Neurofeedback and Post Traumatic Stress Disorder (PTSD)

Hi all, Nigel Barnim of Hamilton Neurofeedback here. I wrote this review paper on Neurofeedback and PTSD as a part of my Masters of Psychotherapy degree, as I’d like to work using both Neurofeedback and Psychotherapy in the treatment of trauma in the future. I figured it could be useful and interesting for clients - and anyone else interested in the subject - to read through. Despite it being an academic paper I’ve tried to make it minimally jargonny. That said, if there’s something you don’t understand or something piques your interest, you’re always welcome to email me about it at hamiltonneurofeedback@gmail.com, or schedule a time to chat on the scheduling page.

Enjoy, be well:

Narrative Review - Neurofeedback and Post-Traumatic Stress Disorder

Introduction

Post Traumatic Stress Disorder (PTSD) is a significantly impairing psychiatric condition (Jellestad et al., 2021) with a high lifetime prevalence (13-20.4% in females, and 6.2-8.2% in males; Bryant, 2019) resulting in high economic burden ($232.2 billion lost in the United States in 2018; Davis et al., 2022).

Though current treatments for PTSD are moderately efficacious, trauma-focused psychotherapies show high dropout rates, mixed client engagement due to the avoidance-related symptoms of PTSD, and less-than-desired clinical response (Norman, 2022). Medication as well affords only modest symptom reductions and can present a host of side effects (Zhang et al., 2023).

An emerging treatment for PTSD is Neurofeedback (NFB). NFB has risen in public awareness after its mention in the popular book The Body Keeps the Score (van der Kolk, 2014) and through a growing body of clinical research in the previous 20 years (Ali et al., 2024). Mechanistically, NFB treats PTSD by reducing the chronic neurological, physiological and emotional dysregulation common in patients suffering from PTSD (Nicholson et al., 2020). NFB does this by teaching patients to control the electrical activity of their brains (S. Fisher, 2014). First accomplished in 1968 (Kamiya, 1968), NFB can be conceptualized as a cyclical four-step process (see Figure 1 below): 1) a patient’s brain produces electrical activity; 2) sensors detect this activity; 3) a computer processes and abstracts this raw data into a simplified representation (e.g. how ‘relaxed’ one’s brain is), and; 4) the patient is rewarded for desirable brain activity in real time through clear visual or auditory feedback (e.g. a green checkmark appears on a screen or a bell rings when one’s brain is ‘relaxed’). Through repeated exposures to this closed-loop feedback system and the gradual raising of the minimum threshold for rewards, patients can shape long-term, resilient changes in the resting state activity of their brains, which corresponds with symptom relief for variety of psychiatric diagnoses including PTSD (Marzbani et al., 2016). Accordingly, studies reveal a variety of stereotyped, heterogeneous abnormalities in the electrical activity of the brains of traumatized individuals, which are normalized through NFB (S. F. Fisher et al., 2016).

Figure 1.

1) a patient’s brain produces electrical activity; 2) sensors detect this activity; 3) a computer processes and abstracts this raw data into a simplified representation (e.g. how ‘relaxed’ one’s brain is), and; 4) the patient is rewarded for desirable brain activity in real time through clear visual or auditory feedback (e.g. a green checkmark appears on a screen or a bell rings when one’s brain is ‘relaxed’).

Thus, given the psychological, societal, and economic burden of PTSD, the relative inefficacy and complexities of current treatments, and the rising social awareness of NFB, it is imperative for the informed therapist to understand the nature of NFB as a treatment for PTSD. Toward this aim, this narrative review seeks to communicate the present state of the clinical research on NFB for PTSD, as well as to analyze the dynamic ways in which NFB influences the psychotherapeutic process, presenting both opportunities and challenges for trauma treatment.

Meta Analyses & Systematic Reviews

Choi et al. (2023) performed a meta-analysis of 8 randomized controlled trials (RCT) and two non-RCT’s which examined the effectiveness of NFB in treating adults with PTSD. Several findings stand out among their results: 1) NFB was effective at reducing overall PTSD severity and the severity of most symptoms (e.g. arousal, anxiety, numbing) for all sample groups except single-episode trauma; 2) 20 or more sessions was more effective than fewer than 20, and sessions longer than 20 minutes were more effective than sessions shorter than 20 minutes, and; 3) Alpha-Theta NFB and traditional linear NFB stood out as more effective than other options. The overall effect size for PTSD symptom reduction was a Hedges g of 0.74, which, according to norming on PTSD symptom severity in United States veterans by Bovin et al. (2016), places the average NFB recipient into the sub-diagnostic range for PTSD (i.e. no longer meeting diagnostic criteria). However, this paper reported a high risk of bias in the design of the included studies.

Next, Panisch & Hai, (2020) performed a systematic review of 10 studies, looking particularly at behavioural outcomes in adults with PTSD. Across all studies, participants diagnosed with PTSD showed clinically significant improvements across a range of symptoms, with at least one symptom area improving in each study. Notably, the studies did not exclude participants with comorbid diagnoses (which most patients with PTSD possess; Brady et al., 2000), lending to greater generalizability of their results. The authors highlight NFB’s utility in treating complex, developmental trauma in particular; a valuable finding given these patients are known to respond more poorly to traditional psychotherapy for PTSD (e.g. prolonged exposure) due to their chronically elevated arousal (Panisch & Hai, 2020).

Finally, Steingrimsson et al. (2020) performed a systematic review and meta-analysis of four RCT’s. The results mirror the above findings that NFB is an effective, clinically significant treatment for PTSD. However, in addition to (Choi et al., 2023), this study also assessed the methodological rigour of the studies it analyzed and found a very low level of certainty due unclear randomization, lack of predefined or preregistered analyses, low sample sizes, et cetera.

Taken together, these review papers found strong support for NFB in the treatment of PTSD. However, although it is likely that the direction of the effect is valid (i.e. NFB is effective in treating PTSD), due to methodological shortcomings the size of the effect could be exaggerated.

Integrating Neurofeedback and Psychotherapy

There are few more informed on NFB, psychotherapy and trauma than Sebern Fisher, a near-30-year veteran in the field. Fisher is likely the world’s most skilled practitioner, theoretician, and advocate when it comes to integrating NFB and psychotherapy in the treatment of trauma, and she has written extensively on the unique, dynamic opportunities and challenges inherent to the combination of these treatments. To communicate these for the benefit of the discerning psychotherapist who is interested in NFB, two of her case studies are explored below.

First, Fisher discusses (2016) the case of Bea: a woman with severely impairing complex PTSD resultant from traumatic stressors during childhood. This highly medicated woman presented with a history of multiple suicide attempts, ongoing self injurious behaviour, and chronic, extreme physiological and affective dysregulation. Despite 19 years of psychodynamic and dialectical behavioural therapy, her symptoms were unremitting. After ten sessions of NFB intended to restore her “[brain’s] own capacity for regulation in the [electrical] frequency domain,” (S. F. Fisher et al., 2016), Bea’s latent capacity for self-regulation of the emotions of fear, shame and rage began to emerge – a latent capacity left unlearned during her traumatic childhood. As treatment progressed Bea began to further stabilize – and eventually fully remit – from her PTSD symptoms. Fisher describes that through Bea’s affective stabilization, she experienced the emergence of a “more robust sense of self,” (S. F. Fisher et al., 2016).

The unique psychotherapeutic challenges posed by this emerging sense of self are described further in the case of Eleanor: a teenage girl with severe developmental trauma, Aspergers, and an eating disorder (S. Fisher, 2014). Before therapy, Eleanor’s life was characterized by unremitting affective instability, uncontrollable bingeing and purging episodes, and an unformed sense of self and other – this last issue being particularly common in those who have experienced trauma (Horowitz, 2018). Through treatment with NFB, Fisher describes the “unfolding of this girl [...] and the emergence of a young adult,” as she “[gained] access to a deeper region of self perception.” (S. Fisher, 2014). Amongst the common – if notably expedited – psychotherapeutic tasks of trauma treatment (e.g. the integration of the trauma into one’s life experience, the deconstruction of maladaptive beliefs caused by the trauma, the detachment from associated shame, rage or fear) psychotherapeutic tasks emerged which are relatively unique to NFB. Eleanor grew, matured, and “[leapt] across developmental milestones,” which had been left stunted due to her dysregulated home environment and – resultant – brain activity (S. Fisher, 2014), creating the emergence of a sense of self in and of itself – the rapid and pronounced flourishing of an identity where before Eleanor considered herself essentially afloat on and fused with waves of negative affect. Through enhanced emotional regulation, she began experiencing a continuous sense of self who experienced affect. The coalescence of her identity was not an entirely smooth experience, however. As her chronic fear subsided, Eleanor began to cling to her fear-based identity, as, for many, “it is the only self they know.” (S. Fisher, 2014), posing complexities in therapeutic goals and dynamics.

Overall, Fisher’s work suggests the clinical picture of best practice in NFB for trauma-populations necessitates effective, NFB-informed psychotherapy, as the challenges patients experience: 1) are often more rapid, intense processing of trauma afforded by enhanced affective stability, and; 2) require psychotherapeutic techniques or practices designed to effectively “ [negotiate] with [the patient] a changing and unfamiliar identity.” (e.g. Acceptance and Commitment Therapy, Internal Family Systems Therapy, and Mindfulness-Based therapies. S. F. Fisher, 2010).

Summary and Implications

Overall, meta-analyses and systematic reviews support NFB in the treatment of PTSD (Choi et al., 2023; Panisch & Hai, 2020; Steingrimsson et al., 2020). NFB offers a unique means of resolving trauma-related disorders: teaching long-lasting bottom-up affect (read: brain) regulation skills, without the complexities of therapy or medication (Nicholson et al., 2020). However, even the most cutting-edge, well-controlled research appears to lack methodological rigour (Choi et al., 2023; Ros et al., 2020; Steingrimsson et al., 2020). Though this does not invalidate research findings (particularly noting the triangulation of positive results from on-the-ground clinicians’ case reports), additional, higher quality research is required.

A solution to this problem may be the Consensus on the Reporting and Experimental Design of Clinical and Cognitive-Behavioural Neurofeedback Studies (CRED-nf; Ros et al., 2020). The CRED-nf is the result of a large collaboration of NFB researchers and practitioners which is intended to serve as a gold-standard checklist for research design, execution, and reporting, similar to tools available in other research domains (Ros et al., 2020).

Critically, more methodologically rigorous research will allow for translation of research into practice, which is notably lacking in the field (Norris et al., 2024). Evidently, the meta-analyses and systematic reviews discussed above failed to report on the types of NFB devices used, rationale for protocol selection, decision criteria for changing protocols over time, et cetera. Further, like so many other fields, leading practitioners are years ahead of clinical research in terms of their protocols and results (S. Fisher, 2014). Thus, the problem goes both ways: there is a concurrent lack of translation from practice into research.

As a final word, meta-analyses represent the average of many studies, and studies represent the average of many individuals. Critically, no one individual is captured by the average of their group, lending importance to the value of individualized treatment, both in the form of NFB and the psychotherapy it necessitates (S. Fisher, 2014). It is likely the case that effective psychotherapy is more rather than less necessary when working with patients with PTSD, particularly of a complex, developmental nature. However, the promise remains: when combining NFB and psychotherapy, the whole can be greater than the sum of its parts – the ‘one-plus-one’ of NFB and psychotherapy likely equals not two, but three, or five. There is hope that through additional high-quality research, the clinical advancements of on-the-ground practitioners, and growing public awareness and acceptance, that NFB may be a promising solution for reducing the suffering in so many patient’s lives.

References

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