Okay. And special thanks, Hogan, to you for figuring out the CMEs. And yeah, please explain it to me because it's the first time we have CMEs available for these seminars, these APA Integrative Psychiatry seminars. And apparently, if it's really not that complicated and we can have it for all of them and they create an option for us to do it into the past also. I just don't know how much paperwork that involves. So, okay, the floor is yours. Thank you. I want to speak briefly to the CME question. It was really much more doable than I thought. And I'm so pleased because I have been trying for years with the Maryland Psychiatric with the APA saying, how can we do CMEs for neurofeedback? And I get crickets. And so I'm very pleased that it was not so hard to navigate. The reason I'm so passionate about the CMEs is that I've been doing neurofeedback for about 15 years. And what's become clear to me is that doctors really are not using it. And a lot of psychologists aren't using it. So it feels important to me to share my experience and help people navigate some of the, what feel like are artificial hurdles because of lack of information. So this is a real opportunity. I'm going to be continuing to give this presentation wherever anyone will listen. So I'm also happy to have feedback. So after my training at Hopkins, I have primarily been in private practice and do meds, psychotherapy. Often a lot of my practice has been part-time and I think that's one of the reasons I had the time to explore the neurofeedback, but I don't think you have to be part-time to start doing neurofeedback. I am going to tell you my story, my experience, how I found out about it. I'm going to briefly talk about the research and some of those hurdles that are there. I think a deep dive into the research would take a whole hour, a whole 45 minutes. And I hope the end result is that those of you who would like to explore neurofeedback will feel more confident moving forward and feel that it is something that is more doable than you thought before. So the way I found out about neurofeedback, I ran into a couple of social workers on the Eastern shore who were surprised to know that there was a psychiatrist in the area. And they mentioned to me, we're doing this really interesting thing with EEG. It's called EEG neurofeedback. And I was floored. I thought when they mentioned we treat sleep, we first, we work on sleep and we'll get rid of the migraines and then we'll start working on attention. I thought, whoa, how could this be? How could I not have heard about it? So they invited me to their office. They put electrode sensors on my scalp and I watched them playing with EEG lines and working with their computer. And I saw that thing that as I was watching and intending to move what was on the screen, I was doing it with my EEG. And I called around, I couldn't find anybody that knew anything about it or thought that it might be real. When I called back over to Hopkins where I trained, I thought someone would know. Psychologists there didn't know about it. I finally said, I guess I've just got to go check it out. I checked into the cost. The cost was not much for just having an initial training. You could leave there if you wanted with the equipment. So I said, I'll go to the four day training, which happened, I believe Ed Hamlin taught that original training. So the other thing that made me receptive is it was the perfect moment. I was in perimenopause and feeling increasing irritability, increasing migraines, increasing insomnia. Now I didn't have sleep issues just right before my period. It was more longer. And I was regularly having to refill my packages of max salt, which is an abortive for the migraines. And I looked around and I said, well, I know that if I do this, I will have to have something, some people to start with. And usually when you take a neurofeedback training, they say, find a family member or a friend. And I had a volunteer. I had a volunteer I was worried about because of those symptoms. I'm not going to list them off. You can see them. And I had most of my patients are complex patients. They often have an old concussion. They often have bipolar symptoms and some personality issues. They're often on more than one med. People that are simple don't come to me. We know primary care is taking care of people that easily respond to a medication and other therapists are doing the therapy. So I had these two patients, you can see they were complex. And I thought if I can help these, if I can help me and this friend, then it's worth it. Even if I have to pay $10,000 for equipment. And I thought if I can work well on a few patients, I can easily afford to do this. So I went to the training. It was a wonderful and riveting experience. I was the only physician there. And I would love to say more about that. But what I want to get onto is what happened when I took it home. And keep in mind, I barely knew what I was doing. I called the tech to make sure I could see EEG. Because initially, I couldn't even figure out how to scale the EEG. And within 30 minutes with the tech, I was looking at what we were looking at in our trainings. And I could tell I was getting good connections. So even as a rookie, barely understanding how to run an efficient session, the first volunteer got dramatic relief, complete relief. I knew it would take 30 or 40 sessions. And I thought I should see changes earlier than I did. But we just kept going because they were fully tolerable. I knew. And I spoke with a mentor. All the first patients that I saw that I worked with, I reviewed with a mentor. That person helped me pick the protocol, answered questions about the equipment if I needed that. And I needed that weekly, initially, and was happy to pay for that. So the first volunteer, in about 20, 25 sessions, I could start seeing that person was looking happier, looking more relaxed. He didn't feel it was doing anything, but so much one in relief, he was willing to keep going. In about 5 or 10 sessions more, he was sleeping and he was less anxious. I won't go into all the details. You can see what I've written there. I was just, I was amazed and so happy. And while I was working on him, I was fitting in time to work on me, maybe just one session a week. Ideally, we were advised to do two to three a week. And he was doing two to three a week. I was fitting in one for me. And as soon as he was done, because he wouldn't even let me taper, he would say, I'm done. I'm good. Now he did need a few more sessions, maybe between 5 and 10, about six months later. But once he got those, it was six years before I detected anything. And at the first hint of sleep issues, I would give this person a few sessions and he's been good to go. And for me, and remember, I'm a rookie. I hardly knew how to run the sessions and not how to over-correct and interfere too much, which I was definitely messy. I, I just kept doing the sessions and I increased it to twice a week. And I was just plugging along. I wasn't even sure how many I had done. And I was starting to work on my other patients because I felt confident. And I didn't realize how much I had helped myself until we had to go on a trip. And I went to find my Maxalt because I went nowhere without that Maxalt. And the Maxalt container was full. None had been used and it was expired. I was dumbfounded. I was, I was amazed. I was like, oh, I guess my migraines are better. It's a, it's something we see a lot in our feedback is people will not necessarily know that they're better if they're still having some symptoms. And those are, those are still bad. Gotta really look at function and look at some other hints as to what's getting better. Just, just like in other parts of psychiatry. Also, I, I got to where I never knew when my period was coming. I always knew when my period was coming because I was thin skinned and not sleeping. Now I had to start writing down my period too bad. Right. I was so, so pleased. So the two patient volunteers also the, the, this one had dramatic response. She had migraines most days. And after her first session, she did not have any more migraines. I was like, how could this be? I was able to taper her three mood stabilizers all the way down to a tiny dose, like 300 of lithium got rid of her Ambien. And I actually got to do some mentoring with Seaborn Fisher and started her own FPO2 for her PTSD. She loved that. And she did a lot of sessions because it took a while. I wanted to maintain the sessions while we tapered her meds. And eventually we didn't need to do any more for her bipolar. We moved on to the FPO2. Eventually she tapered off the nerve feedback and was free of any of her bipolar symptoms, no complaints of her PTSD symptoms. And she moved away and I haven't tried to contact her. I wanted, I was pleased that she stayed on a tiny bit of lithium and I gave her the name of a neurofeedback provider. And I felt like she would be able to, to go for help if she started getting more symptoms. The other patient was a woman who had a 10, 30 foot fall with a TBI, a history of a psychotic bipolar illness in adolescence, alcoholism and recovery. This is a woman who I sometimes wanted to put her on a neuroleptic, but she didn't want to take it. And that was because of, it was hard to follow her speech. She had a lot of anxiety and she did not have the quick dramatic response. She had a mild improvement with the initial EEG training. And then this is how I found out about the other neurofeedback training that I do, that I will be telling you about, which is called passive infrared hemoencephalography biofeedback that works on the frontal lobe. But because I realized I wasn't getting as good a response with her, and I had used a QEEG at the beginning, but didn't feel like I got a lot of information from the QEEG consultant, I sent the QEEG collection, which is a collection of EEG for 10 minutes I was open, 10 minutes I was closed. It's packed. I actually sent her for that. I can now collect QEEG, but I sent her for the EEG, but I took that collection and I sent it to a different expert who was, who had worked in neuro rehab and he did some specialized trainings with connectivity using the same system that I use. So when I consulted with him and he looked at the QEEG for me, he said, her frontal lobe is dark. It's offline. And I thought, oh, okay. And he said, I want you to look into getting this other kind of neurofeedback. And I'm like, oh no, no, I can't buy another one. I barely know what I'm doing. I still have so much to learn. He said, no, this is easy. I can teach you to do it. And I'm like, okay. So I learned about it. I got the unit and he did tell me how to use it. And he said, normally you would give this once a week, maybe 15 to 30 minutes with this patient, get her to turn the movie back on once, maybe twice. Don't give her more than five minutes of training. Do it three times a week. Normally it's once a week. So I did it and she did have some response. It was either her a little bit of anxiety improvement or depression improvement. And he said, just keep going, give her 30. Now, even if she doesn't show any clear response, she agreed to that. And as long as there was nothing negative, we just stayed in there and she was getting free or reduced fee trainings because she was a volunteer. And so he said, after that, do this training with the EEG told me a training that I've never done since. And he told me to put the sensors on the temples up front. And it was a connectivity training. It's when it's bi-hemispheric, you're getting the two sides of the brain to, to work together. And with this training, I don't remember how many we did. She actually started to feel normal. She had never felt normal and she felt almost thought disordered and hard to follow. It felt like it was anxiety, scattered thinking, disorganized. It was just remarkable. I'll have to say she also had a lazy eye and that got fixed somewhere during all this. So this woman was just transformed. So after these four, I was like, I'm a rookie and I'm barely know what I'm doing. How can this be this powerful? And I never heard about it. My doctor friends have never heard about it. At this point, 15 years later, what's clear to me is that the brain is just so capable and it is like magic. We don't understand all of it. We don't understand much of it. So recently I've read a book by Wayne Jonas, how healing works. And one of the things that he mentioned, he described three things that are essential in the healing of chronic illness. He makes a point that silver bullets really don't work well for chronic illness. And I feel like I'm speaking to the choir, what I'm speaking to a complimentary and integrative psychiatrist. But the third one, the third requirement he felt of a treatment that's going to work is the regular stimulation of a biological response. And I'm thinking, well, that's what we're doing with our feedback. We're not adding stimulation, but we're, we're interacting with the biology and somehow the brain is figuring out how to do what we're asking it to do. So what I'm hoping you will finish with the belief that the learning curve with neurofeedback is manageable. I still feel like a rookie because neurofeedback and biofeedback haven't been most of what I do, but I'll have to say, I've thought about not doing any more meds and just focusing on the treatment of migraines because the people that have migraines so often have so many other issues that that would keep me busy and would be a simple retirement gig. Be fun. I think I love doing the infrared training. So again, for the next 15 years, I've continued thunderstruck and perplexed because there are so many good things about neurofeedback because it has such broad applications across diagnoses. And I'm not going to list these. You're going to have the slide set. It's just, it feels like an obviously great addition to our toolbox, never a replacement for medications, but what an adjunct. Also with all the mandates on us to, to simplify medications and the aging population and lack, lack of options with TBI and chemo brain. Chemo brain is one that responds wonderfully to the infrared training. Sometimes I've had, I've had at least three patients, either post-infectious or after chemotherapy for cancer. And then I had a patient that was on that triple regimen for hepatitis that used to be used. And you know, the, the, I talked with her hematologist, I mean, her hepatologist, and he said, just, you know, this, we're just trying not to kill her, just see if you can help her make it through it. And she was starting to crumple over and she was already did treatment with me for depression. And I said, let's try this. And she perked up that day. She couldn't wait to come back for her next session. A lot of the neurofeedback, you know, is it, people feel better initially, but as they get repeated trainings, the improvement starts to hold and hold, and then you can stretch out the trainings. And she did wonderfully. She, she ended up free of virus. So again, the neurofeedback has both wellness and treatment applications. So part of my passion is the awareness of, of how much these modalities could help many of the things that are plaguing our communities and making people get sick and the epigenetics. I mean, just to be able to use neurofeedback to help someone with their rage problem has so many ripple effects in all the arenas of our community. And I, I wish I could see it in prisons to see if it would reduce recidivism from impulse control. So the research is what I am no expert with. And what I wanted to do is briefly touch on it and give you some thoughts to keep in mind when you are hearing thoughts about the research, especially from the medical world. You may have seen the article, the editorial in a recent American Journal of Psychiatry, is it time to give up on neurofeedback? That was the editorial that was in accompanying the article on fMRI neurofeedback that showed no results. So what my point with this is that we need to ask the right question. First of all, why did they use a title like that? Is fMRI neurofeedback used in clinical practice? No, it really can't be because too many of them are toxic. And then would we expect a clinical response in only two weeks of training if we were doing traditional EEG neurofeedback? No. So it felt like the editorial made no sense. Why did they allow a title like that? And it wasn't that surprising, but it was disappointing because I'm used to neurofeedback being an underdog in the medical world. And there's lots I could say about that. And again, I'm not going to read the slide to you. What I believe is that it's mostly a lack of education and information. It's hard to even get the education in front of doctors. It's been this hard for me to even do a single CME presentation. These are just two articles to also keep in mind that were presented at a recent neurofeedback conference on how long even the medical world has been recognizing the problems with reliability in the peer-reviewed journal. It was there in 2009, there in 2015. And then we see it again with that article. Time to give up on neurofeedback. One of the biggest issues that people don't realize is that we're not used to using medical or wellness devices in psychiatry. And medical devices are regulated differently and what we're permitted to do with them is different. And the level of evidence needed is different because of the safety of these devices. So I would like to posit the better questions. Do very safe medical devices require the same kind of research for FDA approvals or the same evidence for off-label use as medications that enter the body? No. Has there been adequate research to support the use of EEG neurofeedback devices in the treatment of stress-related conditions in medicine? Yes. Here's the publication I would suggest to read. It was done by a Maryland organization. It was funded by the Mental Health Association of Maryland, which is the second oldest mental health advocacy organization in our country. And their conclusion that neurofeedback is an efficacious treatment for behavioral health. The Kennedy Forum published something similar in terms of conclusions, but they did not have the exhaustive look at the research in the publication. Trullinger was one of the editors of that publication, and he listed some of the diagnoses that are appropriate. But we could use neurofeedback off-label for all sorts of things that are anxiety, wellness-related. Third question, can psychiatrists and other physicians use class 2 medical devices off-label based on their clinical judgment? Yes. And that use is not investigational, but insurance companies are still being allowed to make that claim and avoid pain. But with advocacy, sometimes they will come off of that, especially if you have data and can show that to them. Blue Cross Blue Shield is covering neurofeedback, and Medicaid is covering neurofeedback in Maryland because of Mark Trullinger. And mainly with him, because not many people are doing it. He went in and talked to the lawyers and made it happen. So again, the FDA approvals for biofeedback and neurofeedback devices, to have additional formal approvals with the HCC regulations for devices for neurofeedback do not require large studies or placebo or sham-controlled studies. All that's required are small studies with validated measures that show improvement long enough to outlast placebo. That is the misdirection. We keep being told we have to have these studies like the drug company studies. And to be honest, the drug companies don't want this. If this is more available, they'll sell less meds. I don't know what that has to do with the attitudes, but I know it's involved. So, I want to tell you more about the EEG traditional neurofeedback and the PIR-HEG neurofeedback. If I have time, I will talk some about the peripheral biofeedback that I use. The EEG neurofeedback is a medical device. The PIR-HEG neurofeedback is a wellness device. It doesn't require FDA evaluation other than that it's safe and it's, and so forth. It's exempt because there is no electrical interface. It uses a camera. Then there's more to say about that. The peripheral biofeedback, you can use medical devices, and it's great to go get the extra training, but you can also use wellness devices that patients can buy. You can encourage patients to buy them and just teach them to use them. I do that with heart rate variability and hand warming. So, essentially, biofeedback and neurofeedback exploit conscious windows into the unconscious brain or autonomic processes. There's something about an individual being able to see information about their physiologic performance in this unusual way, different from whatever natural feedback is happening within the brain and body. Being able to see it or sense it or hear feedback about those unconscious processes, with that, an individual can then make those physiologic measures change through something we don't understand. So, we can measure all these physiologic processes, feed them back, and patients can learn to adjust them. Peripheral or CNS, we can provide audio feedback, visual, tactile. This is a child using the kind of neurofeedback that I do. He's doing traditional neurofeedback. So, I want to show you these pictures and have you think about, how are these pictures similar? These all involve highly skilled behaviors and relaxed behaviors or behaviors where the level of arousal is key. Highly coordinated, these are like brain function. Highly coordinated, highly unconscious, highly practiced, highly learned, and highly adaptable. So, one of the things that became much more apparent to me by doing neurofeedback with patients is the relevance of optimum performance to our field. I mean, essentially, we're trying to improve people's brain performance and their interpersonal performance, their work performance, but we hardly ever use that term. One of the things that's talked about a lot in optimum performance and in neurofeedback is that there's an optimum arousal level for every task, and having the right kind of arousal in the different areas of the brain is important for the functions that those areas of the brain handle. If arousal is poorly managed, if it's too high or too low, performance suffers. So, these are the same things those three pictures were showing, and good performance requires all of these attributes in a well-regulated brain. And our brain, these are all things that we will evaluate our patients for, and we know that the brain is regulating that, and our options are to talk with patients and use medications, and those are often potent with these, but we have another tool. We can work on the way the brain is signaling more precisely. Here's a picture that I think this is a little bit more like what the brain is doing if we multiply it by, say, a billion, and probably the audience would be throwing things in, and people would be falling down and having to change clothes in the middle of it, and somehow our brain manages this. So, I want to give you one of the jaw-dropping moments that I experienced in one of the nerve feedback trainings. You know, I've been to many trainings or workshops since my original training. There was a researcher who was showing how the frequencies showed in a young man with an auditory receptive language disorder. He just couldn't process language very well, and all of his frequencies from low frequencies to high frequencies were just where they should be except one frequency. It might have been nine hertz. It was low. It was off from where a normal child's frequencies would be while listening, and they trained this kid. His nine hertz was increased, and then all of his language measures became normal, and I just thought, how could we not be taking advantage of this? So, what happens when areas of the brain have underdeveloped or problematic regulation or poor connectivity, poor coordination with other areas? Here's the picture that speaks to me. So, neurofeedback is like adding a tail to a kite, center board to a sailboat, training wheel adjustments, but it's also like lifting weights. Patients have to learn to do these things with endurance and with reliability. Are y'all all hearing me fine? Yes. Yes. Okay. Thank you. I'm not used to just talking and talking. All right, good. So, EEG neurofeedback targets specific electrical activity. I've already mentioned this. Better regulation, improved performance. I'm going to get on. So, I want to show you a little bit more about the kind of screens you look at when you're doing EEG neurofeedback. Essentially, we collect a brain measure, feed it back, and the participant learns to control the signal by noticing and intending. We have to think about the brain. We usually train along the sensory motor strip there, and then we might move laterally, move forward or back, depending on what function we are trying to address. A lot of the training I do is right at the central. It's conservative at the sensory motor strip, and I rarely move off of that without talking to a mentor because, again, this is just a little part of my practice, but I can do a lot of sessions based on just the sensory motor strip. So, what's happening here is the child has a sensor at C4, C3. That's sending the electricity from his brain into that little box, which is an amplifier. That sends information into the therapist's computer, which will organize the EEG and select certain bandwidths to train in the therapist. We'll adjust things on that computer. The patient is watching this other screen where the EEG is represented in the targets, and I'll say more about that in a minute. This is a closer look at the therapist's screen. What you see along the top is the raw EEG. Most of us are not exposed to EEG after medical school and residency. So, essentially, the raw EEG is all the different frequencies added together, and this is the raw EEG at that site. A hospital EEG would show a line like that for all the 19 channels that are being recorded for that hospital EEG. Underneath there is where a bandwidth like 2 to 8 hertz, 15 to 18, 22 to 36, those have been selected as targets to train, and there are some very common targets. Often, the low, slow waves, the 2 to 5, 4 to 7, 6 to 9, will be selected as inhibits because those improving the slow wave, reducing the amplitude of that is often very helpful in just improving regulation. Some neurofeedback people think if you just exercise the brain, even if you don't know that the slow waves need to be less, the brain benefits just from going through the exercise. It's like it conditions it, and it finds new flexibility within the range of what it can produce. Often, the reward band is in the average beta range, 15 to 18, 12 to 15, and that is selected based on whether you're trying to pull arousal up or pull arousal down. The other inhibit is often related. If it's a high inhibit, it's usually because the person's anxious. Sometimes, you'll inhibit two of the sections of slow waves. Underneath is a spectral display. Each one of those bars represents a single hertz, so you're still watching the whole EEG down there, and that's showing the range, the amplitude at all the frequencies where that red perpendicular line is. It changes instantaneously, but you can see that those represent those bands. The colors correspond. Here's an EEG that looks normal up on that top raw band. That's a normal looking EEG. It's small in height, and if you look down at that spectral display, that's also nice and small. If you look under that spectral display, there's those little bars. Those are corresponding to the selected frequencies, and you can see how, again, the colors correspond. You could be watching. If you see a surge in two to five, you could start watching there and see if all of it's coming from four hertz, and you can narrow your focus and try to inhibit that more closely. There's lots of information in all the displays, I'm sure, with all the different forms of EEG feedback. This one shows an EEG that has excessive, again, excessive slow brain waves, and you can see, if you look at two to eight where the purple is, you can see when those get big, it's reflected in that raw EEG because all of the frequencies add up in the raw EEG, but you can see that if you can get that two to eight smaller, then the whole EEG will be better organized, and you can see again down at the bottom how excessive those slow waves are. You get used to that eventually. To me, a lot of slow waves are like trying to think through fog. A person with excessive slow waves is going to have trouble managing anxiety. They're going to have trouble quieting anxiety. They might have trouble focusing. They may have visual problems if that's the kind of EEG they have in the occipital cortex, or they might have sensory integration issues if they have a lot of slow waves or disorganized EEG in some other way in the parietal cortex. If it's memory issues, it might be in the temporal area. If it's attention, it'd be in the front. That's what theta-beta training is bringing down the theta. Those are the slow waves, so again, normal, excessive. These are the kind of things that they showed us at our initial training, and I was like, wow, we can know this? I was surprised. This is a display that you can see after you've trained someone, and it shows minute by minute. It just plays the session for you, so if you haven't been able to see, get a true sense of does this person have too many big waves, this makes it more clear. This is somebody that has too much slow activity. This one has too much slow activity. That's what it should look like. To me, that was amazing to see that. This is a feedback display. It's not unlike the other display in that the three things that are being trained or the four things that are being trained are demonstrated in this, so what you would be telling the patient with this feedback display is keep Pac-Man going, keep him bright, see if you can have him stop less often. He goes black if your high inhibit is up. He goes, he gets stuck, or the little wafers he's eating will get big if your slow waves are too big, so you got to keep your wafers little so he can go fast. With this display, the slow waves are the purple usually, or they could be the purple and the yellow. It could be two to five on one side and four to seven on the other with some overlap, and you would be telling the patient pull both of those ships back and only keep the green one forward, and if you do all that you're being asked to do, you will also hear a beep, and there are nerve feedback therapists that feel like the beeps are much more important than the visuals because the processing is quicker, and some people will let patients just not even pay attention to the screen because as long as the brain's hearing the beep, they'll be okay with you sitting and reading a book if you don't get too much artifact because the brain pays attention to those beeps. The more experienced nerve feedback clinicians have more confidence in that. I still ask my patients to watch the display, so let me think. Oh, I'm doing my time. I've got to go faster. Can I keep going, Beata? Yes, you're good. Don't worry. Yeah, okay, so PIR-HEG nerve feedback is the one that my mentor told me how to do over the phone. Now you can get trainings, formal trainings in PIR-HEG. There's a one-day training, a two-day training, and there are a lot of people out there that could talk you through how to get started, and then you could go for training when you're ready. It's relatively inexpensive. There are two kinds. I know that at least one of them is around $2,000 plus a dedicated computer. So the cost is very manageable. And I actually have had techs administering the EEG. Once I get a good training protocol and a patient just needs to do 30 to lock it in, I have a tech who I sent for training so that she can help me assess the patient. And she's a nurse, she's very good at it. And she also can do the PIR HEG. She says, I could do this all day. And she could collect QEEG. I also had a college graduate doing the repeated trainings of EEG nerve feedback and the PIR HEG trainings. I feel like I could teach community members to administer PIR HEG to each other. And I can have patients come in, hook themselves up and train themselves. I've had patients take a PIR HEG computer, purchase it and train from home. I don't like doing that as much, but it is doable. So PIR HEG works on the prefrontal cortex, lots of reasons. You guys know about executive function. I won't belabor that. What I will mention is what the people who developed PIR HEG will say that it works for anything. It has a good chance of being helpful in any conditions where you see excessive rate and magnitude of response to relatively benign stimuli. Because the frontal lobe works by inhibition, if we can raise its function, if we can teach someone to get their prefrontal cortex dominant quickly, reliably, and with some endurance, it can change a lot of symptoms. And that's what I've seen. It's my favorite nerve feedback to use. Many disorders are associated with too much response to benign stimuli. Sometimes it works in depression, particularly depression that has more frontal lobe issues. You can get an infrared camera to take pre and post pictures. I have one, I'm still not real confident about my images and I don't plan on ever charging anybody for them, but you can use it to see if you're overtraining people because it's very important to stop just at the point of frontal fatigue or the person might not have a good day. They'll go home and sleep and either that day or the next day, if they're going to have a positive response, they'll still have it, but you really want to avoid giving someone a migraine. This kind of nerve feedback was developed for migraine. It is considered a wellness device, but even so there are possible contraindications, particularly because theoretically it's increasing the blood flow in order to remove heat or to bring nutrients to the prefrontal cortex when it's activated. So you want to think about any signs of AVM, recent head injury, and if I have any questions or the person's under the care of a neurologist, I always will review that with a neurologist. I haven't had anybody tell me not to do it and it's wonderful for migraines. This is what it looks like, the patient's watching a movie and when the movie pauses, she's supposed to come out of the movie and focus on the feedback, raise the feedback bar up past the target, and then as soon as the movie starts, she's supposed to allow herself to get absorbed in the movie again. There's a bit of preparation and coaching and refining of that so that patients know what it is they're supposed to do, but it's pretty straightforward. You just have to keep the patient from doing math problems or gimmicks to try to get the movie to come back on. That's what it looks like when the movie's playing, you have some information in the blue that you can tilt the screen so patients can't see it. I use an external monitor and headphones so it's immersive. That's what it looks like when people are trying to raise the bar, it will go up and down. And initially there's more coaching while they're looking at the bar, encouraging them to not worry about it, trust that the brain is working on it. It's like the brain's in the basement switching the electric buttons and somebody's in the attic saying on off. Your brain's working and doing things, even if it's still, your brain is trying and it's not working yet. So just detach and watch it. There's a very mindfulness component that's a part of this, a conscious coaching, but the power is in the feedback, I believe. So what the clinician is watching is the length of time in the pause condition. People don't need very much of that. Some patients need to turn it back on one time and some patients have said they can't do anymore. It might take them 30 seconds to get the movie to come on and they literally are tired. That was very shocking to me. And those are the patients that are sometimes getting the biggest benefit. There are other patients who might be able to spend 10, seven minutes in pause. Overall, you want about a third of the time in pause and the rest of the time watching the movie so that you're not overworking the brain. So there are things you refine over time and you get good at, and there's a listserv, you can ask questions. It's a very elegant system. So I have patient examples I can give with this. I'll mention two of them, three of them real quick. This one was a complex patient. She had just recognized that she was abused. She knew it all the time, but she had suddenly started having overwhelming triggering. But she was also into menopause, too many hot flashes, insomnia, muscle tension. I gave her PIR-HEG and she was like some of my other patients with the EEG nerve feedback. She pretty much had no migraines after that, or if she had stopped doing it and she started to get a migraine, she would eliminate them again with one refresher session for a long time, for months. We went on to EEG feedback with her because she was having hot flashes, insomnia and muscle tension. Some of her insomnia and anxiety did improve the PIR-HEG, but she was wanting as much as she could get and get better. And she had a wonderful response to EEG training. She also had a lot of muscle tension from a back injury and upper back issues. And one of the trainings, she just, all of it melted away in the first training and it held. So every once in a while, she would wanna come back and get that training, but rarely. So she just had a great experience and was seeing me during COVID. So she ended up doing EEG home training, logging on with my tech. She learned how to put her electrodes on. She didn't wanna run them herself. I think mostly we did them for her, but I've had this second patient was a very bright young woman. And she had initially a decent response to the PIR-HEG, but then we also added in the EEG neurofeedback to take her further. She also did remote training, did at least two thirds of the sessions of remote training on her own. And this is a young woman I thought would do a significant amount of psychotherapy, but she got so much benefit. She really, she didn't feel that she needed the therapy. She did great. So I wanna show you, these are the infrared images that were shared by the developer of the system. This is normal. Get ready for this. I was shocked when I saw this. He said, that is not all people with depression, but some people with depression look like that. After a training, that's what they look like. A week later, another week later, then to the second session. So that's the baseline another week later. So you can see that compared to that first one where he was all dark, he's holding onto the gains. This is a patient with anxiety. That's after her session, first session. Second session baseline. So she held onto some of it. That's after the second session. This is the baseline five before the fifth session and after that session. And just, so the developer of this said that the effect is from frontal inhibition rather than relaxations. Frontal inhibition is smoother and lasts longer. So, you know, these, I think I've pretty much run out of time so I can't get into the biofeedback unless y'all want me to talk more about that. But there are a lot of slides that are self-explanatory. To me, the neurofeedback feels a lot like an anticonvulsant because of its broad applications and it's the stabilizing impact. It's wonderful because customers want it. Customers want it. Patients want it. And it can be offered as optimum performance tools with less stigma. Lot of advantages, but wonderful along with medications. With medications, we need to make sure that we are prepared to reduce medicines because a better functioning brain can have more side effects from the same dose of medicine. So what I've seen is that I have to make sure that I don't make the mistake of thinking that the neurofeedback is making people sleepy. If other things have gotten better and now they're complaining of feeling sluggish, I need to reduce their meds and then they're better. So you just have to be thoughtful about that. And if you refer to neurofeedback providers, be very open to the possibility you may be needing to reduce meds. All right. Thank you. Thank you for letting me talk. Y'all have questions. Thank you, Hogan. I can't hear you. Can you hear me? I'm unmuted. Yeah? Yes. Okay. So if you're done with your slides, maybe unshare your slides and then we can see each other. Okay. I didn't finish all of them, but I'm going to share them with you so that you can send them. Sure. Because the peripheral biofeedback, I think a lot of it's self-explanatory and I think we should take questions instead. Okay. I'll stop share. Okay. And I will unpin you. Let me see how to do that. Remove pin. Okay. Okay. Now we can all see each other. Okay. Thank you so much for the presentation. This is a complex topic and I see we have questions. So I'll just start with Barbara because I see your hand is raised, but I also see that there are questions in the chat. Hi. Hi, this is Barbara Bartlett. I heard about a type of neurofeedback that tells you what kind of nutritional supplements would be beneficial for the patient. Do you know what kind that is? I don't know. I have no idea, but I would imagine it's involving some research, that they've developed a program that correlates research studies. I've not heard of it. Okay. Thank you. Thanks Barbara. That's very interesting. Yeah. I don't know either, but that would be great to track down. Like what is that? Yeah. There was a woman named Helena and she comes into New York a couple of days a week. And she was at a conference I was at and the type of neurofeedback she has does tell you, okay, this patient really could use more magnesium or N-acetylcysteine, or this person has a problem with Lyme and maybe you ought to start using herbals. And so at any rate, I could track her down, but I think it's very interesting. It's fascinating. Yeah. With AI, I saw a presentation by a woman who's working with artificial intelligence and some of her work is with neurofeedback. And she said that they did a, they put it through their artificial intelligence paradigm to see what neurofeedback people do that seems to have the biggest impact. And one of the biggest impacts had to do with the time spent beforehand. And I would say assessment is really, really important and the time, the level of understanding the patient had about what they were trying to do and supposed to be doing and what was happening. Those were very important and that makes sense. Thank you. Dirk. Yes. Hi, thanks. It's nice to see you have a lot of experience and I'm still sort of getting my head around all the different types of neurofeedback that there are. One question I've had or that comes up intermittently is sometimes people have neurofeedback where there is not a conscious feedback system where you're not making something go. They just sort of sit there passively and listen to music and it's still sort of called neurofeedback. They say, oh, like I had one patient who sort of found this on his own. I've heard this several times. I don't know what that is. Do you know what that is? When people just sort of passively tap into a neurofeedback system and they say, oh, we're aligning your- I don't. I don't know what that is. And there are geniuses in this field who have each gone their own way and developed a system. And there are people who know more about it than I do, even though they're not using the system. Some people dabble and they try stuff and they find that this- I think where we're gonna end up is that we're gonna be able to look at phenotypes and figure out which kind of system or which kind of approach works best for which kind of people. But it's still so creative and expanding that it can be overwhelming. And I feel lucky that I went with traditional neurofeedback because there's so much knowledge about it and so many mentors. And the PIR, just to clarify, so that one is focused more on the frontal lobe. The prefrontal cortex. The prefrontal cortex. It sits right here and the patient raises their- has to raise the infrared output of the front of their brain in order to raise the bar and get the movie back on. So it exploits the absorption into the movie. When a film director is making a film, they want people to stop thinking and just be in an experiential mode and an emotional mode. So when you watch a patient do this, you see predictably when it turns off. And if it doesn't make sense when it turned off, often you will find out they had a thought. They got distracted. They're worrying about their mother's appointment or something like that. And yep, movie turns off. We use it anyway, right? And they have to come into the moment and be in the moment, attentive, intending gently without striving. And you watch. Eventually, you find a way to ask the patient about it afterwards. You know, when it turned off and you had such a hard time getting it on, what were you doing? Oh, I was getting mad because I couldn't get it up and I wanted to see the rest of the movie, right? So there's this interactive psychotherapeutic aspect, but also it's as people get better, they're able to get it on reliably, they get it on more times, they have more endurance. And it's translating into, they'll say, you know, it's like I just have a few more minutes before I blow or a few more seconds before I blow. I think twice they get this control and their migraines get better. And the infrared, I'm going to stop in a second, but the infrared, is that measuring brain frequency or is that measuring conductance or what does infrared measure? It's measuring infrared heat, infrared waves, the same way if you put your hand on the other side of a door and you're shown an infrared camera through the door, you would see, it's the same way the military see people at night. It's an infrared camera that just sees the heat, the energy coming out of things, right? So is that similar to heating your hand when you do the bio hand heating? Yes, except it's not pure temperature. It's not pure temperature, it's energy. I think it's wavelengths of, I don't know if it's light. Have to ask the developer, but it's not just temperature and it factors out the skin temperature. Thank you. Yeah. Great, thank you. Yeah, that is, yeah, I'm joking. I'm also trying to wrap my mind around it, right? But there are these, all these images of like the brain activities, low in depression on the, you know, left side and then when- What's that shotgun? That improves, so it fits with that. Yeah, Noah, go for it. Yeah, I've experienced using that, H-I-R-P-I-R-H-E-E-G. My understanding, it's the blood flow. You're getting the brain, you're bringing more blood to the front of the brain and that gets you, gets the front of the brain warmer and increases the activity. Well, it's a little bit different in that the increased, the theory is that it's the increased activity of the prefrontal cortex when it is doing the work of becoming, making itself dominant. It has to do things to make itself dominant and that causes increased blood flow because of the increased activation. The blood flow comes in to cool the brain and it comes in to bring in food, remove byproducts. Interesting. My understanding is the dorsolateral prefrontal cortex is just so key in a lot of treatment. This somehow also affects that part of the brain too, is that? So those are the, it's supposed to be more- I don't, I don't think we know, but what we do know is that the prefrontal cortex regulates a lot of the rest of the brain. The frontal lobe regulates a lot of the brain. One of the things I remember Jay Gunkelman, I believe, saying, he's an engineer that's big in the neurofeedback field. He's identified EEG phenotypes, done a lot of research. And he said, we have to remember that if we, if you work on one node, you know, we have all these networks now and they have like five or six places, and we're all trying to figure out, okay, what's that network and where is it? But if you, if you can affect one node of a network, you can affect the whole network, right? So you don't have to put something on every node. Just like if you improve the police department in a community, a lot of things happen and you don't realize it was because you, not everyone realizes because you have six more police officers, that the street looks cleaner and there's fewer red lights being, you know, people are going slower. And the PIR, you don't need to put on EEG leads, is that right? No, there is no electrical interface. It's a camera that sits in that little box. It has a headband. There's a little box and it has two little cameras that are reading for the prefrontal cortex and that wires into your computer. Dirk, I was similar and I was similarly like, I did a neurofeedback five-day training like 12 years ago. And then I got so overwhelmed with all the different systems and the sticky gooey stuff. And I was like, it was so techie. And it just felt like it would be such a big investment of time to like make the right decision and figure it out that I just like did not pursue it. And last year I accidentally found someone like a tech who's been doing it for five years and just hired him. It was like, you'll figure it out. Wow. It's me. Yes. He had so much experience, right? He kind of like went, you know, he brought it in for us. Wonderful. So that's one strategy for psychiatrists, just find some like geeky tech guy who's been doing it for five years, bring onto your team, you know, and these texts, they don't have to be clinicians, right? So the tech I have right now is in social work school, but he was doing this as like a college student and post-college, right? So it's not a very high cost to hire a tech, someone who's like really geeky and really into it to pull the physician, the busy physician along. Right. Like he's teaching me. Right. So I mean, he helped with like, okay. And I was like, choose the easiest system because the complexity of these systems was what like prevented me from implementing this for 12 years. Me too. Yeah. And now there are these new companies with new technology that, you know, avoids the wet sticky gooey stuff, right? You just put, you know, the system I'm using uses like a band or like a cap or like this crown, right? So these are like just devices you put on your head and there's no goop. It takes a little bit of like, I don't know. And if you've had a chance to do some sessions, but you haven't had, yeah, but I've been doing sessions, right. And, and they, they set it up like easy. So then you can also teach your patient and then send them home with it. Right. And they go there because it's so many sessions, right. Three sessions a week out where patients don't want to come for 30 questions. Right. So that's a big obstacle. Yeah. What system is easy enough for people to take home and just do their own training. Right. So you can rent these devices. You can buy these devices. The price of the devices was high, but now it's coming down, right? Like the cap is a thousand dollars. The band is $500. The crown is like seven 50, right. And you can rent them for also for like 60 bucks a month, right. Which is like affordable for people. And then, you know, the technician just sets up the protocol and checks in and helps, but you can kind of do it all remotely, which is in a way like there's less income or less motivation for any physician to do it. That's why it's mostly like therapists and coaches, because it's not necessarily that much money because, you know, you just do it like patients just do it at home. Right. But if this really works and it's a non-medication treatment and it fits within our like integrative psychiatry, you know, these more holistic, less medication-based treatments, right. Like I want to really figure it out, but we're all busy. Right. So how to figure it out without like hundreds of hours, you know, reading these like dry textbooks, which I have now two of them, but it's like, Oh my goodness. Yeah. Yeah. Me too. There are shortcuts now. I think it's wonderful that you've been able to do that. I'm very curious about how we can get to some models where people can share neurofeedback centers, where we can have multiple clinicians use, utilizing the same equipment and the same texts and coming in and learning if they want to learn. And I think happy for New York, you know, I mean, Brooklyn for anyone in New York, like my tech is like so friendly and eager to like, you know, and he'll come to you even he's willing to go to people's homes to do these training sessions. So like I said, everyone in my practice can just like try it, you know, I'm trying it. I'm like, come to my house. Let's try it on my children. What happens? Yes. No. How much does that cost? I mean, how much investment does the patient have to make with into their computer gear to set this up? Nothing. It's you use your, you know, the app is on my phone. Right. And then the, the, the unit you can give to the patient rent out and you decide how much you charge, or if they rented from the company, it's like 60 bucks a month. Right. And then I pay a fee to the neurofeedback you know, training platform, which is all like on a regular computer. I don't have to buy any special computer. It's like the technology really jumped. So, and you can even do like brain mapping. It's not as sophisticated. It's not a 19 channel. Right. But it's like a six channel or nine channel. You move the thing around, you have the crown and that's the, you know, the device is $950. Right. So it's suddenly even like brain mapping costs, which used to be $20,000. When I looked into it 12 years ago, now it's under a thousand dollars. Right. And it's, it takes, you know, 20 minutes and you have like the whole report. Now I'm just like sitting there trying to learn quickly, like how it's interpreted, but like the technology like really jumped and we can have, you know, some speakers. I don't, I don't like to bring people from the industry side. Yeah. So I never invite them. So it's, we need someone, you know, who's using these newer to tell us also about like, how does this one compare to that one? Because when I went through this process, they're all competing. They're a bunch of, they're new companies, they're startups, they're, you know, venture capital funded. There's like ones in Canada, one's here and they're competing for a share of the market. You know, the company I went with is like brand new. So their fees were way lower than they're like one that's like a few years ahead and more established, but it's like, it's, it's just to encourage people. It's like the technology it's affordable. It's simple. It's easy for patients. You know, now I feel like I need to like just invest time to like do 30 sessions myself, you know, for this and for that and convince myself. Well, and another thing to keep in mind is that a full brain map, a full QEEG, it shouldn't cost very much to actually go somewhere and get a full QEEG. The collection is, is one thing I don't, I think often it's fairly low if you go to somebody that does a lot of them. And then you, for me, when I sent the collection in, it was only $250 to have a fully certified, qualified person look at that QEEG. And one thing I would say about doing the brain maps is that if you can have somebody look at the raw collection, that's so much different and better than only getting the pictures and the tables. Those come from a comparison to a database, but there's a lot of information in the raw collection that neurologists won't call it abnormal, but if you can get rid of some of those transient, slow wave activities, those get factored out in the comparison to the database, but those are just those slow waves. And you can do a very simple protocol and eliminate those. Sometimes they're called slow waves of childhood when they're, they're still excessive and there's a straightforward treatment and those might get missed with depending on what kind of brain map it is. You want to know, are they, are they looking at the raw EEG with their eyeballs and telling you, is it, or is it all artifacted with artificial intelligence? Is this some, some artificial intelligence will say, oh, that's an artifact. That was an eye roll. And it wasn't, it was EEG production. That's that kid wobbling on their bike, right? So, so I want to bring attention to the questions in the chat. So there's a question, what specific system do you use? Am I allowed to say, I don't know if I'm supposed to not do that. Go for it. This is us like teaching each other. Okay. Yeah. I, I trained with Eager. So I trained with Ed Hammond and Joy Lunt was one of my main mentors. She's been doing it for 30 years. She trained with that original, the Othmers. And so for me, if I had it to do again, I would have made sure I took something like the eight week course that she, eight hours, three, three days course that she did on assessment. She's a, she's a brain whisperer. She really, she does at least a two hour intake. That's different from our psychiatric intake with all the history. And she's asking things like, so what do you do? What kind of thing calms you down when you're angry? You need a loud person to argue with you and, and be mad about what's happened to you? Or do you need somebody that talks real sweet and gentle? And she'll use lots of information like that to determine, is this person over aroused or under aroused? And then she'll look at the QAEG with me and look at the frequencies and help me decide, you know, I really leaned on mentors like that. Could you type maybe the name into the chat? Joy Lunt. Joy Lunt and the system I trained in is Eager. And if somebody wanted me to tell them which system to get, I would be looking at a few additional ones as alternatives. A lot of what I would be looking at is, is there tech support available during work hours? Are they, how responsive are they? You really want to know that. And how, how bound are you to asking people what to do or having to put in rating scales and they're telling you how to train the patient? Is it a person that is helping you learn? Or is it, are you dependent on collecting a QAEG and every single time you've got to pay them for the training? You know, I think there's, Eager has a remote training platform. You can have as many patients as you want that you're training remotely. Patients have to pay for the amp and get a dedicated computer and they send them a dongle and they rent the software. So they have a way of doing that. I think some systems have much fancier bells and whistles and you can turn the brain around and show them where their spot of problem is. Eager doesn't offer any of those pretty things, but it has a very interactive platform where you can change what you're doing on the fly, not have to pull out and put things in and come back and start training again. And probably each of the systems has little things that are there reason to be, you know? Is anyone else using any other systems that you'd like to comment on? Maybe. I, so I trained with the Eager, Ed Hamlin, and that was the system that Bessel van der Kolk was recommending for his trauma group. And he was with, connected with Seaborn Fisher who, but he is also very close with this Swiss group and I can look them up. And so he recently switched his team to the Swiss and this, in Europe, they have insurance reimbursement for neurofeedback. So it's, it's really big and widely used. I am actually going to the trauma conference next week again. So I'll try to find out what those Swiss people are going to show up again. So I'll, I'll ask them again. I forget. What conference that you keep going to? This is the Bessel van der Kolk trauma conference in Boston. It has like Richard Schwartz will be there. And this year, Gaber Mate will be there. And there's, there's a bunch of, I went for the first time last year. I really enjoyed it. So I have one thing to say that you might keep in mind, Dirk. I think, and this is probably true with any of the systems, you really want the people giving you training and how to run a session to provide computers for you to, to manipulate and to make sure you know how to run an efficient session, be there with you. You're training somebody in front of the instructor so that you know how to, to make, adjust thresholds, how not to, how to, how to optimize the chances of learning in each session. And then you really want someone to help you not just go for protocol, the protocol for trauma or the protocol for this and the protocol for that. You want to be able to think for yourself about what is this brain's idling frequency that's optimum. And it's the veterans that know how to get you there. There are a lot of young people teaching now, and it's not clear to me what kind of training people are coming out with. You want to make sure you know how to run the training hands-on and you've been watched. Like when, when Joy, when I started getting trained, mentoring with Joy, she said, well, why did you change the threshold then? Why, why, you just changed the other threshold. Don't change another one within the same period. Wait at least two periods. You're confusing the brain. It's waiting for a beat, but now you took them away again, right? Took me to the mat and had to go over it and over it and over it. We even started graphing it for about a year. My tech and I graphed every session. And when we changed the thresholds, you reviewed them with Joy, right? You want some one-on-one instruction if you're using that kind of system, I think. So we're at time. Hogan, thank you so much. Thank you. If you would like to get the CME credits, please just click the link and complete the evaluation of this session. And you can get, I think it's one hour, right? Of CME credit. Thank you, Hogan, for making that happen. And y'all make sure you look at the other slides on peripheral biofeedback. It's really easy. I could teach any of you in an hour to do the peripheral biofeedback with the wellness tools. And then you will learn more as you do it. You can teach yourself. Go get it and practice. Hogan, would you give us your email address again one more time? Yes, I can say it and I will include it when I send the, it's on my slides. Oh, okay. Thank you so much. Okay. All right. Yeah. I will send the slides. If you send me the slides, I will send them together with the recording and reminder to complete the evaluation. Good. Thank you. Where is that link that you were referring to? The CME link. I see someone also asked in the chat. I haven't been able to find where that is. It's in the reminder email that I sent today. It's right under this presentation is free or no registration right under that. There's a link. I hope it works. I checked it earlier today. It was working. I'll try it. And if I can't do it, I'll look into it. We'll fix it and we'll send it. I think that was the correct link. It was working today, but we'll send it. When you click it, I clicked it on there. It sounds like you'll look into it and send it, but when you click it, it just takes you to a page that says redeem with a button and you have to put an access code in. So I didn't see a survey, but maybe I'm not doing it right. Oh, okay. So we need to include all those instructions. They did send the APA, CME people did send us some codes and instructions. I wasn't sure how much of that, and you do have to be a member of the APA and like log into your thing. Let me look into it so you don't have to do more. I told you I would try to take care of it. Thank you. I saw the instructions, but they seemed like they were about a different presentation than I emailed about that. Okay. I'll keep you in the loop. And send it with the recording in the next couple of days. Thank you guys. It was fun. Thank you so much. Have a great night. Bye.

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PIR HEG