. The mice were observed to have increased anxiety and decreased memory function. I have witnessed these symptoms in people who have been exposed to environmental mold, and I believe that these experimental results can be extrapolated to humans.
The simple, but time-consuming, step of getting a good environmental exposure history is essential for those who suffer symptoms beyond the usual and do not seem to respond to conventional treatments.
Neurofeedback and Schizophrenia
National Public Radio (npr) has done an interesting story on brain training as a way to control symptoms of schizophrenia.
http://www.npr.org/blogs/health/2014/11/03/359655855/a-new-way-of-thinking-about-schizophrenia-could-lead-to-new-treatments?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=202503
Neurofeedback has been a successful type of brain training for the salience issue for those with schizophrenia. Often medication dosage can be lowered in those being treated with neurofeedback.
The future of Neurofeedback?
This is a very interesting video on the Wall Street Journal Website. Someday we may be doing neurofeedback like this!
http://www.wsj.com/video/take-a-virtual-tour-of-a-wsj-columnist-brain/CB75AA89-4E10-4F83-970C-7BB142F9DE2B.html
Deep Brain Stimulation
Scientific American has posted a guest blog on their MIND feature from psychiatrist Don Malone of the Cleveland Clinic. He has been involved with research on Deep Brain Stimulation (DBS) for a number of brain conditions including obsessive-compulsive disorder and depression. Here is his article:
http://blogs.scientificamerican.com/mind-guest-blog/2014/10/28/a-miracle-technology-can-lift-severe-depressionbut-real-recovery-has-only-just-begun/
My first reaction to this article was, “Why have the patients he describes received trials of medication, counseling, electro-convulsive therapy (ECT), and other treatment modalities, but not EEG neurotherapy before undergoing as drastic and invasive a procedure as DBS.” DBS involves introducing a foreign object, a wire, into the brain. It needs to be connected with the electronic stimulator. This has the potential to be a major cause of complications just as any time the integrity of the body is breached. On top of all this, it seems to work well in only about 50% of those who undergo the procedure and it is very expensive to set up and maintain.
EEG neurofeedback significantly helps around 80% of those who undergo neurotherapy for depression and OCD. It is non-invasive and usually costs considerably less than 1/10th of initial DBS. Few patients need follow up neurofeedback sessions to maintain their functional gains. Wouldn’t this be a much more productive way to spend our healthcare dollars? Those who seem to be good candidates for DBS after a fair trial of EEG neurofeedback could then be referred on for the procedure.
Secondly, I agree with the main premise of his blog. While a few people seem to grab better brain function and soar with it, others need to be coached and counseled into using their brains in ways that they have never know or realized possible. This is a learning process and like any learning process takes time, effort and persistence. Brain health needs to be supported by excellent health habits such as diet, exercise, sleep, appropriate brain challenges, good mental health support, and minimizing stress. Quick and easy fixes are rare.
The Evolution of Memory
Today’s Washington Post had an interesting interview of Michael Kahana of the University of Pennsylvania. He is working with the US military to develop an implantable device that will help those with memory disorders. However, his bottom line is that those of us with more-or-less normal brains need to go through the tedious task of practice to learn any skill in which we wish to be proficient. The practice is skill specific. So practicing mental exercises on the computer seems to improve one’s skills in those mental exercises. I know that my skills in crosswords and sudoku have improved remarkable in the years that I have enjoyed doing them, but it does not seem to help my ability to remember people’s names.
He implies that the converse, not practicing skills may promote losing the ability to do those skills, is also true. There is a discussion on relying on electronic devices as our memories. I believe in a compromise. Continue to keep up a regular intellectual tasks through a variety of exposures. However, since knowledge increases in such a spectacular way, knowing how to look something up on your electronic device is a wonderful way to further explore new intellectual and cognitive challenges.
http://www.washingtonpost.com/national/health-science/study-set-for-brain-stimulation-device-to-help-restore-memory/2014/10/24/c8cada24-4583-11e4-b437-1a7368204804_story.html
Neurofeedback seems to be a good way to put the brain through a series of challenges to remediate or improve memory abilities. It’s utility in helping recovery from traumatic brain injury is well documented. Evidence that it can help stabilize deterioration in dementia has also been described. However, I agree with Professor Kahana that specific practice in the tasks that we wish our brain to perform must be part of any memory improvement scheme. After all, how many people do you know who learned how to speak Chinese by learning to ride a bicycle?
Neurofeedback for Traumatic Brain Injury
There are approximately 1.7 million traumatic brain injuries (TBI) in the US annually. Automobile accidents and falls account for the majority of these injuries. Recently, awareness of TBI is rising because of the need for rehabilitation of some 200,000 Americans who suffered head injuries in recent military conflicts and the publicity surrounding both acute and chronic head injuries in the National Football League.
Catastrophic head injuries are easily identified, but closed head injuries are often quite subtle. Part of the problem with diagnosing brain injury is the limitation of our imaging techniques. Conventional studies such as CT scanning and MRI may not be sensitive to the microscopic level of disruption of brain anatomy. Functional imaging techniques, such as fMRI, SPECT scanning, and PET scanning, are also limited since we are able to see only static “snapshots” of brain function, and scan readings are open to interpretation.
Even when structural disruptions of the brain are demonstrated, functional symptoms often do not closely correspond with known neuroanatomy. In fact, many symptoms of TBI, such as headache, dizziness, fatigue, cognitive deficits, anxiety, depression, irritability, mood swings, memory impairment, sleep disturbances, attention issues, and personality changes, are considered generalized and cannot be localized to a specific area of the brain.
In particular, headaches occur in about 70% of TBI and are still present in 40% of patients after 12 months. Interestingly, headaches are not correlated with the severity of the injury, but do correlate with past headache history and happen more often in female patients.
Because it is difficult to image changes in the brain due to TBI and symptoms may be non-specific, we need to think of many TBI injuries as disruptions on the level of neurons and neuronal circuitry. This certainly seems to be the case with the types of injuries, Post Concussion Syndrome and Chronic Toxic Encephalopathy, which have been described in NFL players. This is the area where neurofeedback can play an important role.
In animal models of brain injury, the initial healing response seems to be geared towards preservation of neurons and their axonal branches (neuron connectors). Unregulated regrowth of neurons may not restore previous connections within important functional networks. In addition, generalized metabolic activation may make it difficult for neurons to function correctly in distinguishing useful neuronal activity from background “noise”. So the patient experiences undesirable, non-specific symptoms. Unless the TBI patient can rewire their brain in beneficial ways, the ease and usefulness cognitive abilities will remain compromised.
This leads to the concept of “recovery burden”. TBI causes brain stress. It is well demonstrated that people under stress make inferior decisions that result in lessened cognitive performance. Repeating these behaviors tends to strengthen them. Thus dysfunctional patterns are reinforced. This is why rest is prescribed initially for TBI. Rest and sleep allow for brain repair without external distraction and demands.
Neurofeedback and other behavioral techniques have been demonstrated to decrease brain stress and restore functional connectivity in the brain. Othmer method neurofeedback enables brain calming by guiding the brain to lower activation states. Then once the brain is ready for gentle challenges, neurofeedback guides restoration of functional networks as an experienced clinician utilizes her skills in functional neuroanatomy to encourage coordination of brain function.
Studies using neurofeedback to enable functional recovery from TBI have been very encouraging.
Study 1: 16 patients, who were all at least 2 years post TBI, were given symptom questionnaires. All patients had been determined to be medically disabled and were no longer receiving active treatment. After regular neurofeedback treatments, all patients had at least 50% reduction in their TBI symptoms with an average of 85% reduction in symptoms. All 14 of the 16 patients who held jobs prior to their TBI were able to return to those jobs.
Study 2: 26 patients who were 3-70 months post TBI completed a course of neurofeedback. 25 of 26 patients showed an improvement of at least 50% (average improvement was 72%) on pre- to post-treatment symptom checklist.
In my practice, I have been impressed with how the combination of neurofeedback and rest has helped patients with mild-moderate TBI get back to their normal lives. The functional rehabilitation approach engendered by neurofeedback is a potentially power tool in recovery from TBI for many patients.
The Length of Neurofeedback Training
Many people are surprised by the recommendation that at least 40-60 sessions of neurofeedback are needed to obtain lasting positive changes in the brain. Are these same people surprised that it takes many hours of careful physical effort to build up a healthy, muscular physique? Would they also be shocked that it takes most people years of concentrated study to earn an advanced university degree?
I would argue that just the opposite is true—it is surprising that only 40-60 sessions of neurofeedback is adequate to achieve lasting positive changes for most people! After all, the brain is an extremely complex organ that is so intricate that we are still in the early stages of exploring its functions. Even though the 10,000 hours of practice “rule” to become truly expert at a skill has been debunked, there is no doubt that lots of high-quality and disciplined practice is necessary to acquire an ability (http://www.brainpickings.org/2014/01/22/daniel-goleman-focus-10000-hours-myth/).
Neurofeedback using the Othmer method guides the brain towards the ability of calm and well-ordered function. During each session, the patient is asked to make better and better approximations towards desired brain states. The therapist, acting as a coach or teacher, is an essential part of the process since she determines the areas of the brain to be trained, evaluates the response to training, and then adjusts the neurofeedback accordingly. The goal of neurofeedback is to create default brain functioning that is controlled and orderly.
Within an individual session of neurofeedback, the brain often shows changes in its electrical activity over seconds to minutes of effort. However, there is a marked difference between the short-termed “learning” that occurs over a session with the long-term expertise that happens with repeated sessions of neurofeedback. The brain redevelops its “physique” and functioning just like an athlete develops the proper musculoskeletal physique, muscle memory, and mental state over months to years of practice and being well coached to excellent performance. New neuron-to-neuron connections with appropriate neurotransmitters are made in response to repeated practice. As newer and better brain pathways are reinforced, old, poorly functioning pathways are weakened and pruned. Practice over extended periods of time enables these types of structural changes of the brain. Repetition of healthy brain tasks via neurofeedback complemented with excellent brain maintenance in everyday life confers long-term brain health and function. The website, http://thebrain.mcgill.ca/flash/i/i_07/i_07_p/i_07_p_tra/i_07_p_tra.html, has explanations of memory formation that describe the formation of long-term changes such as those induced via neurofeedback.
Some brain conditions such as autism can be so complex that many more sessions than the average may be required to enable improved brain performance. Some patients benefit from occasional “touch up” sessions to maintain effective brain operation.