The client in the following case study chose to come to BRI to address his problems of high blood pressure, headaches, and anxiety attacks. His physician had prescribed medication to lower his blood pressure, but he believed that biofeedback training could give him the skills he needed to improve his overall health and improve the quality of his life.
This client, B. B., was 33 years old, unmarried and with no children. He was a self-employed construction worker, specializing in industrial exhibits for trade shows. He was self-referred; after investigating several biofeedback training facilities, he chose BRI because of the equipment available and the Institute's philosophical direction.
Family medical history revealed a father with heart problems, a mother with arthritis problems, and brothers and sisters in good health.
Drug usage included caffeine (four cups of coffee a week); one glass of beer or wine a day; blood pressure medication (a 50 mg tablet of the beta blocker Tenormin per day; half a tablet of aspirin every other day). He reported having four to five cold infections per year, and periodic outbreaks of herpes which took about 7 days to subside.
The client's cholesterol level was 208. When asked if he had ever had a traumatic or consciousness altering experience, he reported having had a panic reaction subsequent to taking LSD.
When asked his current health concerns, he reported high blood pressure, headaches, and anxiety reactions at inappropriate times, lasting 10-20 minutes each.
When asked what percent of his life was scheduled, he reported 25% scheduled and 85% unscheduled. He responded "no" when asked if that balance suited him, saying that he thought he performed better "in a disciplined, constant pattern." He stated that lately he had found it hard to do one thing at a time and really focus his attention on it, attributing this to "a lot going on in my life."
When asked what he did to release tension from work, he replied, "I work part-time year round, so I have free time often." He stated that is was important to have time for himself, and that it was not easy for him to take what he needed because he "had too many things going on." He reported that his work was "draining at times, and boring," adding that this led to his being "moody."
He stated that his most important relationship was with his girlfriend of 4 years. He stated that the relationship was changing, since she was becoming "more outgoing and expressive." He had moved in with her the day before coming to BRI.
The client reported that it was only easy for him to express his feelings to those closest to him, and that it was particularly hard to express anger to anyone who was not a close acquaintance. He stated that it was easy for him to express love, but only easy to ask for help from those closest to him, saying that he felt "like I'm imposing or whiney" when he tried. He felt that he was more self-critical than self-accepting, and that it was not easy for him to know what he wanted and ask for it because "there's a lot of choices -- I'm afraid to decide." Currently, he reported that he was "under a little more stress lately."
His hobbies included song writing (his songs have been published), and art (which has been sold). He reported giving himself three or four hours a day for these pursuits. When asked what new learnings or personal growth experiences he had undertaken in the past year, he reported "none."
He stated that to reward himself, he would "get away from my environment for a day" with his girlfriend, once a month. When asked what he did for fun, he responded "write lyrics" and "get away." When asked to list three things under $2.00 that made him feel good, he responded "sex, falling asleep, music." When asked for suggestions and expectations about how he might be helped at BRI, he stated, "I'd like to locate my own `center' and use it as a tool toward better physical/mental health."
B. B.'s initial temperature readings were low and fractionated, and varied approximately 8 degrees between right and left hand throughout. In the first 5 minutes, his temperature readings declined 2 degrees; during the second 5 minutes they recovered to approximately their initial level. During the discussion of stressful issues they again decreased, dropping approximately two degrees, and during the self-soothing response they continued to drop for 5 minutes before rising approximately 2 degrees in the last 2 minutes.
The initial EMG reading for scalp and jaw was approximately 7 microvolts. During the first 5 minutes, activity decreased to approximately 3 microvolts. During the second 5 minutes, there was a sharp increase to 10 microvolts, which lasted about a minute before averaging approximately 5 microvolts for the remainder of that segment. Upon beginning the discussion phase of the baseline, jaw and scalp EMG rose immediately to 20 microvolts, and crept up to approximately 24 microvolts. During the self-soothing response, jaw and scalp readings dropped from a high of 24 to approximately 14 microvolts, then rose back to 18 microvolts, and in the last 4 minutes declined to approximately 2 microvolts.
The initial EMG reading for trapezius muscles was 14 microvolts. This slowly declined to 10 microvolts during the first 5 minutes. During the second 5 minutes, there was an initial increase to 13 microvolts, which declined to an average of approximately 5 microvolts. During the discussion phase, shoulder EMG readings rose sharply to 17 microvolts and crept up to approximately 28 microvolts. During the self-soothing baseline, the readings dropped initially to 20 microvolts, climbed back to 26, and declined sharply to an average of approximately 4 microvolts.
The initial level of B. B.'s skin conductance level was 3.8 micromhos, which slowly declined to an average of approximately 3.3 micromhos during the first 5 minutes. During the second 5 minutes, SCL decreased steadily to approximately 2.5 micromhos. During the discussion phase of the evaluation, SCL rose steadily to 4.4 micromhos, and slowly declined to approximately 3.0 micromhos. During the self-soothing response, SCL continued to decrease to a low of approximately 2.2 micromhos.
The initial level of GMAX (phasic activity) was approximately 50 units. During the first 5 minutes, this reading rose approximately 60 units and returned to its original level. During the second 5 minutes, it rose to approximately 150 units, and fell off sharply to a low of -20 units, thereafter maintaining an average of approximately 30 units. At the beginning of the talking baseline, GMAX rose dramatically to approximately 290, and more or less steadily declined (with two small peaks at minute 19 and minute 23), averaging approximately 40 units. During the self-soothing response, GMAX rose slightly and declined abruptly.
B. B.'s heart rate at the beginning of the evaluation was 53 beats per minute. During the first 5 minutes, this rose to 61. Within two minutes of beginning the second 5-minute baseline, it dropped to 52.5, and then rose again to 59 before dropping to 55. During the discussion baseline, the reading rose and fell periodically, in a range of approximately 8 beats per minute. During the self-soothing response, heart rate declined sharply and steadily lowered to a reading of approximately 51.5.
The initial levels for theta, beta and gamma were not significant; however, alpha production was dramatic. During the second 5 minutes, beta and theta activity more than doubled, while gamma rose from essentially 0 to approximately 25 microvolts per second and alpha dropped sharply while remaining the most active bandwidth. During the discussion baseline, alpha essentially remained constant; however, beta and gamma rose dramatically, with theta increasing as well. During the self-soothing baseline, alpha increased dramatically, while theta, beta and gamma returned to their initial levels. EEG hemisphere difference by bandwidth. The readings during both the first 5 minutes and second 5 minutes were essentially the same, with alpha, beta and gamma biased slightly to the left hemisphere and theta approximately balanced. However, during the discussion baseline, beta and gamma activity jumped markedly to left hemisphere bias, while alpha increased somewhat in that hemisphere, and theta shifted markedly to the right hemisphere. During the self-soothing baseline, all bandwidths slowly returned to relative balance.
This chart (charts will be coming to this web site at a later date) represents similar information to that displayed in the two-dimensional EEG charts, the difference being that it is shown in a three-dimensional format. When viewing this chart, the most significant aspect is the left hemisphere bias in beta and gamma frequencies. The large alpha peaks occurred during the two eyes-closed baselines.
B. B. came to BRI after conducting a survey of local biofeedback practitioners. Since he intuitively knew he would benefit from a nonmedical approach to his concerns, and he also wanted a degree of technical sophistication, he had telephoned several facilities and visited one before calling BRI and describing what he wanted. I invited him to visit BRI so he could look around and meet me, and rapport was quickly established between us. At the conclusion of this visit he made an appointment for a comprehensive evaluation.
B. B.'s initial complaint was high blood pressure, and anxiety responses, which suggested that Temp, EDA, and Respiration would be the most appropriate modalities for training. During his initial evaluation, B. B. showed elevated levels of activity and gross imbalance in hand temperature. Clinically significant levels of activation also appeared in B. B.'s EEG measures, primarily in terms of left hemisphere bias.
During the initial sessions, we concentrated on EMG, since B. B. exhibited good control of this modality and it provided an initial success upon which to build.
We shifted our focus to Temps next, initially with frustrating results. I explained to B. B. that training itself causes sympathetic nervous system outflow, and this predictably leads to activation and lower measures in Temp. As I explained this, I noticed that while B. B. was listening, his Temps would stabilize and tend to rise. I began to call his attention to this phenomenon when it occurred, and this gentle reinforcement through praise and support resulted in a remarkable shift upwards of 2 or 3 degrees within a minute. B. B. was amazed that this interaction between us could have such clear results, and his sense of control and belief of potential success was enhanced. By the fourth session, we were intermixing Temp and EMG training throughout the session, and by the sixth session B. B.'s mean Temps were 95 degrees at both channels, while both channels of EMG measured 2.5 microvolts.
Between sessions six and eight, I frequently used a bilateral EMG placement or right and left trapezius to balance these sites. Also, I placed greater focus on symmetry between Temps measurements. We found this to be a challenge, but an enjoyable one. During this period, we also placed periodic focus on BSR and Respiration. B. B. found training to be quite difficult in both of these, and was able to stay focused on either one for only brief amounts of time. I slowly encouraged him to increase his length of focus, but I was careful not to pressure him to the point where he might terminate training prematurely.
By the eighth session, satisfactory progress in the body modalities had been achieved, and I sensed that B. B. was potentially capable of attempting serious EEG training. This initial belief proved correct, and B. B. responded very well to EEG.
In sessions nine through twelve, I introduced Heart Rate and RSA training. In this procedure the goal is to cause the moving line graph to shift up and down in an even pattern. This sine-wave like pattern was then graphed with the shoulder EMG line graph. As the two line graphs moved across the screen, the additional goal was to bring both lines into synch with each other.
B. B. found this training technique to be significant in helping bring down heart rate and at the same time cause a slower and more even respiration cycle to occur. During these sessions, EEG was on the audio, with the bandwidth ranging from 13 to 35 Hz. B. B.'s goal was to bring down the tone, indicating less activity in that bandwidth.
Between sessions fourteen and twenty, our primary focus was EEG training. I placed a line graph of EEG amplitude density with the bandwidth 13 through 35 Hz, and set the audio tone to reflect the same. Although our primary focus was on EEG, I encouraged B. B. to monitor the numerics at the bottom of the screen that reflected all the body measure channels. I did this for several reasons: a) so that continued progress could be made in body measures, b) so that progress achieved could be maintained, c) so that further integration of mind and body would occur, and d) so that when EEG training became boring or frustrating, B. B. could shift focus.
As we proceeded through this complex mind/body training protocol, I encouraged B. B. to become even more capable of handling the information presented on screen. This included two channels Temp, two channels EMG, Heart Rate, GSR and BSR, and some EEG measurements.
During sessions thirteen through twenty, I increasingly expected B. B. to integrate the psychophysiological skills he was learning at BRI into his daily life. I asked most of my questions regarding this before and after training, as he was working more or less independently during the actual feedback time.
Early in B. B.'s training, he reported having tension headaches in addition to his presenting complaint of anxiety responses and hypertension. On his intake form, he stated a desire to "find his center," which suggested a developmental approach to training that in this case involved practice in modalities that were not particularly suggested by the presenting complaint, and encouragement of a sense of exploration during training. By the eighth session, B. B. reported that his headaches had disappeared, and his elevated blood pressure and anxiety responses had begun to respond to training.
As B. B.'s understanding of the effects of multi-modality training increased, his skills continued to grow. This in turn encouraged him to continue training and empowered him to take increasing control over physiological functions, beyond his original expectations.
In the comprehensive evaluation, B. B. had exhibited clinically significant levels of activation in EEG measures, particularly in the left hemisphere. We focused on EEG training from the fourteenth through twentieth sessions, and B. B. was particularly gratified by his success in this area. His intellectual bent inclined him toward wanting to get in touch with his brain activity and gain control over it. He felt better able to deal with his anxiety responses when he had associated them with particular levels of brain activity.
After 20 sessions of biofeedback training, B. B.'s temperature readings showed a marked shift toward left and right-hand balance, as well as an average increase of approximately 12 degrees to 97 degrees, a level he maintained throughout the session. This indicates an ability to profoundly relax smooth muscles, achieving a very significant state of relaxation within that system.
As the EMG chart for B. B.'s twentieth session shows, this client was able to reduce scalp and trapezius muscle activity significantly, bringing it within the goal zone throughout the session. Muscle activity at the varying sensor locations reflected a global reduction as compared with that displayed in the comprehensive evaluation chart above.
Through his training series, B. B.'s overall SCL level decreased. During session 20, GMAX (a phasic measure) varied. This variance was largely connected to a level of excitement the client experienced as he was able to create specific states of consciousness while working primarily with EEG feedback.
B. B.'s heart rate was not measured for session 20.
As the charts show, EEG activity after training was remarkably different in all bandwidths, showing a balance between left and right hemisphere activity (particularly in the beta and gamma bandwidths), in contrast to that exhibited during the comprehensive evaluation. Particularly notable is the fact that alpha is the dominant frequency throughout the twentieth session. This substantially greater activity in alpha was achieved in an eyes-open training protocol, indicating that the client achieved an unusual level of mastery in this modality. Throughout the session, gamma, beta and theta activity remained at very low levels in both channels, while alpha began at 150 microvolts per second and followed a somewhat regular up-and-down pattern throughout the session that corresponded to his training exercise. Right-hemisphere alpha activity was usually higher, in contrast to the left-hemisphere dominance exhibited in the comprehensive evaluation.
EEG hemisphere difference by bandwidth. Comparison of the comprehensive evaluation chart and that taken during B. B.'s twentieth session reveals excellent progress in hemispheric balance in theta, beta and gamma bandwidths. As stated above, it is not uncommon when high levels of alpha are occurring to see a hemisphere difference in alpha, generally towards right hemisphere bias.
Information presented in B. B.'s EEG line graphs is reflected in the three-dimensional brain maps. The significant aspect of this chart is the powerful bias shown in alpha activity. Further, this was accomplished by the client with eyes open. This is a relatively unusual skill. One may also note the very low and even level of beta and gamma activity.
At the completion of B. B.'s course of training, his hypertension had ceased to be a problem and he had discontinued his medication. He also stopped having headaches and reported that his anxiety responses were greatly reduced. He had become aware of when his psychophysiology was becoming overactivated and was able to self-regulate it in time to prevent discomfort. He also reported that his personal life had become more comfortable and rewarding, with less moodiness and anxiety; his girlfriend commented on his more relaxed attitude and approach toward problems.
One should choose a biofeedback practitioner who has been certified by the Biofeedback Certification Institute of America (BCIA) as having completed a series of courses and personal training experiences that lead to competency in the field.