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Chapter 28: Psychotherapies
electromyogram (EMG), which measures the electrical poten-
tials of muscle fibers; the electroencephalogram (EEG), which
measures alpha waves that occur in relaxed states; the galvanic
skin response (GSR) gauge, which shows decreased skin con-
ductivity during a relaxed state; and the thermistor, which mea-
sures skin temperature (which drops during tension because
of peripheral vasoconstriction). Patients are attached to one
of the instruments that measures a physiological function and
translates the measurement into an audible or visual signal that
patients use to gauge their responses. For example, in the treat-
ment of bruxism, an EMG is attached to the masseter muscle.
The EMG emits a high tone when the muscle is contracted and
a low tone when at rest. Patients can learn to alter the tone to
indicate relaxation. Patients receive feedback about the masse-
ter muscle, the tone reinforces the learning, and the condition
ameliorates—all of these events interacting synergistically.
Many less-specific clinical applications (e.g., treating insom-
nia, dysmenorrhea, and speech problems; improving athletic
performance; treating volitional disorders; achieving altered
states of consciousness; managing stress; and supplementing
psychotherapy for treating anxiety associated with somatic
symptom and related disorders) use a model in which frontalis
muscle EMG biofeedback is combined with thermal biofeed-
back and verbal instructions in progressive relaxation. Table
28.6-1 outlines some important clinical applications of biofeed-
back and shows that a wide variety of biofeedback modalities
have been used to treat numerous conditions.
Relaxation Therapy
Muscle relaxation is used as a component of treatment pro-
grams (e.g., systematic desensitization) or as treatment in its
own right (relaxation therapy). Relaxation is characterized by
(1) immobility of the body, (2) control over the focus of atten-
tion, (3) low muscle tone, and (4) cultivation of a specific frame
of mind, described as contemplative, nonjudgmental, detached,
or mindful.
Progressive relaxation was developed by Edmund Jacobson
in 1929. Jacobson observed that when an individual lies
“relaxed,” in the ordinary sense, the following clinical signs
Table 28.6-1
Biofeedback Applications
Condition
Effects
Asthma
Both frontal electromyogram (EMG) and airway resistance biofeedback have been reported as
producing relaxation from the panic associated with asthma, as well as improving air flow rate.
Cardiac arrhythmias
Specific biofeedback of the electrocardiogram has permitted patients to lower the frequency of
premature ventricular contractions.
Fecal incontinence and enuresis
The timing sequence of internal and external anal sphincters has been measured, using triple
lumen rectal catheters providing feedback to incontinent patients to allow them to reestablish
normal bowel habits in a relatively small number of biofeedback sessions. An actual precursor
of biofeedback dating to 1938 was a buzzer sounding for sleeping enuretic children at the first
sign of moisture (the pad and bell).
Grand mal epilepsy
A number of electroencephalogram (EEG) biofeedback procedures have been used experimentally
to suppress seizure activity prophylactically in patients not responsive to anticonvulsant
medication. The procedures permit patients to enhance the sensorimotor brain wave rhythm or
to normalize brain activity as computed in real-time power spectrum displays.
Hyperactivity
EEG biofeedback procedures have been used with children with attention-deficit/hyperactivity
disorder to train them to reduce their motor restlessness.
Idiopathic hypertension and
orthostatic hypotension
A variety of specific (direct) and nonspecific biofeedback procedures—including blood pressure
feedback, galvanic skin response, and foot–hand thermal feedback combined with relaxation
procedures—have been used to teach patients to increase or decrease their blood pressure.
Some follow-up data indicate that the changes may persist for years and often permit the
reduction or elimination of antihypertensive medications.
Migraine
The most common biofeedback strategy with classic or common vascular headaches has
been thermal biofeedback from a digit accompanied by autogenic self-suggestive phrases
encouraging hand warming and head cooling. The mechanism is thought to help prevent
excessive cerebral artery vasoconstriction, often accompanied by an ischemic prodromal
symptom, such as scintillating scotomata, followed by rebound engorgement of arteries and
stretching of vessel wall pain receptors.
Myofacial and temporomandibular
joint (TMJ) pain
High levels of EMG activity over the powerful muscles associated with bilateral TMJs have been
decreased, using biofeedback in patients who are jaw clenchers or have bruxism.
Neuromuscular rehabilitation
Mechanical devices or an EMG measurement of muscle activity displayed to a patient increases
the effectiveness of traditional therapies, as documented by relatively long clinical histories in
peripheral nerve–muscle damage, spasmodic torticollis, selected cases of tardive dyskinesia,
cerebral palsy, and upper motor neuron hemiplegias.
Raynaud’s syndrome
Cold hands and cold feet are frequent concomitants of anxiety and also occur in Raynaud’s
syndrome, caused by vasospasm of arterial smooth muscle. A number of studies report that
thermal feedback from the hand, an inexpensive and benign procedure compared with surgical
sympathectomy, is effective in about 70 percent of cases of Raynaud’s syndrome.
Tension headaches
Muscle contraction headaches are most frequently treated with two large active electrodes spaced
on the forehead to provide visual or auditory information about the levels of muscle tension.
The frontal electrode placement is sensitive to EMG activity regarding the frontalis and occipital
muscles, which the patient learns to relax.
