No one is more aware of the limitations of pharmacology in addressing mental disorders than the psychiatrist himself. And perhaps no one is more cognizant of the fact that simple models of efficacy of pharmacological agents are not adequate to encompass clinical realities and complexities. As Peter Kramer has suggested in his book, Listening to Prozac, medications in general don’t address specific disorders, but rather impinge upon biochemical (specifically neuromodulatory) systems. Further, it is coming to be realized that the mechanism of action is not simply compensation for a simple deficit (serotonin in the case of depression, for example), but rather that the medications restore more efficient regulation. This focuses attention on the brain as a self-regulatory system, in which the neuromodulator systems play a central role.

It is also true, however, that neuromodulation must be organized in the bioelectrical domain as well. This is accomplished, it is now recognized, via rhythmic thalamic firing modes which modulate cortical excitability, and which are in turn modulated by inputs from the reticular formation. It is these rhythms that dominate the observed EEG at low frequencies.

It is now becoming clear through clinical research that restoration of efficient neuroregulation can also be accomplished by behavioral techniques such as operant conditioning of the EEG in the frequency range of the thalamocortical rhythmic activity (2-30 Hz). This is consistent with the findings from pharmacology, as we can see from the following argument: The beneficial effects of most psychotropic medications take considerable time to develop (days to weeks). It is therefore not the first-order response of the brain to the medication, but rather the long-term changes induced (the second-order response), which effect the desired remediation. The drugs challenge the brain to function better. I.e., they move the brain to a better operating point. It is the same with operant conditioning of the EEG. In this case, the bioelectrical mechanisms are challenged, and the brain reacts (the first-order response). Eventually, the brain learns to function or self-regulate better (the second-order response). The time-course of remediation is similar to that involved in medication response.

And just as medications such as Prozac are not specific to certain diagnostic categories, neither is EEG biofeedback. Rather, it produces a greater robustness, resilience, stability, and range in nervous system functioning with respect to arousal, attention, and affect. This greater functionality and stability may have particular benefit for persons suffering from a variety of psychiatric disorders. The addition of EEG biofeedback as a modality to a psychiatric practice can allow the practitioner to address many conditions currently found to be relatively intractable: end-stage bipolar disorder; post-traumatic stress disorder, suicidality, dissociative identity disorder, the dementias, and obsessive-compulsive disorder. The training can also be very helpful in ordinary cases of anxiety and depression.

Just as the last sixty years have seen a transition to biological psychiatry, in which psychiatric disorders are seen primarily in terms of their biochemical underpinnings, the addition of operant conditioning of the EEG as a successful intervention will complete this fundamental shift in perspective. (This could happen quite quickly. After all, EEG biofeedback already has a robust thirty-year research history behind it.) Psychiatric diagnostic categories will increasingly come to be seen as specific failure modes of a dynamic, multi-faceted control system. Disregulation in one or more of the functional entities of the CNS will come to be seen as the primary point of reference. Both pharmacology and EEG biofeedback will be standard interventions to achieve renormalization of range of function. It is already becoming clear that there are a few key failure modes to which the brain is heir. This will allow a return to the “spectrum theory” of mental illness (as Peter Kramer has already projected), in which the exponentially increasing number of diagnostic categories will be reframed in terms of these few key failure modes of regulation.

Psychiatrists who have added EEG biofeedback to their practice have found that a significant fraction of their patient population that is already optimally medicated can achieve additional gains from the biofeedback. These gains may come from improved level of function, or they may come from a reduction in medication dose, reduced side effects of the medication, and improved compliance.

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