Mark Schwartz & Frank Andrasik (Eds.). (2016). Biofeedback: A Practitioner’s Guide.

Fourth

Edition. The Guilford Press, New York, xx + 764pp., $115.00 (hardcover) $60.00 (softbound).

Mark Schwartz is, for all intents and purposes, the founder of the Biofeedback

Certification Institute of America (BCIA) now termed the Biofeedback Certification

International Alliance. Schwartz continues to serve on the Mayo Clinic Emeritus Staff and

maintains a private practice in Jacksonville Florida. He is Past President of the Association for

Applied Psychophysiology and Biofeedback (AAPB). His contributions to the field of

biofeedback have been enormous.

Andrasik, Distinguished Professor and Chair of Psychology at the University of

Memphis, is Editor-In-Chief of Applied Psychophysiology and Biofeedback, Associate Editor of

Cephalalgia and past Editor-In-Chief of Behavior Therapy. He served as Senior Research

Scientist at the Institute for Human and Machine Cognition and has also been Professor of

Psychology at the University of West Florida, Pensacola. He was past president of the

Association for Applied Psychophysiology and Biofeedback. These two Editors bring with them

many years of expertise as well as a commitment to the researcher/practitioner model. Both

Editors contribute to this Fourth Edition, with 15 of the 42 chapters written or co-written by

Schwartz and 4 by Andrasik. Andrasik directed his copious talent toward organizing, editing and

insuring the timely publication of this work.

The First Edition of this Practitioner’s Guide appeared in 1987. Between 1987 and 1995 the

Second Edition of this Practitioner’s Guide added new authors and increased topic coverage

including ethics, diabetes, expanded use of computers, ADD and urinary incontinence. In the

ensuing years, there was remarkable improvement in signal detection and computerized signal
processing. In their Third Edition, the Editors added 11 new chapters on EEG instrumentation,

biofeedback applications for athletes and musicians, pediatric headache and other pediatric

applications, a chapter on pelvic floor disorders and one on emerging professional issues. A

chapter on respiratory sinus arrhythmia, with research by Paul Lehrer at the University of

Medicine and Dentistry of New Jersey (now Rutgers Medical School where I continue to lecture)

was also added. Lehrer’s role in this Fourth Edition has been expanded with contributions to

three chapters, focusing on relaxation interventions and cardiorespiratory biofeedback.

This Fourth Edition contains 11 new chapters such that the chapter count is now 42. Schwartz

and Andrasik note that several of the chapters from the previous Edition have been combined

and condensed into single chapters. Chapters on EEG biofeedback and neurofeedback have been

expanded. Three new chapters on instrumentation highlight surface electromyography,

quantitative EEG and the use of consumer-based biofeedback products. Other new chapters

focus on the integration of cognitive behavior therapy (CBT) and relaxation skills into

biofeedback practice. Use of biofeedback in the workplace and the expansion of biofeedback into

the management of psychiatric disorders such as anxiety, autism and substance use are added

together with chapters focusing on such divergent conditions as asthma and traumatic brain

injury. Interestingly, this current Edition includes effort by 65 authors, half who are new

contributors.

As noted, Schwartz is greatly responsible for the BCIA certification program and the

examinations associated with it. I served on the advisory panel creating questions for the very

first certification examination. Wisely, the Board of the BCIA has not only improved their

examinations, enabled web-based examination administration is also added a certification by

prior experience. Schwartz and Frederick Schaffer detailed blueprint of knowledge behind the
2015 revision of the current certification assessment. They also specify the rigorous in-service

and continuing education requirements for certification by prior experience.

This Practitioner’s Guide is organized into 10 parts, with Part I providing an orientation to many

aspects and applications of biofeedback. Part II provides seven chapters dealing with

instrumentation, while Part III provides information regarding adjunctive and complementary

interventions, such as dietary considerations and CBT integration with biofeedback. Part IV

contains two chapters, focusing on relaxation interventions. Part V details six chapters, focusing

on biofeedback practice, such as intake and preparation, adherence, ethical practices, research

evaluation, professional topics including problems associated with relaxation procedures and

biofeedback and guidelines for management. Part VI includes 10 chapters focusing on the

disorders found in a traditional, general biofeedback practice. Disorders including headache,

temporomandibular joint disorders, hypertension, diabetes, tinnitus, fibromyalgia, irritable bowel

syndrome, asthma and anxiety disorders each receive a dedicated chapter to name a few. Part VII

involves clinical applications of EEG, and includes five chapters, starting with attention deficit

hyperactivity disorder, neuromuscular reeducation and gait training, bowel, bladder and pelvic

floor disorders. Part VIII follows with two chapters detailing the use of biofeedback with

performing artists and its use in sports medicine. Part IX provides two chapters dealing with

pediatric applications and work-related musculoskeletal disorders. The book ends with part X,

focusing on emerging biofeedback uses, such as the use of biofeedback on slow cortical

potentials in epilepsy, traumatic brain injury, autism spectrum disorders, brain-computer

communication for paralyzed patients, and substance use disorders. The last chapter of this part

focuses on continuing frontiers with an eye towards future utilization and possible gains in the

use of biofeedback. Due to the encyclopedic nature of this book, this review, unlike those of the
past, will primarily focus on the newly included chapters and chapters providing fresh insights

and usages of biofeedback.

Quantitative electroencephalography (QEEG) surpasses conventional, visual examination of

EEG traces and can measure cortical network dynamics that are typically unseen by the naked

eye. The accuracy, sensitivity and resolution of QEEG have steadily increased. (see my review

of Evans, R. (Ed.) (2005) Forensic Application of QEEG and Neurotherpy. New York: Haworth

Medical Press, in JCFBT Vol 30, 1, 76-81.) Visually inspected traces of EEG recordings can

often localize positions of space occupying lesions due to changes in gross brain anatomical

structures and its impact on surface EEG recordings. Computer-based analysis using Fast Fourier

Transformations (FFT) have supported the theory that the brain is a functional system with

complicated interactions between various brain localizations. Functional Magnetic Resonance

Imagery (fMRI), together with Positron Emission Tomography (PET), Single Photon Emission

Computed Tomography (SPECT), QEEG and, of late, MagnetoEncephalography (MEG) have

expanded knowledge regarding distributed functional systems for perception, memory, drives,

emotions and voluntary and involuntary movements. Knowledge has expanded the reality that

there is no absolute functional localization because of the dynamic coupling of the various

regions of the brain. The brain, like any good distribution system, has “hubs” such that there is

increased efficiency and less need for multiple, complex long-distance interconnections together

with heightened shorter, more localized interconnections. A better understanding of these

matrices has evolved such that there is now an increasingly understandable relationship between

patient systems and dysregulations observed in QEEG assessments. Z scores were developed to

compare an individual to a referenced normative database of means and standard deviations. The

Z score is the difference between the value from any individual in that normative reference group
divided by the standard deviation of that group. This led to the development of real-time EEG Z

score biofeedback which has improved the relationship between the complaints and symptoms of

any particular patient and localization of functional systems within the brain related to those

complaints. Such neural feedback has been successfully used for chronic pain, obsessive-

compulsive disorders and anxiety disorders. Much work needs to be done to further improve the

clinical efficacy of EEG biofeedback. This is an exciting area in that, it is nonpharmacological

and noninvasive. Work on thalamic mediated phase shift and phase lock, cross frequency phase

synchrony, coherence and the expansion and availability of Low-Resolution Electromagnetic

Tomography (LORETTA) provide an exciting avenue of expanding research into improving

mental health and healthcare in general.

Vincent Monastra and Joel Lubar author the chapter on Attention Deficit Hyperactivity Disorder

(ADHD). Interestingly, Lubar (1976) cites his article found in Biofeedback and Self-Regulation

but not his groundbreaking book (Lubar and Deering, 1981) where utilization of Fast Fourier

Transformations and EEG feedback of sensorimotor rhythm (SMR) in reducing ADHD were

detailed. Much research has occurred over the past almost 40 years such that the understanding of

this disorder is now more sophisticated. Early studies detected increased slow wave activity in

central (brainstem reticular) and frontal regions of the brain. Computed Tomography evaluations

now suggest three different subtypes of ADHD, one with frontal lobe deactivation, a second

showing deficits in limbic system activation and a third group with increased activity in the medial

superior frontal gyrus. Those with the first cluster evidenced by frontal lobe deactivation are the

most common group and tend to be good candidates for stimulant medications as well as

neurofeedback. Those with limbic system activity deficits tend to have increases in oppositional

and defiant behavior, impulsiveness and emotional dyscontrol. This group tends to be good
candidates for tri-cyclic antidepressants. The third identified cluster tends to have attention deficit

that is interlaced with obsessive-compulsive disorder. They have short attention span and can be

impulsive and oppositional. They have difficulty discriminating between relevant and irrelevant

and therefore take extended time to complete tasks. This group tends to respond better to

clomipramine or antihypertensives. As it pertains to biofeedback management of ADHD, there has

been a consistent finding of improvement of core ADHD symptoms throughout decades of

research. Research has been impacted by small sample size, the absence of randomization of

participants to the neural feedback or alternative control conditions, the absence of a placebo or

bona fide treatment comparison as well as other problems which may have contributed to the lack

of wide acceptance of what can be an efficacious treatment. At the moment, there is only one FDA

recognized diagnostic assessment for ADHD. It is computer-based and uses EEG data. This too,

has not found acceptance within the medical community. One can hope that, as continuing EEG

based neuroimaging protocols further define areas of dysregulation and improved neurofeedback

outcome studies continue to be published that show efficacy in decreasing ADHD

symptomatology, increased dissemination and acceptance into the medical community might be

forthcoming. Efforts to present results of improved diagnostic accuracy to neurologists and,

physicians in general, will be required to overcome the resistance to heed EEG based data as

important.

Kirtley Thornton provides a timely and interesting chapter on use of QEEG and EEG

biofeedback with traumatic brain injury (TBI). It is not a coincidence that many of the symptoms

of TBI mirror the symptoms of ADHD, including memory impairment, irritability, sleep

disturbance, clouded judgment and significant difficulty in maintaining focus. Thornton details

the QEEG findings typically associated with TBI. One must keep in mind that EEG biofeedback
does not treat a specific disorder and instead treats brain dysregulation which can overlap many

different diagnoses. Cognitive rehabilitation has, to date, been the most widely utilized

intervention following brain injury even in the face of limited supporting documentation. To

date, EEG biofeedback applications have shown to be effective in improving auditory memory

and in some cases cognitive functioning in general. This is an area of fruitful future research.

Schwartz and Andrasik have long held that home-based biofeedback instruments should not be

marketed directly to the public as they discourage the involvement of properly trained and

certified clinicians and supervision of appropriate use. In the first through third editions,

consumer and home-based biofeedback instruments were purposefully not included as it was felt

that such home-based devices should be available for supplemental use when individuals already

working with a trained biofeedback therapist. Excluded from the review contained in this Edition

are devices that are small thermometers attached to fingers which have been available for many

years, EMG biofeedback devices, electrodermal devices and small portable devices only

available to practitioners. This chapter focuses on three devices which focus on respiration rate

and on heart rate variability. Schwartz and Andrasik note that the devices included are well-

designed and function well. The devices can most likely be useful when used properly and

regularly in teaching slow, deep diaphragmatic breathing or increased control over heart rate

variability. Their hope continues to be that these devices are used in conjunction with and under

the direction of a professional. They note that these devices can be contraindicated in individuals

taking heart rate regulating medication and in individuals who have a pacemaker. Excessive

movement, low finger temperatures and individuals with poor circulation might experience

misleading readings from these devices.

Respiratory feedback has been used to deal with hyperventilation syndrome, some instances of

functional chest pain, panic disorder and, in many cases, where medical symptoms are poorly

understood or explained. Such conditions as irritable bowel syndrome, asthma, fibromyalgia and

white coat syndrome have been shown to improve with increased respiratory control and the use

of diaphragmatic procedures. Breathing provides a gateway into many autonomically regulated

disorders. Many psychological processes including anger, anxiety, reactions to stress and many

others produce sympathetic activation. Heart rate variability (HRV) is one index which can be

used to assess psychophysiological profiles and stress reactivity. Both sympathetic or

parasympathetic hyper-arousal or hyperreactivity can be reflected in increases or decreases in

various HRV parameters. HRV can be measured in both time and frequency domains based

using the intervals between R spikes (in the QRS complex) in the electrocardiogram. Respiratory

Sinus Arrhythmia (RSA) reflects the increase and decrease of cardiac sinus rhythm which

corresponds with inhalation and exhalation. Inhalation, being sympathetically mediated, is

associated with increases in heart rate while exhalation, being parasympathetically mediated, is

reflected through decreases in heart rate. RSA is a function of processes controlling respiration

and therefore gas exchange. Baroreceptors modulate pressure variability. When blood pressure

rises, heart rate falls and when blood pressure falls, heart rate rises. Heart Rate Variability

biofeedback increases self-control over autonomic balance and can have a positive impact on

various emotional and somatic symptomatology. The procedure to affect Heart Rate Variability

Biofeedback is outlined by Lehrer, one of the chapter authors (Lehrer et al. 2000b).

Lehrer is also a contributing author of the chapter on asthma. Asthma is interesting in that it is

one of the very few (or only) somatic disorders that is parasympathetically mediated. Early

biofeedback attempts to deal with asthma tried to teach direct voluntary control of pulmonary
functioning or used electromyographic biofeedback to induce relaxation. Significant, but small

effects have been shown with the effects not reaching a point leading to clinical utilization. Some

concern exists that with relaxation of facial musculature, interaction between the trigeminal and

vagus nerve parasympathetically induces relaxation in the upper body and particularly influences

the cardiovascular and respiratory systems. This can increase tone in the smooth muscle of the

lung which, for those with asthma often results in increased bronchoconstriction and possible

worsening symptoms. Studies focusing on EMG as a possible treatment for asthma tended to not

require very low EMG levels as the criteria for skill acquisition. In general, very low EMG

activity is not necessarily correlated with treatment success and sometimes even statistically

significant reduction of EMG levels does not guarantee a decrease in clinical symptomatology.

As noted above, HRV biofeedback affects a broad range of somatic conditions and has found

utility in dealing with asthma. As with EMG biofeedback, it is unusual that a procedure that

produces vagal stimulation which is linked to bronchoconstriction has been shown to be both

reliable and clinically significant when used with asthma. Typically, sympathomimetics are used

to produce bronchodilation. Continued research needs to focus on the mechanism by which HRV

positively impacts asthma symptomatology.

Anyone in clinical practice with a specialty or focus on pain and behavioral medicine has, no

doubt, seen many patients complaining of weakness, fatigue and systemic pain that eludes a

definitive medical diagnosis. Of late, fibromyalgia (FM) has been increasingly diagnosed and

represents a constellation of symptoms or a syndrome but not a disease, per se. In decreasing

order of prevalence, pain is a requirement for the diagnosis of FM followed in prevalence by

fatigue, insomnia, headache, restless legs, paresthesias, impaired memory, leg cramps, impaired

concentration, nervousness and depression. The syndrome is not an “itis” as inflammation is not
implicated. Nonetheless there tends to be systemic soft-tissue tenderness. Epidemiologically, FM

is believed to affect slightly less than 4% of the adult population in the United States with the

syndrome primarily affecting women over men in an 8 to 1 ratio. In one quarter of those

affected, symptoms are of such degree as to cause an impairing disability. The cause of FM is

not well understood. Traditional medical treatments are typically unsuccessful or insufficiently

successful. As there is sometimes a mismatch between observed decrements in function and

reported levels of pain and disability, such individuals often are referred to mental health

specialists for management. Stress management procedures, cognitive behavior therapy,

hypnotherapy relaxation procedures, psychotropic medication and tailored physical exercises

have been shown to give benefit to those with this syndrome. Within CBT, psychoeducation,

relaxation, behavioral activation, scheduling pleasant activities, a focus on sleep hygiene,

cognitive restructuring, working on problem solving, improving interpersonal skills and

improving’s coping skills have all found to be positive interventions. Meta-analysis cautiously

supports the use of CBT as it pertains to improving depression, increasing self-efficacy relative

to pain, but not reduction in pain, fatigue, sleep disturbance and health-related quality of life. A

newer model of FM is emerging based upon sympathetic autonomic system dysregulation,

leading to the speculation that abnormalities in efferent hypothalamus flow is critical to the

development of FM symptoms. The hypothalamus is additionally responsible for appetite

regulation, mood and sleep rhythms which are also highly correlated with FM symptomatology.

With this conceptualization, systemic norepinephrine release induces vagally mediated reduced

pain inhibition and increased sensitization of pain receptors. There is growing pharmacological

evidence for this theory in that, plasma catecholamine concentrations are increased in patients

with FM which, in turn is related to increased pain sensitivity. A very comprehensive review of
the chemical interplay between substance P, calcitonin generated peptides, somatostatins,

bradykinins, histamine and serotonin as well as other body chemistries are carefully detailed.

Pharmacologically, anti-inflammatories and opioids tend to have poor efficacy with FM while

SSRIs, particularly duloxetine, muscle relaxants and antiseizure medication which reduce nerve

irritability have been shown to have positive effect. Given the face validity and increasing

support for this conceptualization, biofeedback interventions which reduce sympathetic

activation and generate increases in parasympathetic tone are gathering increasing support for

use for this challenging issue.

Diabetes is not typically a disorder where biofeedback use comes to mind. That said, there is

significant support implicating stress as a disruptive element in the management of diabetes.

Stress can result in excessive release of glucose or increased tissue resistance to insulin.

Stimulation of the sympathetic nervous system releases glucagon from the pancreas and

decreases secretion of insulin whereas increased sympathetic (vagal) activity also results in

decreasing the availability of insulin. Because of this and other similar relationships between the

psychological reactivity of individuals and their ability to manage diabetes, a team approach to

treatment of diabetes is gaining favor. Biofeedback assisted relaxation coupled with

psychoeducation, activity, diet, and more functional stress management skills all contribute to

better long-term diabetes management.

Biofeedback is finding utilization in the management of epilepsy. Slow cortical potentials

(SCP’s) are related to cortical excitability. Negative SCP’s are found before and during epileptic

seizures. Positive potential shifts are seen after seizures abate, leading to the hypothesis that

epilepsy may involve a deficit in regulating cortical hyperactivation. Ute Strehl provides a

chapter on use of biofeedback to improve SCP self-regulation. Two multicenter studies have
shown that patients are able to learn to regulate their SCP’s and this does lead to a significant

decrease in seizure rate. A 13 week training program which begins with 20 in-clinic daily session

and then ends with 15 daily in clinic sessions with an eight week in-between period of home

practice is detailed. As appropriate commercial equipment becomes more available, together

with sufficient well-trained practitioners, this can represent significant promise for those with

seizure disorders.

Chapters are detailing the use of biofeedback in rehabilitative settings such as for neuromuscular

reeducation and gait training as well as its use in sports medicine. A complete chapter is devoted

to work-related medical disability and motion disorders, detailing the use of EMG biofeedback

for this issue.

One area which is not available to most practitioners is that of the use of biofeedback for bowel,

bladder and pelvic floor disorders as it falls outside of the purview most practitioners licensing.

Jeanette Tries and Eugene Eisman provide an information filled chapter on the use of

biofeedback for illumination disorders. In previous editions, these two were the authors of

separate chapters on urinary incontinence and fecal incontinence. These chapters have been

combined, starting with an overview pelvic floor anatomy, functional components of micturition

and urine storage and repeat the anatomy lesson for bowel function. Manometry is utilized and,

in some locations biofeedback manometry is used in gastroenterological colorectal surgical

departments. They detail the pathophysiology of bowel incontinence as well as urinary

incontinence. Interview questions are detailed along with descriptions of proper assessment

instrumentation. Training in pelvic floor contraction is detailed along with graphic

representations of manometric feedback results. The use of relaxation training for pelvic floor

hypertonus and dyssynergia as well as paradoxical contraction is mentioned. A home program

coupled with behavioral strategies accompany in hospital or in clinic treatment protocols. Tries

and Eisman do not mention whether there is any data for the use of these very specific

biofeedback procedures for individuals with muscular disorders such as cerebral palsy who often

have difficulty with incontinence. As it is occasionally difficult to identify and contact trained

individuals these effective and helpful procedures it would be very helpful to provide either a

web link to providers for a listing of clinics where individuals can be referred who are in need of

such training.

As noted, this review only skims the surface of this book with most of the chapters not being

addressed. Anyone interested in biofeedback would absolutely need this book on their shelf as

there is nothing currently equal to it. Schwartz threatened (personal communication) after writing

the third edition of this text that it might be the last. Fortunately, the continued growth of the field

has changed both his and Andrasik’s mind and they have collaborated to produce yet another gold

mine of information. This book will be absolute reading in any graduate program where

biofeedback is covered or taught.

Schwartz and Andrasik state, “This book continues to provide the broadest scope of topics in the

field of biofeedback and applied psychophysiology, prepared by a diverse and highly acclaimed

set of authors.” They are quite correct! This encyclopedic volume and its previous editions set

the standards for all other books in this field. I had the pleasure of reviewing both the Second and

Third Edition of their Practitioner’s Guide and it was difficult to restrain myself and not overdo

the superlatives. In previous years I was heavily involved with biofeedback, a past president of

the New Jersey Biofeedback Society and a participant in generating questions for the new

Biofeedback Certification examination. Truly excited with Schwartz and Andrasik’s work, then,

as now, it is a tour de force in both presentation and thoroughness. Schwartz and Andrasik do
explain that they were under some pressure from their publisher to reduce the page count from

over 930 to “just” 764 pages. I am quite certain that, as Editors, it was quite a chore to include all

of the information contained in this volume and keep it succinct and focused. A cost of $115.00,

given the amount of work required, the complexity of the topic and the expertise of the many

chapter authors is more than reasonable.

References:

Lehrer, P. M., Vaschillo, E., & Vaschillo, B. (2000b). Resonance frequency biofeedback training

to increase cardiac variability: rationale and manual for training. Applied psychophysiology and

biofeedback, 25(3), 191.

Lubar, J. F., & Deering, W. M. (1981). Behavioral Approaches to Neurology. New York:

Academic Press.

Lubar, J. F. & Shouse, M. N. (1976). EEG and behavioral changes in a hyperkinetic child

concurrent with training of the sensorimotor rhythm (SMR): a preliminary report. Biofeedback

and Self-Regulation, 3, 306.

Howard A. Paul, Ph.DF. A.B.P.P.

JCFBT Book Review Editor

Howardpaulphd.com

happhd@optonline.net