This article was written by our trainer Anna Jusek
Pregnancy can be an emotionally challenging time for many expecting mothers as they become more susceptible to stressors (e.g., pregnancy-specific stress such as foetal health and birth outcomes. As well as issues concerning finance, relationships and discrimination.) due to the biological, psychological and social changes that occur during pregnancy [1,2,13]. Anxiety and depression are a particular concern as various research demonstrates that ~ 1 in 5 pregnant women will have an anxiety disorder, 10-14% will meet the criteria for major depression disorder (MDD), whereas 25-50% will exhibit symptoms of anxiety and depression that do not meet the full diagnostic criteria [1].
Why is anxiety during pregnancy of concern?
Acute and chronic stress cause an imbalance in homeostasis and thus increase the likelihood of pregnancy issues, e.g., neonatal comorbidity and preterm birth that is further associated with long-term complications in vision, neuro-developmental delays and short-term cardiovascular, neurological and metabolic complications [1,3,13].
For example, physically stressed mothers (e.g., they exhibit high blood pressure) are at a higher risk of delivering infants with decreased heart rate movement coupling (this can be indicative of the central nervous system developing at a slower rate). Whereas psychologically stressed mothers may undergo more birth complications [4].
Regarding the mother’s wellbeing, anxiety increases the frequency of nausea, vomiting and the likelihood of developing depression [2,10].
Stress induced birth complications are partially due to the increase of various pro-inflammatory cytokines alongside the decrease of anti-inflammatory cytokine IL-10. This imbalance in inflammatory markers can negatively effect the mother’s immune system, thereby increasing the likelihood of a poor pregnancy outcome [1].
The recent pandemic has led to an increase in stress, anxiety and depression, especially within women [2,5,7,8]. Thus, several studies have highlighted the importance of monitoring the mental health of antenatal women after heightened anxiety levels in expectant mothers have been observed.
Several studies have demonstrated neurofeedback training (NFT) efficacy in decreasing anxiety and related symptoms [17,22,24,27,28,29,30].
Targeting anxiety with Neurofeedback
Oscillations acquired from the brain are closely tied to behavioural arousal, i.e., low frequency oscillations (such as delta, theta and alpha) are characteristics of low cortical and behavioural arousal due to reduced neuronal firing and excitability. Vice versa, high frequency oscillations may connote high cortical and behavioural arousal [26].
States of lower arousal are ensued by decreased awareness of stimuli in one’s environment. For example, patients with PTSD are reported to exhibit higher power of beta rhythms, i.e., high frequency oscillations, alongside reduced alpha power rhythms [26,28,29]. Whilst increased high-frequency gamma band activities (again, very high frequency oscillations) are observed in generalised anxiety disorder (GAD) [27].
Similar to many studies, Wang et al observed that neurofeedback successfully reduced high-beta at the parietal cortex which was accompanied by reduced anxiety and depression in their patients [17].
In further support of this concept, Liu and colleagues observed an increase in SMR (this is a low beta frequency that has been linked to relaxed focus and improved performance) within post-training EEG assessments – this increase in SMR resulted in reduced anxiety after two weeks of neurofeedback training.
Why is depression during pregnancy of concern?
Similar to anxiety, depression or the continuous use of SSRIs (selective serotonin reuptake inhibitors) during pregnancy are reported to result in preterm birth rates surpassing 20%. Furthermore, both anxiety and depression increase the likelihood of post-partum depression [10].
This is significant to note as the goal of improving depression and anxiety isn’t just to support the health of mother and foetus during pregnancy - but to also mitigate the downstream issues these disorders can evoke on parenting and attachment styles as well as the child’s emotional regulation capabilities [1,6].
For example, the children of very anxious mothers are twice as likely to develop ADHD [10].
Once again, Neurofeedback training has been demonstrated to be effective in the treatment of depression [17,18,19,20,21,22,23].
Targeting depression with Neurofeedback
Method 1: Training Alpha asymmetry.
This protocol is widely used for the treatment of depression. The model is based on the consensus that it is predominantly the right prefrontal cortex that modulates positive emotions and approaching behaviour patterns.
The training of positive emotions involves either:
• Increasing left frontal beta while decreasing beta on the right, OR
• Increasing right frontal alpha (i.e., suppressing right frontal activity) while decreasing alpha activity in the left
The alpha band is of particular interest for depression-targeted NFT as occipital alpha is indicative of a calm resting state whereas frontal alpha is involved in emotion and motivation. For example, Choi and colleagues observed that alpha training resulted in higher levels of frontal alpha power and improvements in depression and automatic thoughts within their subjects [31].
Method 2: Alpha-Theta (A-T) alongside high beta power or SMR beta training.
This protocol rewards greater occipital theta power over alpha. The aim is to attain deep relaxation, diminish stress and promote easier retrieval of unconscious thoughts. The benefits of this protocol were established in the 90s during the treatment of substance dependence. It has been suggested that the positive results were due to the protocols impact on endorphin levels and its ability to improve subjective estimates of depression [18,19].
Since then, alpha/theta training has shown promising results on an array of personality scores (e.g., Millon Clinical Multiaxial inventory and the Minnesota multiphasic personality inventory) by inducing a shift towards more warm-hearted, emotionally stable, satisfied, relaxed and self-positive attributes [20]. While increasing low beta (SMR) oscillations improves the lack of motivation and executive functioning often observed in depression.
Additional Neurofeedback-mediated pregnancy support: Increasing Resilience
The most vital news is that not all expecting mothers facing stress will have negative pregnancy outcomes.
Hogue and his team highlighted that effective coping in pregnant women can reduce the negative effects of stress, such as preterm birth. While Ineffective coping allows for stress to cause homeostatic imbalance and its associated risks [11].
Similarly, Xuemei et al demonstrated that resilience during pregnancy acts as a protective factor for mitigating or diminishing the impacts of anxiety and depression [12].
Neurofeedback training can support expectant mothers with anxiety and depression to improve physiological and neuronal resilience and promote a healthy nervous system that will act as a positive tuning fork for the baby: calm mother equals calm baby. Both emotional and physiological resilience can be further enhanced with biofeedback.
1. The Mindfulness approach
Mindfulness fosters resilience by enhancing present focus which facilitates effective decision-making and actions, increasing flexibility which enables individuals to adapt to present obstacles and improving self-control [32,33].
Whether it is a result of increased resilience or a further by-product of practicing mindfulness; Meta-analyses of 17 studies in 2016 and 14 studies in 2017 demonstrated that mindfulness interventions also improved depression, anxiety and stress [14,15]. The power of mindfulness is that it enables individuals to be aware of their internal states. This awareness allows for a better understanding and sometimes control over one’s circumstances. Neurofeedback acts similarly to meditation by providing a mirror through which the brain can observe itself and make vital adjustments to enhance self-regulation.
Additionally, neurofeedback training (NFT) in combination with mindfulness practices is reported to enhance results. Hunkin and team showed that participants receiving auditory feedback via EEG NFT during meditation entered a deeper state of mindfulness and had reduced incidences of mind wandering compared to the controls that meditated without feedback [16]. Concomitantly, Arpaia’s team found an increase of emotional acceptance within their cohort that received neurofeedback in combination with emotional acceptance-based mindfulness training [17].
2. Heart Rate Variability (HRV) training
HRV training has been demonstrated to increase resilience to stress during nonstress periods as well as to traumatic events [34]. As posited by Hogue et al and Xuemei et al, increased resilience attenuates stress induced birth complications.
In two studies comprising pregnant women (the first consisted of women at threat of preterm labour while the latter entailed women in the early postpartum period), HRV was demonstrated to induce positive results.
For the antenatal group at risk of preterm birth, women that received HRV training exhibited a reduced perception of chronic stress and a lower rate of preterm birth compared to the controls. Whereas in the postpartum cohort, HRV training improved scores in the Edinburgh postnatal depression scale, meaning that HRV reduced depression. A further supporting study reported that HRV training reduced anxiety symptoms and improved overall psychological well-being in their pregnant cohort [1].
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References:
1. Traylor CS, Johnson JD, Kimmel MC, Manuck TA. Effects of psychological stress on adverse pregnancy outcomes and nonpharmacologic approaches for reduction: An expert review. American Journal of Obstetrics & Gynecology MFM. 2020;2(4):100229.
2. Salehi L, Rahimzadeh M, Molaei E, Zaheri H, Esmaelzadeh‐Saeieh S. The relationship among fear and anxiety of Covid‐19, pregnancy experience, and mental health disorder in pregnant women: A structural equation model. Brain and Behavior. 2020;10(11).
3. Shankaran S, Natarajan G. Short- and long-term outcomes of moderate and late preterm infants. American Journal of Perinatology. 2016;33(03):305–17.
4. Walsh K, McCormack CA, Webster R, Pinto A, Lee S, Feng T, et al. Maternal prenatal stress phenotypes associate with fetal neurodevelopment and birth outcomes. Proceedings of the National Academy of Sciences. 2019;116(48):23996–4005.
5. Rashidi Fakari F, Simbar M. Coronavirus Pandemic and Worries during Pregnancy; a Letter to Editor. Arch Acad Emerg Med. 2020 Mar 16;8(1):e21. PMID: 32185371
6. Nasiri S, Akbari H, Tagharrobi L, Tabatabaee AS. The effect of progressive muscle relaxation and guided imagery on stress, anxiety, and depression of pregnant women referred to health centers. J Educ Health Promot. 2018 Mar 1;7:41. doi: 10.4103/jehp.jehp_158_16
7. Tzur Bitan D, Grossman-Giron A, Bloch Y, Mayer Y, Shiffman N, Mendlovic S. Fear of covid-19 scale: Psychometric Characteristics, reliability and validity in the Israeli population. Psychiatry Research. 2020;289:113100.
8. Preis H, Mahaffey B, Heiselman C, Lobel M. Pandemic-related pregnancy stress and anxiety among women pregnant during the coronavirus disease 2019 pandemic. American Journal of Obstetrics & Gynecology MFM. 2020;2(3):100155.
9. Wisner KL, Sit DKY, Hanusa BH, Moses-Kolko EL, Bogen DL, Hunker DF, et al. Major depression and antidepressant treatment: Impact on pregnancy and neonatal outcomes. FOCUS. 2009;7(3):374–84.
10. Fairbrother N, Young AH, Janssen P, Antony MM, Tucker E. Depression and anxiety during the perinatal period. 2021;
11. Hogue CJ, Bremner JD. Stress model for research into preterm delivery among black women. American Journal of Obstetrics and Gynecology. 2005;192(5).
12. Ma X, Wang Y, Hu H, Tao XG, Zhang Y, Shi H. The impact of resilience on prenatal anxiety and depression among pregnant women in Shanghai. Journal of Affective Disorders. 2019;250:57–64.
13. Ibrahim SM, Lobel M. Conceptualization, measurement, and effects of pregnancy-specific stress: Review of research using the original and revised prenatal distress questionnaire. Journal of Behavioral Medicine. 2019;43(1):16–33.
14. Lever Taylor B, Cavanagh K, Strauss C. The effectiveness of mindfulness-based interventions in the perinatal period: A systematic review and meta-analysis. PLOS ONE. 2016;11(5).
15. Dhillon A, Sparkes E, Duarte RV. Mindfulness-based interventions during pregnancy: A systematic review and meta-analysis. Mindfulness. 2017;8(6):1421–37.
16. Hunkin H, King DL, Zajac IT. EEG neurofeedback during focused attention meditation: Effects on state mindfulness and Meditation Experiences. Mindfulness. 2020;12(4):841–51.
17. Wang S-Y, Lin I-M, Fan S-Y, Tsai Y-C, Yen C-F, Yeh Y-C, et al. The effects of alpha asymmetry and high-beta down-training neurofeedback for patients with the major depressive disorder and anxiety symptoms. Journal of Affective Disorders. 2019;257:287–96.
18. Peniston EG, Kulkosky PJ. Alpha-Theta Brainwave training and beta-endorphin levels in alcoholics. Alcoholism: Clinical and Experimental Research. 1989;13(2):271–9.
19. Saxby E, Peniston EG. Alpha-Theta Brainwave Neurofeedback training: An effective treatment for male and female alcoholics with depressive symptoms. Journal of Clinical Psychology. 1995;51(5):685–93.
20. 14,4,6 - E. Bodehnamer-Davis et al.Extended follow-up of Peniston protocol results with chemical dependency, J.N. Butcher et al.MMPI-2: Manual for Administration and Scoring
21. Raymond J, Varney C, Parkinson LA, Gruzelier JH. The effects of alpha/theta neurofeedback on personality and mood. Cognitive Brain Research. 2005;23(2-3):287–92.
22. Cheon E-J, Koo B-H, Seo W-S, Lee J-Y, Choi J-H, Song S-H. Effects of neurofeedback on adult patients with psychiatric disorders in a naturalistic setting. Applied Psychophysiology and Biofeedback. 2015;40(1):17–24.
23. Lee Y-J, Lee G-W, Seo W-S, Koo B-H, Kim H-G, Cheon E-J. Neurofeedback treatment on depressive symptoms and functional recovery in treatment-resistant patients with major depressive disorder: An open-label pilot study. Journal of Korean Medical Science. 2019;34(42).
24. Gomes JS, Ducos DV, Akiba H, Dias ÁM. A neurofeedback protocol to improve mild anxiety and sleep quality. Revista Brasileira de Psiquiatria. 2016;38(3):264–5.
25. Hammond DC. Neurofeedback treatment of depression with the Roshi. Journal of Neurotherapy. 2000;4(2):45–56.
26. Micoulaud-Franchi JA, Jeunet C, Pelissolo A, Ros T. EEG neurofeedback for Anxiety Disorders and post-traumatic stress disorders: A blueprint for a promising brain-based therapy. Current Psychiatry Reports. 2021;23(12).
27. Rice KM, Blanchard EB, Purcell M. Biofeedback treatments of generalized anxiety disorder: preliminary results. Biofeedback Self-Regul. 1993;18:93–105.
28. Van der Kolk BA, Hodgdon H, Gapen M, Musicaro R, Suvak MK, Hamlin E, et al. A randomized controlled study of neurofeedback for chronic PTSD. PLoS One. 2016;11:e0166752.
29. Noohi S, Miraghaie AM, Arabi A, Nooripour R. Efectiveness of neuro-feedback treatment with alpha/theta method on PTSD symptoms and their executing function. Biomed Res. 2017;28(5):2019–27.
30. Gadea M, Aliño M, Hidalgo V, Espert R, Salvador A. Effects of a single session of SMR neurofeedback training on anxiety and cortisol levels. Neurophysiologie Clinique. 2020;50(3):167–73.
31. S. W. Choi, S. E. Chi, S. Y. Chung, J. W. Kim, C. Y. Ahn, and H. T. Kim, “Is alpha wave neurofeedback effective with randomized clinical trials in depression? A pilot study,” Neuropsychobiology, vol. 63, no. 1, pp. 43–51, 2011
32. Waldeck, D. B. S., Tyndall, I., & Chmiel, N. (2015). Resilience to ostracism: A qualitative inquiry. The Qualitative Report, 20(10), 1646-1670.
33. Linder, Jason N. & Mancini, Jay A. (2021) Observations on the relationship between resilience and mindfulness. Counseling and Family Therapy Scholarship Review: Vol. 3 : Iss. 2 , Article 1.
34. An E, Nolty AAT, Amano SS, Rizzo AA, Buckwalter JG, Rensberger J. Heart Rate Variability as an Index of Resilience. Mil Med. 2020 Mar 2;185(3-4):363-369.