Are EEG Neurofeedback Benefits Due to Placebo Effects?

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      Summary: A new study argues that clinical improvements reported as being the result of neurofeedback are more likely due to a placebo effect.

      Source: McGill University.

      Neurofeedback using electroencephalograpy boasts thousands of practitioners and appears to both improve normal brain function and alleviate a wide variety of mental disorders – from anxiety to alcoholism. But after examining the scientific literature and consulting experts in Europe and the U.S., McGill University researchers Robert Thibault and Amir Raz conclude that clinical improvements from this increasingly popular alternative therapy are due to placebo effects.

      Writing in Lancet Psychiatry, they report that “sham neurofeedback” improves outcomes as much as true EEG neurofeedback. “Patients spend thousands of dollars and dedicate up to six months training their brain with neurofeedback,” Thibault says. “Yet, they are chasing elusive brain-based processes.”

      Future research should focus on the psychological and social influences that account for clinical improvement from these treatments, and study how to apply these elements “in a fashion that is both scientifically judicious and ethically acceptable,” the researchers write. One hopeful note: unlike neurofeedback with EEG, they say, nascent findings from neurofeedback with functional magnetic resonance imaging “seem to pave a promising, albeit tentative, road” toward the coveted “self-regulating brain.”

      Image shows a brain plugged up to a smart phone.
      Robert Thibault and Amir Raz conclude that clinical improvements from this increasingly popular alternative therapy are due to placebo effects. NeuroscienceNews.com image is credited to McGill University.
      About this psychology research article

      Source: Cynthia Lee – McGill University
      Image Source: NeuroscienceNews.com images are credited to McGill University.
      Original Research: Abstract for “When Can Neurofeedback Join the Clinical Armamentarium?” by Robert T. Thibault and Amir Raz in Lancet Psychiatry. Published online June 1 2016 doi:10.1016/S2215-0366(16)30040-2

      Cite This NeuroscienceNews.com Article

      [cbtabs][cbtab title=”MLA”]McGill University. “Are EEG Neurofeedback Benefits Due to Placebo Effects?.” NeuroscienceNews. NeuroscienceNews, 5 June 2016.
      <https://neurosciencenews.com/eeg-neurofeedback-placebo-4379/>.[/cbtab][cbtab title=”APA”]McGill University. (2016, June 5). Are EEG Neurofeedback Benefits Due to Placebo Effects?. NeuroscienceNews. Retrieved June 5, 2016 from https://neurosciencenews.com/eeg-neurofeedback-placebo-4379/[/cbtab][cbtab title=”Chicago”]Wyss Institute/Harv ard. “Are EEG Neurofeedback Benefits Due to Placebo Effects?.” https://neurosciencenews.com/eeg-neurofeedback-placebo-4379/ (accessed June 5, 2016).[/cbtab][/cbtabs]

      Abstract

      When Can Neurofeedback Join the Clinical Armamentarium?

      Neurofeedback appears both to improve normal brain function1 and to treat a wide range of mental disorders, including attention deficit hyperactivity disorder (ADHD), epilepsy, depression, anxiety, insomnia, autism spectrum disorder, and alcoholism.2 However, despite a relatively long history, the medical community continues to question the clinical utility of this technique. To earn widespread recognition as evidence-based medicine, neurofeedback must meet three challenges: first, perform at least on par with standard-of-care treatments in randomised controlled trials for each disorder that neurofeedback purports to help; second, consistently outperform highly comparable placebo control conditions (eg, sham neurofeedback); and third, establish a clear mechanism for the claimed therapeutic benefits.

      “When Can Neurofeedback Join the Clinical Armamentarium?” by Robert T. Thibault and Amir Raz in Lancet Psychiatry. Published online June 1 2016 doi:10.1016/S2215-0366(16)30040-2

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      8 Comments

      1. It should be recognized that the psychiatric/medical community, evidence-based databases, and insurance companies routinely rely upon psychiatric treatments as “efficacious” without a preoccupation with whether these treatments involve substantial placebo influences, without apparent consideration of the serious flaws in medication treatment research design, or even the common side effects. Expectation of effectiveness has been shown to be the largest variable in antidepressant improvement and yet it is considered evidence based. There are many potential problems in utilizing what many persons consider to be the “gold standards” in designing placebo controlled studies to evaluate the efficacy of neurofeedback. These include: controlling for the nuances of therapist-subject interaction in a training paradigm; the lack of genuine feedback reward in utilizing sham feedback; the inherent transparency to an experienced clinician who is coaching neurofeedback when only sham feedback is being provided; the significant number of sessions required in effective neurofeedback treatment; and the issue of experienced versus clinically inexperienced neurotherapists. It could be argued that double blind placebo controlled studies, therefore, have limited applicability in evaluating neurofeedback outcomes. It is as unrealistic as trying to do a placebo-controlled study of psychotherapy.

        Medication outcome research helps to provide an invaluable perspective that must be kept in mind with regard to the degree to which medical and psychiatric treatments are actually evidence based. Despite the aura that modern psychiatry and medicine are evidence-based, Tricoci, Allen, Kramer, Califf, and Smith (2009) in the Journal of the American Medical Association recently revealed that only 11% of 2711 treatment recommendations in a medical specialty were based on level A evidence (multiple randomized trials). Of the remaining recommendations, 41% were based on level B evidence (a single randomized trial or non-randomized studies), and 48% were based on level C evidence (expert opinion or case studies). Thus although all scientifically minded neurofeedback practitioners acknowledge a need for additional outcome research, much of current medical and psychiatric treatment is not based on sound scientific evidence. Medical ethicists (Andrews, 2001; Lurie & Wolfe, 1997; Rothman, 1987), neurofeedback advocates (La Vaque, 2001), and the Declaration of Helsinki (World Medical Association, 2000) have expressed the view that requiring placebo controlled studies in conditions where there is a known effective treatment already available is considered unethical.

        Some placebo controlled studies have demonstrated efficacious and specific effects of neurofeedback with learning disabilities (Fernandez, Herrera, Harmony, Diaz-Comas, Santiago, Sanchez, et al, 2003), anxiety (Raymond, Varney, Parkinson & Gruzelier, 2005), sleep latency and declarative learning (Hoedlmoser, Pecherstorfer, Gruber, Anderer, Doppelmayr, Klimesch, & Schabus, 2008), cognitive enhancement in the elderly (Angelakis, Stathopoulou, Frymiare, Green, Lubar, & Kounios 2006) and depression (Choc, Chi, Chung, Kim, Ahn, & Kim, 2011). Certainly animal studies (e.g., Sterman, 1973; Larsen, Larsen, Hammond, Sheppard, Ochs, Johnson, Adinaro, & Chapman, 2006) also suggest that neurofeedback has therapeutic effects independent of placebo effects. We would not anticipate that cats would form positive expectancies about being more seizure resistant simply because an experimenter was putting electrodes on their heads.
        For purposes of arguing with skeptical academics, let us consider, “What if the majority of the positive effects of neurofeedback treatment were nothing more than placebo effects?” If this were the case it would not be so different from the findings of research documenting that the effects of psychopharmacological medications primarily represent placebo effects. But, if this were the case, the major difference would still be that the risk/benefit and side effect profile appears much better with neurofeedback (the Monastra et al. [2005] review of neurofeedback with ADD/ADHD estimated side effects to occur in 1-3%). In addition to side effects and withdrawal effects, medication treatments are disempowering because improvements are attributed to the effects of continuing to take the medication, whereas neurofeedback presents treatment effects to the patient as representing an enduring reconditioning of brain patterns or as a self-regulation skill, which increases their sense of self-efficacy and confidence in their ability to cope with future eventualities.

      2. (1) Neuroscience News reports that the Thibault & Raz paper is a “new” study. It is just a highly selective and slanted review of old studies.
        (2) Thibault & Raz argue that neurofeedback must both (a) equal or beat the best standard of care and (b) beat a “placebo” treatment. If the best standard of care has beaten a placebo treatment, how is (a) different from (b)?
        (3) How are placebo or sham treatments are appropriate controls for a form of psychotherapy? Have you heard of a “sham psychotherapy” control for a cognitive behavioral therapy? What would that look like? How is neurofeedback different? What would “sham” weight training to prove that weight training increases strength look like? What would “sham” studying, to prove that studying for an academic exam improves grades, look like? I recently asked a certified applied behavior analyst: has applied behavior analysis (roughly, the structuring of rewards and punishments to modify behavior) ever been compared to a “sham” or “placebo” treatment? She said she hadn’t heard about it. Why then, is ABA the standard of care for autism and developmental disabilities? Neurofeedback is a form of operant conditioning firmly in the behaviorist tradition. I don’t see physicians telling people “Don’t waste your money on ABA; it’s never been tested in a double-blind placebo controlled study.”

      3. It seems that every so often people come along and think they have a new “debunking” study.
        In this case focusing in on one study instead of doing a meta analysis of the by now fairy extensive literature on Neurofeedback, has led to a published article that is a disgrace to the authors.

        I am even more surprised that Lancet Psychiatry has let this slip through their peer review process.

      4. Hi, we’ve been in the neurofeedback field for over 30 years. We are an organization of serious scientists and serious inquiry into the clinical applications of neurofeedback, along with a personal family reason for beginning in this field. Here is my response: https://youtu.be/xFu8SqSKOUk

      6. Many of the null results cited are from highly defective studies, see for example

        Cannon R. L., Pigott H. E., Surmeli T., Simkin D. R., Thatcher R. W., Van den Bergh W., et al. . (2014). The problem of patient heterogeneity and lack of proper training in a study of EEG neurofeedback in children. J. Clin. Psychiatry 75, 289–290. 10.4088/JCP.13Lr08850 [PubMed] [Cross Ref]

        For a collection of material showing positive results with controlled as well as clinically founded studies,: https://brainmaster.app.box.com/s/6990ri80kklwts9ogxj7rj8zdl0l2f0x

      7. This is an interesting study but in my view Thibault and Razemail failed to comment on studies that evaluated the effectiveness of Neurofeedback against an active control group (i.e. pharmacological treatment) like those conducted by Flisiak-Antonijczuk et al., (2015), or even the earlier work of Ali Nazari et al., (2011). These studies proved that Neurofeedback is as effective as pharmacotherapy in reducing the number of symptoms and demonstrated that EEG biofeedback can significantly improve several behavioral and cognitive functions in children with ADHD. The results of these studies are not attributable to placebo since Neurofeedback was evaluated against an active control group that complied with standard drug therapy which showed: 1) sensitivity to drug effects (passed placebo controlled trials) and 2) assay sensitivity (results within the expected size).

        Halina Flisiak-Antonijczuk, Sylwia Adamowska, Sylwia Chładzińska-Kiejna, Roman Kalinowski, Tomasz Adamowski (2015). Treatment of ADHD: comparison of EEG-biofeedback and methylphenidate. Archives of Psychiatry and Psychotherapy, 4:31, doi: 10.12740/APP/60511

        Mohammad Ali Nazari, Laurent Querne, Alain De Broca, Patrick Berquin (2011). Effectiveness of EEG Biofeedback as Compared with Methylphenidate in the Treatment of Attention-Deficit/Hyperactivity Disorder: A Cinical Out-Come Study. Neuroscience & Medicine, 2:2, dOI: 10.4236/nm.2011.22012

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