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Jay Gunkelman, QEEG- Diplomate CSO, Brain Science International PowerPoint Presentation
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Jay Gunkelman, QEEG- Diplomate CSO, Brain Science International

Jay Gunkelman, QEEG- Diplomate CSO, Brain Science International

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Jay Gunkelman, QEEG- Diplomate CSO, Brain Science International

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  1. The Midwest Society for Behavioral Medicine and Biofeedback (MSBMB) DSM-5 and Biomarkers/Phenotypes Jay Gunkelman, QEEG-Diplomate CSO, Brain Science International Jay@brainsinternational.com

  2. The modern dilemma in psychology: Diagnosis, when the DSM is being abandoned by the author.

  3. Top-down change

  4. Reliability but no Validity

  5. The Research Domain Criteria (RDoC) project transforms diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information, forming a foundation for a new classification system. “That is why NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system.”

  6. “RDoC, for now, is a research framework, not a clinical tool. This is a decade-long project that is just beginning. … RDoC is nothing less than a plan to transform clinical practice by bringing a new generation of research to inform how we diagnose and treat mental disorders.”

  7. The DSM is based on behavior • The linkage from genetics to behavior is indirect • The intermediate step between genetics and behavior is the phenotype • Behaviorally driven therapy can succeed, but is it optimized?

  8. Prior studies using EEG have documented “clusters” of EEG/qEEG features within psychiatric populations John ER, et al. Subtyping of Psychiatric Patients by Cluster Analysis of QEEG. Brain Topography 1992; 4:321-326). Chabot, R. J., & Serfontein G. (1996). Quantitative electroencephalographic profiles of children with attention deficit disorder. Biological Psychiatry, 40, 951-963. Prichep LS, Mas F, Hollander E, Liebowitz M, John ER, Almas M, De Caria CM, & Levine RH. (1993) Quantitative electroencephalographic subtyping of obsessive-compulsive disorder. Psychiatry Research, 50(1), 25-32. Prichep LS, & John ER. (1992). QEEG profiles of psychiatric disorders. Brain Topography, 4(4), 249-257. Suffin SC, & Emory WH. (1995). Neurometric subgroups in attentional and affective disorders and their association with pharmacotherapeutic outcome. Clinical Electroencephalography, 26, 76-83.

  9. The underlying assumption in the DSM is: “diagnosis, thus treatment” • The DSM does not yield optimal treatment efficacy following diagnosis • Diagnoses have multiple “EEG subtypes”, but they ARE NOT SPECIFICTO THE DIAGNOSIS • Frontal alpha in ADD • Frontal alpha in depression • Frontal alpha in early dementia • Frontal alpha in anxiety • Frontal alpha in OCD

  10. Phenotypic patterns are not isomorphic with the DSM categories Phenotypes have powerful implications for both medication, and Neurofeedback. Wright, C, & Gunkelman J. (1998). QEEG evaluation doubles the rate of clinical success. Abstracts of the 6th Annual Conference, Society for the Study of Neuronal Regulation, Austin, TX. Suffin SC, & Emory WH. (1995). Neurometric subgroups in attentional and affective disorders and their association with pharmacotherapeutic outcome. Clinical Electroencephalography, 26, 76-83. Johnstone, J., Gunkelman, J.,& Lunt, J.. (2005). Clinical database development: Characterization of EEG Phenotypes. Clinical EEG and Neuroscience, 2, 99-107.

  11. Phenotypes have led to enhanced outcomes clinically • S. Suffin and H. Emory (attentional and affective, medication) • L. Prichep (OCD, medication) • Chabot, et al. (ADD/ADHD, medication) • C. Wright (ADD/ADHD, Neurofeedback) • M.I.N.D. (U.C. Davis, Autism) Databases for EEG are starting to include the genetic component (Brain Resource Company, Australia)

  12. Some EEG patterns have strong genetics links • Low voltage EEG Enoch, MA, et al. (2002). The relationship between two intermediate phenotypes for alcoholism: Low voltage alpha EEG and low P300 ERP amplitude. Journal of Studies on Alcohol, 63(5), 509-17. Porjesz B, et al. (2002). Linkage disequilibrium between the beta frequency of the human EEG and a GABAA receptor gene locus. Proceedings of the National Academy of Sciences of the United States of America; 99(6): 3729-3733. Gunkelman J. (2001). Low voltage or absolute power. Journal of Neurotherapy; 5:1-2. • Epileptiform bursts Kaneko S., Iwasa H., & Okada M. (2002). Genetic identifiers of epilepsy. Epilepsia, 43 (Suppl 9), 16-20. Huag K, et al. (2003) Mutations in CLCN2 encoding a voltage-gated chloride channel are associated with idiopathic generalized epilepsies. Nature Genetics; 33:527-532.

  13. A limited set of phenotypic divergence patterns can characterize the bulk of the variance of the EEGThese EEG phenotypes predict effective therapy (medication and NF)The following table is not a substitute for professional evaluation and consultation

  14. Epileptiform Transient spike/wave, sharp waves, paroxysmal EEG Anticonvulsant medication Inhibit low and high frequencies over affected regions, reward SCP and/or SMR. Generally low magnitudes (fast or slow) Metabolic support (LVS), nutraceuticals Reward alpha activity posteriorly. (Penniston protocol for LVF) Faster alpha variants, not low voltage Alpha frequency greater than 12 Hz over posterior cortex. GABA related medication (slightly slows the EEG frequencies) Reward 9-10Hz alpha at Pz, shift alpha frequency lower with alpha/theta protocol Spindling excessive beta High frequency beta with a spindle morphology, often with an anterior emphasis. Anticonvulsants Inhibit beta frequencies, wide band inhibit, possibly Penniston if alpha levels are depressed. Persistent alpha with eyes open Lack of appreciable alpha blocking with eye opening, generally this is slower alpha SNRI or amphetamine Reward beta frequencies, inhibit alpha. Reward higher frequency alpha.

  15. Diffuse slow activity, with or without low frequency alpha. Increased delta and theta (1-7 Hz) with or without slow posterior dominant rhythm StimulantInhibit midline frontocentral activity below 10 Hz., add reward anterior beta frequencies for increased effect Focal abnormalities, not epileptiform. Focal slow activity or focal lack of activity. Inhibit slow activity (<10 Hz) and reward higher frequencies(> 12 Hz). Mixed fast and slow Increased activity below 8 Hz., lack of alpha, increased beta frequency activity Combine across classes, e.g. stimulant + anticonvulsant Inhibit slow frequencies, reward SMR. Frontally dominant excess theta or alpha frequency activity Antidepressant, stimulant Inhibit midline frontocentral activity below 10 Hz., add reward anterior beta frequencies for increased effect Frontal asymmetries Variable asymmetry L>R or R>L, primarily at F3, F4. Antidepressant Reward F3 beta, inhibit F3 theta and alpha frequencies. Excess temporal lobe alpha Increased alpha activity generated in temporal lobe Stimulant Inhibit 9-12 Hz activity over affected temporal region(s), + inhibit frontal slow activity.

  16. Slow variant

  17. Epileptiform (myoclonus)

  18. Beta spindle

  19. Failure of alpha blocking

  20. Addiction outcomes are about more than sobriety… a dry drunk is not “cured”… we look for “optimal function” when the “brain works better”.

  21. Big data meets EEG/qEEG

  22. Beta spindles: N=390 (with 49 ADHD)

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  26. Sterman MB. Basic concepts and clinical findings in the treatment of seizure disorders with EEG operant conditioning. Clinical Electroencephalography 2000; 31(1):45-55. • Lantz D, Sterman MB. Neuropsychological assessment of subjects with uncontrolled epilepsy: effects of EEG biofeedback training. Epilepsia 1998; 29(2):163-171. • Birbaumer N, Elbert T, Rockstroh B et al. Biofeedback of event-related slow potentials of the brain. International Journal of Psychology 1981; 16:389-415. • Gibbs FA, Gibbs EL. Atlas of electroencephalography. Reading MA: Addison-Wesley, 1950. • Niedermeyer E, Lopes Da Silva F (Eds). Electroencephalography: Basic Principles, Clinical Applications, and Related Fields, 4th edition, Baltimore: Lippincott, Williams & Wilkins, 1999. • Prichep LS, John ER. QEEG profiles of psychiatric disorders. Brain Topography 1992; 4(4):249-257. • Donaldson S. Society for Neuronal Regulation Annual Meeting, Scottsdale, AZ., 2002. • Gunkelman J. Low voltage or absolute power. Journal of Neurotherapy 2001; 5:1-2. • Kolb, B. and Whishaw, I. Fundamentals of Human Neuropsychology, 5th Edition, New York, NY: W.H.