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Effects of Neurofeedback Training on Anxiety Symptoms Among University Students

Authors:
Effects of Neurofeedback Training on Anxiety
Symptoms Among University Students
Jasmine Adela Mutang1*, Chua Bee Seok2, Guan Teik Ee3
1Faculty of Psychology and Education, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia
2Faculty of Psychology and Education, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia
3Faculty of Psychology and Education, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia
*Jasmine Adela Mutang. E-mail: jasmine@ums.edu.my
ABSTRACT
Previous studies reported that university students are a population at risk of that mental health problems. The
most common intervention for anxiety disorders are pharmacological and/or nonpharmacological strategies such
as psychotherapies. Besides that, there is a growing interest neurofeedback training for various mental health
conditions including depression, Post Traumatic Stress Disorder (PTSD), stress and anxiety. Therefore, the
objective of this study is to determine the effectiveness of neurofeedback training in reducing symptoms of
anxiety. A quasi-experimental study with a pretest-posttest design was employed in this study. Thirty eight
students (M= 22.47 years, SD= .69 years) with moderate and severe anxiety symptoms based on the Beck
Anxiety Inventory (BAI) and Generalized Anxiety Disorder-7 (GAD-7) were randomly assigned to either
neurofeedback training or waiting list. The neurofeedback group undergone a total of 20 neurofeedback training
(3 sessions per week). The post test results indicated that neurofeedback training significantly reduce symptoms
of anxiety in the neurofeedback group than those of in the waiting list group in both BAI and the GAD-7
instruments with effect size ranged from .49 to .62. Wilcoxon signedrank test was conducted to assess the
statistical differences between the pre-scores and post-scores of BAI and GAD-7 measurements within the NFT
group. Significant differences within the NFT group was found between the pre-test and post-test scores in the
BAI and GAD-7 measurements. In general, the current study suggest that neurofeedback was an effective
treatment for anxiety symptoms among university students.
Keywords: Anxiety, Mental Health, Neurofeedback, University Students.
1. INTRODUCTION
Psychological wellbeing is very important to
function in daily life. Mental health problem such as
depression and anxiety may impair a person daily
function. The World Health Organization (WHO)
reported that the number of people experiencing
mental health problems are increasing worldwide [1].
The Malaysian National Health and Morbidity
Survey 2017 [2] reported that every two in five
adolescents are anxious, one in five adolescents are
depressed and every one in ten adolescents are
stressed. The NHMS 2017 reported a drastic increase
of mental health problems among Malaysian as
compared to the survey done in 2012. Similar trend is
observed globally. The World Health Organization
estimated the total number of people suffer from
anxiety disorders worldwide is 264 million. About
23% or 60.05 million are from the South East Asian
region [1].
Anxiety disorders is the most prevalent mental
health conditions and can be just as disabling as other
mental health disorders if not treated well [3].
Excessive worry, hyperarousal and fear are the
common characteristics of symptoms. Anxiety
symptoms ranged from mild to severe [1]. Panic
disorder, generalized anxiety disorder (GAD), post-
traumatic stress disorder (PTSD), and social anxiety
disorder are types of anxiety disorders [4][5][6][7].
Studies showed that university students are
vulnerable to mental health problem because they are
in a phase of adapting to a new environment such as
independent living, decision making, financial
management, academic challenges and coping with
new social life [8][9][10][11]. These stressors may
affect their everyday life, life satisfaction, physical
health, emotional stability, academic achievement as
well as their relationship with friend and family.
Continuous stress can lead to serious mental health
such as anxiety and depression which may affect their
future after university life [10][12][13].
Advances in Social Science, Education and Humanities Research, volume 530
Proceedings of the International Conference on Psychological Studies (ICPSYCHE 2020)
Copyright © 2021 The Authors. Published by Atlantis Press SARL.
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Depression and anxiety are the most prevalence
mental health problems among the public including
university students. A study done on among 506
university students involving four public universities
in the Klang Valley, Malaysia reported that the
prevalence of anxiety is higher than depression and
stress. Specifically, 29% had severe and extremely
severe anxiety; and 18.6% reportedly had moderate
anxiety [11]. A recent study in Malaysia on the
prevalence of anxiety by [14] involving a total of
1821 university students across Malaysia revealed
that the prevalence of anxiety was 29%. Studies on
the prevalence of mental health problems among
university students across the globe showed a similar
trend. A previous meta-analysis conducted on global
prevalence of anxiety among medical students
indicated anxiety was most prevalent among medical
students from the Middle East and Asia [15]. A study
on first year university students in Hong Kong
revealed that 41% had moderate severity or above
symptoms of anxiety, notably 7.6% extremely severe
anxiety, 11.3% severe anxiety, and 22.3% moderate
anxiety [16].
Generally, the interventions for anxiety disorders
are pharmacotherapy or/and psychotherapy
depending on the severity of the condition [17][18].
Pharmacological intervention is often used to treat
anxiety disorder besides psychotherapy. Medication
such as antidepressants, benzodiazepines or
anxiolytic drugs are often prescribed for anxiety
disorders [18][19]. The most common drugs are the
selective serotonin reuptake inhibitors and serotonin-
norepinephrine reuptake inhibitors but not everyone
response well to medication [17][20][21][22]. Some
experience adverse effects such as jitteriness, nausea,
restlessness, headache, fatigue, increased or
decreased appetite, weight gain, weight loss, tremor,
sweating, sexual dysfunction, diarrhoea, constipation,
urination problems, and other side effects [20][21]
Even though Benzodiazepines is safer that
barbiturate, it is not recommended for routine use
because it can also cause other side effects such as
withdrawal, forgetfulness, confusion and worsened
the anxiety disorder [19][20], [23]. Therefore, a safer
alternative and non-invasive intervention such as
neurofeedback training should be considered to help
alleviate anxiety disorder.
The most common psychotherapy treatment for
anxiety disorders is Cognitive Behavioural Therapy
(CBT) due to its highest level of empirical evidence.
Many controlled studies reported the efficacy of CBT
for most anxiety disorders [24][25]. Therefore, CBT
is widely implemented as the primary options of
psychotherapy for anxiety disorders [26][27][28].
Other types of psychotherapy treatment for anxiety
disorders are psychoanalysis, psychodynamic
psychotherapy, talk psychotherapy, and eye
movement desensitization and reprocessing (EMDR)
[29].
It was known that anxiety disorders have to do
with functional brain abnormalities [22][30][31].
Anxiety is associated with reduced left-hemisphere
and increased right-hemisphere activity. A study
reported that anxious individuals in their study
showed a larger asymmetry in the left hemisphere
and selective increase in the right parietal activity
[31]. Studies also reported the linked of anxiety
disorders with several neurotransmitter system and
certain brain areas [30].
Neurofeedback or also known as
Electroencephalography (EEG) feedback was
originally developed as a relaxation technique [32].
Neurofeedback training operate using operant
conditioning technique [33][34] by altering the
brainwaves at certain location of the brain which are
related to emotional or behavioural problem [35].
Individual undergoing neurofeedback training learn
to control their brain waves consciously based on the
visual or/and audio feedback [17][36]. In a
neurofeedback session, electrodes are connected to
certain part/s of the head and ears. These electrodes
are then connected to a computer which is installed
with a neurofeedback software and an amplifier to get
real time response of the brain waves activities. The
neurofeedback training changes the brainwaves
activities using visual and/or audio feedback. Better
pattern of brainwaves can be obtained with consistent
feedback and training [37].
A study done by Singer [38] using neurofeedback
training on two dancers to reduce their performance
anxiety reported a significant decrease in anxiety
symptoms. Both dancers were assessed using the
State Trait Anxiety Inventory (STAI) before and after
their neurofeedback session and each major
performance. The state and trait scores of both
dancers reduced significantly after underwent 20
neurofeedback sessions. However, the limitations of
this study are its small sample size, same protocol for
both dancers and no control group to ascertain the
effectiveness of the neurofeedback training in
reducing anxiety symptoms.
Another study done by [39] to examine the effects
of neurofeedback training in two patients diagnosed
with anxiety disorder. The patients undergone 30
neurofeedback sessions. The Symptom Checklist-90-
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83
Revised (SCL-90-R) and patients' self-reports
showed a significant reduction in anxiety-related
symptoms. Additionally, the results of SCL-90-R
showed all clinical scales within normal range after a
one-year follow-up. Patient self-reports indicated that
the patients were symptom free as well. Overall, the
study demonstrated that neurofeedback is an effective
modality of treatment for anxiety disorder. However,
the study lack of control group and lack of placebo.
This study is an extension of a preliminary study
done previously to assess the effectiveness of
neurofeedback training to improve symptoms of
anxiety in among 20 university students in Malaysia
[37]. The participants were assigned to either the
neurofeedback group or control group. The
participants anxiety symptoms were assessed using
the DASS-21, The Beck Anxiety Inventory (BAI)
and the State Trait Anxiety Inventory (STAI)
measurements before the training and after the
training. The findings showed an overall
improvement in all the psychological measurements
in the neurofeedback group hence provide additional
evidence to the field of neurotherapy that
neurofeedback training is a viable option to improve
anxiety symptoms among university students.
However, the current study employed an
individualized training protocol based on the arousal
checklist taking into consideration that everyone is
different in the arousal symptoms.
1.1 Objective
The main objective of this study is to investigate
the effectiveness of neurofeedback training in
reducing anxiety symptoms among university
students.
2. METHOD
This study employed a quasi-experimental
method with a pretest-posttest design involving 38
university students (M=22.47 years, SD= .69 years) at
a local university in east Malaysia. The study was
conducted following approval by the University
Malaysia Sabah Ethic Committee (JKEtika 2/18(7)).
Anxiety symptoms was measured using the Beck
Anxiety Inventory (BAI) and Generalized Anxiety
Disorder-7 (GAD-7). Participants with moderate and
severe anxiety symptoms based on the BAI ad GAD-
7 questionnaire were randomly assigned to either
neurofeedback training or waiting list. The
neurofeedback group attended 20 sessions (three
times a week) of approximately 30 minutes
(including preparations) individual neurofeedback
training in a span of eight weeks. Both groups
completed the BAI and GAD-7 self-reported
questionnaires before (week 0) and after the
intervention (week 8). Participants were evaluated in
terms of effectiveness of neurofeedback training in
reducing anxiety symptoms based on the pretest-
posttest results.
2.1 Participants
A total of 38 participants who scored mild and
severe level of anxiety symptoms based on the BAI
and scored 8 points and above on the GAD-7
participated in the study. The participants were
randomly assigned to either the neurofeedback group
(n=18; mean age = 22.44, SD = .78) or waiting list
group (n=20; mean age = 22.5, SD = 0.61). Table 1
displays the participants data.
Table 1. Demographic and characteristics of the
neurofeedback group and the waiting list group
Neurofeedback Group (n=18)
Waiting List Group
(n=20)
Mean
SD
Mean
SD
Age
22.4
.78
22.5
.61
Sex
Male
Female
(n)
5
13
(%)
27.78
72.22
(n)
6
14
(%)
30
60
BAI
26.61
9.91
26.7
8.59
GAD-7
12.39
3.62
12.55
2.63
All participants (neurofeedback and waiting list
group) neither had neurofeedback training previously,
not clinically diagnosed of having history of
psychiatric and neurological disorders, free from
substance abuse, do not have any history of seizures
and concussions, and free of psychotropic
medication.
Written informed consent was obtained from
participants after a thorough description of the study
procedures and requirements. The study was
conducted following approval by the University
Malaysia Sabah Ethic Committee (JKEtika 2/18(7)).
2.2 Instruments
2.2.1 The Beck Anxiety Inventory (BAI)
The Beck Anxiety Inventory (BAI) is a self-
reported instrument consisting of 21 items measuring
common symptoms of anxiety (emotions, physiology,
Advances in Social Science, Education and Humanities Research, volume 530
84
and cognitive) which focuses on somatic symptoms
of anxiety that have occurred over the past week. It
was developed for individuals aged 17 to 80 years
old. Higher scores indicating more severe anxiety
symptoms. The symptoms rated on a four-point scale,
ranging from “not at all” (0) to severely (3). The
instrument has excellent internal consistency (α=.92)
and high test-test reliability (r=.75) in previous study
[40]. The current study employed the Bahasa
Malaysia version (BAI-Malay) [41] with the
Cronbach alpha coefficients (α) ranged from 0.66 to
0.89 with satisfactory overall alpha value of .91.
2.2.2 The Generalized Anxiety Disorder-7
(GAD-7)
The Generalized Anxiety Disorder (GAD-7) [42]
(Spitzer et al., 2006) consists of seven items
measuring worry and anxiety symptoms. Each item is
scored on a four-point Likert scale (03) with total
scores ranging from 0 to 21 with higher scores
reflecting greater anxiety severity. The GAD-7 has
shown good reliability and construct validity [42],
[43]. This study employed the GAD-7 (Malay
Version) by [44]. The Malay version of the GAD-7
was found to have good internal reliability
(Cronbach’s alpha = 0.74) with good sensitivity,
specificity, concurrent and convergent validity [44].
Participants scored 8 points and above were classified
as having anxiety disorders on the GAD-7.
2.3 Neurofeedback Training
The neurofeedback training utilized the EEGer
Neurofeedback software by EEG Spectrum
International Education and Research, Inc. and
Thought Technology LTD manufactured amplifier.
Participants in the neurofeedback group underwent a
total of 20 neurofeedback training (twice a week) for
a duration of eight weeks. Each session took
approximately 30 minutes including preparations.
The training protocol employed for each participant
were individualized based on the arousal checklist.
The training site is either at C3-A1 site or C4-A4 site
depending on the participants’ response on the
arousal checklist. The training protocol intended to
teach participants to decrease the power spectrum of
slow (2-5 Hz and 6-9 Hz) and fast (22-36 Hz) activity
while at the same time increasing mid-range (12-15
Hz) activity. Impedance was measured for both active
and reference electrodes and maintained below 12
kOhms. Training involved game-like format training
which utilized both visual and auditory feedback as
reinforcement. The waiting list group did not receive
any intervention during the study.
2.4 Data Analysis
The data were analysed using IBM SPSS
Statistics 25 for Windows. Since the number of
participants is small nonparametric analysis was
conducted to analyse the results. Mann-Whitney U
test was conducted to assess statistical differences in
the scores of BAI and GAD between the
neurofeedback group and waiting list group. In order
to assess the statistical differences between the pre-
scores and post-scores of BAI and GAD-7 within the
neurofeedback group, the nonparametric Wilcoxon
signedrank test was conducted.
3. RESULT
In order to evaluate the effect of neurofeedback
training, the neurofeedback group and waiting list
group filled up the self-reported BAI and GAD-7
measurements before the intervention and after the
intervention. The data were analysed using
nonparametric (Mann-Whitney U test and Wilcoxon
Signed-Ranks test) analyses. The nonparametric
Mann-Whitney U test did not show any statistical
difference in the BAI and GAD-7 measurements
before the intervention. However, the Mann-Whitney
U test indicated that there are significant differences
between the neurofeedback group (Mean Rank=
13.83, n=18) and the waiting list group (Mean Rank=
20.13, n= 20) in the BAI (U=78.00, z= -2.99, p=
.003) measurements. This effect can be described as
large (r=.49). As in the GAD-7 measurement, the
Neurofeedback group also showed significant
difference (Mean Rank= 12.31, n= 18) as compared
to the waiting list group (Mean Rank= 25.98, n= 20),
U=50.5, z= -3.80, p= .000 with large effect size
(r=.62). Table 2 displays the Mann-Whitney U Test
between the neurofeedback group and the waiting list
group.
Table 2. Comparisons between neurofeedback
group and waiting list group of pre-test and post-test
in BAI and GAD-7
Mean Rank
U
Z
p
Pre
Post
Pre
Post
Pre
Post
Pre
Post
BAI
NF
(n=18)
18.81
13.83
167.5
78.0
-3.66
-2.99
.718
.003
WL
(n=20)
20.13
24.25
GAD-7
NF
(n=18)
18.44
12.31
161.0
50.5
-.562
-3.80
.593
.000
WL
20.45
25.98
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85
(n=20)
Note: NF =Neurofeedback Group; WL=Waiting List
Group
In order to assess the statistical differences
between the pre-scores and post-scores of BAI and
GAD-7 measurements within the NFT group, the
nonparametric Wilcoxon signedrank test was
conducted. As depicted in Table 3, there are
significant differences between the pretest and
posttest scores for the neurofeedback group before
and after the intervention for both BAI (Z=-.3.11,
p=.002) and GAD-7 (Z=-.3.26, p=.001)
measurements.
Table 3. Comparisons of pretest and posttest scores
BAI and GAD-7 within the neurofeedback group and
waiting list group
N
Median
Z
P
BAI
Neurofeedback
18
Pre
24.00
-3.11
.002
Post
14.0
Waiting List
20
Pre
27.0
-1.59
.112
Post
25.5
GAD-7
Neurofeedback
18
Pre
11.00
-3.26
.001
Post
6.00
Waiting List
20
Pre
12.0
-1.22
.224
Post
12.5
The analysis indicated that the anxiety symptoms
based on the post-test scores was significantly
reduced in all measurements among the NFT
participants after the neurofeedback training. The
effect size for the pre and post-test of the BAI
measurement within the neurofeedback group is
r=.73. In addition, the effect size for the pre and post
test scores of the GAD-7 measurement within the
neurofeedback group is r=.77. These effect size can
be considered large. Therefore, the hypothesis that
stated that there is a significant difference in anxiety
symptoms before and after the intervention for the
neurofeedback group is supported.
3.1. Discussion
Anxiety can affect one’s everyday life and may
contribute to psychological and physical wellbeing.
The aim of this study is to examine the effect of
neurofeedback training on reducing anxiety
symptoms among university students. According to
the results, significant difference was in the pre and
posttest scores for the neurofeedback group as
compared to the waiting list group. This result
showed that neurofeedback training may be a
promising treatment for anxiety related disorders.
Overall, the study indicated that participants’ anxiety
symptoms based on the BAI and the GAD-7 scores
reduced significantly. This result is consistent with
other studies done by other researchers on different
samples and different neurofeedback protocol [39],
[45], [46], [47].
It is worth to note that the training protocol is not
the same for participants in the neurofeedback group.
Since the participants are non-clinical population,
they are trained at either C3-A1 site or C4-A4 site
depending on the participants’ response on the
arousal checklist. It is unreasonable to expect that a
‘‘one-size-fits-all’’ approach in neurofeedback
training as the brain complex and differ for everyone.
Other studies used different training protocol such as
increase alpha activity with increased theta activity or
increase alpha and beta and to inhibit beta 2 at
different sites and different populations [22], [39],
[48].
Neurofeedback training generally aim to alter
abnormalities in brain electrical activity identified
through comparisons to a normative EEG database.
Unfortunately, this study was not able to assess
change in targeted EEG parameters. Future research
may need to consider this aspect.
Positive reinforcement using operant and classical
condition techniques in the neurofeedback training is
used by using games, animations or analogical
feedback was employed. Participants can choose
which type of feedback according to their preferences
apart from minimal verbal prompts from the
neurofeedback trainer. Future research may analyse
the usage of different feedback in the treatment
outcomes.
The participants faced different life stressors that
may influenced the results of the study. Two
participants (one in each experimental group) self-
reported that they lost their loved ones during the
study. The participants were at various degree
programs and years. The first-year participants may
Advances in Social Science, Education and Humanities Research, volume 530
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experience adaptation to new university life and the
final year participants may experience more academic
stressors that other participants. Inconsistence in
attendance of the weekly neurofeedback training due
to health problem may be a source of confounding
variables.
Lastly, results need to be interpreted by
considering a few limitations of the study such as
small sample size and lack of randomization. The
small sample size may influence the statistical power
to differentiate the efficacy the neurofeedback
training. Thus, larger sample size with appropriate
effect size and randomized controlled trial design are
warranted.
Despite the mentioned limitations, this study was
an effectiveness study in which the intervention was
employed in a non-clinical setting with complex
participants. The study also employed the same
neurofeedback trainers to carry out the neurofeedback
training for each participant. Therefore, the
improvement in the participants’ symptoms can be
attributed to protocols of treatment, and not to the
trainer effect.
3.2. Conclusion
The alarming numbers of university students in
particular facing mental health problems such as
stress, anxiety and depression make them a
population at risk [49]. Even though the application
of neurofeedback as one of the methods of treatment
for anxiety disorder, especially in the area of ADHD
and autism spectral disorder, it is a potential
intervention to significantly improve anxiety
symptoms. More rigorous methodological research
needed to be done as an additional
nonpharmacological treatment alongside other
standard treatment.
AUTHORS’ CONTRIBUTIONS
The authors confirm contribution to the paper as
follows: study conception and design: Jasmine Adela
Mutang, Chua Bee Seok, Guan Teik Ee; data
collection: Jasmine Adela Mutang; analysis and
interpretation of results: Jasmine Adela Mutang,
Chua Bee Seok.; draft manuscript preparation:
Jasmine Adela Mutang, Guan Teik Ee. All authors
reviewed the results and approved the final version of
the manuscript.
ACKNOWLEDGMENTS
This research is supported by the Postgraduate
Research Grant (UMSGreat; No: GUG0207-1/2018),
Universiti Malaysia Sabah.
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Anxiety, although as common and arguably as debilitating as depression, has garnered less attention, and is often undetected and undertreated in the general population. Similarly, anxiety among medical students warrants greater attention due to its significant implications. We aimed to study the global prevalence of anxiety among medical students and the associated factors predisposing medical students to anxiety. In February 2019, we carried out a systematic search for cross-sectional studies that examined the prevalence of anxiety among medical students. We computed the aggregate prevalence and pooled odds ratio (OR) using the random-effects model and used meta-regression analyses to explore the sources of heterogeneity. We pooled and analyzed data from sixty-nine studies comprising 40,348 medical students. The global prevalence rate of anxiety among medical students was 33.8% (95% Confidence Interval: 29.2–38.7%). Anxiety was most prevalent among medical students from the Middle East and Asia. Subgroup analyses by gender and year of study found no statistically significant differences in the prevalence of anxiety. About one in three medical students globally have anxiety—a prevalence rate which is substantially higher than the general population. Administrators and leaders of medical schools should take the lead in destigmatizing mental illnesses and promoting help-seeking behaviors when students are stressed and anxious. Further research is needed to identify risk factors of anxiety unique to medical students.
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La profesion –formacion- docente es un tema crucial en los actuales debates educativos. La existencia de dos decretos y el desplazamiento del verdadero sentido del ser maestro reclaman de los analisis un ejercicio de comprension del orden discursivo oficial. La calidad es el sustrato de la sociedad de control. En este marco se agencia nuevas practicas de subjetivacion del maestro los cuales podriamos situar en la calidad, flexibilidad, adaptabilidad, eficiencia, eficacia. En cualquier caso, el esfuerzo por hacer del maestro un intelectual de la educacion fue borrado. La gran cuestion consiste en saber que discursos regula el saber del docente a la luz de la sociedad de control.