Psychology

Nothing gives one person so much advantage over another as to remain
always cool and unruffled under all circumstances.Thomas Jefferson

Abstract
Biofeedback is an alternative therapy where instead of drugs various scientific instruments are used to measure, amplify, and feed back physiological information to the patient being monitored. This information is then used by the patient to gain self regulation of the physiological process being monitored. Biofeedback helps by setting various set points to newer levels thereby achieving desired response. The patient is taught to control the physiologic affect of various stressful conditions as well as various pathological conditions in the body. The report also takes a look at the mechanism of biofeedback as well as various theories and philosophy of biofeedback. It also takes a detailed look at theoretical foundation of whole body breathing and exercise and how its beneficial for the patients. The report analyses and suggests the process of biofeedback for Thomas who presents with extreme stress and anxiety and finally also reviews a review article showing the beneficial clinical effect of biofeedback on incontinence.

Introduction
Oxford Dictionary (Oxford Dictionary) defines stress as a state of affair involving demand on physical or mental energy. Stress is the normal physiological response to a stressful stimulus resulting in release of hormones, cortisone and adrenalin. Certain amount of stress is normal and beneficial for the survival however when the stress becomes too much it may adversely affect the normal functioning of human body warranting interventions from the experts. Stress management is a specialized science that uses many scientific methods. This paper takes a close look at some of those methods namely biofeedback, whole body breathing and exercise. The paper also analyses a case scenario and a research article.

1.1 Mechanisms of biofeedback
According to the Free Dictionary (Free Dictionary) , Biofeedback is defined as a patient-guided treatment that teaches an individual to control muscle tension, pain, body temperature, brain waves, and other bodily functions and processes through relaxation, visualization, and other cognitive control techniques. The consortium (2008) of Association for Applied Psychophysiology and Biofeedback (AAPB), Biofeedback Certification Institution of America (BCIA), and the International Society for Neurofeedback and Research (ISNR) (2008) define biofeedback as, a process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance. Precise instruments measure physiological activity such as brainwaves, heart function, breathing, muscle activity, and skin temperature. These instruments rapidly and accurately feed back information to the user. The presentation of this information often in conjunction with changes in thinking, emotions, and behavior supports desired physiological changes. Over time, these changes can endure without continued use of an instrument

1.2 Physiology of Biofeedback
Human body has an excellent regulatory system brought about by certain hormones released in response to various stimuli. Typically the body responds either by a flight response brought about by cortisone or by a fight response brought about by adrenalin. Human brain especially the hypothalamus and limbic system control the secretion of these hormones and have variable set points. Under normal condition the body maintains a perfect homeostasis. For example under normal circumstances the human heart will beat at a rate of 60 - 80 beats per minute. This heart rate is regulated by sympathetic nerves and parasympathetic nerves both working in perfect harmony. A sudden stimulus such as fear or anger will stimulate sympathetic over activity resulting in an increase in the heart beat (tachycardia). Alternatively certain activities such as sleep, meditation and relaxation will stimulate parasympathetic system resulting in a slowing of heart rate (bradycardia). 

Biofeedback is an alternative therapy where instead of drugs, various scientific instruments are used to measure, amplify, and feed back physiological information to the patient being monitored. This information is then used by the patient to gain self regulation of the physiological process being monitored.  By actually seeing his  her bodys reaction to pain, worry or anxiety, patient can learn to interrupt the cause-and-effect mechanism. During the biofeedback training, patient may see an actual link between the psychological activity and its affect on the breathing, heart rate, blood pressure, skin temperature, perspiration, muscle tension and brain activity. Biofeedback training can provide extremely important insight into physiology. When a change in the functioning of body systems is desired for health reasons, it may be easier to bring it about by methods that stimulate a cluster of physiologic systems.

The idea of using biofeedback training to modify illness follows naturally from demonstrations that people can learn to control responses such as heart rate (Levene H I, Engel B T, Pearson J A 1968), blood pressure (Shapiro D, Tursky B, Gershon E, et al 1969), vasomotor response (Roberts A H, Kewman D G, MacDonald H, 1973), and EEG frequency (Kamiya J 1969). Biofeedback training has produced effects in conditions as varied as hypertension (Elder ST, Ruiz ZR, Deabler H L, et al, 1973) and epilepsy (Sterman M B, Friaz L 1972)

Biofeedback therapy always involves a therapist, a patient, and a monitoring instrument capable of providing accurate physiological information. Generally, a session for training in biofeedback takes 30 to 60 minutes. During one of these sessions, the therapist places electrical sensors on different parts of the body in order to monitor the bodys responds to stress. These responses, e.g. muscle contractions, trigger a response with the equipment being used for monitoring, such as a beeping sound. This way, the person being trained in biofeedback can begin to make associations between the bodys responses with the way the body is functioning

1.3 How Biofeedback produce a relaxing state of mind and body
An Electroencephalogram (EEG) can also be used in biofeedback training. The EEG is capable of monitoring brain waves. Three types of waves are important the alpha rhythm, measured from the back of the head, is between eight and twelve cycles per second. Alpha waves typically accompany drowsy, relaxed states where the mind is drifting in a somewhat unfocused manner. Alpha waves are associated with experiences such as relaxing, passive, anxious, letting go, submissive, high, pleasant, etc. According to Kasamatsu A. and Hirai T,( n d) The beta rhythm is faster, between 18 and 30 cycles per second and is often present in abundance in the brainwave tracings of experienced meditators during their meditation, and sometimes outside of it as well. (Kasamatsu A. and Hirai T, n d)

According to Dr. Gary Schwartz (1975), one of the most important things to realize when trying to influence various bodily systems is that they typically operate in patterns, something, which in the first flush of enthusiasm about biofeedback, may not have been properly appreciated. Schwartz (1975) found, for instance, that he could train a subject in his lab to reduce his blood pressure a few points in response to a signal sent to him whenever his blood pressure lowered itself even slightly, but if the subject was taught this and nothing else, his blood pressure would go down while his heart rate remained the same. Biofeedback can be applied to brain waves as well as to other physiological systems to produce a relaxed state. A subject who is hooked up to an electroencephalograph (EEG) machine need only attend to a signal which goes on when their brain is producing a strong burst of the desired type of brain wave and with this information can usually learn to produce the desired brain-wave pattern on command, often within fifteen sessions or less.

1.4 Theories of Biofeedback
Various theories pertaining to biofeedback are as follows

The Operant Conditioning Model
Early researchers such as Skinner B F (1950) applied the methods, language, and goals of animal research to biofeedback training with humans termed and termed is as operant conditioning model of learning that focus on concepts such as the stimulus. Many researchers have assumed direct parallels between human learning and laboratory animal learning. Some researchers postulate that biofeedback acts like a reinforcer and the subjects who do not have it seem to be extinguishing more rapidly than subjects who do. From this perspective, voluntary changes such as reduced muscle bracing and lowering of blood pressure are strengthened by reinforcing consequences and thus being monitored as feedback display.

The Drug Model
The drug model (Furedy, 1985, p. 159) asserts that biofeedback treatment corrects symptoms like a drug. Application of the drug model to biofeedback training results in conceptual issues and research designs unique to the model that have occurred repeatedly in biofeedback research. It is assumed that like a drug, biofeedback has specific effects and that these specific effects must be demonstrated independently of any other non-specific effects. In addition, the drug model recognizes a potential placebo effect, and must be controlled for or eliminated
 
The cybernetic model
The cybernetic model (Biofeedback Concepts) proposes that biofeedback is like a thermostat. The components of a thermostat system include a set point or goal, system variable or what is controlled such as room temperature, negative feedback in the form of corrective instructions and positive feedback such as commands to continue action. From this perspective the biofeedback training supplements a patients proprioception bringing about a poorly functioning system variable such as blood pressure under better control.

Placebo model
Therapists (Furedy, 1985, p. 159) using the Placebo model believe that biofeedback produces nonspecific effects, like a placebo owing to the patient beliefs.

2.1 Theoretical foundations of whole body breathing and exercise
Respiratory biofeedback provides many health benefits

Efficient breathing brings more air into the lungs thereby increasing oxygen delivery to the brain, improving various neurological imbalances.

It can increase production of alpha waves that reduce harmful stress hormones, especially cortisol. It balances the autonomic nervous system and promotes muscle relaxation.

Respiratory feedback can help restore and improve normal breathing. Improper breathing is often associated with brain and spinal cord injuries and is sometimes a hidden problem even in relatively healthy people.

It can help improve the function of the diaphragm and abdominal muscles. Because of its effect on the brain and nervous system, respiratory biofeedback can also help improve the function of other muscles in the body as well, and help reduce pain.

It has been observed that many people who were unable to produce certain healthy brain waves also had abnormal breathing patterns. Brain wave activity provides useful information on brain function. Understanding some basic information about brain waves is an important component of respiratory biofeedback.  An analysis through brain mapping such as the quantitative EEG (QEEG), areas of the brain can be trained to function better through biofeedback, often referred to as neurofeedback. The ability to produce alpha waves is associated with an overall healthy brain and body, especially in relation to controlling stress. Alpha waves can reduce high levels of the stress hormone cortisol, and help balance the autonomic nervous system. The human brain produces large number of alpha waves when it is relaxed, creative, meditating and happy. The inability to produce alpha waves is abnormal.

Conditions such as diabetes, inadequate sleep, nutritional imbalance and very high levels of stress hormones can impair the ability to produce alpha waves. For these reasons, main focus of respiratory biofeedback is the creation of alpha waves.

2.2 Whole Body Breathing (WBB)
The approach of whole-body breathing (WBB) follows various principles that allow for dealing with a high level of uncertainty and complexity in the etiology of complaints (Dixhoorn, 2008, p 55). The process takes a systems view of breathing as a starting point and, the whole-body involvement of breathing approach allows one to search for and test the presence of functional or dysfunctional patterns of breathing. The approach is based on the self-regulation of tension, which integrates the usual forms of self-regulation and completes it by adding passive, internal self-regulation (Dixhoorn, 2008, pp104108). Whole Body Breathinginvolves the entire respiratory system and expands the lungs to maximum.  The complete breath is not just deep breathing it is the deepest possible breathing using accessory respiratory muscles including that of abdomen. In this type of breathing a person actually retrain the muscles surrounding the entire respiratory system thus increasing his VO2 max, maximal oxygen uptake even when one is not exercising. In this practice person focuses on what he she feels physically with each inhale and exhale. The person identifies what is moving and how to expand beyond a normal shallow breath. This can lead to profound awareness, altered states of consciousness, ecstasy and peace. In this stress-free state the body releases chemicals, fires neurons in the brain and makes new associations to life. Breathing and relaxation therapy bring about a patients attention to himself and his inner experiences, and demonstrate him ways to induce a clear and perceptible change within himself. Internal self-regulation and body awareness became realities. It is clear that an attention shift (Dixhoorn, 2008, pp104108) and subsequent reduction of mental tension occurred, as well as a change in posture. Both are important to restore a sense of self-confidence, which helped reduce anxiety and worries about the future.

2.3 Mechanism of whole body breathing and exercise
By taking deep breaths and exercising the person brings both the cerebra hemispheres in synchronization. The brain waves change from Beta to Alpha, Theta and even Delta waves. Each of these waveforms stimulates different effects to the whole body. As already mentioned the alpha waves are associated with relaxation with the eyes closed and the mind moderately active. The Theta state is the state of healing, repairing and perhaps even asleep. The Delta state the brain wave activity that brings one the feelings of being aware of connected to all things and have a complete oneness with life itself. Pure joy and bliss are felt in this state and one can even explore the subconscious and super-conscious within this realm. It is similar to lucid dreaming only one is not asleep (Dixhoorn, 2008, p 55-56).

2.3 Uses and Contraindications
Breathing training has been widely used as a component of treatment packages for panic disorder (Telch et al., 1993 Wilhelm  Margraf, 1997). Khan, Staerk, and Bonk (1973), used a combination of biofeedback and other reinforcement techniques, trained asthmatic children to reduce experimentally induced bronchospasm. There are many beneficial effects of whole body breathing however there are some contraindications such as
Exercise induced asthma
Pneumothorax
Abnormality of chest wall such as kypho scoliosis or lardosis.

3.0 The case study
Thomas, the 45-year-oldclient a manager at a local food store has been having severe anxiety of losing his job. On top of that he has the responsibility of raising two teenage sons at this difficult period of their own adolescence related issues. The matter is further complicated by Thomass mothers illness. No wonder he presents with the symptoms of extreme stress and anxiety. The best treatment modality for this stage of Thomass illness is Biofeedback. Biofeedback is a clinically-proven therapy that uses biofeedback equipments. Personal biofeedback training is an effective treatment for anxiety disorders that produces results comparable to those achieved by relaxation procedures like meditation and Progressive Relaxation.

3.1 Mechanism
Biofeedback training methods may combine cognitive behavior therapy (CBT), which is a form of psychotherapy, with one or more kinds of biofeedback training, including (Alternative medicine zone)
EEG biofeedback (brain electrical activity)
EMG biofeedback (skeletal muscle activity)
Heart rate variability biofeedback (timing between heartbeats)
Respiratory biofeedback (breathing patterns)
Skin conductance biofeedback (sweat gland activity)
Temperature biofeedback (blood flow through small arteries)

3.1 Procedure
Thomas should be advised to undergo biofeedback sessions. He should be motivated and should be explained about the whole procedure. Thomas will have to be evaluated by a medical practitioner to rule out medical diseases and medications that can produce the symptoms of anxiety. The therapist may conduct a psycho physiological profile that monitors, breathing, EEG, finger temperature, heart rhythm, skeletal muscle activity, and skin conductance during resting, mild stressor, and recovery conditions using biofeedback electrodes. The psycho physiological profile will enable his biofeedback provider to develop an individualized training program to correct abnormal physiological changes associated with his anxiety episodes. Frequent findings during biofeedback stress tests of typical patients with anxiety disorders include
Shallow, rapid breathing
Imbalances between fast-wave (beta rhythm) and slow-wave (alpha and theta rhythm) activity in the EEG
Constriction of the small arteries of the fingers
Reduced heart rate variability
Contraction of muscles in the upper shoulders, neck, and forehead
Increased sweat gland activity

During a biofeedback session, a therapist will apply electrical sensors to the different parts of his body. These sensors will monitor his bodys physiological state, such as brain waves, skin temperature or muscle tension. This information will be fed back to Thomas via cues, such as a beeping sound or a flashing light. The feedback will teach him to change or control his bodys physiological reactions by changing his thoughts, emotions and behavior. This way he can reduce his symptoms of anxiety and stress.  For example biofeedback can pinpoint tension in his neck muscles that might be causing headaches. He would then learn to invoke positive physical changes in his body, such as relaxing those specific muscles, to reduce the pain. The ultimate goal for him would be to learn these relaxation techniques and use them at home on his own. A typical biofeedback session would last for approximately 30 to 60 minutes. The length and number of sessions will be determined by his condition and how quickly he learns to control his physical responses. He may need a series of 10 sessions or so.

3.2 Types of biofeedback for Thomas
The therapist may use different biofeedback techniques depending on his overall health status and objectives. Biofeedback techniques include (Alternative medicine zone)

Electromyography (EMG) biofeedback. This type gives information about bodys muscle tension so that one can practice relaxation.

Temperature (thermal) biofeedback. The Sensors attached to patients fingers or feet measure the skin temperature. Under stress the temperature often drops which can be read by the sensor and Thomas can be prompted to begin relaxation techniques.

Galvanic skin response training. Sensors measure the activity of the sweat glands and the amount of perspiration on the skin, thereby alerting one to anxiety.

Heart rate variability biofeedback. This type of biofeedback, commonly used in commercial devices, helps one control his  her heart rate in an effort to improve blood pressure, lung function, and stress and anxiety.

It is expected that biofeedback will be helpful to Thomas as it is likely to help him control his symptoms as well as reduce the amount of medication he would require. Eventually, Thomas may be able to practice the biofeedback techniques on his own. On the downside, learning biofeedback can take a lot of time, and Thomas may get impatient and disappointed. The treatment could be expensive too. An alternative to biofeedback could be trying other less expensive relaxation techniques, such as yoga.

4.0 Article Review
Biofeedback Therapy for Incontinence (altmd.com)
Overview
This recent review article demonstrates the efficacy of biofeedback training to restore control of pelvic floor muscles.

4.2 Hypothesis
The hypothesis of this article is that, Pelvic muscle biofeedback is effective in treating fecal incontinence and urinary incontinence in men and women.

Incontinence
Fecal incontinence involves the involuntary release of wastes due to impaired control of the rectal sphincters. The rectum contains two rings of muscle called rectal sphincters that control the elimination of stools. The internal rectal sphincter opens to admit feces when pressure builds inside the rectum. Normally, one can postpone a bowel movement by intentionally constricting the external rectal sphincter. In fecal incontinence, patients lose control over this sphincter and cannot prevent voiding. According to the website altmd.com, the prevalence of fecal incontinence is 2.2. Fecal incontinence is eight times more common in women than men since childbirth is its most frequent cause.

Causes of incontinence are
Rectal sphincter damage due to vaginal delivery and surgery
Congenital abnormalities that damage the spinal cord
Inflammatory conditions
Medical conditions like diabetes mellitus, stroke, spinal cord trauma, and neurodegenerative disorders

Methodology
After medical evaluation to determine the cause of patients fecal incontinence, a biofeedback practitioner teaches the patient to control elimination by using muscle and pressure sensors to help the patient to increase external rectal sphincter strength (altmd.com). This helps prevent the unwanted loss of feces and to develop internal cues so that signals from stretch receptors in the rectal wall will contract the external rectal sphincter to prevent leakage. The process also helps patients to increase the strength of pelvic floor muscles.

For urinary incontinence, biofeedback therapy uses computer graphs or lights as a teaching tool to help the patients identify and learn to control the correct muscles. Biofeedback helps patients to locate the pelvic muscles by changing the graph or light when the patient squeezes the right muscle. Optimal biofeedback therapy includes visualization of both pelvic and abdominal muscle movement, thus a two channel system is preferable. Multi-channel systems can allow for both pressure and electromyography (EMG) channels. These systems can allow the clinician to be most versatile in the approach to biofeedback. The instrument used for delivering biofeedback therapy must be appropriate for the patients. For older persons, a systemthat has auditory components must have a lower frequency sound which the aging ear can appreciate.

4.6 Significance
Biofeedback instructions can teach a majority of patients to regain bowel control. The website (altmd.com) quotes (AAPB), where a recent review of biofeedback clinical trials found that biofeedback achieved a 67-74 success rate. The biofeedback therapy for fecal incontinence has the third-highest rating of probably efficacious (AAPB). Similarly Biofeedback techniques can help most patients regain control of urination. In another study (altmd.com), training using biofeedback devices reduced incontinence episodes 75.9-82 in about 5 sessions.

Middaugh et al (1989) report Four male subjects with post stroke urinary incontinence associated with an average 1.6 to 7.5 accidental voiding per week, participated in an outpatient study with a 4-week scheduled-voiding baseline, 2 to 5 sessions of biofeedback-assisted bladder retraining, and 6- to 12-month follow-up. All four subjects achieved and maintained continence thereby underlying the importance of biofeedback in incontinence.

Conclusions
Biofeedback is an alternative therapy where instead of drugs various scientific instruments are used to measure, amplify, and feed back physiological information to the patient being monitored. This information is then used by the patient to gain self regulation of the physiological process being monitored. Biofeedback helps by setting various set points to newer levels thereby achieving desired response. The patient is taught to control the physiologic affect of various stressful conditions as well as various pathological conditions in the body. The report also takes a look at the mechanism of biofeedback as well as various theories and philosophy of biofeedback. It also takes a detailed look at theoretical foundation of whole body breathing and exercise and how its beneficial for the patients. The report analyses and suggests the process of biofeedback for Thomas who presents with extreme stress and anxiety and finally also reviews a review article showing the beneficial clinical effect of biofeedback on incontinence.