Biofeedback and Anxiety
by Alan Brauer, M.D.
Psychiatric Times February 1999
Considered a "fringe" therapy 25 years ago, biofeedback
has matured today to a modality much closer to mainstream
treatment. Its value is accepted by a growing number of professionals,
and it is covered by Medicare for some conditions, as well
as by most health insurers.
Applied psychophysiology has yet to fulfill early enthusiastic
predictions of the benefits of learning and applying self-regulatory
skills. However, the field has amassed sufficient research
and clinical data to justify an important secondary role in
treating a number of specific disorders. Fueled by advances
in technology and increasing interest in alternative therapies,
biofeedback remains a dynamic force that continues to tantalize
with possible-though as yet unproved-applications.
Biofeedback, also referred to as applied psychophysiological
feedback, is the process of displaying involuntary or subthreshold
physiological processes, usually by electronic instrumentation,
and learning to voluntarily influence those processes by making
changes in cognition. It provides a visible and experiential
demonstration of the mind-body connection. Biofeedback is
also a therapeutic tool to facilitate learning self-regulation
of autonomic functions for improving health.
In a quiet room, seated in a comfortable chair with sensors
attached to the skin, the trainee (patient) views a monitor.
Advances in hardware and software technologies allow simultaneous
monitoring of multiple modalities and the flexible shaping
of visual and sound feedback to reinforce desired physiological
states. Extensive data can be collected for immediate display
with automatic storage for research.
There are six commonly employed feedback modalities:
Electromyographic (EMG): Frontalis, masseter, trapezius and
sternocleidomastoid are the most frequently monitored sites.
Skin Conductance Level (SCL): Also referred to as Galvanic
Skin Response (GSR). Finger electrodes register sweat gland
Thermal: Finger thermistors measure vasoconstriction by minute
changes in peripheral blood flow.
Respiratory: Strain gauges measure abdominal and thoracic
excursions; a capnometer monitors exhaled CO2.
Heart Rate (HR): Finger photoplethysmography registers rate
and pulse volume.
Brainwave/Neurofeedback (EEG): Multichannel equipment with
more sophisticated software and new treatment protocols have
replaced the simple single channel alpha training of earlier
Used alone as relaxation therapy, biofeedback is as efficacious
as other forms of relaxation training, such as hypnosis, progressive
muscle relaxation or transcendental meditation. However, most
applications of biofeedback are used as adjuncts to other
types of therapy, treating physiological as well as psychological
Physiological disorders with credible research to support
the ancillary use of biofeedback include headaches, chronic
pain, rheumatoid arthritis, asthma, temporomandibular joint
disorders, dysmenorrhea, epilepsy, hypertension, irritable
bowel syndrome, intestinal motility, motion sickness, neuromuscular
rehabilitation, Raynaud's disease and fecal incontinence (Crabtree
et al., 1995; Schwartz, 1995).
Biofeedback also seems to be a useful tool in the treatment
of a broad range of problems commonly seen by psychiatrists.
The adjunctive use of biofeedback is reasonably well-documented
for the psychological disorders of anxiety and insomnia. Many
forms of psychotherapy, including dynamic, behavioral and
brief, appear to have enhanced efficacy when biofeedback-assisted.
Both the patient and therapist benefit from a display of physiological
responses, which can help identify resistance, denial and
other defense mechanisms. Biofeedback monitoring can provide
a uniquely vivid demonstration of the connection between thoughts
and feelings. Brain wave feedback is showing promise in the
treatment of attention-deficit/hyperactivity disorder, addictive
disorders and posttraumatic stress disorder (PTSD).
Biofeedback and GAD
Anxiety in some form is a problem that all psychiatrists
must deal with on a daily basis. It is one of the most frequently
observed categories of emotional disorders in the American
population and often seriously interferes with the quality
of everyday life. All of the anxiety disorders are defined
by the dual characteristics of physiologic hyperarousal and
excessive emotional fear.
Biofeedback has demonstrated value for hyperarousal reduction
training in generalized anxiety disorder (GAD) and exposure
desensitization in panic disorder (PD) and PTSD.
Multimodal cognitive/behavioral therapy (CBT), which may
include biofeedback, offers an equally effective alternative
to medications, particularly for patients who do not respond
well, who have a potential for dependency or who refuse prescription
drugs. Optimum treatment outcome for GAD and PD is more likely
to be achieved with a combination of pharmacotherapy and CBT.
Biofeedback is one of the most useful adjuncts in treating
physiologic hyperarousal-both episodic and chronic-seen in
anxiety disorders. It has also proved helpful for patients
who are learning to reduce fearful anticipation triggers through
Biofeedback training is a part of the behavioral treatment,
which includes relaxation training, because of its additional
specificity. Biofeedback offers a nonpharmacological approach
to direct symptom reduction and can be tailored to the individual
patient's psychophysiological profile. Those patients experiencing
symptoms of muscle tension have EMG sensors attached to muscle
sites showing the highest activity. Patients with mainly autonomic
symptoms generally receive thermal, GSR, heart rate and respiration
feedback. EEG feedback may be useful when an assessment documents
brain wave pattern dysregulation.
Behavioral treatment may also include cognitive interventions
to identify negative thinking, and to develop more appropriate
assessment of life events. Where specific fears can be identified,
behavioral fear reduction techniques, such as desensitization,
modeling or flooding, may be used. Concomitant use of biofeedback
may enhance the therapeutic effectiveness of these techniques.
Like most behavioral treatments, biofeedback is most effective
with patients willing to assume an active role in the treatment
process, including home practice.
Most studies document improvement and significant symptom
reduction in six to 12 sessions of biofeedback training, with
more complex or chronic patients requiring more sessions.
For instance, in 1993 Rice et al. studied 45 GAD subjects
(38 of whom met the DSM-III criteria). The study subjects
were randomized to four treatment groups: frontal EMG biofeedback,
EEG alpha enhancement biofeedback, EEG alpha suppression biofeedback
or a pseudomeditation control. Results were compared against
wait-list controls. All treated subjects showed significant
reductions in STAI-Trait Anxiety and psychophysiological symptoms
on the Psychosomatic Symptom Checklist. Decreased self-report
of anxiety was maintained at six weeks posttreatment.
CBT, Biofeedback and Panic
David H. Barlow, Ph.D., developed a comprehensive model of
panic disorder in which he explained that panics were sustained
in patients because they developed a fear of bodily sensations
associated with panic attacks (1988). Anxious apprehension
causes chronic increased autonomic arousal, which increases
vigilance with heightened sensitivity to evermore minute body
sensations. A vicious cycle of apprehension and physiological
activation results in panic disorder.
By allowing heightened internal awareness, low arousal relaxation
training may actually precipitate increased anxiety in some
patients with panic disorder. This relaxation-induced anxiety
is less likely to occur with biofeedback than other general
Diagnostic accuracy increases when biofeedback is used to
monitor physiological reactions to questions about anxiety.
EMG, SCL, HR, temperature and respiration are measured. The
treatment of PD with CBT has four components, each of which
may be more effective with biofeedback. Three focus on managing
panic; the fourth aims to eliminate it.
Educational, Informational: Patients learn the causes of
panic, the "fear of fear" cycle and the rationale
for treatment. Various biofeedback modalities help in experiencing
and understanding on a gut level the relationship between
thoughts, feelings, images, bodily sensations and the actual
body responses. "Biofeedback information seems to help
patients 'get it' a lot faster," noted Hugh Baras, Ph.D.,
reporting on a study of biofeedback and panic disorder presented
at the recent 24th Annual Conference of the Biofeedback Society
of California in Monterey, Calif.
Somatic Management Strategies: Patients use these techniques
to manage anxious apprehension. They include diaphragmatic
breathing retraining, slow breathing and muscle relaxation.
"Biofeedback-assisted breathing retraining and biofeedback-assisted
muscle relaxation can be very helpful in providing motivation
for patients and in providing the experience of mastery over
their panic reactions," reported Baras.
Cognitive Restructuring: This technique provides instruction
and practice in constructive self-talk to reduce fears of
anxiety sensations. Exaggerated fears of somatic symptoms
or the probability of negative reactions and adverse outcomes
are replaced with more realistic attitudes. Trainees are often
surprised to see the biofeedback equipment demonstrate a striking
difference between the responses from their fearful thoughts
as compared to responses as a result of their restructured
Fear Exposure Strategies: The aim of these strategies is
to eliminate the experience of panic. They are also the nonpharmacological
treatment of choice for specific phobias, including agoraphobia
and obsessive-compulsive disorder. In a systematic and controlled
way, exposure therapy elicits the physical sensations that
trigger anxiety. The goal-fear extinction-is to break the
associations between increased body sensations and panic reactions.
There are two types of fear exposure:
1. Brief and graduated (systematic desensitization): The
arousal-provoking event is presented for about a minute, spaced
with intervals of relaxation. The intensity of arousal is
gradually increased, creating the experience of anxiety mastery.
2. Prolonged and intense (flooding): Ten to 15 minutes of
repeated exposure to maximal intensity stimulus demonstrates
to the patient that the feared negative consequences do not
occur. This results in fear extinction. Exercises to help
induce flooding include rapid head movements, breath holding,
restricted breathing, hyperventilation and muscle tensing.
Substantial research data support the value of using cognitive
restructuring and fear exposure in preventing relapse. Like
a pilot turning on the radar, exposure therapy is more effective
when therapist and patient have immediate autonomic feedback
to guide the process. The advantages of biofeedback-assisted
CBT for PD include increased awareness and control of the
stress response, increased motivation for treatment and willingness
to practice home assignments, and heightened self-confidence.
Biofeedback for Children
There are several controlled studies showing the efficacy
of using biofeedback to reduce anxiety in children. In 1996,
Wenck et al. studied 150 seventh- and eighth-graders identified
as anxious by their teachers. The students were randomly assigned
to biofeedback intervention, which included six sessions each
of EMG and thermal biofeedback, or control groups. The researchers
found that the biofeedback group had significantly lower posttest
states and trait anxiety.
Referrals and Certification
Biofeedback therapy is commonly performed by clinical psychologists,
or by a biofeedback trainer under the direct supervision of
a psychologist or psychiatrist. The Biofeedback Certification
Institute of America has a written/practicum certification
process. The Association for Applied Psychophysiology and
Biofeedback in Wheat Ridge, Colo., sponsors an annual conference
and provides information and referrals. Larger states have
biofeedback societies for local referrals.
Dr. Brauer has been certified since 1976 by the Biofeedback
Certification Institute of America and is the founder and
director of TotalCare Medical Center in Palo Alto, Calif.
He is clinical assistant professor, department of psychiatry
and behavioral sciences, Stanford University and was founder
of the university's Biofeedback and Stress Reduction Clinic.
Barlow DH (1988), Anxiety and Its Disorders: The Nature
and Treatment of Anxiety and Panic. New York: Guilford Press.
Crabtree M, Kase J, Bland A et al. (1995), An Annotated Bibliography
on Clinical Applications of Biofeedback and Applied Psychophysiology.
Wheat Ridge, Colo.: Association for Applied Psychophysiology
Rice KM, Blanchard EB, Purcell M (1993), Biofeedback treatments
of generalized anxiety disorder: preliminary results. Biofeedback
Self Regul 18(2):93-105.
Schwartz MS (1995), Biofeedback: A Practitioner's Guide. New
York: Guilford Press.
Wenck LS, Leu PW, D'Amato RC (1996), Evaluating the efficacy
of a biofeedback intervention to reduce children's anxiety.
J Clin Psychol 52(4):469-473.