ArticlePDF Available

QEEG Guided Neurofeedback Treatment for Anxiety Symptoms



Anxiety represents one of the most commonly diagnosed mental illnesses among adults in the United States, affecting an estimated 19.1% of the adult population annually, with a lifetime occurrence of 31.1% (NIMH, 2017). This retrospective study intended to assess whether qEEG-guided amplitude neurofeedback (NF) is a viable treatment for anxiety symptom reduction. Forty participants were assessed for anxiety using symptom and EEG measures. Demographics include age ranges from 19 to 62 (M = 37.7, SD = 13.87). Gender identification comprised 21 male and 19 female. Fifteen clients self-identified as White (Non-Latino; 38%), 14 as Latino/Latina (35%), and 11 did not self-report ethnicity (28%). Pre- and postassessments were given to the participants. Symptom assessments included the Zung Self-Rating Anxiety Scale and Achenbach System of Empirically Based Assessment (ASEBA) Adult Self-Report (ASR). A qEEG was used to determine protocols for each participant. Participants were scheduled to receive 30-min NF treatment sessions twice a week for one academic semester. The range of attended sessions was 7–19 (M = 12.72, SD = 2.78), where accurate number of session data was unavailable for four of the subjects. Symptom measures showed statistically significant improvement. Limitations include small sample size and no control group or sham NF group. Suggestions are included for future studies.
85 | Vol. 5(3):8592 2018 doi:10.15540/nr.5.3.85
QEEG-Guided Neurofeedback Treatment for Anxiety
Mark S. Jones* and Heather Hitsman
The University of Texas at San Antonio, San Antonio, Texas, USA
Anxiety represents one of the most commonly diagnosed mental illnesses among adults in the United States,
affecting an estimated 19.1% of the adult population annually, with a lifetime occurrence of 31.1% (NIMH, 2017).
This retrospective study intended to assess whether qEEG-guided amplitude neurofeedback (NF) is a viable
treatment for anxiety symptom reduction. Forty participants were assessed for anxiety using symptom and EEG
measures. Demographics include age ranges from 19 to 62 (M = 37.7, SD = 13.87). Gender identification
comprised 21 male and 19 female. Fifteen clients self-identified as White (Non-Latino; 38%), 14 as Latino/Latina
(35%), and 11 did not self-report ethnicity (28%). Pre- and postassessments were given to the participants.
Symptom assessments included the Zung Self-Rating Anxiety Scale and Achenbach System of Empirically Based
Assessment (ASEBA) Adult Self-Report (ASR). A qEEG was used to determine protocols for each participant.
Participants were scheduled to receive 30-min NF treatment sessions twice a week for one academic semester.
The range of attended sessions was 719 (M = 12.72, SD = 2.78), where accurate number of session data was
unavailable for four of the subjects. Symptom measures showed statistically significant improvement. Limitations
include small sample size and no control group or sham NF group. Suggestions are included for future studies.
Keywords: anxiety; anxiety symptoms; qEEG-guided amplitude neurofeedback; neurofeedback
Citation: Jones, M. J., & Hitsman, H. (2018). QEEG-guided neurofeedback treatment for anxiety symptoms. NeuroRegulation, 5(3), 8592.
*Address correspondence to: Dr. Mark S. Jones, Department of
Counseling, The University of Texas at San Antonio, 501 Cesar
Chavez Blvd., Durango Building 3.304E, San Antonio, TX 78207,
USA. Email:
Copyright: © 2018. Jones and Hitsman. This is an Open Access
article distributed under the terms of the Creative Commons
Attribution License (CC-BY).
Edited by:
Rex L. Cannon, PhD, Knoxville Neurofeedback Group, Knoxville,
Tennessee, USA
Reviewed by:
John Davis, PhD, McMaster University, Hamilton, Ontario, Canada
Randall Lyle, PhD, Mount Mercy University, Cedar Rapids, Iowa,
According to the National Institute of Mental Health
(NIMH), anxiety disorders rank as the top leading
diagnosis by clinicians within the mental health field.
Anxiety disorders affect approximately 19.1% of the
U.S. adults annually, with a lifetime prevalence of
approximately 31.1% (NIMH, 2017). While the
majority of Americans experience stress periodically
within their lifespan, individuals diagnosed with
anxiety have severe pervasive symptoms that
interfere with their daily lives (NIMH, 2018).
Psychotherapy, cognitive behavioral therapy (CBT),
meditation, or support groups may be helpful in
reducing symptoms (NIMH, 2018).
With the onset frequently developing during
childhood, many anxiety disorders can be persistent
if not treated and present more frequently in women
at a 2:1 ratio (American Psychiatric Association,
2013). A variety of symptoms are reported by
individuals with anxiety disorders including sleep
problems, fatigue, muscle tension, or intense fear
(NIMH, 2018). More severe symptoms can include
sudden and repeated attacks of fear, pounding and
racing heart, and purposely excluding oneself from
certain people or places.
Literature Review
Various biofeedback modalities have been
implemented by clinicians in the treatment of anxiety
including electromyography (EMG), peripheral
temperature, and electrodermal response (EDR)
prior to neurofeedback’s (NF) popularization (Price &
Budzynski, 2009). NF, a subcategory of
biofeedback, has been used to lower anxiety
Jones and Hitsman NeuroRegulation
86 | Vol. 5(3):8592 2018 doi:10.15540/nr.5.3.85
symptoms in a variety of populations, as addressed
throughout the following reviewed literature.
Singer (2004) used NF on two female dancers, 27
and 52 years of age, who had persistent levels of
performance anxiety. A State-Trait Anxiety
Inventory (STAI; Spielberger, 1983) assessment was
taken by each participant before a NF session and
before each of their major dance performances. The
course of NF treatment included 20 sessions at the
time interval of 30 min per session. Sensors were
placed on site locations T3 and T4, and thresholds
were adjusted during each session dependent upon
the participant’s response. Postassessments
indicated a significant decrease in anxiety symptoms
associated with performance. The trait anxiety
portion of the first participant’s assessment indicated
a decrease in score from 59 to 43.5, while the state
portion underwent a decrease in score of 66 to 44.
The trait anxiety portion of the second participant's
assessment indicated a decrease in score as well,
from 52 to 36, while the state portion underwent a
decrease in score of 56 to 30. Limitations to this
study included a small sample size, lack of
individualized protocols, and no control group.
A study by Kerson, Sherman, and Kozlowski (2009)
illustrates how the various modalities of earlobe
temperature training, alpha suppression, and alpha
symmetry training were used in eight adults who
either were diagnosed with generalized anxiety
disorder or presented with multiple anxious
behaviors. Participants were assessed for high
alpha frequency at the International 10-20 Electrode
system sites Fp1, Fp2, F3, F4, F7, and F8. A 5-min
baseline electroencephalogram (EEG) of the
participants was recorded with their eyes open for
the initial measurement and with their eyes closed
for the secondary measurement. Postbaseline
measures were also recorded 1 week after the last
NF training occurred. The initial six sessions were
used to increase the participants earlobe
temperature. The following 616 sessions consisted
of decreasing alpha magnitude by 10% in the
anterior lobes for 30 or more minutes. Once alpha
was suppressed, the protocol shifted to
improvement of alpha symmetry by a 15% increment
for 30 minutes or more during 832 sessions. All
sessions were conducted on a biweekly basis.
Continued assessment of participants was
conducted throughout the study by means of the
STAI, in which a significant improvement in scores
resulted. The pre- and postmean change in EEG
was 1.41 z-scores towards the mean. Limitations
mentioned within the study include a limited amount
of participants, lack of variance in protocols, and the
lack of a control group.
Walker (2009) implemented a study based upon
whether NF could lower anxiety symptoms for 19
clients diagnosed with posttraumatic stress disorder
(PTSD). Four clients, who were originally diagnosed
with PTSD and in the NF group but had dropped out
after the quantitative electroencephalography
(qEEG), were included in the control group. Each
received a qEEG examination using the Neuroguide
software and Lifespan Normative database.
Excessive high frequency beta (2130 Hz) was then
downtrained for 57 sessions for each site that
presented excessive high frequency beta;10 Hz
activity was uptrained at the same sites. The sites
were in various and multiple areas depending on
where the excessive beta was located, as protocols
were determined by a qEEG. A self-rated anxiety
Likert scale from 110 was also used to determine
the amount of anxiety each participant had felt. The
number of sessions per individual ranged from 57.
Participants who had NF training had a significant
reduction in self-rated anxiety with a pretreatment
score of 5/107/10 to a posttreatment score of 0/10
2/10, and 1 month after NF training the scores
remained at 0/102/10. Subjects who did not have
NF training had little or no reduction in self-rated
anxiety 3 months after their qEEG. Limitations with
this study include using a self-rating scale for anxiety
rather than an evidence-based assessment.
A study by Scheinost et al. (2013) evaluated 10
subjects with contamination anxiety to undergo
functional magnetic resonance imaging (fMRI) NF
training and compared their neural connectivity with
real-time functional magnetic resonance imaging (rt-
fMRI). A matched control group of 10 subjects that
received sham fMRI-NF (SNF) of their matched pair
was used. Subjects had an initial fMRI to localize
their activity in the orbitofrontal cortex (OFC) from
contamination anxiety. They then met with a
psychologist to discuss strategies for manipulating
brain activity that could later be refined during fMRI-
NF. There were eight sessions total where subjects
were shown contamination-related photos and
asked to rate their anxiety on a scale of 15. The
first and the last session consisted of subjects being
asked to implement the personal coping
mechanisms which they would typically use to try to
lessen their anxiety. The middle six sessions
consisted of 90 min of fMRI-NF. The fMRI-NF
sessions consisted of subjects receiving cues of
when to increase activity their OFC area, when to
decrease activity, and when to rest based on their
OFC output. Resting cues included a neutral image.
Jones and Hitsman NeuroRegulation
87 | Vol. 5(3):8592 2018 doi:10.15540/nr.5.3.85
Between-group differences in fMRIs were identified
using Wilcoxon’s rank-sum test. The fMRI-NF group
reported greater self-reported reduction in anxiety (p
= .02) compared to the SNF group (p = .45). The
fMRI-NF group had significant (p < .05) neural
changes compared to the SNF group as recorded by
the last fMRI taken several days after the last fMRI-
NF session. The fMRI-NF group had significant
decrease in connectivity for the brain regions
associated with emotion processing, including the
insula and adjacent regions, the hippocampi,
parahippocampal and entorhinal cortex, the right
amygdala, the brain stem in the vicinity of the
substantia nigra, the temporal pole, superior
temporal sulcus, thalamus and fusiform gyrus. The
fMRI-NF group also had an increased degree of
connectivity that was seen in prefrontal areas
associated with emotion regulation and cognitive
control, including right lateral prefrontal cortex and
bilateral portions of Brodmann’s area 8. This study
illustrated how changes directly resulting from fMRI-
NF were possible and how structural changes can
last days after a fMRI-NF session. This study also
supported the idea of finding and confirming a
localized area related to a symptom and using that
area for fMRI-NF. Limitations to this study include
low number of fMRI-NF sessions and a small sample
A study conducted by Cheon et al. (2015)
researched NF implemented on 77 adults diagnosed
with various psychiatric disorders within a psychiatric
setting. The following disorders are listed in order of
prevalence according to the research: depressive
disorders, anxiety disorders, sleep disorders,
somatoform disorders, adjustment disorders, bipolar
disorder, schizophrenia, attention-
deficit/hyperactivity disorder, alcohol dependence,
game addiction, and impulse control disorder.
Protocols were designed depending on the
participant’s chief complaint (e.g., anxiety, emotional
instability, lethargy, etc.), the opinion of the attending
psychiatrist, neuropsychiatric evaluation results, and
the subjective symptom rating scale. The Clinical
Global Impression-Severity Scale (CGI-S; Busner &
Targum, 2007) and the HillCastro Checklist (Hill &
Castro, 2002) were also implemented on a weekly
basis as a measure of treatment effectiveness. NF
protocols included training sensorimotor rhythm
(SMR), beta, and/or also contained alpha-theta
training. The various frequency bandwidths which
were rewarded during training, included SMR
between 1215 Hz, beta between 1518 Hz, theta
between 58 Hz, and alpha between 812 Hz. The
individualized site locations in which training was
implemented included Fp1, Fp2, F3, F4, F7, F8, T3,
T4, C3, C4, P1, P2, O1, O2, and Oz based on the
International 1020 Electrode system. Alpha-theta
training was conducted at the PZ site location.
Protocols were evaluated and finalized during
weekly NF meetings which included a team of three
psychiatrists trained in NF, as well as a trained NF
therapist. The number of appointments for client’s
training ranged from 1 to 20 or more sessions. The
HillCastro Checklist score showed an improvement
in multiple symptom areas including anxiety (p
< .001). The pre- and post-CGI score showed a
significant reduction in the severity of symptoms (p
< .001). Limitations mentioned within the study
included having a heterogenous group and no
control group, as well as not utilizing the qEEG to
determine protocols.
Dreis et al. (2016) published a pilot study of NF
provided to 14 anxious clients at a university-based
community counseling center, showing significant
improvements in symptoms measured by the Zung
Anxiety Scale and Achenbach System of Empirically
Based Assessment (ASEBA) checklists. This study
is a continuation of that pilot.
These studies illustrate how NF can be a viable tool
in lowering anxiety symptoms. They each have their
strengths and limitations. A substantial limitation is
either using the same protocol for each patient
and/or using a protocol based on symptoms alone.
Hammond (2010) expresses the importance of using
a qEEG to identify heterogeneity in brain wave
patterns, finding comorbidities, and looking for
effects from medication.
The correlation between frontal alpha symmetry,
negative affect and anxiety was studied by Mennella
et al. (2017), comparing two neurofeedback
treatments of F4-F3 alpha asymmetry with Fz alpha
uptraining on respective groups of 16 right-handed
females each. The findings indicated a significant
increased frontal alpha asymmetry, which correlated
with symptom improvements, as compared to the
midfrontal alpha group.
Krigbaum and Wigton (2014) argue the importance
of qEEG-guided and z-score NF as it allows the
clinician to develop a more individualized treatment
plan which encompasses a qEEG baseline, clinical
status, and history of the client. Wigton and
Krigbaum (2015) further assert how 19-channel z-
score NF (19ZNF) protocols facilitate identifying the
link between localized cortical dysfunctions and
connectivity issues associated with mental health
symptoms. In this modality, qEEG metrics are
compared to a normative database to create z-
Jones and Hitsman NeuroRegulation
88 | Vol. 5(3):8592 2018 doi:10.15540/nr.5.3.85
scores; then, those z-scores are incorporated into
the NF protocol in real time during the session. This
allows for pretreatment assessment, a helpful tool in
measuring progress with the client, and combining
real-time assessment with the operant conditioning
of NF. Thus, 19ZNF training is used to bring these
scores closer to the mean, otherwise known as
normalizing. Moreover, 19ZNF protocols also
reduce the number of sessions which is more
economical for the clients. Wigton and Krigbaum’s
pilot study used 19ZNF to train the deviant z-scores.
Unlike Wigton and Krigbaum (2015), this research is
a study which used single-channel amplitude
training, rather than z-score training, for three
reasons: (1) it is commonly used by many
practitioners, (2) it is a straightforward method for
students in training to learn before advancing to
other modalities, and (3) the numerous one-channel
amplitude training studies which exist in the
literature, as reviewed by Wigton (2014). Therefore,
based on the literature review, this study sought to
assess whether individualized qEEG-guided
amplitude NF is a viable treatment for anxiety
symptom reduction.
Clients contacted the Sarabia Family Counseling
Center at the University of Texas at San Antonio
(UTSA) to receive therapy and NF treatment free of
charge. Clients learned about the clinic through
community referral sources and/or university media
relations. Upon calling, clients were screened by
master- or doctoral-level students in the UTSA
Department of Counseling to determine if they met
the criteria for receiving NF treatment, including
primary anxiety symptoms, availability, and age
requirements. If the individual satisfied the clinical
criteria, as well as the required biweekly availability
and willingness to complete the treatment
requirements on an ongoing basis, the clients were
then scheduled to meet with a NF student clinician.
Prior to completing any formal assessments of
anxiety, student clinicians acquired a comprehensive
informed consent from each client. As retrospective
research, the study was deemed to be exempt from
review by the UTSA Institutional Review Board.
Demographics include age ranges from 19 to 62 (M
= 37.7, SD = 13.87). Gender identification
comprised 21 male and 19 female. Fifteen clients
self-identified as White (Non-Latino; 38%), 14 as
Latino/Latina (35%), and 11 did not self-report
ethnicity (28%). Pre- and postassessments were
given to the participants. Symptom assessments
included the Zung Self-Rating Anxiety Scale and
ASEBA Adult Self-Report (ASR). A qEEG was used
to determine protocols for each participant.
Participants were scheduled to receive 30-min NF
treatment sessions twice a week for one academic
The student clinicians consisted of master and
doctoral-level students within a program certified by
the nationally accredited Council for Accreditation of
Counseling and Related Education Programs
(CACREP). These students are also in the
supervision phase of pursuing their Board
Certification in NF (BCN); thus, they were overseen
by a certified and licensed supervisor. Students had
previously completed the required graduate
curriculum, which met the blueprint required by the
Biofeedback Certification International Alliance
A within-subjects research design was implemented
which included the following precondition and
postconditional assessments: the Zung Self-Rating
Anxiety Scale for adults, the age-appropriate self-
reports for the Achenbach System of Empirically
Based Assessment (ASEBA), and qEEG. The
symptom measurements were selected on the bases
of their focus on anxiety symptoms, widespread
acceptance in the therapeutic community, and
The qEEG measures assessed patterns in the EEG
and qEEG, such as attenuated alpha, fast alpha
tuning, excess beta and/or high beta along the
midline, and hypercoherent frontal alpha.
The qEEGs were acquired via 19-channel
recordings in the eyes-closed and eyes-open
conditions in a resting state, using a BrainMaster
(BrainMaster Technologies, Inc., Bedford, OH)
Discovery 24 high-impedance amplifier and
Neuroguide (Applied Neuroscience, Inc., Largo, FL)
software. Recordings utilized correctly sized
Electro-Cap (Electro-Cap International, Inc., Eaton,
OH) 10-20 electrode appliances which were fitted as
per manufacturer’s guidelines and ear-clip leads
placed. Preparation of electrodes was performed in
a manner adequate to achieve impedance levels of
less than 5 kohms (Jones, 2015). NF was provided
utilizing BrainMaster Atlantis two-channel amplifiers
and BioExplorer (Cyberevolution, Inc., Seattle, WA)
software. Electrode site preparation was done by
Jones and Hitsman NeuroRegulation
89 | Vol. 5(3):8592 2018 doi:10.15540/nr.5.3.85
cleaning the site, ground, and reference locations
with rubbing alcohol and abrading using PCI prep
pads and Nuprep. Gold-plated electrodes were
attached to the clients using Ten-20 paste.
Impedance measurements were taken to ensure
that interelectrode impedance was less that 5 kohms
(Jones, 2015).
Clients agreed to attend a minimum total number of
15 NF training sessions that were to be held at the
same time, twice per week, and free of charge.
Participants were instructed to discontinue the
consumption of caffeine or any other nonessential
substances on treatment days, prior to their session.
At least a 24-hour window prior to the qEEG
recording was suggested for clients to restrict
consumption for nonessential substances, unless
otherwise medically directed. All medically directed
substances were factored into qEEG interpretation
and protocol development.
The range of attended sessions was 719 (M =
12.72, SD = 2.78). An accurate number of session
data was unavailable for four of the subjects. The
training protocols consisted of amplitude uptraining
and/or downtraining of selected frequency bands
based on qEEG findings. Protocol selections were
based on current research and reflect markers found
to be associated with anxiety issues (Dantendorfer
et al., 1996; Demerdziev & Pop-Jordanova, 2011;
Gold, Fachner, & Erkkilä, 2013; Gunkelman, 2006;
Heller, Nitschke, Etienne, & Miller, 1997; Johnstone,
Gunkelman, & Lunt, 2005; Price & Budzynski, 2009;
Savostyanov et al., 2009; Siciliani, Schiavon, &
Tansella, 1975; Stern, 2005, p. 196;
Tharawadeepimuk & Wongsawat, 2014; Walker,
Based on the preferences of the clients and clinical
judgment of the practitioners, feedback was
presented using a variety of formats: games,
animations, sounds, and analog presentations (such
as the size of boxes representing the amplitude of
the respective bandpass filtered EEG signals).
Thresholds were set manually at the beginning of
the session based on the aimed percentage of a
successful reward rate of approximately 50% of the
time. Periodic adjustments were made to the
threshold settings within and between sessions as
needed to shape behavior towards the client’s
specific treatment goals. Records were made for
each session, which included frequency bands,
threshold settings, session average amplitude
levels, type of feedback utilized, and significant
details from client reports and clinician impressions.
EEG data was recorded for each session.
Statistical Analysis
The statistical analysis for the symptom measure
assessments were paired t-tests using IBM SPSS
Statistics Version 25. Means were compared for
prepost scores on the Zung Anxiety Scale and the
ASEBA scales most pertinent to anxiety symptoms:
Anxious/Depressed, Anxiety Problems (DSM), and
Total Problems. The Total Problems Scales was
selected as it represents a wide-range sampling of
other scales to reflect overall severity.
Symptom Measures
All grouped, averaged prepost comparisons of the
Zung Anxiety Scale resulted in improvements. A
cumulative summary of these results are presented
in Table 1. On the Zung Anxiety Scale, for all
subjects, the mean of the prescores was 44.90 (SD
= 8.32) and the mean of the postscores was 37.18
(SD = 8.19). The t-test yielded a statistically
significant improvement, with t(df) = 7.750(39), p
< .001, d = 1.23.
On the ASEBA, a statistically significant
improvement was measured in three scales deemed
most pertinent to the study: Anxious/Depressed,
Anxiety Problems (DSM), and Total Problems. The
results are presented in Table 2.
Table 1
Zung Anxiety Scale
Zung Anxiety Scale
Note. n = 40.
Jones and Hitsman NeuroRegulation
90 | Vol. 5(3):8592 2018 doi:10.15540/nr.5.3.85
Table 2
Achenbach Behavior Checklist (Adult Self-Report)
Anxiety Problems (DSM)
Total Problems
Note. *p < .01, **p < .001. n = 40.
As the number of sessions per client varied, an
opportunity existed to compare number of sessions
with reductions symptom measures. The Zung
Anxiety Scale changes (pre to post) are plotted on a
scale of number of sessions in Figure 1. Based on
the sixth order polynominal trendline of
improvements in the Zung Anxiety Scale measures,
it may be inferred that symptom reduction was
associated most highly with 1114 sessions of
Figure 1. Scatter plot of changes in Zung Anxiety Scale scores (pre to post) by number of sessions. Lower scores
reflect improvement.
Symptom improvement was made evident with
various assessments including the Zung Anxiety
Scale and ASEBA. Taken together, the symptom
scales present evidence of a significant
improvement in clients’ anxiety symptoms and sense
of well-being.
Due to accreditation restrictions at the university-
based counseling center in which the study was
conducted, no treatment sessions may be provided
between semesters. As a result, the number of
sessions was limited to what may be provided during
a semester. Therefore, the design was built around
the time available for pre- and postassessments and
the beginning and end of the semester, respectively,
and treatment provided in the intervening weeks.
While the results based on an average of
approximately 12 sessions were significant, it
remains unknown what additional improvements
may have been achieved with more treatment
Jones and Hitsman NeuroRegulation
91 | Vol. 5(3):8592 2018 doi:10.15540/nr.5.3.85
sessions. The scatter plot in Figure 1, however, may
indicate that 12 sessions may be an adequate
number of treatment events to achieve a significant
The variety of sessions per client reflects an
additional factor of the study as a retrospective
analysis. The researchers were somewhat at the
mercy of clients who had varying degrees of
motivation and means to complete a full regimen of
sessions. For example, some clients struggled with
transportation challenges, employment issues
and/or schedules, and lack of family support. That
sessions were conducted during daytime hours on
week days only compounded some of these
A small sample size and the lack of a sham/control
group were roadblocks to an effective research
design in some aspects of the study. Given that the
study was retrospective, clients were seeking
treatment with a valid expectation of receiving bona
fide therapy. In addition, the resources and purpose
of the program were not compatible for a controlled
A prepost measure of physiological changes would
have strengthened the research design. Due to the
wide variability in protocols and qEEG findings,
significant challenges existed for quantifying specific
treatment effects which may then be assessed at a
group level. As the program moves forwardand
with additional equipmentprepost ERP findings
will be incorporated as one way to measure
physiological changes.
There was variability in the skill and experience
levels of the student counselors. Students were at
various levels in their studies within their degree
program and in the NF program. Controls for the
effect of student bias and skill level differences were:
supervision from the professor who monitored the
treatment via informal verbal reports from students
and clients, session notes, closed-circuit television,
and weekly case conferences.
Client variables that were not controlled for which
may have influenced treatment outcomes include
adjunct therapies (previously or concurrently used),
medications, familial/financial/extraneous life
stressors and major life events, injuries/illnesses,
changes in sleep, and other therapeutic lifestyle
changes (i.e., diet, exercise, and medication). Some
of the clients in the study were taking psychotropic
medications, such as benzodiazepine-class
anxiolytics and SSRIs. While these effects on the
EEG were assessed as part of the qEEG analysis,
they remain as a confounding variable for treatment
Training was conducted using amplitude measures
and monopolar site placements only. While this was
by design, it excluded other forms of NF which may
be based on connectivity measures and multiple site
Finally, it is worth emphasizing that the setting of the
study is a community counseling center, located on
a university campus, operated as part of a graduate
counseling educational program. As such, the
prevailing values in the treatment are (1) the well-
being and therapeutic needs of clients and (2) the
learning opportunities for students. It became
obvious to the professor and students that these
priorities, at times, took precedence over a purely
NF-based research design in ways that may have
compromised the acquisition of “clean” data.
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Washington,
DC: Author.
Busner, J., & Targum, S. D. (2007). The clinical global
impressions scale: Applying a research tool in clinical
practice. Psychiatry (Edgmont), 4(7), 2837.
Cheon, E.-J., Koo, B.-H., Seo, W.-S., Lee, J.-Y., Choi, J.-H., &
Song, S.-H. (2015). Effects of neurofeedback on adult
patients with psychiatric disorders in a naturalistic setting.
Applied Psychophysiology and Biofeedback, 40(1), 1724.
Dantendorfer, K., Prayer, D., Kramer, J., Amering, M., Baischer,
W., Berger, P., Katschnig, H. (1996). High frequency of
EEG and MRI brain abnormalities in panic disorder.
Psychiatry Research: NeuroImaging. 68(1), 4153.
Demerdzieva, A., & Pop-Jordanova, N. (2011). Alpha asymmetry
in QEEG recordings in young patients with anxiety. Prilozi /
Makedonska Akademija Na Naukite i Umetnostite, Oddelenie
Za Biološki i Medicinski Nauki = Contributions / Macedonian
Academy of Sciences and Arts, Section of Biological and
Medical Sciences, 32(1), 229244.
Dreis, S. M., Gouger, A. M., Perez, E. G., Russo, G. M.,
Fitzsimmons, M. A., & Jones, M. S. (2015). Using
Neurofeedback to Lower Anxiety Symptoms Using
Individualized qEEG Protocols: A Pilot Study.
NeuroRegulation, 2(3), 137148.
Gold, C., Fachner, J., & Erkkilä, J. (2013). Validity and reliability of
electroencephalographic frontal alpha asymmetry and frontal
midline theta as biomarkers for depression. Scandinavian
Journal of Psychology, 54(2), 118126.
Gunkelman, J. (2006). Transcend the DSM using phenotypes.
Biofeedback, 34(3), 9598.
Gurnee, R. (2003). QEEG/Topographic Brain Maps: Generalized
Anxiety Disorder Subtypes. Retrieved from http://www.add-
Hammond, D. C. (2010). The need for individualization in
neurofeedback: Heterogeneity in QEEG patterns associated
Jones and Hitsman NeuroRegulation
92 | Vol. 5(3):8592 2018 doi:10.15540/nr.5.3.85
with diagnoses and symptoms. Applied Psychophysiology
and Biofeedback, 35(1), 3136.
Heller, W., Nitschke, J. B., Etienne, M. A., & Miller, G. A. (1997).
Patterns of regional brain activity differentiate types of
anxiety. Journal of Abnormal Psychology, 106(3), 376385.
Hill, R. W., & Castro, E. (2002). Getting rid of Ritalin: How
neurofeedback can successfully treat attention deficit disorder
without drugs. Charlottesville, VA: Hampton Roads.
Johnstone, J., Gunkelman, J., & Lunt, J. (2005). Clinical database
development: Characterization of EEG phenotypes. Clinical
EEG and Neuroscience, 36(2), 99107.
Jones, M. S. (2015). Comparing DC offset and impedance
readings in the assessment of electrode connection quality.
NeuroRegulation, 2(1), 2936.
Kerson, C., Sherman, R. A., & Kozlowski, G. P. (2009). Alpha
suppression and symmetry training for generalized anxiety
symptoms. Journal of Neurotherapy, 13(3), 146155.
Krigbaum, G. & Wigton, N. L. (2014) When discussing
neurofeedback, does modality matter? NeuroRegulation. 1(1),
National Institute of Mental Health (NIMH). (2017). Any Anxiety
Disorder. Retrieved from
National Institute of Mental Health (NIMH). (2018). Anxiety
Disorders. Retrieved from
Mennella, R., Patron, E., & Palomba, D. (2017). Frontal alpha
asymmetry neurofeedback for the reduction of negative affect
and anxiety. Behaviour Research and Therapy, 92, 3240.
Price, J., & Budzynski T. (2009). Anxiety, EEG patterns, and
neurofeedback. In T. H. Budzynski, H. K. Budzynski, J. R.
Evans, & A. Abarbanel (Eds.), Introduction to Quantitative
EEG and Neurofeedback: Advanced Theory and Applications
(2nd ed., pp. 453472). Burlington, MA: Elsevier Academic
Savostyanov, A. N., Tsai, A. C., Liou, M., Levin, E. A., Lee, J.-D.,
Yurganov, A. V., & Knyazev, G. G. (2009). EEG-correlates of
trait anxiety in the stop-signal paradigm. Neuroscience
Letters, 449(2), 112116.
Scheinost, D., Stoica, T., Saksa, J., Papademetris, X., Constable,
R. T., Pittenger, C., & Hampson, M. (2013). Orbitofrontal
cortex neurofeedback produces lasting changes in
contamination anxiety and resting-state connectivity.
Translational Psychiatry, 3(4), e250.
Siciliani, O., Schiavon, M., & Tansella, M. (1975). Anxiety and
EEG alpha activity in neurotic patients. Acta Psychiatrica
Scandinavica, 52(2), 116131.
Singer, K. (2004). The effect of neurofeedback on performance
anxiety in dancers. Journal of Dance Medicine & Science,
8(3), 7881.
Spielberger, C. D. (1983). State-Trait Anxiety Inventory for Adults.
Redwood City, CA: MindGarden, Inc.
Stern, J. M. (2005). Atlas of EEG Patterns. Philadelphia, PA:
Lippincott Williams & Wilkins.
Tharawadeepimuk, K., & Wongsawat, Y. (2014, November).
QEEG evaluation for anxiety level analysis in athletes. Paper
presented at the 7th 2014 Biomedical Engineering
International Conference, Fukuoka, Japan, pp. 14. /BMEiCON.2014.7017400
Walker, J. E. (2009). Anxiety associated with posttraumatic stress
disorderThe role of quantitative electroencephalograph in
diagnosis and in guiding neurofeedback training to remediate
the anxiety. Biofeedback, 37(2), 6770.
Wigton, N. L. (2014). Evaluating 19-channel z-score
neurofeedback: Addressing efficacy in a clinical setting
(Doctoral dissertation). Available from ProQuest Dissertations
and Theses database. (UMI No. 3625170)
Wigton, N. L. & Krigbaum, G. (2015). Attention, executive
function, behavior, and electrocortical function, significantly
improved with 19-channel z-score neurofeedback in a clinical
setting: A pilot study. Journal of Attention Disorders. Advance
online publication.
Received: August 26, 2018
Accepted: September 5, 2018
Published: September 29, 2018
... Clinicians display use of various forms of biofeedback modalities for treating anxiety (Jones & Hitsman, 2018). Some biofeedback modalities include heart rate variability (HRV) training and electromyography (EMG). ...
... Data collection for this retrospective study consisted of methods inspired by z-score training. Since the current study's data was collected from a student training clinic, the neurofeedback clinic director decided on single-channel amplitude training for three reasons: (a) this training is commonly used by clinicians, (b) it is an easier starting point for students in training versus more advanced modalities, and (c) numerous one-channel amplitude training research literature is reviewed by Wigton (2014;Jones & Hitsman, 2018). Therefore, the retrospective data included in this study were examining reduction of anxiety symptoms while utilizing qEEG-guided amplitude neurofeedback training protocols. ...
... Clients' qEEG recordings included fittings for the correct size of Electro-Cap (Electro-Cap International, Inc., Eaton, OH) 10-20 electrode placement with impedance levels less than 5 k. Preparation for the qEEG also included cleaning the ground and reference locations with abrading PCI prep pads, Nuprep skin prep gel, and rubbing alcohol (Jones & Hitsman, 2018). A member of the research team used the resulting data to develop an individualized protocol for anxiety. ...
Full-text available
In this retrospective study, researchers examined effects of quantitative electroencephalography (qEEG), individualized neurofeedback treatment protocols for anxiety. The present study includes 52 clients with 53.8% (n = 28) self-reporting as male and included two time points (pre and post). Secondary analyses utilized a subset of client data (n = 21) with measurements from three time points (pre, post, and follow-up). All clients completed qEEG and self-report assessments. Clients agreed to attend a minimum of 15 biweekly sessions, for one academic semester. Findings from regression analyses revealed three predictors of posttreatment outcomes. In addition, analysis of a subsample of data assessed at three time points revealed statistically significant improvement from pre to post and sustained outcomes from post to follow-up. We discuss limitations and implications for future research.
Despite the documented efficacy of neurofeedback (NFB) in the treatment of people with anxious symptomatology, many insurance companies identify NFB as experimental, which prohibits individuals from utilizing benefits to obtain this therapeutic treatment. In order to examine this discrepancy, the present meta‐analyses were conducted to examine the overall effectiveness of NFB, examine the impact of participant characteristics, and identify the extent of the differences in anxiety‐spectrum outcomes. Twenty‐six articles were divided based on design (12 single group (SG); 14 between‐group (BG)) and analyzed in separate meta‐analyses. Overall, results indicated that anxiety‐spectrum self‐report assessments were reduced by nearly one (SG SDM= −0.94; BG g = −0.87) standard deviation unit with relatively small degrees of bias. This study reports findings from the first exhaustive search of the literature, which included articles coming from a total of 17 databases/repositories. Applications of the findings are limited to Caucasian adults with symptoms of anxiety or PTSD.
Full-text available
Introduction: Anxiety disorders affect approximately 40 million Americans ages 18 and over (NIMH, 2015). Although qualitative and small-scale quantitative neurofeedback (NF) studies show reduction in anxiety symptoms, large-scale studies and quantitative electroencephalogram (qEEG) driven protocols are non-existent. This retrospective pilot study intended to assess whether qEEG guided amplitude NF is viable in symptom reduction of anxiety. Methods: Nineteen clients were assessed for anxiety, 14 were included in the data. Demographics include age ranges from 11–61 (M = 31.71, SD = 16.33), 9 male and 5 female; six identified as Caucasian, five as Hispanic/Latino, and three Caucasian/Hispanic ethnicity. Pre- and post-assessments included the Zung Self-Rating Anxiety Scale, Screen for Child Anxiety Related Disorders (SCARED), and the Achenbach System of Empirically Based Assessment (ASEBA). Clients received 30-min qEEG guided NF treatment sessions, twice a week. The range of attended session was 7–28 (M = 12.93, SD = 6.32). Results: Enhancement in clients’ well-being was evidenced by statistically significant improvement in symptom measures scores. Although improvements for the two most anxiety-related categories on the ASEBA were not significant, other anxiety-related categories did show significant improvement. Yet, qEEG findings were not statistically significant. Directions for future research are discussed. Keywords: anxiety; anxiety symptoms; qEEG guided amplitude neurofeedback; neurofeedback; z-scores Citation: Dreis, S. M., Gouger, A. M., Perez, E. G., Russo, G. M., Fitzsimmons, M. A., & Jones, M. S. (2015). Using Neurofeedback to Lower Anxiety Symptoms Using Individualized qEEG Protocols: A Pilot Study. NeuroRegulation, 2(3), 137–148.
Full-text available
Electroencephalograph (EEG) electrode impedance measurements of 5,000 ohms or less are required by common standards of practice to minimize artifacts due to electro-magnetic interference (EMI). Some manufacturers of amplifiers geared toward the neurofeedback market do not provide on-board impedance monitoring, but provide direct current (DC) offset measurements. To examine if DC offset is a reliable measure of connection quality, measurements of DC offset and impedance, each independently taken by students in a university graduate level course in neurofeedback over a one year period were analyzed retrospectively. DC offset was not found to have predictive value of a standard impedance level. Additionally, 19 channel EEGs collected within manufacturer recommended parameters of DC offset using a high-impedance amplifier were analyzed to assess the level of EMI pollution of quantitative EEG (QEEG) data. Visible peaks of EMI in the spectra in at least one channel in each of these recordings were identified. A sample of EMI pollution of QEEG results is presented. Together, these findings suggest that DC offset is not a reliable measure of electrode connection quality. Keywords: EEG, electrode, interference, impedance, DC offset, QEEG
Frontal alpha asymmetry has been proposed to underlie the balance between approach and withdrawal motivation associated to each individual's affective style. Neurofeedback of EEG frontal alpha asymmetry represents a promising tool to reduce negative affect, although its specific effects on left/right frontal activity and approach/withdrawal motivation are still unclear. The present study employed a neurofeedback training to increase frontal alpha asymmetry (right - left), in order to evaluate discrete changes in alpha power at left and right sites, as well as in positive and negative affect, anxiety and depression. Thirty-two right-handed females were randomly assigned to receive either the neurofeedback on frontal alpha asymmetry, or an active control training (N = 16 in each group). The asymmetry group showed an increase in alpha asymmetry driven by higher alpha at the right site (p < 0.001), as well as a coherent reduction in both negative affect and anxiety symptoms (ps < 0.05), from pre-to post-training. No training-specific modulation emerged for positive affect and depressive symptoms. These findings provide a strong rationale for the use of frontal alpha asymmetry neurofeedback for the reduction of negative affect and anxiety in clinical settings.
There were two objectives of this paper. The first objective of this paper was to observe the brain activity of Asian athletes before the match. Second, the paper aimed to study the anxiety symptom showing on the brain via QEEG (Quantitative Electroencephalography) maps. The anxiety level for Asian athletes can be classified using the index of brain topographic map (Absolute power) relative to the normative database used for analysis. Firstly, Asian athletes have to complete revised competitive state anxiety inventory-2 (CSAI-2R) questionnaires. The Asian athletes then were recorded for their QEEG twice in 2 weeks (1 time/week) before competing in a match. In the competition, the anxiety symptom and performance of Asian athletes are observed and their feedbacks from the coach are asked. Lastly, the anxiety level is classified from results of QEEG maps, the CSAI-2R questionnaires and condition in the competition. The result of anxiety level showed that the quantity of alpha frequency band in posterior head region (parietal and occipital lobes) is less than the normal condition in term of brain topographic map. In addition, amateur Asian athletes have lower quantity of alpha frequency band than the experienced Asian athletes when the time of competition becomes nearer. Furthermore, the focal area that showed in brain connectivity (Coherence) was presented in lower interactions between position to position in the frontal lobe.
This chapter briefly reviews definitions of anxiety and anxiety disorders, identifies specific EEG and QEEG patterns which in clinical practice and/or research have been found to be correlates of some anxiety disorders, and cites neurofeedback protocols for treating anxiety as suggested by experienced clinicians and/or by research. Augmenting procedures such as breathwork, muscle relaxation, heart rate variability training, AVE, EMDR, cognitive behavioral therapy, and other psychotherapy forms are given only a brief mention. That anxiety states are complex disorders is obvious, not only because of the multiple patterns of differences displayed by QEEG, fMRI and SPECT, but also due to the disparate manifest emotional/behavioral symptoms that may or may not correlate with the above physiological measurements. Despite the diversity of EEG anxiety patterns, clusters of them often occur, constituting an emotional/behavioral clinical picture such as obsessive-compulsive disorder. There are some QEEG patterns found by research, and/or through clinical experience, to be associated with general or specific anxiety disorders, and there are some neurofeedback training protocols rather consistently cited by expert clinicians as efficacious for treatment of these disorders. For example, given a fairly clear anxiety-related behavioral state, or given one or more specific EEG/QEEG pattern, attention to increasing posterior alpha power and/or decreasing beta power in frontal or temporal sites is a commonly reported approach.
Neurofeedback (NF) is gaining recognition as an evidence-based intervention grounded in learning theory, and 19-channel z-score NF (19ZNF) is a new NF model. This pilot study sought to evaluate the efficacy of 19ZNF in a clinical setting. Outcome measures framed groups such that 19ZNF was evaluated, as it relates to the neuropsychological constructs of attention (n = 10), executive function (n = 12), behavior (n = 14), and electrocortical functioning (n = 21). One-tailed t tests compared pre-post difference scores. For all pre-post comparisons, the direction of change was in the predicted direction, and differences were statistically significant (p = .000 to p = .008, effect sizes 1.29 to 3.42). Results suggest 19ZNF improved attention, executive function, behavior, and electrocortical function. This study provides beginning evidence of 19ZNF's efficacy, adds to what is known about 19ZNF, and offers an innovative approach for using quantitative electroencephalographic (QEEG) metrics as outcome measures. © 2015 SAGE Publications.
Over the years, several new models and variations of neurofeedback (NF) have been developed. As such, NF has grown from traditional amplitude based modalities to now include slow cortical potential NF, as well as various approaches grounded in QEEG technology, including z-score NF models. These differing modalities have important implications in terms of outcomes, the number of sessions required, and treatment specificity. This, in turn, impacts clinical practice, research, and marketing considerations. In an effort to gain some perspective for where the field is today, a comparative review is presented to illustrate the importance of noting what particular modality is being referenced when discussing NF.
Few well-controlled studies have considered neurofeedback treatment in adult psychiatric patients. In this regard, the present study investigates the characteristics and effects of neurofeedback on adult psychiatric patients in a naturalistic setting. A total of 77 adult patients with psychiatric disorders participated in this study. Demographic data and neurofeedback states were retrospectively analyzed, and the effects of neurofeedback were evaluated using clinical global impression (CGI) and subjective self-rating scales. Depressive disorders were the most common psychiatric disorders (19; 24.7 %), followed by anxiety disorders (18; 23.4 %). A total of 69 patients (89.6 %) took medicine, and the average frequency of neurofeedback was 17.39 ± 16.64. Neurofeedback was applied to a total of 39 patients (50.6 %) more than 10 times, and 48 patients (62.3 %) received both β/SMR and α/θ training. The discontinuation rate was 33.8 % (26 patients). There was significant difference between pretreatment and posttreatment CGI scores (<.001), and the self-rating scale also showed significant differences in depressive symptoms, anxiety, and inattention (<.001). This is a naturalistic study in a clinical setting, and has several limitations, including the absence of a control group and a heterogenous sample. Despite these limitations, the study demonstrates the potential of neurofeedback as an effective complimentary treatment for adult patients with psychiatric disorders.
The literature regarding neurofeedback treatment of anxiety associated with post traumatic stress disorder (PTSD) is reviewed. The results of quantitative electroencephalograph (QEEG) guided neurofeedback training for anxiety in nineteen PTSD patients is analyzed, along with the change in anxiety in four control patients who did not do neurofeedback. Those who did neurofeedback training experienced clinically significant reductions in anxiety, whereas there was no significant change in anxiety in the control group. QEEG-guided neurofeedback appears to be effective in a higher percentage of patients than non–QEEG-guided training in increasing alpha and theta, based on results in the published literature.