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Ann. psychophysiol. 
ISSN 2412-3188 (Online)|2410-1354 (Print) 

APP| Published By AEIRC| https://doi.org/10.29052/2412-3188.v10.i2.2023.91-110 
 

 
Mini Review  

Red Flags Warning for providers about  
risks in applying psychophysiologically 
based interventions 
Richard A. Sherman, Cynthia R. Kerson, Eric K. Willmarth,  
Phoebe L. Manalang-Monnier & Jerry R. DeVore 
Saybrook University, California-United States. 
 

Abstract 
Many behaviorally oriented practitioners applying psychophysiologically based 
interventions to symptoms such as headaches, early dementia, dysfunctional 
breathing, low back pain, anxiety, noncardiac chest pain, and irritable bowel 
syndromes may lack the training to recognize very serious underlying medical 
etiology, resulting in potentially life-threatening symptoms. Thus, some 
psychophysiologically based interventions should be deferred until an 
appropriately trained medical specialist clears clients. Practitioners may lack an 
appreciation of the limitations and challenges of certain psychophysiologically 
based interventions, such as hypnosis, neurofeedback, respiratory training, and 
biofeedback, for a variety of symptoms, including cluster headaches, 
temporomandibular joint (TMJ) disorder, psychosis, and neurodegenerative 
disorders. This paper identifies red flag warnings associated with specific 
symptoms and the psychophysiologically oriented interventions employed to treat 
them. 
 

Keywords 
Screening, Biofeedback, Neurofeedback, Psychophysiology, Hypnosis 

 

 

 

 

 

 

 

 

 

 

Citation: Sherman RA, Kerson CR, 
Willmarth EK, Manalang-Monnier PL, 
DeVorce JR. Red Flags Warning for 
Providers About Risks in Applying 
Psychophysiologically Based Interventions. 
APP. 2023;10(2):91-110 
 
Corresponding Author Email: 
drrichsherman@gmail.com 
 
DOI: 10.29052/2412-3188.v10.i2.2023.91-110 
 
Received 20/10/2023 
 
Accepted 20/11/2023 
 
Published 01/12/2023 
 
Copyright © The Author(s). 2023. This is an 
open-access article distributed under the 
terms of the Creative Commons Attribution 
4.0 International License, which permits 
unrestricted use, distribution, and 
reproduction in any medium, provided the 
original author and source are credited.  
 

 
 
Funding: The recording devices and 
computer were purchased by the 
Behavioral Medicine Research and 
Training Foundation (Port Angeles, 
Washington, USA) and then loaned to the 
investigators to use in the study. 
 
Conflicts of Interests: The authors have 
declared that no competing interests exist. 
 

https://doi.org/10.29052/2412-3188.v10.i2.2023.
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Introduction 
Some behaviorally oriented practitioners 
lack the training to recognize very serious 
underlying medical conditions that are not 
amenable to psychophysiological 
interventions and may be life-threatening. 
They may also not be aware of when specific 
psychophysiological interventions should 
not be applied to clients presenting with a 
variety of symptoms. This paper 
summarizes some of the red flags 
practitioners should be aware of (a) before 
providing psychophysiologically oriented 
interventions for a variety of conditions such 
as headache, anxiety, dementia, and 
depression, and (b) providing specific 
behaviorally- oriented interventions such as 
hypnosis, neurofeedback, and biofeedback 
for a variety of symptoms. The key is for 
practitioners to know when to get assistance 
in assessing symptoms and when 
psychophysiologically based interventions 
are not appropriate. 

Some disorders are amenable to 
psychophysiological but not 
psychotherapeutic interventions, such as 
phantom limb pain, incontinence, and reflex 
sympathetic dystrophy1. There are also 
disorders that usually have a physical 
etiology and may include psychological 
components that could be helped by 
psychotherapeutic interventions (e.g., male 
impotence). Developing a treatment plan 
that addresses the patient's symptoms and 
the causes of those symptoms requires a 
thorough assessment. A vital part of the 
assessment includes identifying problems 
that may not be responsive to 
psychophysiologically based interventions - 
especially those problems that require 
medical attention that is not currently being 
provided. 

Practitioners must keep in mind that their 
scope of practice may limit them to assessing 

and treating only certain disorders using 
specific techniques. Commonly applied 
techniques such as electrical stimulation 
may be outside the scope of practice for 
many behavioral practitioners. In general, 
unlicensed practitioners can assess and treat 
stress or assess and assist optimal 
functioning among essentially healthy 
people such as athletes desiring to improve 
their performance. Only trained medical 
professionals who are licensed to do so can 
diagnose symptoms that could have severe 
consequences if not medically managed. 

This paper reviews experiential and 
behavioral symptom presentations that may 
be secondary to serious medical conditions. 
It addresses what a behavioral health 
provider should assess to determine 
whether a referral for conventional medical 
or psychological evaluation and care is 
needed. An appropriate assessment of 
clients considering psychophysiologically 
based services involves obtaining 
information from interviews and a careful 
review of their current status and history—
including medications, psychophysiological 
measurements, and psychometric 
measurements—before deciding to provide 
a psychophysiologically based intervention 
for a patient. 

Headache problems, for instance, are often 
referred to practitioners who employ 
biofeedback as their main interventional 
modality. However, no behavioral modality 
will cure a brain tumor presenting with 
symptoms similar to those of common 
headaches. This is why properly trained 
medical professionals must assess 
symptoms such as headaches before 
practitioners without such credentials 
attempt to treat what may appear to be 
common problems. This can be true if a 
medical professional who is assessing 
outside the realm of their expertise refers the 
client. In other words, do not assume all 



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appropriate medical evaluations have been 
performed when the referral is from a 
medical professional without training and 
expertise in the symptom area.  

Three key points paraphrased from 
Psychophysiological Assessment and 
Intervention for Chronic Pain1: 

1. Many disorders are a collection of
comorbid symptoms that do not have well-
defined explanations or etiologies. Some
examples are migraine headaches, ADHD,
and phantom limb pain. Several very
independent underlying problems can
result in the same collection of symptoms
defining these disorders. The same cluster
of symptoms can derive from
psychological or medical mechanisms or
some combination of both. For example, as
recently as 20 years ago, reflex sympathetic
dystrophy (RSD), now-called complex
regional pain syndrome (CRPS), male
impotence, and phantom limb pain were
considered to be primarily psychologically
based. Some behavioral therapists are still
treating these disorders as if they are
primarily caused by behavioral problems2.
There are literally hundreds of articles by
behavioral therapists, including
psychiatrists and psychologists, attesting
to the psychological causes of many of
these problems. For example, numerous
authors characterized phantom pain as
being a manifestation of some mental or
emotional problem such as unresolved
grief3, depression4, a psychosomatic
manifestation of an unstable
personality2,5,6, and psychopathological
misinterpretation of ordinary phantom
sensations7. CRPS was considered to be
caused by adolescent attachment problems
to the mother primarily in young girls8.
Male impotence was related to all manner
of psychological problems9. Of course, for
some, it is. However, empirical research
has demonstrated that these problems are

not usually primarily psychologically 
based. 

2. Physical and behavioral symptoms are
often subjective and can be magnified by
stress and other psychological problems.

3. Behavioural interventions can help and
even resolve physically based problems
such as migraine and tension headaches.
Symptoms and Conditions Requiring
Review by Appropriately Trained and
Licensed Clinicians like Early
Dementia/Memory, Problems/Cognitive,
and Processing Problems. Cognitive
problems initially present as 
neuropsychological issues—such as 
problems with cognition and adaptive 
functioning. Medications and medical 
conditions can produce or exacerbate these 
symptoms. Behavioral practitioners 
should not treat clients with memory 
problems unless thyroid and medication 
levels have been checked and 
acknowledged by a medical practitioner. 

Hypothyroidism 
This is an important consideration for the 
behavioral therapist. Hypothyroidism is 
clearly a common cause (not a correlate) of 
early dementia. This is not open to question 
any longer because far too many studies 
have demonstrated the relationship10. 
Hypothyroidism (low levels of thyroid 
hormone) and thyrotoxicosis (very high 
levels of thyroid hormone) can cause 
dementia. These thyroid issues are common 
in people diagnosed with early dementia, 
and they duplicate every symptom of both 
early- and late-onset dementia. A thyroid 
panel ordered by a medical professional can 
determine this, and proper adjustment of 
thyroid hormone levels may eliminate the 
problem if given in a timely manner. 

Sleep Apnea 
Sleep apnea is associated with symptoms of 
widespread cognitive decline. Screening 
questions—including whether the patient 



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snores a lot, whether sleep is restorative, and 
whether the patient falls asleep frequently 
during the day—especially if this pattern is 
not associated with recent stressors—should 
trigger a medical referral to evaluate for 
sleep apnea11. 

Medication 
Medication can have cognitively impairing 
consequences, especially when given to 
geriatric populations. For instance, 
benzodiazepines to assist with anxiety and 
insomnia management significantly 
contribute to cognitive impairment and fall 
risks12, 13. Many sleep medications can have 
similar adverse effects14.  

Behavioral practitioners should not treat 
clients with memory problems unless 
thyroid and medication levels have been 
checked and acknowledged by a medical 
practitioner. 

Headaches 
If the headache symptoms are unremitting 
and constant in intensity, or if the basic 
character of the headache changed within 
the last 3 months, an immediate neurology 
consult is recommended, as these can be 
indications of severe problems, such as 
aneurysms and tumors. In this case, ask 
whether the pain is worse in the morning 
and gets better during the day. Such a 
pattern may reflect increased intracranial 
pressure (due to tumors, etc.). Ask if the pain 
gets worse when lifting or other exertions, 
including sexual intercourse. This pattern 
may reflect a leaking cerebral aneurysm, for 
example. A headache in people over 50 years 
of age that includes throbbing temples is 
frequently temporal arteritis rather than a 
migraine. This condition can lead to 
blindness and strokes if not treated 
promptly1, 15-17.  

Refer patients for medical evaluation 
(preferably to a neurologist) if there is/are: 

1. History of treatment for cancer and a
change in or onset of headaches.

2. Any recent-onset sensory or motor
deficits (e.g., weakness or numbness in
an extremity or slurred speech) that have
not been previously medically
evaluated.

3. Headaches that begin after a trauma to
the head or neck. Cervical compression
can cause headaches for years and is
frequently overlooked in neurological
examinations.

4. A unilateral headache.
5. Recent onset of a throbbing headache

centered on the temples that do not abate
but may vary in intensity, especially
among people over 50 years of age.

6. Report of a noticeable change in
personality, behavior, memory, or
another revealing symptom.

7. Vomiting accompanying a tension-type
headache.

Refer patients to a dentist specializing in 
TMJ disorder if there is a history of jaw 
issues such as clicking or misalignment. 

Many medications cause headaches, 
especially as they wear off. Discontinuing 
them (including some headache 
medications), especially without medically 
monitored tapering, may cause headaches. If 
your patient starts getting headaches or 
notices a change in headache activity a few 
days to a few weeks after starting a new 
medication or after stopping a medication 
used for some time, a medical professional, 
preferably the prescriber, to determine if the 
medication is the cause of the headaches, 
should check the patient. Following is a list 
of some medications that are commonly 
associated with a high incidence of 
headache17:  

• Adalat/Nifedipine (23%)

• Indocin (11%)

• Clinoril (3–9%)



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• Isordil (25%)

• Halcion (10%)

• Lopressor (10%)

• Mexitil (6%)

• Minipress (8%)

• Sorbitrate (25%)

• Naprosyn (3–9%)

• Nitroglycerine products (25–60%)

• Terazol (25%)

• Procardia (15–23%)

• Tolectin (3–9%)

• Prozac (20%)

• Any nitroglycerine drugs (over 50%)

• Retrovir (1 0 42%)

• Trental (1–6%)

• Seldane (16%)

• Xanax (13%)

Frequent use of analgesics (e.g., aspirin, 
acetaminophen), barbiturates, ergotamines 
(i.e., Cafergot, Wigraine), and caffeine can 
cause or exacerbate headaches during use, as 
well as when withdrawing. 

Low back pain 

Patients reporting low back pain sometimes 
go directly from general medical 
practitioners to healthcare providers who 
may have little medical training. This means 
that patients occasionally are not 
appropriately screened for serious 
underlying issues. It is very important that a 
qualified practitioner screen for these. Turk 
and Melzack (2002) suggest the following 
red flags to use in identifying patients who 
may require further evaluation by 
specialists18. The nonmedical provider 
should document these as reasons to 
encourage the primary care provider to 
consider specialty consultation: 

1. Severe back pain different from previous
episodes (if any) in people below 20 and
above 55 years of age

2. Recent violent trauma (falls, auto
accidents, etc.)

3. Constant, progressive pain not related to
movement

4. Thoracic pain
5. Previous history of cancer and ovarian

cysts
6. Chronic use of systemic steroids
7. Use of illegal drugs
8. Positive for HIV
9. Chronically unwell, including 

unexplained weight loss, etc. 
10. Severe restriction of lumbar flexion
11. Obvious structural deformities

Contacting the primary care provider may 
be indicated if one of the following is 
evident: 

1. Widespread neurological signs
2. Erythrocyte sedimentation rate above

25
3. Plain X-ray showing vertebral collapse

or bone destruction

If any of these signs are present, or if any 
other finding seems to warrant concern, err 
on the side of caution and report to the 
primary care provider with a 
recommendation for further investigation by 
a specialist. If these signs are absent, 
practitioners should be reasonably 
comfortable proceeding with an evaluation. 
Nonphysician providers would be 
practicing beyond their scope of practice in 
attempting to evaluate CAT scans, MRIs, X-
rays, etc.  

Empirical evidence concerning the teaching 
of self-regulation for low back pain only 
supports the use of biofeedback if, indeed, 
pain is secondary to or exacerbated by 
muscle tension. The psychophysiological 
evaluation needs to determine whether this 
relationship exists and if the pain is 
exacerbated by stress responses leading to 
increased muscle tension. For increased pain 
due to stress responses, behavioral 
interventions such as cognitive behavioral 



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therapy (CBT), which is intended to educate 
patients about stress responses that may 
increase back pain from any cause, may be 
appropriate. 

Dysfunctional Breathing/ 
Respiratory Problems 
Many behaviorally oriented practitioners 
teach clients to modify their breathing 
patterns through capnometry and the use of 
respiration belts mounted over the chest and 
abdomen to help their clients perform better 
in sports and reduce respiration-related 
symptoms, including anxiety, noncardiac 
chest pain, and asthma. Some may not 
realize that distorted respiratory patterns are 
frequently caused by underlying medical 
problems that are not amenable to 
psychophysiologically based 
interventions19,20. Dyspnea and 
hyperventilation are a type of dysfunctional 
breathing (DB) that involves a sensation of 
breathlessness/shortness of breath, labored 
breathing, or difficulty breathing. Primary 
and secondary dysfunctional breathing is 
marked by abnormal breathing patterns in 
the absence of organic conditions such as 
anxiety or secondary to 
cardiopulmonary/neurological diseases20. 
Behaviorally oriented providers can only 
teach breathing methods for dysfunctional 
breathing or respiratory problems secondary 
to non-medically caused conditions. The 
evaluation, therefore, should assess the 
matter and determine if the condition is 
caused by physical deconditioning of 
respiratory muscles, underlying 
psychological causes, or both21. 

Structural causes of dysfunctional breathing. 
Medical conditions, diseases, and 
underlying physical conditions of the 
respiratory and cardiovascular systems may 
cause dysfunctional or labored breathing22. 
Improving DB requires adequate breathing 
assessments, subjective clinical and 
psychophysical scales, and questionnaires to 

measure, predict, and/or determine the 
pathophysiology of the underlying 
disease22,23. The most common physical 
diagnoses of DB include lower respiratory 
tract infection, heart, liver, or kidney failure, 
pneumothorax, allergic reaction, chronic 
obstructive pulmonary disease, and 
asthma24. If a patient has been diagnosed 
with any of these, they should be referred to 
their primary care provider for specially 
trained respiratory consultations. If a patient 
has not been diagnosed but exhibits one or 
more of the following symptoms in 
conjunction with DB, refer them to their 
primary care provider for further care: 

• Pulse rate >120 bpm
• Tachypnea – Respiratory rate > 30 rpm
• Systolic blood pressure <100 mm Hg
• Oxygen saturation < 90%
• Peripheral edema
• Wheezing
• Special populations: Pregnancy
• Anatomical restriction of the nasal

passages, chest, and abdominal cavity
(i.e., heart, lungs, hernia, cesarean, etc.)

If none of these signs are present or pertain 
to the patient, proceed with the evaluation. 
Analysis of chest X-rays, lab analysis (serum 
electrolytes, white cell counts, assays, etc.), 
CT pulmonary angiographs, or lung 
ultrasounds performed by a nonphysician 
provider are outside the provider's scope of 
practice. Refer these patients to their primary 
care provider for recommendations 
regarding analyses of diagnostic reports and 
exams. 

Psychological causes of DB. Acute or chronic 
cases of DB, such as hyperventilation 
syndrome (HVS) or idiopathic 
hyperventilation (IH), may be triggered by 
other factors that cannot be attributed to 
underlying diseases20 and may not always be 
improved with pathophysiological 
treatments. Aside from pharmacological 



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interventions, nonpharmacological 
approaches that modify the brain’s 
processing of signals from the respiratory 
afferent nerves may be used to modify the 
psychological and emotional management 
connected with DB25. Jack et al. (2003) 
showed that idiopathic hyperventilation can 
become a condition caused by psychological 
factors26. Anxiety disorders, including panic 
attacks, are two major psychological 
disorders that could cause or contribute to 
DB. Patients with sustained arterial and 
alveolar hypocapnia below 30 mmHG need 
to be referred to their primary care provider 
to rule out arterial hypoxemia or metabolic 
acidosis before beginning respiratory 
training sessions26. 

Dysfunctional Breathing and Pain.  
Bartz-Overman et al. (2022) found that pain 
and DB might utilize inherently linked 
neurological structures and networks27. For 
example, the role of the insular cortex as a 
central modulator for both pain and dyspnea 
has been established, and his recent research 
has shown that, from a patient's perspective, 
dyspnea and pain may share the same 
fundamental experiences, so when one 
symptom is treated, the other may improve 
as well. In the event that DB is related to 
pain, refer patient to their primary care 
provider prior to commencing treatment. 

Anxiety 
Physical causes of anxiety are frequently 
overlooked. Many diseases, some normally 
ingested substances (foods, drinks), and 
some prescribed and over-the-counter 
medications can cause intense, disabling 
anxiety. It is the provider’s job to review the 
patient’s medical record and patient reports 
to evaluate all substances the patient takes to 
identify any potential substances and 
diseases capable of causing sufficient anxiety 
that could account for the presenting 
symptoms.  

An error made by too many therapists is 
noting that a patient is taking a medication 
that rarely causes intense anxiety—say in 
only one in 10,000 patients—then ignoring 
that medication because the effects are rare. 
However, this could be that one in 10,000 
patients. Medical conditions and commonly 
ingested substances that can produce 
symptoms of anxiety include: 

• Dietary: Some vitamin deficiencies, too
much caffeine, monosodium glutamate,
magnesium

• Diseases: Anemia, secreting tumors
(pheochromocytoma, insulinoma, 
carcinoid), neurologic conditions 
including encephalopathies and some 
seizure disorders, and metabolic 
problems including Cushing’s disease, 
hypoglycemia, and porphyria 

In practice, nonmedical providers can use a 
checklist to identify anxiety-associated 
disorders and substances. The provider then 
can decide when patients with these issues 
should be referred for further medical 
evaluation. An expensive work-up to treat a 
condition that might resolve with a few 
treatment sessions of anxiety management 
training is not a model that is cost-effective 
or that is expected of any clinician. However, 
if behavioral and psychophysiological 
interventions do not provide the expected 
benefits, further evaluation would be 
warranted. 

Breathing Disorders and Anxiety 
DeGuire et al. (1996) have determined that 
any anxiety disorder presentation may 
actually hold a breathing disorder as the 
primary diagnosis and that once the 
breathing disorder is corrected, the 
symptoms of anxiety may be alleviated 
without further intervention28. Thus, it is 
important to determine which is the primary 
diagnosis. 



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Hypoglycemia 
Hypoglycemia can be extenuated by poor 
breathing. A drop in blood sugar causes 
extreme reactions in the nervous system, 
including feelings of anxiety, confusion, and 
even panic attacks29. Thus, people subject to 
hypoglycemia need to be monitored 
carefully. 

Depression 
Nelson and Kriegsfeld (2017) noted that 
depression is often evoked by endocrine 
changes30. The symptoms of depression may 
include reduced mood, low self-esteem, 
general fatigue, feelings of guilt, sleep 
disturbances, anger, irritability, and 
reductions in sexual motivation and food 
consumption. 

Many people are very depressed without 
any obvious reason for such deep 
depression. This endogenous depression 
used to be ascribed to such causes as a 
"wandering uterus." It turns out that the 
uterus doesn't wander much, but there are 
lots of changes in the body's hormonal 
control system that go out of whack and can 
cause depression. Many diseases (such as 
diabetes) seem to cause depression by 
altering hormonal balances—entirely 
separate from people's natural reaction of 
becoming depressed because they are sick. It 
could be that some environmental event 
originally triggered a change in hormones, 
but there isn't evidence supporting this idea. 
Both high and low levels of some 
hormones—such as cortisol—can cause the 
same depressive symptoms. 

According to Nelson and Kriegsfeld (2017): 
1. Thyrotropin-releasing hormone and

thyroid-stimulating hormone 
administration can ameliorate 
depressive symptoms. 

2. Abnormalities in amounts of growth
hormone and prolactin are linked to
depression.

3. About half of depressed patients have
elevated cortisol production.

4. Estrogen deficits are associated with
depression, and estrogen replacement
therapy can elevate mood in depressed
women30.

Nelson and Kriegsfeld (2017) conclude that 
depressed patients may have experienced an 
alteration in the neuroendocrine 
mechanisms underlying the feedback 
control systems of the hypothalamic-
pituitary-adrenal axis30.  

The practical implication for the 
nonphysician provider is to consider referral 
for medical evaluation for depressed 
patients who are in the mild to moderate 
range and who are not responding to 
psychological treatment. Cases in the severe 
range of symptoms should always have a 
medical evaluation with consideration of 
specialty consultation, as medications and 
other medical interventions may be 
necessary. 

Noncardiac Chest Pain 
Using psychophysiologically based 
interventions for anxiety-initiated or -
amplified noncardiac chest pain can be 
problematic even when the patient has been 
cleared by a general practice provider 
because the actual underlying factors are 
difficult to identify by nonspecialists. 
Problems include:  

1. People with noncardiac-related chest
pain can also have or develop cardiac-
related chest pain

2. The noncardiac-related chest pain may
not be due to anxiety but some other
problem that is amplified by stress

3. Patients sometimes leave out important
information when talking with a
healthcare provider, perceived to be
hurried, so what looks like a simple case



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of stress-related noncardiac pain can 
mask a cardiac-related event1.  

The following are some of the symptoms to 
consider and include in your interview. 
If the patient reports a new pain in the chest 
area or chest pain that differs in any way 
(sensation, location, intensity, duration) 
from previous episodes that were evaluated 
and treated appropriately, they should be 
referred to a specialist.  

If the nonphysician provider notes these 
symptoms, they should be included in 
documentation to the primary care 
physician to ensure that the patient consults 
with a qualified medical provider who can 
perform an appropriate evaluation in a 
timely manner. 

If the patient reports burning pain that seems 
to come from the central chest—especially 
near the sternum—that spreads to the upper 
back and both arms (not just the left) and is 
not particularly affected by exercise, there is 
a distinct possibility that the patient has 
gastroesophageal reflux disease (GERD) 
and/or a hiatal hernia. Many people over 
age 50 have asymptomatic hiatal hernias. At 
the same time, nonphysician providers 
should not assume that the known presence 
of a hiatal hernia explains the pain. GERD is 
probably caused by a weakness in or other 
problem with the lower esophageal 
sphincter, which results in stomach acid 
leaking up into the esophagus. The most 
common symptom is heartburn. 

Pulmonary embolisms and pericarditis can 
cause noncardiac chest pain. Chest pain is 
nothing to be complacent about. Any 
rational patient having chest pain will be 
highly anxious. They may need the 
therapist’s help to deal with the anxiety and, 
perhaps, chest pain caused by anxiety, but a 
specialist needs to be sure that the pain is 

only due to anxiety and not a missed 
diagnosis1. 

Irritable Bowel Syndrome (IBS) 
It is important to ensure that the patient has 
IBS before initiating treatment because most 
other abdominal problems with similar 
symptoms do not respond to behavioral 
interventions, and a few can be life-
threatening. It is important to appreciate that 
(1) people with IBS can also have and or
develop a similar symptom set for other
reasons, (2) the obviousness of IBS’s
symptoms can mask a life-threatening
problem, and (3) patients sometimes omit
important information when consulting
with a healthcare provider. Typical
symptoms of irritable bowel syndrome (IBS)
include pain and bloating that usually occur
together but not always. Constipation,
diarrhea, cramps, urgency, mucus in the
bowel movement, and a gassy-bloated
feeling can also occur32. Symptoms are
amplified by stress for at least one-third of
patients. A patient with some or all of these
symptoms may have IBS but could also have
several serious medical conditions with
similar symptoms that may also be
exacerbated by stress. Providers with
expertise in diagnosing organ-related pain
are likely to rule out rectal bleeding as it is
not a symptom associated with IBS. Expert
providers assessing for severe pain in the
abdomen described it as a constant dull pain,
knife-like pain, or cramping pain when
accompanied by tenderness to touch in the
stomach area, bloody diarrhea, vomiting,
black/tarry bowel movements, temperature
above 101 °F, history of previous abdominal
surgery, history of diverticulosis, pregnancy
or likelihood of being pregnant. The
combination of any of the above-presenting
concerns could indicate appendicitis,
infectious diarrhea, bleeding from the
bowels, perforated appendix, bleeding ulcer
or diverticula, miscarriage, ectopic
pregnancy, pancreatitis, or bowel blockage.



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If the patient has cramps and non bloody 
diarrhea (and perhaps even abdominal 
burning) without the problematic 
combinations noted above, IBS may not be of 
concern, even if symptoms are induced or 
worsened by stress. A combination of 
symptoms can indicate chronic 
gastroenteritis, especially if accompanied by 
fever, aches, chills, nausea, or vomiting. If 
burning is present, an ulcer or chronic 
gastritis may be the culprit. If the patient is a 
woman, vaginal discharge accompanied by 
typical symptoms of IBS may indicate a 
chronic infection. The same symptoms as 
above, accompanied by occasional blood or 
mucus in feces, can indicate ulcerative colitis 
and Crohn's disease33. Pancreatitis can also 
mimic these symptoms34.  

Changes in Medications Caused by 
Behavioral Interventions 
Individuals using medications including 
insulin, oral hypoglycemics, thyroid 
replacement, antidepressants, diuretics, 
vasodilators, anticonvulsants, and 
antihypertensive medication may require 
gradual modification in the dosage of these 
medications. The prescribing healthcare 
provider should be informed of the patient's 
participation in behavioral interventions. 

Patients maintained on antihypertensive 
medication, vasodilators, antidepressants, 
diuretics, or any other medication with a 
potential side effect of postural hypotension 
should avoid any sudden changes in 
posture, such as standing abruptly from a 
sitting position. This practice should 
especially be observed while practicing 
biofeedback/relaxation training. 

Warnings Related to Specific Techniques 
This section contains warnings about pitfalls 
likely to be encountered when applying 
psychophysiologically based interventions 
for specific symptoms and individuals. 

Peripheral Biofeedback 
Not all psychophysiological recording and 
biofeedback sensors are safe to use with all 
patients. Galvanic skin response (GSR/SCL) 
systems send a small current across the skin 
to record the amount of sweat (essentially a 
conductive salt solution) on the skin, which 
changes in response to autonomic nervous 
system reactions. As current follows the 
easiest—rather than the shortest—path, GSR 
should never be used with people with 
broken skin as the current may penetrate 
breaks in the skin, across the heart, and then 
out again. Some respiration sensors— such 
as belts for recording changes in chest 
circumference—may contain electronics that 
could interfere with pacemakers. Be sure to 
read the warnings in the equipment’s 
manuals.  

It is strongly recommended that behavioral 
interventions not be used to treat patients 
with cluster headaches, trigeminal 
headaches, hypertension, or TMJ disorder 
(the joint problem as opposed to TMD, the 
jaw area muscle problem). Empirical 
evidence fails to support the utilization of 
behavioral interventions for the 
aforementioned conditions. Note that 
because of a file drawer effect (i.e., negative 
studies are rarely published)35, 36, citations 
supporting this assertion are rare, and the 
implication is based primarily on anecdotal 
experience. Two exceptions to the file 
drawer effect are Sherman's 1985 study 
concluding that SEMG biofeedback does not 
help alleviate TMJ pain and Sherman et al.'s 
1978 study showing that relaxation training 
and biofeedback do not reduce blood 
pressure among pregnant hypertensive 
women37, 38. It is noteworthy that it has taken 
over 45 years since Sherman's initial 
publication in 1978 for sufficient evidence to 
accrue to determine that biofeedback is not 
effective either alone or in conjunction with 
relaxation training or cognitive restructuring 
to reduce stress labile hypertension39. Both 



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cognitive restructuring and relaxation 
training can reduce stress labile 
hypertension, but adding any form of 
biofeedback does not improve outcomes.  

Respiratory Training Paced Breathing 
Methods.  
Although variations of paced breathing 
methods (resonance frequency training, 
heart rate variability (HRV) training, slow-
paced breathing, etc.) have been used as a 
noninvasive strategy in modulating 
autonomic nervous system (ANS) 
functioning, improving overall health, 
reducing stress, and reducing anxiety, 
aberrant reactions have been documented in 
certain populations. Paced breathing 
methods, for instance, may trigger anxious 
arousal and a dynamic of defensive 
responses that result in an increased 
respiratory rate40,41. Therefore, paced 
breathing methods should be employed only 
after a thorough medical history and 
assessment that includes the Suffocation 
Fear Subscale (SFS)42, Anxiety Sensitive 
Index-3 (ASI-3)43, Body Vigilance Scale 
(BVS)44, and the trait portion of the State-
Trait Anxiety Inventory (STAI)45. High 
scores recorded from these questionnaires 
have been correlated with predicted anxiety 
and panic attacks, exaggerated anxious 
response, and increased defensive 
mobilization40. It is advised that individuals 
who score high in one or more of these 
inventories need additional support, such as 
education and the use of a pulse oximeter 
while training41. It is also advised that these 
individuals train under supervision to 
ensure dynamic defensive responses are not 
triggered prior to having them practice at 
home on their own. 

Capnometry 
Sidlecki et al. (2017) found that individuals 
with post-concussion syndrome (weeks to 
years after injury) will have abnormal 
ETCO2 readings due to alterations of 

cerebral physiology and deficits in the 
ANS46. Mild traumatic brain injury (mTBI) 
may alter cardiorespiratory processes, 
resulting in poor prognosis, especially for 
individuals with respiratory disease46. 
Damage to the brain stem or reduced blood 
flow to the thalamus can cause breathing 
issues. A thorough history should include 
screening for concussions due to the varying 
duration of post-concussion syndrome46. 
Capnometry training will need to be 
modified to account for individuals who 
have histories of post-concussive syndrome 
and complicated mTBI. 

Neurofeedback 
Unlike peripheral biofeedback, 
neurofeedback (NFB), or 
electroencephalography (EEG), biofeedback 
trains the central nervous system (the brain). 
While the feedback is usually obvious—a 
sound accompanied by visual feedback such 
as a bar increasing and decreasing based 
upon the strength of the signal, the felt 
experience is not as tangible as with 
peripheral modalities. For example, in the 
case of muscle tension, one can easily 
acknowledge (and appreciate) the reduction 
of tension in a muscle. In the case of 
breathing and HRV training, it is very 
apparent when the patient's breath and heart 
rate have slowed. This is one reason it 
usually takes more sessions with NFB 
training. 

The brain is the most complicated natural 
system known. Chemical and electrical 
phenomena combine to create 
communication and connections between 
brain areas that then realize specific tasks—
and these phenomena are what make us who 
we are. These functions are the target of NFB 
training, and one can see that they are less 
observable when the brain is learning from 
the training than when one is practicing 
biofeedback.  



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Care should be taken when considering 
candidates for NFB training. In addition to 
the many cautions below, articulating what 
one should feel or experience while training 
and, ultimately, from the NFB training 
program itself can be challenging. For those 
who might become frustrated or confused, 
another modality, such as stimulation 
technology (audiovisual entrainment, 
transcranial direct current stimulation, etc.), 
may be indicated. 

Patterns in the EEG vs. Behavior.  
Often, the EEG does not contain patterns that 
are considered specific to a behavioral 
presentation. Clinicians may record an EEG 
for evaluation and discover biomarkers that 
do not match the behavioral symptoms. As 
well, the EEG assessment may show one 
finding, and different NFB software will 
show something else47. Therefore, 
neurofeedback should include an 
assessment—ideally a 19-channel EEG 
recording, but minimally a 2- or 4-channel 
sequential recording—and the healthcare 
provider should not rely on a decision tree 
based on presentation alone or assume EEG 
patterns will be present based solely upon 
behavior.  

Another important concern with NFB, with 
any client, is that the changes in the EEG do 
not always reflect behavioral patterns. It is 
not uncommon for the EEG to make 
remarkable advances from the protocols and 
modalities used without any noticeable 
behavioral change. There may even be an 
increase in symptom intensity. Conversely, 
the EEG may be stubborn, with no real 
sustained response to the training, and yet 
the client reports an alleviation or reduction 
of symptoms. 

Many clients of neurofeedback take 
medications. Depending on what 
medications they are taking, which can be an 
extremely complicated cocktail, the 

medications' effects can override any 
advances due to the neurofeedback training. 
For example, Adderall will increase beta and 
decrease lower frequencies, which may be 
great if it is needed. Generally, anxiolytics 
will reduce faster frequencies (if taking the 
appropriate dose). However, if the anxiolytic 
is a benzodiazepine, widespread increased 
amplitudes in beta frequencies are common 
and thought to reflect the activation of 
neuroinhibitory processes that are GABA-
mediated. In fact, too high a dose of this class 
of medications can result in extremely 
elevated beta and possibly beta spindling. 
So, here you have two medications that have 
contradictory mechanisms, and now you 
want to add some operant conditioning to 
influence beta. While you may have a 
temporary shift in the EEG in response to the 
NFB, as soon as either of these medications 
is consumed, all positive gains will be 
overshadowed.  

It is also important to frequently query 
clients, preferably at every session, about 
changes in their medications and/or 
dosages. While neurofeedback generates 
some positive changes in the EEG, the effects 
of medication dosage may become 
amplified, which can lead to unpleasant side 
effects. When this happens, faith in 
medications can overrule confidence in the 
neurofeedback training, and the client—and 
perhaps even their prescribing clinician—
may blame the neurofeedback for 
unpleasant experiences. Watch the client 
carefully when on medications and, if 
possible, communicate with the prescriber 
so that any ill effects due to the effectiveness 
of the NFB can be considered as just that, and 
a reduction in dosage can be contemplated. 
Depending on the medication and the 
interest the prescriber has in 
neurofeedback's success, this can be 
challenging. 



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While not necessarily a red flag (meaning 
that you can still work with patients on 
medications), understanding the effects of 
certain medications on EEG recordings is 
essential. The clinician should refer to Drug 
Effects on the EEG: A Reference Guide47 or 
other references to enhance confidence 
concerning where and how EEG patterns 
originate. 

Neurofeedback for Anxiety.  
One of the main concerns when using 
neurofeedback with people who present 
with anxiety is, well, their anxiety—notably 
anxiety about whether the neurofeedback is 
working. You might see clinical changes in 
the EEG, meaning that the operant 
conditioning is working and the brain is 
responding well. However, as discussed 
above, this may not translate to the efficacy 
of treating the behavioral presentation. 
People with anxiety syndromes, including 
PTSD and phobias, have little patience and 
fear the continuation of their anxious 
symptoms, which often spiral into more 
intense symptomology. Positive 
reinforcement of their successes in their EEG, 
no matter how small, can be reassuring if 
presented often and consistently, and this 
may be what the client needs to start 
experiencing lower levels of anxiety. It may 
be a slow process and could be 
contraindicated if anxiety levels are severe.  
It is common knowledge that alpha-theta 
training can result in abreaction or 
unexpected negative emotional response48. 
This is especially true if this protocol is 
administered too soon in the healing process. 
As with any therapy, slow and steady 
provocation of underlying fears and 
memories is required. The client's emotional 
state is very important for influencing how 
they may respond to the uprising feelings 
and memories. If they are very anxious, they 
may lack the capacity to deal with the 
feelings and abreact (form a negative 
reaction). Conversely, if the patient is in a 

state of lowered vigilance and arousal, the 
coupling of the more relaxed state and 
emotional experience will become a more 
fitting association, leading the client to be 
able to manage these resurfaced feelings and 
memories. 

Neurofeedback for Schizophrenia. 
Schizophrenics are poor candidates for 
neurofeedback. They generally have 
extremely high levels of paranoia and are 
unlikely to trust the efforts of the clinician or 
what is happening in their brain during 
neurofeedback. I (Cynthia Kerson) once 
worked with a client who reported anxiety, 
but after eight sessions, I questioned the 
authenticity of his report. He came to the 
practice complaining that the protocol I had 
chosen was destroying his brain and 
demanded I do neurofeedback to reverse the 
effects. He admitted to having been 
diagnosed with schizophrenia, and we 
ceased the neurofeedback training. 
Unfortunately, for this client, the emotional 
and perceptual implications of the disorder 
challenged his ability to trust the process and 
ultimately sabotaged any gains. This client 
might fear any change that may be taking 
effect, especially without their conscious 
knowledge, and the changes that occur with 
NFB are generally unconscious until the 
behavioral presentation is changed and 
observed. 

Neurofeedback for ADHD. 
Often, parents seek NFB for their children 
once they are diagnosed with ADHD, 
primarily in an effort to avoid the use of 
stimulant medications. In the interview 
phase, be sure to observe the child carefully. 
There are times when their motives don’t 
seem aligned with their parent/caregiver—
or they may not fully understand that their 
behavior is undesirable. Giving them an 
opportunity to articulate their perceptions 
can help them understand what they 
understand about their behavior. As well, 



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there are times when medication is indicated 
to make initial progress with NFB. If the 
child is severely hyperactive, suggesting 
sitting and attending for even 20 minutes is 
challenging. There are times when a low 
dose of a stimulant will help the child settle 
enough for neurofeedback to start working 
with the intention of titrating and ultimately 
eliminating medication as neurofeedback 
takes effect. Collaboration with prescribing 
providers is therefore essential for the 
coordination of care and enhancing the 
likelihood that stimulant medication is 
discontinued if NFB is effective. In this case, 
try to work with the prescriber. Be sure they 
know that the patient plans a short trial and 
that reducing the dose over a few months is 
the plan.  

Children with ADHD are also less frustrated 
with their symptoms than the people around 
them. This generates a challenge for using 
NFB as it may be a chore they are not 
interested in. Secondary rewards may 
provide the essential incentive and 
motivation needed for children with ADHD 
to participate in NFB. In practice, I (CK) 
provided coupons that tallied the session's 
points (which can be made up in any 
formula necessary to have success each 
time). Essentially, the children are deceived 
into being successful in NFB. The family 
maintains the coupons and creates a 
program for the transfer of the points to a 
reward. Some give the child some desired 
item at 1,000 points. Or a penny a point. Or 
maybe a sleepover. This is more effective 
and less wasteful than having inexpensive 
prizes in a basket for them to choose from. 
They're usually cheap plastic (bad for the 
environment), and the kids generally don't 
care much about them. Using the coupon 
system raises the bar, and kids really want to 
get the reward that they chose. They don't 
realize or, sometimes, don't even care that 
their ADHD symptoms are improving, but 
with that much effort towards getting points 

(rewards when the brain is being trained), 
they do care, and your NFB will be a success. 

Neurofeedback for Oppositional Defiant 
Disorder (ODD).  

ODD children will likely not tolerate NFB. It 
will likely be too boring, and children 
diagnosed with ODD often engage in defiant 
behaviors to get what they want. Parents of 
ODD children may enable, be in denial 
and/or be inappropriately strict. When these 
children are introduced to NFB, they can be 
quite stubborn and—predictably—
oppositional. It is not uncommon for parents 
to assign too much authoritative 
responsibility to the practitioner, requiring 
the practitioner to maintain a professional 
role with appropriate boundaries. Parents 
may assume that you, as a professional, are 
skilled in managing the child's behavior. 
And you may well be, but not in the context 
of NFB training. If the child doesn't engage 
in secondary reward systems, such as the 
coupon system mentioned above, there is 
little hope for the ODD behavior to dissipate 
enough to make meaningful brain shifts. An 
alternative strategy could be to refer or 
engage the parents in coaching or other 
therapeutic alternatives. 

Neurofeedback for Neurodegenerative 
Diseases.  
Parkinson’s, multiple sclerosis (MS), 
Alzheimer’s, progressive neuropathies, and 
other neurodegenerative diseases are not 
indicated for NFB as a resolution. NFB can 
help lessen, though not alleviate, the 
symptoms of this class of diseases. Some 
anecdotal evidence demonstrates temporary 
symptom relief, such as with pulsed 
electromagnetic field therapy, but there is no 
evidence that neurofeedback has completely 
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Neurofeedback When There are Structural 
Issues.  
Shunts, plates, scar tissue, skull damage, and 
other head or brain assaults can cause 
complications in reading the EEG. 
Consequently, location and functional 
implications need to be carefully 
understood. The scalp at the site of injury 
may be thicker, which will attenuate any 
signal from below. This can be incorrectly 
read as a deficit in power, and the clinician 
may attempt to train at that site. In fact, there 
isn't an attenuation of power; there is only an 
attenuation of the signal. As well, the plastic 
brain may redirect and arborize neurons to 
skirt a structural issue. These are functional 
pathways, but they are not normal. If 
compared to a normative database, they will 
appear to be disregulated. However, they 
provide an alternate functional route and 
need to be valued as such. These cases 
should only monitored with the consent of 
an overseeing practitioner who is aware of 
the structural implications.  

Neurofeedback and Epilepsy. 
It is normal for brain function to occasionally 
go offline. These offline moments may be 
represented in the EEG as subtle 
epileptiform transients that do not constitute 
a diagnosis of epilepsy. However, a patient 
seeking NFB for seizure reduction or 
cessation must be carefully studied. First and 
foremost, only those who are licensed to 
treat this medical disorder can treat it using 
NFB. Secondly, the clinician can misinterpret 
and even overlook an epileptic transient, 
failing to properly diagnose epilepsy. When 
unsure, proceed with caution and consult 
with an epileptologist. 

Herein lies one of the main issues with brain 
mapping services that use artificial 
intelligence (AI) to complete the artifacting 
process. If a client seizures only periodically 
and there is only one small epileptic 
transient present, the AI system will 

eliminate it or average it into the parts of the 
EEG that are used for evaluation. Needless 
to say, not recognizing an epileptic transient 
can be detrimental to the well-being of the 
client. Additionally, more of these 
undetected EEG behaviors may occur during 
the NFB sessions if the practitioner is 
unaware of their morphology or simply not 
paying attention.  

Neurofeedback and Headaches. 
There are three types of headaches: tension, 
migraine, and cluster. The intensity, 
duration, and frequency of headaches are 
important measurements when considering 
treatment options. Tension headaches are 
the most common type and are better 
controlled with electromyographic (EMG) 
biofeedback since they are the result of tense 
shoulder, neck, scalp, and/or facial muscles. 
About 10–15% of headache patients have the 
more debilitating migraine type. These may 
be categorized as primary or secondary 
when they are triggered by neurologic 
disorders, infections, hormonal shifts, 
allergies, stress, and/or medications. Thus, it 
is better to treat the etiology rather than the 
symptom (which is the headache).  

As is well documented49,50, migraine 
headaches are better treated with distal 
temperature training. Combined-type 
headaches need attention to both the 
migraine and the tension aspects. Cluster 
headaches should not be treated with 
neurofeedback. These cause severe pain to 
one side of the head; their etiology is not 
understood, and there is no evidence that 
neurofeedback can work to resolve these 
symptoms. While there are some studies that 
report success with neurofeedback for 
headaches in general51, it is best to consider 
the above and refer to or complement other 
modalities.  

This population may regularly cancel 
appointments or keep appointments in 



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hopes of remediation during a headache 
event. Doing neurofeedback when a 
headache is present is not advised. It is 
compelling to think the training will 
alleviate the headache, but this is not 
substantiated and should be avoided. In 
addition to the many possible EEG profiles 
that could emerge during their headache, 
they could also be exhausted from a bout of 
headaches and the accompanying loss of 
sleep, so doing neurofeedback at this time 
may result in an exacerbation of the pain and 
frustration.  

Headache medications (triptans) tend to 
disrupt alpha power and reduce task 
response efficiency, which cannot be 
rectified by the training, causing a cycle of 
shifts in the EEG that cannot be sustained. 
(As noted above, this is true for all 
medications that have lasting effects on the 
EEG.)  

Mild Traumatic Brain Injury (mTBI).  
Mild traumatic brain injuries occur from a 
multitude of causes, including direct head 
impact from falls, having objects dropped on 
the head, or accidents that insult the brain 
from the side or neck. Additionally, blast 
injuries—those caused by a nearby 
explosion—result in back-and-forth 
acceleration of the brain without blunt, local 
impact and cause diffuse global damage. 
Thus, they result in subtle global effects on 
the EEG, making it difficult to target the 
damage. The behavioral changes—such as 
anxiety, anger issues, headaches, and 
others—may guide the training and 
assessment, but this is not always an 
accurate picture of what needs to be resolved 
physiologically. Commonly, mTBI patients 
experience connectivity issues in the EEG, 
which can be trained, however, some 
disregulations may be compensatory and 
training can cause reversal of progress 
and/or more intense symptoms.  

A full history of the injury is very important 
and should include the length of time since 
impact and whether (and how long) the 
client was concussed and/or unconscious. 
The brain naturally heals during the first few 
months of recovery with slower and 
prolonged improvement thereafter. 
Assessment revealing excess slow wave 
power should not be considered 
pathological. Removing the power 
shutdown forces the brain to work rather 
than heal. Waiting until the EEG assessment 
reveals a return to somewhat normal 
patterns—likely about 4–6 months, 
depending on the extent of the damage—is 
highly suggested. 

Clinical Hypnosis 
Patients have been benefiting from the 
therapeutic use of hypnosis for hundreds of 
years, and yet there remains a good deal of 
misinformation and mistrust related to this 
adjunctive technique. While there are 
thousands of books on the topic of hypnosis, 
this section will review a few of the most 
important red flag considerations here.  

First, unlike the popular presentation in 
movies, cartoons, and television shows, 
hypnotic ability resides within the patient, 
not the clinician (i.e., hypnotist). Just as a 
music teacher does not "do" music to a 
student, a practitioner using hypnotic 
techniques does not "do" hypnosis to 
anyone. Rather, a skilled practitioner 
educates and creates a positive context to 
maximize an individual's skill in accessing 
their own hypnotic ability.  

Secondly, learning hypnosis does not 
typically qualify anyone to treat a patient 
they were not qualified to treat before 
learning hypnosis, though there are some 
exceptions to this rule. Many clinicians may 
not have treated individuals with chronic, 
acute, or procedural pain prior to learning 
hypnosis, though they are quite qualified 



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and competent to do so upon the completion 
of appropriate clinical hypnosis workshops 
and hours of individual and/or group 
consultation with a more experienced 
clinician. Hypnotic techniques should 
increase one's effectiveness in many 
situations, but learning to teach the ability to 
alter the perception of pain, for instance, 
does not remove any of the considerations 
related to pain listed above. In fact, covering 
the perception of pain without prior medical 
evaluation can result in major problems.  

Also, individuals vary in their level of 
hypnotic ability, and the success of a 
hypnotic intervention can vary due to 
multiple factors, including the context of the 
intervention, the skill of the practitioner, the 
relationship and trust level between 
practitioner and patient, environmental 
factors, patient attitudes, and prior 
experience with hypnosis, just to name a 
few. In most settings, hypnosis can be best 
characterized as a collaborative relationship. 
In the emergency room, however, the 
approach might be more effective when it is 
very directive or even authoritarian if that is 
what best serves the patient and their 
situation. 

There are few absolute red flags related to 
the use of hypnosis by a trained professional. 
The following, in particular, deserve special 
consideration.  

Psychosis, Schizophrenia, or Other 
Disorders of Consciousness. Hypnosis is 
often described as a set of skills and 
interventions used for effecting an altered 
state of consciousness. This definition, of 
course, assumes that there is something akin 
to a normal state of consciousness. Still, if a 
patient struggles already in their efforts to 
hold a common reality with others, 
intentionally altering this reality should only 
be attempted by those highly experienced 

with this population and only then if there is 
clear potential for benefit to the patient.  

Legal Issues. 
Hypnosis is often used to help trauma 
patients safely review past events through 
techniques such as age regression. However, 
most states within the United States do not 
allow testimony related to the use of 
hypnotically enhanced memory in court. By 
using this technique, you may be eliminating 
a client’s ability to testify on their own 
behalf. In contrast, federal courts often 
permit hypnotic testimony but only if very 
specific procedures are followed. As a 
practitioner, you are not likely to know what 
might come to light in a hypnotic session, so 
a discussion of the potential legal 
complications is highly encouraged as an 
element of informed consent.  

Symptom Removal Without Prior Medical 
Evaluation. As already discussed, behavioral 
interventions for the treatment of medical 
symptoms should always be preceded by 
medical evaluation. While even a 
comprehensive medical evaluation cannot 
guarantee anything, all reasonable steps 
should be taken to rule out dangerous 
etiologies. For example, sudden adult onset 
of severe headaches should never be treated 
with hypnosis and/or biofeedback before 
tumors or other neurological conditions 
have been ruled out. 

Religion. 
Unfortunately, the 300+ year history of 
therapeutic hypnosis comes with a good deal 
of baggage related to religious objections 
and the inaccurate portrayals of hypnosis by 
stage hypnosis, popular books, TV, and 
movies. Religious objections can be 
particularly delicate since some patients will 
belong to churches or denominations with a 
long history of admonitions to avoid 
hypnosis. A popular Baptist minister 
published a book and video referring to 



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hypnosis as "a portal to lucifer." In general, if 
a patient has a strong belief that hypnosis is 
wrong, bad, or evil, it is best to avoid this 
intervention and find an alternative 
treatment option that is more acceptable to 
the patient. For those who are on the fence 
about this topic, the book Hypnosis, Healing, 
and the Christian by John Court (1997) can 
be very useful52. 

Conclusion 
While this is an overview of 
contraindications to biofeedback, hypnosis, 
and neurofeedback training, there are others 
that may exist due to individual patterns and 
experiences. Each and every case should be 
considered from a personal medicine 
approach and assessed with multiple 
instruments. 

Acknowledgment 
This review is dedicated to all the mental 
health survivors.  

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