Neurofeedback for Anxiety: Traditional and Direct

• What is neurofeedback, and how is it different from therapy?
• Which kind might fit?

By Dr. Douglas Cowan, Psy.D., MFT

I have used neurofeedback in my practice for over thirty-five years. I started with traditional EEG neurofeedback in the late 1980s, and I have watched the field grow into several different technologies, including direct neurofeedback.

Neurofeedback is described in many different ways, and the claims vary widely. In this article I want to give you a clear picture: how it works, how the two main types differ, what the research shows so far, and what I have seen in my own office.

What is happening in the brain

The brain runs on electrical activity. The patterns of that activity, often called brainwaves, are linked to how revved up or how settled you feel. In anxiety, the alarm system in the brain is overactive and the calming systems do not balance it well. The brain has trouble shifting down.

Neurofeedback works with those electrical patterns directly. It does not go through chemistry, and it does not go through thinking. It gives the brain information about itself, and the brain, which is built to adapt, responds.

Two ways to do it

Traditional neurofeedback is learning. Sensors on the scalp pick up your brainwaves. You watch a video or a game that plays smoothly when your brain produces the target pattern and dims when it drifts. Over repeated sessions, often twenty to forty, the brain gets better at finding that pattern. It is like practicing scales on an instrument. The strength is that you build a skill. The cost is time and attention. It can be harder for young children or for people in acute distress.

Direct neurofeedback works differently. It includes infra-low frequency (ILF) training and low energy neurofeedback (LENS). Instead of asking the brain to learn a target, the provider delivers a very small signal, well below anything you can feel. You sit quietly and do nothing. The idea is that the signal helps the brain shake loose from stuck, overactive patterns and reorganize itself (1). Sessions are often short. This approach can be a better fit for children, for trauma survivors, and for people who cannot sustain a long active training.

What the research shows

I want to be straightforward with you here, because honesty is part of caring for you.

For traditional neurofeedback, the picture for anxiety is promising but still developing. One review of the field concluded that neurofeedback was a reasonable option for anxiety and depression, with most of the evidence coming from smaller studies (2, 3). In a controlled trial with a sham comparison, people trained to shift brain activity in the front of the brain reported less negative feeling and lower anxiety afterward (4). In a trial of adults with generalized anxiety disorder, people who completed neurofeedback training had lower anxiety traits and depressive symptoms than before training (5).

For direct approaches, the research base is smaller. The clinical literature, including the work of the Othmer group on infra-low frequency training, describes a consistent method and consistent clinical reports (1). Independent, large, sham-controlled trials are still needed.

What I can say from three and a half decades of work is that many of my clients have felt calmer and slept better. I can also say that neurofeedback does not replace the basics. It works best on top of them.

Who might benefit

• People whose anxiety has not eased with therapy and lifestyle changes alone
• People who want a non-drug approach, or want to add to one
• Children, teens, and trauma survivors who find talk-based work hard (direct approaches especially)
• People who sleep badly, feel keyed up, or cannot shift out of “on” mode

How to choose a provider

• Look for a licensed clinician with specific neurofeedback training, such as BCIA certification.
• Ask what assessment they do first, and what protocol they plan to use.
• Ask how they will measure progress, and when you will decide whether it is working.
• Be careful about big promises. A good provider tells you what is known and what is not.

What helps alongside it

Neurofeedback works best inside a full plan: counseling, sleep, movement, slow breathing, and a steady daily rhythm. Cognitive behavioral therapy remains the best-studied treatment for anxiety (6). Some people also use CES. A 2018 review found some signs of benefit for anxiety, but rated the evidence low in strength and called for better trials (7).

Start today

• Take our GAD-7 check-in so you know where you are starting.
• Talk with your doctor or therapist about whether neurofeedback fits your situation.
• Interview two providers before you choose.
• Start the basics now: a steady sleep schedule, daily movement, five minutes of slow breathing. See our breathing guide.

The brain is built to adapt, and the alarm system can learn a lower threshold. I have watched it happen in many people, and I believe it can happen for you.

There is a path forward, and you do not have to walk it alone.

This article is for education and is not a substitute for professional diagnosis or treatment. If you are in crisis, call or text 988 in the United States.

References

1. Othmer, S., Othmer, S. F., Kaiser, D. A., & Putman, J. (2013). Endogenous neuromodulation at infralow frequencies. Seminars in Pediatric Neurology, 20(4), 246-257. https://doi.org/10.1016/j.spen.2013.10.006
2. Hammond, D. C. (2005). Neurofeedback treatment of depression and anxiety. Journal of Adult Development, 12(2-3), 131-137. https://doi.org/10.1007/s10804-005-7029-5
3. Larsen, S., & Sherlin, L. (2013). Neurofeedback: An emerging technology for treating central nervous system dysregulation. Psychiatric Clinics of North America, 36(1), 163-168. https://doi.org/10.1016/j.psc.2013.01.005
4. Mennella, R., Patron, E., & Palomba, D. (2017). Frontal alpha asymmetry neurofeedback for the reduction of negative affect and anxiety. Behaviour Research and Therapy, 92, 32-40. https://doi.org/10.1016/j.brat.2017.02.002
5. Hou, Y., Zhang, S., Li, N., Huang, Z., Wang, L., & Wang, Y. (2021). Neurofeedback training improves anxiety trait and depressive symptom in GAD. Brain and Behavior, 11(3). https://doi.org/10.1002/brb3.2024
6. Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427-440. https://doi.org/10.1007/s10608-012-9476-1
7. Shekelle, P. G., Cook, I. A., Miake-Lye, I. M., Booth, M. S., Beroes, J. M., & Mak, S. (2018). Benefits and harms of cranial electrical stimulation for chronic painful conditions, depression, anxiety, and insomnia. Annals of Internal Medicine, 168(6), 414-421. https://doi.org/10.7326/M17-1970