|Year : 2019 | Volume
| Issue : 1 | Page : 26-30
Biofeedback as an adjunct to conventional stress management and relaxation techniques in substance abuse disorders: A randomized controlled interventional study
Anand Manohar Ghadse1, Lokesh Kumar Ranjan2, Pramod Ramlakhan Gupta3
1 Department of Occupational Therapy, Central India Institute of Mental Health and Neuro Science, Rajnandgaon, Chhattisgarh, India
2 Department of Psychiatric Social Work, Central India Institute of Mental Health and Neuro Science, Rajnandgaon, Chhattisgarh, India
3 Department of Psychiatry, Central India Institute of Mental Health and Neuro Science, Rajnandgaon, Chhattisgarh, India
|Date of Submission||18-Nov-2018|
|Date of Acceptance||22-Mar-2019|
|Date of Web Publication||19-Apr-2019|
Dr. Anand Manohar Ghadse
Central India Institute of Mental Health and Neuro Science, G. E. Road, Dewada Chowk, Kopedih Road, Rajnandgaon - 491 441, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Background: Biofeedback has been employed in substance abuse disorder over the last three decades. Stress, anxiety, and depression are commonly seen in patients with substance abuse disorders. Biofeedback employed in conjunction with other relaxation therapies may be useful in enhancing certain outcome of therapy. Biofeedback either alone for alcoholism or in combination with other relaxation techniques for stimulant and mixed substance abuse and combined with residential treatment program is probably efficacious. Objectives: This study is aimed at assessing effectiveness of biofeedback-assisted relaxation techniques and stress management for substance abuse population. Study Design: A randomized controlled interventional study design was chosen for the research. Methods: The study sample consisted of 60 in-patient males aged 18–55 years, diagnosed with mental and behavioral disorders due to multiple drug use and use of other psychoactive substance, according to the International Classification of Diseases-10, Diagnostic Criteria for Research (1992) criteria (30 in biofeedback and 30 in control groups). The patients were first screened for inclusion criteria and then recruited from CIIMHANS Mental Health Institute of Central India using lottery method for random allocation. A randomized controlled interventional study design was chosen for the research. Sociodemographic data and clinical details of all the patients were assessed using Depression-Anxiety-Stress Scale followed by biofeedback-assisted relaxation techniques, which was conducted for 30 days. Results: The present study shows that there was significant difference in the stress (t = 3.841, P < 0.01, 95% confidence interval [CI]: 3.06–9.73), anxiety (t = 3.849, P < 0.01, 95% CI: 2.06–6.53), and depression (t = 2.03, P < 0.05, 95% CI: 0.03–0.67) among patients of substance abuse disorders in the biofeedback group as compared to control group. Conclusion: The present study found that the biofeedback-assisted relaxation technique is efficacious in decreasing level of depression, anxiety, and stress in patients with substance abuse disorders.
Keywords: Anxiety, Biofeedback, Depression, Relaxation Technique, Stress, Substance Abuse Disorders
|How to cite this article:|
Ghadse AM, Ranjan LK, Gupta PR. Biofeedback as an adjunct to conventional stress management and relaxation techniques in substance abuse disorders: A randomized controlled interventional study. Indian J Occup Ther 2019;51:26-30
|How to cite this URL:|
Ghadse AM, Ranjan LK, Gupta PR. Biofeedback as an adjunct to conventional stress management and relaxation techniques in substance abuse disorders: A randomized controlled interventional study. Indian J Occup Ther [serial online] 2019 [cited 2020 May 24];51:26-30. Available from: http://www.ijotonweb.org/text.asp?2019/51/1/26/256602
| Introduction|| |
The central nervous system and peripheral nervous system are the seat of stress system which is activated when a stress threshold is exceeded, which in turn helps re-establish homeostasis by a complex behavioral and physical response. It has been suggested that stress and negative affect can be improved through adaptive emotion regulation., High resting heart rate variability has been shown to predict self-regulatory strength and reduced negative emotion during acute stress. India is home to an estimated 57 million people (18% of the global estimate) affected by depression. Between 2005 and 2015, the number of people living with depression worldwide increased by an estimated 18.4%. Depressive disorders accounted for nearly one-third of the total global disability-adjusted life years caused by mental and substance use disorder. Substance abuse as a social phenomenon is one of the health problems of the present era. Inclination to substance abuse like other social phenomena is complex and multi-casual. According to the World Health Organization, substance abuse is persistent or sporadic drug use inconsistent with or unrelated to acceptable medical practice. About 190 million people all over the world consume one drug or the other. There are studies showing that low distress tolerance is a key risk factor for substance abuse.,, Biofeedback-assisted relaxation is a process in which a patient under goes relaxation technique in which the patient can visualize their physiological changes. Biofeedback practitioner can use any relaxation technique, which induces physiological and emotional relaxation response, and can use any modality of physiology as feedback. The goal of biofeedback-assisted relaxation is to develop self-awareness of a person's physiology being tense and relaxed and learn a conscious control over their own physiology so that, in emotionally challenging situations, he or she would be able to lower one's tension and replace it with relaxation response without any feedback., Biofeedback is an evidence-based mind–body technique where individuals learn to consciously control their physiology and emotional thoughts. Patients with chronic anxiety trained in biofeedback achieve symptom reduction similar to those taking conventional anti-anxiety medications., The aim of the study was to assess and compare effectiveness of biofeedback-assisted relaxation techniques in patients with substance abuse. The present study had following objectives:
- To assess and compare sociodemographic variables among patients of substance abuse disorders in biofeedback and control groups
- To assess and compare the depression in the patients with substance abuse disorders using biofeedback-assisted relaxation techniques with biofeedback and control groups
- To assess and compare the anxiety in the patients with substance abuse disorders using biofeedback-assisted relaxation techniques with biofeedback and control groups
- To assess and compare the stress in the patients with substance abuse disorders using biofeedback-assisted relaxation techniques with biofeedback and control groups.
| Methods|| |
The research was a hospital-based randomized controlled interventional study design among the patients of substance abuse disorders with biofeedback and control groups. The sample was drawn from the inpatient department of the CIIMHANS Mental Health Institute of Central India through lottery method for random allocation in two groups. A total of 60 patients who were under pharmacological treatment were screened by Depression-Anxiety-Stress Scale (DASS). The score found in depression was at mild level and anxiety and stress was at moderate level. Selected patients for this study were randomly divided into 30 patients of substance abuse in study group, i.e., biofeedback-assisted relaxation technique, and 30 patients of substance abuse in control group without any biofeedback therapy. The patients of both the groups underwent conventional occupational therapy which was task oriented that ranged from parallel play to cooperative group.
Patients' age ranged from 18 to 55 years; all were male patients; patients were diagnosed by a psychiatrist at the hospital with mental and behavioral disorder due to multiple drug use and use of other psychoactive substance; and patients with depression, anxiety, and stress as recognized in DASS were included in the study.
Patients with hallucination and other psychiatric problem, patients with multiple and severe physical deficits, and patients with speech, hearing, and voice deficit were excluded.
The study was approved by the Institutional Ethics Committee of Central India Institute of Mental Health and Neuro Sciences, Rajnandgoan, Chhattisgarh, before the start of collecting data. Male patients were with final diagnosis of mental and behavioral disorders due to multiple drug use and use of other psychoactive substance, according to the International Classification of Diseases-10, Diagnostic Criteria for Research (1992) criteria. Only patients who gave written informed consent and voluntarily participated in the study were included. During each session of biofeedback, patients were taught and explained about effectiveness of biofeedback, stress management, and relaxation technique and about previous research supporting the effectiveness of biofeedback training in causing relaxation. Patients in the biofeedback group were treated individually for 30 successive days at the Occupational Therapy Department of Central India Institute of Mental Health and Neuro Sciences, Dewada, Rajnandgaon, Chhattisgarh. There was an isolated therapy room with proper light and ventilation without any external disturbance from outside. The therapy sessions for each patient were carried out for approximately 30 min. After placement of electrodes of electromyography equipment, at frontal aspect of the head, i.e., at forehead, and at occipital region over the scalp, galvanic skin response electrode was placed at palmer surface of index and middle finger, respiratory belt was placed at lower abdomen, and pulse meter was placed at index finger of the left hand. Patients were asked to relax in a comfortable position during the session. All the patients were asked to practice relaxation and stress management technique in the ward, daily in the morning. The last session of biofeedback therapy was carried out after the practice of relaxation and stress management techniques. A therapist documented whether each patient regularly practiced in the ward, throughout the therapy period. After completion of all sessions, posttherapy DASS score was evaluated of all the 60 patients involved in the experimental group and as well as control group.
Sociodemographic data sheet
The sociodemographic data sheet was semi-structured and developed for the present study and consisted of variables such as age, education, occupation, domicile, and socioeconomic status.
DASS was developed by Lovibond and Lovibond The DASS is a 42-item questionnaire which includes three self-report scales designed to measure the negative emotional states of depression, anxiety, and stress. Each of the three scales contains 14 items, divided into subscales of 2–5 items with similar content. The patients are asked to use 4-point severity/frequency scales to rate the extent to which they have experienced each state over the past week. It shows that high score is the indicators of the high level of depression, anxiety, and stress. The test–retest reliability coefficient of this test is 0.48, and the Cronbach's alpha internal consistency coefficients' ranges from 0.89 to 0.96.
The statistical analysis was done using Statistical Packages for the Social Science (SPSS)-16 software package for windows(SPSS Inc., Chicago, IL, US). For sociodemographic and variables, descriptive statistics were used such as frequency, percentage, mean, and standard deviation (SD). For testing of variance, Chi-square and Student's t-test were used. The results were evaluated by computing 95% confidence interval (CI) and significance level of P < 0.05 was set at the outset of the study.
| Results|| |
The outcomes of 60 male patients with 30 in each experimental and 30 in control groups aged between 18 and 55 years were analyzed. The mean age and SD of the biofeedback group substance abuse patients were 34.83 ± 10.03 years. The mean age and SD of the control group substance abuse patients were 31.23 ± 5.89 years. There was no significant difference in age between patients of substance abuse with biofeedback and control groups (t = 1.694, P > 0.05, 95% CI: 7.85–0.65) [Table 1].
|Table 1: Comparison of Age between Substances Abuse Patients with Biofeedback Group and Control Group|
Click here to view
There was no significant difference in education, occupation, socioeconomic status, and domicile between both the groups. Eleven (36.7%) illiterate in biofeedback group and 6 (20.0%) illiterate in control group, whereas 19 (63.3%) literate in biofeedback group and 24 (80.0%) literate in control group; the value of χ2 = 2.052 and P > 0.05. 17 (56.7%) employed biofeedback group and 14 (46.7%) employed in control group, whereas 13 (43.3%) unemployed in biofeedback group and 16 (53.3%) unemployed in control group; the value of χ2 = 0.601 and P > 0.05. 10 (33.3%) low class in biofeedback group and 8 (26.7%) low class in control group, 13 (43.3%) middle class in biofeedback group and 12 (40.0%) middle class in control group, 7 (23.3%) high class in biofeedback group and 10 (33.3%) high class in control group the value of χ2 = 0.792 and P > 0.05. 10 (33.3%) rural area in biofeedback group and 11 (40.0%) rural area in control group, 18 (60.00%) urban area in biofeedback group and 16 (53.3%) urban area in control group, 02 (06.7%%) semi-urban area in biofeedback group and 03 (10.0%) semi-urban area in control group the value of χ2 = 0.365 and P > 0.05 [Table 2].
|Table 2: Comparison of Sociodemographic Variables between Substances Abuse Patients with Biofeedback Group and Control Group|
Click here to view
The mean and SD score of depression in the biofeedback group with substance abuse patients were 10.36 ± 5.49 and in control group with substance abuse patients were 13.10 ± 4.91. [Table 2] shows that there is significant difference in depression among biofeedback group and control group with substance abuse patients (t = 2.03, P < 0.05, 95% CI: 0.03–0.67). The present study found that biofeedback-assisted relaxation techniques were effective in reducing depression of patients with substance abuse disorder. The mean and SD score of anxiety in biofeedback group with patients of substance abuse were 8.83 ± 3.63 and control group with substance abuse patient were 13.13 ± 4.92. This shows that there is significant difference in anxiety among the biofeedback group and control group with substance abuse patients (t = 3.849, P < 0.01, 95% CI: 2.06–6.53). This study shows that biofeedback-assisted relaxation techniques are effective in reducing anxiety of patients with substance abuse disorder. The mean and SD score of stress in biofeedback group with substance abuse patients were 16.13 ± 7.97 and control group with substance abuse patients were 22.53 ± 4.43. [Table 2] shows that there is significant difference in stress among biofeedback group and control group with substance abuse patients (t = 3.841, P < 0.01, 95% CI: 3.06–9.73). The present study finds out biofeedback-assisted relaxation techniques are effective in reducing stress of patients with substance abuse disorder [Table 3].
|Table 3: Comparison of Depression, Anxiety, and Stress Among Substance Abuse Patients with Biofeedback and Control Group|
Click here to view
| Discussion|| |
The present study has found that there was no significant difference in areas of sociodemographic variables such as age, education, occupation, socioeconomic status, and domicile among patients of substance abuse disorders with biofeedback and control groups.
The present study also shows that there is a significant difference in depression-anxiety-stress in patient of substance abuse disorder with biofeedback and control groups. This study shows the potential of biofeedback-assisted relaxation technique is effective in reducing level of depression-anxiety-stress in biofeedback group. Some earlier studies also support this. Anxiety symptoms and alcohol consumption declined in participants after biofeedback-assisted muscular relaxation training in an experimental stress situation relative to a no-treatment control. Biofeedback training regulates emotions through physiological parameters such as heart rate which plays an important role to control negative emotions. Biofeedback training lowered high heart rate in the person having high stress level. Biofeedback-assisted relaxation training can help in decreasing stress through diaphragmatic breathing or progressive muscle relaxation or autogenic training. It is effective for increasing ego strength. Progressive muscle relaxation exercise can be used as a tool for assisting a person to achieve relaxation of one's own body and mind. Progressive muscle relaxation was effective for lowering students' cognitive and physiological stress symptoms. It can also strengthen nervous and immune systems. Therefore, it may also enhance distress tolerance. Biofeedback-assisted muscular relaxation was effectively relative to a placebo condition in reducing anxiety of the inpatient. The individuals who received the biofeedback had greater treatment retention and had to be beneficial for both sedative and stimulant of substance abuse. Biofeedback training has received increasing attention as a potential treatment for a variety of disorders, including anxiety and stress.
There were some methodological limitations in this study that need to be mentioned here. Major limitations of this study were as follows:
- Only one posttherapy assessment
- Small sample size
- Only males were assessed.
Majority of substance abuse patients suffer from stress, anxiety, and depression. This study will be extremely helpful to professionals working in mental health to extend their help and support their patients. The finding of this study suggests that biofeedback is effective in reducing anxiety and stress of patient with substance abuse; hence, this can be addressed by the occupational therapist and other mental health professionals while dealing with a person with substance abuse disorder in clinical settings. A large sample-sized, long-term study in both males and females can be researched.
| Conclusion|| |
Research showed that biofeedback-assisted relaxation technique is efficacious in patients with substance abuse disorders in decreasing depression, anxiety, and stress. This study also suggests that biofeedback-assisted relaxation training helps patients to control their physiological alteration effectively, during otherwise stressful situations of daily life.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
| References|| |
Gross JJ. Emotion regulation: Affective, cognitive, and social consequences. Psychophysiology 2002;39:281-291.
Hofmann SG. Interpersonal emotion regulation model of mood and anxiety disorders. Cognit Ther Res 2014;38:483-492.
Khodik K. Self-Regulation and Heart Rate Variability Biofeedback: Promoting Emotional and Spiritual Fitness in Alcohol Addiction Treatment. Ph.D. Dissertation, Institute for Graduate Clinical Psychology Widener University. Available from: http://www.healthmath.org/research/research-library/dissertation
. [Last accessed on 2019 Feb].
Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A, et al
. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1545-1602.
World Health Organization. Technical Report Series. No. 886. World Health Organization; 1999. p. 48.
Miller WR, Sanchez VC. Motivating young adults for treatment and lifestyle change. In: Howard G, editor. Issues in Alcohol Use and Misuse in Young Adults. Notre Dame, Indiana: University of Notre Dame Press; 1993. p. 55-82.
Zvolensky MJ, Marshall EC, Johnson K, Hogan J, Bernstein A, Bonn-Miller MO. Relations between anxiety sensitivity, distress tolerance, and fear reactivity to bodily sensations to coping and conformity marijuana use motives among young adult marijuana users. Exp Clin Psychopharmacol 2009;17:31-42.
Dennhardt AA, Murphy JG. Associations between depression, distress tolerance, delay discounting, and alcohol-related problems in European American and African American college students. Psychol Addict Behav 2011;25:595-604.
Kaiser AJ, Milich R, Lynam DR, Charnigo RJ. Negative urgency, distress tolerance, and substance abuse among college students. Addict Behav 2012;37:1075-1083.
Shaffer F, Moss D. Biofeedback. In: Yuan CS, Bieber EJ, Bauer BA, editors. Text Book of Complementary and Alternative Medicine. 2nd
ed. Abingdon, Oxfordshire, UK: Informa Healthcare; 2006. p. 291-312.
Peper E, Harvey R, Takebayashi N. Biofeedback an evidence based approach in clinical practice. Jpn J Biofeedback Res 2009;36:3-10.
Peira N, Pourtois G, Fredrikson M. Learned cardiac control with heart rate biofeedback transfers to emotional reactions. PLoS One 2013;8:e70004.
Frank DL, Khorshid L, Kiffer JF, Moravec CS, McKee MG. Biofeedback in medicine: Who, when, why and how? Ment Health Fam Med 2010;7:85-91.
Rice KM, Blanchard EB, Purcell M. Biofeedback treatments of generalized anxiety disorder: Preliminary results. Biofeedback Self Regul 1993;18:93-105.
Sarkar P, Rathee SP, Neera N. Comparative efficacy of pharmacotherapy and bio-feedback among cases of generalised anxiety disorder. SIS J Proj Psychol Ment Health 1999;6:69.
Lovibond PF, Lovibond SH. The structure of negative emotional states: Comparison of the depression anxiety stress scales (DASS) with the beck depression and anxiety inventories. Behav Res Ther 1995;33:335-343.
Strickler DP, Tomaszewski R, Maxwell WA, Suib MR. The effects of relaxation instructions on drinking behavior in the presence of stress. Behav Res Ther 1979;17:45-51.
Prato CA, Yucha CB. Biofeedback-assisted relaxation training to decrease test anxiety in nursing students. Nurs Educ Perspect 2013;34:76-81.
Khanna A, Paul M, Sandhu JS. Efficacy of two relaxation techniques in reducing pulse rate among highly stressed females. Calicut Med J 2007;5:23-25.
Hurley JD. Differential effects of hypnosis, biofeedback training, and trophotropic responses on anxiety, ego strength, and locus of control. J Clin Psychol 1980;36:503-507.
Matsumoto M, Smith JC. Progressive muscle relaxation, breathing exercises, and ABC relaxation theory. J Clin Psychol 2001;57:1551-1557.
Pawlow LA, Jones GE. The impact of abbreviated progressive muscle relaxation on salivary cortisol and salivary immunoglobulin A (sIgA). Appl Psychophysiol Biofeedback 2005;30:375-387.
Psychol1 Steffen JJ. Electromyographically induced relaxation in the treatment of chronic alcohol abuse. J Consult Clin Psychol 1975;43:275.
Scott WC, Kaiser D, Othmer S, Sideroff SI. Effects of an EEG biofeedback protocol on a mixed substance abusing population. Am J Drug Alcohol Abuse 2005;31:455-469.
Lehrer PM, Gevirtz R. Heart rate variability biofeedback: How and why does it work? Front Psychol 2014;5:756.
[Table 1], [Table 2], [Table 3]