The patients
The study included 42 patients. In their medical history, none of the patients declared current or past psychiatric treatment. All patients were also found to have no neurological or psychiatric diseases in their family history. No comorbidities were present and no medication was taken during the study (Table 1).
The patients’ mental health issues began in March/April 2020. All patients also suffered from panic attacks, which caused them to hyperventilate. They also had other common symptoms such as restlessness, sweating, frequent shortness of breath, high blood pressure, body tremors, excessive restlessness and anxiety. All patients were referred for psychological counseling by their family physician. During the psychological interviews, most of the subjects declared anxiety aroused by the declaration of the Pandemic in March/April 2020. All the subjects declared having experienced the isolation very badly, accompanied by the fear of losing their job. Additionally, lack of contact with some family members and fear for their health troubled respondents almost daily after the pandemic hit. The psychological diagnosis was created from:
Structured Clinical Interview for DSM-SCID-I46.
QEEG
Patients were then QEEGed to clinical standards that represented brain wave amplitudes. This allowed in the subsequent analysis to compare the neurofeedback training with the baseline of the patients and to assess its effect. The QEEG exam normally takes about 10-15 minutes and is divided into two stages of 2-3 minutes each. The first stage records eyes closed and the second stage records eyes open20. The tests are carried out after having obtained the consent of the patient and with his full involvement. Quantitative EEG provides amplitude and power information for specific frequencies and locations on the head. It also shows ratios and standard deviations46. Quantitative electroencephalography (QEEG) data were collected by a researcher with board certification in EEG biofeedback. Considering the basic principles of QEEG analysis in adults (at rest and with eyes open), it is assumed that the lower the frequency of the waves, the lower the amplitude (delta less than 20 mV, theta in adults less than 15 mV, alpha in adults less than 10 mV, SMR, beta1 and beta2 between 4 and 10 mV). QEEG data was collected by measuring all waves from center points (Cz, C3, C4), based on the international 10–20 system46.47. The curvature of the skull is imaged here in three planes: sagittal, horizontal and coronal48.49. The EEG signal was transformed using a Cz montage (Cz is the common reference site)49,50,51 and quantifying with Elmiko software, DigiTrack (version 14, PL) (ELMIKO, Warsaw, Poland) to examine central wave asymmetry. The spectrum of a signal is a representation of this signal as a function of its frequency. Most of the time, the FFT algorithm is used for the analysis, resulting in the function: f(z) = A(z) + j*F(z). Spectral analysis results in the FFT panel in DigiTrack show peak-to-peak amplitudes, to easily compare NF results to literature results. Removal of artifacts from the EEG recording was performed manually and automatically. The QEEG results of patients with panic attacks are shown below. The study included delta, theta, alpha, SMR, beta1 and beta2 waves at electrodes Fz, Cz, C3, C4, P3, P4, F3 and F4. In this manuscript, we present the results of central pathway (C3, C4) QEEG diagnostics, as EEG Biofeedback therapy was conducted at the same points.
EEG Biofeedback
The test was performed before treatment, after treatment, 6 months after treatment and at follow-up visits. Based on the results provided by the QEEG study, all patients received EEG biofeedback therapy. The main objective was to observe the effectiveness of the therapy in modifying brain activity in people suffering from panic attacks. All waves, namely Delta, Alpha, Theta, SMR, Beta 1 and Beta 2, of both hemispheres were taken into account. Points C3 and C4 were used for training. Training sessions were performed for 15 minutes for each point. The rounds lasted about 1-3 minutes. EEG Biofeedback therapy took place in the central pathway of the C3-C4 assembly. We started therapy with the left hemisphere, then moved to the right hemisphere. The frequencies we worked with corresponded to adult frequencies developed by Sterman Delta 0.5–3 Hz, Theta 4–8 Hz, Alpha 8–12 Hz, SMR 12–15 Hz, Beta 15–20 Hz, Beta2 20–34 Hz. During training, patients were seated in a chair with a comfortable headrest, slightly raised legs (relax type chair) and comfortable armrests. During the training, the SMR/Theta and SMR/Delta therapy protocols with active Beta2 were used to achieve the following relationships in the QEEG: Delta > Theta > SMR > Beta1 > Beta2. During EEG Biofeedback training, depending on turn and hemisphere, the patient’s attention was focused on a different waveform. With an apparent increase in beta2, the patient would switch to working on beta2, with an increase in theta or delta, to control that particular wave. Everything was done with the cooperation and coordination of the therapist. EEG Biofeedback training is not predictable. They don’t follow patterns or patterns. The most important thing is a correctly performed QEEG diagnostic test, on the basis of which we are able to correctly select the treatment protocol. The task of the therapist is to observe the changes in the EEG and QEEG recordings so that the training sessions are effective and lead to a lasting change in QEEG. QEEG-biofeedback is used to enhance and inhibit selected waveform amplitudes. The goal we aim for in all patients was to improve SMR waves. For Delta, Theta, Beta 1 and Beta 2 waves, inhibition of their amplitudes was desired. In the case of the Alpha wave, the goal was to keep it constant. All drives were monitored and checked for disordered amplification or inhibition of the waves in question. The amplification and inhibition thresholds of the amplitudes were modified proportionally in response to the changing value of this wave. During the first training sessions, we also focused on patient education. The patient learned to observe his own variability in neurophysiological activity in order to influence his own activity and adopt changes.
statistical analyzes
The comparison of the values of the quantitative variables in three repeated measurements was carried out using the Friedman test. After detecting statistically significant differences, post-hoc analysis (paired Wilcoxon tests with Bonferroni correction) was performed to identify statistically significantly different measures. A significance level of 0.05 was adopted in the analysis. Thus, all p values less than 0.05 were interpreted as showing significant relationships. The analysis was performed in R software, version 4.2.1 (R Core Team (2022). R: A language and environment for statistics computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/.).
Ethics approval
The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the University of Rzeszow (protocol code 8/12/2021).
Consent to participate
Studies involving human participants have been reviewed and approved by the Ethics Committee of the University of Rzeszow – issue 8/12 of authorization dated December 8, 2021. Patients provided written informed consent to participate in this study . No ethical concerns are present.
