Abstracts of papers presented at the 21st Annual Meeting of the Association for Applied...

Biofeedback and Self-Regulation, VoL 15, No. 1, 1990

Abstracts of Papers Presented at the 21st Annual Meet- ing of the Association for Applied Psychophysiology and Biofeedback

Franeine Butler Association for Applied Psychophysiology and Biofeedback

The 21st Annual Meeting of the Association for Applied Psychophysiology and Biofeedback was held at the Ramada Renaissance Hotel Techworld, Washington, D.C., March 23-28, 1990. The theme for the 1990 program was Exploring the Future: New Frontiers in Biofeedback and Psychophysiolo- gy. The program committee was chaired by Lilian Rosenbaum, with comit- tee members Maria Mannarino, Barry Gruber, John Arena, Richard Sher- man, Kathy Wells, Virendrakumar Desai, and Andrew Baum.

The 22nd Annual Meeting will be held at the Fairmont Hotel at the Dallas Arts District, Dallas, Texas, March 15-20, 1991.

Printed proceedings of the 1989 meeting, containing 500- to 800-word abstracts, may be ordered from:

Association for Applied Psychophysiology and Biofeedback 10200 West 44th Avenue, Suite 304 Wheat Ridge, Colorado 80033 (303) 422-8436

47 0363-3586/90/0300-0047506,00/0© 1990 Plenum Publishing Corporation

48 Abstracts of Papers Presented at the Annual Meeting

Biofeedback, Autogenic, and Visualization Training in the Treatment of Pedi- atric Migraine and Tension Headache

Barry S. Anton, ~ University of Puget Sound Stephen Langer, Private practice

Seventeen children between the ages of 7 and 12 years (8 males and 9 fe- males) suffering f rom migraine (N = 11) or tension headache (N = 6) underwent neurological evaluation to confirm the diagnosis. The diagnostic criteria were recurrent, intermittent headache. The two groups were assessed for localization of maximal EMG, and a headache diary was kept for 3 weeks. Another E M G scan was conducted after the headache diary was completed. Then, four t reatment sessions utilizing EMG biofeedback, autogenic training, and relaxation were administered. Following the treatment sessions another headache diary was kept for 1 week, followed by a final EMG scan. The data indicated that both groups demonstrated reduced E M G responses following treatment. There were no differences between the tensioners and the migrainers. In addition, the reported number of headaches was decreased, as was the intensity of the headaches that the children did experience. The data are discussed in terms of treatment approaches to the treatment of headaches in children.

1Communications should be addressed to Dr. Barry S. Anton, Department of Psychology, Univer- sity of Puget Sound, 1500 North Warner, Tacoma, Washington 98416.

Controlled Evaluation of Muscle Contraction Headache: Investigating the Addit ion of Cognitive Strategies to the Standard Relaxation Protocol

Kenneth A. Appelbaum, 1 Edward B. Blanchard, and Nancy L. Nicholson, State University of New York at Albany Cynthia Radnitz and Cynthia Kirsch, Medical University of Soath Carolina Virginia Attanasio, University of Medicine and Dentistry of New Jersey Frank Andrasik, University of West Florida

Chronic tension headache sufferers were randomized in the approximate ra- tio of 2:2:1 into one of three regimens: (1) standard self-regulatory treat-

1Communications should be addressed to Kenneth A. Appelbaum, Stress Disorders Clinic, 1535 Western Avenue, Albany, New York 12208.

Abstracts of Papers Presented at the Annual Meeting 49

ment (SRT), including progressive muscle relaxation training delivered as a home-based treatment; (2) SRT plus selected cognitive coping techniques, also delivered as a home-based treatment; or (3) a headache-monitoring wait list control condition. All patients participated in both the pre- and post- assessment and treatment aspects of this study. In general, the two active treatment groups were significantly improved relative to the wait list control group. The two active treatment groups did not differ from each other. On a measure of clinical improvement, and medication consumption, these same results were obtained. Thus, it appears that the addition of cognitive stress-coping strategies to home-based SRT does not add significantly to treatment outcome.

New Evidence for EMG and Vascular Abnormalities in Tension Headache: Implications for Psychophysiological Assessment and Treatment

John G. Arena, l Susan L. Hannah, James D. Smith, and Kimford ,1. Meador, Veterans Affairs Medical Center and Medical College o f Georgia

To further investigate the relationship between muscle tension levels in the forehead and neck regions and to explore the role of blood flow in the etiology of tension headache, 21 tension headache sufferers (1) were given a psychophysiological assessment in which neck and forehead EMG were monitered during and between headache states and during six positions (standing, bending, rising, sitting with back supported and unsupported, and prone), and (2) had near-surface blood flow of the face, temple, and neck regions recorded through videothermography. The EMG assessment was also repeated twice on 15 nonpain controls. Results indicated no effect of headache state on EMG levels, but headache sufferers had more clinically significant EMG abnormalities (60%) than did controls (13%). Moreover, 52°70 of tension headache sufferers had significant thermographic asymmetries, indicative of abnormal blood flow patterns. Overall, 80% of the headache sufferers had some kind of psychophysiological abnormality. Implications for psychophysiological assessment and treatment are discussed.

'Communications should be addressed to Dr. John G. Arena, Biofeedback and Psychophysio- logical Disorders Clinic, Psychology Service 116B, Veterans Affairs Medical Center, Augus- ta, Georgia 30910.


Analgesic Withdrawal in the Treatment of Chronic Headache: A Pilot Study

Virginia Attanasio, 1 UMD-New Jersey

Joanne L. Fowler, Institute for Behavioral Medicine

Recent research has suggested that frequent and regular analgesic use, both narcotic and nonnarcotic, may contribute to the exacerbation and maintenance of chronic daily headache. Although the mechanism of action is un- clear, evidence has suggested that the discontinuation of analgesic medication is associated with decreases in pain; however, there are few controlled inves- tigations. This has potential implications for treatment since evidence suggests that patients with continuous daily headache tend to have poorer treatment outcome than patients with more intermittent headache. The present pilot study examined the effectiveness of analgesic withdrawal and a cognitive stress coping treatment with patients with daily headache. Three patients were treated with gradual analgesic withdrawal and cognitive stress coping, in a sequential manner. Headache and medication use were monitored for a 2-week baseline, for 2 weeks between sequential treatments, and for 4 weeks posttreatment, as well as throughout treatment. All patients had experienced headache on a daily basis for at least 10 years, and used the equivalent of at least 40 aspirin tablets per week. Following treatment, all three patients experienced a significant decrease in medication use (50°70), although one patient continued to use significant amounts of medication at posttreatment, and this patient's headache remained relatively unchanged. Interestingly, the remaining two patients experienced markedly significant reductions in headache, as well as virtual elimination of analgesic use. They also reported that analgesic medication was markedly more effective in reliev- ing their headaches when used on an infrequent basis. This is consistent with anecdotal reports and previous research, and suggests that analgesic withdrawal may be a useful adjunct in the treatment of chronic daily headache.

~Communications should be addressed to Virginia Attanasio, UMD-New Jersey, Departments of Psychiatry and Anesthesiology, 185 South Orange Avenue, Newark, New Jersey 07103-2757.


Changes in Anxiety and Depression Among Irritable Bowel Syndrome Patients Following Active Treatment, Attention Placebo, and Wait List

Control

Charles H. Berreman, ~ Edward B. Blanchard, Jerry M. Sub, Shirley P. Schwarz, Lisa Scharff, and Barbara Greene, State University o f New York at Albany

Irritable bowel syndrome is a functional disorder of the lower gastrointestinal (GI) tract characterized by abdominal pain and altered bowel habit (di- arrhea and /o r constipation) in the absence of an identifiable physical cause. Psychological treatment of IBS has been shown to be efficacious and to have the desirable side-effect of reducing reported anxiety and depression, This study compares an empirically validated treatment with an attention placebo and a wait list control group on pre- and post treatment Beck Depression Inventory (BDI) and Spielberger State-Trait Anxiety Inventory (STAI) scores. Surprisingly, the attention-placebo group did as well as or better than the active treatment group.

1Communications should be addressed to Charles H. Berreman, Center for Stress and Anxiety Disorders, 1535 Western Avenue, Albany, New York 12203.

A Placebo-Controlled Evaluation of Abbreviated Progressive Muscle Relax- ation and Relaxation Combined with Cognitive Therapy in the Treatment

of Tension Headache

Edward B. Blanehard, 1Kenneth A. Appelbaum, Cynthia L. Radnitz, Denise Michultka, Belin- da Morrill, Cynthia Kitsch, Virginia Attanasio, and Frank Andrasik, State University o f New York at Albany

Mark P. Dentinger, Albany Medical College

Sixty-six tension headache patients were randomly assigned to one of four conditions for 8 weeks: (1) progressive muscle relaxation (PMR) alone, (2) PMR plus cognitive therapy (PMR + Cog), (3) pseudomeditation, a credi-

1Communications should be addressed to Dr. Edward B. Blanchard, Center for Stress and Anxiety Disorders, 1535 Western Avenue, Albany, New York 12203.


ble attention-placebo control, or (4) continued headache monitoring. A com- parison of overall headache activity (Headache Index, HI), derived from a daily headache diary, for 4 weeks before treatment to the 4 weeks after treatment, revealed that active treatment (PMR and PMR + Cog) was superior to either control condition. Moreover, level of headache medication consumption decreased significantly for the active treatment groups. While compari- sons of the two active treatments on HI showed no advantage for adding cognitive therapy to PMR, a measure of clinically significant change showed a trend (p = .065) for PMR + Cog (62% improved) to be superior to PMR alone (32%).

The Contribution of Regular Home Practice to the Thermal Biofeedback Treatment of Vascular Headache

Edward B. Blanchard, 1 Nancy L. Nicholson, Kenneth A. Appelbaum, Cynthia L. Radnitz, Ann E. Taylor, Bruce Steffek, Denise Michultka, Belinda Morrill, and Daniel R. Jones, State Univer- sity o f New York at Albany

Regular home practice is typically an integral part of the thermal biofeedback (TBF) treatment of vascular headache (HA). We have conducted an empirical test of the contribution of regular home practice by randomly as- signing 33 patients with vascular HA (18 migraine, 15 combined HA) to one of two 12-session TBF regimens over 8 weeks. In one condition patients were urged to practice handwarming at home on a daily basis and given a home practice device for assistance. In the other condition, the office treatment was the same but no mention was made of home practice. Results showed significant (p = .014) reductions in HA activity, as measured by daily HA diary, but no effect of the home practice. On a measure of achieving clinically significant (50%) reductions of HA activity, there were no differences, with 5 1 . 5 % showing clinically significant improvement.

'Communications should be addressed to Dr. Edward B. Blanchard, Center for Stress and Anxiety Disorders, 1535 Western Avenue, Albany, New York 12203.


A Controlled Evaluation o f the Addition o f Cognitive Therapy to a H o m e - Based Biofeedback and Relaxation Treatment of Vascular Headache

Edward B. Blanchard, 1 Nancy Nicholson, Kenneth A. Appelbaum, Cynthia L. Radnitz, and Cynthia Kirseh, State University o f New York at Albany Mark P. Dentinger, Albany Medical College

Seventy-six patients with vascular (migraine or mixed migraine and tension) headache (HA) participated in a controlled evaluation of a minimal-therapist- contact, largely home-based treatment program that combined relaxation (R) training with thermal biofeedback (TBF). One group received TBF + R administered in three office visits over 8 weeks, supplemented by audiotapes and manuals. A second group received the TBF + R plus instruction in cognitive stress coping techniques, all o f which was administered in five office visits over 8 weeks. A third group monitored headache activity for 8 weeks. Evaluations, based on 4 weeks of headache diary at pretreatment and after treatment, revealed significantly greater reductions in headache activity and medication consumption for both treated groups than for the H A monitoring controls, who did not change. Significantly more of the treated patients had clinically significant reductions in HA activity than the controls. The two treated groups did not differ on any measure.


Preliminary Results o f a Placebo-Controlled Evaluation of Behavioral Treat- ment o f Irritable Bowel Syndrome

Edward B. Blanchard, 1 Shirley P. Schwarz, Jerry Suls, Lisa Scharff, Charles Berreman, Ann E. Taylor, and Barbara Greene, State University o f New York at Albany Howard Malamood, Albany Medical College

A multicomponent treatment program for irritable bowel syndrome (IBS), which had previously been reported to yield good clinical results in several



small studies, was evaluated by means of daily symptom diaries in a controlled group outcome study. The multicomponent treatment (n = 21), consisting of training over 12 sessions in progressive muscle relaxation, thermal biofeedback, and cognitive stress coping techniques, was compared to an ostensible attention-placebo condition (n = 21), consisting of training, also over 12 sessions, in pseudomeditation and biofeedback for suppression of EEG alpha, and to a GI symptom monitoring condition (n = 18). Results showed more significant symptom reduction for the ostensible attention- placebo condition than for the primary multicomponent treatment. There was a trend (p = .08) for both treated groups to show more clinically significant improvement than the symptom monitoring controls. Patients appeared to convert the attention-placebo condition to an active coping treatment combining relaxation and distraction.

Biofeedback Treatment of Erythromelalgia: A Case Study

Timothy S. Cahn, Private practice Annabaker Garber, Private practice

Erythromelalgia is a rare disorder characterized by intermittent episodes of vasodilation causing severe pain, redness, and heat in any of the extremities precipitated by exposure to warmth. The sufferer learns to fear warm temperature in the affected extremity, and that "cold is good." The patient, P.R., has suffered from this condition for the past 6 years. Any casual exposure to environmental heat, exercise, polyester clothing, or eating or drinking hot foods could trigger a symptom flare-up. Treatment was designed to help P.R. learn to gradually warm her extremities without precipitating an attack. A multimodal treatment approach was employed, with thermal biofeedback, plethysmograph (BVP) biofeedback, respiration biofeedback, progressive muscle relaxation, and open focus relaxation. The patient was instructed in home practice, and she worked with biofeedback practitioners in her hometown and at the Menninger Clinic. A criticial component of treatment was convincing the patient that "warm was good." P.R. worked for a year to raise her foot temperature to above 90.0 F consistently. She was able to decrease her symptoms by more than 90070, from an average of 56.0 attacks per month during the summer of 1988 to an average of 5.3 attacks per month during the summer of 1989.

~Communications should be addressed to Dr. Timothy S. Cahn, 901 Boren Avenue, Suite 1010, Seattle, Washington 98104.


A Preliminary Study of the Effects on Daily Activities of Participating in 24-Hour Ambulatory Blood Pressure Monitoring

Peter 3. Corn&h, 1 Edward B. Blanchard, David A. Wittrock, Jim Jaccard, and George Eisele, State University o f New York at Albany and Albany Medical College

The present study examined whether or not the wearing of a 24-hour ambulatory blood pressure monitor (ABPM) led to alterations in subject activity type or level in such a manner that could potentially affect (diminish) how truly representative the obtained blood pressures were. Twenty-eight hypertensives, with an average age of 51 years, participated and were en- rolled in studies on nondrug treatments of hypertension. As part of an overall pretreatment assessment, subjects self-monitored activities, locations, and postural positions while they wore an alarm watch and then while they wore the ABPM. Significant differences in frequency of being at home or in miscellaneous settings, in standing and reclining positions, and in mental, physical, and miscellaneous activities between the two occasions were found.

1Communications should be addressed to Peter J. Cornish, Center for Stress and Anxiety Dis- orders, 1535 Western Avenue, Albany, New York 12203.

Citation Poster

The Effects of Biofeedback-Assisted Breathing Retraining on Lung Func- tion in Patients with Cystic Fibrosis

Kerry Delk, and Richard Gevirtz, 1 California School for Professional Psychology-San Diego

This research project examined the effects of respiratory muscle feedback and oximetry as operant guides in breathing retrairting (BRT) with cystic fibrosis patients. A combination of pneumographic or strain-gauge feedback from the abdominal muscles, EMG feedback from accessory respiratory muscles, and noninvasive blood oximetry were used to assist subjects in establishing effective deep-breathing patterns. Subjects were measured pre and post on standard respiratory spirometry to determine the effects of training on lung function. The results of the experimental group were compared with a con-

1Communications should be addressed to Dr. Richard N. Gevirtz, CSPP-San Diego, 6212 Fer- ris Square, San Diego, California 92121.


trol group receiving peripheral hand temperature biofeedback-assisted relaxation training. The results of this study show that cystic fibrosis patients can substantially alter inefficient patterns of respiratory muscle activity. It was also shown that biofeedback-assisted breathing retraining can lead to clinically significant changes in measures of lung function.

Prevalence of Temporomandibular Symptoms in a Large United States Metropolitan Area

Paul N. Duckro, 1 Ronald B. Margolis, Raymond C. Tait, and Teresa L. Deshields, St. Louis University Medical Center

Estimates of prevalence of temporomandibular or related myofascial pain (TMJ/MPD) have been unreliable owing to the lack of a consensual and replicable definition and the failure to use random/nonclinic samples. The present study surveyed prevalence of specific symptoms and used a random sampling technique. The prevalence of five symptoms of temporomandibular disorder and associated symptoms of pain, headache, and stress were es- timated using a random telephone survey in a large United States population area. The prevalence for nocturnal bruxing, joint noise with use, soreness on waking, soreness with use, and diurnal clenching were roughly equivalent (ranging from 8 to 12°70) and were within the range of prevalences reported in previous studies. Overall, 149 of the 500 respondents reported one or more of the five symptoms. Symptoms were not more prevalent among women than among men but were more prevalent among younger respondents. Soreness on waking and daytime clenching were the only symptoms significantly associated with report of pain. These two variables emerged as potential clinical markers of more severe T M J / M P D syndromes. On the contrary, joint noise was not associated with pain, consistent with other research suggesting that joint noise is a relatively common complaint not inevitably associated with pain or joint pathology. Pain was more commonly reported by respondents with multiple (four or five) symptoms. The need for greater consistency in the methods and questions of epidemiological studies in this area is clear.

xCommunications should be addressed to Dr. Paul N. Duckro, Division of Behavioral Medi- cine, St. Louis University Medical Center, 1221 S. Grand Boulevard, St. Louis, Missouri 63104.


An Analysis o f Physiological Response Stereotypy in Migraine and Muscle- Contraction Headache

Jerry Duvinsky, 1 Southern Tier Biofeedback and Stress Management Clinic Stephen Lisman, State Univesity of New York, Binghamton

Equivocal and contradictory findings from previous research on the psychophysiology of headache reflect an array of methodological problems and an arbitrary selection of stressor tasks. The present study compared the effect of "traditionally" employed stressor tasks (e.g., 2 minutes of mental math) with stressors of longer duration and predictably greater ecological validity. In addition, we conducted comprehensive statistical analyses to elucidate the nature of physiological response stereotypy. Three groups of 16 subjects, each comprising migraine, muscle-contraction headache, or no-headache controls, were exposed to a series of stressor and recovery conditions across two assessment sessions. One session included a 2 minute mental arithmetic stressor and 2 minute anagram task designed to better approximate headache- producing conditions. The other session employed the same tasks except they were of 10 minutes' duration. Dependent measures included five physiological measures as indexed by minute means of absolute response level, percent change, and standard deviation scores subsequently analyzed by split-plot ANOVAs. These analyses yielded significant group differences, which were especially apparent during the long-duration anagram stressor task in accor- dance with our predictions. For our analyses of response stereotypy, we employed relative response ranking across Z-transformed physiological measures. Results showed clear differential pattern stereotypy and specifici- ty between headache groups. This study provides clear testimony to the efficacy of the methodological refinements we introduced by demonstrating clear and qualitative distinctions in physiological activation between the headache groups.

1Communications should be addressed to Dr. Jerry Duvinsky, Southern Tier Biofeedback Clinic, 503 Plaza Drive, Binghamton, New York 13903.


The Effectiveness of Relaxation-Visualization Training on the Natural Killer (NK) Cells o f Breast Cancer Patients

Morry Edwards 1 and Andrew Huang, Western Michigan University R. Hope Kerr, Community Mental Health Chris Koronakos, Western Michigan University

Phillip Stott, Midwest Oncology Center, Borgess Medical Center

A large number of studies have found that stress qualitatively and quantita- tively reduces a variety of immune components. Several recent studies have examined relaxation skills and their ability to increase immune measures. The primary hypothesis of this project was that relaxation-visualization training (RVT) would enhance natural killer (NK) activity as well as produce beneficial psychological effects. Six volunteer breast cancer patients who were at least 3 months posttreatment were taught a passive form of relaxation that included visualizing an increase in their NK cell activity. They were studied using a single-subject repeated-measures multiple-baseline design with 11 blood samples taken over a 20-week period, with a 4-week baseline, a 6-week treatment, and a 10-week follow-up. Pre and post psychosocial batteries were administered. Psychophysiological monitoring of EMG, pulse rate, skin temperature, and skin conductance level were taken during all 13 clinic sessions. A MANOVA found a significant increase for NK °/0 Lysis (t7 < .02) during the training period. This increase was not maintained during follow-up largely owing to a decrease in practicing the intervention. Five psychosocial measures did show improvement. Individual as well as group data are presented. Implications of the results and future trends are discussed.

1Communications should be addressed to Dr. Morry Edwards, DeLano Clinic, Inc., 1722 Shaffer, Kalamazoo, Michigan 49001.

Night and Shift Work as Stressors on Duration and Quality of Sleep: Impli- cations for National Health Care Policies and Laws

Frida Marina Fischer, University o f Sao Paulo, Brazil, Frederick M. Brown, 1 Pennsylvania State University, Adelaide Berwerth, Health Secretary of the State of Sao Paulo, and Antonio deCastro Bruni, CETESB, Technology and Environmental Sanitation Company of the Sao Paulo State

Worldwide data demonstrate that night and shift work on continous work- weeks are stress-producing. These pose potential health problems to count-

1Communications should be addressed to Dr. Frederick M. Brown, Department of Psycholo- gy, Pennsylvania State University, 440 Moore Building, University Park, Pennsylvania 16802.


less workers, and to the public that relies on 24 hour monitoring of dangerous industries and health care services. Shift work, both permanent and rotating, is not simple time-shifting of workers' lives. Studies show that among effects, shift work sleep is easily disturbed. Examples here are from two coun- tries. From Brazil, dally surveys were analyzed from 34 continously rotating- shift petrochemical workers. Following seven night shifts of work, daily length of main sleeptime was least among the workshifts, along with rated quality. Although other daily shorter sleeps or naps were longest for night shift, their quality too was not best. From the United States, 147 permanent-shift hospital nurses surveyed showed for night shift the greatest decrease in main- sleep length, greatest number of sleep difficulties, and greatest frequency of shorter sleeps or naps. Sensitivity to importance of workers' health prompt- ed the Brazilian government to reduce by law the total length of individual shift work on a continous workweek to 36 hours maximum. Except for child labor laws, there are no laws in the United States protecting adult workers from shift work's known health hazards.

C i t a t i o n P a p e r

Desensitization of o~2-Adrenergic Receptors During Stress in Man

Robert R. Freedman, 1 Jennifer Embury, and Peter Migaly, Wayne State University G. iV. Pandey, J. L Javid, and John M. Davis, University o f Illinois

Biochemical receptors mediate end-organ responses to neurohumoral signals. The sensitivities and densities of these receptors are dynamically regulated by circulating catecholamines and other factors. However, the regulation of adrenergic receptors during acutely stressful states has not been investigated in humans. We studied 30 first-year medical students during final exam week and 1 month earlier. Thirty minutes after insertion of an I.V. catheter, 100 ml of blood was drawn. Platelets and lyrnphocytes were isolated for subsequent analysis of a2 and/32 receptors by 3H-yohimbine and ~25I-CYP bind- ing, respectively. Norepinephrine (NE) levels were measured by HPLC and cortisol by RIA. The State Anxiety scale of the STAI and a health habits questionnaire were completed. State anxiety was significantly higher (p < .0001) during exam week (46.9 ___ 2.3) compared with the earlier period (32.7 _+ 1.6). The sample was then split into those reporting greater (> 10 units) versus lesser increases in anxiety from the earlier week to exam week. Bmax (receptor density) and Kd (dissociation constant) were determined for a2 and

1Communications should be addressed to Andrea Maloney-Schara, Georgetown University Fam- ily Center, 4380 MacArthur Boulevard, Washington, D.C. 20007.


/32 receptors by Scatchard analysis. During the earlier week, the High Anx- ious group had significantly (p < .05) higher (2.3 + .3) c~2 Kd (i.e., l o w e r

sensitivity) compared with the Low Anxious group (1.6 +__ .2). During exam week, the ~2 Kd for the High Anxious group increased significantly further (3.2 + .6, p < .01), while that of the Low Anxious group did not significantly change (1.4 _+ . 1). Students with the highest initial NE levels showed the greatest amount of o~2 desensitization during exam week (r = .43, p < .02). There were no significant changes in any other measure. These data demonstrate significant desensitization of platelet ~2-adrenergic receptors in High Anxious students before and during an acutely stressful period. (Sup- ported by HL-30604 from NHLBI. )

Economics of Biofeedback Practice

Kenneth R. Gaarder, t Center for the Study o f the Therapeutic Process, Inc., and George Washing- ton University

Many competing and interacting economic pressures cause the practice of biofeedback therapy to have clear limits to its growth and success relative to other methods of treating the same condition. These pressures include es- calating health costs, redefinition of medical dominion, insurance restric- tions, fragmentation of health care, consumer alienation, and increased governmental regulation. Because treatment is labor-intenslve, there are limits to costs, profits, and size of therapeutic organizations. It does not appear that explosive growth of the field of biofeedback therapy will occur, and it does appear that, contrary to preference, each practitioner must be aware of the economics and marketing of his or her practice.

iCommunications should be addressed to Dr. Kenneth R. Gaarder, Center for the Study of the Therapeutic Process, Inc., 4221 Oakridge Lane, Chevy Chase, Maryland 20815.

Preliminary Results of the Effects of Measurement Frequency on Baseline Blood Pressures in Unmedicated Hypertensives

Michael A. Gordon,~Edward B. Blanchard, Peter J. Cornish, and Bruce D. Steffek, State Univer- sity o f New York at Albany George Eisele, Albany Medical College

Twelve umedicated borderline hypertensive subjects seeking thermal biofeedback treatment participated in this study. Borderline hypertension was de-

'Communications should be addressed to Dr. Frank R. maurio, south Shore Rehabilitation Associates, 400 Montauk Hwy, No. 118, Babylon, New York 11702.


fined to be average diastolic blood pressure (DBP) _ 85 or an average sep- tolic blood pressure greater than or = to _> 135 as measured by random zero sphygmomanometer on two out of three screening visits. All subjects completed an initial assement that included potential mediators of blood pressure change such as weight, dietary sodium levels derived from a 24-hour urine collection, the State-Trait Anxiety Inventory (STAI), and daily kilocalories expended based on a 1-week retrospective exercise activity survey. During the 8-week period following the initial assessment, one group (n = 7) was seen by clinic staff weekly for BP measurements, while the second group (n = 5) were told that they would be contacted for a reevalua- tion. At the end of the 8-week period, both groups were reassessed on the aforementioned potential mediators. The preliminary results of this study show that the individuals who received weekly BP measurement and contact with clinic staff showed significant reductions (p = .05) in DBP, while the individuals who received no contact during this time did not. Furthermore, the change in BP was not related to any of the potential mediators with the exception of a significant correlation between decrease in trait anxiety and decrease in DBP. Thus, these results seem to indicate that there may be a desensitization to the BP measurement process.

Training with Biofeedback: Preparation for the Assault of the North Pole with Psychophysiological Feedback

Dr. Sylvie Goulet, 1 Royal Victoria Hospital

In preparation for his solo expedition to the North Pole, Dr. Jean-Louis Etienne followed a training program with biofeedback. The objectives were to better adapt to cold temperatures, and to control reactions to stress. Six thermal biofeedback training sessions (Autogen 2000) were conducted in the laboratory. Ability to control hand temperature was then verified by testing handwarming in a humid, 14°C refrigerator with high air flow. Stress training was carried out at home, using a compact, portable G S R / T E M P 2 and relaxation exercises, with visualization of stages of the expedition that would present obstacles. During training, Dr. Etienne was able to confirm the degree of control he was able to exercise over the temperature of his fingers and his own level of stress. This feeling of self-control seemed to be one of the key factors in psychological preparation for the expediction. Biofeedback applications in this area should be further investigated.

1Communications shoud be addressed to Dr. David B. Van Zak 11600 Wilshire Blvd. No. 210, West Los Angeles, California 90025.


Long-Term Monitoring of Psyehosoeial Stress and Disease Symptoms in Pa- tients with Inflammatory Bowel Disease

Barbara R. Greene, 1 Edward B. Blanchard, and Jerry M. Suls, State University of New York at Albany

Nine individuals with inflammatory bowel disease (IBD) (Crohn's disease or ulcerative colitis) are participating in a long-term self-monitoring study of psychosocial stress and IBD symptomatology. Two measurement instruments, the IBD Symptom Diary and the Psychosocial Stress Diary, are completed by each subject for 7 consecutive days each month. Six months of data have been collected for analysis while data collection continues throughout the ensuing months to complete a full year. Evaluations, based on the first 6 months of recordings on the symptom and stress diaries, revealed highly significant correlations between daily stress and global symptom ratings within each of the 6 months. Significant correlations between daily stress and individual symptom ratings were found during 2 of the 6 months. Subjects differed in the degree of association between stress and symptom ratings, with two-thirds of the sample showing highly significant correlations.

'Communications should be addressed to Barbara Greene, Center for Stress and Anxiety Dis- orders, 1535 Western Avenue, Albany, New York 12203.

Citat ion Poster

Changes in the T-Wave Vector Loop of the Three-Dimensional Vectorcardiogram During Exposure to Cold Pressor Stress

John P. Hatch' and Steve Borcherding, University of Texas Health Science Center at San Antonio

The purpose of this study was to use three-dimensional vectorcardiographic techniques to characterize changes in the T-wave vector loop during exposure to cold pressor stress. Data were collected from four male and four female subjects during baseline, cold pressor, and recovery periods of 30 seconds each. In addition to interbeat interval and respiration frequency, the following variables were derived from the T-wave vector loop on each cardiac cy- cle: maximum vector length, polar angle of the longest vector, azimuth angle

1Communications should be addressed to Dr. John P. Hatch, Dpartment of Psychiatry, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78284-7792.


of the longest vector, vector sum, polar angle of the vector sum, azimuth angle of the vector sum, surface area of the T-wave loop, and maximum distance between adjacent vectors. All variables were referenced to an isoelec- tric potential measured before the preceding P-wave. In addition, the one- dimensional T-wave amplitude was computed as the maximum amplitude of the T-wave along the left-right axis. The mean baseline interbeat interval of 879 msec decreased to 793 msec during the task and rose to 946 msec during recovery (F(2, 12) = 15.2, p = .001). Mean one-dimensional T-wave amplitude during baseline was 423 microvolts. During the task, T-wave amplitude fell to 369 microvolts, and during recovery it increased to 414 microvolts (F(2, 12) = 7.09, p = .009). Of the three-dimensional vectorcardiographic measures, only maximum vector length (F(2, 12) = 7.70, p = .007) and vector sum (F(2, 12) = 11.56, p = .002) showed statistically significant change, both of which decreased sharply during the cold pressor and returned to baseline level during recovery. In addition to F tests, the omega-squared statistic was computed for each measure. Omega-square measures the proport ion of variance in the independent variable that is accounted for by knowledge of each dependent variable. Omega-squared was equal to .53 for the vector sum, .47 for the maximum vector length, and .46 for the one-dimensional T-wave amplitude. The responses of the male and female subjects did not differ significantly on the interbeat interval or one- dimensional T-wave amplitude measures. For the vector sum (F(1, 6) = 10.35, p = .018) and maximum vector length (F(1, 6) = . 8.31, p = .028) measures, however, the women had significantly smaller values than the men. No clear advantage was shown for any of the three-dimensional variables over the easier to record one-dimensional T-wave amplitude in characterizing the response to cold pressor stress.

The Use of Electromyography and Muscle Palpation in the Diagnosis o f Tension-Type Headache with and without Pericraniai Muscle Involvement

John P. Hatch, ~ Patricia J. Moore, Margaret @r-Provost, Nashaat N. Boutros, Ermias Seleshi, and Steve Borcherding, University o f Texas Health Science Center at San Antonio

The Headache Classification Committee of the International Headache So- ciety recently issued diagnostic criteria for headache, which allow for the sub-

1Communications should be addressed to Dr. John P. Hatch, Department of Psychiatry, Univer- sity of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78284-7792.


classification of tension-type headache according to the presence or absence of pericranial muscle disorder. It was suggested that the presence or absence of pericranial muscle disorders should be evaluated by palpating the muscles for tenderness or by measuring electromyographic (EMG) activity. However, no quantitative, objective norms exist for either muscle tenderness or EMG activity, and there are no standard protocols for patient evaluation. In this study, pericranial muscle tenderness and EMG activity were compared in 27 subjects with episodic tension-type headache and 32 headache- free controls. A neurologist palpated suboccipital, posterior cervical, upper trapezius, sternocleidomastoid, masseter, and temporalis muscles bilateral- ly and rated the patient's response on a 4-point scale. Subjects returned on two later occasions, and EMG levels were monitored from the frontal, posteri- or cervical, left temporal, and right temporal regions. Muscle palpation and EMG monitoring were performed while subjects were in the headache-free state. Muscle tenderness but not EMG elevation was associated with the presence of headache disorder. Only a weak association was found between muscle tenderness and EMG elevation and between EMG elevation and pain. Elevated pericranial EMG activity and muscle tenderness may index different aspects of abnormal muscle function.

EMG Training for Paradoxical Puborectalis in Patients with Chronic Constipation

Steve Heymen 1 and Steven Wexner, Cleveland Clinic Florida

Six patients (3 male, 3 female; ages 36-72) with chronic constipation, diag- nosed as having paradoxical puborectails syndrome, were referred for biofeedback EMG retraining of the pelvic floor musculature. Prior to biofeedback training, all patients required the use of either laxatives or enemas to stimulate defecation. The mean frequency of bowel evacuation was once per day for those using daily laxatives and twice per week for those patients using only enemas. Symptom duration ranged from 2 years to 30 years. Four of the six patients had marked subjective and objective sympto- matic improvement after 5 to 11 sessions of biofeedback training and, at 3-month follow-up, continued to have 10 to 21 spontaneous and unassisted bowel movements (BM) per week and had completely discontinued use of laxatives or enemas. Two patients were unimproved after 7 and 12 biofeed-

1Communications should be addressed to Steve Heymen, Department of Colorectal Surgery, Cleveland Clinic Florida, 3000 West Cypress Creek Road, Fort Lauderdale, Florida 33309.


back sessions, respectively. Although these two patients seemed to comply with both the home practice and supervised session exercises, neither demonstrated any degree of mastery over the pelvic floor muscles. Their inability to discriminate between "squeeze" and "push" exercises was evidenced by in- consistent and continued paradoxical pelvic floor muscular contractions. All four patients who became symptom-free demonstrated discrimination between "squeeze," "rest," and "push" techniques and increased contractile strength and control (in terms of duration of contractions) of the pelvic floor muscles, as demonstrated by electromyography, thus eliminating the paradoxical contractions thought to have prevented unassisted bowel evacuation.

The Use of B iofeedback in the Treatment of C o m a

David L. Hopper I and Clara Cruz, University Medical Center of Southern Nevada

A technique has been developed to integrate the principles of evoked potentials with that of electroencephalographic (EEG) feedback in such a way as to monitor subcortical electrophysiological brain activity and shape this activity through selective feedback stimulation in response to preselected functional parameters. Traditionally the process of biofeedback requires the presentation of internal physiological information back to a conscious, motivated patient in such a manner as to enable acquisition of voluntary control of these events in order to restore normal function. Coma patients do not exhibit cortical activity, thus rendering conventional EEG techniques inade- quate for diagnostic and feedback purposes. Brainstem evoked potentials are the most commonly employed evoked potential type with coma. A Dan- tec Neuroscope was interfaced with an Autogen 120a EEG unit using a spe- cially designed cable. An Autogen AC-10 unit was connected to the Autogen EEG unit to regulate feedback stimulation to the patient. Various forms of feedback stimuli are used, such as visual, auditory, and somatosensory, which are selected on an individual basis following family consultation and preliminary electroneurodiagnostic findings. Electrodes are placed on the scalp using the International 10-20 system. Filter settings using a bandwidth of 150 to 1500 Hz are used. Sensitivity is set at 50/zV for amplitude evaluation. A repetitive auditory click of 11.1 clicks per second at 80-dB intensity is most commonly used. Frequency and amplitude settings on the Autogen EEG unit

1Communications should be addressed to Dr. David L. Hopper, Department of Physical Medi- cine and Rehabilitation, University Medical Center of Southern Nevada, 1800 W. Charleston Boulevard, Las Vegas, Nevada 89102.


for shaping is determined by initial electroneurodiagnostic findings. Subse- quent adjustments are made as established frequency and/or amplitude goals are attained 60°7o or more of recording time. The advantages of using this new technique in the treatment of coma are discussed.

T w o Types o f Phys io log ic Disregulat ion: Tens ion Headache

Christine Hovanitz 1 and Marilyn Wander, University of Cincinnati

A recently revised theory of physiologic disregulation attempts to account for the etiologiy of many psychosomatic or psychophysiological disorders by emphasizing the roles of (1) attention to physiologic functioning and (2) the presence or absence of action intended to return physiologic functioning to a more optimal state. The ability of individuals to attend to their physiology, at whatever level of awareness is involved, as well as to act in a physiologic "optimal" manner while engaged in a stressful encounter is believed to be critical. To evaluate the hypothesis that deviations from the typical "attention or action" are etiologically implicated in the production of tension headache, this study evaluated the self-report and EMGs of low and high life-stress tension headache subjects (and their low and high life-stress matched controls). The low life-stress headache group were predicted to be poor attenders to their physiologic functioning, while the high life-stress headache group were predicted to be good attenders but unable to return their physiologic functioning to more optimal levels. Both headache and control groups were administered a series of stressful tasks while frontalis area EMG data were obtained. Correlations between the subjects' subjective report and their EMGs supported the predictions. Negative correlations were obtained between these data for the life-stress headache group (r = - .09 to - .54), while positive correlations were obtained for the low life-stress headache group (r = .33 to 64). Of the six pairs of correlations, four were significantly different. All analogous correlations with the matched control groups were positive (r = .25 to 65), and no correlations for the high life-stress control group were significantly different from the low life-stress control group. In- addition, the high life-stress headache group obtained significantly higher EMGs at each measurement interval than the matched control group. These data were interpreted as good support for the disregulation theory.

1Communications should be addressed to Dr. Christine Hovanitz, Department of Psychology, University of Cincinnati, Cincinnati, Ohio 45221.


Babyfeedback

Marc Lehrer I

Principles of biofeedback have been succesfully applied during the past 10 years in clinical programs of prenatal stimulation. Prenatal stimulation programs first began in Hayward, California, in general obstetric practice and currently have been used with over 2,500 children, some of whom are now over 9 years old. The Prenatal University program uses such standard feedback techniques as having the mother and father pat back to the baby's in utero kicks, play music to soothe the baby's quiet times, and condition the baby to specific words, feelings of movement, and experiences of light and dark. Several research papers and information about manuals of instruction are reviewed.

1Communications should be addressed to Dr. Marc Lehrer, 1959 Pine Flat Road, Santa Cruz, California 95060.


Electrophysiological Validation of Subgroups of Attention Deficit Disorder and Implications for Brain Wave Biofeedback

Michael K. L inde# Mission Psychological Consultants

This study examined differences in event-related potentials (ERPs) and reaction times (RTs) among two subgroups of attention deficit-disorder children, AD-HD and mixed (AD-HD and aggressive), and a normal control group. An auditory oddball paradigm was used with a total of 59 subjects (AD-HD = 21, Mixed = 24, Control = 14), aged 5-12 years, none of whom were taking any medication at the time of evaluation. Specific dependent measures consisted of P1, N1, P2, N2, P3 components for latency and baseline-peak amplitude, and reaction time. Results indicated that the children with AD-HD had abnormal electrophysiology in terms of their ERPs and RTs compared with the mixed and control groups. This subgroup effect

~Communications should be addressed to Dr. Michael K. Linden, Mission Psychological Con- sultants, Biofeedback Division, 31877 Del Obispo, Suite 207, San Juan Capistrano, Califor- nia 92675.


becomes even more pronounced when developmental age effects are examined. The younger AD-HD group (5-9 years) had slower N1 and P2 latency, suggesting delayed information processing and stimulus evaluation, and smaller P2 amplitude, suggesting arousal differences. It may be possible to use biofeedback to alter these ERP abnormalities of AD-HD children. These results suggest that the younger AD-HD subjects may have underaroused CNS or suffer from a maturational lag. Finally, it is concluded that distinct subgroups and age divisions are necessary in studies of attention deficit- disorder or hyperactive children.

In Vivo Hand Temperature Monitoring: Easy Doesn't Do It

John M. Lowenbergh I and Nancy E. Lowenbergh, University of Michigan Eric M. Morrell, Talent, Oregon

Our previous research supported the importance of baseline in vivo hand temperature monitoring as an enhancement of clinical biofeedback assessment. The purpose of this study was to evaluate sufficiency of wake-up and bedtime hand temperatures as an adequate representation of hand temperature patterns in the natural setting. Subjects were 27 patients (11 male, 16 female) referred for a range of psychophysiological disorders. Patients were trained and checked for accuracy of reporting in vivo skin temperature monitoring from accurate hand-held thermometers. Data were analyzed by a one-way repeated-measures ANCOVA consisting of three time points on a day registering lowest hand temperature of the week-wake-up temperature, lowest hand temperature, and bedtime temperature- with ambient temperatures serving as covariates (adjusted means 89.6, 78.6, 90.1, respectively, F = 39, P < .0001). Using paired t test with a Bonferroni correction, wake- up and bedtime temperatures failed to differ from each other; both were significantly higher than the lowest hand temperature of the day (P < .001). The data suggest that wake-up and bedtime temperatures will not serve as sufficient indices of hand temperature patterns in the natural setting. It is recommended that additional data points be included to achieve this goal.

I Communications should be addressed to Dr. John M. Lowenbergh, Behavioral Medicine Pro- gram, Riverview Building, University of Michigan, 900 Wall Street, Ann Arbor, Michigan 48105.


Clinical Psychophysiology: Its Effectiveness on a Non-Drug-Responsive Sam- ple of Honduran Children with Migraine Headache

11. Patricio Machado 1 and Ana Maria Leon Gornez, University Nacional Autonoma de Honduras Marco Molinero, Hospital Escuela

The effectiveness of psychophysiological techniques on adults with migraine headaches is well known. Studies with children are less common even though better improvement rates have been reported. The present study assessed the clinical efficacy of thermal biofeedback and relaxation training in 12 nondrug-responsive Honduran children with migraine headaches. The subjects were between the ages of 6 and 13 years and were referred by the staff neurologist. The study took place at the Clinica de Investigaci6n en Medicina Conductual, Hospital Escuela, Tegucigalpa. The treatment consisted of an average of 10 weekly 20-minute sessions (2 baseline and 8 treatment sessions) using thermal biofeedback and daily home practice of PMR. Headache diaries were given each week and hand temperature was recorded. Paired t tests were used to compare the first and last 3 sessions of treatment on five clinical parameters. Results showed statistically significant differences for frequency of headaches 6O = .002), intensity 6o = .008), disability 6O = .003) and duration (p = .025). The Index of Headache Activity approached significance (p = .057). Mean percentages of improvement were as follows: frequency 88.36%, intensity 87.18%, disability 87,89%, duration 89.94%, and Index of Headache Activity 96.46%. The 1- to 3-month follow-ups show improvement maintenance. The above results suggest that psychophysiological techniques are effective in the treatment of children who are unrespon- sive to pharmacological treatment.

1Communications should be addressed to H. Patricio Machado, M.A., C.A.S., Colonia Matamoros # 403, Tegucigalpa, Honduras.

Designer Jeans Syndrome: The Effect o f Clothing on Inhalation Volume

Merrie MacHose , K u t z t o w n University

Er i k Peper , ' San Francisco State University

Increasingly, diaphragmatic breathing is included as an important component of relaxation training protocols. In the present study, we report on the

1Communications should be addressed to Dr. Erik Peper, Institute of Holistic Healing Studies, San Francisco State University, 1600 Holloway Avenue, San Francisco, California 94132.


effectiveness of a simple behavioral technique to illustrate that choices of tight, restraining clothing significantly affect the inhalation volume of the breathing pattern. This study investigates the clinical use of the incentive inspirometer and the effects of tight versus loose clothing on inhalation volume with 17 volunteer subjects. All had been trained in the use of the incentive inspirometer and slow diaphragmatic breathing (SDB) techniques. Inhala- tion volumes in the studies were measured with a 4,000-ml incentive inspirometer and were recorded for one or two sequential breaths using SDB before and after loosening restrictive clothing. Loosening the subjects' clothing significantly increased inhalation volume. The results indicate that a "designer jeans" syndrome may exist whereby tight clothing significantly interferes with diaphragmatic breathing and may contribute to the hyperventilation syndrome. We suggest that the demonstration of the effect of tight versus loose clothing can increase the clinician's awareness of the effects of clothing on breathing patterns. The technique also facilitates the acquisition of diaphragmatic breathing skills, and raises client awareness that choices, such as clothing, can directly affect physiology.

Biofeedback and Family Systems Psychotherapy in the Treatment of HIV Infection

Andrea Maloney-Schara, 1 Georgetown University Family Center

The ability to learn to establish and/or maintain constructive relationships with emotionally important people has been correlated with the development of fewer symptoms. In a research project with eight families, biofeedback was used as a method to lower arousal after approximately 30 minutes of psychotherapy. The data collected over 2 years will demonstrate that a percentage of people who test positive for HIV have affected both physiological and relationship functioning. The recovery from various physical and emotional symptoms is compared with average course of AIDS. Improve- ments in relationship functioning were also correlated with the ability to slow down the destruction of T 4 cells. The assumption was that the thinking part

1Communications should be addressed to Andrea Maloney-Schara, Georgetown University Fa- mily Center, 4380 MacArthur Boulevard, Washington, D.C. 20007.


of self could be used to manage physiological reactions. Arousal was measured by EMG, hand temperature, and EDR readings. Evidence suggests that the important relationships are calmer if one person can achieve a better level of functioning. Although each person has some ability to function emotionally separate from important others, only a certain segment of people were actually able to alter their ability to relate to significant others. Both descrip- tive and factual data show that there has been an ability for six of these eight people to recover some immune system functioning when emotionally important relationships were activated.

Ambulatory EMG Home Training in Treating the Paretic Hand of the Chronic Hemiparetic

Frank R. Maurio, ~ South Shore Rehabilation Associates

The present investigation was conducted to determine if ambulatory home trainers could further improve upper-limb functioning with a group of chronic hemiparetic patients. Three male and 3 female subjects were recruited for the study. The average age was 62 years, and time since onset of stroke was 1.5 years. All subjects were left hemiparetic. Treatment consisted of perform- ing four wrist and four finger flexion exercises at 10 repetitions each. These exercises were performed daily at home for 5 weeks. Subjects were seen in the office for 15 sessions in a 5-week period. Silver chloride electrodes were placed on the forearm of the paretic limb between the medial epicondyle and the styloid process of the ulna. The following measures were used: (1) Beck Depression Inventory, (2) Bobath Movement Test, (3) EMG strength measure of maximum EMG potential. Results indicated that there was a significant reduction on the Beck Inventory from a pretest score of 13 to a posttest of 9. EMG strength measures indicated significant posttest strength of 21.3; pretest was 10.8. There was significant interrater improvement on the Bobath movement with a rating of 6. Overall, these results, when compared with those of chronic hemiparetic patients who received biofeedback without home training, provide support for the use of structured home training with an ambulatory EMG unit.

1Communications should be addressed to Dr. Frank R. Maurio, South Shore Rehabilitation Associates, 400 Montauk Hwy, No. 118, Babylon, New York 11702.


Psychological Predictors of Improvement in Anxiety Treated with Biofeedback-Based Stress Management

Nancy McClain and Thomas J. Yock, ~ University o f Colorado

Inconsistencies in outcomes in earlier biofeedback research have led to a focus on predicting success in a number of patient populations. This explorato- ry study looked specifically at the relationship between personality types (scores on MCMI) and anxiety patients' rated symptom improvement. Sub- jects were six general anxiety patients at the University of Colorado Student Health Service, Biofeedback Clinic. They were given standard treatment of an average of six sessions. Treatment included EMG training, temperature control training, GSR, and relaxation tapes, both in treatment sessions and in home practice. Participants also completed the MCMI and posttreatment questionnaire. Four relationships between MCMI variables and symptom improvement were significant, including the Schizoid, Avoidant, Histrion- ic, and Borderline personality types. The Schizoid (r = - . 8 7 ) and Avoidant (r = - . 9 4 ) scales negatively correlated, and Histrionic (r = .83) and Bor- derline types (r = .86) positively correlated with success in this group. Fac- tors common to these four types, such as sociability and affectivity, were discussed, as was the larger issue of heterogeneity of clinical symptom groups in prediction research.

1Communications should be addressed to Dr. Thomas J. Yock, Wardenburg Student Health Service, University of Colorado, Campus Box 119, Boulder, Colorado 80309-0119.


Biofeedback-Assisted Relaxation in Type I Insulin-Dependent Diabetes: A Controlled Study

Angele McGrady/ Marion Good, and Barbara Bailey, Medical College of Ohio

Several small studies of biofeedback-assisted relaxation have shown improvement in some measures of glycemic control in Type I insulin-dependent diabetes

~Communications should be addressed to Dr. Angele McGrady, Department of Physiology and Biophysics, Medical College of Ohio, P.O. Box 10008, Toledo, Ohio 43699.


(IDDM), while other reports have not. Our overall objective is to provide a controlled test of biofeedback-assisted relaxation in Type I IDDM. Sub- jects were recruited, interviewed, and treated by a biofeedback therapist and a clinical nurse specialist. The experimental group (n = 6) underwent relaxation training, biofeedback, review of blood glucose records and some diabetes education. The control group (n = 6) received only the review Of blood glucose logs and diabetes education. Results showed a significant advantage for the experimental group in three measures of glycemic control: average blood glucose, percent of values at target, and percent of values above 200 mg/dl. Since a common concern of patients with Type I IDDM is the disruptive effects of stress on blood glucose, relaxation-based treatment deserves serious consideration as an adjuvant to standard medical care.

The Effect of Biofeedback-Assisted Relaxation on White Blood Cell Counts and on T-Cell Response to Experimental Mitogens in Healthy Subjects

A ngele McGrady, 1 Daniel Garman, Edmund Farris, Philip Conran, and Douglas Dickey, Medica/ College of Ohio

Little is known about the ability of stress-reduction techniques to enhance immunity in normal, healthy individuals. Our goal is to investigate the effects of biofeedback-assisted relaxation on white blood cell dynamics and cell-mediated immunity in healthy students under low stress conditions. Eight- een subjects were randomly divided into experimental (E) and control (C) groups. The E group underwent eight sessions of biofeedback-assisted relaxation. A significant difference occurred in total white blood cell count and number of neutrophils in the E group compared with the C. The blastogenic response to experimental mitogens increased in the E group in comparision with the C. The present data suggest that relaxation training and biofeedback can enhance cellular immunity as measured by response to mitogens in normal, healthy individuals. In addition, a significant decrease in total white blood cell count due to a significant decline in circulating neutrophils was observed.

1Communications should be addressed to Dr. Angele McGrady, Department of Physiology and Biophysics, Medical College of Ohio, P.O. Box 10008, Toledo, Ohio 43699.


Stress Management of Hypertension with Biofeedback-The Irish Stethoscope

Dr. Derek McGrath, ~ St. Vincent's Hospital Dr. Sinead O'Brien, Trinity College Aisling Molloy, St. Vincent's Hospital Dr. Aine Tubridy, Vergemount Hospital

Biofeedback is now recognized as an important clinical t reatment technique for a variety of disorders, including hypertension. It is only in recent years that it has begun to be used in Ireland in treating this common condition. In a stress-biofeedback clinic in a large general hospital in Dublin, 10 patients with hypertension were assessed during a course of biofeedback-assisted relaxation training. Ages ranged f rom 34 to 66 years. There were 7 men and 3 women; 7 were already taking hypertensive treatment. Initial assessment of each patient included blood pressure measurement, stress questionnaire, full psychophysiological profile, and a psychotherapeutic interview to assess pathological mental mechanisms. Seven sessions of biofeedback-assisted relaxation treatment followed at weekly intervals. Daily home practice of taped relaxation exercises was advised. Results showed that a majori ty of patients experienced a fall in blood pressure that was maintained at 6-month follow-up. Caution is advised in interpreting these results because of the small numbers involved, but a large project is planned to further examine this question. With a general increase in work-related stress and a high prevalence of essential hypertension in Ireland, the possibility of more widespread use of stress biofeedback is envisaged.

~Communications should be addressed to Dr. Derek McGrath, Stress-Management Clinic, St. Vincent's Hospital, Elm Park, Dublin 4, Ireland.

Utilization of a Portable EMG Device for Treatment of TMJ Dysfunction: Verification Through Data Gathered at Home

Doil D. Montgomery, ~ Center for Neurological Services

The patient was a 33-year-old white male injured in an industrial accident. He suffered t rauma to the head, neck, shoulders, and lumbar area. He was

1Communications should be addressed to Dr. Doil D. Montgomery, Center for Neurological Services, 5601 North Dixie Highway #407, Fort Lauderdale, Florida 33334.


undergoing neurosurgical and dental treatment during the course of this study. The focus of this report is on the treatment of his TMJ problem with EMG feedback, both in the clinic and with a portable EMG device that allowed for data to be gathered in the home. The home data included the time spent above or below a programmable threshold of muscle activity. Data were gathered for an 8-month period. The data gathered at home demonstrate a clear effectiveness of the utilization of home practice EMG relaxation techniques for hyperactivity of the muscles in the masseter area. This study vali- dates the utilization of home practice biofeedback therapy for TMJ problems. It also indicates that this technique may be effective for both treatment and validation of the effectiveness of treatment for other sites of muscle hyperactivity.

The Effects o f Aerobic Exercise on Olfact ion

Norbert R. Myslinski,' University of Maryland

We investigated the acute effects of aerobic exercise on olfactory sensitivity. Previous research in this area is lacking. However, work with other sensory systems suggests that there is a relationship. Fourteen healthy volunteers, from 10 to 53 years of age, were administered an olfactory test before and after a 5-mile foot race. The test consisted of 14 different odors. The subjects were first asked if they could detect an odor, second, if they could recog- nize the odor, and, third, to identify the odor by name. Differences between the pre- and postrace results were determined by comparing the total number of positive or correct responses. It was conducted in a double-blind, randomized manner. In all groups before and after the race there were a greater number of detections (12.64 _+ 0.31) than there were recognitions (10.10 _+ 0.47; p < .0001) and a greater number of recognitions than there were correct identifications (3.75 _+ 0.55; p < .0001). After the race there was a significant increase in the number of odors that were detected (p < .025), recognized (p < .001), and identified (p < .05). Improvement in detection and recognition scores was greater for the subjects that were more physi- cally fit (.025). There was no significant change in the speed of adaptation.

1Communications should be addressed to Dr. N. Myslinski, Physiology, 666 W. Baltimore Street, Baltimore, Maryland 21201.


The Utility of Neurological Testing for the Patient Presenting for the Non- pharmacological, Self-Regulatory Treatment of Chronic Headache

Belinda Morrill and Edward B. Blanchard, 1 State University o f New York at Albany

An important question for the biofeedback practitioner treating chronic headache is what, if any, neurological testing should be performed. In the interest of both patient and practitioner, it is crucial to establish what neurological testing is necessary to rule out underlying structural disorder that might preclude self-regulatory treatment for headache. Experts have been unable to give definitive guidelines of what testing should be done. In light of this uncertainty, the present study was undertaken to examine the comparative advantage of having all patients undergo a routine neurological assessment with an EEG and skull X-rays versus having patients evaluated by a neurologist and given additional laboratory tests only when deemed necessary by the neurologist. A total of 278 patients underwent neurological evaluations prior to beginning self-regulatory treatment for headache; 112 patients received routine laboratory tests; the other patients received laboratory testing only when deemed clinically necessary on an individual basis. No advantage was found for routine neurological testing. The rate of abnormal EEG and skull X-ray findings was no greater than that found in the normal population. However, the CT scan, over other methods, had a comparative advantage in detecting structural abnormalities. Even with abnormal laboratory tests (most of which were only mildly abnormal), the majority of the patients still saw substantial headache reduction with self-regulatory treatment for chronic headache.

~Communications should be addressed to Dr. Edward B. Blanchard, Center for Stress and Anxiety Disorders, 1535 Western Avenue, Albany, New York 12203.

Positive Side Effects of Nondrug Treatment of Chronic Headache: Reduc- tion in Other Psychophysiological Symptoms

Nancy L. Nicholson, ~ Edward B. Blanchard, & Kenneth A. Appelbaum, State University of New York at Albany

The Psychosomatic Symptom Checklist (PSC) was administered to 150 chronic headache patients (50 migraine, 50 tension, and 50 with combined

1Communications should be addressed to Nancy L. Nicholson, Center for Stress and Anxiety Disorders, 1535 Western Avenue, Albany, New York 12203.


migraine and tension) as part of a pretreatment assessment and readmirdstered after self-regulatory treatment of headache in order to evaluate possible psychophysiological side effects of treatment. Individual scores on 15 different symptoms were computed, with special attention to those symptoms that we defined as clinically meaningful (occurred at least once a week and caused moderate distress). Eight weeks of treatment included some combination of relaxation training, thermal biofeedback, cognitive stress-coping techniques, or meditation training. There were significant decreases in total PSC scores (exclusive of the headache and depression items) for all three diagnostic groups, with no significant differences between groups seen at posttreatment. Differential treatment effects were seen on the individual symptoms, with 7 of the 15 showing significant reduction. There was a significant reduction in the percentage of patients reporting clinically meaningful symptoms from pre- to posttreatment. Self-regulatory treatment effects generalize beyond the targeted headache reduction. Small decreases in all individual symptoms may be the result of an actual change in low-level symptoms or an improvement in general overall sense of well-being. Differential effects on individual symptoms would suggest that reductions are not solely attributable to regres- sion effects. Since many of the symptoms on the PSC could be associated with anxiety or depression, decreases in some of the reported symptoms may reflect decreases in these constructs following treatment.

The Role of Regular H o m e Practice in the Acquisit ion of the Handwarming Response in the Thermal Biofeedback Treatment of Vascular Headache

Nancy L. Nicholson, ~ Edward B. Blanchard, Ann E. Taylor, Bruce Steffek, and Kenneth L. Appelbaum, State University o f New York at Albany Cynthia L. Radnitz, Medical University o f South Carolina

Regular home practice is an integral component of self-regulatory treatment programs, including thermal biofeedback (TBF) treatment of vascular headache. Home practice is usually assumed to result in more rapid acquisition and better control of the handwarming response. We tested these as- sumptions in 32 vascular headache patients, randomly assigned to one of two treatment groups (home practice or no home practice). Both groups received 12 sessions of computer-assisted TBF training in the clinic. The patients in the home practice condition were provided with home temperature

1Communications should be addressed to Nancy L. Nicholson, Center for Stress and Anxiety Disorders, 1535 Western Avenue, Albany, New York 12203.

78 Abstracts of Papers Pre~ented at the Annual Meeting

trainers, told that home practice would lead to more rapid headache relief, and asked to practice handwarming at home on a daily basis. Initial baseline temperatures, baseline high, and session high temperatures were recorded for each of the 12 clinic sessions. Repeated-measures ANOVA of these values revealed significant differences in temperature across sessions and phases within session but no significant between-group differences or interactions of condition with phase or session. We also found a lack of relation between acquisition of temperature control and clinic outcome.

Psychometric Profile of PTSD, Anxious, and Healthy Vietnam Veterans: Correlations with Psychophysiologic Responses

Scott P. Orr. James M. Claiborn, Bruce Altman, ~ Dennis Forgue, Jacob de Jong, and Roger K, Pitman, Veterans Administration Medical Center, Manchester, New Hampshire, and Depart- ment o f Psychiatry, Harvard Medical School

Three groups of Vietnam combat veterans, posttraumatic stress disorder (PTSD, n = 25), anxious (n = 7), and healthy (n = 18), completed the Min- nesota Multiphasic Personality Inventory (MMPI), Mississippi Scale for Combat-Related PTSD, Impact of Even Scale, State-Trait Anxiety Invento- ry, Beck Depression Inventory, Rotter I-E (Internal-External Locus of Con- trol) Scale, Dissociation Experiences Scale, Questionnaire upon Mental Imagery, and Sensation Seeking Scale. Measurement of psychophysiologic responses to imagery of individualized combat experiences followed the psy- chometrics. The PTSD subjects differed significantly from the healthy subjects on almost all the psychometric measures but showed fewer differences from the anxious subjects. The typical PTSD subject was characterized as anxious, depressed, prone to dissociation, and external in locus of control. Correlations with the physiologic responses supported the validity of the scales specifically designed to measure PTSD. However, these correlations cast doubt on the interpretation of certain MMPI validity scale scores as indica- tors of overreporting or dissimulation of PTSD.

1Communications should be addressed to Dr. Bruce Altman, 189 Cranberry Meadow Road, Berwick, Maine 03901.


The Role of Session-by-Session Acquisit ion of the Handwarming Response with Thermal Biofeedback for the Treatment o f Irritable Bowel Syndrome

Annette Payne, l Ann E. Taylor, and Edward B. Blanchard, State University o f New York at Albany

Twenty-five irritable bowel syndrome (IBS) patients were introduced to thermal biofeedback as an integral portion of self-regulatory treatment for IBS. An important element of the treatment for irritable bowel syndrome is the acquisition of the handwarming response. Patients were given six thermal biofeedback sessions within the total treatment regimen. There were good correlations between the in-session treatments for the acquisition of the handwarming response. Correlations were derived from the difference between the highest in session baseline temperature and the highest in session biofeedback temperature. Interestingly, there were negative correlations found between the second biofeedback session and four of the other five sessions. These results would suggest that there was a systematic difference between the second biofeedback session and the other sessions regarding the physiological performance of patients. The first session is introduced as a learning session; consequently, the second biofeedback session is the first clinical "test" for the patients to perform raising their fingertip temperature. The effect of performance anxiety could be manifesting itself in the negative correlations found. With this systematic "difficulty" in the second biofeedback session, it would be essential that these patients not become discouraged with their ability to perform the task.

~Communications should be addressed to Annette Payne, Center for Stress and Anxiety Dis- orders, 1535 Western Avenue, Albany, New York 12203.

Imagery Pollution: The Efeect of Imagery on Inhalation Volume

Erik Peper,1 San Francisco State University

Merrie MaeHose, Kutztown University

Two studies are reported that test the effects of positive and stressful imaging on inhalation volume. Thirty-five volunteer subjects (X age 40.6) previously

*Communications should be addressed to Dr. Erik Peper, Institute of Holistic Healing Studies, San Francisco State University, 1600 Hotloway Avenue, San Francisco, California 94132.


trained in slow diaphragmatic breathing (SDB) with the incentive inspirometer participated in the studies. Inhalation volumes for four sequential breaths per condition were recorded with a 4,000-ml incentive inspirometer. In Study A, inhalation volumes for half of the subjects were recorded in conditions of slow diaphragmatic breathing (SDB), stressful imagery, SDB; the other half of the subjects received the conditions of SDB, positive imagery, SDB. In Study B, inhalation volumes were recorded in conditions of SDB, stressful imagery, SDB, positive imagery, SDB for half the subjects, with the other receiving conditions of SDB, positive imagery, SDB, stressful imagery, SDB. All conditions were sequential. In both studies, stressful imagery significantly lowered inhalation volume as compared with the initial diaphragmatic breathing trials. Volumes during the positive imagery trials were not significantly different from the pre-SDB trials. Study B showed no order effect. This methodology can be used to help clients become aware that thoughts influence breathing patterns. The clinical implications of this strategy are discussed.

Inducing Anxiety by 70070 Exhalation

Erik Peper ~ San Francisco State University

Merrie MacHose, Kutztown University

This study investigates the effects of the inhibition of exhalation and its relationship to feelings of anxiety. A strategy of sequential 70°70 exhalations was devised to simulate a frequently observed breathing pattern in the hyperventilation syndrome. Thirty-five volunteer subjects (14 male, 21 female, X age 40.6) were trained in slow diaphragmatic breathing (SDB). Subjects rated their anxiety levels in conditions of SDB, 70°70 exhalation, and SDB. During the 70°70 exhalation phase, subjects were instructed to breathe and limit their exhalation to 70°70 of the inhaled volume during each consecutive breath. The 70°70 condition significantly raised subjects' anxiety levels as compared with the initial SDB baseline, while a return to SDB significantly reduced the anxiety levels. The implications of the study are that (1) breath patterns are related to feelings of anxiety and (2) the 70070 strategy can be used in the clinical setting as a symptom prescription technique to facilitate therapist and client awareness of dysfunctional breathing patterns. In addition, a rever- sal of the dysfunctional breathing pattern can be used to reduce anxiety and enhance performance for people who experience breathlessness.

1Communications should be addressed to Dr. Erik Peper, Institute of Holistic Healing Studies, San Francisco State University, 1600 Holloway Avenue, San Francisco, California 94132.


The Use o f Biofeedback to Control Breathing Problems and Improve Perceived Health Status in the Elderly

Francisco L Perez, ~ George Alan Brown, Robert Teague, and Suzanne Summerhill, Baylor College o f Medicine

In elderly patients suffering from COPD, any daily experience that causes anxiety may exacerbate or precipitate the sensation of dyspnea. The purpose of this study was to determine if a simple form of biofeedback training would (1) lesson the patient's perception of dyspnea and (2) improve quality-of-life measures. Five COPD patients with disabling dyspnea served as subjects in the study. Each patient had pretraining and posttraining testing, which included spirometry, psychological measures, and the Sickness Impact Profile (SIP). Patients received 12 sessions of EMG biofeedback training. Results show that all patients learned to reduce their EMG activity and improve respiration patterns. Improvements in scores of the SIP demonstrated a perceived improvement by the patients in their daily functioning. Although the exact mechanism for this change is not clear, suggestions may be that the ability to self-regulate may generalize into feelings of control over one's illness and environment.

~Communications should be addressed to Dr. F. I. Perez, Behavioral Medicine Consultants of Houston, 6560 Fannin, Suite 1224, Houston, Texas 77030.

Psychophysiologic Responses to Combat Imagery of Vietnam Veterans with Posttraumatic Stress Disorder versus Other Anxiety Disorders

Roger K. Pitman, Scott P. Orr, Dennis Forgue, Bruce Altman, 1 and Jacob B. de Jong, Vete- rans Administration Medical Center, Manchester, New Hampshire, and Department o f Psy- chiatry, Harvard Medical School

This study utilized psychophysiologic techniques to assess responses to imagery of psychologically stressful past experience in medication-free Viet- nam combat veterans classified on the basis of DSM-III-R criteria into posttraumatic stress disorder (PTSD, n = 7) or non-PTSD anxiety disorder (anxious, n = 7) groups. "Scripts" describing each individual's own combat experiences were recorded and played back in the laboratory. Subjects were

1Communications should be addressed to Dr. Bruce Altman, 189 Cranberry Meadow Road, Berwick, Maine 03901.


instructed to imagine the events the scripts portrayed while heart rate, skin conductance, and frontalis electromyogram were recorded. PTSD subjects' physiologic responses were higher than those of anxious subjects. A dis- criminant function derived from a previous study of PTSD and mentally healthy combat veterans identified five of the seven current PTSD subjects as physiologic responders and all seven of the anxious subjects as non- responders. Results of this study replicate and extend results of the previous study and support the validity of PTSD as a separate diagnostic entity.

E M G Biofeedback Training Has S o m e Cardiovascular Effect in the Treatment o f Chronic Pain Patients

Iwao Saito, ~ Hokkaido University

The present study was performed to examine whether EMG biofeedback training for the treatment of chronic pain might have any cardiovascular effects. The subjects were 19 male and 18 female patients with mean age of 42.3 years who were suffering from muscle contraction headache or neck, shoulder, or back muscle pain. A P-303 (Cyborg Co.) and a UT-201 (Unique Med Co.) were used to provide EMG biofeedback. Cardiovascular function was measured using the noninvasive GP-303S Pulse Korotkoff Sound Mo- nitor manufactured by the Palama Co. Cardiovascular measures were obtained before and after EMG biofeedback training. Both systolic blood pressure and the rate-pressure product showed a convergent pattern of modification toward homeostasis in both the upper and lower subgroups. Mean arterial blood pressure (> 86 mm HG), diastolic blood pressure (> 80 mm HG), and heart rate (> 75 bpm) showed a convergent modification in the upper subgroups. Basal metabolic rate (> 15%) showed a convergent modification in the lower subgroup. The results suggest that cardiovascular parameters show modification in the homeostatic direction during EMG biofeedback training in chronic pain patients.

1Communications should be addressed to Dr. Iwao Saito, 1st Department of Pharmacology, Hokkaido University School of Medicine, Sapporo, 060, Japan.


A Biofeedback Apparatus for Head Position Using a Paper Speaker

Iwao Saito/ Hokkaido University

We tried a simple and cheap apparatus for training head position. The apparatus is easy to make and utilizes the principles of biofeedback control. The parts for the apparatus are a paper speaker, a headband, a paired magic band, a lamp with lens, a flashlight, and two 1.5-V dry cell batteries. Paper speakers are available from used greeting cards in which they are embedded. The paper speaker is fixed on the surface of the headband with an inch-high collar around it so that it receives light only from the front. The flashlight is positioned in front of the patient at the patient's sitting height, and the patient is instructed to keep the music on as much as possible. If the patient's face swings in only one direction, the "on" and "off" of the music ac- curately follow the movement. However, if the patient has multidirectional movements, the apparatus does not track as well because it does not receive adequate light f rom the front. Three patients agreed to use the apparatus. Two of them were able to use it successfully and reported that they could practice under relaxed conditions when they wanted to, and that they had enough time to practice at home. The other patient was not successful because her spasm was multidirectional.

iCommunications should be addressed to Dr. Iwao Saito, 1st Department of Pharmacology, Hokkaido University School of Medicine, Sapporo, 060, Japan.

Biofeedback in Mexico: Origins, Development, and Current Research and Applications

Juan Josd Sdnchez-Sosa 1 and Jorge Palacio-Venegas, National University o f Mexico

Since the beginning of its development around the year 1980, biofeedback has fostered increasing interest, mainly from psychologists and psychiatrists in Mexico. The most important germinal work occurred within the universi-

'Communication should be addressed to Juan Jos6 Sfinchez-Sosa, Department of Psychology, University of California, Riverside, Riverside, California 92521.


ties, especially in the departments of psychophysiology, experimental psychology, and clinical psychology, at the School of Psychology of Mexico's National University. Even though formal training at the graduate level is not yet part of curricula, concerning biofeedback, increasing communication at most Mexican Universities, among both researchers and clinicians, has led to more systematic attention from institutions, nonspecialized private practitioners, and the media. Other institutions actively involved in the progress of biofeedback include the Mexican Institute of Psychiatry and the departments of psychology of two health centers run by the federal government. In late 1986, after intense organizational efforts that involved more formal interaction among biofeedback scholars and search for support, the Mexican Biofeedback Academy was founded as a specialized branch of the Mexican Psychological Society. Against serious odds, mainly derived from Mexico's severe financial crisis, biofeedback is alive and growing. Several research lines are gradually beginning to get funded, and a pilot graduate residencelike program has recently included biofeedback as an important research field and a tool for both prevention and treatment.

Psychiatric Diagnosis as a Predictor of Outcome in Self-Regulatory Treatment of Irritable Bowel Syndrome

Lisa Scharff, Edward B. Blanchard, 1 Jerry M. Suls, and David H. Barlow, State University o f New York at Albany

Forty-four patients with irritable bowel syndrome (IBS) were given a structural psychiatric interview, the ADIS, to arrive at DSM-III-R diagnoses. All subsequently participated in one of two self-regulatory treatment programs involving either a combination of progressive muscle relaxation, thermal biofeedback and cognitive therapy or a combination of meditation and biofeedback for suppression of alpha in the EEG. The treatments were equally effective. Twenty-two of the patients received one or more Axis I psychiatric diagnoses (mostly anxiety disorders). Using a score of 50 or greater on com- posite primary IBS symptom reduction scores to indicate clinically meaningful improvement, we found significantly more IBS patients with no psychiatric diagnosis clinically improved (72.7%) than among the IBS patients who also had an Axis I psychiatric diagnosis (36.4°70) (p = .05).



Citat ion Pos t er

Effects of Subject Prediction and Awareness in EMG Training and Transfer

Joyce Segreto, ~ Youngstown State University

The interaction between subjects' predictions about their ability to change EMG and their EMG awareness was examined. On the basis of responses to a questionnaire, four groups were selected: high and low EMG awareness, half who predicted they would be better at decreasing EMG and half who predicted increasing. Subsequent to a 4-rain baseline, subjects (N = 64) were trained for 16 min to either decrease or increase EMG. Half were trained in the direction they had predicted they would be better at and half were trained in the direction opposite to their prediction. After training, subjects underwent a 4-min transfer period and then completed a postexperimental questionnaire (PEQ). High and low awareness groups did not differ during training and transfer. Subject prediction, however, played a significant role in learning, with increase prediction subjects who were trained to increase achieving higher EMG than decrease prediction subjects trained to increase. The PEQ data showed that groups trained in the direction corresponding to their predictions felt they had greater control over EMG and tried longer to change EMG than groups trained in the direction opposite to their predictions. These findings may be accounted for by theories of effectance motiva- tion, which propose that a sense of competency enhances learning.

tCommunicafions should be addressed to Dr. Joyce Segreto, Department of Psychology, Youngs- town State University, Youngstown, Ohio 44555.

Evaluation of a Biofeedback-Based Behavior Modification Program for the Treatment of Chronic Constipation

Janice Singles, ~ Ghent Psychological Pracice

Daniel Cox, University o f Virginia

The efficacy of a brief, noninvasive method of treatment for subjects experienc- ing chronic constipation due to external anal sphincter (EAS) dyscoordina-

1Communications should be addressed to Dr. Janice M. Singles, 622 W. Princess Anne Road, Norfolk, Virginia 23517.


tion was examined. Surface electrodes for EMG biofeedback were used for monitoring and measuring muscle tension of the EAS. Major goals of the study were to determine if the eight subjects could learn to control their EAS muscle and if this comprehensive treatment could be helpful in alleviating symptoms. Preliminary information on the psychological symptom pattern of these subjects was collected. The results show that treatment was typically brief and subjects experienced a decrease in the percentage of laxatives used and an increase in the number of bowel movements unaided by laxatives, enemas, or digital removal. This suggests that EMG surface biofeedback is as effective as more invasive or lengthy methods of treating chronic constipation. There was also a decrease in interpersonal sensitivity and anxiety, suggesting an impact of the treatment on the subjects' psychological status. Although no overall effect was found for treatment on EMG levels, results suggest that subjects can use biofeedback within a treatment session to control the EAS muscle. This is an important finding since this treatment attempts to retrain the EAS muscle.

Potentials and Problems with Digital CAPSCAN EEG Coherence-Phase Angle-Synchrony Biofeedback

Charles F. Stroebel, 1 Institute f o r Advanced Studies

Multiple-channel digital computer EEG biofeedback systems sensitive to phase angle, coherence, and synchrony such as CAPSCAN offer potential for self-regulation of pathophysiological variants of normally lateralized higher brain functions. This study of 6- to 13-Hz EEG regulation by four experienced meditators under eyes-open and eyes-closed control conditions, and then (1) with digital CAPSCAN visual display biofeedback or (2) variable real time to 2.4 seconds delayed analog audio, or (3) analog visual biofeedback, demonstrates that "real-time" feedback delays longer than 0.8 seconds are more confusing than meaningful in EEG biofeedback of synchrony indices and are detrimental to self-regulation. Unfortunately, a mathe- matical restriction in digital computer processing of the EEG inserts an inherent 2.4-second delay, some three times the useful limit. Visual atten-

~Communications should be addressed to Dr. Charles F. Stroebel, Institute for Advanced Studies, 280 Main Stress, Old Wethersfield, Connecticut 06109.


tion to the computer video display also interferes with the brain's production of alpha-theta rhythm, altering the very EEG state one is attempting to self- regulate.

Preliminary Results of the Treatment of High Medication Consumption Headache Patients

Ann E. Taylor, i Edward B. Blanchard, and Denise M. Michultka, State University o f New York at Albany Mark P. Dentinger, Albany Medical College

Headache patients who are taking high levels of analgesic medication when presenting for treatment have been found to be somewhat refractory to standard self-regulatory treatments. It has been suggested that this high consumption of medication actually leads to analgesic rebound headache. We have found a significant relationship between medication reduction and headache reduction in the high medication consumers. A treatment strategy was developed including a period of drug withdrawal followed by behavioral treatment. This paper presents preliminary results on six patients who were identified as being high medication consumers. Their weekly average medication indexes ranged from 59 to 175. They were scheduled for a drug-tapering consultation with a board-certified neurologist. They also received progressive muscle (16 muscle groups) relaxation training and support in dealing with problems associated with drug withdrawal. After medication reduction they completed progressive muscle relaxation training followed by six sessions of biofeedback. Three patients dropped out after completing drug withdrawal. Although their average weekly medication index was reduced, their headache index averaged over the 2 weeks after their last visit with the neurologist was higher than that of patients who continued. Dropout patients had medication reduction scores of 81, 90, and 44%. The treated group had scores of 86, 39, and 85%. Those patients who were able to differentiate the original headache and the rebound headache, and who utilized relaxation techniques as a way of "self-treating" (self-medicating), did the best. These patients were better motivated to continue with treatment.

1Communications should be addressed to Ann E. Taylor, Center for Stress and Anxiety Dis. orders, 1535 Western Avenue, Albany, New York 12203.


A 4-Year Follow-Up of Behaviorally Treated Irritable Bowel Syndrome Patients

Ann E. Taylor/Shirley P. Schwarz, Lisa Scharff, and Edward B. Blanchard, State University o f New York at Albany

Irritable Bowel Syndrome (IBS) is a functional gastrointestinal disorder. It is the most common diagnosis made by gastroenterologists on new referrals. Because of the resistance of IBS to traditional medical therapies and the im- plication of psychological and environmental stressors in its exacerbation, behavioral strategies have been implemented with promising results. The present study evaluates a group of IBS patients 4 years after treatment with a multicomponent package consisting of both progressive muscle relaxation and thermal biofeedback, instruction in cognitive coping strategies, and education about IBS. Of 27 patients from two studies, 19 were located and asked to participate in the follow-up. All 19 agreed to be interviewed, and 12 kept and submitted symptom diaries for a 2-week period. The 19 were interviewed over the telephone by a researcher as to current symptom status, life stressors during the past year, current level of practice using muscle relaxation and /o r thermal biofeedback, and the general level of satisfaction with the treatment program. Seventeen of the 19 patients rated themselves as at least 50070 improved over pretreatment symptom levels. Symptom scores for 12 individuals who completed follow-up symptom diaries showed 6 of the 12 patients to be clinically improved at 4-year follow-up. Four of the 6 who did not show clinically significant improvement at 4-year follow-up were significantly improved at posttreatment. One who did not show significant improved at posttreatment was now significantly improved, at four, upon follow-up. This global rating, as well as the diary data, leads us to feel that such programs are advantageous to pursue in the treatment of IBS.

1Communications should be addressed to Ann E. Taylor, Center for Stress and Anxiety Dis- orders, 1535 Western Avenue, Albany, New York 12203.

Effects of Paced Breathing on Inhalation Volumes

Vicci Tibbets and Erik Peper, ~ San Francisco State University

The purpose of this study was to explore how covert exhalations affected subjects's breath patterns. Fifteen volunteer subjects participated in the paced

1Communications should be addressed to Dr. Erik Peper, Institute for Holistic Healing Studies, Hensil Hall, Room 714, San Francisco State University, 1600 Holloway Avenue, San Francis- co, California 94132.


breathing study. Breath patterns and inhalation volume were measured with an incentive inspirometer. The subjects inhaled 20 normal sequential breaths with their eyes closed. During the normal respiration phase (breaths 1-4 and 10-14), the trainer sat quietly collecting data with no audible sounds present. During the paced exhalation phase (breaths 5-9 and 15-19), the experimenter would begin to exhale audibly at the subject's midexhalafion phase and continued until the subject began to inhale. The results showed that the subjects's inhalation volumes significantly increased during the initial pacing as compared with the initial normal breathing period (17 = .04, two-tailed T test). The response of this covert activity was most obvious during the first paced phase; thereafter the response was lessened. The findings reinforce that clinicians must be self-experienced and be able to model, both covertly and overtly, the skill they demand of their clients.

Treatment of Inflammatory Bowel Disease: Comparing a Multicomponent Psychological Treatment with a Wait List Control

Shirley P. Schwarz' and Edward B. Blanchard, State University o f New York at Albany

Inflammatory bowel disease (IBD) is a term used to encompass two related gastrointestinal tract diseases, ulcerative colitis (UC) and Crohn's disease (CD). Although UC and CD represent two distinct disorders, they are usually considered together because they share many of the same symptoms and have a similar chronic clinical course, and because their etiology is unknown. This study evaluated the effectiveness of a multicomponent treatment package (encompassing IBD education, progressive relaxation training, thermal biofeedback, and cognitive coping strategies) with 11 IBD patients compared with 10 symptom-monitoring IBD control patients. Eight of the control patients were treated after completing the symptom-monitoring phase. At posttreatment, the treatment group showed reductions on five IBD symptoms, with two reaching statistical significance. Symptom monitoring by the control group led to reductions on all nine monitored symptoms, with statistically significant reductions on five symptoms. When the control subjects were evaluated at posttreatment, all nine symptoms had increased over end-wait- list levels. At 3-month follow-up, these same treated controls reported reductions on all symptoms while the treatment group subjects showed increases on all symptoms. It seems likely that these fluctuations in symptoms were not clinically significant since subjects' body weights and medication usage

1Communications should be addressed to Shirley Schwarz, Center for Stress and Anxiety Dis- orders, 1535 Western Avenue, Albany, New York 12203.


remained relatively unchanged. Subjects perceived themselves as improved on a number of parameters at posttreatment, including measures on the IBD Stress Index, and several other coping indices indicated improvement. Sub- jects also showed decreases in depression and anxiety; they felt that treatment was logical and important, and would be helpful in reducing future IBD problems. It is hypothesized that there may have been inherent differences between subjects based on their IBD diagnosis; CD subjects were more distressed at pretreatment on every psychological inventory and reported greater symptom severity than did UC subjects. These differences could have led to the differences in treatment responses seen between the treatment and control groups. Further research is needed to investigate for which IBD patients this multicomponent treatment would be beneficial, and for which patients, if any, such techniques might actually be detrimental.

Vis ion and the H y p o t h a l a m u s

Joseph N. Trachtman 1 and Catherine M. Venezia, Brooklyn, N e w York

Vision has been defined typically by its sensory and motor processes. The purpose of this report is to present evidence for autonomic nervous system (ANS) involvement with the vision system, with particular emphasis on the role of the hypothalamus. The most studied ANS component of the vision system is the accommodative mechanism via parasympathetic and sympathetic innervation to the ciliary muscle for the focusing process known as accommodation. The accommodative proccess is related to the etiology of near- sightedness, farsightedness, and other vision disorders. In addition to accommodation, other aspects investigated in relation to the ANS are in- traocular pressure (IOP), EMG tension, attention, brain wave patterns, and color vision. The results demonstrated a significant relationship between vision and the ANS on many levels. Sympathetic nervous system fibers pass through the hypothalamus on their way from the superior cervical ganglion to the ciliary muscle. Fibers also have been discovered to go from the retina to the hypothalamus. Such a dynamic, closed-loop system demonstrates the interdependence of vision and hypothalamic activity. An independent series of studies has reported on the effect of visualization on the immune system. The suggested center for this activity has been identified as the hypothalamus. A discussion of the specific neurophysiological mechanisms will conclude the presentation.

tCommunications should be addressed to Dr. Joseph N. Trachtman, 26 Schermerhorn Street, Brooklyn Heights, New York 11201.


Biofeedback Treatment of Premenstrual Affective Syndrome

David B. Van Zak, 1 United States International University

Premenstrual affective syndrome (PAS) include psychological symptoms of depression, lethargy, irritability, and mood lability. It appears to be a separate diagnosis from premenstrual syndrome (PMS). This syndrome has been linked to deficiency in the circulating ovarian hormone progesterone, which has a thermogenic (warming) effect on vaginal and uterine tissue. The present study addressed the problem of whether vaginal temperature biofeedback is an effective treatment for PAS, and whether the mechanism mimics vaginal warming of progesterone. A sample of 30 PAS women was randomly assigned to either true or no vaginal temperature biofeedback. Treatment consisted of 12 weekly 30-minute office vaginal temperature biofeedback sessions, plus twice-daily 10-minute relaxation sessions at home. The experi- ment was double-blind. Results show that group mean data for the experimental group demonstrated a reduction in overall mood symptomatology, as measured by paper-and-pencil data. Other results show that psychological (affective) symptoms decreased in severity through an increase in voluntary control, measured by increasing mean vaginal temperature on com- mand. The mechanism for symptom relief appears to be self-regulation of the affective symptoms. It may be that increasing vaginal temperature mimics the warming effect of progesterone on uterine and vaginal tissue.

~Communications should be addressed to Dr. David B. Van Zak, 1 i600 Wilshire Blvd. No. 210, West Los Angeles, California 90025.

Progressive Relaxation Training as Adjunct Therapy for Seizure Reduction

Steven Whitman and Vicki Legion, 1 Northwestern University

It is widely accepted that stress is a seizure-inducing factor, yet there have been few controlled studies on the effect of relaxation training on seizure reduction. Such a behavioral treatment would be of particular importance to the 20 to 40% of people with epilepsy whose seizures are not adequately controlled through medication alone. Recently our group completed a series

~Communications should be addressed to Vicki Legion, Center for Urban Affairs and Policy Research, Northwestern University, 2040 Sheridan Road, Evanston, Illinois 60208-4100.


of three controlled studies showing that progressive relaxation training (PRT) can significantly reduce numbers of seizures in many people with epilepsy. Thirty-three subjects f rom three settings received PRT. Twenty-four of the subjects had complex partial seizures, two had generalized seizures, and seven had a combination. The main components of our experimental design are described below:

Study 1 Study 2 Study 3

Required

baseline: seizures/week 2/wk. 6/8 wks. 6/8 wks.

N of subjects 8 13 12

How selected consec, eligible consec, eligible referred by staff

N of sessions 1 6 3

Total hours of training 1.5 hrs. 6 hrs. 4.5 hrs.

Experimental design

Baseline 3 wks. 8 wks. 8 wks.

Treatment 3 wks. 3-8 wks. 2.6 wks.

Follow-up 0 wks. 8 wks. 6 mos.

Among 33 subjects receiving PRT, the median number of seizures decreased 49% from baseline to follow-up. Eighty-eight percent of the subjects experienced some seizure reduction. PRT appears to be an effective, easily learned adjunct therapy that encourages patients to take an active role in controlling their own seizure disorders.

Premenstrual Syndrome Treatment with Biofeedback and Hypnotherapy

Elliot Wineburg, 1 Leslie Hartley Gise, and Aaron Gelfand, Mount Sinai School of Medicine

Prementrual syndrome (PMS) is a collection of symptoms and signs: ner- vousness, irritability, emotional lability, depression, headaches, bowel dysfunction, and edema, which occur 7 to 10 days prior to the onset of menses

1Communications should be addressed to Dr. Elliot Wineburg, Associated Biofeedback Medi- cal Group, 145 West 58th Street, New York, New York 10019.


and cease at the time of menstruation. This paper describes the application of stress reduction, relaxation, and symptom management mediated through biofeedback and hypnotherapy. A 40-year-old single white writer with a 15-year history of disruptive premenstrual symptoms improved significantly during 14 months of treatment in a premenstrual syndrome program but felt that her functioning was still impaired. Prior to her presentation at the Premen- strual Syndrome Program she had been treated unsuccessfully with diet, exercise, progesterone, oral contraceptive agents, evening primrose oil, acupunture, and vitamins. In the Premenstrual Syndrome Program she received support, education, diuretics, nonsteroid anti-inflammatory agents, an antidepressant, and antianxiety medication. The main symptoms were irritability, depression, fatigue, weepiness, difficulty at work, increased anxiety, tension of the upper body, and severe cravings for food. The patient showed immediate response to the initial phase of biofeedback evaluation. The control illustrated gave her a sensation of calmness. Following the initial hypnosis session she also reported a remission of anxiety lasting for 3 days. Over the course of additional treatment (4 months) compulsive bingeing decreased and her ability to handle stress improved. The patient herself par- ticularly noted the improvement in her ability to tolerate symptoms. In spite of anxiety and fatigue, she found herself taking less medication. The patient's overall summary was: "The quality of my life is better." We conclude that further exploration of biofeedback and hypnotherapy for the patient who is seriously impaired by premenstrual symptoms is indicated.

The Effects o f Otol i thic Vest ibular St imulat ion on Sleep

Suzanne Woodward, 1 Wayne State University School of Medicine

This study evaluated the effects of otolithic vestibular stimulation in the form of a linearly accelerated parallel swing on nighttime sleep parameters and daytime sleep tendency in eight normal subjects. This protocol allowed com- parison between 1 adaptation night followed by 2 motion nights and 1 adaptation night followed by 2 stationary nights. This method of otolithic stimulation resulted in a decrease in stage 2 sleep on the motion nights as well as a facilitative effect on sleep latency on the last motion night. In addition, an increase in the number of REMs per night was found without a significant alteration of sleep quality or the architecture of REM sleep.

~Communications should be addressed to Dr. Suzanne Woodward, Lafayette Clinic, 951 E. Lafayatte, Detroit, Michigan 48207.

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