Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 28: Psychotherapies

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

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

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. Specific biofeedback of the electrocardiogram has permitted patients to lower the frequency of premature ventricular contractions. 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). 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. EEG biofeedback procedures have been used with children with attention-deficit/hyperactivity disorder to train them to reduce their motor restlessness. 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. 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. 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. 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. 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. 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.

Cardiac arrhythmias

Fecal incontinence and enuresis

Grand mal epilepsy

Hyperactivity

Idiopathic hypertension and orthostatic hypotension

Migraine

Myofacial and temporomandibular joint (TMJ) pain Neuromuscular rehabilitation

Raynaud’s syndrome

Tension headaches