Biofeedback in Stress Management


Stress is a necessary mechanism for survival. However, severe and/or long-term stress poses a threat to our health and disrupts normal brain structure and function. That is why it is necessary to manage stress to prevent changes that it causes in our organism to keep our well-being. The best way to prevent this kind of change in the organism is to use the different modalities of biofeedback in stress management.


Stress is not what happens to you, but how you react to what happens.

Everyone experiences stress to some degree. The way you respond to stress, however, makes a big difference to your overall well-being. Stress is the body’s physical response to a real or perceived threat, demand, or danger. Stress can be defined as any type of change in the organism that causes physical, emotional, or psychological strain. When you feel threatened, your body releases stress hormones which prepare the body to respond. This is called the “fight or flight” response.

Although stress is a necessary mechanism for survival, severe and/or long-term stress disrupts normal brain structure and function. Mental stress, which may range in intensity from mild to severe posttraumatic stress disorder (PTSD), has been reported to impair memory possibly by elevating excitatory amino acid and glucocorticoid levels, which in turn induce excitotoxicity and hippocampal atrophy.

Factors that cause Stress

Stress factors broadly fall into four types or categories:

  • physical stressors,
  • psychological stressors,
  • psychosocial stressors,
  • psycho-spiritual stressors.

Physical stressors

  • trauma (injury, infection, surgery),
  • intense physical labor/over-exertion,
  • environmental pollution (pesticides, herbicides, toxins, heavy metals, inadequate light, radiation, noise, electromagnetic fields),
  • illness (viral, bacterial, or fungal agents),
  • fatigue,
  • inadequate oxygen supply,
  • hypoglycemia I(low blood sugar),
  • hormonal and/or biochemical imbalances,
  • dietary stress (nutritional deficiencies, food allergies, and sensitivities, unhealthy eating habits),
  • dehydration,
  • substance abuse,
  • dental challenges,
  • musculoskeletal misalignments/imbalances.

Psychological stressors

  • emotional stress (resentments, fears, frustration, sadness, anger, grief/bereavement),
  • cognitive stress (information overload, accelerated sense of time, worry, guilt, shame, jealousy, resistance, attachments, self-criticism, self-loathing, unworkable perfectionism, anxiety, panic attacks, not feeling like yourself, not feeling like things are real, and sense of being out of control/not being in control),
  • perceptual stress (beliefs, roles, stories, attitudes, world view).

Psychosocial stressors

  • relationship/marriage difficulties (partner, siblings, children, family, employer, co-workers, employer),
  • lack of social support,
  • lack of resources for adequate survival,
  • loss of employment/investments/savings,
  • loss of loved ones, bankruptcy,
  • home foreclosure,
  • isolation.

Psycho-spiritual stressors

  • a crisis of values, meaning, and purpose;
  • joyless striving (instead of productive, satisfying, meaningful, and fulfilling work);
  • a misalignment within one’s core spiritual beliefs.

Pathophysiology of stress

Stress response relies on Neuronal pathways of the cerebral cortex, the limbic system, the hypothalamus, the thalamus, the pituitary gland, and the reticular activating system (RAS).

1. The cerebral cortex deals with vigilance, cognition, and focused attention.
2. The limbic system is associated with emotional components like fear, rage, and anger of the stress response.
3. Thalamus acts as a relay center and helps in receiving, sorting out, and distributing sensory input.
4. Hypothalamus coordinates endocrine and autonomic responses.

The inputs from the prefrontal cortex flow to the dorsomedial amygdala complex, which appears to represent the highest point of origination for the “fight-or-flight”.

Amygdala detects things that are scary or dangerous in the environment.

 Stress and Prefrontal Complex.

The inputs from the prefrontal cortex flow to the dorsomedial amygdala complex.

The different types of stressors engage different brain networks, requiring fine-tuned functional neuroanatomical processing. This integration of information from the stressor itself may result in rapid activation of the Hypothalamus-Pituitary-Adrenal (HPA) axis and the Sympathetic-Adreno-Medullar (SAM) axis, the two major components involved in the stress response.

The Hypothalamus-Pituitary-Adrenal (HPA) axis is a neuroendocrine system that mediates a stress response.

Paraventricular neurons in the hypothalamus release vasopressin and corticotropin-releasing hormone, which travel through the vessel and bind to the corticotropin-releasing hormone (CRH) receptor on the anterior pituitary gland. Multiple CRH receptors have been identified in multiple areas of the brain, including the amygdala. CRH is the main regulatory molecule for the release of adrenocorticotropic hormone (ACTH) from the Pituitary gland. The secretion of ACTH into systemic circulation allows stimulates the release of glucocorticoid hormones (cortisol) by the adrenal cortex.

The Sympathetic-Adreno-Medullar (SAM) axis may activate the fight-or-flight response through the sympathetic nervous system, which dedicates energy to more relevant bodily systems for acute adaptation to stress

The inputs from the prefrontal cortex flow to the dorsomedial amygdala complex, which appears to represent the highest point of origination for the “fight-or-flight”. From the dorsomedial amygdala complex, the downward flow of neural impulses passes to the lateral and posterior hypothalamic regions and continues to descend through the thoracic spinal cord, converging at the celiac ganglion, and then innervating the adrenal medulla.

Adrenal glands produce adrenal medullary catecholamine: norepinephrine (noradrenaline) and epinephrine (adrenaline).

The activity of the sympathetic nervous system drives what is called the “fight or flight” response.

Video - Stress Factors & Pathophysiology

The “fight or flight” response to emergency or stress involves

  • Increase in arterial blood pressure due to vasoconstriction.
  • Increase in blood supply to the brain (moderate).
  • Increase in heart rate and cardiac output.
  • Increase in the stimulation of skeletal muscles.
  • Increase in plasma-free fatty acids, triglycerides, and cholesterol.
  • Increase in the release of endogenous opioids.
  • Decrease in blood flow to kidneys
  • Decrease in blood flow to the gastrointestinal system (decreased motility of the digestive system).
  • Decrease in blood flow to the skin.
  • Increase in risk of hypertension.
  • Increase in risk of thrombosis formation.
  • Increase in risk of angina pectoris attacks in persons so prone.
  • Increase in risk of arrhythmias.
  • Increase in risk of sudden death from lethal arrhythmia, myocardial ischemia, myocardial fibrillation, and myocardial infarction.

Types of Stress and Symptoms

There are three different types of stress, and each can take a toll on our bodies. Stress can affect many aspects of your health and well-being, even though you might not realize it.

Acute stress

Acute stress is the most common type of stress and can be helpful in short doses. We experience acute stress multiple times each day. It can occur when there is a challenge, a perceived threat, or when something unexpected happens: giving a speech, arguing with a spouse, getting stuck in traffic, or getting a speeding ticket. The symptoms of acute stress develop quickly and do not last long:

  • Pupil dilation (As part of the fight-or-flight reaction, our pupils dilate to allow more light to enter the eyes and enable us to see our surroundings more clearly);
  • Fast and heavy breathing (This symptom is also part of the fight-or-flight reaction. It aims to introduce more oxygen into the body’s systems so it can more effectively react to stress);
  • Anxiety (this is the feeling of worry and fear that results from exposure to a stressor);
  • Poor concentration (this symptom is a consequence of stress hormones and chemicals released into the body by the fight-or-flight response);
  • Heart rate increases (this is another part of the fight-or-flight reaction that can be disconcerting if it feels like heart palpitations);
  • Raised blood pressure;
  • Perspiration (when we are stressed, our body temperature rises, which causes us to sweat more);
  • Increased muscle tension;
  • Headache,
  • Back Pain,
  • Jaw Ache,
  • Stomach Upset.

Episodic acute stress

This occurs when we frequently experience acute stress and can develop as a result of taking on too much responsibility or being overburdened. Type “A” personalities or people who worry constantly are more prone to experience this type of stress.

The symptoms of episodic acute stress are similar to those of acute stress; however, they occur more often and accumulate.

  • Poor concentration – more pronounced than with acute stress, you may also notice increased difficulty with memory and recall.
  • Feeling overwhelmed. This is the feeling of not being able to cope nor able to visualize effective solutions to the causes of your stress.
  • Uncontrolled anger and irritability. We find ourselves lashing out more often and with less provocation. We may also find ourselves reacting strongly to things that normally we would tolerate.
  • Muscle tension. This is meant to help our bodyguard against injury and pain. When exposed to episodic acute stressors, our muscles don’t get the opportunity to relax.
  • Tension headache/Migraines. These are often the result of muscle tension. The frequency and severity of migraines are likely to increase under episodic acute stress.
  • Hypertension. A majority of people will be unaware of having high blood pressure. The only reliable way to detect hypertension is to have your blood pressure measured by a health professional.

If not managed properly, symptoms can lead to serious health problems such as clinical depression or heart disease.

  • Emotional ups and downs (irritability and swings in emotions)
  • Poor sleep (our sleep is often disrupted by our anxiety and the cocktail of hormones produced by the fight-or-flight reaction).

Chronic stress

Chronic stress is constant and persists over an extended period of time stress. It is the most harmful type of stress to our overall health.

Chronic stress can be caused by poverty, abuse of any kind, a poor work environment, having a dysfunctional marriage or family, or substance abuse.

The symptoms of chronic stress can become overwhelming or debilitating.

Some people may experience

  • Fatigue,
  • Changes in appetite – Weight gain. This is often the result of “stress eating,” but it can also result from long-term hormonal imbalances caused by chronic stress.
  • Heightened levels of adrenaline and cortisol. Long-term effects of heightened levels of adrenaline and cortisol can affect memory and digestion. They can also suppress the immune system.
  • Difficulty sleeping – Insomnia. Difficulty in falling and staying asleep, often resulting in not feeling rested from whatever sleep you did get.
  • Tension headaches or migraine – Frequently occurring tension headaches, generally defined as occurring more than 15 days in a month.
  • Panic attacks – Sudden onset of feelings of fear and anxiety accompanied by the symptoms of acute stress.
  • Feelings of helplessness.
  • Depression. Feeling that you are not able to do anything to help yourself or improve your situation.
  • Emotional fatigue. This manifests as feeling tired a majority of the time, irrespective of the type of rest you’re getting or sleep.
  • Difficulty concentrating
  • Problems with working memory.

Chronic stress left untreated for a long period of time can have serious consequences and lead to health problems such as insomnia, obesity, heart disease, hypertension, or diabetes.

If you think stress might be affecting you, there are a few things you can watch for:

  • Psychological signs such as difficulty concentrating, worrying, anxiety, and trouble remembering
  • Emotional signs such as being angry, irritated, moody, or frustrated
  • Physical signs such as high blood pressure, changes in weight, frequent colds or infections, and changes in the menstrual cycle and libido
  • Behavioral signs such as poor self-care, not having time for the things you enjoy, or relying on drugs and alcohol to cope


Although stress is inevitable, it can be manageable.

When you understand the toll it takes on you and the steps to combat stress, you can take charge of your health and reduce the impact that stress has on your life.
When you start to feel symptoms of emotional exhaustion, it’s a sign that you need to find a way to get a handle on your stress.

Try to get regular exercise. Physical activity has a big impact on your brain and your body. Whether you enjoy Tai Chi or you want to begin jogging, exercise reduces stress and improves many symptoms associated with mental illness.

Take care of yourself. Incorporating regular self-care activities into your daily life is essential to stress management. Learn how to take care of your mind, body, and spirit and discover how to equip yourself to live your best life.

Practice mindfulness in your life. Mindfulness isn’t just something you practice for 10 minutes each day. It can also be a way of life. Discover how to live more mindfully throughout your day so you can become more awake and conscious throughout your life.

Different modalities of Biofeedback and Neurofeedback in stress management are brain-computer interface technology, which teaches people to control behavioral and autonomic nervous system reactions to stress.

Different modalities of biofeedback in stress management

The use of different modalities of biofeedback in stress management depends on what symptoms are prevailing.

In case you have more expressed psychological conditions, such as headaches, concentration, memory problems, insomnia, appetite changes, depression, anxiety, or panic attacks it could be more effective the use Neurofeedback (one of the biofeedback modalities) management of stress and its consequences.

Video - Biofeedback in stress management. How to choose Biofeedback Modality

Neurofeedback management of stress and its consequences

Neurofeedback is a scientifically based method used worldwide to measure and improve brain activity. A distinction is usually made between 5 different brain wave patterns that can be assigned to certain states and can overlap. Brain activity can be made visible by measuring devices. Normally, it cannot be perceived by our senses. Measuring devices record the very low stresses on the skull and amplify them and display them, often in the form of a graph, pictures, video, or game. Based on the composition of brainwave different frequency components, it is divided into certain states of consciousness and brain wave patterns. The training is aimed at the improvement of self-regulation through feedback.

Without the feedback, this training effect would not be achievable, since brain activity cannot be perceived in this analytical way without devices.

The aim of neurofeedback training is to have a lasting positive influence on perception, thinking, attention, behavior, and well-being by optimizing brain waves.

Anyone can increase their ability to concentrate and memory capacity, sometimes drastically, through neurofeedback training.

Learning and memory skills are also improved. Stress can be reduced effectively and for a long time. The various states of the brain can be influenced by self-regulation. Specific states such as relaxation or sleep can also be trained in this way.

Recommendations on how to choose among different modalities of biofeedback in stress management and eliminate its vegetative symptoms

The choice among different modalities of Biofeedback in stress management depends on what symptoms are prevailing.

In the table below you can find recommendations on how to choose biofeedback modalities to manage stress and its vegetative symptoms.

  • cold hands or feet,
  • general stress and tension,
  • poor peripheral circulation,
  • blood pressure fluctuations,
  • increase the depth of meditation
  • Raynaud’s syndrome
  • migraine or tension headache
  • neurosis,
  • chronic pain,
  • phobias,
  • anxiety,
  • panic attack,
  • depression
  • sweaty hands,
  • anxiety,
  • distracted thoughts,
  • agitated mood,
  • low anger threshold,
  • poor impulse control
  • high blood pressure
  • tinnitus,
  • insomnia (sleep disorders)
  • anxiety,
  • panic disorders,
  • specific phobias
  • fast shallow breathing,
  • hyperventilation,
  • lightheadedness,
  • train abdominal breathing,
  • balance breath cycle
  • migraine or tension headache
  • depression
  • attention and concentration problems
  • anxiety disorders
  • insomnia problems
  • asthma and other bronchial tract and lung problem
  • hyperventilation
  • heart disease and hypertonia
  • racing heartbeat (tachycardia),
  • arrhythmia
  • chest tightness,
  • chronic generalized stress,
  • difficulties in relaxing,
  • rapid shallow breathing,
  • low daily energy
  • high blood pressure
  • anxiety,
  • depression,
  • heart disease
  • insomnia,
  • emotional instability,
  • deficiency in concentration, attention, and memory
  • muscles tension,
  • inner tension,
  • bad coordination,
  • weak muscles,
  • back, muscles, or joint pain
  • tension headache,
  • panic attack/anxiety,
  • coordination exercises,
  • support psycho-education/self-awareness

In case you have more expressed psychosomatic conditions, such as arrhythmia or tachycardia, high blood pressure, stomach or other digestive problems, obesity or other endocrine changes, etc., it could be more effective the use one of the following modalities of biofeedback in stress management and elimination of its vegetative symptoms:

  • Temperature biofeedback (especially effective in case of tension or migraine headache, peripheral capillary circulation problems, Raynaud’s syndrome, etc.),
  • Electrodermal Skin Response biofeedback (for therapy of high blood pressure, tinnitus, sleep disorders, and many other conditions that are caused by an imbalance of the Autonomic Nervous System).
  • Breathing biofeedback (in case of hyperventilation, tachypnea, attention and concentration problems, anxiety disorders, insomnia problems, etc.).
  • Heart rate variability with respiration (in case of arrhythmia/tachycardia, high blood pressure, insomnia, bronchospasm, etc.),
  • EMG biofeedback (more effective in case of locomotors function affection – back, muscles or joint pain, etc.).

Home-use device for biofeedback in stress management

Temperature biofeedback

The skin temperature on the hands is directly related to tension and relaxation.

The skin’s surface temperature changes according to blood circulation through body tissue. The small blood vessels (arterioles) crossing through the tissue are surrounded by fibers of smooth muscle controlled by the sympathetic nervous system.

In a state of increased exertion, excitement, and stress, these muscle fibers contract and narrow the blood vessels. This leads to a reduction in skin temperature because blood circulation through the tissue is reduced.

By contrast, in a resting or calm state, the muscles relax and the blood vessels expand. The skin temperature rises.

Conscious control of physiological stress can help you react more relaxed and more efficiently to many situations.

A particularly effective and frequently used biofeedback training method is “hand-warming training”. During hand-warming training, you will learn how to specifically increase blood circulation in your hands, which leads directly to stress reduction and relaxation.

Conscious control of physiological stress can help you react more relaxed and more efficiently to many situations.

Skin temperature biofeedback is easy to use and learn. It has a high success rate and brings about a general improvement in well-being.

Temperature Biofeedback can be practiced using the eSense Temperature Biofeedback home-use device in your home comfort.

Electrodermal skin response Biofeedback

Skin response, also known as galvanic skin response (GSR), electrodermal response (EDR), or skin conductance (SC) is a measurement method based on the bio-electrical properties of the skin. Skin conductance depends on the activity of the sweat glands of the skin and reacts to the smallest changes, which we can’t detect as wet hands yet. Through the changes of this small current, we can measure the activity of the perspiration glands of the skin far below the threshold of self-perception. 

The higher the stress, the more activity of the sweat glands, the more the skin gets wet, and the better the current is conducted. As a result, the skin conductance rises.

Stress and its vegetative symptoms can be greatly reduced through electrodermal skin response biofeedback training, where you intentionally work on lowering your skin response.

Skin response is a universal tool for biofeedback training. It is widely used in the therapy of anxiety, panic disorders, and specific phobias. Further fields of use are high blood pressure, tinnitus, and sleep disorders.

With the eSense Skin Response Biofeedback home-use device, you can measure your stress level and effectively reduce it with biofeedback training in your home comfort.

Breathing Biofeedback

Respiration is special, as in contrast to other biofeedback parameters it can be controlled consciously. This means that biofeedback respiration training is especially suited for beginners.

In everyday life, we rarely think of our breathing and breathe almost exclusively unconsciously. If our unconscious breathing patterns are disturbed by chronic stress, pain, or other psychological or physical stresses, this often leads to discomfort and the maintenance of stress. With breathing biofeedback training, it is possible to train and improve breathing, achieve deep relaxation states, and significantly increase general well-being. Breathing, therefore, plays an important role in almost all relaxation techniques such as autogenic training, yoga, meditation, and progressive muscle relaxation.

When measuring respiration, there are two main measurements: the Respiration Amplitude (RA) and the breathing frequency (breaths per minute).

Our state of mind is reflected in our breathing. If we are pleased or tense, we usually breathe quickly, irregularly, and flatly. Positive as well as negative stress is reflected by quick, irregular, and flat breathing. If, on the other hand, we are relaxed and calm or sleepy, our breathing is usually slow and even deep.

With the eSense Respiration biofeedback home-use device, you have a powerful tool to enhance your breathing in a modern way and overcome stress and its vegetative symptoms.

The eSense Respiration biofeedback device works only with an eSense Skin Response.

Heart Rate Variability Biofeedback

In order to reduce stress and its symptoms, heart rate variability biofeedback training can be performed seeking to increase heart rate variability.

Heart rate variability (HRV) refers to the ability to change the frequency of the heart rhythm. Even at rest, there are spontaneous changes in the time between heartbeats. The heartbeat is related to tension and relaxation and is a potential stress indicator.

A healthy person constantly adapts the heart rhythm to current requirements. In addition to physical exertion, such as sports or physical work, psychological exertion such as stress also results in an increase in the heart rate. The heart rate sinks again when the strain is relieved, and the body relaxes.

In humans, heart rate variability ranges from 10 (low, a sign of stress) to 30 (high, a sign of relaxation).
The more our body is able to regulate the heart rate (the greater the heart rate variability), the healthier we are. If the heart beats only rigidly, a person is on the verge of death.

The aim of HRV biofeedback is to increase heart rate variability, specifically its amplitude. In other words, to maximize the difference between low heart rhythm and high heart rhythm in the interplay of inhalation and exhalation, rest and demands.

The heart rate increases when inhaling and decreases again when exhaling.

This phenomenon is called respiratory sinus arrhythmia (RSA) and is used to check the balance of the nervous system. Biofeedback training in the eSense App uses this phenomenon to improve heart rate variability with the help of a breathing target.
With the eSense Pulse biofeedback home-use device, you can measure and effectively reduce your stress level by improving heart rate variability with Heart Rate Variability (HRV) biofeedback training.

If respiration is included, the eSense App offers various ways to visualize it and define respiration in a certain rhythm.

The coupling of heartbeat and respiration is greatest in most people when breathing at about 4.5 to 6.5 breaths per minute.

EMG Biofeedback

Transverse striated muscles are controlled by our somatic nervous system and are subject to voluntary control. Every volitional action of a muscle can therefore be observed in an electromyogram. Thus, the tension of a muscle on which surface EMG electrodes are placed immediately leads to increased trace in the EMG signal. However, involuntary reactions, such as stress, inner tension, and emotional experience, can also be measured as (tonic) activity in the EMG.

The interplay between the autonomic and somatic nervous systems can be depicted particularly well in the EMG. Increased muscle tone is mainly based on an increase in sympathetic activity. A decrease can be attributed to more robust parasympathetic activation.

EMG biofeedback training can be performed to reduce stress and its vegetative symptoms by decreasing the muscle tone of specific “stress muscles”.

Typical stress muscles are the frontal muscles (M.Frontali), the jaw muscles (M.Masseter), and the shoulder muscles (M. Trapezius).

Exercises that include targeted contraction and relaxation (like progressive muscle relaxation) can lower the baseline tone of these “stress muscles”, resulting in a concomitant reduction in stress.

Typical Location of electrodes for stress emg biofeedback

The NeuroTrac Simplex EMG Biofeedback Unit is a low-cost device, an advanced and modern single-channel EMG unit featuring an easy-to-see bright LED bar graph and LCD display for feedback training.

BioSignals Combined Multimodal Biofeedback Home-Use Device

A combination of different modalities of biofeedback in stress management training is more effective. It gives a high rate of stress vegetative symptoms elimination because simultaneously rewires different pathways.