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 relaxation procedures.
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 thoughts.
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.
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 and Biofeedback.
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.