In 2012, among the 43.7 million adults aged eighteen and older that met the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria for any mental illness (AMI), 19.2 percent (8.4 million people) also met the criteria for substance use disorder (SUD) (SAMHSA, 2013). Among the 8.4 million with co-occurring AMI and SUD, 46.3 percent (approx. 3.9 million people) received substance use treatment at a specialty facility or mental health care center in 2012 (SAMHSA, 2013). Therefore it’s important to find evidence-based practices that treat mental illness and substance abuse simultaneously. This article is a brief literature review of biofeedback and its use as a treatment for anxiety disorders and substance abuse. Through the literature review, it was assessed that biofeedback has been primarily researched as treatment with alcohol dependence and only in the past decade has it been more heavily researched for other dependencies. This article will begin by discussing a systematic review of biofeedback as a treatment method for anxiety and personality disorders, followed by a brief overview of a more recent study that looked at the effects of biofeedback on heart rate variability. The article will continue with a discussion of the current literature that looks at the effectiveness of biofeedback as a treatment for substance abuse, and will end with recommendations and further readings that can enhance an understanding of biofeedback.
Through the literature that was examined, it appears that biofeedback is an effective treatment method for reducing anxiety and increasing treatment successes, including length of stay and decrease of relapses. This may be attributed to the concept that biofeedback essentially helps an individual to recognize their own feelings and pay more attention to their physiological reactions to various stressors. In turn, the skill of recognizing their reactions allows the individual to better monitor their responses, which is particularly helpful for individuals who are working on their treatment or those who have anxiety disorders. The skills that are taught to people during biofeedback sessions appear transferrable to various aspects of their lives and appear to be effective long-term, closely resembling the practice of mindfulness and in some cases spirituality (Trudeau, 2005). Prinsloo, Derman, Lambert, and Rauch (2013) also indicated that mindfulness training in addition to biofeedback may be beneficial in part because mindfulness has been shown to decrease anxiety and increase well-being.
Biofeedback and Anxiety Disorders
A systematic review of biofeedback and psychiatric disorders—specifically anxiety, autism spectrum disorders, depression, dissociation, eating disorders, schizophrenia, and psychoses, with anxiety being the most commonly treated—was completed by Schoenberg and David in 2014. Through the systematic review of various types of biofeedback and their studies, Schoenberg and David (2014) found that, “biofeedback may not be useful for disorders characterized by limited or low physiological responsivity, difficulties in recognizing physiological/affective states, or where physiological mechanisms are not centrally involved in the onset and perpetuation of symptoms (e.g. personality disorders)” (pp. 131). This finding indicates that biofeedback may not be appropriate for all clients and designates an importance for assessing where a client is at in terms of his or her diagnoses. The systematic review did find that individuals with anxiety disorders required less biofeedback sessions, which may be indicative of an efficient and effective treatment for them since they did better in a shorter length of time (Schoenberg & David, 2014). Lastly, it was concluded that biofeedback can help enable individuals with psychiatric disorders to regulate their physiological responses and allow them to learn how to increase their sense of relaxation and increase positive states of mind (Schoenberg & David, 2014). Although there were several concerns that indicated a need for more standardized methods of biofeedback and controlled studies, the conclusion indicates that biofeedback may be helpful for individuals, especially those with anxiety, and specified the need to continue to research and utilize what appears to be working.
In a short-term, quantitative study, participants viewed negative and neutral pictures and were asked to control their heart rate variability (HRV) (Peira, Fredrikson, & Pourtois, 2014). Specifically, HRV biofeedback uses a device to measure the heart rate and then displays the respiratory sinus arrhythmia wave—which is the cyclical change in heart rate in response to respiration—on a screen (Prinsloo et al., 2013). Participants are then instructed to breathe, maintaining focus on their heart rate so that the two may become better regulated (Prinsloo et al., 2013). Participants in the quantitative study were given either real or fake biofeedback concerning their heart rates and this was indicated as HRV biofeedback (Peira et al., 2014). It was concluded that when participants were shown negative pictures and given real feedback regarding their heart rate, they were able to better regulate and control their physiological responses to the negative stimuli and anxious reactions (Peira et al., 2014). However, when viewing neutral pictures, it did not make a difference whether the biofeedback was real or fake, participants were able to control their responses. Peria and colleagues wrote, “It is well established that the most successful regulation strategies are started at an early stage and that there is a lack of emotion regulation strategies that are efficient to regulate negative emotions at a late stage” and highlighted the importance of using heart rate biofeedback as a strategy to regulate emotions when they appeared more unexpectedly (2014). The importance of this study to the proposed research question regarding biofeedback and its effect on anxiety is that it is a recent study that shows there is the possibility for biofeedback to benefit individuals when they are at a high level of anxiety. The study also showed that introducing the HRV biofeedback one time to clients has the potential to have a significant impact on regulating anxiety caused from negative stimuli.
Biofeedback and Substance Abuse Treatment
The first randomized, controlled study that was completed with biofeedback as a treatment for addiction was completed in 1989, in a VA hospital, on adult males with diagnosed chronic alcoholism (Trudeau, 2005). There were multiple positive outcomes which included reduced depression scores on the Beck inventory; a thirteen-month follow up which showed that participants receiving the biofeedback training had a significantly more sustained relapse prevention, which is defined as nonconsecutive use for six days; and positive changes on personality tests (Trudeau, 2005). From this study, the “Peniston Protocol” was developed, which comprised of a temperature session of biofeedback prior to sessions, an induction script read with guided imagery before individuals received alpha-theta biofeedback, and then a therapy session (Trudeau, 2005). Replication studies have shown mixed results, some indicating that the Peniston Protocol was effective while others have found that there is no significant difference between more traditional methods for substance abuse and meditation, thus completing more research on the topic was identified as a need (Trudeau, 2005).
In another study by Scott, Kaiser, Othmer, and Sideroff (2005), the Peniston Protocol was viewed as an effective biofeedback method and was examined further. The study was also placing emphasis on the idea that individuals who abused substance also tended to have a comorbid condition which affected their cognitive states and their attention levels, citing a study that showed lower cognitive functioning to be a predictor of relapse. Scott et al. (2005) also indicated that previous studies had focused primarily on alcohol abuse and recognized the lack of research on biofeedback in mixed substance abusing populations. Their study included the use of alcohol, crack/cocaine, heroin, and methamphetamine, though those with a diagnosis of personality disorder were excluded. Each randomized group at an inpatient treatment center received treatment based upon the Twelve Step model while those in the experimental group received forty to fifty EEG biofeedback sessions (Scott et al., 2005). The results indicated that those individuals that received additional biofeedback sessions averaged 136 days in residential treatment, while those who did not only averaged ninety days, while therapists reported that individuals in the experimental group were also more cooperative and attentive as biofeedback sessions occurred (Scott et al., 2005). Furthermore, it was reported that those in the experimental group appeared to have reduced levels of distress and discomfort, alienation and depression, and defensiveness, indicating the importance of those decreased feelings while in treatment. There were also a larger number of individuals that stayed abstinent twelve months after treatment who had received the biofeedback sessions, indicating that perhaps protective factors had been increased for those individuals (Scott et al., 2005). While there were limitations to this study in terms of sample size and generalizability, this study indicated that biofeedback played a significant role in individuals staying in treatment for a longer time and a lower risk of relapse in a twelve-month period while also reducing negative feelings of anxiety.
The prior studies each indicate that biofeedback has been shown to help individuals regulate their physiological responses to negative stimuli and can help to increase states of relaxation. In this regard, biofeedback appears to mimic the effects of mindfulness and this is perhaps another area of study that would also need to be expanded with the two perhaps becoming entwined. There is a substantial amount of literature on biofeedback but there does not appear to be a specific way that biofeedback is utilized. The studies that were reviewed indicated various instruments that were used during biofeedback sessions and the type of biofeedback that was used also varied (alpha-theta, HRV, etc.). This is potentially problematic if an agency would like to implement biofeedback into sessions and it would be suggested that the least costly instruments be utilized first in order to analyze success rates among clients. Being aware of one’s own reactions and actions to stimuli appears to be the central component of biofeedback and this may be a valid reason of why it is beneficial for substance abuse treatment. If an individual is aware of their triggers and is able to control their response, relapse prevention could become less difficult to accomplish. It is also highlighted that the length of stay for individuals in treatment was increased when biofeedback was added to their therapy sessions. In order to successfully implement biofeedback, it would be recommended that staff members attend trainings on the various types of biofeedback.
In sum, there appears to be a need for more rigorous research, but biofeedback appears to be established as a positive mechanism to improve an individual’s feelings of stress and anxiety, improving their overall states of well-being.
References and additional readings
Egner, T., Strawson, E., & Gruzelier, J. H. (2002). EEG signature and phenomenology of alpha/theta neurofeedback training versus mock feedback. Applied Psychophysiology & Biofeedback, 27(4), 261–70.
Hammond, D. C. (2011). What is neurofeedback: An update. Journal of Neurotherapy, 15(4), 305–36.
Peira, N., Fredrikson, M., & Pourtois, G. (2014). Controlling the emotional heart: Heart rate biofeedback improves cardiac control during emotional reactions. International Journal of Psychophysiology, 91(3), 225–31.
Prinsloo, G. E., Derman, W. E., Lambert, M. I., & Rauch, H. G. L. (2013). The effect of a single episode of short duration heart rate variability biofeedback on measures of anxiety and relaxation states. International Journal of Stress Management, 20(4), 391–411.
Saxby, E., & Peniston, E. G. (1995). Alpha-theta brainwave neurofeedback training: An effective treatment for male and female alcoholics with depressive symptoms. Journal of Clinical Psychology, 51(5), 685–93.
Schoenberg, P. A., & David, A. S. (2014). Biofeedback for psychiatric disorders: A systematic review. Applied Psychophysiology and Biofeedback, 39(2), 109–35.
Scott, W. C., Kaiser, D., Othmer, S., & Sideroff, S. I. (2005). Effects of an EEG biofeedback protocol on a mixed substance abusing population. American Journal of Drug & Alcohol Abuse, 31(3), 455–69.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2013). Results from the 2012 National Survey on Drug Use and Health: Mental health findings. Retrieved from http://www.samhsa.gov/data/NSDUH/2k12MH_FindingsandDetTables/2K12MHF/NSDUHmhfr2012.htm
Trudeau, D. L. (2005). EEG biofeedback for addictive disorders—The state of the art in 2004. Journal of Adult Development, 12(2/3), 139–46.