Level 4 Efficacy
Anxiety Research
Neurofeedback has been ranked as a Level 4 ("Efficacious") treatment for anxiety!
Level 4 Efficacy Meaning
According to the Association for Applied Psychophysiology and Biofeedback (AAPB) and the International Society for Neurofeedback and Research (ISNR), neurofeedback for anxiety has achieved a Level 4: Efficacious rating. This designation means that multiple well-controlled studies have demonstrated that neurofeedback is significantly more effective than placebo treatments in reducing anxiety symptoms.
In practical terms, this means that neurofeedback is not just a promising therapy—it is a proven method for helping individuals manage and alleviate anxiety.
Supporting Research
A comprehensive review published in the Journal of Counseling & Development analyzed 26 studies on neurofeedback for anxiety. The meta-analysis concluded that neurofeedback leads to significant reductions in anxiety symptoms, reinforcing its status as an effective treatment option.
“The results indicated that neurofeedback training significantly reduced anxiety symptoms across various anxiety disorders.”
— Russo, G. M., Balkin, R. S., & Lenz, A. S. (2022)
You can read the full study here: Efficacy Evaluation of Neurofeedback-Based Anxiety Relief
| Feature / Benefit | Neurofeedback | Medication | Talk Therapy (CBT) |
|---|---|---|---|
| How it Works | Trains brainwave patterns using real-time feedback | Alters brain chemistry with pharmaceuticals | Addresses thoughts, emotions, and behaviors |
| Evidence-Based for Anxiety | ✔ Yes (Level 4 Efficacious – multiple studies) | ✔ Yes, especially for short-term symptom relief | ✔ Yes, widely researched and effective |
| Non-Invasive | ✔ Yes | ✘ No – involves chemical intervention | ✔ Yes |
| Side Effects | Minimal to none | Possible (e.g., drowsiness, weight changes) | Minimal |
| Addresses Root Brain Patterns | ✔ Yes – targets dysregulated brain activity | ✘ No – manages symptoms rather than correcting cause | ✘ No – focuses on coping, not brain regulation |
| Duration of Benefits | Long-lasting with proper training | Short-term; may require ongoing use | Medium to long-term, varies by individual |
| Custom-Tailored | ✔ Yes – based on brain maps (QEEG) | ✘ Usually generalized by diagnosis | ✔ Yes – therapist adjusts per session |
| Works Well with Other Treatments | ✔ Yes – complements therapy & meds | ✔ Often used with therapy | ✔ Often used with meds or neurofeedback |
| Typical Treatment Duration | 20–40 sessions (2–3 months average) | Ongoing or long-term use | Weekly sessions over several months |
Key Neurofeedback Research Articles Supporting Anxiety Treatment
1) Mennella, R., et al. (2017, published online 2018). "Efficacy of Neurofeedback for Anxiety Disorders: A Systematic Review and Meta-Analysis." Frontiers in Human Neuroscience.
Summary: This meta-analysis reviewed 15 studies (including 7 RCTs, 613 participants) evaluating neurofeedback for anxiety disorders, including generalized anxiety disorder (GAD) and social anxiety. Protocols like alpha/theta and SMR training significantly reduced anxiety symptoms (Hedges’ g = 0.72, p < 0.01), with effects comparable to cognitive-behavioral therapy (CBT) in some trials. The study highlights neurofeedback’s ability to modulate brain activity (e.g., reducing excessive beta waves) as a mechanism for anxiety relief.
Access: Open-access article available via Frontiers.
The PDF can be downloaded directly from the journal’s website.
Why It Supports Neurofeedback: The meta-analysis provides robust evidence of moderate-to-large effect sizes for anxiety reduction, with sustained benefits at follow-up (3–6 months), supporting neurofeedback as a non-invasive treatment option.
2) Hou, Y., et al. (2021). "Neurofeedback Training for Anxiety: A Randomized Controlled Trial." Journal of Affective Disorders.
Summary: This RCT with 80 participants compared alpha/theta neurofeedback to a sham control in adults with GAD. The neurofeedback group showed significant reductions in anxiety scores on the Hamilton Anxiety Rating Scale (HAM-A) (p < 0.001, Cohen’s d = 0.85) after 20 sessions, with improvements in alpha power and reduced beta activity. Benefits persisted at a 3-month follow-up, suggesting lasting effects.
Access: Not fully open-access, but available via ScienceDirect.
Link: ScienceDirect
Access through an institutional subscription, or request the PDF via ResearchGate or by contacting the corresponding author (Yingjie Hou).
Why It Supports Neurofeedback: The RCT demonstrates specific effects of alpha/theta training on anxiety symptoms, with neurophysiological changes (e.g., enhanced alpha power) supporting the mechanism of action.
3) Kerson, C., et al. (2019). "Alpha Suppression and Symmetry Training for Generalized Anxiety Disorder: A Randomized Controlled Trial." NeuroRegulation.
Summary: This RCT (n = 54) tested alpha suppression and symmetry training against a waitlist control for GAD. After 30 sessions, the neurofeedback group showed significant reductions in State-Trait Anxiety Inventory (STAI) scores (p < 0.01, d = 0.78) and improved EEG symmetry in frontal regions. The study suggests that targeting alpha asymmetry can normalize brain activity linked to anxiety.
Access: Open-access article available via NeuroRegulation.
Link: NeuroRegulation
The PDF can be downloaded directly from the journal’s website.
Why It Supports Neurofeedback: The study provides evidence that alpha-based protocols directly address neurophysiological markers of anxiety, with clinically significant symptom improvements.
4) Blaskovits, T., et al. (2023). "Neurofeedback as a Treatment for Anxiety in Adolescents: A Systematic Review." Applied Psychophysiology and Biofeedback.
Summary: This systematic review analyzed 12 studies (including 5 RCTs, 387 adolescents) on neurofeedback for anxiety disorders in adolescents. Protocols like SMR and theta/beta ratio training reduced anxiety symptoms (average effect size SMD = 0.65), particularly in social anxiety and GAD, with improvements in self-reported and parent-reported outcomes. The review notes neurofeedback’s feasibility in school settings.
Access: Not open-access, but available via Springer.
Link: SpringerLink
Access through an institutional subscription, or request the PDF via ResearchGate or by contacting the corresponding author (Tiffany Blaskovits).
Why It Supports Neurofeedback: The review highlights neurofeedback’s efficacy in a specific population (adolescents), with moderate effect sizes and practical applications, supporting its use in diverse settings.
5) Wang, Y., et al. (2022). "EEG Neurofeedback for Anxiety and Depression: A Meta-Analysis of Clinical Trials." Clinical Neurophysiology.
Summary: This meta-analysis of 20 clinical trials (896 participants) examined EEG neurofeedback for anxiety and depression. For anxiety, neurofeedback (primarily alpha/theta and SMR protocols) yielded a significant reduction in symptoms (SMD = 0.68, p < 0.001), with stronger effects in GAD than in mixed anxiety disorders. The study found neurofeedback to be particularly effective when combined with psychotherapy.
Access: Not open-access, but available via Elsevier.
Link: Clinical Neurophysiology
Access through an institutional subscription, or request the PDF via ResearchGate or by contacting the corresponding author (Yibo Wang).
Why It Supports Neurofeedback: The meta-analysis confirms neurofeedback’s efficacy across anxiety subtypes, with neurophysiological evidence (e.g., reduced beta power) supporting its mechanism.