Biofeedback for Post-traumatic Stress Disorder (PTSD)

Biofeedback is widely used to treat stress-related disorders. Promising findings in PTSD have been reported in two specialized areas of biofeedback based on cardiac coherence training using heart-rate variability (HRV) monitoring and brain wave recordings (ie, electroencephalography), respectively.

Cardiac coherence training for PTSD

Cardiac coherence is an indicator of heart rate variability (HRV). Abnormal low HRV is associated with deficits in attention and short-term memory in combat veterans diagnosed with PTSD. In a small pilot study, all participants who received visual feedback in HRV patterns while undergoing relaxation training (Ginsberg 2010) had improved cardiac coherence (ie increased HRV) as well as improvements in attention and short-term memory. The researchers inferred that increased cardiac coherence may lessen the severity of cognitive symptoms that often accompany PTSD. The findings of a pilot study suggest that veterans diagnosed with combat-related PTSD who receive HRV biofeedback experience significant increases in HRV and reduced PTSD symptom severity compared to veterans receiving treatment as usual (Tan 2011). In a small 3 week open exploratory study a group of active-duty service members diagnosed with PTSD or depressed mood who received heart-rate variability biofeedback plus treatment as usual did not report greater reductions in symptom severity compared to a group receiving treatment as usual only (Lande 2010).

Neurofeedback for PTSD

Neurofeedback can be conceptualized as a specialized kind of operant conditioning in which pre-selected EEG frequencies or other EEG features are provided to the trainee in the form of a game that employs visual, auditory, and tactile feedback. The individual is ‘rewarded’ by progressing in the game only when specific EEG frequencies corresponding to a calmer or more regulated mental or emotional state exceed threshold. Repetitive ‘training’ in select frequencies reinforces the individual’s ability to achieve a target state of baseline EEG activity corresponding to enhanced cognitive functioning or improved emotional self-regulation. The technique is currently widely used to treat Attention Deficit Disorder and a range of anxiety disorders in both children and adults.

Recent research findings suggest that neurofeedback involving very low frequencies, between 0.02 and 0.2 Hz, results in rapid significant reductions in the severity of PTSD symptoms (Othmer et al, 2011) and improvements in overall cognitive functioning (Legarda et al, 2011). Such ‘infra-low frequencies’ may induce beneficial shifts in the functional connectivity of the brain’s resting state networks resulting in reduced overall arousal, enhanced cognitive functioning and emotional stability.

In a pilot study, seven Vietnam-era war veterans with chronic treatment-refractory PTSD who trained with the infra-low frequency neurofeedback protocol reported significant reductions in symptom severity after twenty sessions (Kelson 2012). Wait-listed controls subsequently reported similar improvements. More recently, neurofeedback training using infra-low frequencies has been extensively field-tested at six U.S. military bases. At one large military base more than 500 active duty combatants who had been diagnosed with PTSD were trained in infra-low frequency (ILF) neurofeedback. Training was done 1 to 3 times per week and was administered by licensed psychotherapists certified in neurofeedback therapy. Symptom severity was evaluated weekly using the PCL-5—the military version of the PTSD Checklist (PCL)—and other standardized symptom rating scales. Findings from a cohort analysis of 300 of the 500 active duty Marines in the original group suggest that 75% of individuals with moderate to severe symptoms experienced significant clinical improvement based on a review of symptoms frequently associated with PTSD including psychological, cognitive, psychophysiological and physiological symptoms that were tracked using a custom computerized symptom tracking program. 25% of subjects in the cohort reported that all symptoms had resolved completely with fewer than twenty neurofeedback sessions; another 50% experienced significant reductions in symptom severity after forty sessions (Othmer 2012). The remaining subjects took much longer to respond to treatment, continued to report clinically significant symptoms, discontinued training prematurely, or were non-responsive to the neurofeedback training protocol. The above findings have led to formal evaluation of infra-low frequency training in connection with the Navy’s OASIS program for the most severely symptomatic and most treatment-resistant cases of PTSD.