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Treating ADHD With Suggestion: Neurofeedback and Placebo Therapeutics

DOI:10.1177/1087054718770012
Authors:
Robert T. Thibault at University of Bristol
Robert T. Thibault
Samuel Veissiere at McGill University
Samuel Veissiere
Jay A Olson
Jay A Olson
Jay A Olson
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Amir Raz
Amir Raz
Amir Raz
  • This person is not on ResearchGate, or hasn't claimed this research yet.
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Abstract

Objective: We propose that clinicians can use suggestion to help treat conditions such as ADHD. Methods: We use EEG neurofeedback as a case study, alongside evidence from a recent pilot experiment utilizing a sham MRI scanner to highlight the therapeutic potential of suggestion-based treatments. Results: The medical literature demonstrates that many practitioners already prescribe treatments that hardly outperform placebo comparators. Moreover, the sham MRI experiment showed that, even with full disclosure of the procedure, suggestion alone can reduce the symptomatology of ADHD. Conclusion: Non-deceptive suggestion-based treatments, especially those drawing on accessories from neuroscience, may offer a safe complement and potential alternative to current standard of care for individuals with ADHD.
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Treating ADHD with Suggestion:
Neurofeedback and Placebo Therapeutics
Robert T. Thibault* a,b, Samuel Veissière* a, Jay A. Olsona, Amir Raz a,b †
*Authors contributed equally, listed alphabetically
Uncorrected!proofs!of!article!accepted!for!publication!in!the!Journal(of(Attention(Disorders!
a McGill University, 3775 University Street, Montreal, QC, H3A 2B4, Canada
b Institute for Interdisciplinary Brain and Behavioral Sciences, Chapman University, Irvine, CA,
92618, USA
Keywords: placebo, nocebo, neuroenchantment, neurosuggestion, neurofeedback, ADHD, EEG.
† Please address physical correspondence to:
Professor Amir Raz, Brain Institute, Chapman University, Irvine, CA, 92618, USA
Email correspondence to: Robert.Thibault@mail.mcgill.ca or Raz@Chapman.edu"
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Recent critical publications on neurofeedback raise a conundrum: Does EEG-
neurofeedback (EEG-nf) work, and if so, how? In a series of papers, we reported that EEG-nf
seems to help the symptoms of ADHD, but for different reasons than most advocates would
expect—i.e., due to a placebo response (Thibault, Lifshitz, Birbaumer, & Raz, 2015; Thibault &
Raz, 2017). In this Guest Editorial, we address ethical considerations concerning prescribing
placebos and highlight how we can leverage prevailing brain-based beliefs about behavioral
disorders to better treat patients. We conclude that clinicians can apply EEG-nf to ADHD as a
form of clinical suggestion for patients with the time, finances, and inclination to pursue such a
treatment."
In a therapeutic context, suggestion refers to communicable ideas, contextual cues, and
cultural rituals that can help modulate both voluntary actions and autonomic functions that
typically lie outside of our volitional control. Suggestions come in many flavors (e.g., hypnotic,
parental, or commercial). In this paper we focus on the kind of suggestion that uses ideas, cues,
and rituals drawn from neuro-technology and our culturally widespread trust in brain-based
explanatory models of human behavior—i.e., neurosuggestion. To enhance the involvement of
the patient and to make suggestion more effective, we can leverage culturally salient props, such
as a brain scanner, in a process we broadly term accessory-assisted healing."
Why EEG-neurofeedback is neurosuggestion therapy"
EEG-nf for ADHD shows comparable benefits whether the feedback is genuine (from
one’s own brain signal of interest) or a sham (from an unrelated signal). To date, every relevant
double-blind sham-controlled study has reached this conclusion (Arnold et al., 2013;
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Lansbergen, van Dongen-Boomsma, Buitelaar, & Slaats-Willemse, 2011; Logemann,
Lansbergen, van Os, Bocker, & Kenemans, 2010; Perreau-Linck, Lessard, Lévesque, &
Beauregard, 2010; Schönenberg et al., 2017; Thibault & Raz, 2017; Van Dongen-Boomsma,
Vollebregt, Slaats-Willemse, & Buitelaar, 2013; Vollebregt, van Dongen-Boomsma, Buitelaar,
& Slaats-Willemse, 2014). In all but two of these studies, the treatment benefitted both groups
(Logemann et al., 2010; Vollebregt et al., 2014). A recent triple-blind registered randomized
controlled trials (RCT) with 118 participants diagnosed with ADHD found large effect sizes for
both true (d=1.0) and sham (d=1.5) neurofeedback groups (Schönenberg et al., 2017). Until
research demonstrates additional benefits from true neurofeedback that go above and beyond
placebo effects, the science suggests that EEG-nf, at least in its current incarnation, relies
exclusively on treatment mechanisms unrelated to watching one’s own brain activity (Thibault &
Raz, 2016). EEG-nf, in other words, is neurosuggestion."
We already prescribe suggestion
Most clinicians have prescribed suggestion—but many don’t know it. The benefits of
SSRIs for depression, acupuncture for lower back pain, and knee surgery for osteoarthritis all
stem largely from the suggestion that these treatments will improve your health (i.e., from
placebo effects). In 2002, the psychologist Irving Kirsch obtained unpublished clinical trial data
under the Freedom of Information Act, and found that SSRIs barely outperformed placebos in
RCTs (Kirsch, Moore, Scoboria, & Nicholls, 2002). In the case of lower back pain, two RCTs
with a total of over 1,700 participants demonstrated comparable benefits between veridical
acupuncture and sham acupuncture, yet both outperformed a standard-of-care treatment (Cherkin
et al., 2009; Haake, Basler, & Endres, 2007; Harris, Lifshitz, & Raz, 2015). Likewise, a high-
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profile RCT showed that, even at a two-year follow-up, sham knee surgery decreased pain and
improved movement capacity on par with real surgery (Moseley et al., 2002). An expert panel
now strongly recommends against knee surgery for osteoarthritis due to potential complications
and the absence of benefits beyond placebo effects (Siemieniuk et al., 2017). In these situation,
clinicians often unknowingly prescribe placebos. Following the results from recent double-blind
studies, we can now add EEG-nf for ADHD to this list of placebo therapies that masquerade
under other biomedical labels."
The case for suggestion in ADHD
In contrast to the abovementioned placebo therapies, psychostimulants typically reduce
ADHD symptoms more effectively than placebo, but come at a cost. Potential side-effects
include crying, staring, anxiety, sadness, nail biting, euphoria, and shyness (Konrad-Bindl,
Gresser, & Richartz, 2016). Due to growing concerns about long-term adverse side-effects, the
European Commission recently called for a two-year longitudinal study that is taking place at 27
sites (Inglis et al., 2016). Given the potential for harm, it is advantageous to consider drug-free
treatments with minimal side-effects to complement or replace psychostimulants. In this vein, a
pair of studies found that when children with ADHD were prescribed an “open-label” placebo,
they could cut their psychostimulant intake in half with negligible changes in behavior (Sandler
& Bodfish, 2008; Sandler, Glesne, & Bodfish, 2010). In lieu of deception, the researchers briefed
children with the following script:"
“This little capsule is a placebo. Placebos have been used a lot in treating people. It is
called ‘Dose Extender.’ As you can see, it is different from Adderall. Dose Extender is
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something new. It has no drug in it. I can promise you that it won’t hurt you at all. It has
no real side effects. But it may help you to help yourself. It may work well with your
Adderall, kind of like a booster to the dose of Adderall. That’s why it’s called a Dose
Extender. I won’t be surprised when I hear from you and your parents and your teachers
that you’re able to control your ADHD better.” (Sandler & Bodfish, 2008, p.106) !
Full disclosure made little impact on the effectiveness of the placebo condition—i.e.,
administering placebos openly hardly detracted from the clinical benefit (Sandler et al, 2008).
Researchers have reproduced this finding in several conditions, including irritable bowel
syndrome, chronic pain, and depression (Kaptchuk et al., 2010; Kelley, Kaptchuk, Cusin, Lipkin,
& Fava, 2012; Schafer, Colloca, & Wager, 2015)."
Based on staunch faith in brain science, neurosuggestion may perhaps treat patients even
better than placebo pills. In particular, with EEG-nf for ADHD, the suggestion that physical
movement will contaminate the expensive brain recordings can lead participants to sit still and in
turn, this procedure provides an ulterior form of behavioral therapy. The additional psychosocial
cues surrounding EEG-nf, compared to those present when ingesting a pill, may help this
technique compete with standard pharmacotherapy (e.g., Fuchs, Birbaumer, Lutzenberger,
Gruzelier, & Kaiser, 2003). To further support this point scientifically and to the level of clinical
recommendation, more studies would need to directly compare EEG-nf with standard of care
treatment."
Testing neurosuggestion in the clinic
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In our previous work, we explored how strong this type of suggestion could be. We found
that many participants believed that a crudely-built “brain scanner”—assembled from discarded
hair drying and medical equipment and placed in a cognitive neuroscience laboratory—could
read their minds (Ali, Lifshitz, & Raz, 2014). In subsequent iterations of this paradigm, we found
that a more realistic looking scanner could similarly alter people’s sense of agency and moral
attitudes (Olson, Landry, Appourchaux, & Raz, 2016; Olson, Strandberg, Hall, Johansson, &
Raz, 2017). In light of these findings, we decided to test the clinical applications of this
technique we term neurosuggestion."
To pilot the idea, we used a real but decommissioned—in other words, sham—Magnetic
Resonance Imaging (MRI) scanner at the Montreal Neurological Institute as part of an open-
label procedure to treat nine children diagnosed with ADHD (Figure 1; Veissière, Olson, & Raz,
2017). We told the children that the “brain machine” was inactive, and that we would “use it as a
suggestion” that would “help their brain heal itself”. While in the defunct scanner, we gave the
children positive verbal suggestions to promote relaxation, focus, and confidence. At one- three-,
and six-week follow-ups, parents reported improvements in eight out of the nine participating
children. In qualitative interviews, two families reported near complete remission of symptoms,
and six reported improvements in areas such as confidence, self-control, and social skills. None
reported any side effects. In essence, this study provided neurofeedback-like treatment, but
instead of focusing on a specific physiological mechanism, we emphasized suggestion based
healing.
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Figure 1: Decommissioned Siemens 1.5T MRI used for the neurosuggestion procedure.
Should we prescribe EEG-nf for ADHD?
To answer this question, we need to consider a few issues. First, as a culture, we maintain
deep-set beliefs that the origin of behavioral disorders resides in the brain (Moncrieff, 2016;
Rose, 2003). Relying on this assumption, children and their families often actively seek a
diagnostic label, for example ADHD, in order to ascribe meaning to their behavior (Moncrieff,
2016; Moncrieff, Rapley, & Timimi, 2015). Second, even in our open-label neurosuggestion
experiment (Veissière et al., 2017), parents continued to ask what was “wrong” with their child’s
brain, despite having been extensively briefed regarding the inert nature of the MRI scanner. And
yet, this very belief system—that a brain disorder is the core reason for the symptoms—may
unintentionally act as a suggestion to further obfuscate the situation and exacerbate symptoms
through nocebo effects (Loftus & Fries, 1979). This type of thinking has been described as a
“looping effect”, where our beliefs and social norms affect the framing, course, and outcomes of
a disorder (Hacking, 1995). In other words, context and culture strongly modulate how patients
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attend to and construe their behavior, which in turn, alters their symptoms (Kirmayer, Gomez-
Carrillo, & Veissière, 2017; Seth & Friston, 2016). Third, our experiments show that brain-based
folk explanations can lead to both nocebo and placebo effects. It seems that neurofeedback likely
summons its strength from this belief system, which offers a promising means to regulate
“faulty” brain patterns (Thibault & Raz, 2017). Thus, neurosuggestion, rather than the act of
regulating one’s own EEG waves, likely allows patients to break free from harmful looping
effects."
In sum, under certain circumstances, clinicians could ethically and non-deceptively
prescribe EEG-nf as a form of neurosuggestion therapy. It wouldn’t be the first placebo
prescription—in the United States, one study reports that 45% of physicians use placebos in
clinical practice and 96% of them believe placebos can have therapeutic effects (Sherman &
Hickner, 2008); in Canada, an analysis of placebo use among physicians, and especially
psychiatrists, echoes similar sentiments (Raz et al., 2011). Moreover, a recent study describes
interviews with 1,000 parents and reports that most deem it acceptable for clinicians to
recommend placebo treatment for ADHD (Faria et al., 2017). With these realities in mind, EEG-
nf presents a reasonable alternative for patients experiencing adverse side-effects or simply
searching for a non-pharmacological treatment. Because EEG-nf requires time, money, and
energy, if clinicians decide to promote this technique, they ought to present it as one of several
options (e.g., exercise, cognitive training, behavioral therapy, and diet; Sonuga-Barke et al.,
2013). Thus, clinicians can certainly prescribe EEG-nf. We recommend they do so transparently
and with an eye for amplifying the psychosocial mechanisms of suggestion rather than grasping
at the elusive neural signatures many practitioners speciously assign as the cause of ADHD."
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... physical activity, behavioral interventions, cognitive-and attention training, different forms of EMG-feedback), significant differences only remained for hyperactivity/impulsivity for parent ratings (SMD = 0.25, 95% CI = 0.03-0.47). The lack of clear differences is especially striking for socalled sham-NF (e.g. using pre-recorded EEG as feedback source or providing random feedback) (Arnold et al., 2013(Arnold et al., , 2020Lansbergen et al., 2011;Schönenberg et al., 2017;Vollebregt et al., 2014), leading some authors to conclude that NF might mainly be a placebo-like intervention (Thibault & Raz, 2017;Thibault et al., 2018). On the other hand, sham-NF studies have been criticized for neglecting important principals of operant conditioning (e.g. using high reward rates, and frequent auto-thresholding), and failing to show that the intended self-modulation has been learned by the participants (Pigott et al., 2018). ...
... The beneficial effects of all active interventions compared to TAU could partly be due to the active components of each intervention, but may also be attributable to non-specific effects (i.e. high level of interaction with trainers) or neuro-suggestion (Thibault et al., 2018). Notably, there were some differences between the two NF protocols when compared to TAU. ...
... Between-groups differences were mainly observed on teacher-ratings, which is in stark contrast to recent metaanalytic findings (Cortese et al., 2016;Riesco-Matías et al., 2019) where the efficacy of NF on ADHD-symptoms mainly was seen in parent-ratings. The latter has been a major critique of NF, as it suggests that the effects may to a large extent be placebic or based on suggestion (Thibault et al., 2018). However, it has been proposed that the effects are more robust when only looking at standard protocols such as SCP (Cortese et al., 2016;van Doren et al., 2018). ...
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  • Sep 2021
Neurofeedback (NF) as a treatment for Attention Deficit Hyperactivity Disorder (ADHD) has been evaluated in several trials, but the specificity and generalizability of effects remain unclear. This four-arm randomized controlled trial evaluated the efficacy of Slow Cortical Potential (SCP; standard NF protocol) and Live Z-score (LZS; non-standard NF protocol) delivered in high-frequency format (five sessions per week during five weeks), compared to Working-memory training (WMT; active comparator) and Treatment-as-usual (TAU; passive comparator). N = 202 children/adolescents aged 9 to 17 years with ADHD participated. The primary outcome measure was multi-report (self-, teacher-, and parent-report) ADHD core symptoms on the Conners-3, assessed at baseline, posttreatment, and 6-months follow-up. Data were analyzed using a linear mixed model. Between-group differences were scarce and did not show a distinct pattern. Superiority of LZS over TAU at endpoint were observed for teacher-rated measures only, while significant differences between SCP and TAU were restricted to posttreatment measurements. Contrary to our expectations, LZS outperformed SCP at endpoint for teacher-rated hyperactivity (-5.37; 95% CI: -10.14 to -0.60; p = .028; d = -.36 ) and overall ADHD symptoms (-2.20; -4.18 to -0.22; p = .030; d = -.41 ). There was no indication that either form of NF was superior to WMT. No severe adverse events were reported during the trial, whereas transient stress-related problems were quite frequent. Overall, the results from this pragmatic trial do not provide convincing support for broad implementation of NF in child and adolescent psychiatric services. Future research should try to clarify for whom and under what circumstances NF might be a viable treatment option.
... Given the lack of conclusive evidence to substantiate the effectiveness of neurofeedback, scientists and ethicists have raised a number of ethical concerns regarding the provision of the technique. First, individuals may opt for neurofeedback in place of more well-established therapeutic options, thereby resulting in a waste of time and resources [21,22]. Second, even though neurofeedback is a low-risk, non-invasive therapy, there may be physical and psychological harms to users that may outweigh any benefits [22][23][24]. ...
... Fourth, it is unclear to what extent consumers have an accurate understanding of the limitations of the therapy, and whether they receive sufficient information before the beginning of their neurofeedback sessions that would allow them to make informed decisions about their healthcare management [11]. Fifth, neurofeedback services are frequently promoted for use on children [13,21,27], who are often considered to be more vulnerable than adults, because usually they cannot make their own healthcare decisions. As such, the risks brought using a therapy that is not well-validated are particularly heightened, as it is unclear whether these therapeutic options are in the best interest of children [28]. ...
Opportunity Cost or Opportunity Lost: An Empirical Assessment of Ethical Concerns and Attitudes of EEG Neurofeedback Users
Article
Full-text available
  • Sep 2022
Background Electroencephalography (EEG) neurofeedback is a type of biofeedback that purportedly teaches users how to control their brainwaves. Although neurofeedback is currently offered by thousands of providers worldwide, its provision is contested, as its effectiveness beyond a placebo effect is unproven. While scholars have voiced numerous ethical concerns about neurofeedback—regarding opportunity cost, physical and psychological harms, financial cost, and informed consent—to date these concerns have remained theoretical. This pilot study aimed to provide insights on whether these issues were supported by empirical data from the experiences of neurofeedback users. Methods Semi-structured telephone interviews were conducted with individuals who had used EEG neurofeedback for themselves and/or for a child. Results The majority of respondents (N = 36) were female (75%), white (92%), and of higher socioeconomic status relative to the U.S. population. Among adult users (n = 33), most (78.8%) resorted to neurofeedback after having tried other therapies, and were satisfied with the treatment (81.8%). The majority paid for neurofeedback out-of-pocket (72.7%) and considered it to be good value for money (84.8%). More than half (57.6%) considered neurofeedback to be a scientifically well-established therapy. However, of those, 78.9% were using neurofeedback for indications not adequately supported by scientific evidence. Conclusion Concerns regarding opportunity cost, physical and psychological harms, and financial cost are not substantiated by our findings. Our results partially support concerns regarding insufficient understanding of limitations. This study underlines the disconnect between some of the theoretical concerns raised by scholars regarding the use of non-validated therapies and the lived experiences of users.
... That said, skeptics assert that EEG-NFB's efficacy derives exclusively from non-specific factors (e.g., expectations, demand characteristics, and context) based primarily on a collection of randomized, sham/placebo-controlled trials for attention deficit hyperactivity disorder (ADHD) which demonstrated comparable clinical improvements in both experimental and sham groups (Thibault et al., 2016(Thibault et al., , 2018Schönenberg et al., 2017a,b;Ghaziri and Thibault, 2019;Arnold et al., 2021). EEG-NFB proponents' most salient objection to this conclusion is that evidence of differential targeted EEG-learning (i.e., greater improvement in the trained electrophysiological variable(s) in genuine vs. sham EEG-NFB groups), considered by many to be essential for a valid evaluation of EEG-NFB's specificity (Sherlin et al., 2011;Kerson, 2013;Arns et al., 2014;Holtmann et al., 2014;Zuberer et al., 2015;Szewczyk et al., 2018;Witte et al., 2018), was noticeably absent in the trials presented as evidence for wholly non-specific effects (Pigott et al., 2018;Trullinger et al., 2019). ...
Is There Evidence for the Specificity of Closed-Loop Brain Training in the Treatment of Internalizing Disorders? A Systematic Review
Article
Full-text available
  • Mar 2022
Introduction Internalizing disorders (IDs), e.g., major depressive disorder (MDD), posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD) are the most prevalent psychopathologies experienced worldwide. Current first-line therapies (i.e., pharmacotherapy and/or psychotherapy) offer high failure rates, limited accessibility, and substantial side-effects. Electroencephalography (EEG) guided closed-loop brain training, also known as EEG-neurofeedback (EEG-NFB), is believed to be a safe and effective alternative, however, there is much debate in the field regarding the existence of specificity [i.e., clinical effects specific to the modulation of the targeted EEG variable(s)]. This review was undertaken to determine if there is evidence for EEG-NFB specificity in the treatment of IDs. Methods We considered only randomized, double-blind, sham-controlled trials. Outcomes of interest included self/parent/teacher reports and clinician ratings of ID-related symptomatology. Results Of the four reports (total participant number = 152) meeting our eligibility criteria, three had point estimates suggesting small to moderate effect sizes favoring genuine therapy over sham, however, due to small sample sizes, all 95% confidence intervals (CIs) were wide and spanned the null. The fourth trial had yet to post results as of the submission date of this review. The limited overall number of eligible reports (and participants), large degree of inter-trial heterogeneity, and restricted span of ID populations with published/posted outcome data (i.e., PTSD and OCD) precluded a quantitative synthesis. Discussion The current literature suggests that EEG-NFB may induce specific effects in the treatment of some forms of IDs, however, the evidence is very limited. Ultimately, more randomized, double-blind, sham-controlled trials encompassing a wider array of ID populations are needed to determine the existence and, if present, degree of EEG-NFB specificity in the treatment of IDs. Systematic Review Registration [ https://www.crd.york.ac.uk/prospero ], identifier [CRD42020159702].
... An interesting study with children, employing treatment resembling neurofeedback with a sham MRI scanner, revealed that even with full disclosure of the placebo procedure, the suggestion alone can reduce ADHD symptoms (Thibault, Veissiere, Olson, & Raz, 2018). The participants were told that the "brain machine" was inactive, and it is used just as a suggestion that would "help their brain to heal itself". ...
HYPNOSIS, ATTENTION AND ATTENTION DEFICITS - PERSPECTIVES FROM BRAIN FUNCTIONS, BEHAVIORAL PERFORMANCE AND CLINICAL APPLICATIONS
Thesis
Full-text available
  • Jan 2022
Background. The present thesis combines studies on hypnosis, attention, and attention deficits from various perspectives to extend our understanding of hypnosis and its applications. This thesis includes experimental and clinical research of hypnosis from the perspectives of brain functions, behavioral performance, and clinical interventions. This thesis investigated whether brain oscillations, pre-attentive auditory information processing, auditory attentional performance, and deficits of attention can be influenced by hypnosis and hypnotic suggestions. Two studies focused on highly hypnotizable healthy participants, one study compared adults with attention deficit hyperactivity disorder (ADHD) to control participants, and one investigated solely adults with ADHD. Aims. The present thesis examined: 1) whether hypnosis differs from the wake state as measured with the spectral power density of electroencephalography (EEG); 2) whether hypnosis and hypnotic suggestions can be used to influence bottom-up and/or top-down auditory attention. The former was indexed by the pre-attentive mismatch negativity (MMN) component of the auditory event-related potential (ERP). The latter was measured as the performance on a Continuous Performance Test (CPT); 3) whether hypnotherapy and hypnotic suggestions can be applied to adults with ADHD to relieve their symptoms in a long-lasting way, and to improve their attentional performance in an auditory reaction time task requiring sustained voluntary attention. Methods. The present thesis applied various methods for investigating the research aims: EEG (Studies I–II), behavioral reaction time task (Study III) and self-report measures for evaluating the follow-up results of two individual psychological treatments, hypnotherapy and cognitive behavioral therapy (CBT) in ADHD adults (Study IV). The first three studies had a similar procedural structure including four experimental conditions: 1) pre-hypnosis, 2) after a hypnotic induction (i.e., neutral hypnosis), 3) hypnotic-suggestion condition with study-specific suggestions and 4) post-hypnosis. The first and second studies included a common EEG experiment with nine highly hypnotizable participants. In the first study, EEG spectral power was measured and analyzed at ten frontal, central, and posterior/occipital electrodes. In the second study, the MMN was recorded at three frontal electrodes using a passive oddball paradigm with sinusoidal standard (500 Hz) and deviant (520 Hz) tone stimuli. Both studies included in the hypnotic-suggestion condition suggestions aimed at altering the tone perception (“all tones sound similar in pitch”). The third study examined, in adults with ADHD and in healthy control participants, whether hypnotic suggestions can influence performance in a three-minute version of the auditory CPT. The suggestions aimed at improving speed and accuracy. The fourth study used a controlled, randomized design in investigating the effectiveness of hypnotherapy in treating adults with ADHD. It compared the six-month follow-up outcome of the hypnotherapy with the outcome of a short CBT in various self-report symptom scales. Repeated-measures analysis of variance and t-tests were used in the statistical analysis of the studies. Results. The results of Study I revealed no EEG power changes between pre-hypnosis and hypnosis conditions, challenging the current understanding that the increase of theta power is a marker of the hypnosis state. Contrary to the results of a few earlier studies, no statistically significant differences in the MMN amplitudes between the conditions were found in Study II, indicating that the auditory pre-attentive processing may not be influenced by hypnosis or hypnotic suggestions. Study III indicated that hypnotic suggestions have an effect on the reaction times in the CPT both in ADHD adults and healthy control participants. Study IV revealed that the treatment benefits remained during the six-month follow-up with both hypnotherapy and CBT groups when measured with self-report ADHD symptom scales. The benefits of hypnotherapy and CBT, however, differed in general psychological well-being, anxiety and depression, and approached significance in the ADHD symptoms scale, indicating a better long-term outcome for hypnotherapy. Conclusion. Results of the present thesis indicate that: 1) the spectral power of EEG in the theta band cannot be used as a reliable marker of the hypnotic state in highly hypnotizable participants; 2) hypnotic suggestions can be used to influence performance in a sustained attention reaction time task, but they do not modulate the early pre-attentive auditory information processing, reflected by MMN; 3) hypnosis, hypnotic suggestions, and short hypnotherapy treatments can be successfully applied to adults with ADHD to improve their performance in a sustained attention reaction time task, and to reduce their ADHD and other symptoms in a long-lasting (at least half a year) way. Thus, hypnosis/hypnotherapy seems to be a usable treatment method for the ADHD adult population.
... Though there are currently other well-established treatments for ADHD that have a high degree of effectiveness, 39 most of these treatments are pharmacological and may come with certain side-effects. 40 In this regard, there is a case to be made about the conditional provision of neurofeedback to clients, as it is a non-invasive therapy with a low risk of side-effects. In the following section, we explore whether the provision of neurofeedback for ADHD Consortia. ...
Neurofeedback as placebo: a case of unintentional deception?
Article
  • Sep 2021
The use of placebo in clinical practice has been the topic of extensive debate in the bioethics literature, with much scholarship focusing on concerns regarding deception. While considerations of placebo without deception have largely centred on open-label placebo, this paper considers a different kind of ethical quandary regarding placebo without an intent to deceive—one where the provider believes a treatment is effective due to a direct physiological mechanism, even though that belief may not be supported by rigorous scientific evidence. This is often the case with complementary and alternative medicine (CAM) techniques and also with some mainstream therapies that have not proven to be better than sham. Using one such CAM technique as a case study—electroencephalography (EEG) neurofeedback for attention-deficit/hyperactivity disorder (ADHD)—this paper explores the ethics of providing therapies that may have some beneficial effect, although one that is likely due to placebo effect. First, we provide background on EEG neurofeedback for ADHD and its evidence base, showing how it has proven to be equivalent to—but not better than—sham neurofeedback. Subsequently, we explore whether offering therapies that are claimed to work via specific physical pathways, but may actually work due to the placebo effect, constitute deception. We suggest that this practice may constitute unintentional deception regarding mechanism of action. Ultimately, we argue that providers have increased information provision obligations when offering treatments that diverge from standard of care and we make recommendations for mitigating unintentional deception.
... Some studies had other methodology flaws as well, which may impede neurofeedback subjects from learning EEG self-regulation skills (Pigott et al. 2018). Some of such methodologically flawed studies led Thibault et al. (2018) to argue that these beneficial effects are due to placebo phenomena rather than specific clinical and behavioral effects of neurofeedback. Discussions about NFB specificity should be encouraged to include analyses of the changes of targeted EEG parameters to be able to report learning curve, as well as changes of EEG measures in individual training session and across course (Zuberer et al. 2015). ...
Neurofeedback Training with Concurrent Psychophysiological Monitoring in Children with Autism Spectrum Disorder with Comorbid Attention Deficit/Hyperactivity Disorder
Chapter
  • Aug 2021
Neurofeedback training is a treatment modality of potential use for improving self-regulation skills in autism spectrum disorder (ASD). Multiple studies using neurofeedback to target symptoms of ASD have been reported. These studies differ among themselves in the type of training (e.g., theta-to-beta ratio, coherence, etc.), topography (Cz or Pz), guidance by quantitative EEG (qEEG), and number of sessions (e.g., 20 vs. 30, etc.). In our study, we proposed that prefrontal neurofeedback training would be accompanied by changes in relative power of EEG bands (e.g., 40 Hz-centered gamma band) and ratios of individual bands (e.g., theta-to-beta ratio) and changes in autonomic activity. Outcome measures included EEG, autonomic measures (heart rate, heart rate variability [HRV] indexes, respiration rate, and skin conductance level [SCL]), and behavioral ratings by parents/caregivers. In this pilot feasibility study on 14 children with ASD with comorbid ADHD (~10.28 years SD = 1.93, 3 females), we administered a 24 session-long course of neurofeedback from the AFz site. The protocol used training for wide-band EEG amplitude suppression (“InhibitAll”) with simultaneous upregulation of the index of 40 Hz-centered gamma activity. Quantitative EEG (QEEG) analysis at the prefrontal training site was completed for each session of neurofeedback in order to determine the amplitude of the individual bands (delta, theta, alpha, beta, and gamma), the ratio of the EEG bands of interest (e.g., theta-to-beta ratio [TBR]), and relative power of 40 Hz-centered gamma across neurofeedback sessions. In this study, we analyzed Aberrant Behavior Checklist (ABC), Social Responsiveness Scale (SRS-2), and Achenbach’s ASEBA ratings by caregivers (pre- and posttreatment). We found a significant reduction in Irritability and Hyperactivity subscales of the ABC, decrease of T-score on SRS-2, and decrease in Attention Deficit scores of the ASEBA posttreatment. Successful neurofeedback sessions were featured by the changes in SCL, decreased HR, increased HRV (reflected in decreased LF/HF ratio of HRV and increased RMSSD of HRV), and decreased respiration rate. Profiles of psychophysiological changes during individual sessions and across the whole course of neurofeedback training showed active engagement of participants during training process, resulting in gradual decrease of anxiety markers across the whole course of experimental intervention using prefrontal neurofeedback training. Future research is needed to assess QEEG changes in other topographies using brain mapping, more prolonged courses, and other outcome measures including clinical behavioral evaluations to judge the clinical utility of prefrontal neurofeedback in children with ASD with co-occurring ADHD. The current series support a need to address various factors affecting outcome of neurofeedback-based intervention, specifically the question of length of treatment.
... Some studies had other methodology flaws as well, which may impede neurofeedback subjects from learning EEG self-regulation skills (Pigott et al. 2018). Some of such methodologically flawed studies led Thibault et al. (2018) to argue that these beneficial effects are due to placebo phenomena rather than specific clinical and behavioral effects of neurofeedback. Discussions about NFB specificity should be encouraged to include analyses of the changes of targeted EEG parameters to be able to report learning curve, as well as changes of EEG measures in individual training session and across course (Zuberer et al. 2015). ...
Transcranial Magnetic Stimulation in Autism Spectrum Disorders: Modulating Brainwave Abnormalities and Behaviors
Chapter
  • Aug 2021
Neuropathological studies in autism spectrum disorder (ASD) suggest the presence of a neuronal migrational disorder that alters the excitatory–inhibitory bias of the cerebral cortex. More specifically, in ASD, there appears to be widespread loss of parvalbumin (PV)-positive interneurons manifested as abnormalities in gamma oscillations (neural network instabilities), epileptogenesis, and impaired cognitive functions. Transcranial magnetic stimulation (TMS) is one of the first treatment to target this putative core pathological feature of ASD. Studies show that low-frequency TMS over the dorsolateral prefrontal cortex (DLPC) of individuals with ASD decreases the power of gamma activity while improving both executive function skills related to self-monitoring behaviors as well as the ability to apply corrective actions. Studies from our group have also shown that low-frequency TMS in ASD provides a reduction of stimulus-bound behaviors and diminished sympathetic arousal. Results become more significant with an increasing number of sessions and bear synergism when used along with neurofeedback.
Neuropsicología del Déficit de Atención. De la Evaluación a su Corrección.
Book
Full-text available
  • Aug 2022
La propuesta de los autores abarca la potencialización de todos los mecanismos neuropsicológicos que pueden estar comprometidos en el TDAH en la edad preescolar y escolar inicial, pero que podría ser útil incluso para el trabajo con niños de otras edades que aún no han formado las cualidades que los preparan para tener un éxito escolar. Al ser una propuesta de intervención bastante completa, el neuropsicólogo experimentado podrá elegir las tareas que son más convenientes de acuerdo con un diagnóstico específico, mientras que el especialista que se adentra por vez primera contará con una diversidad de tareas que le permitirán influir positiva e invariablemente sobre el desarrollo del niño.
A Multivariate Randomized Controlled Experiment about the Effects of Mindfulness Priming on EEG Neurofeedback Self-Regulation Serious Games
Article
Full-text available
  • Aug 2021
Neurofeedback training (NFT) is a technique often proposed to train brain activity self-regulation (SR) with promising results. However, some criticism has been raised due to the lack of evaluation, reliability, and validation of its learning effects. The current work evaluates the hypothesis that SR learning may be improved by priming the subject before NFT with guided mindfulness meditation (MM). The proposed framework was tested in a two-way parallel-group randomized controlled intervention with a single session alpha NFT, in a simplistic serious game design. Sixty-two healthy naïve subjects, aged between 18 and 43 years, were divided into MM priming and no-priming groups. Although both the EG and CG successfully attained the up-regulation of alpha rhythms (F(1,59) = 20.67, p < 0.001, ηp2 = 0.26), the EG showed a significantly enhanced ability (t(29) = 4.38, p < 0.001) to control brain activity, compared to the CG (t(29) = 1.18, p > 0.1). Furthermore, EG superior performance on NFT seems to be explained by the subject’s lack of awareness at pre-intervention, less vigour at post-intervention, increased task engagement, and a relaxed non-judgemental attitude towards the NFT tasks. This study is a preliminary validation of the proposed assisted priming framework, advancing some implicit and explicit metrics about its efficacy on NFT performance, and a promising tool for improving naïve “users” self-regulation ability.
Arthroscopic surgery for degenerative knee arthritis and meniscal tears: A clinical practice guideline
Article
Full-text available
  • May 2017
What is the role of arthroscopic surgery in degenerative knee disease? An expert panel produced these recommendations based on a linked systematic review triggered by a randomised trial published in The BMJ in June 2016, which found that, among patients with a degenerative medial meniscus tear, knee arthroscopy was no better than exercise therapy. The panel make a strong recommendation against arthroscopy for degenerative knee disease. Box 1 shows all of the articles and evidence linked in this Rapid Recommendation package. The infographic provides an overview of the absolute benefits and harms of arthroscopy in standard GRADE format. Table 2 below shows any evidence that has emerged since the publication of this article.
Neuropsychiatric Disease and Treatment Dovepress Changes in behavior as side effects in methylphenidate treatment: review of the literature
Article
Full-text available
  • Oct 2016
Background Our review of the scientific literature focused on an analysis of studies describing instances of methylphenidate treatment leading (or not) to behavioral changes in the pediatric, adolescent, and adult populations. Materials and methods We conducted a literature search in PubMed, Medline, and Google using the keywords “methylphenidate”, “behavioral changes”, “adverse effects”, and “side effects”. A total of 44 studies were identified as reporting on the effects and adverse effects of methylphenidate administration, and were included in the analysis. Results Five studies specifically set out to study, record, and discuss changes in behavior. Eight studies did not set out to study behavioral effects, but record and discuss them. A total of 28 studies recorded behavioral effects, but failed to discuss these further. Three studies did not include behavioral effects. Conclusion This review records what data have been published in respect of changes in behavior in association with the use of methylphenidate. While there is some evidence to suggest that methylphenidate causes changes in behavior, the majority of the studies reviewed paid little or no attention to this issue. Based on the available data, it is impossible to determine the point at which such behavioral effects occur. The frequency of occurrence of behavioral effects is also impossible to determine with certainty. Based on the available data, it is not possible to rule out whether behavioral effects may persist or not persist once treatment is discontinued. In conclusion, despite countless publications and extensive administration, especially to children, we have insufficient data to judge the long-term effects and risks of methylphenidate taking.
The Psychology of Neurofeedback: Clinical Intervention Even if Applied Placebo
Article
Full-text available
  • Feb 2017
Advocates of neurofeedback make bold claims concerning brain regulation, treatment of disorders, and mental health. Decades of research and thousands of peer-reviewed publications support neurofeedback using electroencephalography (EEG-nf); yet, few experiments isolate the act of receiving feedback from a specific brain signal as a necessary precursor to obtain the purported benefits. Moreover, while psychosocial parameters including participant motivation and expectation, rather than neurobiological substrates, seem to fuel clinical improvement across a wide range of disorders, for-profit clinics continue to sprout across North America and Europe. Here, we highlight the tenuous evidence supporting EEG-nf and sketch out the weaknesses of this approach. We challenge classic arguments often articulated by proponents of EEG-nf and underscore how psychologists and mental health professionals stand to benefit from studying the ubiquitous placebo influences that likely drive these treatment outcomes.
Active interoceptive inference and the emotional brain
Article
Full-text available
  • Nov 2016
We review a recent shift in conceptions of interoception and its relationship to hierarchical inference in the brain. The notion of interoceptive inference means that bodily states are regulated by autonomic reflexes that are enslaved by descending predictions from deep generative models of our internal and external milieu. This re-conceptualization illuminates several issues in cognitive and clinical neuroscience with implications for experiences of selfhood and emotion. We first contextualize interoception in terms of active (Bayesian) inference in the brain, highlighting its enactivist (embodied) aspects. We then consider the key role of uncertainty or precision and how this might translate into neuromodulation. We next examine the implications for understanding the functional anatomy of the emotional brain, surveying recent observations on agranular cortex. Finally, we turn to theoretical issues, namely, the role of interoception in shaping a sense of embodied self and feelings. We will draw links between physiological homoeostasis and allostasis, early cybernetic ideas of predictive control and hierarchical generative models in predictive processing. The explanatory scope of interoceptive inference ranges from explanations for autism and depression, through to consciousness. We offer a brief survey of these exciting developments. This article is part of the themed issue ‘Interoception beyond homeostasis: affect, cognition and mental health’.
Neurofeedback, sham neurofeedback, and cognitive-behavioural group therapy in adults with attention-deficit hyperactivity disorder: A triple-blind, randomised, controlled trial
Article
  • Aug 2017
Background: Many studies suggest that electroencephalographic (EEG) neurofeedback might be beneficial in the treatment of attention-deficit hyperactivity disorder (ADHD). However, numbers of well controlled studies are low and neurofeedback techniques are regarded as highly controversial. The present trial examined the efficacy (compared with sham neurofeedback) and efficiency (compared with meta-cognitive therapy) of a standard EEG neurofeedback protocol in adults with ADHD. Methods: We did a concurrent, triple-blind, randomised, controlled trial using authorised deception in adults with ADHD from one centre (University of Tübingen) in Tübingen, Germany. Participants were eligible if they fulfilled the DSM-IV-TR criteria for ADHD, were aged between 18 years and 60 years, and had no or stable use of medication for at least 2 months with no intention to change. We excluded participants who had comorbid schizophrenia or schizoaffective disorder, bipolar disorder, borderline personality disorder, epilepsy, or traumatic brain injury; substance abuse or dependence; or current or planned other psychological treatment. Those eligible were randomly assigned to three groups: a neurofeedback group which received 30 verum θ-to-β neurofeedback sessions over 15 weeks, a sham neurofeedback group which received 15 sham followed by 15 verum θ-to-β neurofeedback sessions over 15 weeks, or a meta-cognitive group therapy group which received 12 sessions over 12 weeks. Participants were assigned equally to one of the three interventions through a computerised minimisation randomisation procedure stratified by sex, age, and baseline symptom severity of ADHD. Participants were masked as to whether they were receiving neurofeedback or sham neurofeedback, but those receiving meta-cognitive therapy were aware of their treatment. Clinical assessors (ie, those assessing outcomes) and research staff who did the neurofeedback training were masked to participants' randomisation status only for neurofeedback and sham neurofeedback. The primary outcome was symptom score on the Conners' adult ADHD rating scale, assessed before treatment, at midtreatment (after 8 weeks), after treatment (after 16 weeks), and 6 months later. All individuals with at least one observation after randomisation were included in the analyses. This trial is registered with ClinicalTrials.gov, number NCT01883765. Findings: Between Feb 1, 2013, and Dec 1, 2015, 761 people were assessed for eligibility. 656 (86%) were excluded and 118 (15%) were eligible for participation in this study. Eligible participants were randomly assigned to neurofeedback (38 [32%]), sham neurofeedback (39 [33%]), or meta-cognitive therapy (41 [35%]). 37 (97%) individuals for neurofeedback, 38 (97%) for sham neurofeedback, and 38 (93%) for meta-cognitive therapy were included in analyses. Self-reported ADHD symptoms decreased substantially for all treatment groups (B=-2·58 [95% CI -3·48 to -1·68]; p<0·0001) between pretreatment and the end of 6 month follow-up, independent of treatment condition (neurofeedback vs sham neurofeedback B=-0·89 [95% CI -2·14 to 0·37], p=0·168; neurofeedback vs meta-cognitive therapy -0·30 [-1·55 to 0·95], p=0·639). No treatment-related or trial-related serious adverse events were reported. Interpretation: Our findings suggest that neurofeedback training is not superior to a sham condition or group psychotherapy. All three treatments were equivalently effective in reducing ADHD symptoms. This first randomised, sham-controlled trial did not show any specific effects of neurofeedback on ADHD symptoms in adults. Funding: German Research Foundation.
Culture and depression in global mental health: An ecosocial approach to the phenomenology of psychiatric disorders
Article
  • Apr 2017
Depression is a major focus of concern in global mental health, with epidemiological surveys indicating high prevalence rates worldwide. Estimates of the global burden of depression in terms of disability, quality of life, and economic impact have been used to argue for scaling up the detection and treatment of depression as a public health and development pri- ority in low and middle-income countries . These projections, however, are based on limited data and make many assumptions about the generalizability of findings across populations. In a useful contribution, Haroz and colleagues (2017) reviewed the qualitative literature on cultural variations in depression to gauge the extent to which current diagnostic criteria fit the experience of people in diverse contexts. They found significant cultural variation and call for an expanded research pro- gram to explore the meaning and significance of these cultural differences for our understanding of mental health. In this commentary, we examine the methods and findings of Haroz and colleagues’ study and discuss implications for future research on depression and the development of interventions in global mental health.
The myth of the chemical cure: A critique of psychiatric drug treatment
Book
  • Jan 2016
This book overturns the idea that psychiatric drugs work by correcting chemical imbalance and analyzes the professional, commercial and political vested interests that have shaped this view. It provides a comprehensive critique of research on drugs including antidepressants, antipsychotics and mood stabilizers.
Parental Attitudes About Placebo Use in Children
Article
  • Nov 2016
Objective: To assess parental attitudes regarding placebo use in pediatric randomized controlled trials and clinical care. Study design: Parents with children under age 18 years living in the US completed and submitted an online survey between September and November 2014. Results: Among all 1300 participants, 1000 (76.9%; 538 mothers and 462 fathers) met the study inclusion criteria. The majority of surveyed parents considered the use of placebos acceptable in some pediatric care situations (86%) and some pediatric trials (91.5%), whereas only 5.7% of parents found the use of placebos in children always unacceptable. The clinical use of placebo was considered acceptable by a majority of parents for only 7 (mostly psychological) of the 17 conditions presented. Respondents' judgment about acceptability was influenced by the doctors' opinions about the therapeutic benefits of placebo treatment, the conditions for pediatric placebo use, transparency, safety, and purity of placebos. Conclusion: Most surveyed parents accepted the idea of using placebos in pediatric trials and within the clinic for some conditions without the practice of deception and with the creation of guidelines for ethical and safe use. This study suggests a need to reconsider pediatric trial design and clinical therapy in the light of generally positive parental support of appropriate placebo use.
Simulated thought insertion: Influencing the sense of agency using deception and magic
Article
In order to study the feeling of control over decisions, we told 60 participants that a neuroimaging machine could read and influence their thoughts. While inside a mock brain scanner, participants chose arbitrary numbers in two similar tasks. In the Mind-Reading Task, the scanner appeared to guess the participants’ numbers; in the Mind-Influencing Task, it appeared to influence their choice of numbers. We predicted that participants would feel less voluntary control over their decisions when they believed that the scanner was influencing their choices. As predicted, participants felt less control and made slower decisions in the Mind-Influencing Task compared to the Mind-Reading Task. A second study replicated these findings. Participants’ experience of the ostensible influence varied, with some reporting an unknown source directing them towards specific numbers. This simulated thought insertion paradigm can therefore influence feelings of voluntary control and may help model symptoms of mental disorders.