UNDERSTANDING ANXIETY

Anxiety is an uncomfortable, overwhelming, persistent feeling similar to fear. This feeling of worry is often difficult to control. For example, even if you know you have a strong, anxious response when you do tests or exams, it is still difficult to calm yourself down and really demonstrate you know your stuff. Anxiety can manifest as emotional symptoms (feeling unmotivated and discouraged), physical symptoms (fatigue, fluctuations in weight, changes in appetite, pain in the body, etc.), behavioural symptoms (avoiding people and events, reduced interest in sex, reduction in self-care activities), and cognitive symptoms (struggling with concentration and alertness, issues with planning and organization, forgetting things, etc.). Sometimes individuals who are anxious may also feel or be experiencing depression. See our section on depression.

Anxiety can also affect a person’s instrumental activities of daily living (IADLs) which can be simply defined as a person’s daily self care activities. Some IADLs include cooking, cleaning, communication, accessing transportation, laundry, shopping, and managing personal finances. Anxiety is usually diagnosed by a clinical psychologist or psychiatrist, but can also be diagnosed by your family physician. It is usually diagnosed after the symptoms related to Anxiety do not go away after 6 months. There are many different types of anxiety which range from a specific situation to most or all aspects of life.

OUR APPROACH TO ANXIETY

We start with a Clinical Intake Interview to review background history, medical history, identify specific symptoms and their severity, review previous assessments and interventions, and identify if any other assessments are required. The next step is to complete a QEEG (Quantitative Electroencephalogram) assessment to analyze your brainwave patterns. The best way to understand brain waves is to compare them to each section of an orchestra. Every section of an orchestra needs to work together to make sure the music sounds good. Sometimes one section of the orchestra is more dominant than the other, but all sections are necessary to produce beautiful music. In the same way all brain waves are necessary to balance each other out, complement each other, and become dominant when necessary. For example, when you need to analyze and engage in higher level thinking you want your brain to be dominant in faster brain wave patterns to accomplish this task. When you are getting ready for sleep you want your brain to gradually slow down and be dominant in slower brain wave patterns.

People who usually have anxiety demonstrate an excess or dominance of fast brain wave patterns even where there is no task in front of them. Their brain is stuck in a processing or analyzing mode and they find it tough to relax. They may also have a reduction in calm and alert brain wave patterns such as alpha and sensorimotor rhythm (SMR). Once we figure out what brain wave patterns are related to your symptoms we can design a personalized program to target and improve them. During each session we monitor your brain waves in real time and when there is greater balance of brain wave patterns we reward you with video and sound. These audio and visual rewards help train and guide your brain to have improved balance and improve your symptoms.

Sometimes clients require additional support in conjunction with neurofeedback training. Some options are psychotherapy and somatic experiencing therapy.

RESEARCH ARTICLES ON ANXIETY

This section is meant to highlight research that has been done in the field. The following brief summaries are resources that we have gathered for the public. For an in-depth look at each research article we recommend using the citation to find and read the original article. We hope to add additional resources when possible!

Zhao, Z., Yao, S., Li, K., Sindermann, C., Zhou, F., Zhao, W., Li, J., Luhrs, M., Goebel, R., Kendrick, K., Becker, B. (2019). Real-Time Functional Connectivity-Informed Neurofeedback of Amygdala-Frontal Pathways Reduces Anxiety. Psychotherapy and Psychosomatics, 88:5-15

Deficient emotion regulation and exaggerated anxiety represent a major transdiagnostic psychopathological marker. On the neural level these deficits have been closely linked to impaired, yet treatment-sensitive, prefrontal regulatory control over the amygdala. This study suggests that by gaining control over these pathways it could provide an innovative intervention to regulate exaggerated anxiety. In a randomized crossover sham-controlled design, 26 healthy subjects with high anxiety underwent real-time fMRI-guided neurofeedback training to enhance connectivity between the ventrolateral prefrontal cortex (vlPFC) and the amygdala (target pathway) during threat exposure. A follow up study was done after 3 days to track progress levels. The results showcased that training of the target pathway significantly increased amygdala-vlPFC connectivity and decreased levels of anxiety. At the group level stronger connectivity increases were significantly associated with higher anxiety reduction. Thus, the study acts to emphasize the therapeutic potential of connectivity-informed real-time neurofeedback.

Harris, S., Hundley, G., Lambie, G. (2018). The effects of Neurofeedback on Depression, Anxiety, and Academic Self-Efficacy. Journal of College Student Psychotherapy, DOI: 10.1080/87568225.2019.1606689

This preliminary study examined the effects of 16 sessions of neurofeedback training on levels of depression, anxiety, and academic self-efficacy in college students with attention deficit hyperactivity disorder (ADHD). Participants were screened using three different measures, completed at four points throughout the investigation. Statistically significant results identified that neurofeedback was a viable option for mitigating depression and anxiety symptoms as well as increasing academic self-efficacy scores in college students with ADHD, based on their scores over time.

Mennella, R., Patron, E., Palomba, D. (2017). Frontal alpha asymmetry neurofeedback for the reduction of negative affect and anxiety. Behaviour Research and Therapy, DOI:10.1016/j.brat.2017.02.002

This study draws on previous research in the field that proposes, frontal alpha asymmetry underlies the balance between approach and withdrawal motivation associated with an individual’s affective style. The study employed thirty-two right-handed females who underwent neurofeedback training to increase frontal alpha asymmetry. This was done in an effort to evaluate discrete changes in alpha power at left and right sites, as well as in positive and negative affect, for anxiety and depression. Participants were randomly assigned to receive either the neurofeedback training, or an active control training. Results from the neurofeedback training group, showcased a significant increase in alpha asymmetry driven by higher alpha at the right site, as well as a reduction in both negative affect and anxiety symptoms, from pre-to post-training. In summary, these findings provide a strong basis for the use of the frontal alpha asymmetry neurofeedback for the reduction of negative affect and anxiety in clinical settings.

Blaskovits, F., Tyerman, J., Luctkar-Flude, M. (2017). Effectiveness of neurofeedback therapy for anxiety and stress in adults living with a chronic illness: a systematic review protocol. JBI Database of Systematic Reviews and Implementation Reports, DOI: 10.11124/JBISRIR-2016-003118

In this review the authors systematically examine the effectiveness of neurofeedback therapy for managing anxiety and stress in adults living with a chronic illness. When compared with traditional methods of treatment for anxiety – such as pharmacological modalities – neurofeedback may act to reduce or eliminate the use of these medications. Anxiety and stress have direct neurobiological consequences that act to alter certain brain-specific regions. This alludes to the usefulness of neurofeedback therapy as it targets those specific brain regions. Neurofeedback targets the internal variable such as operant brain waves in an attempt to decrease anxiety, thereby providing the patient with an appropriate level of personalized intervention based on the their own biofeedback.

Lu, Y., Wang C., Su, L., Ma, Z., Li, S., Fan, Y. (2017). Effects of Neurofeedback on Panic Disorder Patients’ anxiety. Neuroquantology, DOI: 10.14704/nq.2017.15.3.1083

This article aimed to examine the effectiveness of a 7-week neurofeedback training programme that acted to increase the range of the alpha band and improve abnormal anxiety in patients with panic disorder. A randomized controlled trial was conducted where patients were assigned to one of two groups; Neurofeedback training and a control group. The neurofeedback group received 20 sessions of personalized training whereas the control group received baseline routine care. The results showcased significantly higher changes in the neurofeedback group than the control group. This was characterized through the increased range of the alpha band in the neurofeedback group. In conclusion, an intervention involving neurofeedback significantly improved abnormal anxiety in adverse situations.

Scheinost, D., Stoica, T., Saksa, J., Papademetris, X., Constable, R., Pittenger, C., Hampson, M. (2013). Orbitofrontal cortex neurofeedback produces lasting changes in contamination anxiety and resting-state connectivity. Translational Psychiatry, DOI: 10.1038/tp.2013.24

In this study, the authors used functional magnetic resonance imaging (fMRI) neurofeedback (NF) to noninvasively alter patterns of brain connectivity and to reduce contamination anxiety. Activity from a region of the orbitofrontal cortex associated with contamination anxiety was measured and provided to subjects with significant but subclinical anxiety. Subjects exhibited reduced resting state connectivity in limbic circuitry and increased connectivity in the dorsolateral prefrontal cortex. Critically significant changes were observed in connectivity several days after the completion of neurofeedback training, subjects showed increased control of contamination anxiety.Thereby demonstrating that such training can lead to lasting modifications of brain functional architecture. Matched subjects that underwent treatment in the control group showed no such reorganization nor improvement in anxiety control. This article thereby suggests that neurofeedback can enable enhanced control over anxiety and support the potential of it as a clinically useful therapy.

Koush, Y., Meskaldji, D., Pichon, S., Rey, G., Rieger, S., Linden, D., Van De Ville, D., Vuilleumier, P., Scharnowski, F. (2015). Learning Control Over Emotion Networks Through Connectivity-Based Neurofeedback. Cerebral Cortex, DOI:10.1093/cercor/bhv311

This study builds on the knowledge that most mental functions are associated with dynamic interactions within functional brain networks. Therefore, training individuals to alter their functional brain network may allow them with a novel means to improve cognitive performance and emotions. The authors of the study taught participants control over a key component of the emotion regulation network by using a connectivity-neurofeedback approach based on functional magnetic resonance imaging (fMRI). Participants learned to increase top-down connectivity from the dorsomedial prefrontal cortex, which is involved in cognitive control, onto the amygdala, which is involved in emotion processing. Fifteen healthy volunteers took part in 3 neurofeedback training sessions. Follow-up tests revealed that participants in the experimental group were able to control top-down connectivity significantly better after neurofeedback training and showcased significantly higher learning success than those in the control group. The results demonstrate that connectivity-based neurofeedback training of emotion regulation networks enhances emotion regulation capabilities and can potentially lead to therapeutic protocols for neuropsychiatric disorders.

Gomes, J., Ducos, D., Akiba, H., Dias, A. (2016). A neurofeedback protocol to improve mild anxiety and sleep quality. Brazillian Journal of Psychiatry, DOI: 10.1590/1516-4446-2015-1811

Similar to most psychiatric disorders, anxiety and depression are conditions whose severity can be represented over a continuum that ranges from subclinical manifestations to full-blown biosocial disabilities. The alpha band (8-12 Hz) asymmetry in the left frontal cortex has emerged as the most prominent electroencephalographic (EEG) correlate of both anxiety and depression, followed by excessive band power in beta 1 (12-20 Hz) and beta 2 (20-3- Hz) waves in the right parietal lobe. In this study a 29-year-old woman, with no previous psychiatric history, presented with anxiety symptoms, sleep problems and mild cognitive impairments. The training protocol lasted for 20 sessions, during which the subject was trained to increase beta 1 at C4 with eyes open and eyes closed. A marked improvement in anxiety, depression, and sleep quality, as well as some improvements in executive functions were observed. From an endophenotypic viewpoint, there was an overall increase in beta 1, low alpha (8-10 Hz), and high alpha (10-12 Hz) powers and a decrease in beta 2 (a stress biomarker). These results suggest that neurofeedback can be used as an adjunct in the treatment of subclinical anxiety with minimal risk and low technology costs

Sandhu, J., Paul, M., Agnihotri, H. (2007). Biofeedback Approach in The Treatment of Generalized Anxiety Disorder. Iranian Journal of Psychiatry, 2(3):90-95

Generalized anxiety disorder (GAD) is a common anxiety disorder that typically has an early age of onset, a chronic course and a high degree of comorbidity with other anxiety and mood disorders. This study compares the efficacy of two most commonly used biofeedback relaxation techniques in the treatment of GAD. 45 individuals were randomly assigned to three groups: Group I received electromyographic biofeedback relaxation training, Group II received alpha-electroencephalographic biofeedback relaxation training and Group III served as the control group. At follow-up, both treatment groups resulted in more consistent patterns of generalized relaxation changes reflected in galvanic skin resistance, state and trait anxiety as compared to the control group. Further follow-up studies showcased the prolonged persistence of effects that was initially observed in both treatment groups. The authors conclude that both biofeedback training are effective in the treatment of Generalized Anxiety Disorder.

Moradi, A., Pouladi, F., Pishva, N., Rezaei, B., Torshabi, M., & Mehrjerdi, Z. A. (2011). Treatment of anxiety disorder with neurofeedback: Case study. Procedia – Social and Behavioural Sciences, 103-107.

In this case study the authors report the effects of combining beta-increase and alpha-increase in EEG feedback training and alpha-theta biofeedback training for two patients suffering from chronic anxiety which did not respond to previous attempts to manage through psychopharmacological interventions. Both patients, in their twenties, underwent medical evaluation which showed no physical reason for presenting complaints of anxiety, ruminative thought, nervousness etc. A 90-item self-report inventory of adult psychological symptoms called the SCLR-90-R was administered to evaluate the patients complaints and assess the effectiveness of the treatment during the course of therapy at the beginning and the end of the therapy program; and again 1-year after they ended therapeutic intervention in a follow-up. Patients were also interviewed. Treatment involved attending three 50-minute sessions a week over a period of 10 weeks. Audio-visual neurofeedback programs were used to assist in reinforcing desired brainwave activity. When set thresholds were met, level of difficulty was increased. Following 30 sessions, both patients reported a significant reduction in anxiety-related symptoms; at the 1-year follow up all clinical scales were within normal range and self-reports confirmed that the patients were symptom-free. In summary, the findings from this study clearly demonstrate that neurofeedback is effective in the treatment of anxiety disorders.

Hammond, D. C. (2005). Neurofeedback with anxiety and affective disorders. Child and Adolescent Psychiatric Clinics of North America, 14, 105-123.

This article engages with existing research on functional brain abnormalities associated with depression, anxiety, and obsessive-compulsive disorder. The authors describe, in detail, the neurophysiological basis for various symptoms and differentiate these factors from biological predisposition. It is argued that despite psychiatry’s strong reliance on the use of medication for the treatment of depression and anxiety; current evidence seems to suggest that pharmacologic treatment may not be as effective as was previously believed. The authors provide a brief overview of the research done to determine the efficacy of more traditional treatment models and stress the point that an increasing number of patients seem interested in less invasive treatment than medication. Neurofeedback is introduced as an alternative treatment option for modifying dysfunctional, biologic brain patterns that are associated with various psychiatric conditions and the advantages are discussed.

White, E. K., Groeneveld, K. M., Tittle, R. K., Bolhuis, N. A., Martin, R. E., Royer, T. G., & Fotuhi, M. (2017). Combined neurofeedback and heart rate variability training for individuals with symptoms of anxiety and depression: A retrospective study. NeuroRegulation, 4(1), 37–55. http://dx.doi.org/10.15540/nr.4.1.37

This report is the first of its kind to observe the impact of concurrent neurofeedback (NFB) and heart rate variability (HRV) training as a viable intervention strategy for symptoms of anxiety and depression. 183 children and adults with anxiety and/or depression symptoms underwent treatment consisting of concurrent NFB and HRV training for a total of 30 sessions within a time period of 6 to 24 weeks. Results showed that symptoms of anxiety and depression reduced in both adults and children. Both questionnaire assessment and changes in EEG, breathing rate and HRV were of clinical significance. The authors concluded that NFB and HRV training is an effective, non-pharmaceutical option for intervention to reduce symptoms of anxiety and depression. It was also concluded that NFB and HRV may improve EEG, blood pressure, resting breathing rate and HRV.

Costa, M. A., Gadea, M., Hidalgo, V., Perez, V., & Sanjuan, J. (2016). An effective neurofeedback training, with cortisol correlates, in a clinical case study. Universitas Psychologica, 15(5). The purpose of this case study was to determine the reproducibility and practicality of an economic short term neurofeedback intervention (10 sessions). The participant of this study was a 33 year old woman suffering from a set of symptoms that fulfills the diagnostic criteria of an anxiety syndrome according to the DSM-V. Over the course of 5 weeks the participant underwent treatment consisting of a well-established beta1/theta neurofeedback protocol to enhance beta1 without causing increases in theta rhythm. State anxiety and salivary cortisol levels were measured during each of the 10 sessions following a pre/post design. A significant decrease in the evaluated state of anxiety was observed during the last five sessions of treatment. Since this study is the first longitudinal study of its kind to assess neurofeedback, hormonal, cognitive and emotional variable; the observational relationship between beta1 and cortisol levels suggest that brain activity may be considered a marker of anxiety in the near future.

Ghaziri, J., Tucholka, A., Larue, V., Blanchette-Sylvestre, M., Reyburn, G., Gilbert, G., . . . Beauregard, M. (2013). Neurofeedback Training Induces Changes in White and Gray Matter. Clinical EEG and Neuroscience, 44(4), 265-272. doi:10.1177/1550059413476031

In this study, Health university students were randomly assigned to the experimental group, sham group or control group. Participants in the experimental group trained to enhance beta waves at F4 and P4. Attentional performance and MRI data were recorded one week before training and one week after training. Higher scores on auditory and visual sustained attention were present in experiment group. Gray matter volume increases were detected in cerebral structures involved in this type of attention. This study constitutes the first empirical demonstration that neurofeedback training leads to microstructural changes in white and gray matter.

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