Proc. 4th Congr. Int. College Psychosom. Med., Kyoto 1977 Psychother. Psychosom. 31: 24 32 (1979)
Biofeedback and Behavioral Medicine: an Overview 1 David Shapiro Department of Psychiatry, University of California, Los Angeles, Calif.
Abstract. Biofecdback is a behavioral method of achieving or enhancing voluntary control of physiological processes. Basic studies indicate that a variety of autonomic nervous system and other internal bodily changes can be modified with the method. It has been shown that specific responses and patterns of responses can be controlled. Biofecdback appears to be a promising method of altering symptoms of psychophysiological and medical disorders, e.g., high blood pressure, vascular changes in migraine, neuromuscular abnor malities, and cardiac arrhythmias. This research has stimulated a renewed interest in the role of behavior and the usefulness of behavioral principles in the etiology, treatment, and prevention of medical disorders. The term ‘behavioral medicine’ calls attt ntion to this new perspective in medicine.
In 1973, Birk (3) edited a book of articles describing clinical applications of biofeedback techniques to various disorders, including migraine headache, ten sion headache, essential hypertension, Raynaud’s disease, cardiac arrhythmias, and others. The book was called ‘Biofeedback: Behavioral Medicine’, a title which reflected Birk's (3) behavioral orientation to psychiatry and medicine and which called attention to the fact that biofeedback techniques are largely derived from behavioral research, particularly from operant conditioning, and to the idea that biofeedback is essentially a form of behavioral therapy for the control of physical symptoms of medical disorders. Operant conditioning is one of two major methods, the other being classical or Pavlovian conditioning, for
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1 Preparation of this paper and the author’s current research are supported by National Institute of Mental Health research grant MH26923, National Heart, Lung, and Blood Institute research grant HL19568, Office of Naval Research Contract N00014-75-C-0150, NR201-152, and the Department of Psychiatry, University of California, Los Angeles.
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the study of learned or acquired change in behavior as a function of particular events or temporal associations of stimuli in the environment. These methods constitute the most systematic and productive means that have been devised by modern behavioral scientists for generating information about the plasticity of behavioral and physiological adjustments to stimuli or situations that previously did not elicit the same responses. The methods provide means of describing, explaining, predicting, and controlling transient or permanent modifications of behavior occurring as a consequence of experience in the environment. As a form of operant conditioning, biofeedback is applied to the control or regulation of physical symptoms of disease in more or less the same fashion as other methods of conditioning or learning are applied to the management of purely behavioral manifestations of maladaptation to the environment. I believe that biofeedback and its associated methods and concepts derived from experimental psychology and psychophysiology has been one force that has been instrumental in broadening the horizons of what has generally been thought of as ‘psycho somatic medicine’. The term ‘behavioral medicine’ calls attention to this new perspective. What is new about ‘behavioral medicine’ is not the principle that behavior and the environment have a significant role to play in predisposition, initiation, development, maintenance, treatment, and rehabilitation of disease. This belief has long guided the thinking and research of investigators in searching for associations between disease and a host of social and psychological processes, e.g., sociocultural factors, personality and individual differences, life stress, psychodynamic complexes, behavioral patterns, and psychophysiologjcal predis positions. The major inadequacies of psychosomatic medicine have been its excessive reliance on poorly defined personality processes as a means of ex plaining why particular people developed particular diseases and its paucity of specific behavioral strategies for relieving or controlling symptoms. Psychological treatment approaches were generally not seen as direct methods of symptom control but as a means of enhancing the effectiveness of more standard medical treatments, such as drugs or surgery. Moreover, psychodynamic approaches did not seem to be particularly powerful or effective in the treatment of psychophysiological disorders. This is not to say that there has not been a growing sophistication in psychosomatic research, such as on the interaction between behavioral and biological processes in disease. Biofeedback and other methods derived from the experimental analysis of behavior have a great potential for producing further advances in our knowledge of and ability to treat diseases, particularly those in which behavioral processes play a role.
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 11:11:48 AM
Biofcedback and Behavioral Medicine: An Overview
Shapiro
26
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 11:11:48 AM
What is attractive about the broad concept o f ‘behavioral medicine’? First is the availability of specific techniques derived from behavioral analysis, such as biofeedback and conditioning, for the direct control or alleviation of physical symptoms of disease. Second is its reliance on objective definitions and measures of behavior and its use of empirically verified principles of behavior in research on etiology, treatment, rehabilitation, and prevention. Third is its applicability, at least in principle, to all medical disorders, rather than only to disorders traditionally defined as purely psychophysiological in nature. This last point is important from a number of standpoints. It opposes the simplistic organic-func tional dichotomy that has tended to define a disease as psychosomatic only by excluding strictly physical causes. Behavioral processes can in principle enter into any disease process, although they may function in different ways and in different phases of the disease with regard to predisposition, initiation, and maintenance. It does not oppose the operation of biological processes in a disease, including diseases o f a more obvious psychological nature. Thus, it keeps open the possibility of behavioral processes contributing to what are assumed to be purely physical diseases, either to their pathogenesis or to their rehabilitation. Finally, it tends to oppose the arbitrary separation of medical disciplines, particularly the split between psychology and psychiatry and other specialties, and it emphasizes the importance of incorporation into individual clinicians and medical scientists of behavioral as well as physiological and medical viewpoints. The biofeedback approach to behaviorally oriented treatment of disease probably comes closer than any other psychological method to the approach of conventional medicine in which a treatment is supposedly rationally devised to deal directly with the symptom or with the cause of the disease. In a way, biofeedback is akin to the use of specific drugs or surgery to correct a deficiency or control a symptom. This potential has its origins in basic research in biofeed back which shows that specific responses or patterns of response can be mo dified by biofeedback techniques. I will briefly review some of these funda mental findings from biofeedback research to highlight this unique feature. Before proceeding, in response to a request by Prof. Ikemi, I would like to comment about biofeedback and behavioral medicine as it relates to an integra tion of Eastern and Western traditions and orientations. In my discussion of biofeedback, I have emphasized the rational ex planatory systems of science, focusing on description, prediction, and control. I have talked about biofeedback as a specific approach to treatment, on a par with drugs and surgery. That is, I have discussed biofeedback as a concrete behavioral technology. Yet, biofeedback has also been associated with other ideologies and
27
conceptions. In the United States, for example, biofeedback has itself seemed to stimulate a renewed interest in research on and clinical use of hypnosis, sug gestion, imagery, autogenic methods, meditation, yogic exercises, and other disciplines, some of which have their origin in Eastern cultures. Workshops have been organized in the United States for medical audiences in which the term ‘holistic medicine’ is used, and sometimes religious, spiritual, faith healing, and parapsychological phenomena are discussed. Frankly, I do not know how the various Eastern and Western conceptions interrelate. They are interrelated, I believe; however, the Western scientific traditions would seem to focus on techniques that are highly practical, relatively quick, and easily rationalized or explained in behavioral terms. The media image of biofeedback as ‘electronic yoga’ says what I mean. However, there is more to biofeedback than a technology. That is, there is more to behavioral regulation of bodily responses than a technology. And here, we can look to other sources of knowledge and traditions, whether Eastern or Western, that may help us under stand the nature of such regulations. In some respects, Eastern orientations serve to alert us to a variety of other sources of self-regulation. Concern with the role of variations in breathing, focus of mental concentration, physical discipline and postures, and attention to and awareness of internal bodily functions have been stimulated by observations made by Western and Eastern scientists alike of various religious, meditational, and physical practices, particularly those having their origin in the East. There is much more to learn from such observations and particularly from experimental research geared to test our hypotheses about the significance of the various beliefs and practices. In the remainder of my talk today, I would like to review briefly some of the basic concepts and methods of biofeedback, indicating the unique features of specificity of control of physiological response patterns and outlining the applications of biofeedback in behavioral medicine. I will draw on previously published papers of mine concerned with the role of biofeedback in behavioral medicine and psychophysiological research. My own involvement in research on biofeedback and the operant con ditioning of autonomic responses was stimulated by Razran's (6) article. ‘One striking Russian experiment on psychic or cognitive control’ was described in which five subjects were given prolonged and moderately painful stimulation, while changes in the volume of blood vessels of the arm were recorded with a photoplethysmograph. The typical response to the noxious stimulation was vasoconstriction. The experimenter (Lisina) arranged it so that any instance of the opposite response tendency, vasodilatation, would terminate the stimulation.
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 11:11:48 AM
Biofeedback and Behavioral Medicine: An Overview
Shapiro
28
This avoidance conditioning procedure, however, was effective only when sub jects were able to watch their own blood volume tracings on the polygraph recorder. Razraris (6) summary of the importance of this experiment follows.
This particular emphasis on subjects being able to watch their own physio logical responses as they are occurring in order to ‘voluntarily’ control these very responses is one of the earliest scientific recognitions of the concept of ‘biofeed back’. It could be thought of as a combined cognitive-conditioning approach to enhance behavioral or self-regulation of physiological processes. Biofeedback means biological feedback. It entails providing to the individual a visual, auditory, or other type of sensory display or analogue of his own physiological responses as they are occurring in time. Through the provision of biofeedback, the individual learns to develop a certain degree of voluntary control of the physiological processes that are being fed back. The direct and immediate link in time between the actual physiological responses occurring in the body and the sensory analogue of the same responses is critical to the feedback concept and thought to be essential to the process of self-regulation. Note that the biofeedback information is channeled back into the central nervous system through normal sensory channels. There is also natural afferent feedback of visceral responses into the central nervous system occurring through direct interoceptive pathways. Such interoceptive information serves to regulate the natural functioning of visceral organs through homeostatic mechanisms that operate reflexively. Biofeedback may be considered to ‘augment’ inherent feed back processes through external sensory pathways. To what extent biofeedback methods alter internal homeostatic mechanisms is not clearly understood. The Soviet example prompted my colleagues and myself to begin research on the operant modification of fluctuations in electrodermal activity, commonly called the galvanic skin response or GSR (9). In one of our early studies, a spontaneous fluctuation of palmar skin potential of a given amplitude was selected as the response to be brought under control. Subjects were told that the purpose of the experiment was to study the effectiveness of various devices for measuring thought processes. The subjects were also told that each time our apparatus detected an ‘emotional thought’ they would hear a tone and also earn a monetary bonus, the latter as a further incentive to concentrate on the task. One group of subjects was given rewards each time the skin potential response
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 11:11:48 AM
In terms of current American psychology, the experiment offers two key findings: that contrary to assertions, autonomic reactions can be modified by subsequent reinforcement in operant fashion, and that such reinforcement is effective only when cognition is present.
Biofeedback and Behavioral Medicine: An Overview
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occurred. A second group was given the same number of rewards but at times when the response was absent. The first group showed increases in response rate relative to the second group, which showed decreases in response rate over time. Another significant result emerged from this study. Learned variations in electrodermal response rate were found not to be associated with other physiologi cally related functions such as skin potential level and heart rate. Nor were the variations associated with differences in breathing rate or breathing irregularities. Cognitive factors (images, thoughts), aside from the biofeedback itself, as mea sured by blind ratings of recorded postsession interviews, were not obviously relevant to the observed effects. In the two experimental groups, one rewarded for increasing and the other for decreasing electrodermal responses, subjects reported the same moderate relationship between the reinforcer, which was a tone indicating a monetary bonus, and their thoughts or images. The level of involvement in the task was also about the same for the two groups. The results supported the idea that the biofeedback procedure was effective in controlling a specific physiological response or process. This line of research continued on the operant control of human blood pressure and its association with heart rate and other variables (11). Subjects rewarded for increases or decreases in systolic blood pressure showed relative pressure changes in the appropriate direction without differential changes in heart rate. Similarly, subjects could learn to increase or decrease their heart rate without corresponding changes in systolic blood pressure. Starting with these reports, a model for research and theory on the control of ‘multiautonomic’ functions was elaborated. It was hypothesized that if two functions such as heart rate and systolic blood pressure are very highly correlated, then when one is reinforced and shows learning, the other should do the same. If they are uncorrelated, however, then reinforcing one should result in learned changes in that function but not in the other. Furthermore, if feedback and reward are given for a given function and it shows learning, the degree to which other concurrent functions also show learning is informative about the natural inter relations of the functions to begin with. In an empirical test, Schwartz (7) found that when subjects were reinforced for a pattern of simultaneous change in both heart rate and systolic blood pressure, these two functions could either be deliberately associated (both going in the same direction) or deliberately dissociated (going in opposite directions). The degree of association or dissociation was further limited by certain biological and adaptive constraints. Phasic changes in the two functions — systolic blood pressure and heart rate —were found to be relatively unrelated in
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pre-experimental conditions, confirming the ability to shape their association in different directions with feedback and reward. On the other hand, changes in diastolic blood pressure and heart rate were found to covary from heart beat to heart beat. In this case conditioning one system, diastolic pressure, resulted in associated changes in the other, heart rate (10). Furthermore, it was not possible to make these two highly integrated functions go in opposite directions by deliberately reinforcing differential patterns of the two (8). The specificity of effects produced by biofeedback would seem to dis tinguish it from other methods for producing relaxation or so-called low-arousal states (meditation, relaxation response, progressive relaxation). However, in clinical conceptions and applications of biofeedback, there is a tendency to abstract out such a principle of voluntary control or self-regulation as a means of reducing states of arousal or increasing relaxation. The evidence that biofeed back methods can be used to alter such a general dimension of behavior is not consistent. The very selectivity of control often achieved by biofeedback methods would argue against their direct usefulness in this way. In fact, a rationale for the clinical use of biofeedback is clearer if the symptom is quite specific. Examples of the latter are the reduction of blood pressure or other critical cardiovascular parameters in essential hypertension (2, 5), increase or decrease of activation of particular muscles in various neuromuscular disorders (1), control of cardiac arrhythmias that are dependent on either increases or decreases in heart rate (14), control of migraine symptoms by reducing the dilatation of particular blood vessels (4), control of epileptic symptoms through the facilitation of certain central nervous system inhibitory processes (12), and the control of asthma through decreases of respiratory resistance (13). The clinical potential of biofeedback in altering complex patterns of multiple res ponses has not been exploited very much, although pattern feedback is ob viously useful in enhancing one activity and suppressing another, as in the antagonistic action of muscles in coordinated movement. In current research in progress by Sterman on the control of symptoms in certain epileptic patients, various combinations of central EEG frequency ranges are used in pattern feedback, e.g., enhance 12—15 Hz, suppress 6—9 Hz. Whether patterns of func tions appropriately related to total arousal or relaxation can be similarly altered is a question for research. It seems to me that such applications of biofeedback are coherent and consistent with the scientific principles of learning and behavioral regulation underlying the method. Undoubtedly and hopefully, more efforts will be made in the future to attempt such specifically rationalized therapeutic procedures in
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other disorders. Obviously, we have only scratched the surface. More im portantly, critical and careful research will be needed to appraise the reliability and validity of the procedures. Are they practical, economical, and effective? How can they be used to result in long-lasting and maintained reductions of symptoms? The answers to these questions will require a great deal of time and effort. They will also require the assimilation and integration of behavioral, physiological, and medical knowledge on the part of clinicians and researchers. I have emphasized the potential of biofeedback as a treatment procedure. This is clearly the unique and most interesting feature of the field as it regards behavioral medicine. There is obviously more to behavioral medicine than biofeedback, which is geared to the control of physical symptoms. Behavioral medicine also involves interventions geared to the control of other behaviors related to health and disease, e.g., controlling smoking, increasing compliance with needed drugs, enhancing the delivery of health care, improving diet, controlling obesity, and managing pain, for examples. As to research on the etiology and pathogenesis of illness from a behavioral standpoint, there is much more to discuss that goes beyond the scope of this paper. The emphasis that I have placed on principles of learning and conditioning may be appropriately given to such research as we know so little about the role of experience in association with biological factors in producing illness. In conclusion, let me say that I have presented only a skeleton of a conception concerning biofeedback in an evolving field of behavioral medicine. The promise is there, and I am optimistic that future developments in conceptual ization and in empirical research will have a major impact for our understanding of the role of behavior in disease and in the promulgation of health. Returning finally to the theme of Eastern and Western orientations and their interrelation, both have added greatly to our knowledge of the role of behavior in disease and in health. No single method or conception is likely to provide all the answers. It will be useful, I believe, to attempt further integration and assimilation of the various methods and approaches, both highly specific and highly general ones. What is in common between the self-control and selfawareness achieved through Zen and yoga disciplines with that achieved by biofeedback and conditioning? From my own standpoint as a Western be havioral scientist, my approach has been to try to analyze, dissect out the critical features of mental attitude, focus of attention and concentration, and physical posture and subject them to laboratory study in various combinations and under different sets and instructions. This analytical approach is not always ap preciated by those who practice the various disciplines, including scientists
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themselves, but I believe it is necessary. By the same token, scientists and thinkers with Eastern orientations have to appraise Western conceptions and methods in the light of their own thinking and practices. Much of this process of communication and mutual understanding is evident in the program of this congress, and I am hopeful that our future efforts will continue along these productive lines. Refer«- ces
3 4 5 6
7 8
9 10 11
12
13 14
Basmajian, J.V.: Electromyography comes of age. Science 176: 603-609 (1972). Benson, H.; Shapiro, D.; Tursky, B., and Schwartz, G.E.: Decreased systolic blood pressure through operant conditioning techniques in patients with essential hyperten sion. Science 173: 740-742 (1971). Birk, L.: Biofeedback. Behavioral medicine (Gruñe & Stratton, New York 1973). Friar, L.R. and Beatty, J.: Migraine. Management by trained control of vasoconstric tion. J. consult. Psychol. 44: 46 -5 3 (1976). Kristt, D.A. and Engel, B.T.: Learned control of blood pressure in patients with high blood pressure. Circulation 51: 370-378 (1975). Razran, G.: The observable unconscious and the inferable conscious in current Soviet psychophysiology. Interoceptive conditioning, semantic conditioning and the orienting reflex. Psychol. Rev. 68: 81-147 (1961). Schwartz, G.E.: Voluntary control of human cardiovascular integration and differentia tion through feedback and reward. Science 175: 90- 93 (1972). Schwartz, G.E.: Toward a theory of voluntary control of response patterns in the cardiovascular system; in Obrist, Black, Brener and DiCara, Cardiovascular psycho physiology; pp. 406-440 (Aldine, Chicago 1974). Shapiro, D.; Crider, A.B., and Tursky, B.: Differentiation of an autonomic response through operant reinforcement. Psychonom. Sci. 1: 147-148 (1964). Shapiro, D.; Schwartz, G.E., and Tursky, B.: Control of diastolic blood pressure in man by feedback and reinforcement. Psychophysiology 9: 296-304 (1972). Shapiro, D.; Tursky, B., and Schwartz, G.E.: Differentiation of heart rate and systolic blood pressure in man by operant conditioning. Psychosom. Med. 32: 417-423 (1970). Sterman, M.B.: Clinical implications of EEG biofeedback training. A critical appraisal; in Schwartz and Beatty, Biofeedback. Theory and research, pp. 389-411 (Academic Press, New York 1977). Vachon, L. and Rich, E.S., jr.: Visceral learning in asthma. Psychosom. Med. 38: 122-130 (1976). Weiss, T. and Engel, B.T.: Operant conditioning of heart rate in patients with pre mature ventricular contractions. Psychosom. Med. 33: 301-321 (1971). David Shapiro, PhD, Department of Psychiatry, University of California at Los Angeles, 760 Westwood Plaza, Los Angeles, CA 90024 (USA) Downloaded by: King's College London 137.73.144.138 - 3/5/2018 11:11:48 AM
1 2
Biofeedback and Behavioral Medicine: an Overview 1 David Shapiro Department of Psychiatry, University of California, Los Angeles, Calif.
Abstract. Biofecdback is a behavioral method of achieving or enhancing voluntary control of physiological processes. Basic studies indicate that a variety of autonomic nervous system and other internal bodily changes can be modified with the method. It has been shown that specific responses and patterns of responses can be controlled. Biofecdback appears to be a promising method of altering symptoms of psychophysiological and medical disorders, e.g., high blood pressure, vascular changes in migraine, neuromuscular abnor malities, and cardiac arrhythmias. This research has stimulated a renewed interest in the role of behavior and the usefulness of behavioral principles in the etiology, treatment, and prevention of medical disorders. The term ‘behavioral medicine’ calls attt ntion to this new perspective in medicine.
In 1973, Birk (3) edited a book of articles describing clinical applications of biofeedback techniques to various disorders, including migraine headache, ten sion headache, essential hypertension, Raynaud’s disease, cardiac arrhythmias, and others. The book was called ‘Biofeedback: Behavioral Medicine’, a title which reflected Birk's (3) behavioral orientation to psychiatry and medicine and which called attention to the fact that biofeedback techniques are largely derived from behavioral research, particularly from operant conditioning, and to the idea that biofeedback is essentially a form of behavioral therapy for the control of physical symptoms of medical disorders. Operant conditioning is one of two major methods, the other being classical or Pavlovian conditioning, for
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 11:11:48 AM
1 Preparation of this paper and the author’s current research are supported by National Institute of Mental Health research grant MH26923, National Heart, Lung, and Blood Institute research grant HL19568, Office of Naval Research Contract N00014-75-C-0150, NR201-152, and the Department of Psychiatry, University of California, Los Angeles.
25
the study of learned or acquired change in behavior as a function of particular events or temporal associations of stimuli in the environment. These methods constitute the most systematic and productive means that have been devised by modern behavioral scientists for generating information about the plasticity of behavioral and physiological adjustments to stimuli or situations that previously did not elicit the same responses. The methods provide means of describing, explaining, predicting, and controlling transient or permanent modifications of behavior occurring as a consequence of experience in the environment. As a form of operant conditioning, biofeedback is applied to the control or regulation of physical symptoms of disease in more or less the same fashion as other methods of conditioning or learning are applied to the management of purely behavioral manifestations of maladaptation to the environment. I believe that biofeedback and its associated methods and concepts derived from experimental psychology and psychophysiology has been one force that has been instrumental in broadening the horizons of what has generally been thought of as ‘psycho somatic medicine’. The term ‘behavioral medicine’ calls attention to this new perspective. What is new about ‘behavioral medicine’ is not the principle that behavior and the environment have a significant role to play in predisposition, initiation, development, maintenance, treatment, and rehabilitation of disease. This belief has long guided the thinking and research of investigators in searching for associations between disease and a host of social and psychological processes, e.g., sociocultural factors, personality and individual differences, life stress, psychodynamic complexes, behavioral patterns, and psychophysiologjcal predis positions. The major inadequacies of psychosomatic medicine have been its excessive reliance on poorly defined personality processes as a means of ex plaining why particular people developed particular diseases and its paucity of specific behavioral strategies for relieving or controlling symptoms. Psychological treatment approaches were generally not seen as direct methods of symptom control but as a means of enhancing the effectiveness of more standard medical treatments, such as drugs or surgery. Moreover, psychodynamic approaches did not seem to be particularly powerful or effective in the treatment of psychophysiological disorders. This is not to say that there has not been a growing sophistication in psychosomatic research, such as on the interaction between behavioral and biological processes in disease. Biofeedback and other methods derived from the experimental analysis of behavior have a great potential for producing further advances in our knowledge of and ability to treat diseases, particularly those in which behavioral processes play a role.
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 11:11:48 AM
Biofcedback and Behavioral Medicine: An Overview
Shapiro
26
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 11:11:48 AM
What is attractive about the broad concept o f ‘behavioral medicine’? First is the availability of specific techniques derived from behavioral analysis, such as biofeedback and conditioning, for the direct control or alleviation of physical symptoms of disease. Second is its reliance on objective definitions and measures of behavior and its use of empirically verified principles of behavior in research on etiology, treatment, rehabilitation, and prevention. Third is its applicability, at least in principle, to all medical disorders, rather than only to disorders traditionally defined as purely psychophysiological in nature. This last point is important from a number of standpoints. It opposes the simplistic organic-func tional dichotomy that has tended to define a disease as psychosomatic only by excluding strictly physical causes. Behavioral processes can in principle enter into any disease process, although they may function in different ways and in different phases of the disease with regard to predisposition, initiation, and maintenance. It does not oppose the operation of biological processes in a disease, including diseases o f a more obvious psychological nature. Thus, it keeps open the possibility of behavioral processes contributing to what are assumed to be purely physical diseases, either to their pathogenesis or to their rehabilitation. Finally, it tends to oppose the arbitrary separation of medical disciplines, particularly the split between psychology and psychiatry and other specialties, and it emphasizes the importance of incorporation into individual clinicians and medical scientists of behavioral as well as physiological and medical viewpoints. The biofeedback approach to behaviorally oriented treatment of disease probably comes closer than any other psychological method to the approach of conventional medicine in which a treatment is supposedly rationally devised to deal directly with the symptom or with the cause of the disease. In a way, biofeedback is akin to the use of specific drugs or surgery to correct a deficiency or control a symptom. This potential has its origins in basic research in biofeed back which shows that specific responses or patterns of response can be mo dified by biofeedback techniques. I will briefly review some of these funda mental findings from biofeedback research to highlight this unique feature. Before proceeding, in response to a request by Prof. Ikemi, I would like to comment about biofeedback and behavioral medicine as it relates to an integra tion of Eastern and Western traditions and orientations. In my discussion of biofeedback, I have emphasized the rational ex planatory systems of science, focusing on description, prediction, and control. I have talked about biofeedback as a specific approach to treatment, on a par with drugs and surgery. That is, I have discussed biofeedback as a concrete behavioral technology. Yet, biofeedback has also been associated with other ideologies and
27
conceptions. In the United States, for example, biofeedback has itself seemed to stimulate a renewed interest in research on and clinical use of hypnosis, sug gestion, imagery, autogenic methods, meditation, yogic exercises, and other disciplines, some of which have their origin in Eastern cultures. Workshops have been organized in the United States for medical audiences in which the term ‘holistic medicine’ is used, and sometimes religious, spiritual, faith healing, and parapsychological phenomena are discussed. Frankly, I do not know how the various Eastern and Western conceptions interrelate. They are interrelated, I believe; however, the Western scientific traditions would seem to focus on techniques that are highly practical, relatively quick, and easily rationalized or explained in behavioral terms. The media image of biofeedback as ‘electronic yoga’ says what I mean. However, there is more to biofeedback than a technology. That is, there is more to behavioral regulation of bodily responses than a technology. And here, we can look to other sources of knowledge and traditions, whether Eastern or Western, that may help us under stand the nature of such regulations. In some respects, Eastern orientations serve to alert us to a variety of other sources of self-regulation. Concern with the role of variations in breathing, focus of mental concentration, physical discipline and postures, and attention to and awareness of internal bodily functions have been stimulated by observations made by Western and Eastern scientists alike of various religious, meditational, and physical practices, particularly those having their origin in the East. There is much more to learn from such observations and particularly from experimental research geared to test our hypotheses about the significance of the various beliefs and practices. In the remainder of my talk today, I would like to review briefly some of the basic concepts and methods of biofeedback, indicating the unique features of specificity of control of physiological response patterns and outlining the applications of biofeedback in behavioral medicine. I will draw on previously published papers of mine concerned with the role of biofeedback in behavioral medicine and psychophysiological research. My own involvement in research on biofeedback and the operant con ditioning of autonomic responses was stimulated by Razran's (6) article. ‘One striking Russian experiment on psychic or cognitive control’ was described in which five subjects were given prolonged and moderately painful stimulation, while changes in the volume of blood vessels of the arm were recorded with a photoplethysmograph. The typical response to the noxious stimulation was vasoconstriction. The experimenter (Lisina) arranged it so that any instance of the opposite response tendency, vasodilatation, would terminate the stimulation.
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 11:11:48 AM
Biofeedback and Behavioral Medicine: An Overview
Shapiro
28
This avoidance conditioning procedure, however, was effective only when sub jects were able to watch their own blood volume tracings on the polygraph recorder. Razraris (6) summary of the importance of this experiment follows.
This particular emphasis on subjects being able to watch their own physio logical responses as they are occurring in order to ‘voluntarily’ control these very responses is one of the earliest scientific recognitions of the concept of ‘biofeed back’. It could be thought of as a combined cognitive-conditioning approach to enhance behavioral or self-regulation of physiological processes. Biofeedback means biological feedback. It entails providing to the individual a visual, auditory, or other type of sensory display or analogue of his own physiological responses as they are occurring in time. Through the provision of biofeedback, the individual learns to develop a certain degree of voluntary control of the physiological processes that are being fed back. The direct and immediate link in time between the actual physiological responses occurring in the body and the sensory analogue of the same responses is critical to the feedback concept and thought to be essential to the process of self-regulation. Note that the biofeedback information is channeled back into the central nervous system through normal sensory channels. There is also natural afferent feedback of visceral responses into the central nervous system occurring through direct interoceptive pathways. Such interoceptive information serves to regulate the natural functioning of visceral organs through homeostatic mechanisms that operate reflexively. Biofeedback may be considered to ‘augment’ inherent feed back processes through external sensory pathways. To what extent biofeedback methods alter internal homeostatic mechanisms is not clearly understood. The Soviet example prompted my colleagues and myself to begin research on the operant modification of fluctuations in electrodermal activity, commonly called the galvanic skin response or GSR (9). In one of our early studies, a spontaneous fluctuation of palmar skin potential of a given amplitude was selected as the response to be brought under control. Subjects were told that the purpose of the experiment was to study the effectiveness of various devices for measuring thought processes. The subjects were also told that each time our apparatus detected an ‘emotional thought’ they would hear a tone and also earn a monetary bonus, the latter as a further incentive to concentrate on the task. One group of subjects was given rewards each time the skin potential response
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 11:11:48 AM
In terms of current American psychology, the experiment offers two key findings: that contrary to assertions, autonomic reactions can be modified by subsequent reinforcement in operant fashion, and that such reinforcement is effective only when cognition is present.
Biofeedback and Behavioral Medicine: An Overview
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occurred. A second group was given the same number of rewards but at times when the response was absent. The first group showed increases in response rate relative to the second group, which showed decreases in response rate over time. Another significant result emerged from this study. Learned variations in electrodermal response rate were found not to be associated with other physiologi cally related functions such as skin potential level and heart rate. Nor were the variations associated with differences in breathing rate or breathing irregularities. Cognitive factors (images, thoughts), aside from the biofeedback itself, as mea sured by blind ratings of recorded postsession interviews, were not obviously relevant to the observed effects. In the two experimental groups, one rewarded for increasing and the other for decreasing electrodermal responses, subjects reported the same moderate relationship between the reinforcer, which was a tone indicating a monetary bonus, and their thoughts or images. The level of involvement in the task was also about the same for the two groups. The results supported the idea that the biofeedback procedure was effective in controlling a specific physiological response or process. This line of research continued on the operant control of human blood pressure and its association with heart rate and other variables (11). Subjects rewarded for increases or decreases in systolic blood pressure showed relative pressure changes in the appropriate direction without differential changes in heart rate. Similarly, subjects could learn to increase or decrease their heart rate without corresponding changes in systolic blood pressure. Starting with these reports, a model for research and theory on the control of ‘multiautonomic’ functions was elaborated. It was hypothesized that if two functions such as heart rate and systolic blood pressure are very highly correlated, then when one is reinforced and shows learning, the other should do the same. If they are uncorrelated, however, then reinforcing one should result in learned changes in that function but not in the other. Furthermore, if feedback and reward are given for a given function and it shows learning, the degree to which other concurrent functions also show learning is informative about the natural inter relations of the functions to begin with. In an empirical test, Schwartz (7) found that when subjects were reinforced for a pattern of simultaneous change in both heart rate and systolic blood pressure, these two functions could either be deliberately associated (both going in the same direction) or deliberately dissociated (going in opposite directions). The degree of association or dissociation was further limited by certain biological and adaptive constraints. Phasic changes in the two functions — systolic blood pressure and heart rate —were found to be relatively unrelated in
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pre-experimental conditions, confirming the ability to shape their association in different directions with feedback and reward. On the other hand, changes in diastolic blood pressure and heart rate were found to covary from heart beat to heart beat. In this case conditioning one system, diastolic pressure, resulted in associated changes in the other, heart rate (10). Furthermore, it was not possible to make these two highly integrated functions go in opposite directions by deliberately reinforcing differential patterns of the two (8). The specificity of effects produced by biofeedback would seem to dis tinguish it from other methods for producing relaxation or so-called low-arousal states (meditation, relaxation response, progressive relaxation). However, in clinical conceptions and applications of biofeedback, there is a tendency to abstract out such a principle of voluntary control or self-regulation as a means of reducing states of arousal or increasing relaxation. The evidence that biofeed back methods can be used to alter such a general dimension of behavior is not consistent. The very selectivity of control often achieved by biofeedback methods would argue against their direct usefulness in this way. In fact, a rationale for the clinical use of biofeedback is clearer if the symptom is quite specific. Examples of the latter are the reduction of blood pressure or other critical cardiovascular parameters in essential hypertension (2, 5), increase or decrease of activation of particular muscles in various neuromuscular disorders (1), control of cardiac arrhythmias that are dependent on either increases or decreases in heart rate (14), control of migraine symptoms by reducing the dilatation of particular blood vessels (4), control of epileptic symptoms through the facilitation of certain central nervous system inhibitory processes (12), and the control of asthma through decreases of respiratory resistance (13). The clinical potential of biofeedback in altering complex patterns of multiple res ponses has not been exploited very much, although pattern feedback is ob viously useful in enhancing one activity and suppressing another, as in the antagonistic action of muscles in coordinated movement. In current research in progress by Sterman on the control of symptoms in certain epileptic patients, various combinations of central EEG frequency ranges are used in pattern feedback, e.g., enhance 12—15 Hz, suppress 6—9 Hz. Whether patterns of func tions appropriately related to total arousal or relaxation can be similarly altered is a question for research. It seems to me that such applications of biofeedback are coherent and consistent with the scientific principles of learning and behavioral regulation underlying the method. Undoubtedly and hopefully, more efforts will be made in the future to attempt such specifically rationalized therapeutic procedures in
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other disorders. Obviously, we have only scratched the surface. More im portantly, critical and careful research will be needed to appraise the reliability and validity of the procedures. Are they practical, economical, and effective? How can they be used to result in long-lasting and maintained reductions of symptoms? The answers to these questions will require a great deal of time and effort. They will also require the assimilation and integration of behavioral, physiological, and medical knowledge on the part of clinicians and researchers. I have emphasized the potential of biofeedback as a treatment procedure. This is clearly the unique and most interesting feature of the field as it regards behavioral medicine. There is obviously more to behavioral medicine than biofeedback, which is geared to the control of physical symptoms. Behavioral medicine also involves interventions geared to the control of other behaviors related to health and disease, e.g., controlling smoking, increasing compliance with needed drugs, enhancing the delivery of health care, improving diet, controlling obesity, and managing pain, for examples. As to research on the etiology and pathogenesis of illness from a behavioral standpoint, there is much more to discuss that goes beyond the scope of this paper. The emphasis that I have placed on principles of learning and conditioning may be appropriately given to such research as we know so little about the role of experience in association with biological factors in producing illness. In conclusion, let me say that I have presented only a skeleton of a conception concerning biofeedback in an evolving field of behavioral medicine. The promise is there, and I am optimistic that future developments in conceptual ization and in empirical research will have a major impact for our understanding of the role of behavior in disease and in the promulgation of health. Returning finally to the theme of Eastern and Western orientations and their interrelation, both have added greatly to our knowledge of the role of behavior in disease and in health. No single method or conception is likely to provide all the answers. It will be useful, I believe, to attempt further integration and assimilation of the various methods and approaches, both highly specific and highly general ones. What is in common between the self-control and selfawareness achieved through Zen and yoga disciplines with that achieved by biofeedback and conditioning? From my own standpoint as a Western be havioral scientist, my approach has been to try to analyze, dissect out the critical features of mental attitude, focus of attention and concentration, and physical posture and subject them to laboratory study in various combinations and under different sets and instructions. This analytical approach is not always ap preciated by those who practice the various disciplines, including scientists
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themselves, but I believe it is necessary. By the same token, scientists and thinkers with Eastern orientations have to appraise Western conceptions and methods in the light of their own thinking and practices. Much of this process of communication and mutual understanding is evident in the program of this congress, and I am hopeful that our future efforts will continue along these productive lines. Refer«- ces
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Basmajian, J.V.: Electromyography comes of age. Science 176: 603-609 (1972). Benson, H.; Shapiro, D.; Tursky, B., and Schwartz, G.E.: Decreased systolic blood pressure through operant conditioning techniques in patients with essential hyperten sion. Science 173: 740-742 (1971). Birk, L.: Biofeedback. Behavioral medicine (Gruñe & Stratton, New York 1973). Friar, L.R. and Beatty, J.: Migraine. Management by trained control of vasoconstric tion. J. consult. Psychol. 44: 46 -5 3 (1976). Kristt, D.A. and Engel, B.T.: Learned control of blood pressure in patients with high blood pressure. Circulation 51: 370-378 (1975). Razran, G.: The observable unconscious and the inferable conscious in current Soviet psychophysiology. Interoceptive conditioning, semantic conditioning and the orienting reflex. Psychol. Rev. 68: 81-147 (1961). Schwartz, G.E.: Voluntary control of human cardiovascular integration and differentia tion through feedback and reward. Science 175: 90- 93 (1972). Schwartz, G.E.: Toward a theory of voluntary control of response patterns in the cardiovascular system; in Obrist, Black, Brener and DiCara, Cardiovascular psycho physiology; pp. 406-440 (Aldine, Chicago 1974). Shapiro, D.; Crider, A.B., and Tursky, B.: Differentiation of an autonomic response through operant reinforcement. Psychonom. Sci. 1: 147-148 (1964). Shapiro, D.; Schwartz, G.E., and Tursky, B.: Control of diastolic blood pressure in man by feedback and reinforcement. Psychophysiology 9: 296-304 (1972). Shapiro, D.; Tursky, B., and Schwartz, G.E.: Differentiation of heart rate and systolic blood pressure in man by operant conditioning. Psychosom. Med. 32: 417-423 (1970). Sterman, M.B.: Clinical implications of EEG biofeedback training. A critical appraisal; in Schwartz and Beatty, Biofeedback. Theory and research, pp. 389-411 (Academic Press, New York 1977). Vachon, L. and Rich, E.S., jr.: Visceral learning in asthma. Psychosom. Med. 38: 122-130 (1976). Weiss, T. and Engel, B.T.: Operant conditioning of heart rate in patients with pre mature ventricular contractions. Psychosom. Med. 33: 301-321 (1971). David Shapiro, PhD, Department of Psychiatry, University of California at Los Angeles, 760 Westwood Plaza, Los Angeles, CA 90024 (USA) Downloaded by: King's College London 137.73.144.138 - 3/5/2018 11:11:48 AM
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