EEG

Biofeedback

as

a

Treatment

for

Substance

Use

Disorders

Review

Rating

of

Efficacy

and

Recommendations

for

Further

Research

Electroencephalographic

-LRB-

EEG

-RRB-

biofeedback

has

been

employed

in

substance

use

disorder

-LRB-

SUD

-RRB-

over

the

last

three

decades

The

SUD

is

a

complex

series

of

disorders

with

frequent

comorbidities

and

EEG

abnormalities

of

several

types

EEG

biofeedback

has

been

employed

in

conjunction

with

other

therapies

and

may

be

useful

in

enhancing

certain

outcomes

of

therapy

Based

on

published

clinical

studies

and

employing

efficacy

criteria

adapted

by

the

Association

for

Applied

Psychophysiology

and

Biofeedback

and

the

International

Society

for

Neurofeedback

and

Research

alpha

theta

training

either

alone

for

alcoholism

or

in

combination

with

beta

training

for

stimulant

and

mixed

substance

abuse

and

combined

with

residential

treatment

programs

is

probably

efficacious

Considerations

of

further

research

design

taking

these

factors

into

account

are

discussed

and

descriptions

of

contemporary

research

are

given

Introduction

Substance

use

disorders

-LRB-

SUD

-RRB-

include

disorders

related

to

the

taking

of

a

drug

of

abuse

-LRB-

including

alcohol

-RRB-

and

represent

the

most

common

psychiatric

conditions

-LRB-

APA

-RRB-

resulting

in

serious

impairments

in

cognition

and

behavior

Acute

and

chronic

drug

abuse

results

in

significant

alteration

of

the

brain

activity

detectable

with

quantitative

electroencephalography

-LRB-

qEEG

-RRB-

methods

The

treatment

of

addictive

disorders

by

electroencephalographic

-LRB-

EEG

-RRB-

biofeedback

-LRB-

or

neurofeedback

as

it

is

often

called

-RRB-

was

first

popularized

by

the

work

of

Eugene

Peniston

-LRB-

Peniston

and

Kulkosky

-RRB-

and

became

popularly

known

as

the

Peniston

Protocol

This

approach

employed

independent

auditory

feedback

of

two

slow

brain

wave

frequencies

alpha

-LRB-

Hz

-RRB-

and

theta

-LRB-

Hz

-RRB-

in

an

eyes

closed

condition

to

produce

a

hypnagogic

state

The

patient

was

taught

prior

to

neurofeedback

to

use

what

amounts

to

success

imagery

-LRB-

beingsober

refusing

offers

of

alcohol

living

confidently

and

happy

-RRB-

as

they

drifted

down

into

an

alpha-theta

state

Repeated

sessions

reportedly

resulted

in

long-term

abstinence

and

changes

in

personality

testing

Because

the

method

seemed

to

work

well

for

alcoholics

it

has

been

tried

in

subjects

with

cannabis

dependence

and

stimulant

dependence

but

with

limited

success

until

the

work

of

Scott

and

Kaiser

-LRB-

Scott

and

Kaiser

Scott

et

al.

-RRB-

They

described

treating

stimulant

abusing

subjects

with

attention-deficit

type

EEG

biofeedback

protocols

followed

by

the

Peniston

Protocol

with

substantial

improvement

in

program

retention

and

long-term

abstinence

rates

This

approach

has

become

known

widely

as

the

Scott

Kaiser

modification

-LRB-

of

the

Peniston

Protocol

-RRB-

This

white

paper

on

EEG

biofeedback

for

SUD

will

offer

an

assessment

of

efficacy

according

to

the

guidelines

jointly

established

by

the

Association

for

Applied

Psychophysiology

and

Biofeedback

-LRB-

AAPB

-RRB-

and

the

International

Society

for

Neurofeedback

and

Research

-LRB-

ISNR

-RRB-

Assessing

the

efficacy

of

neurofeedback

for

SUD

involves

several

considerations

The

first

of

these

involves

difficulties

assessing

the

efficacy

of

any

treatment

method

for

SUD

Outcome

benchmarks

-LRB-

i.e.

total

abstinence

improved

function

and

quality

of

life

-RRB-

and

time

points

of

outcome

-LRB-

i.e.

one

year

two

years

post

treatment

-RRB-

are

not

clearly

established

Outcome

assessment

for

treatment

of

SUD

in

itself

is

a

complex

topic

well

beyond

the

scope

of

this

article

Because

different

drugs

of

abuse

are

associated

with

different

patterns

of

EEG

abnormality

as

will

be

discussed

in

detail

in

this

article

it

is

difficult

to

assign

broad-brush

EEG

biofeedback

solutions

to

SUD

as

a

whole

Any

statements

of

efficacy

will

need

to

describe

specific

EEG

biofeedback

protocols

for

specific

substances

of

abuse

Furthermore

substance

abuse

is

often

mixed

substance

type

and

comorbid

conditions

are

common

and

vary

from

subject

to

subject

as

will

also

be

borne

out

in

this

article

As

of

yet

there

are

no

gold

standard

medication

or

other

treatments

for

the

various

types

of

SUD

and

efficacy

of

any

SUD

treatment

method

likely

falls

into

the

possibly

effective

to

probably

effective

range

according

to

the

efficacy

guidelines

jointly

established

by

the

AAPB

and

ISNR

Finally

all

of

the

studies

of

EEG

biofeedback

in

SUD

to

date

employ

EEG

biofeedback

as

an

add

on

to

cognitive

behavioral

or

twelve

step

treatment

regimes

so

any

statements

of

efficacy

would

have

to

acknowledge

that

EEG

biofeedback

is

not

a

stand

alone

treatment

for

SUD

This

article

is

divided

into

several

sections

In

the

first

section

after

Introduction

we

review

SUD

prevalence

and

describe

qEEG

changes

typical

for

the

most

widespread

drugs

of

abuse

-LRB-

alcohol

marijuana

heroin

cocaine

and

methamphetamine

-RRB-

The

second

section

describes

treatment

studies

employing

EEG

biofeedback

in

SUD

Studies

that

have

used

the

Peniston

Protocol

are

described

first

along

with

critical

commentaries

of

these

studies

In

the

second

part

of

this

section

a

description

of

the

Scott

Kaiser

modification

is

given

along

with

some

discussion

of

a

rationale

for

why

this

approach

may

be

more

successful

with

stimulant

abusers

This

section

also

describes

some

current

research

The

third

section

assesses

efficacy

of

the

Peniston

Protocol

and

the

Scott

Kaiser

modification

The

fourth

section

takes

a

look

at

the

clinical

implications

of

comorbidities

in

neurobiofeedback

treatment

of

alcohol

and

drug

abuse

The

fifth

section

discusses

the

clinical

implications

of

standard

cognitive-behavioral

therapies

in

SUD

treatment

and

reviews

the

rationale

for

the

application

of

qEEG-guided

neurofeedback

intervention

in

SUD

in

conjunction

with

these

therapies

The

final

section

summarizes

findings

in

qEEG

and

neurofeedback

in

SUD

and

additionally

proposes

further

directions

for

clinical

research

in

this

area

This

article

represents

an

update

of

earlier

reviews

-LRB-

Trudeau

b

-RRB-

of

EEG

biofeedback

for

addictive

disorders

extended

with

a

review

on

qEEG

in

SUD

This

review

is

presented

as

one

of

a

series

of

papers

in

both

The

Journal

of

Neurotherapy

and

The

Journal

of

Applied

Psychophysiology

Biofeedback

describing

and

reviewing

biofeedback

applications

for

adult

populations

No

attempt

will

be

made

to

review

the

fields

of

qEEG

and

neurobiofeedback

generally

-LRB-

see

current

reviews

by

Hammond

Kaiser

-RRB-

or

the

field

of

addictive

disorders

generally

although

some

references

will

be

made

to

specifics

the

authors

feel

are

pertinent

to

a

discussion

of

emerging

concepts

of

qEEG

as

a

sensitive

tool

for

the

brain

function

assessment

in

SUD

and

EEG

biofeedback

as

a

treatment

approach

for

SUD

SUD

Prevalence

and

qEEG

Changes

Drug

addiction

can

be

described

as

a

mental

disorder

with

idiosyncratic

behavioral

cognitive

and

psychosocial

features

The

SUD

commonly

referred

to

as

drug

addiction

is

characterized

by

physiological

dependence

accompanied

by

the

withdrawal

syndrome

on

discontinuance

of

the

drug

use

psychological

dependence

with

craving

the

pathological

motivational

state

that

leads

to

the

active

drug-seeking

behavior

and

tolerance

expressed

in

the

escalation

of

the

dose

needed

to

achieve

a

desired

euphoric

state

Drug

addiction

is

a

chronic

relapsing

mental

disease

that

results

from

the

prolonged

effects

of

drugs

on

the

brain

-LRB-

Dackis

and

O'Brain

Volkow

et

al.

-RRB-

Drug

addiction

can

take

control

of

the

brain

and

behavior

by

activating

and

reinforcing

behavioral

patterns

that

are

excessively

directed

to

compulsive

drug

use

-LRB-

Di

Chiara

Gerdeman

et

al.

-RRB-

From

the

classes

of

substances

listed

in

the

DSM-IV

we

will

discuss

in

our

review

only

alcohol

cannabis

-LRB-

marijuana

-RRB-

heroin

and

such

psychostimulants

as

cocaine

and

methamphetamine

Addiction

leads

to

behavioral

cognitive

and

social

adverse

outcomes

that

incur

substantial

costs

to

society

In

it

was

estimated

from

the

Substance

Abuse

and

Mental

Health

Service

Administration

-LRB-

SAMHSA

-RRB-

that

million

Americans

have

a

substance

abuse

or

dependence

disorder

and

million

of

them

were

current

cocaine

users

-LRB-

Vocci

and

Ling

-RRB-

In

there

were

million

persons

who

were

current

cocaine

users

which

is

more

than

in

-LRB-

SAMHSA

-RRB-

The

number

of

current

crack

users

increased

from

in

to

in

According

to

the

revised

National

Survey

on

Drug

Use

and

Health

nearly

million

Americans

have

tried

methamphetamine

and

of

them

are

chronic

methamphetamine

users

-LRB-

SAMHSA

-RRB-

In

an

estimated

million

persons

aged

or

older

were

classified

with

substance

dependence

or

abuse

in

the

past

year

-LRB-

of

the

population

aged

or

older

-RRB-

Of

these

million

were

classified

with

dependence

on

or

abuse

of

both

alcohol

and

illicit

drugs

million

were

dependent

on

or

abused

illicit

drugs

but

not

alcohol

and

million

were

dependent

on

or

abused

alcohol

but

not

illicit

drugs

There

were

million

persons

classified

with

dependence

on

or

abuse

of

alcohol

in

-LRB-

-RRB-

The

specific

illicit

drugs

that

had

the

highest

levels

of

past

year

dependence

or

abuse

in

were

marijuana

followed

by

cocaine

and

pain

relievers

Of

the

million

persons

aged

or

older

classified

with

dependence

on

or

abuse

of

illicit

drugs

million

were

dependent

on

or

abused

marijuana

in

This

number

represents

of

the

total

population

aged

or

older

and

of

all

those

classified

with

illicit

drug

dependence

or

abuse

Marijuana

was

the

most

commonly

used

illicit

drug

-LRB-

million

past

month

users

-RRB-

In

it

was

used

by

of

current

illicit

drug

users

Among

current

illicit

drug

users

used

only

marijuana

used

marijuana

and

another

illicit

drug

and

the

remaining

used

only

an

illicit

drug

other

than

marijuana

in

the

past

month

-LRB-

SAMHSA

-RRB-

Fatal

poisoning

which

include

overdoses

-LRB-

ODs

-RRB-

on

illicit

drugs

alcohol

and

medications

is

the

leading

cause

of

injury

death

for

individuals

age

and

the

third

leading

cause

of

injury

death

overall

trailing

motor

vehicle

accidents

and

firearm-related

deaths

-LRB-

CDC

-RRB-

Heroin-related

ODs

have

increased

at

an

alarming

rate

in

portions

of

the

US

and

other

countries

-LRB-

Darke

and

Hall

Landen

et

al.

-RRB-

and

OD

has

surpassed

HIV

infection

as

the

primary

cause

of

death

for

heroin

users

Not

surprisingly

heroin

is

frequently

associated

with

opioid-related

ODs

both

as

a

single

drug

and

in

combination

with

other

substances

-LRB-

CDC

-RRB-

Many

patients

seeking

treatment

for

addiction

have

multiple

drug

dependencies

and

psychiatric

comorbidities

-LRB-

Volkow

and

Li

-RRB-

Information

from

epidemiological

surveys

indicates

that

drug

addiction

is

a

common

phenomenon

and

is

associated

with

significant

effects

on

both

morbidity

and

mortality

Large

individual

and

societal

costs

of

drug

abuse

make

research

and

treatment

of

drug

addiction

imperative

-LRB-

French

et

al.

Mark

et

al.

-RRB-

Recently

through

intensive

clinical

neurophysiological

research

and

biological

psychiatric

studies

many

specific

components

of

cognitive

emotional

and

behavioral

deficits

typical

for

SUD

have

been

identified

and

investigated

However

the

practical

values

of

these

cognitive

neuroscience

and

applied

psychophysiology-based

treatment

-LRB-

e.g.

neurofeedback

-RRB-

findings

depend

on

a

further

integration

of

these

methodological

approaches

qEEG

in

Substance

Use

Disorders

EEG

in

Alcoholism

EEG

alterations

have

been

described

extensively

in

alcoholic

patients

-LRB-

Porjesz

and

Begleiter

-RRB-

but

any

attempt

at

drawing

a

common

picture

from

qEEG

data

is

difficult

due

to

significant

methodological

differences

such

as

different

definitions

of

frequency

bands

different

filtering

methodology

number

of

channels

reference

choice

etc.

However

most

reports

of

alcoholic

patients

agree

in

describing

alterations

mainly

within

the

beta

-LRB-

Bauer

Costa

and

Bauer

Rangaswamy

et

al.

-RRB-

and/or

alpha

bands

-LRB-

Finn

and

Justus

-RRB-

The

qEEG

and

LORETA

mapping

studies

of

detoxified

alcohol-dependent

patients

as

compared

with

normal

controls

showed

an

increase

in

absolute

and

relative

beta

power

and

a

decrease

in

alpha

and

delta/theta

power

-LRB-

Saletu

et

al.

-RRB-

which

is

in

agreement

with

earlier

reports

of

low-voltage

fast

EEG

patterns

as

often

encountered

by

visual

EEG

inspection

-LRB-

Niedermeyer

and

Lopes

da

Silva

-RRB-

As

slow

activities

are

considered

to

be

inhibitory

alpha

activity

may

be

viewed

as

an

expression

of

normal

brain

functioning

and

fast

beta

activities

as

excitatory

the

low-voltage

fast

desynchronized

patterns

may

be

interpreted

as

hyperarousal

of

the

central

nervous

system

-LRB-

CNS

-RRB-

-LRB-

Saletu-Zyhlarz

et

al.

-RRB-

The

investigations

by

Bauer

-LRB-

-RRB-

and

Winterer

et

al.

-LRB-

-RRB-

showed

a

worse

prognosis

for

the

patient

group

with

a

more

pronounced

frontal

CNS

hyperarousal

It

may

be

hypothesized

that

these

hyperaroused

relapsing

patients

require

more

CNS

sedation

than

abstaining

ones

The

EEG

maps

of

alcohol-dependent

patients

differ

significantly

from

those

of

normal

controls

and

patients

suffering

from

other

mental

disorders

and

might

be

useful

for

diagnostic

purposes

-LRB-

Pollock

et

al.

Saletu

et

al.

Saletu-Zyhlarz

et

al.

-RRB-

Decreased

power

in

slow

bands

in

alcoholic

patients

may

be

an

indicator

of

brain

atrophy

and

chronic

brain

damage

while

an

increase

in

the

beta

band

may

be

related

to

various

factors

such

as

medication

use

family

history

of

alcoholism

and/or

hallucinations

suggesting

a

state

of

cortical

hyperexcitability

-LRB-

Coutin-Churchman

et

al.

-RRB-

Abnormalities

in

resting

EEG

are

often

associated

with

a

predisposition

to

development

of

alcoholism

Subjects

with

a

family

history

of

alcoholism

were

found

to

have

reduced

relative

and

absolute

alpha

power

in

occipital

and

frontal

regions

and

increased

relative

beta

in

both

regions

compared

with

subjects

with

a

negative

family

history

of

alcoholism

These

results

suggest

that

resting

EEG

alpha

abnormalities

are

associated

with

risk

for

alcoholism

although

their

etiological

significance

is

unclear

-LRB-

Finn

and

Justus

-RRB-

Alcohol-dependent

individuals

have

different

synchronization

of

brain

activity

than

light

drinkers

as

reflected

by

differences

in

resting

EEG

coherence

-LRB-

Kaplan

et

al.

Michael

et

al.

Winterer

et

al.

-RRB-

and

power

-LRB-

e.g.

Bauer

Enoch

et

al.

Rangaswamy

et

al.

Saletu-Zyhlarz

et

al.

-RRB-

Most

differences

in

EEG

coherence

and

power

are

found

in

the

alpha

and

beta

bands

Non-alcohol-dependent

relatives

of

alcohol-dependent

individuals

also

have

EEG

differences

in

alpha

and

beta

coherence

-LRB-

Michael

et

al.

-RRB-

and

power

-LRB-

Bauer

and

Hesselbrock

Finn

and

Justus

Rangaswamy

et

al.

-RRB-

as

compared

to

subjects

without

alcohol-dependent

relatives

This

indicates

that

differences

in

functional

brain

activity

as

measured

with

qEEG

in

alcohol-dependent

patients

not

only

relate

to

the

impact

of

long-term

alcohol

intake

but

possibly

also

to

genetic

factors

related

to

alcohol

dependence

Both

alcohol

dependence

-LRB-

Schuckit

and

Smith

-RRB-

and

EEG

patterns

-LRB-

Van

Beijsterveldt

and

Van

Baal

-RRB-

are

highly

heritable

In

addition

some

genes

coding

for

GABA

receptors

in

the

brain

which

mediate

the

effects

of

alcohol

are

related

to

certain

EEG

patterns

-LRB-

Porjesz

et

al.

Winterer

et

al.

-RRB-

Moreover

some

GABA-receptor

genes

that

are

related

to

EEG

patterns

are

also

associated

with

the

risk

to

develop

alcohol

dependence

These

associations

again

suggest

that

genetic

factors

play

a

major

role

in

the

EEG

differences

associated

with

alcohol

dependence

The

EEG

coherence

analysis

is

a

technique

that

investigates

the

pairwise

correlations

of

power

spectra

obtained

from

different

electrodes

It

measures

the

functional

interaction

between

cortical

areas

in

different

frequency

bands

A

high

level

of

coherence

between

two

EEG

signals

indicates

a

co-activation

of

neuronal

populations

and

provides

information

on

functional

coupling

between

these

areas

-LRB-

Franken

et

al.

-RRB-

De

Bruin

et

al.

-LRB-

-RRB-

investigated

the

pure

effects

of

alcohol

intake

on

synchronization

of

brain

activity

while

minimizing

the

confounding

influence

of

genetic

factors

related

to

alcohol

dependence

They

showed

that

heavily

drinking

students

with

a

negative

family

history

had

stronger

EEG

synchronization

at

theta

and

gamma

frequencies

than

lightly

drinking

students

with

a

negative

family

history

This

study

suggests

that

in

students

heavy

alcohol

intake

has

an

impact

on

functional

brain

activity

even

in

the

absence

of

genetic

factors

related

to

alcohol

dependence

The

findings

of

studies

on

the

effects

of

alcohol

dependence

on

EEG

coherence

can

be

summarized

as

follows

Kaplan

et

al.

-LRB-

-RRB-

reported

lower

frontal

alpha

and

slow-beta

coherence

in

alcohol-dependent

males

and

females

Michael

et

al.

-LRB-

-RRB-

found

higher

central

alpha

and

slow-beta

coherence

but

lower

parietal

alpha

and

slow-beta

coherence

in

males

with

alcohol

dependence

Winterer

et

al.

-LRB-

b

-RRB-

described

higher

left-temporal

alpha

and

slow-beta

coherence

and

higher

slow-beta

coherence

at

right-temporal

and

frontal

electrode

pairs

in

alcohol-dependent

males

and

females

De

Bruin

et

al

-LRB-

-RRB-

showed

that

moderate-to-heavy

alcohol

consumption

is

associated

with

differences

in

synchronization

of

brain

activity

during

rest

and

mental

rehearsal

Heavy

drinkers

displayed

a

loss

of

hemispheric

asymmetry

of

EEG

synchronization

in

the

alpha

and

slow-beta

band

Moderately

and

heavily

drinking

males

additionally

showed

lower

fast-beta

band

synchronization

Therefore

qEEG

alterations

have

been

described

extensively

in

alcoholics

Most

EEG

reports

in

alcoholic

patients

agree

in

describing

alterations

mainly

within

the

beta

and

alpha

bands

Patients

with

a

more

pronounced

frontal

hyperarousal

have

worse

prognosis

Decreased

power

in

slow

bands

in

alcoholic

patients

may

be

an

indicator

of

chronic

brain

damage

while

increase

in

beta

band

may

be

related

to

various

factors

suggesting

cortical

hyperexcitability

Abnormalities

in

resting

EEG

are

highly

heritable

traits

and

are

often

associated

with

a

predisposition

to

alcoholism

development

The

studies

on

the

effects

of

alcohol

dependence

on

EEG

coherence

can

be

summarized

as

lower

frontal

alpha

and

slow-beta

coherence

in

alcohol-dependent

patients

with

some

topographical

coherence

abnormality

differences

between

alcohol-dependent

males

and

females

EEG

in

Marijuana

Abuse

Several

lines

of

evidence

suggest

that

cannabis

-LRB-

marijuana

tetrahydrocannabinol

THC

-RRB-

may

alter

functionality

of

the

prefrontal

cortex

and

thereby

elicit

impairments

across

several

domains

of

complex

cognitive

function

-LRB-

Egerton

et

al.

-RRB-

Several

studies

in

both

humans

and

animals

have

shown

that

cannabinoid

exposure

results

in

alterations

in

prefrontal

cortical

activity

-LRB-

Block

et

al.

O'Leary

et

al.

Whitlow

et

al.

-RRB-

providing

evidence

that

cannabinoid

administration

may

affect

the

functionality

of

this

brain

area

Despite

the

fact

that

a

number

of

transient

physiological

perceptual

and

cognitive

effects

are

known

to

accompany

acute

chronic

marijuana

-LRB-

THC

-RRB-

exposure

in

humans

persistent

qEEG

effects

in

humans

resulting

from

continuing

exposure

to

this

drug

have

been

difficult

to

demonstrate

-LRB-

Wert

and

Raulin

-RRB-

In

early

reviews

of

EEG

and

ERP

studies

of

acute

and

chronic

THC

exposure

in

humans

-LRB-

Struve

et

al.

-RRB-

it

was

reported

that

significant

associations

between

chronic

exposure

and

clinically

abnormal

EEG

patterns

had

not

been

demonstrated

and

that

attempts

to

use

visual

EEG

analyses

to

detect

transient

acute

THC

exposure

induced

EEG

alterations

failed

to

demonstrate

consistent

THC

EEG

effects

across

studies

Quantitative

methods

of

analyzing

EEG

spectra

from

single

posterior

scalp

derivations

began

to

be

applied

to

studies

of

acute

THC

exposure

These

early

studies

reported

that

acute

THC

exposure

produced

transient

increases

in

either

posterior

alpha

power

decreases

in

mean

alpha

frequency

or

increases

in

alpha

synchrony

-LRB-

Fink

et

al.

Struve

et

al.

Tassinari

et

al.

Volavka

et

al.

-RRB-

These

studies

found

that

THC

produced

a

transient

dose-dependent

rapid

onset

-LRB-

-RRB-

increase

in

relative

power

-LRB-

amount

abundance

-RRB-

of

alpha

-LRB-

-RRB-

decrease

in

alpha

frequency

and

-LRB-

-RRB-

decrease

in

relative

power

of

beta

as

measured

from

posterior

scalp

electrodes

Later

studies

of

Struve

et

al.

-LRB-

-RRB-

demonstrated

and

replicated

a

significant

association

between

chronic

marijuana

use

and

topographic

qEEG

patterns

of

persistent

alpha

hyperfrontality

-LRB-

i.e.

elevations

of

alpha

absolute

power

relative

power

and

interhemispheric

coherence

over

frontal

cortex

-RRB-

as

well

as

reductions

of

alpha

mean

frequency

These

findings

from

chronic

users

are

consistent

with

both

non-topographic

-LRB-

Hockman

et

al.

Tassinari

et

al.

Volavka

et

al.

-RRB-

and

topographic

-LRB-

Lukas

et

al.

Struve

et

al.

-RRB-

transient

EEG

effects

of

acute

THC

administration

Therefore

chronic

daily

THC

use

was

found

to

be

associated

with

distinct

topographic

qEEG

features

Compared

with

non-users

THC

users

had

significant

elevations

of

absolute

and

relative

power

and

interhemispheric

coherence

of

alpha

activity

over

the

bilateral

frontal

cortex

-LRB-

referred

to

as

alpha

hyperfrontality

-RRB-

A

second

finding

was

that

the

voltage

-LRB-

not

relative

power

or

coherence

-RRB-

of

all

non-alpha

frequency

bands

was

significantly

elevated

in

THC

users

although

the

voltage

increase

was

generalized

and

not

frontally

dominant

A

third

finding

involved

a

widespread

decrease

in

the

relative

power

of

delta

and

beta

activity

for

cannabis

users

particularly

over

the

frontal

cortical

regions

A

fourth

finding

was

that

interhemispheric

coherence

of

theta

and

possibly

delta

activity

was

also

significantly

elevated

over

frontal

cortex

for

marijuana

users

Because

most

studies

included

daily

THC

users

and

non-users

drawn

from

an

inpatient

psychiatric

population

the

effects

of

psychiatric

diagnoses

or

medication

were

not

controlled

Thus

qEEG

studies

on

acute

THC

exposure

reported

a

transient

dose-dependent

increase

in

relative

power

of

alpha

decrease

in

alpha

frequency

and

decrease

in

relative

power

of

beta

at

posterior

EEG

recording

sites

Chronic

marijuana

abuse

is

known

to

result

in

a

number

of

physiological

perceptual

and

cognitive

effects

but

persistent

qEEG

effects

from

continuing

exposure

to

THC

have

been

difficult

to

demonstrate

However

recent

studies

of

Struve

and

his

colleagues

have

demonstrated

a

significant

association

between

chronic

marijuana

use

and

topographic

qEEG

patterns

of

persistent

elevations

of

alpha

absolute

power

relative

power

and

interhemispheric

coherence

over

frontal

cortex

as

well

as

reductions

of

alpha

mean

frequency

Another

important

qEEG

finding

was

the

elevated

voltage

of

all

non-alpha

bands

in

THC

users

A

third

qEEG

finding

involved

a

widespread

decrease

in

the

relative

power

of

delta

and

beta

activity

over

the

frontal

cortical

regions

in

marijuana

users

EEG

in

Heroin

Addiction

Only

a

few

studies

have

investigated

qEEG

changes

in

heroin

addicts

Qualitative

changes

were

observed

in

more

than

of

heroin

addicts

in

the

early

abstinence

-LRB-

acute

withdrawal

-RRB-

period

and

these

included

low-voltage

background

activity

with

diminution

of

alpha

rhythm

an

increase

in

beta

activity

and

a

large

amount

of

low-amplitude

delta

and

theta

waves

in

central

regions

-LRB-

Olivennes

et

al.

Polunina

and

Davydov

-RRB-

Franken

et

al.

-LRB-

-RRB-

found

that

abstinent

heroin-dependent

subjects

have

an

enhanced

fast

beta

power

compared

with

healthy

controls

and

this

finding

is

concordant

with

other

EEG

studies

on

alcohol

and

cocaine

abusing

subjects

-LRB-

Costa

and

Bauer

Herning

et

al.

Rangaswamy

et

al.

Roemer

et

al.

-RRB-

Spectral

power

and

event-related

potentials

-LRB-

ERP

-RRB-

in

heroin

addicts

strongly

relate

to

abstinence

length

-LRB-

Shufman

et

al.

Bauer

Polunina

and

Davydov

-RRB-

Most

studies

showed

considerable

or

even

complete

normalization

of

EEG

spectral

power

or

magnitude

of

ERP

components

in

heroin

ex-addicts

who

maintained

abstinence

for

at

least

months

-LRB-

Bauer

Costa

and

Bauer

Papageorgiou

et

al.

Polunina

and

Davidov

Shufman

et

al.

-RRB-

Some

quantitative

changes

were

also

reported

in

methadone-maintenance

heroin

addicts

-LRB-

Gritz

et

al.

-RRB-

current

heroin

addicts

and

subjects

in

heroin

abstinence

less

than

days

-LRB-

Shufman

et

al.

-RRB-

Gritz

et

al.

-LRB-

-RRB-

demonstrated

a

significant

slowing

of

occipital

alpha

rhythm

peak

frequency

in

methadone-maintained

patients

and

the

same

trend

in

abstinent

heroin-addicted

subjects

In

one

study

-LRB-

Polunina

and

Davydov

-RRB-

slowing

of

slow

alpha

-LRB-

Hz

-RRB-

mean

frequency

was

significantly

related

to

the

amount

of

heroin

taken

by

these

patients

daily

before

withdrawal

The

prolongation

of

ERP

component

latencies

in

heroin

addicts

was

also

reported

-LRB-

Papageorgiou

et

al.

-RRB-

and

these

delays

significantly

correlated

with

years

of

heroin

use

rather

than

with

abstinence

length

in

the

study

of

Bauer

-LRB-

-RRB-

Polunina

and

Davydov

-LRB-

-RRB-

demonstrated

frequency

shifts

in

the

fast

alpha

range

at

the

frontal

and

central

recording

sites

and

a

slowing

of

slow

alpha

mean

frequency

at

the

central

temporal

and

occipital

sites

of

recording

in

heroin

abusers

who

used

heroin

for

at

least

months

In

general

pronounced

desynchronization

is

characteristic

for

acute

heroin

withdrawal

but

as

it

was

mentioned

above

several

studies

-LRB-

Bauer

Costa

and

Bauer

Papageorgiou

et

al.

Polunina

and

Davydov

Shufman

et

al.

-RRB-

showed

that

spectral

power

of

EEG

tends

to

normalize

almost

completely

after

several

weeks

of

abstinence

The

most

consistent

changes

in

EEG

of

heroin

addicts

were

reported

in

alpha

and

beta

frequencies

and

included

a

deficit

in

alpha

activity

and

an

excess

of

fast

beta

activity

in

early

heroin

abstinence

The

latter

abnormality

appears

to

reverse

considerably

when

heroin

intake

is

stopped

for

several

months

and

therefore

it

may

be

viewed

as

an

acute

withdrawal

effect

The

dynamics

and

characteristics

of

spectral

power

changes

within

the

early

opiate

withdrawal

suggest

the

participation

of

catecholamine

imbalances

especially

noradrenaline

and

perhaps

to

a

lesser

degree

dopamine

which

are

widely

recognized

as

a

main

cause

of

opiate

physical

dependency

symptoms

-LRB-

Devoto

et

al.

Maldonado

-RRB-

Acute

opiate

administration

has

been

shown

to

increase

while

abstinence

from

chronic

opiate

use

has

been

shown

to

decrease

extracellular

dopamine

-LRB-

DA

-RRB-

in

the

nucleus

accumbens

In

contrast

extracellular

DA

in

the

prefrontal

cortex

is

not

modified

by

acute

opiate

use

but

is

markedly

increased

during

morphine

and

heroin

abstinence

syndrome

-LRB-

Devoto

et

al.

-RRB-

Relationships

between

theta

and

beta

frequencies

shifts

and

neurotransmitter

imbalances

characteristic

for

heroin

withdrawal

remain

unclear

Withdrawal

state

in

heroin

addicts

is

known

to

elicit

a

strong

craving

for

drug

anxiety

nervousness

deficits

in

inhibitory

control

dysphoric

motivational

state

and

intrusive

thoughts

related

to

drugs

-LRB-

Franken

Franken

et

al.

Stormark

et

al.

-RRB-

Research

on

functional

connectivity

in

drug

withdrawal

states

is

restricted

to

a

few

studies

on

coherence

of

the

EEG

signal

in

abstinent

heroin

users

-LRB-

Franken

et

al.

Fingelkurts

et

al.

-LRB-

-RRB-

active

heroin

abusers

-LRB-

Fingelkurts

et

al.

-RRB-

and

in

abstinent

polysubstance

abusers

-LRB-

Roemer

et

al.

-RRB-

In

a

study

on

opioid-dependent

patients

under

acute

opioid

influence

Fingelkurts

et

al.

-LRB-

-RRB-

showed

that

longitudinal

opioid

exposure

impairs

cortical

local

and

remote

functional

connectivity

and

found

that

local

connectivity

increased

whereas

the

remote

one

decreased

These

findings

were

interpreted

as

specific

signs

of

independent

processing

in

the

cortex

of

chronic

heroin

addicts

It

has

been

suggested

that

such

independent

processes

may

constitute

the

candidate

mechanism

for

a

well-documented

pattern

of

impairment

in

addicts

that

expresses

the

lack

of

integration

of

different

cognitive

functions

for

effective

problem

solving

and

helps

to

explain

the

observed

deficits

in

abstract

concept

formation

behavioral

control

and

problems

in

the

regulation

of

affect

and

behavior

Specifically

Fingelkurts

et

al.

-LRB-

-RRB-

found

that

the

number

and

strength

of

remote

functional

connections

among

different

cortical

areas

estimated

by

the

index

of

EEG

synchrony

was

significantly

higher

in

patients

in

acute

heroin

withdrawal

than

in

healthy

controls

for

most

categories

of

functional

connections

Although

this

result

was

observed

in

the

alpha

as

well

as

in

the

beta

frequency

bands

it

was

most

prominent

for

the

beta

range

In

the

same

patient

sub-sample

under

acute

opioid

influence

the

authors

-LRB-

Fingelkurts

et

al.

-RRB-

observed

the

opposite

a

significant

decrease

in

the

number

and

strength

of

remote

functional

connections

when

compared

with

healthy

controls

Thus

the

increase

of

remote

synchronicity

among

cortical

areas

during

the

short-term

withdrawal

period

may

indicate

the

selective

attentional

focus

on

cues

and

memories

related

to

drugs

while

ignoring

neutral

cues

-LRB-

Franken

et

al.

Sokhadze

et

al.

-RRB-

Generally

this

can

explain

a

narrowing

of

the

behavioral

repertoire

and

compulsive

drug

seeking

in

abstinent

addicted

subjects

-LRB-

Vanderschuren

and

Everitt

-RRB-

Therefore

the

elevated

synchrony

within

the

beta

frequency

band

in

these

studies

-LRB-

Fingelkurts

et

al.

b

-RRB-

may

reflect

a

state

of

CNS

activation

toward

reward-seeking

behavior

with

this

being

a

prerequisite

of

relapse

among

opiate

drug

dependent

patients

-LRB-

Bauer

-RRB-

qEEG

changes

in

heroin

addicts

in

the

acute

withdrawal

period

have

been

described

as

low-voltage

background

activity

with

a

diminution

of

alpha

rhythm

an

increase

in

beta

activity

and

a

large

amount

of

low-amplitude

delta

and

theta

waves

in

central

regions

In

general

pronounced

desynchronization

is

characteristic

for

acute

heroin

withdrawal

but

the

spectral

power

of

EEG

tends

to

normalize

almost

completely

after

several

weeks

of

abstinence

The

most

consistent

changes

in

EEG

of

heroin

addicts

were

reported

in

the

alpha

and

beta

frequencies

and

included

a

deficit

in

alpha

activity

and

an

excess

of

fast

beta

activity

in

early

heroin

abstinence

The

excess

of

beta

appears

to

reverse

considerably

when

heroin

intake

is

stopped

for

several

months

and

therefore

it

may

be

viewed

as

an

acute

withdrawal

effect

Recent

studies

found

that

the

number

and

strength

of

remote

functional

connections

among

different

cortical

areas

estimated

by

the

index

of

EEG

synchrony

for

the

beta

range

was

significantly

higher

in

patients

in

acute

heroin

withdrawal

than

in

healthy

controls

for

most

categories

of

functional

connections

EEG

in

Cocaine

Addiction

Qualitative

and

quantitative

EEG

measures

are

highly

sensitive

to

the

acute

and

chronic

effects

of

neurointoxication

produced

by

such

psychostimulants

as

cocaine

as

well

as

effects

from

withdrawal

and

long-term

abstinence

from

cocaine

use

-LRB-

Ehlers

et

al.

-RRB-

However

some

EEG

characteristics

observed

in

cocaine

addicts

are

considered

to

be

due

to

the

toxic

effects

of

this

drug

on

the

brain

whereas

some

EEG

characteristics

in

cocaine

addicts

may

also

indicate

a

predisposition

toward

the

development

of

SUD

-LRB-

Porjesz

et

al.

-RRB-

Hans

Berger

-LRB-

cited

by

Gloor

Herning

et

al.

-RRB-

was

the

first

to

study

the

effects

of

cocaine

on

human

EEG

reporting

an

increase

in

activity

in

the

beta

bandwidth

This

was

replicated

in

subsequent

studies

with

a

larger

number

of

subjects

-LRB-

Alper

Alper

et

al.

Costa

and

Bauer

Herning

et

al.

Noldy

et

al.

Prichep

et

al.

Roemer

et

al.

-RRB-

Beside

beta

effects

studies

have

reported

an

increase

in

delta

activity

-LRB-

Herning

et

al.

-RRB-

and

frontal

alpha

activity

-LRB-

Herning

et

al.

-RRB-

while

others

have

reported

an

increase

in

alpha

wave

EEG

associated

with

bursts

of

cocaine-induced

euphoria

-LRB-

Lukas

-RRB-

More

recently

researchers

have

begun

analyzing

qEEG

profiles

of

cocaine-dependent

patients

using

the

spectral

power

of

each

primary

bandwidth

over

the

different

topographic

cortical

areas

Excess

alpha

activity

-LRB-

Alper

et

al.

Herning

et

al.

Lukas

Prichep

et

al.

-RRB-

and

decreased

delta

activity

-LRB-

Alper

et

al.

Noldy

et

al.

Prichep

et

al.

Roemer

et

al.

-RRB-

have

been

reported

while

others

have

reported

increased

beta

power

-LRB-

Herning

et

al.

Noldy

et

al.

-RRB-

in

cocaine-dependent

patients

recorded

in

eyes

closed

resting

conditions

The

qEEG

abnormalities

primarily

found

in

anterior

cortical

regions

were

shown

to

correlate

with

the

amount

of

prior

cocaine

use

-LRB-

Herning

et

al.

Prichep

et

al.

Roemer

et

al.

Venneman

et

al.

-RRB-

The

qEEG

has

been

used

more

often

to

characterize

the

effects

of

withdrawal

in

cocaine-dependent

patients

Several

studies

reported

that

during

protracted

abstinence

from

cocaine

qEEG

effects

are

featured

by

long-lasting

increases

in

alpha

and

beta

bands

together

with

reduced

activity

in

delta

and

theta

bands

-LRB-

Alper

et

al.

Prichep

et

al.

Roemer

et

al.

-RRB-

Recently

Reid

et

al.

-LRB-

-RRB-

investigated

qEEG

profiles

in

cocaine-dependent

patients

in

response

to

an

acute

single-blind

self-administered

dose

of

smoked

cocaine

base

-LRB-

mg

-RRB-

versus

placebo

Cocaine

produced

a

rapid

increase

in

absolute

theta

alpha

and

beta

power

over

the

prefrontal

cortex

lasting

up

to

min

after

administration

of

the

drug

The

increase

in

theta

power

was

correlated

with

a

positive

subjective

drug

effect

-LRB-

high

-RRB-

and

the

increase

in

alpha

power

was

correlated

with

nervousness

Cocaine

also

produced

a

similar

increase

in

delta

coherence

over

the

prefrontal

cortex

which

was

correlated

with

nervousness

Placebo

resulted

only

in

a

slight

increase

in

alpha

power

over

the

prefrontal

cortex

These

data

demonstrate

the

involvement

of

the

prefrontal

cortex

in

the

qEEG

response

to

acute

cocaine

and

indicate

that

slow

wave

qEEG

delta

and

theta

activity

are

involved

in

the

processes

related

to

experiencing

rewarding

properties

of

cocaine

Prichep

et

al.

-LRB-

-RRB-

extended

the

idea

of

relating

baseline

EEG

activity

to

outcome

in

cocaine-dependent

patients

in

treatment

programs

Subjects

with

cocaine

dependence

have

persistent

changes

in

brain

function

assessed

with

qEEG

methods

present

when

evaluated

at

baseline

days

after

last

reported

crack

cocaine

use

and

persistent

at

one

and

six

month

follow-up

evaluations

-LRB-

Alper

Alper

et

al.

Prichep

et

al.

Venneman

et

al.

-RRB-

Several

recent

studies

employing

qEEG

techniques

have

already

demonstrated

an

association

between

the

amount

of

beta

activity

in

the

spontaneous

EEG

and

relapse

in

cocaine

abuse

-LRB-

Bauer

-RRB-

A

decrease

in

the

delta

and

theta

bands

of

the

EEG

can

be

regarded

as

a

specific

sign

of

brain

dysfunction

However

this

sign

as

well

as

other

qEEG

abnormal

patterns

can

be

found

in

many

different

psychiatric

disorders

and

of

them

can

be

considered

as

pathognomonic

of

any

specific

mental

or

neurological

disorder

EEG

coherence

in

cocaine

addiction

was

investigated

in

only

one

study

-LRB-

Roemer

et

al.

-RRB-

The

authors

reported

globally

reduced

interhemispheric

coherence

in

the

delta

and

theta

bands

and

frontally

in

the

beta

band

It

should

be

noted

that

subjects

in

this

study

were

cocaine-preferring

polysubstance

abusers

during

abstinence

and

these

results

can

hardly

be

generalized

to

crack

cocaine-only

users

or

other

categories

of

cocaine-dependent

subjects

not

enrolled

in

any

treatment

Therefore

acute

effects

of

smoked

crack

cocaine

have

been

shown

to

produce

a

rapid

increase

in

absolute

theta

alpha

and

beta

power

over

the

prefrontal

cortex

lasting

up

to

half-an-hour

after

administration

of

the

drug

The

increase

in

theta

power

was

reported

to

correlate

with

a

positive

subjective

drug

effect

while

the

increase

in

alpha

power

was

reported

to

correlate

with

nervousness

qEEG

measures

are

also

sensitive

to

the

acute

and

chronic

effects

of

cocaine

as

well

as

the

effects

from

withdrawal

and

long-term

abstinence

from

cocaine

use

Some

EEG

characteristics

observed

in

cocaine

addicts

are

considered

to

be

due

to

the

neurotoxic

effects

whereas

some

EEG

characteristics

in

cocaine

addicts

may

also

indicate

a

predisposition

toward

the

development

of

cocaine

addiction

qEEG

has

been

used

more

often

to

characterize

the

effects

of

withdrawal

in

cocaine-dependent

patients

During

protracted

abstinence

from

cocaine

qEEG

effects

are

featured

by

long-lasting

increases

in

alpha

and

beta

bands

together

with

reduced

activity

in

delta

and

theta

bands

Several

recent

studies

employing

qEEG

techniques

have

demonstrated

an

association

between

the

amount

of

beta

activity

in

the

spontaneous

EEG

and

relapse

in

cocaine

abuse

EEG

in

Methamphetamine

Addiction

Several

studies

have

examined

the

neurobiological

consequences

of

methamphetamine

dependence

using

qEEG

methods

-LRB-

e.g.

Newton

et

al.

-RRB-

It

was

found

that

methamphetamine

dependent

patients

exhibited

a

significant

power

increase

in

the

delta

and

theta

bands

as

compared

to

non-drug-using

controls

-LRB-

Newton

et

al.

-RRB-

These

results

are

in

accordance

with

other

neurocognitive

studies

-LRB-

Kalechstein

et

al.

-RRB-

suggesting

that

methamphetamine

abuse

is

associated

with

psychomotor

slowing

and

frontal

executive

deficits

Within

the

methamphetamine-dependent

subjects

increased

theta

qEEG

power

was

found

to

correlate

with

response

time

and

was

accompanied

with

reduced

accuracy

-LRB-

Newton

et

al.

-RRB-

To

our

knowledge

qEEG

patterns

associated

with

acute

withdrawal

and

recent

abstinence

in

methamphetamine

dependence

have

not

yet

been

sufficiently

described

One

study

reported

-LRB-

Newton

et

al.

-RRB-

that

methamphetamine

dependent

volunteers

with

days

of

abstinence

had

increased

EEG

power

in

the

delta

and

theta

but

not

in

the

alpha

and

beta

bands

Within

the

methamphetamine

dependent

group

a

majority

of

the

conventional

EEGs

were

abnormal

-LRB-

-RRB-

compared

to

in

the

non-methamphetamine

using

group

The

qEEG

may

provide

a

sensitive

neurophysiological

outcome

measure

of

methamphetamine

abuse-related

persistent

alterations

in

neurocognitive

functions

-LRB-

Newton

et

al.

-RRB-

In

a

study

by

Simon

et

al.

-LRB-

-RRB-

when

performance

of

patients

with

SUD

was

compared

to

their

matched

non-using

control

groups

both

methamphetamine

and

cocaine

abusers

were

impaired

on

cognitive

measures

but

the

type

and

degree

of

impairments

were

somewhat

different

Some

of

these

differences

between

methamphetamine

and

cocaine

effects

on

cognitive

functions

and

electrophysiological

alterations

can

be

explained

by

differential

pharmacokinetics

of

these

two

drugs

as

cocaine

is

rapidly

metabolized

with

an

elimination

half-life

of

several

hours

whereas

methamphetamine

is

eliminated

more

slowly

with

an

elimination

half-life

averaging

h

-LRB-

Cook

et

al.

Jeffcoat

et

al.

-RRB-

Moreover

cocaine

differs

from

methamphetamine

in

that

cocaine

inhibits

the

reuptake

of

dopamine

serotonin

and

norepinephrine

whereas

methamphetamine

mobilizes

and

releases

these

monoamines

from

storage

granules

thus

producing

rapid

and

large

increases

in

synaptic

concentrations

-LRB-

Simon

et

al.

-RRB-

This

might

be

responsible

for

the

discrepancies

in

observed

qEEG

manifestations

associated

with

chronic

methamphetamine

and

cocaine

abuse

Only

a

few

studies

have

examined

the

qEEG

consequences

of

methamphetamine

dependence

They

report

that

methamphetamine

dependent

patients

exhibited

a

significant

power

increase

in

the

delta

and

theta

bands

as

compared

to

non-drug-using

control

The

qEEG

patterns

associated

with

acute

withdrawal

and

recent

abstinence

in

methamphetamine

dependence

have

not

yet

been

sufficiently

described

One

study

reported

that

abstinent

methamphetamine

dependent

patients

had

increased

EEG

power

in

the

delta

and

theta

but

not

in

the

alpha

and

beta

bands

In

general

qEEG

studies

of

methamphetamine

addiction

are

in

accordance

with

other

neurocognitive

studies

suggesting

that

methamphetamine

abuse

is

associated

with

psychomotor

slowing

and

frontal

executive

deficits

Abnormalities

in

Cocaine

Methamphetamine

Heroin

Addiction

and

Alcoholism

The

component

of

the

ERP

occurring

ms

post-stimulus

is

the

most

widely

used

ERP

in

psychiatry

and

other

clinical

applications

-LRB-

Polich

et

al.

Polich

and

Herbst

Pritchard

Pritchard

et

al.

-RRB-

The

amplitude

of

the

reflects

the

allocation

of

attentional

resources

while

the

latency

is

considered

to

reflect

stimulus

evaluation

and

classification

time

-LRB-

Katayama

and

Polich

Polich

and

Herbst

-RRB-

The

is

usually

obtained

in

an

oddball

paradigm

wherein

two

stimuli

are

presented

in

a

random

order

one

of

them

frequent

-LRB-

standard

-RRB-

and

another

one

rare

-LRB-

target

-RRB-

-LRB-

Polich

-RRB-

A

modification

of

the

oddball

task

has

been

used

where

a

third

also

rare

stimulus

-LRB-

distracter

-RRB-

is

presented

along

with

standard

and

target

stimuli

It

was

reported

that

these

infrequent

distracters

elicit

a

frontocentral

so

called

whereas

the

rare

targets

elicit

a

parietal

so

called

-LRB-

Katayama

and

Polich

-RRB-

The

is

recorded

at

the

anterior

scalp

locations

and

has

been

interpreted

as

reflecting

frontal

lobe

activity

-LRB-

Gaeta

et

al.

Knight

-RRB-

Though

the

response

in

general

is

thought

to

represent

context

updating/closure

in

a

three-stimuli

oddball

task

the

is

interpreted

as

orienting

and

the

is

viewed

as

an

index

of

the

ability

to

maintain

sustained

attention

to

target

-LRB-

Näätänen

-RRB-

The

anterior

indexes

the

contextual

salience

of

the

rare

stimuli

whereas

the

posterior

is

indexing

task-relevance

of

the

stimuli

-LRB-

Gaeta

et

al.

-RRB-

A

robust

finding

in

ERP

studies

on

alcoholism

is

that

alcoholics

as

well

as

individuals

at

high

risk

to

develop

alcoholism

have

been

shown

to

have

a

low

amplitude

in

various

task

paradigms

-LRB-

Cohen

et

al.

Hada

et

al.

Porjesz

et

al.

Porjesz

and

Begleiter

-RRB-

Kouri

et

al.

-LRB-

-RRB-

examined

the

component

in

patients

who

were

dually

dependent

on

cocaine

and

heroin

The

results

showed

no

amplitude

differences

between

the

patients

and

healthy

non-drug-dependent

volunteers

when

patients

presented

for

detoxification

However

after

the

course

of

detoxification

the

amplitude

was

significantly

smaller

in

the

cocaine

and

heroin-dependent

group

than

in

the

non-dependent

control

group

In

a

study

by

Bauer

-LRB-

-RRB-

the

did

not

differentiate

among

patients

characterized

by

histories

of

either

cocaine

or

cocaine

and

alcohol

or

heroin

dependence

Across

all

the

patient

groups

the

was

significantly

reduced

in

amplitude

relative

to

the

ERPs

recorded

from

individuals

with

no

history

of

alcohol

or

drug

dependence

This

study

also

demonstrated

that

continued

abstinence

from

heroin

and

from

cocaine

and

alcohol

is

also

associated

with

a

trend

toward

normalization

of

the

In

a

recent

study

of

Papageorgiou

et

al.

-LRB-

-RRB-

the

component

was

evaluated

during

the

anticipatory

period

of

a

short

memory

task

in

patients

characterized

by

a

past

history

of

heroin

dependence

-LRB-

months

abstinence

-RRB-

in

current

heroin

users

and

in

matched

healthy

subjects

Abstinent

heroin

addicts

exhibited

a

significant

reduction

of

the

amplitude

at

the

central

frontal

region

relative

to

the

other

two

groups

The

results

of

early

work

examining

the

effect

of

cannabis

use

and

THC

administration

on

visual

and

auditory

ERPs

have

been

inconclusive

-LRB-

Rodin

et

al.

Roth

et

al.

-RRB-

Later

studies

of

Patrick

et

al.

-LRB-

-RRB-

could

not

find

latency

differences

in

audio

and

visual

oddball

tasks

between

THC

users

without

psychiatric

problems

and

controls

Although

THC

users

displayed

reduced

auditory

and

visual

amplitudes

in

this

study

when

age

differences

between

THC

users

and

controls

were

removed

all

significant

amplitude

differences

were

removed

as

well

Acute

and

chronic

use

of

cocaine

exerts

neuropharmacological

effects

on

amplitude

and

latency

of

both

anterior

and

posterior

ERP

components

-LRB-

Biggins

et

al.

Fein

et

al.

Herning

et

al.

Kouri

et

al.

Polich

-RRB-

Longer

-LRB-

-RRB-

latency

without

abnormalities

in

amplitude

was

reported

in

several

studies

on

cocaine

withdrawal

-LRB-

Herning

et

al.

Lukas

-RRB-

Noldy

and

Carlen

-LRB-

-RRB-

demonstrated

effects

of

cocaine

withdrawal

on

the

latency

of

the

in

an

auditory

oddball

task

In

cocaine-dependent

patients

amplitude

decrements

over

frontal

areas

are

persistent

even

after

long

periods

of

abstinence

-LRB-

Bauer

-RRB-

The

latency

of

the

was

delayed

and

the

amplitude

was

reduced

to

novel

non-targets

in

cocaine

and

alcohol-dependent

subjects

compared

to

controls

-LRB-

Biggins

et

al.

Hada

et

al.

-RRB-

in

auditory

and

visual

three-stimuli

oddball

tasks

Several

studies

have

investigated

ERP

changes

associated

with

methamphetamine

abuse

and

dependence

The

component

of

the

auditory

ERP

was

reported

to

show

a

prolonged

latency

in

the

oddball

task

in

methamphetamine

dependent

subjects

with

a

history

of

psychosis

compared

to

normal

controls

-LRB-

Iwanami

et

al.

-RRB-

In

particular

the

patients

with

methamphetamine

dependence

showed

reduced

amplitude

in

the

reading

task

and

delayed

latency

with

normal

amplitude

in

the

auditory

oddball

task

This

was

interpreted

as

indicating

a

prolonged

central

noradrenergic

dysfunction

due

to

earlier

methamphetamine

use

In

most

ERP

studies

the

did

not

differentiate

among

patients

characterized

by

histories

of

either

cocaine

or

cocaine

and

alcohol

or

heroin

dependence

Across

all

the

patient

groups

the

was

significantly

reduced

in

amplitude

relative

to

ERPs

recorded

from

individuals

with

no

history

of

alcohol

or

drug

dependence

The

latency

of

the

frontal

and

parietal

was

reported

to

be

delayed

and

the

amplitude

was

reduced

to

novel

non-targets

in

cocaine

and

alcohol-dependent

subjects

compared

to

controls

in

auditory

and

visual

three-stimuli

oddball

tasks

Continued

abstinence

from

heroin

cocaine

and

alcohol

was

shown

to

be

associated

with

a

trend

toward

normalization

Several

studies

have

investigated

ERP

changes

associated

with

methamphetamine

abuse

and

dependence

In

general

chronic

psychoactive

substance

abuse

and

drug

dependence

are

associated

with

delayed

and

attenuated

cognitive

ERP

in

auditory

and

visual

oddball

tasks

qEEG

and

ERP

Abnormalities

in

Addiction

Psychopharmacological

Effects

or

Trait

Markers

Whether

qEEG

alterations

and

decrements

found

in

most

of

SUD

are

only

a

coincident

marker

of

vulnerability

or

make

a

direct

etiologic

contribution

to

risk

for

substance

dependence

is

still

unknown

-LRB-

Bauer

and

Hesselbrok

Carlson

et

al.

O'Connor

et

al.

Polich

et

al.

Porjesz

and

Begleiter

-RRB-

The

reduction

and

abnormal

qEEG

patterns

are

seen

in

mental

disorders

that

often

are

comorbid

with

substance

abuse

such

as

conduct

disorder

-LRB-

Bauer

and

Hesselbrock

-RRB-

ADHD

-LRB-

Bauer

O'Connor

et

al.

-RRB-

and

bipolar

or

major

affective

disorder

-LRB-

Friedman

and

Squires-Wheeler

-RRB-

Reduced

amplitude

related

to

prefrontal

brain

dysfunction

may

suggest

that

a

deficit

in

inhibitory

control

is

an

underlying

mechanism

shared

by

different

psychopathologies

-LRB-

Bauer

and

Hesselbrock

Clark

et

al.

Tarter

et

al.

-RRB-

According

to

Bauer

-LRB-

-RRB-

certain

ERP

and

qEEG

abnormalities

and

impaired

functioning

on

complex

cognitive

tests

in

patients

formerly

dependent

on

cocaine

might

not

be

proximately

caused

by

drug

use

per

se

but

be

more

related

to

comorbid

alcohol

use

or

another

psychiatric

condition

Taken

together

the

findings

converge

on

the

conclusion

that

there

exists

an

inherited

predisposition

for

an

externalizing

psychopathology

that

includes

ADHD

conduct

disorder

and

substance

abuse

PTSD

seems

to

heighten

the

risk

for

addiction

as

well

Thus

the

reviewed

findings

support

the

hypothesis

that

addicted

subjects

may

manifest

a

amplitude

reduction

and

qEEG

abnormalities

as

a

trait

reflecting

the

CNS

disinhibition

which

may

be

a

predisposing

factor

for

addiction

liability

resistance

to

drug

habit

extinction

and

relapse

vulnerability

Heritability

and

Neurotransmitter

Considerations

in

Substance

Use

Disorders

There

has

been

a

consistent

drift

in

addiction

research

between

the

psychosocial

cognitive

and

behavioral

aspects

of

addiction

and

the

biological

and

genetic

emphasis

In

much

of

the

present

data

relating

to

genetics

and

animal

models

-LRB-

Blum

et

al.

Porjesz

et

al.

Ryabinin

and

Weitemier

Samochowiec

et

al.

-RRB-

studies

suggest

that

a

genetic

predisposition

for

SUD

is

an

accepted

concept

Much

of

the

genetic

research

addresses

the

influence

of

alleles

thought

responsible

in

coding

for

genes

that

express

phenotypic

neurotransmitter

production

and

distribution

mainly

involving

endorphins

dopamine

and

serotonin

These

neurotransmitters

dopamine

in

particular

are

also

suspect

in

other

appetitive

and

mood

disorders

and

psychopathologies

of

particular

note

Reward

Deprivation

Syndrome

-LRB-

RDS

-RRB-

RDS

is

described

as

a

dysfunction

in

the

Brain

Reward

Cascade

and

proposes

that

abnormal

craving

behavior

is

a

consequence

of

defects

in

the

and

and

dopaminergic

receptor

genes

-LRB-

Blum

et

al.

-RRB-

Blum

and

colleagues

-LRB-

-RRB-

described

this

syndrome

and

identified

the

dopamine

receptor

gene

as

a

possible

candidate

for

susceptibility

to

alcoholism

in

severe

alcoholics

-LRB-

Blum

et

al.

-RRB-

and

proposed

this

gene

's

association

with

dopamine

production

and

distribution

may

produce

a

sevenfold

increase

in

the

likelihood

of

developing

alcohol

use

problems

-LRB-

Uhl

et

al.

-RRB-

This

dopamine

receptor

gene

and

polymorphisms

within

its

genetic

coding

specific

to

addiction

remain

unclear

due

to

its

involvement

in

other

disorders

including

obesity

-LRB-

Blum

et

al.

-RRB-

Tourette

's

syndrome

-LRB-

Comings

et

al.

-RRB-

pathological

aggression

and

violence

PTSD

-LRB-

Comings

et

al.

-RRB-

and

schizoid

avoidant

disorder

-LRB-

Chen

et

al.

-RRB-

SUD

were

classified

as

a

subtype

of

RDS

and

treatment

regimens

for

these

disorders

have

been

classified

as

inadequate

-LRB-

Blum

et

al.

-RRB-

and

research

continues

in

developing

possible

genetic

interventions

that

may

produce

dopamine

and

other

neurotransmitter

regulation

in

substance-induced

rapid

dopamine

increase

in

limbic

regions

-LRB-

Blum

et

al.

-RRB-

It

is

clear

that

heritability

plays

an

important

role

in

addictive

disorders

however

to

what

extent

environment

perception

and

synaptic

permanency

and

plasticity

influence

the

course

of

genetic

adaptation

or

maladaptive

traits

requires

further

investigation

Suggested

neuroanatomical

substrates

involved

in

SUD

implicate

mesolimbic

and

diencephalon

regions

including

the

substantia

nigra

reticular

formation

medial

forebrain

bundle

nucleus

accumbens

septum

pediculum

olfactory

tubercule

and

hippocampus

and

suggest

that

any

concentration

of

alcohol

exposure

to

these

regions

would

make

alcohol

use

virtually

unavoidable

-LRB-

Myers

and

Privette

-RRB-

Studies

of

EEG

Biofeedback

in

Substance

Abuse

Treatment

The

Peniston

Protocol

-LRB-

Alpha-Theta

Feedback

-RRB-

The

early

studies

of

Kamiya

-LRB-

e.g.

Nowlis

and

Kamiya

-RRB-

on

self-regulation

of

alpha

rhythm

elicited

substantial

interest

in

the

potential

clinical

applications

of

alpha

biofeedback

for

SUD

treatment

There

were

reported

several

uncontrolled

case

studies

and

conceptual

reviews

on

alpha

EEG

training

for

alcohol

-LRB-

DeGood

and

Valle

Denney

et

al.

Jones

and

Holmes

Passini

et

al.

Tarbox

Watson

et

al.

-RRB-

and

drug

abuse

treatment

-LRB-

Brinkman

Goldberg

et

al.

Lamontagne

et

al.

Sim

-RRB-

but

the

impact

of

alpha

biofeedback

training

as

a

SUD

therapy

was

not

significant

The

bulk

of

the

literature

to

date

regarding

EEG

biofeedback

of

addictive

disorders

is

focused

on

alpha-theta

biofeedback

The

technique

involves

the

simultaneous

measurement

of

occipital

alpha

-LRB-

Hz

-RRB-

and

theta

-LRB-

Hz

-RRB-

and

feedback

by

separate

auditory

tones

for

each

frequency

representing

amplitudes

greater

than

pre

set

thresholds

The

subject

is

encouraged

to

relax

and

to

increase

the

amount

of

time

the

signal

is

heard

that

is

to

say

to

increase

the

amount

of

time

that

the

amplitude

of

each

defined

bandwidth

exceeds

the

threshold

A

variety

of

equipment

and

software

has

been

used

to

acquire

process

and

filter

these

signals

and

there

are

differences

in

technique

inherent

with

equipment

and

software

Alpha-theta

feedback

training

was

first

employed

and

described

by

Elmer

Green

and

colleagues

-LRB-

Green

et

al.

-RRB-

at

the

Menninger

Clinic

This

method

was

based

on

Green

's

observations

of

single

lead

EEG

during

meditative

states

in

practiced

meditators

during

which

increased

theta

amplitude

was

observed

following

an

initial

increased

alpha

amplitude

then

a

drop

off

of

alpha

amplitude

-LRB-

theta/alpha

crossover

-RRB-

When

the

feedback

of

the

alpha

and

theta

signal

was

applied

to

subjects

states

of

profound

relaxation

and

reverie

were

reported

to

occur

The

method

was

seen

as

useful

in

augmenting

psychotherapy

and

promoting

individual

insight

It

could

be

seen

as

a

use

of

brain

wave

signal

feedback

to

enable

a

subject

to

maintain

a

particular

state

of

consciousness

similar

to

a

meditative

or

hypnotic

relaxed

state

over

a

or

feedback

session

Goslinga

-LRB-

-RRB-

gave

the

first

description

of

the

use

of

alpha-theta

feedback

in

a

SUD

treatment

program

This

integrated

program

started

in

at

the

Topeka

VA

and

included

group

and

individual

therapies

Daily

EEG

biofeedback

sessions

-LRB-

integrated

with

EMG

biofeedback

and

temperature

control

biofeedback

-RRB-

were

conducted

over

weeks

resulting

in

free

loose

associations

heightened

sensitivity

and

increased

suggestibility

Patients

discussed

their

insights

and

experiences

associated

with

biofeedback

in

therapy

groups

several

times

a

week

augmenting

expressive

psychotherapy

The

first

published

clinical

reports

of

efficacy

of

alpha-theta

training

at

the

Topeka

VA

were

by

Twemlow

and

Bowen

-LRB-

-RRB-

who

explored

the

impact

of

alpha-theta

training

on

psychodynamic

issues

in

non-psychotic

chronic

male

alcoholics

in

an

inpatient

treatment

program

In

this

non-controlled

study

they

found

that

religiousness

as

a

predictor

of

self-actualization

may

have

increased

as

a

result

of

imagery

experienced

in

theta

states

This

was

seen

as

positive

to

the

program

goal

of

augmenting

Alcoholics

Anonymous

as

a

recovery

philosophy

The

high

suggestibility

of

the

method

was

acknowledged

treatments

such

as

brainwave

training

which

utilize

abstract

ill

understood

techniques

are

potential

repositories

of

magical

projection

and

fantasy

and

would

logically

be

more

acceptable

to

alcoholics

who

are

able

to

have

faith

-LRB-

devoutly

or

moderately

religious

-RRB-

-LRB-

Twemlow

and

Bowen

-RRB-

In

another

uncontrolled

study

at

the

Topeka

VA

alcoholics

were

reported

to

exhibit

within

and

across

session

increases

in

raw

theta

amplitudes

at

occipital

areas

bilaterally

measured

by

single

lead

EEG

during

the

course

of

alpha-theta

training

becoming

more

able

to

achieve

deep

states

as

manifested

by

EEG

-LRB-

Twemlow

et

al.

-RRB-

These

initial

studies

advanced

the

utility

of

biofeedback

induced

theta

states

in

promoting

insight

and

attitude

change

in

alcoholics

with

the

assumptions

that

biofeedback-induced

theta

states

are

associated

with

heightened

awareness

and

suggestibility

and

that

this

heightened

awareness

and

suggestibility

would

enhance

recovery

Outcome

data

regarding

abstinence

were

not

reported

In

the

first

reported

randomized

and

controlled

study

of

alcoholics

treated

with

alpha-theta

EEG

biofeedback

Peniston

and

Kulkosky

-LRB-

-RRB-

described

positive

outcome

results

Their

subjects

were

inpatients

in

a

VA

hospital

treatment

program

all

males

with

established

chronic

alcoholism

and

multiple

past

failed

treatments

Following

a

temperature

biofeedback

pre-training

phase

Peniston

's

experimental

subjects

-LRB-

n

-RRB-

completed

sessions

of

eyes

closed

occipital

alpha-theta

biofeedback

Compared

to

a

traditionally

treated

alcoholic

control

group

-LRB-

n

-RRB-

and

nonalcoholic

controls

-LRB-

n

-RRB-

alcoholics

receiving

brainwave

biofeedback

showed

significant

increases

in

percentages

of

EEG

recorded

in

the

alpha

and

theta

rhythms

and

increased

alpha

rhythm

amplitudes

-LRB-

single

lead

measurements

at

international

site

-RRB-

The

experimentally

treated

subjects

showed

reductions

in

Beck

Depression

Inventory

scores

compared

to

the

control

groups

Control

subjects

who

received

standard

treatment

alone

showed

increased

levels

of

circulating

beta-endorphin

an

index

of

stress

whereas

the

EEG

biofeedback

group

did

not

Thirteen-month

follow-up

data

indicated

significantly

more

sustained

prevention

of

relapse

in

alcoholics

who

completed

alpha-theta

brainwave

training

as

compared

to

the

control

alcoholics

defining

successful

relapse

prevention

as

not

using

alcohol

for

more

than

six

contiguous

days

during

the

follow-up

period

In

a

further

report

on

the

same

control

and

experimental

subjects

Peniston

and

Kulkosky

-LRB-

-RRB-

described

substantial

changes

in

personality

test

results

in

the

experimental

group

as

compared

to

the

controls

The

experimental

group

showed

improvement

in

psychological

adjustment

on

scales

of

the

Millon

Clinical

Multiaxial

Inventory

compared

to

the

traditionally

treated

alcoholics

who

improved

on

only

two

scales

and

became

worse

on

one

scale

On

the

personality

inventory

the

neurofeedback

training

group

demonstrated

improvement

on

seven

scales

compared

to

only

one

scale

among

the

traditional

treatment

group

This

small

n

study

employed

controls

and

blind

outcome

evaluation

with

actual

outcome

figures

of

positive

outcome

versus

in

the

traditional

treatment

control

condition

at

follow

up

The

protocol

described

by

Peniston

at

the

Fort

Lyons

VA

cited

above

is

similar

to

that

initially

employed

by

Twemlow

and

colleagues

at

the

Topeka

VA

and

Elmer

Green

at

the

Menninger

Clinic

with

two

additions

i.e.

-LRB-

-RRB-

temperature

training

and

-LRB-

-RRB-

script

Peniston

introduced

temperature

biofeedback

training

as

a

preconditioning

relaxation

exercise

along

with

an

induction

script

to

be

read

at

the

start

of

each

session

This

protocol

-LRB-

described

as

follows

-RRB-

has

become

known

as

the

Peniston

Protocol

and

has

become

the

focus

of

research

in

subsequent

studies

Subjects

are

first

taught

deep

relaxation

by

skin

temperature

biofeedback

for

a

minimum

of

five

sessions

that

additionally

incorporates

autogenic

phrases

Peniston

also

used

the

criteria

of

obtaining

a

temperature

of

before

moving

on

to

EEG

biofeedback

Participants

then

are

instructed

in

EEG

biofeedback

and

in

an

eyes

closed

and

relaxed

condition

receive

auditory

signals

from

an

EEG

apparatus

using

an

international

site

single

electrode

A

standard

induction

script

employing

suggestions

to

relax

and

sink

down

into

reverie

is

read

When

alpha

-LRB-

Hz

-RRB-

brainwaves

exceed

a

preset

threshold

a

pleasant

tone

is

heard

and

by

learning

to

voluntarily

produce

this

tone

the

subject

becomes

progressively

relaxed

When

theta

brainwaves

-LRB-

Hz

-RRB-

are

produced

at

a

sufficiently

high

amplitude

a

second

tone

is

heard

and

the

subject

becomes

more

relaxed

and

according

to

Peniston

enters

a

hypnagogic

state

of

free

reverie

and

high

suggestibility

-LRB-

Although

theta

increase

and

alpha

decrease

are

thought

by

Peniston

to

be

associated

with

a

deeply

relaxed

state

where

hypnagogic

reverie

is

present

this

may

simply

represent

drowsiness

-RRB-

-LRB-

Niedermeyer

-RRB-

Following

the

session

with

the

subject

in

a

relaxed

and

suggestible

state

a

therapy

session

is

conducted

between

the

subject

and

therapist

where

the

contents

of

the

imagery

experienced

is

explored

and

abreactive

experiences

are

explored

-LRB-

Peniston

and

Kulkosky

-RRB-

Saxby

and

Peniston

-LRB-

-RRB-

reported

on

chronically

alcohol

dependent

and

depressed

outpatients

using

this

same

protocol

of

alpha-theta

brainwave

biofeedback

Following

treatment

subjects

showed

substantial

decreases

in

depression

and

psychopathology

as

measured

by

standard

instruments

Twenty-one

month

follow-up

data

indicated

sustained

abstinence

from

alcohol

confirmed

by

collateral

report

These

male

and

female

outpatients

received

sessions

of

feedback

Bodenhamer-Davis

and

Calloway

-LRB-

-RRB-

reported

a

clinical

trial

with

chemically

dependent

outpatients

of

whom

were

probationers

classified

as

high

risk

for

re-arrest

Subjects

completed

an

average

of

alpha-theta

biofeedback

sessions

Psychometrics

demonstrated

improvements

in

personality

and

mood

Follow-up

at

months

indicated

of

the

treatment

subjects

were

abstinent

Re-arrest

rates

and

probation

revocations

for

the

probation

treatment

group

were

lower

than

those

for

a

probation

comparison

group

-LRB-

vs.

-RRB-

Fahrion

-LRB-

-RRB-

gave

a

preliminary

report

-LRB-

n

-RRB-

on

a

large

randomized

study

of

alpha-theta

training

for

addiction

in

the

Kansas

Prison

System

using

group-training

equipment

A

report

of

the

completed

study

-LRB-

n

-RRB-

-LRB-

Fahrion

-RRB-

showed

little

difference

between

the

two

groups

overall

at

outcome

But

when

results

were

analyzed

for

age

race

and

drug

of

choice

neurofeedback

emerged

as

a

more

efficacious

treatment

for

younger

and

non-white

and

non-stimulant

abusing

participants

Interestingly

this

protocol

was

not

effective

for

cocaine

abusers

-LRB-

Stimulant

abusers

will

be

discussed

later

in

this

article

under

the

Scott

Kaiser

modification

of

the

Peniston

protocol

-RRB-

The

issue

of

alpha-theta

biofeedback

in

culturally

sensitive

groups

that

have

not

responded

to

traditional

modes

of

addiction

treatment

-LRB-

such

as

confrontational

group

therapies

-RRB-

has

been

considered

in

an

open

case

series

reported

by

Kelly

-LRB-

-RRB-

This

three

year

follow-up

study

presented

the

treatment

outcomes

of

Dine

-LRB-

Navajo

-RRB-

clients

Four

-LRB-

-RRB-

participants

achieved

sustained

full

remission

-LRB-

-RRB-

achieved

sustained

partial

remission

and

-LRB-

-RRB-

remained

dependent

The

majority

of

participants

also

showed

a

significant

increase

in

level

of

functioning

Schneider

et

al.

-LRB-

-RRB-

used

slow

cortical

potential

biofeedback

to

treat

unmedicated

alcoholic

patients

in

four

neurofeedback

sessions

after

hospitalization

Seven

patients

participated

in

a

fifth

session

an

average

of

months

later

Six

out

of

these

seven

patients

had

not

had

a

relapse

at

the

follow-up

These

results

are

similar

to

those

reported

for

alpha

theta

training

Several

other

studies

using

the

Peniston

protocol

and

its

modifications

reported

cases

with

positive

clinical

effects

-LRB-

Burkett

et

al.

DeBeus

et

al.

Fahrion

et

al.

Finkelberg

et

al.

Skok

et

al.

-RRB-

These

studies

suggest

that

an

applied

psychophysiological

approach

based

on

an

alpha-theta

biofeedback

protocol

is

a

valuable

alternative

to

conventional

substance

abuse

treatment

-LRB-

Walters

-RRB-

Nevertheless

most

of

these

results

were

reported

at

the

society

meetings

and

only

few

of

these

studies

were

published

in

mainstream

peer-reviewed

journals

other

than

The

Journal

of

Neurotherapy

A

critical

analysis

of

the

Peniston

Protocol

is

discussed

at

length

in

the

previous

reviews

-LRB-

Trudeau

b

-RRB-

Several

controlled

studies

of

the

Peniston

protocol

for

addictions

completed

by

Lowe

-LRB-

-RRB-

Moore

and

Trudeau

-LRB-

-RRB-

and

Taub

and

Rosenfeld

-LRB-

-RRB-

suggest

that

alpha-theta

training

for

addictions

may

be

non-specific

in

terms

of

effect

when

compared

to

suggestion

sham

or

controlled

treatment

or

meditational

techniques

By

contrast

Egner

et

al.

-LRB-

-RRB-

showed

that

alpha-theta

training

results

in

an

increase

of

theta/alpha

ratios

as

compared

to

a

control

condition

In

an

in

depth

critical

analysis

that

examines

inconsistencies

reported

in

the

original

Peniston

papers

Graap

and

Freides

-LRB-

-RRB-

raise

serious

issues

about

the

reporting

of

original

samples

and

procedures

in

these

studies

In

their

analyses

the

results

may

have

been

due

as

much

to

the

intense

therapies

accompanying

the

biofeedback

as

due

to

the

biofeedback

itself

The

subjects

may

have

been

comorbid

for

a

number

of

conditions

which

were

not

clearly

reported

particularly

PTSD

which

may

have

been

the

focus

of

the

treatment

In

his

reply

to

these

criticisms

Peniston

-LRB-

-RRB-

acknowledges

that

it

remains

unknown

whether

the

temperature

training

the

visualizations

the

ATBWNT

-LRB-

alpha-theta

brain

wave

neurotherapy

-RRB-

the

therapist

the

placebo

or

the

Hawthorne

effects

are

responsible

for

the

beneficial

results

The

criticism

raised

above

by

Graap

and

Friedes

-LRB-

-RRB-

regarding

Peniston

's

papers

could

also

be

applied

to

earlier

replication

studies

Neither

Peniston

's

studies

nor

the

replication

studies

provide

sufficient

detail

regarding

the

specifics

of

the

types

of

equipment

used

for

alpha-theta

feedback

including

filtering

methods

for

the

EEG

signal

or

other

technical

information

to

permit

exact

reproduction

of

the

feedback

protocols

with

other

equipment

Outcome

criteria

also

vary

in

the

replication

studies

with

varying

measures

of

abstinence

and

improvement

An

exception

to

these

concerns

is

the

report

of

Scott

et

al.

-LRB-

-RRB-

which

will

be

discussed

later

in

greater

detail

It

should

be

noted

that

psychostimulant

-LRB-

cocaine

methamphetamine

-RRB-

addictions

may

require

approaches

and

neurofeedback

protocols

other

than

alpha/theta

training

Persons

who

are

cocaine-dependent

are

cortically

under-aroused

during

protracted

abstinence

-LRB-

Roemer

et

al.

-RRB-

qEEG

changes

such

as

a

decrease

in

high

beta

-LRB-

Hz

-RRB-

power

are

typical

for

withdrawal

from

cocaine

-LRB-

Noldy

et

al.

-RRB-

Cocaine

abusers

who

are

still

taking

this

drug

often

show

low

amounts

of

delta

and

excess

amounts

of

alpha

and

beta

activity

-LRB-

Alper

Prichep

et

al.

-RRB-

whereas

chronic

methamphetamine

abusers

usually

exhibit

excessive

delta

and

theta

activity

-LRB-

Newton

et

al.

-RRB-

Thus

cocaine

and

methamphetamine

users

may

warrant

a

different

EEG

biofeedback

protocol

at

least

at

the

beginning

stages

of

neurofeedback

therapy

The

Scott

Kaiser

Modification

of

the

Peniston

Protocol

Scott

and

Kaiser

-LRB-

-RRB-

describe

combining

a

protocol

for

attentional

training

-LRB-

beta

and/or

SMR

augmentation

with

theta

suppression

-RRB-

with

the

Peniston

protocol

-LRB-

alpha-theta

training

-RRB-

in

a

population

of

subjects

with

mixed

substance

abuse

rich

in

stimulant

abusers

The

beta

protocol

is

similar

to

that

used

in

ADHD

-LRB-

Kaiser

and

Othmer

-RRB-

and

was

used

until

measures

of

attention

normalized

and

then

the

standard

Peniston

protocol

without

temperature

training

was

applied

-LRB-

Scott

et

al.

-RRB-

The

study

group

is

substantially

different

than

that

reported

in

either

the

Peniston

or

replication

studies

The

rationale

is

based

in

part

on

reports

of

substantial

alteration

of

qEEG

seen

in

stimulant

abusers

associated

with

early

treatment

failure

-LRB-

Prichep

et

al.

-RRB-

likely

associated

with

marked

frontal

neurotoxicity

and

alterations

in

dopamine

receptor

mechanisms

-LRB-

Alper

-RRB-

Additionally

preexisting

ADHD

is

associated

with

stimulant

preference

in

adult

substance

abusers

and

is

independent

of

stimulant

associated

qEEG

changes

These

findings

of

chronic

EEG

abnormality

and

high

incidence

of

preexisting

ADHD

in

stimulant

abusers

suggest

they

may

be

less

able

to

engage

in

the

hypnagogic

and

auto-suggestive

Peniston

protocol

-LRB-

Trudeau

et

al.

-RRB-

Furthermore

eyes-closed

alpha

feedback

as

a

starting

protocol

may

be

deleterious

in

stimulant

abusers

because

the

most

common

EEG

abnormality

in

crack

cocaine

addicts

is

excess

frontal

alpha

-LRB-

Prichep

et

al.

-RRB-

In

their

initial

report

Scott

and

Kaiser

-LRB-

-RRB-

described

substantial

improvement

in

measures

of

attention

and

also

of

personality

-LRB-

similar

to

those

reported

by

Peniston

and

Kulkosky

-RRB-

Their

experimental

subjects

underwent

an

average

of

SMR-beta

-LRB-

Hz

-RRB-

neurofeedback

training

sessions

followed

by

alpha-theta

sessions

during

the

first

days

of

treatment

Treatment

retention

was

significantly

better

in

the

EEG

biofeedback

group

and

was

associated

with

the

initial

SMR-beta

training

A

subsequent

published

paper

-LRB-

Scott

et

al.

-RRB-

reported

on

an

expanded

series

of

inpatient

drug

program

subjects

randomized

to

condition

followed

up

at

year

Subjects

were

tested

and

controlled

for

the

presence

of

attentional

and

cognitive

deficits

personality

states

and

traits

The

experimental

group

showed

normalization

of

attentional

variables

following

the

SMR-Beta

portion

of

the

neurofeedback

while

the

control

group

showed

no

improvement

Experimental

subjects

demonstrated

significant

changes

-LRB-

p

-RRB-

beyond

the

control

subjects

on

of

the

scales

of

the

Subjects

in

the

experimental

group

were

also

more

likely

to

stay

in

treatment

longer

and

more

likely

to

complete

treatment

as

compared

to

the

control

group

Finally

the

one-year

sustained

abstinence

levels

were

significantly

higher

for

the

experimental

group

as

compared

to

the

control

group

The

approach

of

beta

training

in

conjunction

with

alpha-theta

training

has

been

applied

successfully

in

a

treatment

program

aimed

at

homeless

crack

cocaine

abusers

in

Houston

as

reported

by

Burkett

et

al.

-LRB-

-RRB-

with

impressive

results

Two

hundred

and

seventy

-LRB-

-RRB-

male

addicts

received

sessions

of

a

protocol

similar

to

the

Scott

Kaiser

modification

One-year

follow-up

evaluations

of

treatment

completers

indicated

that

of

subjects

were

maintaining

a

regular

residence

were

employed/in

school

or

training

and

had

no

subsequent

arrests

Self-report

depression

scores

dropped

by

and

self-report

anxiety

scores

by

Furthermore

reported

no

alcohol

or

drug

use

months

after

biofeedback

and

used

drugs

or

alcohol

only

one

to

three

times

after

their

stay

This

was

a

substantial

improvement

from

the

expected

or

less

expected

recovery

in

this

group

The

remaining

reported

using

drugs

or

alcohol

more

than

times

over

the

year

Urinalysis

results

corroborated

self-reports

of

drug

use

The

treatment

program

saw

substantial

changes

in

length

of

stay

and

completion

After

the

introduction

of

the

neurofeedback

to

the

mission

regimen

length

of

stay

tripled

beginning

at

days

on

average

and

culminating

at

days

after

the

addition

of

neurotherapy

In

a

later

study

the

authors

reported

follow-up

results

on

subjects

after

completion

of

neurofeedback

training

-LRB-

Burkett

et

al.

-RRB-

The

follow-up

measures

of

drug

screens

length

of

residence

and

self-reported

depression

scores

showed

significant

improvement

It

should

be

noted

that

this

study

had

limitations

because

neurofeedback

was

positioned

only

as

an

adjunct

therapy

to

all

other

faith-based

treatments

for

crack

cocaine

abusing

homeless

persons

enrolled

in

this

residential

shelter

mission

and

was

an

uncontrolled

study

Yet

the

improvement

in

program

retention

is

impressive

and

may

well

be

related

to

the

improved

outcome

Continuing

Research

Self-Perception

and

Experimental

Schemata

in

the

Addicted

Brain

Rex

Cannon

Joel

Lubar

and

Deborah

Baldwin

of

the

Brain

Research

and

Neuropsychology

Laboratory

at

University

of

Tennessee

at

Knoxville

are

performing

research

with

three

goals

in

mind

First

to

attempt

to

reconcile

and

integrate

data

from

all

disciplines

involved

in

addiction

research

in

order

to

develop

a

novel

approach

for

neurophysiological

study

pertaining

to

SUD

and

conceivably

determine

and

describe

EEG

source

generators

that

are

instrumental

in

the

processes

of

self-perception

and

experiential

schemata

utilizing

a

recently

developed

assessment

instrument

Second

to

utilize

this

information

to

develop

an

integrative

treatment

model

for

addictive

disorders

based

on

this

research

involving

novel

group

processing

methods

and

spatial

specific

neurophysiological

operant

learning

-LRB-

LORETA

Neurofeedback

-RRB-

-LRB-

Cannon

et

al.

Congedo

Congedo

et

al.

-RRB-

and

finally

third

to

utilize

both

the

assessment

and

neurophysiological

data

for

development

of

statistical

models

for

possible

diagnostic

and

predictive

purposes

and

to

provide

a

means

for

a

neurophysiological

measure

of

treatment

efficacy

Research

indicates

that

substance

abusers

have

elevated

beta

activity

in

an

EEG

resting

state

as

compared

with

normative

groups

-LRB-

Rangaswany

et

al.

-RRB-

and

elevated

alpha

activity

after

administering

a

mood

altering

substance

-LRB-

Cohen

et

al.

Kaplan

et

al.

-RRB-

It

is

suggested

that

many

of

the

neurophysiological

markers

may

provide

information

about

the

state

of

the

individual

prior

to

the

development

of

an

addictive

disorder

and

that

these

brain

functions

are

under

genetic

control

-LRB-

Porjesz

et

al.

Tapert

-RRB-

Kaplan

et

al.

-LRB-

-RRB-

reported

lower

frontal

alpha

and

slow-beta

coherence

in

alcohol-dependent

males

and

females

Michael

et

al.

-LRB-

-RRB-

found

higher

central

alpha

and

slow-beta

coherence

but

lower

parietal

alpha

and

slow-beta

coherence

in

males

with

alcohol

dependence

contrarily

other

findings

suggest

that

morphine

alcohol

and

marijuana

show

increased

alpha

power

in

the

spectral

EEG

and

relate

this

to

the

euphoric

state

produced

by

the

drug

-LRB-

Lukas

-RRB-

Winterer

et

al.

-LRB-

b

-RRB-

described

higher

left-temporal

alpha

and

slow-beta

coherence

and

higher

slow-beta

coherence

at

right-temporal

and

frontal

electrode

pairs

in

alcohol-dependent

males

and

females

De

Bruin

et

al.

-LRB-

-RRB-

showed

that

moderate-to-heavy

alcohol

consumption

is

associated

with

differences

in

synchronization

of

brain

activity

during

rest

and

mental

rehearsal

Heavy

drinkers

displayed

a

loss

of

hemispheric

asymmetry

of

EEG

synchronization

in

the

alpha

and

low-beta

band

Moderately

and

heavily

drinking

males

additionally

showed

lower

fast-beta

band

synchronization

Decision-making

processes

and

the

ability

to

form

a

resistance

to

drugs

i.e.

the

ability

to

say

no

involve

numerous

brain

regions

including

the

insular

somatosensory

orbitofrontal

anterior

cingulate

and

dorsolateral

prefrontal

cortices

as

well

as

the

amygdala

hippocampus

and

thalamic

nuclei

-LRB-

Bechara

-RRB-

This

research

considers

the

integration

of

the

features

of

addicted

persons

as

reported

in

earlier

studies

case

reports

and

theoretical

concepts

as

vital

in

understanding

behavioral

manifestations

of

the

suspected

neural

pathways

that

are

premised

to

be

involved

in

the

development

of

SUD

Some

of

the

fundamental

descriptions

of

addicted

individuals

portray

them

as

passive

with

dependent

strivings

emotionally

immature

abounding

with

fears

of

responsibility

or

independent

action

and

ultimately

infantile

inadequate

personalities

-LRB-

Coodley

-RRB-

as

well

as

emotionally

socially

and

educationally

underdeveloped

-LRB-

Meyerstein

-RRB-

and

immature

and

regressive

-LRB-

Dorsey

Gerard

and

Kornetsky

Hill

-RRB-

These

individuals

are

reported

to

struggle

with

affirming

positive

thoughts

of

self-esteem

tendencies

to

undervalue

themselves

and

be

self

deprecating

and

exhibit

difficulty

adjusting

to

others

and

these

tendencies

are

veiled

by

overt

behavioral

patterns

including

physical

or

verbal

abuse

Individuals

with

SUD

present

with

a

vast

number

of

paradoxical

characteristics

including

an

overwhelming

sense

of

inadequacy

disguised

by

an

apparent

overwhelming

sense

of

confidence

Similarly

an

apparent

abundance

of

anger

and

aggression

utilized

as

a

disguise

for

a

paralyzing

sense

of

fear

more

specifically

fear

of

people

economic

insecurity

rejection

and

alienation

which

paradoxically

are

exacerbated

by

the

continued

use

of

the

substance

One

of

the

more

profound

idiosyncratic

characteristics

of

this

population

is

the

tendency

to

ruminate

and

associate

past

events

perceptions

and

the

associated

emotions

with

both

present

and

future

The

perception

of

experience

is

often

clouded

by

the

personalization

of

events

-LRB-

real

or

imagined

-RRB-

and

reinforced

with

a

deliberate

ambiguous

effort

to

avoid

reconciling

this

confound

which

reinforces

an

uninhibited

association

of

all

current

interactions

and

situations

with

past

events

Opposite

to

what

often

is

implied

these

features

may

not

originate

from

the

consequences

of

substance

abuse

but

from

earlier

periods

in

development

-LRB-

Vos

-RRB-

and

in

the

perspective

of

this

research

these

features

and

others

have

an

etiology

in

specific

neurophysiological

regions

that

are

the

direct

result

of

dendritic

pruning

that

occurs

in

early

development

that

continues

on

into

adolescence

and

unless

intervention

or

awareness

of

these

schemata

are

achieved

they

remain

problematic

into

adulthood

To

date

studies

identifying

such

schematic

source

generators

and

their

relationship

with

SUD

using

qEEG

and

standardized

low-resolution

electromagnetic

tomography

-LRB-

sLORETA

-RRB-

are

scant

This

research

is

designed

to

assess

the

neural

activation

patterns

relative

to

schemata

regarding

the

self

in

recovering

addicts

and

identify

possible

generators

in

the

cortex

as

compared

to

controls

In

this

research

it

is

hypothesized

that

there

is

dendritic

pruning

early

in

developmental

phases

that

contribute

to

frequency

specific

activity

in

neuronal

populations

in

the

ventromedial

portions

of

the

prefrontal

cortex

and

limbic

regions

Furthermore

it

is

proposed

that

these

neural

pathways

hinder

the

integration

of

affect

cognition

reward

and

decision-making

processes

and

adversely

influence

the

perception

of

self

and

self

in

relation

to

experience

and

the

development

of

adaptive

schemata

and

personality

characteristics

Integration

of

Cognitive

Neuroscience

Approaches

in

Assessment

of

Functional

Outcomes

of

Neurofeedback

and

Behavioral

Therapy

Based

Interventions

in

SUD

Sokhadze

et

al.

-LRB-

-RRB-

in

their

conceptual

review

proposed

an

integrated

approach

to

assessment

and

treatment

utilizing

cognitive

neuroscience

methods

-LRB-

e.g.

qEEG

ERP

-RRB-

conventional

psychotherapeutic

treatment

and

neurofeedback

therapy

to

assess

the

recovery

of

cognitive

and

emotional

functions

affected

by

chronic

psychostimulant

drug

abuse

co-occurring

with

PTSD

Cognitive

neuroscience

methodologies

used

for

assessment

of

the

outcome

effects

of

psychotherapy

and

neurofeedback

interventions

for

comorbid

disorders

have

significant

potential

for

additionally

identifying

neurophysiological

and

clinical

markers

of

treatment

progress

-LRB-

Sokhadze

-RRB-

These

outcome

markers

may

provide

useful

information

for

planning

bio-behavioral

interventions

in

this

form

of

dual

diagnosis

Stotts

and

colleagues

-LRB-

-RRB-

at

the

University

of

Texas

at

Houston

in

collaboration

with

researchers

at

Rice

University

used

motivational

interviewing

-LRB-

MI

-RRB-

with

personalized

feedback

particularly

employing

the

ERP

markers

of

deficiencies

in

selective

attention

task

produced

by

cocaine

abuse

in

crack

addicts

In

a

randomized

controlled

pilot

study

these

authors

-LRB-

Stotts

et

al.

Sokhadze

et

al.

-RRB-

evaluated

the

feasibility

and

preliminary

efficacy

of

a

brief

MI

intervention

using

EEG/ERP

graphical

feedback

for

crack

cocaine

abusers

Treatment-seeking

cocaine

abusers

-LRB-

N

-RRB-

were

randomly

assigned

to

a

two-session

MI

intervention

or

a

general

educational

drug

conseiling

-LRB-

control

-RRB-

condition

All

participants

received

EEG

assessments

based

on

dense-array

ERP

tests

in

a

selective

attention

task

at

intake

and

post-treatment

Results

indicated

that

the

MI

intervention

was

feasible

and

the

subjective

impact

of

the

EEG/ERP

feedback

was

positive

Significant

group

differences

in

percentage

of

cocaine

positive

urine

screens

across

the

study

were

found

favoring

the

MI

group

for

the

control

group

and

in

the

MI

group

In

a

current

study

at

the

University

of

Louisville

Tato

Sokhadze

and

his

colleagues

are

utilizing

dense-array

qEEG/ERP

variables

and

measures

of

behavioral

performance

on

mental

tasks

-LRB-

reaction

time

accuracy

-RRB-

to

explore

the

cognitive

functions

in

patients

with

cocaine

abuse/dependence

diagnosis

and

the

recovery

of

these

functions

during

bio-behavioral

intervention

based

on

an

integrated

neurofeedback

approach

-LRB-

NFB

Scott

Kaiser

protocol

-RRB-

and

motivational

enhancement

therapy

-LRB-

MET

-RRB-

in

an

outpatient

population

The

purpose

of

this

research

is

also

to

characterize

changes

in

cognitive

functioning

associated

with

the

success

rate

of

three

arms

for

cocaine

addiction

treatment

-LRB-

MET

NFB

combined

MET

NFB

-RRB-

Prior

during

and

subsequent

to

the

above

bio-behavioral

therapies

individual

differences

in

qEEG

and

dense-array

ERP

are

being

assessed

during

cognitive

tasks

containing

drug-related

and

generally

affective

cues

and

during

cognitive

tasks

aimed

to

test

cortical

inhibitory

capacity

selective

attention

response

error

processing

and

cortical

functional

connectivity

Preliminary

data

from

this

study

were

presented

at

the

annual

meeting

of

ISNR

-LRB-

Sokhadze

et

al.

-RRB-

and

are

being

prepared

for

the

publication

Efficacy

of

Alpha

Theta

Training

The

Guidelines

for

Evaluation

of

Clinical

Efficacy

of

Psychophysiological

Interventions

-LRB-

LaVaque

et

al.

-RRB-

which

have

been

accepted

by

AAPB

and

ISNR

specify

five

types

of

classification

for

the

effectiveness

of

biofeedback

procedures

ranging

from

Not

empirically

supported

to

Efficacious

and

Specific

The

requirements

for

each

classification

level

are

summarized

in

brief

below

A

more

complete

description

may

be

found

in

LaVaque

et

al.

-LRB-

-RRB-

Criteria

for

Levels

of

Evidence

of

Efficacy

Level

Not

empirically

supported

This

classification

is

assigned

to

those

treatments

that

have

only

been

described

and

supported

by

anecdotal

reports

and/or

case

studies

in

non-peer

reviewed

journals

Level

Possibly

efficacious

This

classification

is

considered

appropriate

for

those

treatments

that

have

been

investigated

in

at

least

one

study

that

had

sufficient

statistical

power

well-identified

outcome

measures

but

lacked

randomized

assignment

to

a

control

condition

internal

to

the

study

Level

Probably

efficacious

Treatment

approaches

that

have

been

evaluated

and

shown

to

produce

beneficial

effects

in

multiple

observational

studies

clinical

studies

wait

list

control

studies

and

within-subject

and

between-subject

replication

studies

merit

this

classification

Level

Efficacious

In

order

to

be

considered

efficacious

a

treatment

must

meet

the

following

criteria

In

a

comparison

with

a

no-treatment

control

group

alternative

treatment

group

or

sham

-LRB-

placebo

-RRB-

control

utilizing

randomized

assignment

the

investigational

treatment

is

shown

to

be

statistically

significantly

superior

to

the

control

condition

or

the

investigational

treatment

is

equivalent

to

a

treatment

of

established

efficacy

in

a

study

with

sufficient

power

to

detect

moderate

differences

The

studies

have

been

conducted

with

a

population

treated

for

a

specific

problem

from

whom

inclusion

criteria

are

delineated

in

a

reliable

operationally

defined

manner

The

study

used

valid

and

clearly

specified

outcome

measures

related

to

the

problem

being

treated

The

data

are

subjected

to

appropriate

data

analysis

The

diagnostic

and

treatment

variables

and

procedures

are

clearly

defined

in

a

manner

that

permits

replication

of

the

study

by

independent

researchers

andThe

superiority

or

equivalence

of

the

investigational

treatment

have

been

shown

in

at

least

two

independent

studies

-LRB-

LaVaque

et

al.

p.

-RRB-

Level

Efficacious

and

Specific

To

meet

the

criteria

for

this

classification

the

treatment

needs

to

be

demonstrated

to

be

statistically

superior

to

a

credible

sham

therapy

pill

or

bona

fide

treatment

in

at

least

two

independent

studies

Using

these

criteria

and

based

on

the

studies

reported

to

date

alpha-theta

training

can

be

classified

as

Level

probably

efficacious

when

combined

with

an

inpatient

rehabilitative

treatment

modality

in

subjects

with

long

standing

alcohol

dependency

This

classification

is

based

on

the

original

randomized

and

controlled

study

of

the

Peniston

Protocol

-LRB-

Peniston

and

Kulkosky

-RRB-

and

multiple

observational

and

uncontrolled

studies

that

preceeded

-LRB-

Twemlow

and

Bowen

Twemlow

et

al.

-RRB-

and

followed

these

studies

-LRB-

DeBeus

et

al.

Burkett

et

al.

Fahrion

et

al.

Finkelberg

et

al.

Skok

et

al.

Bodenhamer-Davis

and

Calloway

Saxby

and

Peniston

Fahrion

-RRB-

Using

these

criteria

and

based

on

reported

studies

to

date

the

Scott

Kaiser

modification

of

the

Peniston

Protocol

can

also

be

classified

as

probably

efficacious

-LRB-

Level

-RRB-

when

combined

with

residential

rehabilitation

modalities

in

stimulant

abusers

This

rating

is

based

on

one

controlled

study

of

subjects

in

which

Peniston

's

outcomes

of

both

psychometric

improvement

and

abstinence

improvement

were

replicated

-LRB-

Scott

et

al.

-RRB-

and

one

observational

study

of

subjects

-LRB-

Burkett

et

al.

-RRB-

Alpha-theta

training

protocols

do

not

completely

meet

the

criteria

for

the

Level

efficacious

classification

Although

there

are

sufficient

studies

that

show

statistically

significant

superiority

of

randomly

assigned

treatment

groups

to

no-treatment

control

groups

and

studies

have

been

conducted

with

populations

treated

for

a

specific

problem

from

whom

inclusion

criteria

are

delineated

in

a

reliable

operationally

defined

manner

and

the

studies

cited

use

valid

and

clearly

specified

outcome

measures

related

to

the

problem

being

treated

with

data

subjected

to

appropriate

data

analysis

there

remains

the

shortcoming

cited

by

Graap

and

Freides

-LRB-

-RRB-

for

the

initial

reports

of

Peniston

and

Kulkosky

-LRB-

-RRB-

We

recall

the

qualifying

limitations

of

LaVaque

et

al.

-LRB-

-RRB-

who

stated

that

the

diagnostic

and

treatment

variables

and

procedures

are

not

clearly

defined

in

a

manner

that

permits

replication

of

the

study

by

independent

researchers

-LRB-

p.

-RRB-

However

the

Scott

et

al.

-LRB-

-RRB-

report

does

appear

to

clearly

delineate

treatment

variables

and

procedures

One

other

independent

study

showing

the

superiority

of

modified

alpha-theta

training

to

control

condition

would

meet

the

stated

criteria

for

a

Level

efficaceous

classification

To

be

considered

Level

-LRB-

efficacious

and

specific

-RRB-

modified

alpha-theta

training

would

need

to

be

shown

to

be

superior

to

sham

or

bona

fide

treatment

It

has

not

been

demonstrated

that

the

Peniston

type

alpha-theta

feedback

is

more

efficacious

than

sham

treatment

-LRB-

Trudeau

b

Lowe

Moore

and

Trudeau

-RRB-

or

alternative

treatment

that

involves

meditation

-LRB-

Taub

and

Rosenfeld

-RRB-

Clinical

Considerations

Comorbidities

of

SUD

and

Implications

for

Individualized

-LRB-

qEEG-Guided

-RRB-

Neurofeedback

There

are

several

conditions

commonly

associated

with

addictive

disorders

that

have

known

neurophysiological

aberrations

The

co-occurrence

of

alcohol

and

other

SUD

with

other

psychiatric

disorders

has

been

widely

recognized

Co-occurrence

of

SUD

and

other

psychiatric

diagnosis

-LRB-

e.g.

PTSD

antisocial

personality

disorder

ADHD

unipolar

depression

etc.

-RRB-

is

highly

prevalent

-LRB-

Drake

and

Walach

Evans

and

Sullivan

Grant

et

al.

Jacobsen

et

al.

-RRB-

Persons

with

co-occurring

other

mental

disorders

and

SUD

have

a

more

persistent

illness

course

and

are

more

refractive

to

treatment

than

those

without

dual

diagnoses

-LRB-

Brown

et

al.

O'Brien

et

al.

Schubiner

et

al.

Swartz

and

Lurigio

-RRB-

Depression

occurs

in

approximately

of

chronic

alcoholics

-LRB-

Regier

et

al.

-RRB-

In

treatment

settings

these

depressed

patients

can

present

particular

challenges

to

the

clinician

as

they

may

not

respond

as

well

to

treatment

as

other

patients

may

have

greater

relapse

attrition

and

readmission

rates

and

may

manifest

symptoms

that

are

more

severe

chronic

and

refractory

in

nature

-LRB-

Sheehan

-RRB-

Independent

of

other

psychiatric

comorbidity

ADHD

alone

significantly

increases

the

risk

for

SUD

-LRB-

Biederman

et

al.

-RRB-

Associated

social

and

behavioral

problems

may

make

individuals

with

comorbid

SUD

and

ADHD

treatment

resistant

-LRB-

Wilens

et

al.

-RRB-

In

males

ages

the

presence

of

childhood

ADHD

and

conduct

disorder

is

associated

with

non-alcohol

SUD

-LRB-

Gittleman

et

al.

Manuzza

et

al.

-RRB-

In

summary

childhood

ADHD

associated

with

conduct

disorder

in

males

is

an

antecedent

for

adult

non-alcohol

SUD

and

anti-social

personality

disorder

-LRB-

Wender

-RRB-

The

incidence

of

ADHD

in

clinical

SUD

populations

has

been

studied

and

may

be

as

high

as

for

adults

-LRB-

Downey

et

al.

-RRB-

and

adolescents

-LRB-

Horner

and

Scheibe

-RRB-

Adult

residual

ADHD

is

especially

associated

with

cocaine

abuse

and

other

stimulant

abuse

-LRB-

Levin

and

Kleber

-RRB-

Monastra

et

al.

-LRB-

-RRB-

in

a

white

paper

review

of

ADHD

cite

positive

treatment

outcomes

of

just

under

in

treatment

of

ADHD

with

neurofeedback

Rates

of

PTSD

occurring

in

persons

primarily

identified

with

or

in

treatment

for

substance

abuse

vary

from

-LRB-

Breslau

et

al.

-RRB-

up

to

-LRB-

Triffleman

et

al.

-RRB-

In

a

general

population

study

Cottler

et

al.

-LRB-

-RRB-

reported

that

cocaine

abusers

were

three

times

more

likely

to

meet

diagnostic

criteria

for

PTSD

compared

to

individuals

without

a

SUD

Kalechstein

et

al.

-LRB-

-RRB-

found

that

methamphetamine-dependent

individuals

are

at

greater

risk

to

experience

particular

psychiatric

symptoms

There

was

reported

a

significant

dependence-by-gender

effect

with

methamphetamine-dependent

females

reporting

significantly

more

overall

posttraumatic

stress

symptomatology

compared

to

females

reporting

no

dependence

whereas

males

significantly

differed

only

with

respect

to

depression

Peniston

and

Kulkosky

-LRB-

-RRB-

reported

effective

treatment

of

PTSD

using

a

protocol

similar

to

the

one

they

employed

for

alcoholics

Hughes

and

John

-LRB-

-RRB-

review

the

applicability

of

qEEG

findings

in

SUD

They

note

that

in

numerous

qEEG

studies

there

is

a

consensus

of

increased

beta

relative

power

in

alcoholism

and

increased

alpha

in

cannabis

and

crack

cocaine

users

They

conclude

that

the

evidence

provided

by

studies

to

date

is

insufficient

to

recommend

qEEG

as

a

routine

clinical

assessment

tool

in

SUD

although

it

may

be

useful

in

differential

diagnosis

in

difficult

cases

A

number

of

specific

qEEG

abnormalities

have

been

described

as

specific

to

suspected

neurotoxicities

associated

with

chronic

stimulant

abuse

These

studies

-LRB-

Alper

et

al.

Noldy

et

al.

Prichep

et

al.

Roemer

et

al.

Trudeau

et

al.

-RRB-

based

on

reasonably

uniform

abstinence

times

and

employing

different

EEG

technology

and

analytical

approaches

have

produced

remarkably

similar

findings

of

alpha

relative

amplitude

excess

with

delta

relative

amplitude

deficit

that

is

striking

Excess

alpha

amplitude

with

slowing

of

alpha

frequency

associated

with

chronic

cannabis

abuse

has

been

reported

-LRB-

Struve

et

al.

-RRB-

As

noted

Scott

and

Kaiser

-LRB-

-RRB-

describe

combining

a

protocol

for

attentional

training

-LRB-

beta

reward

-RRB-

with

alpha-theta

training

in

a

population

of

subjects

whose

primary

drugs

of

abuse

were

stimulants

and

who

had

features

of

ADHD

It

may

make

good

sense

clinically

to

consider

specific

neurotherapy

treatment

of

these

disorders

either

in

place

of

or

preceding

alpha-theta

therapy

similar

to

the

Scott

Kaiser

approach

Second

applicable

neurotherapy

approaches

are

attractive

alternative

therapies

for

coexisting

or

underlying

conditions

in

SUD

clients

who

have

high-risk

behaviors

for

medication

treatment

such

as

overdosing

abuse

or

poor

compliance

While

there

are

no

published

systematic

studies

of

neurotherapy

treatment

of

co-occurring

depression

TBI

ADHD

PTSD

or

drug

neurotoxicity

on

the

course

and

outcome

of

addictive

disorders

several

recent

reports

of

neurotherapy

for

addictions

based

on

qEEG

findings

which

in

turn

may

be

related

to

comorbidities

have

been

presented

Basically

this

technique

involves

the

use

of

qEEG

to

identify

patterns

of

EEG

that

deviate

from

standardized

norms

and

individualized

EEG

biofeedback

protocols

to

correct

them

-LRB-

Romano-Micha

-RRB-

DeBeus

et

al.

-LRB-

-RRB-

are

presently

conducting

a

randomized

controlled

study

of

neurotherapy

for

SUD

that

examines

the

difference

between

a

qEEG-based

treatment

a

research-based

-LRB-

Scott

Peniston

-RRB-

treatment

and

a

wait-list

control

for

chemically

dependent

outpatients

Preliminary

results

are

promising

While

historically

alpha-theta

training

has

been

the

accepted

approach

in

treating

chemical

dependency

this

study

suggests

qEEG-based

training

is

a

viable

alternative

demonstrating

similar

outcomes

for

personality

change

and

abstinence

rates

Future

directions

include

determination

of

those

likely

to

benefit

from

one

of

the

particular

treatments

or

a

combination

of

the

two

and

analysis

of

long-term

abstinence

rates

Gurnee

-LRB-

-RRB-

has

presented

data

on

a

series

of

sequential

participants

with

SUD

who

were

treated

by

qEEG-based

neurotherapy

with

marked

heterogeneity

of

qEEG

subtypes

and

corresponding

symptom

complexes

In

this

clinically

derived

scheme

qEEGs

that

deviate

from

normative

databases

mainly

with

excess

alpha

amplitude

are

associated

more

often

with

depression

and

ADD

Those

with

deficient

alpha

amplitude

are

associated

with

anxiety

insomnia

and

alcohol/drug

abuse

Beta

excess

amplitude

is

associated

with

anxiety

insomnia

and

alcohol/drug

abuse

Central

abnormalities

are

interpreted

as

mesial

frontal

dysfunction

and

are

associated

with

anxiety

rumination

and

obsessive

compulsive

symptoms

The

therapeutic

approach

is

to

base

neurotherapy

on

correcting

identified

qEEG

abnormalities

i.e.

train

beta

excess

amplitude

down

when

present

while

monitoring

symptoms

Tentative

findings

suggest

that

qEEG

variables

may

be

used

to

predict

those

alcoholics

and

drug

abusers

most

at

risk

for

relapse

Winterer

et

al.

-LRB-

-RRB-

were

able

to

predict

relapse

among

chronic

alcoholics

with

success

significantly

outperforming

prediction

from

clinical

variables

Although

they

found

more

desynchronized

-LRB-

less

alpha

and

theta

and

more

beta

activity

-RRB-

over

frontal

areas

in

alcoholics

in

general

those

individuals

who

relapsed

displayed

even

more

of

this

activity

Bauer

-LRB-

-RRB-

obtained

EEG

data

on

alcohol

cocaine

or

opioid

dependent

patients

after

months

of

sobriety

Those

who

had

relapsed

by

months

later

were

also

characterized

by

increased

beta

-LRB-

Hz

-RRB-

activity

relative

to

those

maintaining

abstinence

Relative

beta

power

was

superior

to

severity

of

the

alcoholism

depression

level

antisocial

personality

disorder

childhood

conduct

problems

family

history

or

age

as

predictors

and

was

unaffected

by

the

substance

of

abuse

The

EEG

differences

between

relapse-prone

and

abstinence-prone

groups

were

found

to

be

related

to

the

interaction

of

two

premorbid

factors

childhood

conduct

disorder

and

paternal

alcoholism

These

findings

receive

further

support

from

Bauer

-LRB-

-RRB-

and

from

Prichep

et

al.

-LRB-

-RRB-

who

also

found

that

beta

activity

was

predictive

of

treatment

failure

They

found

two

clusters

among

cocaine

addicts

One

had

more

severe

damage

-LRB-

alpha

-RRB-

and

tended

to

remain

in

treatment

Those

with

less

severe

alpha

excess

and

more

beta

activity

tended

to

leave

treatment

They

also

discovered

that

dropouts

could

not

be

determined

from

the

presence

of

anxiety

or

depression

or

demographic

variables

Treatment

of

patients

with

substance

abuse

disorder

by

neurofeedback

may

become

more

complicated

when

patients

present

various

psychiatric

conditions

When

addiction

is

comorbid

with

ADHD

it

is

suggested

that

SMR

-LRB-

or

beta

increase

theta

decrease

-RRB-

training

should

be

conducted

to

address

the

related

ADHD

disorder

first

-LRB-

Biederman

et

al.

-RRB-

Applicability

of

neurofeedback

methods

to

treat

anxiety

and

affective

disorders

is

reviewed

by

Hammond

-LRB-

-RRB-

Peniston

and

Kulkosky

-LRB-

-RRB-

describe

personality

normalization

in

alcoholics

treated

with

EEG

biofeedback

Alpha-theta

feedback

has

also

been

reported

as

efficacious

in

alcoholics

with

depressive

symptoms

-LRB-

Saxby

and

Peniston

-RRB-

There

are

only

a

few

case

studies

on

the

efficacy

of

neurofeedback

for

treating

generalized

anxiety

disorder

-LRB-

Vanathy

et

al.

-RRB-

and

PTSD

-LRB-

Huang-Storms

et

al.

Graap

et

al.

-RRB-

Alpha-theta

feedback

has

been

described

as

efficacious

in

post-combat

PTSD

-LRB-

Peniston

and

Kulkosky

Peniston

et

al.

-RRB-

However

additional

research

needs

to

be

completed

to

determine

the

clinical

outcome

and

efficacy

of

bio-behavioral

treatment

based

on

brain

wave

self-regulation

in

addiction

disorders

that

are

comorbid

with

various

anxiety

disorders

and

PTSD

Clinical

Considerations

Cognitive-Behavioral

and

Neurofeedback

Treatment

in

Substance

Use

Disorders

Because

of

its

chronic

nature

long-term

treatment

for

SUD

is

usually

necessary

-LRB-

Crits-Christoph

et

al.

-RRB-

Effective

agonist

and

antagonist

pharmacotherapies

as

well

as

symptomatic

treatments

exist

for

opioid

dependence

but

neither

agonists

nor

antagonists

have

been

approved

as

uniquely

effective

for

treatment

of

stimulant

abuse

or

dependence

-LRB-

Grabowski

et

al.

-RRB-

There

is

no

current

evidence

supporting

the

clinical

use

of

carbamazepine

-LRB-

Tegretol

-RRB-

antidepressants

dopamine

agonists

-LRB-

drugs

commonly

used

to

treat

Parkinson

's

and

Restless

Leg

Syndrome

-RRB-

disulfiram

-LRB-

Antabuse

-RRB-

mazindol

-LRB-

an

experimental

anorectic

-RRB-

phenytoin

-LRB-

Dilantin

-RRB-

nimodipine

-LRB-

Nimotop

-RRB-

lithium

and

other

pharmacological

agents

in

the

treatment

of

cocaine

dependence

-LRB-

de

Lima

et

al.

Venneman

et

al.

-RRB-

Because

no

proven

effective

pharmacological

interventions

are

available

for

cocaine

addiction

or

for

methamphetamine

addiction

treatment

of

stimulant

addiction

has

to

rely

on

existing

cognitive-behavioral

therapies

-LRB-

CBT

-RRB-

or

CBT

combined

with

other

biobehavioral

approaches

-LRB-

Van

den

Brink

and

van

Ree

-RRB-

According

to

Volkow

et

al.

-LRB-

-RRB-

successful

strategies

for

behavioral

treatment

in

drug

addiction

may

include

-LRB-

-RRB-

interventions

aimed

to

decrease

the

reward

value

of

the

drug

and

simultaneously

increase

values

of

natural

reinforcement

-LRB-

-RRB-

approaches

aimed

to

change

stereotype

conditioned

drug-seeking

behaviors

and

-LRB-

-RRB-

methods

to

train

and

strengthen

frontal

inhibitory

control

Because

stressful

events

can

result

in

relapse

to

drug

taking

behavior

-LRB-

Koob

and

Le

Moal

-RRB-

an

adjunct

treatment

strategy

is

to

interfere

with

the

neurobiological

responses

to

stress

-LRB-

Goeders

Koob

and

Le

Moal

-RRB-

Treatment

of

comorbid

mental

conditions

may

also

require

the

concurrent

treatment

of

drug

addiction

In

some

cases

however

comorbid

drug

addiction

may

result

from

attempts

to

alleviate

the

psychiatric

disorder

through

self-medication

-LRB-

i.e.

co-occurring

cocaine

use

and

ADHD

and/or

heroin

addiction

co-occurring

with

PTSD

-RRB-

In

other

cases

severity

of

a

psychiatric

disorder

symptom

may

increase

as

a

result

of

drug

abuse

-LRB-

Volkow

et

al.

-RRB-

In

patients

with

drug

abuse

arising

from

an

attempt

to

self-medicate

-LRB-

Khantzian

-RRB-

treatment

of

the

comorbid

mental

disorder

may

help

prevent

abuse

For

instance

treatment

of

the

preexisting

condition

of

ADHD

may

prevent

cocaine

abuse

-LRB-

Biederman

et

al.

-RRB-

In

some

cases

though

the

persistent

qEEG

abnormalities

associated

with

chronic

SUD

may

happen

to

be

independent

from

ADHD

clinical

status

-LRB-

Trudeau

et

al.

-RRB-

The

co-occurrence

of

ADHD

and

SUD

has

received

considerable

attention

in

the

recent

clinical

and

scientific

literature

-LRB-

Davids

et

al.

-RRB-

These

two

disorders

are

often

linked

to

one

another

Because

the

core

symptoms

of

ADHD

may

be

mimicked

by

the

effects

of

psychoactive

drugs

it

is

difficult

to

diagnose

one

disorder

in

the

presence

of

the

other

-LRB-

Davids

et

al.

-RRB-

ADHD

has

been

found

to

be

associated

with

an

earlier

onset

of

SUD

-LRB-

Horner

and

Scheibe

-RRB-

It

is

generally

assumed

that

untreated

ADHD

is

a

risk

factor

for

SUD

development

-LRB-

Biederman

et

al.

Manuzza

et

al.

Trudeau

b

-RRB-

In

a

case

of

comorbidity

in

which

the

use

of

drugs

antecedes

a

mental

disease

-LRB-

e.g.

substance-induced

anxiety

disorder

DSM-IV-TR

APA

-RRB-

or

is

not

driven

by

self-medication

strategies

the

simultaneous

treatment

of

both

psychiatric

conditions

may

be

required

In

this

situation

treatment

could

be

guided

by

the

two

following

concepts

-LRB-

-RRB-

Behavioral

interventions

to

activate

and

strengthen

circuits

involved

in

inhibitory

control

such

as

bio-behavioral

self-regulation

training

may

increase

successful

abstinence

from

drug

taking

-LRB-

-RRB-

Considering

the

important

role

of

cognitive

and

emotional

processes

involved

in

the

predisposition

for

drug

abuse

the

development

of

non-pharmacological

interventions

-LRB-

e.g.

CBT

stress

management

neurofeedback

-RRB-

is

a

feasible

strategy

Directions

for

Further

Research

Specific

patterns

of

qEEG

abnormality

associated

with

specific

substance

use

toxicity

such

as

those

found

in

stimulant

abuse

or

alcohol

abuse

or

with

comorbidities

such

as

ADHD

-LRB-

Chabot

and

Serfontein

-RRB-

PTSD

-LRB-

Huang-Storms

et

al.

-RRB-

or

TBI

-LRB-

Thatcher

et

al.

-RRB-

suggest

underlying

brain

pathologies

that

might

be

amenable

to

EEG

biofeedback

that

is

tailored

to

the

person

These

approaches

would

likely

be

individualized

rather

than

protocol

based

and

would

be

used

independently

or

in

conjunction

with

classic

alpha-theta

training

By

way

of

example

these

could

include

protocols

specific

to

the

qEEG

abnormality

such

as

frontal

delta

reward

to

correct

the

frontal

delta

deficit

in

cocaine

abuse

that

Alper

-LRB-

-RRB-

hypothesizes

may

be

related

to

cocaine

sensitization

and

changes

in

dopamine

transmission

To

our

knowledge

this

has

never

been

studied

and

is

clearly

a

research

-LRB-

not

a

clinical

-RRB-

recommendation

The

qEEG

patterns

and

abnormalities

depend

significantly

on

whether

the

subject

is

still

currently

using

the

chronicity

of

use

and

the

current

stage

of

withdrawal

or

protracted

abstinence

A

neurofeedback

protocol

selected

for

an

individual

client

with

SUD

should

be

directly

related

to

the

level

of

current

substance

use

or

abstinence

especially

in

such

classes

of

drugs

as

heroin

where

the

withdrawal

syndrome

results

in

substantial

physiological

manifestations

including

transient

qEEG

changes

Even

though

there

are

no

reported

systematic

studies

of

EEG

biofeedback

treatment

of

commonly

occurring

comorbidities

of

SUD

it

makes

sense

that

clinical

EEG

biofeedback

treatment

study

protocols

consider

the

presence

of

ADHD

TBI

depression

and

drug-associated

neurotoxicity

This

approach

may

improve

outcome

especially

in

conventional

treatment

resistant

participants

Unfortunately

only

a

few

large-scale

studies

of

neurofeedback

in

addictive

disorders

have

been

reported

in

the

literature

Most

if

not

all

of

the

recommendations

previously

made

regarding

further

research

-LRB-

Trudeau

-RRB-

have

yet

to

be

implemented

These

recommendations

are

summarized

as

follows.Studies

require

external

systematic

replicability

of

brain

wave

feedback

methods

and

results

in

diverse

populations

that

include

various

control

and

alternative

treatment

conditions

wherein

the

groups

are

matched

on

key

dimensions.Details

need

to

be

given

regarding

the

equipment

that

was

used

and

the

associated

technical

specifications

-LRB-

e.g.

details

about

amplification

filtering

spectral

extraction

windowing

and

other

pertinent

information

-RRB-

needed

by

neurofeedback

specialists

for

replication

and

comparison.The

essential

components

and

durations

for

brain

wave

feedback

required

for

therapeutic

advantage

need

to

be

stated

including

double-blinded

studies

that

control

for

all

other

possible

therapeutic

effects.Open

clinical

trials

that

investigate

efficacy

of

the

types

of

protocols

used

for

ADHD

PTSD

depression

and

TBI

remediation

with

SUD

subjects

comorbid

for

those

conditions

need

to

be

reported.Open

clinical

trials

that

assess

the

efficacy

of

EEG

biofeedback

in

addressing

the

specific

qEEG

changes

of

chronic

alcohol

heroin

cannabis

and

stimulant

abuse

need

to

be

reported.The

physiological

and

psychological

processes

of

the

therapeutic

effects

of

EEG

biofeedback

including

studies

of

qEEG

and

ERP

changes

need

to

be

investigated

and

reported.Studies

need

to

adhere

to

clearly

defined

outcome

measures

that

have

established

reliability

and

validity

Other

important

recommendations

for

future

development

of

the

field

are

listed

below

The

availability

of

an

increased

number

of

channels

for

EEG

and

ERP

recording

-LRB-

e.g.

higher

spatial

sampling

rate

-RRB-

makes

it

possible

to

better

localize

the

source

of

brain

activity

More

focused

research

of

this

type

seems

warranted.There

are

several

specific

functional

diagnostic

tools

from

the

cognitive

neuroscience

arsenal

that

are

very

specific

for

testing

addictive

disorders

Those

that

may

be

especially

valuable

include

cue

reactivity

tests

using

qEEG

and

ERP

measures

Cue

reactivity

is

a

very

sensate

test

of

motivational

relevance

of

drug-related

items

-LRB-

Carter

and

Tiffany

-RRB-

that

can

be

detected

using

EEG

methods.In

addition

to

using

more

traditional

neurocognitive

tests

-LRB-

TOVA

IVA

etc.

-RRB-

that

are

commonly

included

in

neurofeedback

research

-LRB-

e.g.

in

particular

in

studies

on

effectiveness

of

neurotherapy

in

ADHD

treatment

-RRB-

there

may

be

value

in

incorporating

standardized

tests

with

EEG/ERP

recording

to

assess

executive

functions

in

addicts

Tests

that

warrant

mention

are

the

Continuous

Performance

Test

-LRB-

Go-NoGo

task

-RRB-

Stroop

test

Eriksen

flanker

test

etc.

Some

of

these

tests

are

sufficiently

sensitive

for

assessing

recovery

of

cortical

inhibition

function

commonly

known

to

be

impaired

in

patients

with

SUD.Testing

emotional

reactivity

and

responsiveness

in

addiction

is

another

important

domain

where

qEEG

and

ERP

methods

may

help

to

obtain

more

effective

evaluation

of

the

affective

state

of

recovering

addicts

In

future

neurofeedback

treatment

for

SUD

attempts

should

be

made

to

integrate

neurotherapy

with

other

well

known

behavioral

interventions

for

drug

abuse

such

as

cognitive-behavioral

therapy

-LRB-

CBT

-RRB-

and

motivation

enhancement

therapy

-LRB-

MET

Miller

and

Rollnick

-RRB-

As

a

population

drug

addicts

are

very

difficult

to

treat

characterized

by

a

low

motivation

to

change

their

drug

habit

and

a

reluctance

to

enter

inpatient

treatment

CBT

and

MET

are

powerful

psychotherapeutic

interventions

that

can

help

to

bring

about

rapid

commitment

to

change

addictive

behaviors

These

behavioral

therapies

are

especially

useful

for

enhancing

compliance

with

drug-dependent

individuals

and

facilitating

their

neurofeedback

treatment

engagement

Neurofeedback

may

be

among

the

most

promising

biofeedback

modalities

for

the

treatment

of

adolescents

with

addictive

disorders

because

of

the

neuroplasticity

potential

of

the

adolescent

brain

While

there

is

little

work

available

on

the

prevention

and

treatment

of

SUD

in

adolescents

utilizing

neurotherapy

there

is

no

reason

to

suspect

that

the

approaches

used

in

adults

would

not

be

applicable

in

SUD

adolescents

-LRB-

Trudeau

-RRB-

The

EEG

biofeedback

treatment

of

ADHD

may

be

important

in

prevention

for

children

and

adolescents

at

risk

for

developing

SUD

It

may

be

possible

that

EEG

biofeedback

therapy

of

childhood

ADHD

may

result

in

a

decrease

in

later

life

SUD

-LRB-

Wilens

et

al.

-RRB-

This

remains

speculative

as

there

have

been

no

reported

studies

of

the

effects

of

neurofeedback

treatment

on

prevention

of

SUD

to

date

There

are

several

important

applications

of

the

neurofeedback

protocols

for

enhancement

of

cognitive

performance

in

healthy

subjects

-LRB-

reviewed

in

Vernon

-RRB-

This

promising

new

line

of

neurofeedback-based

cognitive

neuroscience

research

-LRB-

Barnea

et

al.

Egner

and

Gruzelier

b

Egner

et

al.

Vernon

et

al.

-RRB-

has

significant

potential

to

elucidate

neurobiological

mechanisms

explaining

how

neurofeedback

training

may

alter

and

enhance

cognition

and

behavioral

performance

in

patients

with

SUD

as

well

Drugs

of

abuse

can

impair

cognitive

emotional

and

motivational

processes

More

qEEG

and

cognitive

ERP

research

is

needed

to

characterize

the

chronic

and

residual

effects

of

drugs

on

attention

emotion

memory

and

overall

behavioral

performance

More

research

is

needed

also

to

relate

cognitive

functionality

measures

to

clinical

outcome

-LRB-

e.g.

relapse

rate

drug

screens

psychiatric

status

etc.

-RRB-

Such

qEEG/ERP

studies

may

facilitate

the

translation

of

clinical

neurophysiology

research

data

into

routine

practical

tools

for

assessment

of

functional

recovery

both

in

alcoholism

and

addiction

treatment

clinics

We

believe

that

administration

of

some

of

above

described

qEEG

assessments

at

the

pre-treatment

baseline

might

provide

useful

predictors

of

clinical

outcome

and

relapse

risk

Incorporation

of

cognitive

tests

with

EEG

and

ERP

-LRB-

e.g.

-RRB-

measures

into

cognitive-behavioral

and

neurofeedback

based

interventions

may

have

significant

potential

for

identifying

whether

certain

qEEG/ERP

measures

can

be

used

as

psychophysiological

markers

of

treatment

progress

-LRB-

and/or

relapse

vulnerability

-RRB-

and

also

may

provide

useful

information

in

planning

cognitive-behavioral

and

neurotherapy

treatment

when

substance

abuse

is

comorbid

with

a

mental

disorder

With

the

advances

made

in

the

last

several

years

it

is

hoped

that

continued

interest

will

be

generated

to

further

study

brainwave

biofeedback

treatment

of

addictive

disorders

Effectiveness

in

certain

hard

to

treat

populations

-LRB-

conventional

treatment

resistant

alcoholics

crack

cocaine

addicts

cognitively

impaired

substance

abusers

-RRB-

is

promising

The

prospect

of

an

effective

medication

free

neurophysiologic

and

self-actualizing

treatment

for

a

substance

based

brain

impaired

and

self-defeating

disorder

such

as

SUD

is

attractive

neurofeedback
neurotherapy
eeg biofeedback
quantitative eeg
substance use disorder
alcoholism
erp