Effectiveness of Neurofeedback Therapy Adjunct to Cognitive Behavioral Therapy in Agoraphobia: A Case Study

Abstract

Agoraphobia has been defined as marked fear or anxiety being in enclosed or open places, using public transportation, and being in a crowd or outside of home alone. Such individuals make active attempts to avoid those places which cause intense distress. The neuronal areas that play a significant role in agoraphobia are uncinate fasciculus, which connects the prefrontal lobe and amygdala and various alterations in anterior cingulate cortex, insula, amygdala, and lateral prefrontal cortex. Neurofeedback is a type of biofeedback which teaches self-control of brain functions by measuring brain waves with the help of electroencephalography (EEG) and providing a feedback signal. With the help of alpha and beta training protocol, neurofeedback therapy will help in enhancing the connectivity between prefrontal cortex and amygdala. The present study aims to explore the therapeutic effectiveness of neurofeedback therapy as an adjunct treatment with cognitive behavioral therapy (CBT) in patients with agoraphobia disorder. A single case study method was adopted. The patient having the symptoms of agoraphobia disorder diagnosed as per ICD-10 criteria was taken in the study. After going through detailed case history and mental status examination, the patient was assessed on psychological measures on baseline and other follow-up visits. A total of 18 therapeutic sessions of neurofeedback therapy (alpha and beta protocol) along with CBT were conducted. Intermittent assessments on Draw A Person Test (DAPT), EEG parameters, Visual Analogue Scale (VAS), and Panic and Agoraphobia Scale (PAS) were conducted to compare the pre- and post-assessment findings. The results indicated significant improvement in the symptoms of the patient after intervention. The pre- and post-assessment findings and the neurofeedback therapy along with CBT were observed to be effective in treating the symptoms of agoraphobia. Neurofeedback therapy and CBT were proven to be effective in removing the symptoms of agoraphobia disorder within the patient.

Introduction

Agoraphobia has been defined as marked fear or anxiety being in enclosed or open places, using public transportation, and being in a crowd or outside of home alone. Such individuals make active attempts to avoid those places which cause intense distress. ¹ In the DSM-5, the disorder is defined as “marked fear or anxiety about actual or anticipated exposure of public spaces, with the symptoms of fear or anxiety occurring most of the time in at least two of five common, different situations.” The duration of the illness must be at least 6 months in order to diagnose patients with agoraphobia, and the fear and anxiety should be out of proportion of realistic threat, sociocultural circumstances, or in the absence of substance use or withdrawal. ² Patients with panic disorder develop fear of successive attack and are occupied with the consequences of “catastrophic” thinking (e.g., the panic attack would lead to heart attack, fainting, stroke, and loss of control). ³ The biological causes of agoraphobia are abnormal or excessive physiological arousal, role of biochemical neurotransmitters such as monoamine oxidase inhibitors, tricyclic antidepressants, and β-adrenergic blockers as well as medical disorders such as hypoglycaemia and hypothyroidism. ⁴ Some of the etiological factors that contribute to the development of agoraphobia are parental overprotection, low maternal care, presence of family psychiatric illness, parental loss, and childhood fear of separation anxiety or night terrors.^{4, 5}

The neuronal areas that play a significant role in agoraphobia are uncinate fasciculus, which connects the prefrontal lobe and amygdala and various alterations in anterior cingulate cortex, insula, amygdala, and lateral prefrontal cortex. ⁶ The electroencephalography (EEG) findings among patients with agoraphobia with panic disorder indicate decline in the power density of α rhythm and an increase in the power density of β rhythm in the right hemisphere displaying activation of reticular formation as compared to patients without agoraphobia where there is an increase in the power density of θ rhythm in the right temporal areas, suggesting activation of temporal limbic structures. ⁷ There have been high frequencies of septo-hippocammal during EEG test reflecting significant morphological brain abnormalities. ⁸

The management of agoraphobia comprises pharmacological and psychological intervention. The first line of pharmacological treatment for panic disorders are serotonin norepinephrine reuptake inhibitors and selective serotonin reuptake inhibitors, followed by tricyclic antidepressants and monoamine oxidase. ⁹ Among psychological treatment, cognitive behavioral therapy (CBT) is proven to be the most effective treatment for anxiety disorders, followed by psychodynamic therapies. ¹⁰

The emerging and non-invasive treatment used to treat anxiety disorders is neurofeedback therapy. Neurofeedback is a type of biofeedback which incorporates self-regulation of brain functions by computing the brain waves with the help of EEG and providing a feedback signal. ¹¹ With the help of alpha and beta training protocol, neurofeedback therapy will help in enhancing the connectivity between prefrontal cortex and amygdala.

Thus, the present study aims to explore the therapeutic effectiveness of neurofeedback therapy as an adjunct treatment with CBT in patients with agoraphobia disorder.

Method

A single case study method was adopted. The patient having the symptoms of agoraphobia disorder diagnosed as per ICD-10 criteria was taken in the study. After going through detailed case history and mental status examination, the patient was assessed on psychological measures on baseline and other follow-up visits. A total of 18 therapeutic sessions of neurofeedback therapy (alpha and beta protocol) along with 10 sessions of CBT were conducted. Intermittent assessments on Draw A Person Test (DAPT), EEG parameters, Visual Analogue Scale (VAS), and Panic and Agoraphobia Scale (PAS) were conducted to compare the pre- and post-assessment findings.

Case Details

The patient Mr. S, 21 years old, male, pursuing Bachelors (2nd year), residing in Faridabad, belonging to middle SES, nuclear, urban, Hindu family, visited with chief complaints of palpitations, shortness of breath, trembling of hands, nervousness, and feelings of suffocation and uneasiness. The patient reported experiencing difficulties in various situations such as closed places (e.g., elevator, cinema halls, underground metro, and tunnel), social interaction (meeting unfamiliar people), crowded places (e.g., market places), and height (e.g., hill station).

The patient would have thoughts of getting trapped and unable to escape (“ventilation kaha se milegi, yahi pe trap ho jaunga……bahar kaise nikalunga”). The patient is reluctant to visit any enclosed places such as metro or public places such as restaurants resulting in avoidant behavior. This has severely impacted the patient’s personal and professional life, resulting in poor attendance in college and dissatisfaction among the family members. The onset of the illness was abrupt with episode course and precipitating factor of death of the cousin sister in a road accident. There has been a significant family history of psychiatric illness, that is, mother committed suicide and grandfather has delusional beliefs but not diagnosed due to faith in religious practices. Significant findings on mental state examination also revealed anxious mood and dysfunctional cognitions with no history suggestive of any organic involvement, suspiciousness, or any psychotic symptoms, and the patient was diagnosed as a case of agoraphobia with panic disorder.

Structure of Therapy Sessions

The total number of sessions were planned while keeping in view the clinical history, nature of illness, severity, observations on base line assessments, and effectiveness of neurofeedback therapy and CBT in agoraphobia disorder. Thus, a total of eight sessions of neurofeedback therapy with a duration of 15 minutes and 10 sessions of CBT with a duration of 45 minutes to 1 h was administered on the patient.

Initial Phase

In the initial phase, the emphasis was on case history taking, psychodiagnostics assessments, psycho-educating the patient about the problem (disorder), the cognitive behavioral model, and the process of therapy. After the completion of first two sessions, a clinical case formulation was prepared and shared with the patient. A feedback was elicited from the patient, which further strengthened the rapport and gave the patient a chance to express and resolve any misunderstandings.

An agenda was set for every therapy session. The patient was explained the rationale of setting an agenda, making the process of therapy more understandable and eliciting the patient’s active participation to proceed in a structured and productive way. The therapist and the patient collaboratively prepared a problem list and the goals to work on in the treatment process, and the therapist helped the patient prioritize these problems. Further, a daily activity schedule was prepared by asking the patient how he spends his time and was asked to describe his typical day, which gave the therapist an additional insight into his daily experience and facilitated in choosing the activities.

Middle Phase

The sessions focused on the implementation of the therapeutic technique, that is, neurofeedback therapy as well as CBT, which was conducted simultaneously.

1. Neurofeedback Therapy: During the neurofeedback therapy, anxiety provoking thoughts and situations were reduced through visual imagery and the patient was facilitated to overcome the anxiety by taking the help of feedback from the physiological responses. Neurofeedback is a technique that guides the patients to control their brain waves consciously with the help of EEG. Its distinct components are extracted and fed to the patient using online feedback loop in the form of video or audio. ¹¹ Thus, depending on the availability and suitability to the patient’s symptoms, one channel recording of EEG was adopted.

2. Alpha and Beta Training: The patient was instructed to train alpha predominance in the right prefrontal cortex, which eventually helped to overcome the automatic negative thoughts within the patient. Beta training was facilitated to keep the bandwidth within the normative value (13–20 Hz) to reduce the underlying anxiety as the high activity of beta (>21Hz) is directly associated with anxiety.

3. Cognitive Behavioral Therapy: The patient was explained the relationship among triggering situations, automatic thoughts, and reactions (emotional, behavioral, and physiological) and how dysfunctions contribute to anxious tendency forming a vicious cycle. The patient was also demonstrated the various domains under which there can be a possibility of change, what influence the vicious cycle, how to break this vicious cycle, and how to form a new schema by restructuring the ongoing dysfunctional belief system. The patient was also introduced about the concept of false alarms and presentation of anxiety graphs to understand the nature of illness and to gain a good insight about the psychological features of an illness which is purely functional in nature. Further, a daily activity schedule was prepared by asking the patient how he spends his time and to describe his typical day, which gave the therapist an additional insight into his daily experience and facilitated in choosing the activities. Finally, the patient was given appropriate homework to maintain the thought diary (dysfunctional thought record) of events, thoughts, feelings (emotions), behavior, and its corresponding physiological effects.

4. Techniques used during CBT: The following techniques were used for modifying the beliefs:

   • Cognitive restructuring

   • Socrative questioning

   • Behavioral experiments

   • Cognitive rehearsal.

Termination Phase

Last two sessions focused on the termination phase. The termination session was planned as the patient had achieved all the mentioned goals of the therapy. A review session of whole therapeutic process was taken. During the sessions, the patient was prepared for a potential setback; what was learned in therapy was reviewed; the patient was given an insightful learning about how individuals get affected by dysfunctional cognition and what preventive measures should be taken before forming an assumption; and lastly, illustrative achievements were recalled during the therapy sessions. Further, a booster session was planned to review the progress after 1 month of the termination session.

Results

The results of the assessment tools were analyzed quantitatively as well as qualitatively.

The pre-intervention findings on the Draw a Person test revealed emotional fixation at age depicted or wish to return to youth, anxiety, insecurity, uncertainty, effeminacy, possible homosexual tendency, timidity, introversive, self-oriented, and tense behavior, and social anxiety with need for contact. Post-intervention drawings on DAPT revealed mature self-concept and expressive, coherent thought process, self-confidence, positive self-evaluation, and so on. The scores on panic and agoraphobia scale and visual analog scale during the pre-intervention and post-intervention findings displayed significant reduced scores, indicating effective improvement in the patient’s anxiety symptoms (as shown in Figures 1 and 2).

Figure 1. Graph Displaying Pre-intervention and Post-intervention Scores on Panic and Agoraphobia Scale.

Figure 2. Graph Displaying Pre-intervention and Post-intervention Scores on Visual Analog Scale.

The pre- and post-EEG absolute power values were obtained by seeing the amplitude change from first EEG NFT session to eighth EEG NFT session. There was a statistically significant difference in the pre- and post-intervention on EEG power values. Since the amplitude of beta was too low, it was brought to an optimal level of functioning. Morphological (wave pattern) changes were also evident. In pre-assessment, the wave pattern is more dysrhythmic and polymorphic, that is, presence of polyspikes (multiple frequencies that combine to form a complex waveform) as compared to post-assessment (as shown in Figures 3 and 4).

Figure 3. Graph Depicting Pre- and Post-treatment Ratings of the Patient’s Symptoms.

Figure 4. Figure Showing Pre-test and Post-test Intervention of EEG Bands.

Discussion

Agoraphobia is a rare mental and behavioral disorder, which is mainly treated using antidepressant medications and anxiolytic medications in combination with CBT. ¹² However, with the novel advancements in the area of clinical psychology and psychiatry, the present study was able to establish the significance of neurofeedback therapy as an adjunct to CBT in treating the symptoms of agoraphobia. Various studies have suggested an effective use of CBT to treat patients with agoraphobia with or without panic disorder.^{13, 14} According to the manual of Clarks (1986) and Bowlby (2000), the main elements of CBT are psychoeducation followed by progressive muscle relaxation, cognitive restructuring, and behavioral experiments.^{3, 15} CBT has shown to be 74% to 76% effective among patients of panic disorder with agoraphobia as compared to in-vivo exposure therapy treatment. ¹⁶

Neurofeedback therapy also showed promising results in reducing the anxiety symptoms among patients with agoraphobia with panic disorder. Biofeedback therapy addresses the physiological components which can be administered alone or in conjunction with medication and/or psychotherapy. ¹⁷ The neurofeedback mindfulness regulation had a significant impact on the brain activity pattern among patients with anxiety disorder, such as the average alpha, gamma, and theta power was increased after the training which was very low before the intervention. ¹⁸ Further, EEG alpha-increase and EEG beta-increase protocols and trainings are instrumental for patients who exhibit low amplitude alpha and beta. ¹⁹ These test findings have been consistent with the research study suggesting significant improvement in the anxiety symptoms. The amplitude of beta wave is usually less than 30 µV. ²⁰ Beta waves are responsible for focusing, thinking, and sustained attention which are mainly produced by the frontal lobe. Thus, a low amplitude beta wave leads to lack of attention and concentration as well as presence of ruminative thought. ²¹ Alpha wave is mainly produced by occipital and parietal lobes. ²² Thus, studies suggest that applying alpha increase or decrease protocols among patients with anxiety disorders is dependent on the alpha amplitude in the brain. If the alpha amplitude is high, alpha reduction would be beneficial in reducing the anxiety symptoms, and if the alpha amplitude is low, alpha reinforcement would show significant improvement in reducing anxiety symptoms. ¹⁹ Thus, the patient reported mental calmness and deep relaxation after applying the alpha and beta training protocols.

Conclusion

Neurofeedback therapy and CBT were proven to be effective in removing the symptoms of agoraphobia disorder within the patient. Due to its chronic and persistent nature, it is essential that agoraphobia is diagnosed at an early stage and intervention is initiated promptly. Neurofeedback therapy is a non-invasive psycho-physiological treatment technique which will show promising results to treat patients with agoraphobia and an eminent tool in near future. Thus, neurofeedback therapy has shown to be a promising adjunctive element for CBT that can be easily implemented and used as a strategy for increasing efficacy of agoraphobia treatment.

Statement of Ethics

Ethical approval was taken from the departmental ethics committee, and all procedures involving human participants such as taking informed consent, were followed and approved by the Head of the Department of Psychology and Mental Health and associated team member. However, there is no local or regional body associated with the university.