Integrating Neurofeedback with Psychotherapy: A Case Study

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Download the full version as a PDF here: Myron H Koch CaseStudy

Treatment of A Neurologically Delayed Preadolescent Boy
Integrating Neurofeedback and Trauma-informed Psychotherapy
With EFT, EMDR and HANDLE techniques

By: Myron H. Koch, M.D. and Kip Patterson, Ph.D.

A primary difficulty faced by current diagnosis and case management is often a failure to deal directly with the neurophysiological etiology of the behavioral symptoms that are used as diagnostic criteria. The integration of Neurofeedback (aka EEG biofeedback) with other therapeutic modalities allows the therapist to address the underlying neurophysiological components of the etiology that have been largely neglected heretofore by psychotherapists. Such an approach requires a more integrated case formulation. Directly addressing neurophysiological deficits and delayed developmental stages with Neurofeedback — as well as addressing, with trauma-informed psychotherapy, the neurophysiological sequelae of traumatic events and inappropriate psychosocial learning— may significantly enhance the probability of a successful outcome.

Integrating Neurofeedback with other treatment modalities also requires on the therapist’s part a willingness to be more dynamic and less dogmatic, since as one issue such as anxiety is resolved, another, such as poor attention skills, may be revealed. The therapist must then re-formulate an approach to a particular patient based on the feedback provided by the patient’s self-reporting, behavioral changes, as well as reports from the patient’s significant others; in effect, successful resolution of problematic issues using Neurofeedback and other forms of psychotherapy may reveal other underlying neurophysiological deficits. The following case study utilizes just such an integrated formulation and therapy regimen. The patient’s name has been altered to protect confidentiality.

Initial Presentation

Alec’s mother brought him for therapy after reading an article about Neurofeedback in the local newspaper. Her nine-year-old son was very immature and had significant difficulties in school, particularly in special subjects involving sequencing and physical coordination, such as music and gym. In addition, his focus was too frequently outside the structure of the school program. She complained that he needed constant verbal reminders throughout the day to remain focused on tasks and that he was sleeping in bed with her.


The pregnancy was complicated by preeclampsia . Despite a previous delivery by caesarian section, a vaginal delivery was performed resulting in a prolonged and complicated delivery during which Alec’s shoulder was dislocated, requiring immediate repair as well as physiotherapy in the delivery room. His Apgar score was 1 . He required a chest tube and was maintained on life supports for 5 days before being allowed to leave the hospital.

Despite the preeclampsia, the difficult delivery and need for life supports, he was reported to have been, “a really good baby.” He slept and ate well, touch sense and suck response were intact, all indications that basic life processes controlled by the brain stem were intact. Motor functions were intact and —although Mrs. V. was unable to recall the exact times—motor milestones were reportedly achieved at expected rates for normal development, indicating that no anatomical neurological damage was present. It seemed as though the physical integrity of the central nervous system had been preserved.

Exciting on one hand, but unfortunately traumatic on the other, was the presence of a high level of Persistence, experienced by his mother as “willfulness.” Persistence is one of the nine aspects of inborn temperamental characteristics described by Chess, Thomas and Birch in their 20-year longitudinal study of temperament. One is born with them and they remain present throughout one’s life. Persistence consists of a tendency to continue an activity or thought pattern over long periods of time. When a child is learning to ride a bicycle it is seen as positive but when the child persists in a behavior such as refusing to use the toilet for bowel movements it is seen as problematic. In a power struggle with the parent it is seen as —and indeed becomes— obstinacy. Mrs. V stated, “There was a great power struggle. He developed encopresis and was treated with laxatives.” Unless these characteristics are recognized and adapted to, behavioral problems requiring counseling or treatment of parents and child arise. His tendency to be persistent was incorporated into the therapy so that Alec, when the issue was brought to his attention, could persist in correcting the behavior.

School History

While Alec’s first year in nursery school appeared to have gone well, his situation was complicated by the fact that his parents were then in the process of divorce: marital conflict, involving domestic violence, was an important part of the family history at that time. In kindergarten, he began to show “inconsistencies.” By the time he was in first grade he was taking 27 mg of Concerta per day, prescribed by his pediatrician; “And he took it for a long time,” reported Mrs. V. When that dose failed to resolve the problem, the medication was increased and in his mother’s words, “He became a zombie”. Asperger’s Syndrome was the diagnosis posed by a Psychologist at the local clinic.

This psychiatrist saw Alec for the first time two days after the consultation with his mother.

True to his mother and teachers’ description, his presenting symptoms fell within the autistic spectrum (dyspraxia, difficulty with verbal communication, eccentric and disruptive behaviors, learning difficulties, high anxiety, hyper-reactivity, poor sensory integration, difficulties with sequencing and coordination). He showed a lot of extraneous foot movements and a lack of continuity in his thinking, which made it difficult to follow what he was saying. But the warm-hearted child I met in my office failed to meet a key criterion for the Asperger diagnosis with which he had most recently been labeled. He displayed a striking eagerness to connect and tell his own story. When the psychiatrist coughed during that first session, Alec showed an immediate concern for his well-being.

Initial Case Formulation:

Alec’s initial presentation as a concerned, motivated youngster eager to tell his story partially ruled out the Asperger diagnosis. Neurophysiological damage from the intrauterine trauma as well as the trauma of delivery could produce behaviors consistent with an Asperger diagnosis. On the other hand, Alec’s willingness to connect socially and his demonstrated concern for his doctor’s health mitigated against that diagnosis.

Here was a child traumatized in utero, traumatized during the delivery and further traumatized by the separation from his parents for eight days. In retrospect, it is likely that the stress the mother experienced during the pregnancy affected her autonomic nervous system. This in turn could have affected the child’s autonomic nervous system, contributing to the complex of behavioral symptoms with which he presented.

With an impaired autonomic nervous system, Alec had developed inappropriate behaviors. His classmates’ consequent derision created interpersonal problems in school, resulting in a profound sense of humiliation. A classroom observation early in the treatment revealed that he was seated separately from his peers, permitting very little if any communication with either the teacher or his peers.

When Alec began treatment, he met the diagnostic criteria for major depression. Suicidal thoughts became a concern when a note from his teacher quoted him as saying, “Maybe Mrs. X can shake my heart out so I can die.” and “Maybe I should run away and go die someplace.”

Developmental Trauma Disorder, proposed by Bessel Van Der Kolk in 2009 , appeared to be the best diagnosis given the complex developmental history and the resulting behavioral symptoms.

The treatment plan for this patient required prioritization including the need for protecting and enhancing developmental maturation. The first step, in this psychiatrist’s experience, is quieting the brain with Neurofeedback, reducing the intensity of anxiety interfering with intellectual function. Once the brain has been quieted one may then determine the dysfunctional neurophysiological issues and develop specific protocols to address them. Taking into account the different layers and interacting aspects of the patient’s problematic behaviors necessarily involves the integration of other modalities: EFT, EMDR and a course of psychotherapy. The latter would not only involve learning how to negotiate an intimate interpersonal relationship with the psychiatrist but also learning techniques for the auto-regulation of affective states, especially Alec’s impulsive urges.

Alec was seen for a total of 112 sessions; 95 included Neurofeedback.
At the next to last session, when asked how he felt about himself, he responded with, “Improvement of two years. I feel more alive and not little anymore. Anxiety, sometimes when the teacher calls on me. I panic, sweat and don’t know the answer. Sometimes it comes to me.” He followed this with, “I like novels. I read a 443 page novel in a week.”

During what turned out to be his last treatment session, we reviewed his phenomenal progress. He was able to perceive and express how far he had come, able to identify his emotions and sit with them as he continued to work on the construction of his sense of who he is. A week later, his mother called to say that Alec was so busy with afterschool activities that he really didn’t have time to continue therapy. During a follow-up phone call two weeks after therapy had concluded, his mother reported that he was doing very well in school and was active in after school sports. In another follow up call, shortly before the undertaking of this article, his mother repeated how well he was doing both academically and behaviorally.

Alec actually called back after his mother told him about the phone call, to relate that he was very happy with his treatment, that he was now on the high honor roll and that he was a member of the Junior Honor Society in his school.

Treatment Course
The treatment of this preadolescent required discovering and understanding who this young person actually was.
Again, as described by his mother and teachers, his presenting symptoms fell within the autistic spectrum (dyspraxia, difficulty with verbal communication, eccentric and disruptive behaviors, learning difficulties, high anxiety, hyper-reactivity, poor sensory integration, difficulties with sequencing and coordination). But the warm-hearted child I met in my office failed to meet a key criterion for the Asperger diagnosis with which he had most recently been labeled.

It was immediately clear that there were underlying developmental deficits related to early traumatic experiences. Furthermore, whatever the underlying neurophysiological problems might be, they had been masked and compounded by misdiagnosis and the inappropriate pharmaceutical approach based on that misdiagnosis.

The patient’s history of prenatal, perinatal and neonatal trauma (i.e., Developmental Trauma) provided the first major clue to the direction the treatment would take. Since trauma-induced anxiety was like a static overriding mental processes, it would have to be reduced so that the processes themselves might be studied. Hence the choice to start the treatment with a Neurofeedback protocol designed to decrease arousal, complemented with EMDR. This facilitated focus, albeit inconsistently at first. The patient’s mother started to notice positive results as early as the second session.

With this baseline established, it became possible to work toward neurological and personality maturation. This was done using Neurofeedback protocols designed to address different functions located at different areas of the brain. Due to the developmental delays in infancy caused by his overactive sympathetic nervous system, it was necessary to conduct in parallel the construction of the foundational skills of self-awareness and coordination appropriate to a very young child as we helped him develop his budding age-appropriate cognitive, emotional and social skills. It is important to note that development occurred in a non -linear way: the undertow of old habits and expectations would recur whenever stressful events triggered earlier experiences of humiliation. The initial calming protocol was often required at the beginning of a session.

The first ‘specialized’ protocol was a protocol addressing codependency issues — parental counseling was provided to help the patient’s mother adjust to new poorly modulated self-assertive behaviors elicited by this change.

Once the young patient was able to perceive and name emotions that had long been dissociated, it became necessary (and possible) for him to become proprioceptively connected with his own body. Neurofeedback offered a protocol which jumpstarted this development. This new protocol would help maturation of his physical and cognitive skills as well as opening windows into the world of relationships with his peers. Soon he was able to participate more comfortably and successfully in gym and chorus. Reports from the school to his mother were much improved from the past: he was reported to be bright and able to pay attention in class. Now that he was feeling his own body, he also became comfortable sleeping in his own bed. Humiliation was a predominant emotion. After working on his experience of being in his body, the task of improving his self-image was done successfully with a ‘specialized’ Neurofeedback protocol. Again, there were examples of overcompensation, causing a teacher to suggest a label of Bipolar Disorder.

He became able to perceive and eventually discuss in more detail his emotional experiences, as well as providing personal evaluations of the result of his treatment. His developing level of self-confidence opened the way to begin self-regulation of stress levels, affective surges and hyper-reactivity by learning EFT so that he, himself, could take control of his emotional states.

The patient engaged in learning to modulate his aggressive drive requiring him to take notice of a state of sympathetic nervous system arousal, contain himself and think before he acted. This he did eventually by identifying the emotion, remaining conscious of it in order to talk about it. Next he began to notice things about adults that were problematic. Here too he was becoming age appropriate.

At that point he was still occasionally using the room pass in the bathroom in order to avoid the stress of the classroom, an improvement over the past but leaving him with feelings of humiliation. His stress, (right hemisphere) was not alleviated by good problem solving, (left hemisphere). Neurofeedback was used once again in order to facilitate proper inter-hemispheric cooperation. A developing depression was treated with another Neurofeedback protocol while he and his mother continued making use of self-help techniques at home. With the challenge of passage into Middle School, old fears and negative self-expectations reappeared. He needed to use his insights on yet another issue.

This is true of all therapy: each time an issue comes up about which one has developed insight, that insight must be applied to that new situation. This process is known as working through. It can be a long and cumbersome process, but is a most important aspect of a successful therapy. Alec took up the challenge, helped by Neurofeedback at Broca’s area (speech area) and an adjacent site connected with attitude towards the self. The combination worked well. This resulted in fine-tuning of his communication with others, especially his peers. In time, the patient became comfortable with reporting inner voices, some going back to this early childhood, some current. Discussing them with his therapist led to the development of excellent reality-testing skills, a prognosticator of therapeutic success.

Discussion about life and its vicissitudes was an ongoing part of his psychotherapy. The signaling of a painful emotion was followed by the ability to discuss it. He showed himself capable of discussing problem issues in greater detail and working on them successfully so that his next first day of school was described as “awesome”. His improvement in school and with his peers continued, although irregularly. He complained that now his peers were complaining about his superior attitude. It took more work in session until he arrived at his balance.

Important feedback was provided by the patient’s mother and teachers, reporting behavioral changes. More rewarding for the patient and the therapist was the patient’s increasingly proactive self-awareness and self-reflectiveness. He became more socially aware, polite, engaged in self-examination about the effects of his actions on others, as well as being an excellent student. As his treatment arrived at a successful conclusion, he was a young man engaging in cognitive planning and reflection, a huge change from the emotionally driven, depressed boy first encountered.


Chronological stages of Neurofeedback Treatment in Alec’s case

Reduce anxiety, inhibit limbic hyper-reactivity:
Delta, Theta and Alpha amplitude reduction at FT8-A2 accompanied by EMDR

Address codependency issues
Delta, Theta and Alpha amplitude reduction at FT7-A1

Proprioceptive Awareness:
Decreased amplitude of Delta, Theta and Alpha at P3-A1, (Orientation Association Area in the left parietal lobe)

Delta, Theta and Alpha amplitude reduction protocol at T3-A1 (the left temporal lobe is an area of logical sequencing and cognitive constructs and the locus T3-A1 deals specifically with a more realistic attitude towards the self)
Complemented with EFT

Inter-hemispheric Integration: eliminate the static in the cingulate gyrus and the corpus callosum, thus facilitating a clearer passage between the two hemispheres, Inhibiting Delta, Theta and Alpha at AFZ and FPZ

Decreased amplitude Delta, Theta and Alpha at FP1-A1. (When the amplitude of Alpha is greater in the left prefrontal area than the right, depression is often the result as demonstrated by previous NFB research. Since the brain responds more favorably to Neurofeedback via inhibition, Alpha amplitude inhibition in the left prefrontal lobe is preferred to Alpha amplitude increase in the right prefrontal lobe).

Communication Skills:
Work with Broca’s Area FC5-A1 (Speech production) and T3-A1 (self-awareness, self-esteem)

Sensory-Motor experience of emotions:
P3-A1 combined with EFT, and Eye-tracking EMDR

Throughout the therapy Eye tracking, borrowed from the EMDR protocol, was used in almost each session because of its information/memory consolidation properties.

Download the full version as a PDF here: Myron H Koch CaseStudy

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