Document Type : Original Articles


1 Department of Psychiatry, Pt. Jawahar Lal Nehru Memorial Medical College, Raipur, India

2 Department of Psychology, Pt. Ravishankar Shukla University, Raipur, India


Background: Anxiety disorders have high prevalence in diabetes patients and
low-middle income countries like India. Research has provided evidence about
biofeedback effectiveness on stress-related psychophysiological parameters. This
study aimed to verify the impact of GSR biofeedback relaxation on stress-related
psychophysiological parameters (galvanic skin resistance, stress, and anxiety)
among type II diabetes patients with high levels of anxiety.
Methods:  The present study was a single-blinded
randomized controlled trial. Initially, 228 type II diabetes patients were assessed
with the state trait anxiety inventory (STAI). Seventy participants identified as
having high anxiety with STAI scores above the 75th percentile were invited to
participate. Patients were randomly divided into a biofeedback relaxation and a
sham-control group. Participants of the biofeedback group received training on
how to use the GSR biofeedback device for management of stress parameters for
twenty 30-minute sessions. The sham-control group received no intervention.
Both groups were assessed before and after the biofeedback relaxation training
program. The results of the STAI, GSR, and the inventory of stress for type II
diabetes patients were compared. SPSS 16 version was used for analysis.
Results: The biofeedback group reported a significant change in the state of
anxiety (t=5.089; p <0.001), GSR (t=-2.199; p <0.035), and stress (F=46.850;
p <0.001) post-test. The control group reported a moderate increase in stress and
trait anxiety at the same time. These results are consistent with previous studies.
Conclusion: Biofeedback relaxation is a useful technique for managing stress
and anxiety in diabetes type II patients. During an emotional disturbance, it
may also be helpful in promoting overall psychological health. Further research
is necessary to determine the long-term effects of GSR biofeedback relaxation
and the effects of cortisol on mood among diabetes patients.


  1. King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: Prevalence, numerical estimates, and projections. Diabetes Care.1998;21:1414-31.
  2. Ramachandran A. Epidemiology of type 2 diabetes in Indians. J Indian Med Assoc. 2002;100(7):425-7.
  3. Rajput R, Gehlawat P, Gehlan D, Gupta R, Rajput M. Prevalence and predictors of depression and anxiety in patients of diabetes mellitus in a tertiary care center. Indian J Endocr Metab. 2016;20:746-51.
  4. Grigsby AB, Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. Prevalence of anxiety in adults with diabetes: a systematic review. J Psychosom Res. 2002;53(6):1053-60.
  5. Pouwer F, Kupper N, Adriaanse MC. Does emotional stress cause type 2 diabetes mellitus? A review from the European Depression in Diabetes (EDID) Research Consortium. Discov Med. 2010;9(45):112-8.
  6. Esch T, Stefano GB, Fricchione GL, Benson H. Stress in cardiovascular diseases. Med Sci Monit. 2002;8(5):RA93-RA101.
  7. Smith KJ, Béland M, Clyde M, Gariépy G, Pagé V, Badawi G, et al. Association of diabetes with anxiety: a systematic review and meta-analysis. J Psychosom Res. 2013;74(2):89-99.
  8. Roelofs J, Huibers M, Peeters F, Arntz A. Effects of neuroticism on depression and anxiety: Rumination as a possible mediator. Personality and Individual Differences. 2008;44(3):576-586. 
  9. Carrillo FXM, Vázquez MB, Emotional variables on diabetes control: intervention strategies.  anales de psicología. 1994;10(2):189-198.

10. Berlin I, Bisserbe JC, Eiber R, Balssa N, Sachon C, Bosquet F, et al. Phobic symptoms, particularly the fear of blood and injury, are associated with poor glycemic control in type I diabetic adults. Diabetes Care. 1997;20(2):176-8.

11. Kojima K, Mohamed S, Fujimaru Y, Mori Y, Kaname H, Sumida Y, et al. Effects of both the emotional behavior and feeding conditions on the circulating plasma volume and plasma glucose levels in cats. Auton Neurosci. 2000;86(1-2):58-64.

12. Lloyd CE, Dyer PH, Barnett AH. Prevalence of symptoms of depression and anxiety in a diabetes clinic population. Diabet Med. 2000;17(3):198-202.

13. Niemcryk SJ, Speers MA, Travis LB, Gary HE. Psychosocial correlates of hemoglobin A1c in young adults with type I diabetes. J Psychosom Res. 1990;34(6):617-27.

14. de Kloet ER. Stress in the brain. Eur J Pharmacol. 2000;405(1-3):187-98.

15. Kumar M, Pandey D, Shrivastva P. Effect of GSR biofeedback relaxation training on blood glucose and anxiety level of type 2 diabetic patients. International Journal of Indian Psychology. 2016;4(1):82.

16. Lustman PJ, Griffith LS, Clouse RE, Freedland KE, Eisen SA, Rubin EH, et al. Effects of alprazolam on glucose regulation in diabetes. Results of double-blind, placebo-controlled trial. Diabetes Care. 1995;18(8):1133-9.

17. Rubin RR, Peyrot M. Psychological issues and treatments for people with diabetes. J Clin Psychol. 2001;57(4):457-78.

18. Agnihotri H, Paul M, Sandhu JS, Biofeedback Approach in the Treatment of Generalized Anxiety Disorder. Iran J Psychiatry. 2007;2:90-5.

19. Bembalgi V, Naik K. Comparative study on the efficacy of electromyography and galvanic skin resistance biofeedback in tension type headache: a single blinded randomized controlled trial. International Journal on Disability and Human Development. 2013;12(3):353-361.

20. Khanna A, Paul M, Sandhu JS, Efficacy of two relaxation techniques in reducing pulse rate among highly stressed females. Calicut Medical Journal. 2007;5:2.

21. Kumar M, Srivastava P, Sahu MK, Tripathi S. Effect of computerized biofeedback relaxation on stress related physiological parameters. International Journal Of Community Medicine And Public Health. 2021; 8(6): 2977-2982.

22. Boucsein  W.  Electrodermal  activity.  New York,  NY  and  London,  UK:  1992.Plenum Press.

23. Lang PJ, Greenwald MK, Bradley MM, Hamm AO. Looking at pictures: affective, facial, visceral, and behavioral reactions. Psychophysiology. 1993;30(3):261-73.

24. Mohan A, Sharma R, Bijlani RL. Effect of meditation on stress-induced changes in cognitive functions. J Altern Complement Med. 2011;17(3):207-12.

25. Karthikeyan P, Murugappan M, Yaacob S. Analysis of Stroop Color Word Test-Based Human Stress Detection using Electrocardiography and Heart Rate Variability Signals. Arab J Sci Eng.2014; 39:1835–1847. 

26. Lee DS, Jo NY, Lee KC. A Physiological Approach to Creativity under Stress and Non-stress Conditions. In: , et al. U- and E-Service, Science and Technology. UNESST 2011. Communications in Computer and Information Science;264:197–206.

27. Ryu, Kilseop, Rohae M. Evaluation of mental workload with a combined measure based on physiological indices during a dual task of tracking and mental arithmetic. International Journal of Industrial Ergonomics. 2005;35(11):991-1009.

28. Wilson GF. An analysis of mental workload in pilots during flight using multiple psychophysiological measures. The International Journal of Aviation Psychology. 2002;12(1):3–18.

29. Roscoe AH. Assessing pilot workload. Why measure heart rate, HRV and respiration? Biol Psychol. 1992;34(2-3):259-87.

30. Kumar M, Shrivastava P. A Study of Psychological factor discriminating diabetic and non-diabetic patients, Indian Journal of Health and Wellbeing. 2017;8 (8):881-884.

31. Mohan A, Sharma R, Bijlani RL. Effect of meditation on stress-induced changes in cognitive functions. J Altern Complement Med. 2011;17(3):207-12.

32. Yucha C. and Montgomery D. Evidenced-Based Practice in Biofeedback and Neurofeedback, Association for Applied Psychophysiology and Biofeedback, Wheat Ridge, Colo, USA, 2008.

33. Biofeedback Certification International Alliance, Overview of Biofeedback, 2012,

34. Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods. 2009;41(4):1149-60.

35. Rice KM, Blanchard EB, Purcell M. Biofeedback treatments of generalized anxiety disorder: preliminary results. Biofeedback Self Regul. 1993;18(2):93-105.

36. Ossebaard HC. Stress reduction by technology? An experimental study into the effects of brainmachines on burnout and state anxiety. Appl Psychophysiol Biofeedback. 2000;25(2):93-101.

37. Wenck LS, Leu PW, D'Amato RC. Evaluating the efficacy of a biofeedback intervention to reduce children's anxiety. J Clin Psychol. 1996;52(4):469-73.

38. Edinger JD, Wohlgemuth WK, Radtke RA, Marsh GR, Quillian RE. Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial. JAMA. 2001;285(14):1856-64.

39. Sharma B, Sharma RK, Agarwal T, Jindal M, Singh K. Study of the effect of 61-point relaxation therapy in premenstrual syndrome. National Journal of Physiology, Pharmacy and Pharmacology. 2019;9(2):155-159.

40. Agnihotri H, Paul M, Sandhu JS. Biofeedback Approach in The Treatment of Generalized Anxiety Disorder. Iran J Psychiatry. 2007;2:90-95.

41. Palekar TJ, Mokashi MG, Anwer S, Kakrani AL, Alghadir AH. Khandare SD , et al. Effect of Galvanic Skin Resistance Aided Biofeedback Training in Reducing Pulse Rate, Respiratory Rate  and Blood Pressure Due to Perceived Stress in Physiotherapy Students. Turk J Phys Med Rehab. 2016;61:116-9.

42. Ghazavi Z, Talakoob S, Abdeyazdan Z, Attari A, Joazi M. Effects of massage Therapy and muscle relaxation on glycosylated haemoglobin in children. Shiraz E - Medical Journal. 2008;9 (1).

43. Heidari Gorji MA, Davanloo AA, Heidarigorji AM. The efficacy of relaxation training on stress, anxiety, and pain perception in hemodialysis patients. Indian J Nephrol. 2014;24(6):356-61.

44. Fuller, George D. GSR or Galvanic Skin Response. Blog 2002.

45. Hammond DC. Neurofeedback with anxiety and affective disorders. Child Adolesc Psychiatr Clin N Am. 2005;14(1):105-23.

46. John S, Verma SK, Khanna GL. The Effect of Music Therapy on Salivary Cortisol as a Reliable Marker of Pre Competition Stress in Shooting Performance. Journal of Exercise Science and Physiotherapy. 2010;6(2): 70-77.

47. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385-96.

48. Pal R, Tiwari G. Manual for State trait anxiety inventory. Agra psychological research cell. 1998; 1-8.

49. Kumar M, Shrivastava P. Sinha M. Mishra GJ. Singh R. Psychological Factors as Predictors of Hyperglycemia in Type 2 Diabetes Mellitus. An International Bilingual Peer Reviewed Refereed Research Journal, Shodh Sarita. 2020;7 (28).

50. Kumar M, Mishra GY, Saxena S, Singh V, Kumar M, Yanjana. Predicting effect of Personality Traits and Age on Emotional Intelligence. Indian J Public Health Res Dev.2020;11(3):764–769.