Neurofeedback: Unlocking New Pathways to PTSD management
By Goretti Hurtado Barbeito
Post-Traumatic Stress Disorder (PTSD) is a severe mental health condition that arises after experiencing or witnessing a traumatic event. Characterised by symptoms such as intrusive thoughts, flashbacks, emotional numbness, hyperarousal, and avoidance, PTSD can profoundly disrupt daily life, relationships, and overall well-being (Bremner, 2006). Traditional treatments for PTSD, such as cognitive-behavioural therapy, exposure therapy, and medication, have shown efficacy for many but not all sufferers (Watkins et al., 2018). In recent years, neurofeedback has emerged as a promising alternative or complementary approach to treating PTSD, offering a non-invasive way to help patients regulate brain activity and improve emotional and cognitive functioning.
Benefits of Neurofeedback for PTSD
One of the key advantages of neurofeedback is that it directly targets the brain, the organ at the heart of PTSD. Many PTSD treatments rely on talk therapy, which can be emotionally taxing and may not reach the root neurological causes of the disorder. Medications like antidepressants and anti-anxiety drugs may reduce symptoms but often come with side effects and do not necessarily address underlying brainwave dysregulation (Davis et al., 2016). Neurofeedback offers a non-invasive, drug-free alternative that works with the brain’s natural capacity for self-regulation and healing.
A growing body of research supports the efficacy of neurofeedback for PTSD. Several studies have shown significant reductions in PTSD symptoms following neurofeedback treatment, including improvements in mood regulation, sleep quality, anxiety, and hyperarousal.
In one 2016 study, veterans with PTSD underwent 24 sessions of neurofeedback training, leading to substantial reductions in both PTSD and depressive symptoms (van der Kolk et al., 2016). Another study reported similar findings, noting that neurofeedback was associated with decreased trauma-related anxiety and improved emotional regulation in PTSD sufferers (Nicholson et al., 2020). A summary of the most recent body of research in support of the use of NF in PTSD is presented in Table 2.
Brainwave Patterns May Become Dysregulated In PTSD
Neurofeedback (NF), also known as electroencephalographic (EEG) biofeedback, is a form of brain training that aims to retrain abnormal brainwave patterns associated with various conditions, including PTSD. By providing real-time feedback about brainwave activity, neurofeedback allows individuals to gain control over their own neurological processes (Hammond, 2007). NF operates on the principle of neuroplasticity, the brain’s ability to adapt and reorganise itself in response to new experiences or learning. The technique uses EEG to measure brainwave activity, capturing real-time data about electrical patterns in the brain. Brainwaves fall into different frequency bands—delta, theta, alpha, beta, and gamma—each associated with specific cognitive and emotional states. Delta waves (0.5-4 Hz) are linked to deep sleep, theta waves (4-8 Hz) to relaxation and creativity, alpha waves (8-13 Hz) to calm focus, beta waves (13-35 Hz) to problem-solving alertness, and gamma waves (35+ Hz) to heightened awareness (Abhang et al., 2016).
In individuals with PTSD, certain brainwave patterns may become dysregulated. For example, hyperarousal, a common symptom of PTSD, is often associated with elevated beta activity, which reflects heightened alertness (Butt et al., 2019). Meanwhile, alpha waves, which are associated with calm and relaxation, may be underactive (Sherin & Nemeroff, 2011).
Neurofeedback aims to correct these imbalances by helping the brain "retrain" itself to adopt healthier patterns. The process is simple: individuals receive real-time feedback—often in the form of audio-visual stimuli like a moving image or sound—that reflects their brainwave activity. When their brainwave activity moves toward a desired state, they are rewarded with positive feedback, encouraging the brain to self-regulate.
Neurofeedback for PTSD: How It Works
The application of neurofeedback in PTSD treatment focuses on correcting the brainwave imbalances caused by trauma.
PTSD often leads to both overactivity in certain regions of the brain, particularly the amygdala (which is responsible for fear processing) (Badura-Brack et al., 2018), and under-activity in others, such as the prefrontal cortex (which governs executive functions and emotional regulation) (Selemon et al., 2019). Neurofeedback works by targeting these regions and fostering a healthier balance between them.
A typical neurofeedback session involves the person sitting in front of a computer screen with EEG sensors attached to their scalp to monitor brain activity. The person is shown a video game or animation that changes based on their brainwave patterns. For example, if the person’s brain is producing too many high-frequency beta waves associated with hypervigilance and anxiety, the feedback system might reduce the brightness of the screen. When brain activity shifts toward a calmer, more regulated state, the screen brightens, signalling to the brain that it is moving in the right direction. Over time, this process encourages the brain to adopt more normalised patterns of activity, reducing PTSD symptoms.
Research in support of the use of NF in PTSD
Table 2. Body Of Research in Support of The Efficacy of Neurofeedback Training in PTSD.
Key: CAPS = Clinician Administered PTSD Scale; PCL-5- = PTSD Checklist for DSM-5; MMPI = Minnesota Multiphasic Personality Inventory; IASC = The Inventory of Altered Self-Capacities; DTS =Davidson Trauma Scale; IES = Impact of Event Scale; HTQ = Harvard Trauma Questionnaire.
In studies examining the efficacy of NF training for PTSD, different measures are used to evaluate the frequency and severity of PTSD symptoms. The main ones are summarised below (Table 1):
Table 1. Common Instruments Used to Measure Symptoms of PTSD
The studies reviewed indicate that various neurofeedback protocols, including Alpha-Theta training and infra-low (ILF)-neurofeedback protocols are associated with significant reductions in PTSD symptoms, anxiety, and depression across diverse populations. In some studies, improvements were maintained over time, as indicated in the Follow-up column of Table 2. The effectiveness varied, depending on the specific neurofeedback approach used.
In this sense, it is important to differentiate between traditional dynamic neurofeedback (e.g., Alpha-theta training), and infra-low frequency neurofeedback, as used in Kelson (2013), as they differ in both methodology and approach.
Traditional Dynamic Neurofeedback (Alpha-Theta Training) in PTSD: The Role of the Amygdala
Peniston's work with Alpha-Theta (A-T) training has been a significant contribution to the use of neurofeedback for treating PTSD, particularly among veterans with combat-related PTSD syndrome.
A-T training is a form of dynamic neurofeedback that targets the alpha and theta brainwave frequencies, promoting a relaxed state while accessing deeper unconscious processing (Egner et al., 2002). Peniston's research demonstrated that this technique could be particularly effective in alleviating symptoms of PTSD by facilitating emotional processing and reducing traumatic memories' intensity. This effect seems to be associated with increased brainwave synchrony (Peniston & Kulkosky, 1991).
In his studies, Peniston found that A-T training helped veterans reprocess traumatic memories by inducing a deep relaxation state, where the brain could access theta waves, often linked to the unconscious and emotional processing. This training was shown to reduce symptoms like hyperarousal, intrusive thoughts, and emotional numbing, which are common in PTSD. Peniston’s protocol involved multiple sessions that gradually trained veterans to enter these brainwave states, helping them process past trauma in a safe and controlled environment.
Neuroimaging studies in PTSD have revealed neuroplastic changes in several brain structures, including the prefrontal cortex (PFC), hippocampus, thalamus, and amygdala (Alexandra Kredlow et al., 2022; Olff et al., 2007). The amygdala, specifically, plays a key role in fear conditioning and the processing of negative emotions, making it especially relevant to PTSD research. In fact, heightened activity within the amygdala complex is a notable neural marker of the disorder (Diamond & Zoladz, 2016).
A key reason A-T training was found to be effective in treating PTSD lies in the way it influences brain structures, particularly the amygdala, which is central to emotional regulation and the processing of fear (Nicholson et al., 2016). Studies suggest that A-T downregulation training can help improve control over amygdala activity, reducing hyperactive responses to trauma-related stimuli (Zhao et al., 2023).
Additionally, by strengthening the connectivity between the amygdala and prefrontal cortex, A-T may help improve emotional regulation and reduce anxiety responses (Berboth & Morawetz, 2021).
Overall, A-T neurofeedback has proven particularly effective for veterans suffering from PTSD because it addresses both the emotional and physiological responses tied to trauma. By helping veterans reprocess traumatic memories and regulate brain activity in areas such as the amygdala, this technique provides a comprehensive treatment approach that combines emotional healing with cognitive restoration. The positive outcomes observed in Peniston's studies underscore the potential of A-T training as a therapeutic tool for those struggling with PTSD.
Effectiveness of Infra-Low Frequency (ILF)-Neurofeedback Training in PTSD
While traditional dynamic NF, such as A-T training, primarily focuses on brainwaves in the 8-25 Hz range (Alpha and Beta-band activity), promoting cognitive flexibility and emotional regulation (Hammond, 2007), ILF-neurofeedback emphasises altering slower brainwave patterns (i.e., below 0.1 Hz). Importantly, clinical findings from ILF-Neurofeedback are increasingly aligning with neurological research showing that fluctuations in brain activity are linked to various neurophysiological processes, including heart rate variability, blood pressure, oxygenation, and cortical excitability (Bazzana et al., 2022). This body of research indicates that ILF rhythms may play a significant role in the self-organisation and regulation of the central nervous system (Grin-Yatsenko et al., 2020).
In the context of PTSD, IFL-Neurofeedback has shown effectiveness in reducing PTSD symptoms. For example, Nilsson & Nilsson (2014) carried out a pilot study involving refugees who had experiences trauma due to war and/or torture. The treatment involved 8-10 ILF-Neurofeedback sessions over a period of 10-15 weeks, starting with electrode placements ate T3-T4 or T4-P4 (i.e., temporal/parietal lobes). Five different instruments, including the PCL, were used to measure differences in PTSD symptom severity. The results showed a significant improvement on 4 out of the 5 scales over time in the treatment group, compared to the control group. Furthermore, Gerge (2020a) outlines the positive effects of 10 sessions of ILF-Neurofeedback training for a patient with complex PTSD and significant distress. Along with patient’s self-reported subjective improvements, enhancements were also observed on several standardised scales, including the PCL-5.
Interestingly, Spreyermann (2022) concluded that over a 7-year period, the combination of trauma-focused psychotherapy and ILF-Neurofeedback yielded unexpected and encouraging results. For about 25% of patients examined, there was initial symptom improvement, but progress plateaued during the course of therapy. In these cases, the authors suggest that incorporating additional methods such as mindfulness training, heart-rate variability (HRV) training, exercise, or respiratory therapy may be beneficial.
In short, infra-low-frequency neurofeedback is becoming a promising approach for assisting patients with PTSD. Note, however, that while results are promising, these are case studies, and further longitudinal trials are needed to corroborate the effectiveness of IFL-Neurofeedback for symptom reduction in PTSD.
Challenges and Considerations
Despite its potential, neurofeedback is not without its challenges. One of the most prominent issues is the variability in results across different individuals, with some people experiencing significant symptom reduction, while others see only modest improvements. This variability can stem from several factors. Differences in individual brain structures may play a significant role, as neurofeedback outcomes can depend on how flexible or "trainable" a person’s neural circuitry is (Linden, 2014). Additionally, the severity and chronicity of PTSD can impact effectiveness, as individuals with more longstanding or complex trauma histories might need more intensive intervention to see meaningful changes (Askovic et al., 2017). Furthermore, the number of neurofeedback sessions completed is also crucial: most research suggests that 20 to 40 sessions are typically necessary to achieve sustained results, with improvements often accruing gradually over time (Peniston & Kulkosky, 1991; Gerge, 2020).
It is important to note that neurofeedback is generally not a standalone treatment for PTSD. While it can significantly reduce symptoms, such as hyper-arousal and emotional dysregulation, it is often most effective when combined with other therapeutic modalities. Cognitive-behavioral therapy (CBT), for example, helps individuals process trauma-related thoughts and beliefs, which may enhance the self-regulatory effects of neurofeedback (Askovic et al., 2017). Eye Movement Desensitisation and Reprocessing (EMDR) is another therapy frequently used in conjunction with neurofeedback, as it helps process trauma memories and can facilitate the neurological benefits of brain training (Gerge, 2020b). Studies suggest that integrating neurofeedback with these evidence-based therapies results in more holistic and enduring outcomes (Orndorff-Plunkett et al., 2017).
Neurofeedback: A New Hope for PTSD Recovery
Neurofeedback represents a promising frontier in the treatment of PTSD, offering a novel, brain-centered approach to addressing trauma-related symptoms. Current research indicates that Alpha-Theta down-regulation protocols targeting the amygdala are effective in treating PTSD symptoms, with additional evidence highlighting infralow frequency (ILF) neurofeedback as a promising approach. By leveraging the brain's natural plasticity, neurofeedback helps retrain abnormal brainwave patterns, leading to improved emotional regulation, reduced anxiety, and overall symptom relief. While it may not work for everyone and requires ongoing research to refine its application, neurofeedback has the potential to transform the landscape of PTSD treatment. Moreover, when used in conjunction with other therapeutic modalities, neurofeedback may enhance overall treatment effectiveness, providing a more comprehensive approach to recovery.
As more research emerges, neurofeedback could become a cornerstone of integrated, personalised treatment plans for PTSD. Its non-invasive, drug-free nature makes it an attractive option for patients seeking alternative solutions to trauma recovery. By healing the brain, neurofeedback holds the promise of healing the mind and restoring hope to those affected by PTSD. However, as the field evolves, ongoing research is crucial to establish best practices that ensure effective and personalised neurofeedback interventions. This includes the development of standardized neurofeedback protocols to optimise treatment outcomes.
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Published in Neurolmage: Clinical, the clinical trail found that neurofeedback was effective in reducing symptoms of PTSD.
“Brain connectivity involves different parts of the brain communicating with each other and helps to regulate states of consciousness, thought, mood and emotion”, explains Dr Ruth Lanius, scientist at Lawson, professor at Western’s Schulich School of Medicine & Dentistry and psychiatrist at Londin Health Sciences Centre. “Individuals with PTSD tend to have disrupted patterns of brain connectivity, but our research suggests they can exercise their brain to restore patterns to a healthy balance”.
Neurofeedback uses a system called a neurofeedback loop in which a person’s brain activity is measured through sensors placed on the scalp and displayed back to them using a computer interface. This allows the individual to complete exercises and visually see the results.
The trail tested neurofeedback with a total of 72 participants, including 36 participants with PTSD and 36 healthy control participants. Of those with PTSD, 18 were randomized to participate in neurofeedback treatment while the other 18 acted as a comparison group.
The study found that the severity of PTSD symptoms decreased in participants randomized to receive neurofeedback treatment. After treatment, 61.1 percent of participants no longer met the definition for PTSD. This remission rate is comparable to gold standard therapies like trauma-focused psychotherapy.
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References
Abhang, P. A., Gawali, B. W., & Mehrotra, S. C. (2016). Technological Basics of EEG Recording and Operation of Apparatus. In Introduction to EEG- and Speech-Based Emotion Recognition (pp. 19–50). Elsevier. https://doi.org/10.1016/B978-0-12-804490-2.00002-6
Alexandra Kredlow, M., Fenster, R. J., Laurent, E. S., Ressler, K. J., & Phelps, E. A. (2022). Prefrontal cortex, amygdala, and threat processing: implications for PTSD. Neuropsychopharmacology, 47(1), 247–259. https://doi.org/10.1038/s41386-021-01155-7
Askovic, M., Watters, A. J., Aroche, J., & Harris, A. W. F. (2017). Neurofeedback as an adjunct therapy for treatment of chronic posttraumatic stress disorder related to refugee trauma and torture experiences: two case studies. Australasian Psychiatry, 25(4), 358–363. https://doi.org/10.1177/1039856217715988
Badura-Brack, A., McDermott, T. J., Heinrichs-Graham, E., Ryan, T. J., Khanna, M. M., Pine, D. S., Bar-Haim, Y., & Wilson, T. W. (2018). Veterans with PTSD demonstrate amygdala hyperactivity while viewing threatening faces: A MEG study. Biological Psychology, 132, 228–232. https://doi.org/10.1016/j.biopsycho.2018.01.005
Bazzana, F., Finzi, S., Di Fini, G., & Veglia, F. (2022). Infra-Low Frequency Neurofeedback: A Systematic Mixed Studies Review. Frontiers in Human Neuroscience, 16. https://doi.org/10.3389/fnhum.2022.920659
Berboth, S., & Morawetz, C. (2021). Amygdala-prefrontal connectivity during emotion regulation: A meta-analysis of psychophysiological interactions. Neuropsychologia, 153, 107767. https://doi.org/10.1016/j.neuropsychologia.2021.107767
Bremner, J. D. (2006). Traumatic stress: effects on the brain. Dialogues in Clinical Neuroscience, 8(4), 445–461. https://doi.org/10.31887/DCNS.2006.8.4/jbremner
Butt, M., Espinal, E., Aupperle, R. L., Nikulina, V., & Stewart, J. L. (2019). The Electrical Aftermath: Brain Signals of Posttraumatic Stress Disorder Filtered Through a Clinical Lens. Frontiers in Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00368
Davis, L., Hamner, M., & Bremner, J. D. (2016). Pharmacotherapy for PTSD: effects on PTSD symptoms and the brain. In Posttraumatic Stress Disorder (pp. 385–412). Wiley. https://doi.org/10.1002/9781118356142.ch16
Diamond, D. M., & Zoladz, P. R. (2016). Dysfunctional or hyperfunctional? The amygdala in posttraumatic stress disorder is the bull in the evolutionary China shop. Journal of Neuroscience Research, 94(6), 437–444. https://doi.org/10.1002/jnr.23684
du Bois, N., Bigirimana, A. D., Korik, A., Kéthina, L. G., Rutembesa, E., Mutabaruka, J., Mutesa, L., Prasad, G., Jansen, S., & Coyle, D. H. (2021). Neurofeedback with low-cost, wearable electroencephalography (EEG) reduces symptoms in chronic Post-Traumatic Stress Disorder. Journal of Affective Disorders, 295, 1319–1334. https://doi.org/10.1016/j.jad.2021.08.071
Egner, T., Strawson, E., & Gruzelier, J. H. (2002). EEG signature and phenomenology of alpha/theta neurofeedback training versus mock feedback. Applied Psychophysiology and Biofeedback, 27(4), 261–270. https://doi.org/10.1023/A:1021063416558
Gerge, A. (2020a). A multifaceted case-vignette integrating neurofeedback and EMDR in the treatment of complex PTSD. European Journal of Trauma & Dissociation, 4(3), 100157. https://doi.org/10.1016/j.ejtd.2020.100157
Gerge, A. (2020b). A multifaceted case-vignette integrating neurofeedback and EMDR in the treatment of complex PTSD. European Journal of Trauma & Dissociation, 4(3), 100157. https://doi.org/10.1016/j.ejtd.2020.100157
Grin-Yatsenko, V. A., Ponomarev, V. A., Kara, O., Wandernoth, B., Gregory, M., Ilyukhina, V. A., & Kropotov, J. D. (2020). P93 Effect of Infra-Low Frequency Neurofeedback on Infra-Slow EEG Fluctuations. Clinical Neurophysiology, 131(4), e223. https://doi.org/10.1016/j.clinph.2019.12.091
Hammond, D. C. (2007). What Is Neurofeedback? Journal of Neurotherapy, 10(4), 25–36. https://doi.org/10.1300/J184v10n04_04
Leem, J., Cheong, M. J., Lee, H., Cho, E., Lee, S. Y., Kim, G.-W., & Kang, H. W. (2021). Effectiveness, Cost-Utility, and Safety of Neurofeedback Self-Regulating Training in Patients with Post-Traumatic Stress Disorder: A Randomized Controlled Trial. Healthcare, 9(10), 1351. https://doi.org/10.3390/healthcare9101351
Nicholson, A. A., Ros, T., Densmore, M., Frewen, P. A., Neufeld, R. W. J., Théberge, J., Jetly, R., & Lanius, R. A. (2020). A randomized, controlled trial of alpha-rhythm EEG neurofeedback in posttraumatic stress disorder: A preliminary investigation showing evidence of decreased PTSD symptoms and restored default mode and salience network connectivity using fMRI. NeuroImage: Clinical, 28, 102490. https://doi.org/10.1016/j.nicl.2020.102490
Nicholson, A. A., Ros, T., Frewen, P. A., Densmore, M., Théberge, J., Kluetsch, R. C., Jetly, R., & Lanius, R. A. (2016). Alpha oscillation neurofeedback modulates amygdala complex connectivity and arousal in posttraumatic stress disorder. NeuroImage: Clinical, 12, 506–516. https://doi.org/10.1016/j.nicl.2016.07.006
Nilsson R. M., Nilsson V. (2014). Neurofeedback Treatment for Traumatized Refugees-A Pilot Study. (dissertation/master's thesis). Lund (Sweden). Lund University. Available online at: http://lup.lub.lu.se/student-papers/record/4459760 [Google Scholar]
Olff, M., de Vries, G.-J., Güzelcan, Y., Assies, J., & Gersons, B. P. R. (2007). Changes in cortisol and DHEA plasma levels after psychotherapy for PTSD. Psychoneuroendocrinology, 32(6), 619–626. https://doi.org/10.1016/j.psyneuen.2007.04.001
Orndorff-Plunkett, F., Singh, F., Aragón, O., & Pineda, J. (2017). Assessing the Effectiveness of Neurofeedback Training in the Context of Clinical and Social Neuroscience. Brain Sciences, 7(8), 95. https://doi.org/10.3390/brainsci7080095
Peniston, E.G., & Kulkosky, P.J. (1991). Alpha-Theta Brainwave Neuro-Feedback for Vietnam Veterans with Combat¬ Related Post-Traumatic Stress Disorder.
Selemon, L. D., Young, K. A., Cruz, D. A., & Williamson, D. E. (2019). Frontal Lobe Circuitry in Posttraumatic Stress Disorder. Chronic Stress, 3. https://doi.org/10.1177/2470547019850166
Sherin, J. E., & Nemeroff, C. B. (2011). Post-traumatic stress disorder: the neurobiological impact of psychological trauma. Dialogues in Clinical Neuroscience, 13(3), 263–278. https://doi.org/10.31887/DCNS.2011.13.2/jsherin
Spreyermann, R. (2022). Case Report: Infra-Low-Frequency Neurofeedback for PTSD: A Therapist’s Perspective. Frontiers in Human Neuroscience, 16. https://doi.org/10.3389/fnhum.2022.893830
van der Kolk, B. A., Hodgdon, H., Gapen, M., Musicaro, R., Suvak, M. K., Hamlin, E., & Spinazzola, J. (2016). A Randomized Controlled Study of Neurofeedback for Chronic PTSD. PloS One, 11(12), e0166752. https://doi.org/10.1371/journal.pone.0166752
Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A Review of Evidence-Based Psychotherapy Interventions. Frontiers in Behavioral Neuroscience, 12, 258. https://doi.org/10.3389/fnbeh.2018.00258
Zhao, Z., Duek, O., Seidemann, R., Gordon, C., Walsh, C., Romaker, E., Koller, W. N., Horvath, M., Awasthi, J., Wang, Y., O’Brien, E., Fichtenholtz, H., Hampson, M., & Harpaz-Rotem, I. (2023). Amygdala downregulation training using fMRI neurofeedback in post-traumatic stress disorder: a randomized, double-blind trial. Translational Psychiatry, 13(1), 177. https://doi.org/10.1038/s41398-023-02467-6
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