ISNR, 2008, EZPIR HEG SYSTEM Jeffrey A. Carmen, Ph.D. Private practice Manlius, New York

TECHNICAL OVERVIEW OF pIRHEG WHAT IS MEASURED? WHERE? HOW? ARTIFACTS? SIDE EFFECTS?

WHAT IS MEASURED? THERMAL (INFRARED) OUTPUT FROM THE BRAIN AS A FUNCTION OF BRAIN ACTIVITY, MEASURED AT THE CENTER OF THE FOREHEAD INFRARED IS HEAT ENERGY IN THE FORM OF LIGHT THAT IS BELOW THE VISIBLE SPECTRUM THE MEASUREMENT IS CARRIED OUT WITHIN THE 7 TO 14 MICRON BAND USING A CAMERA-LIKE SENSOR

ELECTROMAGNETIC SPECTRUM

WAVELENGTH METRICS METER= 1.0= 1 -0 =LONG deci(METER)= 0.1= centi(METER) = 0.01 = milli(METER) = = micro(METER) = = nano(METER) = = 10 -9= SHORT

WAVELENGTHS

CRITICAL QUESTIONS: HOW IS pIRHEG DONE? WHAT IS THE MENTAL STATE NEEDED TO PRODUCE AN INCREASE IN pIRHEG?

HOW THIS PROCESS ACTUALLY WORKS! Yoda manages to do things mentally by creating a state of high mental effort combined with emotional tranquility. When this state is achieved in humans, the pIR HEG signal increases. Under stress/distress, the signal decreases.

MECHANISMS OF EFFECT MENTAL EFFORT IN THE PRESENCE OF A QUIET EMOTIONAL STATE FRACTIONATING (FLIPPING BACK AND FORTH BETWEEN TWO INCOMPATIBLE BRAIN STATES)

WHAT IS ACTUALLY MEASURED? The pIR HEG sensor picks up a signal that is related but not equal to temperature. It is more accurately thought of in terms of the amount of thermal energy the brain must get rid of to maintain thermal stability. The displayed signal represents a combination of baseline surface skin temperature along with a superimposed rapidly varying signal that is a thermal waste product of cellular metabolism. It is this varying signal that is of interest in training the prefrontal cortex.

Q: How much session gain is needed for an effective session? A: None! The effect of the session is not based on gain but on mental effort and repetitions. Effective sessions often have zero gain but many episodes of relative signal increases in response to demand.

ORIGINAL INSTRUMENTATION (1998)

ORIGINAL HEADSET

CURRENT INSTRUMENTATION (2007)

HEADSET PLACEMENT Fpz for everything When I originally developed the system, I tried a wide variety of placement locations. None of these were as effective as Fpz. This may have something to do with the large field of view of the headset, which enables picking up a large signal area from the brain. However there are also unclear variables. For example depression responds faster at Fp1 than Fpz but it is a “disconnected” and unsatisfactory feeling. It also does not last as long. Fpz “feels right” comes on smoother and lasts longer.

ORIGINAL DISPLAY AND CONTROL UNIT

The box on top of the TV controlled the VCR that fed the movie to the TV screen. This system evolved into control of a physical DVD player. Movie control was binary (play/pause).

THRESHOLD SET AT 92.00, MOVIE HAS PAUSED

THRESHOLD SET AT 92.00, MOVIE IS PLAYING

This is a screen shot of the computer display of the current EZPIR HEG system. The number in the upper left is the signal output from the headset. The yellow horizontal line below that is the threshold. The blue vertical line below that represents the difference between the signal and the threshold. The threshold is set either manually or automatically. As with the original system, the movie will switch from “play” to “pause” and back again.

ARTIFACTS? Artifacts associated with the original system have been reduced or eliminated in the EZPIR system. However a person who sweats profusely may still fog the lenses, causing a slow steady drop of several degree equivalents.

SIDE EFFECTS? SLEEP (stabilizing or interfering with circadian rhythms – the first 3 or 4 sessions are best done in the morning to avoid sleep interference) HEADACHE (mild, transitory, typcially less than one minute) INHIBITION FUNCTION (general loss of frontal inhibitory function until recovery after a good night’s sleep) DRY EYES (from reduced blink rate as a function of improvement in sustained attention)

CHANGE MEASURES It is important to measure change. The best measures are repeating behaviors the individual typically exhibits that are not easily self monitored. Some examples are: Blink rate (slower is a sign of less anxiety and better attention) Squirms per minute (less is better) Clarity of speech Headache activity Sleep patterns Rate and magnitude of emotional responses Formal and informal cognitive and attentional measures

RESPONSE PATTERNS WITH MIGRAINE The most common first response pattern is a reduction in the perceived pain of the migraine. This applies to migraines in progress and those yet to come. This is followed by a perceived reduced migraine frequency. NOTE: frequency remains the same but perception of the event is softened.

WHAT CONSTITUTES AN EFFECTIVE SESSION? AMOUNT OF COGNITIVE “EFFORT” IS PROBABLY MORE IMPORTANT THAN THE ABSOLUTE INCREASES LENGTH OF SESSION CORRELATES POSITIVELY WITH EFFECT NUMBER OF “BURSTS” UPWARDS (.10 TO.20 INCREASES) CORRELATE POSITIVELY WITH EFFECT TOTAL SESSION GAIN IS PROBABLY NOT IMPORTANT. AN EFFECTIVE SESSION MAY HAVE NO GAIN AT ALL.

CURRENT pIRHEG PROCEDURAL GUIDLINES THE FIRST 3 OR 4 SESSIONS ARE DONE ONLY IN THE MORNING TO LIMIT ADVERSE SLEEP EFFECTS AND ENHANCE NORMAL SLEEP PATTERNS LIMIT SESSIONS TO 30 MINUTES USE ONLY Fpz PLACEMENT

WHEN TO DISCONTINUE? This is a joint decision between me and the the client or parent. Initially I see people once a week. As symptoms stabilize, I spread the appointments out to 2 weeks, then 3, then 4, and so on. As long as the target symptoms remain stable, the days and weeks between sessions keeps increasing. I have some folks who return every 6 months just for a “checkup”.

MY PRACTICE MOSTLY HEADACHES (about 85%), either as a primary condition or correlated problem. most of the them involve migraine or migraine variant). Within the headache population, most will also present with other symptoms of frontal fatigue or frontal shut-down.

HEADACHES TYPES AND CHARACTERISTICS

MAJOR TYPES OF HEADACHES MIGRAINE (PROBABLY MOST COMMON) TENSION TYPE (MAYBE LESS COMMON) INFLAMMATORY (VASCULITIS) SINUS INFECTION AND INFLAMMATION

DIFFERENTIAL DIAGNOSIS MIGRAINE HEADACHES TEND TO HIT ON RELEASE FROM PROLONGED STRESS TENSION TYPE HEADACHES TEND TO INCREASE IN PAIN DURING STRESS AND DECREASE IN PAIN AS STRESS IS RELEASED

DIFFERENTIAL (CONT) IF A HEADACHE HITS AT THE END OF A HARD DAY OR WEEK, IT IS PROBABLY MIGRAINE IF A HEADACHE HITS DURING A HARD DAY, AND GOES AWAY AT THE END OF THE DAY IT IS MORE LIKELY TENSION TYPE

HOW MANY SESSIONS DOES IT TAKE FOR MIGRAINES? 4 TO 6 SESSIONS TO HAVE AN IMPACT (TYPICAL) ANOTHER 10 OR 20 OR 30 OR MORE TO FINE TUNE THE PROCESS SESSIONS ARE PROGRESSIVELY SPREAD APART BASED ON SYMPTOMS

MIGRAINE HEADACHE HEADACHE TRIGGERS ON RELEASE FROM STRESS MAY LOCALIZE TO SPECIFIC REGIONS OF THE HEAD MAY POUND IN SYNCHRONIZATION WITH PULSE MAY HURT A LOT OR A LITTLE OR NOT AT ALL THERE ARE USUALLY NEUROLOGICAL AND/OR PSYCHOLOGICAL CORRELATES

CLASSIC MIGRAINE HEADACHE (ONE SIDED)

EMOTIONAL CORRELATES OF MIGRAINE HEADACHES EMOTIONS LESS STABLE PRIOR TO THE ONSET OF THE HEADACHE EMOTIONAL STABILITY RETURNS AT ONSET OF HEADACHE

SEXUAL HEADACHE (MAY BE TENSION-TYPE OR MIGRAINE VARIANT OR PSYCHOGENIC OR ANATOMICAL)

AURA (THE VISUAL ONES ARE EASY TO DETECT)

AURA (SOME ARE MORE “SILENT”)

PATHOPHYSIOLOGY (THE VASCULAR HYPOTHESIS)

PATHOPHYSIOLOGY (TRIGEMINAL / BRAINSTEM HYPOTHESIS)

TENSION TYPE HEADACHE PAIN INTENSITY RISES AND FALLS WITH LEVEL OF STRESS TENDS TO BE GENERALIZED AROUND THE HEAD OR BAND AROUND THE HEAD DOES NOT USUALLY POUND

EMOTIONAL CORRELATES OF TENSION TYPE HEADACHES EMOTIONS LESS STABLE DURING HEADACHE

INFLAMMATORY (VASCULAR) HEADACHE INFLAMMATION OF BLOOD VESSELS MAY OR MAY NOT POUND NOT USUALLY RELATED TO STRESS CORRELATES WITH DISEASE ACTIVITY

MIGRAINE VS TENSION- TYPE HEADACHES 2 THEORIES: –MIGRAINE AND TENSION-TYPE REPRESENT A CONTINUUM RATHER THAN DISTINCT ENTITIES –MIGRAINE AND TENSION-TYPE ARE TWO DISTINCT ENTITIES –SUSPICIOUS EVIDENCE: IT APPEARS AS THOUGH ONLY MIGRAINES AND CLUSTER HEADACHES SHOW AN INCREASE IN CALCITONIN GENE-RELATED PEPTIDE.

EMOTIONAL CORRELATES OF INFLAMMATORY (VASCULAR HEADACHES) EMOTIONS MAY BE LESS STABLE BEFORE AND DURING HEADACHE “AURA” MAY OCCUR BEFORE OR DURING HEADACHE EMOTIONS AND HEADACHE MAY BE AN EARLY WARNING INDICATOR OF LUPUS FLARE MAY OCCUR WITH DEPRESSION

SINUS INFECTION AND INFLAMMATION COMMON IN CENTRAL NEW YORK SIGNIFICANT IN ABILITY TO MIMIC OTHER HEADACHES COMPLICATED REFERRED PAIN CAN TRIGGER “REAL” MIGRAINE HEADACHES

EMOTIONAL CORRELATES OF SINUS HEADACHES NONE OTHER THAN USUALLY FEELING MISERABLE

HEADACHE IMAGES IN INFRARED HEAT OUTPUT COLOR CODE: BLACK IS COLD WHITE IS HOT RANGE: ABOUT 10 DEGREES (F) JUST NOTICABLE DIFFERENCE.1 DEGREE (F)

GENERAL OBSERVATIONS ON INFRARED IMAGES (FOR RIGHT HANDED PEOPLE) DARK AREAS OVER LEFT EYE CORRELATE WITH DEPRESSION DARK AREA OVER RIGHT EYE CORRELATE WITH ANGER OR ASPERGER / AUTISTIC PROBLEMS DARK AREA IN CENTER CORRELATES WITH ATTENTIONAL PROBLEMS FULL DARK FOREHEAD CORRELATES WITH FATIGUE, SLEEP DEPRIVATION

35yo female, severe anxiety

11 yo male, depression and anger

15 yo male, moderate adhd

16 yo male, Asperger’s and depression

22 yo male, severe ocd and anxiety

35 yo female, severe anxiety

40 yo female, severe anxiety and anger

MAXILLARY SINUS INFECTION (female, 56) DIAJ

ETHMOIDAL SINUS INFECTION ETHMOIDAL AND MAXILLARY (male, 42) BOBW, MRI VALIDATED

PRE/POST IMAGES

ANGER, 1 ST SESSION, BASELINE IMAGE, FEMALE, 45, 10/18/01,KATH R

END OF SESSION

ANGER, 2 ND VISIT, PRE

ANGER, 2 ND VISIT, POST

THAT’S ALL! THANKS FOR YOUR INTEREST