shamoon noushad 1 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 editorial psychophysiology escalating in pakistan shamoon noushad advance educational institute & research centreaeirc interest within the mind/body relationship is as ancient because it is large, and also the field of physiological psychology is researching and confirming this association. in developed countries there has been a gap between the allopathic and alternative medical worlds with regard to views on psychophysiology because the allopathic model continuous to differentiate the mind and body as a separate entity, while the alternative medical field opinions confidently on the concept that the mind and body are complexly connected. now western world has gotten the fact at which the emphasis is more and more on mind/body healthcare. patients as well as general practitioner are selecting to make use of treatments built upon the holistic models in which psyche (mind) and soma (physical body) are seen as one. they are working to reduce overall stress and to heal various psychosomatic illnesses. on the other hand in pakistan there is a huge conflict among psychologist & physiologist, the main reason behind this conflict was that who will own the psychophysiology? while according to book psychophysiology is the branch of physiology that is concerned with the relationship between mental (psyche) and physical (physiological) processes; it is the scientific study of the interaction between mind and body. a psychophysiological complaint is considered by somatic symptoms that are moderately induced by emotional factors. the above detail provides all the answers for the conflicts in pakistan. in previous years several new organizations were formed in the domain of mind sciences, which shows that pakistan has positive interest in this field. but on the other hand these new organization lack reference research papers to support their therapies and it was also seen that most of the therapies developed were the old psychological techniques with new names. it was also found that research frame work is quite week in these areas and therefore we have very few data regarding physiological processes as sleep rhythms, heart rate, canal functioning, immune reaction, and brain performance techniques, electroencephalograms (eegs), resonance imaging (mri), and computerized axial pictorial representation (cat) scans in this field. while there are many interpretations of what a healthy psychophysiology science might seem like, these were only few important examples of psychophysiology tests & techniques which are required to establish this new field in our country. when we discuss about stresses, traumas, or emotional states area unit gift, people might expertise physiological unrest. psychophysiology is the field of science which is proving that therapies that integrate mind/body processes are shown to help the healing processes for varied diseases. ultimately, such a holistic state exists once internal and mental awareness becomes sturdy enough to make a way of embodiment, balance, and presence in a person's body. the medical aid medical world has achieved nice breakthroughs in human health, notably with relation to the treatment of traumatic and dangerous injuries and diseases. medically, socially, and environmentally, a lot of holistic and preventive approach to aid is being sought-after, one that integrates and balances the mind/body relationship. abundant work is being done to develop new knowledge; the sphere of physiological psychology could be a major contributor to the exploration. in pakistan advance educational institute & research centreaeirc is the first institute which has develop a research division separately for psychophysiology under the guidance & leadership of dr. sadaf ahmed, an only phd in psychophysiology in pakistan, this super women has established a psychophysiology research laboratory in university of karachi (public sector, government university) furthermore she has also launched the pakistan first psychophysiology research journal entitled “annals of psychophysiology”. a variety of psychophysiology professional’s courses were developed by her, such as body brain & behavior, community mental health worker program, clinical psychophysiology program. she has also established free stress clinics & stress evaluation tool for pakistani population with the objectives to promote professional standards of practice, ethics, and education. pakistan society of psychophysiology was founded by her & this society is conducting an annual conference to promote this field in pakistan. pakistan has a great potential and people like dr.sadaf ahmed are the key turning point of alternative medical world, which will surely help to make better health care system in this country. http://www.aeirc-edu.com/ maria altaf 69 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 perspective piece neurological disturbances caused by nutritional deficit maria altaf & sadaf ahmed advance educational institute and research center corresponding author: maria@aeirc-edu.com nutrition plays an important role in our lives to fight against any certain chronic state and its deficiency creates a damage that is termed as nutritional stress (sadaf ahmed, shamoon noushad 2014). consequences stressing life events can lead to the onset and course of mood deterioration and affective disorders such as depression. malnutrition has been observed to affect a variety of the organ systems in body with central nervous system being on top to be disrupted. around 792 million people in the world are having a malnutrition state due to food deficits (thornhill s et al, 2000). a number of nutritional conditions have been observed to raise the global burden of nutritional disorders; these include the protein deficiency, iron deficiency and vitamin a deficiency. the neurological disorders associated with malnutrition can be reverted and hence it is of great importance for the public health concern. there are several disorders associated with the nutritional deficiency; some of them are briefly discussed in this review. the epidemiology, risk factors and the burden of disease the dietary nutrients required by human body can be grouped as macro nutrients and micro nutrients. the macronutrients are observed to yield energy from nutrients as the proteins, carbohydrates and fats, whereas, the micronutrients yield minerals and vitamins. the macronutrient serves as “firewood” and “building blocks” for the body, whereas, the micronutrients serves as a building blocks to enzymes and hormone. the term malnutrition addresses both the macro and micro nutrients. the total energy required in childhood is 2200 kcal and if any individual is deprived of this energy, the long term mental deficits are seen with these consequences. the deficiency of vitamin b1 (thiamine) causes beriberi, polyneuropathy and wernicke’s encephalopathy. vitamin b3 (niacin) with rda of 15 mg is required, its deficiency causes dementia and depression. the deficiency of vitamin b6 (pyridoxine) causes polyneuropathy. vitamin b12 (cobalamine) deficiency causes the sensory disturbance in legs and the folate (rda= 180 μg) deficiency causes the neural tube defects in fetus. the iron deficiency has been observed to cause delayed mental development in children, whereas, the zinc deficiency causes delayed motor development in children, depression and anxiety in adults. the contribution of epidemiological studies suggested that the intake of fish, green vegetables and fruits can reverse back the adverse condition associated with these disorders. the mediterranean diet is beneficial to prolong the quality life survival of an alzheimer’s patient. the neurological complications associated with malnutrition macronutrient deficiency the macronutrient deficiency involves the deficits caused due to protein, carbohydrate and fats. the under nutrition consequences can estimate by the body weight measurements. the body weight measurements along with the aspects of age and sex can evaluate the energy stores of the individual. the stunted growth is observed as a wide spread consequence in underprivileged populations. the global standard for stunting amongst children in low income countries is 32% (rimel rw et al, 1982). long-term effects of malnutrition malnourished people lacks energy, so they become less curious and communicate less with the people, this weakens their physical, mental and cognitive development. literature depicts the long term neurological deficits has been caused by malnutrition (masson f et al, 2003; tagliaferri f et al, 2006). several studies concluded that stunting in younger age causes a cognitive decline; these studies proved their results by evaluating the cognitive decline of school going children by testing their iq level, reading, arithmetic calculations, reasoning questions, vocabulary, and visual-spatial working memory, simple and complex working memory (masson f et al, 2003). micronutrient deficiency the micronutrient serves as cofactors for enzymes and is engaged in various biochemical reactions. http://www.aeirc-edu.com/ maria altaf 70 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 vitamin a regulates two important functions of body, the systemic functions and the visual functions. vitamin a is being an important element for the production of mucopolysaccharides and helps to protect against infections. the wetness of mucous membrane is diminished with the deficiency of vitamin a; this can be observed as xerophthalmia (dry eye). vitamin a deficiency develops rapidly in children with measles, as in infections the body utilizes its vitamin a stores immediately. the vitamin d deficiency has been associated with multiple sclerosis. vitamin b1 deficiency causes beri-beri and the main symptom is a polyneuropathy in the legs (berg j, tagliaferri f, servadei f, 2005). the wernicke’s encephalopathy has been observed with the prolong use of alcohol, it has been characterized by confusion, unsteadiness and eye movement disorders. it can be reversed if treated with accurate dosage at right time (berg j, tagliaferri f, servadei f, 2005). vitamin b 3 deficiency leads to “pellagra”, it represents the roughness of skin, occasionally it has been appeared along with the with three ds: dermatitis, diarrhoea and dementia. vitamin b6 (pyridoxine) regulate the mental functions, the neurological disorders associated with vitamin b6 deficiency are seizures, migraine and depression. conclusion nutrition plays an important role in our lives to fight against any certain chronic state and its deficiency creates a noticeable damage to the health status. a strong relationship has been found between the nutritional deficiency and neurological disorders. these nutritional factors may contribute to the pathogenesis of neurological diseases. the intake of fish, green vegetables and fruits can reverse back the adverse condition associated with these disorders. references  berg j, tagliaferri f, servadei f. cost of trauma in europe. european journal of neurology, 2005, 12(suppl. 1):85–90  masson f et al. epidemiology of traumatic comas: a prospective population-based study. brain injury, 2003, 17:279–293.  rimel rw et al. moderate head injury: completing the clinical spectrum of brain trauma. neurosurgery, 1982, 11:344–351.  sadaf ahmed, shamoon noushad :do nutrition cause stress?; review your diet. nutritional stress :2014  tagliaferri f et al. a systematic review of brain injury epidemiology in europe. acta neurochirugica, 2006, 148:255–268.  thornhill s et al. disability in young people and adults one year after head injury: prospective cohort study. bmj, 2000, 320:1631–163 http://www.aeirc-edu.com/ editorial www.aeirc-edu.com volume 12014 page | 1 ©advance education institute & research centre-2014 what is psychophysiology? where to go next? kaneez fatima shad medical and molecular biosciences -university of technology sydney, australia. corresponding author email: kaneez.fatima-shad@uts.edu.au psychophysiology is an area of science which helps us to differentiate between self-reported emotion and physiological expression of emotion. many techniques such as emg, eeg and meg (magnetoencephalograph) can be used for measuring muscular and electrical activities as well as event related potentials (erp). emg of facial muscles (e.g. corrugator, zygomatic, and levator labii superioris/alesque) patterning plus autonomic physiology (e.g. heart rate and skin conductance level) gives a basic picture of a person sense for certain situations. for example activity at a facial muscle, the levator labii was higher during disgust than during anger (kuhl, 2008). psychophysiology deals with the exploitation of psychological variables and their equivalent pragmatic effects on physiological processes. thus, this discipline examines the interactions between physiological and psychological events. in general, psychophysiology studies the behavioral consequences of physiological properties of the body at a biochemical and anatomical level, and vice versa. in short this discipline examines the perception of emotion, behavioral states, stress, cognitive task performance, personality and intelligence. the initiation, execution, maintenance and termination of behavioral events can be determined by observing the relationships between psychological factors, stimulus perception and recognition, physiological response are used to better understand these perceptions. this discipline is generally divided into six major areas: developmental psychophysiology: deals with the changes in the physiological system with the age and related behavior. usually brain activities such as event-related potentials (erps) are used to examine these behavioral changes. cognitive psychophysiology: this branch deals with the association between the cognitive task performance and physiological events. for example, it looks at how perception, movement, attention, language and memory may be associated with particular features of the brain electrical and magnetic activities. the vision of having an electrophysiological index of cognitive process has led to the exploration of p300 event of erp and at present p300 amplitude and latency can be used as a guide for the nature and timing of a subject’s cognitive response to a stimulus. many reasons such as attentiveness, orientation, decision making have been suggested to explain the observed variation in p300. ray johnson described beautifully the three dimension relationship of event perception and p300 amplitude, indicating the importance of information transmission, subjective probability and stimulus meaning (johnson, 1986). clinical psychophysiology: the study of psychological disorders and their relationship with physiology and pathophysiology. this area also deals with the observation for the effectiveness of treatment regimens and drug effects on the psychological behavior. benefits of any treatment applied should be measured in terms of behavioral outcomes as well as changes observed both in physiological parameters and biochemical assays. applied psychophysiology: it is a branch which deals with the application of psychophysiological techniques to occupational, recreational and clinical areas. applied psychophysiologist monitors certain physiological activities within an individual, and provides instant and appropriate feedback called the biofeedback. this branch deals with a variety of practical problems such as stuttering, respiration control and can be cured by self-control therapeutic techniques. individual differences: this area looks specifically at the relation of physiological processes and anatomical structures to measure the personality and intelligence. in the past histological surveys of human cadavers’ shows that the number of dendrites and their length are positively correlated with the level of education within individuals. at present we can measure such relationships by using different types of mris and other electrical activity measuring techniques. social psychophysiology: it is deals with the relationship between physiology and social behavior. for example an individual’s group dynamics can be observed by monitoring the physiological changes such as pupil size, muscle tone and skin electrical resistance. all areas of psychophysiology require a number of measurement processes for describing the activity of a particular physiological system and its psychological outcome. in the muscular system, skeletal muscle activity is carried out by electromyography, in which the electrical potentials that are associated with contractions of muscle fibers are measured and can be assessed for their psychological effects. for example electromyographic activity is associated with real smiles when conducting easier mental tasks. as mentioned in the beginning that autonomic physiology closely reflects the psychological effects and skin conductance and heart rate are good examples of such expressions. electrodermal activity or galvanic skin response is used to measures the sweat gland action by evaluating the electrical properties of the skin that are associated with the gland. this skin response is receptive to any changes in emotional and cognitive activities. likewise, pupillary response depicts the dilation of the pupil of the eye, while electrooculography describes the measurement of eye movement. in addition, eye blink rate and duration can be measured. pupillary dilation is considered to be an indicative of subject’s extreme interest and excitement, while electro-oculograms are regularly used in sleep research, for instance, as one indicator of entry to the phase of sleep known as rem (rapid eye movement) sleep. electrocardiography refers to the recording of the electrical potentials generated by the heart muscles over the period of one heartbeat. the electrical waveform produced by the sequence of contractile responses in a heartbeat is referred to as the pqrst complex. measures such as heart beat variability have been widely used to indicate the mental workload. correspondingly, measures of the breathing and gas-exchange process are made by using oximetry for examining the arterial blood oxygen (o2) levels and infrared capnometry for the lung carbon dioxide (co2) levels. there is a strong relationship between respiration and editorial www.aeirc-edu.com volume 12014 page | 2 ©advance education institute & research centre-2014 psychological factors. an interesting finding from the analysis of respiration is that the individuals suffering from panic disorder have greater irregularity and complexity in their breathing patterns, which may make them more vulnerable to panic attacks. similarly, the electrical activity generated by the neurons from the different areas of the brain can be measured by using electroencephalography and electrical currents generated magnetic fields, can be assessed by magnetoencephalography. psychophysiological methods offer insight into a wide range of human behaviors and experiences with a range of techniques available to the psychophysiological researchers. now the questions are: where we are going to go from here? is this a journey from mind to molecules? or is there any organ other than brain in our body which is capable of dictating the behavioral features and cognitive outcomes? references:  kuhl, p., & rivera-gaxiola, m. (2008). neural substrates of language acquisition. annu. rev. neurosci., 31, 511-534.  johnson, r. (1986). a triarchic model of p300 amplitude. psychophysiology, 23(4), 367-384. waseem hassan 19 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 perspective piece proponents of harmonization between body, mind and soul waseem hassan institute of space and planetary astrophysics, university of karachi corresponding author:abadallah.wh@gmail.com “the rhythm of the body, the melody of the mind and the harmony of the soul creates the symphony of life”. b.k.s. iyengar, a foremost yoga teacher from india correlated the symphony of life with a balance of body, mind and soul in such a way that it answers most of the questions by people suffering from stressful lives. it must be understood that according to who constitution, health is defined as a complete well-being of mental, physical and social aspects of a person, not the absence of disability or disease (who, 1950). not to forget that the aspect of soul is generally not considered in scientific world, this article steps forward initialising the understanding of soul as an integral part of human body in terms of philosophy as well as science. considering the aspect of health sciences; a mind fully synchronised with the body and soul is a sign of having a greater intelligence than iq and eq as a mind convinced with current conditions of body and soul will be able to boost up the usage of intellect and wisdom in order to achieve greater and much effective results in terms of creativity, health and spiritual growth. one of the best ways adopted by greats of their time to achieve harmony is through meditation (thera, 2014). the three opinions taking in consideration, the interaction between the body and soul, in terms of its operations between one and the other and one over the other, there are three opinions (bowne, 1887). the first opinion is called the physical influx in which the sensory organs receive incoming data from the world in forms of vision when it comes to the eye and sound waves when it comes to the ears; similarly, for the senses of touch, taste and smell. since the organs carrying such senses receive firstly the impressions made by the direct interaction with the surroundings, these impressions trigger mind to think and will to act accordingly. due to this reason, philosophers from ancient times believed that physical influx is a result derived from these organs and hence it enters the soul of a person. the second opinion named as spiritual influx suggested by the law itself in order to illustrates the useful findings in this regard. however, soul is an important component of spirituality which demonstrates the inner substance of an individual. the important element of spiritual soul is purity, internal aspects and previous materials that human body possesses within its self. further, the relationship between body and its soul is termed as spiritual influx as suggested by different scholars and previous researchers. therefore, human body is nothing without these illusions because soul gets into the grosser with related aspects such as posterior, interior and exterior. the spiritual material cannot be reversed at any means by natural phenomenon. the human mind which has the functionality of memorizing the items, recall the previous scenarios and importantly thinks about certain situations and accordingly react with respective surrounding. the things or different situations, in which we react or interact on daily basis, collectively developed the personality traits along with soul perspective. the third opinion which determines or called as preestablished harmony is learning in different modern theories due to its purposeful findings in human nature. the misconceptions of the mind and its thinking process acts collectively at the same time and place with human body and its spiritual soul. the success factor hidden in influx spirituality is harmony that has the link with different or simultaneous operations. initially, the minds think and then its gives substantial power to the speaking skills which human beings exhibits in their self. the establishment of these operations exclude all the components of power and energy as mind plays his role. the interaction of human soul with its body is not possible as it must operate with existing body with its soul and sometimes both operate collectively. the science of soul “the day science begins to study non-physical phenomenon, it will make progress in one decade than in all the previous centuries of its existence” – nikola tesla since the beginning of human awareness of soul, psychologically, a soul is considered to be the consciousness of a human body (pereira, 2015). taking this point in view, one can certainly deduce that consciousness is the driving force of the body which makes a body endorsing its existence in the universe. different aspects of consciousness are defined and concluded by many researchers http://www.aeirc-edu.com/ mailto:abadallah.wh@gmail.com waseem hassan 20 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 throughout time. the presence of soul in a body is widely accepted and understood when a person dies; considering the fact that each and everything is present in a person essential to live, what makes a person die? a research by duncan macdougall in 1907 proved that there is a soul in a person’s body and the soul has a weight of about 21grams (roehner, 2010). in this experiment, macdougall took a sample of 6 patients who were about to die and put them in an industrial sized weighing machine that can weigh any substance as little as 5.5 grams. when soul is departed by the body, the weight which was reduced from the body was recorded by macdougall with other doctors from the hospital to be about 21 grams or approximately one ounce. such discovery has put most of the scientists to think beyond material and hence the concept of body and mind synchronisation was tuned up to body, mind and soul harmonisation (pandya, 2011). the proponents harmonisation between body and mind is taken through various concepts by psychologists, psychophysiologists and psychiatrists on accordance to their knowledge and experiences. a proponent is defined as something which advocates and supports in achievement of something. considering the harmonisation of body, mind and soul, as it speaks of itself, would not be something which should be done through just one way; a person needs to get through multiple practices and multiple understandings in order to achieve harmony of body, mind and soul which would both differ and coincide with each other. a person is said to be in complete harmony when his/her body, mind and soul is completely utilised throughout the day before he/she sleeps and when he/she wakes up, he is optimised for his/her work. such state is achieved when a person performs physical work in order to exhaust his/her body, analyses and attempts different intellectual tasks up to his/her limits to drain his/her mental energy and goes in a world of imagination to tire his/her soul. when a person goes through such processes during the time he or she is awake and sleeps afterwards, his/her body, mind and soul makes up a connection between each other in order to optimise to the fullest. it is one of the easiest ways to achieve harmonisation between them. one other way to harmony is both psychological and philosophical and also advised by the author. in order to achieve harmony, firstly, one should be able to gain the state of peace throughout his/her existence and that is done by acceptance. as a person accepts everything which comes into his/her interaction, no matter if it impacts him/her good or bad, it will naturally allow him/her to gain state of peace within the body. in such condition, the person is harmonised with all the aspects of his/her existence, i.e. the body, mind and soul. conclusion since harmonisation of body, mind and soul is a wider study which cannot be confined in a single study, it must be noted that the aspects and concepts mentioned in this article are just drops in an entire ocean. once simply cannot claim to withhold all the knowledge of such harmonisation since there is a gradual increase in the understanding of body, mind and soul of a human body. one thing which we should think of is, to what level does the synchronisation of body, mind and soul extends to? references  world health organization, 1950. the preamble of the constitution of the world health organization.  bowne, b.p., 1887. interaction of soul and body.  pereira, c., 2015. soul & consciousness. scientific god journal, 6(7).  roehner, b.m., 2010. fifteen years of econophysics: worries, hopes and prospects. arxiv  preprint arxiv:1004.3229.  pandya, s.k., 2011. understanding brain, mind and soul: contributions from neurology and neurosurgery. mens sana monographs, 9(1), p.129.  thera, n., 2014. the heart of buddhist meditation: the buddha's way of mindfulness. weiser books. http://www.aeirc-edu.com/ original article www.aeirc-edu.com volume 12014 page | 10 ©advance education institute & research centre-2014 the prevalence of somatic symptom disorders among regular female patients of faith healers zaufishan qureshi 1 anum shahzad 2 & sehrish naeem 3 1. department of psychology, foundation university islamabad 2. department of psychology, fatima jinnah women university, rawalpindi 3. department of psychology, university of poonch, rawalakot corresponding author: zaofishan.qureshi@gmail.com abstarct: the study aimed to study the prevalence of somatic symptom and related disorders among regular female patients of faith healers. the study was exploratory in nature and case studies of ten females were taken. the study aimed to investigate the prevalence of somatic symptom and related disorders among those women who regularly visit faith healers for the cure of all major to minor illnesses and do not trust doctors after nil diagnosis. the cases were taken from rawalakot and rawalpindi. detailed histories and current condition of the patients were obtained. the patients were asked for their symptoms, incidence and onset of symptoms, severity and intensity of symptoms and recurrence. on the basis of which, the patients were diagnosed according to dsm-v (2013) criteria for somatic symptom and related disorders cluster. the results showed that 7 out 10 women were suffering from some type of somatic symptom and related disorders. the patients needed to seek psychological help but they weren‟t aware of this fact. all of the patients turned to faith healers because doctors provided nil diagnosis as their bodily symptoms were purely psychological. keywords: somatic symptoms disorder, faith healers, dsm-v introduction: psycho-somatic disorders are those which involve bodily complaints due to psychological reasons. medical checkup mostly result in nil diagnosis because no evidence of the bodily symptom can be found. the history of such bodily complaints with no medical evidence has been a subject of interest for both psychiatrists and psychologists. it is important that both communities work on the study and investigation of this disorder as it concerns both communities. somatoform disorders are referred as somatic symptom and related disorders in the recent edition of the diagnostic and statistical manual of mental disorders (dsm, v, 2013). such a disorder tends to be long lasting and chronic. it includes physical complaints that can last up to a couple of years causing substantial impairment in social life as well as daily routines of the individual. there might or might not be medical explanations for the symptoms such individuals experience. dsm-iv excluded organically explainable comorbidities for instance cancer and cardiovascular diseases in the patients. however, such conditions can be a part of ssd diagnosis now, increasing the chances of suitable and correct treatment. as per dsmv, somatic symptoms include factitious disorder, conversion disorder, psychological factors effecting other medical conditions, illness anxiety disorders, other specified somatic symptom and related disorder, and unspecified somatic symptom and related disorder. the term somatization is defined in icd-10 as numerous, physical symptoms which are regularly varying as well as recurring and are present for a minimum of two years before the individual can be referred to a psychiatrist. for patients who had physical symptoms and visited medical help recurrently regardless of negative investigations, the term of unexplained somatic complaints was presented. it is very much likely for such patients to be the victims of stigmatization and disregarded by their general physicians or medical doctors; they can be labeled as having problems which are not real or are all in their heads. nevertheless, with the increase in research in this area and the link between brain, immunity and other biological systems, it is becoming clear that ssd is not merely a condition that patients make up and have control over, thereby the symptoms should be considered unfeigned instead of malingering. healing may be physical or psychological and not without the mutual reception of these two dimensions of human health. in psychiatry and psychology, healing is the process by which neuroses and psychoses are resolved to the degree that the client is able to lead a normal and healthy life and a fulfilling existence in the world. religious and spiritual beliefs and practices are important in the lives of many patients, yet medical students, residents and physicians are often uncertain about whether, when, or how, to address spiritual or religious issues. faith based healing is an umbrella term for a family of treatment methods which are based upon mysticism or claimed revelations, rather than the empirical evidence which is the foundation of scientific medicine. many, though not all, faith healing methods implicitly assume some form of substance dualism, based upon the hypothesis that physical symptoms of illness are a manifestation of disturbances in some nonphysical component of the person. the language used to describe this spiritual substance varies, but common examples are spirit, soul, chakra, or human energy field. despite this, faith healing traditions are also known to occur in cultures in which some form of monism is dominant, such as certain schools of hinduism. some faith based healing methods invoke the intervention of a nonhuman supernatural being or beings, supposedly to heal the patient on behalf of the practitioner. these methods remain controversial, both as a result of innate conceptual difficulties (for instance, many philosophers question how a nonphysical agent could interact with a physical body), as well as the lack of reproducible, scientifically documented evidence for the efficacy of any of these healing methods (vyse, 2000; egnew, 2005). people from non-western and nonchristian context may also have a belief that there mental distress, anxious mood and other forms of psychological pathology can be better cope through religious and spirituality practices including (offering prayers, meditation, wearing taweez & talismans etc. (watson-franke ,1977 ; helming, 2011). a research conducted in india depicts that indians were more likely to prefer different strategies of spiritual page | 9 ©advance education institute & research centre-2014 original article www.aeirc-edu.com volume 12014 page | 10 ©advance education institute & research centre-2014 practices in order to alleviate distress, including „indigenous forms of medicine and healing, homeopathic medicines, yoga, and the exorcism of evil spirits (laungani, 1994). pew research centre conducted survey on world muslims namely nine countries were included, after the results it was conclude that: peoples have different views related to supernatural forces like, amulet, magic or sorcery, witchcraft, demons & devil and the evil eye (pew, 2012). objectives of the study: to investigate the prevalence of somatic symptom and related disorders among regular female patients of faith healers research question: what is the prevalence of somatic symptom and related disorders in regular female patients of faith healers? method: the proposed study intended to find out the prevalence of somatic symptom disorders among regular female patients of faith healers. the study followed a “survey” research design. both “faith healing” and “possible somatic symptom and related disorders” are perceived as dependent variables. participants: convenient sampling technique and snowball sampling technique was used to select the respondents of the study. the researcher included 10 female cases from rawalpindi and rawalakot. instruments: a specific interview schedule was developed for the proposed study which would address the research questions in detail. dsm-v (2013) was used as a valid and reliable measure and diagnostic tool for somatic symptom disorder. procedure: the researcher organized meetings with the prospective respondents. they visited easily approachable cities and villages of punjab and kashmir. the researcher gathered the data after building a satisfactory level of rapport with the respondents. the issues of confidentiality and compliance to the ethical standards were given proper consideration. data analysis: the analysis of the interview schedules was carried by using dsmv (diagnostic & statistical manual for mental disorders). percentages were computed. result: 7 out of 10 females had proneness to somatic symptom and related disorders. the prevalence of somatic symptom and related disorders was 70%. conversion disorder proneness was most prevalent (4 out of 10). discussion: the current study involved 10 case studies of those women who regularly visit faith healers for their bodily complaints. the findings are discussed as follows: commonly prevalent symptoms the symptoms for which the subjects sorted faith based healing included sleeplessness, anxiousness about one‟s illness, nightmares, irritability, restlessness, depressed mood, no sexual arousal, lack of interest in occupational and pleasurable activities, suspicious attitude towards others, headache, anxious feelings, dissatisfaction, over eating, poor appetite, auditory hallucinations, aggressive behavior, delusions (including persecutory and somatic), body pain , loneliness, hearing disturbance, weeping and insomnia . the prevalent disorders were conversion disorder, somatic symptom disorder, and illness anxiety disorders, which were diagnosed in the respondents (by applying the criteria of dsm v) after interviews and analyzing their symptoms. patients diagnosed with conversion disorder experienced sensory and motor problems along with somatic complaints. these cases also involved many psycho-social and economic stressors such as, marital problems, poverty, migration to another city, and loneliness. the complaints included a non-stop shaky arm, sensation and throbbing in ears, twitching of foot finger, and sensation of termites crawling over body. the symptoms were experienced for more than 6 months. medical diagnosis was nil. patients with somatic symptom disorder involved severe pain in variety of body parts that lasted for more than 6 months. they also experienced psycho-social, psycho-sexual and financial issues. one of the cases was going through a pending divorce case. another was dissatisfied sexually from husband since the first day of marriage and also faced domestic violence and marital rape. pain was severe and genuine but no medical evidence was there and diagnosis was nil. illness anxiety disorder was also prevalent. patient was constantly worried about the bodily symptoms and constantly wept and feared her pain and condition. it impaired her married life, interpersonal relationships and daily functioning. the symptoms were experienced for more than six months. conclusion: the study concludes that awareness about somatic symptom and related disorders should be given by general physicians so that people seek psychological help rather than faith based healing methods that have not only high rate of recurrence but also aren‟t genuine in most of the cases. the study investigated the prevalence somatic case 1 case 2 case 3 case 4 case 5 case 6 case 7 case 8 case 9 case 10 percentages symptom and related disorders conversion 1 1 1 1 40% disorder somatic 1 1 20% symptoms disorder illness anxiety 1 10% disorder table 1: shows percentages of somatic symptoms and related disorders among cases. page | 10 ©advance education institute & research centre-2014 original article www.aeirc-edu.com volume 12014 page | 10 ©advance education institute & research centre-2014 of only one cluster of disorders among so many mental disorders and yet it found that 7 out of 10 female cases (70%) were suffering from somatic symptom and related disorders. it is dreading to imagine how many others could be diagnosed with other sort of disorders that need psychological and medical help. references:  american psychiatric association. (2013). diagnostic and statistical manual of mental disorders (5th ed.). washington, dc.  helming mb. (2011) healing though prayer: a qualitative study. holistic nursing practice, 25(1):33-44.  laungani, e. 1994. cultural differences in stress: india and england. counseling psychology review 9(4): 25-37.  thomas r. egnew (2005) the meaning of healing: transcending suffering. annals of family medicine. 3(3): 255–262.  vyse, stuart a (2000). believing in magic: the psychology of superstition. oxford, england: oxford university press. pp. 19–22.  watson, l. c. and watson-franke, m.-b. (1977), spirits, dreams, and the resolution of conflict among urban guajiro women. ethos, 5: 388–408.  world health organization. (1992). icd-10 classifications of mental and behavioral disorder: clinical descriptions and diagnostic guidelines. geneva. world health organization. page | 11 ©advance education institute & research centre-2014 sadia shah 2 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 original article empathy levels among medical students: a psycho-social analysis sadia shah1, muhammad muneeb2 & aatir h.rajput2 1-liaquat university of medical & health sciences, jamshoro 2-lumhs research forum corresponding author: drsadiashah@outlook.com abstract empathy is an important component in a doctor-patient relationship. it is an objective and relatively a stable constitutional trait. the apprehension among educationalists that clinical training may have an adversative effect on medical trainees and student empathy levels, holds truth as indicated by the existing literature. long work/study hours and sleep deprivation may be the potential reasons believed to contribute to empathy decline. the aim of the study was to determine the changes in the empathy levels among the students, during their medical school years. the opinions and observations of medical students were recorded and interpreted hoping to determine the main reasons behind the changing empathy levels (if present). a psychosocial cross-sectional analysis of medical students’ empathy levels was conducted at liaquat university of medical and health sciences jamshoro. a 20 item jspe-s (jefferson scale of physician empathy–student version) self-administered structured questionnaire including 7point likert scale was used to evaluate empathy levels among students. convenient sampling procedure was used. a total of 300 students were approached during their class timings at lecture halls. a prior verbal informed consent was taken and those who agreed were included in the study. the duration of study was from may, 2014 to august, 2014. data analysis was done via spss 16.0.41% (n=123) out of 300 participants were male while 59% (n=177) were females. the mean empathy value of first year students (91.29) was greater than that of final year students (84.53). e.s value i.e. effect size value comes out to be 0.5, which is moderately significant. study concluded that the students at lumhs have the least empathy score in comparison to the standard values. this decline in the empathy levels explains the change of social behavior of the students across their medical school years. it is related to the hectic and difficult time period of their studies, their personal experience with the patients, realization of the difficulties and challenges in seeking medical services. keywords empathy, medical students, liaquat university introduction empathy is a psychological term which shouldn’t be confused with sympathy. empathy is an objective and relatively a stable constitutional trait in contrast to sympathy, which is an irregular, non-objective and a non-critical sentiment (helena, 2014; lt: col. r., 2014). empathy refers to the insightful awareness of an individual to the emotions, feelings and conduct of someone else. it is all about showing warmth, recognition and compassion for the people (areeb, 2013; sandara, 2014) .empathy is considered as an extremely important component in a doctor-patient relationship that involves careful and active listening to the patients, in order to identify, distinguish and understand their problems, show concern about their feelings, and passing on this comprehension. this understanding allows the patient to feel respected and comfortable and can trust the doctor give an appropriate data or history (m. rahimi, 2010; deleing, 2013). empathy is as important and crucial for the medical students as it is for the physicians. the apprehension among educationalists that clinical training may have an adversative effect on medical trainees and student empathy levels, holds truth as indicated by the existing literature. empathy should be flourished and can be developed among the medical undergraduates during their stay in the medical schools (kataoka, 2009; hojat, 2009). the aim of the current study is to measure empathy levels amongst medical students in the first and the final year of their medical curriculum and to check weather this existing phenomenon holds truth in ours locality. methodology this cross-sectional quantitative study was conducted at liaquat university of medical and health sciences, jamshoro from may, 2014 to august, 2014. a total number of 300 students (including 123 males and 177 females) from first and final year mbbs were enrolled after taking an informed consent. students were chosen by simple random sampling and were approached during their class timings in lecture halls, ward classes and practical labs. students were advised not to identify themselves in any manner except age, gender and medical study year. every 3rd student in a row was requested to be indulged in the research procedure. a pre-formed structured questionnaire (including student version of jefferson scale of physician empathy) was used to get knowledge about students’ name, age, gender, educational status, frequency of interaction with people, their classification as emotional or practical, and time given to medical practice daily. the student version (sversion) of jspe (jefferson scale of physician empathy) was used in the study, in its original http://www.aeirc-edu.com/ mailto:drsadiashah@outlook.com sadia shah 3 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 language (english) and format which took approximately 5–7 minutes to get completed. jspe is a self-administered inventory, containing 20 items. negative and positive items were equally phrased. each item was answered on a seven-point likert-type scale, ranging from 1 (strongly disagree) to 7 (strongly agree). for negative items, scoring is reversed (1= strongly agree to 7= strongly disagree). the total score was obtained by the sum of all items (scores can range from 20 to 140). higher values indicate higher level of empathy. the jspe was originally developed in 2001 to measure medical students’ attitudes about physician empathy in a patient-care situation. items included in the scale were derived from an extensive review literature followed by studies with groups of physicians, medical students and residents. (hojat et al. 2001; hojat et al. 2002c). the scale has been validated and found to be reliable in usa, mexico and japan (hojat et al. 2001; alcorta-garza et al. 2005; kataoka et al. 2009). all the responses to the jpse-s by the medical students were coded and analyzed using spps version 16.00. for categorical data, percentages and frequencies was used. for numeric data, mean and standard deviation was used. an independent e.s value i.e. the effect size value was applied to assess the clinical and statistical difference between the empathy levels. (mean empathy score of final year – mean empathy score of 1st year)/st. deviation of 1st year score. results of the 330 questionnaires distributed, 91% i.e. n=300 questionnaires were responded completely and included in the study. there were 41% (123) males and 59% (177) females. 147 (49%) respondents were from first year whereas, 153 (51%) respondents from final year. figure 1 showing gender distribution of respondents. 59% of the sample was consisted of female population while males were 41% of the sample. a comparative analysis reveals that the mean empathy score for the first year students is 91.29 which is significantly greater than that of the final year students, i.e. 84.53. though, final year students did not have a higher level of empathy than their first year counterparts, but the difference in the standard deviation was not statistically significant. while the e.s value i.e. the effect size value, comes out to be 0.5, which shows that the clinical and statistical difference between the empathy levels, which is moderately significant. (e.s= mean empathy score of final year – mean empathy score of 1st year/st. deviation of 1st year score). figure 2; representing educational status of respondents. there were 49% first year students while 59% of the sample was from final year figure: 3 shows a decline in mean empathy score i.e. 91.29 from first year to 84.53 in final year. first year 49% final year 51% 91.29 84.53 80 82 84 86 88 90 92 first year final year mean empathy score males 41% females 59% http://www.aeirc-edu.com/ sadia shah 4 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 table: 1. the background demographic of empathy mean scores (n=300) discussion the results revealed that empathy among the medical students’ builds up during the first year of medical education, however it starts to come down after the clinical exposure begins and remains down through the final year of medical school. the variation in jspe-s score is as incredible as 6.76 between the first year and final year students. the study, albeit crosssectional, is reliable with past studies, recommending that empathy diminishes after the clinical exposure in the medical school. different stressful aspects of medical training for example long working hours, lack of sleep, depending on technology for diagnosis, shorter hospitalizations of patient and limited bedside interactions may contribute to diminish empathy levels (rose, 2006; benbassat, 2004). another alternate conceivable clarification for the observed decrease in the empathy levels may be cultural assimilation or acculturation phenomenon (kay, 1990). medical students encounter an extensive range of emotions and feelings and may struggle to keep up their empathy levels (kramer, 1989). the results also show that the overall empathy of students at lumhs is less than the international standard. bangladesh (mean = 110.41), china (mean = 109.60), japan (mean = 104.3), kuwait (mean = 104.6), iran (mean = 105.1) and american medical students (mean=115). the possible explanation for this is the overwhelming clinical exposure in our settings which probably train the minds of students in such a way that their empathy levels starts to come down and they start thinking more professionally and practically rather emotionally (marcus, 1999; branch, 1993). conclusion the study concluded that there are differences in empathy among the different classes and that empathy declines with increased clinical training in the medical school. empathy serves as a key factor in establishing a good doctor-patient relationship. it is thus essential that empathy should be nurtured in medical students rather than swept away with time and clinical exposure, so that the upcoming physicians can serve their patients in the best possible way. limitations there were several limitations to the study. due to cross-sectional nature of the study, only the empathy levels among first year and final year students could be examined. it would be of interest to measure how empathy varies with each year throughout the five years of medical school using a prospective longitudinal study design. secondly, the candidates own self-perception influences his/her choices while filling out the questionnaire and this may vary from the actual behavior that is implemented in their everyday interactions. recommendations it would be profitable to do a prospective study where the students under study are emulated every year from the first year until graduation, to give a genuine representation of progress in empathy levels. in spite of the fact that the study is constrained to our medical university, we feel that our results could be summed up to restorative universities that have a customary structure like our own. references  areeb sohail bangash, nasreen feroze ali, published online, 16th july, 2013, maintenance of empathy levels among first and final year students: a cross-sectional study; 2:157  m. rahimi, madiseh tavakol, jafar nasiri, published online at webpaper.com in 2010, empathy in iranian medical students:a preliminary psychometric analysis and differences by gender and year of medical school, vol: 32, no:11 pg.: 471-478  hojat m. vergara mj, maxwell k, acad med, 2009, the devil is in third year:a longitudinal study of erosion of empathy in medical school, vol-84 (n), 1616  rose im, gimotty pa, shea ja, bellini lm, acad med. 2006, sleep deprivation, mood disturbances, empathy and burnout among interns; 81:82-85.  benbassat j, baumal r. acad med. 2004 what is empathy, and how can it be promoted during clinical clerkships? 79:832-839  kay j. jama. 1990 traumatic deidealization and the future of medicine;263:572-3  kramer d, ber r, moore m, mes educ. 1989; increasing empathy among medical students;23:168-173  marcus er. . acad med. 1999 empathy, humanism, and the professionalization process of medical education; 74:1211-5.  branch w, pels rj, lawrence rs, arky r. n engl j med. 1993 becoming a doctor. criticalincident reports from third year medical students;329:113032  helena b.m.s.paro, paulo s.p.silveria, published in april 04, 2014, empathy among medical students: is there a relation with quality of life and burnout? d01:10.1371/journal.pone 0094133 demographic variables no. mean/s.d first year 147 91.29/13.2 final year 153 84.53/12.4 http://www.aeirc-edu.com/ sadia shah 5 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188  kataoka mu, koide.n, ochi.k, hojat m. acad med. 2009, september; measurements of empathy among japanese medical students:psychometrics and score differences by gender and level of medical education; 84 (a) 1192-7  lt: col. r. shashi kumar, richa chaudhary, april 2014 cross-sectional assessment of empathy scores among undergraduates from a medical college, medical journal of armed forces, india, vol: 70, issue: 2, pg. 179-185  sandara dehning, eshetu girma, published online, may,24,2014,comparative cross-sectional study of empathy among first year and final year medical students in jimma, university, ethiopia, steady state of heart and opening of eyes; 12:34  deleing wen, xiao dan ma, hong he li; , published online, sep,23,2013; empathy in chinese medical students: psychometric characteristics and differences by gender and year of medical education, bmc med edu.2013 13:130 http://www.aeirc-edu.com/ sadaf ahmed 3 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 editorial suicide; a manic engulfing youth sadaf ahmed, shamoon noushad & salman sheikh advance educational institute & research center corresponding author: sadaf@aeirc-edu.com whoever attempts to commit suicide and does any act towards the commission of such offence shall be punished with simple imprisonment for a term which extends to one year or with fine or both”. (major criminal acts, ppc-1860 p; 209 ed.2005). it is always disturbing to know that so many adolescents committing suicide in such quick succession, one can only wonder about the frolic snuffed so callously. youth is a more exposed group that is daily opened to the stress in pakistan and opt for risky behaviors. though the figures are alarming still more than half of cases go unreported due to reluctant families to register the case as attempted suicide. world health organization estimated that over 15,000 suicides get committed in pakistan; however psychiatrist estimated it around 7,000 annually. other than this there are approximately 150,000 reported cases of attempted suicides by people under the age of 30 years (who, 2016). there is by all accounts an expansion in suicides among youngsters these days. there was the miserable loss of a 27-yearold student of bachelors who set himself ablaze on the grounds that he wasn't permitted to give an exam paper. essentially, the tragic instance of the 17year-old saqiba kakar, who ingested toxic pills after the school central supposedly declined to send her examination forms to the board. (syed ali shah, 2016). we had likewise run over the unfortunate demise of suleman, 14, who shot himself after the guardians of the young lady he loved, rejected his marriage proposal. (riaz ahmed, 2016). furthermore, the rundown goes on:  a 15-year-old student shot himself to death in the federal capital on monday after he fell in love with his teacher. (samaa web desk, 2017).  yaqoob shot himself dead with a pistol at his home after his father, kaleem, scolded him for not taking interest in his studies. (zofeen t. ebrahim, 2012).  eighteen-year-old khursheed, was a student at the islamabad model college for boys, khursheed had apparently refused to take some entry tests, on which his father had scolded him. (web desk, 2012).  shan, 17, a resident of gharibabad near khanpur, swallowed poison. he did so after his parents stopped him from spending time with friends and concentrate on his studies instead. (the express tribune, 2012).  a class six student allegedly committed suicide inside his house in nazimabad on tuesday night. he was 13 years old he apparently committed suicide by hanging himself by the ceiling fan out of fear of his parents as he perhaps failed at school. (the express tribune, 2012).  in september of 2013 at the age of 12, rebecca jumped to her death from atop an abandoned cement silo. the girls had apparently been spurred by jealousy over rebecca’s former involvement with a local boy. these messages included “why are you still alive?” and “go kill yourself.” (jim goad, 2015). http://www.aeirc-edu.com/ sadaf ahmed 4 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188  a 13 year-old boy committed suicide inside his house, he hanged himself from ceiling fan in his suicide note, he wrote that he was fed up of hostel, where he was often subjected to severe punishment at the hands of a teacher he left unnamed. (the express tribune, 2012)  on april 16th, 2010 a 21 yearold medical student from chitral hung himself from ceiling fan of his dorm room. (yusra salim, 2016).  14 year-old schoolboy suicide in peshawar, he shot himself after the parents of the girl he loved, declined his marriage proposal. the girl’s parents maintained that she was too young to get married. (riaz ahmed, 2016).  on april 21st, 2016 the nursing student allegedly hanged himself from the ceiling fan on wednesday night; he was from gilgit and had been studying at nursing school since 2014. (yusra salim, 2016).  on may 11th, 2014 a teenaged girl and a boy in his twenties, both were the students of university, they committed suicide by eating poison, and their bodies were mysteriously found dead in the boy’s car parked in the parking area. (dunya news, 2016).  on june 19th, 2016 a young man and women recently graduates of a private university in hyderabad, committed a suicide by eating poison. the family says the couple wanted to marry but their parents were opposed to it. (express tribune, 2016).  on april 11th, 2016 a final year medical student committed suicide after a university refused to allow him to appear in the final year exam for being late. (dunya news , 2016)  on september 1st, 2015 teen kill’s girlfriend, commits suicide (in school) because parents weren’t ready to accept relationship. (web desk, 2015).  a university student tried to commit suicide by selfimmolation, the 24 yearold boy tried to set himself on fire by sprinkling kerosene all over his body. the burn injuries cover 90 percent of his body, (express tribune, 2014).  a teenage girl from baluchistan’s killa saifullah district committed suicide after college principal refused to send her examination form to the intermediate education board. (syed ali shah, 2016).  a young teenage couple has allegedly committed suicide by hanging themselves on a tree in the cholistan desert after they were not allowed by their families to marry. (srafraz ali, 2017).  a university student has committed suicide, his mother asked him to go to university but he did not want to continue his studies. as his mother scolds him on his refusal, he hanged himself with the ceiling fan. (pakistan today, 2017)  a young 14 year old boy, 9th class student committed suicide in his hostel room by hanging himself with the ceiling fan for unknown reason. (pakistan today, 2017).  a girl student of “a” levels committed suicide by shooting her. the reason behind the suicide could not be ascertained. (pakistan observer, 2017).  a young teenage boy committed suicide after he flunked the entry test of private university. (atiq ali, 2016).  a 22 year old girl aspirant for admission on sport basis in university, committed suicide for domestic reason at girl’s hostel, she hang herself with the ceiling fan. (salim ahmed, 2016). the principal cause is lack of communication between parents and teenagers. sometimes the kids are going through mixed emotions and the fear to discuss issues with adults or peers. anyone with emotional imbalances can take such drastic steps. the foundation of each heinous is financial discrepancies. the parental strain on their high school youngsters to push for the expert universities http://www.aeirc-edu.com/ sadaf ahmed 5 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 and organizations is a sort of future protection, which unleashes the intellectual pressure on the youngsters; however, they can't confront the ferocious conflicts within the community without appropriate facilities. this is the basic explanation for the young people to go for suicidal results to free themselves. for future research, then, it will be interesting to explore the interaction there may between people with a predisposition to suicide, i.e. where clinical depression is present, and the pressures on families that arise from increasingly competitive economic environments. the interaction between these sorts of pressures and the presence of clinical depression may be a cocktail that is increasingly lethal over time. references  atiq ali (2016, november 25). suicide. retrieve from: http://pakobserver.net/suicide/  dunya news (2016, april 21). karachi: aga khan university's student commits suicide. retrieve from: http://dunyanews.tv/en/pakistan/333303karachi-aga-khan-universitys-studentcommits-sui  dunya news (2016, august 4). sargodha: girl, boy commit suicide over love marriage refusal from parents. retrieve from: http://dunyanews.tv/en/pakistan/347754sargodha-girl-boy-commit-suicideover-love-marri  jim goad (2015, april 22). a pervert leaked a topless photo of amanda todd, then a group of girls bullied her until she ended up taking her own life. retrieve from: https://thoughtcatalog.com/jimgoad/2015/04/15-teen-bullying-cases/  pakistan observer (2017, august 2). ‘a’ levels girl student commits suicide. retrieve from: http://pakobserver.net/a-levels-girlstudent-commits-suicide/  pakistan today (2017, january 18). student commits suicide. retrieve from: https://www.pakistantoday.com.pk/2017 /01/18/student-commits-suicide-2/  pakistan today (2017, january 18). university student commits suicide. retrieve from: https://www.pakistantoday.com.pk/2017 /04/25/university-student-commitssuicide/  riaz ahmed (2016, february 27). 14year-old schoolboy commits suicide in peshawar over marriage refusal. retrieve from: https://tribune.com.pk/story/1055453/14year-old-schoolboy-commits-suicide-inpeshawar-over-marriage-refusal/  salim ahmed (2016, october 26). girl commits suicide in pu hostel. retrieve from: http://pakobserver.net/girlcommits-suicide-in-pu-hostel/  samaa web desk (2017, january 16). islamabad teen commits suicide after falling in love with teacher. retrieve from:https://www.samaa.tv/pakistan/201 7/01/islamabad-teen-student-commitssuicide-after-falling-in-love-withteacher/  sarfraz ali (2017, may 27). cholistani teenage couple commits suicide together after family disapproval. retrieve from: https://en.dailypakistan.com.pk/pakistan/ cholistani-teenage-couple-commitssuicide-together-after-familydisapproval/  state of human rights. 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(2016). world health statistics 2016: monitoring health for the sdgs sustainable development goals. world health organization.  yusra salim (2016, april 21). aku student commits suicide. retrieve from: https://tribune.com.pk/story/1089158/ak u-student-commits-suicide/  zofeen t. ebrahim (2012, june 8).the alarming rise of teenage suicides in pakistan. retrieve from: https://www.dawn.com/news/724902 http://www.aeirc-edu.com/ https://tribune.com.pk/story/385086/suicide-17-year-old-swallows-poison/ https://tribune.com.pk/story/385086/suicide-17-year-old-swallows-poison/ https://tribune.com.pk/story/385947/fear-of-failure-class-vi-student-commits-suicide/ https://tribune.com.pk/story/385947/fear-of-failure-class-vi-student-commits-suicide/ https://tribune.com.pk/story/385947/fear-of-failure-class-vi-student-commits-suicide/ https://tribune.com.pk/story/385829/tangled-in-misery-to-evade-punishment-schoolboy-ends-his-life/ 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https://defence.pk/pdf/threads/teenage-couple-carry-out-suicide-pact-during-school-assembly-in-karachi.395189/ https://defence.pk/pdf/threads/teenage-couple-carry-out-suicide-pact-during-school-assembly-in-karachi.395189/ https://tribune.com.pk/story/1089158/aku-student-commits-suicide/ https://tribune.com.pk/story/1089158/aku-student-commits-suicide/ https://www.dawn.com/news/724902 muhammad muneeb 33 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 original article impending early marriage leading to depression, anxiety and stress: woes of female medical students at hyderabad muhammad muneeb1, aatir h. rajput2, tahir hanif3, anam shaikh4, abid ali5 and sadia khan6 liaquat university hospital lumhs research forum sir cowasjee jehangir institute of psychiatry, hyderabad liaquat university of medical & health sciences, jamshoro combined military hospital (c.m.h.), hyderabad corresponding email: muhammadmuneebchauhan@gmail.com abstract background pakistan, like the rest of south-east asia, is plagued with old trends and traditions that target the fairer sex in particular. marriage tops all charts in this regard and every parent in our increasingly misogynistic society wishes to marry off their daughter as soon as possible. doctor brides however have always been seen positively. parents wish to benefit from this factor and get their daughters married even before they graduate. objective we hypothesize that the fear of an impending marriage leads to depression, anxiety and stress among female medical students. this study hopes to gauge the psychosocial and psychosomatic effects. methodology this observational cross sectional psychosocial analysis was carried out on a total of 100 female medical students of liaquat university of medical & health sciences and isra university from march to june 2014. informed consent was obtained and complete anonymity guaranteed. “google docs” was used to collect data via online structured questionnaire forms. the data obtained was analyzed in spss. v. 16.0. results 43 percent of the sample confessed that their families had, at least once, been approached for purpose of marriage. 16 percent admitted that they had themselves received marriage proposals. 88 percent of the sample held negative views regarding early marriage before graduation. upon inquiry, 78 percent of those who had encountered prospects of marriage before graduation admitted to have felt depression, anxiety and stress along with mild psychosomatic symptoms. conclusion females constitute a significant majority of medical students in pakistan and early marriage is known to adversely affect the prospects of a successful career. on the basis of our result, we conclude that even the fear of impending marriage is inducing depression, anxiety and stress among female students and can potentially harm their education and health. keywords psychosocial, psychosomatic, marriage, depression, anxiety and stress. introduction pakistan, like the rest of south-east asia, is plagued with age old trends and traditions that target the fairer sex in particular. marriage tops all charts in this regard and every parent in our increasingly misogynistic society wishes to marry off their daughter as soon as possible. it used to be that she only needed to be fair, from a good family, charming, and pliable. now it seems the perfect bride for the darling son of this or that family – must also be a doctor. gone are the days when too much education was a boon on the backs of the bride-to-be, a consternation that suggested the chance for possible rebellion; the desire to overturn age old traditions. today, the doctor bride signifies status, not simply the cache of brains in addition to beauty, but rather of the incredible largesse of having the option to work, to make lots of money, and then to forego it all in the path of devoted wifehood and motherhood. in this misogynistic equation a man who can boss a woman around is quite manly, but a man who bosses a doctor around is the manliest. (rafia. z, 2013). more than 70 percent of pakistan’s medical students are women but few go on to practice, according to the government body that regulates medical profession, pakistan medical and dental council (pmdc). however only 23% of the nation’s doctors are women. (zohra. b, 2015). while no figures are officially kept in pakistan of the numbers of doctors that are lost to the bridal belt of wife and motherhood, sources suggest that of 132,988 practicing doctors registered with the pakistan medical and dental council, 58,789 are http://www.aeirc-edu.com/ mailto:muhammadmuneebchauhan@gmail.com muhammad muneeb 34 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 women. of 28, 686 specialist physicians in the country, a paltry 7,524 are women. the percentage of female medical students may be high enough, but the bridal market places more urgent demands, promises more stability and social acceptance than the job market. (rafia. z, 2013) in a poor country, where healthcare is inaccessible to millions, female students, especially those that attend public universities take up already meager resources. when these girls do not practice they take away income generating opportunities from others who would utilise them. on another scale, the lost doctors represent an expenditure on healthcare that produces a net loss in that the benefits of the education are never dispersed into the general population. the problems are not pakistan’s alone. in post-apartheid south africa, a country where indian muslims present a significant demographic, rumors have been circulating about the application of unofficial quotas that reject applications from female indian muslim students because too many of them fail to practice medicine after marriage and motherhood. while administrators of medical schools insist that they do not exist, the issue remains a contentious one even in that country. (rafia. z, 2013) the educational burden of medical school alone is stress worthy but when coupled with the fear that all their efforts and their hard earned degree shall go in vain and they will be wedded off at a tender age. we hypothesize that the fear of an impending marriage leads to depression, anxiety and stress among female medical students and this study hopes to gauge the psychosocial and psychosomatic effects. methodology this observational cross sectional psychosocial analysis was carried out on a total of 100 female medical students of liaquat university of medical & health sciences and isra university from march to june 2014. informed consent was obtained and complete anonymity guaranteed. “google docs” was used to collect data via online structured questionnaire forms. the data obtained was analyzed in spss. v. 16.0. information was also gathered from online reports and news periodicals. results majority of the sample validated the claims made by most reports and confessed to have received marriage proposals during their university life i.e. they were found marriage worthy by men even before they had graduated. figure 1: a significant proportion of female medical students reported to have received marriage proposals even before graduation. 43 percent of the sample confessed that their families had, at least once, been approached for purpose of marriage. 16 percent admitted that they had themselves received marriage proposals. figure 2: ethical norms of the country dominated our result trend with most proposals being made to the family and not directly to the individual students. 88 percent of the sample held negative views regarding early marriage before graduation. 63% 37% ever received a marriage proposal at university yes no 43% 16% family self mode of approach http://www.aeirc-edu.com/ muhammad muneeb 35 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 3: the majority of girls wished to continue their medical education and practice their profession. the admitted to be well aware of the consequences of marriage and hence saw it as contradictory to their present interests. this coupled with the burden of responsibilities they would shoulder after marriage made them see marriage as a negative entity upon inquiry, 78 percent of those who had encountered prospects of marriage before graduation admitted to have felt depression, anxiety and stress along with mild psychosomatic symptoms. figure 4: the psychological distress that the female medical students are faced with, is evident in this figure. depression is the mainstay of the symptoms while anxiety and stress too follow immediately. the self-admitted psychosomatic symptoms that female medical students felt due to the impending feeling of marriage are described in the figure below. fatigue, back-ache and abdominal pain were the most prominent among the lot. figure 5: the top 5 symptoms were fatigue, headache, backache, abdominal pain and shortness of breath. 12% 88% views regarding early marriage positive negative 88% 81% 78% depression anxiety stress troubles encountered 84% 75% 67% 64% 34% 12% 11% 9% 4% 4% 4% psychosomatic symptoms http://www.aeirc-edu.com/ muhammad muneeb 36 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 discussion many women in the developing world are subject to marriage at an early age. most such women have little choice in the age at which they marry, or whom they marry. rebeca. j, 2013 in her article, examined patterns and trends of early marriage in the developing world. the incidence varies widely, from a high of 70 per cent in south asia to a low of 30 per cent in south east asia. women who marry young tend to have less decision-making power in the household. they are also more likely to experience domestic violence. (rebeca. j, 2013). hence justifying the fear of early impending marriage. the average age at marriage of women has been rising in most developing countries including south asia. (caldwell j.c, 1983). the rise in the age at marriage of women was explained by a marriage squeeze resulting from changes in the age structure of the population with mortality decline, an increasing concern of parents of daughters to secure sons-in-law with education and urban occupations, and a growing concept of child dependency. there was no evidence of the rise being a conscious effort to control family size. in the immediate future some women will probably remain unmarried, (caldwell. j.c, 1983) and it is this fear that is driving the all parents of daughters to get them married early and it is the more likeable ones (i.e. doctors) that get married the earliest. it is a general perception in pakistan that uneducated people do not allow women to work and girls should be provided education to make them an effective part of society. but the fact highlighted by our study is that even the educated men and their families force their wives to stay home as housewives and abandon their medical practice and their duty towards humanity. ikram. j, 2014, too validates our claims in his report that states that the elite class too preferred that female medical students should marry and serve their in-laws instead of doing their duty as a doctor. the problem thus lies at many levels (i.e. personal and societal) and the practice of young female medical students being approached and coerced for marriage is not only distressing for the primary victims (i.e. the female medical students) who suffer depression anxiety and stress but also the society at large who suffers from the dearth of doctors available to them. pmdc statistics that were quoted by the then president of pmdc state that “70 percent of the female students did not practice medicine after becoming doctor and completing their studies” (faheem a, 2012). the discussion on the problems can continue forever and the evidence too is endless, suggesting that early marriage may lead to a myriad of issues including poverty (otoo-oyortey n, 2003), low quality of life (unicef, 2005) and poor reproductive health (prakash r. et al, 2011) and increase in infant mortality rate (finlay je, 2011). the solution too can be dual-pronged. we can educate parents to not marry off their daughters at an early age and thus easing the psychosomatic burden that the female medical students carry. in addition to that, the students can be made to sign bonds that make it mandatory for them to practice their profession for at least a certain amount of years. that would not only let the females retain a sense of their old self after their marriage and give them confidence, but also empower them to fight off the depression, anxiety and stress. another solution that has surfaced just recently is the innovative idea of allowing female doctors who have discontinued their medical practice due to marriage is to work from home by joining platforms such as “docthers” and others that use video consultation setup that facilitates doctor-patient interactions. (ilyas f, 2016). conclusion females constitute a significant majority of medical students in pakistan and early marriage is known to adversely affect the prospects of a successful career. on the basis of our result, we conclude that even the fear of impending marriage is inducing depression, anxiety and stress among female students and can potentially harm their education and health. conflict of interest all the authors disclosed that there is no conflict of interest associated in the preparation of this article. acknowledgements we would like to acknowledge the intellectual assistance and technical support provided by lumhs research forum http://www.aeirc-edu.com/ muhammad muneeb 37 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 references  rafia. z. (2013). the doctor brides. the dawn news. retrieved from: http://www.dawn.com/news/1032070  zohra. b. (2015). pakistan sees a high rate of female medical students, but only few doctors. women in the world in association with the new york times. retrieved from: http://nytlive.nytimes.com/womenintheworld/2015/ 08/30/pakistan-sees-high-rate-of-female-medicalstudents-but-few-doctors/  rebeca. j, rebecca. t. (2013). early female marriage in the developing world. journal of gender and development. vol 11, issue 2. page 9 – 11.  caldwell j.c, reddy p.h, caldwell. p. (2013). the causes of marriage change in south india. journal of demographics. vol 37, issue 3. page 343 – 361.  ikram. j. (2014). 50pc female doctors never work after graduation. the dawn news. retrieved from: http://www.dawn.com/news/1139557  faheem. a. (2012). 70 percent of girls do not practice after becoming a doctor. aaj news. retrieved from: http://aaj.tv/2012/12/70-percent-ofgirls-do-not-practice-after-becoming-a-doctor/  oyo-oyortey n, pobi s. (2003). early marriage and poverty: exploring links and key policy issues. gender and development. volume 11, issue 2. page 42 51.  unicef. (2005). early marriage: a harmful traditional practice. isbn: 92-806-3869-6.  prakash r. et al. (2011). early marriage, poor reproductive health status of mother and child wellbeing in india. j famm plan reprod health care. doi: 10.1136/jfprhc-2011-0080  finlay je. (2011). the association of maternal age with infant mortality, child anthropometric failure, diarrhoea and anaemia for first births: evidence from 55 lowand middle-income countries. bmj open. doi:10.1136/bmjopen-2011-000226.  ilyas f. (2016). from ‘doctor brides’ to practicing physicians. the express tribune. retrieved from: http://tribune.com.pk/story/969805/docthers-fromdoctor-brides-to-practicing-physicians/ http://www.aeirc-edu.com/ http://www.dawn.com/news/1032070 http://nytlive.nytimes.com/womenintheworld/2015/08/30/pakistan-sees-high-rate-of-female-medical-students-but-few-doctors/ http://nytlive.nytimes.com/womenintheworld/2015/08/30/pakistan-sees-high-rate-of-female-medical-students-but-few-doctors/ http://nytlive.nytimes.com/womenintheworld/2015/08/30/pakistan-sees-high-rate-of-female-medical-students-but-few-doctors/ http://www.dawn.com/news/1139557 http://aaj.tv/2012/12/70-percent-of-girls-do-not-practice-after-becoming-a-doctor/ http://aaj.tv/2012/12/70-percent-of-girls-do-not-practice-after-becoming-a-doctor/ http://tribune.com.pk/story/969805/docthers-from-doctor-brides-to-practicing-physicians/ http://tribune.com.pk/story/969805/docthers-from-doctor-brides-to-practicing-physicians/ amaila fazal 14 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 original article effect of exercise on cognition in healthy males. a comparative study. amaila fazal1 and faizan mirza2 1. hej research institute of chemistry, international center of chemical and biological sciences, university of karachi, pakistan 2. department of physiology, university of karachi, pakistan corresponding author: faizan@aeirc-edu.com abstract cognition is an intellective action of understanding and gaining knowledge through speculation, acquaintance and practices that result in awareness, impression and perception. cognition, proprioception and balance all are aspects of ability of the brain to perform at high level at expense of endurance, speed and power. however, increasing age is linked with decrements in periodic memory. thus, exercise positively impacts brain utility during middle age, particularly frontal lobe-mediated intellectual processes, like organization, programing, reticence and operational memory. the aim of the present study was to observe whether exercise improve cognitive skills or not. the study was conducted on 200 healthy male subjects equally divided in two groups: exercising males and non-exercising males. the subjects were asked to fill in a proforma consisting of visual test and a reading test, which aimed at comparative evaluation of the duration of short term memory between exercisers and non-exercisers. it was found that exercise impacts on frontal lobe to enhance intellectual processes and hippocampus memory processing. keywords exercise, cognition, hippocampus, memory. introduction cognition is an intellective action of understanding and gaining knowledge through speculation, acquaintance and practices that result in awareness, impression and perception. it describes intellective processes that are involved in gaining knowledge and apprehension, including knowing, thinking, judging, remembering and problem-solving. they all are brain’s higher-level functions and beset intelligence, language, inventiveness, planning and perception (clegg, 2015). exercise positively impacts brain utility during middle age, particularly frontal lobemediated intellectual processes, like organization, programing, reticence, and operational memory. exercise also has the advantage of improving cognitive enactment supports the imperious for interferences that are fruitful in enhancing physical performance, with the results of stimulating fitness and efficiency (ratey and loehr, 2011). cognition in cognitive and psychology sciences is referred to a view of information processing of psychological functions of an individual. it is called social cognition in branch of social psychology to analyze mood, ascription and group fluctuations. cognition, proprioception and balance all are aspects of ability of the brain to perform at high level at expense of endurance, speed and power (clegg, 2015). gross motor control for stabilization or movement of the muscle fibers is the function of cerebral cortex while the fine motor control of the muscle fibre is the function of cerebellum. these fine motor controls are used for accurate movements which are skill based (clegg, 2015). eight habits that improve cognitive function • physical activity • openness to experience • curiosity and creativity • social connections • mindfulness meditation • brain-training games • enough sleep • reduce chronic stress (bergland, 2014). physical activity is somewhat an acute response stress that facilitates an individual to react to the alarm response. the rapid reaction system is the central nervous system along with sympathetic nervous system where perception and elucidation occurs. and the peripheral nervous system where coordination is made with effector muscles (wilbourn and prosser, 2003). physical activity is favourable for brain health and cognition while certain hormones that are elevated during exercise also help to improve memory, cognition and protects against neuro-degeneration as individuals engaged in physical activity had a lower risk of dementia (bergland, 2014). leisure-time http://www.aeirc-edu.com/ amaila fazal 15 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 physical activity (ltpa) executed at least two times a week generated extreme neuroprotective effects for individuals transversely across sex, capricious grades of genetic vulnerability and ages (tolppanen, et al., 2014). eustress and a definite amount of neural provocation are necessary to ensure ideal performance (wilbourn and prosser, 2003). fig: 1 benefits of exercise (laux, 2015) fig: 2 effects of exercise on brain (laux, 2015) fig: 3 exercise induces hippocampal bdnf through a pgc-1α/fndc5 pathway (wrann, et al., 2013). http://www.aeirc-edu.com/ amaila fazal 16 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 neurons are petulant; changes in their surrounding can change their rate of depolarization and results in changing behavior, feelings and ways of thinking. normal cognitive functions can become reversibly compromised when physiological or biochemical fluctuations occur in the surrounding of nerve cells. psychosomatic stress sources a series of neural and endocrine reactions that assist to preserve the individual in an active state of enthusiasm to deal with challenge (wilbourn and prosser, 2003). thickness of cortex of athletes is more in some areas and it is related to outstanding visual processing ability (wei, et al., 2011) while thickness of superior temporal sulcus is involved in training experience of athletes (lahnakoski, et al., 2012). physical activity unswervingly progresses the blood flow to the brain and increases the functional ability of innumerable neurotransmitters that are involved in intellectual procedures. mood enhancing properties of physical workout may ultimately employ an affirmative effect on cognitive working (kashihara, et al., 2009). during endurance exercise, brain produced specific molecule through chain reaction called irisin, which have a neuro-protective effect. artificially increasing irisin levels in blood over expresses genes that are involved in learning and memory. neurogenesis is also stimulated by the release of brain-derived neurotrophic factor (bdnf) during aerobic exercise (bergland, 2014). bdnf controls irritation, recovers the communication of signals within cells, and also adjusts the functions of the synapses. physical activity aids both sexes, but there is some indication that it might be of better advantage to females (at older ages). this may be related to the presence of estrogen. brain regions affected by exercise nevertheless, the prominence located on the hippocampus, an important area for knowledge and remembrance. specifically, it is found that decisionmaking functions were particularly improved by exercise that is primarily taken in the prefrontal cortex. it is also found that there is reduced grey and white matter in the frontal, temporal, and parietal cortexes of those who were less physically fit. the differences in the middle-frontal and superior parietal regions of the brain were also found due to aerobic fitness. interestingly, it was also possibly found that higher cognitive function during sustained and moderate exercise reliant on the prefrontal cortex were weakened, but not those demanding little prefrontal activity (dietrich and sparling, 2004). methodology the study was conducted on 200 male subjects, in the age group of 19-32, bearing weight in the range of 50 kg to 90 kg and height in the range of 5ft to 6ft. they were all the resident of karachi, pakistan and were not suffering from any pathological condition at the time of survey. survey was done randomly in the campus of university of karachi as well as from local gyms of karachi city. standard group: it comprises of 100 subjects. the individuals of this group were used as a control. questionnaire was filled by the individual consisting of visual and reading short term memory test and time was calculated. all the subjects in this group were healthy and were not engaged in any sort of physical activity or exercise. experimental group: it comprises of 100 subjects. the individuals of this group were used as test. questionnaire was filled by the individual consisting of visual and reading short term memory test and time was calculated. all the subjects in this group were healthy and were engaged in exercise from couple of years. result all the individuals show increase in their cognitive skills after exercise as took less time during reading and visual test while testing short term memory. reading test: subjects took about 8% (10.57 ± 5.285) less time to complete reading test than control group indicating increased short term memory after exercise. visual test: subjects took about 11% (8.01 ± 4.005) less time to complete visual test than control group indicating enhanced cognitive skills after exercise. parameter non exercising males exercising males visual test (time in seconds) 29.21 ± 2.4893 18.64 ± 1.4365 reading test (time in seconds) 39.65 ± 1.7691 31.64 ± 1.5995 http://www.aeirc-edu.com/ amaila fazal 17 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 discussion time taken by exercising males is far less than nonexercising group in visual test. p value was found to be 0.001 in visual test, which is less than 0.05, so difference between exercising group and nonexercising group is significant. exercise positively impacts frontal lobe-mediated intellectual processes during middle age (ratey and loehr, 2011). thickness of cortex of athletes is more in some areas that are related to outstanding visual processing ability (wei, et al, 2011). psychosomatic stress sources a series of neural and endocrine reactions that assist to preserve the individual in an active state of enthusiasm to deal with challenge (wilbourn and prosser, 2003). time taken by exercising males is less than nonexercising group in reading test. p value was found to be 0.000 in reading test, which is less than 0.05, so difference between exercising group and nonexercising group is significant indicating increased exercise induced cognitive skills. physical activity is favourable for brain health and cognition while certain hormones that are elevated during exercise also help to improve memory and cognition (bergland, 2014). it was found that exercise impacts on frontal lobe to enhance intellectual processes. exercise also impact hippocampus memory processing as observed by reading test. specifically, it is found that decisionmaking functions were particularly improved by exercise that is primarily taken in the prefrontal cortex (dietrich and sparling, 2004). conclusion exercise do increase memory along with cognitive skills and also improve hippocampal function by elevating level of hormones like irisin and elevating levels of brain derived neurotropic factor that ultimately improves synaptic plasticity. further investigations could also be done in this field by doing animal studies on mice using morris water maze that is widely used to study spatial learning and memory. competing interests no competing interests found. acknowledgment the authors would like to acknowledge the authorities of murtaza gym, rangers head quarter gym and eidgah gym for their valuable participation and the efforts of students of university of karachi, for their valuable input in completing questionnaire. 0 10 20 30 40 test (exercising) control (non exercising) time visual test 31.64 39.65 0 10 20 30 40 50 test (exercising) control (non exercising) time reading test http://www.aeirc-edu.com/ amaila fazal 15 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 references  clegg, m. (2015). cognition in sports. seed of speed. http://www.seedofspeed.com/cognition-insport/  ratey, j. j., & loehr, j. e. (2011). the positive impact of physical activity on cognition during adulthood: a review of underlying mechanisms, evidence and recommendations. reviews in the neurosciences, 22(2), 171-185.  bergland, c. (2014). eight habits improve cognitive function. www.psychologytoday.com/blog/theathletes-way/201403/eight-habits-improvecognitive-function  wilbourn, m., & prosser, s. (2003). the pathology and pharmacology of mental illness. nelson thornes.  bergland, c. (2014). regular physical activity can improve brain function throughout a lifespan. www.psychologytoday.com/blog/the-athletesway/201404/physical-activity-improves-cognitivefunction  tolppanen, a. m., solomon, a., kulmala, j., kåreholt, i., ngandu, t., rusanen, m., & kivipelto, m. (2015). leisure-time physical activity from midto late life, body mass index, and risk of dementia. alzheimer's & dementia, 11(4), 434-443.  wei, g., zhang, y., jiang, t., & luo, j. (2011). increased cortical thickness in sports experts: a comparison of diving players with the controls. plos one, 6(2), e17112.  lahnakoski, j. m., glerean, e., salmi, j., jääskeläinen, i. p., sams, m., hari, r., & nummenmaa, l. (2012). naturalistic fmri mapping reveals superior temporal sulcus as the hub for the distributed brain network for social perception. frontiers in human neuroscience, 6, 233.  kashihara, k., maruyama, t., murota, m., & nakahara, y. (2009). positive effects of acute and moderate physical exercise on cognitive function. journal of physiological anthropology, 28(4), 155-164.  dietrich, a., & sparling, p. b. (2004). endurance exercise selectively impairs prefrontal-dependent cognition. brain and cognition, 55(3), 516-524.  laux, e. (2015). exercise and cognition. http://www.bodbot.com/cognitive_health.html  wrann, c. d., white, j. p., salogiannnis, j., laznik-bogoslavski, d., wu, j., ma, d., & spiegelman, b. m. (2013). exercise induces hippocampal bdnf through a pgc-1α/fndc5 pathway. cell metabolism, 18(5), 649-659.  smith, m., robinson, l., & segal, r. (2016). age-related memory loss. http://www.helpguide.org/articles/memory/agerelated-memory-loss.htm 18 http://www.aeirc-edu.com/ http://www.seedofspeed.com/cognition-in-sport/ http://www.seedofspeed.com/cognition-in-sport/ http://www.psychologytoday.com/blog/the-athletes-way/201403/eight-habits-improve-cognitive-function http://www.psychologytoday.com/blog/the-athletes-way/201403/eight-habits-improve-cognitive-function http://www.psychologytoday.com/blog/the-athletes-way/201403/eight-habits-improve-cognitive-function http://www.psychologytoday.com/blog/the-athletes-way/201404/physical-activity-improves-cognitive-function http://www.psychologytoday.com/blog/the-athletes-way/201404/physical-activity-improves-cognitive-function http://www.psychologytoday.com/blog/the-athletes-way/201404/physical-activity-improves-cognitive-function http://www.bodbot.com/cognitive_health.html http://www.helpguide.org/articles/memory/age-related-memory-loss.htm http://www.helpguide.org/articles/memory/age-related-memory-loss.htm original article www.aeirc-edu.com volume 12014 page | 24 ©advance education institute & research centre-2014 exaggerating and retraining factors leading to migraine incidence in pakistan sadaf ahmed, 1 shamoon noushad, 1, rida nasir,1 huma khalid,1 & shaikh mohammad tahir 1 1. psychophysiology research division, advance educational institute & research centre 2. neurovascular physiology & biophysics unit, department of physiology, university of karachi corresponding author: sadaf@aeirc-edu.com abstract migraine is a neurological disorder with primary episodes of headache pain affecting populations worldwide. almost people of all ages and family history are able to develop this pattern of throbbing and unilateral pain with visual disturbance to physical sensations. the key triggers that are most likely to initiate this headache includes psychosocial, economical, environmental or physical stress, hormonal disturbances, dietary variations, high sensitivity to light, smell and sounds.185 subjects both male and females of different ages from 16-60 years were interviewed to investigate the key triggering reasons for migraine attacks. meanwhile they were also inquired by any restraining factors that help them to get instant or long-lasting relief. evaluation was done on the basis of ichd-ii criteria. moreover the family history, socio-economic status and demographic data were also noted. our results gave a clear view that emotional and mental stress was the key trigger that can exaggerate the feeling of headache with physical strain as the other main burden. secondly exposure to immense sunlight and bright lights was frequently reported. other minor initiators observed were lack of sleep, dietary changes, skipped meals, menstruation, and particular smells like fragrance or unpleasant odors. while excessive sleep and medications were noted as chief controls this can restrain headache pain incidence. in this study, emotional stresses were significant in female. psychological stress is reported to be a major contributor to headaches. the attacks may be relief by proper medication and sleep. stress and sunlight trigger migraine head pain in majority that can be cure by proper medicine and sleep. keywords migraine, triggers, exaggerating, stress, headache introduction: migraine is the primary episodes of headache/neurological pain. it is followed by unilateral pain and throbbing and in many cases it may be severe. it can occur in the normal functioning brain, causing it to act abnormally (goadsby, 2002; may, 1999; ayata, 2006). recent studies throughout the world (africa, asia, australia, europe, north america, central and south america) showed an average rate prevalence of migraine while western world showed higher than the japanese population. 4 according to world health organization’s estimation, 303 million people suffered migraines worldwide and every day at least 20 million attacks of migraine happen (who, 2006). headache is ranked at fifth position in most disabling condition for women globally (samaan, 2010). rate of migraine is more prevalent in females than in males (goadsby, 2002; hauser, 2012 & martelletti, 2005). in adulthood, the likelihood of women suffering from migraine is three times more than men. in childhood, boys are affected more than girls, but after adolescence, when estrogen influence begins in young girls, the risk of migraine and its severity rises in females. some scientist have suggested that gonadal steroid may be the reason for headache or migraine as changes occur in estrogen levels at menarche, menstrual period, pregnancy, and menopause (goadsby, 2002; dzugan, 2004). female sex hormones can control majority mediators and receptor systems; these actions may be preserving at the central nervous system and peripheral, neurovascular level. for illustration, women sex hormone have been revealed to enhance: (i) neuronal excitability by increased ca2+ and decreasing mg2+ concentrations, an action that may occur with other mechanisms triggering migraine; researchers have demonstrated that increase in estrogen leads a decrease in ionized magnesium but when progesterone levels rise, ionized magnesium levels also rise. (ii) the synthesis and release of nitric oxide (no) and neuropeptides, such as calcitonin gene-related peptide cgrp, a mechanism that reinforces vasodilatation and activates trigeminal sensory afferents with stimulation of pain centers. (iii) the function of receptors mediating vasodilatation, while the responses of receptors inducing vasoconstriction are weakened (gupta, 2007 & dzugan, 2006). the migraine attacks may start at any age; the effect increases more in early to mid-adolescence (goadsby, 2002). unfortunately it is also very common in children although there are various theories as to the potential cause(s) of migraine, one of them is the genetic factors (lin, 2005; anjum, 2012; haan, 1997). diverse numbers of factors were reported that can initiate headache in particular individuals while they are not universal as they vary from person to person. the major triggering factors include food, missed meals, alcohol, menstrual periods, environmental condition, stress and hormonal factors (who, 2006; zagami, 2006; sauro, 2009 ;bokhari,2009 & sauro, 2009). psychological and emotional stressors include moods like depression, anger; anxiety, reported a common initiative factor in migraine patients (anjum, 2012). the aim of this study was to evaluate the most common factors in our population that trigger migraine we also targeted the factors that can contribute to the cure and reduction of migraine in our people. method: 185 subjects, including both male and females, ages ranging between 16-60 years were interviewed in order to investigate the major triggering factors that stimulates migraine attacks and restraining factors that help them to get rid of headache and provide long-lasting relief. the inclusion and exclusion criteria was based on sensation of pain in the head, people who reported the pain sensation were studied on the basis of the intensity of pain and other factors like duration, causes, feeling, impact, side of head where pain feels the most, family history etc. socio-economic status and demographic data were also collected. the data was collected before and during examination while evaluation was done on the basis of ichd-ii criteria. original article www.aeirc-edu.com volume 12014 page | 25 ©advance education institute & research centre-2014 results: table 1: most common exaggerating factors for both headache and migraine relieving factors percentage of respondents sleeping 38.38 rest 28.64 eating 14.59 spinal adjustment 2.16 improving posture 5.40 dark quiet room 29.73 medication 36.76 nothing helps 10.27 drinking coffee 27.57 muscle massage 12.43 cold pack 3.24 other 2.2 table 2: most common relieving factors for both headache and migraine. the most common exaggerating factors were emotional stress, bright light, and period after emotional stress. the most common factors that relieve migraine were: sleeping, medication, dark room, rest and drinking coffee. discussion: diverse number of precipitating factors that initiate headache and migraine included in this study were also examined by different authors (who, 2006; anjum, 2012; sauro, 2009). the current study focused on finding the most common migraine exaggerating factors and relieving factors among headache and migraine sufferers. the major triggers of headache pain in both categories are shown in table 1, emotional stress, evening time, bright light and hunger are the most common triggers. stress and bright light are the most common triggers. studies indicate that stress is the major factor in migraine (fakhsheena, 2012; sauro, 2009 & bokhari, 2008). rasmussen and robbins l et al. reported in their studies that most recurrent factor of migraine and headache was stress and mental tension. stress/anxiety as activated the central mechanism of the ascending reticular pathway (1994; spierings, 1997). here we have seen that evening time was also a major factor that plays a role in initiating migraine. it was mentioned in previous study that finds out the time onset of migraine and indicates a same factor trigger head pain with a low rate (sauro, 2009). while on another study showed hassles in the afternoon led to migraine headache that similar to evening or during the night. (friedman,2009 & soleimanpour, 2012). martins and prarreira identified six exercises tried by the people, most commonly the migraineurs to improve the head pain during and attack. it is a common observation, by clinicians involved in the headache field that many patients use some natural exercises, of their own that improve their pain. in one of the study that recognize the relieving factors they also observed that sleeping, rest were very useful practice attempt by both groups. references:  al-shimmery, e.k.(2010) precipitating and relieving factors of migraine headache in 200 iraqi kurdish patients. oman medical journal.25 (3), 212.  ayata, c., jin, h., kudo, c., dalkara, t., & moskowitz, m. a. (2006). suppression of cortical spreading depression in migraine prophylaxis. annals of neurology, 59(4), 652-661.  bokhari, f. a., sami, w., shakoori, t. a., ali, s. a., & qureshi, g. a. (2008). clinical characteristics of 226 collegegoing female migraineurs in lahore, pakistan--putting ichd-2 to the road test. neuroendocrinology letters, 29(6), 965.  cohan, w. (2013). what nurses know... headaches. demos medical publishing.  dzugan, s., & armond, s. (2006). le magazine.progesterone misconceptions.  dzugan, s.a. (2004).an innovative new treatment for migraine. life extension. 64-73.  friedman, d. i., & de ver dye, t. (2009). migraine and the environment.headache: the journal of head and face pain, 49(6), 941-952.  goadsby, p. j., lipton, r. b., & ferrari, m. d. (2002). migraine—current understanding and treatment. n engl j med, 346(4), 257-270.  gupta, s., mehrotra, s., villalón, c. m., perusquía, m., saxena, p. r., & maassenvandenbrink, a. (2007). potential role of female sex hormones in the pathophysiology of migraine. pharmacology & therapeutics, 113(2), 321-340.  haan, j., terwindt, g. m., & ferrari, m. d. (1997). genetics of migraine.neurologic clinics, 15(1), 43-60.  haque, b., rahman, k. m., hoque, a., hasan, a. h., chowdhury, r. n., khan, s. u., ... & mohammad, q. d. (2012). precipitating and relieving factors of migraine versus tension type headache. bmc neurology, 12(1), 82.  hauser, l. (2012). migraines and perimenopause. nursing for women's health, 16(3), 247-250. initiating factors percentage of respondents morning 7.56 evening 37.30 afternoon 15.13 during sleep 14.59 beginning of week 4.32 middle of week 8.65 end of week 8.65 bright light 33.51 during or after having sex 0.54 period after emotional stress 37.84 after emotional stress 23.24 during physical exertion 10.81 after not eating several hours 27.57 after napping or over sleep 17.84 after drinking alcohol 0.54 before menstrual cycle 7.57 during menstrual cycle 5.40 after menstrual cycle 1.08 after bending your head downwards 17.84 no pattern 11.35 original article www.aeirc-edu.com volume 12014 page | 26 ©advance education institute & research centre-2014  lin, j., p. wang, c. chen, k. yueh, s. lin, h. harn.(2005). homozygous deletion genotype of angiotensin converting enzyme confers protection against migraine in man. acta neurologica taiwanica.14(3), 120.  martelletti, p., haimanot, r. t., láinez, m. j., rapoport, a. m., ravishankar, k., sakai, f., ... & steiner, t. j. (2005). the global campaign (gc) to reduce the burden of headache worldwide. the international team for specialist education (itse). the journal of headache and pain, 6(4), 261-263.  may, a., ashburner, j., büchel, c., mcgonigle, d. j., friston, k. j., frackowiak, r. s. j., & goadsby, p. j. (1999). correlation between structural and functional changes in brain in an idiopathic headache syndrome. nature medicine, 5(7), 836-838.  samaan, z., macgregor, e. a., andrew, d., mcguffin, p., & farmer, a. (2010). diagnosing migraine in research and clinical settings: the validation of the structured migraine interview (smi). bmc neurology, 10(1), 7.  sauro, k. m., & becker, w. j. (2009). the stress and migraine interaction.headache: the journal of head and face pain, 49(9), 1378-1386.  sauro, k. m., & becker, w. j. (2009). the stress and migraine interaction.headache: the journal of head and face pain, 49(9), 1378-1386.  selby, george, james w. lance.(1960) observations on 500 cases of migraine and allied vascular headache.journal of neurology, neurosurgery, and psychiatry. 23(1), 23.  singh, s., harsh, n. s. k., & gupta, p. k. a novel method of economical cultivation of medicinally important mushroom, ganoderma lucidum.  spierings, e. l., sorbi, m., maassen, g. h., & honkoop, p. c. (1997). psychophysical precedents of migraine in relation to the time of onset of the headache: the migraine time line. headache: the journal of head and face pain, 37(4), 217220.  world health organization.(2006). "headache disorders. fact sheet no. 277. march 2004." retrieved from http://www.who.int/mediacentre/factsheets/fs277/en/  zagami, a. s., & bahra, a. (2006). symptomatology of migraines without aura.the headaches, 3rd edn. lippincott williams & wilkins, philadelphia, 399-405. afshan tabassum 16 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 original article menstruation; a cause of recurrent emotional stress in young females afshan tabassum1, sadaf ahmed1&2 & shamoon noushad2 1-department of physiology university of karachi 2advance educational institute & research centre corresponding author: afshantabassum124@yahoo.com abstract the event in the early & late proliferative period of the menstrual cycle can be experienced as physical, psychological, physiological & emotional indicators, sometimes it is well observed as premenstrual syndrome (pms) among reproductive aged women, specifically characterized by emotional & physical symptoms that consistently occur during the leutal phase of the menstrual cycle. the purpose of our study was to determine the frequency and severity of occurrence of these characterizing symptoms as well as to compare these with pms in young girls. we also investigated about the impact of these conditions on the quality of life. women aged 17-35 years with pre-menstrual pain were recruited in the study. pms related data was collected on record of severity of pain while emotional stress score were calculated by using sadaf stress scale (sss). according to our results 48% of these women reported sharp pain with 39% having pain in abdomen back and thigh region. according to sss 26% lies in moderate emotional stress, 30% in mild and 11% in severe emotional stress. those women having severe intensity of pain reported 80% moodiness, 60% irritability and 40% abnormal laughter. the present results showed consistent and strong relationship between pms symptoms and level of interference in all domain of women’s quality of life. we can conclude that pms is the most common problem in women that distresses their educational performance and emotional well-being. there should be modified strategies for the detection and management of pms on women for better quality of life. keywords sadaf stress scale, premenstrual syndrome, emotional stress, pain introduction menstruation a reproductive cycle solely conducted & regulated by hormonal abrupt releases & fluctuations under the control of hpo-axis involving the glands and reproductive organs (wilson, 1996; norman, et al., 1997 and messinis, 2006). during this 28days menstrual cycle body go through many physiological events (grayce, 2014) results to develop several pre & peri-menstrual symptoms. the set of physiological, psychological & behavioral symptoms starts to appear just before the onset of menstruation & subside till the 3-4day of bleeding, termed as premenstrual syndrome ‘pms’ (govind, et al., 2007). pms highly prevalent gynecological condition & according to a familiar study in pakistan, reported high prevalence of pms with varying intensities (hashim, et al 2014) not only this, but numerous other researches conclusions also supports that pms is highly prevalent as every female experiences at least 1-2 symptoms though the severity varies. pandey, et al., 2013 concluded pms with 100% of prevalence and according to many other studies the prevalence rate lies up to 95%in females vary with symptomatic severity (khater, 2011) but only 2-5% suffers from severe symptoms. recurrent long term encounter, a considerably significant factor to develop stress in young reproductive aged females suffering with pms because any chronic trigger/stressor can develop stress response when exceeded its threshold (chrousos, et al., 1992). stress is a condition that develops when body faces circumstances (stressors) interrupting the chain of body’s homeostasis cascade, triggers the stress response mechanisms to cope up with the situation and bring the equilibrium back but in the mean while body must experience some characterizing symptoms of stress which intensity must be under the influence & potential of stressors. but the frequency & occurrence of stress symptoms are more likely to relate with the category of stress, the body dealing with at the time (sadaf, 2014). periodic menstrual cycle, with recurrent encounters of pre & peri-menstrual symptoms co-relate it with the chronic negative stress, as defined by (sadaf, 2014) ‘when a long term stressor is present around for a phase or prolong period of life results in chronic stress that could be dangerous in many ways first, because of people get used to it and ignore this stress harming their mental and physical health secondly persistence pressure can lead to even more retarded health conditions.’ the menstrual distressing pms symptoms like pelvic pain & rest are potential stressors to develop emotional stress in menstruating females by establishing unpleasant & uncomfortable impacts reflect behavioral and emotional status develop characterizing symptoms of emotional stress in females during pre & peri-menstrual phase. the purpose of our study was to determine the frequency & severity of occurrence of menstrual characteristics symptom as well as to compare these with pms in young girls. and also investigate its impact on their quality of life. methodology a cross-sectional study design with sample size (n=100). the participants were selected from different fields like students, house wives & working women. http://www.aeirc-edu.com/ afshan tabassum 17 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 all selected subjects were healthy reproductive age females between 17-35 years of age & not diagnosed with any medical disease condition to make sure that all the reported symptoms were not due to any pathological condition but physiological menstrual distress. both married & unmarried females were included in the study whereas, pregnant and menopausal women were excluded. firstly a prequestionnaire comprised of 20 questions was filled by every participants in which we asked basic information related to their menstrual cycle like age of menarche, cyclic regularity, blood flow, daily physical activity/exercise & other related questions. the prequestionnaire was designed to focus on data collection related to pms & symptoms, their rate of prevalence & its relating link with stress occurrence. an important criteria was set in order to get the most accurate answers, we asked the subjects to fill the questionnaire within first 3days of their menstrual cycle so that the participants can able to answer exactly according to that condition they were experiencing at that time. in the 2nd step for emotional stress evaluation we asked the subjects to fill the sadaf stress scale (sss). in which 15 emotional stress associated symptoms are included. participant rated the symptoms according to their experienced severity & frequency of occurrence. the data was analyzed by using spss method. sadaf stress scale (sss): sss is a tool for stress evaluation. it’s a questionnaire type scale measures the various types of stresses in ages 14 and above. there are different associated symptoms provided in the scales for different 7 types of stress. for stress evaluation and intensity determination calculation & scoring are also provided. according to the scores the stress level were categorized as normal, mild, moderate and severe. by calculating the data according to formula & following the provided scoring in the sss manual we can evaluate & score the level or intensity of symptoms from normal, mild, moderate & severe level of stress. results & discussion our present study results positively establish a connection between chronic negative stressor (pms) & emotional stress. pelvic pain, one of the characterizing menstrual distress symptom is highly reported by females as shows in fig 1 the pain intensity during pms reported by participating females. fig 1: pain intensity during pms fig 2: mood changes during period the pain prevalence as presented by our study result is 100% because every female reported with a certain type & intensity of pain. sharp was most highly reported type of pain by 48% of females. pgs as hyper contractility & inflammatory cascade inducer consider to be the key factor behind the menstrual pain, cramps/bloating, mm, sleep disturbance and other git symptoms (mannix, 2008; baker, et al., and bernstein, et al., 2014). with periodic pms encounters the mood instability also monitored as females experience different sets of mood wavering during their cycle. aggressiveness, the most reported mood change by 37% females whereas other mood were also reported by participant’s considerable scale, as shows in fig. 2.the exact etiology of pms is not known yet but due to its periodic appearance just after the leutal phase and probable aggravation with onset of menstrual flow relates pms with the hormonal events involve the ovarian changes & corpus leutum formation consider an initiator to bring on the cyclic mood changes and symptomatic appearances that supported by, an ovulatory asymptomatic phase followed by ovulatory symptomatic phase (govind, et al., 2007).chronic negative stressor (pms) with its repetitive encountering waves can potentially leads the body to swim into emotional stress because our study results shows that all the pain perceiving females endorse the emotional stress symptoms of sss with high frequencies & varying intensities (fig: 3). fig 3: frequency of emotional stress symptoms according to sss reported by females 32% 48% 17% 3% mild sharp shooting burning 88% 81% 48% 72% 87% 67% 49% 65% 38% 42% 58% 66% 47% 84% 61% 21% 14% 37% 11% 4% http://www.aeirc-edu.com/ afshan tabassum 18 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 hormonal fluctuations exclusively progesterone and estrogen consider core factor in pms symptoms generation. progesterone is a primary precursor in the biosynthesis of the adrenal corticosteroids impaired corticosteroid production results in a decrease in the ability to handle stress, e.g., surgery, trauma or emotional stress. if estrogen not maintained by progesterone peak it results in; irritable mood, bad temper, chronic fatigue and headache. decreased estrogen also associated with negative mood swings ‘crying spells, anxiety, and depression’(sellman, 1996) but there are many theories regarding to the etiology behind cyclic mood changes and physical symptoms related to pms and an established statements still needed more explorations (stearns, 2001 and govind, et al., 2007). fig.4: frequency of emotional stress symptoms reported by females perceiving sharp pain fig 5: severity level of emotional stress pms can cause severe physical and emotional disability when it gets severe or intense (stearns, 2001 and govind, et al., 2007) and if accompanied with dysmenorrhea(pelvic pain) can produce significantly intense emotional and physical stress symptoms ultimately leads the body towards more exertion producing profound physical and emotional stresses which also demonstrated by results of our study that those females reported with dysmenorrheal and pms symptoms, also evaluated with severe , moderate, and with mild emotional stress and along with this they also perceives emotional stress symptoms comparatively more frequent, evaluated with varying severity categorized on the basis of symptoms and their intensities the participants experienced ( as shows in fig: 4). overall 67% females were evaluated with different stress severity level, which is a very considerable proportion that every female bearing a load of emotional stress of unlike burden. along with this the rest of 33% female were also reported different pms & emotional stress symptoms with slighter intensity so they placed in normal level of stress, as presented in fig: 5. fig. 6: limiting social activities. the figure showed that 45% reported that they limits their social activities during menstruation, 25% females reported that they always limit their social activities while 30% females reported that they don’t limit/skip their social activities. this chronic stress also impacts the quality of life and capability to cope with routine activities as in our study significant number of participants reported that they always or sometimes skip their social/educational or interpersonal activities reflects the intruding effect of menstrual distress on quality of life. conclusion & recommendation our research results demonstrate a very high prevalence rate of pms in young adult females because a large proportion of participants reported characterizing symptoms of physical & emotional menstrual distress (pms) & endorsed the theory that every women at least perceive 1-2 symptoms of pms. we also evaluate 67% females with different severity level of emotional stress & the rest of population were also reported emotional stress symptoms but with slighter intensity & frequency. hence it’s a supportive study to suggest that these gynecological conditions profoundly stressed up the body physically and emotionally and continuous symptomatic alterations lead to hindrances in daily life. so we conclude that with recurrent pattern of menstrual distresses i.e.; pms leading to physiological & psychological stress can moodiness 26% agitation, inability to relax… sence of lonliness and isolation… anxiety 7% feeling insecure 7% forgetfullness 7% relationships conflicts 7% abnormal laughter 13% irritability (bad temper) 20% normal 33% mild 30% moderate 26% severe 11% http://www.aeirc-edu.com/ afshan tabassum 19 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 profoundly establish emotional stress symptoms in young adult females. we recommend that menstrual symptoms must get concerns to make timely detection possible if symptoms getting more intense or frequent because it’s vital to adopt healthier management strategies & balance quality of life. references •wilson kathleen, j. w. (1996). ross and wilson, anatomy and physiology in health and illness, churchill livingstone. •norman, a. w., & litwack, g. (1997). hormones. academic press. •messinis, i. e. (2006). from menarche to regular menstruation. annals of the new york academy of sciences, 1092(1), 49-56. •grayce p. storey 2014. the effect of hormones on female sexuality and menopause by the yale-new haven teachersinstitute •govind, a., & o'brien, p. m. s. (2007). dysmenorrhoea and premenstrual syndrome. gynaecology for postgraduate and practitioners, 96. •hashim, r., ayyub, a., hameed, s., qamar, k., ali, s., & raza, g. (2014). premenstrual syndrome: messes with my academic performance. pakistan armed forces medical journal, 64(2). •khater, b. dysmenorrhea & premenstrual syndrome. primary (2011) care clinical guide, 80. •chrousos, g. p., & gold, p. w. (1992). the concepts of stress and stress system disorders: overview of physical and behavioral homeostasis. jama, 267(9), 1244-1252. •sadaf, a. & shamoon, n. (2014). psycophysiology of stress published by aeirc & international journal of endorsing health and science (pg. 20-38) issn-2307 3748 1st edition december 2014. •shamoon noushad & sadaf ahmed ,sadaf stress scale(sss) manual, advance educational institute &research center(aeirc) &international journal if endorsing health science issn-2307 3748 (2014). •bernstein, m. t., graff, l. a., avery, l., palatnick, c., parnerowski, k., & targownik, l. e. (2014). gastrointestinal symptoms before and during menses in healthy women. bmc women's health, 14(1), 14. •mannix, l. k. (2008). menstrual-related pain conditions: dysmenorrhea and migraine. journal of women's health, 17(5), 879-891.er •baker, f. c., driver, h. s., rogers, g. g., paiker, j., & mitchell, d. (1999). high nocturnal body temperatures and disturbed sleep in women with primary dysmenorrhea. american journal of physiology-endocrinology and metabolism,277(6), e1013-e1021. •sellman, s. estrogen's deadly truth, part. (1996) •stearns, s. (2001). pms and pmdd in the domain of mental health nursing. journal of psychosocial nursing and mental health services, 39(1), 16-27 http://www.aeirc-edu.com/ orginal article www.aeirc-edu.com volume 12014 page | 16 ©advance education institute & research centre-2014 mental, behaviopral and physical effects of power enhancing drugs in chronic users faizan mirza, 1 & sadaf ahmed 1&2 1. neurovascular physiology & biophysics unit, department of physiology, university of karachi 2. psychophysiology research division, advance educational institute & research centre corresponding author: fm.faizan.mirza@gmail.com abstract exercising in gym is largely aimed at getting a desirably muscled physique that is subject to peer approval as well as associated with a higher self-esteem. many people opt for workouts that define the lean body mass, whereas others aim at getting a beefed up body. the latter being a long and tiring process, pushes many people to opt for power enhancing drugs, for boosting their athletic endurance. among others; steroids, erythropoietin, creatine, protein supplements are available over the counter all over pakistani pharmacies. together with increasing the muscle bulk, they exert highly undesirable effects on hematological as well as lipid parameters. the present study evaluated and compared the side effects reported by the users of such ped on their mind, personality and body. a proforma was filled by each subject. the results showed that depending on the type of ped used, it has altered the personality of the individual significantly. attributes that their personality and body did not have initially were observed by them upon chronic usage of these ergogenic aids. this lead us to conclude that “amount in prs” is not the only price these ped users pay for attaining their desired beefed up physique, with which emerged another question, is that cost actually worth it?!! keywords exercise, power enhancing drug, gym, workout, personality introduction positive influence of exercise on psychological and physiological attributes has been agreed upon by several scientists (sime, 1987). strenuous exercise affects mood of the individual right away (veale, 1987). physical activity is linked with raised level of endorphins in brain (colt , 1981). here has been evidence that endogenous opioids in frontolimbic region of brain increases upon regular physical activity which can be linked with the euphoric state that the individuals feels as runners high (henning, 2008). the present study focuses on individuals who workout in gym and use power enhancing drugs (ped) such as steroids, creatine, protein, erythropoietin that are easily available over the counter in our country. these aid athletes to help in their performance on field and among non-athletes they result in better shaped body (koch, 2002). such ped are the favorite choice of youth in here to boost up their performance in gym, that quite soon gets translated into a wellmuscled physique. ped usage is reported to be causing an increased rage of anger as well as frustration (mirza, 2013). objectives of the study to evaluate and compare various side effects observed by individuals exercising and using different peds. materials & methods the study was conducted on 75 healthy male subjects, in the age group of 19-31, bearing weight in the range of 61kg to 138kg and height in the range of 5ft 6inches to 6ft 3inches, who have been doing regular exercise in a gym for last four to nine consecutive years and have been using peds for at least three years. they were asked to fill a proforma that aimed at analyzing the side effects that they started experiencing since they started abusing ped. they were divided in following groups s; 10 steroid users se; 6 steroids+epo users sc 8 steroids+creatine users c; 7 creatine users cz;13 creatine+zinc users p; 19 protein users pz 12 protein+zinc users results & discussion animal models have shown that exercise leads to an increased calcium level in brain, which might be associated with altered brain functions such as mood etc. (denetsu, 1996). figure. 1 shows noticeable changes in moods of male users. majority of peds’ users have observed changes in their mood ever since they started taking peds. the reported changes included sudden mood swings, mood fluctuations mainly. all of the users believe that they did not have those mood-related issues before. of steroids users’ majority of users of steroids together with erythropoietin reported noticing such changes. all the individuals using creatine alone also shared similar experience. and so did individuals using protein supplements with zinc. among all these, the creatine users were found to be most significantly affected. figure 1. noticeable changes in moods hassmén, (2000) reported how regular exercise could result in less anger and depression in the exercising individual. however, the findings of present study as shown in figure. 2 accounts for individuals who workout and use ped as well, came up with the findings otherwise. increased testosterone levels in the blood are associated with masculine behavior, aggressiveness and increased sexual desire, whereas an aggressive attitude is required for boosting athletic performance in gym it may result in unnecessary violence outside the gym as well (kuipers, 1998). all the users of steroid with erythropoietin and those using creatine alone too reported increase in aggression level. individuals of group s and group pz showed a similar increment in aggression, while majority of group cz also showed this tendency. on the other hand more than half of 0 50 100 150 s se sc c cz p pz yes no orginal article www.aeirc-edu.com volume 12014 page | 17 ©advance education institute & research centre-2014 individuals of groups sc and p claimed to be more aggressive now as compared to when they did not take supplements. this aggressive attitude probably has something to do with the way one perceives image of his body, since, irrespective of the ped used, individuals who were physically stronger reported more aggression than those who were not physically that strong. group c again was found to be overtly affected, together with users of steroid and erythropoietin combination. figure 2. an increase in aggression figure 4. reported side effects in steroids users (group s) due to decreased plasma glucose psychological processes that demand a conscious mental effort like self-control or decisionmaking gets impaired (fairclough, 2004), which might be attributed to the findings presented in the study. figure. 3 depicts that majority of individuals in groups s, se and c reported noticing behavioral changes. while majority of individuals of groups sc, cz, p and pz reported not noticing any behavioral changes since they started taking their respective ped. the most common behavioral changes reported in all the groups were similar. these ranged from anxiety to vivid imaginations, difficulty in adjusting in the same age group to clumsy attitude, from extremist attitude to negative thoughts. in both genders hairloss, acne, sebaceous gland hypetrophy is reported upon using steroids (kuipers, 1998). hyperresponsivness and hyperproliferation of sebocytes as well as follicular keratinocytes can be attributed to androgen stimulation, which itself is the reason behind acne vulgaris (thiboutot 1995; thiboutot 1998). increased acne was also a major finding in this group as shown in figure. 4. the affected parts were not just face, but also neck and chest. majority of the individuals using steroids alone had observed the side effects in the form of general hair loss. androgen paradox is the phrase given to male pattern hair loss where androgen promotes hair growth on face suppressing it on temples and scalp vertex (inui, 2012). the reported hair loss ranged from severe hair loss to hair thinning, from balding to general body hair thinning/loss which can be attributed to increased steroids in body. many individuals also reported insomnia and non-restful sleep, especially on the day of loading dozes. arvary (2000) reported how majority of cases admitted to a private treatment center for recouping with opioids addiction had abused these to counteract the insomnia and irritability caused by steroidal usage. youqi (2004) suggested that athletes suffer from increased sleep onset latency due which leads to exercise induced insomnia. muscle cramps was also common in group s, this might be due to overtraining or overstraining of muscles. figure 5. shows that most of the individuals using steroids in combination with erythropoietin were also suffering from general hair loss and hair thinning. increased facial acne was also very common, together with sparse acne on neck and chest in some individuals. this was reported together with an increasingly oily skin, which added to the acne problem. some individuals claimed 0 50 100 150 s se sc c cz p pz yes no 0 20 40 60 80 100 s se sc c cz p pz yes no figure 3. noticeable changes in behavior figure 5. reported side effects in steroids+ erythropoietin users (group se) figure 6. reported side effects in steroids + creatine users (group sc) orginal article www.aeirc-edu.com volume 12014 page | 18 ©advance education institute & research centre-2014 that they did not have oily skin before using the peds. the individuals of group se also reported insomnia and improper sleeping habits. some individuals, who claimed that since the use of ped they perspire even at room temperature with minimal physical activity, and so increased sweating problem was also reported. users of steroids with creatine reported results that are shown in figure.6, where increased acne followed by general hair loss were major findings. the occurrence of acne problem in majority of the users can be accounted for by the combinational usage of steroids and creatine supplements. insomnia and non-restful sleeping habits were also reported in this group. increasingly oily skin as well as muscle cramps were also reported in group sc. figure 7. reported side effects in creatine users (group c) figure. 7 show results of individuals using creatine supplements alone most commonly reported heat intolerance. most of them claimed that they avoided going out in direct sunlight. they also reported severe suntans. and they also suggested that in an environment where heat was unavoidable, they easily got frustrated, irritated and aggressive. they also suggested that heat intolerance drove them to train more ferociously during workout. an increased level of heat intolerance can be a result of underlying thyroid hormone abnormalities (wilkins, 2007). a large majority also reported muscle cramps that maybe because of overstraining of muscles. atheletes using cholesterol lowering drugs suffer from muscle cramps (sinzinger, 2014). this hints that the users of this group and others who are suffering from muscle cramps might also be suffering from hypercholesterolemia. git abnormalities including nausea, indigestion, acidity and abdominal cramps were also reported. insomnia was also a finding in this group c. heat intolerance together with muscle cramps continues to be a common finding in majority of the users of creatine supplements in all combinations. the individuals using creatine with zinc claimed having heat intolerance problems also shared similar effects of heat intolerance on their mind and body as shown in figure. 8 which are in line with those reported by individuals of group c previously. together with heat intolerance, increased sweating was also a common characteristic in this group. apart from these, git abnormalities were also found quite commonly in this group, which further cements the idea that creatine supplements have a tendency of disturbing the normal digestive system physiology. users of protein supplements are asked to include more than usual carbohydrates in diet. increased intake of refined carbohydrates has been linked with worsening acne (mahmood, 2014). figure. 9 depicts what individuals using protein supplements. git abnormalities were most commonly reported. frequent indigestion, oral ulcers, acidity, abdominal cramps and nausea were reported by each one of these facing git abnormalities. muscle cramps were also a common finding, most probably because of intense weight training. increased acne problem was also reported commonly, where acne were limited to face only. this acne problem was also further worsened by increasingly oily skin, as reported by some individuals. many individuals in this group also claimed increased sweating. some of them also reported general hair loss, which was way less severe than steroids users. moreover, hair loss did not seem to be a common factor in majority of the individuals, those who reported it may have a genetic predisposition to balding and hair loss. an eyebrow-raising finding was the frequent occurrence of nightmares in many individuals. an increased metabolism together with increased brain activity due to high energy diet has a potential to trigger nightmares (stephen, 2007). these changes can be attributed to constantly high protein rich dietary supplements, which normally our body is not used to handling. the side effects reported by individuals using protein supplements together with zinc are shown in figure. 10, these were of similar pattern as reported by protein users. a large majority shared facing same git abnormalities as reported by individuals using protein supplements only. frequent nightmares were also a common feature in this group too, which further pillars the idea that constantly high amount of protein in blood has got the activation of specific pathways in brain that lead to the frequent occurrence of nightmares. insomnia was also commonly reported. nightmares affect sleep figure 9. reported side effects in group p figure 8. reported side effects in creatine + zinc users (group cz) figure 10. reported side effects in group pz orginal article www.aeirc-edu.com volume 12014 page | 19 ©advance education institute & research centre-2014 pattern and it has been linked with nocturnal awakenings as well as difficulty in falling back asleep (simor, 2014). the users of protein and zinc combination supplements appear to be suffering from the same. they also reported an increased incidence of facial acne in collaboration with increasing tendency to break into a sweat even a room temperature, with minimal of physical activity. muscle cramps were also commonly reported in group protein plus zinc combination users owing to over-training of skeletal muscles. conclusion the present study outlines that ped usage exert there effects on mind, body and personality of the users. where mood swings and increase in aggression were reported by users of all ped included in the study, former was mostly reported by creatine users mainly the latter being most common in steroids-eryhtropoietin as well as creatine users. a mixed response was given for changes in behavior by all ped users, indicating variables other than ped being responsible for the reported changes. apart from these insomnia and frequent nightmares suggest influence of ped on mind of users. changes reported on body by users ranged from excess sweating, heat intolerance, increasingly oily skin, frequent acne breakouts, male pattern alopecia, muscle cramps and git abnormalities. findings of this study throw light on the fact that when ped usage ensures a muscled physique it also triggers certain influences on the users which in turn raise a question, is attaining a beefy physique fair enough to trade for one’s original physiologically balanced mind, personality and body? this question must be answered by gym going individual himself before letting the drug enter the circulatory system. references:  arvary, d., pope, hg., j.r. (2000). anabolic-androgenic steroids as a gateway to opioid dependence. new engl. j. med. 342:1532  colt ewd, wardlaw sl, frantz, a.g. (1981). the effect of running on plasma b-endorphin. life sci 25:1637-1640.  d. m. w. de coverley veale (1987). exercise and mental health acta psychiatr academic department of psychiatry, the royal free hospital, london, united kingdom.. scand. 76:113-120.  denetsu, s., & kayo, a.k. (1996). the mechanism by which exercise modifies brain function physiology & behavior 60(1) 177-181.  fairclough, s.t. & houston, k. (2004). "a metabolic measure of mental effort", biol. psychol. 66 (2): 177–90, doi:10.1016/j.biopsycho.2003.10.001, pmid 15041139  henning, b., till, s., mary, e., spilker, gjermund, h., marcus, k., klaus, j., wagner., michael, v., achim, b., & thomas, r. t. (1998). the runner’s high: opioidergic mechanisms in the human brain. cereberal cortex doi:10.1093/cercor/bhn013  inui, s. & itami, s. (2012). "androgen actions on the human hair follicle: perspectives". experimental dermatology22 (3): 168–71. doi:10.1111/exd.12024  jason, j., koch. (2002). pediatrics in review. american academy of pediatrics southdale pediatrics, edina, mn 23:310-317.  kuipers, h. (1998). anabolic steroids: side effects. in: encyclopedia of sports medicine and science, t.d.fahey (editor). retrieved from internet society for sport science: http://sportsci.org. .  mahmood, sn; bowe, wp. (2014). "diet and acne update: carbohydrates emerge as the main culprit.” journal of drugs in dermatology: jdd 13 (4): 428–35. pmid 24719062  mirza f & ahmed s (2013). psychological effects of using power-enhancing drugs on gym-exercising individuals. int j pharm sci res 4(4); 1565-1568.  peter, h., nathalie, koivula., a. u. (2000). physical exercise and psychological well-being: a population study in finland preventive medicine 30(1) 1725doi:10.1006/pmed.1999.0597.  sime, w.e. (1987). exercise in the prevention and treatment of depression. in exercise and mental health (edited by wp morgan and se goldston). washington dc: hemisphere publishing corp.  simor, p., horváth, k., gombos, f., takács, k. p., & bódizs, r. (2012). disturbed dreaming and sleep quality: altered sleep architecture in subjects with frequent nightmares. european archives of psychiatry and clinical neuroscience, 262(8), 687696.  sinzinger, h., & o'grady, j. (2004). professional athletes suffering from familial hypercholesterolaemia rarely tolerate statin treatment because of muscular problems. british journal of clinical pharmacology, 57(4), 525-528.  stephen, l., (2006). "nightmares". retrieved from http://www.psychologytoday.com/conditions/nightmares.  thiboutot, d., harris, g., iles, v., cimis, g., gilliland, k., & hagari, s. (1995). activity of the type 1 5&agr;-reductase exhibits regional differences in isolated sebaceous glands and whole skin. journal of investigative dermatology, 105(2), 209-214.  thiboutot, d., knaggs, h., gilliland, k., & lin, g. (1998) activity of 5-α-reductase and 17-β-hydroxysteroid dehydrogenase in the infrainfundibulum of subjects with and without acne vulgaris. dermatology 196:38-42  wilkins., & lippincott., w. (2007). interpreting signs & symptoms. lippincott williams & wilkins; isbn 9781582556680. p. 306–307.  youqi, s., zhihong, z., ke, n., jianhong, l. a. (2004). preolympic congress the epidemiological survey of exerciseinduced insomnia in chinese athletes. retrieved from http://cev.org.br/biblioteca/the-epidemiological-survey-ofexercise-induced-insomnia-in-chinese-athletes http://sportsci.org/ aatir h. rajput 50 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 original article depressive symptoms among patients of myocardial infarction aatir h. rajput1, hina naz2 & anser iqbal3 virtual university of pakistan1 liaquat university hospital, hyderabad2 and 3 liaquat university of medical & health sciences, jamshoro1, 2 and 3 corresponding author: aatirh.rajput@gmail.com abstract objective to investigate the prevalence of depressive symptoms among pre-diagnosed patients of myocardial infarction at a tertiary care hospital in hyderabad. methodology this observational, cross-sectional communal survey comprised of a sample of 100 patients chosen via simple random sampling from 1st december 2015 to 28th february 2016. written informed consent was obtained before collecting data using interview based structured questionnaires. the data obtained was analyzed using spss v. 19.0 and microsoft excel 2013. results all the patients in the study belonged to an age group between 40 to 90 years. 69% of them being males and 31% females. 48% were uneducated while 52% were educated. 54% belonged to lower economic class, 43 were middle class and just 3% belonged to higher economic class. mean depression score remained 16.12 for the patients with single heart attack whereas for the patients with repeated heart attacks the score was 19.62. 83% of the patients showed symptoms of anxiety. 51% were retarded in their speech and thought process, while 90% complained of difficulty in work. 62% complained of general aches, 54% had loss of appetite 38% had somatic complaints. 63% of the patients has health worries, 59% lost weight while 52% felt depressed. conclusion study suggests that patients belonged to an age group of mostly 40 and onwards. major number of patients belonged to male gender. a significant number of patients were un-educated. patients with repeated attacks showed higher levels of depression. majority of the patients showed symptoms of depression and complaints due to it. keywords ischemia, myocardial infarction, depression, anxiety, heart attack and depressive symptoms. introduction although abundant scientific literature regarding mood disorders following myocardial infarction (mi) exists, the severity, prevalence, and persistence of depression have been uncertain, and standard rating scales and criteria for depressive disorders have infrequently been utilized. in 1912, herrick reported an absence of significant psychopathology in patients recovering from acute myocardial infarction (herrick, 1912), but subsequent investigators observed a high prevalence of depression (weiss, 1957; verwoerdt, 1964 & rosen, 1964) with adverse effects on rehabilitation (wynn, 1967). hackett and colleagues found that 80 percent of admissions for acute mi were anxious, 58 percent depressed, and that these symptoms were the most common cause for consultation referrals (hackett, 1968 & cassem, 1971). lloyd and cawley examined 100 consecutive males admitted for first acute mi using the http://www.aeirc-edu.com/ mailto:aatirh.rajput@gmail.com aatir h. rajput 51 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 standardized psychiatric interview (spi) and icd-8 psychiatric diagnoses (lloyd, 1978; lollyd & cawley, 1982, 1983). “psychiatric morbidity” was found among 35 percent of the sample at one week post-mi: sixteen patients were judged to have been psychiatrically ill at the time of mi, whereas nineteen developed their psychiatric disorder after the cardiac event. in the latter group, twelve patients had “depressive neurosis” and six had “anxiety neurosis,” but only 25 percent maintained a psychiatric diagnosis at four and twelve months follow-up. there was a much wider range of psychiatric diagnoses in the sixteen patients whose psychiatric disorder preceded myocardial infarction, and 75 percent were still psychiatrically ill at follow-up. more recently, schleifer et al. interviewed 283 acute mi patients using the schedule for affective disorders and schizophrenia (schleifer, et al., 1989). they found that 18 percent had “probable or definite” major depression (the proportion of “definite” cases was not specified) and 27 percent had minor depression by research diagnostic criteria. seventy-seven percent of the patients with major depression in hospital had major or minor depression at three months follow-up. failure to return to work was most frequent among patients with persisting cardiac symptoms who also had major depression. we report the initial evaluation of a longitudinal investigation of patients hospitalized for acute mi. methodology this observational, cross-sectional communal survey comprised of a sample of 100 patients chosen via simple random sampling from 1st december 2015 to 28th february 2016. written informed consent was obtained before collecting data using interview based structured questionnaires. the data obtained was analyzed using spss v. 19.0 and microsoft excel 2013.our study utilized a structured psychiatric interview, standardized rating scales (for depression, social function, and intellectual or physical impairment), and dsm-iii diagnostic criteria. results all the patients in the study belonged to an age group between 40 to 90 years. 69% of them being males and 31% females. 48% were uneducated while 52% were educated. 54% belonged to lower economic class, 43 were middle class and just 3% belonged to higher economic class. the figure 1 below, graphically illustrates the demographic spectrum of the sample clearly. http://www.aeirc-edu.com/ aatir h. rajput 52 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 1 uneducated males belonging to the lower socioeconomic class dominated the sample in terms of quantity. while uneducated females belonging to higher socioeconomic class were present in the least quantity in the sample. figure 2 mean depression score remained 16.12 for the patients with single heart attack whereas for the patients with repeated heart attacks the score was 19.62. 83% of the patients showed symptoms of anxiety. 51% were retarded in their speech and thought process, while 90% complained of difficulty in work. http://www.aeirc-edu.com/ aatir h. rajput 53 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 3 difficulty in work was the most common complaint, immediately followed by the complaint of anxiety. however, less than half of the sample complained of retardation in thinking and speech. 62% of the sample complained of general aches, 54% had loss of appetite 38% had somatic complaints. figure 4 shows the problems in relation to each other graphically. figure 4 shows the greatest proportion of patients reported to suffer from general aches, followed by the complaint of loss of appetite and then somatic complaints. all of these complaints can lead to serious discomfort if experienced chronically. 63% of the patients has health worries, 59% lost their weight while 52% felt depressed. figure 5 below illustrates the intensity of the said problems. http://www.aeirc-edu.com/ aatir h. rajput 54 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 5 shows worries were high frequent among the patients and complaints of weight loss too were common. a little more than half of the sample self-professedly suffered from depression as well. discussion the present study has demonstrated that 19 percent of a series of acute mi patients had the dsm-iii symptom cluster of major depression: less severe forms of depression were far less prevalent: only 2 percent of the population had dysthymic disorder, and just 5 percent had depressed mood in the absence of a dsm-iii affective or anxiety disorder. eight percent of the patients had generalized anxiety disorder. several factors were associated with the diagnosis of mood disorder and its severity: gender, past history of mood disorder, large myocardial infarction (as indicated by peak ck > l500), severity of functional physical impairment (jhfi), and quality of social relationships (sfe). our study population was predominantly male, and from lower socioeconomic classes. thus, our results may not be fully applicable to patients with different demographic characteristics. moreover, we could not reliably examine the most critically ill patients, and chose not to examine those scheduled for emergency bypass surgery or angioplasty (whose mental state would have been affected by intraoperative and postoperative variables in addition to mi). however, we did sample patients from three different hospital settings, and this should enhance the generalizability of our findings to other groups of patients of similar medical acuity. finally, we failed to enlist a substantial number of patients secondary to refusal or early discharge. whether assessments of such patients would have substantially affected the prevalence of depression is uncertain. future studies with other patient groups are needed to corroborate the generalizability of our findings. early studies of acute mi inpatients reported prevalence rates for depression ranging from 22 percent to 64 percent, although none of http://www.aeirc-edu.com/ aatir h. rajput 55 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 these studies utilized strict diagnostic criteria and structured psychiatric interviews for the assessment of depression (weiss, 1957; verwoerdt, 1964; rosen, 1964; hackett, 1968 & cawley, 1971). the largest outpatient study of depression in patients with ischemic heart disease found that depression contributed to disability in 40 percent of cases (wynn, 1967). this important study, however, investigated only patients “whom standard medical measures had failed to rehabilitate,” and therefore probably exaggerated the prevalence of psychiatric cases. the comparatively lower prevalence of depression found in our study is in accord with more recent investigations: cay et al. found that 26 percent of 131 acute mi patients were depressed and 32 percent were anxious, using “maximal clinical estimates” without specific diagnostic criteria (cay, et al.,1972). stem and colleagues found depression in 25 percent of acute mi cases, using clinical impressions in their initial study and zung self-rating depression scales > 40 as the criterion in their second investigation (stem et al; 1972, 1973). lloyd and cawley’s work, detailed above, found icd-8 “depressive neurosis” in 18 percent of patients (lloyd, 1978; 1982 & 1983). schleifer, et al., did observe depressive syndromes in 45 percent of their sample, but the majority of these were minor depressions (schleifer, et al., 1978). stem et al. found that six weeks after mi, 25 percent to 50 percent of depressed patients admitted to anxiety or depression in the preceding year. (stern m. j. et al., 1976 & 1977). (cay, et al., 1972) reported that two thirds of the patients they rated as emotionally disturbed post-mi reported mounting psychological distress pre-mi. lloyd and cawley found that one third of their patients with depressive neurosis were psychiatrically ill prior to their mi (lloyd, 1978; 1982 & 1983). schleifer, et al., found no such correlation with prior mood disorder, but speculated that their patients may have underreported their past histories (schleifer, et al., 1978). we suspect that the greater frequency of major depression versus dysthymic disorder in our study is partly the reflection of preexisting genetic vulnerability to severe forms of mood disorder being precipitated by the physiological and emotional distress of mi. perhaps those without such a constitutional vulnerability develop only mild depressions, if they become depressed at all. such a conclusion, of course, remains speculative because most of our patients with major depression had no known prior history of mood disorder, and family histories of mood disorder did not distinguish our diagnostic groups. yet, we had only one informant for past personal and family psychiatric histories, and this probably underestimated such risk factors for affective disorder. our observation of a greater vulnerability to depression among females post-mi has been suggested by stem et al., and confirmed by (schleifer, et al., 1978). this observation, which appears to be independent of prior history of mood disorder, warrants further inquiry. despite cassem and hackett’s comment that severity of depression positively correlated with severity of myocardial infarction (cassem, 1971), subsequent quantitative assessments have generally failed to support this observation. severity of infarction as measured by peel and norris indices have not positively correlated with psychiatric morbidity (lloyd; 1978, 1982 & 1983) and stem found no difference between depressed and non-depressed patients for peak ck values (stern, m. j., et al., 1977). our study, one of the few to quantitate peak ck as an independent variable, found no significant http://www.aeirc-edu.com/ aatir h. rajput 56 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 evidence that large mis contribute to depression severity. many investigators have described post-mi depressions as “seldom pathological” (hackett, t. p., et al., 1968; cassem, n. h., et al., 1971) or “neurotic rather than psychotic” (stern, 1976 & 1977). others have noted more severe depressive problems requiring specific antidepressant treatment (wynn, 1967; schleifer, 1978 & wishnie, 1971). it is difficult to reconcile these divergent views simply because uniform diagnostic measures have not been used. although certain aspects of our findings have been reported by other investigators, our study is one of the few to utilize a structured psychiatric interview with well-defined diagnostic criteria. since our patients were examined in hospital within two weeks of mi, a strict dsm-iii duration criterion for major depression obviously could not be utilized. it can however be argued that the dsm-iii duration criterion for major depression is, at best, arbitrary, but it is a matter for inquiry whether the major depressive syndromes seen acutely in our patients will persist on longer term follow-up. if symptoms of major depression persist as reported by (schleifer, et al., 1978) we believe that these are the patients most likely to benefit from specific antidepressant treatment, treatments which are safe if used carefully in this population (goldman, 1986). conclusion study suggests that patients belonged to an age group of mostly 40 and onwards. major number of patients were male. a significant number of patients were un-educated. patients with repeated attacks showed higher levels of depression. majority of the patients showed symptoms of depression and complaints due to it. acknowledgements we would like to acknowledge the intellectual assistance and technical support provided by dr. muhammad muneeb and lumhs research forum. conflict of interest all the authors disclosed that there is no competing interest associated with the preparation of this article. funding we declare that we did not acquire funding from any source. references  beck, a. t., ward, c. h., mendelson, m., mock, j., & erbaugh, j. (1961). an inventory for measuring depression. archives of general psychiatry, 4(6), 561-571.  cassem, n. h., & hackett, t. p. (1971). psychiatric consultation in a coronary care unit. annals of internal medicine, 75(1), 9-14.  cay, e. l., vetter, n. j., philip, a. e., & dugard, p. (1970). psychological reactions to a coronary care unit. scandinavian journal of rehabilitation medicine, 2(2), 78.  cay, e. l., vetter, n., philip, a. e., & dugard, p. (1972). psychological status during recovery from an acute heart attack. journal of psychosomatic research, 16(6), 425-435.  folstein, m. f., folstein, s. e., & mchugh, p. r. (1975). “mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. journal of psychiatric research, 12(3), 189-198.  goldberg, d. p., & hillier, v. f. 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(1966). psychological reactions of hospitalized male patients to a heart attack: age and social-class differences. psychosomatic medicine, 28(6), 808-821.  schleifer, s. j., & macari-hinson, m. m. (1989). the nature and course of depression following myocardial infarction. archives of internal medicine, 149(8), 1785-1789.  starr, l. b., robinson, r. g., & price, t. r. (1983). reliability, validity, and clinical utility of the social functioning exam in the assessment of stroke patients. experimental aging research, 9(2), 101-106.  stern, m. j., pascale, l., & ackerman, a. (1977). life adjustment postmyocardial infarction: determining predictive variables. archives of internal medicine, 137(12), 1680-1685.  stern, m. j., pascale, l., & mcloone, j. b. (1976). psychosocial adaptation following an acute myocardial infarction. journal of chronic diseases, 29(8), 513-526.  tarrier, n., barrowclough, c., vaughn, c., bamrah, j. s., porceddu, k., wing, j. k., ... & sartorius, n. (1974). the measurement watts s. & freeman h. (1989). community management of schizophand classification of psychiatric symptoms. cambridge university renia. a two-year follow-up of a behavioural intervention with families. press: cambridge. british journal of psychiatry, 154, 625-628. http://www.aeirc-edu.com/ aatir h. rajput 58 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188  forrester, a. w., lipsey, j. r., teitelbaum, m. l., depaulo, j. r., andrzejewski, p. l., & robinson, r. g. (1992). depression following myocardial infarction. the international journal of psychiatry in medicine, 22(1), 33-46.  verwoerdt, a., & dovenmuehle, r. h. (1964). heart disease and depression. geriatrics, 19, 856-864.  weiss, e., dlin, b., rollin, h. r., fischer, h. k., & bepler, c. r. (1957). emotional factors in coronary occlusion: 1. introduction and general summary. ama archives of internal medicine, 99(4), 628-641.  wishnie, h. a., hackett, t. p., & cassem, n. h. (1971). psychological hazards of convalescence following myocardial infarction. jama, 215(8), 1292-1296.  wynn, a. l. l. a. n. (1967). unwarranted emotional distress in men with ischaemic heart disease (ihd). the medical journal of australia, 2(19), 847-851. http://www.aeirc-edu.com/ aatir h. rajput 7 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 original article depression, anxiety & stress among patients of end stage renal disease undergoing hemodialysis aatir h. rajput1, maryam shaikh2& sooraj kumar3 virtual university of pakistan1 liaquat university hospital, hyderabad2& 3 liaquat university of medical & health sciences, jamshoro1, 2 &3 corresponding author: aatirh.rajput@gmail.com abstract objective this study is projected to check the prevalence of depression, anxiety and stress in the patients of end stage renal disease (esrd) undergoing hemodialysis at centers in hyderabad and investigate the reasons behind it. methodology this observational, multi-center study comprised of a sample of 100 patients of esrd undergoing hemodialysis selected (via simple random sampling) from different hospitals of hyderabad. the data was collected using interview based structured questionnaires, after taking informed consent, from 1st dec 2014 to 10th feb 2015. levels of depression, anxiety and stress were gauged using the das scale approved by the australian center for posttraumatic mental health. results according to the mean scores obtained, moderate levels of depression and stress while severe levels anxiety prevailed. 69% patients declared diet control rules as bothersome. although, 50% of respondents were on dialysate for more than a year and 83% underwent dialysis twice per week yet the mean levels of serum albumin and urea were not within normal range. conclusion on the basis of this result we come to know that great numbers of patients of esrd undergoing hemodialysis were suffering from anxiety depression and stress and uremia. keywords end stage renal disease, hemodialysis, psychological distress, depression, anxiety and stress introduction researchers from far and wide, have recognized depression to be the chief mental health concern among patients struggling with end stage renal disease (esrd) (kimmel, 2008 & hedayati, 2006). fresh statistics hint towards a staggering twenty to thirty percent prevalence of psychological distress (depression, anxiety and stress) in the esrd patients undergoing hemodialysis (cukor, et al., 2006). second only to hypertension, depression is the most frequent comorbid diagnosis among esrd patients (us renal data system, 2004) but sadly, this grave issue still remains under-researched (kimmel, 2002) and is rarely, if at all, dealt with appropriately in patients of esrd undergoing hemodialysis (kimmel, et al., 2006). in addition to that, depression has the potential to stall the process of healing and heighten the mortality rate of the ailments (katon, 2002 & evans, 2003) and particularly in esrd (kimmel, 2003 &1993). anxiety and stress, two of the common comorbid psychological conditions were found slightly mentioned in published literature but we believe that they too, like depression, need to be taken seriously. in spite of the heightened incidence of depression and the abundant scientific proof of its complications, clinical interventions of http://www.aeirc-edu.com/ mailto:aatirh.rajput@gmail.com aatir h. rajput 8 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 the problem are seldom researched among patients struggling with esrd (rabindranath, 2005). while the reason of lack of interventionist approach against anxiety and stress is its absence from academic literature, unavailability of baseline statistics and information about them as significant comorbidities. one problem however, that may obstruct effective investigation of this issue, is the fact that depressive symptoms are very similar to uremic symptoms, and a clear diagnosis is thus often put in doubt against the backdrop of the uremic illness (kimmel, 2001, 2004, 2000 & 2002). for instance, it is difficult to identify whether the cognitive dysfunction, encephalopathy or plain irritability is stemming from a psychological cause, uremia, and inadequate dialysis or due to the effect of drugs (kimmel, et al., 2001, 2004, 2000, 1993) in their work, revealed that anxiety disorder was common in patients struggling with esrd, but in our thorough and detailed literature review, we did not find any parallels to our own study that screens patients with esrd for multiple psychiatric complaints and not just one. we therefore attempted to screen the esrd patient population for a range of comorbid psychiatric complaints at various hemodialysis centers across the city that cater to the needs of patients from all sociodemographic backgrounds. we did not attempt to dissociate the symptoms of depression from those of uremia, however further research can be conducted using a novel approach based on the identification of depression-specific cognitive schema. methodology this observational, multi-center study comprised of a sample of 100 patients, undergoing hemodialysis at major professional hemodialysis centers (namely; maaji hospital, liaquat university hospital, k.k dialysis center, bhittai hospital, rajputana hospital, hafeez memorial dialysis centre, mohinibai hospital and m.k hospital) located in different strata of hyderabad, selected (via simple random sampling) from different hospitals of hyderabad. the data was collected using interview based structured questionnaires, after taking informed consent, from 1st dec 2014 to 10th feb 2015. levels of depression, anxiety and stress were gauged using the das scale approved by the australian center for posttraumatic mental health. data was analyzed using spss v. 19.0 and microsoft excel 2013. results the sample hemodialysis patient population we selected had varied socio-demographic background. we recorded the superficial factors and the figure 1 below depicts them in detail. http://www.aeirc-edu.com/ aatir h. rajput 9 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 1 showed that a greater proportion of male patients (70.7%) visited hemodialysis centers as compared to females (29.3%). the diseased patients rarely belonged to the higher socioeconomic class (18.2%). middle class was the predominant socioeconomic fraction that reported at hemodialysis centers (61.6%) and this is worrisome since this fraction that thrives on limited earning. the uneducated patients (68.3%) patients were far more than educated patients (31.3%) owing to our low national literacy rate. according to the mean scores obtained, moderate levels of depression and stress while severe levels of anxiety prevailed. the combined psychological effect of the three problems takes a big toll on the patients. figure 2 below further describes this fact. figure 2 shows the effects of depression, anxiety and stress were marked in the patient population that we studied. the depression, anxiety & stress score (dass), approved by the australian center for post traumatic health, validated our hypothesis by confirming that these three were indeed present at significant levels. http://www.aeirc-edu.com/ aatir h. rajput 10 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 the factors leading up to such levels of depression, anxiety and stress, other than the chronicity of the illness, were investigated. the findings we reached, showed that the need to frequently visit and pay for the clinics, diet control rules and the chronicity of the illness were the main culprits. figure 3 shows a very handsome percentage of the population (69%) were bothered by the diet control rules and identified them as important stressors that and sources of anxiety that triggered depression. serious thought must be put into modifying these rules so that they not only ensure good physical but mental health. figure 4 shows 50% of the respondents were on dialysate for more than a year. the general trend observed is exhibited by the dotted trend-line above. the respondents were divided into 4 groups and the groups increased in size as time increased. we believe that the longer patients endure their medical problems, the greater their chances of falling prey to depression, anxiety and stress. http://www.aeirc-edu.com/ aatir h. rajput 11 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 5 shows that 83% of the patients were required to pay two visits to the dialysis centers per week. 11% of the patients visited the dialysis center almost every other day and only 6% of the patients paid single visits to the dialysis center per week. dialysis, in itself is not a very comfortable process, and the deed to get a dialysate often indicate failure of treatment, heightened symptoms and problems. hence the greater the frequency, the greater the psychological impact. http://www.aeirc-edu.com/ aatir h. rajput 12 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 6 showed uremia was common as the average serum urea levels were well above normal. hyper-albuminemia was also marked in the entire sample. hemoglobin was, however, worryingly low. such levels, despite the frequent dialysate treatment indicate failure of treatment and hence give birth to negative psychological factors such as depression, anxiety and depression. but, as discussed above, symptoms of uremia match those of depression closely and often overlap. giving rise to doubt and suspicion over the validity of presence of depression and other closely resembling psychiatric comorbidities. discussion our research attempted to investigate a greater range of psychopathology in patients struggling with esrd then what has been reported earlier in literature. our sample comprised of urban patients from hyderabad suffering from end stage renal disease (esrd) and currently being treated to hemodialysis. a total of one hundred such patients from the different hemodialysis center were included in the study and their data was utilized to obtain our results. our study population reported higher incidence and prevalence of uremia with average levels reaching above 100g/dl, as determined by pathology reports. rates of depression too far exceeded the levels reported by most authors but it is important to point out that there have been instances when even higher rates of depression have been reported in literature and a few examples include watnick et al., (twenty six percent), hedayati et al., (twenty seven percent) and kimmel et al., (twenty five percent). none of the patients diagnosed with depression reported receiving mental health treatment, neither did any patient with a diagnosis of anxiety or stress were currently receiving treatment. this highlights how under-recognized depression, stress and anxiety are and perhaps suggests a tolerance of depression, stress and anxiety by physicians and staff, accepting them as part of the esrd experience. the average level of http://www.aeirc-edu.com/ aatir h. rajput 13 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 comorbid depression, stress and anxiety (20.7 for depression, 16.1 for stress and 15.1 for anxiety disorder) was found. it is possible that the depression demonstrated in esrd populations is causally linked to esrd, because there has been some research suggesting a causative link through inflammatory processes (cukor, 2000) and a psychodynamic literature linking depression and dialysis. literature suggests that the health related quality of life (hrqol) score of esrd patients that do not suffer from either depression, anxiety or stress is significantly higher than those patients that do suffer from comorbid psychological distress (i.e. either depression, anxiety or stress), (kimmel, 2006). this suggests that despite undergoing hemodialysis, patients (without comorbid psychological distress), especially depression, can benefit from a higher quality of life. these results re-iterate the strong and increasingly important need for psychiatric/psychological help for esrd patients, since clear indications have now been unearthed that such help may not only decrease depression and other forms of psychological distress, but also improve health related quality of life (cukor, 2005 & rabindranath, 2005). conclusion on the basis of our result, we conclude that depression, anxiety and stress are a marked feature in end stage renal disease (esrd). often, uremia can mimic the depressive symptoms and may lead to a false diagnosis but the main concern we wish to highlight by this study is towards the psychological health of the patients that both comorbid depression, anxiety, stress and uremia put at a high risk. further research is advised to differentiate and separately gauge the effects of depression, anxiety, stress & uremia. however, main focus should be directed towards countering the adverse effects caused by psychological comorbidities and uremia that subdue the will to live and the will to recover. acknowledgements we would like to acknowledge the intellectual assistance and technical support provided by dr. muhammad muneeb and lumhs research forum during the preparation of this manuscript. conflict of interests all the authors disclosed that there is no competing interest associated with the preparation of this article. funding we declare that we did not acquire funding from any source for any aspect of this research. references  black, d. w., winokur, g., & nasrallah, a. (1987). treatment and outcome in secondary depression: a naturalistic study of 1087 patients. journal of clinical psychiatry.  cukor, d. (2007). the hemodialysis center: a model for psychosocial intervention. psychiatrserv, 58, 711-712.  cukor, d., & friedman, s. (2005). towards the psychosocial treatment of depressed patients on dialysis. internet j nephrol, 2(2), 3.  cukor, d., peterson, r. a., cohen, s. d., & kimmel, p. l. (2006). depression in end-stage renal disease hemodialysis patients. nature clinical practice nephrology, 2(12), 678-687. http://www.aeirc-edu.com/ aatir h. rajput 14 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 england journal of medicine, 353(17), 1819-1834.  evans, d. l., & charney, d. s. 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(2004). longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization. archives of internal medicine, 164(6), 659-663.  kessler, r. c., chiu, w. t., demler, o., & walters, e. e. (2005). prevalence, severity, and comorbidity of 12-month dsm-iv disorders in the national comorbidity survey replication. archives of general psychiatry, 62(6), 617-627.  kimmel, p. l. (2001). psychosocial factors in dialysis patients. kidney international, 59(4), 1599-1613.  kimmel, p. l. (2002). depression in patients with chronic renal disease: what we know and what we need to know. journal of psychosomatic research, 53(4), 951-956.  kimmel, p. l., & peterson, r. a. (2004). depression in end-stage renal disease patients treated with hemodialysis: tools, correlates, outcomes, and needs. in seminars in dialysis (vol. 18, no. 2, pp. 91-97).  kimmel, p. l., & peterson, r. a. 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(2001). new psychopharmacologic treatment strategies. annals of internal medicine, 135(11), 1008.  watnick, s., kirwin, p., mahnensmith, r., & concato, j. (2003). the prevalence and treatment of depression among patients starting dialysis. american journal of kidney diseases, 41(1), 105110.  whooley, m. a., & simon, g. e. (2000). managing depression in medical outpatients. new england journal of medicine, 343(26), 1942-1950. http://www.aeirc-edu.com/ uzma naseem 56 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 original article physical, emotional and catastrophizing upshots of chronic pain the study on pain stress uzma naseem, sadaf ahmed & shamoon noushad psychophysiology research lab, uok corresponding author: uzma@aeirc-edu.com abstract there are original physical basis of pain, even when an anatomical site or pathophysiological basis cannot be established, but pain also recognizes the importance of affective, cognitive, behavioral, and social factors as contributors to chronic illness behavior. it is also linked with catastrophizing in relation with sufferer’s threshold of pain intensity, pain related disability and psychological distress are found to be significantly high regardless of any type of pain. unlike acute nociceptive pain chronic pain is not self-limiting and usually neurological in origin, it may evolve in the damaging of either central nervous system or peripheral nervous system results into anxiety, fear, depression, sleeplessness and lack of social interaction so there is a self-perception of stress. in this study stress has been taken as an amplified condition of psychological effects which is being induced by chronic pain. aim of the present study was to highlight the presence of physical and emotional constraint relative to other related stresses like traumatic, nutritional and mental stress among chronic pain survivor both by observing the ability and intensity to catastrophize. in a cross sectional study, 140 individuals have been enrolled from general population who have been suffering from any type of chronic pain with exception of menopausal women, cardiovascular diseases, nephropathy and cancer, and age between 18 to 50 years. for evaluation multistage random selection procedure have been performed by governing questionnaire to examine their pain duration, intensity, frequency, and degree of multi psychological feeling using pcs of michael jl sullivan and stress by sss. it is concluded that sufferers rise to the challenge of difficult painful situations that leads to a number of psychophysiological disorders and raised emotional distress, especially depressive symptoms, these are often poorly controlled. on the basis of the available evidence that it is not clear whether chronic pain sufferers really do have higher levels of distress compared to others it is recommended that ability of being catastrophize as well as emotional and physical distress can be improved by various relaxation and counselling therapies that can relieve the cycle of pain. keywords neuropathic, nociceptive, catastrophizing, rumination. pain catastrophizing scale (pcs), sadaf stress scale (sss), central nervous system (cns), peripheral nervous system (pns). osteoarthritis (o.a). introduction unlike acute nociceptive pain chronic pain is not self-limiting and usually neurological in origin, it may evolve in the damaging of either cns or pns results into anxiety, fear, depression, sleeplessness and lack of social interaction so there is a selfperception of stress (waxman, 2006). the individuals facing chronically stressful incidents are being undergone physiological, biochemical, and psychological alterations, subsequently in stress related neuropsychiatric disorders, such as depression or anxiety (lazarus r, 1984 & cyril, 2010). moreover, the fundamental changes also being observed in the brain called as neuroplasticity (jensen, 2009). in addition, by brain scanning techniques structurally and functionally important part of limbic system, the hippocampus involves in learning and memory significantly sensitive to stress hormone (glucocorticoids) (cheryl, 2008), appeared to be resorbed or shrinked (mcewen, 1968). these defective changes leads to experience of pain from non-painful stimuli said to be allodynia as well as hypersensitivity to pain said to be hyperalgesia. the resultant changes in the region of brain are analyzed under biophysical techniques via eeg which illustrate augmented activity of beta waves. comparatively the decreased activity of alpha waves whereas diminished activity of theta waves (jensen, 2009 & sapolsky, 1986). sustained stress cause tissue trauma which consequently leads to biochemical, physiological and psychological alteration (lazarus r, 1984). (fig: 1). catastrophizing has been constantly associated with increased pain sensitivity moreover diminished endogenous pain inhibitory controls (edwards r, 2005 & goodin, 2009). catastrophizing has been defined as an exaggerated negative mental set brought to bear during actual or anticipated painful experience (alice, 2013). catastrophizing is a http://www.aeirc-edu.com/ uzma naseem 57 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 tendency to magnify or exaggerate the threat value or seriousness of pain sensations. the pain catastrophizing has been observed across diverse patient groups, including mixed chronic pain, low back pain, rheumatoid arthritis, aversive diagnostic procedures, surgery, dental procedures, burn dressing changes, whiplash injuries, and survey samples of young adults, asymptomatic individuals participating in experimental pain procedures, and varsity athletes (mark 2012 & kabat 1994). women and men may differ in their emotional responses to pain. studies have revealed that, when responding to pain, girls and women show more of an emotional response and tend to be more worried and irritated about pain (unruh, 1996). expectations regarding social roles may alter how women and men respond to pain. there have been multiple roles for women for example caring for children or older adults, household and work responsibilities and may attend to pain more readily so as to reduce its impact (unruh, 1996). oa is a very common degenerative disease affecting up to 70% of adults over the age of 65 years (felson, 1998). women are more likely to report oa pain than men (davis, 1981, cooper et.al, 1998 & felson, 1998). several investigations have revealed that women are more disposed in pain catastrophizing to a greater extent than men. a relation between gender and catastrophizing has been observed in both clinical and experimental research, using a variety of assessment instruments. for example, in a sample of patients with musculoskeletal pain reported that women scored higher than men (jensen et al, 1994 and rosenstein et al, 1983). there are many studies which advocate that catastrophizing has led to risk factor for the development of pain-related disability (sullivan et al., 2001, vlaeyen et.al, 2000 & waddell, 1998) means that physical stresses are provoked by pain catastrophizing due to chronic pain. poor sleep efficiency and frequent awakenings results from little slow wave (delta), leads to insomnia. experimentally, it has been observed that people with inadequate sleep and poor sleep quality are more disposed to having poor control on pain experiences hence perceive stress. e.g., poor sleep quality is related to greater pain severity (smith mt 2004). study was carried out on laboratory and clinical studies of sleep and pain and revealed about direct or indirect impact on pain feelings due to sleep lacking (flor 1993). psychosocial aspects clarify how sleep associates with pain, principally pain catastrophizing. some studies have displayed being in state of anxiety and emotional distress results from poor sleep quality which indirectly relates to pain catastrophizing (edell-u, 2002 & chang pp et. al, 1997). furthermore, individual having poor sleep quality suffer from deleterious impact not only on physical and mental health, in fact on occupational functioning, and overall quality of life (knudsen hk 2007). the stress and chronic pain is initiated by biological response. (chart 2). the link between stress, stressors, and chronic pain is complicated and supported by a number of biological, psychological, and social factors that mediate this association (anthony k, 2010). the innate biochemical responses to stress modulate the pain perception. some studies illustrated that pain is often endured in the absence of peripheral pathology means that psychogenically. because number of papers proposed that where even low ‘stress’ there may be pain. on the other hand, stressor may be a trauma and it is associated with a peripheral pathology (e.g. skin abrasion, fracture) that directly associates to a painful experience, there are several other types of stress (including psychological, social, and chemical). the most important question here is that how to conclude whether pain in the absence of peripheral pathology is ‘real’ or not. this can be accessed by stress symptoms caused by peripheral pathologies such as irritable bowel syndrome and chronic fatigue etc. by analyzing whether the symptoms are fake as part of attention-seeking behavior. one of the idea suggested that individual that possess low pain threshold will undergo pain and depiction will be observed by pupillary dilation due to perceiving pain (hapman cr et.al 1999). methodology aim of the present study was to demographically evaluate the prevalence of chronic pain in male & female, identify possible cause of its severity, its cascade of amplification leading to physical and emotional stresses as well as on psychologic site. this study was need to be conducted, because in number of reviews, it was observed that increase in chronic pain often leads to interruption and physically inactive lifestyle, moreover various study given the idea about in old age, the coping intervention do not effectively work as compare to middle age because of aging phenomena. therefore, study was interestingly carried out among adult age subjects. in a cross sectional study, 140 individuals had been enrolled from general population of karachi, who had been suffering from any type of chronic pain, because in acute pain condition being undergo catastrophizing very likely to occur in order http://www.aeirc-edu.com/ uzma naseem 58 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 to interface unusual stress and brain is not adapted to it. in exclusive criteria menopausal women, cardiovascular diseases, nephropathy and cancer and severely ill individual were not enrolled. males and females subject were considered to be eligible if they lied in age range between: 18-50. moreover, it contained pain location scale to facilitate in pain reporting easily. in addition, the questionnaire was designed precisely with different scales. furthermore, pcs was used to analyze level of pain and its related thinking which can be completed and scored in less than 5 minutes. as this scale contain 13 self-reporting questions derived from descriptions of catastrophizing described in the literature. this scale also asked participants to reflect on past painful events by degree of occurrence on 5-point scales 0 means not at all while 4 means all the time. moreover, psychological distress such as physical and emotional stresses are measured by sadaf stress scale. data was primary collected from hospitals, office, and different department within university, homes, and general shops etc. the respondents were randomly selected on stratified random sampling basis. we assessed any type of pain by a validated self-report questionnaire in the general healthy population, next the respondents were instructed to report whether they had experienced pain or discomfort more than three months. in addition, obtaining frequency or occurrence of an event or status. the questionnaires included demographic and socioeconomic factors, and variables concerning lifestyle, work, function, and psychological status to be asked. moreover, participant was usually asked to recall pain experience over a period of time to allow to obtain maximum possible pain symptoms which they had been perceiving. spss version 16.0 was utilized to analyze the data. furthermore, pearson’s product movement correlation coefficient was analyzed to calculated and find the relationship between profile of psychological symptoms and pain catastrophizing scale outcomes. finally, microsoft office 2013 was used to access graphical representations of our different parameters obtained via study. result this survey based adult population study was basically conducted to investigate the pattern of pain in order to access the behaviors and relative psychophysiological aspects which either limits or influence different health care issues. with the help of findings of our study it was concluded that most of the pain enduring subjects were reported by osteoarthritis as compare to other. moreover, due to chronic pain, superficially the type of stresses observed by them were emotional and physical stress among mental, nutritional and traumatic stresses. on the other side among components of catastrophizing, subjects were significantly found to be under rumination and helplessness, a type of depressive disorder. statistical analysis pearson correlation coefficients were calculated to explore the most abundant interrelations between rumination, magnification and helplessness with physical, mental and emotional stress respectively. our results demonstrated that intensity of pain and catastrophizing were significantly not only directionally proportional to each other but also plenteous correlated with helplessness. http://www.aeirc-edu.com/ uzma naseem 59 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 55% 30% 51% helplesness magnification rumination figure 1 shows distinct pain location with their prevalence reported by chronic pain survival in our study. figure: 2 shows depiction of comparative various stress outcomes with obtained by sss. figure 3 shows three components of pain catastrophizing with respective percentages of findings. figure 4 shows the increased outcomes of rumination and helplessness in catastrophizing scale at the same time significant upshots of physical, mental and emotional stress in sadaf stress scale. figure: 5 shows percentage of incident of chronic pain in male and female significantly females reported more than males. moodness depression fatigue headache conc. problem repeatitive thinking worry all the time of pain anxiously want to pain to go away 68% 67% 68% 67% 64% 61% 43% 55% yes no 22% 13% 49% 14% male % female % traumatic stress physical stress nutrional stress mental stress emotional stress 54 56 49 55 56 muscular pain headache joints burning visceral pain 19% 9% 26% 1% 5% http://www.aeirc-edu.com/ uzma naseem 60 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 6 pearson correlation for physical stress and helplessness. pearson correlation for mental stress and helplessness. pearson correlation for emotional stress and helplessness. discussion our findings have supported the assumptions of the chronic pain leads to physical and emotional stresses and subsequently results into exaggerated thoughts which are termed as catastrophizing. furthermore, our study determined that structural differences in females as well as nutritional insufficiencies may contribute to frequencies of joints pain. our study enforced that behavioural discrimination is also the important fact to provoke stress induces catastrophic pain (michael j et. al 2004). likewise, in generally if women in working field having expose higher than men to risk factors for musculoskeletal pain, it will also be affected by the prevalence of pain (j orthop .et.al 1996). because within the same task or profession, performance is different. such as carry specific amount of load is given to carry from one way to other. male can finish it in a single time while female cannot so. this may cause physical stress (susan h, 2010) however, female hormone estrogen, plays a role in cartilage protection. when estrogen decreases monthly during the menstrual cycle as well as during menopause, the amount of cushioning the cartilage provided also decreases and if individuals are prone to anxiety, then it is possible that they suffer regular back pain for years as a result of stress. moreover, we know that sustain abnormal stimulation to neurons may elicit the heat shock proteins which provoke beneficial stress in body. but if these stresses are diverged into further categories of stress like in our results physical and emotional stresses shown high even patients taking interventions which indicated that they are enduring psychogenic pain which require counselling to minimize this stress. pcs analysis assessed that great number of subjects were under catastrophizing with highest percent of rumination and helplessness, the symptoms of depression. peoples undergo depression not only unable to banish sad memories, but also get paranoid. hence, number of studies reflected that distress can be improved by various relaxation techniques, such as meditation or breathing exercises, biofeedback therapy also suggested as to maintain the stress level (paul r, 2012). studies recommended that increasing the focus of treatment on tolerance, will decreasing the power of unnecessarily dispiriting thoughts and enhancing psychological flexibility (kevinal et. al 2006). http://www.aeirc-edu.com/ uzma naseem 61 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 references  alloy lb, abramson ly, whitehouse wg, et al. depressogenic cognitive styles: predictive validity, information processing and personality characteristics, and developmental origins. behave res ther. 1999; 37:503–531.  anson w and marie b, 2007 study offers clues into rumination, symptoms of severe depression, and association of psychological science.  anthony k.pet. al, the biological response to stress and chronic pain anthony chronic pain epidemiology, from etiology to public health, oxford university press, 2010  arntz a , dreesen l , merckelbach h . attention, not anxiety, infl uences pain. behave res ther 1991; 29: 41 – 50 .  baker sl, kirsch i. cognitive mediators of pain perception and tolerance. pers soc psychol 1991; 61:50 510.  brekke, m., hjortdahl , p. and kvien , t.k. 2002: severity of musculoskeletal pain: relationship to socioeconomic inequality . soc sci med 54 , 221 – 228 .  brosschot jf, gerin w, thayer jf. the preseverative cognition hypothesis: a review of worry prolonged stress-related physiological activation, and health. j psychosom res 2006; 60: 113-24.  brown, jonathon d, taylor, shelley e.; illusion and well-being: a social psychological perspective on mental health.jonathon d.psychological bulletin, vol 103(2), mar 1988, 193-210.  chang pp, ford de, mead la, cooper-patrick l, klag mj. insomnia in young men and subsequent depression: the johns hopkins precursor study. am j epidemiol. 1997;146:105–114.  chang pp, ford de, mead la, cooper-patrick l, klag mj. insomnia in young men and subsequent depression: the johns hopkins precursor study.am j epidemiol. 1997;146:105–114.  cheryl. d conrad, chronic stress-induced hippocampal vulnerability: the glucocorticoid vulnerability hypothesis, rev neurosci. 2008; 19(6): 395–411. pubmed central  chronic stress and brain plasticity: mechanisms underlying adaptive and maladaptive changes and implications for stress-related cns disorders  komaroff, anthony "does "mindfulness meditation" really help relieve stress and anxiety?". ask doctor k. harvard health publications. retrieved, 22 april 2014.  kori sh, miller rp,todd dd. kinesiophobia: a new view of chronic pain behaviour. pain management. 1990;3:35-43.  kulkarni b, et. al. arthritic pain is processed in brain areas concerned with emotions and fear. arthritis rheum. 2007 apr ;56(4):1345-54.  messing k, et.al :evaluation of exposure data from men and women with the same job title. j occup med 36:913-917  mcewen bs et. al, cortisol levels during human aging predict hippocampal atrophy and memory deficits.nat neurosci. 1998 may;1(1):69-73.  smith mt, haythornthwaite ja. how do sleep disturbance and chronic pain interrelate? insights from the longitudinal and cognitive-behavioral clinical trials literature. sleep med rev. 2004  smith yr ,et. al. 2006 : pronociceptive and antinociceptive effects of estradiol through endogenous opioid neurotransmission in women . j neurosci 26 : 5777 – 5785  somers et. al, pain catastrophizing in borderline morbidly obese and morbidly obese individuals with osteoarthritic knee pain, pain research management 2008 sep-oct;13(5):401-6.  sullivan mj , adams a , horan s , et al. the role of perceived injustice in the experience of chronic pain and disability: scale development and validation . j occup rehabil 2008 ; 18 : 249 – 61 .  sullivan mj , thorn b , haythornthwaite ja , et al. theoretical perspectives on the relation between catastrophizing and pain . clin j pain 2001 ; 17 : 52 – 64 .  the biological response to stress and chronic pain anthony k.p. jones , john mcbeth , and andrea power  wijnhoven hah , et.al . hormonal and reproductive factors are associated with chronic low back pain and chronic upper extremity pain in women – the morgen study . spine 13 : 1496 – 1502, 2006 .  weinberger, d.a., schwartz, g.e. and davidson, r.j., low anxious, high anxious and repressive coping styles: psychometric patterns and behavioral and physiological responses to stress, j. abnorm. psychol., 88 (1979) 369–380. http://www.aeirc-edu.com/ http://www.ncbi.nlm.nih.gov/pubmed/?term=conrad%20cd%5bauth%5d http://www.askdoctork.com/mindfulness-meditation-really-help-relieve-stress-anxiety-201403316226 http://www.askdoctork.com/mindfulness-meditation-really-help-relieve-stress-anxiety-201403316226 http://www.askdoctork.com/mindfulness-meditation-really-help-relieve-stress-anxiety-201403316226 http://www.ncbi.nlm.nih.gov/pubmed/?term=kulkarni%20b%5bauthor%5d&cauthor=true&cauthor_uid=17393440 http://www.ncbi.nlm.nih.gov/pubmed/17393440 http://www.ncbi.nlm.nih.gov/pubmed/10195112 http://www.ncbi.nlm.nih.gov/pubmed/10195112 http://www.ncbi.nlm.nih.gov/pubmed/10195112 alvira ali 38 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 review article of scents and brain: olfactory stimulation for neuropoeisis and intervention for neurodegenerative disorders alvira ali advance educational institute and research centre corresponding author: alvira@aeirc-edu.com abstract aromatherapy is an ancient scent treatment that has gained a lot of attention in the contemporary research for its various benefits. the role of olfactory stimulation leading to neuropoeisis has been a major consideration for treating neurodegenerative disorders like dementia, alzheimer’s and parkinson’s as well as psychiatric symptoms like mood disturbances, anxiety and sleep problems. the literature review has concentrated on the significance of the olfaction in the mammalian physiology and enlightened the hypothesis with noteworthy evidences to support the idea that with more research and clinical trials aromatherapy can attest to be a major breakthrough in treating alzheimer’s disease and reversing neurodegeneration. keywords aromatherapy, neurpoeisis, alzheimer’s, dementia, neuro-degeneration aromatherapy aromatherapy is one of the simplest and natural approaches used for healing. literally, it is a derivative of two different words: aroma meaning fragrance, smell or scent and therapy meaning remedy, cure or treatment (university of maryland medical center, 2013). it is a blend of biological and manipulative techniques that uses the fragrances or scented oils usually with massage, acupuncture or any other suitable treatment (british columbia, 2012). thus, healing process involves the combination of two senses: touch and smell. the treatment is presumed to be helpful in supporting and balancing the mind, body and soul where each fragrance has a distinct effect on the nervous system and body. the practice involves the topical application, infusion in bath water, inhalation, and ingestion under strict supervision only. yet, the manner of therapy is chosen according to the need of the consumer and requirement of the target. it is because each application has its own mode of action. for example, the inhalation of scents activates the limbic system while the topical application stimulates the thermal receptors of the dermis (nordqvist, 2014 and demetriou 2000). research in aromatherapy clinical studies have showed that fragrances treatment provides relaxation from anxiety, stress, depression, cancer related symptoms, agitation in dementia, pain and quality of sleep (najafi, et al, 2014, williams, 2006, holmes, et al, 2002, ballard, et al, 2002, fayazi, et al, 2011 and diego, 1998). aromatic therapy relieves both the mental and physical stress and has a tendency of enhancing the parasympathetic nervous system and autonomic nervous system (liu, et al, 2014, glass, et al, 2013 and chang k.m, et al, 2011). senses; smells and behaviors out of five senses, the aromatherapy engages two, touch and smell, for bringing upon the effects. these two senses are believed to have an emotional connection. for instance, the most sacred relationship of a mother and her child bonds by these exceptionally strong senses (demetriou, 2000). studies show that babies tend to be finely sensitive towards the touch and scent of their biological mothers. these interactions bring physiological and psychological serenity to the babies and improve their growth and health (agneta, 2014, elizabeth et al, 2012, delaunay-el, et al, 2010 and doucet, et al, 2007). baby’s response to mother’s touch positively elevates when is accompanied with the odor (durand k, 2013). the olfaction has an extraordinary significance in various physiological processes and psychological perceptions. for example, pheromones are the chemical substances secreted by the body of an animal that unlike all hormones, produce alterations in the physiology of other animals and not on one’s own body (mostafaa, et al, 2012 and tirindeli r, et al, 2009). pheromones provide individuals with their characteristic odor which allows baby to identify their mother and a person to distinguish their partner http://www.aeirc-edu.com/ alvira ali 39 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 from others (lundstorm, et al, 2013 and 2008 and sobel n, et al, 2001). mammals have a distinct region in their olfactory system that senses the odors from pheromones and recognize them. the region is known as vomeronasal organ (ogura, et al, 2010 and tirindeli, et al, 2009) or jacobson’s organ (moran, et al, 1991), and is located in the nose (brennan, et al, 2006). the neuronal cells of this organ synapses with the amygdala and then hypothalamus (nordqvist, 2014). olfaction of pheromones chiefly determines the physiology that fortifies the survival and is required for the determination of the sexual preferences, mating behavior, reproduction cycle, hormonal secretions, alertness, defensive nature, social behavior and territory mark (woodley, et al, 2015; dibattista, et al, 2012; ogura, et al, 2010; salazar, et al, 2009; richard, et al, 2009; snowdown, et al, 2006 and mcclintock, 1998). even though scents have similar effects on humans but it only plays a small role. it is because homosapiens have more developed and complex nervous system and evaluate situations and preferences with higher level of cognition (mostafaa, et al, 2012). furthermore, pheromones have a very unusual function in some mammals like scientists have observed that when a pregnant mouse shares the vicinity with an unfamiliar male mouse, the pregnancy gets terminated naturally. this phenomenon is called the bruce effect and mainly involves the olfaction. the pregnant female senses the odor of a strange mouse, as the male secretes the pheromones. the scent influences the pregnancy in a way that it dampens the prolactin secretion in the female body. prolactin is a precursor for progesterone and thus, the production of this hormone inhibits and as progesterone supports the gestation, the reduction causes the abortion. the nature is said to be adaptive because when new male animals take the dominancy, they do not father the unrelated baby, and rather they kill those newborns and mate with the females to give rise to their own bloodline. this adaptation saves the female from undergoing the stress of pregnancy and delivery, as the child would have no chances of living (rajendren, et al, 1987, yong, 2012 and science whiskers, 2012). scents and brain the sense of smell is found to be 10,000 times stronger than the other senses. a stimulus from sensing a fragrance travels more quickly towards the brain than others. it is estimated that our nose can sense 10,000 different scents distinctively (nordqvist, 2014 and damian, 1995). the stimulus of an odor is taken from the nasal reception to brain, where it stimulates the amygdala and hippocampus (jorge, et al, 2014) in the limbic system (halcon, 2013). if the functions of these brain areas are summarized then it can be stated that amygdala holds the responsibility of generating an appropriate behavioral response while hippocampus determines the behavioral patterns and stores the memories (guyton, 2010). primarily, the reward and punishment centers are located in this region while hypothalamus is also responsible for the regulation of arterial pressures, heart rate, body temperature, thirst, water reabsorption from kidneys, uterine contractility, milk ejection, hunger, feeding reflexes and hormonal secretion from the anterior pituitary (guyton, 2010). thus, the fragrances can cause the alterations in body’s physiological processes. the evidence of promising relationship between the hypothalamus, endocrine system and olfaction is the kallmann syndrome. kallmann syndrome is an x-linked genetic disorder which is characterized by the lack of olfactory perception and a delay in puberty. the mutated gene causes anomaly in the migration of olfactory receptor cells and gonadotropin releasing cells that disturbs the hypothalamus-pituitary axis that ultimately delays the puberty. thus any defect in the olfactory bulb interrupts the communication between the hypothalamus and anterior pituitary gland (lutz, et al, 1993 and rugarli, et al, 1993). it is also reported that scents have an ability to bring upon emotional changes in an individual depending on the consumer’s perception and memory. this is called the proust effect, where a scent can evoke certain memories (chen, 2013, campen, 2013 and hamilton, 2012). olfactory system evolutionary studies have confirmed that olfactory system is the oldest system that perceives the sensations in the mammalian body and has an ability to regenerate (purves, 2001). the olfactory ensheathing cells or oecs in the olfactory bulb provides the fascicles for the repair and regrowth of the mature olfactory neuronal cells. scientists have been successful in utilizing regenerative properties of these cells by implanting them into the sites of spinal damage and successfully treating the lower body paralysis (bbc news, 2014). the olfactory system has a prominence in all the sensory processes due to various reasons which may http://www.aeirc-edu.com/ alvira ali 40 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 include the sensitivity, association with memory and behavior, harmony with endocrine functions and a reputation of being the oldest. nonetheless, amongst all these the one peculiar aspect is that the olfactory sensations reach the cerebral cortex directly (li, et al, 2007), without relaying information through the thalamus (guyton, 2011). the electro-olfactogram further activates the nerves of the nervous system along the olfactory tract. the significance of olfactory nerve activation is its ability of potentiating the power of incoming stimulation. hence, our nose holds a remarkable sensitivity even towards a small concentration of odor (tortora, 2010). figure: stimulation of olfactory cells by the odor and activation of electro-olfactogram. (adapted from chen, et al, 2012, guyton, 12th edition, moran, 2007, knecht, et al, 2004, scott, et al, 2002 and furukawa, et al, 1989). conclusion aromatherapy has gain a lot of attention in contemporary research for treating neurodegenerative conditions like dementia and psychiatric symptoms like anxiety, sleep problems and mood disturbances (perry, et al, 2006). although the neurophysiological, biochemical and pharmacological basis of the aromatic treatments are not well-recorded yet researchers are still working dedicatedly on the clinical trials to establish a ground for the efficacy of the techniques involving the scent therapies. the aromatic treatment has been recently observed to have some influence on deteriorating cognitive functions and thus attained a status of interest in the domain of alzheimer’s disease. anosmia, the loss of sense of smell, is often developed along with dementia in the ad because of the gradual neurodegeneration and development of neurofibrillary tangles and plaques. neuroscientists have stated the fact that neurons in the olfactory bulb can undergo regeneration throughout the life. with regard to this observation, it is hypothesized that the olfactory excitation provided by the aromatherapy can help in stimulating the neuropoiesis in the olfactory bulb. as olfactory region tends to be directly in communication with the hippocampus and limbic system, it is believed that the neuronal regeneration reaches these regions and initiates neuropoeisis that ultimately improves the cognition and prevents further deterioration and memory loss (jimbo, et al, 2009). working on these aspects with clinical trials and molecular studies can be a major breakthrough in treating alzheimer’s disease and other neurodegenerative conditions like dementia and parkinson’s. it is not though possible to utilize the benefits of aromatherapy without noting down the general effects and thus reliable evidence is required to include these therapies to the clinical practices. therefore, thorough research is needed in future where these interventions can help with mental health issues and more studies involving physiological and biochemical analysis for learning the association between hormonal and neurotransmitters must also be performed. references  agneta a.c, et al, 13 october 2014, “parental experiences of providing skin-to-skin care to their newborn infant part 1: a qualitative systemic review”, international journal of qualitative studies on health and well-being, ncbi. http://www.aeirc-edu.com/ alvira ali 41 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188  ballard c.g, et al, july 2002, “aromatherapy as a safe and effective treatment for the management of agitation in severe dementia: the results of a double-blind, placebo-controlled trial with melissa” pubmed.  bbc news report, walsh f, 21 october 2014, “paralyzed man walks again after cell transplant” 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complementary and alternative medicine, volume 3, issue no. 3, page 373-377.  woodley s.k, et al, 14 november 2015, “effects of vomeronasal organ removal on olfactory sex discrimination and odor preferences of female ferrets”, pmc.  yong e, 23 february 2012, “the bruce effect – why some pregnant monkeys abort when new males arrive” www.blog.discoverscience.com http://www.aeirc-edu.com/ review article www.aeirc-edu.com volume 12014 page | 12 ©advance education institute & research centre-2014 night owls – the “b” people kisa fatima altaf dow university of health science corresponding author: canceria3791@gmail.com if you find it hard to get up in the morning, don't despair you're not lazy, you're just genetically programmed that way, says the b-society by chris morris (2007). a night owl is person who tends to stay up until late at night, and the opposite of night owl is an early bird, a lark, someone who tends to begin sleeping at a time that is considered early and also wakes early. . in many countries, early birds are called "a-people" and night owls are called "b-people." some of us are clearly "larks" -early risers while others of us are diversely night owls. the rest of us fall more or less in between the two. in study magazine, reported that iq average and sleeping patterns are most definitely related, proving that those who play under the moon are, indeed, more intelligent human beings said satoshi kanazawa (2010), a psychologist at the london school of economics and political science. night owls have more stamina stamina in terms of across the board axis. research has shown that night owls can remain focused on tasks at hand longer and better than their morning lark counterparts. they are more open minded things that happen at night are things you can’t get away with during the day. it’s the time of booming passionate, underhanded trade and unseemly professions. it’s when the bars are opened and the poets write. it’s when musicians pour over instruments, geniuses have their refinements and artists come alive. they would probably be good at cryptic crosswords. there are things to be explored at night that early risers will never witness. there are ideas articulated and tasks completed that early risers never get to finish. their minds are freer to roam and think at night when people are asleep and when you are not absorbing their anxious energy (which deters the natural thinking mind). average brains are conditioned to follow this sleep pattern, while the more curious, geeky ones want to mock that pattern and create their own. they are prone to be risk takers: this current entrepreneurial age is the perfect time to be a risktaker. with so much competition they have to be a little different to stand out from the rest of the crowd. luckily for night owls, they are unlike and tend to be bigger risk-takers compared to morning people.psychologists have found that those who stayed up later tend to have a higher sense of entitlement and seemed to be more exploitative. evening types were more extroverted, more people-oriented. teenagers and night owls: school-age children are commonly early birds, while teenagers tend to be night owls, and then as they age, adults gradually transition back into morning people," a recent study in belgium found that night owls are able to stay more focused as the day goes on, compared with early risers. there late nights are partly biologically driven. hormonal changes during puberty affect the body's internal clock, which means most high schoolers -even ones who used to be early risers -tend to stay up well after dark and sleep until noon. they make more money according to a research at the university of madrid (2013), because of their higher iqs, creative and risk-taking competencies, it makes sense that night owls also tend to earn large incomes. this may be the reason why some of the most successful people are night owls. stay-up-late types, according to research, attain greater financial and professional success on average than those people with earlier bedtimes and wake times. president barack obama is reputed to a night owl as was charles darwin, adolf hitler, keith richards, marcel proust, elvis presley and james joyce. other night owls such as the former us president bill clinton, and the former british prime minister winston churchill. some studies have shown that people who stay up late are more productive than early risers, and have more stamina around the length of their days. on the other hand research indicates that people who stay up late are at higher risk for depression. night owls tend to be prone to a host of different health and mood disorders, involving just a general sense of mental instability; however, depression was by far the most common shared trait next to obesity. studies have also shown night owls are more prone to more significant tobacco and alcohol use, as well as inclined to additional eating, and also less healthy diets than early risers or people with intermediate sleep patterns. but research on the impact of chronotype isn't all bad news for night owls. other research has shown that night owls display greater reasoning and analytical abilities than their earlier-to-bed counterparts. psychologists have found that people who are constantly described as “night owls” display more signs of egocentrism, machiavellianism and psychopathic tendencies than those who are “morning larks”. morning people, however, also have upper hand. "larks typically sleep better, have more periodic sleep patterns, and have more flexible personalities," said sharkey (2012). they also tend to be happier and feel healthier than b people, according to a recent study from the university of toronto. famous morning larks embrace napoleon, ernest hemingway and george w bush. conclusion: night owls perform better than early risers at inductive reasoning and demonstrate a greater capacity to think conceptually as well as analytically. on the other hand, night owls should take advantage of their nocturnal productivity, and think about alterable businesses that are suitable for them to be the happiest, healthiest owl they can be. i think it's more about taking the time away from noise, away from draining society, away from other people and most do this at night. i doubt one's socio-economic status is an indicator of a lower or higher iq. studies showed that limiting nighttime exposure to artificial light and increasing exposure to daytime sunlight can shift sleep-wake cycles earlier. the moon is enchanted, however, you can also dance under the review article www.aeirc-edu.com volume 12014 page | 13 ©advance education institute & research centre-2014 sun. both have jolting energy....isn't it all about balance? references:  james, kyle, march 2007."late sleepers in denmark rally for societal change". deutsche welle. retrieved2009-1101  dr. michael j. breus, 2013; board certified sleep specialist night owls and early risers have different brain structures. anum haider 16 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 review article time to fix the perceived physical and psychiatric disanalogy anum haider aq khan center, institute of behavioral sciences, karachi. corresponding author: dranum.haider@gmail.com abstract health is a combination of good physical and mental well-being. hence, it is important to cater both physical and psychiatric health elements equally. current practice is mismatch of this ideology and both specialties are very much separately working. in this article, the association between these two health aspects along with underlying mechanisms, underpinning factors for such dissociation, appropriate recommendations and implications will be discussed. keywords physical, psychiatric, health, factors, mechanisms. background according to the health definition by who (world health organization), the complete health is with both physical and mental (psychiatric) well-being of a person. if health compromises in either way it may hamper functioning or productivity of a person (alonso, et al., 2011). however the research pool is not sufficient in relation to the demand of this subject. nevertheless, to date studies have clearly mentioned the connection between physical and psychiatric disorders rather considering these as separate entities. the linkage between physical and psychiatric disorders they can present either as a comorbidity or as an associated condition. as a comorbidity a person with one kind of disorder is more susceptible to develop the other (druss, 2011). chronic physical conditions like cardiovascular diseases, diabetes mellitus (d.m), pulmonary diseases (vogele, 2008), renal diseases(moreira, 2008), neurological or dental diseases (tomar, et al., 2011 & kisley, et al., 2011), if not managed well, it can lead to psychiatric problems, most commonly depression, anxiety and suicide (jones, et al., 2004). almost half (58%) of the population with medical problems develop psychiatric problems (druss, 2011). similarly chronic and severe psychiatric disorders (depression, bipolar disorder, schizophrenia) can also produce physical problems such as cardiovascular disorders, d.m and chronic pain (hert, et al., 2009 & smith, 2011). more than half (68%) of the population with mental disorder can develop comorbid medical problems (druss, 2011). as an associated condition psychiatric problems like depression are very much associated with physical problems that are chronic, multiple in number and poorly managed. (gunn, et al., 2012). physical problems may also manifest as psychiatric problems like sle (systemic lupus erythromatosis) (hajighaemi, 2016). psychiatric problem may present as medical problems for instance, chronic pain syndromes. (phillips, 2011). richard et al. in his study re-explained that 46% of cases http://www.aeirc-edu.com/ anum haider 17 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 appear as medical disorders once reassessed in comparison with previously diagnosed psychiatric cases with full battery (physical, psychiatric, neurological exam and labs), (nousin, et al., 2013) the underpinning mechanisms of linkage it is a well-established fact that inflammatory markers get increased when a person suffers from physical problems. the inflammatory markers are involved in almost all kind of physical illnesses in form of predisposing, triggering or maintaining factor. there are also similar evidences for psychiatric disorders in terms of potentiated proinflammatory mediators and inflammatory reactions and decreased immunity (druss, 2011 & nousin, et al., 2013). hence inflammation is a common underpinning factor that plays a bidirectional role in the manifestation of physical or psychiatric conditions (druss, 2011). the proinflammatory markers and cytokines (creactive proteins, tnf-tumor necrosis factor 𝛼, gamma interferons,interleukin-6, interleukin-8) are responsible to execute inflammatory process and production of physical and psychiatric problems while on the other hand physical or psychiatric disorders may also turn on the inflammatory cascade (druss, 2011 & leboyer, et al., 2012). the common negative health behaviors in both kinds of disorders that are responsible to start the inflammatory cascade are poor diet, lack of exercise, alcohol, smoking or other psychoactive substance use (druss, et al., 2011 & larsen, 2009). these negative health behaviors are commonly observed in patients with mental disorders and chronic medical problems. these patients also have shared genetic predisposition to develop metabolic disturbances and psychopathologies (nousin, et al., 2013). other than genetic basis, medications make the person susceptible to develop metabolic disturbances (obesity, impaired glucose tolerance, hypertension, and dyslipidemia) like antipsychotics as well anti-hypertensive or prescribed medications may cause psychological disturbances (hert, et al., 2011). metabolic disturbances may itself drift into various psychopathologies (schizophrenia, adhd-attention deficit hyperactivity disorder, asd-autism spectrum disorder), (nousin, et al., 2013). inflammatory process is good to handle the short term stress but when the stress becomes chronic or prolonged, it brings damaging health consequences by decreasing immunity and release of common pro-inflammatory mediators (cytokines, interleukins, tumor necrosis factors), (sareen, 2007). this results in devastating changes in neuronal structure and functions by alteration in synaptic proteins and intracellular signaling, loss of neurotropic support, inhibited neurogenesis, inhibited neuronal network connectivity, cytoskeletal destabilization and glutamate toxicity. these changes manifest as different neuropsychiatric and medical conditions (duric, 2016). broadly it disrupts the hypothalamic pituitary axis (hpa) and neuro-modulatory apparatus (like neurotransmitters). these are common risk factors that underpin this inflammatory cascade to bring various physical and psychiatric problems on the surface (druss, 2011 & taylor, et al., 2012). biological factors genetics leptin sensitivity obesity smoking or other psychoactive substance use. poor nutrition http://www.aeirc-edu.com/ anum haider 18 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 psychological factors adverse life events abuse/neglect chronic stressors negative cognitive process and emotions maladaptive personality traits social factors poverty poor social support isolation sedentary life style poor neighborhood / household beside biological factors; the psychosocial factors (exposure to early life trauma, chronic stressors, and low socioeconomic status) have equal role in the causation of different medical and psychiatric disorders by disruption of hpa-axis (druss, et al., 2011 & sareen, 2007). hence there is a complex interplay of various neurobiological and psychosocial factors for the production of almost any kind of medical or psychiatric disorders (druss, 2011 & taylor et al., 2012). perception and practice in the community despite the strong association between these two kinds of disorders the comorbidity remains unattended or mislabeled as psychosomatic, functional or self-inducing at a significantly higher rate. it ultimately worsens the psychological stability, treatment adherence, quality of life and life expectancy (phillips, et al., 2011 & gray, 2012). (erwin, et al., 2011) in his study has found high rate of physical comorbidity in psychiatric disorders (43%) and found both physician and psychiatrists to be least proficient in identification and management of such comorbidities and associated conditions both in primary care and mental health settings (walker, 2011). factors behind this perception the ultimate question arises in mind,” how such an important presentation can be overlooked by health professionals?” the research has proposed the possible answers: -there are lack of expertise of psychiatrists to identify and treat medical conditions or they discount it due to lack of available resources. -the physicians at their end feel discomfort to treat medical conditions in psychiatric patients or take it for granted. -there is lack of adequate communication and coordination between physician and psychiatrist. consequences-facts and figures (scoll, et al., 2009) have worked to measure the burden of disability due to physical (medical) and psychiatric problems. the disability due to psychiatric problems is high than physical problems and it carry remarkable synergistic effects on disability burden as a result of comorbidity with physical disorders. it increases the burden usually in two ways: increasing the rate of comorbidity the properly unaddressed physical or psychiatric disorders result in high rate of comorbidity. in patients with severe mental illness there is high comorbidity with physical disorders like cvd, d.m, pulmonary, dental. similarly many chronic medical conditions may be worsened due to comorbid psychiatric conditions such as depression in diabetic patient decreases motivation for maintaining diet control, exercise and other stress relieving activities. premature mortality mortality gap is very higher (2-4 fold), around 15-20yrs earlier people with severe http://www.aeirc-edu.com/ anum haider 19 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 mental illness (i.e., schizophrenia) get die even in high income countries due to suicide and other unattended physical health conditions. grossly on a broader view, theses unrecognized and unmanaged physical and psychiatric comorbidities affects person both at individual and community level. at individual level it impairs functioning, productivity and quality of life while on community level poses high economic burden (druss & thornicroft, 2011; gray, 2012 & lawrence, 2013). conclusion the understanding of psychophysiological mechanisms made the clear relationship between physical and psychiatric disorders. the present health care system is not such integrated and coordinated to cater this realistic relationship. clinical and policy implications are urgently needed to look into this matter. implications and recommendations clinical education and awareness of health professionals psychiatrists can play crucial role by expanding the clinical paradigm by inclusion of physical monitoring and evidence based prescription in daily practice along with education of patients regarding promotion of healthy life style and behaviors (hert, et al., 2011). nurses and primary care physicians are equally needed to be aware and educated about various common mental health problems in patients with medical illness (hardy, et al., 2011 & bradshaw, 2012). improving communication good level of communication is instrumental in any health setting especially in our setup where mostly mental health setting is separated from medical setting. there is crucial need to develop good communication bonding between the medical and mental health settings for appropriate referral and management (druss, 2011). monitoring of physical and mental health status and effect of treatment the standardized monitoring tools and storage system must be formulated to record this monitoring and to appreciate and identify health disruptions at the earliest level (carlier, 2012 & eldridge, 2011). promotion of healthy health behavior healthy health behaviors like cessation of smoking and other psychoactive substances, exercise, healthy diet, proper sleep must be equally promulgated in all health settings (happel, 2012). involvement of significant others in patient’s care the significant others in patient’s life can ensure good care act as a role model to emulate and maintain healthy behavers and habits in patients (thoits, 2011). policy the stake holders and government must do take it alarming and derive some policies accordingly, few are suggested below. expansion of health budget from the total health budget only 0.4% is allocated to mental health (mental health atlas, 2014). expansion of health budget is intensely needed for the provision of services adequately. integration of mental health in general health setup according to world health organization recommendation mental health facility must be as accessible as that of physical health. depression declared to be the leading cause morbidity and mortality and found in almost 42% of the patients with physical diseases (who report 2017 http://www.aeirc-edu.com/ anum haider 20 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 march). hence it is essential to integrate both medical and psychiatric care. development of financial collaboration with international agencies in third world under developed countries like pakistan international funding collaboration with the agencies targeting common area (i.e. substance use, suicide) can improve the care, evidence based working and research. building trained workforce there is scarcity of psychiatrists (mental health professionals) in relation to the given population size. primary care physicians, nursing staff, lady health workers, social workers or voluntary community workers must have necessary training to work effectively in their circles to improve health globally. behavioral sciences and psychiatry must be included in the curriculum of all medical students to develop adequate insight for career selection. prioritize preventive strategies preventive strategies must be implemented both at primary and secondary level. primary level global awareness and promotion of healthy life strategies like balanced diet, exercise, cessation of smoking and other psychoactive substances and acquiring good social circle. secondary level specific high risk groups are focused and targeted for specific health measures like chronic medically ill for screening and treatment of depression/ anxiety or other psychological issues. this article may initiate further research under observational (such as, association of physical and psychiatric disorders in our population in both urban and rural setting) and interventional grounds (such as effect of education and monitoring on clinical outcome, liaison work). references  alonso, j., petukhova, m. v., vilagut, g., bromet, e. j., hintov, h., & karam, e. g. (2013). days totally out of role associated with common mental and physical disorders. the burdens of mental disorders: global perspectives from the who world mental health surveys, 137-48.  bradshaw, t., & pedley, r. (2012). evolving role of mental health nurses in the physical health care of people with serious mental health illness. international journal of mental health nursing, 21(3), 266-273.  carlier, i. v., meuldijk, d., van vliet, i. m., van fenema, e., van der wee, n. j., & zitman, f. g. (2012). routine outcome monitoring and feedback on physical or mental health status: evidence and theory. journal of evaluation in clinical practice, 18(1), 104-110.  de hert, m., dekker, j. m., wood, d., kahl, k. g., holt, r. i. g., & möller, h. j. (2009). cardiovascular disease and diabetes in people with severe mental illness position statement from the european psychiatric association (epa), supported by the european association for the study of diabetes (easd) and the european society of cardiology (esc). european psychiatry, 24(6), 412-424.  duric, v., clayton, s., leong, m. l., & yuan, l. l. (2016). comorbidity factors and brain mechanisms linking chronic stress and systemic illness. neural plasticity, 2016.  eldridge, d., dawber, n., & gray, r. (2011). a well-being support program http://www.aeirc-edu.com/ anum haider 21 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 for patients with severe mental illness: a service evaluation. bmc psychiatry, 11(1), 46.  goodell, s., druss, b. g., walker, e. r., & mat, m. (2011). mental disorders and medical comorbidity. the synthesis project.  gray, r. (2012). physical health and mental illness: a silent scandal. international journal of mental health nursing, 21(3), 191192.  gunn, j. m., ayton, d. r., densley, k., pallant, j. f., chondros, p., herrman, h. e., & dowrick, c. f. (2012). the association between chronic illness, multimorbidity and depressive symptoms in an australian primary care cohort. social psychiatry and psychiatric epidemiology, 47(2), 175-184.  hajighaemi, f., etemadifar, m., & bonakdar, z. s. (2016). neuropsychiatric manifestations in patients with systemic lupus erythematosus: a study from iran. advanced biomedical research, 5.  hall, r. c., gardner, e. r., stickney, s. k., lecann, a. f., & popkin, m. k. (1980). physical illness manifesting as psychiatric disease: ii. analysis of a state hospital inpatient population. archives of general psychiatry, 37(9), 989-995.  happell, b., davies, c., & scott, d. (2012). health behaviour interventions to improve physical health in individuals diagnosed with a mental illness: a systematic review. international journal of mental health nursing, 21(3), 236247.  hardy, s., white, j., deane, k., & gray, r. (2011). educating healthcare professionals to act on the physical health needs of people with serious mental illness: a systematic search for evidence. journal of psychiatric and mental health nursing, 18(8), 721727.  hert, m., cohen, d. a. n., bobes, j., cetkovich‐bakmas, m. a. r. c. e. l. o., leucht, s., ndetei, d. m., & gautam, s. (2011). physical illness in patients with severe mental disorders. ii. barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. world psychiatry, 10(2), 138-151.  hert, m., correll, c. u., bobes, j., cetkovich‐bakmas, m. a. r. c. e. l. o., cohen, d. a. n., asai, i., ... & newcomer, j. w. (2011). physical illness in patients with severe mental disorders. i. prevalence, impact of medications and disparities in health care. world psychiatry, 10(1), 52-77.  hitchen, l. (2011). psychiatrists neglect patients' physical health problems, says study. bmj: british medical journal, 343.  jones dr, macias c, barreira pj, et al. (2004). prevalence, severity and cooccurrence of chronic physical health problems of persons with severe mental illness. psychiatr serv (11):1250-57.  kisley s, quek l, pais j, et al. (2011). advanced dental disease in people with severe mental illness: systematic review and metanalysis. br j psychiatry (3):187-93  koryani ek. (1979). morbidity and rate of undiagnosed physical illnesses in a psychiatric clinic population. arch gen psychiatry (4):414-9.  larsen ba and christenfeld njs (2009). cardiovascular disease and http://www.aeirc-edu.com/ anum haider 22 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 psychiatric comorbidity: the potential role of perseverative cognition. cardiovascular psychiatry neurol. 791017:8 pages.  lawrence d, hancock kj, kisley s. (2013). the gap in life expectancy from preventable physical illness in psychiatric patients in western australia: retrospective analysis of population based registers. bmj 346:2539.  leboyer m, soreca i, scott j, et al. (2012). can bipolar disorder be viewed as a multisystem inflammatory disease? j affect disord (1):1-10.  mercer, s. w., gunn, j., bower, p., wyke, s., & guthrie, b. (2012). managing patients with mental and physical multimorbidity.  moreira, j. m., matta, s. m. d., kummer, a. m., barbosa, i. g., teixeira, a. l., & silva, a. c. s. (2014). neuropsychiatric disorders and renal diseases: an update. jornal brasileiro de nefrologia, 36(3), 396400.  nousen, e. k., franco, j. g., & sullivan, e. l. (2013). unraveling the mechanisms responsible for the comorbidity between metabolic syndrome and mental health disorders. neuroendocrinology, 98(4), 254-266.  phillips, k., & clauw, d. j. (2011). central pain mechanisms in chronic pain states–maybe it is all in their head. best practice & research clinical rheumatology, 25(2), 141154.  sareen, j., cox, b. j., stein, m. b., afifi, t. o., fleet, c., & asmundson, g. j. (2007). physical and mental comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large community sample. psychosomatic medicine, 69(3), 242-248.  scott, d., & happell, b. (2011). the high prevalence of poor physical health and unhealthy lifestyle behaviours in individuals with severe mental illness. issues in mental health nursing, 32(9), 589-597.  scott, k. m., von korff, m., alonso, j., angermeyer, m. c., bromet, e., fayyad, j., & haro, j. m. (2009). mental–physical co-morbidity and its relationship with disability: results from the world mental health surveys. psychological medicine, 39(1), 33-43.  taylor, v. h., mcintyre, r. s., remington, g., levitan, r. d., stonehocker, b., & sharma, a. m. (2012). beyond pharmacotherapy: understanding the links between obesity and chronic mental illness. the canadian journal of psychiatry, 57(1), 5-12.  thoits, p. a. (2011). mechanisms linking social ties and support to physical and mental health. journal of health and social behavior, 52(2), 145161.  thornicroft, g. (2011). physical health disparities and mental illness: the scandal of premature mortality.  tomar b, bhatia nk, kumar p, et al. (2011). the psychiatric and dental interrelationship. delhi psychiatry j (1).  vogele c, leupoldt av. (2008). mental disorders in copd. respir med.102:764-73.  zheng, z., zeng, y., & wu, j. (2013). increased neuroplasticity may protect against cardiovascular disease. international journal of neuroscience, 123(9), 599-608. http://www.aeirc-edu.com/ kisa fatima altaf 47 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 perspective piece understanding déjà vu kisa fatima altaf advance educational institute and research centre dadabhoy institute of higher education corresponding author: kisa@aeirc-edu.com have you ever witnessed that, say for instance, you are migrating to northern areas of pakistan for the first time or you are playing basketball on a court and being cheered up by audience shouting only your name, and all of a sudden it feels like as if you have been in that very moment before or maybe you are having pizza with a group of friends, teasing a friend, and you have the feeling that you've already experienced this very thing -same friends, same dinner, and same topic 60% of the populations, those who have experienced it for the first time assume it as reincarnation. the phenomenon is comparatively complicated, and termed as déjà vu. the word déjà vu is french and means, actual, "seen before". those who have witnessed the feeling defined it as an astounding sense of familiarity with something that shouldn't be usual at all. there are various logics on that. absolute reason is, sometimes our instinct gets puzzled that the occasion is happening in the present or past. so for 1-2 seconds, we sense like we have lived this minute before. but not actually, 67% of people have had a déjà vu experience (a median of 41 surveys). charles dickens mentioned that we all have some wisdom of an awareness, that comes over us sometimes, of what we are doing and saying having been said and done before, in an isolated time—of our having been surrounded, dim ages ago, by the same faces, substances, and prospects—of our knowing completely what will be said next, as if we suddenly remembered it! there are countless philosophies as to why déjà vu happens. swiss scholar arthur funkhouser proposes that there are certain "déjà experiences" and defends that in order to study better the phenomenon, the implication among the experiences need to be recognized. in the examples quoted above, funkhouser would describe the first incidence as déjà visite (“visited already") and the other as déjà vecu/ déjà vu ("seen before or lived through"). deja vu refers to those different and generally strange moments when the current moment feels like the former. it is difficult to explain. a few people hunt their thoughts for dreams that might have been like the current situation. others think that the action is what appears when things from past lives proceeds in this one. both assumptions are impractical to justify, confound, or (until recently), interrogate. the assumption that it is about previous lives is a matter of belief. the perception that it has to do with dreams is less a matter of belief only a specified people plea to recall previous lives, but relatively everyone commemorates few of their dreams. some recall many of them. the concept of reincarnation that is most persistent with modernized brain science concludes that no thoughts or memories are passed from one life to the other. what is shifted is a set of alarms that emulates the states of consciousness. thoughts don't need to go along. (todd murphy 1999) as i know and can judge, dream is a fantasy or projection of visuals we see every day but with different scenarios we have never been through. it is a process in which the physiological aspects of the body and its psychological responses by the brain are saved in a part of the brain called sub-conscious. it is a part of the mind where the memories are saved and are highly approachable in dreams as all the other functions of the body are hibernated during sleep. (w. hassan 2014). the subconscious and conscious mind is intertwined involving the same point in space and time at any one moment. the most persistent data in the déjà vu history is that the prevalence with which it is experienced declines with age. as well as 75% people reports that they have experienced few forms of déjà vu. a large number of incidents happen in people of about 15 to 25 years older than in any other age group. déjà-vu is a non-cognitive fault in which a situation has the sense of intimacy despite there being no definite antecedent in the past. incidence of déjà-vu is most when people are in their 20s and almost fade after age 50. (brown, alan s. 2003). http://www.aeirc-edu.com/ mailto:kisa@aeirc-edu.com kisa fatima altaf 48 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 since déjà vu happens in people with and without any medical status, there is much belief as to how and why this episode happens. many psychoanalysts characterized déjà vu to simple illusion or gratification; at the same time some psychiatrists attribute it to an imbalance in the brain that originates the brain to oversight the present for the past. some interesting researches on brain function cites that what we concern as "deja vu" is basically a "misfire" of the brain in between notion and encoding into memory, by which something that we "see" is literally encoded twice -once, subliminally, and the next superluminally. this left us with the "feeling" that we have experienced what we are observing in the past, because in our brains, we have. there is a massive time lag between all of our actions happening at the certain moment which is being composed at the subconscious level and the conscious point we experience as the real moment. conclusion many parapsychologists consider that it is linked to a past-life experience. certainly, there are more researches, studies and reviews to be done. time only runs in one direction. what i conclude is that deja vu is a sensual paradox, and not associated to time itself. neuroscientists have come up with many assumptions about the experience of déjà vu, but no one had ever been justified. authors and scientists have presented mystical statements. reference  brown, alan s. "a review of the deja vu experience." psychological bulletin129.3 (2003): 394.  w.hassan (2014). understanding dreams. annals of psychophysology (1) 14-15.  todd murphy (1999). “the experience of déjà vu in clinical and spiritual terms.” sacred pathway: the brains role in religious and mystic experiences. http://www.aeirc-edu.com/ review article www.aeirc-edu.com volume 12014 page | 27 ©advance education institute & research centre-2014 work-place stress??? maria altaf fatima jinnah dental college corresponding author: maria3188@gmail.com dr. hans selye said “following the right attitude can covert a negative stress into positive one and one can easily successful life”. stress is not always negative or dangerous and indeed, the absence of stress is death. eustressa positive stress, it is very healthy and person get more energy and strength to conquer the stress, this way it helps to resolve the different situation in a shortest possible time, and one gets more positive thinking and get good results at the end of the stress. it elaborates motivation and inspiration. according to hans sclye “adopting the right attitude can convert a negative stress into positive one”. there has been an almost 100% rise in the occurrence of mental disability, particularly stress, depression and anxiety, in the country over the past 10 years, mainly due to the outcomes of personal insecurity, financial condition, lack of education, rising inflation, said senior psychiatrist, the president of the pakistan association of mental health (pamh), dr. haroon ahmed, directing the press conference, which held in connection with the world mental health day that falls on oct 10. from the last decades changing nature of work, and indeed changes in society itself, means that it is important to regularly update available information on the scale of occupational stress. indeed, at times it will execute that there is little relevant information on the current situation, as can be seen from the following quote: 'there are no dependable estimates of the incidence of occupational stress and related disorders in the working population'. however, in the last few years a number of surveys have attempted to provide information on these topics. nowadays, quality productivity is very essential for organizational survival. therefore, stress at workplace becomes a leading concern to organization administrators. beehr, (1999) used a very general definition in which ‘anything about an organizational role that produces adverse consequences for the individual’ was called role stress. they proceeded to conclude that a condition termed role overload was viable and this correlated positively with job stress. stress indicators related to role expressions in the study indicated low motivation to work (cooper,1999). occupational stress has often been termed as an aversive characteristic of the working ambiance. this has often led to stress being assembled with physical hazards, such as noise, and research being directed to measurement of exposure levels and examination of the relationship between these and health/ performance outcomes. a country like pakistan where, physical resources at educational institutions are deficient, salaries are inappropriate, discipline problems are frequent, most of the workers are not well equipped with modern methods of technology as well as many managerial issues, which keep the employees stressful at workplace. job performance is the result of three factors working together: skill, effort and the nature of working conditions. skills include knowledge, power and competencies the employee brings to the job; effort is the degree of motivation the employee puts forth toward getting the job done; and the nature of work conditions is the degree of accommodation of these conditions in facilitating the employee’s productivity (levey, 2001) . stress can be defined as a vibrant situation in which a person get an opportunity, or demand to achieve any objective but the results are perceived to be uncertain and imperatives. there are three interrelated aspects of stress: environmental demands; adaptive response; and individual differences (kinicki , 2001). the complication of these definitions is primarily overcome by lazarus (1999) description about the stress that it is situation, we involved when demands perceived exceeding from the ability, we have to perform the task. moorhead and griffin (2001) stated that “stress is caused by a stimulus that can be either physical or psychological, and that the unique response to the stimulus in some way. here, we define stress as a person’s adaptive response to a stimulus that places excessive psychological or physical demands on him or her”. fleet van (1991) has successfully attempted to compose the numerous definitions of stress into single meaningful definition that “stress is a person’s adaptive response to excessive psychological or physical demands ground by some stimulus”. the symptoms may involve body aches like rashes, muscle and body aches, muscle spasm, headache, increase or decrease appetite, diarrhea or constipation, change in weight, gastric problems, dermatitis, eczema, allergies, chest pain, fast heartbeat, heartburn, difficulties in breathing, high blood pressure, loss of sexual desire, frequent urination, frequent cold, tremors, trembling/tremors, fatigue, tiredness, low energy, obsessive compulsive behaviors, low work efficiency, constant blushing, sweating, dry mouth. hui and chan (1996) brought up various research studies, which have been undertaken to investigate the prevalence and major sources of teacher stress in england, wales, usa, australia, malta and west indies (borg, 1991; dunham,1992) and brought forward sources of faculty stress along with occupational stressors. university faculty faces high stress because of their dynamic responsibility to respond to social and institutional change, positional clash and task obscurity. other identified sources of stress in the university setting include meager working conditions, faculty interpersonal relationships, institutional management, administrative style, and pressure posed by stakeholders. job satisfaction indicates fair treatment, mutual respect; better functioning that positively influences performance of university teachers. the developing countries are in transitional phase of evolution, newly exposed to economic integration and started experiencing workforce diversity to larger extent. wisniewski (1990) conducted a study in response to the number of issues related to faculty job satisfaction is raised in academic conversation such as to what extent teacher is satisfied, applicability of work with teacher’s own desire, opportunity cost of being a teacher, favor and disfavor of work characteristics and overall perception towards teaching profession. he found some major factors such as: competitive pay scale, smooth working conditions, pleasant institutional culture and rooms for new experiments, and betterment. at the university level, expectations from teachers have raised. at the same time, they have to experience very challenging and demanding tasks related to teaching and research. they go review article www.aeirc-edu.com volume 12014 page | 28 ©advance education institute & research centre-2014 through a lot of occupational stress while performing their duties. this occupational stress relates to the incapability of worker to respond to the dynamic work requirement. work-related health issues are generally caused by occupational stress and considered as one of ten leading health problems. stress disorders have negatively affected the industry, causing loss over $150 billion dollars because of decreased productivity, absenteeism and incapability (blix et al., 1994). by working on occupational stress, we can make substantial refinements in teaching ability of faculty, overall graduates learning consequences’ and quality of education. the class sizes, conditions of classroom and academic burden of faculty contribute a lot in the productivity of university faculty (rocca & kostanski 2001). the stress bearing capacity is backed by their level of satisfaction to the institutions. the greatly stressed and poorly satisfied faculty cannot help the universities to compete such global queries. the universities in pakistan and other countries particularly of developing nations need to adopt continuous job satisfaction and occupational stress assessment programs and investigate their causal relationship. due to the service oriented character of the job, faculty of universities is in direct contact with graduates/customers, and highly satisfied faculty with low level of stress can produce stratified graduates and make long-term impact on university branding. the documented consequences of stress on medical trainees include: alcohol and drug abuse, interpersonal relationship adversity, depression, anxiety, and suicide (levey,2001; shapiro, 2000) other studies have also shown stress can be detrimental to the medical trainees’ or professional’s academic achievement, effectiveness in delivering health services by decreasing attention span, concentration, decision-making, and a cognition to establish physician-patient relationships. (shapiro, 2000, michie, 2003) in addition to affecting psychological and emotional wellbeing, stress can also disrupts physical health, such as the development of high blood pressure, heart disease, and immuno deficiency disorders ( stewart, 1996). the physical and psychological demands of the profession often make physicians more vulnerable to high levels of stress. the effects of stress on practice are evidenced as increased errors in prescribing, limited team working, more patients’ complaints and sickness absence (niaz , 2003). a study conducted by abu al-rub indicated a curvilinear (u-shaped) relationship between job stress and job performance; nurses who reported moderate levels of job stress believed that they performed their jobs less well than did those who reported low or high levels of job stress (abualrub , 2006) conclusion: stress has been viewed as a physiological reaction to a threatening or harming environment. another approach has viewed stress in terms of an interactional framework, one of the best examples being karasek's model, suggesting that job demands and decision latitude interact to influence health. however it can be managed by various techniques like daily use exercise, healthy diet plan, yoga, meditation, treatment, relaxation, patient counseling, medication and alternative therapies, herbal medicine and aroma therapy helps in reducing the stress. refferences:  abualrub, r.f. (2006). the relationship between job stress, job performance and social support among hospital nurses. j nurs scholarsh (38), 200–4.  beehr, t.a. (1999).perceived situational moderators of the relationship between subjective role ambiguity and role strain . j appl psychol (61), 35–40.  blix, a. g., cruse, r. j., mitchell, b. m. m. b., & blix, g. g. (1994). occupational stress among university teachers. educational research, 36, 157-170.  borg, m. g., & riding, r. j. (1991). occupational stress and satisfaction in teaching. british educational research journal, 17.  cooper, c., marshal j.(1999). understanding executive stress. new york: petrocelli.  dunham, j. (1992). stress in teaching (2nd ed.). london: rout ledge  fleet, d. d. (1991). behaviur in organization. new jersy: houghton mifflin company.  hui, e. k. p., & chan, d. w. (1996). teacher stress and guidance work in hong kong secondary school teachers. british journal of guidance & counseling, 24(2).  levey, r.e.(2001). sources of stress for residents and recommendations for programs to assist them. acad med (76),142–50.  michie s, williams s.2003 reducing psychological ill health and associated sickness absence: a systematic literature review. occup environ med (60), 3–9.  moorhead, g., & griffin, r. w. (2001). organizational behaviors managing people and organizations (5th ed.).  new york: houghton mifflin company.  niaz u, sehar h, ali s. 2003 stress in women physicians in pakistan. pak j med sci;19(2):89–94  rocca, a. d., & kostanski, m. (2001). burnout and job satisfaction amongst victorian, secondary school teachers: a comparative look at contract andpermanent employment. paper presented at the conference on teacher education: change of heart, mind and action.  shapiro ,s.l., schwartz. (2000) stress management in medical education: a review of the literature. acad med (75), 748–59.  stewart,w., barling, j.(1996). daily work stress, mood and interpersonal job performance: a mediational model. work ress. (10), 336–51.  wisniewski, w. (1998). the job satisfaction of teachers in poland. comparative education, 26(2/3). junaid ahmed 12 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 original article to evaluate the relationship between social anxiety & life-satisfaction among adolescence in karachi junaid ahmed1, shamoon noushad2 & sadaf ahmed2&3 1-fedral udru university of science & technology (fuusat) 2-advance educational institute & research centre (aeirc) 3-psychphysiology research lab, universuty of karachi corresponding author: jaajfze@hotmail.com abstract the purpose of the present study is to investigate the relationship between social anxiety and life satisfaction in adolescence of karachi. the sample of 106 adolescents was randomly collected from karachi (54 male & 49 females) age range from 18 to 25. it was hypothesized that there would be significant negative correlation between social anxiety & life satisfaction score. for measuring socially anxiety “social interaction anxiety scale” (mattick, r. p., & clarke, j.c) was administered and for life satisfaction “life-effectiveness questionnaire” (james, t. neill.) was administered. whole questionnaire was self-reported and in life satisfaction eight domains was focused with the help of life-effectiveness questionnaire (1)time management, (2)social competence, (3)achievement motivation, (4)intellectual flexibility, (5)task leadership, (6)emotional control, (7)active initiative, (8)self confidence. for statistical analysis pearson product correlation was applied on the ratio/equal interval data scores with the help of spss 22.0v. result shows significant negative correlation between social anxiety & life satisfaction scores r=-.343, p<0.01. it is concluded that social anxiety has significant negative impact on life satisfaction among adolescence and researches reported that social anxiety convert in social anxiety disorder then it effects different areas of daily life (stein & kean, 2000). keywords social anxiety, life-satisfaction, adolescence introduction the diagnostic and statistical manual-v (apa, 2013) social anxiety (social phobia) is fear or anxiety (feeling of shyness, uncomfortable in participating daily activities) in one or more social situation. a survey based study was conducted on 200 general population of karachi (both genders male & female) which showed significant results that reported that 45% of sample population is suffering from social anxiety (fear of speaking & meeting other people also in different social situations. it is also noted that social interaction is being observed while eating or drinking in public, performing tasks in social environment. it leads to individual avoid social situation which leads fear or anxiety and it shows clinically significant distress in daily functioning (naveed, s. et al. 2015). social anxiety can be a provoking stimulus for different disability. researchers reported that 69% individual faced impairment in general social relationship, and in them the half of population was unmarried who got impairment in opposite sex relation. however research explored that disability may also vary individual to individual in same situation and intensity (schneier et al. 1994). wittchen et al. (1999) demonstrated that adolescence is the period which marks the highest risk of social anxiety. adolescence is the period which catches researchers’ attention from which they found the different problems in adolescence, especially in social functioning, trouble in peer relationship and also negative perception of self (la greca & lopez, 1998). individuals who were suffering with social anxiety reported low level of educational achievement and less productive in working environment (stein, et al. 2000). furthermore, that people who suffering from social anxiety disorder reported frequently visits of medical treatment (davidson, et al. 1993). a study reported that in pakistan general adolescents facing social anxiety which after going ahead lead low of confidence and low self-esteem in them. after this factor many student become anxious in social situation in interaction with others, speaking or giving speech in audience (ahmed, z. r. et al. 2013). in the contras research in pakistani culture revealed that culture is also predictor of life satisfaction. age also effects on life satisfaction although found no difference in life satisfaction of male & females (bibi, f. et al. 2015). in one study kashani (1989) explored that chance of social anxiety increase in both genders (male & female) when satisfaction of life bends toward peer from family. psychometric properties of disability study conduct for knowing the relation with social anxiety disorder and it is found that social anxiety is strongly negative correlated with quality of life. also found that chances of other disabilities are commonly noted in social anxiety patients (hambrick, j. p. 2004). same results found between confidence, self-esteem & social interaction (saras on et al. 1990). brown (1991) reported in his study that people who found most popular among peers & social situation have more positive self-image & satisfaction in life. children who found social anxious also reported low social acceptance, self-esteem & interaction among peers (ginsberg, 1998). http://www.aeirc-edu.com/ junaid ahmed 13 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 some researchers also emphasized on this question to find out that how much social anxiety attributed association with other disorders like depression (stein et al., 1999; weiller et al., 1996). social anxiety also associated with reduced work performance, effect negatively on social interaction, and found problems in children & adolescence (schneier et al., 1994; wittchen et al. 2000). quality of life researched explained that severity of social anxiety also effect on quality of life, when social anxiety severity increase quality of life decrease (candilis, p.j., 1999; meltzer-brody s., 2000). although christine (2002) findings reported significant load of illness associated with anxiety disorder and quality of life. most studies indicated that parenting raising style, biological, family structure play important role in developing social anxiety which showed by empirical evidences (parker, g., 1983). lieb, r., (2000) empirically explore that multiple family factors are involved for developing social anxiety (parental psychopathology). some other researches depicted that individual judge life satisfaction by comparing own life with self-imposed standard and done this comparison with the cognitive ability (diener, e.d. 1985; shine, d.s 1978). john reported that individual who experience more positive effects in life than negative see self-image as more satisfied, strong in subjective well-being and report life same as his/her desired standard (john, f. 2011). a recent research in asia also explored that gender plays major role in life satisfaction. results showed that male found more satisfied with their lives than females (yaremtchuk, s. k. 2014). another research on life satisfaction tells that life satisfaction is correlated with self-esteem. it is also reported that it is explored with the help of empirical research that boys found more in life satisfaction & self-esteem than girls (khatib, s.a. 2013). research on gender difference in life satisfaction & loneliness depicts that gender has also significantly effect on life satisfaction & loneliness. also reported that loneliness and life satisfaction have negative correlation although female students found more in loneliness &less in life satisfaction in opposite male students found more in life satisfaction & less in loneliness (bugay, a. 2007). samaranayake (2011) conducted a research on medical & other students for knowing their relationship with anxiety & depression disorders and results revealed that female students reported more on anxiety & depression, in opposite those medical students found more satisfied with their lives than other students. research on african american & caucasian american tells that there is strong and significant correlation between life satisfaction and social support (joh, f. 2011). methodology this study was conducted on the general population& sample was randomly selected from adolescents of karachi. in this study total 106 participants were selected from both genders (male & female). selected participants belong to age group18 to 25 years and everyone had an equal chance to participate because survey sampling method was used in this study. the demographic sheet was used for measuring other extraneous & confounding variables like; age, gender, birth order, siblings, and socio-economic status (dependent/independent). social interaction anxiety scale (mattick, r.p, & clarke, j.c., 1998) is a selfreport measure consist of 20 items with 3 reverse items (5, 9 & 11). it is helpful in measuring social anxiety symptoms over time, and also helpful as part of an assessment for social phobia or other anxiety related disorders. life-effectiveness questionnaire (james t. neill ph.d.) is also a self-reported scale consists of24 items with no reverse item. it is focused on eight domains of life-effectiveness (1) time management, (2) social competence, (3) achievement motivation, (4) intellectual flexibility, (5)task leadership, (6)emotional control, (7)active initiative, (8)self confidence. participants were approached at difference places and asked to fill out the self-reported questionnaires after giving a short brief about the study. if they were agree to participate, they were given consent form to fill and then explain that how to fill questionnaires. some participants faced difficulty in attempting questions due to non-native language (english) so the questions were explained to them. in the end, participants who participated were appreciated. results after collecting all questionnaires they were scored according to their procedure, and data was pulled on spss 22.0v for statistical analysis. pearson product correlation was applied for seeing the correlation between social anxiety & life satisfaction scores. table 1: pearson’s correlation between social anxiety & life effectiveness life effectiveness social anxiety life effectiv eness social anxiety pearson correlation sig. 1-tailed n pearson correlation sig. 1-tailed n 1 106 -.343** .000 106 -.343** .000 106 1 106 http://www.aeirc-edu.com/ junaid ahmed 14 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 **correlation is significant at the 0.1 (1-tailed) discussion in the present study, alternate hypothesis is proved which showed by result the significant negative correlation between both variables (social anxiety & life-satisfaction). result supported to the hypothesis r= -343, p<0.01. previous studies on social anxiety & life-satisfaction also demonstrated that social anxiety has significant negative impact on life satisfaction (stein & kean, 2000). another study revealed that confidence, self-esteem & social interaction have a strong negative relation (saras on et al. 1990). brown (1991) reported in his study that people who found most popular among peers & social situation have more positive self-image & satisfaction in life. children who found social anxious also reported low social acceptance, self-esteem & interaction among peers (ginsberg, 1998). present study showed significant negative relation in among both variables but not enough strong correlation, it is nearby moderate relationship between both variables although other researchers reported strong negative correlation (stein & kean, 2000). it can be due to different confounding & extraneous variables that adolescent is age in which youngsters do not take interest participating in research which was observe during study. participant observed exhaustive due to lengthy questionnaire & language barrier (nonnative language questionnaire). it is also found female most cooperative than male participants. it is concluded that social anxiety affects the different domain of life-satisfaction and significant low performance found in daily activity. social anxiety also further leads to different disabilities in daily life. research defined that social anxiety convert in social anxiety disorder then it affects different areas of daily life (stein & kean, 2000). further researched for curing social anxiety disorders researches are being conducted in clinical setting which reported relationship of social anxiety & life satisfaction in the domain of cognitive behavioral therapy revealed that people who are facing social anxiety disorder found significantly low in life satisfaction. it is also showed that with the help of cbt their anxiety can be reduced and a significant result increase in their life satisfaction was measured after a series of sessions with patients of social anxiety disorders (eng, w. 2005). furthermore researched are necessary with good representative population in general public & for developing clinical implications of social anxiety disorder. references  ahmed, z. r., bano, n., ahmed, r. &khanam, s. j. (2013). social anxiety in adolescents: does selfesteem matter? asian journal of social sciences & humanities, 2(2), 91-98.  american psychiatric association (2013). diagnostic & statistical manual for mental disorders (dsm-v).  bibi, f., chaudhry, a.g., & awan, e.a. (2015). impact of gender, age & culture on life satisfaction. pakistan association of anthropology, islamabad, pakistan, sci.int.(lahore), 27(2), 16491652.  brown, l. & alexander, j. (1991). self-esteem indes examiner’s manual. austin, tx: pro-ed.  bugay, a. (2007). loneliness and life satisfaction of turkish university students. education in a changing environment conference, 371-376.  candilis, p.j., mclean, r.y., otto, m.w., et al (1999). quality of life in patients with panic disorder. journal of nerv mental disorders, 187, 429-434.  davidson, j.r.t., hughes, d.l., george, l.k., & blazer, d.g. (1993) . the epidemiology of social phobia: findings from the duke epidemiological catchment area study. psychological medicine, 23, 709-718.  diener, e.g., emmons, r.a., larsen, r.j., & griffin, s. (1985). the satisfaction with life scale. journal of personality assessment, 49(1), 71-75.  eng, w., coles, m.e., heimberg, r. g. &safren, s.a. (2005). domains of life satisfaction in social anxiety disorder: relation to symptoms and response to cognitive-behavioral therapy. journal of anxiety disorders, 19, 143-156.  ginsburg, g.s., la greca, a.m., & silverman, w.k. (1998). social anxiety in children with anxiety disorder: relation with social and emotional functioning. journal of abnormal child psychology, 26, 175-185.  hambrick, j.p., turk, c.l., heimberg, r.g., schneier, f.r., &liebowitz, m.r. (2004). psychometric properties of disability measures among patients with social anxiety disorder. journal of anxiety disorders, 18, 825-839.  john, f., adekunle, a., jamal, m. &tashia, b. (2011). religious commitment, social support and life satisfaction among college students. college students journal, 45(2), 1649-1652.  khatib, s.a. (2013). satisfaction with life, selfesteem gender and marital status as predictor of depressive symptoms among united arab emirates college students. international journal of psychology and counseling, 5(3), 53-61. http://www.aeirc-edu.com/ junaid ahmed 15 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188  la greca, a. m., lopezen. (1998). social anxiety among adolescent, linkages with peer relations and friendships. journal of abnormal psychology, 26, 83-94.  lieb, r., wittchen, h-u., hofler, m., et al (2000). parental psychopathology, parenting styles, and the risk of social phobia in offspring. american medical association; arch gen psychiatry, (57), 859-866.  naveed, s., sana, a., rehman, h., qamar, f., abbas, s.s., et al. (2015). prevalence & consequences of phobia, survey based study in karachi. j. bioequivavailab 7: 140-143. dio: 10.4172/jbb.1000228.  parket, g. (1983). affectionless control as an antecedent to adult depression: a risk factor delineated. arch gen psychiatry, (40), 956-960.  samaranayake, c.b. & fernando, a.t. (2011). satisfaction with life and depression among medical students in auckland, new zealand. new zealand medical journal, 124(1341) 12-17.  sarason, i.g., sarason, b.r., & pierce, g. (1990). social support: the search for theory. journal of social and clinical psychology. in s. cohen (ed). stress, social support and disorder. u.s.a.  schneier, f.r., heckelman, l.r., garfinkel, r., et al. (1994). functional impairment in social phobia. journal of clinical psychiatry, 55(8).  shin, d.c. & johnson, d.m. (1978). avowed happiness as an overall assessment of the quality of life. social indicators research, 5(1-4), 475-492.  stein, m., & kean, y. (2000). disability and quality of life in social phobia: epidemiological findings. american journal of psychiatry, 157, 1606-1613.  stein, m., mcquaid, j., laffaye, c., & cahillm (1999). social phobia in the primary medical care setting. the journal of family practice, 49, 514-519.  weiller, e., bisserbe, j., boyer, p., lepine, j., & lecrubier, y. (1996). social phobia in general health care: an unrecognized undertreated disabling disorder. british journal of psychiatry, 168, 169174.  wittchen, h., stein, m., & kessler, r. (1999). social fears and social phobia in a community sample of adolescents and young adults; prevalence, risk factors and co-morbidity. psychological medicine, 29, 309-323.  wittchen, h.u., fuetsch, m., sonntag, h., muller, n., & liebowitz, m. (2000). disability and quality of life in pure and comorbid social phobia. findings from a controlled study. europe psychiatry, 15, 4658.  yaremtchuk, s.v. (2014). age, gender and life satisfaction in early adulthood in the far east of russia. life science journal, 11(11), 161-165. http://www.aeirc-edu.com/ review article www.aeirc-edu.com volume 12014 page | 14 ©advance education institute & research centre-2014 understanding dreams waseem hassan preston institute of management sciences and technology corresponding author: abadallah.wh@gmail.com “royal road to the unconscious” as considered by dr. sigmund freud during his dream analysis in 1900 gives a good start to the philosophers when it comes to satisfy their theories in psychophysiological manner. during the early stages of human evolution, there have always been physical and materialistic needs that were to be fulfilled as a necessity of survival. dreams on the contrary, laid rest in the hands of myth and mysticism and hence been defined in illogical manner which were taken for granted by most of the scholars of the times. time passed, and the exploration of human psychology became extensively useful for medication and cure of gradually increasing diseases. the point of interest and consideration of scholars were merely diverted to the origination of dreams and the phenomenon of sleeping. it became feasible to study the psyche of behavior when the classification of conscious, sub-conscious, preconscious and unconsciousness were first made. dreams have been described by various scientists/psychological scholars as they perceived it to be. as i know and can judge, dream is an illusion or projection of visuals we see every day but with different scenarios we have never been through. it is a process in which the physiological aspects of the body and its psychological responses by the brain are stored in a part of the brain called sub-conscious. it is a part of the mind where the memories are saved and are highly approachable in dreams as all the other functions of the body are hibernated during sleep. dreams work on 1+1=2 principal. it states that a specific event, let’s say war, was seen in a movie by a person which was stored in his/her subconscious. later on after 3 days, he/she happens to go in a funeral and weeps a lot. now the emotions his/her mind perceives from both the movie and funeral was then combined when he’s asleep and the brain projects a scenario where that person stuck in an abandoned church where people are crying over their dead ones and the country is on war. a survey was done where 30 people were asked about being injured in dream and suffers pain in same part/organ of the body as they wake up from unbearable pain. out of all, 4 were able to state that something hit/bit them on the exact area while they were asleep while others were unable to find a reason. cause and effect is it called where both physiology and psychology is merged in a dream in a single moment of time. the observation was then conducted on a group of 10 people which were pinched while they’re asleep. every subject was pinched with increasing force to see at what point they wake up of pain. each and every subject explained a different type of scenario from a knife cut to a gunshot in the same part of the body which resulted that each subject undergo pain with their own psychological aspects of bearing specific amount of pain by predefined object which they’ve either been through in their life or have ever imagined to go through. now the fact about time; the pain which was injected for 3-5 seconds was felt for minutes in dream. this notifies that the time duration in dream and in this physical world is different from each other. one other aspect, which is still unsolved part of this puzzle, is that either the pain was expected before it is injected and brain projects similar scenario where subject is exposed to pain and the subject feels pain in reality and dream altogether. or that the subject feels pain in real and it is projected in dream bits of seconds later. out of all the types of dream which fascinates both psychophysiology and philosophy is lucid dreaming. it is such type of dream in which the person is fully aware that he is dreaming and hence controls his/her actions in dream. lucidity is a state in which a person accesses his consciousness in unconscious state, i.e. in dream. most of the lucidity is experienced when a person undergo a false awakening. a false awakening is a state in which a person wakes up in a dream and is convinced that he/she has woken up in physical reality. it usually occurs when a person experiences a dream within a dream. as soon as the dreamer realizes that he/she is still dreaming, the consciousness is activated within a dream. another fact which is attained by lucid dreaming is: as the level of dreaming increases, (dream within a dream within a dream and so on), the dreamer gradually loses controls on his/her basic senses. for example, a person cannot feel intense pain or shock in a dream and hence is awakened. similarly, the sense of pain is unable to experience in 2nd level of dreaming and as a person go deeper in dream, the basis senses would start to disappear/decrease gradually. dreams: from the eyes of scholars and researchers: since the beginning of the understandings of dreams to date, dreams have been divided in several types according to the behavior and nature observed by researcher’s globally. dr. sigmund frued (1900) said that dreams are useful in establishing the contents of the unconscious. since the foundation of unconscious is built in early years of life, before the age of five or six, and consists of repressed material from the psycho-sexual stages, dreams analysis constitutes only a few methods for studying early psychological development. frued separated the dreams in two kinds of contents: the manifest (conscious) content, a content in which a person dreams something and remembers it, and the latent (unconscious) content, which is then discovered by means of free association. another study was conducted by beck and hurvich (1959). they predicted that depressed patients are likely to have more manifest dreams with masochistic content than other non-depressed patients. they collected a number of dreams from both depressed and non-depressed patients who were scored, and their hypothesis was confirmed at an appropriate level of significance. carl jung (1960) was convinced that there was sufficient evidence in dreams and other types of material, e.g., myths and religion, which validated the concept of collective consciousness. while frued used dreams to study the beginning formative years of a person’s life, jung used them to explore the psychological development of the race. jung also observed, in contradistinction to freud, that dreams are oriented to the past as well as to future. they mark out for the individual, the proper path to a more complete actualization of personality and help reveal poorly developed parts of the personality. conclusion: dreaming is a wider and yet partially unknown aspect of human psychology which is still under exploration as the technology prospers. the above mentioned observations and theories play a review article www.aeirc-edu.com volume 12014 page | 15 ©advance education institute & research centre-2014 small part in a wider perspective of human evolution throughout time. it is to be understood that as technological and physical boundaries are being enhanced, the psychological aspects of dreaming and brain accessing is equally important. what my motto is, my observations and research about dreaming would become another step to conquer the complete understanding of dream psychology. as lucid dream makes a perception that we control the specific amount of senses in that dream and consider the dream as our reality, and realizes that we have more than these senses when we wake up, would it be possible that this physical reality is also a dream we are living and understanding this fact, would we be able to control more senses than we do now? references:  freud, s. (1953). distortion in dreams. the standard edition of the complete psychological works of sigmund freud.  beck, a. t., & hurvich, m. s. (1959). psychological correlates of depression: 1. frequency of" masochistic" dream content in a private practice sample. psychosomatic medicine, 21(1), 50-55.  jung, c. g. (2010). synchronicity: an acausal connecting principle.(from vol. 8. of the collected works of cg jung)(new in paper) (vol. 20). princeton university press. sadaf ahmed 1 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 mind body determination, insight connectedness neurons, chemicals, organs, heart emotions, behavior, cognition, beliefs editorial mind body & soul harmony sadaf ahmed & shamoon noushad corresponding author: sadaf@aeirc-edu.com psychophysiological science consider foundations of the mind is exemplified as mental processes influence the physiological state of the body and changes in the body's physiology influence thoughts, feelings and motivational behavior. however, harmony is a ubiquitous principle based on motivations arise from physiological need to preserve the integrity of the organism, via processes and the ways we process or react to our environment depends on our internal bodily state. for example, if we are thirsty or hungry, the manner in which we behave toward food stimuli differs and biases perceptions, hedonics, cognitions and memory. motivations drive behavior, while changes in the internal state of the body anticipate, facilitate or accommodate the consequences of motoric action. the result is an individual system in a state of vibrant instability internally that contributed to physical and social interaction with the external environment (jonah l., 2009). the individual make-ups of character and behaviors has emerged out of such patterns of chemical release. the mind is supposed to be a virtual entity, one that reflects the workings of the neural networks, chemical and hormonal systems in our brain (bennett, r. 2007 & kaku, 2014). it cannot be localized to particular areas within the brain, though the entire cerebral cortex and deep grey matter form important components. realization, sensitivity, conduct, intelligence, linguistic, impulse, energy, the urge to excel and intellect of the most complex kind are the product of the wide-ranging and multifaceted linkages between the different parts of the brain (santoro, 2009). likewise, anomalies attributed to the mind, such as the spectrum of illnesses dealt with by psychoanalysts are consequences of widespread aberrations, often in the chemical processes within different parts of the brain (pinker s. 2003). the psychophysiological connections being content mean diverse things to different individuals as it can base on a moral extent like charity, kindness, responsiveness and values whereas others associate these with substantial wealth, decent professions and high principles of living. in any case the esoteric world it is recognized that to achieve a truly rewarding and fulfilling life one must gain balance between soul, mind and body. congruence in the mind body and soul is the key to ultimate wellness and contentment, and as such attaining this balance should be an important goal for every individual (o’connor m., 2008 & zeman a. 2007). however, the understanding of physical and psychological existence of soul in connection with mind and body is still a rare thought. as most individuals rely on the phase and energy that is associated with the brain and body while totally ignoring the mind and soul (jonah l.2009). we as humans are aware of highly-competitive culture with multi variant stress and burdens with fast paced life that lead to disproportion of mind, body and soul. with this happening the fulfillment and contentment reduces and sufferings emerges like stress, angst, unhappiness, fear, dullness, low self-assurance and hopelessness. as humans we need to trust the understanding of nature and its physical as well as psychological existence (zeman a. 2007). let’s take one at a time like the physical body; known to designed for basic communications related to essentials, aversions, sensual insights. the actions and reactions are focused via senses i.e. vision, odor, flavor, touch, and hearing. these are all mere reflections of inner being and give a clear indication of state mind, body and soul harmony. in disordered mind, body and soul the out of alignment components lost the connections and the complex device of body become unserviceable (pandya, s., 2011). though the senses support the connection as with time they associate the way brain leads with adaptations in life choices and desires e.g. as brain get familiarize that it is in disharmony then the senses start mechanisms to satisfy an intellect of balance and harmony (bennett, r. 2007). the mind on the other hand can function at altered higher levels with the thought mechanism that energies our bodily experience (kaku, 2014), it is s o u l http://www.aeirc-edu.com/ mailto:sadaf@aeirc-edu.com http://trivedieffect.netcommlabs.net/ sadaf ahmed 2 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 postulated that it works with the brain as it happens in new born with the intuition and desire of suckling depending on need while over time the mind loses this strong connection to intuition as stimuli in the milieu start to impact performance. the soul is the third important part and supposed as core of being (santoro, 2009 & jonah l.2009). however, there are many cases reported when illness, mishaps or surgical procedures directly or indirectly resulted in altered behavior and personality with changes in memories, moods, and consciousness. a minor injury might even cause dramatic variations in personality. as brain is proven bench of selfawareness, intelligence, compassion, and ingenuity (o’connor m., 2008). the neurotransmitters and psychopharmacological agents are also here to crush the idea of soul as these can do physiological alteration to bring an individual to good and peace. and neuroscience has strong evidence s that soul cannot overcome biology, that’s why mental health can be lifted by the accurate medicine that shows the origin of moods as biological in nature ((pandya, s., 2011). the frontal lobes that are the latest parts of our brains to develop from the gestation also proofs that small drip in blood sugar levels can hinder self-control as these lobes require lots of energy to operate normally. a lot of times behind crankiness, irritability and related negative emotions are due to low energy supply to prefrontal cortex (santoro, 2009). cerebral good wil l , ease and lucidity to bring upon the philosophical mind in early teens made individuals so deep-rooted in very young age and there are some good scientific views explaining this enrichment of thoughts that what world knows as ‘strong soul’; science has always been the reason behind. being a psychophysiologist we are more influenced of the interpretations executed by brain as it received information via various spur and make us intellect well creature (sadaf a. 2013a). these sets of information’s are anthology from our right mind (bennett, r. 2007), that percept an emotional upshot and feel connected with things, situations, people and places, but to put it in here the sway that make one’s cognition and personality, so for the arriving information, the brain also have believed and past experience to be added in this fresh set of sensations. behaviors are also the other side of the coin that represents not only the thoughts but the state of mental health and complexities in brain. while all these behavioral patterns may be altered and can be recognized as certain psychiatric illness both mild and severe-from weak and confused personality to angry and hysteric personalities—these disturbances of brain functions affect feelings and thoughts. getting stressed in life causes both positive and negative loops of our brain to stimulates, the positive one makes us more conscious, emotionally tough and to deem in ourselves, while negative one just grime minds with regrets, moan and undignified believes (kaku, 2014). now this is the reciprocated spot where psyche has its role to play and no soul is completed without this astonishing existence (sadaf a. 2013 b). researchers have revealed many previously unknown aspects of goodwill and concern that can convincingly enlighten pure side of soul. it does not only support the view of the emotions as rational, functional, and adaptive origins in darwin’s expression of emotion in man and animals but also support the view that empathy and kindness are essential features of human brain which have their role in evolved human nature, ingrained in brain and its physiology that can commence and nurture the spirit of goodness in human being. our brains are all wired up to speak, to respond and to applaud and there are also recent evidences that realistically explain many worth experiencing human behaviors such as when a mother looks at her baby she experiences pure love compared to the sight of other children. it is also well demonstrated by distinctive bustle brain regions associated with the positive emotions, this could be related to other relations and associations as this wholesome impulse isn’t restricted to parents‟ brains however it’s an inborn human response entrenched into the wrinkled brain (jonah l.2009 & pandya, s., 2011). in other researches, the neuroscientists declared that serving relatives and others stimulate caudate nucleus and anterior cingulate i.e. the reward centers in brain which convey the feeling of bliss and satisfaction with our own will (sadaf a. 2013 b). the brain seems wired up to respond to others‟ suffering without a doubt and it makes a mind feel good when one can ease misery of people around. there is also a slack involvement of autonomic nervous system (ans) in adaptable blood flow and breathing patterns for different sort of events and related feelings. the ans is responsible for various actual physiological alterations in heart rate that can be increased or slowed down. oxytocin endorses attachment and dedications, as well as makes us the unique brand of nurturing deeds like concern, overpowering sentiment of affection and association we feel towards our dear ones. indeed, breastfeeding and massages elevate oxytocin levels in the blood. an affectionate smile, a kind, responsive gesture and positive vibes can produce more oxytocin causing a http://www.aeirc-edu.com/ sadaf ahmed 3 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 chemical reaction in the body that motivates us to be even more concerned (sadaf a. 2013a). expression of love, care, gratitude and pleasure through nonverbal signals also promote many adaptive functions to pacify people who are in pain or sorrow. it allows others to discover the goodness of souls of those with whom they feel connected and helps strengthen relationships. one of the most valuable nonverbal signals is touch, conveyed by human skin receptors that have the ability to convert pattern of tactile stimulation like a pat on the back or hug into deep-seated feelings. many convincing and positive touches can elicit the release of oxytocin that adds up warmth and pleasure in such gestures (sadaf a. 2013 b). many researches also shed light on the collective functions of concern associated with the way people expect thankfulness and appreciation from loved ones that might rely on touch to soothe, reward, and bond in daily life that robustly points out human nature, a universal gift of communication and indulgence. inspiring altruism is a precious feeling that reflects selfless behavior which not only fills up human capacity with moral opinions and social bonds but even allows us to be noble human beings and to act in a self-serving way, deeply rooted in human nature. it has natural roots from brain to body (sadaf a. 2013a). care and gratitude all the way through gestures and feel, and this exhibit of emotions, love and warmth can dish up collective life purposes that are full of essence and soul. on the other hand, evolution of human nature by experiences, selfish concerns and other mean motivations can lead to negative, down beat and egotistical apprehensions. cultivation of this goodness, kindness, gratitude and thankfulness is a part of our heritable characteristics, recent studies in compassion also suggest that constructive emotions are less heritable and poorly determined by our dna when compared with negative emotions and highly dependent on environmental input such as psycho-social impacts. sometimes mind set up and decide to ‘get honest mode’ but these pleasures keep brain in denial of that honest voice within and the filthy voice with in influence that i can’t give up this pleasure!!! and individuals keep denying their thought processes (pinker s. 2003). mounting cerebral simplicity is an easier said than done task that can be an outcome of the mind’s attitude reliant on inner instincts. the study of the brain, mind and soul has engaged some of the finest intelligences of pasts. it remains an ennobling and stirring quest, worthy of all those who are dedicated votaries of science. references  bennett mr1. 2007 development of the concept of mind. aust n z j psychiatry. ;41(12):943-56.  pandya, s. k. (2011). understanding brain, mind and soul: contributions from neurology and neurosurgery. mens sana monographs, 9(1), 129– 149. http://doi.org/10.4103/0973-1229.77431  zeman a. 2007. sherrington’s philosophical writings–a ‘zest for life’ brain. ;130(8): p1984– 1987  kaku (2014), "the future: mind beyond matter", digital location 4468-4495  jonah lehrer (2009)"the decisive moment: how the brain makes up its mind" p148-149.  santoro g, wood m.d, merlo l, anastasi g.p, tomasello, francesco g. a. 2009 the anatomic location of the soul from the heart, through the brain, to the whole body, and beyond: a journey through western history, science, and philosophy. neurosurgery. ;65: p633–643  pinker s. 2003. the blank slate. the modern denial of human nature. new york: penguin;  o’connor m-f, wellisch d.k, stanton a.l, eisenberger n.i, irwin m.r, lieberman m.d. 2008 craving love? enduring grief activates brain’s reward center. neuroimage. ;42: p969–972.  sadaf ahmed. 2013 a my brand is gratefulness what’s yours????? escalating research volume 2, issue 3; 12-13.  sadaf ahmed. 2013 b. most needed sanitation of minds!!!! escalating research volume 2 issue 4 page | 7 -9. http://www.aeirc-edu.com/ https://www.ncbi.nlm.nih.gov/pubmed/?term=bennett%20mr%5bauthor%5d&cauthor=true&cauthor_uid=17999267 https://www.ncbi.nlm.nih.gov/pubmed/17999267 http://doi.org/10.4103/0973-1229.77431 http://www.amazon.co.uk/exec/obidos/asin/1847673139/65536-21 http://www.amazon.co.uk/exec/obidos/asin/1847673139/65536-21 syeda farah batool 43 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 original article life hassles; cause and effect relations among diverse age groups syeda farah batool1, shamoon noushad1,2 & sadaf ahmed1,2 1psycho-physiology research lab, university of karachi 2advance educational institute and research centre corresponding author: emanraza14@gmail.com abstract this study was done to evaluate the basic cause of trauma among people of different ages. stress levels in subjects were observed and their reported symptoms were analyzed on the basis of physiological indications towards neurological disorder. impact of stress on individual’s mental health and social life were determined. sadaf stress scale (sss) was used to determine the level of stress in subjects, a questionnaire based performa was filled for evaluation of physiological symptoms regarding their trauma. subjects were divided into four groups according to their ages. moderate to severe stress was observed among the age group of 18-24 and 25-31, and severe stress was found in 32-38 while subjects lying in last age group i.e. 40+ were in least stress. a cause of trauma varies among different age groups. stress does have a great impact on nervous system by altering and modulating its function. continuous exposure to stress or stressful environment can cause severe damage to memory and perception, which either lead you to severe psychological issues or may tempt you to commit suicide. introduction an individual can be a fruitful addition to the society if the person realizes his potential and has a stamina to fight with the daily stresses of life, but all this is only possible if a person is mentally healthy (shamoon naushad et al.,). a nation cannot proceed onto the track of success if the people are not mentally healthy. as pakistan is going through the worst law and order conditions and has emerged as a country with limited resources or a country which is unable to utilize its resources. people of different age group are suffering from various type of stresses now a day especially in karachi. these traumatic stresses are leading them to state of depression, especially people of young to middle age are the most affected categories among all. trauma is basically a reflex action of a negative event that utterly affects the individual’s mental and emotional state (hogan et al., 2014). according to national institute of mental health (nihm), trauma is not always associated with being a part of that traumatic event, it can also occur just by watching the event from a distance. there is no age or gender restriction to sustain trauma from a trauma-inducing event, although the rate at which an individual is affected varies from person to person (hogan et al., 2014). materials and methods individuals of age between 18-40 were investigated through a pre-designed questionnaire which determines the mental state of the subjects and evaluate the ultimate cause their trauma. sss (sadaf stress scale) is used as a tool for analyzing and grading the level of trauma from normal to severe. results were analyzed by using ms excel and spss version 16. to make the analysis easier and to identify the trauma in particular age and gender, we made groups according to their age and gender as follow and then concluded the results.  group a = 18-24 years  group b = 25-31 years  group c = 32-38 years  group d = 39-45 years  group e = above 45 years as we had the lowest number of subjects that fall in group d and e so we combine these group and make them a single group “d” that has subjects above 40 years. http://www.aeirc-edu.com/ syeda farah batool 44 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 results the above graph is showing the level of stress among individuals of different age groups, in which group a (18-24) and group b (25-31) has approximately similar numbers of subjects that are moderately and severely stressed subjects and has secured the second position in most stressed age group. the group that stays at top in most stressful age group is group c (32-38), which has the largest percentage of subjects that are severely stressed out. this graph represents the cause of trauma in the subjects of group a (18-24), in which the most reported cause was emotional abuse. collectively 41% of subjects reported admission and education related problems, while accidents and death of loved ones was reported by 37% subjects. another consequence of trauma, “domestic violence” was reported by 32% people. 42 44 0 56 3 0 10 11 21 19 40 22 34 37 50 11 0 50 100 a b c d n mi mo s 0 20 40 60 44.3 3.2 13 11.5 19.3 26 13 29 16.1 16.1 13 26 8.3 17.9 0 20 40 60 80 37 4.3 12 2 32 37 0 71 21 39 43 6 6 22 http://www.aeirc-edu.com/ syeda farah batool 45 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 0 10 20 30 40 50 60 70 80 0 0 0 0 0 71.4 43 57.1 0 0 0 14.2 0 43 this graph is representing the reason behind the trauma of subjects belong to age group b (25-31), indicating that accident was the cause that affect 44.3% subjects of this group, while 29% reported emotional abuse and 26% reported unemployment as their cause of trauma. trauma of individuals of group c is illustrated in this graph. emotional abuse and death of loved ones were the most reported causes of trauma among this age group. individuals of group d has trauma that are mentioned in the graph above, which indicates that death of loved ones, emotional abuse and marriage as their cause of trauma, while 14.2% reported unemployment as consequence of trauma. fig# 1. is showing the case studies we have found during this study, in which a 42-year-old female with a very strong background of traumatic stress, was diagnosed with multiple sclerosis afterwards, even the worst case was observed during this study was a suicide attempted by a 24-year-old boy. 0 10 20 30 40 50 60 10 20 20 20 0 50 1 60 0 0 0 10 20 0 case# subject data stress lead them to 1. age: 42 gender: f multiple sclerosis 2. age: 24 gender: m suicidal attempt http://www.aeirc-edu.com/ syeda farah batool 46 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 psychological trauma sense of helplessness and fear disturbance in neurological and behavioral patterns discussion according to this study, people belong to age group a, b and c were the most affected ones from stress especially subjects of group c were found to be the most affected group that has the maximum numbers of subjects that are severely affected by their trauma. kathleen. j, moroz et al., 2005 concluded from a number of surveys done on us population regarding psychological trauma that the youth of united states of america was more psychologically affected by the stressful event than does the adult or old, but as far as this study was concerned it reveals that late adults are more affected by trauma than youth and adolescents, but the fact that we cannot see through is the level of stress that keep on increasing in adolescent and it showed itself with a bang at mid-aged individuals. this might be because of the regrets of past and unrevealed wishes. the cause of trauma could differ from age groups but the reason is just as mentioned above (peter a. levine et al., 1997). another factor that cannot be neglected in pakistan especially in karachi robberies, target killings, snatching and brutal attacks from terrorists have now became routine and almost every single person is a victim either direct victim or indirect (s. ahmed et al.,2014). this is the major reason why our population is suffering from that much emotional distress. emotional abuse, death of loved and accidents were the most reported cause of trauma of the individual while education related issues and unemployment stands just after the above three issues. the international labor organization (ilo) presented in the report “global employment trends” that the unemployment rate in pakistan was 5.17% in 2013 and it has been raised to 5.29% in 2014 (ali sidiki et al., 2014). this is an alarming situation for everyone that approximately 50% of our population is suffering from stress majority of them are young, and they are choosing death over life. as “the regional directorates of the ministry of law, justice and human rights in karachi, lahore, peshawar and quetta”, has revealed that 50% of the total suicidal cases reported in pakistan are because of poverty and economic crashes (the express tribune pakistan, 2010). unemployment is one of the most reported cause of trauma by the subjects of this study and they were suffering from severe stress, if this stress persist for a longer period of time it will start to alter behavioral and neurological pattern (w.miller et.al.,2014). table#1. (adapted from w. miller’s article entitled as “traumatic stress, oxidative stress, ptsd, neurodegeneration and cell aging hypothesis, 2014) conclusion stress does have a great impact on nervous system by altering and modulating its function. continuous exposure to stress or stressful environment can cause severe damage to memory and perception, which either lead individuals to severe psychological issues or may tempt ones to commit suicide. references  american psychiatric association (1994). diagnostic and statistical manual of mental disorders, 4th edn. washington, dc: american psychiatric association.  kathleen j. moroz, the effects of psychological tr auma on children and adolescents, june 30, 2005  ninds traumatic brain injury information page.  patricia a. resick, stress and trauma, january 1, 2001,  peter a. levine, waking the tiger, july 7th 1997 by north atlantic books.  sadaf ahmed1&2, shamoon noushad, sehrish shahzad, syed zain azher, adnan aziz, muhammad taha saleem, postraumatic stress disorder in karachites due to random events of violence. 2014  s ahmed, m shaukat, a hasni, s noushad, psycho-social stress as a risk factor for cognitive decline in houswives, 2011, indian journal of health and wellbeing 2 (5), 935-937  mark w. miller and naomi sadeh traumatic stress, oxidative stress and posttraumatic stress disorder: neurodegeneration and the accelerated-aging hypothesis, pmcid: pmc4211971, 2014  kay hagon m. t m.ed, the physiological effects of trauma and benefits of tomatis-based sound stimulation, 2014. http://www.aeirc-edu.com/ http://d.researchbib.com/f/4nljicpzzgmje1yzaiof93pp1wo250mj50y3ijot9umuzizgwxo3qhot9ump1zqjkfykouptilzf5jmtl.pdf http://d.researchbib.com/f/4nljicpzzgmje1yzaiof93pp1wo250mj50y3ijot9umuzizgwxo3qhot9ump1zqjkfykouptilzf5jmtl.pdf http://d.researchbib.com/f/4nljicpzzgmje1yzaiof93pp1wo250mj50y3ijot9umuzizgwxo3qhot9ump1zqjkfykouptilzf5jmtl.pdf https://scholar.google.com.pk/citations?view_op=view_citation&hl=en&user=nv7szaoaaaaj&citation_for_view=nv7szaoaaaaj:sp6oxdckpogc https://scholar.google.com.pk/citations?view_op=view_citation&hl=en&user=nv7szaoaaaaj&citation_for_view=nv7szaoaaaaj:sp6oxdckpogc http://www.ncbi.nlm.nih.gov/pubmed/?term=miller%20mw%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=sadeh%20n%5bauth%5d aatir h. rajput 21 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 original article relation between quality and quantity of sleep and psychological distress among hospitalized patients aatir h. rajput1, nimra aslam2, farheen yousaf 3 & muhammad muneeb4 liaquat university hospital1 & 4 lumhs research forum 1, 2, 3 & 4 sir cowasjee jehangir institute of psychiatry, hyderabad 1 & 4 liaquat university of medical & health sciences, jamshoro 1, 2, 3 & 4 corresponding email: aatirh.rajput@gmail.com abstract background sleep is a fundamental component of good health, however its promotion in acute hospital settings does not appear to be a priority. causes of sleep disruption are varied and include environmental and bio-cognitive factors, including pain, bright light, noise, anxiety and stress. the environmental and bio-cognitive consequences of sleep deprivation on the health and recovery of hospital inpatients are various. inadequate sleep can lead to both psychological and physiological consequences. objective this observational study was aimed at determining the pattern, quantity and quality of sleep and the prevalence, causes and effect of sleep deprivation / disturbance among patients hospitalized at the elective wards of a tertiary care hospital. methods this observational study was conducted from august 2015 to january 2016, upon a sample of 50 patients admitted to liaquat university hospital (who had spent at least 4 weeks at the hospital). the sample of patients (chosen via simple random sampling), were interviewed consecutively every morning for 4 days and their mean response was evaluated to account for irregularities in experience. data was collected using interview based structured questionnaire which included the 42 point das scale approved by australian center for posttraumatic mental health. the data was analyzed in spss v. 17.0 and ms excel 2013. results during the stay at the hospital, das score of depression, anxiety and stress all rose. the most reported bothersome elements that disturbed sleep included, pain (30%), noise (6%), and feeling of unease, irritation and panic (6%). majority of the sample comprised of female (56%) respondents coming from rural areas (74%) with a low socioeconomic background (86%). the quantity of sleep dwindled between (but not more than) 5 to 6 hours. the quality too (self-rated by the respondents did not rise above a value of 6.5. conclusion the conclusion is in line with our hypothesis. with the hustle and bustle happening at all hours in a hospital, patients have trouble getting adequate sleep, which has an evident the quality and quantity of sleep during their stay. owing to the belief that sleep-deprived patients are less likely to be fully active participants in their care. it is recommended that steps should be taken to deal with this problem on a priority basis. keywords sleep, depression, anxiety, stress, psychological distress. introduction sleep is a fundamental component of good health, however its promotion in acute hospital settings does not appear to be a priority. causes of sleep disruption are varied and include environmental and biocognitive factors, including pain, bright light, noise, anxiety and stress. the environmental and biocognitive consequences of sleep deprivation on the health and recovery of hospital inpatients are various. inadequate sleep can lead to both psychological and physiological consequences. hospitalized patients, particularly those who are critically ill, are known to have severe sleep fragmentation and disturbed sleep. the sleep typical of an ill patient is characterized by a predominance of wakefulness and light sleep (sleep stages i and ii), and a relative lack of rapid eye movement (rem) and deep sleep (delta sleep, formerly referred to as nonrem sleep stages iii/iv) (cooper ab. et al, 2000; aurell j. et al, 1985; freedman ns. et al, 2001; gabor j. et al, 2003). sleep deprivation is known to lead to several clinical, physiologic and psychological manifestations such as depression, anxiety and stress. dement and vaughan studied the effects of prolonged wakefulness, and observed that healthy volunteers who were sleep deprived would become confused, ill-tempered, and extremely sleepy; however, they never became either psychotic or hyperactively delirious (dement wc. et al, 1999). the longest observed case of sleep deprivation involved an 18-year-old who stayed awake for 264 hours. at times during his long-term sleep deprivation, he would become angry that he was not http://www.aeirc-edu.com/ mailto:aatirh.rajput@gmail.com aatir h. rajput 22 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 being allowed to fall asleep. he was not, however, reported to experience symptomatology consistent with hyperactive delirium or hallucinations (gulevich g. et al, 1966). however, if ill patients are subjected to wakefulness of even disturbed sleep for a fraction of the above listed experience, they are more prone to develop psychological distress. this observational study was aimed at determining the pattern, quantity and quality of sleep and the prevalence, causes and effect of sleep deprivation / disturbance among patients hospitalized at the elective wards of a tertiary care hospital. methodology this observational study was conducted from august 2015 to january 2016, upon a sample of 50 patients admitted to liaquat university hospital (who had spent at least 4 weeks at the hospital). the sample of patients (chosen via simple random sampling), were interviewed consecutively every morning for 4 days and their mean response was evaluated to account for irregularities in experience. data was collected using interview based structured questionnaire which included the 42 point das scale approved by australian center for posttraumatic mental health. the data was analyzed in spss v. 17.0 and ms excel 2013. results during the stay at the hospital, das score of depression, anxiety and stress all rose. figure 1: the mean stress levels rose continuously. starting from 2.4 and reaching up to 7.74. (i.e. a 3-fold rise) the increase in levels of stress was less marked, however the fact that it started from a higher baseline projected it well above anxiety. figure 2: the levels rose from a mean value of 5.9 to 8.83. http://www.aeirc-edu.com/ aatir h. rajput 23 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 3: depression reached the highest levels reported by either of the three factors gauged by the das scale. it started from 6.1 and went up till 9.76. the most reported bothersome elements that disturbed sleep included, pain (30%), noise (6%), and feeling of unease, irritation and panic (6%). figure 4: interestingly, majority of the patients either refrained from reporting any bothersome elements or were affected to such a less extent by the elements that they did not recognize them as bothersome. majority of the sample comprised of female (56%) respondents coming from rural areas (74%) with a low socioeconomic background (86%). the quantity of sleep dwindled between (but not more than) 5 to 6 hours. http://www.aeirc-edu.com/ aatir h. rajput 24 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 5: the who recommended sleep mark of 8 hours per 24 hours was from what the patients expected to get. even the best of the patients did not rise above 6 hours while the still less fortunate ones struggled to get 5 hours at best. the quality too (self-rated by the respondents did not rise above a value of 6.5. figure 6: the quality standards too were below the recommended levels and poor even to below average standards. discussion although previous investigators evaluating sleep patterns in hospitalized patients have demonstrated altered sleep architecture and sleep deprivation (richards k. et al, 1988; broughton r. et al, 1978; aurell j. et al, 1985; hilton b. et al, 1996), little is actually known about the effects that this casts on the psychological wellbeing of the patients. most of our current knowledge is based on studies evaluating only nocturnal sleep, rather than over 24-h periods (richards k. et al, 1988; broughton r. et al, 1978). two studies have monitored polysomnography continuously for ⩾ 24 h, albeit in only a total of 19 patients (aurell j. et al, 1985; hilton b. et al, 1996). hilton b. et al, 1996, demonstrated a mean total sleep time per 24-h period of 5.5 ± 3.4 h (range 0.1–13.3) in 10 patients with respiratory insufficiency. aurell and elmquist (1985) found the mean total sleep time http://www.aeirc-edu.com/ aatir h. rajput 25 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 per 24-h, to be 4.6 ± 1.6 h (range 0–7) in 9 postoperative patients. in addition to the reduction in total sleep time, these studies demonstrated altered sleep architecture with a predominance of stage 1 and 2 sleep, decreased or absent stage 3, stage 4, and rapid eye movement (rem) sleep, shortened rem periods, and sleep fragmentation. sleep distribution was also abnormal, as up to 50% of the total sleep time occurred during the day. the etiologies of these sleep disturbances in the hospital are presumed to be multifactorial, although little is actually known about the mechanisms responsible for sleep–wake cycle disturbances in the hospital. environmental stimuli are proposed to be the most disruptive factors to achieving sleep in the hospital (aaron j. et al, 1996; bentley s. et al, 1977; meyer t. et al, 1994; topf m, 1992; topf m. et al, 1993; cropp a. et al, 1994; woods n. et al, 1974). the environmental stimulus most often cited in the literature to disturb sleep is noise (bentley s. et al, 1977; meyer t. et al, 1994). several studies have shown that noise levels in the hospital are substantially higher than the environmental protection agency (epa) recommendations for maximum hospital room noise levels, both at night and during the day (bentley s. et al, 1977; meyer t. et al, 1994; woods n. et al, 1974, gowan n, 1979; falk s. et al, 1973) polysomnographic studies evaluating the effect of nocturnal icu noise on sleep in normal individuals in a sleep laboratory demonstrated decreased total sleep time, total rem time, and sleep efficiency, and increased rem latency and arousal index (number of arousals per hour of sleep). however, nocturnal polysomnographic studies of icu patients have only indirectly linked noise to sleep disruption by attempting to correlate environmental noise levels with arousals from nocturnal sleep. these studies had small sample sizes and were not designed to determine the specific etiologies of the sleep disruption. literature has demonstrated that although hospital patients subjectively experienced significantly poorer sleep quality in the hospital than at home, hospital noise was not perceived as the most disruptive environmental stimulus (freedman n. et al, 1973). hospital patients perceived frequent interruptions from vital signs and diagnostic testing to be as disruptive to achieving quality sleep as noise, although statistically no single environmental factor was perceived as significantly more disruptive than any other (freedman n. et al, 1973). our data however, shows pain to be a factor too, despite its absence from existing literature. this may be due to poorer care placed at relieving pain of the patients by the hospital. conclusion the conclusion is in line with our hypothesis. with the hustle and bustle happening at all hours in a hospital, patients have trouble getting adequate sleep, which has an evident the quality and quantity of sleep during their stay. owing to the belief that sleepdeprived patients are less likely to be fully active participants in their care. it is recommended that steps should be taken to deal with this problem on a priority basis. conflict of interest all the authors disclosed that there is no conflict of interest associated in the preparation of this article. acknowledgements we would like to acknowledge the intellectual assistance and technical support provided by lumhs research forum references  aaron j, carlisle c, carskadon m, meyer t, hill n, millman r. (1996). environmental noise as a cause of sleep disruption in an intermediate respiratory care unit. sleep. 19 (9), 707-10.  aurell j, elmquist d. (1985). sleep in the surgical intensive care unit: continuous polygraphic recording in nine patients receiving postoperative care. bmj. 290 (6474), 1029-32  aurell j, elmqvist d. (1985). sleep in the surgical intensive care unit: continuous polygraphic recording of sleep in nine patients receiving postoperative care. br med j. 290, 1029-1032.  bentley s, murphy f, dudley h. (1977). perceived noise in surgical wards and an intensive care area. bmj. 2, 16.  broughton r, baron r. (1978). sleep patterns in the intensive care unit and on the ward after acute myocardial infarction. electroencephal clin neurophysiol. 45 (3), 348-360.  cooper ab, thornley ks, young gb, slutsky as, stewart te, hanly pj. (2000). sleep in critically ill patients requiring mechanical ventilation. chest. 117, 809-818.  cropp a, woods l, raney d, bredle d. (1994). name that tone: the proliferation of alarms in the intensive care unit. chest. 105 (4), 1217-20  dement wc, vaughan c. (1999). the promise of sleep. new york. (delacorte press). http://www.aeirc-edu.com/ aatir h. rajput 26 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188  falk s, woods n. (1973). hospital noise-levels and potential health hazards. new engl j med. 289 (15), 774-81.  freedman n, kotzer n, schwab r. (1999). patient perception of sleep quality and etiologies of sleep deprivation in the intensive care unit. am j respir crit care med. 159 (4), 1155-62  freedman ns, gazendam j, levan l, pack ai, schwab rj. (2001). abnormal sleep/wake cycles and the effect of environmental noise on sleep disruption in the intensive care unit. am j respir crit care med. 163, 451-457.  gabor j, cooper a, crombach s, lee b, kadikar n, bettger he, hanly pj. (2003). contribution of the intensive care unit environment to sleep disruption in mechanically ventilated patients and healthy subjects. am j respir crit care med. 167, 708-715.  gowan n. (1979). the perceptual world of the intensive care unit: an overview of some environmental consideration in the helping relationship. heart lung. 8 (2), 340-2  gulevich g, dement w, johnson l. (1966). psychiatric and eeg observations on a case of prolonged (264 hours) wakefulness. arch gen psychiatry. 15, 29-35.  hilton b. (1976). quantity and quality of patient's sleep and sleep disturbing factors in a respiratory intensive care unit. j adv nurs. 1 (6), 453-68  meyer t, eveloff s, bauer m, schwartz w, hill n, millman r. (1994). adverse environmental conditions in the respiratory and medical icu settings. chest. 105 (4), 1211-1216  richards k, bairnsfather l. (1988). a description of night sleep patterns in the critical care unit. heart lung. 17 (1), 35-42.  topf m, davis j. (1993). critical care unit noise and rapid eye movement (rem) sleep. heart lung. 22 (3), 252-8  topf m. (1992). effects of personal control over hospital noise on sleep. res nurs health. 15 (1), 19-28  woods n, falk s. (1974). noise stimuli in the acute care area. nurs res. 23 (2) 144-50 http://www.aeirc-edu.com/ fahad khan 4 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 original article determinants of sleep quality among undergraduate students of universities of karachi fahad khan1,2, husna haroon2, hafsa murtaza2 & erum anwar2 1. civil hospital karachi, pakistan. 2. dow medical college, duhs karachi, pakistan corresponding author: husnadragneel@gmail.com abstract background: the goal of this study is to evaluate the extent to which caffeine consumption, cigarette smoking, technology use, and academics are associated with the sleeping habits of university students. methods: 643 undergraduate students aged 18 to 23 from five universities of karachi completed a cross-sectional survey about sleep patterns and lifestyle habits between december 2014 and november 2015. pittsburgh sleep quality index (psqi) was used to assess the sleep quality. data was entered and analyzed using spss version 22. pearson chisquare test was applied to determine relationship between sleep patterns and factors affecting sleep. threshold of significance was set at <0.05. results: majority of the participants (60.5%) reported poor sleep quality (psqi score >5), with an average psqi score of 6.5 (±3.033). sleep duration was less than 7 hours for 71.8% (n=462) of the participants. also, most participants went to bed between 9pm to 12am, with 52.5% of males (n=136) sleeping after 12am compared to 46.1% (n=177) of the females. other than energy drinks, no stimulant beverage showed significant relation with sleep quality. however, coffee, tea and energy drinks had a negative impact on sleep onset latency. smoking too showed an association with poor sleep quality (p-value <0.009) and delayed sleep onset (p-value <0.009). mobile phone was by far the most frequently used technological device. conclusions: poor sleep quality is prevalent among college students of karachi. behavioral habits like consumption of caffeinated drinks, smoking, and technology use are associated with increased odds of poor sleep quality. keywords sleep quality, psqi, technology, beverages, college students introduction college, a terminal educating and nurturing ground for professional education, is indispensable for the overall development and progress of any nation. it provides young individuals with the requisite skills for their preferred fields, along with enabling them to support themselves and contribute to their society. but the price paid can be dear. the hectic schedules, towering burden of studies and assignments, and the never ending stress of deadlines dispose individuals to constant self-neglect, not the least of which is compromise on their night-time sleep. on an average, a young adult needs around 8 hours of sleep per day (ohayon, carskadon, guilleminault, & vitiello, 2004; van dongen, maislin, mullington, & dinges, 2003). yet majority of the students are sleep deprived, as shown by one study in which 70.6% of the college students reported sleeping less than 8 hours with mean total sleep time being 7.02 hours (lund, reider, whiting, & prichard, 2010). college students are prone to sleep related problems (peltzer & pengpid, 2016; a. a. schlarb, d. kulessa, & m. d. gulewitsch, 2012). a research conducted among lebanese university students (kabrita, hajjar-muca, & duffy, 2014) found out that more than half of the students scored in the poor-sleeper category on the pittsburgh sleep quality index (psqi). sleep repairs physical and mental functions of one’s body and restores its normal activity along with consolidation of learning and memory (ohlmann & o'sullivan, 2009). the repercussions of compromising on sleep can be severe as sleep deprivation and unhealthy sleep hygiene can result in, loss of cognitive functions (wiebe, cassoff, & gruber, 2012), poor academic performance (dewald, meijer, oort, kerkhof, & bögels, 2010), as well as increased risk of road accidents (horne & rumbold, 2015). according to the current literature, chronic sleep loss has been shown to have a link with several common health problems, such as cardiovascular diseases, weight gain, type ii diabetes, poor memory, depression, digestive problems, and cancer (ohlmann & o'sullivan, 2009). http://www.aeirc-edu.com/ mailto:husnadragneel@gmail.com l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 fahad khan 5 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 voluntarily staying up late is only one part of the problem, however. different habits adopted by students contribute to unhealthy sleep hygiene; for instance, the untimely use of caffeine, cigarettes, and media devices. the present study is aimed at finding out the effect on sleep of these activities. caffeine has a well-documented effect on sleep quality. present in varying amounts in coffee, energy drinks, tea, soft drinks and even chocolate, it is commonly consumed by young adults. it was found that consumers of any stimulant beverage were 80% more likely to have poor sleep quality than nonconsumers (velez et al., 2013). drake et al (drake, roehrs, shambroom, & roth, 2013) showed that consuming caffeine 0,3 or even 6 hours before bedtime significantly disrupts sleep. electronic media occupies an indispensable niche in young adults’ life. increased portability and affordability has made these devices available to all and sundry. according to national sleep foundation 2006, almost all (97%) adolescents had at least one technological device in their bedroom. however, in concern with their effect on sleep, not only the frequency, but the time and duration of media use are essential variables to be examined. gradisar et al. (2013) reported in their research that 90% of american adolescents used some form of technology in the hours before bedtime (tv 60%, mobile 39%, computer/laptops 36%). they found a significant relation of evening technology use with sleep, where the quality of sleep and sleep latency were both affected by technology use in the hour before bedtime. high screen time was also found to have a positive significant relation with poor sleep quality among chinese college students (wu, tao, zhang, zhang, & tao, 2015). in pakistan, a few studies have been carried out on sleep quality of students (u. bhatti, rani, memon, & wali, 2015; surani et al., 2015). one study was conducted among school-going children which found that more than three-fourth of the secondary school children of karachi slept late, with homework and tv shows being more frequent reasons for later bedtimes, whereas parental influence was reported more by the early-sleepers (nusrat, khan, hamid, hussain, & kadir, 2012). the sleep habits of first and final year medical students have also been evaluated (a. a. bhatti et al., 2012). yet another research studied the relation between sleep and academic performance in medical students (waqas, khan, sharif, khalid, & ali, 2015). but, to the best of our knowledge, the present study is the first in pakistan to assess sleep quality with its determinants among college students in detail. methodology a) subjects: the study was approved by ethical review board of dow university of health and sciences. this was a cross-sectional study conducted in 5 private and public universities of karachi in late fall 2014 and early spring 2015. these include dow medical college, ned university of engineering and technology, karachi university, indus university and iqra university. subjects for this study were undergraduate students aged 18-23 years, who did not have any known disorder or acute or chronic psychiatric illness. approval to conduct this study was obtained from deans of all selected universities. b) apparatus/ equipment: 700 questionnaires were distributed among students, out of which 213 were sent through facebook via google docs as online forms. the students were also encouraged to pass on the questionnaires to students of other universities who could fit into our criteria. the remaining 487 were distributed hand-to-hand. students were first orally briefed about the purpose and importance of the study. those who expressed an interest were given the questionnaires after obtaining consent. the questionnaires were anonymous and no personal identifiers were collected. students enrolled in online or night time school programs were not included in the study. after excluding subjects of missing sleep quality components, the final analyzed sample consisted of 643 participants. a 32-item self-administered questionnaire, consisting of four parts was used. the first part comprised of demographics including age (years), sex, employment status, participation in physical exercise. height and weight were also asked for bmi and thresholds were set according to who protocol (underweight: <18.5kg/m2; normal: 18.5–24.9kg/m2; overweight:25.0–29.9kg/m2; obese: ≥30kg/m2) (samuelson, 1997). the second part consisted of pittsburgh sleep quality index (psqi), by which sleep quality was assessed (buysse, reynolds, monk, berman, & kupfer, 1989). it is a 19-item self-reported questionnaire that http://www.aeirc-edu.com/ l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 fahad khan 6 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 evaluates sleep quality over past month. it possesses 7 sleep components including sleep duration, sleep disturbance, sleep latency, habitual sleep efficiency, sleep medicine, daytime dysfunction, and overall sleep quality. the questionnaire was further modified by including bedtimes and arousal times on weekdays and weekends. these components yield a score of 0-3 with 3 indicating greatest dysfunction. all the components are summed up to give a total score (global score) from 0 to 21 with higher total score indicating poor sleep quality. participants with a score below 5 are referred to as good sleepers while those ≥5 are poor sleepers (buysse et al., 1989). the third part consisted of inquiry about technology use before bedtime over the past month. participants were asked about the presence of technological devices in the bedroom (tv, computer/laptop, mobile, video games, dvd) in yes or no format and frequency of technology use per week. questions were also asked about duration of device(s) used, the activities performed online, the contents viewed on tv/dvd and the type of music listened in the hour before bedtime. participants were also asked selfanalysis about the technology device affecting the sleep most and frequency of sleep disturbance due to technology use in a 4-point likert scale ranging from always to never. the fourth part consisted of questions on consumption of stimulants and academics. participants were asked if they consumed any caffeinated beverage during past month. those answering yes were further asked about type of caffeinated beverages (coffee, tea, carbonated soft drinks, energy drinks, others), frequency of use per week and their time of consumption. we asked the participants whether they smoked during the past month. those answering yes were asked further about number of cigarettes (frequency) smoked per week. in the academics portion we asked the participants about frequency of attending university per week, their study onset timings and grade points average (gpa). they were also asked their selfrating whether admission in university and academic stress affected their sleep. data were entered and analyzed using spss version 22 and microsoft excel 2013 for windows. frequency and percentages were calculated for categorical data and mean and standard deviation for continuous data. pearson chisquare test was applied to determine relationship between sleep patterns and other variables. threshold of significance was set at <0.05. results demographic characteristics and lifestyle habits: a total of 643 students completed the questionnaires. their average age was 20.03 ± 1.245 years. majority of the respondents were females 59.7% (n=384); lived with their family (93.1%); attended university daily (59.7%) and were unemployed (79%). about 62.4% said they exercised regularly or occasionally. only 6.8% (n=44) reported having stress. table 1 summarizes the demographic characteristics of respondents. sleep variables and patterns: majority of the participants, about 60.5% (n=389) reported poor sleep quality (psqi score >5), with an average psqi score of 6.5 (±3.033). sleep duration was less than 7 hours for 71.8% (n=462) of the participants with most sleeping 6 to 7 hours each night. mean sleep duration for weekdays was 6.82 (±1.758) and for weekends was 8.73(±2.695). for 67.5% of the participants sleep latency was ≤30 minutes. also, most participants went to bed between 9pm to 12am with majority of males 52.5% (n=136) sleeping after 12am compared to 46.1% (n=177) of the females. most of the females took daytime naps 60.4% (n=232) compared to 45.6% (n=118) males. the results are represented in table 2. association of sleep and lifestyle habits: there was no significant relationship between psqi and age, sex, bmi, place of living, employment, or education level. behaviorally, exercise and university attendance were not significantly related to psqi either. naps were found to decrease nocturnal sleep duration. 76.3% of the people who took naps had sleep duration of <7 hours compared to the 66.6% who did not (pvalue 0.006). http://www.aeirc-edu.com/ l%20 fahad khan 7 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 table 1: demographics and lifestyle characteristics of respondents variables n (n=643) % mean ± sd age(years) 20.03±1.245 gender male 259 40.3 female 384 59.7 educational level junior 233 36.2 sophomore 201 31.3 senior 209 32.5 employment status yes 65 10.1 no 578 89.9 exercise yes 401 62.4 no 242 37.6 smoking status yes 98 15.2 no 545 84.8 body mass index (bmi) underweight 212 33.0 normal 365 56.8 overweight 47 7.3 obese 19 2.9 table 2: sleep variables characteristics all n = 643 n (%) male n =259 n (%) female n = 384 n (%) p-value 1. tst (hours) <5 75(11.7) 35(13.5) 40(10.4) 0.536 5-6 163(25.3) 63(24.3) 100(26.0) 6-7 224(34.8) 85(32.8) 139(36.2) >7 181(28.2) 76(29.4) 105(27.4) 2.sol (minutes) 0-15 250(38.9) 108(41.7) 142(37.0) 0.669 >15-30 184(28.6) 72(27.8) 112(29.2) >30-60 105(16.3) 39(15.1) 66(17.2) >60 104(16.2) 40(15.4) 64(16.6) 3.bedtime 6pm-9pm 10(1.6) 2(0.8) 8(2.1) 0.024 >9pm-12am 321(49.9) 121(46.7) 200(52.0) >12am-3am 282(43.9) 117(45.2) 165(43.0) >3am-6am 30(4.6) 19(7.3) 11(2.9) 4.naps yes 350(54.4) 118(45.6) 232(60.4) <0.01 no 293(45.6) 141(54.4) 152(39.6) http://www.aeirc-edu.com/ fahad khan 8 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 table 3: consumption of caffeinated beverages and cigarette smoking stimulants frequency of consumption sleep quality n (%) pvalue sleep latency n (%) pvalue good sleep quality poor sleep quality <30 mins ≥30 mins coffee 0-3 times/week n = 530 205(38.7) 325(61.3) 0.355 367(69.2) 163(30.8) 0.04 ≥4 times/week n = 113 49(43.4) 64(56.6) 67(59.3) 46(40.7) tea 0-3 times/week n = 297 124(41.8) 173(58.2) 0.280 212(71.4) 85(28.6) 0.051 ≥4 times/week n = 346 130(37.6) 216(62.4) 222(64.2) 124(35.8) energy drinks 0-3 times/week n = 541 223(41.2) 318(58.8) 0.040 383(70.8) 158(29.2) <0.05 ≥4 times/week n = 102 31(30.4) 71(69.6) 51(50.0) 51(50.0) carbonated soft drinks 0-3 times/week n = 519 213(41.0) 306(59.0) 0.103 352(67.8) 167(32.2) 0.718 ≥4 times/week n = 124 41(33.1) 83(66.9) 82(66.1) 42(33.9) others 0-3 times/week n = 632 252(39.9) 380(60.1) 0.145 427(67.6) 205(32.4) 0.783 ≥4 times/week n = 11 2(18.2) 9(81.8) 7(63.6) 4(36.4) cigarette smoking smokers n = 98 27(27.6) 71(72.4) 0.009 55(56.1) 43(43.9) 0.009 non-smokers n = 545 227(41.7) 318(58.3) 379(69.5) 166(30.5) figure 1: frequency of technological devices used in the hour before bedtime. 292 337 604 491 140 364351 306 39 152 503 279 0 100 200 300 400 500 600 700 computers/ laptops tv dvd games mobiles music <4 times per week 4 times or more per week http://www.aeirc-edu.com/ fahad khan 9 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 caffeine consumption: overall, 548 respondents (85.2%) consumed at least one type of caffeinated beverage once during the previous month. tea was the most frequently consumed stimulant beverage (63.8%), followed by carbonated soft drinks (43.2%), coffee (35%), and energy drinks (29.8%). frequency of consumption of the 643 participants who consumed energy drinks greater or equal to 4 times per week 69.6% had poor sleep quality whereas 58.8% of those who consumed < 3 times per week had poor sleep. no significant association was found between other beverages and psqi. on the other hand, frequency of consumption of tea, coffee and energy drinks was found to significantly increase sleep latency by ≥30 minutes when consumed ≥ 4 times per week compared to 3 times or less per week consumption (table 3). no relation was found with sleep duration. time of consumption time of consumption of stimulant beverages was found to have a significant relation with psqi and bedtime of the respondents. latenight consumption of stimulant beverage led to poor sleep quality as demonstrated by 77.9% of latenight consumers having poor sleep quality compared to 57.1% of those who were not (p-value<0.01). also, majority of those participants (61.3%) consuming beverage in the morning had bedtimes before 12(p-value=0.003) whereas majority of the latenight consumers (67.3%, p-value <0.05) had their bedtimes delayed until after midnight. smoking: smokers (15.2%), who smoked during the previous month, showed poor sleep quality (72.4%) compared to 58.3% of non-smokers who had poor sleep quality (pvalue 0.009). also, more smokers showed delayed sleep latency as compared to non-smokers (pvalue 0.009) (table 3). furthermore, majority (80%) of respondents who woke up during the night to smoke displayed poor sleep quality and delayed sleep. technological devices: 98.25% of the participants had at least one technological device in their bedrooms, with 53% (n=341) having at least 3 devices in their bedrooms. mobile phones were found to be the most frequently used device in the hour before bedtime, followed by computer/laptops and television. (figure 1) those respondents who watched television (p-value 0.007), used mobile phones (p-value 0.012) or listened to music (p-value 0.001) in the hour before bedtime ≥ 4 times per week during the previous month had a greater tendency of having a sleep onset latency of greater than 1 hour compared to those who used those devices ≤3 times. also, increased television, dvd and music player usage had increased prevalence of poor sleep quality. 61.6% of those who used mobile phones more frequently had poor sleep compared to 56.4% of the people who used it less frequently, though the association was not significant. presence of videogames in bedroom had a significant relation with psqi. 72.9% of those who had video games in their bedrooms had poor sleep quality compared to 58.6% who did not (p-value 0.012). content viewed on television or activities performed online were not found to have any significant relation with sleep quality or other sleep variables. type of music listened to in the hour before bedtime was found to have a significant relation with sleep latency. 38.7% of heavy music listeners reported sleep onset latency of >30 minutes, whereas 29.9% of light music listeners and those who did not listen to any music had delayed sleep (p value 0.028). 43.1% of the respondents reported mobile phone being the major device affecting their sleep. yet, 78.4% said their sleep was never or rarely disturbed by any incoming call or text message. 36.2% of the participants admitted that their sleep was frequently or always affected by the use of technological devices. academics: gpa and study onset time of the participants were not found to have any significant relation with sleep quality or its variables. 35.9% of the students who attended university regularly reported a sleep onset latency of >30mins compared to the 29.6% of the ones who attended 2-4 times and 21.9% who attended once or less per week (pvalue 0.038). majority (75.6%) agreed that admission in university had altered their sleeping habits, while 54.7% of students reported that they always or frequently sacrificed their nocturnal sleep for studies and assignments. 39.2% of students admitted that they had difficulty sleeping due to anxiety for studies or academic stress. http://www.aeirc-edu.com/ fahad khan 10 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 discussion poor sleep quality as determined by psqi global score of greater than 5 was prevalent among majority of the university students, as was found in a prior study conducted among medical students of karachi (surani et al., 2015) and college students in north america (lund et al., 2010), as well as among lebanese (kabrita et al., 2014) and chinese university (suen, tam, & hon, 2010) students. also, majority of the participants slept between 912 am, a habit that was similar to the majority of german university students (72.4%) who went to bed between 10 pm and 12 am. on the other hand, unlike german students (angelika a schlarb, dominika kulessa, & marco d gulewitsch, 2012), most of whom (84.1%) fell asleep within 30 minutes, majority of university students of karachi had delayed sleep latency of ≥ 30 minutes. consumption of caffeine, cigarette smoking and sleep: caffeine, a well-known adenosinergic receptor antagonist, is one of the most widely consumed psychoactive substance mostly taken to restore low levels of wakefulness, modulate the activities of brain and improve task performance. our study reveals that caffeine consumption is prevalent among the undergraduate university students of karachi. majority of the poor sleepers are tea consumers, though it did not reach statistical significance, which corroborate with a similar study (hindmarch et al., 2000). the study also revealed that 3 out of 10 respondents consumed energy drinks, which is found to be strongly associated with sleep quality. this is in general agreement with prior studies (aslam et al., 2013; lemma et al., 2012; reissig, strain, & griffiths, 2009; velez et al., 2013). besides caffeine, which is the main stimulant of energy drink, it may also contain other stimulating ingredients. the amino acid, taurine, a frequent ingredient in energy drinks, is thought to increase the effects of caffeine (rath, 2012). out of all the sleep quality variables, only sleep latency is found to be associated with frequency of caffeine consumption (tea, coffee, energy drinks), no other sleep parameters approached significance. majority of the respondents who said that they consumed beverages right after wake up had early bedtimes, that is, before midnight, while more than half of the late night consumers reported going to bed after midnight. more than three fourth of the late night consumers are poor sleepers. thus, morning consumption is not found to be associated with sleep quality whereas late night consumption showed significant impact on sleep. the results are in accordance with previous findings (drake et al., 2013). however, this result is contrary to some previous studies that found no association between caffeine use and sleep quality (brick, seely, & palermo, 2010; lund et al., 2010). investigators have shown that caffeinated beverages have a dosedependent negative effect on sleep onset, sleep time, and sleep quality (hindmarch et al., 2000). however, we did not have information regarding dose of caffeine consumption to confirm previous findings. smokers demonstrated considerably more often than never smokers an overall reduced sleep quality represented by a psqi global score of above 5. this was consistent with the results of previous researches (araujo et al., 2014; cohrs et al., 2014). furthermore, the finding of a disturbed sleep latency with a higher number of smokers reporting an increased time to fall asleep is in accordance with studies reporting smokers to have more difficulty getting to sleep (botelloharbaum, haynie, murray, & iannotti, 2011; cohrs et al., 2014; mcnamara et al., 2014) on the other hand, variables such as sleep duration and bedtime did not show any significant association with smoking. no significant association was found between the number of cigarettes smoked per day and sleep quality or sleep duration, as was found in a prior research (cohrs et al., 2014). however, our study found that increased sleep latency was found to be associated with a decreased number of cigarettes smoked (table 3). a possible reason could be the role of other confounding factors affecting sleep. electronic media and sleep: we studied the effect of technology usage on sleep of young adults. considering the extent to which media devices have infiltrated our day to day lives, it was not surprising to find that there was an association found between the frequency of use of television, cell phone and music player, and the sleep onset latency. those who used these devices ≥ 4 times per week had more chance of having sleep latency of greater than one hour, compared with those people who used the devices ≤ 3 times per week. this finding is consistent with that of previous studies (u. bhatti et al., 2015; gradisar et al., 2013; polos et al., 2015) which found that the stimulating activities performed on interactive devices (cell phones, computers, video games) in the hour before bedtime were associated with difficulty falling asleep. it is possible that the cognitive and physiological arousal resulting from their usage http://www.aeirc-edu.com/ l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 fahad khan 11 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 inhibits normal sleep initiation (ivarsson, anderson, åkerstedt, & lindblad, 2009; weaver, gradisar, dohnt, lovato, & douglas, 2010). it has been found that evening exposure to led-backlit computer screens, despite increasing the cognitive functioning, can suppress melatonin and interfere with our normal sleep cycle (cajochen et al., 2011). a recent research further highlighted the positive correlation between poor sleep quality and greater texting and ipod dependence (ferraro, holfeld, frankl, frye, & halvorson, 2015). an interesting finding was that the type of music listened to in the hour before bedtime was significantly associated with sleep onset latency. individuals who preferred listening to heavy music reported greater difficulty in falling asleep as compared to those who listened to light music or none at all. studies show that while soothing music is conducive to relaxation and falling asleep (de niet, tiemens, lendemeijer, & hutschemaekers, 2009) and can improve sleep quality in insomniacs (harmat, takacs, & bodizs, 2008), music can also elevate the heart rate and thus play a role in maintaining arousal and causing difficulty in falling asleep (bonnet & arand, 2000). even though 43.1% of the entire sample reported cell phones to be the device which most affected their sleep, majority (78.4%) claimed that their sleep was never or rarely disturbed by an incoming call or text. in light of a research conducted among americans (gradisar et al., 2013) which found that 10% of all the participants went to bed with the cell phone ringer turned on and consequently had difficulty returning to sleep after an awakening, a possible reason for the present finding could be that those participants left their ringer turned off. academics and sleep: sleep problems in university students might lead to suppressed academic performance (genzel et al., 2013; haraszti, ella, gyongyosi, roenneberg, & kaldi, 2014; lund et al., 2010). one cannot remain refreshed and alert in university after insufficient or poor sleep the night before. our findings showed that 6 of 10 participants regularly attended the university during past month. of those, majority of the students went to bed before midnight. however, more than half of the students, who attended the university ≤ 1 time per week, went to bed after midnight which reached significance. an overwhelming 39.2% of students stated that academic stress negatively impacted their sleep. this is consistent with the results of a previous study (lund et al., 2010). prior studies also reported that later bedtimes are more likely to affect one’s academic performance than short sleep duration (genzel et al., 2013; haraszti et al., 2014). limitations of the study: our study has certain limitations. the non-longitudinal and cross-sectional nature of the study made it impossible to infer causality i.e. what came first. data collection was done using self-reported questionnaires which might lead to recall bias. respondents were inquired about their past month only, without taking into consideration their academic schedules, which could have influenced on their sleep quality ratings. sleep quality was assessed using psqi having cut-off value 5, below which are good sleepers and above are poor sleepers. this grouping leads to substantial heterogeneity among large group of poor sleepers, hiding essential correlations. finally, we asked the respondents about frequency of consumption of stimulants without asking them brands (companies) and dose of consumption (in grams or milligrams). it might be possible that caffeine content varied for beverages/stimulants of different brands. future researches must use sleep/health diaries for subjective measures or actigraph for objective measures so that their self-report biasing might be eliminated. conclusion in summary, poor sleep quality is prevalent among college students of karachi, pakistan. despite the aforementioned limitations, we found evidence that behavioural habits like consumption of caffeinated drinks, smoking, and technology use can adversely affect sleep to various extents. considering these factors are the zeitgeist of youth, and have many benefits if used wisely, interventions can be made to ensure that students are benefited more than harmed by them. college students in karachi, indeed all over pakistan, need to be made aware of the impact their activities have on their sleep. emphasis needs to be placed on the fact that it isn’t simply how often they perform these activities, but also the time that is important and with proper education we can hope for students to adjust their schedule such that due importance is given to night time sleep. acknowledgements the authors thank tayyab raza fraz, for his contribution in the early stages of data input and analysis. http://www.aeirc-edu.com/ l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 l%20 fahad khan 12 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 conflicts of interest all authors declare that they have no conflict of interest. disclosure of financial support the authors have not used any financial support references  araujo, m. f., freitas, r. w., lima, a. c., pereira, d. c., zanetti, m. l., & damasceno, m. m. 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(2012). sleep characteristics, sleep problems, and associations of self-efficacy among german university students. nature and science of sleep, 4, 1.  suen, l. k., tam, w. w., & hon, k. l. (2010). association of sleep hygiene-related factors and sleep quality among university students in hong kong. hong kong med j, 16(3), 180-185.  surani, a. a., zahid, s., surani, a., ali, s., mubeen, m., & khan, r. h. (2015). sleep quality among medical students of karachi, pakistan. j pak med assoc, 65(4), 380-382.  van dongen, h. p., maislin, g., mullington, j. m., & dinges, d. f. (2003). the cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. sleep, 26(2), 117-126.  velez, j. c., souza, a., traslavina, s., barbosa, c., wosu, a., andrade, a., . . . williams, m. a. (2013). the epidemiology of sleep quality and consumption of stimulant beverages among patagonian chilean college students. sleep disord, 2013, 910104.  waqas, a., khan, s., sharif, w., khalid, u., & ali, a. (2015). association of academic stress with sleeping difficulties in medical students of a pakistani medical school: a cross sectional survey. peerj, 3, e840.  weaver, e., gradisar, m., dohnt, h., lovato, n., & douglas, p. (2010). the effect of presleep video-game playing on adolescent sleep. journal of clinical sleep medicine: jcsm: official publication of the american academy of sleep medicine, 6(2), 184.  wiebe, s. t., cassoff, j., & gruber, r. (2012). sleep patterns and the risk for unipolar depression: a review. nature and science of sleep, 4, 63.  wu, x., tao, s., zhang, y., zhang, s., & tao, f. (2015). low physical activity and high screen time can increase the risks of mental health problems and poor sleep quality among chinese college students. plos one, 10(3), e0119607. http://www.aeirc-edu.com/ maria mirza 20 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 short communication attention deficit hyperactivity disorder (adhd)a matter of concern. maria mirza dadabhoy institute of higher education corresponding author: maria@aeirc-edu.com attention deficit hyperactivity disorder (adhd), a serious neurodevelopmental disorder that is associated with deterioration in various domains of major life activities. however, various exceptional cases with the disorder may be observed functioning well in some areas of life (e.g., michael phelps and swimming, ty pennington and destroying and rebuilding houses, glenn beck and political commentary, etc.), they probably have conflicts with other areas of functioning (dwis, managing money, social relationships, etc.) but even if well-altered, these exceptional success stories do not represent the more typical reactions of children with adhd followed to adulthood. it is one of the most difficult diagnoses to classify as evident from changing definition norm observed in the revisions of diagnostic and statistical manual (apa 1980, apa 1987, apa 1994). adhd is reportedly the most pervasive disorder of childhood influencing approximately 3% to 5% of school-aged children with prevalence rates increasing significantly over the past two decades (pastor & reuben, 2008; timimi & radcliffe, 2005). children with adhd struggle with symptoms of inattention, hyperactivity, or impulsivity above and beyond what is developmentally appropriate. adha is diagnosed in childhood, most of the children diagnosed with adhd exhibit symptoms that persist into adolescence and adulthood (langley et al., 2010). inattention in adhd patients can be seen in social, occupational, and academic settings, accompanied with difficulty sustaining attention, difficulty in completing tasks, not following through on instructions and requests, and inability to complete chores and schoolwork. hyperactivity symptoms may include wiggling fidgeting, inability to sit still in classroom settings, being always “on the go,” and excessive talking, while a symptom of impulsivity is difficulty waiting their turn and restlessness. it should be noted that in the new diagnostic and statistical manual of mental disorders (5th ed.; dsm-5; american psychiatric association [apa], 2013) criteria, an individual can be easily diagnosed with adhd to the age of 12 years but not at 6 years as was previously mentioned, while most of the symptoms must occur in more than one setting (yousesf m et al 2015). according to pliszka children with adhd suffer from conduct disorder and have a higher possibility of developing antisocial and uncommunicative personality disorder as adults, they also have anxiety and bipolar disorders with significant behavioral and emotional sequels. however the comorbidity of adhd and major depression is not much studied. 20% to 25% children also have difficulty learning (pliszka sr 1998). previously biederman, newcorn and sprich, have formulated that children with adhd have heterogeneous disorder, the available literature supports that there is a noticeable amount of comorbidity of adhd with conduct disorder, oppositional defiant disorder, mood swings, anxiety disorder, learning disabilities and other conditions like intellectual disability (biederman j et al 1991). even with lack of some neurophysiological or neurochemical basis for adhd, it is predictably accompanied with conditions causing minimal brain damage. hence, the possible factors for the developing adhd may include any prenatal, perinatal and postnatal problem that can be peered with brain damage. serious head injuries, meningitis, hydrocephalus, and brain surgery can also increase the risk of developing adhd (pasquale accardo 1999). adhd is best manipulated by a multidisciplinary team effort accompanied with pharmacotherapy usually with stimulant medications, behavioral interventions and environmental changes. in a developing country like pakistan there are few allied specialist services. dilemma is associated with poor awareness and acceptance on part of parents, teachers and health professionals. this is evident from low referral rate from schools and inadequate follow-up seen at our clinic. pharmacological management of adhd calls for prescription of stimulant medication like methylphenidate. there is significant refusal and controversy regarding the use of stimulant medication both on part of physicians and parents. there lies a battle against the use of chemical methods for management of adhd and a call upon a need to establish awareness regarding the prevalence of adhd and co morbid conditions and make efforts to developed links with the services and resource persons that are available both within the country and abroad (syed, e. u et al 2006). school teachers play a vital role argument notwithstanding, the interruption produced by adhd typed nature is undisputed. adhd behavior tends to worsen in ambiance where attention for long periods of time, silent activities, and waiting one’s turn is enforced (apa, 2013). such behaviors are needed within the formal classroom setting, and if other opportunities such as physical activity are not provided to equalize learning approaches, behavioral frustration can often first be encountered in school. http://www.aeirc-edu.com/ maria mirza 21 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 children with adhd are classified as being destructive in the classroom, have conflictual relationships with family and friends, and are incapable to understand social cues and experience academic combat, which ultimately affect their life’s aspect (bender & smith, 1990; frick et al., 1991; hinshaw, heller, & mchale, 1992). while the initial challenges of inattention and classroom disruption along with primary school decline in secondary school, as well as secondary school students with adhd often face an academic challenge and the dissatisfaction associated with declined conduct (travell & visser, 2006). all of these conditions mean that students with adhd are often at greater risk of school dropout and academic defeat (bussing, mason, bell, porter, & garvan, 2010). these findings depicts the important role that teachers play in identifying children who need extraordinary support, making referrals for their assessment, and being able to incorporate them in the classroom (sherman, rasmussen, & baydala, 2008). as such, within upcoming years, there has been a huge emphasis on teachers’ knowledge and practice toward adhd. conclusion of several studies from different parts of the world shows that teachers’ knowledge is at best reasonable and in many cases, insufficient, requiring intervention (ghanizadeh, bahredar, & moeini, 2006; nur & kavakc, 2010; perold, louw, & kleynhans, 2010; west, taylor, houghton, & hudyma, 2005). the prevalence of adhd the prevalence is conservatively estimated as being from 3% to 7% of the school age children in the united states (apa 2000). the prevalence of adhd in pakistan has been found to be around 2.49% (karim r et al.1998). boys with adhd outnumber girls, but ratio varies significantly from 2:1 to 9:1. gender differences are less obvious for inattentive type of adhd. boys are more likely to be aggressive and to have other behavioral problems (guab m et al 1997). adhd children make up 30-40% of referrals to child mental health practitoners (barkely ra 1998). adha was believed to be outgrown in mid to late adolescence. it is now declared that two thirds of children with adhd will continue to have problems leading adhd as adults and because adhd is a chronic disorder, will require treatment throughout their lives (resnik rj 2000). the causes of adhd the etiological pathways for adhd are not known but the recent hypotheses regarding etiology of adhd are as follows: genetic factors: parents having children with adhd are affected by adhd themselves, suggesting a significant genetic component (biederman j et al 1992). the random chance of parents with a child who has adhd, having another child with adhd is about 1 in 3(breslau n et al. 1996). brain damage: it has been suggested that some children affected by adhd suffered serious damage to the central nervous system and brain development during their fetal and perinatal periods. it may be associated with circulatory, toxic, metabolic, mechanical or physical insult to the brain during early infancy caused by infection, inflammation, and trauma. (milberger s et al. 1997; thapar a et al. 2003) neurochemical factors: the most widely studied drugs in the treatment of adhd, the stimulants, alter both dopamine and norepinephrine, leading to neurotransmitter hypothesis that include possible decline in both dopaminergic and noradrenergic systems. neurophysiological factors: eeg event related potentials suggest an arousal dysfunction related to hypo reactivity to salient informative stimuli. thus the individual with adhd is relatively unable to recognize his or her sensations of salient informative stimuli. this results in the paradoxical reaction to stimulant medication, where individuals with adhd become less instead of more active after taking stimulant medication, as they become more attentive to salient informative stimuli (cohen ra 1993). psychosocial factors: as per beiderman family-circumstances variables such as severe marital discord, large family size, paternal misconduct, maternal mental disorder and anxiety, and foster care placement are associated with the possibility factors in the development of adhd. diagnosis according to diagnostic and statistical manual of mental disorders-1v (apa 2000). * children having six of nine symptoms to qualify for either the inattentive or hyperactive/ impulsive subtypes of adhd, or six of nine symptoms of both subtypes to qualify for the combined type. * symptoms must have been present before the age of seven. * symptoms must create impairment in two or more settings (e.g. home, school, and neighborhood). * symptoms must cause clinically significant deterioration in social, academic or occupational functioning. adhd symptoms fall into two major categories as shown below in the table. dsm-1v identifies three subtypes of adhd as predominantly inattentive type, predominantly hyperactive/ impulsive type and combined types. the icd 10 (international classification of diseaseswho) diagnosis of hyperkinetic disorder is the briefer category. in icd 10, all three problems of inattention, hyperactivity and http://www.aeirc-edu.com/ maria mirza 22 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 impulsivity should be present, the presence of another disorder such as anxiety state is in itself an exclusion criteria the expectation is that most cases will have a single diagnosis. inattention hyperactivity/impul sivity * failing to concentrate for details or making careless mistakes when doing schoolwork or other activities. * difficulty retaining attention in tasks. * appearing not to listen, when spoken to. * failing to follow instructions or finishing tasks. * problematic for organizing tasks and activities. * avoidance of the tasks requiring high amount of mental effort. * frequently losing items required to facilitate tasks or activities. * distractibility. * forgetful in daily chores. * fidgeting with hands or feet or squirming in seat. * leaving seat often, even when inappropriate. * running or climbing at inappropriate times. * difficulty in quiet play. * often on the go. * excessive talking. * answering a question before the speaker has finished. * failing to wait one’s turn. * distracting the activities of others at inappropriate times. management adhd children have many problems which can usually be managed along with psycho education, behavioral intervention, medication and diet also used for children with hyperkinetic disorders, multimodal intervention is usually indicated (nice 2002). psycho educational measures awareness regarding illness symptoms, etiology, clinical course, prognosis, and treatment should be provided. counseling with school after parental allowance is mostly needed. parent training and behavioral interventions in the family: these interventions have been shown to be very effective (pelham we et al 1998).according to expert consensus guidelines (conners ck et al 2001) behavioral-psychosocial treatment is an effective first level treatment in the following instances: * for milder adhd. * for pre-school–age children with adhd. * when there is the presence of co-morbid internalizing disorders and social skills deficits. * when the family prefers psychosocial treatment. the most effective and relevant technique is to pay positive attention to appropriate behavior and compliance, giving commands more effectively, and using appropriate negative consequences for problem behaviors. behavioral interventions in the school: it is effective in minimizing hyperactive behavior and promoting social adjustment. some behavioral interventions which are found to be helpful in classrooms include (austin vl 2003). * child should be seated near to the teacher. * brief academic assignments. * reinforcement and reiteration. * posting daily schedules and assignments. * using graphic organizers. * providing a notebook for writing down the homework assignments. * interspersing classroom lectures with short periods of physical exercises, may be useful psychopharmacological treatment there is significant evidence for the use of medications in the treatment of adhd. the challenge for the doctor is to establish a treatment regimen that has a rapid predictable onset of action, duration of action that does not require re dosing, no negative side effects (e.g. sleep problems, eating disorders, mood swings) and advantageous effect on co morbidities. conclusions adhd has proceeded from the 20th century with a huge amount of scientific work questioning and investigating its validity and simplifying clinical controversies. the disorder is greatly prevalent worldwide, is associated with significant impairments and frequently persists in adulthood. the emerging knowledge about the causes and pathophysiology of adhd should lead to an improved understanding of the neural mechanisms underlying the disorder, which should upgrade and promote diagnostic and treatment strategies. references •american psychiatric association. 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(2008, july). diagnosed attention deficit hyperactivity disorder and learning disability: united states, 2004-2006 (vital and health statistics series 10, no. 237). hyattsville, md: u.s. department of health and human services, centers for disease control and prevention, national center for health statistics. •timimi, s., & radcliffe, n. (2005). the rise and rise of attention deficit hyperactivity disorder. journal of public mental health, 4(2), 9-13. •langley, k., fowler, t., ford, t., thapar, a. k., van den bree, m., harold, g., . . .thapar, a. (2010). adolescent clinical outcomes for young people with attention-deficit hyperactivity disorder. the british journal of psychiatry, 196, 235-240. •youssef, m. k., hutchinson, g., & youssef, f. f. (2015). knowledge of and attitudes toward adhd among teachers. sage open, 5(1), 2158244014566761. •pliszka sr,. comorbidity of attentiondeficit/hyperactivity disorder with psychiatric disorder: an overview. j clin psychiatry, 1998;59;50-8. •biederman j, newcorn j, sprich s. comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders,1991; 148 (5);564-77. •pasquale accardo. a rational approach to the medical assessment of the child with adhd. pediatr clin north am 1999;46:845-56 •syed, e. u., naqvi, h., & hussein, s. a. (2006). frequency, clinical characteristics and co-morbidities of attention deficit hyperactivity disorder presenting to a child psychiatric clinic at a university hospital in pakistan.journal of pakistan psychiatry society, 3(2), 74-77. •american psychiatric association. (2013). diagnostic and statistical manual of mental disorders (5th ed.). arlington, va:american psychiatric publishing. •hinshaw, s. p., heller, t., & mchale, j. p. (1992). covert antisocial behavior in boys with attentiondeficit hyperactivity disorder: external validation and effects of methylphenidate. journal of consulting and clinical psychology, 60, 274-282. •bender, w. n., & smith, j. k. (1990). classroom behaviour of children and adolescents with learning disabilities: a meta-analysis. journal of learning disabilities, 23, 298-305. •frick, p. j., kamphaus, r. w., lahey, b. b., loeber, r., christ, m. a., hart, e. l., & tannenbaum, l. e. (1991). academic underachievement and the disruptive behavior disorders. journal of consulting and clinical psychology, 59, 289-294. •bussing, r., mason, d. m., bell, l., porter, p., & garvan, c. (2010). adolescent outcomes of childhood attention-deficit/ hyperactivity disorder in a diverse community sample. journal of the american academy of child & adolescent psychiatry, 49, 595-605. •travell, c., & visser, j. (2006). “adhd does bad stuff to you” young people’s and parents’ experiences and perceptions of attention deficit hyperactivity disorder (adhd). emotional and behavioural difficulties, 11, 205-216. •sherman, j., rasmussen, c., & baydala, l. (2008). the impact of teacher factors on achievement and behavioural outcomes of children with attention deficit/hyperactivity disorder (adhd): a review of the literature. educational research, 50, 347-360. •ghanizadeh, a., bahredar, m. j., & moeini, s. r. (2006). knowledge and attitudes towards attention deficit hyperactivity disorder among elementary school teachers. patient education & counseling, 63, 84-88. •nur, n., & kavakc, o. (2010). elementary school teachers’ knowledge and attitudes related to attention deficit hyperactivity disorder. healthmed, 2, 350355. •west, j., taylor, m., houghton, s., & hudyma, s. (2005). a comparison of teachers’ and parents’ knowledge and beliefs about adhd. school psychology international, 26, 192-208. •perold, m., louw, c., & kleynhans, s. (2010). primary school teachers’ knowledge and misperceptions of attention deficit hyperactivity disorder (adhd). south african journal of education, 30, 457-473. •american psychiatric association diagnostic and statistical manual of mental disorders. (4th edition, textrevised). washington, dc: 2000. •karim r., shakoor a, azhar l, ali a. prevalence and presentation of adhd among the attendees of child psychiatric clinic. mother & child 1998;36(1):71-5. •gaub m, carlson cl. gender differences in adhd: a meta analysis and critical review. j child adolesc psychiatry 1997;36:1036-45. •barkley ra. attention deficit hyperactivity disorder: a handbook for diagnosis and treatment. (2nd edition) 1998. new york: guilford press. •resnick rj. the hidden disorder: a clinician guide to attention deficit hyperactivity disorder in adults. washington, dc; american psychological association 2000. •biederman j, faraone s, keenan k. further evidence for family-genetic risk factors in attention deficit hyperactivity disorder. arch gen psychiatry 1992;(49):728-38. •breslau n, brown gg, deldotto je, kumar s, et al. psychiatric sequelae of low birth weight at 6 years of age. j abnormal child psychol 1996;24:385-400. http://www.aeirc-edu.com/ maria mirza 24 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 •milberger s, biederman j, faraone sv, guite j, tsuang mt. pregnancy, delivery and infancy complications and attention deficit hyperactivity disorder: issues of gene-environment interaction. biol psychiatry 1997;41:65-75. •thapar a, fowler t, rice f, scourfield j, van den bree m, thomas h, et al. maternal smoking during pregnancy and attention deficit hyperactivity disorder symptoms in offsprings. am j psychiatry 2003;160:1985-9. •cohen ra. the neuropsychology of attention. new york: plenum press 1993. •american psychiatric association diagnostic and statistical manual of mental disorders. (4th edition, text revised). washington, dc: 2000. •international classification of diseases. world health organisation.geneva 1992 •richard w, root ii, robert j resnick. an update on the diagnosis and treatment of attention deficit hyperactivity disorder in children. prof psychol research and practice 2003;34:34-41 •dickey wc, blumberg sj. revisiting the factor structure of the strengths and difficulties questionnaire: united states, 2001. j am acad child adolesc psychiatry 2004; 43:1159-67. •conners ck, sitarenios g, parker jd, epstein jn. revision and restandardization of the conners teacher rating scale (ctrs-r): factor structure, reliability, and criterion validity. j abnorm child psychol 1998; 26(4):279-91. •conners ck, sitarenios g, parker j, epstein jn. the revised conners parent rating scale (cprs-r): factor structure, reliability and criterion . j abnorm child psychol 1998; 26:257-68. •achenbach tm, rescorla la. manual for aseba school age forms and profiles.burlington: university of vermont, research centre for children, youth and families 2001. •dupau gj, power tj, anastopoulos ad, reid r. the adhd rating scale iv: checklists, norms and clinical interpretations. newyork; guilford 1999. •taylor e, dopfner, m, sergeant j. european clinical guidelines for hyperkinetic disorder-first upgrade. euro child adolesc psychiatry 2004; 13(suppl.1):1730. •nice guidance for the treatment of adhd. (2002). united kingdom. •pelham we, wheeler t, chronis an. empiricallysupported psychological treatment for adhd. j clinical child psychol 1998;27:190-205. •conners ck, march js, frances a, wells kc, ross r.treatment of attention-deficit/hyperactivity disorder: expert consensus guidelines. j atten disord 2001; 4:7-128. •austin vl. pharmacological interventions for students with add. intervention in school clinic 2003; 38:289-96. http://www.aeirc-edu.com/ salman shaikh 78 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 original article pain, self-medication and administration of over-the-counter analgesics: an observational study salman shaikh2, yusra saleem2, shamoon noushad 2,3& sadaf ahmed1,2&3 psychophysiology research lab, department of physiology, university of karachi1 advance educational institute & research center2 dadabhoy institute of higher education3 corresponding author: yusra@aeirc-edu.com abstract objective self-medication is identified as a behavioral approach that indulges an individual in the substance use as self-administration for the treatment of any physical or psychological pain. over the counter drugs are the most widely used medicines that are commonly available and administered without the prescription of a doctor. the aim of the study was to identify the prevalence and associated factors that reinforce the self-administration of the analgesics. methodology an observational study had been designed that enrolled males and females participants of more than 18 years of age, from the city of karachi. the recruited individuals were asked to fill out a structured questionnaire inquiring about the incidence of pain and prevalence of self-administration of analgesics. results the study had 500 participants that involved 59% males and 41% females with the average age of 24.14 + 5.02 years. 100% of the participants reported some intensity of pain with average intensity being the most prevalent. it turned out that the individuals reported mild grades of physical and chemical with a high prevalence of headaches. conclusion the study concludes that even though the intensity of pain remains within the bearable edge, the availability of the pain killers, and accessibility of instant relief and also the possibility of decrease in tolerance has spoiled the population to opt for over the counter analgesics time and again. keywords pain, self-medication, otc – analgesics. introduction according to the who, self-medication is a part of self-care. however, it may cause more harm than good due to any irresponsible use (who, 2009). self-medication with analgesics is common and accepted and in order to avoid reimbursement it is even recommended by health systems. selfmedication, nevertheless, is not an easy task, since making choices is difficult for patients on the basis of the available standard information. guiding information for patients has to be improved, but also physicians need to be trained how to handle self-medication of their patients (therapie, 2002). selfmedication is responsible to treat the diseases that do not require medical attention and may reduce overuse of medical services; selfmedication’s purpose is to solve minor health issues (zaffani, et al., 2006). self-medication can frequently cause unwanted side effects that would increase healthcare costs, creating an additional burden on the sanitary system (talevi, 2010). surveys show that otc medications are considered as more effective as prescription medications (world selfmedication industry, 2006). the reasons for using self-medication are poorly understood. http://www.aeirc-edu.com/ salman shaikh 79 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 most studies point to loose regulations about medication, and inadequate access to health care, as the main reasons (who, 2002). an observational cross-sectional study was conducted among people of all phases questionnaire consisted of close-ended questions related to personal data, symptoms that led to analgesic use, type of most used analgesics, most important source of information, and frequency of analgesics use by people (amit & nadeem, 2016). this study showed higher prevalence of analgesic use in males as compared to female (kasulkar, 2015). people all over the world suffer common health problems (e.g. colds, headaches, digestive problems and muscle aches) in roughly the same frequency and respond in the same way to these problems (el nimr et al., 2015). surveys show that otc medications are seen by many people as being as effective as prescription medications (world self-medication industry.2006), the reasons for using self-medication are poorly understood (el nimr et al., 2015). the aim of the present study was to estimate the prevalence of self-medication with drugs and complementary/alternative medicines among people of karachi, pakistan; to describe the patterns of medication use; and to identify reasons for self-medication (el nimr et al., 2015). it was hoped that the results would guide decision-makers to take action to address self-medication and limit its potential effects. the most commonly used analgesic for self-medication was acetaminophen (paracetamol), followed by fixed-dose combinations of paracetamol and other no steroidal anti-inflammatory drugs such as ibuprofen and diclofenac. paracetamol is the most commonly available analgesic preparation with favorable side effect profile (amit & nadeem., 2016). the underlying motivation for this study is the prevailing health issues associated with inappropriate use of drugs, which is increasingly becoming a challenge in our environment. this study was designed to determine the proportion of general outpatients who self-medicate, types of drugs used and the reasons for resorting to self-medication. it is hoped that our findings will guide us in evolving strategies to reduce self-medication to its barest minimum. in pakistan, people have easy access to medication and can purchase prescribed medications, such as anti-acne medications and antibiotics, over the counter without the need for a prescription from a physician. one of the basic causes of self-medication is psychological factor. methodology the survey was conducted among 500 participants including both males and females, of more than 18 years of age, from the city of karachi. the recruited individuals were asked to fill out a structured questionnaire that consisted of 16 mcq’s and the data was analyzed using spss and microsoft excel. questions regarding the demographic data (age, sex, educational level, income, occupation and marital status), incidence, origin, intensity of pain, knowledge about the analgesic bought and prevalence of self-administration of analgesics were asked to the subjects. results the study had 500 participants that involved 59% males and 41% females with the average age of 24.14 + 5.02 years. results of the study suggested 100% of the participants reported some intensity of pain with average intensity being the most prevalent. it turned out that the individuals reported mild grades of physical pain with a high prevalence of head, neck and muscles pain and the less common are arthritis dysmenorrheal pain. http://www.aeirc-edu.com/ salman shaikh 80 annals of psychophysiology volume 4, july 2017©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 table 1 demographics age 24.3 + 5.07 gender (n) male 295 female 205 education (%) under-matric matric intermediate under-graduate graduate post-graduate 0.2 1.6 14.4 49.3 29.3 5.2 smoking (%) none occasional regular 67.3 11.0 21.6 self-medication history (%) yes 10.4 no 89.6 family history (%) yes 17.6 no 82.4 figure 1 shows that approximately 15% of the targeted population reported the duration of pain for less than a day while the same ratio of population reported long lasting pain for more than three months and the highest % of people i.e. 27.7% reported the pain lasting for less than a month. 14.6 25.5 27.7 16.6 15.6 less than a day less than a week less than a month more than a month/two more than three months duration of pain (%) http://www.aeirc-edu.com/ salman shaikh 81 annals of psychophysiology volume 4, july 2017©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 2 shows the major reasons of pain as reported by the people, in which a large group of people i.e. (36% of the targeted population) reported pain as a result of previous illness while 18% reported pain because of accidents, 15 % reported pain to be as the result of any surgery and 21% of the subjects were unable to report the cause of pain. figure 3 majority of the population was observed purchasing the analgesics lastly in between one week to one month while approximately 40% people last bought analgesics less than one week ago. injury or accident at home/work 18% result of illness 36% result of surgery 15% unknown cases 21% others 10% reasons of pain (%) less than one week one week to one month one to six months more than six month/year 40.3 50.7 7.6 1.4 analgesic last purchased (%) http://www.aeirc-edu.com/ salman shaikh 82 annals of psychophysiology volume 4, july 2017©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 4 showing types of analgesics people usually prefer in their routine with the maximum use of flurbiprofen (24%) and acetaminophen (23%) and normal use of ibuprofen and other combination drugs. conclusion the study concludes that even though the intensity of pain remains within the bearable edge, the availability of the pain killers, accessibility of instant relief and also the possibility of decrease in tolerance has spoiled the population to opt for over the counter use of analgesics either prescribed or suggested by friends and relatives without seeking advice from the doctor. subjects usually increase the dosage according to their own requirements because the prolong use of the drug makes the body resistant to the drug effect, so an increase in dose may help. pain is one of the primary reasons that influence people towards self-medication and otc (gualano et al., 2015 & langelove, 2016). acknowledgements we are thankful for the co-operation of ms. kisa fatima and ms. alvira ali in initial execution of the study objectives. conflict of interest there is no conflict of interest between the authors. references  el nimr, n. a., wahdan, i. m. h., wahdan, a. m. h., & kotb, r. e. (2015). self-medication with drugs and complementary and alternative medicines in alexandria, egypt: prevalence, patterns and determinants. emhjeastern mediterranean health journal, 21(4), 256-265.  ely, l. s., engroff, p., guiselli, s. r., cardoso, g. c., morrone, f. b., & carli, g. a. d. (2015). use of antiinflammatory and analgesic drugs in an elderly population registered with a family health program. revista brasileira de geriatria e gerontologia, 18(3), 475-485. salicyle acid 0% caffeine 4% acetaminophen 23% morphine 1% flurbiprofen 24%aspirin 5% ibuprofen 18% don't know 6% combination drugs 19% types of analgesics used (%) http://www.aeirc-edu.com/ salman shaikh 83 annals of psychophysiology volume 4, july 2017©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188  gualano, m. r., bert, f., passi, s., stillo, m., galis, v., manzoli, l., & siliquini, r. (2014). use of self-medication among adolescents: a systematic review and meta-analysis. the european journal of public health, 25(3), 444-450.  humayun, s., imran, w., naheed, i., javid, n., hussain, m., & azhar, m. (2016). analysis of self medication practices. professional medical journal, 23(5), 608-613.  kasulkar, a. a., & gupta, m. (2015). self-medication practices among medical students of a private institute. indian journal of pharmaceutical sciences, 77(2), 178.  kumar, a., & vandana, a. n. a. (2016). analgesics self-medication among undergraduate students of a rural medical college. journal of pharmacology & pharmacotherapeutics, 7(4), 182.  lagerløv, p., rosvold, e. o., holager, t., & helseth, s. (2016). how adolescents experience and cope with pain in daily life: a qualitative study on ways to cope and the use of over-the-counter analgesics. bmj open, 6(3), e010184.responsible self-care and selfmedication. (2006). a worldwide review of consumer surveys. ferney-voltaire, franc: world self-medication industry.  talevi, a. (2010). the new patient and responsible self-medication practices: a critical review. current drug safety, 5(4), 342-353.use of analgesics in selfmedication,therapie. (2002); 57(2):1158.  who drug information. (2002). the benefits and risks of self-medication.14 (1): 81.  world health organization. (2009). selfcare in the context of primary health care.  zaffani, s., cuzzolin, l., & benoni, g. (2006). herbal products: behaviors and beliefs among italian  women. pharmacoepidemiology and drug safety, 15(5), 354-359. http://www.aeirc-edu.com/ nimra siddiqui 38 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 original article obsessive compulsive disorder is more flyer in new generation nimra siddiqui*, syedd anamta knawal, syeda zarfshan fatima & kainat ghaffor jinnah university for women, karachi, pakistan. corresponding author: nimrasiddiqui185@gmail.com abstract obsessions are thought, images and impulses that occur repeatedly. persons having obsessive compulsive disorder do not want to have these thoughts because these thoughts disturbing them. ordinarily, individuals having obsessive compulsive disorder recognized that these thoughts are senseless. the common symptoms of ocd is avoid contamination such as washing hand excessively, cleaning household, etc. now a days, the use of modern technology such as online video games, selfies and social media is increased. the over use of this technology can lead to obsessive compulsive disorder in young generations. in ocd there is serotonin deficiency in synapse this low levels of serotonin can cause ocd symptoms. antidepressants (ssri’s) is used to treat ocd because it increased the serotonin level in synapse the drugs include: clomipramine (anafranil), fluoxetine (prozac), fluvoxamine, sertraline (zoloft) and paroxetine (paxil, pexeva).the psychological treatment of ocd is very effective when it takes the form of cognitivebehavioral therapy (cbt) and lot of research is required for the same before it affects large population of the world and will be on the top of the list of global burden of diseases. keywords obsessive compulsive disorder, young generation, contamination, selfies, smart phone, online video games. introduction the principal aim of this study were to examine the prevalence rate, clinical characteristic and related factors of obsessive compulsive disorder. obsessions are thought, images and impulses that occur repeatedly. persons with obsessive compulsive disorder do not want to have these thoughts because these thoughts disturbing them. ordinarily, individuals having obsessive compulsive disorder recognized that these thoughts are senseless. obsession are typically accompanied by intense and uncomfortable feelings such as doubt, fear etc. (clark, et al., 2014). compulsion is the subsequent part of obsessive compulsive disorder. these are repetitive thoughts or behavior that the person uses with the impulsion of neutralizing, counteracting or making their obsession go away. people having obsessive compulsive disorder realized that it is a temporary solution but without a better way to confront they rely on the compulsion as a temporary evade. compulsions can also include avoiding situation that trigger obsession (clark, et al., 2014). serotonin is an important neurotransmitter in the brain. the primary use of serotonin to communicate between the brain’s deeper structure i.e. basal ganglia and the front part of the brain i.e. cortex .in ocd there is serotonin deficiency in synapse this low levels of serotonin can cause ocd symptoms (ocd-uk). the psychological treatment of ocd is very effective when it takes the form of cognitivehttp://www.aeirc-edu.com/ nimra siddiqui 39 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 behavioral therapy (cbt) or behavior therapy these treatment are closely linked to learning and cognitive-behavioral theories of the maintenance of ocd (meyer v., 1966).certain psychiatric medications can control the obsessions and compulsions of ocd. antidepressants (ssri’s) approved by the food and drug administration is used to treat ocd include: clomipramine (anafranil), fluoxetine (prozac), fluvoxamine, sertraline (zoloft) and paroxetine (paxil, pexeva) (mfmer 19982017). in this modern world technology is a big part of our society and our foreseeable future. the use of modern technology such as online video games and social media is increased over the last decade (cheng & li, 2014; kuss & griffiths, karila & billieux, 2014; mazzoni & lannone, 2014; ryan, chester, reece & xenos, 2014; young, 2015). these technology has been associated with many positive attributes such as cognitive skill development, social interaction, entertainment and many more but the excessive use of this technology lead to addiction and this addiction further lead to adhd, mood swings and obsessive compulsive disorder. researchers demonstrated that both women and men use different online activities men’s are more addicted to online video gaming whereas women’s are more addicted to social media, texting, and online shopping (andreassen c. s., et al., 2016).the another obsession is smartphone. ahonen (2011) research by nokia company that the average person look at their phone about 150 times a day. a survey studied show that 45% of british adults indicated they feel worried when they cannot access their email and social sites even many of them check there smartphone in every 1 hour (rosen, l. d., et al., 2013). ocd is the most common disorder, its affect over 2% population about more than in 50 people in the world. the more people suffer from obsessive compulsive disorder than from depression and bipolar (obsessivecompulsivedisorder-2012). according to one of such study which was held in pakistan in 2012 on fisherman community, it was found that 3% population was suffering from ocd among them 56% were females and 50% young generation under the age of 25. the most recurring symptoms were found to be dirt, contamination, checking fear of losing things and religious thoughts. according to the author pakistan need more intuitions into the presence of this disorder and more research work are needed to determine the consequences of this disorder (gadit, a. a, 2012). common obsession in ocd (clark, d. a., & radomsky, a. s. 2014).  contamination such as body fluid (examples: urine, feces), germs/disease (example: hiv, herpes), environmental contamination, house hold chemicals (example cleaner solvents), dirt, etc.  losing control such as fear of acting on an impulse to harm others or oneself, fear of violet or horrific images in one’s mind, fear of blurting out obscenities or insults and fear of stealing things  harm: fear of being responsible for something terrible happening (example fire burglary); fear of harming other because of not being careful enough (example: dropping something on the ground that might cause someone to slip and hurt him/herself.)  unwanted sexual thoughts such as forbidden or perverse sexual impulses for others, forbidden or perverse sexual thoughts or images, obsession about homosexuality, obsession about http://www.aeirc-edu.com/ nimra siddiqui 40 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 aggressive sexual behavior towards other.  obsession related to perfectionism such as concern about evenness or exactness, concern with a need to know or remember, fear of losing or forgetting important information when throwing something out, fear of losing thing.  other such as excessive concern about right or wrong thing morality, concern with a getting physical illness or diseases (not by contamination e.g. cancer). common compulsion in ocd (wilhelm, s., & steketee, g. s., 2006).  cleaning and washing such as hand washing, showering, bathing, tooth brushing, excessively and doing other thing to prevent contamination.  checking such as checking that you did/will not harm other or yourself, checking that you did not make a mistake, checking some parts of your physical condition or body, checking that nothing terrible happened.  repeating such as rewriting or rereading, repeating routine activities (examples: going in or out doors, getting up or down of the chair), repeating body movement (example: touching and blinking), repeating activities in multiple times.  mental compulsion such as mental review of event to prevent harm, praying to prevent from harm, counting while performing a task to end on a ‘good’, ‘right’ or ‘safe’ number, undoing or cancelling (example: replacing a bad word with a good word to cancel it out).  other compulsion such as putting things in order or arranging things until right it ‘feel right’, telling asking or confessing to get reassurance, avoiding situation that trigger obsession. methodology the study was conducted among the people(n=150) of all age groups belonging to various categories of our society including students , housewife, working men and women, there was no exclusion criteria, the questionnaire can be filled by anyone. the study is based on general ocd symptoms open ended questionnaire and general interviews which are taken at different places of metropolitan city of pakistan i.e. karachi. people were asked about general ocd symptoms including fear of losing thing, checking of social accounts or smart phone, washing and cleaning practice, playing video games and maximum number of selfies taking at a time. results after careful evolution we interpreted that 62 % females are affected by this disorder whereas 38 % male have obsessive compulsive disorder. the 20 -30 age group is mostly affected i.e. 64.20% whereas under 20 is affected 23 % and above 30 age group is less affected i.e. 12.80% as shown in figure # 1 and 2. according to the survey result this show that 49% of the population in the metropolitan city is aware of this disorder while the rest of the 51% people were unaware of this disorder and they think that it is normal thing which they do regularly that is shown in figure # 3 people were asked about how much they conscious about contamination? the survey result shows that 55.60% people were concerned with contaminations like dust, germs, chemicals, radiations or by getting any serious illness such as aids and while other 44.40 % population are not concerned with any type of contamination that is sown in figure # 4. http://www.aeirc-edu.com/ nimra siddiqui 41 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 the current study shows that washing and cleaning practices are observed in the population that 30.60% peoples consider them helpless to overcome their impulses to wash out their hand over and over again because every time after washing out their hand they again become phobic about contamination and they again wash their hands.19.40% individuals avoid to touching thing because of contamination , while 4.20% individuals face difficulty in picking up items that have dropped on the floor because of contamination or germs, whereas 11.80% peoples clean their home a lot because of their skeptical behavior about cleanness and contamination mostly above 30 women’s are obsessive of cleaning their household excessively ,while 6.30% individuals think overly about contamination and also become phobic. whereas 19.40% are not conscious about any contamination and germ this is consider as they are not obsessive that is shown in the figure # 5. the result show it clearly that 7.60% individuals does excessive cleaning or washing of their house or even clean them self-many time it is one of most common type of ocd in which individuals do such type of acts , where 34.70% individuals repeatedly check switches ,water faucets. some of these individuals may be ocd patient about which they actually unaware of this disorder, where 2.80% of individuals count or arranging thing repeatedly but there is a less chance of ocd and we don’t easily consider it ocd because it may be their conscious that they may not be shameful in their social circle about these embarrassed thing but we can't neglect it as ocd so we also should have to do proper ocd test, where 1.40% of individuals repeat their routine work but it is rare case and if seen so don’t take it too easily , where 52.50% of peoples not repeat their task which is an good condition that show clearly that they are non ocd and nonphobic patient ,whereas 0.70% excessively charge their mobile which also an disadvantage of mobile which make people to conscious about charging and make them obsessive , while 0.70% of individuals check their important documents which is another sign of perfectionism but also may be ocd condition that is shown in the figure # 6. the graph (figure # 7) result show that 24% people do not avoid throwing things away because they are afraid that they may be need them later but 35% people a bit avoid throwing things away because they are afraid that they may be need them later, 22% people averagely avoid throwing things away because they are afraid that they may be need them later, 11% people mostly or amassment avoid throwing things away because they are afraid that they may be need them later , 8% people maximal avoid throwing things away because they are afraid that they may be need them later. the graph (figure # 8) result show that 26.40% people do not frequently get nasty thoughts and have difficulty in getting rid of them 36.80% people a bit frequently get nasty thoughts and have difficulty in getting rid of them 22.90% people averagely frequently get nasty thoughts and have difficulty in getting rid of them 8.30% people mostly or amassment frequently get nasty thoughts and have difficulty in getting rid of them 5.60% people maximal frequently get nasty thoughts and have difficulty in getting rid of them. the graph result show that 60% people constantly worried that something bad will happen because they forgot something important, 40% people do not constantly worried that something bad will happen http://www.aeirc-edu.com/ nimra siddiqui 42 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 because they forgot something important as shown in figure # 9. the (figure # 10) shows that 81.40% take selfies occasionally while 18.6% take selfies all the times a day and these people become obsessive. the figure #11 shows that 21.40% people say that his/her partner or parents complained that they spend more time on using phone while talking to them this obsession is very common in female.49% people say that there partner or parents do not complained that they are spend too much time on cell phone whereas remaining 29.70% people say that there partner or parents say once or twice a day this shows that these people are obsessive in using cell phone. the question which is asked to the people of karachi that what the first thing is they do when they wake up? 53.10% people say that they reach their phone next to their bed and check facebook and twitter these indicate that they are obsessive to social media while 17.90% people say that they stumble into the shower and other 29 % people say that that again go back to sleep as shown in figure #12. people were asked about did they play video game and if yes then how much time they play video game? 63.60% people say that they play video game where as 36.40 % people say that they have no interest in video games mostly male are obsessive of playing video games most of the people 22.40% say that they only play video game in free time while 22.20 % people say that they play video game 1-2 hours whereas 33.30 % people say that they play video game all the time of the day they are very addicted to video game according research these people are obsessive of playing video game due to loneliness as shown in (figure #13) figure 1 shows gender. female 62% male 38% http://www.aeirc-edu.com/ nimra siddiqui 43 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 2 indicates age wise ocd patients. figure 3 showing knowledge about obsessive compulsive disorder. 23% 64.20% 12.80% below 20 20-30 above 30 49% 51% yes no http://www.aeirc-edu.com/ nimra siddiqui 44 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 4 showing individual concern with contamination or getting a serious illness (aids) figure 5 washing and cleaning 55.60% 44.40% yes no 19.40% 4.20% 11.80% 30.60% 8.30% 6.30% 19.40% i avoid touching certain things because of possible contamination i have difficulty picking up items that have dropped on the floor i clean my household excessively i wash my hand excessively i often take extremly long shower bath i am overly concern with germs and disease i am not concern with any contamination http://www.aeirc-edu.com/ nimra siddiqui 45 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 6 showing repeat certain act over and over again figure 7 avoid throwing things away to save it for future use. 7.60% 34.70% 2.80% 1.40% 52.50% 0.70% 0.70% excessive or ritualized washing ,cleaning and grooming checking light switches,water faucets,the stove,door locks or the emergency brake? counting,arranging or evening up behaviuor(making sure soaks are at the same heights) repeat routine actions(in/out of chairs,relighting cigratte) a certain number of times or untill it feels just right? i don't repeat any task mobile charging checking documents 24% 35% 22% 11% 8% not at all a little moderately a lot extremly http://www.aeirc-edu.com/ nimra siddiqui 46 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 8 shows getting nasty thoughts and facing difficulty getting rid of them. figure 9 afraid losing something important. figure 10 habitual of taking selfies. 26% 36.80% 22.90% 8.30% 5.60% not at all a little moderately a lot extremly yes no 68.10% 31.90% occasionally you might take one but not every day all the time--it's a good way of checking how you look 81.40% 18.60% http://www.aeirc-edu.com/ nimra siddiqui 47 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 11 spending more time using mobile phone. figure 12 first thing individual does when she/he wakes up. 49% 21.40% 29.70% no yes,all the time a day once or twice a day 53.10% 17.90% 29% reach for your phone next to your bed to check facebook and twitter stumble into the shower hit snooze and go back to sleep http://www.aeirc-edu.com/ nimra siddiqui 48 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 13 shows time spend by an individual in playing video games. discussion a survey result which was conducted in the city of karachi in which many people participated according to the result almost both gender are affected by this disorder but females are highly affected 20-30 age group is highly obsessive. whereas above 30 age is less affected approximately half population of the karachi city are unaware of this disorder and people think that it is the normal thing which they do their routine activities the most common symptom of obsessive compulsive disorder is contamination that 55.60% people say that they are very conscious about contamination people were asked about what they do to avoid contamination people were said that they wash their hand excessively because they think that their hand are not wash completely or its hand are not free from germs so they wash their hand again and again hence it is a kind of anxiety. the women’s above 30 age and married said that they wash their household excessively some people said that they avoid picking thing from the ground due to contamination. repetition is the common symptom of compulsion people were asked about this symptoms most of the individuals repeatedly check switches, water faucets because they are afraid that something bad is happen if they don’t check switches ,locks, etc. these individuals may be ocd patient about which they are actually unaware of this disorder, whereas individuals who count or arranging thing repeatedly but there is a less chance of ocd and we don’t easily consider it ocd because it may be their conscious that they may not be shameful in their social circle about these embarrassed thing but we can't neglect it as ocd so we also should have to do proper ocd test. in this current study shows that smart phone is the major factor of causing obsessive compulsive disorder. people spent too much time to using cell phone such as 21.40% people said that his/her partner or parents complained that they spend more time on using phone while talking to them this obsession is very common in female.49% people said that there partner or parents do not complained that they are spend too much time on cell phone whereas remaining 29.70% people said that there partner or parents say once or twice a day this shows that these people are obsessive 63.60% 36.40% 22.20% 33.30% 22.40% yes no 1-2 hours all the time a day free time http://www.aeirc-edu.com/ nimra siddiqui 49 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 of using cell phone. the 84% people say that they take selfies occasionally. these indicated that are not obsessive compulsive disorder but all the time a day taking selfies indicate obsessive compulsive disorder. according to american psychiatric association especially in young girls selfies causes obsessive compulsive disorder .the majority of people said that they are using cell phone when they wake up and check facebook, twitter and other social sites and these technologies take our new generation towards obsessive compulsive disorder. conclusion we have concluded that ocd is the most prevailing disorder .the young generation is highly obsessive to the latest technologies such as smart phone, selfies, online video games, facebook, twitter, etc. the people are unaware of this disorder and they think that these are normal thing. we have to educate young generation that selfies capturing, spending too much time of playing video games, social media is not the normal practice and they should use latest technologies in limited time. we should organize seminar to aware the people about this disorder and its treatment. the lot of research is required for the same before it affects large population of the world and will be on the top of the list of global burden of diseases. references  andreassen, c. s., billieux, j., griffiths, m. d., kuss, d. j., demetrovics, z., mazzoni, e., & pallesen, s. (2016). the relationship between addictive use of social media and video games and symptoms of psychiatric disorders: a large-scale cross-sectional study. psychology of addictive behaviors, 30(2), 252.  clark, d. a., & radomsky, a. s. (2014). introduction: a global perspective on unwanted intrusive thoughts. journal of obsessive-compulsive and related disorders, 3(3), 265-268.  gadit, a. a. (2012). obsessivecompulsive disorder (ocd): is this disorder under-recognized? jpma. the journal of the pakistan medical association, 62(9), 974-975.  guenther, p. m., casavale, k. o., reedy, j., kirkpatrick, s. i., hiza, h. a., kuczynski, k. j., ... & krebs-smith, s. m. (2013). update of the healthy eating index: hei-2010. journal of the academy of nutrition and dietetics, 113(4), 569580.  meyer, v. (1966). modification of expectations in cases with obsessional rituals. behaviour research and therapy, 4(1), 273-280.  “obsessivecompulsivedisorder”.webm d.com. feb. 20, 2012. <http://www.webmd.com/anxiety panic/guide/obsessive-compulsivedisorder>.  radomsky, a. s., alcolado, g. m., abramowitz, j. s., alonso, p., belloch, a., bouvard, m., & garcia-soriano, g. (2013). journal of obsessive-compulsive and related disorders.  rosen, l. d., whaling, k., rab, s., carrier, l. m., & cheever, n. a. (2013). is facebook creating “idisorders”? the link between clinical symptoms of psychiatric disorders and technology use, attitudes and anxiety. computers in human behavior, 29(3), 1243-1254.  what causes ocd? ocd –uk, https://www.ocduk.org/what-causes-ocd.  wilhelm, s., & steketee, g. s. (2006). cognitive therapy for obsessive compulsive disorder: a guide for professionals. new harbinger publications. http://www.aeirc-edu.com/ naima akhlaq 62 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 original article evaluate personality disorders symptoms in different individuals naima akhlaq* urooj asghar, tanzeela gul, syeda yusra ali,noma shah jinnah university for women corresponding author: tanzeela608@gmial.com abstract a personality disorder is a disorder described by unchangeable patterns of thinking, feeling, or disclose to others that causes problems in personal, communal, and work situations. they are characterized into three types: those characterized by odd/eccentric behavior, those characterized by suspenseful/erratic behavior, and those characterized by anxious/inhibited behavior. (catalog) bpd is widely diagnosed up to 20% of psychiatric patients have the borderline personality disorder, and it may occur in up to 2% of the general population. biological and environmental factors are both implicated in the improvement of antisocial personality disorder. a survey was conducted in city of lights karachi to ascertain the knowledge of building a character or how to build a character. the personality disorder test was administered by 500 persons who included mostly students, some physicians, some older persons and single and married persons from age below 20 -above 30. the questionnaire was based on mcqs asking people to give fair opinion about what they feel about their emotion dysregulation, impulsivity, risktaking behavior, irritability, feelings of emptiness, suicide, self-injury and fear of abandonment, as well as changeable interpersonal relationships. thus, this study examined the temporal dynamics of emotions, self-esteem, anger, social relationships with others and ability speaks about your rights. some of the questions asked by us included: they have difficulty in trusting others, his/her need is more important than others, usually mood swings, feeling depressed. this survey study show that personality disorder is mostly seen in females of age between 20 30. keywords personality disorders, suicidal thoughts, self-harming, mood swings, adhd purpose of study to know the personality disorder in normal individual and how pd effect their lives. introduction people vary in the ways that they view themselves and others, secure in relationships. it is quite common for these characteristics to periodically inhibit with a person’s skill to cope with life, and may also lead to difficulties in social communications. when these difficulties are severe and endless, and when they lead to significant personal or social problems, they are described as personality disorders. (nic alvin, et al. 2006) personality disorders are common situation in our society. epidemiological estimates suggest that between 5% to 13% of people living in the community have problems that would meet the diagnostic criteria for pd (coid, j et al., 2006)among 30% to 40% of psychiatric out-patients and 40% to 50% of psychiatric in-patients are thought to meet the principles for pd.8 some 50 to 78% of prisoners have been found to have pd.(casey p. 2000)risk of suicide and accidental death is high and it is predicted that between 47% to 77% of people who commit suicide have pd.( moran & alvin ,2002, 2006)suicide rates in prison remain many times higher than for the normal population. because some people with pd enroll in dangerous way of acting, they have a higher risk of abnormal or accidental death. (martin, cloninger, et al 1985) personality disorders are over the most frequent of psychiatric disorders, and they regularly co-exist with each other as well as with other psychiatric disorders. (oldham , et al. 1995) having no psychiatric disability appeared in an or for life span substance reliance of 1.0; having one disorderliness 2.7, two disorders 3.9, and three or more shambles 9.1 (95% ci). (glantz el at., 2009)therefore, having a psychiatric disability at all and/or having more than one psychiatric disorder occur to increase the relative risk for life span individual dependence. a personality disorder is a disorder described by unchangeable patterns of thinking, feeling, or disclose to others that causes problems in personal, communal, and work situations. they are characterized into three types: those characterized by odd/eccentric behavior, those characterized by dramatic/erratic behavior, and those characterized by anxious/inhibited behavior. (widiger, 2006). the personality disorders are highly http://www.aeirc-edu.com/ naima akhlaq 63 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 comfort; if a person has one, it’s likely that he or she has others personality disorder as well. also, the number of people with personality disorders is predicted to be as high as 15% of the population. (grant et al, 2004) pd characterized into clusters. (american psychiatric association. 2000) cluster a: odd/eccentric (schizotypal, paranoid and schizoid) schizotypal: weird manners of speaking or dressing. they have difficulty to forming relationships. may react strangely in conversation, not answer back, or talk to self. speech elaborate or difficult to follow. (it may be a mild form of schizophrenia) (mayo clinic staff, 2016) paranoid: suspicion in others. apart to challenge the honesty of friends and read hateful intentions into others’ actions. flat to anger and aggressive outbreak but otherwise emotionally cold. often jealous, over careful, reserved, overly serious. (bressert, s. 2016) schizoid: extreme self-questioning and withdrawal from relationships. wish to be alone, little interest in others. self-opinionated, distant, fantasizer. fearful of close to others, with poor social skills, often seen as a “loner”. (mayo clinic staff 2016) cluster b: erratic/ dramatic (antisocial, histrionic, narcissistic, borderline) antisocial: conscience history of betrayal, crime, legal problems, emotional and cruel behavior. regret for hurting others. cautious, careless, insensitive. at high risk for substance exploitation and alcoholism. histrionic: steady attention seeking. egoistic language, inspirational dress, melodramatic illnesses, all to gain attention. believes that everyone loves him. affecting, lively, overly dramatic, fascinated, and excessively flirty. (american psychiatric association, et al., 2014) narcissistic: show feel of self-importance, absorbed by fantasies of self and success. overestimate own achievement, imagine others will recognize they are great. good first impressions but poor longer-term relationships. dishonest to others. borderline: unsteady moods and extreme, stormy personal relationships. self harm or suicidal threats. selfimage variation and an ability to see others as “all good” or “all bad.” cluster c: inhibited/anxious (avoidant, dependent, obsessive-compulsive) avoidant: psychologically anxious and distressed except for he or she is assured of being liked. in comparison with schizoid person, thirst for social communication. fears disapproval and fear about being abashed in front of others. avoids social communication due to fear of rejection. dependent: obedient, dependent, requiring extra approval, help, and advice. be true to people and worried in losing them. lacking self-confidence. depressed when alone. may be suicidal if separation is threatened. obsessive-compulsive: careful, well behaved, perfectionist. extra need to do everything correct. fear of failure can make this person accurate and controlling. less expression of emotions. borderline personality disorder is a continued disorder of personality followed by mood swings, unstable personal relationships, and identifying problems and it is generally associated with suicide. since 1980, the year of the initial similarity of the criteria for personality disorders are indicated that bpd is clearly more common in women than men. according to the most recent edition of the book. (rhee & waldman, 2002) there is a 3:1 female to male gender ratio. biological and environmental factors are both implicated in the improvement of antisocial personality disorder (huesmann, et al., 2007) biological abnormalities include low autonomic activity during stress, schizophrenia, right hemisphere abnormalities, sexual disorder, biochemical imbalances and reduced gray matter in the frontal lobes. (lyons-ruth et al., 2007) people with schizotypal personality disorder are usually termed as odd, if any, nearest relationships. they usually don't understand the result of their behavior on others. they establish expressive mistrust of others. these problems may start to serious anxiety and a set to turn incoming in social setting. (mayo clinic staff 2011) schizoid personality disorder is a state in which people avoid social actions and normally shy away from inter-communication with others. they also have a finite range of emotional verbalization. (mayo staff 2016) narcissistic personality disorder is a psychological disorder in which people have a bloated sense of their selfimportance, extra need for adoration and a lack of pity for others. but afterwards this mask of overconfidence lies a weak self-esteem that's sensitive to the smallest judgment. (mayo staff 2014) all of the personality clusters have been recorded in case with element offense, with unfriendly personality usually being the most frequent; borderline personality is commonly the second most frequent cacciola et al,. 2001) we all have different manners of thinking, feeling and behaving and these are the segments that make us who we are, our personality. we don’t always behave http://www.aeirc-edu.com/ naima akhlaq 64 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 in the same way, as our thinking, feelings and behaviors will often depend on the situation. but most of the time, we behave in totally a predictable way, or pattern. these patterns are those that make up our personality and express us as kind, shy, selfish, ambitious, and loving and so on. (memiah limited 2016) methodology a survey was conducted in city of lights karachi to ascertain the knowledge of building a character or how to build a character .the personality disorder test was administered by 500 persons which included mostly students, some physicians, some older persons and single and married persons from age below 20 -above 30, to determine the rate of personality disorder in pakistan .the questionnaire was based on mcqs asking people to give fair opinion about what they feel about their emotion dysregulation, impulsivity, risk-taking attitude, irritability, feelings of emptiness, suicide, self-injury and fear of abandonment, as well as changeable interpersonal relationships. which shows more prevalent in the general community than previously thoughts, and thus represents an important public health issue. thus, this study examined the temporal dynamics of emotions, self-esteem, anger, social relationships with others and ability speak about your rights. result the personality diagnostic questionnaire is a selfreport questionnaire derived from personality disorder section. the survey based study of personality disorder symptoms have produced inconsistent results, the result show that the females most affected by personality disorder i.e.: 78% female and 22% males affected by personality disorder shows in fig 1. by the help of survey this is observed that in the age of 20-30 mostly females affected i.e.: 39% whereas 22% males affected in this age which shows in fig 2. the survey showed that mostly people have difficulty to trust the people which show paranoid personality disorder i.e.: 41% people have difficulty, 28% people have no difficulty and 31% people sometimes feel difficulty to trusting on people which shows in fig 3. those people that thinks that their needs are most important than others have narcissistic personality disorder. in this survey 27% people say yes, 46% people say no and 27% people say sometimes which shows in fig 4. mood swings, depression, afraid of being alone, thoughts of suicide and self-harming are the symptoms of borderline personality disorder. we observed that in people mood swings are most common i.e.: 42% that show in fig 5 and few people have depression i.e.: 41% that show in fig 6. the highly educated people not think to suicide or self-harming by frustrated to life. therefore, in our survey mostly people say no thoughts for suicide i.e.: 70% and for no self-harming are 64% that show in fig 8 & 9. figure 1 male 22% female 78% gender http://www.aeirc-edu.com/ naima akhlaq 65 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 1 figure 2 figure 3 figure 4 7% 12% 3% 30% 39% 9% below20 20-30 above 30 age wise pd patient male female 41% 28% 31% yes no sometime trust problems 0 10 20 30 40 50 yes no some time 27 46 27 importance of need 0 20 40 60 yes no some time mood swings http://www.aeirc-edu.com/ naima akhlaq 66 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 5 figure 6 figure 7 0 20 40 60 yes no some times 30 29 41 depression 0 20 40 60 26 47 27 afraid of being alone yes no some times yes 18% no 70% sometime 12% thought of suicide http://www.aeirc-edu.com/ naima akhlaq 67 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 8 figure 9 discussion a survey study which was conducted in the city karachi in which many people participated and according to result people have difficulty in trusting others, they are afraid of being alone, they get depressed without a reason, sometimes they feel uncomfortable in a social gathering and try to avoid people these all are leading factors to destroy a person personality. which can lead to disorders in the person. (john m. grohol, psy. d. 2016) personality disorder are circumstances in which an individual vary significantly from an average person, in terms of how they think, feel or relate to others. as the results show that among male and females mostly females between age 20-30 affected by disorders of personality. in a person personality different types of disorder can be developed. as we collected data we saw people facing fear of trusting others which can be symptoms leading towards paranoid personality disorder, among the participates there were people who thinks to fulfill their needs firstly and then of others those people are affected with narcissistic personality disorder, there were people fighting with stress , depression and uncontrollable emotions and also cases of suicidal attempt were seen by people those people are affected by borderline personality disorder and commonly people were facing symptoms of borderline personality disorder in this survey participants are those who fear of being alone are affected with dependent personality disorder.(mind.org. 2016) despite of all of these types of disorders this studied shows that people are dealing with various faults in their character which need to be corrected by creating different schemes or test to polish their personality. conclusion this survey study show that personality disorder is mostly seen in females of age between 20 -30. the result shows that people are facing through paranoid personality disorder and borderline personality disorder that is they have problem of trusting people, mood swings and depression mostly. survey study concluded that majority of people have personality disorder of age between 20 -30 due to stress, bipolar disorder, attention deficit hyperactivity disorder (adhd), brain tumor and fear and genetically etc. references  nic alwin, ron blackburn, kate davidson, maggie hilton, caroline logan & john shine. 2006 understanding personality disorder: a professional practice board report by the british psychological society. published by the british psychological society, st andrews house, 48 princess road east, leicester le1 7dr.  coid, j. (1998) axis 2 disorders and motivation for serious criminal behaviour, in psychopathology and 33 64 3 0 10 20 30 40 50 60 70 yes no some time self harming 12% 69% 19% 0% 20% 40% 60% 80% cold behaviour by parents yes no sometimes http://www.aeirc-edu.com/ naima akhlaq 68 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 violent crime (ed. a.e. skodol), american psychiatric association, washington dc, pp. 53– 96. coid, j., yang, m., roberts, a. et al. (2006a)  casey, p. (2000) the epidemiology of personality disorders. in tyrer, p. (ed.) personality disorders: diagnosis, management and course. wright, london. 2nd edition pp 71-79  moran p., walsh e., tyrer , p., et al., (2003) the impact of co-morbid personality disorder on violence in psychosis – data from the uk 700 trial. british journal of psychiatry, 182. 129-13  martin, r., watson, d., & wan, c. k. (2000). ...review of factor analytic studies of temperament measures based on the thomas-chess structural model: implications for the big five. in c. f. halverson, g. a. kohnstamm, & r. p. martin (eds.),  oldham jm, skodel ae, kellman hd, hyler se, doidge n, rosnick l, gallaher pe. comorbidity of axis i and axis ii disorders. am j psychiatry. 1995; 152:571–578.  glantz md, anthony jc, berglund pa, et al. mental disorders as risk factors for later substance dependence: estimates of optimal prevention and treatment benefits. psychol med. 2009; 39:1365– 1377.  widiger, t.a. (2006). understanding personality disorders. in s. k. huprich (ed.), rorschach assessment to the personality disorders. the lea series in personality and clinical psychology (pp. 3–25). mahwah, nj: lawrence erlbaum associates.  grant, b., hasin, d., stinson, f., dawson, d., chou, s., ruan, w., & pickering, r. p. (2004). prevalence, correlates, and disability of personality disorders in the united states: results from the national epidemiologic survey on alcohol and related conditions. journal of clinical psychiatry, 65(7), 948–958.  mayoclinic staff/ diseases-conditions of schizotypal-personality-disorder 2016  bressert, s. (2016). paranoid personality disorder symptoms. psych central. retrieved on september 29, 2016 last reviewed: by john m. grohol, psy.d. on 17 jul 2016  mayoclinic on diseases-conditions of schizoidpersonality-disorder 2016  american psychiatric association diagnostic and statistical manual of mental disorders, fourth edition, revised national institutes of health, national library of medicine  last reviewed 11/24/2014  rhee, s. h., & waldman, i. d. (2002). genetic and environmental influences on anti-social behavior: a meta-analysis of twin and adoptions studies. psychological bulletin, 128(3), 490– 529. twin and adoption studies suggest a genetic predisposition (rhee & waldman, 2002),rhee, s. h., & waldman, i. d. (2002).  l. rowell huesmann and lucyna kirwil why observing violence increases the risk of violent behavior by the observer 2007  lyons-ruth, k., holmes, b. m., sasvari-szekely, m., ronai, z., nemoda, z., & pauls, d. (2007). serotonin transporter polymorphism and borderline or antisocial traits among low-income young adults. psychiatric genetics, 17, 339–343; raine, a., lencz, t., bihrle, s., lacasse, l., & colletti, p. (2000). reduced prefrontal gray matter volume and reduced autonomic activity in antisocial personality disorder. archive of general psychiatry, 57, 119– 127.  mayoclinic staff on diseasesconditions/schizotypal-personality-disorder 2016  mayoclinic organisation diseasesconditions/schizoid-personality-disorder 2016  mayoclinic staff diseases-conditions/narcissisticpersonality-disorder/basics 2016  cacciola js, alterman ai, mckay jr, rutherford mj. psychiatric comorbidity in patients with substance use disorder: do not forget axis ii disorders. psychiatr ann. 2001; 31:321–331.  mind we're a registered charity in england (no. 219830) and a registered company (no. 424348) in england and wales. published in august 2016 http://www.aeirc-edu.com/ http://www.mayoclinic.org/diseases-conditions/schizoid-personality-disorder/home/ovc-20214901 http://www.mayoclinic.org/diseases-conditions/schizoid-personality-disorder/home/ovc-20214901 http://www.mayoclinic.org/diseases-conditions/schizotypal-personality-disorder/home/ovc-20198939?p=1 http://www.mayoclinic.org/diseases-conditions/schizotypal-personality-disorder/home/ovc-20198939?p=1 http://www.mayoclinic.org/diseases-conditions/schizoid-personality-disorder/home/ovc-20214901 http://www.mayoclinic.org/diseases-conditions/schizoid-personality-disorder/home/ovc-20214901 original article www.aeirc-edu.com volume 12014 page | 20 ©advance education institute & research centre-2014 prevalence of depression in undiagnosed populace; a study on gender and age syed zain azher 1, shamoon noushad 1, nida naeem 1, sadaf ahmed 1&2 & nelofer sultana 3 1. psychophysiology research division, advance educational institute & research centre 2. department of physiology – university of karachi 3. shaheed mohtarma benazir bhutto medical college corresponding author: zain@aeirc-edu.com abstract: depression is a psychological disorder that affects mental state of an individual for a long and short period of time the mental disturbance sometimes occurs due to sadness. depression is the feeling of past and present experiences in one’s life but another feeling often goes together with the depression that is the future feeling. the purpose of this study is to present the vulnerability rate to depression in relation to age and gender in general population of pakistan .the data was collected from general population in pakistan from 228 subjects. the integration of age and depression was investigated in different age groups of teenagers (12-19 years), young adults (20-30years) and adults (> 30 years).the age and gender difference in relation to depression was studied through a 21-item bdi-ii (beck depression inventory-ii) scale & result analyzed by spss 20.0. results shows females are at higher risk of depression as compared to male however according to age teenagers are at higher risk. keywords: depression, age, gender, bdi-ii scale introduction: depression is a serious psychological disorder that affects mental state of an individual for a long time (sandy, 2014). this mental disturbance sometimes occurs due to sadness. sadness is a natural feeling that lasts mostly for few minutes but when it goes longer than it is an indicator that person is going through a painful state of mind and body to which we called as depression (roy, 2005). depression is the feeling of past and present experiences in one’s life but another feeling often goes together with the depression that is the future feeling (although future may be the next minute or hour). we refer that feeling as anxiety (butrym, 1983). depression is not a personality defect but it is actually a disease very painful for those who have it and more difficult for its family and friends. it aff1ects people of all ages, genders and background. depression affects a person’s mood, behavior, physical changes in the body accompanied by aches and pain. person may feel angry, irritable or tired (roy, 2005). clinically depression is a feeling of sadness, loss, anger or frustration that is the mood disorders and they interfere with daily life for weeks or longer (la torre, 2011). every minute of the day our brain is going through complex physiological changes that involve emotions and thoughts as well. this may happen due to the production and breakdown of various chemicals like hormones and neurotransmitters (miller, 2008). imbalance of neurotransmitters and hormones inside and outside the brain cells of body and making the brain cells more vulnerable to depression. the relationship between depression and neurotransmitter is very strong and it can be judged by giving any antidepressant to the depressed person. it will clearly be observed that the serotonin levels lowers down while taking the drug and the person will feel better. besides neurotransmitter, other chemical involve are the hormones that affects mood. hormones play a greater role in causing depression, when a person is going through any stressful situation, the cortisol level will rise depending on the intensity of depression that how much depression the person feel. the level of cortisol gradually lowers down when the stress passes but if it remains higher for a long time than it might lead to high blood pressure that eventually causes the person more vulnerable to depression (miller, 2008). continuous sad mood, little or no interest in activities that were previously enjoyed significant changes in appetite, trouble falling asleep or oversleeping, loss of energy, worthlessness feelings with irrelevant regret, difficult in thinking and concentration, frequent thoughts of death or suicide are the symptoms of depression (james, 2014). men and women have equal chances of developing depression but the women depression ratio is very high as they feel depression more deeply and show very clear response like becoming sad, tearful and hope less. lack of social support increases vulnerability rate to depression in all women who are divorced, widowed, and single or married everyone feels depression at equal rates. (hales, 2010) although men depression ratio is very high but they show different responses then women. they become irritated or fatigued and they are more drowned to lose their lives and feel like they are dead from inside. the suicidal rate is also very high in men them women with a ratio of 4:1(hales, 2010) and there is a complex relationship between depression and age with the rates of depression seen higher in younger adults. the key contributions to depression include any abusive substance like alcohol or cigarette and sleep loss in young individuals. however epidemiologic and clinical studies reviewed the relationship between depression and disability in older adults opening a new way to the directions for the future research (bruce, 2001) family history of depression also plays a great role in developing depression among young persons and it has also been noticed that teens that spend more time in watching television or spending time on computer are at a greater risk of developing depression. (myrna, 2008). depression in indicated by cigarette smoking as more teens or people are under the false impression that smoking will make them feel better. this is actually a false perception, nicotine makes the depression symptoms worsens by altering the brain chemistry (zain, 2012). the purpose of this study is to present the vulnerability rate to depression in relation to age and gender in general population. method: the sample of participants was drawn from randomly selected individuals with (n=228) that include females (n=155) and males (n=73). the sample consists of 31 (12-19 years) age teenagers, 26 (20-30 years) young adults and 171 (>30 years) adults. participants completed the beck depression inventoryii ( bdiii), a 21-item measures of depression symptoms severity of which is rated on 4-point likert scale (0-3 point anchors), with items summed to form a total score. the instrument has been designed with a scale that rates the level of depression for the participants. original article www.aeirc-edu.com volume 12014 page | 21 ©advance education institute & research centre-2014 the bdi-ii measures level of depression with the following scale, 0-14= minimal or no depression, 15-20= mild depression, 21-29= clinical or borderline depression, 30-63= severe depression. the data was collected by survey method survey was designed to study the vulnerability rate to depression in different age groups of male and female. the study is a prospective study that is being carried out in different areas of pakistan through e-mail and on the spot filling of the questionnaire. questions were asked that look at the individuals mood and physical state (less interest in doing things, feeling of sadness and hopelessness, trouble concentrating on things, feeling tired or little energy, trouble falling asleep, suicidal thinking) and the questions about the current feeling state and how you feel about the future & psychological depression this includes the questions about the alcohol or smoke use, any recent or past significant stressors or if they are taking any antidepressant to release their depression. the questions also includes related to family support, parents attitude with the participant and parents relationship with each other. all these are important aspects to evaluate the psychological history of depression. result: according to the analysis of the data recorded by calculating the depression rate among different age groups it was noted that young adults mostly between the ages (20-30 years) are at greater risk of developing depression when we checked on a large sample size, 8.33% of the young adults are at the risk of depression. the risk of developing depression among teenagers is very low only 1.3% teenagers are at higher risk. the adults with an age of greater than 40 shows 0.44% ratio at the risk of developing depression. according to the study report while considering depression in relation with gender, female shows increased ratio of depression as compare to male. 8.77% females were at the risk of developing depression 1.32% were at the risk of developing depression. discussion: among many universal facts it is also very well known that number of female depression sufferers are more than male depression sufferers with a ratio of 2:1 which means that an average of two women experience major depression to every one male sufferer (nolen-hoeksema, 1986). practically no such difference have been found for depression in terms to gender but then why women are more at a risk of depression? many surveys have been done to study why women are more vulnerable to depression. studies suggest that women an experience loses more m in im al m ild m o d er ea te se ve re m in im al m ild m o d er ea te se ve re m in im al m ild m o d er ea te se ve re teenagers young adults adults 7.89% 0.88% 3.51% 1.32% 28.51% 17.54% 14.47% 8.33% 6.58% 4.55% 6.41% 0.44% minimal mild modereate severe minimal mild modereate severe female male 25.00% 14.47% 19.74% 8.77% 17.98% 8.33% 4.39% 1.32% graph 2 : this graph depression level according to age graph 1: this graph depression level according to gender original article www.aeirc-edu.com volume 12014 page | 22 ©advance education institute & research centre-2014 deeply that makes them more vulnerable to depression. marital status is another factor that shows a greater difference of men and women depression. estimations suggests that married men have lower rate of depression than single men but when it comes to female depression level seems to be the same for women who are married, divorced and those who had never been married. hormonal shifts also play a very vital role for developing depression in women during pregnancy. these are just the hypothesis and testable ideas that have a chance to be proved as right or wrong (depaulo, 2002).a longitudinal study suggests that the peak age to study vulnerability to depression is 15-18 years, it is the most critical time to observe the higher risk of depression at this age and it also shows greater gender difference between the ages 13-15 years showing female sufferers greater than male (hankin, 2001). a psychopathological approach is required to study depression in children and young adults (cicchetti, 1998). prevelance studies tells us that psychologically disturbed children are at more greater risk of developing depression especially those that have a history of psychiatric disorders are at 3 times of greater risk for developing depression than those who had no psychological symptoms (costello, 2003). psychological symptoms include hopeless feelings, with poor concentration, having less energy for doing things and sometimes lead to suicidal thinking and self-criticism (robinson, 2008). there is a very easy to escape from problems or troubles and most people in our society attempt to do that. when they are sad and want to relieve their sadness they mistakenly belief that drugs are a solution this is the easiest way that most teenagers adopt and it is also seen that if a close family member is an alcoholic, an experimenting teen is at a great risk (wilkinson, 1994). if a psychiatrist diagnosed depression than the fastest way to feel better is the combination of medication and psychotherapy through talking with a therapist. there are many medicine designed for this purpose that helps to feel better while recovering from illness under the proper guidance of an expert under whose observation the medications effects and its changes to the personality can be seen (cobain, 2007) patients show positive attitude in their performance when taking any professional help such as an antidepressants or having discussions with the experts. for the treatment of depressed patients group counseling is very necessary while educating the patients for the primary care of the depressed patients. (hansson, 201). conclusion: rate of depression such as mild, moderate and severe was observed higher in the young adults groups than adults and was found to be lowest in the teenagers. adults have shown a different response as the age increases they show little interest in physiological activities and there severity to depression decreases. with the passage of time as they move towards older age they show hopelessness feelings towards life and their response towards severity of depression is minimal. teenagers are independent and free from any kind of responsibilities and fewer teens were at clinical or borderline depression. according to the gender differences females show greater response towards the severity of depression than males. this has also been proven from many past researches that women are more vulnerable to depression than men and they get upsets quickly at minor annoyances. depression symptoms often go together with anxiety so there might be a possibility of anxiety along with depression. scientist are still struggling to maintain and develop the reasons behind the women depression rate as women’s attempt to obtain a position equal to that of men in society. references:  bruce, m. l. (2001). depression and disability in late life: directions for future research. the american journal of geriatric psychiatry, 9(2), 102-112.  cicchetti, d., & toth, s. l. (1998). the development of depression in children and adolescents. american psychologist, 53(2), 221.  cobain, b., & elizabeth, v. (2007). when nothing matters anymore: a survival guide for depressed teens. minneapolis, mn: free spirit pub, print. pg 123  costello, e. j., mustillo, s., erkanli, a., keeler, g., & angold, a. (2003). prevalence and development of psychiatric disorders in childhood and adolescence. archives of general psychiatry, 60(8), 837-844.  depaulo jr, j. r., & horvitz, l. a. (2002). understanding depression: what we know and what you can do about it. john wiley & sons.  hales, d. (2011). an invitation to health: choosing to change. cengage learning.  hankin, b. l., & abramson, l. y. (2001). development of gender differences in depression: an elaborated cognitive vulnerability–transactional stress theory.psychological bulletin, 127(6), 773.  hansson, m., chotai, j., & bodlund, o. (2012). what made me feel better? patients' own explanations for the improvement of their depression. nordic journal of psychiatry, 66(4), 290-296.  la torre, g., & saulle, r. (2011). david crawford, robert w. jeffery, kylie ball, and johannes brug (eds). obesity epidemiology. from aetiology to public health. the european journal of public health, 21(5), 676-676.  la torre, g., & saulle, r. (2011). david crawford, robert w. jeffery, kylie ball, and johannes brug (eds). obesity epidemiology. from aetiology to public health. the european journal of public health, 21(5), 676-676.  miller, allen r. (2008).living with depression. new york, ny: facts on file.  nolen-hoeksema, s., girgus, j. s., & seligman, m. e. (1986). learned helplessness in children: a longitudinal study of depression, achievement, and explanatory style. journal of personality and social psychology, 51(2), 435.  robinson, p., & strosahl, k. (2008). the mindfulness and acceptance workbook for depression: using acceptance and commitment therapy to move through depression and create a life worth living. new harbinger publications.  roy, j.r. (2005). depression new york: benchmark books, print.pg 10, 11  sandy street (2014) depression in women:emphasis on the impact of marriage and motherhood, university of evansville, retrived from http://faculty.evansville.edu/jl3/psych490/best%20senio r%20theses/06%20street.doc  zain, a., sadaf, a., shamoon, n., zainab, q., & azam, y.(2012). the major apprehensions in young chronic cigarette smokers to quit smoking, fuuast journal of biology, 2 (2), 59-63 original article www.aeirc-edu.com volume 12014 page | 23 ©advance education institute & research centre-2014  wilkinson, beth. (1994).drugs and depression. new york: rosen pub. group.  james hunter & nimh (2014). research on depression. retrieved from http://psychcentral.com/disorders/depressionresearch.htm aatir h. rajput 8 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 original article depression, anxiety and stress among primary caregivers of thalassemia patients in hyderabad aatir h. rajput1, faris nadeem2 & vikram kumar2. 1-lumhs research forum 2-liaquat university of medical & health sciences, jamshoro aatirh.rajput@gmail.com abstract a chronic genetic disorder; thalassemia major is a disease, characterized by continuing and severe anemia, bone deformities, hepato-splenomegally and growth retardation. it is a potentially life threatening and serious life-limiting disease that brings about considerable disturbance in all aspects of life. therapies such as transfusion of blood have enhanced the physical health status of the thalassemia major patients but numerous treatment sessions and alteration in physical appearance effects on the quality of life of the patients and their families. depression while battling surviving thalassemia is increasingly accepted, globally. but we hypothesized that psychiatric morbidities aren’t limited to the patient, in fact they extend to the caregivers as well. our study screens the primary caregivers for depression, anxiety and stress which more often than not are the parents. this observational study encompassed all 3 major thalassemia centers in hyderabad namely; fatimid foundation, zainabia center and saharo human aid center. the city-wide survey included 79 caregivers presenting at these centers (via convenience sampling) from 1st dec 2014 to 10th february 2015. data was collected using interview based structured questionnaire which included the 42 point das scale approved by australian center for posttraumatic mental health. the data was analyzed in spss v. 19.0 and ms. excel 2013. moderate levels of depression (16.06), anxiety (10.44) and stress (19.11) were all unearthed in the caregivers. majority of the sample comprised of male (60.8%), educated respondents (78.5%) living in joint families (57%). the caregivers mainly belonged to lower (35.4%) and middle (54.5%) economic class and were forced to miss an average of 2-3 days of work per week. the unending therapeutic process of thalassemia, its cost and impending health problems have adverse effects not only on the patients but on the caregivers as well who spend their time struggling and praying for the patients’ health. the mental health of the caregivers should be taken into account and psychiatric consultations should be provided to the caregivers so they may be better able to tend to the patients. keywords ß-thalassemia, depression, anxiety, stress, primary caregivers, blood transfusion, chromic illness. introduction ß-thalassemia major, an ailment largely associated with excessive breakage of red blood cells and malproduction of hemoglobin. hemoglobin (hb) is comprised 4 protein subunits, 2 alpha and 2 beta units. mutations in the gene coding for the protein ß subunits, leads to a lessened or totally missing ability to synthesize the globin ß-chains, leading to absence of the synthesis of ß hemoglobin or, in less severe cases, to abnormal hemoglobin this error leads to anemia often stemming from the abnormal synthesis of red blood cells, which is the hallmark of thalassemia. mediterranean region is plagued with a high prevalence of thalassemia; the highest incidence is reported in italy, the greek islands and in asia, where the peak prevalence of the genetic mutations underlying thalassemia is reported in the maldives (pignatti bc, 2004). the conventional treatment comprises of repeated transfusions of blood that may lead to overload of iron in the tissues. younglings on hyper-transfusion regimens will continue to grow normally probably till puberty. an estimate of the body iron is derived from serum ferritin; levels exceeding 2500 mg/l for over 15 year are thought as a factor increasing the risk for cardiac disease (pignatti bc, 2004). the concept of health, as explained by who, “a state of complete physical, mental, and social well-being, not merely the absence of disease” states clearly importance of mental health. similar to other long term illnesses, beta-thalassemia burdens not only the individual patient but the entire family which includes (but is not limited to) social and psychological consequences which ultimately affects the wellbeing of the patient (porter j, 2002). so it is imperative to study the psychological factors which incorporate, add to distress of the family alongside other factors. previous studies focused on these points have shown improvement in the quality of life of such patients and their ability to integrate well into their society (porter j, 2002).. parents of children suffering from thalassemia not only worry regarding their children’s standard of life, goals and their expectations but, also the influence of the constant realization of disease, repeated treatment visits to the morbid environment of the hospital on family dynamics and the family’s financial, psychological and social stability. major concerns of the parents regarding the disease are related to the physical outlook of their child, short stature, bone deformities, poor self-image, and hampered fertility, absent or delayed absent sexual http://www.aeirc-edu.com/ aatir h. rajput 9 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 development and other such complications; infections, diabetes, bone and heart disease (mazzone l, 2009). if viewed from the patient’s perspective, it is a worrying and scary experience where they have no choice but to face the mentally tiresome psychosocial aspects of thalassemia. in addition to that, their regular visits to the thalassemia centers for blood transfusions and blood tests with iron chelation therapy too are mentally and physically exhaustive. parents of patients suffering from β-thalassemia have to battle a significant psychological influence, leading to hopelessness, emotional burden and difficulty with social accommodation. they often experience adverse thoughts about their life, heightened anxiety, guilt and lessened self-esteem. if the ability to cope up with painful situations abandons them, they are prey to severe psychosocial problems. on one or more account, souring of relationship amongst family members, heightened isolation and marginalization too are persistent problems faced by many. our study aims to focus mental health in particular and studies the parents of thalassemic patients. this will help us gain insight into the pain and the impaired domains of life (physical health, psychological health and quality of life). our study screens the caregivers for depression, anxiety and stress. methodology this observational, cross-sectional study encompassed all 3 major thalassemia centers in hyderabad namely; fatimid foundation, zainabia center and saharo human aid center. the city-wide survey included 79 caregivers presenting at these centers (via convenience sampling) from 1st dec 2014 to 10th february 2015. data was collected using interview based structured questionnaires which included the 42 point das scale approved by australian center for posttraumatic mental health. after obtaining verbal informed consent, respondents were requested to fill the proforma’s at the clinic. the data was analyzed in spss v. 19.0 and ms excel 2013. results the sample population belonged mainly to different localities of hyderabad representing different gender, ethnic, socio-economic, educational and age groups. a few of these demographics along with the family structure of the respondents is depicted in the figure 1. figure 1: majority of the caregivers visiting the thalassemia clinic were males (60.8%) owing to our conservative societal values and traditions. another aspect that can be attributed to our societal trends and traditions is the family structure. 57% of the respondents were a part of joint family set-up while only 43% belonged to nuclear family set-up. however, a finding defying perceived societal statistical norms is the educational status of the respondents. a vast majority (78.5%) of the respondents were educated while only a meagre 21.5% were uneducated. care givers of thalassemic patients poured in at the transfusion centres from varied self-defined age group. the decade long groups started from 21 ears and went above 51 years. figure 2 below further explains the age dynamics in detail. figure 2: the greatest proportion (42.5%) of the respondents fell within the age group from 31 to 40 years. the second most common age group, attracting 30.4% of the sample, was 21 to 30 years. the remaining two age groups 41 to 50 years and 51 and above years each contained 22.8% and 5.2% of the sample respectively. the age classification serves as a testimony to the primary assumption that primary care givers are parents since the respondent and early parental age coincide strongly. depression, anxiety and stress were all unearthed in the caregivers. the values are a mean of the values of 60.80% 39.20% 21.50% 78.50% 57% 43% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 30.40% 42.50% 22.80% 5.20% 21 30 31 40 41 50 51 and above http://www.aeirc-edu.com/ aatir h. rajput 10 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 all respondents. further detail can be derived from figure 3. figure 3: the height of the bars indicate individual levels only and no comparison can be drawn with each other since the standard scales and values differ for each. depression level falls within the moderate range (14-20). anxiety falls within the moderate range (1014) and stress too falls within the moderate range (1925) defined by the dass scoring manual. the origins of depression, anxiety and stress aren’t always psychological and emotional in origin. we believe that in our modern society, depression, anxiety and stress are often materialistic and financial in origin. the figure 4 below sheds light on the economic class of the patients and their primary caregivers presenting at the thalassemia centers. figure 4: majority of the respondents belonged to the middle socioeconomic class (54.5%), shortly followed by the lower socioeconomic class (35.4%). only a small minority of the respondents belonged to the higher socioeconomic class (10.1%). the socioeconomic distribution of synonymous with the national demographics of 2013. as a consequence of the disease, debility is seen in not only the patients but indirectly in the caregiver as well. many of whom were forced to miss their work. figure 5 describes the phenomenon further below. discussion individuals (children especially) suffering from thalessemia are battling a severe chronic hemolytic anemia that requires transfusions as the sole mode of survival. the long-term illness not only induces psychological distress among the children but their families as well. this often leads to numerous adverse types of behavioral patterns and emotional responses in the family, which influences the relationships of family members with each other and with their surroundings. lon-term diseases of childhood affect the daily life and routine of the patients parents the most and that too at several levels (cognitive levels, emotional level) (monastero r, 2000). figure 5: on average, the respondents missed 2 – 3 days of work per week owing to their responsibility of caring for the patient. on extremes, 15% of the respondents needed miss only 1 work day while 4% of them missed the entire week of work. the battle with beta thalessemia is an unending sojourn and leads to heightened psychological burden to the patients and their families. on numerous accounts. rao p, pradhan pv has claimed that the incidence of psychopathological disorders is higher in parents of children with disabling and chronic illnesses (thalassemia) as compared to the normal population (economou m, 2006). it is claimed by deepika shaligram that 57% of the caregivers were troubled with psychological distress and had a lessened quality of life in as much as 50% of the studied population. existing literature also claims that caregivers of thalassemia patients are faced with higher incidence of developing psychological distress as compared to healthy children (zafeiriou di, 2006). this rate of 1 day 15% 2 days 36% 3 days 34% 4 days 6% 5 days 5% 6 days 4% 1 day 2 days 3 days 4 days 5 days 6 days 16.06 10.44 19.11 0 5 10 15 20 25 depression anxiety stress d a s score 35.40% 54.50% 10.10% lower economic class middle economic class higher economic class http://www.aeirc-edu.com/ aatir h. rajput 11 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 psychological distress leading to parental stress is higher due to the multiple problems which parents have to tackle while their children undergo the difficult and painful treatment procedures of thalassemia. parents are troubled with issues such as the difficulty of psychosocial adjustment of the child, financial woes, treatment provision, travelling and other social problems. existence of long-lasting diseases in children especially those that do not have complete cures is a situation which causes stress for mothers and can rile them with against life situations and make them more prone to suffer from depressive disorders (sharghi a, 2006). medical centers tending to chronically/seriously ill children, should additionally provide psychiatric consultation in an attempt to monitor and control depressive disorders plaguing mothers. this can hopefully aid mothers get through the child’s disease in a healthier manner and allow them care for their ill child, and their family, effectively and efficiently. low educational status in caregivers may lead to lesser realization of the nature of illness and consequently greater propensity of tumbling into psychological distress. it is likely that the traits of harsher diseases (younger age of onset, frequent transfusions and behavioral problems in the young patient) prompted more apprehensions and psychiatric morbidity in the caregiver. also, the buffering effect of the nuclear family setup against psychiatric troubles may be because of the protection from societal troubles in ways that are not available to the joint/extended family systems. (shaligram d, 2007) conclusion briefly, this study concludes that the caregivers’ concerns pertaining to thalessemia and their own psychiatric problems are worryingly high. the study helped bring to light multiple aspects of psychological distress which might facilitate in designing intervention strategies. the psychological troubles of the caregiver influence many facets of the lives of the caregiver including work. thus support for the caregiver in the form of mental health intervention, self-help groups and education and medicine should be an essential part of managing thalassemia in order to improve outcomes. further research in this area with a control group, vaster sample size and repeated evaluations would offer better understanding of the problems that the caregivers are faced with and strengthen the case for an cohesive management approach. conflict of interest all the authors disclosed that there is no conflict of interest associated in the preparation of this article. acknowledgment we would like to acknowledge the intellectual assistance and technical support provided by lumhs research forum. references •pignatti bc, rugolotto s, stefano pd, et al. (2004). survival and complications in patients with thalassemia major treated with transfusion and deferoxamine. haematologica, 89, 1187–1193. •porter j, & davis ba. (2002). monitoring chelation therapy to achieve optimal outcome in the treatment of thalassaemia. best pract res clin. haematol, 15, 329– 368. •mazzone l, battaglia l, andreozzi f, romeo ma and mazzone dl. (2009). division of child neurology and psychiatry, department of pediatrics, university of catania, catania, italy clinical practice and epidemiology in mental health, 5, 5. •monastero r, monastero g, ciaccio c, padovani a, camarda r. (2000). cognitive deficits in betathalassemia major. acta neurol scand, 102, 162-168. •economou m, zafeiriou di, kontopoulos e, gompakis n, koussi a, perifanis v, et al. (2006). neurophysiologic and intellectual evaluation of betathalassemia patients. brain dev, 28, 14-18. •zafeiriou di, economu m, athanasiou-metaxa m. (2006). neurological complications in betathalassemia. brain dev, 28, 477-81. •sharghi a, karbakhsh m, nabaei b, meysamie a, farrokhi ar. (2006). depression in mothers of children with thalassemia or blood malignancies: a study from iran. clinical practice and epidemiology in mental health. 2, 27. •shaligram d, girimaji sc and chaturvedi sk. (2007). quality of life issues in caregivers of youngsters with thalassemia. indian j pediatrics. 74 (3), 275-278. http://www.aeirc-edu.com/ zehra ashraf 27 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 original article prevalence of nosocomephobia – hospital related depression zehra ashraf, syeda arooba raza, fizza khalid, zahra sabzwari and dur-re-shahwar faculty of pharmacy, jinnah university for women, karachi, pakistan corresponding author: dr.zehra.ashraf@gmail.com abstract aim of research study: the aim of study was to assess hospital phobia and its variation of depressive symptoms in primary care population. introduction: nosocomephobia is the fear of hospitals. it is a fairly common phobia; many people are known to suffer from it. like that “if i go to a hospital, i’m fairly sure it is a fact that my life is not guaranteed.” patients are afraid of hospitals, especially the emergency rooms. hospitals are the mark of cure and health. they even usually result in huge expenses. most people understand that it is a medical necessity and that one does not and fear must be overcome in case of nosocomephobia though, the patient simply refuses to go to a hospital and the result often are not desirable including death especially in case of major life threatening conditions. result: in primary care population (pcp) severity of hospital-phobia is very high. patients show different depressive symptoms like nausea, loss of appetite, mood swing etc. the result of survey shows that insomnia is the highest number found in depressive patients which is approximately 50% in male patients alone. female the percentage is slightly low i.e. approximately 40%. discussion and conclusion: a survey has been conducted at karachi to ascertain how many people are suffering from hospital phobia. our survey result showed that the hospital fear (nosocomephobia) is very common in the biggest city of pakistan i.e. karachi. the best way to overcome the nosocomephobia is to change the mindset of the patient through some self-help techniques. keywords depression, hospital, phobia, phobic disorders, patient care population introduction the research into the problem of phobic disorders is very extensive. (beidel, d.c. and turner, s.m., 2007). a fear of hospitals and doctors is commonly found in the community but is not bounded. when such a fear is become irrational and sufficiently severe situation and health should be the just concerns may arise (zigmond, a.s. and snaith, r.p., 1983). there are fears in common people about hospitals. first of all, it is commonly understood that whenever doctor’s advices patient for hospitalization it means the illness is very serious marks, (i.m. and gelder, m.g., 1966). although it is not necessary but people think like that. the second fear of hospital is the expenses occurs this in. unnecessary tests are advised which resulted in heavy financial burden as well as a painful process (singh, t.k., ahmad, a. and chowdhury, a., 2014). nosocomephobia is the fear of hospitals. it is a fairly common phobia; many people are known to suffer from it. like that “if i go to a hospital, i’m fairly sure it is a fact that my life is not guaranteed.” (pellosmaa, h.b. and desouky, t.f., 2013) normally, patient found ways of dealing with a surge of emotions are associated with hospitals. most people understand that it is a medical necessity and that one does not and fear must be overcome in case of nosocomephobia though, the patient simply refuses to go to a hospital and the result often are not desirable including death especially in case of major life threatening conditions. (peters, l., 2000) symptoms of depression are visible in body, mood and thoughts and that affects the way a person eats, sleeps, self-concern by over thinking. (hamilton, m.a.x., 1959) depression is not the same as a passing blue mood. fear is not a sign of personal weakness. people with depression cannot merely pull themselves together’ and get better. (liebowitz, m.r., 1987) physicians are unable to detect emotional disorder because they are not confident enough in procedure of detection or patient may think that his complaint was not being taken seriously. the information about this order can be gathered by a questionnaire which the patient may complete. (zimmerman, m., mcdermut, w. and mattia, j.i., 2000). the questionnaire should be simple and should not include reference to abnormal perception. the patient’s own views should be considered as he/she is the best judge of his/her state .by this questionnaire, it http://www.aeirc-edu.com/ mailto:dr.zehra.ashraf@gmail.com zehra ashraf 28 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 was considered that the methods usually adopted are prolonged and desired administration by a trained worker, or if short and designed, recognition is necessary for proper diagnostic of the patients then another questionnaire will be made which will distinguish between anxiety and depression and the information collected will be very much helpful and reliable for the patient to know about the disorder for which he was consulting. (torgersen, s., 1983) other than this order that is psychiatric lexicon we have seen some various state of stress like grief, loss of self-esteem and so on (fava, m., rankin 2000). a questionnaire includes all these states would be not much useful for physicians, so physicians focus on loss on pleasure response which is the obligatory state of depressive disorder and this is supposed to be that it is due to disturbance of neurotransmitter mechanism which can be improved by antidepressant medication. these depressive states reduce the ability to experience pleasure. (malasi, t.h., mirza, i.a. and el‐islam, m.f., 1991) the goal of study was to assess hospital phobia and its variation of depressive symptoms in primary care population. methodology domain of study: the study of plat was paris of asia (karachi) which is the sizeable and populous city of pakistan. the 7th largest and most populous urban agglomeration in the world. karachi metro has an estimated population of over 23.5 million people as 2013. purpose of study: the survey was conducted among 200 patients, it has been supervise to perceive about hospital phobia. for this purpose, a survey was sketch to conduct fresh enumeration from different parts of karachi (pakistan). it was disseminate among various divisions of society. the questionnaire was based on mcq’s asking the people to give their fair point of view about nosocomephobia that is hospital phobia. most of the people understand that it is a medical necessity and that one does not have a choice but to get over with it. the patient simply refuses to go to a hospital which results in some very negative. some of the questions asked by us included: 1. worrying thoughts go through my mind. 2. i get sudden feelings of panic 3. i can sit at ease and feel relaxed. 4. i feel rest less and have to be on the move. 5. do you experience any of these symptoms? (like diarrhea, insomnia, abdominal cramps, nausea, less appetite) 6. what kind of treatment/tests makes you frightened? (like i/v , i/m, different tests, many medicines, drips) result in primary care population (pcp) severity of hospital-phobia is very high. patients show different depressive symptoms like nausea, loss of appetite, mood swing etc. the survey shows that on nosocomphobia i.e. hospital related phobia provided us a consistent result as follows: table 1 shows the depression scale which is further divided into three categories that are (1) normal having answer scale in range 0-7 (2) borderline depression having answer scale in range 8-10 and (3) depression having answer scale in range 11-21. table 2.1 and figure 2.1 representing the depression’s symptoms regarding the aspect of males in which four symptoms are shown along with their respective percentages, these symptoms include diarrhea experienced by 16.88% males, insomnia by 40.25%, abdominal cramps by 18.16%, nausea by 22.60% and less appetite by 25.95% males respectively. similarly, depression’s symptoms are also seen in females, table 2.2 and figure 2.2 represents these symptoms along with their respective percentages, these symptoms includes diarrhea experienced by 21.94% females, insomnia by 39.83%, abdominal cramps by 23.57%, nausea by 16.26% and less appetite by 16.26% females respectively reasons of depression being arise from admitting to hospital are also taken under consideration of this survey which are the sort of treatments which make people little worried, depression experienced by males from certain treatments is shown in table 3.1 and figure 3.1 which includes i/v by 33.76%, i/m by 24.67%, different tests by 40.25%, many medicines by 40.25% and drips by 32.46% respectively. similarly, depression experienced by females with respect to treatment are discussed in table 3.2 and figure 3.2 respectively which includes i/v by 30.08%, i/m by 14.63%, different tests by 24.34%, many medicines by 20.32% and drips by 35.77% respectively. as the age is essential factor which plays a great role in any research or survey, the depression according to age is also considered and table 4.1 is and figure 4.1 are representing the depression scale along with respective ages with respect to males, the ranges of age under which the percent of depression lies are: (a)15-25 in which depression % is about 11.68% (b) 26-36 in which depression % is about 9.09% (c)37-47 in which depression % is about 3.89% (d) 48-60 in http://www.aeirc-edu.com/ zehra ashraf 29 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 0-7 8-10 11-21 answer scale normal borderline depression depression which depression % is about 3.89% respectively. similarly, the ranges with respect to females are: (a)15-25 in which depression % is about 14.28% (b) 26-36 in which depression % is about 7.79% (c)37-47 in which depression % is about 5.19% (d) 48-60 in which depression % is about 11.6% respectively. table 5.1 and figure 5.1 represents borderline depression related to hospital with respect to males which comprises of age range along with percentages of borderline depression, these are: (a)15-25 in which depression % is about 14.28% (b) 26-36 in which depression % is about 7.79% (c)37-47 in which depression % is about 5.19% (d) 48-60 in which depression % is about 11.6% respectively. similarly, table 5.2 and figure 5.2 represents borderline depression related to hospital with respect to females which comprises of age range along with percentages of borderline depression, these are: (a)15-25 in which depression % is about 17.88% (b) 26-36 in which depression % is about 8.94% (c)37-47 in which depression % is about 4.87% (d) 48-60 in which depression % is about 2.43% respectively. normal people without any sort of depression are also taken under consideration, the table 6.1 and figure 6.1 showing the % of normal males according to age range which are as follows: (a)15-25 in which normal % is about 18.18% (b) 26-36 in which normal % is about 7.79% (c)37-47 in which normal % is about 3.89% (d) 48-60 in which normal % is about 3.89% respectively. similarly, the table 6.2 and figure 6.2 showing the % of normal females according to age range which are as follows: (a)15-25 in which normal % is about 32.52% (b) 26-36 in which normal % is about 4.87% (c)37-47 in which normal % is about 4.06% (d) 48-60 in which normal % is about 1.62% respectively. figure # 2.1: hospital depression’s symptoms appears in male figure # 2.1: hospital depression’s symptoms appear in male figure # 2.2: hospital depression’s symptoms appear in female 16.88% 40.25% 18.16% 22.60% 25.95% diarrhea insomnia abdominal cramps nausea less apetite symptoms 21.94% 39.83% 23.57% 16.26% 16.26% diarrhea insomnia abdominal cramps nausea less apetite symptoms http://www.aeirc-edu.com/ zehra ashraf 30 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure # 3.1: reasons of depression from admitted to hospital (male) figure # 3.2: reasons of depression from admitted to hospital (female) figure # 4.1: hospital depression in male figure # 4.2: hospital depression in female 33.76% 24.67% 40.25% 40.25% 32.46% i/v i/m different tests many medicines drips treatments 30.08% 14.63% 24.34% 20.32% 35.77% i/v i/m different tests many medicines drips treatments 11.68% 9.09% 3.89% 3.89% depression 15-25 26-36 37-47 48-60 8.94% 3.25% 6.50% 3.25% depression 15-25 26-36 37-47 48-60 http://www.aeirc-edu.com/ zehra ashraf 31 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure # 5.1: hospital’s borderline depression in male figure # 5.2: hospital’s borderline depression in female figure # 6.1: normal male among survey people figure # 6.2: normal female among survey people 14.28% 7.76% 5.19% 11.60% borderline depression 15-25 26-36 37-47 48-60 17.88% 8.94% 4.87% 2.43% borderline depression 15-25 26-36 37-47 48-60 18.18% 7.79% 3.89% 3.89% normal male 15-25 26-36 37-47 48-60 32.52% 4.87% 4.06% 1.62% 15-25 26-36 37-47 48-60 age range normal female http://www.aeirc-edu.com/ zehra ashraf 32 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 discussion & conclusion a survey has been conducted at karachi to ascertain how many people are suffering from hospital phobia. our survey result showed that the hospital fear (nosocomephobia) is very common in the biggest city of pakistan i.e. karachi. many people are frightened to enter the hospital buildings, some of them are scared of blood, germs, surgical procedures, some patients feel nervousness about the procedures because they can cause pain in the body. (starcevic, v. and bogojevic, g., 1997) nosocomephobia causes different depressive symptoms like heart palpitations, dizziness, insomnia, diarrhea etc. (robertson, j.g., 2003). result of survey shows that insomnia is the highest number found in depressive patients which is 40.2% in male whereas in female it is slightly low i.e. 39.8% the best way to overcome the nosocomephobia is to change the mindset of the patient through some self-help techniques. if you are in phobia never go to hospital alone take some friends with you. in hospital’s waiting area read your favorite books or talk with your friends otherwise go to hospital café and enjoy tea/coffee to relax your mind (brinton, h.g., 2012). some treatments are also available for nosocomephobia, it is treated with the combination of medicine (robertson, j.g., 2003). prescriber prescribes anti-anxiety a medication which helps to decrease the depressive disorders but it is not recommended for long time treatment/use. some psychotherapy, talk therapy are also recommended. for the facilitations of patients minimize the unnecessary pathological tests which irritate patients which also increase the hospital charges. references  beidel, d.c. and turner, s.m., 2007. shy children, phobic adults: nature and treatment of social anxiety disorder (pp. 11-46). washington, dc: american psychological association.  brinton, h.g., 2012. the welcoming congregation: roots and fruits of christian hospitality. westminster john knox press.  fava, m., rankin, m.a., wright, e.c., alpert, j.e., nierenberg, a.a., pava, j. and rosenbaum, j.f., 2000. anxiety disorders in major depression.comprehensive psychiatry, 41(2), pp.97-102.  hamilton, m.a.x., 1959. the assessment of anxiety states by rating. british journal of medical psychology, 32(1), pp.50-55.  liebowitz, m.r., 1987. social phobia (pp. 141173). karger publishers.  malasi, t.h., mirza, i.a. and el‐islam, m.f., 1991. validation of the hospital anxiety and depression scale in arab patients. actapsychiatricascandinavica, 84(4), pp.323-326.  marks, i.m. and gelder, m.g., 1966. different ages of onset in varieties of phobia. american journal of psychiatry, 123(2), pp.218-221.  pellosmaa, h.b. and desouky, t.f., 2013. hospital anxiety. in encyclopedia of behavioral medicine (pp. 985-988). springer new york.  peters, l., 2000. discriminant validity of the social phobia and anxiety inventory (spai), the social phobia scale (sps) and the social interaction anxiety scale (sias). behaviour research and therapy, 38(9), pp.943-950.  robertson, j.g., 2003. an excess of phobias and manias. senior scribe publications.  singh, t.k., ahmad, a. and chowdhury, a., 2014. differences of thought.  starcevic, v. and bogojevic, g., 1997. comorbidity of panic disorder with agoraphobia and specific phobia: relationship with the subtypes of specific phobia. comprehensive psychiatry, 38(6), pp.315-320.  torgersen, s., 1983. genetic factors in anxiety disorders. archives of general psychiatry, 40(10), pp.1085-1089.  zigmond, a.s. and snaith, r.p., 1983. the hospital anxiety and depression scale. acta psychiatrica scandinavica, 67(6), pp.361-370.  zimmerman, m., mcdermut, w. and mattia, j.i., 2000. frequency of anxiety disorders in psychiatric outpatients with major depressive disorder. american journal of psychiatry, 157(8), pp.1337-1340. http://www.aeirc-edu.com/ syeda farah batool 59 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 original article prevalence of compulsive sexual behavior/hyper sexuality disorder and its psychological manifestations in youth syeda farah batool & sadaf ahmed psychophysiology research lab, department of physiology, university of karachi. corresponding author: emanraza14@gmail.com abstract sexuality or sexual behaviors are very complex to understand and what better place to understand. “sex” is a no word in our families and society, however this a natural phenomenon in which male and female genes combine to form off springs. every person on this planet have felt or experienced sexual desire or got engage in sexual activities. many parts of the brain are involved in generating a cascade of sexual events within the body but limbic system plays a primary role in the initiation of sexual drive/ desire. when a person gets attracted towards someone these parts of the brain become active and induce sexual desire, this is a normal body response, but sometimes these parts become hyperactive and sexual desire is uncontrollable such condition is termed as “hyper sexuality”. in pakistan, live-in relationships are not very common, so mostly unmarried individuals are involved in sex addiction. this study revolves around the increasing rate of compulsive sexual behavior in youth. a random survey has been conducted with approximately equal number of male and female participants. subjects belong to the age group from 16-25 years. almost 200 subjects have participated in this study. exclusion criteria was above 25 years and below 16 years. people with any other neurological or psychological disorders were excluded. approximately a 70% of the subjects were found to be on the track of getting hyper sexuality disorder and 15% of them were suffering from this disorder. this is the high time to break the barriers. we need to start thinking and try to discuss and resolve our issues on our own. so, think and talk. keywords sexual behavior, hyper sexuality, sex addiction, orgasm, masturbation compulsive sexual behavior/hyper sexuality disorder/sex addiction is it a myth or reality? “a 12-year-old girl is being gang raped in a small district of pakistan”. this and many more incidents like these are happening around every single day, what is the core reason behind the increasing rate of sexual intolerance in pakistan? “sex” is a no word in our families and society, however this a natural phenomenon in which male and female genes combine to form off springs. every person on this planet have felt or experienced sexual desire or got engage in sexual activities. sexuality or sexual behaviors are very complex to understand and what better place to understand this complexity of thoughts than human “brain” (zimmer, carl et al., 2009). the sex cycle in a human could be classified in four phases as follow . http://www.aeirc-edu.com/ syeda farah batool 60 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 table 1.1 (keith a. et al., 2008). desire resolution arousal orgasm before we go in depth of neuroscience of sexual behaviors one must be aware of certain terminologies like sex desire, which is a behavioral drive that motivates an individual to have sex. whereas sexual arousal is a cascade of physiological process that prepares the body for sexual activity (pfaus j et al., 2006). many parts of the brain are involved in generating a cascade of sexual events within the body but limbic system plays a primary role in the initiation of sexual drive/ desire. limbic system is responsible for inducing euphoria in the body and avoid pain of aversive stimuli and stress (kristian adams et al., 2011). sympathetic and parasympathetic nervous system are also involved in sexual arousal especially in orgasm. sympathetic nervous system prepares our body for fight or flight response creating a slight stress within the body (reid rc. et al., 2009). when a person gets attracted towards someone these parts of the brain become active and induce sexual desire, this is a normal body response, but sometimes these parts become hyperactive and sexual desire is uncontrollable such condition is termed as “hyper sexuality” (christopher lane et al., 2012). it is very difficult to characterize this condition because one cannot estimate that how many times a person should have sex. bill maher once said “a day without sex is a day wasted”. this should be classified as a psychological disorder; however, american psychiatric association has refused to accept this as a psychological disorder. but in 2010, american psychiatric association has setup criteria for the diagnosis of sex addiction. this includes several signs and symptoms, a few of them are as follow.  masturbation  obsession with sex  phone sex  frequent viewing of pornography  multiple sex partner  emotional detachment with sex partner  ruining the moral values. if a person is unable to feel resolution or pleasure after sex, it will lead to the generation of stress in the body. to get over the stress and for seeking the pleasure, the person unintentionally gets involved in above mentioned scenarios. in pakistan, live-in relationships are not very common, so mostly http://www.aeirc-edu.com/ syeda farah batool 61 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 unmarried individuals are involved in sex addiction. that does not mean that married ones are not involved in such activities but the ratio is comparatively low (anonymous). if females are into such activities the condition is known as “nymphomania” and for males the term is “satyriasis”. this study revolves around the increasing rate of compulsive sexual behavior in youth. domestic, social and cultural barriers are the biggest reason that our youth is suffering from this condition and pakistan has secured its position in top 5 countries of the world which has the highest viewership of porn sites. methodology a random survey has been conducted with approximately equal number of male and female participants. subjects belong to the age group from 16-25 years. almost 200 subjects have participated in this study. exclusion criteria was above 25 years and below 16 years. people with any other neurological or psychological disorders were excluded. results and discussion when the subjects were asked that have they ever visited a porn site? following response has been recorded. . figure 1.1 shows the number of male visiting porn site is higher than female but a 68% female is not a number to ignore. majority of participants have reported that they feel uncomfortable even when their cousins sit next to them. 85 68 male female http://www.aeirc-edu.com/ syeda farah batool 62 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 1.2 showed that how emotionally weak the subjects are, which replicates the state of their minds. a huge number of subjects were surprisingly engaged in activities like phone, sex and masturbation. figure 1.3 shows that most of the subjects thought that stress is the basic cause of these sensations. 0 10 20 30 40 50 60 70 80 90 100 male female 69 57 31 43 yes no 79 47 male female http://www.aeirc-edu.com/ syeda farah batool 63 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 1.4 showing the results when the subjects were asked about how do they feel before and after the sexual sensations/activities they replied as follow. figure 1.5 shows before the activity/sensation/masturbation. these results prove that stress is the primary cause of sexual addiction. strikingly most of the subjects have reported that family pressure, study or examination stress, lover issues, and being single are the major causes that induces stress in individuals. 0 10 20 30 40 50 60 70 80 90 100 male female 75 81 25 19 yes no 0 10 20 30 40 50 60 70 80 90 100 uncomfortable anxiety stress anger suicidal thoughts 74 80 70 89 45 78 83 95 53 67 female male http://www.aeirc-edu.com/ syeda farah batool 64 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 1.6 shows after the activity/sensations/masturbation fig 1.6 shows approximately 90% of female suffer from stress before and after the sexual activity, whereas about 70% were the victims of stress. as per reported by the subjects when they are stressed the tends to have the sexual pleasure and after masturbation or sexual activity they were stressed because they consider themselves a sinner and even tried to harm themselves. this shows that 41% females and 43% males try or think about suicide. when the subjects were asked that have their parents ever talked with them about puberty or changes that they are going to face in future after puberty, the answers are exactly what we have hypothesized. sleepy stress muscle fatigue anxiety restlessness headache itching happiness relaxation suicidal thoughts 78 75 41 50 23 33 5 80 70 43 76 90 39 73 15 40 3 80 75 41 female male 0 10 20 30 40 50 60 70 80 90 100 male female 3 1 97 99 no yes http://www.aeirc-edu.com/ syeda farah batool 65 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 this is all because of our silence. parents think that their only responsibility towards their child is to pay their expenses, they don’t even realize that how much their child need them. we don’t even know that we are raising a ‘rapist’ or a ‘rape victim’ under the shadow of our so-called “social norms”. we all are responsible for the increasing rate of prostitution and rape in pakistan, because we don’t want to discuss our problems and do not want to share our stress. religion, society, culture, family none of them is a barrier unless we make them one. we all are accountable for raising a generation with all the unstable mind set. conclusion this is the high time to break the barriers. we need to start thinking and try to discuss and resolve our issues on our own. if parents are not vocal about these issues, then never hesitate to ask. acknowledgements we would like to acknowledge shamoon noushad for his effort in finalizing the study. conflict of interest none. funding none. references  allen, l. s., & gorski, r. a. (1992). sexual orientation and the size of the anterior commissure in the human brain. proceedings of the national academy of sciences, 89(15), 7199-7202.  dawson, g. n., & warren, d. e. (2012). evaluating and treating sexual addiction. american family physician, 86(1), 74.  devinsky, j., sacks, o., & devinsky, o. (2010). klüver–bucy syndrome, hypersexuality, and the law. neurocase, 16(2), 140-145.  freimuth, m., waddell, m., stannard, j., kelley, s., kipper, a., richardson, a., & szuromi, i. (2008). expanding the scope of dual diagnosis and co-addictions: behavioral addictions. journal of groups in addiction & recovery, 3(3-4), 137160.  haines, j. d. the skeptics society & skeptic magazine.  håkon, p. c. n. o. j., palmstierna-roger, b. h. n. t., & thomas, a. b. violence in clinical psychiatry.  kristian adams, (2011). “the neuroscience of the sexual desire”.  marshall, l. e., & marshall, w. l. (2006). sexual addiction in incarcerated sexual offenders. sexual addiction & compulsivity, 13(4), 377-390.  merton, r. k. (1957). priorities in scientific discovery: a chapter in the sociology of science. american sociological review, 22(6), 635-659. "  mick, t. m., & hollander, e. (2006). impulsive-compulsive sexual behavior. cns spectrums, 11(12), 944955.  montgomery, k. a. (2008). sexual desire disorders. psychiatry (edgmont), 5(6), 50.  reid, r. c., & carpenter, b. n. (2009). exploring relationships of psychopathology in hypersexual patients using the mmpi-2. journal of sex & marital therapy, 35(4), 294-310.  reid, r. c., carpenter, b. n., spackman, m., & willes, d. l. (2008). alexithymia, emotional instability, and vulnerability to stress proneness in patients seeking help for hypersexual behavior. journal of sex & marital therapy, 34(2), 133-149. http://www.aeirc-edu.com/ syeda farah batool 66 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188  rinehart, n. j., & mccabe, m. p. (1997). hypersexuality: psychopathology or normal variant of sexuality? sexual and marital therapy, 12(1), 45-60.  seegers, j. a. (2003). the prevalence of sexual addiction symptoms on the college campus. sexual addiction & compulsivity, 10(4), 247-258.  toledano, r., & pfaus, j. (2006). outcomes assessment: the sexual arousal and desire inventory (sadi): a multidimensional scale to assess subjective sexual arousal and desire. the journal of sexual medicine, 3(5), 853-877.  van der meij, l., almela, m., buunk, a. p., fawcett, t. w., & salvador, a. (2012, january). men with elevated testosterone levels show more affiliative behaviours during interactions with women. in proc. r. soc. b (vol. 279, no. 1726, pp. 202208). the royal society.  whipple, b., & komisaruk, b. r. (2008). functional magnetic resonance imaging (fmri) during orgasm in women. sexologies, 17(1), s45. http://www.aeirc-edu.com/ aatir h. rajput 49 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 original article a cross-sectional analysis of potential stressors leading to depression among medical students of public sector universities of sindh aatir h. rajput1, muhammad muneeb2, tahir hanif3, abid ali4, anam shaikh5, uraza noor6 & usama shaikh7 liaquat university hospital lumhs research forum sir cowasjee jehangir institute of psychiatry liaquat university of medical & health sciences, jamshoro combined military hospital (c.m.h.), hyderabad corresponding email: aatirh.rajput@gmail.com abstract background: till the 70's, it was believed that depression among students was rare or even non-existent. this concept has now begun to change. research studies that show presence of depressive problems in students have started surfacing but much more need to be explored. objective: to find out the causes and level of stress and depression among undergraduate medical students of public sector medical universities and medical colleges of sindh. methods: this cross sectional psycho-social analysis included 587 undergraduate medical students from 6 public sector medical institutes of sindh. multistage sampling was implemented. sampling procedure includes both stratified sampling and simple random sampling. stratification was done on the basis of location of university and medical college and year of study. informed consent was taken from every student. stress and depression levels were measured in accordance to academic and non-academic stressors. data analysis was done on spss version 17.0. results: girls showed a much higher depression score in comparison with boys. hostilities had a significantly greater depression score than those who were living with their families. it was revealed that students having higher grades and gpa had much higher scores of depression compared to students having lower grades and gpa. fear of unemployment after studies and lack of positive response from parents and institution were few of the most potent stressors. conclusion: on the basis of our result we conclude that a decrease in medical syllabus and time extension in semesters may directly reduce students’ workload and consequently decrease the depression level. stress management programs should be conducted in every institute for coping with the stress. efficacious moral and substantial support from faculty, teachers and families is crucial to ameliorate of students’ health. keywords stress, depression and medical students. introduction although there are many case studies on depression since the 17th century but scientific interest on depression among medical students is developed recently. the aim of medical education is to get knowledge, to be a highly skilled, competent and a professional physician who is equipped enough to care for the nation’s illness, who proceeds advancement in field of medicine, and public health. depending on these particular characteristics, one may anticipate a medical institute would be a time of personal growth, demand, and a great source of stress and depression. till the 70's, it was believed that depression among students was rare or even nonexistent (maria a. et al, 2013; besseghini vh, 1997). this concept has now begun to change. research studies that proved presence of depressive problems in students have also suggested changes in this conception. major depression (md) in students is commonest, debilitating and recurrent type of depression that involves a high degree of morbidity and mortality and it is a great public health concern, although still often not diagnosed nor much treated. several studies noticed the phenomenon of depression in students has been occurring more frequently and earlier than before. but there are some epidemiological studies about depression at this period of life (maria a. et al, 2013; mirza kah. et al, 1996) epidemiological studies about depression and depressive symptoms in students have shown differences of occurrence, in the different rates of the specific age groups and in the gender distribution. a rise in occurrence of depression and depressive symptoms during teenage has been accepted widely, http://www.aeirc-edu.com/ mailto:aatirh.rajput@gmail.com aatir h. rajput 50 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 but the exact time or age in which it happens is still not clearly known. it is also not found yet whether there are high chances of predominantly depressive symptoms associated with age and gender differences or not (maria a. et al, 2013; mirza kah. et al, 1996). stress is usually defined as any unusual need of a body based on one’s internal or external resources that makes a person to utilize more energy reserves in excess of what would be necessary for dealing with ordinary life events. signs of being stressed can be demonstrated through observable behaviors such as tremors or tics, thumb or finger sucking, nail biting, hair twirling, helplessness, physical hostility, complaints of physical aches and pains, irritability, nervous laughter, outbursts, crying, and withdrawal. stress affects most people in some way. acute stress causes rapidly change along whole body. almost all biological systems of the body like circulatory system, immune system, respiratory, digestive system, sensory organs, and nervous system, are accelerated efficiently to cope with upcoming danger. chronic stress can have serious effects on one’s health and it should be treated like any other health concern in order to get a sound physically and psychologically fit individual. (roberts re. et al, 1995) medical institutes demand more academic and clinical knowledge and to cope up with this, students’ working hours into nights and weekends, are much extended [1]. a number of sources of stress are frequent examinations, exam phobia, time limits, reduced leisure time, an over demanding curriculum, complicated treatments, possible conflicts with patients, fellow students, institution staff and faculty, lack of self-esteem, and most important the differences between the student’s expectations and reality. (rajab l, 2001) based on the current literature and scientific studies on depression and stress among students, i strongly consider that medical students among all have greatest risks of depression and depressive symptoms because of the increasing needs and challenges of the medical profession related to both quality and quantity of academic and clinical performance. this study proves that a change is strongly needed in curriculum planning and working environment of medical institutions. academic as well as non academic sources of stress should be minimized. furthermore, effective communication and assistance from faculty, administration and families is essential in order to get better results from students. methodology this cross sectional multi-center study was designed to get a complete picture of the prevalence of stress and depression among undergraduate medical students of public sector medical colleges and universities of sindh, namely dow medical college, karachi, sindh medical college, karachi, liaquat university of medical & health sciences, jamshoro, peoples university of medical & health sciences for women shaheed benazirabad, chandka medical college, larkana and ghulam mohammad maher medical college, sukkur, and to find out the causes, perceptions and preventive measures for stress and depression. 587 undergraduate medical students both male and female took participation in the study. multistage sampling was implemented and equal numbers of questionnaires were assigned to each public sector medical university or college of sindh. sampling procedure includes both stratified sampling and simple random sampling. stratification was done on the basis of location of university and medical college (being public sector university is foremost decisive factor), and year of study. 20 questionnaires were assigned to each studying year and further sampling procedure was conducted according to simple random sampling. every 17th student according to call roll number was selected for the study. a prerequisite informed consent was taken from every student. a semi quantitative questionnaire based on hamilton scale of depression for adults was designed, having full information of demographic bio data and information about financial status, place of residence (hostel or home) and life luxuries. other questions were about duration of study in normal days and during exams, number of assignments and tests, number and types of recreational activities occurring in institutions and type of hobby and time given to it, were also asked from every participant. data collection took three and half month, started from 10th of february, 2014 to 26th of may, 2014 and data processing and analysis was done by using spss version 17.0. total duration of study was 6 months i.e. from 15th of january, 2014 to 15th of june, 2014. results a total of 600 questionnaires were administered to both male and female undergraduate medical students by using multistage sampling procedure (100 to each public sector university or medical college) out of which 587 (98%) questionnaires was returned. out of which 64.05 % (376) were girls and 35.95 %( 211) were boys. mean age was 20.13 while standard deviation was found to be of + 1.73. http://www.aeirc-edu.com/ aatir h. rajput 51 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 453 435 376 478 409 545 134 152 211 79 178 42 less time for preparataion for exams lack of time for assignments fear of unemployment after study fear of parents after failure lack of positive response from parents & teachers lack of recreational activities main stressors yes no 64.05 39.95 gender distribution among medical students girls boys as in general, girls showed much higher depression score (22.76) in comparison with boys (20.34). combine depression score of all undergraduate medical students was 21.67. hostilities had significant depression score i.e. 21.35 than those who were living with their families i.e. 19.28. massive syllabus, day to day assignments, weekly and monthly tests and lack of recreational activities among students had highly overburdened them. it can be assumed by the study that students having higher grades and gpa had much higher scores of depression compared to students having lower grades and gpa. the divergence in observed problems among public sector medical colleges and universities of sindh were investigated. trouble in getting good study material, poor time management and fear of parents in case of being failed, were reported as main stressors by the students. fear of unemployment after studies and lack of positive response from parents and institution had significantly raised stress and depression among students. http://www.aeirc-edu.com/ aatir h. rajput 52 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 534 173 473 508 53 214 114 79 vast syllabus language difficulty unsuitable semester length difficulty in time management students complaints no yes 21.67 20.34 22.76 21.35 19.28 overall score boys girls hostilite day scholars mean depression score discussion studies revealed that unskilled students have always been vulnerable to many stressful situations in their life, especially in pursuing of their professional education in much competitive environment. students suffered from depression at least once or more during the course of their professional education. being most needy, challenging and stressful learning places (polychronopoulos a. et al, 2005) medical institutions are greatly renowned. studies suggested that a considerable portion of medical students’ i.e.15-26% had been suffering from one or other kind of emotional disturbance and they were seriously in need of prompt treatment (jenny f, 1986; pitts fn. et al, 1961). it is evident that the duration of stress is of much worth and there is a decrease in stress with advancing year of medical training (adsett ca, 1968). spotting out of significant problems is of much importance in medical programs as it may give students and faculty an opportunity to take preventive measures for stress (yap. et al, 1996). this can be proven by the fact that majority of medical students are not well adopted to the educational environment and to the workload imposed by the medical institution which leads to higher levels of stress and depression (bradley i. et al, 1989). higher levels of psychiatric illness in medical students were found during a study in us when compared with general population. more than 20% of medical students met diagnostic criteria for psychiatric illness (lloyd c. et al, 1984). a number of studies have demonstrated the relation between stress concept in regards or several factors like gender, marital status, professional courses, academic year, living environment, and socio-cultural factors that affects student’s mental health (polychronopoulos a. et al, 2005; yap a. et al, 1996; tedesco la, 1986; tedesco la. et al, 1987; grandy t. et al, 1989; westerman g. et al, 1993; heath jr. et al, 1999). studies also suggest a higher prevalence rate of depression in women than in men. (adsett ca, 1968; yap. et al, 1996; bradley i. et al, 1989; lloyd c. et al, 1984; tedesco la, 1986; tedesco la. et al, 1987; grandy t. et al, 1989; westerman g. et al, 1993; heath jr. et al, 1999). although there are not much studies that shows discrimination factor among male and female students but the fact that female doctors who are doing postgraduate training have noticeably higher rates of mental health problem than male http://www.aeirc-edu.com/ aatir h. rajput 53 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 doctors is revealed by some researchers. (borrill cs. et al, 1996) modern educational systems have been a cause of increase prevalence of stress, anxiety and depression among medical students, suggested by a number of studies (ball s. et al, 2002; tyssen r. et al, 2001). furthermore it is also evident that mental distress among doctors in practice (gelfand dv. et al, 2004) has its roots somewhere in medical school (tedesco la. et al, 1986). it is also suggested that the practice of medicine either by qualified physicians (vincent mo, 1983) or medical students (pitts fn. et al, 1961) produces risks to mental health and the link between medical training and mental health problems have also been suggested (reibord sp, 1983). majority of research presented seconds the presence of a relation among stress and depressive episodes, based on sporadic stress causing agents that have an annoying and unwanted content. generally, these agents affect both psychological and physical health of student but some studies also suggest the direct effects of these agents that create hazardous-stress-harmful pathway. an epidemiological study stated that non respondents to questionnaires were supposed to be more depressed than respondents (vernon sw. et al, 1984) but the response rate of my study (98%) in comparison with previous studies particularly makes its finding worth important and it can be applicable to all medical students. a total of 687 undergraduate medical students belonging 7 public sector medical institutions of sindh have been surveyed in this study which shows the differences in observed problems and hence their stress and depression level. students coming from cambridge level system (had studied in ‘a’ levels) showed much less academic and clinical problems in comparison with the students coming from higher secondary college system (intermediate system). it is found that students having low grades and gpa have statistically significant greater number observed problems than that of students with high grades and gpa in overall depression score. this is rational to results of other studies which similarly showed same results that low satisfaction rate of students with their educational environment characteristically causes low academic achievements (mayya ss et al, 2004). fear of talking to patients, improper handling and consoling and following up of proper treatment was a major source of stress as reported by most of students. clinical practice being most valued one has undoubtedly as its leading role in developing stress and depression in students. monthly tests and assignments have also significant role in shattering of mental health of students. third most reported cause of depression is the communication and coordination gap between students and faculty. students living at hostel have less depression rate as compared to those living with families. high depression score for studentfaculty relationship and clinical training is typically found in students living with their families. the probable causes of which are increasing demands of social activities that overburdened student and limit time as well. students those who are disgraced by the teachers in front of their class fellows tend to show more depressive symptoms. feeling of frustration and powerlessness was rate highest on stress incident record while tension and anxietysurprisingly were on second grade. these feeling may become an imminent part of medical students’ nature and they significantly contribute to experience of the ‘learned helplessness’ that is eventually associated with depression. (jenny f, 1986; mayya ss et al, 2004). medical institutions are becoming more demanding: academic and clinical training now require more working hours. examination fear, day to day tests and assignments, short preparation leaves, strenuous curricula, clinical training, anxious and conflicted patients, complicated treatment, difficult procedures and follow-ups, fellow colleagues, staff and faculty, lack of recreational activities and lack of selfconfidence and self-esteem are typical sources of stress for medical students. with proper counseling (mc auliffe we. et al, 1984) and support from teachers (jenny f, 1986; filed d, 1984) a marked reduction in depression levels among medical students can be made possible which will surely result in more, better and efficacious output by medical students and in broad sense it will ultimately be the society that will have maximum benefits. conclusion strenuous and limitless syllabus of medical profession was found to be the major source of depression. conventional methods of teaching, clinical training, fear of patients and lack of studentfaculty relationship were important unanswered matters. a lessen in medical syllabus, a bit time extension in semester may directly reduce students’ workload and indirectly reduces the depression level. it is a recommendation that by up gradation and modification of clinical training system may contribute significant reduction in observed problems of students. this study confirms the fact that needs of medical profession related to both quality and http://www.aeirc-edu.com/ aatir h. rajput 54 annals of psychophysiology volume 3, october 2016 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 quantity of academic and clinical practice are important sources of stress. the sources of stress both academic and clinical must be considered in planning of curricula. working environment, student-faculty relationship and syllabus length should be upgraded and modified for betterment of students’ mental health. stress management programs should be conducted in every institute for coping with the stress. in the last but not the least efficacious moral and substantial support from faculty, teachers and families is crucial for amelioration of students’ health. conflict of interest all the authors disclosed that there is no conflict of interest associated in the preparation of this article. acknowledgements we would like to acknowledge the intellectual assistance and technical support provided by lumhs research forum reference  adsett ca. 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(1987). performance and psychosocial response to the dental school educational experience: exploring barriers to learning. in: paper presented at the american association of dental school annual meeting, chicago.  tyssen r, vaglum p, gronvold nt, ekeberg o. (2001). suicidal ideation among medical students and young physicians: a nationwide and prospective study of prevalence and predictors. j affect disord. 64, 69-79.  vernon sw, roberts re, lees es. (1984). ethnic participation in longitudinal health studies. am j epidemiol. 119, 99-113.  vincent mo. (1983). some sequelae of stress in physicians. psychiar j univ otawa. 8, 120-124.  westerman g., grandy t., ocanto r., erskine c. (1993). perceived sources of stress in the dental school environment. j. dent. educ. 57, 225-231.  yap, a., bhole, s., teo, c. (1996). a crosscultural comparison of perceived sources of stress in the dental school environment. j. dent. educ. 60, 459-464. http://www.aeirc-edu.com/ review article www.aeirc-edu.com volume 12014 page | 3 ©advance education institute & research centre-2014 assessment of major physical stressors and its psychophysiology; a comprehensive review syed zain azher 1 shamoon noushad 1 & sadaf ahmed 1&2 1. psychophysiology research division, advance educational institute & research centre 2. neurovascular physiology & biophysics unit, department of physiology, university of karachi corresponding author: zain@aeirc-edu.com abstract: the purpose of this review was to highlight the concept and understanding of physical stress and to discuss its psychophysiological mechanisms along with characteristics and major causes. the environmental and physical changes that are responsible for alterations in the homeostasis of the body is simply identified as physical stress. the brain is to interpret experiences as alarming or non-alarming which trigger the physiological and behavioral responses in each situation. we gathered a literature data from different published articles, original research papers & online sources. we hypothesized that the continuous imbalances of physiological mechanism due physical and environmental stimulus can cause physical stress and it is concluded that the major factors of physical stress includes injury, excessive exercise, noise, pregnancy, workload, pressures and temperature with the involvements of psycho-physiological mechanism. keywords: stress, psychophysiology, physical stress, stressors, psychological, physiological introduction: stress is a physical state of the brain and body that develops when physical stimuli affect the homeostasis (sadaf, 2013), these situations or stimuli are considered as stress provoking are known as stressors (stevens, 2013). it is known that if the stimulus disturbs the state of equilibrium, it could lead to structural or functional changes (lazarus, 1986). physical stress also defined as the force applied to a given area of biological tissue or is the response to environmental pressures and demands. stress occurs when the demands upon an individual surpass the resources in body to meet such demands. extrinsic factors are factors outside of the body that can influence either the level of stress on tissues or the thresholds for tissue adaptation and injury. however physical stress levels that exceed the maintenance range (i.e. overload) result in increased tolerance of tissues to subsequent stresses, so any exerted force that is characterized by vigorous bodily activity can lead to altered physiological responses is counted as physical stress (syed, 2014). moreover any exerted force that is characterized by vigorous bodily activity can lead to altered physiological responses is counted as physical stress such as aerobics, work outs, injury or aches. it may also count on physical traumas as cuts, burns, sprains, broken bones, surgery, etc. in other words physical stress is bodily response to substantial pressures such as exertion, noise, sickness or exercises (sadaf, 2013). excessive exercises, noise, are major physical stress stressors which change or disturb the body homeostasis. this comprehensive review is divided into two sections: (a) the psychophysiology of stress, (b) to highlight the major physical stress stressors. stress affects the central nervous system leading indirectly to the modulation of the activity of steroid, catecholamine, peptide and opioid systems. it also affects other body systems: behavior, the immune system, cardiovascular responses and the gastrointestinal tract. in response to stress, a cascade of neurohumoral events chiefly at the level of the (hypothalamic-pituitary-adrenocortical) hpa axis, is triggered, the result of which is the termination of the stress reaction leading to normalization i.e. homeostasis (miller, 2007).temperature affects a broad spectrum of cellular components and metabolism, and temperature extremes impose stresses of variable severity that depend on the rate of temperature change, duration and intensity (sung, 2003).moreover at the time of cell damage or injuries body start the process of coagulations which disturb the body homeostasis however excessive blood loss from a damaged vessel can lead to an increased risk of obstructive clotting thrombosis or bleeding hemorrhage (desborough, 2000). stressors effects may vary according to age and sex, individual variations play a major part in this respect in female at the time of pregnancy body feel constant physical stress due to changes of stress hormone, respiratory rate decreases excessive need of oxygen, increases blood pressure and increase insulin resistance which led to increase blood glucose level changes in body weight, total body water, plasma proteins, body fat, and cardiac output is seen (anderson, 2005).during exercise increase in the blood pressure, heart rate, vascular resistance and stress hormone levels are also observed and it also reported that weather high and low responders to exercise stress would show corresponding hpa reactivity to psychological stress. (anita, 1999) physical work load that sets high demands on muscle groups which cause back pain it is the main predictors of physical stress (grant, 2006). negative physical stress if any physical stressor triggers hpa axis for a long period of time and surge the stress hormonal level that cause tension and that may lead to illness, pain, feeling of unpleasant, anxiety decreases performance and overexertion is term as negative physical stress. chronic physical stress that stays approximately for weeks or months it can weaken the immune system and cause high blood pressure, depression, fatigue and gastrointestinal problem and even heart diseases. in meticulous excessive epinephrine can be harmful to your heart. review article www.aeirc-edu.com volume 12014 page | 4 ©advance education institute & research centre-2014 positive physical stress if any physical stressor triggers hpa axis for a short period of time normally and provides enthusiasm and enjoyment, as well as consideration and energy for deadlines, exercising such as jogging or lifting weights entering new situations, motivation for new challenges and achieving maximum performance is term as positive physical stress. in addition, there are various health advantages with a little bit of physical stress. researchers believe that some stress can help to make stronger the immune system. for example physical stress can get better your heart works and protect your body from infection. however individuals who experienced modest levels of stress prior to surgery were able to make progress faster than individuals who had low or high levels. psychophysiology of physical stress the fight or flight response named by cannon and selye in the 1930s is a pattern of physiological responses that prepare the organism to emergency. when the external balance is disputed our body changes its internal balance accordingly. the fact that modern problems do not require such means is exactly the setting of stress-related problems. the manifestations of the f or f are mainly through two channels: the sympathetic branch of the ans and the endocrine system both are closely interconnected the ans effect many bodily functions instantly and directly, while hormones have slower yet wider effect on the body both hormones and neurones communicate with cells and create the delicate dynamic balance between the body and its surrounding, through paired systems and feedback mechanisms by acute and chronic pathway (see flow chart) (ader, 1995; miller, 2007). increased heart rate, blood pressure and respiration and heart pump more blood to the muscles, supplying more oxygen to the muscles and heart and lung system. allowing rapid energy use, and accelerating metabolism for emergency actions. increased sugar rates in the blood. thickening of the blood to increase oxygen supply, facilitate better defense from infections and to stop bleeding quickly, prioritizing increased blood supply to peripheral muscles and heart, to motor and basic-functions regions in the brain; decreased blood supply to digestive system and irrelevant brain regions, this also causes secretion of body waists, leaving the body lighter. secretion of adrenaline and other stress hormones to further increase the response and to strengthen relevant systems & secretion of endorphins is a natural painkiller, providing an instant defense against pain (atkinson, 1996). the immune system protects the body with help of stress hormone; cortisol is responsible for interfering with the production the immune system components like leucocytes and antibodies. however aldosterone is another stress hormone that helps your body keep sodium which keeps more water in your blood, increasing blood pressure and volume. in chronic physical stress immune system is unable to respond to hormonal control, and consequently, produce levels of inflammation that promote disease such as cardiovascular, asthma and autoimmune disorders. repeated firing of the hypothalamicpituitary-adrenal (hpa) axis and sympathetic nervous system (sns) caused constant state of hypervigilance. this dysregulation can contribute to chronic diseases such as cardiovascular disease, metabolic syndrome, autoimmune disease obesity, diabetes (syed, 2013). physical stress stressors we try to highlight the major physical stressors in this review to explore or differentiate from other stress types. noise: noise is the most encountered stressor, produced by urban traffic, air craft’s from work environment and house hold appliances. long term experience to unavoidable noise stress induces exhaustion, defeat, annoyance followed by decreased muscle movement, social contacts and mood changes (shankar, 1999).noise affects the neurotransmitter levels in different regions of brain reduces dendritic count, elevates plasma corticosterone levels. it disrupts the activity or balance of life and causes psychological and physiological or behavioral changes in people. it has been reported to produce atrophy of dendrites and alterations in neurotransmitter levels. even low levels of repeated noise can cause stress. noise is an unavoidable stressor of daily modern life and a large segment of population is exposed to high levels of noise. evidence also shows that repeated stress produces atrophy of dendrites and alterations in neurotransmitter levels (naqvi, 2012). exposure to noise constitutes a health risk. there is enough scientific facts that noise exposure can induce hearing impairment, hypertension and ischemic heart disease, annoyance, sleep disturbance (passchier-vermeer, 2000). there is growing evidence suggesting that noise induced peripheral hearing loss can also induce functional changes in the central auditory system (sun, 2008) is not responsible only for temporary or permanent hearing loss, but can also induce transient or permanent tinnitus, loudness recruitment and hyperacusis as well as reported to decreases the immune functions by reducing natural killer cells (kay, 1998). uneven loud noise during pregnancy had a significant effect on both male and female offspring’s, low weight birth, impaired cognition and post natal growth (shankar, 1999). pregnancy: pregnancy is characterized by dynamic changes in multiple body systems resulting in increased basal oxygen consumption and in changes in energy substrate use by different organs including the feto placental unit. from early pregnancy the human placenta influences maternal homeostasis. nitric oxide (no) is also locally produced by the placenta and together with other reactive nitrogen species contributes to potential oxidative stress (dotsch, 2001) while confirmation of a pregnancy is often exciting news, it can also be the beginning of a very stressful period in the lives of the parents to be. stress also affects labour. the stress response has a profound effect on the female hormonal system and can, in some cases, inhibit contractions and prolong the process (anderson, review article www.aeirc-edu.com volume 12014 page | 5 ©advance education institute & research centre-2014 2005). during pregnancy excessive physical stress may have negative influences on fetal development or a birth of low weight infant (march of dimes, 2006). however normal stress hormones are necessary for normal fetal organ maturation and for preparing the fetus for extra uterine life (challis, 2001; hansen, 2000).there is an association between stress and cortisol secretion in human pregnancy. recent findings in non-pregnant women show that a stress related hormone response is mainly found in evening cortisol levels (powell, 2002). new studies found differences in the associations between chronic stress in early and late pregnancy and cortisol levels indicating that the response to chronic stress is dependent on the stage of the pregnancy (obel, 2005). exercise: exercise is other stressor which lead to body in stress moreover is totally depends on duration and types of exercise aerobic and anaerobic. aerobic exercises use the arm and leg muscles and give the heart and lungs a continuous workout. anaerobic exercises build and tone muscles but are not as beneficial to the heart and lungs as aerobic activities. during anaerobic exercise your body builds up lactic acid, which causes uneasiness and fatigue at sustained levels. for this reason anaerobic exercise or high intensity exercise happens in short bursts. a number of studies have shown that psychological well-being can be influenced by physical activity/training. physical activation is very much a stressor that affects the body’s physiological stress systems (doherty, 2000; hawley, 2002). the release of adrenaline, noradrenaline and cortisol that occurs during physical training is similar to the release that occurs in connection with an acute psychological stress reaction (borer, 2003). however the prevalent view is that regular physical activity of moderate to average intensity improves the function of the immune system and can reduce sensitivity to infections. however, hard or prolonged exercise in endurance sports can lead to immunosuppression and greater infection sensitivity (sweden book) although, it appears that stressful stimuli differentially activate the hpa, it is not known whether a high responder to exercise stress will also be a high responder to psychological stress. this is an important issue because stress reactivity may have implications for health status. it appears that hpa reactivity at the two ends of the continuum, hypo and hyperreactivity, may influence an individual’s susceptibility to developing various psychological, metabolic, inflammatory, and autoimmune disorders (kirschbaum, 1995). several studies have suggested that there is an increased risk of respiratory infections in subjects doing heavy exercise (health, 1991). in literature that has been largely unconcerned with aerobic fitness, certain cardiovascular and biochemical changes have been reported during psychosocial stress, which involves little physical work (singh, 1999). review article www.aeirc-edu.com volume 12014 page | 6 ©advance education institute & research centre-2014 workload employees continually reported that work load is a significant source of stress and they are typically feel tense or stressed out during the workday moreover of employees reporting at time of overwork they make a lot of mistakes at work (galinsky, 2005; american psychological association, 2009). physical work that sets high demands on main muscle groups, for example, in terms of manual materials handling, static-postural load, repetitive movements, and large output of force, is still the main element of many jobs (pongian, 2002) low back pain, a leading cause of disability in the industrialized world, is well recognized as having a multifactorial etiology. the main predictors of back pain include physical stress example, driving, prolonged lifting forceful or repetitive movements involving the back (punnet, 1991). workload as an aspect of objective reality of a job can be viewed as a direct source of stress, such as the frequency of any task or the nature of the task itself (ezra, 2010). however physical workload has been identified within the frame of the sudden unexplained death syndrome (gogh, 1993). temperature changing in temperature is a major cause of disturbing the body physiology. the nervous system is important in thermoregulation as the processes of homeostasis and temperature control are centered in the hypothalamus. the hypothalamus maintains the set point for body temperature through reflexes that cause vasodilatations and sweating when the body is too warm, or vasoconstriction and shivering when the body is too cold however, if this process occur for a long period of time it may cause physical stress. injury the stress response to surgery, injury or trauma comprises a number of hormonal changes initiated by neuronal activation of hpa (axis). this is a part of the systemic reaction to injury which includes a wide range of endocrinological, immunological and hematological effects (desborough, 2000). physical stress is the force, or load, acting on a given area of tissue (tipler, 1982). tissues accommodate to physical stresses by altering their structure and composition to best meet the mechanical demands of routine loading. however biological tissues exhibit responses to physical stress. each response is predicted to occur within a defined range along a continuum of stress levels specific thresholds define the upper and lower stress levels for each characteristic tissue response by decreased stress tolerance (eg, atrophy), maintenance, increased stress tolerance (e.g. hypertrophy), injury, and death (michael). similar in the musculoskeletal and integumentary systems, excessive physical stress can injure tissues in the cardiovascular/pulmonary system. mechanical stretch induced by high blood pressure is thought to be an initial event that leads to cardiac hypertrophy and eventual cardiac failure (yamazaki, 1999). high blood pressure is an established risk factor for conditions such as stroke, myocardial infarction, and atherosclerotic disease (taylor,1999). conclusion: o stress is the summated response of the biological reactions to any adverse stimulus, physical, mental, or emotional, internal or external, that tends to disturb the homeostasis of an organism (erskine, 1972). environment is an important contributor to life style. environmental stresses from noise & heat cause physical dysfunction in people (schachter, 1962). o psychological symptoms are also consequences of many physical factors and can be defined as a set of interactions between the person and the environment. o physical stress not only affects the individual’s performance, work efficiency and group performance but also lost healthy shares in an increasingly competitive era, and may even jeopardize the survival of being in fast moving society (kazmi, 2008). o it is also essential to know the importance of physical workload affecting muscular work that can relate to productivity and work condition however the observations periods are needed to be selected so that they would be as demonstrative as possible (yoopat, 2002). o at the time of pregnancy excessive physical stress may have negative influences on fetal growth or a birth of low weight infant (march of dimes, 2006). o noise disrupts the activity or balance of life and causes psycho-physiological changes. o variations in environmental temperatures, physical activity and tissue exposures to injury are ubiquitous physical stress situations that also involve biochemical changes in body. o the overall knowledge of physical stress is very relevant in the field of psychology, physiology and psychophysiology as it is not mostly considered to cause above mentioned effects. these day to day exposures to such stressors have the potentials to provoke acute as well as chronic stress conditions and need to be explored further. references:  ader r, cohen n, felten d (1995) psychoneuroimmunology: interactions between the nervous system and the immune system. lancet 345: 99–103.  american psychological association. 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(2008). occupational stress and its effect on job performance-a case study of medical house officers of district abbottabad. j ayub med coll abbottabad, 20(3), 135-139. rakhshanda bakht 23 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 original article prevalence of suicidal ideation and suicidal cognition among the local population of karachi, pakistan rakhshanda bakht1, tasmeena saeed1, sadaf ahmed1&2& shamoon noushad2&3 1. psychophysiology research lab, department of physiology, university of karachi. 2. advance educational institute and research center (aeirc), 3. dadabhoy institute of higher education. corresponding author: bakht.rakshanda@yahoo.com abstract objective suicide has become a leading cause of death worldwide, thus it has become a public health problem for every country in the world and thereby in pakistan too. the aim of present study was to find out the prevalence of suicidal thoughts among the local population of karachi. correlations were also assessed among suicidal thoughts and demographic characteristics. method a survey was conducted to fill out a pre-structured questionnaire from the participants between the age group of 18-30. the questionnaire contains beck’s scale of suicide cognition, modified scale of suicide ideation and a detailed demographic profile. subjects were taken from different universities, medical colleges, offices and business schools. mentally ill patients were not included in the study. result severe suicide ideation and suicidal cognitions are prevalent in the population to about 4% and 3% respectively. also in the study, demographic variations exist in subjects with respect to suicidal thoughts; male, non-working, unhappy, in-pain subjects, unmarried, being in the 18-21 age brackets and undergraduate reported higher suicidal thoughts as compared to their correspondent parameters. conclusion it has been concluded that severe suicidal thoughts are prevalent among youngsters. and certain demographic characters are strongly correlated with amplified suicidal thoughts among youth of karachi. keywords suicide, imagination, beck’s scale, suicidal cognitions introduction according to the recent report of world health organization of 2006, about a million people, commit suicide every year in the whole wide world, which is far more than the deaths occurred in wars (who, 2006; kessler et al, 2005 & mann, 2003). thus suicide has become a public health problem affecting entire world at every level with devastating socio-economic cost and consequences (who, 2013 & mann, 2003). it is also revealed that after every 40 seconds a person takes his or her life somewhere in the world (who, 2006). in general, rates are highest in eastern europe and lowest in central and south america, with the united states, western europe, and asia falling in the middle (bertolote & fleischman., 2009 & nock, et al., 2008). previously researchers define suicide as “an outcome of deliberate obliteration or killing of oneself” (kaplan, et al., 1998). similarly, krug in 2002 defined suicide as “an outcome of deliberate acts of the person with considerable initiation and performance of a pattern to knowingly kill oneself” (krug, 2002). meanwhile, the word suicide is etymologically derived from a latin word, http://www.aeirc-edu.com/ rakhshanda bakht 24 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 suicidium (sui=oneself and cidium=killing) (jans, et al., 2012). however, the notion, thought and imagination of self-harm comes under the umbrella of suicide ideation (jacobs, et al., 2003 & kaplan, et al., 1998), which is way more common than the actual suicide attempts. further, it was specified that the ratio of suicide ideation to suicide attempts is about 8 to 10 times higher, which means that people ideate suicide 8 to 10 time more than they actually attempt it (frierson, et al., 2003 & andreason, et al., 1995). on the other hand, attempted suicides are 10 to 40 times more frequent than lethal suicides (schmidtke, et al., 2004 & platt, et al., 1992). therefore, each suicide (whether attempted or completed) is an individual’s own catastrophe who takes his or her life captivating under the dilemmas of life. and this tragic act will unceasingly and vividly influence the lives of his or her family and companions till the very end (who, 2013). similarly, redfield jamison described the sentiments of suicidal mind as, “suicide carries in its aftermath a level of confusion and devastation that is, for the most part, beyond description” (redfield jamison, 2000). the estimated ratio of attempted suicides to completed suicides among adolescents to be 50:1 to 100:1 respectively; at which each adult already had 20 other suicide attempts before he or she could actually die by suicide (who, 2013). if 2003 report of who is assessed solely, it shows that about 877,000 deaths occurred only due to suicide in the year, 2002 (who, 2003). whereas, the most recent report of who suggested that 804,000 people took their lives in 2012 (who, 2013). moreover, on the other aspect, these suicidal attempts reflect about 1.4% of the disease burden on the entire globe in 2002 (who, 2003) and are predicted to be increased as much as 2.4% in 2020 (who, 2013). though there is a plenty of data regarding attempted suicide and completed suicide throughout the world, but little has been researched in relative to the suicidal thoughts, including suicide ideation and suicide cognition; which has proven to be the basic markers of suicidal activities. the present study is thereby conducted to shed some lights on the ground scenarios and milieu on suicidal thoughts, which are the root causes of these increased suicidal acts. the prevalence of suicidal ideation and suicidal cognition has been pondered among the local population of karachi, pakistan. also in this study, different demographic components, like age-group, gender, marital status, life style etc. has been correlated with suicidal ideation and cognition. methodology subjects participants were recruited from different universities and medical colleges of karachi. subjects of this study were mostly undergraduates, however, pre-graduates and post graduates were also included. moreover, the age criterion was set to be 18-30 years who did not have any disorder or any kind of mental illness, whether acute or chronic. tools a pre-structured questionnaire was interviewed from the participants who showed their interest in the present study and voluntarily agreed to give their concerned information regarding this study. the questionnaire included three parts in which the first portion has a detailed demographic information, the second one comprised of a universally recognized scale for suicide cognition, the suicide cognition scale (m.d. rudd, et al., 2007) the remaining third part included the modified scale for suicidal http://www.aeirc-edu.com/ rakhshanda bakht 25 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 ideation (mssi) (miller, et al., 1986) respectively. consent is also attached for ethical purpose in which individual is asked to read out some details about the study and if he or she agrees to take out 10-15 minutes to fill it out; then an agreeable signature is taken and the interview is started. meanwhile, a free space was also given in the questionnaire so as to provide participants with liberty to express their trauma and suicidal thoughts. the personal information however remains confidential and not shared at any level with individual’s specificities. data analysis the collected data was compiled from 519 subjects, of which 247 were female participants and 272 were males. the data was sorted into different groups, according to the severity of parameters been analyzed. the variables are then correlated to each other to evaluate the possible relationships among them. moreover, frequencies of some variables are also assessed. the data is initially analyzed through standardized scoring schemes of scales along with the demographic profile using ms excel 2010. later the data was shifted to spss version 2.0, for graphical analysis and correlations of different variables altogether. results the results of this study are showing in the graphical manner under this heading. figure 1.0 represents the prevalence of suicide ideation among the sample population. less than half of the population reflects low suicide ideation by scoring 42% at this range. similarly mild suicide ideation is prevalent to 41% of the total sample. 42% 41% 13% 4% suicidal_scoring low suicide ideation suicidal_scoring mild suicidal_scoring moderate suicidal_scoring severe http://www.aeirc-edu.com/ rakhshanda bakht 26 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 1.1 shows the prevalence of suicide cognition with the greater proportion of the sample is found to be lying in mild suicide cognition scoring. whereas only 2% of the sample had severe suicide cognition with respect to 10 % of the population which showed moderate suicide cognition. figure 1.2 shows the comparison of gender in suicidal ideation. here females show higher frequency in suicide ideation at normal and mild level whereas both genders are equally populated at severe suicide ideation score. 41% 47% 10% 2% suicide_cognition_scoring normal cognition suicide_cognition_scoring mild suicide_cognition_scoring modeate suicide_cognition_scoring severe 0 50 100 150 200 250 low suicide ideation mild moderate severe suicidal_scoring 108 101 27 11 111 110 41 10 gender male gender female http://www.aeirc-edu.com/ rakhshanda bakht 27 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 1.3 shows the comparison of suicidal cognition among genders in which females show higher frequency in suicide cognition at moderate and severe level. figure 1.4 shows the ratio of suicidal ideation with respect to their social status. the majority of the sample population is found to be normally social comparative to that of anti-social or being a social butterfly. 0 50 100 150 200 250 normal cognition mild modeate severe suicide_cognition_scoring 106 106 28 7 110 136 24 2 gender male gender female 0 50 100 150 200 250 low suicide ideation mild moderate severe suicidal_scoring 16 39 12 3 170 146 51 14 33 26 5 4 social_status social_butterfly social_status normal social_status antisocial http://www.aeirc-edu.com/ rakhshanda bakht 28 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 1.5 shows the ratio of suicidal cognition in relation to their social status. mild suicidal cognition is most prevalent at every social status, either in anti-social, normally social or social butterfly. figure 1.6 shows the prevalence of suicidal ideation in different marital statuses. single people ideate suicide more frequently and intensely as compared to committed and married ones. 0 50 100 150 200 250 normal cognition mild modeate severe suicide_cognition_scoring 23 31 12 4 160 185 33 3 33 26 7 2 social_status social_butterfly social_status normal social_status antisocial 0 50 100 150 200 250 low suicide ideation mild moderate severe suicidal_scoring 178 172 57 18 27 28 7 3 14 11 2 0 0 2 0 marital_status divorced marital_status married marital_status commited marital_status single http://www.aeirc-edu.com/ rakhshanda bakht 29 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 1.7 shows the prevalence of suicidal cognition in different marital statuses. single subjects have the high fraction of mild to moderate suicide cognition as compared to engaged, in related and married population. however, divorced subjects show high rate of severe suicide cognition. figure 1.8 shows the abundance of suicidal ideation in different age groups. age group of 18-21 is more prone to suicide ideation at every level of severity. 0 50 100 150 200 250 normal cognition mild modeate severe suicide_cognition_scoring 176 202 42 5 26 30 9 0 14 9 1 3 0 1 0 1 marital_status divorced marital_status married marital_status commited marital_status single 0 50 100 150 200 250 low suicide ideation mild moderate severe suicidal_scoring 211 204 66 21 8 6 2 0 count age_groups 22-25 count age_groups 18-21 http://www.aeirc-edu.com/ rakhshanda bakht 30 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 1.9 shows the abundance of suicidal ideation in different age groups. age group of 22-25 scores more in severe suicide cognition degree as compared to that of lower age group. figure 2.0 shows the prevalence of suicidal ideation in which non-working subject than working individuals. 0 50 100 150 200 250 normal cognition mild modeate severe suicide_cognition_scoring 213 231 51 7 3 10 1 2 age_groups 22-25 age_groups 18-21 0 50 100 150 200 250 low suicide ideation mild moderate severe suicidal_scoring 160 166 58 17 59 45 10 4 work working work non_working http://www.aeirc-edu.com/ rakhshanda bakht 31 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 2.1 shows the prevalence of suicidal cognition in subjects with suicide cognition at every level is more frequent in the non-working individuals with respect to that of working individuals. figure 2.2 indicate the prevalence of suicidal ideation in the population. the graph reveals that people who are spending an active life-style showed more suicidal ideation as compared to those who live with a lazy life-style. 0 50 100 150 200 250 normal cognition mild modeate severe suicide_cognition_scoring 159 193 44 5 57 49 8 4 work working work non_working 0 50 100 150 200 250 low suicide ideation mild moderate severe suicidal_scoring 31 50 16 4 188 161 52 17 life_style active life_style sedentary http://www.aeirc-edu.com/ rakhshanda bakht 32 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 2.3 shows the prevalence of suicidal cognition with respect to the life-style activities of the individual. here active subjects showed higher suicide cognition as compared to the lazy ones. figure 2.4 shows he relation of suicidal ideation with that of education level. the figure reveals that the subjects pursuing their graduation are seen to ideate suicide more as compared to any other educational level. it means that undergraduate students are more prone towards suicidal thoughts as compared to their correspondant pre-graduates and post graduates. 0 50 100 150 200 250 normal cognition mild modeate severe suicide_cognition_scoring 33 48 17 3 183 194 35 6 life_style active life_style sedentary 0 50 100 150 200 250 low suicide ideation mild moderate severe suicidal_scoring 9 6 2 0 44 77 22 5 149 118 39 16 17 9 4 0 0 1 1 0 qualification pg qualification graduate qualification undergraduate qualification inter qualification matric http://www.aeirc-edu.com/ rakhshanda bakht 33 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure 2.5 shows that severe suicide cognition is highest among undergraduate students as compared to other educational level. discussion the prime objective of the study was to measure the prevalence of suicide ideation and suicide cognition among the local population of karachi. though, results summarized that about 42% of the population is having low suicidal ideation and an approximately same ratio of the populace have mild suicide ideation, which is prone towards severity as shown in figure 1.0. the shocking revelation was that 4 in every 100 persons are severely ideating suicide in this population which is an alarming call for the whole country. similarly, 3 individuals in every 100 subjects are having severe suicide cognition ratio as shown in figure 1.1. previous studies quoted that suicidal ratio among muslim countries and other asian countries are lowest as compared to nonmuslim countries (bertolote & fleischman, 2009 & nock, et al., 2008). but these rising suicidal ideation and suicidal cognition among karachi, pakistan are leading us among those highly suicidal countries. the current study also shows the intensity and frequency of suicidal thoughts with respect to different demographic characteristics of the population. the reported results of the survey and analytical measures reflect that some gender variations are present with respect to suicide ideation. males ideate suicide more than females which is in the line of previous studies, who concluded that males are more supportive of the idea of suicide as compared to female (domino & leenaars., 1989; domino, macgregor, hannah, 1988-89; limbacher & domino, 1985-86.) as it can be seen in figure 1.2 and figure 1.3. similarly, another account of studies suggested similar resulted in a way that men are more likely than women to kill themselves (american foundation for suicide prevention, 2007. sejong, et al., 2005; canetto & lester, 1995). 0 50 100 150 200 250 normal cognition mild modeate severe suicide_cognition_scoring 5 6 5 1 54 74 20 143 147 25 6 13 14 1 2 qualification pg qualification graduate qualification undergraduate qualification inter qualification matric http://www.aeirc-edu.com/ rakhshanda bakht 34 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 however, peter, et al. in 1996 reported that females tend to have significantly more suicide ideation in the course of their life time than males. with respect to social status, it is estimated that a major ratio of the sample was found to be normally social thereby suicidal ratings are condensed at this level, as it can be seen in figure 1.4. however, it is observed that severe suicidal ideation is found more in people who are socially active. in the meantime, mild suicide cognition exists in every social status, shown in figure 1.5. this may be due to the fact that youth is more socialized now, no matter what they feel and think; they tend to express it to as many people as they can. nonetheless, the results are contrary to previous studies that suggested that strong social relations likely to decrease suicidal risks (meadows, 2005). relationship commitments have always been a protective factor for any kind of risky behavior including suicide. the study concluded similar results by showing high suicide ideation and suicide cognition among single and divorced ones while lowest rates among engaged and married ones; which shows that the committed ones are not likely supportive with the idea of suicide as compared to the loners or singles shown in figure 1.6 and figure 1.7. justifiable researches include (lorant, et al., 2005), who stated that marriage has a buffering effect on suicidal risk in the population. similarly, (agerbo, 2005; gove, 1979; qin, agerbo, & mortensen, 2003 & jans, et al., 2012) are further studies summarized in the same array. the age group in which suicidal ideation and cognition is more prevalent is found to be 1821, agreeable by a range of past researches including (who, 2013; national center of health statistics, 2009; mckeown, et al.,2006; kaplan, et al., 1998; jacobs, et al., 2003; watkins, 2006; quin, 2005, department of health statistics, 2000; national youth violence prevention resource centre, 2006; masango, et al., 2008 & waldvogel, et al., 2008). department of health statistics notes, 2000, see figure 1.8 and figure 1.9. the age group which is generally considered to be young adult age has higher suicidal prevalence which may be due to the fact that the maturity has not yet hit these individuals. researches claimed that human brain has not developed completely till this age bracket as prefrontal cortex is still in developing stage. this immaturity reflects in their behavior and they end up ideating and even attempting suicide for few minor invalid reasons. further, in this study, suicide cognition is shown to be associated with employment. generally, where there is un-employment; there comes depression, anxiety, hopelessness and thereby suicide ideation. the results are similar here; unemployed subjects reflect high suicide ideation and suicide cognition, when compared to employed ones, see figure 2.0 and figure 2.1. in 2000, platt and hawton found similar results and they concluded that suicidal risks are increased among un-employed people (platt & hawton, 2000). similarly, kraut and walld in 2003 showed association of unemployment with higher likelihood of suicidal behaviors. though, they compared unemployment with part time job and full time job in their study (kraut a. & walld r, 2003). when life-style was compared with respect to the suicidal thoughts, it was seen that people with active life-style tend to have intensified suicidal ideation and suicidal cognition as compared to those who have sedentary lifestyle, consider figure 2.2 and figure 2.3. one http://www.aeirc-edu.com/ rakhshanda bakht 35 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 of the possible reasons behind these results would be the hyper secretion of epinephrine and nor-epinephrine in these individuals. this hyper-secretion would let them stay active, and sometime very active, but suicidal are occupied their place in their minds. in addition to it, the level of qualification influences suicidal behavior as well. subjects, who are pursuing graduation show high rates of suicidal ideation, consider figure 2.4. the results are in the line of minear and brush (1980-81). this may be due to the peer pressures they are experiencing in their graduation life. further participants who did matriculation and intermediate and also post-graduated ones reflect comparatively lower suicidal ideation and cognition, consider figure 2.5. conclusion the present study concluded that suicidal thoughts, including suicidal ideation and suicide cognition are widespread among the younger population of karachi. and these prevalent self-harming thoughts are simultaneously linked with the demographic characteristics. mild to moderate suicidal thoughts exist dominantly in males but the severity cases are almost equally prevalent among both genders. similarly, being single and, aged 18-21, increases the risk of suicidal thoughts among youth. it is also analyzed that undergraduate students perceive suicidal thoughts more than any other educational level. similarly, non-working subjects think about suicide more as compared to working individuals. recommendations the future recommendations in regards to suicidal behavior, in general mental health, are more pronounced towards research area and awareness sessions on mental wellbeing. thus, in every country, there should be launched some educational and awareness campaigns for the locals in order to spread the words on mental health. for this to happen, the main goal is to treat barriers in treatment and care by increasing awareness of the frequency of mental disorders, their treatability, their recovery process and the human rights of people with mental health. ultimately, well planned public awareness and educational campaigns can reduce stigma and discrimination, increase the use of mental health service, and bring mental health and physical health come closer to each other. furthermore, new researches into biological and psycho-social aspects of mental health are needed in order to increase the understanding of mental disorders and to develop more effective interventions. conclusively, the study suggest that, through educational forum we can spread the awareness of significance of mental health in correspondence with the physical well-being; because one has to maintain a balance between the two in order to enjoy a complete circle of life. references  agerbo, e., gunnell, d., mortensen, p. b., eriksson, t., qin, p., & westergaardnielsen, n. 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(2006). suicide in youth. suicide and the school: recognition and intervention for who sites: mental health. world health organization. "suicide prevention". retrieved 200604-11  world health organization. (2003). the world health report 2003: shaping the future. world health organization.  world health organization. (2014). mental health action plan 2013–2020. geneva: world health organization; 2013. this document was produced in response to the world health assembly resolutions wha66. 8 and wha65. 4, provides the necessary framework for improving mental health globally from the government to individual level, and provides a strong rationale for collaborative care. http://www.aeirc-edu.com/ https://en.wikipedia.org/wiki/world_health_organization http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/ waseem hassan 6 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 short communication experiential evolution from both awakening and dreaming waseem hassan preston institute of management science and technology corresponding author: abadallah.wh@gmail.com since the beginning of human time in this world, the only thing which is found constant is the change in human behavior throughout ages. the gradual change, or in more liberal senses, advancement in human form of both physiological and psychological is called evolution of human race. as humans evolved throughout millions of years uptil now, the behavior, ethics, lifestyle and thought processing have found being enhanced and a wide range of capabilities have been developed in human. in material sciences, there are two aspects of grasping the concept of evolution. one being the darwinian theory of evolution in which he mentioned that all species biologically evolved throughout time from one single gene and from natural inheritance, the form changed gradually to different species and as he says, the purpose of “war of nature” is the production of higher animals (c. darwin, 1872). the other which supports this theory and the rest states that evolution is a process in which the species gained intelligence throughout experiences to shape itself in the most saturated and balanced form, and thus human. both of the definitions covers one aspect of reality which endorses that evolution is a continuous process which does not stop at any given point of time. let us review the evolution of human species in general. a human mind is a combination of conscious, unconscious, subconscious, and super conscious in some cases. in general, a person is observed to evolve in one aspect, i.e. while he/she is awake and experiencing everything that happens around him/her, while the aspect of sleep is undervalued or in other words, neglected. when a person is asleep, he/she is more closely linked to his/her subconscious which plays the most important part in evolution. when a person observes something in consciousness, it is firstly related to the relevant observation predisposed in his/her subconscious, if it is found in favor, the observation is strengthened, if not, it is yet saved in subconscious to reappear in conscious as another observation for confirmation. for example, when a child learns 2+2=4 for the first time, the observation of this calculation is saved in the subconscious as a raw form which later on is strengthened and confirmed when the child relearns it at home and thus it becomes a fact for the child which in future expands the child's learning process for advanced mathematics based on these predisposed facts of early age. how does this mechanism work in dreams? in order to understand this, one must be clear to the point that dreaming is a process in which the physiological aspects of the body and its psychological responses by the brain are stored in a part of the brain called subconscious(w. hassan 2014). a dream is a tool of mind through which the experiential learning throughout time is racked in its place in one's subconscious, in other words, a dream is a way of assuring the experiences subconsciously to maintain a state of conscious when the person wakes up. now as the subconscious of a person is maintained, evolved and expanded by dreams, the consciousness of a person is also evolved by enhancing the ability to attain more experiences and to think from a broader point of view. and if by looking closely, it will appear to be true that the ability to perceive and application of broader thought processing have helped human race from dying of fever to surviving of heart transplant. how do thoughts and perceptions help in physiological manner? "when we imagine something, we actually cause it to become reality". since thoughts and perceptions are purely psychological aspects of human being, it is both linked and disconnected from the physical changes occurring in a person, subject to the transformation of thought requirement in materialism. for example, the thought of human race to fly in the skies was generated in 400bc in china (k.dalamagkidis et al, 2012) by the discovery of kite which could fly in the air and that made humans think about flying in the skies while it was made possible for the first time perfectly in 1905 ad by wright brothers in ohio, usa. in this manner, the evolutionary process of aero planes started from a thought in 400bc and had put its first foot of success in physical reality after 2341 years in 1905 ad. one question which arises in this evolution is the process of forgetting dreams frequently and is thought to be useless. it is to be noted that the difference between dreaming and waking up is the access of the information in subconscious. when a person is awakened, he/she is able to access only such parts of his/her subconscious which is required by the consciousness at a given point of situation. similarly, when a person is asleep and dreaming, he/she accesses the subconscious at a wider angle than being in conscious. by this manner, the importance of accessing subconscious thoroughly while being in http://www.aeirc-edu.com/ mailto:abadallah.wh@gmail.com waseem hassan 7 ©advance educational institute & research centre annals of psychophysiology www.aeirc-edu.com volume 2, december 2015 issn 2412-3188 conscious is a bigger step in order to evolve the physical changes of a human. recent researches about human evolution through thoughts include an important work by cecelia heyes in her research " new thinking: the evolution of human cognition" in which she mentions the importance of thought generation processes which triggered human mind to develop the abilities to invent languages, culture, technology and other aspects. in her research, she mentions that humans are species that specialize in thinking and knowing and the extraordinary cognitive powers as compared to the rest of the species have enabled humans to evolve in every manner, from eating habits to building houses, transportation of bodies in various locations in short interval of time, and transferring of mind in remote places by telescope ad electron microscopes (c. heyes, 2012). another study by erin weyman suggest that humans, when not been able to invent languages, used drawings to convey their messages between people, as drawings are a way to interpret messages which one is unable to explain in vocabulary, if there is any. conclusion evolution is a continuous process. one can neither confine it in a specific direction, nor it is desirable to put an end to it since it is the quality of a human mind to explore endlessly and to gain intelligence at it's finest. dreaming itself is a part of human evolution which helps one to attain a stress free life as most of the exertions of one's emotions are carried in dreams subconsciously in order to soothe the state of mind where required. food for thought, the evolutionary process does not end with human beings only, it is working from cell to universal level if observed correctly. references •philos trans r soc lond b biol sci. 2012 aug 5; 367(1599): 2091–2096. •charles darwin. 1872 origin of species; 390. •w.hassan (2014). understanding dreams. annals of psychophysology (1) 14-15. •k. dalamagkidis et al. 2012, on integrating unmanned aircraft systems into the national airspace system; 13. http://www.aeirc-edu.com/ 3 app| published by aeirc| https://doi.org/10.29052/2412-3188.v7.i1.2020.3-5 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) editorial problems with the continued proliferation of unsubstantiated psychophysiological techniques being promulgated and sold for clinical use jerry r. devore & richard a. sherman saybrook university, california-united states this journal is dedicated to publishing studies and reviews which assist our readers to recognize psychophysiological techniques, assessments, and interventions likely to be useful in a wide range of situations. sadly, this includes informing readers when psychophysiological techniques are being promulgated and sold without sufficient evidence to support their claims of efficacy. this is crucially important because it is all too easy for most of us to mistake sales pitches supposedly supported by poor and nonexistent research, testimonials, and the like for actual evidence of efficacy. thus, readers can’t easily determine whether the technique in question has sufficient support to warrant its use. the journal will begin publishing thorough reviews of such techniques in the next few issues beginning with a review of low current and audiovisual stimulation techniques. an example of a technique which may well be effective but is being promulgated with claims far beyond the research demonstrating its efficacy is the lens system currently being sold to treat a wide variety of clinical problems. the lens (low-energy neurofeedback system) system is advertised as a neurofeedback system in which electroencephalographic (eeg) brain waves are assessed for the dominant frequency and then a low intensity (.0006 microamp) transcranial electric current (tacs) is administered for a few seconds. this brief, very low-intensity signal is said to reorganize cortical functioning and foster adaptive change for a wide variety of clinical conditions. the current tacs system was preceded by a system developed by the same person named the flexyx neurotherapy system (fns) that came on the market in the early 1990s. that system also assessed eeg waves for a few seconds, noted the dominant frequency, and generated a photic flicker at an offset to the dominant frequency in order to facilitate cortical dysregulation and reintegration. it was evaluated through several case studies (shoenberger, et al, 2001) and one longer case series of fibromyalgia cases (mueller, h.h., donaldson, stuart, 2001) which reported favorable results but there was no placebo control. shortly after a randomized control / experimental group design was conducted (kravitz, et al, 2001) with negative results, the system became unavailable. its successor is the lens system which uses tacs. it began being broadly advertised in the early 2000s. it is supposed to rapidly help people with a variety of clinical conditions. according to the developer, he originally didn’t realize that the earlier system (flexyx) was sending a tiny electrical signal into the brain until he had engineers check the system as the results were far quicker than anticipated. 4 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) it is this signal which he ascribes to be the means that produces effects so the flexyx was abandoned and the lens was developed. note that this is the traditional change when an unsubstantiated system is tested and found useless. you can read about hundreds of similar devices (e.g. the use of thermography for detection of breast cancer). as soon as the system is proven useless, the proponents make a minor change in the system and return to the market with specious claims unsupported by any controlled studies. also, note that the proponents of such devices usually claim that appropriate studies are unnecessary as “you can see the changes” or that there is no adequate placebo for the device. usually, but not always, the proponents encourage the use of the device by unlicensed or inappropriately licensed “practitioners” to avoid interference by the government. (an inappropriately licensed practitioner is one whose license does not include the use of such devices within the practitioner’s scope of practice.) they also frequently ascribe the failure of the medical community to accept the device as being due to undue influence by various jealous powers. it is rare for such devices to have fda (us food and drug administration) labels indicating safety and efficacy. the few which do have them for some attribute of the device unrelated to the use promulgated for them (such as being used as transcutaneous electrical stimulation (tens) units). readers can watch a 2011 discussion and demonstration of the photic system. a second video made in 2018 discusses case examples, the reasons why placebos are unnecessary as changes can observed happening, emphasizes patient testimonials, and briefly describes skin temperature monitoring at the millisecond level. data supporting the use of the lens is extremely limited. the total amount of “research” on lens appears to consist of (1) a book with uncontrolled case reports (larsen, stephen, 2006), the healing power of neurofeedback: the revolutionary lens technique for restoring optimal brain function, (2) the 2018 youtube video noted above in which case reports are described, (3) cripe, curtis t, (2006) reported favorable outcomes on 4 individuals described as having neurodevelopmental trauma (note that this is not a specific diagnosis), (4) hammond, corydon, (2007) reported successful treatment in one case of anosmia resulting from tbi, (5) hammond, corydon (2010) reported on 2 cases on anger management, and (6) one case series of 100 participants (larsen, stephen, harrington, kristen and hicks, susan, 2006) with no comparable control group that reports favorable results following a series of lens treatments. there does not appear to be any published literature documenting any demonstrable effect, health-related or otherwise of a 1-2 second exposure of low-intensity (.0006microamps) tacs on cortical functioning. there are a number of entirely unsupported speculative hypotheses intended to explain the effect but there is no evidence that any of those hypotheses have been empirically examined. it is crucial to remember that devices promulgated without placebo-controlled studies having sufficient subjects to demonstrate adequate power and sufficiently long follow-ups to show that initial effects last at least a few months are among those which usually disappear when adequately tested. there are thousands of these devices and techniques scattered across recent practice which disappear when adequately tested or simply hang on indefinitely. due to the lack of adequate research, there is no way to tell whether lens will join this sad group or go on to shine when appropriate studies are performed. references 1. cripe ct. effective use of lens unit as an adjunct to cognitive neurohttps://www.youtube.com/watch?v=hy0ux_ksfxo https://www.youtube.com/watch?v=fz08gigy_ta https://www.youtube.com/watch?v=fz08gigy_ta 5 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) developmental training. j. neurother. 2006; 10(2-3):79-87. 2. hammond dc. can lens neurofeedback treat anosmia resulting from a head injury?. journal of neurotherapy. 2007 jun 20;11(1):57-62. 3. hammond dc. lens neurofeedback treatment of anger: preliminary reports. j. neurother. 2010; 14(2):162-169. 4. kravitz hm, esty ml, katz rs, fawcett j. treatment of fibromyalgia syndrome using low-intensity neurofeedback with the flexyx neurotherapy system: a randomized controlled clinical trial. j. neurother. 2006;10(2-3):41-58. 5. larsen s, harrington k, hicks s. the lens (low energy neurofeedback system): a clinical outcomes study on one hundred patients at stone mountain center, new york. j. neurother. 2006; 10(2-3):69-78. 6. mueller hh, donaldson cs, nelson dv, layman m. treatment of fibromyalgia incorporating eeg‐driven stimulation: a clinical outcomes study. j. clin. psychol. 2001; 57(7):933-952. 7. schoenberger ne, shiflett sc, esty ml, ochs l, matheis rj. flexyx neurotherapy system in the treatment of traumatic brain injury: an initial evaluation. the jhrhe. 2001; 16(3):260-274. 8. ochs l. youtube. eeg driven light and sound stimulation at the neurotechnology forum (seattle 1992). 2011. available at: https://www.youtube.com/watch?v=h y0ux_ksfxo 9. ochs l. youtube. mind mending with low energy neuro feedback system. november 2018. available at: https://www.youtube.com/watch?v=f z08gigy_ta https://www.youtube.com/watch?v=hy0ux_ksfxo https://www.youtube.com/watch?v=hy0ux_ksfxo https://www.youtube.com/watch?v=fz08gigy_ta https://www.youtube.com/watch?v=fz08gigy_ta anum haider 67 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 case study cenesthopathy-the paradigm in schizophrenia anum haider aq khan center, institute of behavioral sciences karachi corresponding author: dranum.haider@gmail.com abstract in this article, the frequently presented but underestimated or neglected area has been unveiled. the abnormal body sensations, cenesthesias has been discussed in the context of schizophrenia. the identified underlying psychophysiological mechanisms and treatment options will also be discussed along with future recommendations. two cases will be presented to contemplate this condition. keywords cenesthopathic, schizophrenia, abnormal body sensations, prognosis introduction the term cenesthopathy coined by dupre and camus in 1907 and described it as a phenomenology in mental illness (takahash et al., 2013).this term has been derived from “cenethesia” which means abnormal body sensations. the abnormal body sensations come as frequent complaint in schizophrenia (jenkins et al., 2007).huber in 1957 proposed cenesthopathic schizophrenia as “a subtype of schizophrenia in which bizarre peculiar abnormal bodily sensations dominate, these are difficult to describe, chronic insidious in course and with limited psychotic symptoms” (takahash, et al., 2013). it not only presents a separate entity of schizophrenia but can also be present as onset and prodromal of schizophrenia (stanghellini, et al., 2014).its prevalence as a separate entity is 6.25-23.3 % (chang, 2014). it may appear as an onset of illness in 40% of cases while the rate of change in form of illness in later course is 75.7% (rajendar, et al., 2010). in this category of schizophrenia, tactile hallucinations and somatosensory delusional beliefs are common (blom, 2012). the most common presentations are dysmorphic or pain like experiences, morbid objectification or devitalization, dynamization of bodily boundaries and construction (stanghellini, et al., 2014). the suggested underpinning neurobiological and psychophysiological mechanisms are central brain atrophy, thalamic disruption, cortical disorganization, alteration in pain perception and modulation (i.e. noxious inhibitory control and excitatory endogenous pain mechanisms). these changes if matches with schizophrenic pathophysiological factors like genetic vulnerability neurochemical changes-decreased inhibitory gabaergic and increased excitatory glutamatergic activities, nmda receptor hypo function, changes in dopaminergic and cholinergic transmission can result in cenesthopathic entity of schizophrenia spectrum disorder (takahash, et al., 2013, chang, et al., 2014). cenesthopathy can present with both psychiatric and organic disorders (dementia). as a psychiatric disorder it can be a sole presentation or a symptom of paranoid psychosis (takahash, et al., 2013 & chang, 2014). despite of such frequent and even dominant presentation, it could not get adequate importance (stanghellini, et al., 2014). moreover the term cenesthopathic schizophrenia has not been introduced in any classification system. http://www.aeirc-edu.com/ anum haider 68 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 however in icd-10 it can be classified in the category of other schizophrenic disorders (jenkins, et al., 2007).it is a very important diagnosis to be aware of because it poses great burden of disability as a result of negative symptoms and personality deterioration (chang, 2014). early recognition and start of treatment is crucial for good prognosis and limiting the disability (stanghellini, et al., 2014 & rohircht, et al., 2010). the aim of presentation of following two cases is to increase the awareness of the problem and to promote early recognition and better prognosis. case-1 mr. y 60years old married male, father of three children, retired, educated up to intermediate, follows muslim religion and belongs to asian ethnicity. he has no known comorbid, presented by daughter in psychiatric clinic with complaints of; excessive hand washing and feeling of sticky secretions from body for more than one year. the illness started with somatic complaints such as difficulty in urination and other gut related symptoms. those had been investigated with unremarkable findings and ultimately handled by different physicians as medically unexplained symptoms. then gradually the illness presented differently by patient with excessive hand washing and preoccupation with body because of the release of sticky secretions from skin including the mouth cavity and ears. the patient was convinced and claimed that he could see those secretions releasing from the skin in almost entire body but most at the conspicuous parts. he used to wash excessively the alleged affected areas and kept vaseline all time with him to apply at the dry skin after washing. he reduced to take food due to those secretions and consequently his body weight was reduced. his sleep was disturbed and sociooccupational functioning was ceased completely. on mental state examination; there was emotional bluntness, physical agitation, scanty speech, refusal of auditory hallucinations. somatic delusion/ hallucination (fully convicted with the secretions and able to see it) preoccupation with the secretions and interested to get rid of it. absence of insight and grossly sound cognitive functions. physical examination and laboratory investigation unremarkable. treatment started with second generation antipsychotics (tab olanzapine 10mg) and called for follow up. case-2 mrs. x, 55years old divorced household lady educated up to graduation, follows muslim religion, belongs to asian ethnicity. she has no known comorbid, presented by brother in psychiatric clinic with complains of; feeling of discharge and malodor from body (including genitalia), avoidance of religious activities. these were insidious in onset and aggravated for past few months. the illness started gradually with social isolation and altered behavior (self-neglect and reduced oral intake). it then became obvious when she clearly started complaining about body secretions and behaving accordingly (excessive hand washing and securing from paravaginal discharge) and as well as asking family members if they could smell the bad odor from her body. she abandoned offering prayers contemplating herself contaminated. she also stopped socialization and started talking limitedly. she argued with baseless justifications on confrontation of family members. on mental state examination; she had found with blunt affect, irritable on skepticism, preoccupied with body odor and discharge, poor rapport, convicted with her beliefs (somatic delusion and hallucination), refusing auditory hallucinations, lack of http://www.aeirc-edu.com/ anum haider 69 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 insight and intact gross cognitive functioning. gynecologist cleared her from any pathology. physical examination and labs were also unremarkable. treatment started with tablet olanzapine10mg and sertraline 50mg and referred for psychological evaluation and therapy. family psychoeducational and counseling also offered. discussion the above presented cases showing common pertinent pattern of presentation such as insidious onset of illness, predominance of somatic complains that were misdiagnosed and mismanaged, involvement of both genders, the change in presentation from the initial illness phase, preoccupation with abnormal physical sensations i.e. secretions from the body, the strong conviction with their beliefs, lack of insight to correct that abnormal belief. nevertheless their lives were revolving around those false perceptions with intense distress and sociooccupational impairment, absence of other physical comorbid and clinical signs of other psychiatric disorders (depression, obsessive compulsive disorder-ocd and mania) as per diagnostic criteria. the insidious course, lack of insight, strong conviction to the belief, behavioral alteration and socio-occupational impairment supported to consider for psychotic disorder i.e., schizophrenia. the other studies in comparison to presented cases also mirrored most of the findings such as chronic insidious course (chang, 2014), the predominant oral symptoms presentation in males, the late onset of presentation in females (>40yrs) (takahash, et al., 2013).there is also a frequent presentation of chronic medically unexplained physical symptoms and misdiagnosis as somatoform disorder (rohircht, et al., 2010).. due to misdiagnosis and neglected care these are usually lately diagnosed as in presented cases (rohircht, et al., 2010). the commonly identified hurdles in the early diagnosis are lack of knowledge and awareness due to non-inclusion of this diagnosis of cenesthopathic schizophrenia as a separate entity as well as appropriate assessment tools are not easily available to facilitate or confirm the diagnosis (jenkins, et al., 2007 & stanghellini, et al., 2014).the delayed diagnosis is usually associated with poor prognosis. early identification and treatment with second generation antipsychotics, electroconvulsive therapy and antidepressants in indicated cases predicts good prognosis (takahash, et al., 2013). almost half of the cases found to respond well on antipsychotics (rohircht, et al., 2010). recommendations first of all it is essential to include this diagnosis as separate entity of schizophrenia in the standard classification systems need to educate the health professional to early recognize these cases for better prognosis improvement in making the health care services more accessible appropriate assessment tools must be easily available both for clinics and research. future research is needed to understand the psychophysiological mechanisms and to establish better evidence of treatment. references  blom, j. d., & sommer, i. e. (2012). hallucinations of bodily sensation. http://www.aeirc-edu.com/ anum haider 70 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 in hallucinations (pp. 157-169). springer new york.  chang w. (2014) cenesthopathic schizophrenia (case conference typc taiwan 20141227)  grignon, s., stavro, k., & potvin, s. (2014). could schizophrenia be a refractory condition to central pain sensitization? in mental health and pain (pp. 157-171). springer paris.  jenkins, g., & röhricht, f. (2007). from cenesthesias to cenesthopathic schizophrenia: a historical and phenomenological review. psychopathology, 40(5), 361368.  rajender, g., kanwal, k., rathore, d. m., & chaudhary, d. (2009). study of cenesthesias and body image aberration in schizophrenia. indian journal of psychiatry, 51(3), 195.195-98.  röhricht, f., gudi, a., & lewisfernández, r. (2010). medically unexplained physical symptoms masking (cenesthopathic) schizophrenia: a case series. journal of psychiatric practice®, 16(4), 258-264.  stanghellini, g., ballerini, m., blasi, s., mancini, m., presenza, s., raballo, a., & cutting, j. (2014). the bodily self: a qualitative study of abnormal bodily phenomena in persons with schizophrenia. comprehensive psychiatry, 55(7), 1703-1711.  stanghellini, g., ballerini, m., fusar poli, p., & cutting, j. (2012). abnormal bodily experiences may be a marker of early schizophrenia? current pharmaceutical design, 18(4), 392-398.  takahashi, t., fuke, t., washizuka, s., hanihara, t., & amano, n. (2013). a review of recent case reports of cenesthopathy in japan. psychogeriatrics, 13(3), 196-198. http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 naureen rehman 54 case report doi: 10.29052/2412-3188.v5.i1.2018.54-58 dealing with the psychosocial and spiritual aspects in palliative care naureen rehman aga khan university, pakistan corresponding author email: nrpunjwani@gmail.com received 03/04/2018; accepted 25/09/2018; published 10/10/2018 abstract background: palliative care is the provision of end of life care to the patient with a terminal disease; its primary focus is on improving the quality of life rather than quantity of life. while palliative care emphasizes over physical body pain reduction, it also suggests psychological comfort and spiritual wellbeing. several research studies corroborate that interventions are done to keep the patient mentally relaxed greatly affects the patient's bodily functions and reduces the sensation of pain. case presentation: in this case, the physical attributes were excellently managed but neglect was done in terms of mental and spiritual need that was evident through her verbalization of hopelessness and fear, that the disease condition is a severe punishment by god. in addition, the patient was less likely to socialize with people including friends and family. therefore, this case has been investigated in light of multiple recent articles (2010-2015) and pointed out the evidenced-based practices that need to be done to provide care emphasizing holistic approach in order to enhance comfort to the terminally sick patients. management & results: it was observed that the health care providers were only concerned for the physical problems and they provided care focusing only physiological component whereas the psychological and spiritual determinants of health were greatly neglected as such that they were not included in the plan of care of the patient. conclusion: palliative care involves not just physiological, but also psychological and spiritual care. based on the findings of the case study, caregivers must consider psychological and spiritual aspects of care in order to provide holistic as well as peaceful end of life care. keywords palliative care, psychosocial support, spirituality, holistic care, quality of life. introduction chronically or terminally ill patient suffers physically, emotionally, socially, morally and spiritually thus they encounter an immense number of symptoms associated with each domain. similarly, the pain of such people is impossible to treat just through painkillers, so it is important to assess every aspect of health in order to provide holistic care (maqsood et al., 2013). according to bio-psycho-sociospiritual model given by george engel in 1977, an individual with a life-threatening disease responds in many different ways like physically, psychologically, socially and spiritually (maqsood et al., 2013). according to world health organization, (2018) the palliative care is defined as “palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by early identification, impeccable assessment, treatment of pain and providing physical, psychosocial and spiritual care (who.int, 2018).” successful palliative care is achieved through a health care provider's ability to elicit and comprehend the problems of dying patients; however, many health care http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 naureen rehman 55 workers are reluctant to talk about it due to lack of comfort (berton, 2015). understanding patients' concerns and addressing it affects positively on patient's wellbeing and improves the dignity of patients (von blanckenburg & leppin, 2018). psychological fears are sometimes associated with spiritual concerns as well that hinders in the achievement of mental peace (gunser, 2017). in other words, spiritual coping is associated with positive mental health, similarly, if health care providers solely emphasize over physical and mental health excluding the spiritual aspect of care then the goal of complete wellbeing will not be attained (selman et al., 2014). active listening, therapeutic communication using a nonjudgmental approach and using therapeutic touch helps in fears verbalization by the patient (rego & nunes, 2016). psychological, social and spiritual distress are common among palliative care patients and they often trigger the thoughts of accelerated death while physical symptoms have been treated that lead to demoralization and hopelessness (fan et al., 2017). according to the proximal-distal model of kidney disease, it has been observed that physiological factor along with psychological factors influences the overall health outcomes (chan et al., 2011). case-presentation a 63 years old female patient with a complaint of chronic renal failure came for routine dialysis at a private hospital. patient's comorbid were type 2 diabetes and hypertension. complete interview using gordon's functional health pattern was conducted with the patient. patient was haemo-dynamically stable and oriented to time, place and person. physical examination showed severe lower back and limb pain, using the numeric pain scale, the patient's pain score was 6/10. secondly, the psychological assessment was done using gordon’s psychological assessment tool, revealed hopelessness and depression related to lack of social support system patient also verbalized spiritual distress due to inability to perform spiritual practices moreover patient’s social domain was also compromised because meeting people increases pessimistic thoughts in her mind. after the case analysis, spiritual and psychological domains of palliative care were prioritized. results based on the patient’s interview and assessment done by gordon’s functional health pattern it was observed that this patient was mentally depressed and hopeless that may be due to lack of someone who actively listens to her and empathize her current health state. it was also observed that most of the time, due to lack of attention from the immediate surroundings such as family, friends, significant others as well as health care personnel, the patient was reluctant to share her concerns, fears, emotions to others that further made her stressed and uninterested to life. further, it was also observed that the patient was spiritually depressed; due to lack of privacy and physical problems, she was unable to perform her practices that increased her stress as well as remorsefulness, therefore, like many other patients, she considered her illness as god's penalty and she was guilty about that. this also increased levels of anxiety in the patient that also resisted her from socialization with other people that is why she needed care providers who not only treat her physically but also psychologically and spiritually in order to provide comfort and healthy mind, body and spirit. discussion suffering involves the perception of feeling fearful, helpless and danger about the disease (juarez et al., 2013). mostly people response in such a way that they think now the life has completely changed and it is irrevocable, while many people face guilt that this is all because of their mistakes in life (mateo-ortega et al., 2018). they http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 naureen rehman 56 regret that if they had approached for the treatment earlier so they might not be this close to death. another thing is that like the above patient, many people with the terminal disease become hopeless and depressed (mateo-ortega et al., 2018). whereas some people feel anxious about the time they have to live with their significant others regarding the fulfillment of their impending responsibilities based on their role within the family (juarez et al., 2013). researchers have also shown that spirituality has a greater impact on individual health and disease onset. it expresses various aspects of individual personality and views of their life (gualdani & pegoli, 2014). according to dallas and his colleague, palliative clients want optimism, hope and gratitude for their values and need to follow all the religious beliefs for the sake of spiritual healing (dallas et al, 2012). people sometimes due to sedation or lack of privacy cannot verbalize their intense need of spirituality thus they face the guilt of not following their practices so they end up into spiritual distress (maqsood et al., 2015). just like mentioned in the above case scenario, many patients perceive illness as god's punishment for them or because of their bad deeds (berton, 2015). several interventions can be helpful for patients to relieve their emotional pain like mind based techniques such as yoga, meditation, muscle tensing exercises, relaxation techniques (malik, & mazahir, 2015). nurses should perform a complete psychological assessment to understand that mind and body are associated so sometimes psychological treatment also reduces patient’s physical suffering (gunser, 2017). active listening, using verbal cues and providing emotional support may help in reducing fears and anxiety regarding death as it allows patients to ventilate their feelings and thoughts (fan et al., 2017) nurses should reassure that they are always available to help them whenever they want. in addition, nurses must also encourage patients to reflect back to their lives, recall their strong and positive points so that they can attain selfsatisfaction (maqsood et al., 2015). it is an important responsibility for nurses to assess clients and families spiritual beliefs to overcome spiritual distress but for that first of all, they need to be self-aware about their own spiritual beliefs (dallas et al., 2012). they must ask those questions to themselves before inquiring the patients (hendrick & cobos, 2010). for this category (dallas et al., 2012). institutes must train the nurses regarding the way of proper psychological and spiritual communication and an assessment on daily basis, in addition, they must get spiritually engaged with the patient for their wellbeing (penman et al., 2013). health care personals should provide culturally appropriate care based on patients beliefs with the purpose of meeting client's needs and optimum care (gualdani & pegoli, 2014). encouraging patients to perform their respective religious practices are helpful in the spiritual expression of individual and family (rego & nunes, 2016). conclusion palliative care deals with the provision of holistic care to terminal patients and caregivers in every aspect of their lives. mind based researches say that making a person mentally relaxed, effects positively on bodily functions so proper psychological assessment must be done to identify their emotional needs and interventions should be done accordingly. everyone has a different way of expression of spirituality so nurses must be aware of the fact that spiritual beliefs also affect a person’s health. health care providers should analyze and understand a patient‘s spiritual concepts. and they must work to find out patients spiritual needs and address them. as it is beneficial in palliative care to provide comfort, reduce pain and other symptoms that improve quality of life. http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 naureen rehman 57 conflicts of interests none. acknowledgment i would like to thank nimira asif for providing support and guidance regarding writing the research paper as well as aga khan university, school of nursing for organizing this project. funding this was an academic assignment so all the funding was done by aga khan university, pakistan. references  baynav.bopdhb.govt.nz. (1994). available at: https://baynav.bopdhb.govt.nz/media/1 349/gordons-functional-healthpatterns.pdf  berton, t. (2015). increasing comfort with end-of-life discussions. university of nevada, las vegas.  chan, r., brooksc, r., erlichc, j., gallagherf, m., snellingg, p., chowb, j., & suranyib, m. (2011). studying psychosocial adaptation to end-stage renal disease: the proximal– distal model of health-related outcomes as a base mode. j psychosom res, 70, 455-464.  dallas, r. m., wilkins, m. l., wang, j., garcia, a., & lyon, m. e. (2012). longitudinal pediatric palliative care: quality of life & spiritual struggle (face): design and methods. contemp clin trials, 33, 1033-1043.  fan, s., lin, i., hsieh, j. and chang, c. (2017). psychosocial care provided by physicians and nurses in palliative care: a mixed methods study. j. pain symptom manag, 53(2), 216-223.  gomez-castillo, b. j., hirsch, r., groninger, h., baker, k., cheng, m. j., phillips, j., pollack, j., & berger, a. m. (2015). increasing the number of outpatients receiving spiritual assessment: a pain and palliative care service quality improvement project. j. pain symptom manag, 50(5), 724-729.  gualdani, s., & pegoli, m. (2014). spirituality in health care: the role of needs in critical care. trends anaes cri care, 4, 175-177.  gunser, p. (2017). the role for psychologists in palliative care and hospice care. baoj psychology, 2(1).  hendrick, s. s., & cobos, e. (2010). practical model for psychosocial care. j oncol pract., 6(1), 34-36.  juarez, r. m., caro, g., calderon, c., riovalle, j. s., chica, a. g., garcı, c. m., & quintana, f. c. (2013). psychological responses of terminally ill patients who are experiencing suffering: a qualitative study. int j nurs stud., 50, 53-62.  malik, a. m., & mazahir, s. (2015). trust, hope and quality of life in renal failure patients. sci int., 27(4), 34933498.  maqsood, a., jabeen, t., & khatoon, h. (2013). assessment of positive effects of illness: implications for an integrative approach of biopsychosociospiritual model. pak j life soc sci, 11(2), 139-146.  mateo-ortega, d., gómez-batiste, x., maté, j., beas, e., ela, s., lasmarias, c. and limonero, j. (2018). effectiveness of psychosocial interventions in complex palliative care patients: a quasi-experimental, prospective, multicenter study. j palliat med, 21(6), 802-808.  penman, j., oliver, m., & harrington, a. (2013). the relational model of spiritual engagement depicted by palliative care clients and caregivers. int j nurs prac, 19, 39–46.  rego, f. and nunes, r. (2016). dealing with the psychosocial and spiritual http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 naureen rehman 58 aspects in palliative care. j. health psychol., 1-9.  selman, l., young, t., vermandere, m., stirling, i., & leget, c. (2014). research priorities in spiritual care: an international survey of palliative care researchers and clinicians. j. pain symptom manag, 48(4), 518-531.  von blanckenburg, p. and leppin, n. (2018). psychological interventions in palliative care. curr opin psychiatry, 31(5), 389-395.  world health organization: who.int. (2018). who definition of palliative care. available at: http://www.who.int/cancer/palliative/d efinition/en/ http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 yusra saleem 17 original article doi: 10.29052/2412-3188.v5.i1.2018.17-26 bullying; a psychosocial stressor yusra saleem1, shamoon noushad1&3, shahana urooj kazmi3, salman shaikh1, nabeela noor2 & mariyam asim2 1advance educational institute & research centre (aeirc) 2department of physiology, university of karachi 3dadabhoy institute of higher education (dihe) corresponding author email: yusra@aeirc-edu.com received 06/06/2018; accepted 23/08/2018; published 10/10/2018 abstract background: the bullying incidences have been increasing in the past few years resulting in a number of psychosocial traumas including depression, anxiety, violence and many other health concerns. despite being a global issue, not a large number of studies have addressed this distressing act. this social threat causes negativity on both sides whether the victim or the perpetrator. the aim of the study was to evaluate the prevalence of this psychosocial stressor, its associated characteristics and bullying perceptions among the study population. methodology: a cross-sectional observational study was conducted for 5 months from july 2017 to december 2017. data was collected from 399 victims between the age of 15-27 years via a structured questionnaire inquiring victim’s demographics and its associated psychosocial outcomes. collected data was then analyzed using spss ver. 22. results: out of the total study subjects there were 204 females and 195 males with the mean age of 25.10 + 5.70 years. around 76% participants reported daily bullying events. bullying incidences were found more common in females i.e. 48.6% of the females were bullied by called out with mean names while only 45.8% males reported so. majority of the bullying cases were reported from educational institutes. the most prominent psychological outcomes observed and reported by the victims in response to bullying was getting revengeful thoughts for the bully. conclusion: in conclusion, the study evaluated the psychological distress resulting from bullying incidences. our study indicated a high prevalence of this public health concern in both genders and majorly in educational sectors. keywords bullying, aggression, psychosocial stressor, adolescents victimization, adult victimization introduction bullying has become a psychosocial stressor worldwide, with greater prevalence among the school aged children and young adults (nansel et al., 2004). it is a repetitive imbalanced behavior depicted with aggression and using power for suppression and to hurt others (carroll, 2014). the negative actions of the perpetrator can be either verbal, physical, social or racial and may include teasing, hitting, threatening and abusing (carroll, 2014 & nansel et al., 2004). the increasing incidences of bullying have been reported in numerous studies, and it has been proved that this destructive act is linked with adverse outcomes for both the victim and the committer as it greatly affects one’s mental and physical health (cdc, 2017). being a social threat, global bullying statistics have shown that it is becoming a chronic stressor for all age groups (cdc, 2017). moreover, the victims especially adolescents rate bullying to be a stressful stimulator of depression and self-hate (carroll, 2014). if these stress events resolve over time there may be a chance for early recovery and retrieval of self-esteem and confidence but those who undergo through such events http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 yusra saleem 18 continuously are more likely to develop stress-related disorders (hjern et al., 2008; laftman et al., 2006 & due et al., 2005) like post-traumatic stress disorder (ptsd) (crosbyet al., 2010 & mynard et al., 2000). however, there are different coping strategies and resources that might be helpful for the victim on an individual level as well as collectively in managing such stressors (compas et al., 2001). it is evident from the previous literature that social support plays a significant role in dealing with bullying (grant et al., 2006). the bullied victim is mostly lacking in social circles and is much likely to be introvert (östberg et al., 2018 & o'brennan et al., 2009). additionally, people who are bullied are actually less convinced with seeking support (barchia & bussey, 2010). the health hazards caused by bullying include poor adjustments, declined selfconfidence, increased hesitations, social isolation, suicidal thoughts, anxiety, sleep difficulties, lack of concentration and vengeful thoughts and activities are also expected from the victim (cdc, 2015). according to the national center for educational statistics 1 out of every 5, students report bullying at least once or twice in a month (national center for educational statistics, 2016). victimized students gradually involve in self-blaming for such an event and undergo severe depression and prolonged maladjustments (perren et al., 2013; shelley & craig, 2010). with the advancement in technology and increased prominence and use of these electronic media by the young population has given a new direction to bullying. cyber or electronic bullying has given a way to propagate aggression via emails, messages, and victimization on social media (smith et al., 2008). the cyberbullying incidences have nearly doubled overtime and the victim merely knows the identity of the perpetrator (patchin & hinduja, 2016). among all the adverse effects related to bullying suicidal tendencies and attempts have been the fatalist (reed et al., 2015). previous studies suggest that there exist a strong inter-connection between bullying and suicide related behaviors (reed et al., 2015). the victims, bullies and even the observers are likely to develop these suicidal tendencies due to affected mental health (cdc, 2015). it is evident that this psychosocial stressor not only causes adverse impacts on the victim but also the bully (espelage & holt, 2013). according to a meta-analysis students are 2.2 times more prone to suicide ideation when facing peer-victimization as compared to those who are not exposed to such an event and such students are 2.6 times more likely to attempt suicide (gini & espelage, 2014). a false concept has been promoted in the society that has made suicide as a general response to being bullied and hence, generating an imitating behavior among youth (cdc, 2014). the current study aims to investigate the association of bullying with the resulting health hazards and psychosocial responses. and to prompt different aspects and perception regarding this psychosocial trauma. despite, of being globally escalating issue there are still many undiscovered facts about bullying, specifically about what factors are actually motivating this aggressive behavior and also the related coping interventions. methodology this cross-sectional, observational study was conducted from july 2017 to december 2017. data was collected with informed consent from study population by structured questionnaire inquiring participant's demographics (age and gender, etc.) and factors assessing bullying (previous bullying events, the frequency of bullying and its impacts, etc.). total 399 victims (195 males and 204 females) with 15-27 years of age from various sectors http://www.aeirc-edu.com/ http://www.cdc.gov/violenceprevention/pdf/bullying_factsheet.pdf http://www.sciencedirect.com/science/article/pii/s0190740915001656 http://www.sciencedirect.com/science/article/pii/s0190740915001656 http://www.sciencedirect.com/science/article/pii/s0190740915001656 http://www.ncdsv.org/images/jah_suicidal-ideation-and-school-bullying_7-2013.pdf http://jamanetwork.com/journals/jama/article-abstract/1892227 http://www.cdc.gov/violenceprevention/pdf/bullying-suicide-translation-final-a.pdf annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 yusra saleem 19 (educational institutes, hostels, home and public places) of karachi, pakistan were enrolled in the study. all victims were included while we did not include any of the perpetrators. the collected data was then analyzed using spss ver. 22. all quantitative variables are presented as mean+sd while all qualitative variables with frequency and percentages. chisquare test was used to depict the association of bullying with various sociodemographic variables among the study subjects. p<0.05 was considered significant. result out of 399, 195 males and 204 females were included in the study with the mean age of 25.10 + 5.70 years i.e. around 57.6% participants were >25 years of age while 42.4% were <25 years. the frequency of bullying among these participants was also assessed. according to the results, as shown in table 1, 4.76% participants reported daily bullying events while 3.8% reported it for 5-10 times a week. around 40% of the study population complained about vivid memories and nightmares associated with previous bullying experience. moreover, 188 out of total 195 males were bullying victims while 195 out of 204 females also reported being bullied. table 1: demographic and other related characteristics of the study participants variable categories n (%) age >25 years 230(57.6) <25 years 169(42.4) gender male 195(48.9) female 204(51.1) bullying victims yes 383(96) no 16(4) bullying incidences males 188(96.41) females 195(95.58) bullying frequency twice a month 365(91.5) 5-10 times a week 15(3.8) daily 19(4.76) altered routine yes 212(53.1) no 187(46.9) vivid memories yes 162(40.6) http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 yusra saleem 20 no 237(59.4) *n=frequency figure 1: nature of bullying reported by study participants figure 1 shows gender wise variation in bullying nature. it is quite clear that no matter what the nature ,of bullying is, these incidences are more common among females as compared to males. 48.6% of the females and 45.8% males were bullied by called out with mean names, 36.5% females and 33.3% males opted for ignorance while 14.2% females and 15.20% males voted for physical bullying. figure 2: form of bullying reported by study participants out of all, 52.06% of the study subjects reported being bullied verbally, 29.73% opted genderbased bullying while a few cases of physical and racial bullying were also observed. cyberbullying despite being very common nowadays was rarely reported. 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% called mean names left out of things on purpose hit, kicked or pushed spread false rumors 45.80% 33.30% 15.20% 32.58% 48.60% 36.59% 14.20% 32.83% males females 0% 10% 20% 30% 40% 50% 60% physical verbal cyber racial gender based 9.76% 52.06% 7.58% 2.00% 29.73% http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 yusra saleem 21 figure 3: major reported sites of victimization educational institutes remain the major site for bullying, the results in figure 4 show that 79% of the study subjects reported being bullied at school while 17% at home followed by hostels and public places. figure 4: perception of victims regarding the reasons of them being bullied figure 4 shows that 19.5% of victims believed that they were mostly bullied due to their appearance, 17.3% thought that they were bullied for their activities, 5.3% said that they were bullied for their way of talking while a huge number of participants gave several different reasons for them being bullied. home 17% educational institutes 79% public places 1% hostels 3% 0 10 20 30 40 50 way you look way you sound what you do how you behave what you wear others 19.5% 5.3% 17.3% 7.0% 4.5% 46.4% http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 yusra saleem 22 figure 5: percentage of bullying victims suffering from psychological distress as shown in above figure, 16.8% of the study subjects agreed that they usually get revengeful thoughts for the bully, 12.8% faced social isolation, and 9.8% reported that they feel to bully others in response to past victimization followed by poor academic achievements and health issues. discussion it has been established from the previous research that bullying is a strong risk factor for the development of adolescence depression (klomek et al., 2007). it is evident that the depressive symptoms are more common among the bullying victims as compared to those who are not exposed to any such events. the aim of this study was to evaluate the overall occurrence of bullying events locally among different sectors of karachi and also to highlight the forms and sites of bullying and the resulting psychosocial symptoms. one of the most prominent outcomes of bullying is suicide that is the victims of bullying are more likely to consider suicide as the best way out as compared to nonvictims. the recent literature regarding suicide suggests that bullying has become the third leading cause of adolescence and adult deaths worldwide. according to center of disease control and prevention (cdc), around 14% of the school going students usually consider suicide and 7 % out of them attempted it due to high psychological distress and declined coping capabilities (cdc, 2017). reports of international research network health behavior in school-aged children (hbsc) suggest bullying as the global mental health problem especially affecting youth i.e. 11% of the school aged children complained of being bullied more than 2 to 3 times/month (inchley & currie, 2013). our findings were in parallel to the reports i.e. a major proportion of our study population belonged to the educational sector (figure 3). moreover, 91.5% of them complained of being bullied twice a month (table 1). moreover, the statistics provided by abc news shows that around 30% of the teenage students are involved in bullying either being victim or bullies i.e. 160,000 kids mostly skip going school just to avoid bullying (matt, 2010). around 96% of study participants reported bullying as a common issue according to our results and of them, more than 50% were usually involved in rushing away from routine activities (table 1). social isolation, 12.80% suicide ideation, 4.00% bully others, 9.80% revengeful desires, 16.80% poor academic achievements, 3.30% health problems, 2.00% http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 yusra saleem 23 when comparing the nature of bullying and its variation between the two genders the most prevalent were called with mean names and left out or ignored (figure 1). similar results have been revealed in a previous study reporting that the most common type of victimization was calling out mean names and in contrast to our findings spreading rumors was the second leading bullying behavior (wang et al., 2009). moreover, according to the bullying statistics by national bullying prevention center, 13% of all bullying victims report being insulted, called mean names and made fun of followed by false rumors regarding the victim and 5% get physically hurt (national center for educational statistics, 2016). among all forms of bullying, verbal bullying is the most noticeable and prevalent i.e. a previous study reported 36.5% subjects reported being bullied verbally, 41.0% for relational, and 9.8% for cyberbullying (wang et al., 2009). our results were parallel with the results of the mentioned study (figure 2). vast data is available on the miseries associated with bullying that leads to loneliness, social isolation, suicidal tendencies, and absenteeism (klomek et al., 2010; hazemba et al., 2008; siziya, et al., 2007 & kim et al., 2005). similar outcomes are observed in the current study, the victims reported suffering from social isolation, suicidal thoughts and associated health issues (figure 5). it is evident that the victims soon develop into a bully and get involve in bullying activities due to the irresistible revengeful thoughts. the common sites for victimization as reported in a study were home and schools, 87% of the bullying victims according to their data were bullied at home while 44% reported the incidences occurring more often at school and mainly with males as compared to females (raskauskas, 2010). in contrast, our results suggest that bullying was more common in educational institutes (either school, colleges or universities) as compared to home (figure 3). these victims percept that they were bullied mainly for the way they look, the way they sound or for their activities while a huge proportion gave different reasons including their religion, cast, color, body structure or sexual orientation (figure 4). that is also supported by a published study which reports that major reasons behind bullying mainly include physical appearance (national center for educational statistics, 2016). gerlsma and his colleague demonstrated the responsiveness and behaviors of the victim totally depends upon the offense type i.e. more forgiving nature is observed in such noncriminal offenses (gerlsma & lugtmeyer, 2016). in contrast, our results suggested that revengeful thought was mostly reported the outcome of the bullying event followed by social isolation, health issues and suicide ideation (figure 5). according to a fact sheet published in 2017, among psychological suppressors of bullying anxiety, depression, decreased self-confidence, feelings of self-harm and drug abuse are the commonest. while declined academic achievements and health issues remain on the forefront (stopbullying.gov, fact sheet, 2017). in addition to the evidence provided by this study regarding the increasing prevalence of bullying incidences in our society and its devastating psychological outcomes, our study had several limitations i.e. this study only focused on the victim and not the bullies, we did not consider the role of bullies and their knowledge and understanding about the issue. moreover, we did not evaluate the role of parents, friends and school environment in preventing bullying activities in our society. despite of these limiting factors, the study had some strength, i.e. the data was collected from diverse groups and we didn’t http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 yusra saleem 24 focus on just school based bullying incidences. the data was collected from all possible institutes, home and different public places were covered during the course of the study to get responses that can depict not whole but at least a part of the population and their perceptions regarding this psychosocial stressor. conclusion it can be concluded from the study results that this distressing issue is burning up way too rapidly, especially affecting the schools and colleges and taking many life’s as it promotes suicide and triggers such harming tendencies among the victims. our study provides an overview of different aspects of bullying, results indicate that there is a dire need to address all forms of bullying victimization and the resulting health outcomes. as it is not only an issue that affects an individual on the personal level but collectively cause harm to the community and surroundings which therefore makes it a public health concern that is to be addressed on the universal level. conflicts of interest none. acknowledgment i would like to acknowledge all the study participants for providing us with all beneficial information for the study. funding none. references  barchia, k., & bussey, k. 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(2009). examining developmental differences in the social‐ emotional problems among frequent bullies, victims, and bully/victims. psychol. sch, 46(2), 100-115. http://www.aeirc-edu.com/ https://nces.ed.gov/fastfacts/display.asp?id=719 https://nces.ed.gov/fastfacts/display.asp?id=719 annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 yusra saleem 26  östberg, v., modin, b., & låftman, s. b. (2018). exposure to school bullying and psychological health in young adulthood: a prospective 10-year follow-up study. j school viol, 17(2), 194-209.  patchin, j. w., & hinduja, s. (2016). summary of our cyberbullying research (2004-2016). cyberbullying research center. retrieved from http://cyberbullying.org/summary -of-our-cyberbullying-research  perren, s., ettekal, i., & ladd, g. (2013). the impact of peer victimization on later maladjustment: mediating and moderating effects of hostile and self-blaming attributions. j child psychol psychiatry, 54, 46-55.  raskauskas, j. (2010). text-bullying: associations with traditional bullying and depression among new zealand adolescents. j school viol, 9(1), 74–97.  reed, k. p., nugent, w., & cooper, r. l. (2015). testing a path model of relationships between gender, age, and bullying victimization and violent behavior, substance abuse, depression, suicidal ideation, and suicide attempts in adolescents. child. youth serv. rev., 55, 125-137.  shelley, d., & craig, w. m. (2010). attributions and coping styles in reducing victimization. can j sch psychol, 25, 84-100.  siziya, s., muula, a. s., & rudatsikira, e. (2007). prevalence and correlates of truancy among adolescents in swaziland: findings from the global school-based health survey. child adolesc psychiatry ment health, 1(1), 15.  smith, p. k., mahdavi, j., carvalho, m., fisher, s., russell, s., & tippett, n. (2008). cyberbullying: its nature and impact in secondary school pupils. j child psychol psychiatry, 49(4), 376385.  the consequences of bullying, (2017). fact sheet, stopbullying.gov. retrieved from:https://www.stopbullying.gov/sit es/default/files/2017-10/consequencesof-bullying-fact-sheet.pdf  wang, j., iannotti, r. j., & nansel, t. r. (2009). school bullying among adolescents in the united states: physical, verbal, relational, and cyber. j adolesc health, 45(4), 368-375. http://www.aeirc-edu.com/ http://cyberbullying.org/summary-of-our-cyberbullying-research http://cyberbullying.org/summary-of-our-cyberbullying-research 15 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v8.i1.2020.15-23 original article association between satisfaction with life and caregiver burden, among psychiatric patients farkhanda emad1, saima masoom ali2, farhan ishaque3, aftab ahmed mirza1, hayatullah khalid4 & abid kamal ansari5 1sindh institute of physical medicine & rehabilitation, karachi-pakistan. 2department of psychology, university of karachi, karachi-pakistan. 3dow institute of physical medicine & rehabilitation, dow university of health sciences, karachi-pakistan. 4multan college of physiotherapy, multan medical & dental college, multan-pakistan. 5college of physiotherapy, jinnah postgraduate medical centre, karachi-pakistan. abstract background: people who are dealing with psychological disorders are not able to take care of themselves; therefore, their family has to take care of them. while dealing with psychological issues is itself difficult for their family members. schizophrenia and bipolar disorder are psychological severe disorder that has a considerable influence not only in the patient but also for the entire family. this study aims to determine a relationship between life satisfaction and caregiver burden among caregivers of patients suffering from psychiatric illness. methodology: we started the research after approval from the board of study and prior consent from the psychiatric hospitals' higher authorities and rehabilitation centers in karachi. the authorities demonstrated the research objectives, the consent letter, and the questionnaire to be filled by the researcher. zarit burden interview scale (zbis) and satisfaction with life scale (swls) (pavot & diener) were used. the sample size of this study was 170 psychiatric patients. psychiatric patients were divided into schizophrenia disorder (n=85) and bipolar disorder (n=85). results: the result indicates that the caregiver burden is the predictor of satisfaction with life in patients with bipolar disorders. it also shows in results that there was a significant difference among the different levels of the duration of illness on the variable of caregiver burden scale and satisfaction life scale among the caregivers of patients with schizophrenia and bipolar disorders. further, findings indicate significant differences between males' and females' caregivers of psychiatric patients on the variable of caregiver burden and satisfaction with life scale. conclusion: we concluded that caregiver burden significantly affects the mental health of the caregivers of patients with psychiatric disorders. also, caregivers of people who are mentally ill patients suffer a lot of burdens. therefore, interventions that can assist them, such as providing them with a support system and counselling services, must be created. keywords caregiver burden, patients, schizophrenia, bipolar, life satisfaction. citation: emad f, ali sa, ishaque f, mirza aa, khalid h, ansari ak. association between satisfaction with life and caregiver burden, among psychiatric patients. app.2021; 8(1):15-23 corresponding author email: farhan.ishauqe@duhs.edu.pk.com doi: 10.29052/2412-3188.v8.i1.2021.15-23 received 30/12/2020 accepted 10/05/2020 published 01/06/2021 copyright © the author(s). 2021 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v8.i1.2020. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 16 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 introduction the health of caregivers got challenged by offering treatment to family members suffering from prolonged illness. when the family member has a significant psychological disorder, the role of providing treatment becomes more daunting as the stigma of mental illness contributes to this strain of caring. the caregiver's burden has similar characteristics, either physical or mental conditions, or caregivers also experience anxiety and depressive disorders and many economic and occupational symptoms. however, through the signs and social response to them, various pathologies have particular effects on caregivers, so these distinctions create unique needs for patient care1. this study's objective was to determine the association of satisfaction with life and caregiver burden among patients with schizophrenia disorder. it aimed to estimate any gender differences on the variables of caregiver burden and satisfaction with life scale among the caregivers of patients with psychiatric disorders. patients suffering from extreme mental disorders develop a heavy reliance on caregivers, primarily because of their disease's significant impairment. this dependence and responsibility for providing care add to their misery of caregivers' quality of life, affecting their health, employment, socializing, and relationships2. in terms of its impact, the literature distinguishes burden as objective (e.g. disturbance in the life of caregivers in terms of household routine, social activities and financial/employment problems) and subjective (emotional distress endured by caregivers, e.g. depression, anxiety, frustration, shame, loss, stigma and rejection3. besides, the socio-demographic factors and disease-related aspects of care recipients and caregivers considered contributing to the workload of the caregiver4, 5. it may neglect their well-being and other social and personal needs of caregivers, which decreases their ability to cope effectively with care demands. most psychiatric disorders also put a heavy burden on caregivers. still, of these disorders, schizophrenia attracts more attention because of the deterioration in the patient's person and social functioning and the symptoms that affect the caregivers' quality of life and the severity and early breakout of the disorder6. past research indicates that the burden of care should be categorized as an objective burden and a subjective burden, as factors that relate to caregivers' physical and mental health and the effect of these types of burden7. burden refers to the inputs pertaining to caregiving activities that could be determined by the time spent on caregiving and the functional level of care recipients. the subjective burden focuses on the self-perceived impact on caregivers of the objective burden8. the critical correlation between objective and subjective treatment among family dementia caregivers explored in several studies identifying higher objective burdens linked to higher subjective burdens9, 10. the physical and mental well-being, social relationships, and caregivers' financial life are impressed by the family caregiver burden11,12. it also correlates with psychological morbidity, lower leisure time, workload, and caregiver burnout13. due to patients' behaviour and a negative attitude towards the patient, they often feel frustration, rage, humiliation, anxiety, sadness, and stress14, 15. schizophrenia is one of the ten disorders contributing to the loss of capacity in individuals, based on research carried out by the world health organization. schizophrenia is a psychological condition that is profoundly debilitating and persistent, affecting all significant aspects of a patient's life. the 17 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 world health organization reports that 29 million people worldwide have been affected by schizophrenia. the prevalence of psychotic disorders is approximately 0.89 percent in an epidemiological analysis of mental disorders done in iran, with schizophrenia being 0.6 percent. methodology the quasi-experimental study was design to draw the association between satisfaction with life and caregiver burden among psychiatric patients. a sample size of 170 psychiatric patients was used for data collection after the purposive sampling technique. the study's objective, operation, and material got approval from the board of advanced studies and research. the university of karachi and psychiatric hospitals and rehabilitation centers of karachi. the clinical psychologist doublechecked the data by following the dsm-5 guidelines (apa, 2013), then was interviewed them and their caregivers. schizophrenic (n=85) and bipolar disorder (n=85), further classified as patients with psychiatric disease. we excluded all the patients who had any psychiatric or medical illness as co-morbidity, the patients who had been meeting the research norms but they are not taking any medicine, or therapeutic intervention, all the intellectually challenged and physically disabled population. one caregiver against each patient participated in the study, and those who have had the prime accountability to look after the patients were contained in the study. caregivers who were experiencing any kind of psychiatric disorder, intellectually challenged or any medical disease that can significantly impact the cognitive level or psychological function were excluded from the study. for the current study, a three-part survey questionnaire comprising the first part consists of informed consent from the caregivers. the second part included demographic variables, and in the third part, the study questionnaire was administered. zarit burden interview scale (zbis) and satisfaction with life scale (swls) were used. regression analysis, t-test and analysis of variance tests are also used to find the study's best results. the data were statistically analyzed using spss version 20.0. result the demographic characteristics of the patient and caregivers are given in table 1 & 2. table 1: demographic characteristics of patients (n= 170) variables categories n(%) gender male 75(44.1) female 95(55.9) qualification primary 14(8.2) middle 16(9.4) matric 34 (20.0) intermediate 39(22.9) graduate 22(12.9) masters 22(12.9) uneducated 23(13.5) marital status single 94(55.3) married 59(34.7) 18 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 divorced 17 (10.0) family system joint 91(53.5) nuclear 79(46.5) diagnosis schizophrenia 85(50.0) bipolar 85(50.0) duration of illness 0-5 years 54(31.8) 6-10 years 60(35.3) 11-15 years 56(32.9) nature of treatment medication 107(62.9) psychotherapy 16(9.4) combined 47(27.6) treatment setting opd 139(81.8) ipd 31(18.2) table 2: demographic characteristics of caregivers (n=170). variables categories n(%) gender male 95(55.9) female 75(44.1) qualification primary 5(3.3) middle 6(3.5) matric 9(5.3) intermediate 31(18.2) graduate 21(12.4) masters 39(22.9) uneducated 27(15.9) occupation employed 51(30.0) unemployed 96(56.5) housewife 13(7.6) student 10(5.9) qualification primary 6(3.5) middle 9(5.3) matric 31(18.2) intermediate 21(12.4) graduate 39(22.9) masters 27(15.9) uneducated 37(21.8) 19 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 the result indicates that the caregiver burden is the predictor of satisfaction with life in the caregivers of patients with schizophrenia disorders [r2, .554; f (1.84) = 36.711, p<0.000]. table 3: linear regression analysis and analysis of variance statistics of life satisfaction scale with caregiver burden scale model r r2 adj. r2 ss df ms f pvalve (constant) caregiver burden .554a .307 .298 1912.035 1 1912.035 36.711 0.000 4322.953 83 52.084 6234.988 84 a. dependent variable: satisfaction with life scale b. predictors: (constant), caregiver burden scale further, it was found that the caregiver burden is a strong predictor of satisfaction with life in the caregivers of patients with schizophrenia disorders (β=.554, p<0.001). table 4: coefficient statistics of life satisfaction scale and caregiver burden scale among the caregivers of patients with schizophrenia model unstandardized standardized t p-value 95% ci β se beta lb ub (constant) 29.912 2.299 13.008 .000 25.339 34.486 swls -.259 .043 -.554 -6.059 .000 -.344 -.174 a. dependent variable: satisfaction with life scale; swls=satisfaction with life scale, se= standard error, lb= lower bond, ub=upper bon the result indicates that the caregiver burden is the predictor of satisfaction with life in the caregivers of patients with bipolar disorders [r2, .701; f (1.84) = 79.97, p<0.000]. table 5: analysis of variance statistics of life satisfaction scale with caregiver burden scale among the caregivers of patients with bipolar disorder model r r2 adj.r2 ss df ms f p-valve (constant) caregiver burden .701a .491 .485 3200.959 1 3200.959 79.975 0.000b 3322.029 83 40.024 6522.988 84 a. dependent variable: satisfaction with life scale b. predictors: (constant), caregiver burden scale results indicate that there were a significant difference among the different level of the duration of illness on the variable of caregiver burden scale among the caregivers of patients with schizophrenia and bipolar disorders [f (2,169) = 396.810; p< .000] 20 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 table 6: variance statistics for the duration of illness with caregiver burden among the caregivers of patients with schizophrenia and bipolar disorders variable ss df ms f p-valve between groups 54890.810 2 27445.405 396.810 0.000 within groups 11550.579 167 69.165 total 66441.388 169 discussion the burden of caregivers is the major predictor of life-scale satisfaction among schizophrenia disorder patients. getting a member of the family with schizophrenia disorganizes the familiar dynamics according to the function theory. roleconflicts arise when the caregiver itself is made up of conflicting and incompatible specifications16. role-conflicts have a range of adverse effects on caregivers, such as physical difficulties, fatigue, burn-out, anxiety and other mental disorders17. expressed emotion is a measure of the family environment that focuses on how the relatives of the psychiatric patient talk about the patient spontaneously15. in patients with mental illness, such as schizophrenia, high levels of expressed emotion in the home may worsen the prognosis and may serve as a potential risk factor for developing psychiatric disorders18. also, this study showed that married caregivers had greater stress levels than unmarried caregivers. the potential cause may be the extra burden of infants, caregivers, and other family members, leading to higher stress levels. the coping mechanisms of caregivers need to be considered to overcome pressures, as they affect the day-to-day functioning of caregivers19,20. as with schizophrenia, the caregivers of bipolar patients have similar degrees of disrupted habits. both conditions affect families and need the same degree of caregiver treatment for their stability. but the level of stress and frustration perceived by bipolar caregivers due to violent and aggressive behaviour is high. these findings are not in line with previous studies that we refer to in this report. it showed that the caregivers of schizophrenia had higher stress levels than those of another group21. regression analysis found that the clinical function of the patient better explained the variance observed in the feis variables as opposed to the characteristics of the patient, which explained no more than 8.5 percent of the variance, while caregiver characteristics explained 11.7 percent variance in the bipolar disorder category for satisfaction with services. past studies have confirmed the correlation between the stress of caregivers and symptoms of severe mental disorders. in patients with mental illness, the disease's length has a significant difference in satisfaction with the life scale. it was noticed that caregivers with two or more years of caregiver experience had a higher degree of caregiver pressure than those with 1-6 months and 1-2 years of care length. similar to the study results, it was found that longer care durations were positively associated with higher caregiver pressures22. three key factors associated with caregiver frustration with the condition, in general, were identified in this analysis included inadequate psychosocial functioning of patients, insufficient use of medication and 21 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 rehabilitative services by patients, and living with the patient. the frustration of caregivers with psychiatric treatment for patients is distinct from their general dissatisfaction in life. if the patients had severe psychotic symptoms or weak life-grip maintenance, caregivers were unhappy with facilities. the stress and frustration of the caregiver are often correlated with psychiatric facilities. the most fundamental aspect that can ensure clinicians' satisfaction is therapeutic interventions that could enhance the functional status of patients and appropriate medication23. past research has shown that treatment is a significant public health challenge that should not be overlooked combined with patient medication and therapeutic facilities24, 25. in this research, it was found that most caregivers of schizophrenia patients are happy with their condition and psychiatric services. in finland, 20-30 percent of caregivers in psychiatric treatment, recovery, and drug care for patients with low functional status and unmet needs are unhappy and depressed. in reality, these caregivers need more participation in therapies, data, support, and therapy. so, caregivers should also be adequately evaluated. caregivers can only serve as a resource in inpatient care if they obtain adequate support26,27. conclusion it is painful to live with a psychiatric illness, both for the patients and the families. the family members coping with such patients were seen to have ranked lower on the scale of life satisfaction. it was also seen that, as opposed to males, female care providers had lower scores on the life satisfaction scale. family support is really important when coping with any disorder, whether mental or physical. but when an individual is dealing with a mental illness, the need to establish and sustain interpersonal relationships, take care of oneself, complete schooling, and maintain jobs interferes with one's ability. when supporting their patients, counsellors or therapists can also have some counselling for their family members, which may help family members understand themselves and their loved ones. and they should clarify that they should not neglect their own needs and demands when taking the caregiver position. acknowledgement the author would like to acknowledge dr. saima masoom ali, assistant professor, university of karachi, for her valuable advice and timely support throughout this research. sincere thanks to dr. farhan ishaque khan, assistant professor at institute of physical medicine & rehabilitation dow university of health sciences, for rendering extraordinary support. i would like to extend the deepest appreciation to dr. aq khan centre institute of behavioral sciences, gulshan psychiatrist hospital, addicare rehabilitation centre, who cooperates and helping in data collection from their respective organizations. references 1. alzahrani sh, fallata eo, alabdulwahab ma, alsafi wa, bashawri j. assessment of the burden on caregivers of patients with mental disorders in jeddah, saudi arabia. bmc psychiatry. 2017;17(1):202. 2. american psychiatric association, dsm-5 task force. diagnostic and statistical manual of mental disorders: dsm-5™ (5th edition) 2013. american psychiatric publishing, inc. 3. asarnow jr, tompson m, woo s, cantwell dp. is expressed emotion a specific risk factor for depression or a nonspecific correlate of psychopathology?. j abnorm child psychol. 2001;29(6):573-583. 22 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 4. ayalew m, workicho a, tesfaye e, hailesilasie h, abera m. burden among caregivers of people with mental illness at jimma university medical center, southwest ethiopia: a cross-sectional study. ann. gen. psychiatry. 2019;18(1): article number: 10. 5. bekdemir a, ilhan n. predictors of caregiver burden in caregivers of bedridden patients. j nurs. res. 2019;27(3):e24. 6. butzlaff rl, hooley jm. expressed emotion and psychiatric relapse: a meta-analysis. arch. gen. psychiatry. 1998;55(6):547-552. 7. cao y, yang f. objective and subjective dementia caregiving burden: the moderating role of intrinsic justice reasoning and social support. int. j. environ. res. public health. 2020;17(2):455. 8. caqueo-urízar a, gutiérrez-maldonado j, ferrer-garcía m, darrigrande-molina p. burden of care in aymara caregivers of patients with schizophrenia. revista de psiquiatría y salud mental (english edition). 2012;5(3):191-196. 9. cetinkaya f, karadakovan a. investigation of care burden in dementia patient caregivers. turk j geriatr. 2012;15(2). 10. corcoran ma. gender differences in dementia management plans of spousal caregivers: implications for occupational therapy. am j occup ther 1992; 46: 10061012. 11. fadaei f, qorbani m, asayesh h, rahmani anaraki m. the effect of poetry therapy group on communicational skills of a schizophrenic patient. j urmia nurs midwifery faculty. 2016;13(11):919–927. 12. 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6(5):380–388. 16. kızılırmak b, küçük l. care burden level and mental health condition of the families of individuals with mental disorders. arch psychiatr nurs. 2016;30(1): 47–54. 17. millier a, schmidt u, angermeyer mc, chauhan d, murthy v, toumi m, cadisoussi n. humanistic burden in schizophrenia: a literature review. j psychiatr res. 2014; 54:85 18. reinhard sc, gubman gd, horwitz av, minsky s. burden assessment scale for families of the seriously mentally ill. eval program plann.1994;17(3):261-269. 19. nallapaneni nr, yendluri p, paritala cb, racharla bn. a study of caregiver burden in bipolar affective disorder. j. evol. med. dent. sci. 2015;4(49):8499-8516. 20. reinhard sc, gubman gd, horwitz av, minsky s. burden assessment scale for families of the seriously mentally ill. eval program plann. 1994;17(3):261-269. 21. rössler w, salize hj, van os j, riecherrössler a. size of burden of schizophrenia and psychotic disorders. eur neuropsychopharmacol. 2005; 15(4):399–409. 22. sharif f, shaygan m, mani a. effect of a psycho-educational intervention for family members on caregiver burdens and psychiatric symptoms in patients with schizophrenia in shiraz, iran. bmc psychiatry. 2012; 12(1):48. 23. sharma n, chakrabarti s, grover s. gender differences in caregiving among familycaregivers of people with mental illnesses. world j psychiatr. 2016;6(1):7-17. 24. siddiqui s, khalid j. determining the caregivers’ burden in caregivers of patients with mental illness. pak j med sci. 2019;35(5):1329-1333. 25. tamizi z, fallahi-khoshknab m, dalvandi a, mohammadi-shahboulaghi f, mohammadi 23 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 e, bakhshi e. defining the concept of family caregiver burden in patients with schizophrenia: a systematic review protocol. syst rev. 2019;8(1):1-6. 26. van wijngaarden bo, schene ah, koeter m, vázquez-barquero jl, knudsen hc, lasalvia a, mccrone p, epsilon study group. caregiving in schizophrenia: development, internal consistency and reliability of the involvement evaluation questionnaire– european version: epsilon study 4. br j psychiatry. 2000;177(s39):s21-7. 27. yu y, liu zw, tang bw, zhao m, liu xg, xiao sy. reported family burden of schizophrenia patients in rural china. plos one. 2017;12(6):e0179425. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v8.i1.2021.15-23 41 app| published by aeirc| https://doi.org/10.29052/2412-3188.v6.i1.2019.41-51 issn 2412 3188 study protocol effects of the guided disclosure protocol on post-traumatic growth: a randomized control trial designed to observe psychophysiological alterations in traumatic stress subjects shamoon noushad1,2,3 & sadaf ahmed1,3 1advance educational institute & research center 2dadabhoy institute of higher education 3psychophysiology research lab, biological research center, university of karachi abstract background: the two constructs traumatic stress and post-traumatic growth (ptg) are distinct and the psychophysiological relationship is yet to be explained. it’s a long debate that the victims who survive through the traumatic event only perceive that their suffering has helped them in improving their lives after the event or the experience actually improved functioning. the purpose of designing this randomized control trial is to observe psychophysiological alterations associated with post traumatic growth in traumatic stress subjects. methodology: this multicenter study is planned to investigate the effectiveness of the guided disclosure protocol for the promotion of post-traumatic growth (ptg), in the traumatic stress subjects and to determine whether ptg is associated with psychophysiological alterations i.e. (c-reactive protein, brain derived neurotropic factor, interlukin-6, cortisol, heart rate variability and brain waves). study subjects meeting eligibility criteria will be randomized into two groups. guided disclosure protocol (gdp) will be used as intervention vs the control. blinded treatment will be provided and the subjects will be made to complete study questionnaires (screening, traumatic stress scale sss, trauma symptom checklist, post-traumatic growth inventory) at baseline and at postintervention (3-months later). discussion: this study might give us insight about application and efficacy of guided disclosure protocol in a population that is seeking help and underrepresented to be clinical. moreover, one of the more hopeful findings of this research will be significant information about trauma-related psychophysiological effects. keywords guided disclosure protocol, post-traumatic growth, psychophysiological alterations, trauma symptom checklist. citation: noushad s, ahmed s. effects of the guided disclosure protocol on post-traumatic growth: a randomized control trial designed to observe psychophysiological alterations in traumatic stress subjects. app. 2019; 6(1):41-51 corresponding author email: shamoon@aeirc-edu.com doi: 10.29052/2412-3188.v6.i1.2019.41-51 received 11/03/2019 accepted 03/06/2019 published 12/10/2019 copyright © the author(s). 2019 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. https://doi.org/10.29052/2412-3188.v6.i1.2019. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 42 issn 2412 3188 app| published by aeirc| volume 6 issue 1 introduction traumatic stress is an outcome of single or a cumulative series of trauma exposure that enduring symptoms conditioned with previous frightening experiences that threatens persons existence and sense of safety in conditions like physical shock, harassment, abusive relationships, sexual abuse, police brutality, judicial corruption, domestic violence, natural disasters, motor vehicle accident, community violence etc. traumatic stress involves both biological and psychological aspects and as research progress in the field there had been exploration of numerous etiological factors with the main mechanisms remain imprecise1. according to the neurobiological findings, the stress and resilience model needs to put together to understand these factors2 as the underlying biology is the major contributing factor for triggering psychological risk and the resilience factors3. it is evident that the symptoms of traumatic stress and post traumatic growth (ptg) cooccur in accordance with trauma type4. where ptg is considered as positive psychosomatic transformation experienced as a result of adversity and other miseries to rise at an improved and quality psychophysiological state. in response to any traumatic event the neurophysiological factors get triggered like hpa axis5, that initiate a cascade to influences neuronal pathways via dopaminergic6,7, glutamatergic8, and serotonergic systems9, to cause changes in the perception and performance. numerous biomarkers associated with different biological domains such as monoaminergic systems, neuroendocrinological pointers, inflammatory molecules, genomics, psychophysiological markers and neuroanatomical changes had been identified for assessment of post-traumatic stress risk and consequences10. the inherent symptomatic diversity among the posttraumatic stress subjects, and other similar psychiatric and medical conditions makes the identification of appropriate biomarker for post-traumatic stress diagnosis much complex11-13. inflammatory markers, brain-derived neurotrophic factor (bdnf), and alterations from the hpa axis are few of the resiliencespecific biological factors that had been discovered and studied in the past14,15. while cortisol remain the key hormone that release in response to stress stimuli from the adrenal gland and controlled by the hpa axis16. the trauma subjects show increased stress sensitivity as the cortisol level is naturally reduced among these subjects after getting exhaust initially17. there is a strong relationship between trauma and inflammatory markers as indicated by a number of comorbidities like physical18, inflammation19 and metabolic illness20. the level of pro-inflammatory cytokines such as interleukin (il)-6, il-1 and il-2 are high in traumatic subjects21,22. while c reactive protein (crp) is considered as psychophysiological biomarker of posttraumatic stress with increased level of crp is observed among traumatic stress subjects23. the most recurrent biological finding in traumatic stress is higher autonomic activity and changes in brain functionality that can be detected by numerous recordings such as, hrv measurement, skin conductance, brain waves and facial electromyography responding during internal, mental imagery of the traumatic event and upon exposure to external, trauma-related cues. according to the posttraumatic growth (ptg) model, traumatic events function as catalyst and aid in individual growth to develop various coping strategies and it must be considered as a challenge24,25. although the memories and feelings associated with a traumatic event are stressful26, but the dealing strategy and experience can be altered by the individual’s perspective regarding the event and through this the aftermath could be transformed25. depending upon psychological symptoms, self-report and patient’s observation, 43 issn 2412 3188 app| published by aeirc| volume 6 issue 1 particularly within military personnel, is inadequate as impairment may occur due to various factors, including other combatrelated injuries like mild traumatic brain injury27,28. similarly, without the assessment of psychological factors associated with perceived stress, resilience, and struggling experiences and only concentrating on the biological foundation would limit one’s knowledge regarding the etiological factors associated with the trauma. the primary mechanisms cannot be studied properly unless the stress related problems are studied along with the coping strategies29,30. for assessment, diagnosis, inhibition and treatment, the markers (psychological, biological, and genetic) could assist mainly in the high-risk groups31,32. several researchers reported immunological differences between studies including participants who disclosed traumatic or upsetting events compared with those in a nondisclosure condition33. results of these type of studies have been interpreted as evidence for the link between inhibition of strong emotions and the development of physical disease34. the benefits of disclosurebased interventions may depend on the extent to which individuals become emotionally and cognitively involved in the disclosure process, reorganize the meaning of the traumatic event, and reduce avoidance of the stressful topic35. a number of studies had been conducted including subjects from public healthcare settings, experienced stress due to ill health or trauma36-39. it is evident that the expressive writing benefits also extend to the normal population other than students40,41. it is noted that the lung function improvises in asthma patients42 and symptomatic relief is observed in patients with rheumatoid arthritis43. additionally, decreased physical symptoms were observed among the patients of stage i or ii breast cancer having received the medical treatment, after 3 months of the handling with expressive writing showed better outcomes as compared to control group44. while there are few outcomes that indicate reduced health related behaviours due to expressive writing i.e. declining clinical attendance and work absenteeism45. written disclosure protocols, in which individuals express their thoughts and emotions about traumatic or stressful life events, have been associated with improvements in both psychological and physical health46. the effectiveness of gdp in comparison to the standard disclosure protocols is under discussion and various studies have investigated the efficacy of the two. the purpose of designing this randomized control trial is to observe psychophysiological alterations associated with post traumatic growth in traumatic stress subjects. methodology study design the study will be conducted as multicenter randomized controlled trial. on the basis of eligibility criteria subjects providing consent to participate in the study will be randomized into two groups, experimental group including those who receive the intervention and a control group receiving control intervention. the study outcomes will be monitored in subjects of both groups at different intervals i.e. at baseline and at 3month follow-up (post-interventional). ethical concerns the study protocol was approved by the ethics committee of pakistan medical association committee on ethics (reference code no. 2019/erc/6-94). and registered by the clinicaltrial.gov (registration number nct04217863)47. participants subjects for the present study will be recruited from 5 centers (based in karachi, pakistan). the targeted population includes subjects from diverse ethnicity and considered eligible for participation in the study if they indicated in a pre-screening form that they had experienced traumatic event. these subjects will be invited to 44 issn 2412 3188 app| published by aeirc| volume 6 issue 1 participate in the study through advertisement on notice board of each center. a written informed consent will be obtained from each study subject after providing detailed information regarding objectives of the study and its duration. eligibility criteria inclusion criteria all subjects fulfilling the below given criteria will be included: 1. subjects aged 18 years or over 2. must be disease free, there must be no evidences of any metastatic disease 3. property of written and spoken english language. 4. experienced any traumatic event in last 12 months. exclusion criteria 1. subjects who received a structured psychological intervention for at least 6 months during the last 3 years performed by a psychologist or psychiatrist will be excluded. 2. those with codified psychiatric disorder (according to the diagnostic and statistical manual of mental disorders, fifth edition (dsm-v) who received psychopharmacological treatment during the last 3 years will also be excluded from the study sample. interventions the experimental intervention (gdp): it includes three writing sessions of 20 minutes where the participants will be made to recall the facts regarding the traumatic event first and then the emotions triggered related to the revealed facts will be channelized. the information related to the immediate priority changes due to the revival of the traumatic history and its reflection on current feelings will be collected. moreover, the learned coping mechanisms will also be inquired and how the traumatic event altered their vision and their personalities and how it helps in coping with future difficulties. the original instructions will be translated into local language and altered according to the specific traumatic experience. in the following, a fusion of the tasks concerning each of the three writing sessions is shown. 1. participants will be required to describe memories associated with traumatic event in a sequential order, with an objective and detached attitude. 2. they will be asked to describe: a. their opinion regarding the traumatic event and emotions perceived during the experience. b. its impact on their daily lives, and how it has altered their attitudes toward life. 3. the actual situation will be focused, while reviving the whole traumatic event experience which aids in exploring the following aspects: a. present thoughts and feelings regarding the traumatic experience, and also clarify the differences between the ones felt at the time of traumatic event in comparison to the current feelings. b. how much they understand and appreciate themselves for successfully dealing with the traumatic event c. to what extent the traumatic event has modified their vision, attitude, knowledge, and skills, and how it can help in their future; d. what will be their future reactions to other similar events. for the writing session it is mandatory to maintain standard experimental environment with maximum silence so that the subject can write peacefully without getting disturbed. two weeks after the initial assessment, the first writing session will be performed followed by two sessions once every 2 weeks. the control intervention: in control intervention the subjects will be required to take three 20-minute writing sessions, in which they will be asked to write about their daily events of the past week, the writing must focus on the facts and highlight an objective and detached attitude. it has shown potential improvements after the guided disclosure protocol (gdp). works through the placebo effect. same protocol 45 issn 2412 3188 app| published by aeirc| volume 6 issue 1 will be followed for these subjects as the one used for gdp. a day prior to each writing session, in both conditions either experimental or control the researcher will communicate with each study subject via telephone in order to give them a reminder to perform the writing task and to check their understanding regarding the instructions given in the booklet. details regarding the inability to contact the subject will also be recorded in the patient form. recruitment & assessment procedures recruitment and baseline assessment: one or more researchers will be involved in the process of recruitment and evaluation. prior training sessions will be conducted by principal investigator regarding study aims and procedures for all the researchers involved in the study. the participants will be directed towards the researchers who are responsible for explaining the study aims and conduction as well. an information sheet including subject’s socio-demographic characteristics will be provided to each individual. a written informed consent will be taken from each subject before initiation of the study. confidentiality will be maintained during and after the study for both written process and assessment records. a baseline questionnaire (screening, tss, ptgi, tsc) and booklet with detailed instructions will be provided to the study subjects according to the groups allocated. the subjects will be kept blinded regarding the study treatment and hypotheses during the study conduction. all the variables (crp, bdnf, il-6, cortisol, hrv, glutamate and brain waves) will also be measured at baseline. post-intervention and follow-up assessments: after 3 months post-interventional assessment will be performed i.e. follow-up evaluation, with the same time tolerance as that for baseline. during this the booklets with written scripts will be returned to each of them individually. procedure the screening questionnaire will be utilized for assessment. subjects reporting of experiencing at least one traumatic experience are kept inclusive. study hypothesis 1. it is hypothesized that higher scores on the post-traumatic growth inventory (ptgi) will be observed among the subjects enrolled in the gdp group as compared to the control group. 2. we expect the variation in psychophysiological markers i.e. crp, bdnf, il-6, cortisol, hrv and brain waves among the subjects of gdp group as compared to those in the control group. 3. it is expected that lower scores on the traumatic stress scale and trauma symptom checklist 40 (tsc-40) with subscale composition of dissociation, anxiety, depression, sati, sleep disturbance and sexual problems will be observed among the subjects enrolled in the gdp group as compared to the control group. measures post-traumatic growth (ptg)48 ptg will be assessed using the italian version of the ptgi. this inventory is comprising of 21 questions based on 5 factors. the 1st factor shares spiritual modifications (2 items), 2nd factor relates to self-conception and alterations in viewpoints (changes in philosophy) (7 items), 3rd factor describes relationship changes (5 items), 4th factor relates to finding new motivations and interests in life (3 items) and the 5th factor explores the discovery of individual resources attainable by themselves and others (3 items). respondents will be tracked for the changes that have been produced due to their illness. likert scale will be used for rating where 0 means no change experienced, to increasing consequently as 5 means change experienced to a greater degree. traumatic stress scale (sadaf stress scale)49 the traumatic stress scale sub section of sadaf stress scale (version 2) measures 46 issn 2412 3188 app| published by aeirc| volume 6 issue 1 exposure to any trauma such as criminal victimization, natural disaster, witnessing or confronting such situations or itself experiencing them as actual or threatened death (or serious injury) to self or others which can dwell a person into traumatic stress. this scale comprises of 8 questions which measures traumatic stress in categories of normal, mild, moderate & severe. trauma symptom checklist50 the tsc-40 is a research measure that evaluates symptomatology in adults associated with childhood or adult traumatic experiences. it measures aspects of posttraumatic stress and other symptom clusters found in traumatized individuals. this measure assesses trauma-related problems in categories like dissociation, anxiety, depression, sati (sexual abuse trauma index), sleep disturbance & sexual problems. brain waves the voltage fluctuations within the neurons or the electrical activity of neurons due to ionic flow is recorded as brain waves through electroencephalogram while the record itself is the eeg that shows waves or oscillations indicating electrical activity. the (muse, rrid:scr_014418) brain-sensing headband51 will be utilized to record the brain waves i.e. alpha waves, beta waves, theta waves & gamma waves. cortisol a negative association exists between cortisol and left hippocampal volume among patients with other psychiatric disorders like depression and ptsd due to trauma. memory and learning skills are affected by elevated cortisol levels. it increases the risk for depression, mental illness, and also decreases the life expectancy. chemiluminescent micro particle immunoassay (cmia) will be used for assessment of cortisol levels. brain-derived neurotrophic factor (bdnf) the changes in the bdnf levels are associated with traumatic stress or the changes in the physiological systems in relation to a stress response. cognitive functioning is mainly altered in cases with alterations in bdnf levels. human bdnf elisa (enzyme-linked immunosorbent assay) kit will be utilized for bdnf assay. c reactive protein (crp) for measuring systemic inflammation, crp is an ideal measure. in vitro immune turbidimetric method will be utilized for the quantifiable determination of crp in human serum and plasma. heart rate variability temperature, heart rate variability, pulse rate, blood pressure will be recorded through electro power lab52 and analysis through matlab. interleukin-6 (il-6) physical and psychological stress alter plasma cytokines levels particularly interleukin-6 (il-6). serum concentrations of il-6, will be assayed by means of enzymelinked immunosorbent assay techniques, based on appropriate and validated sets of monoclonal antibodies. glutamate elevated levels of an excitatory neurotransmitter known as “glutamate” which is an amino acid, is greatly reported in cases of neurotoxicity which causes neuronal death. glutamate assay kit will be utilized for the estimation. sample size a sample size of 246 was calculated with at least 123 subjects will be placed in both groups for statistically significant variation of ptg to be observed among gdp versus control groups. it was calculated according to meta-analysis on ptg53, where an estimated effect size of 0.36 (equally with both hedges’ g and cohen’s d) with a two-sided test using g power 3.1.354, alpha 0.05 and a power of 0.80. 47 issn 2412 3188 app| published by aeirc| volume 6 issue 1 randomization subjects on the basis of eligibility criteria will be randomly allocated to the gdp or control group in the 1:1 ratio. computer generated random numbers are used for randomization. after taking subjects basic information, a unique code will be provided to each included subject by the study center. the code will be mentioned on each form of each individual subject. statistical analysis the data will be analysed using 2 × 2 mixed factorial design analysis of variance (anova) in order to calculate whether there exists a significant change in ptg among the subjects of intervention and control group. after intervention if a higher ratio of ptg will be observed in gdp group, the interventional impact of the five factors of ptg will be examined with further analysis. sequentially for each secondary outcome further anovas will used to examine differences between groups at 3 months and after baseline. adjusted anova will be performed keeping socio-demographic and other variables as co-variants, to determine whether the socio-demographic and other characters could result in alterations in the effect between the two groups. for the effect of gdp on constructed meaning regressionbased approach will be utilized. according to previous literature in order to estimate a simple mediation model ordinary leastsquare regression models is becoming a common practice which is considered as appropriate as structural equation modelling55-57. figure 1: flowchart of study procedure. 48 issn 2412 3188 app| published by aeirc| volume 6 issue 1 discussion psychophysiological studies have demonstrated that what individuals think and feel has a measurable effect on the nervous, immune and behavioural responses, demonstrating that the line between physical and mental health is not as solid as we once believed. this might give us insight about application and efficacy of directed written disclosure in a population that is seeking help and underrepresented to be clinical. moreover, one of the more hopeful findings of this research will be significant information about trauma-related effects that can be managed and possibly reversed and will help trauma survivors for number of specific actions to downregulate their stress response and halt their decline into serious health problems. conceptualizing traumatic stress as a disorder of the brain’s fear system, with emotional processing dysregulation within its circuitry, has generated a significant body of research over the past decade that has illuminated the neuroimmunological and psychophysiological mechanisms that underlie this problem. acknowledgement authors highly appreciate and acknowledge the efforts of yusra saleem. references 1. gandubert c, scali j, ancelin ml, carriere i, dupuy am, bagnolini g, ritchie k, sebanne m, martrille l, baccino e, hermes a. biological and psychological predictors of posttraumatic stress disorder onset and chronicity. a one-year prospective study. neurobiol. stress. 2016; 3: 61-67. 2. kalisch r, müller mb, tüscher o. a conceptual framework for the neurobiological study of resilience. behav. brain sci. 2015; 38:1–79. 3. kalisch r, müller mb, tüscher o. a conceptual framework for the neurobiological study of resilience. behav. brain sci. 2015;38:e92 4. cai wp, pan y, zhang sm, wei c, dong w, deng gh. relationship between cognitive emotion regulation, social support, resilience and acute stress responses in chinese soldiers: exploring multiple mediation model. psychiatry res. 2017;256:71-78 5. liu an, wang 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rl, levy-carrick n, reibman j, xu n, shao y, liu m, ferri l, kazeros a, caplan-shaw ce, pradhan dr, marmor m. elevated c-reactive protein and posttraumatic stress pathology among survivors of the 9/11 world trade center attacks. j. psychiatr. res. 2017;89:14-21 25. wu x, kaminga ac, dai w, deng j, wang z, pan x, liu a. the prevalence of moderate-to-high posttraumatic growth: a systematic review and meta-analysis. j affect disord. 2019;243:408-415. 26. dong x, li g, liu c, kong l, fang y, kang x, li p. the mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis. eur j oncol nurs. 2017;29:47-52. 27. shigemoto y, low b, borowa d, robitschek c. function of personal growth initiative on posttraumatic growth, posttraumatic stress, and depression over and above adaptive and maladaptive rumination. j clin psychol. 2017;73(9):1126-1145. 28. clark al, merritt v, werhane m, bigler ed, bangen k, sorg s, bondi mw, schiehser d, delano-wood l. blastexposed veterans with mild traumatic brain injury show greater frontal cortical 50 issn 2412 3188 app| published by aeirc| volume 6 issue 1 thinning and poorer executive functioning. front immunol. 2018;9:873 29. wright wg, handy jd, avcu p, ortiz a, haran fj, doria m, servatius rj. healthy active duty military with lifetime experience of mild traumatic brain injury exhibits subtle deficits in sensory reactivity and sensory integration during static balance. mil. med. 2018;183(suppl_1):313-320 30. baqutayan sm. stress and coping mechanisms: a historical overview. mediterranean j. soc. sci. 2015;6(2 s1):479 31. bosnjak mc, dobovski-poslon m, bibic z, bosnjak k. the influence of chronic stress on health and coping mechanisms. sanamed. 2019;14(1):97-101. 32. ghezzi p, davies k, delaney a, floridi l. theory of signs and statistical approach to big data in assessing the relevance of clinical biomarkers of inflammation and oxidative stress. proc natl acad sci. 2018;115(10):2473-2477. 33. colvonen pj, glassman lh, crocker ld, buttner mm, orff h, schiehser dm, norman sb, afari n. pretreatment biomarkers predicting ptsd psychotherapy outcomes: a systematic review. neurosci biobehav rev. 2017;75:140-156. 34. köhler m, schäfer h, goebel s, pedersen a. the role of disclosure attitudes in the relationship between posttraumatic stress disorder symptom severity and perceived social support among emergency service workers. psychiatry res. 2018;270:602-610. 35. traue hc, kessler h, deighton rm. emotional inhibition. instress: concepts, cognition, emotion, and behavior 2016 jan 1 (pp. 233-240). academic press. 36. kazlauskas e. challenges for providing health care in traumatized populations: barriers for ptsd treatments and the need for new developments. glob. health action. 2017;10(1):1322399. 37. asnakew s, shumet s, ginbare w, legas g, haile k. prevalence of post-traumatic stress disorder and associated factors among koshe landslide survivors, addis ababa, ethiopia: a community-based, cross-sectional study. bmj open. 2019;9(6):e028550. 38. machado, melissa, "secondary traumatic stress among emergency department nurses" (2018). master's theses, dissertations, graduate research and major papers overview. 267. retrieved from: https://digitalcommons.ric.edu/etd/267 39. gandubert c, scali j, ancelin ml, carriere i, dupuy am, bagnolini g, ritchie k, sebanne m, martrille l, baccino e, hermes a. biological and psychological predictors of posttraumatic stress disorder onset and chronicity. a one-year prospective study. neurobiol. stress. 2016;3:61-67. 40. tinghög p, malm a, arwidson c, sigvardsdotter e, lundin a, saboonchi f. prevalence of mental ill health, traumas and postmigration stress among refugees from syria resettled in sweden after 2011: a population-based survey. bmj open. 2017;7(12):e018899. 41. borimnejad l, mortazavi h, aghazadeh n, halaji z. the effect of 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[updated 2020 jan 6]. available form: https://www.clinicaltrials.gov/ct2/sho w/nct04217863. 48. glass o, dreusicke m, evans j, bechard e, wolever rq. expressive writing to improve resilience to trauma: a clinical feasibility trial. complementary therapies in clinical practice. 2019;34:240-246. 49. baker jm, kelly c, calhoun lg, cann a, tedeschi rg. an examination of posttraumatic growth and posttraumatic depreciation: two exploratory studies. journal of loss and trauma. 2008;13(5):450-65. 50. noushad s, ahmed s. novel stress evaluating tool; sadaf stress scale (sss), tested so far on pakistani population. ijehsr.2013;1(2):57-51. 51. briere j, runtz m. the trauma symptom checklist (tsc-33) early data on a new scale. journal of interpersonal violence. 1989;4(2):151-163. 52. krigolson oe, williams cc, norton a, hassall cd, colino fl. choosing muse: validation of a low-cost, portable eeg system for erp research. frontiers in neuroscience. 2017;11:109. 53. shokr e. practical physiology 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app| published by aeirc| https://doi.org/10.29052/2412-3188.v7.i1.2020.9-18 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) original article psychological response & perceived risk associated with coronavirus disease saima khan1, yusra saleem2 & syed a aziz2,3 1laboratory of skeletal development and regeneration, the institute of life science, chongqing medical university, chongqing-china 2advance educational institute & research centre (aeirc), karachi-pakistan 3university of ottawa & health canada, canada abstract background: the coronavirus disease 2019 (covid-19) was declared a pandemic by who as it is found to be excessively transmissible & to spread throughout the world. the disease has caused a worldwide impact because of the need to establish worldwide activity by extensive social distancing and quarantine due to the daily rising death toll. through this study, we examined intend to examine the psychological effects, perceptual vulnerability, and perceived stress developed among the general population. methodology: the study was conducted from 2nd march to 26th may 2020. a total of 2188 of subjects replied to our informal online survey internationally. the respondent's demographic details and data regarding precautionary measures, perceptual vulnerability, perceived stress, and level of susceptibility of covid-19 was collected. the perceived stress scale (pss-10) was used for assessment of perceived anxiety, stigmatization, and fear of developing covid-19. results: as per the study findings, moderate perceived stress was observed among 66.6% of the respondents. among the protective measures, washing hands was most frequent 56.2%, but the use of face mask wasn't widespread, i.e. 48.9% rarely or never used face masks. 37.1% felt anxious around sick people, 58.5% were usually bothered by the people sneezing without covering their mouths. 32.3% occasionally felt agitated because of no control over the current situation & 18.6% frequently felt stressed and/or nervous. the contact history revealed that 11.2% had close contact, 20.9% had a non-close contact, and 12.9% were those who had suspected connection with a confirmed case. conclusion: evidently, covid-19 has numerous psychological impacts, and the responses vary due to perceived vulnerability & stress. the social distancing, disease fear, and quarantine may have some negative effects which may have some lasting consequences on general population. keywords covid-19, perceived vulnerability, psychological impacts, perceived stress, disease susceptibility. citation: khan s, saleem y, aziz sa. psychological response & perceived risk associated with coronavirus disease. app. 2020; 7(1):9-18 corresponding author email: saima@aeirc-edu.com doi: 10.29052/2412-3188.v7.i1.2020.9-18 received 02/06/2020 accepted 10/09/2020 published 01/10/2020 copyright © the author(s). 2020 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 10 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) introduction the novel outbreak of covid-19 emerged from china by the end of 2019, followed by a continuous spread globally1. although it is not new for the medical community, the current pandemic is the 5th type of coronavirus infection, i.e. severe acute respiratory syndrome, sars-cov21 spread in 2002-2003 8,098 cases and a 10% death rate. however, the associated contingency of covid-19 is reported to be more lethal with a higher rate of symptomatic and asymptomatic fatalities that directed immediate emergency to be led by the scientific and medical community2. the virus has been known to cause a range of illnesses from a minor cold to severe complications like acute respiratory distress syndrome (ards), that were also observed in 2012 through middle east respiratory syndrome (mers-cov) and the sars-cov in 2003. still, this strain of covid-19 is somewhat different from the ones previously identified among humans1,3. covid-19 was declared a pandemic by who due to its transmission mode and reported means of infection spread4. an emergency has been announced to control global health, and severe preventive measures are being taken to prevent the disease from spreading globally2. according to the world health organization (who), there were almost 1,133,681 confirmed cases of covid-19 globally by april 5, 2020, and 62,784 confirmed deaths from 209 affected countries, areas, or territories with confirmed cases4. moreover, specific guidelines for both biomedical and psychological management of this pandemic have been issued by who5. they are recommending that preventive measures are as necessary as medical aid during this physiological health crisis5. the global scenario that is considered a threat to any healthy individual's well-being has created much psychological stress globally and already generated fear among individuals. this might be due to the daily news depiction indicating rising figures of suspected and confirmed covid-19 cases and pertinacious quarantine2. apart from physical suffering, it is not uncommon for confirmed or suspected patients of covid-19 to deal with psychological pressure and other healthrelated problems5. the mental health of the affectees has not been adequately assessed. many of the academic institutes are now providing counselling services for such psychologically affected individuals6. the negative psychological impact of the epidemic and social distancing includes posttraumatic stress (pts) symptoms, depression, anxiety, and anger confirmed amongst individuals6. moreover, numerous studies have presented that front-line healthcare workers and patients are more susceptible to the emotional influences of covid-197. additionally, rejection, loneliness, depression, insomnia, anxiety, and hopelessness were also experienced. increased risk of aggression and suicide were also reported but rarely8. it is noteworthy that this disease is not only disrupting the physical state of humans but also demolishing our psychological wellbeing. furthermore, mass quarantine is expected to elevate anxiety significantly for several reasons. this raised anxiety might also have follow-on consequences for further health dealings9, as the general population is encountering disappointment, boredom, and irritability under the isolation measures7. moreover, strict social distancing and compulsory contact tracing policies by health specialists could cause discrimination, societal rejection, financial loss, inability to perform routine work, and stigmatization6. a recent study, including 4,607 individuals of chinese descent, disclosed that these individuals' cognitive evaluations, particularly their perceived severity of covid-19, are associated with increased negative emotions and behavioural reactions10. 11 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) furthermore, the health experts are of no exception during the crucial time as they are on the forefront, in direct and close contact with the infected patients, suspected cases, families and are also answerable to the public inquiries7. competent efforts are required concerning all disciplines to combat covid-19, both medically and psychologically. there is little to no known evidence on mental health and psychological influences due to the covid19 pandemic within the general population11. most of the covid-19 related research emphasizes epidemiology and the clinical features of the diseased persons12, the genomic description13 and the challenges faced by the global health authorities9. there is no ongoing research investigating the psychological influence of covid19 on the general population to the best of our knowledge. hence, the current study aimed to stimulate research on the psychological impacts of the covid-19 pandemic. it is intended to explore the incidences of psychological distress and identify the perceived risks and protectiveness among general the population. this might support the healthcare authorities in preserving the mental health of the community during this pandemic. methodology the survey was created and distributed using online survey administration app (google forms). data was collected from march 2 to may 26, 2020. a total of 2188 subjects replied to our informal online survey globally. participants were notified that they would not be compensated for their participation in the study and could stop taking the study at any time. they were also informed that the purpose of the study was to investigate their attitudes about covid-19. the institutional ethics committee approved survey procedures. subjects completed the online survey by using their phone or computer. the survey was advertised through social media (e.g., facebook, twitter). the respondent's demographic details were inquired, and the data regarding precautionary measures, perceptual vulnerability, perceived stress, and level of susceptibility of covid-19 were collected. the perceived stress scale (pss-10) was used to assess perceived anxiety, stigmatization, and fear of developing covid-19. the collected data were analyzed using spss version 22.0, and all qualitative variables like gender, regional distribution, protective measures, personal habits, perceptual vulnerability, and perceived stress subscale scoring, etc. were given as frequency and percentages. all quantitative variables like age and perceived stress scores were presented using mean and standard deviation (sd). result respondents’ characteristics overall, 2188 responders from 21 different countries globally took part in the electronic survey. of the total, 68.1% were females, and 31.9% were males with a mean age of 28.22±9.42 years. most of the respondents included post-graduate students (40.3%), followed by under-graduates (24.3%) and graduates (21.5%). the majority of responses were obtained from the eastern mediterranean region (27.90%), i.e. pakistan, saudi arabia, tunisia, and the united arab emirates, followed by countries from the european region (27.51%), namely belgium, finland, france, germany, greece, poland, portugal and the united kingdom (table 1). the demographic characteristics of the study participants are displayed in table 1. predictors for implementation of precautionary measures regarding the protective measures taken by the responders and personal habits developed after the declaration of the covid-19 pandemic, the most reported action and the most frequently established practice was washing hands with soap, i.e. 56.2% of respondents washed their hands very often. moreover, 54% cover their mouth habitually while coughing or sneezing, and 12 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) 28.2% would immediately wash their hands after while 32.7% of respondents would sometimes wash their hands after sneezing, coughing, or rubbing their nose. the essential protective measure of wearing face masks wasn't ubiquitous, as only 22.9% of respondents were using face masks frequently, while 26.9% of the respondents never used face masks. table 1: demographic characteristics & regional distribution of the study participants along with protective measures, personal habits and various aspects of perceptual vulnerability. variables n=2188 gender female 1491(68.1) male 697(31.9) age (years) mean ± standard deviation 28.22±9.42 education graduate 470(21.5) post-graduate 882(40.3) under-graduate 532(24.3) others 304(13.8) countries western pacific region australia 86(3.9) east african region tanzania 69(3.2) east asian region taiwan 86(3.9) south asian region bangladesh 82(3.7) south-east asia region india 151(6.9) eastern mediterranean region pakistan 342(15.6) saudi arabia 71(3.2) tunisia 108(4.9) united arab emirates 90(4.1) european region belgium 63(2.9) finland 66(3) france 60(2.7) germany 106(4.8) greece 62(2.8) poland 103(4.7) portugal 56(2.6) united kingdom 86(3.9) region of the americas canada 108(4.9) united states of america 167(7.6) western pacific region malaysia 95(4.3) new zealand 73(3.3) philippines 58(2.7) habits fairly often never rarely sometime very often wearing face masks 291(13.3) 588(26.9) 480(22) 617(28.2) 212(9.7) washing hands with soaps 606(27.7) 81(3.7) 271(12.4) 1230(56.2) covering mouth while coughing or sneezing 445(20.3) 59(2.7) 96(4.4) 406(18.6) 1182(54) 13 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) washing hands after touching possible contaminated objects 558(25.5) 51(2.3) 221(10.1) 361(16.5) 997(45.4) washing hands immediately after sneezing, coughing or rubbing the nose 495(22.6) 85(3.9) 276(12.6) 715(32.7) 617(28.2) perceptions based on my past experiences, i am not likely to get sick 252(11.5) 632(28.9) 498(22.8) 600(27.4) 206(9.4) i have a history of susceptibility to infectious diseases 239(10.9) 873(39.9) 606(27.7) 344(15.7) 126(5.8) i am more likely to catch an infectious disease than the people around me 190(8.7) 523(23.9) 689(31.5) 617(28.2) 169(7.7) it does not make me anxious to be around sick people 284(12.9) 424(19.3) 441(20.2) 812(37.2) 227(10.4) my immune system protects me from most illnesses that other people get 538(24.6) 151(6.9) 359(16.4) 818(37.4) 322(14.7) *values are given as n(%) the perceptual vulnerability of respondents the respondents' perceived vulnerability was assessed. it was found that 14.7% of the respondents reported that their immune system protects them from most illnesses that often affect others. moreover, 10.3% of the respondents were not very anxious around the sick people, while 37.1% sometimes felt anxious. around 7.7% of the respondents thought they were more likely to catch infectious diseases, 5.8% were sure of disease susceptibly, and 9.4% believed that they were less likely to get sick (table 1). perceived stress among the respondents the respondents' level of perceived stress due to the covid-19 outbreak was assessed through the perceived stress scale (pss-10). both negative and positive subscales were used except for items 4 & 5. as per the analysis, the mean pss score was 19.98±6.08, indicating that most of the respondents had moderate perceived stress (66.6%). moreover, 17.9% were those displaying high perceived stress and 15.4% with low perceived pressure. the descriptive summary shows that 58.5% of the respondents reported that people who sneeze without covering their mouths make them anxious. while 32.3% sometimes felt agitated because the things happened were outside their control, and 29.4% reported that they sometimes felt difficulties piling up so high that they could not recover. 18.6% frequently felt stressed and nervous and fearful, and 17.6% believed they were unable to control the essential things in their life. moreover, 25% very often felt upset because of the unexpected happenings of covid-19, followed by 23.4% reporting it fairly often and 27% sometimes (table 2). table 2: shows the perceived stress among the respondents pss-10 score (mean ± sd) 19.98±6.08 subscale scoring n(%) low perceived stress (≤ 13) 338(15.4) moderate perceived stress (14-26) 1458(66.6) high perceived stress (≥ 27) 392(17.9) descriptive results fairly often never rarely sometimes very often in the last month, how often have you been upset because of 512(23.4) 204(9.3) 334(15.3) 590(27) 548(25) 14 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) something that happened unexpectedly? in the last month, how often have you felt that you could not control the essential things in your life? 456(20.8) 188(8.6) 474(21.7) 680(31.1) 384(17.6) in the last month, how often have you felt nervous and stressed? 454(20.7) 160(7.3) 452(20.7) 712(32.5) 406(18.6) in the last month, how often have you found that you could not cope with all the things you had to do? 456(20.8) 270(12.3) 498(22.8) 624(28.5) 320(14.6) in the last month, how often have you been able to control irritations in your life? 554(25.3) 136(6.2) 334(15.3) 896(41) 246(11.2) in the last month, how often have you felt that you were on top of things? 424(19.4) 286(13.1) 562(25.7) 750(34.3) 150(6.9) in the last month, how often have you been angered because of things that happened that were outside of your control? 400(18.3) 208(9.5) 488(22.3) 706(32.3) 386(17.6) in the last month, how often have you felt difficulties were piling up so high that you could not overcome them? 446(20.4) 322(14.7) 536(24.5) 644(29.4) 238(10.9) it bothers me when people sneeze without covering their mouths 392(17.9) 62(2.8) 136(6.2) 318(14.5) 1280(58.5) *for item 1-3, 6, 9 (0 – never; 1 almost never; 2 – sometimes; 3 fairly often; 4 very often) *for item 7 & 8 (4 – never; 3 almost never; 2 – sometimes; 1 fairly often; 0 very often) level of direct and indirect contact history with diagnosed covid19 cases figure 1: shows the level of susceptibility of the respondents following their contact history 11.2% 20.9% 9.6% 12.9% 78.2% 59.8% 69.4% 53.9% 10.5% 19.3% 21% 33.2% close contact with a confirmed case non-close contact with a confirmed case indirect contact with a confirmed case suspected contact with a case / infected materials yes no may be 15 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) respondents reported their level of susceptibility as per their experience and understanding. around 11.2% of the respondents reported that they had close contact with a confirmed case, and 10.5% were not very sure of any such incident, while 78.2% faced no such circumstances. 20.9% had a non-close contact, 9.6% had an indirect connection with a confirmed case, while 12.9% had contact with a hypothetical case. discussion the outcome of this study has expanded our limited understanding about the influence of the coronavirus pandemic and the associated psychological impacts14, raising a key concern against the negative impact held by the news, social distancing and quarantine in modern times. as it has been identified that covid-19 spreads mainly through close contact from the droplets generated during spitting and sneezing from infected individuals15. although quarantine and social distancing are recommended to lessen the disease transmission, the long-lasting implications associated with the diseases affecting people psychologically must also be considered before implementing these protective measures. we have the evidence indicating a positive history of psychological distress among the sars survivors back in 200416. after the sars outbreak in 2003, the survivors suffered from stress and anxiety even after one year of the outbreak16. despite knowing the adverse and long-term impacts of these preventive measures, we continue to follow the trend. social distancing & quarantine has been accepted and implemented globally to minimize the disease spread. unstable mental health is prominent among the general public and the sufferers of covid-1917. it was revealed that more than 32.3% felt agitated because the things that happened were outside their control, and 18.6% frequently felt stressed, nervous and fearful because of the unprecedented happening of covid-19. the study reveals an association between participants' risk perceptions built on individual experiences and existing circumstances. a wide range of literature depending on health actions and risk of communication provides a context for understanding this link. the risk of transmission should be considered as a critical element in encouraging people to adopt healthy behaviors18. that has been proven by both the health belief model and protective motivation theory, indicating that positive behavioural change is associated with risk prevention. belief in one's ability to make the necessary change and belief that making the change may result in the health benefits for oneself has long been known and practiced19. some of the respondents also ignored protective measures; for instance, 26.9% were not wearing masks, whereas others created new stricter rules for themselves. for example, 45% revealed washing hands after touching possibly contaminated objects, 56% showed washing hand with soap, while 54% cover their mouth while sneezing or coughing (figure 1). similar studies indicated that societal, psychological, and cultural influences modulate risk perceptions20,21. literature suggests that the perceived level of risk associated with any event can be overstated compared to the originality, which might be due to the unmanageability of the associated risks22,23. the psychological health influence of covid-19 among the patients, caretakers, and hospital employees is overwhelming compared to those disasters where contact to a threat was brief. moreover, the perceptual vulnerability, stress, and psychological responses to covid-19 significantly differ amongst people as per the present study's findings. previously, research conducted on 16 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) perception-related responses to the sars epidemic indicated that increased fear, sense of social isolation, and occupational stress were significantly associated with pts symptom levels24. we also assessed the level of suppressibility of covid-19 among the general population as per their understanding. it appears that 11.2% of the respondents had close contact with a confirmed case in the last two months while 78.2% had no close contact, 20.9% had a nonclose contact, and 9.6% had an indirect connection with a confirmed case (figure 1). the study presenting the epidemiological analysis of covid-19 among different age groups indicated that the infection rate and associated mortality is high among older age groups25. moreover, the stress induced by the covid19 outbreak is evident and accepted. who states that this pandemic has widely increased the general population's stress levels, mainly due to unfamiliarity and high mortality within a short duration of time5. the mean pss score was 19.98 ± 6.08, which lies under the moderate category, i.e. most of the respondents (66.6%) had mild perceived stress due to this pandemic for helping the psychological sufferers. who highly recommends minimizing the exposure to covid-19 associated news is the primary reason behind anxiety and depression5. moreover, the exposure must only be limited and acquired only at certain times in a day or two and only from a reliable source giving practical and authentic information5. during this health crisis, it is imperative to bring up facts to combat fear among the population. the information regarding the disease, either related to spreading, prevention, or protective measures, must be scrutinized before implementation and dissemination. one must be very careful while sharing the news, as the intensity of the disinformation and myths depends on how many people believe it and share it. this article outlines the perceived and psychological concerns associated with covid-19 that must be known and considered by healthcare providers, front-line personnel, and the general population while taking preventive measures. social distancing and quarantine are more likely to induce psychological distress because of increased fear of disease, limited knowledge, and altered risk perceptions due to varying emotional states7. the incomplete and evolving understanding of this catastrophic condition has promoted psychological suffering among the general population. conclusion in conclusion, covid-19 has shown to be a strong reason for psychological distress within the global population as perceived by many with moderate intensity. moreover, the state of fear, perceived vulnerability, social distancing, and global panic seem to major contributing factors in causing this stress that can further impact the general population's health and well-being. one of the primary reasons behind the fact is an unknown and unusual situation as the current generations face a pandemic for the first time. the reactions are more precisely associated with one's psychological response towards a new threat. the study can help get some insight and propose any interventional measures to combat the psychological impacts of covid-19 that will curtail the sufferings during this period of uncertainty. acknowledgement we would like to acknowledge all the responders for their time and cooperation. the study was designed & supported by the advance educational institute & research centre (aeirc). references 1. government of pakistan, ministry of national health services, regulation and coordination. national action plan for 17 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) coronavirus disease (covid-19) pakistan. 2020 [cited march 4, 2020]. available at: https://www.nih.org.pk/wpcontent/uploads/2020/03/covid-19-napv2-13-march-2020.pdf? 2. frontiers research topics. coronavirus disease (covid-19): psychological, behavioral, interpersonal effects, and clinical implications for health systems. 2020. 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[updated: april 5th 2020]. available at: https://www.who.int/emergencies/disease s/novel-coronavirus-2019 5. world health organization. mental health and psychosocial considerations during the covid-19 outbreak. 2020 [updated march 18, 2020] [cited march 5, 2020]. available at: https://www.who.int/docs/defaultsource/coronaviruse/mental-healthconsiderations.pdf 6. brooks sk, webster rk, smith le, woodland l, wessely s, greenberg n, rubin gj. the psychological impact of quarantine and how to reduce it: rapid review of the evidence. the lancet. 2020, 395(10227), 912-920. 7. xiang yt, yang y, li w, zhang l, zhang q, cheung t, ng ch. timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. lancet psych. 2020;7(3):228-229. 8. zhao x, zhang b, li p, ma c, gu j, hou p, guo z, wu h, bai y. incidence, clinical characteristics and prognostic factor of patients with covid-19: a systematic review and meta-analysis. medrxiv. 2020. 9. rubin gj, wessely s. the 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aj, kiviniemi mt. treating people with information: an analysis and review of approaches to communicating health risk information. jnci monographs. 1999;25:44-51. 19. floyd dl, prentice‐dunn s, rogers rw. a meta‐analysis of research on protection motivation theory. j. appl. soc. psychol. 2000; 30(2):407-429. 20. kowalewski mr, henson kd, longshore d. rethinking perceived risk and health behavior: a critical review of hiv prevention research. health educ. behav. 1997;24(3):313-325. 21. lion r, meertens rm, bot i. priorities in information desire about unknown risks. risk anal. 2002; 22(4):765-776. 22. marshall rd, galea s, kilpatrick d. psychological reactions to terrorist attacks. findings from the national study of americans’ reactions to september 11: comment. jama, 2002; 288(21): 2683– 2684. 23. marshall rd, bryant ra, amsel l, suh ej, cook jm, & neria y. the psychology of ongoing threat: relative risk appraisal, the september 11 attacks, and terrorismrelated fears. am. psychol. 2007; 62(4): 304-315. 24. maunder rg, lancee wj, rourke s, hunter jj, goldbloom d, balderson k, petryshen p, steinberg r, wasylenki d, koh d, fones cs. factors associated with the psychological impact of severe acute respiratory syndrome on nurses and other hospital workers in toronto. psychosom. med. 2004; 66(6):938-942. 25. sun k, chen j, viboud c. early epidemiological analysis of the coronavirus disease 2019 outbreak based on crowdsourced data: a populationlevel observational study. the lancet digital health. 2020;2(4): e201-e208. annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 sonya arshad 47 original article doi: 10.29052/2412-3188.v5.i1.2018.47-53 brain circuit remapping in blind sonya arshad, muhammad faisal qureshi, syed hasan abbas rizvi, sidra farooq, m. habib amin malik, mahanoor shakeel &rida sabir liaquat national school of physiotherapy corresponding author email: sonya.arshad@lnh.edu.pk received 02/04/2018; accepted 22/09/2018; published 10/10/2018 abstract background: if people dearth something regarding their senses, they mold their brain in accordance with the environs. researches indicate vision is not always a necessity for the ramification of the brain's cortical organization. our real endeavor is to channel people if an individual lacks something the brain rewires in a way that the lacking becomes unrecognizable and their other capabilities improve. methodology: this was a cross-sectional study conducted on 80 subjects of age 15-30 years at liaquat national school of physiotherapy. group a comprised of 40 congenitally blind subjects from dar-ul-sukun and ida rieu school for blind and deaf while group b consisted of 40 sighted subjects. senses of both groups were assessed by smelling, graphesthesia, two-point discrimination, auditory acuity test, foot tap test and sixth sense test. collected data was analyzed on spss version 20 by applying independent sample ttest. result: the results showed that the scores of group a outweighed that of group b as all the tests showed a significant mean difference with p-value<0.05. in foot tap test, group a and group b showed a difference of 7.12+0.9 between their mean scores while in smelling test, there was a difference of 4.6+1.48. in touch test (graphesthesia), the mean scores showed a difference of 2.5+1.22. furthermore, there was also a significant difference between the mean scores of group a and group b for discrimination test, two point discrimination test, auditory acuity test and sixth sense test. conclusion: it can be concluded that the brain has the ability to remold itself according to the milieu. moreover, this reorganization can also be done without deprivation by repetitive trials to augment specific functions. keywords brain plasticity, graphesthesia, extrasensory perception introduction loss, whether physical or emotional, take away a person's attribute to stand upright in front of the world. but when it comes to our brain, it doesn't leave an opportunity when there's a chance that things can work efficiently. globally, a total of 1.4 million childbirths were reported as congenitally blind (courtright et al., 2011; gilbert & awan, 2003). the prevalence of congenital blindness is common in developing countries because of poor maternal/neonatal health as compared to the affluent population (gilbert & awan, 2003). our brain is a complex work of nature, we do not know it neither can we judge the way it works (kolb & whishaw, 1998). similarly, the human brain works on itself in a way that the change isn’t easily felt and is taken by the brain as a normal phenomenon so that it is not felt, this is where the word experience fits (kolb & whishaw, 1998). experience is a major factor in brain plasticity which produces multiple changes in dendritic length, behavior, synapse, increased glial activity and altered metabolic activity (sterr et al., 1998. our brain is like a plastic, yet we ignore it and just believe how rigid its complexity (kolb & whishaw, 1998) is. plasticity directly contradicts rigidity (kolb & whishaw, 1998). brain’s plasticity revolves around 3 levels, the neuronal connections (developmental plasticity in the embryo), the modification of neuronal connections (synaptic moderation) and the http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 sonya arshad 48 capacity for repair (post lesional plasticity) (pascual-leone et al., 2005). plasticity is an inherent property of the human brain which delivers the picture of evolution and enables the central nervous system to challenge its own created restriction to overcome the needs of the body. as we are quite aware of the brain’s ability to change which is more pronounced in the developmental stages of life to acquire new skills and learn through different experiences while memories stay and continue playing its part and storage throughout life (kolb & whishaw, 1998). the brain has the capability to surmount itself and amplify the whole process of automatic rewiring to augment normal functions. neuro-scientific researches indicate that vision is not always an obligatory requirement for the implication of the brain's cortical organization. changes in the cortical organization occur after both increased sensory input to a portion of the brain and decreased sensory input to the other (sterr et al., 1998). neuroimaging shows that in both sighted and non-sighted, similar cortical networks subtend visual and non-visual discernment of form, space or movement as well as action and recognition (johnston, 2009). the changes can be seen on different levels in the brain such as molecular, synaptic, behavioral, perceptual and motor levels. the brain of congenitally blind people is designed in a way that its flexible nature can adapt to any type of environment and start augmenting different stimulus in order to work accordingly (kolb & gibb, 2011). this phenomenon doesn’t occur in acquired blindness (kolb & gibb, 2011). though visual representation is very important for a person to function and we cannot deny how fast the body responds on visual feedback but it has a low impact on memory while the other senses work and respond slow, but they have a high impact factor on memory (kolb & gibb, 2011). based on the scenario given above, following a disability whether it is a limb or a sensory system different parts of brain refashion and play a compensatory role in order to make the body function properly (ricciardi et al., 2014). we live in a world where less fortunate people are neglected and this way their ability to interact with the environment depresses their role as an independent working individual in society. facts like these aren't accepted by the material world as it's a fast working globe, an individual is judged on every other drawback he/she has in order to compete. by this we as an individual of this environment neglect how nature extends its ways and how complicated organization a brain persists to act perfectly. though it cannot be denied that what wonders vision plays but when a person becomes blind the brain doesn't leave behind the cortical networks, in fact, works in a way to compensate and develop a whole new organization to compete with the world. as the world is entirely ignorant of brain plasticity, yet we are not ignorant of a certain type of organization of labor, parttime jobs, temporary contracts, and the demand for absolute mobility, adaptability and creativity (kolb & whishaw, 1998). so, the question arises is the society ready to provide an opportunity for blind individuals to be employed? the purpose of this study is to compare the senses in blind and sighted individuals to prove the difference between the sensory cues of blind and sighted individuals. to explain the reimbursement of everything a blind person's brain beholds. to make the world aware of the benefits a blind employee can provide them and how efficient and career marking landmark they can be. blinds are no less of a competition to sighted individuals. methodology this cross-sectional study was conducted as a single blinded. a sample of 40 congenitally blinded subjects of age group http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 sonya arshad 49 15-35years was recruited from dar-ussukun and ida rieu school for blind and deaf, in whom no other sensory deprivation was reported (group a). it was ensured that the cause of blindness was purely ophthalmic and the participants had no other psychiatric or motor disturbance. the control group consisted of an equal number of sighted individuals with the entire senses unscathed group b). participants using sensory aid devices or prosthesis were excluded from both the groups. informed consent was taken prior to study participation. sighted group was blindfolded during the study to exclude visual stimulus. senses of both the groups were then evaluated on the basis of different tests. smelling was assessed by identifying flash cards in smelling identification test (modification of university of pennsylvania smell identification test) and scoring was done. somatosensory sensations (tactile sensation and discrimination) were evaluated by the mean scores of graphesthesia, stereognosis and two-point discrimination tests. auditory acumen was measured by hearing acuity test using a ringing object while auditory discernment was assessed by foot tap discrimination test in which subjects were asked to identify the specific foot sound. besides these basic senses, extrasensory perceptions were also evaluated using a self-reported questionnaire. to check how strong the wits are, the total scores of both the groups were analyzed on spss version20 by applying independent sample t-test and a p value<0.05 was considered significant. results the results revealed the mean age group for group a to be 21.3+2.9 while for group b, it is found to be 23.6+3.0. additionally, the test results showed that group a has heightened senses than group b as all the tests showed a significant mean difference with p-value<0.05. in foot tap test, group a and group b showed a difference of 7.12+0.9 between their mean scores while in smelling test, there was a difference of 4.6+1.48. in touch test (graphesthesia), the mean scores showed a difference of 2.5+1.22. furthermore, there was also a significant difference between the mean scores of group a and group b for discrimination test, two point discrimination test, auditory acuity test and sixth sense test. table 1: mean scores of various tests between blinds and sighted individuals test group mean +s.d mean difference p-value smelling test a 8.4+1.257 4.6 0.001 b 3.8+1.728 touch test a 7.75+0.981 2.5 0.004 b 5.25+1.463 discrimination test a 9.45+0.783 0.5 0.005 b 8.95+1.154 two point discrimination test a 2+0.00 1.275 0.004 b 0.73+0.847 auditory acuity test a 4.65+0.736 1.55 0.003 b 3.1+1.033 http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 sonya arshad 50 foot tap test a 7.75+1.316 7.125 0.001 b 0.63+0.49 sixth sense test a 6+0.385 5.175 0.001 b 0.83+1.519 *group a=blinds; group b=sighted individuals *sd= standard deviation discussion there is growing evidence that sensory indigence is confederate with cross-modal neuroplastic changes in the brain. neuroplasticity is basically the brain's adaptation after a sensory loss (merabet & pascual-leone, 2010). this study aimed to corroborate experimentally that early blinds have heightened senses including olfaction, tactile, audition and extrasensory perception. many research studies support this phenomenon by neuroimaging studies (voss et al., 2014&théoret et al., 2004). patrice voss and bruce evidenced this reorganizational compensatory mechanism in contrast to disuse atrophy using magnetization transfer ratio and found higher magnetization ratios in the occipital regions of early blinds as compared to the sighted ones with a p-value <0.005 (voss et al., 2014). in a systemic review, t. kujala et al., concluded that the occipital cortex of the blind is activated by auditory stimulus when the task is to detect the change of sound, which highlights the neuroplasticity with attentive processing of stimuli (kujala, 2000). these findings also support the results of this study as in foot tap test, blinds outperformed the sighted ones with a difference of 7.125 points. moreover, they also found some evidence regarding neuroplasticity in the healthy human brain, these findings form the basis for advancements in rehabilitation sector (doucet et al., 2006). our brain is adaptable in nature by some practice or experience. we can mold or adjust our brain according to our need or environment (voss et al., 2014; merabet & pascual-leone, 2010 & jones, 2000). in an annual review by centre of neuroscience, conclusive remarks were made regarding this which states that although visual information is necessary for activity but in any case visual sense is lost, the neurons from surrounding sensory areas sprouts in occipital region along with divergence of preexisting circuits and expression of latent synapses (jones, 2000). in the current study, different tests were performed to experimentally validate the phenomena of neuroplasticity by comparing the intact senses. the first test was smelling identification test, done to assess the olfactory sense, in which the results showed the potential difference between the olfactory capabilities of both the groups with a difference of 4.6 out of 10 (table 1). the results contradicted to the findings of a meta-analysis conducted by agnieszka sorokowska et al. which concluded blindness does not seem to affect odor identification, discrimination or odor thresholds (sorokowska et al., 2018). however cuevas and renier et al., supported functional modulation of occipital cortex in early blinds and reported favored results for early blinds in odor discrimination (p < 0.0002), freeidentification (p < 0.0001) and categorization (p < 0.0004) (renier et al., 2013 & cuevas et al., 2009). tactile sensation was evaluated by graphesthesia, stereognosis and two-point discrimination test (table 1). graphesthesia http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 sonya arshad 51 is the tactile localization of our brain in which stronger mechanoreceptors functions as a tactile sensor, as evident in a study by jones b which records increased cutaneous localization by the blind than the sighted (t = 2.50, df = 236, p < .01) (jones, 1972). stereognosis was also found to be well developed in non-sighted individuals which depend on memory, experience and practice including an intact somatosensory system. heller concludes congruent results to the current findings regarding tactile enhancement in blinds and states that visual experience is not necessary for picture perception (heller, 2002). this enhancement may be a result of practicing tactile discrimination while braille reading (burton et al., 2002). 2pd test was performed to measure it and similar outweighed results were found in favor of the blind population as shown in (table 1). in a study in 2016, bhavana g. bhirud stated that adaptation to environment depends upon quickness of response as he found mean auditory reaction time for blinds to be 0.21+0.03s while 0.32+0.06 for the sighted group which was statistically significant with a p-value 0.000 (bhirud & chandan, 2017). the current study also assessed auditory localization and response time by auditory acuity test and foot tap recognition. in auditory acuity test, blinds were found to have a value of 4.65+0.736s while 3.1+1.033s for the sighted group. the increase in value was expected as the reaction time was also added in the recorded results. in both the tests, blinds outperformed the sighted individuals. results also validate the findings of the studies which favor the recruitment of occipital cortex by auditory modalities (gougoux et al., 2004 & lessard et al., 1998). conclusively, it is evident that despite the lack of vision, congenitally blind subjects are able to build and manipulate neuronal circuit for spatial navigation. this neuronal substitution is more evident in early blinds as compared to late blinds (lessard et al., 1998 & wanet-defalque et al., 1988). conclusion it can be concluded from the results that following sensory deprivation, neurocompensatory mechanisms generate new axonal pathways which makes the brain proficient in other functions. this mechanism should be considered as the basis for the management regimen of the sensory deficient population so that their productivity could be increased. also, healthy people can ameliorate their normal functions by repetitive trials to enhance their specific activity. conflicts of interests none. acknowledgment we acknowledge the administration and staff of dar-ul-sukun and ida rieu school for blind and deaf for extending their immense support. we are also thankful to muhammad nisar, sr. lecturer at department of physiology, university of karachi for his guidance. funding none. references  bhirud, b. g., & chandan, l. m. (2017). comparative study of simple auditory reaction time in blind and blindfolded sighted individuals. natl j physiol pharm pharmacol., 7(1), 64-67.  burton, h., snyder, a. z., conturo, t. e., akbudak, e., ollinger, j. m., & raichle, m. e. (2002). adaptive http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 sonya arshad 52 changes in early and late blind: a fmri study of braille reading. j. neurophysiol., 87(1), 589-607.  courtright, p., hutchinson, a. k., & lewallen, s. (2011). visual impairment in children in middle-and lower-income countries. arch. dis. child, 96(12), 1129-1134.  cuevas, i., plaza, p., rombaux, p., de volder, a. g., & renier, l. (2009). odour discrimination and identification are improved in early blindness. neuropsychologia, 47(14), 3079-3083.  doucet, m. e., bergeron, f., lassonde, m., ferron, p., & lepore, f. (2006). cross-modal reorganization and speech perception in cochlear implant users. brain, 129(12), 3376-3383.  gilbert, c., & awan, h. (2003). blindness in children: half of it is avoidable, and suitable cost effective interventions are available. bmj: br med j, 327(7418), 760.  gougoux, f., lepore, f., lassonde, m., voss, p., zatorre, r. j., & belin, p. (2004). neuropsychology: pitch discrimination in the early blind. nature, 430(6997), 309.  heller, m. a. (2002). tactile picture perception in sighted and blind people. behav brain res, 135(1-2), 6568.j can acad child adolesc psychiatry, 20(4), 265–276.  johnston, m. v. (2009). plasticity in the developing brain: implications for rehabilitation. dev disabil res rev., 15(2), 94-101.  jones, b. (1972). development of cutaneous and kinesthetic localization by blind and sighted children. dev psychol., 6(2), 349-352.  jones, e. g. (2000). cortical and subcortical contributions to activitydependent plasticity in primate somatosensory cortex. annu rev neurosci., 23(1), 1-37.  kolb, b., & gibb, r. (2011). brain plasticity and behaviour in the developing brain.  kolb, b., & whishaw, i. q. (1998). brain plasticity and behavior. annu rev psychol., 49(1), 43-64.  kujala, t., alho, k., & näätänen, r. (2000). cross-modal reorganization of human cortical functions. trends neurosci, 23(3), 115-120.  lessard, n., paré, m., lepore, f., &lassonde, m. (1998). early-blind human subjects localize sound sources better than sighted subjects. nature, 395(6699), 278-280.  merabet, l. b., & pascual-leone, a. (2010). neural reorganization following sensory loss: the opportunity of change. nature rev neurosci, 11(1), 44-52.  pascual-leone, a., amedi, a., fregni, f., & merabet, l. b. (2005). the plastic human brain cortex. annu. rev. neurosci., 28, 377-401.  renier, l., cuevas, i., grandin, c. b., dricot, l., plaza, p., lerens, e., & de volder, a. g. (2013). right occipital cortex activation correlates with superior odor processing performance in the early blind. plos one, 8(8), e71907.  ricciardi, e., bonino, d., pellegrini, s., & pietrini, p. (2014). mind the blind brain to understand the sighted one! is there a supramodal cortical functional architecture? neurosci. biobehav. rev., 41, 64-77. http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 sonya arshad 53  sorokowska, a., sorokowski, p., karwowski, m., larsson, m., & hummel, t. (2018). olfactory perception and blindness: a systematic review and meta-analysis. psychol res, 1-17.  sterr, a., müller, m. m., elbert, t., rockstroh, b., pantev, c., & taub, e. (1998). perceptual correlates of changes in cortical representation of fingers in blind multifinger braille readers. j neurosci, 18(11), 4417-4423.  théoret, h., merabet, l., & pascualleone, a. (2004). behavioral and neuroplastic changes in the blind: evidence for functionally relevant cross-modal interactions. j. physiol. paris, 98(1-3), 221-233.  voss, p., pike, b. g., & zatorre, r. j. (2014). evidence for both compensatory plastic and disuse atrophy-related neuroanatomical changes in the blind. brain, 137(4), 1224-1240.  wanet-defalque, m. c., veraart, c., de volder, a., metz, r., michel, c., dooms, g., & goffinet, a. (1988). high metabolic activity in the visual cortex of early blind human subjects. brain res, 446(2), 369-373 http://www.aeirc-edu.com/ 19 app| published by aeirc| https://doi.org/10.29052/2412-3188.v7.i1.2020.19-24 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) original article psychophysiological effects of gum chewing on cognitive performance: a gender-based comparative study saniya sheikh, amaila fazal & faizan mirza department of physiology, university of karachi abstract background: chewing before performing a cognitive task increases oxygen levels in the central nervous system (cns) areas important for processes of learning and memory. this study was done to evaluate and compare the effects of chewing gum on reaction time, visual short term memory, selective attention, verbal and non-verbal reasoning, and problem-solving ability in healthy male and female subjects. methodology: the comparative, gender-based, interventional study was conducted involving 300 individuals placed in the control (n=150) and interventional group (n=150). participants in the interventional group were required to chew gum till they completed the task. a questionnaire was designed to record the reaction time, memory, attention, executive and intellectual functioning and time took to solve each parameter. each subject in both control and interventional group completed the questionnaire with and without chewing gum, respectively. results for the two groups were compared using spss version 20.0. results: it was found that the gum chewing group performs significantly better than the control group, thus chewing gum significantly improves cognitive performance. these cognitive effects of chewing were comparable among the two genders but relatively more pronounced among male participants as compared to females. conclusion: chewing gum is positively associated with higher level of cognitive performance than controls. keywords chewing gum, mental health performance, cognitive skills, intellectual functioning, reaction time, memory, reasoning. citation: sheikh s, fazal a, mirza f. psychophysiological effects of gum chewing on cognitive performance: a gender-based comparative study. app. 2020; 7(1):19-24 corresponding author email: faizan.mirza@uok.edu.pk doi: 10.29052/2412-3188.v7.i1.2020.19-24 received 04/01/2020 accepted 15/07/2020 published 01/10/2020 copyright © the author(s). 2020 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 20 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) introduction regardless of its fame and commerciality, gum chewing is an unusual action, it’s like eating without the act of associated digestion. the continual use of gum chewing has been promoted due to its breath enhancing properties for decades1. in 1939, the first study was conducted to determine whether chewing gum can reap any other benefits than breath enhancement and it was found that gum can reduce stress2. subsequently, many other studies were conducted to investigate other positive effects of chewing gum, and it was concluded that chewing gum has many useful impacts on brain activity3,4. chewing gum has found to help manage nicotine withdrawal, stress and acid reflux5,6. many researchers figured out that chewing gum is involved in hyposalivation that removes debris from the teeth and also prevents caries1,7. for the dieter or healthconscious individuals, the gum is a lowcalorie snack and a simple way to burn a few extra calories8. one of the most astounding findings is that researchers have recently established that chewing gum can improve the cognitive functioning of the brain areas controlling memory and attention9. the behavioral effects of chewing gum have been studied for over 80 years and much of the research has been concerned with increases in alertness and attention10. there are various conceivable components through which chewing gum may influence stress, alertness, and attention, for example, changes in the activity of the brain or elevated heart rate11. moreover, the length over which the gum is chewed might generate impacts. several studies have demonstrated that chewing helps to maintain cognitive functions in brain regions including the hippocampus, a cns region vital for memory and learning11. currently, there was a debate about the effects of gum chewing on cognition. several well-controlled studies examined the effects of chewing gum on aspects of memory and attention in healthy young adults and found that gum chewing enhances cognitive functioning with regards to learning and memory. because of these positive findings, there was quite some enthusiasm among researchers concerning this beneficial impact of gum chewing on cognition12. thus, if the process of chewing gum really enhances memory then it could be used as a booster to increase learning and memory and also to positively impact the mental health performance of the healthy individuals. this study aimed to evaluate and compare the effects of chewing gum on the mental health performance among healthy male and female subjects by observing the comparative alterations in the reaction time, visual short term memory, selective attention, verbal and non-verbal reasoning, and problem-solving ability in the two genders. methodology this comparative, gender-based, interventional study was conducted including 300 healthy individuals, including both males and females within 19-35 years of age. subjects were randomly selected from university of karachi and placed into two groups namely: a control (non-gum chewing) group and gum chewing group with 150 subjects in each group. all the enrolled participants were required to fill out the study questionnaire. the control group had to answer the questionnaire without chewing gum, while the participants in the interventional group had to solve the questionnaire right after chewing gum until they completed the whole questionnaire. the questionnaire consisted of five cognitive parameters, including: visual short-term memory that was an object learning task. the subjects were given a set of 8 colored images and were told to remember as many of them as possible for 2 minutes. after two minutes, they were asked to point out the objects that were not present in the given list and the time duration was recorded for their task completion. 21 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) selective attention was tested by using the digit symbol substitution test taken from the wechsler adult intelligence scale (wais). the subjects were asked to complete this test within 90 seconds. for each corrected item, the subject scored 1 and for the wrong ones zero was given. verbal and non-verbal reasoning was determined by taking questions from the standard psychometric analysis of alice heim group ability test (ah4) and wais. the subjects were asked to solve logical reasoning questions: 5 for verbal and 5 for non-verbal reasoning. all questions had one correct answer. the time taken by the subjects to solve the questions was noted. problem-solving ability was evaluated by doing calculations and solving word problems. the subjects were asked to solve given math problems, which were tested by two methods: calculations (numerical) and word problems (analytical mathematics/ charts). the time taken by the subjects to solve the questions was noted. reaction time was analyzed through the ruler and drop method (visual analysis). once the measurements were taken, reaction time was calculated using the formula t= √2y/gₒ, where, y = the distance you measured in centimeters, gₒ = the acceleration due to gravity constant (980 cm/sec2), and t = time in seconds. all the statistical calculations were done through ibm spss version 16.0. descriptive statistics were used for categorical variables and independent “t” tests were performed for inferential statistics. thereby, a p-value of less than 0.05 was determined as statistically significant. result the study included 300 random healthy individuals, including both males and females between the ages 19-35 years. our results showed improved cognitive performance following chewing gum in both genders (table 1). table 1: mean-time taken by the individuals to complete the mental health performance tasks with and without chewing gum study parameters male female control intervention control intervention visual short term memory 12.7±5.0 10.3±5.2* 10.8±5.1 8.5±5.6* selective attention 42.4±10.4 40.7±8.7* 45.6±8.2 49.6±8.4 verbal reasoning 53±31.9 63.5±26.5 59±24.1 56.6±18.0* non-verbal reasoning 43±30.4 56.7±31.4 67±37.4 64.1±28.6* problem-solving ability 71.7±43.2 63±22.8* 67±30.3 79.4±39.3 reaction time 0.1±0.0 0.1±0.0* 0.2±0.0 0.2±0.0 *values are given as mean ± sd *statistically significant visual short term memory was evaluated through the object learning task and it was found that less time was taken by subjects in the intervention group as compared to control group i.e. 10.3±5.2 vs 12.7±5.0 among males and 8.5±5.6 vs 10.8±5.1 among females, thereby it could be determined that chewing gum increases visual short term memory, hence the mental health performance of both males and females. in case of selective attention, it was found that the mean time taken by the subjects in the intervention group was 40.7±8.7 among males while 49.6±8.4 among females which was comparatively high as compared to those in the control group. thus, the comparison between the genders determines that males have better selective attention, problem-solving ability and reaction time than females. whereas, the results for verbal and non-verbal reasoning were comparatively better among females. 22 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) discussion currently, there is an ongoing debate about the effects of gum chewing on cognition and mental health performance. to investigate the hypothesis that chewing gum increases cognitive performance, this study was designed to evaluate and compare the effects of chewing gum on cognitive performance among healthy male and female subjects. it was found that visual short term memory was increased among both the genders as a result of chewing gum which is consistent with the previous research, as it determined that chewing sugar-free gum improved aspects of verbal and visual memory13. the results clearly indicate that less time has been taken by both male and female subjects in performing short term memory tests while chewing gum. here the robust effects of gum chewing may be due to increased delivery of glucose to the brain in association with increased metabolic activity14 and may also be associated with increased cerebellar blood flow during mastication15. this is also in agreement with the previous researches which showed that chewing immediately before a cognitive task increases oxygen levels in the prefrontal cortex (pfc) and hippocampus, both cns areas important for processes of learning and memory16,17. additionally, imaging studies have likewise uncovered sex-related hemispheric lateralization of amygdala function in connection to memory for emotional material. in particular, the reviews reliably displayed a special contribution of the left amygdala in memory for emotional material (for the most part visual pictures) in ladies, yet a special inclusion of the right amygdala in memory for similar material in males18-20. it was found that selective attention was increased among males but it was relatively decreased in females following chewing gum. this is because it has been assumed that the cognition-enhancing effect of gum chewing is caused by an increased release of insulin and a changed pattern of regional cerebral blood flow, in particular in frontotemporal regions of the brain13,21,22. furthermore, it has been determined through the researches that the inferior parietal lobule is larger in males than females23 and is related to the mathematical capacity and permits the brain to process data from senses and help in selective attention and perception24. verbal and non-verbal reasoning was found to be decreased in males but it was increased in females. this may be due to the difference in brain morphology between the two genders, females have larger volumes, relative to cerebrum size, particularly in frontal and medial paralimbic cortices. therefore, females have better verbal and nonverbal reasoning then males25. furthermore, the left hemisphere, which is important to communication, is thicker in female-oriented brains25. additionally, the brain of female processes verbal language simultaneously in the two sides (hemispheres) of the frontal brain, while men tend to process it on the left side only26. furthermore, it was also found that problemsolving ability was increased in males but it was decreased in females following chewing gum. this is in agreement with the research that men had larger volumes, relative to cerebrum size, in the fronto-medial cortex, the amygdala and the hypothalamus25. therefore, men have better selective attention and problem-solving ability than females. besides, males possess larger cerebra than women of the same age and health status, even if the body size differences are controlled statistically. male brains are larger than female brains in all locations, though male enlargement was most prominent in the frontal and occipital poles, bilaterally27. the male differentiated brain has a thicker right hemisphere. this may be the reason males tend to be more spatial, and mathematical. chewing gum had a positive effect on reaction time tests among males, enabling them to take less time to respond to the given visual stimulus as compared to females. this may be because males and females differ in the way they estimate time, judge speed of 23 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) things27, carry out mental mathematical calculations, orient in space and visualize objects in three dimensions and the way their brains process language information, emotion and cognition24. males as compared to females can remain occupied with visual or hands-on learning tasks28. moreover, chewing gum increases cerebral blood flow and also the supply of oxygen to the prefrontal cortex. both genders are equivalent in insight, however, gender differences in mental health performance have been associated with their tendency to work differently. males and females seem to utilize distinctive parts of the brain to encode memories, sense feelings, perceive faces, take care of specific issues and decisions. without a doubt, when males and females of comparable knowledge and talent perform similarly well, their brains seem to go about it differently, as though nature had isolated outlines. gender contrasts in the brain may assume a part in learning forms, speech development and progression of neurologically-based ailments. gender contrasts should be considered in studying brain structure and capacity24. males showed more positive effects while chewing gum than females. this is because the proportions of dark to white matter likewise contrast fundamentally between the genders in differing areas of the human cortex29. men have roughly 6.5 times more grey matter in the mind than ladies, and ladies have around 10 times more white matter than men do30. and this grey matter is related to better cognitive performance and better reaction time in males. conclusion it is concluded from the study results that chewing gum improves certain cognitive skills including; memory and intellectual functioning. males showed relatively more positive effects while chewing gum than females. thus it is positively associated with mental health performance, however the precise mechanism for improved cognitive functions due to gum chewing remains unclear. for a more complete picture of the relationship between physiological and cognitive aspects of chewing gum further investigations are required in beta and delta wave patterns. all these transformations in the after-test condition proposed that the pleasant sounds might develop a calm mind and body connection that significantly overcome stress to a certain degree. acknowledgment the author want to acknowledge the students of university of karachi that took part in the study and make this study possible. references 1. hendrickson r. the american chewing gum book. radnor, pa: chilton book. 1996. 2. hollingworth h. chewing as a technique of relaxation. science. 1939; 90(2339):385387. 3. miura h, yamasaki k, kariyasu m, miura k, sumi y. relationship between cognitive function and mastication in elderly females. j. oral rehabil. 2003; 30(8):808-811. 4. sasaki-otomaru a, sakuma y, mochizuki y, ishida s, kanoya y, sato c. effect of regular gum chewing on levels of anxiety, mood, and fatigue in healthy young adults. clin pract epidemiol ment health. 2011;7:133. 5. cohen lm. chewing and stress relief. the benefits of chewing. 2003:18-29. 6. odusola f. chewing gum as aid in treatment of hyposalivation. n y state dent j. 1991;57(4):28. 7. polland k, higgins f, orchardson r. salivary flow rate and ph during prolonged gum chewing in humans. j oral rehabil. 2003;30(9):861-865. 8. levine j, baukol p, pavlidis i. the energy expended in chewing gum. n engl j med. 1999; 341(27):2100. 9. choi yh, jang wh, im su, song kb, lee hk, do lee h, seo ys, jang sh. the brain activation pattern of the medial temporal lobe during chewing gum: a functional 24 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) mri study. neural regen. res. 2017;12(5):812-814. 10. smith ap. chewing gum and stress reduction. j clin transl res. 2016;2(2):5254. 11. teixeira fb, fernandes ld, noronha pa, dos santos ma, gomes-leal w, maia cd, lima rr. masticatory deficiency as a risk factor for cognitive dysfunction. int j med sci. 2014;11(2):209-214. 12. scholey a. chewing gum and cognitive performance: a case of a functional food with function but no food? appetite. 2004;43(2):215-216. 13. wilkinson l, scholey a, wesnes k. chewing gum selectively improves aspects of memory in healthy volunteers. appetite. 2002; 38(3):235-236. 14. stephens r, tunney r. role of glucose in chewing gum-related facilitation of cognitive function. appetite. 2008; 50(23):566. 15. weijenberg r, scherder e, lobbezoo f. mastication for the mind—the relationship between mastication and cognition in ageing and dementia. neurosci biobehav rev. 2011; 35(3):483497. 16. onozuka m, hirano y, tachibana a, kim w, ono y, sasaguri k, kubo k, niwa m, kanematsu k, watanabe k. interactions between chewing and brain activity in humans. novel trends in brain science: springer; 2008:99-113. 17. hirano y, obata t, kashikura k, nonaka h, tachibana a, ikehira h, onozuka m. effects of chewing in working memory processing. neurosci lett. 2008; 436(2):189-192. 18. cahill l, haier rj, white ns, fallon j, kilpatrick l, lawrence c, potkin sg, alkire mt. sex-related difference in amygdala activity during emotionally influenced memory storage. neurobiol learn mem. 2001; 75(1):1-9. 19. cahill l, uncapher m, kilpatrick l, alkire mt, turner j. sex-related hemispheric lateralization of amygdala function in emotionally influenced memory: an fmri investigation. learn. mem. 2004; 11(3):261-266. 20. canli t, desmond je, zhao z, gabrieli jd. sex differences in the neural basis of emotional memories. proceedings of the national academy of sciences. 2002; 99(16):10789-10794. 21. tucha l, koerts j. gum chewing and cognition: an overview. neurosci med. 2012; 3(03):243-250. 22. miles c, charig r, eva h. chewing gum as context: effects in long-term memory. j behav neurosci res. 2008; 6(2):1-5. 23. frederikse me, lu a, aylward e, barta p, pearlson g. sex differences in the inferior parietal lobule. cereb cortex. 1999;9(8):896-901. 24. zaidi z. gender differences in human brain: a review. open anat j. 2010;2:37– 55. 25. shaywitz ba, shaywltz se, pugh kr, constable rt, skudlarski p, fulbright rk, bronen ra, fletcher jm, shankweiler dp, katz l, gore jc. sex differences in the functional organization of the brain for language. nature. 1995; 373(6515):607-609. 26. sowell er, peterson bs, kan e, woods rp, yoshii j, bansal r, xu d, zhu h, thompson pm, toga aw. sex differences in cortical thickness mapped in 176 healthy individuals between 7 and 87 years of age. cereb cortex. 2007; 17(7):1550-1560. 27. sabbatini rm. are there differences between the brains of males and females. brain & mind online magazine. 1997;12(11). 28. gurian m. boys and girls learn differently! a guide for teachers and parents. john wiley & sons; 2010. 29. allen js, damasio h, grabowski tj, bruss j, zhang w. sexual dimorphism and asymmetries in the gray-white composition of the human cerebrum. neuroimage. 2003; 18(4):880-894. 30. ho k, roessmann u, straumfjord j, monroe g. analysis of brain weight. ii. adult brain weight in relation to body height, weight, and surface area. arch pathol lab med. 1980; 104(12):640-645. 25 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) 23 app| published by aeirc| https://doi.org/10.29052/2412-3188.v6.i1.2019.23-29 issn 2412 3188 original article prevalence of depression, anxiety and stress among healthcare professionals at tertiary care hospitals, karachi – pakistan yameema ayub, raheel anjum, shabana margrat, azeem ashraf & saira qayyum st. james institute of nursing and health science abstract background: the prevalence and severity of mental health issues among the healthcare professionals (hps) has escalated during the past few years. depression, anxiety and stress are common complaints among the hp’s, having a profound impact on their personal and professional life. the purpose of this study was to assess the severity level of depression, anxiety and stress among hps at tertiary care hospitals of karachi. methodology: a cross-sectional study was conducted from may to july 2019 at three tertiary care teaching hospitals of karachi including jinnah post graduate medical centre (jpmc), national institute of child health (nich) and national institute of cardiovascular diseases (nicvd). total 260 hps (doctors, nurses, physiotherapist, pharmacist, laboratory technician and nursing technicians) were selected through convenience sampling method. in addition to the demographic details, the prevalence and severity score of depression, anxiety and stress was assessed using depression, anxiety and stress scale 42 (dass 42). the collected data was analyzed using spss version 23. results: among 260 hp’s, 48.5% were males and 51.5% were females, moderate depression was found in 33(12.7%) hp’s, 28(10.8%) had severe depression while 6(2.3%) were suffering from extremely severe depression. anxiety levels were moderate in 67(25.8%), 32(12.3%) and 21(8.1%) reported severe and very severe anxiety respectively. moreover, stress levels were moderate among 45(17.3%) hp’s, while severe and very severe levels were observed among 13(5%) and 7(2.7%) responders respectively. there was no association in between the sociodemographic characteristics and depression, anxiety and stress (p>0.05). conclusion: it was observed that most of the hp’s were suffering from mild to moderate depression, anxiety and stress. further research is required to explore the possible contributing factors and methods for eradication of this health issue. keywords depression, anxiety, stress, dass 42, healthcare professionals. citation: ayub y, anjum r, margrat s, emmanual a, ashraf a, qayyum s. prevalence of depression, anxiety and stress among healthcare professionals at tertiary care hospital, karachi – pakistan. app. 2019; 6(1):23-29 corresponding author email: ymmy_ayub@yahoo.com doi: 10.29052/2412-3188.v6.i1.2019.23-29 received 11/08/2019 accepted 03/10/2019 published 12/10/2019 copyright © the author(s). 2019 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v6.i1.2019. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 24 issn 2412 3188 app| published by aeirc| volume 6 issue 1 introduction highly prevailing mental health condition of the era, depression along with anxiety and stress have become the major public health concern. major etiological factors include unemployment, low socioeconomic status, long work hours, isolation, lack of socializing and substance abuse, etc1. these complaints are more frequent among females as compared to males which may be due to the pressure associated with their social roles in everyday life or it may also be linked to the hormonal imbalances associated with menstruation, childbirth, and menopause1. depression, anxiety and stress significantly affects the individual’s personal, social and as well as professional life. it is evident that regardless of age, gender or professional seniority, the hp’s are frequently exposed to stressful conditions especially in their work setting2-4. modulating the work life, depression and stress associated mood disorders greatly affect the hp’s concentration at work and also compromises the quality of healthcare services they provide5,6,7. based on the systemic review conducted in 2015 including 15 countries, the estimated prevalence of depressive symptoms among the physicians of four asian, seven european and four middle eastern countries was 28.8%, it was suggested that the prevalence ranges in between 20.9% to 43.2% and excel each year8. the incidence rate varies among the different occupational categories i.e. nurses are more affected by depression, the increasing stress is mainly due to the overburdened work routine. a study reported high depression rate (18%) among nurses as compared to other hp’s (9.4%)9. according to a local study including physiotherapists employed in major cities of pakistan, 70.1% were suffering from depression, 53.17% from anxiety and 60.05% were in stress10. however, it is apparent that depression, anxiety and stress are primarily caused by workload while other secondary causes are financial status, job stress and dissatisfaction etc10. nurses all around the world face it and it is linked to their long work hours, frequent night shifts and violence at work-place11 and sometimes it even leads to intentions to quit job12. it not only alters the mental and physical health, also reported to increase the substance use, abuse and suicide risk among the hp’s7,13. the aim of the present study was to estimate the prevalence of depression, anxiety and stress among the hp’s at tertiary care hospitals of karachi. methodology this cross-sectional multicenter study was conducted at three tertiary care hospitals of karachi including jpmc, nich and nicvd from may to july 2019. a sample of 260 was calculated using open epi software version 2.3.1, including six different categories of hps (doctors, nurses, physiotherapists, pharmacist, laboratory technicians and nursing technicians). the targeted population for this study was hp’s involved in preventive, curative and rehabilitative healthcare services at the study setting. the hp’s demographic details including age, gender, marital status, education and profession etc. were taken after attaining the written informed consent. depression, anxiety and stress was assessed using dass 4214. the sum of scores was obtained from the 14 items in each scale and the scale severity was interpreted as per the details shown in the table below. table 1: cut-off score for severity ratings of dass 42 severity scale grades depression anxiety stress normal 0 – 9 0 – 7 0 – 14 mild 10 – 13 8 – 9 15 – 18 moderate 14 – 20 10 – 14 19 – 25 severe 21 – 27 15 – 19 26 – 33 extreme severe 28 + 20 + 34 + *depression, anxiety & stress subscales of dass42 25 issn 2412 3188 app| published by aeirc| volume 6 issue 1 ethical approval was obtained from st. james institute of nursing and health sciences. the collected data was analyzed using spss version 23, where frequency and percentages were used to present the qualitative variables of the study like gender, marital status and socioeconomic status, etc. result during the study period, 260 hp’s from diverse professions and specialties were included in the study, majority were nurses i.e. 58.1% followed 18.1% were doctors and 9.6% were nursing technicians with female predominance 134 vs 126 males. 94.6% had a work experience of <15 years. table 1: socio-demographic characteristics of study participants variables sub-categories (n=260) gender male 126(48.5) female 134(51.5) age group <35 years 224(86.15) >35 years 36(13.84) marital status married 169(65) single/widow/separated 91(35) education undergraduate 56(21.5) postgraduate 43(16.5) others 161(61.9) socioeconomic status <pkr 50,000 83(31.9) pkr 50,000 – 100,000 136(52.3) pkr 100,000 – 150,000 31(11.9) >pkr 150,000 10(3.8) professional categories nurse 151(58.1) nursing technician 25(9.6) laboratory technician 7(2.7) pharmacist 6(2.3) doctor 47(18.1) physiotherapist 24(9.2) affiliation jpmc 73(28.1) nicvd 95(36.5) nich 92(35.4) work experience <15 years 246(94.6) >15 years 14(5.38) *jpmc-jinnah post-graduate medical centre; nicvd-national institute of cardiovascular diseases; nich-national institute of child health the mean dass scores for the prevalence of depression, anxiety and stress are given in table 2. out of the total sample, 51.5% hp’s scored normal on depression subscale while 22.7% fell into the mild category followed by moderate 12.7% and 2.3% showed extreme scores. for anxiety subscale, 39.6% hp’s had normal scores and 25.8% had moderate scores for anxiety while 8.1% were having extremes severity scores. dass42 stress subscale displayed normal 26 issn 2412 3188 app| published by aeirc| volume 6 issue 1 scores among 58.1% hp’s, 17.3% moderate scores, 16.9% mild scores and 2.7% extreme scores. table 2: prevalence of depression, anxiety and stress in study participants score severity ratings depression anxiety stress normal 134(51.5) 103(39.6) 151(58.1) mild 59(22.7) 37(14.2) 44(16.9) moderate 33(12.7) 67(25.8) 45(17.3) severe 28(10.8) 32(12.3) 13(5) extreme 6(2.3) 21(8.1) 7(2.7) * depression, anxiety & stress subscales of dass42 *values are given as n(%) the association of depression, anxiety and stress with various sociodemographic characteristics is given in table 3. no significant relationship observed between the observed variables and the prevalence of depression, anxiety and stress. table 3: stratification of sociodemographic factors with depression, anxiety and stress. associated factors depression pvalue anxiety pvalue stress p-value gender male 63 0.630 76 0.983 49 0.279 female 63 81 61 age groups <35 years 111 0.707 136 0.525 98 0.250 >35 years 15 88 126 marital status single/widow/separated 46 0.621 52 0.433 40 0.693 married 80 105 70 socioecono mic status <pkr 50,000 41 0.957 52 0.537 37 0.809 pkr 50,000 – 100,000 66 81 58 pkr 100,000 – 150,000 15 20 12 >pkr 150,000 4 4 3 professiona l categories nurse 74 0.436 95 0.063 64 0.08 nursing technician 15 14 6 laboratory technician 3 5 2 pharmacist 1 0 1 doctor 20 23 20 physiotherapist 13 20 17 *values are given as frequency discussion the prevalence of depression, anxiety and stress was high among the hp’s enrolled in the current study i.e. 48.46%, 60.38% and 41.92% respectively which is consistent with the findings of alkhazrajy et al.15 (70.25%) and liezel16(55%). while in contrast studies conducted in japan, china and germany showed decreased prevalence of depressive symptoms among hp’s i.e. 11.3%, 8.8%, 31.7%, and 17%, respectively17-19. moreover, a local study in pakistan also showed similar results to the mentioned studies i.e. 25.8% prevalence only20. the high prevalence of depression among the study population may be due to the increasing workload, lack of working staff, limited number of hp’s and low income. 27 issn 2412 3188 app| published by aeirc| volume 6 issue 1 stratification of sociodemographic characteristics of the study population with depression, anxiety and stress showed insignificant results i.e. no significant association was observed between age and depression levels (p=0.707) which is also supported by other studies concluding age as a nonsignificant contributing factor for depressive symptoms in medical profession21,22. moreover, working hours are the significant contributing factors for depression, anxiety and stress as indicated by a number of studies5,21. the physicians who were working for more than 60 hours/week and in double shifts were more likely to experience depressive symptoms as compared to counterparts22. a study indicated that low income was also a common factor among the hp’s with depressive symptoms23 which is contradictory to other studies indicating no significant relationship between the two variables. also supported by our results i indicating contradictory results (p=0.957) to the study conducted by el-hamrawya23. the current study indicated a higher rate of depression among males as compared to females i.e. 63/126 vs 63/134. while globally it is an evident fact that the prevalence of depressive symptoms is higher among females irrespective of professions, also showed by several studies where females were more depressed than males24-26. furthermore, the marital status also plays a significant role in the prevalence of depression, anxiety and stress. it was reported by a study that married doctors are more likely to develop depression as compared to unmarried23. no significant associations observed in the current study which is also supported by gu et al.27, alkhazrajy et al.15, becker et al.21 and fahrenkopf et al.5, concluding that no significant association exist between gender, marital status and prevalence of depressive symptoms. there are several studies conducted both at national and international level determining the prevalence of depression, anxiety and stress among single category of hp’s but our study is unique in the way that it brought various categories of hp’s under one umbrella, like nurses, doctors, laboratory technicians, physiotherapist and pharmacist were all included in this study. moreover, dass 42 is valid tool for depression analysis and three major hospitals of karachi were included for the study but sample size is very limited due to shortage of time and answers of some behaviour questions might be doubtful because participants might have lied about it. therefore, our results do not provide a generalized view. it is recommended that hospitals should be aware of the increasing prevalence of depression, anxiety and stress among hp’s, and assessments should be carried out periodically. moreover, firm policies and campaigns must be designed and implemented to eradicate this health issue so that continuous and balanced services could be provided to the patients. it is also suggested that further studies with more participants from both government and private sectors should be conducted so the results can be properly estimated at whole community level. conclusion the hp’s enrolled in the study were mostly affected by moderate to severe level of depression, anxiety and stress. periodic, monthly or bimonthly assessment of these measures are recommended to control this health concern among the hp’s. as their physical and mental health status plays a very significant role in their practicing environment and also affects the quality of services they are providing. programs and campaigns must be driven in order to increase the knowledge of these concerns among the hp’s and in order to improve the mental health of the employees the 28 issn 2412 3188 app| published by aeirc| volume 6 issue 1 healthcare sectors must take effective measures focusing on better health and healthy working environment. acknowledgement st. james institute of nursing & health science. references 1. salk rh, petersen jl, abramson ly, hyde js. the contemporary face of gender differences and similarities in depression throughout adolescence: development and chronicity. j affect disord 2016; 205:28–35. 2. shanafelt td, sloan ja, habermann tm. the well-being of physicians. am j med 2003;114(6):513–519. 3. rotenstein ls, ramos ma, torre m, segal jb, peluso mj, guille c, sen s, mata da. prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. jama. 2016;316(21):22142236. 4. joules n, williams dm, thompson aw. depression in resident physicians: a systematic review. open j. depress. 2014;3(03):89-100. 5. fahrenkopf am, sectish tc, barger lk, sharek pj, lewin d, chiang vw, edwards s, wiedermann bl, landrigan cp. rates of medication errors among depressed and burnt out residents: prospective cohort study. bmj. 2008;336(7642):488-491. 6. tsai yc, liu ch. factors and symptoms associated with work stress and healthpromoting lifestyles among hospital staff: a pilot study in taiwan. bmc health services research. 2012;12(1): article 199. 7. de oliveira jr gs, chang r, fitzgerald pc, almeida md, castro-alves ls, ahmad s, mccarthy rj. the prevalence of burnout and depression and their association with adherence to safety and practice standards: a survey of united states anesthesiology trainees. anesth analg 2013;117(1):182–193. 8. mata da, ramos ma, bansal n, khan r, guille c, di angelantonio e, sen s. prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. jama. 2015;314(22):2373-2383. 9. letvak s, ruhm cj, mccoy t. depression in hospital-employed nurses. clin nurse spec. 2012;26(3):177–182. 10. babur mn, liaqat m. prevalence and factors effecting depression, stress and anxiety among physiotherapists of pakistan. isra med j. 2017;9(6):427–430. 11. gong y, han t, yin x, yang g, zhuang r, chen y, lu z. prevalence of depressive symptoms and work-related risk factors among nurses in public hospitals in southern china: a cross-sectional study. sci rep. 2015;4:1–5. 12. chiang y-m, chang y. stress, depression, and intention to leave among nurses in different medical units: implications for healthcare management/nursing practice. health policy. 2012;108(2–3):149–157. 13. lebensohn p, dodds s, benn r, brooks aj, birch m. resident wellness behaviors: relationship to stress, depression, and burnout. fam med. 2013;45(8):541–549 14. depression, anxiety and stress (dass). [updated july 26, 2018] [cited june, 21 2019]. available at: http://www2.psy.unsw.edu.au/dass/ 15. alkhazrajy, lujain anwar; sabah, sadik; abed, sm hassan. prevalence of depressive symptoms among primary health care providers in baghdad. int j health psychol res 2014; 2(2):1-20. 16. liezel r. the prevalence of burnout and depression among medical doctors working in the cape town metropole community health care clinics and district hospitals of the provincial government of the western cape: a cross-sectional study [phd thesis]. stellenbosch: stellenbosch university; 2011. 29 issn 2412 3188 app| published by aeirc| volume 6 issue 1 17. wada k, yoshikawa t, goto t, hirai a, matsushima e, nakashima y, akaho r, kido m, hosaka t. association of depression and suicidal ideation with unreasonable patient demands and complaints among japanese physicians: a national cross-sectional survey. int j behav med. 2011; 18(4):384–390. 18. shen ll, lao lm, jiang sf, yang h, ren lm, ying dg, zhu sz. a survey of anxiety and depression symptoms among primary-care physicians in china. int j psychiatry med. 2012; 44(3):257–270. 19. bernburg m, vitzthum k, groneberg da, mache s. physicians' occupational stress, depressive symptoms and work ability in relation to their working environment: a cross-sectional study of differences among medical residents with various specialties working in german hospitals. bmj open 2016; 6(6):e011369. 20. atif k, khan hu, ullah mz, shah fs, latif a. prevalence of anxiety and depression among doctors; the unscreened and undiagnosed clientele in lahore, pakistan. pak j med. sci 2016; 32(2):294–298 21. becker jl, milad mp, klock sc. burnout, depression, and career satisfaction: crosssectional study of obstetrics and gynecology residents. am j obstet gynecol. 2006; 195(5):1444–1449. 22. gong y, han t, chen w, dib hh, yang g, zhuang r, chen y, tong x, yin x, lu z. prevalence of anxiety and depressive symptoms and related risk factors among physicians in china: a cross-sectional study. plos one 2014; 9(7):e103242. 23. el-hamrawya lg, hegazy nn, elhalawany sm. prevalence of depressive symptoms among healthcare providers in shibin el-kom city in menoufia governorate. menoufia med. j. 2018;31(2):708. 24. goebert d, thompson d, takeshita j, beach c, bryson p, ephgrave k, et al. depressive symptoms in medical students and residents: a multischool study. acad med 2009; 84(2):236–241. 25. sen s, kranzler hr, krystal jh, speller h, chan g, gelernter j, guille c. a prospective cohort study investigating factors associated with depression during medical internship. arch gen psychiatry 2010; 67(6):557–565. 26. erdur b, ergin a, turkcuer i, parlak i, ergin n, boz b. a study of depression and anxiety among doctors working in emergency units in denizli, turkey. emerg med j 2006; 23(10):759–763. 27. gu a, onyeama gm, bakare mo, igwe mn. prevalence of depression among resident doctors in a teaching hospital, south east nigeria. int j clin psychiatry 2015; 3(1):1–5. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v6.i1.2019.23-29 annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 syeda farah batool 27 original article doi: 10.29052/2412-3188.v5.i1.2018.27-37 why am i not happy anymore? syeda farah batool ziauddin university, karachi, pakistan. corresponding author email: farahbatool97@gmail.com received 03/05/2018; accepted 25/09/2018; published 10/10/2018 abstract background: a person needs to be happy to be a functional unit of the society and to add a positive and productive contribution on his behalf to the welfare of humanity. there is a very close interaction between sex and joy, and no one can escape from the fact that sexual interaction is mostly a pleasurable experience. the objective of this study was to determine the prevalence of compulsive sexual behavior among youth and to find a relation between happiness and sexual activity. methodology: this cross-sectional survey was conducted in karachi-pakistan. 300 subjects of both genders participated in this study while sadaf stress scale (sss) was used to evaluate the stress level of the individuals and a section of the questionnaire contained questions about the routine activities, sexual needs and its severity. results: results have shown that the symptoms of hypersexuality are prevalent among the youth of ages between 18 to 25 years. while 27% of unmarried subjects have experienced sex and 49% reported masturbation or phone sex is found to be the source of happiness. conclusion: unfortunately, hypersexuality is not yet considered as a psychological disorder/issue in many regions of the world which gives rise to brutal and feeble act like “sexual abuse”. it's high time to look into this matter before it’s too late. keywords happiness, sexual activities, hypersexuality, pain, compulsive behavior introduction is sex a key core of happiness? undoubtedly, strong relationships play a vital role in building a strong and stable personality of an individual. a person cannot serve the society well if his mental and/or physical health is not satisfactory. a person needs to be happy to be a functional unit of the society and to add a positive and productive contribution on his behalf to the welfare of humanity (p. alex linley, 2009). the most important thing to be a strong contender of wellbeing, he/she must feel good about him/herself. euphoria, contentment, delight, joy, gratitude and pride all refer to one feeling that is happiness (p. alex linley, 2009). who doesn’t want to be happy? from the beginning, humans are trying to get that one feeling “happiness”, and they mostly do anything to achieve that sensation (diener & diener, 1996). here the question arises that what exactly this feeling is? a psychology researcher sonja lyubomirsky wrote in her book "the how of happiness" that; "the feeling which makes you think that you are a positive well-being and makes you realize that your life has some meaning and it's worthwhile is known as "happiness" (lyubomirsky, 2009). there are so many phenomena that count for people's well-being and happiness like; http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 syeda farah batool 28 figure 1: sources of happiness, (assisi, 2018) researchers have found that humans need to be completely indulged in an activity to feel happy (bradt, 2015). an activity itself is not a happy activity or a sad activity, it is something in your brain that perceive a specific situation in a certain manner. this perception may vary from person to person. for instance, a situation which makes you feel happy can make others sad or feel nothing. the relation between the person, situations, and circumstances collectively leaves an impact on human’s perception (bradt, 2015). some people might feel happy in what they are doing and are satisfied with what they have. but the existence of those people cannot be neglected who feel happy to see others in pain (colino, 2017). based on psycho-social behaviors, people can be classified into these groups; i.e. grateful and satisfied and others are unsatisfied and distressed (baker, 2011). those who are grateful for what they have and satisfied with what they are doing can live a peaceful life. but unsatisfied and distressed members of the society may lead to the destruction of his own and others’ lives (baker, 2011). jealousy, anger, envy, greed is some of the core reasons behind being distressed and unsatisfied (chhikara, 2013). this clan of stressed people will need something extraordinary or sometimes evil deeds to achieve or to be in a satisfying state (kathrym, 2013). sometimes in severe cases, people usually feel happy while witnessing someone in distress or to imply their power on someone (baker, 2011). people use different ways to gain a satisfactory sense. for example: figure 2: use of power (chhikara, 2013) but the focused criteria of this study is to dig deep into the relationship between "sexual activities and happiness". there is a very close interaction between sex and joy, and no one can escape from the fact that sexual interaction is mostly a pleasurable experience (kashdan, 2014). many people have different sexual personalities. people might express their love and affection through sexual contact or they might elucidate their anger and hatred by means of sex (kathrym, 2013). figure 3: symptoms of hypersexuality (batool, 2017) normally when people have an intense sexual interaction with their partners, they usually feel relaxed and calm (batool, 2017). if a person expresses his love via intimate interactions; this could be a satisfactory experience for both the partners. but if someone wants to impose love and respect appreciation and fame achievement money power controlling others violence bullying sexual or emotional assault masturbation obsession with sex excessive phone sex needs multiple partner http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 syeda farah batool 29 his detestation, hate or power this might lead to worst experience for either or both the partners or only to the victim (chhikara, 2013). in pakistan, the number of incidents of sexual abuse greatly increases during the past few years. (ferozi, 2018). especially with the children and young adults. according to a non-government organization ‘sahil’, approximately 11 cases of “rape and murder” are reported in pakistan every day (ferozi, 2018). the rate is highest in punjab i.e. 1089 and in sindh i.e. 490 cases in 2017 (ferozi, 2018). this issue demands a great deal of attention. the increasing rate of ‘sexual abuse’ in the world, especially in pakistan is an alarming situation not only for the authorities but for all of us. there can be enormous reasons behind this, but an uncontrollable urge to have sex, or in other words ‘hypersexuality or compulsive sexual behavior’ might be the core reason (freimuth et al., 2008). hypersexuality is the increased frequency of sexual desire or intimacy. figure 4: cycle of intimacy (keith & montgomery, 2008) but in some cases, the gap between resolution and desire is very less, or mostly neglectable, which will give rise to an urge of sex (keith & montgomery, 2008). sometimes this feeling is uncontrollable that a person can even abuse others to get distressed. generally, it happens that an individual is not happy with one partner, especially men as their emotional, physical and sexual needs are much different than a woman (assari, 2018). sexual abuse is itself a very pitiful act rather attempt such feeble sin to make others suffer. it is proven through many researches that sometimes the cost of your happiness is someone else's pain (kathrym, 2013). some people feel happy when they impose their power onto others. to cause one to suffer from pain could be a great source of contentment to another (brenner, 2016). a publicly discussed incident of “rape and murder” of a 6-year-old girl child, on 4th january 2018 (tribune, 2018), was an inspiration behind this study. methodology a cross-sectional survey was conducted in a population of about 300 participants with their consent. some of the data was also collected from the male customers in prostitution bars with their proper consent. but for privacy issues, the source and subjects cannot be disclosed. during this survey, all the participants were asked to fill a questionnaire. subjects were then assessed and analyzed based on the answers given. these subjects belonged to different educational and ethnic groups. married and unmarried, both groups are included in this study. an average age group of the subjects in this study is between 18-25 years, (with few exceptions of 26 28 years). to make analysis easier subjects were divided into group: 1 male and married, group: 2 male and unmarried. group: 3 desire arousal orgasm resolution http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 syeda farah batool 30 female and married group: 4 female and unmarried. sadaf stress scale (sss) was used to check the emotional, traumatic and psychological stress whereas microsoft excel was used to calculate and shaping the results into graphical forms. all the subjects with severe ptsd and other psychological disorders were excluded. to avoid biasness and subject manipulation most of the questions in the survey were kept open-ended. results results that were obtained from analyzing the data are alarming. when subjects were asked to answer the questions following responses were obtained. figure 5: things that give feelings of happiness figure 5 shows the percentage of subjects who mentioned things that make them happy and 65% of them have reported sex as a process which can bring happiness. figure 6: prevalence of stress and pain in study subjects figure 6 shows the percentage of the subjects that are suffering from deep pain and stress and most of them had a traumatic background of different severities. 0 10 20 30 40 50 60 70 80 90 money love fame respect power sex reward 81 79 56 89 67 65 85 p er ce n ta ge s yes, 63 no, 43 http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 syeda farah batool 31 figure 7: coping strategies with stress figure 7 shows the percentage of the methods or practice subjects used by the subjects of the study to cope with the stress and many participants have reported that smoking and masturbation as a practice that helps them to de-stress themselves. figure 8: participants who have experienced sex both in married and un-married groups. when the subjects of both the groups (married and unmarried) were asked about their sexual life, an unexpected result was attained. figure 8 shows the percentage of the participants who have experienced sexual intercourse both in married and unmarried groups. 0 10 20 30 40 50 60 35 47 59 33 29 46 49 37 39 p er ce n ta ge s 0 10 20 30 40 50 60 70 80 90 100 sex/married sex/unmarried 95 27 p er ce n ta ge s http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 syeda farah batool 32 figure 9: subjects who perceive sex as a pleasurable experience. figure 9 shows the percentage of the subjects that perceive sex as a pleasurable experience or not. there are a few participants who have reported that sometimes this is a pleasurable experience and sometimes it’s not. figure 10: individuals who had abused someone the worst part of an individual’s personality has come to life when he abuses someone. figure 10 shows the percentage of the participants who have abused someone. 55 30 15 43 27 30 0 10 20 30 40 50 60 yes no sometime percentages se x as p le as u ra b le e xp e ri e n ce female male yes, 13 no, 87 http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 syeda farah batool 33 figure 11: victims of sexual abuse and assault in both male and female it is hard to confess about a bitter truth of abuse, but facing the reality makes it easier to survive. figure 11 shows the percentage of the victims of sexual abuse and assault in both male and female. figure 12: signs and symptoms experienced by the victims of abuse. a person may suffer from a cascade of the symptoms of post-traumatic stress disorder after a traumatic event. figure 12 shows the percentage of the most reported signs and symptoms of the victims of sexual abuse. 3 40 0 10 20 30 40 50 male female percentages v ic ti m s 0 20 40 60 80 100 87 78 69 54 46 37 33 23 19 p e rc e n ta ge s http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 syeda farah batool 34 figure 13: abusing someone give happiness when subjects were asked that abusing someone make you happy? the results were shocking 27% of males have reported that harassing or abusing someone could be a reason for the pleasure of an individual. figure 13 shows the exact results. figure 14: perceive pain as a pleasure pain of any sort could be the worst experience for an individual, but sometimes pain could be a source of satiety especially if it is of others. figure 14 shows the percentage of the subjects who perceives pain as a pleasure. there are some distinct mentions other than the statistical analysis. when the subjects were asked that ‘how many times in a week one must have sex?' the answers vary from 3 times to 14 times* a week. when the highest time mentioned subjects were inquired further 37%* of them have reported that the frequency, as well as the intensity of the sex, is highly important to extract pleasure. *note: the results only implicate males of both groups married and un-married 27 5 73 95 0 20 40 60 80 100 120 male female percentages yes no 0 5 10 15 20 25 30 35 40 45 50 yes no sometime 36 50 14 p e rc e n ta ge s http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 syeda farah batool 35 discussion sex could be a pleasurable experience and has many health benefits without a doubt, as it is a natural need of living beings to make sexual contacts with their mates, people feel happy after any sexual activity or sexual intercourse (stuart, 2010). the needs of male and female are totally different in terms of intensity and frequency (kinsey, 1998.). that might be the reason why more men opted for different intimate means as compared to women (kinsey, 1998.). in figure 5, 65% of the participants have mentioned that sex is a source of happiness for them and many perceive sex as a pleasurable practice. unfortunately, the excessive urge to have sex or hypersexuality is yet not considered as a psychological disorder because there is no upper limit of having sex. there are no such measures through which this condition could be diagnosed. sex can undoubtedly be a pleasurable experience if both partner’s concern is taken (assari, 2018). but this could be miserable one if one is forced to intimate. figure 6 reveals the ratio of stress among the subjects. the high value of stress means less satiety and if a person doesn't feel satisfied he will seek for more (baker, 2011). in a city like karachi, which is the busiest and one of the most stressful city in the world people don't need to look up for stress because it stays at their doorstep. for youngsters, the biggest terror is ‘exams', for teen its ‘love' or ‘relationships' and for married couples its ‘family occupation’ (harvey, 2004). on contrary to this there are so many reasons to stay happy and grateful for example being able to perform daily work, got a chance to meet your friend after a long time. so, we all are surrounded with a bunch of stresses and plenty of reasons to smile, but the choice is ours (baker, 2011). sometimes reason of contentment has shifted to a negative side, and individual start to seek joy only in activities like drinking, smoking, sex or abuse (kathrym, 2013). usually, a more depressed person experiences bad sex or an unwanted or bad sex may lead to depression because it stimulates stress cascade in our brain (assari, 2018). according to this study 43% subjects were in pain or moderate or severe stress and have a traumatic background (figure 6), and when they were asked that what they do to relive their stress approximately 49% subjects have reported by watching porn/masturbation or by having sex (figure 7). results have revealed that about 27% of unmarried subjects have experienced sex and about 13% have tried or did abuse someone (figure 8 & figure 10 respectively). although in many countries having sexual interactions before marriage or live-in relationships are common and acceptable but in pakistan, it's still considered as a bad thing as the majority of the population are muslims, and in such a country this number is alarming! more shocking thing is that a considerable number of the participants of this study wanted to abuse someone and 40% of the subjects were abused most of them were female (figure 11). as after a bad sex you feel stressed (figure 12), it shows that 87% have felt stressed after being abused, 74% felt helpless after the incident and approximately 60% have reported anxiety irritability and anger as their symptoms. this is a huge number of individuals and it is with no doubt that stress can lead to massive personality issues. when subjects were inquired that whether they perceive pain as a pleasure or not 36% were yes and 14% said sometimes (figure 14). aldous huxley wrote in his book “brave new world” in 1932, that; “endless pleasure may lead to dystopian societies”. http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 syeda farah batool 36 “so, pain must be there to feel the goods around us”. but if someone is addicted to pain and causes others to suffer is a psychological condition (keith & montgomery, 2008). it is proven that psychological health matters a lot to build stable and strong relationships (bradt, 2015) conclusion psychology has become a blooming science since past few decades. there are so many psychological issues which need to be dealt with appropriately. unfortunately, pakistan is lacking in this issue as there are so many social and cultural norms that in captivate the people. people usually don't speak up for such things which are making the situation even worse. especially a topic like sex or rape is such a ‘no' ‘no' word in most families. that might be the reason why ‘rape' cases are increasing massively. talking to someone is the best therapy to relieve stress. we need to build tolerance for others and should try to listen to them. the symptoms of compulsive sexual behavior can be controlled if we try to consider as an issue which needs to be resolved. conflict of interest none. acknowledgment hearty gratitude to all the participants and my teachers especially dr. sadaf ahmed and mr. faizan mirza for supporting me throughout the journey. funding none. references  assari, s. 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(2013). sexual activity and psychological health as mediators of the relationship between physical health and marital quality. j gerontol b psychol sci soc sci, 482-492. http://www.aeirc-edu.com/ 24 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v8.i1.2021.24-33 original article assessing the beliefs about antidepressant medication and adherence to therapy in patients with major depressive disorders samia perwaiz khan1 , shagufta naqvi1, rabeea rizwan1, mariam ansari1, shaista emad1,2, habib ur rahman khan1, aafia akhtar1, maniya syed1, naija ehsan1 & anas moorad1 1jinnah medical and dental college (jmdc), karachi-pakistan. 2sohail university, karachi-pakistan. abstract background: patients on antidepressant therapy have no contact with their physicians until their next appointment, which in most cases could be more than two weeks apart. this crucial time is of utmost importance as this could assess the patient's will to follow the prescribed therapy and the general belief about the benefits of using antidepressant treatment. thus medication adherence is necessary to reduce the risk of suicidal tendencies and mortality in these patients. the study aimed to evaluate medication adherence and adherence to antidepressant therapy in patients with major depressive disorder. methodology: in this cross-sectional study, a total of 101 clinically diagnosed patients with major depressive disorder (mdd) were included in the study from psychiatric and medical opd from june 2018 to june 2019, from jinnah medical college hospital (jmch). belief about medicines questionnaire (bmq specific and bmq general), regarding their views about the prescribed medication and the modified questionnaire of the medication adherence scale used, scores were calculated to give a numerical value to measure the adherence to antidepressant medication. results: according to the study, 101 patients with major depressive disorder had an overall good belief about medication but have low adherence. belief about medicines questionnaire (based on bmq) bmqthe specific q1-10 score was 36.54 (necessity, concern), bmq-general 27.98 score, q11-18 (overuse and harm). regarding their views about the prescribed medication. 86% of participants with the major depressive disorder had low adherence (scores 0-5), and those with high adherence were only 14% (scores 6-8). the patients diagnosed with the major depressive disorder who had co-morbid (diabetes, hypertension, hypothyroidism, etc.) had better adherence for their prescribed treatment as compared to those without co-morbid. conclusion: this study indicates that although patients with major depressive disorder from tertiary care hospitals in karachi had a positive belief about medication but have low adherence to antidepressant therapy. keywords major depressive disorder, antidepressant drugs, medication adherence, belief, modified adherence questionnaire. citation: khan sp, naqvi s, rizwan r, ansari m, emad s, khan hr, akhtar a, syed m, ehsan n, moorad a. assessing the beliefs about antidepressant medication and adherence to therapy in patients with major depressive disorders. app.2021; 8(1):24-33 corresponding author email: samiaphk@gmail.com doi: 10.29052/2412-3188.v8.i1.2021.24-33 received 09/12/2020 accepted 12/05/2021 published 01/06/2021 copyright © the author(s). 2021 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v8.i1.2021. https://orcid.org/0000-0003-3154-1785 http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 25 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 introduction according to who, depression is a cause of a major burden on public health globally. depression affects over 350 million people globally1. depression is associated with low mood, loss of interest in daily activities, decreased energy, disturbed sleep and altered appetite, reduced performance and worst scenario, it can lead to suicides1,2. there are two modes of treatment, psychotherapy and antidepressant pharmacotherapy. antidepressant therapy is most important in reducing the symptoms of depression. belief about medicine questionnaire (bmq)2 is useful as a tool to assess the high risk of non-adherence. by improving patients, knowledge about their illness might positively affect their medication adherence. non-adherence to medicines can be defined as patients not taking medication prescribed for the illness, leading to poor patient outcomes. nonadherence leads to an increase in morbidity and mortality. patients with chronic illnesses such as depression have difficulty in drug adherence due to prolonged therapy periods and certain side effects. also, once they start feeling better, they tend to stop taking the much-required medication. belief about medication is an essential factor in adherence, specifically when symptoms of depression are improving. negative beliefs include fear of adverse-effects, drug dependence and expenditure2, 3. a major depressive disorder is a mood disorder that causes sadness and loss of pleasure over a prolonged period once antidepressant therapy has been selected. the initial prescription is of subtherapeutic dose. it can be gradually increased on the follow-up, keeping a close watch for any symptoms of adverse -effects4. it has been reported that major depression is common in primary care hospitals5. this study was conducted to assess antidepressant drug adherence in mdd patients and their belief and outcomes in a tertiary care setting of karachi city of pakistan. methodology the study was performed on patients attending jinnah medical college hospital (jmch) korangi, karachi, to treat the major depressive disorder. a total of 101 patients were interviewed based on a belief about medicines questionnaire (bmq) regarding their views about the prescribed medication. bmq is a tool to measure medication's cognitive representation and is valid and reliable in various diseases medications. bmq has a five-item scale. it has two parts: assessing patients' beliefs about their medications (bmq-specific) and assessing patients' beliefs about medications in general (bmq-general). the bmq-specific part covers two themes; the specific necessity theme evaluates patients' views about the necessity and importance of their medication. the specific concern theme comprises patients' beliefs about potential harm and adverse effects of their medications and each of which has a score ranging from 5 to 25. a high score in the necessity theme means that patients think their medications are vital to them; on the other hand, a high score in the concerns theme means that patients are concerned and worried about their medications. likewise, the bmq-general part has two themes; the general overuse theme assesses how patients perceive the extent of medication usage. the general harm theme represents patients’ beliefs about the harmful nature of medication in general. the scores of the last two themes range from 4 to 20, and the high score in each theme means a negative perception of medications in general. bmq-specific: specific-necessity 26 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 (q1-q10): higher scores represent stronger beliefs for the need for medication to maintain health. bmq-general: overuse (q11-q14): higher scores indicate negative views about the way medicines are prescribed. we changed some of the questions to make them more applicable to our study population. with the help of a modified form of a questionnaire (based on the medication adherence scale), a score was calculated to give a numerical value to measure the adherence to antidepressant medication. low adherence was 0-5, and high adherence scores were 6-14. questionnaires were filled in by interviewing the patients with major depressive disorder concerns about medicines and their perceptions of the medicines' necessity. the research was carried out one year from june 2018 to june 2019. patients included in the research were diagnosed with major depressive disorder and those who gave consent to participate in the research. individuals with any other psychiatric disorder (bipolar, psychosis or substance abuse) or concomitant medications other than antidepressants were excluded from the study. written informed consent were obtained and the study protocol was approved by the ethical committee of jinnah medical and dental college, karachi, pakistan. statistical analysis was carried out using spss version 20.0. new variables were designed by recoding and computing commands. descriptive statistics of continuous variables, mean, standard deviation, and categorical variables, frequency and percentages were calculated. result out of the total, 80 patients were included from the psychiatry out-patient department, and 21 patients were included from the medicine out-patient department. the sample comprised of 41 males and 60 females. around 56% of the participants were employed at the time of data collection and 39% earned within the range of 1130,000 per month. 43% were smokers, consuming average 9 ± 4.09 cigarettes per day. fifty-three participants were overweight. other baseline characteristics of the study participants are given in table 1. table 1: baseline characteristics of the study participants. variable n=101 age (years) 42.85±12.729 number of children 4±2 cigarettes per day 9±4.098 time diagnosed with depression (years) 2.26±2.033 time diagnosed with co-morbid (years) 6.45±5.430 opd psychiatry opd 80(79.20) medicine opd 21(20.79) gender male 41(40.59) female 60 (59.40) employment status not employed 45(44.55) employed 56(55.44) monthly income <10,000 31(30.69) 27 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 11-30,000 39(38.61) 31-50,000 26(25.74) >51,000 5(4.95) smoking status no 58(57.42) yes 43(42.57) bmi (kg/m2) normal (up to 24.99) 38(37.62) overweight (25-29.99) 53(52.47) obese (>30) 10(9.90) no co-morbid 70(69.30) co-morbid condition diabetes mellitus type 1 2(1.98) diabetes mellitus type 2 7(6.93) hepatitis a 1(0.99) hypertension 14(13.86) hypothyroidism 1(0.99) peptic ulcer disease 2(1.98) rheumatoid arthritis 1(0.99) systemic lupus erythematous 3(2.97) medication used bupropion 3(2.97) citalopram 5(4.95) escitalopram 40(39.60) fluoxetine 21(20.79) paroxetine 11(10.89) pregabalin 1(0.99) sertraline 20(19.80) timing of medication evening 46(45.54) morning 32(31.68) morning evening 23(22.77) scheme of medicine once a day 68(67.32) twice a day 33(32.67) opd-outpatient department; bmi-body mass index *values are given as mean±sd or n(%) only sixteen 16% (16 out of 101) of participants in our study had a family member diagnosed with depression, with the most prevalent relation being their mother 6% (total of 6 out of 16). of these family members diagnosed with depression, only 38% (6 out of 16) were being medically treated (table 2). 28 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 table 2: family history of the study participants. variable n(%) a family member diagnosed with depression no 85(84.15) yes 16(15.84) relation to patient brother 4(25.0) cousin 1(6.0) grandmother 1(6.0) mother 6(37.89) sister 2(11.9) son 2(11.9) being treated medically no 10(63.0) yes 6(38.0) table 3: mean scores of believe about medication questionnaire (bmq) variable mean±sd median(iqr) bmq general (q11-q18) 27.98±5.703 29.00(8) bmq specific (q1-q10) 36.54±5.895 38(9) bmq specific-necessity (q1-q5) 17.48±3.882 18(6) bmq specific-concerns (q6-q10) 19.07±2.758 19(4) bmq general overuse (q11-q14) 14.04±3.193 14(5) bmq general-harm (q15-q18) 13.94±3.267 14(5) using the questionnaire on adherence, a score was calculated to give a numerical value to measure the adherence to antidepressant medication. the study has shown 87% of participants had a low adherence score (0-5), while only 14% had a high adherence score (6-8) (table 4). table 4: adherence in patients with major depressive disorder (mdd). variable n(%) adherence low 0-5 86(85.14) high 6-8 15(14.8) 29 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 figure 1: correlation between patients’ adherence levels on a prescribed antidepressant drug regimen. significant correlation was observed between adherence level and escitalopram as shown in figure 1 (r=0.9). discussion this study was conducted in karachi's population to evaluate adherence to antidepressant medication and belief about medication, where 101 opd patients diagnosed with mdd were enrolled from. around 80% of them belonged to psychiatry opd, and 21% from medicine opd. a similar study conducted in a tertiary care setting of karachi in 2012, notified 432 major depressive disorder patients, of which 53% belong to medicine and 47% from surgery units at the age of 405. european studies6,7 showed that adults and people in middle age are frequently ignored and overlooked within mental health policy and research. according to global data of 2015, world health organization (who) stated 322 million people with depression8. they notified it 5.1% more common among females as compared to males (3.6%), where regionally depression noted 50% only in south east asia and western pacific areas with gender prevalence highest and lowest; 5.9% amongst females in africa and 2.5% amongst males in western pacific areas8. while in this study, females 60% were more depressed in comparison to males. the most common relative with diagnosed depression were mother 6%. other studies supporting these findings also narrated that 68% of females and 57% of males and relatives with mental health problems were parents9. in our study in karachi, the highest frequency of these depressive patients was professionally employed at 56% at the highest prevalent income range of 11,000 to 30,000. although in the study done in peshawar at khyber medical college, a major depressive disorder was 64% in adult 30 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 people earning more than 15,000/month10. thus these outcomes are in agreement that socio-economic status plays an essential role in an individual's life. many publications are demonstrating its negative association with depression11-13. our study shows the frequency of smokers as 43% at mean 9 ± 4 cigarettes/ day. a survey conducted in 2011 showed the highest depression in adults who smoke more than five cigarettes/day14. another study supported these outcomes, positive association of tobacco cigarettes with depression was observed among 89% of the enrolled subjects15. it is assumed that people with depression smoke more to relieve their depression; thus, their consumption of cigarettes increases every day15. another demographic variable that is bmi resulting in our findings was 53% highest in depressive patients who were overweight and obese 10% while in contrast to two studies with the highest 34% and 35% incidence of obese16,17. according to who and other studies on depression has indicated depression is the second leading cause of disability in years lived with disability (ylds) 18,19. netherlands mental health survey and incidence study (nemesis-2) represented the meantime since being diagnosed with depression for participants in our study was 2.26 years with the meantime since being diagnosed with a co-morbid being 6.45 years18. additionally, depression itself is also a risk factor for attaining some types of general medical ailments, particularly cardiovascular disease20, which was also reported in our study. the total number of mdd patients reported with co-morbid was 31%. tripathi et al. reported diabetes mellitus as the most common co-morbid 5.78% in depressive patients21. in this study, the common comorbidity observed in mdd patients was 14% hypertension and 9% diabetes mellitus but 70% of patients with no associated comorbidity. other studies stated cardiovascular disease as the most prevalent 57% co-morbid medical condition with depression22,23. it is known that a variety of antidepressant drugs available with different classifications and mechanisms of action. however, improbability persists in which therapeutic medication or its class provides the best therapeutic option. according to current clinical medical treatment guidelines by nice (national institute for health and care excellence), 2019 ssris (e.g. fluoxetine, sertraline, escitalopram, paroxetine) are recommended as the first drug of choice for depression)24,25. cipriani et al. recognized the best three drugs of choice for treating depression: agomelatine, escitalopram, or vortioxetine25. we assessed that escitalopram (40%) and sertraline (20%) were the most commonly prescribed antidepressant drugs while the least prescribed was pregabalin i.e. 1%. a study was done in five tertiary care of india also displayed their data that escitalopram was the most commonly prescribed antidepressant drug to depressive patients. at the same time, trazodone was the least prescribed at 0.96% in the year 201621. as we know that the major problem we come across in treating depressive disorders is the patients' adherence and acceptability to drug therapy. in the past, it resulted in augmented relapsed risk26. therefore we evaluated patients' acceptability and tolerance in our study, which was found 86% low adherence, especially in those patients whose age was above 45 years (95%). in their study, tamburrino et al. showed 10% of patients 31 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 were non-adherent to antidepressant drug therapy, among which all were at age less than 40 years27. a retrospective study also shows its results on analogue to our study of low adherence 77% in the primary psychiatric care of thailand28. a study done as uk defeat depression campaign indicated that the effective antidepressant drug therapy, the treatment duration should not be less than four consecutive months, but in their study, they found only 31% of patients adherence to the fourth month (ssris: fluoxetine: 31%; paroxetine: 30%; sertraline: 24%)25, 29. this study showed that the higher rate of adherence (17%) is in males with the p-value of 0.324, and it was also observed that patients who were never married had a higher percentage of adherence (18%). a study done by hans wouters of netherlands showed females with higher adherence (78%), and the most adherent patients (73%) lived as partners with a spouse30. one of the reasons for the patient's low drug adherence is the social, financial, family barriers and beliefs; mostly, it was noted that the spouses related non-compliance as they discourage their partners from continuing their medication. the other reasons stated are discouragement from family members and fear of drug dependency due to lack of communication with the clinician31. bmq was an important tool to identify psychological factors important in nonadherence to medication in chronic diseases32. this study also has proved the utility of this questionnaire for nonadherence to antidepressant therapy, which may increase the risk of relapse. conclusion this study concluded that the belief about medication in mdd patients on antidepressant therapy was sufficient in participants included from karachi. however, they were evaluated to have low adherence to antidepressant treatment. by assessing and counselling mdd patients and regular follow-up appointments can minimize patients' low drug adherence. successful treatment outcomes in mdd most necessary as they can be at high risk of morbidity, mortality and suicides to unmanaged symptoms of depression. counselling and regular doctor-patient interaction can improve their compliance with medications. acknowledgment the authors would like to acknowledge the patients of jinnah medical hospital for participating in this study. references 1. marcus m, yasamy mt, van ommeren mv, chisholm d, saxena s. depression: a global public health concern. 2012. available at: https://www.who.int/mental_health/mana gement/depression/who_paper_depression_ wfmh_2012.pdf 2. gagnon md, waltemurer e, martin a, fridenson c, gayle e and hausen dl. patient beliefs have a greater impact than barriers on medication adherence in a community health centre. j. am. board fam. med. 2017;30(3):331336. 3. lim gy, tam ww, lu y, ho cs, zhang mw, ho rc. prevalence of depression in the community from 30 countries between 1994 and 2014. scientific rep. 2018;8(1):2861. 4. sweileh wm, sa’ed hz, nab’a rj, deleq mi, enaia mi, sana’a mn, al-jabi sw. influence of patients’ disease knowledge and beliefs about medicines on medication adherence: findings from a cross-sectional survey among patients with type 2 diabetes mellitus in palestine. bmc public health. 2014;14(1):1-8. 5. ng cwm, how ch, ng yp. managing depression in primary care. singapore med j. 2017;58(8):459. 32 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 6. edwards j. fundamental facts about mental health. london: mental health foundation; 2016. available at: https://www.mentalhealth.org.uk/sites/def ault/files/fundamental-facts-about-mentalhealth-2016.pdf 7. depression w. other common mental disorders: global health estimates. geneva: world health organization. 2017:1-24. 8. gatsou l, yates s, hussain s, barrett m, gangavati s, ghafoor r. parental mental illness: incidence, assessment and practice. men health prac. 2016;19(5). 9. ishtiaq m, afridi mi, imranullah, khan sa. depression among the adult population; prevalence & risk factors of depression among adult population of district peshawar. professional med j 2018; 25(8):1229-1234. 10. andrade l, caraveo-anduaga jj, berglund p, bijl r, kessler rc, demler o, walters e, kylyc c, offord d, ustun tb, wittchen hu. crossnational comparisons of the prevalences and correlates of mental disorders. bull. world health organ. 2000;78:413-425. 11. jo sj, yim hw, bang mh, lee mo, jun ty, choi js, lee ms, lee wc, park ym. the association between economic status and depressive symptoms: an individual and community level approach. psychiatry investig. 2011;8(3):194-200. 12. freeman a, tyrovolas s, koyanagi a, chatterji s, leonardi m, ayuso-mateos jl, tobiasz-adamczyk b, koskinen s, rummelkluge c, haro jm. the role of socioeconomic status in depression: results from the courage (aging survey in europe). bmc public health. 2016;16(1):1-8. 13. byeon h. association among smoking, depression, and anxiety: findings from a representative sample of korean adolescents. peer j. 2015;3:e1288. 14. fluharty m, taylor ae, grabski m, munafò mr. the association of cigarette smoking with depression and anxiety: a systematic review. nicotine tob. res. 2017;19(1):3-13. 15. moussa om, ardissino m, kulatilake p, faraj a, muttoni e, darzi a, ziprin p, scholtz s, purkayastha s. effect of body mass index on depression in a uk cohort of 363 037 obese patients: a longitudinal analysis of transition. clinical obesity. 2019;9(3):e12305. 16. qato dm, ozenberger k, olfson m. prevalence of prescription medications with depression as a potential adverse effect among adults in the united states. jama. 2018;319(22):2289-2298. 17. ferrari aj, charlson fj, norman re, patten sb, freedman g, murray cj, vos t, whiteford ha. burden of depressive disorders by country, sex, age, and year: findings from the global burden of disease study 2010. plos med. 2013;10(11):e1001547. 18. reddy m. depression: the disorder and the burden. indian j. psychol. med. 2010;32(1):1. 19. hirschfeld rm. the comorbidity of major depression and anxiety disorders: recognition and management in primary care. prim care companion j clin psychiatry. 2001;3(6):244. 20. tripathi a, avasthi a, desousa a, bhagabati d, shah n, kallivayalil ra, grover s, trivedi jk, shinfuku n. prescription pattern of antidepressants in five tertiary care psychiatric centres of india. indian j med res. 2016;143(4):507. 21. kronick rg, bella m, gilmer tp. the faces of medicaid iii: refining the portrait of people with multiple chronic conditions. center for health care strategies, inc. 2009:1-30. 22. goodell s, druss bg, walker er, mat mj. mental disorders and medical comorbidity. robert wood johnson foundation. 2011;2. 23. sheperd n, parker c. depression in adults: recognition and management. clinical pharmacist. 2017. 24. cipriani a, furukawa ta, salanti g, chaimani a, atkinson lz, ogawa y, leucht s, ruhe hg, turner eh, higgins jp, egger m. comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. focus. lancet. 2018;16(4):420-429. 25. ho sc, jacob sa, tangiisuran b. barriers and facilitators of adherence to antidepressants among out-patients with 33 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 major depressive disorder: a qualitative study. plos one. 2017;12(6):e0179290. 26. tamburrino mb, nagel rw, chahal mk, lynch dj. antidepressant medication adherence: a study of primary care patients. prim care companion j clin psychiatry. 2009;11(5):205. 27. prukkanone b, vos t, burgess p, chaiyakunapruk n, bertram m. adherence to antidepressant therapy for major depressive patients in a psychiatric hospital in thailand. bmc psychiatry. 2010;10(1):64. 28. donoghue j. selective serotonin reuptake inhibitor use in primary care. clin drug investig. 1998;16(6):453-462. 29. wouters h, rhebergen d, vervloet m, egberts a, taxis k, van dijk l, gardarsdottir h. distinct profiles on subjective and objective adherence measures in patients prescribed antidepressants. drugs. 2019;79(6):647-654. 30. ho sc, jacob sa, tangiisuran b. barriers and facilitators of adherence to antidepressants among out-patients with major depressive disorder: a qualitative study. plos one. 2017;12(6):e0179290. 31. wei l, champman s, li x, li x, li s, chen r, bo n, chater a, horne r. beliefs about medicines and non-adherence in patients with stroke, diabetes mellitus and rheumatoid arthritis: a cross-sectional study in china. bmj open. 2017;7(10):e017293. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v8.i1.2021.24-33 1 app| published by aeirc| https://doi.org/10.29052/2412-3188.v6.i1.2019.1-7 issn 2412 3188 original article impact of music on reaction time, attention, short term memory and verbal fluency: a genderbased study ujalla anwar, amaila fazal & faizan mirza department of physiology, university of karachi. abstract background: music is beneficial for adults, it enhances psychological comfort, selfconfidence, self-esteem, and lowers the symptoms of anxiety, pain and depression, relieving stress by improving life quality and thus providing satisfaction. it holds the capacity to initiate a multitude of cognitive processes in the brain. we aim to evaluate and compare the effects of music on reaction time, attention, working capacity of short-term memory and verbal fluency of male and female subjects. methodology: an observational study was conducted on a sample of 300 subjects either males or females between the age groups of 19 to 30 years, affiliated with different universities and institutes. after inclusion, these subjects were divided into two groups, standard and experimental group with 150 subjects in each group. ruler & drop method test and stroop test with or without music were used to test the reaction time (rt) and attention, respectively. whereas, working capacity of short-term memory was tested using the george a. miller rule of memory. and verbal fluency was evaluated using semantic verbal fluency (svf) and phonological verbal fluency (pvf) tests. the data was analyzed using spss version 22. results: the comparative mean values between the groups for rt, attention, shortterm memory and verbal fluency scores were greater among the subjects in the experimental group as the tests were performed in association with musical interference. mean reaction time for both visual and tactile cues were significantly increased in the experimental group i.e. 0.151±0.034 (males) and 0.124±0.050 (females) for tactile cues and 0.150±0.042 (males) and 0.152±0.033 (females). moreover, stroop interference also increased in both genders while short-term memory score declined from high to average and verbal fluency was also compromised due to musical interference. conclusion: it is concluded from the study results that music holds both positive and negative effects on brain activity. it imparts positive effect on both rt and attention but in case of the working capacity of short-term memory and verbal fluency, the effects are negative. keywords reaction time, stroop test, verbal fluency, short-term memory, music. citation: anwar u, fazal a, mirza f, ahmed s. impact of music on reaction time, attention, short term memory and verbal fluency: a gender-based study. app. 2019; 6(1):1-7 corresponding author email: fm.faizan.mirza@gmail.com doi: 10.29052/2412-3188.v6.i1.2019.1-7 received 10/02/2019 accepted 04/05/2019 published 12/10/2019 copyright © the author(s). 2019 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v6.i1.2019.1-4 http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 2 app| published by aeirc| volume 6 issue 1 issn 2412 3188 introduction music is an art form which is now being used as a therapeutic tool for individuals of all age groups and both genders, as it has been known for its social nature of healing. music upregulates the working efficiency, boosts the productivity levels, enhances psychological comfort and self-confidence1,2. it also helps with complex cognitive functioning like critical thinking, reasoning and problem solving3. music activates the deep parts of the brain including amygdala, ventral striatum and hippocampus which in turn activates the euphoric stimulation. where amygdala responsible for expression and perception of fear and the development of fear conditioning, regulates additional cognitive processes like memory or attention4. it is a known fact that intellectual abilities can be improved by fragrances or certain music (i.e., the mozart effect)5. literature suggest that exposure to music, specifically mozart, improves the performances and also increases spatial skills6. apart from reaction time and concentration, music also has effects on the memory. the memory retained for a duration of 15 and 30 seconds is short term memory. it can be verbal or visual, items can be kept in short term memory by repeating them verbally (acoustic encoding)7. while visual shortterm memory involves the ability to temporarily retain a small amount of visual information like shapes, colours, relative locations, or movement directions available for a limited time period8. music also influences stress-related cognitive processes and alters numerous physiological responses9. from a functional point of view, the acoustic data is processed in the motor and auditory areas of the brain through the auditory neural pathways connecting the amygdala and auditory cortex10. several interconnected neural pathways associated with memory, music and emotions are working parallel to each other to create detailed layered memories. verbal fluency is another cognitive function that is enhanced through music listening, it helps in recovering information from memories. however, recovery of information is successfully executed when an individual has control over mental processes like mental set shifting, selective attention, selfmonitoring and internal response generation11. verbal fluency involves both semantic and phonologic contents which engage distinct cognitive processes and brain circuits12. the phonologic content requires functioning of left inferior, middle frontal cortices, putamen and thalamic networks, and also verbal element in addition to executive functions which later involves the unusual generation of strategies based on categorical representations13. in contrast, semantic requires temporal lobe functions and impose a smaller demand on executive processing because performance rely on common and established verbal strategies14. based on the previous literature it is evident that the music improves cognitive abilities and hence contribute better results in memory and language tasks. therefore, this study aims to evaluate the contribution of music on working capacity of short-term memory and verbal fluency of male and female subjects and its effect on reaction time and attention. methodology this observational study was conducted on general population. a sample of 300 subjects between 19-30 years of age affiliated with different universities and institutes were enrolled in the study. subjects suffering from any pathological condition at the time of sampling were excluded. after receiving informed consent, the subjects were divided randomly into two groups i.e. standard and experimental group. in standard group there were 150 subjects including 60 males and 90 females. in this group, all parameters were tested without music. experimental group also contain 150 subjects including 80 males and 70 females. in this group, all parameters were tested with music. 3 app| published by aeirc| volume 6 issue 1 issn 2412 3188 for reaction time, ruler and drop method was used, subject was asked to sit on the table with their dominant hand over the edge. to test the visual response, the ruler was placed at the 30 cm mark so that the 0 cm end is just at the subject's index finger. soon after this the investigator releases the ruler without making any noise or gesture. the subject will react to the visual stimulus of seeing the ruler being released. the experiment is repeated three more times and the centimetre mark is taken for each time. for tactile response, the subject is asked to sit at the table wearing the eye shade and touch the shoulder of their non-dominant arm as the investigator release the ruler. the subject will be given a simple touch while releasing the ruler without any auditory cue. the measurement is recorded and the experiment is repeated thrice switching places. the reaction time was calculated using following formula: t = √2y/gₒ. where, y is the distance measured in cm, gₒ is the acceleration due to gravity constant (980 cm/sec2); and t is the time in seconds. the average reaction time for humans is 0.25 seconds to a visual stimulus, 0.17 for an audio stimulus, and 0.15 seconds for a touch stimulus. stroop effect test was used to assess attention, the subject was made to read out the word printed in black, same words printed in congruent colours, colours printed in incongruent shades and colour of ink from which the word is written and the time was recorded each time. stroop interference and facilitation were calculated using the formula: stroop interference = incongruent control stroop facilitation= congruent control for working capacity of short-term memory assessment, george a. miller rule of memory score was used. harvard-based psychologist george a. miller found that in our short-term memory, the average number of 'chunks' of information (names, numbers, etc) that can be stored is 7±2. according to which a score between 5 and 9 of the words on the list indicate average working capacity of shortterm memory, if less than 5, short term memory is working at low capacity and if the score is above 9 indicates high working capacity of short-term memory. thereby, subjects were provided with a list of words which they can learn for a short period of time (30 seconds – 1 minute), then they were asked to recall the list with or without listening to music. both semantic verbal fluency (svf) and phonological verbal fluency (pvf-fas) tests were performed. in svf test, the participants were asked to evoke and speak as many animal names as they could over a period of 60 seconds. the total number of correct items mentioned by the subject was recorded. moreover, in pvf-fas test, the participants were asked to mention as many words as they could starting with the letter’s “f”, “a” and “s”, over a period of 60 seconds for each letter separately, proper names and numbers were avoided. the total number of correct items mentioned for each letter was recorded. the results in the fas test were computed for the number of the word generated with the initial letter, i.e. f, a, s, and the sum of the all three letters was calculated i.e. f, a and s (σ fas). all of the above mentioned tests were performed on the enrolled study subjects in accordance to the ethical guidelines and the tests were run twice, with and without music and the results were displayed gender wise. data was analysed using spss version 22 and displayed using mean and standard deviation. result based on the results the mean reaction time for both visual and tactile cues was significant improved in both genders. but for attention the stroop interference was prolonged among subjects of experimental group. moreover, the working capacity of short-term memory was decreased from high to average and verbal fluency both semantic and phonologic was compromised while listening music as shown in table 1. 4 app| published by aeirc| volume 6 issue 1 issn 2412 3188 table 1: changes in mean reaction time, attention, short term memory score and verbal fluency among subjects in both standard and experimental group parameters standard experimental male (n=60) female (n=90) male (n=80) female (n=70) reaction time tactile 0.1488 ±0.036 0.118 ±0.043 0.106 ±0.034 0.124 ±0.050 visual 0.148 ±0.036 0.153 ±0.040 0.150 ±0.042 0.152 ±0.033 attention if 35.68 ±7.69 33.584 ±7.978 40.816 ±11.65 38.57 ±11.53 ft -0.93 ±3.10 -0.50 ±3.22 -2.033 ±3.53 -1.211 ±3.54 short term memory score below 5 6±2.831 1±4 6±3 2±4 5 to 9 39±2.7004 37±3.3 45±2.9 46±4.1 above 9 15±2.591 52±3 9±3 42±4 verbal fluency semantic 15.03±4.40 41.32±10.55 13.566±3.48 34.18±9.58 phonologic 16.15±3.89 48.21±12.75 14.65±3.15 38.088±11.43 *values are given as mean ± sd *if-stroop interference; ft-stroop facilitation *standard group – without music; experimental group – with music discussion exposure to music stimulates brain areas, but the process occurs differently among males and females which are attributed to various genetic, hormonal and environmental factors. however, both genders are equal in intelligence, but tend to work in a different manner. this is because both male and female use different parts of their brain to recognize faces, sense emotions, encode memories, make decisions and solve certain problems. according to our results, reaction time was much faster among females as compared to males in the control group as well as experimental group (table 1). however, it is generally accepted that males have faster reaction time as compared to females. men tend to have larger diameter of axons than women. larger diameter of axons causes signals to be transmitted faster up to the nerve fibres, leading to a shorter latency between stimulus and response15. but our results are contradictory to previous researches. this might be due to the neuroanatomical differences among both the genders. that is female have bigger corpus callosum as compared to males which is the larger tract of neural fibres that allows the free flow of communication between both hemispheres of the brain16. furthermore, regions for frontal lobe that are responsible for problem solving and decision making were larger in women17. in addition, our graphs also showed that both the genders took more time in stroop interference (table 1) it is because, there are two brain regions involved in the processing of stroop task cingulated cortex and dorsolateral prefrontal cortex. hemisphere difference has also been proved by a study that right cerebral hemisphere reads the colour, the left cerebral hemisphere insists to read the words. it is easy to recognize the actual colour of the word when the meaning is consistent, while the inconsistent word meaning and colour creates conflicts. the word-recognition and colour-recognition are the two brain processes explaining "conflict". thereby, to resolve this conflict, extra time is required by the brain. word-recognition is slightly faster/stronger as compared to colour-recognition as we are so fluent in our language18. the brain has to inhibit the faster/stronger word-recognition process in order to allow the colour-recognition to win in the final response. this inhibition requires "selective attention" (attention focus) to inhibit the competing conflicting process. the reaction time is an indicator of the "attention process" in the brain it increases with 5 app| published by aeirc| volume 6 issue 1 issn 2412 3188 attention fatigue and/or inattentiveness19. however, when comparing between both the genders, it was found out that females perform somewhat better than males this is because the neurons in the pre frontal cortex of female’s brain are more closely packed together than male’s brain20. and the prefrontal cortex is involved in stroop task and problem-solving ability. many researches have been done proving different effects of music on psychological parameters, all with contradictory conclusions to one another. like authors have concluded that music does not have any effect on memory21. on the other hand, some have also reported that sound in the background actually enhances the learning ability22. in our study, the overall working capacity was decreased along with the verbal fluency (table 1). this can be due to the perspective proposed by kahneman as cognitive capacity model. in this model it is demonstrated that cognitive processing can be done only for a limited pool of resources at a given moment. when multiple tasks occur at the same time, they compete for the limited resources and thereby exceeding the available capacity due to combined demand. and ultimately capacity interference occurs. this causes the processing of only portion of the task and thereby performance deteriorates. thus, increasingly complex distractions due to music cause decline in cognitive performance23. this might be the possible reason that the working capacity of our participants decreased from high to average, in addition to the verbal fluency. this is similar to other researches which demonstrated that background music has small but continuous negative effect on memorizing words or nonsense syllables (especially when listening to loud music)24, remembering advertisements25 and also in memorizing earlier read texts and reading performance26. listening to music has also been reported to hinder with many other cognitive processes, including multimedia learning, performance on diagrammatic, numerical and verbal analysis, the ability to perform arithmetic, reading, performance inhibition on stroop task and also in the learning of new procedures27-29. this study provides the positive effects of music on attention, verbal fluency, and shortterm memory and also on reaction time. however, more significant data is required in future in support of the positive effects associate with music. moreover, the negative effects were not evaluated in this study which play a significant role in one’s health and well-being, thereby, future researches should also focus both the negative and positive aspects of the music and comparative data must be represented in order to evaluate the overall significance and outcomes of musical interventions. conclusion limited data is in favour of positive effect of music on psychological parameters but it is firmly demonstrated that music consistently and reliably interferes with the mental performance, also indicated by our study. but it is recommended that further studies should be performed to compare the positive or negative impacts of music or the specific type of music causing either positive or negative effect on memory and attention. acknowledgement the author acknowledged the support of the students of karachi university who participated in this study and also the colleagues for helping out in the entire research. references 1. chun ll. the influence of different music genres on task performances of employees. nt. j. psychol. couns. psychiatry: theory, research and clinical practice. e-issn no:2590-4272 [cited august 17, 2019]. available at: http://ijpcp.com/journal02/j02a03.asp 2. boothby s, does music affect your mood? healthline: health news [online] april 13, 2017. [cited august 17, 2019]. available at: https://www.healthline.com/health 6 app| published by aeirc| volume 6 issue 1 issn 2412 3188 news/mental-listening-to-music-liftsor-reinforces-mood-051713 3. miendlarzewska ea, trost wj. how musical training affects cognitive development: rhythm, reward and other modulating variables. front. neurosci. 2014;7:279. 4. isaacs s. the roles of the amygdala and the hippocampus in fear conditioning [dissertation on the internet]. sweden: university of skövde, school of bioscience. [online] 2015. [cited april 7, 2017]. available from: http://www.divaportal.org/smash/get/diva2:839668/f ulltext01.pdf. 5. lehmann ja, seufert t. the influence of background music on learning in the light of different theoretical perspectives and the role of working memory capacity. front. psychol, 2017. 8: article 1902. 6. jones mh, west sd, estell db. the mozart effect: arousal, preference, and spatial performance. psychol aesthet creat arts. 2006; s(1): 26–32. 7. atkinson rc, wickens td. human memory and the concept of reinforcement. the nature of reinforcement. 1971:66-120. 8. korczyn ad, peretz c, aharonson v, giladi n. o1-03-02: computer based cognitive training with mindfit® improved cognitive performances above the effect of classic computer games: prospective, randomized, double-blind intervention study in the elderly. alzheimers dement: the journal of the alzheimer's association. 2007;3(3):s171. 9. peretz i, zatorre rj. brain organization for music processing. annu. rev. psychol. 2005. 56:89-114. 10. ehret g. the auditory cortex. j. comp. physiol. 1997;181(6):547-557. 11. patterson j. fas test. encyclopedia of clinical neuropsychology. [online] 2011. [cited august 18, 2019]. available at: https://doi.org/10.1007/978-0-38779948-3_886 12. willcutt eg, doyle ae, nigg jt, faraone sv, pennington bf. validity of the executive function theory of attentiondeficit/hyperactivity disorder: a metaanalytic review. biol. psychiatry. 2005;57(11):1336-1346. 13. perret e. the left frontal lobe of man and the suppression of habitual responses in verbal categorical behaviour. neuropsychologia. 1974;12(3):323-330. 14. gourovitch ml, kirkby bs, goldberg te, weinberger dr, gold jm, esposito g, van horn jd, berman kf. a comparison of rcbf patterns during letter and semantic fluency. neuropsychology. 2000;14(3):353-360. 15. mcdougall s, riad wv, silva-gotay a, tavares er, harpalani d, li gl, richardson hn. myelination of axons corresponds with faster transmission speed in the prefrontal cortex of developing male rats. eneuro. 2018;5(4): e0203-18. 16. leonard cm, towler s, welcome s, halderman lk, otto r, eckert ma, chiarello c. size matters: cerebral volume influences sex differences in neuroanatomy. cerebral cortex. 2008;18(12):2920-2931. 17. zaidi zf. gender differences in human brain: a review. open anat j. 2010; 2(1): 37-55. 18. grandjean j, d’ostilio k, phillips c, balteau e, degueldre c, luxen a, maquet p, salmon e, collette f. modulation of brain activity during a stroop inhibitory task by the kind of cognitive control required. plos one. 2012;7(7):e41513. 19. shalev l, tsal y, mevorach c. computerized progressive attentional training (cpat) program: effective direct intervention for children with adhd. child neuropsychol. 2007;13(4):382-388. 20. witelson sf, glezer ii, kigar dl. women have greater density of neurons in posterior temporal cortex. j. neurosci. 1995;15(5):3418-3428. 21. fassbender e, richards d, bilgin a, thompson wf, heiden w. virschool: the effect of background music and immersive display systems on memory 7 app| published by aeirc| volume 6 issue 1 issn 2412 3188 for facts learned in an educational virtual environment. comput educ. 2012;58(1):490-500. 22. mann g. why does country music sound white? race and the voice of nostalgia. ethn rac studies. 2008;31(1):73-100. 23. kahneman d. attention and effort. englewood cliffs, nj: prentice-hall; 1973 [cited april 7, 2017] available at: http://citeseerx.ist.psu.edu/viewdoc/d ownload?doi=10.1.1.398.5285&rep=rep1 &type=pdf. 24. wen w, michihiko k. the effects of music type and volume on short-term memory. tohoku psychol folia. 2006;64:68-76. 25. oakes s, north ac. the impact of background musical tempo and timbre congruity upon ad content recall and affective response. applied cog psychol. 2006;20(4):505-520. 26. furnham a, allass k. the influence of musical distraction of varying complexity on the cognitive performance of extroverts and introverts. euro j personality. 1999;13(1):27-38. 27. avila c, furnham a, mcclelland a. the influence of distracting familiar vocal music on cognitive performance of introverts and extraverts. psychol. music 2012;40(1):84-93. 28. bloor aj. the rhythm's gonna get ya’– background music in primary classrooms and its effect on behaviour and attainment. ebd. 2009;14(4):261-274. 29. thompson wf, schellenberg eg, letnic ak. fast and loud background music disrupts reading comprehension. psychol music. 2012;40(6):700-708. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v6.i1.2019.1-7 munaza bibi 71 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 original article assessment of sleep quality of university students munaza bibi bahria university karachi. corresponding author: munaza.12star@yahoo.com abstract objective to assess the sleep quality of university students of karachi, and its association with mobile phone use, depression and academic performance. methodology a random cross – sectional study was conducted on 221 students and data was collected from different universities of karachi business students. results show that depression, mobile phone use impact on sleep quality thus affect the academic performance of students. about 38.9% students were nondepressed and 61.1% students were depressed. sleep quality score shows that 8.6% students had good sleep and 91.4 % had poor sleep, academic performance is measured in terms of last semester gpa (38%) students had gpa 2.6-3.00, (30.3%) students had gpa 3.1-3.5, (15.4%) students had gpa 3.6-4.00, (14.5%) students had gpa2.1-2.5 and (1.8%) students’ had gpa <2.0. in terms of mobile phone use, (23.1%) students spend <5 hours, (19.9%) spend 6-8 hours, (24%) spend 9-10 hours and (33%) spend >10 hours on mobile phone. conclusion for the development and growth of this asset “sleep” is a very important aspect vital for normal functioning of physical and mental health of students. there is a need to control sleep problems and prevent its complications through proper counselling of students about the significance of sleep. good quality of sleep can develop better academic, physical and psychological performance of university students. keywords sleep quality, depression, academic performance, mobile phone use introduction there are two categories of normal sleep first one is non-rapid eye movement (nrem) and second one is rapid eye movement (rem), further splitting up of (nrem) further divided into deep stages of sleep: stage n1, stage n2 and stage n3. need strong stimulus by nrem sleep for awakening. phasic component of rem sleep which is resolute sympathetically by rapid eye movements, respiratory variation and twitches in muscle. rem sleep tonic component is para sympathetically determined with no movement of eyes. sleep (nrem) followed by sleep (rem) which occurs between 4-5 times during 8 hours of normal sleep. stage n3 in which presence of sleep in first third and rem sleep during the last third of the night. nrem problem such sleep walking occur in the presence of n3 stage of sleep along with first third during night. stage n1 is the time between alert and sleep it account for 2-5 % of sleep. stage n2 is present throughout the sleep time, it accounts for 4555%of the whole sleep. unconsciousness a physiologic condition in sleep in which brain is more receptive to both (internal and external) stimulus. during sleep brain is less reactive to senses (visual and auditory) and external stimulus during the period from conscious to sleep (steven m.s. et al, 2015). there are two processes which control the sleep, the wake system process s endorse sleep and process c (circadian) that preserve alertness is stimuli across day to neutralize with process s for restlessness and alertness during the day. process c is falling to prop up the sleep (process s). http://www.aeirc-edu.com/ mailto:munaza.12star@yahoo.com munaza bibi 72 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 the process s (homeostatic) of sleep is regulated by neurons, by invigorating the brain to promote the sleep. these neurons are there in hypothalamus (pre-optic area) accountable to turn off the awakening system during the sleep time. the brainstem ascending system is accountable for sleeplessness. it has two main paths that move on the way from the brain stem, the first path; originate from cholinergic neurons in the upper pons, which in reaction activates the thalamus for conduction of sensory nerves (information) to cerebral cortex. the second path, originates in the upper brainstem (cell groups) enter hypothalamus as an alternative of thalamus upper brain stem contains the mono amine transmitters nor epinephrine, serotonin, dopamine and histamine .in hypo thalamus it receives the inputs from nerve cells that include (melanin concentrating hormones and peptides),information traverse the forebrain (basal area) by getting inputs from acetylcholine and gamma – amino butyric acid containing cells, all information go through the cerebral cortex it provoke the nerve cells ( harvey r.& bruce, 2006). an inside biological regulator of sleep in body is circadian rhythm, accountable for sleep and sleeplessness cycle in human beings. circadian rhythm sustains the duration of sleep and restlessness per the day time and night. the process of bringing together of physiologic purpose with day night time called as photo entrainment. as the light changes into dark receptors sense these changes with encouragement of super chiasmatic nucleus (scn) which contain 20,000 nerve cells which activates the neurons where axons move down to the sympathetic (pre ganglionic) neurons in the lateral horn of spinal cord. post ganglionic axons direct to pineal gland (present in dorsal thalamus) generates the sleep promoting neuro hormones melatonin. melatonin level increases between 2:00 -4:00 a.m. aberration in melatonin creation lead to sleep difficulty (purves d. et al., 2001). one of the major physiologic process of human body is sleep, around 25-40% of young people experience sleep problem (lazaratou h. et al., 2005 & garcia l.m.a. et al., 2004). study in china showed 16.9% adults suffering from sleep problem (liu x. et al., 2000). sleep plays an important role for the health and affecting stability of individuals, poor sleep affects emotions in the outward appearance of depression (kimberly. o’ et al., 2016). digital media use (including computer & mobile phone) among university students prior to sleep negatively effect on sleep. good sleep is necessary for proper functioning of body physical & mental health of students (kathryn .m. et al., 2016). study showed that depression, pressures for academic performance and anxiety among university students result in inadequate quality of sleep (seblewngel. l. et al., 2012). study showed that respondents who left their mobile phone in switch on form had poor quality of sleep in relation to those who kept their mobile phone in switch off manner (yen – s. l.et al., 2016). association between depression and sleep quality can be a problem, especially for female students with volatility of emotional aspect were diagnosed as sleep deprived than in association with male students (seoyoun k. et al., 2016). 1st year medical students gave more importance to studies workloads, pressures, and pressure about absence of response and 3rd year students gave high score to reservations about their future, in year 6th students gave high score to not accommodating academic climate”. predominance of depression among students of medicine was 12.9% and along with female students it was 16.9% and 8.1 % http://www.aeirc-edu.com/ munaza bibi 73 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 amongst male students. study showed that students of medicine experienced more depression than other people (marie. d. et al., 2005). ideation of suicides rate be found higher among university students of south africa. depression, tension and anxiety eventually forecast suicidal ideation among students of south africa than ordinary population (jason r. et al., 2016). 71.1% participants experienced sleeplessness and the nightmares rate of occurrence was modest problem among student’s population were about two per fourteen days, increased psychiatric symptoms are linked with sleep problems, circadian rhythm hindrance and nightmares (sheaves b. et al., 2015). methodology the study design was cross sectional study conducted at one point in time or over a short period of time. the target population for this study was business students of different universities of karachi. a sample size of 221 students, including both male and female. non-probability, convenience sampling method was used for this study instruments for this research was a well-structured questionnaire, prepared by using multi item likert scale, part1: questionnaire ascertained demographic information of respondents like gender, age, education, and department. part 2: comprised of the questions regarding depression, sleep quality, academic performance and mobile phone use in university students of karachi. (psqi) is selfrated questionnaire which evaluate the sleep quality. the psqi dealings with seven areas: subjective sleep quality, latency, extent, routine sleeps efficiency, sleeps disorder, utilization of sleeping medicines, and daytime dysfunction over the last month. psqi consist of seven components scores ranging from (0-3), 0 score is good and 3 score is very bad. the total score >5 indicate sleep problems and <5 indicate no sleep problem. ces-d is a questionnaire which is self-rated to quantify the depression symptoms in common population. ces-d score is the summation of 20 items; each piece is scored from 0-3. a score of 16 and above is well thought-out as depression. collected data was analyzed using spss v. 16. results the reliability of overall questionnaire value is .720 which is greater than 0.5 so the questionnaire used for this research is reliable. a random cross – sectional study was conducted, results shows the association with depression, mobile phone use on sleep quality thus affect the academic performance of students. ces-d score shows that 38.9% students were non-depressed and 61.1% students were depressed. sleep quality score (psqi) shows that 8.6% students had good sleep and 91.4 % had poor sleep, academic performance is measured in terms of last semester gpa (38%) students had gpa 2.63.00, (30.3%) students had gpa 3.1-3.5, (15.4%) students had gpa 3.6-4.00, (14.5%) students had gpa2.1-2.5 and (1.8%) students had gpa <2.0. in terms of mobile phone use, (23.1%) students spend <5 hours, (19.9%) spend 6-8 hours, (24%) spend 9-10 hours and (33%) spend >10 hours on mobile phone. a substantial proportion of subjects were sleep deprived and depressed, and increase use of mobile phone and related technologies reflecting the poor sleep quality trend in university students. graphical representations are given below: http://www.aeirc-edu.com/ munaza bibi 74 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 figure1 shows psqi score. figure2 shows depression score. figure3 shows last semester gpa. figure4 shows time spend on mobile phone. discussion this study was done to assess the sleep quality of university students of karachi. subjects involved in this study were mainly business students. students with poor sleep quality score had poor cognitive performance and depression. poor sleep is considered as a key symptom to cause changes in neurotransmitters as a result it leads to depression among adults (david; 2010). (ces-d) score pvalue is 0.001 which is less than 0.005, it shows association between depression and sleep quality of university students. based on ces –d 61.1% students had depression and 38.9 % were not depressed, by treating depression is likely to improve poor to good sleep quality (nour, et al., 2016). 91.4% of the students in reality had poor sleep quality and 8.6% had good sleep quality, poor sleep quality has an association with decrease mental health and performance of students (henrick, et al., 2007). for evaluating association between mobile phone use and sleep quality, students were asked how much time students spend on mobile phone, majority of students spend more time on mobile phone which ultimately affect their sleep (teresa, et al., 2016). mobile phone use indicates p-value is 0.002 which is less than http://www.aeirc-edu.com/ munaza bibi 75 annals of psychophysiology volume 4, july 2017 ©advance educational institute & research centre www.aeirc-edu.com issn 2412 3188 0.005 it is significant showing association between mobile phone use and sleep quality. in terms of mobile phone use, (23.1%) students spend <5 hours, (19.9%) spend 6-8 hours, (24%) spend 9-10 hours and (33%) spend >10 hours on mobile phone, excessive use of mobile affect sleep among students also claimed that use of internet, online playing of game with mobile, sports and hitech sophisticated gadgets was associated with reduced sleep quality including sleeplessness.33% students had difficulty in sleep after mobile phone use. academic performance p-value is 0.001 which is less than 0.005 which also show significant association between academic performance and sleep quality (eyvazlou, et al., 2016 & lam l.t, 2014). a considerable connection was found between lower gpas and lack of sleep. academic performance is measured in terms of last semester gpa (38%) students had gpa 2.6-3.00, (30.3%) students had gpa 3.1-3.5, (15.4%) students had gpa 3.64.00, (14.5%) students had gpa2.1-2.5 and (1.8%) students had gpa <2.0 (kelly, et al; 2001). an association between well sleep measures as a measurement of academic performance. delayed bed timetable was linked with reduced academic performance in terms of cgpa among young person (mari, et al., 2016). strong association was found between sleep troubles and reduced academic performance and educational behaviors (jorge, et al., 2016). students with poor sleep quality score had poor academic performance as compared to those with good sleep, poor sleep eventually influences the academic performance (karl, et al.,2015). conclusion from the results and studies it can be assayed that “sleep” is a very important aspect vital for normal functioning of physical and mental health of students. systemic interference is fundamental to promote healthy practice in the family, addressing in particular, and use of mobile phone, study pattern and sleep behaviors that impacts on sleep quality of student’s. there is a need to control sleep problems and depression to prevent its complications through proper counselling of students about the significance of sleep and cognitive health for good academic performance. good quality of sleep can develop better academic, physical and psychological performance of university students. recommendations future studies should spotlight on detecting poor sleep quality causes and impact of sleep on suicidal ideation in order to understand possible interaction and co morbidities and use longitudinal designs to comprehend the influence of these considered variables. acknowledgement i would like to acknowledge my research supervisor & teacher mumtaz khan (bahria university), who encourage me and support me in writing of this paper. conflict of interest no competing interests were found in the preparation of this paper. references  altevogt, b. m., & colten, h. r. 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(2007). the quality of sleep and factors associated with poor sleep in japanese graduate students. sleep and biological rhythms, 5(4), 234-238.  purves, d., augustine, g. j., fitzpatrick, d., katz, l. c., lamantia, a. s., mcnamara, j. o., & williams, s. m. (2001). neurotransmission in the visceral motor system.  sheaves, b., porcheret, k., tsanas, a., espie, c. a., foster, r. g., freeman, d., & goodwin, g. m. (2016). insomnia, nightmares, and chronotype as markers of risk for severe mental illness: results from a student population. sleep, 39(1), 173181.  steven m.s., benbadis s.r. & armon c. 2015. normal sleep, sleep physiology, and sleep deprivation. medscape. http://www.aeirc-edu.com/ 25 app| published by aeirc| https://doi.org/10.29052/2412-3188.v7.i1.2020.25-30 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) original article relationship of functional dyspepsia with mental and physical stress prem shankar, nikeeta mandhan, syed muhammad hussain zaidi, muhammad saad choudhry & akshay kumar dow medical college, dow university of health sciences (duhs), karachi-pakistan. abstract background: functional dyspepsia is a globally prevalent illness, which although not life-threatening, displays a strong influence on the quality of life. functional dyspepsia is essentially chronic indigestion with no obvious physical cause. the objective of this study was to evaluate the frequency of functional dyspepsia and its association with mental and physical stress. it could have the same significant association as irritable bowel syndrome has with stress. methodology: the data were collected from 221 students from 3 medical colleges of karachi, pakistan. subjects were asked to fill out questionnaires concerning demographics, lifestyle, and dietary habits. rome iii criteria was employed to identify functional dyspepsia and sub-sections of the sadaf stress scale (sss) was used to measure mental and physical stress. results: out of the 221 subjects majority were females (67.4%) with a mean age of 21.47 years. 34.8% of subjects were diagnosed to have functional dyspepsia, out of which around three quarters were females (68.5%). a moderate positive correlation was observed between functional dyspepsia and mental and physical stress. conclusion: it is concluded from the study results that there is a high frequency of functional dyspepsia among individuals with mental and physical stress or functional dyspepsia might cause the stress. keywords functional dyspepsia, physical stress, mental stress, sadaf stress scale (sss), rome iii criteria. citation: shankar p, mandhan n, zaidi smh, choudhry mh & kumar a. app. 2020; 7(1):25-30 corresponding author email: mohdzaidi06@hotmail.com doi: 10.29052/2412-3188.v7.i1.2020.25-30 received 16/02/2020 accepted 02/09/2020 published 01/10/2020 copyright © the author(s). 2020 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 26 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) introduction functional dyspepsia is a common gastrointestinal disorder characterized by chronic indigestion with no obvious physical cause1. it is usually referred to as a diagnosis of exclusion, which is made when all required investigations reveal no identifiable etiology1. the condition is multifactorial and therefore the etiological factors are diverse. globally, the prevalence lies in between 11.3% age ≥ 60 years compared to 9.9% with patients aged below 60, whereas in asian regions the reported frequency is in between 8% to 23%2,3. the prevalence among medical students is unknown. pathophysiological abnormalities accompanying the condition include accelerated gastric emptying, impaired gastric accommodation, gastric or duodenal hypersensitivity to distension, and nutrients4. literature confirms that stress affects the gutbrain communication, and induces pain, bloating and other gastrointestinal problems4,5. stress either be physical or mental greatly influences the gut bacteria which in turn alters the mood, emotion and behaviour. therefore, there is a direct impact of brain and gut activity over one another5. a study indicated that personality patterns including depression, anxiety and stress altered the individual’s gastrointestinal tract activity6. significant exposure to stress increases the risk of gastrointestinal tract diseases7. it is proposed that the mood alterations are associated with irritable bowel syndrome (ibs) and functional dyspepsia6. moreover, the young population is more likely to develop such gastric conditions as the current educational model imposes inadvertently opposing effects on the mental health of the learners and due to high frequency of depression and anxiety, they have increased susceptibility for disorders such as functional dyspepsia8. although it is believed that a little stress makes a positive impact and always makes the immune system stronger. individuals with moderate physical stress usually have improved cardiac health and their immune system performs better against infections. in addition, the progress after surgical procedures is also faster among individuals undergoing modest levels of stress9. it is said that physical stress is necessary for survival but within the optimal range. as chronic physical stress weakens the immune system and causes hypertension, anxiety, depression, fatigue, gastrointestinal, and cardiac difficulties9. mental stress affects parts of the brain involved in memories, perception, thoughts and decision-making processes. moderate stressful events enable the brain to perform better. but continuous academic stress and/or work stress involving increased cognitive functioning leads to psycho-somatic abnormalities which in turn affects the gastrointestinal system and function9. the rome iii criteria is frequently employed to establish the diagnosis of functional dyspepsia and other gastrointestinal disorders which includes postprandial fullness, early satiety, pain and burning sensation in epigastrium providing negative status on the required investigation including an upper gi endoscopy, with the onset of at least six months and the duration of at least three months10. a stress evaluation concept and specific stress evaluating tool for the local pakistani population, sadaf stress scale (sss) has been developed and widely used for the evaluation of seven different types of stresses specifically among the pakistani people11. the scale is divided into seven subcategories comprising of 114 items entitled physical, mental, psychosocial, traumatic, nutritional, emotional, and chemical stress. preliminary data collected showed high variability and predictability. cronbach reality test obtained a value between 0.945 and 0.916. revises sss use 95 items, employing spearmen brown coefficient analysis with significant coefficient levels9. although dyspepsia is not a life-threatening entity, it certainly has dreadful effects on the patient’s quality of life12. it is one of the 27 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) diseases having a significant medical, economic, social, and political impact on the society. in pakistan, information about epidemiology and risk factors for functional dyspepsia and related disorders specifically among university or medical students is scarce. the objective of the present study was to determine the frequency of functional dyspepsia and its association with mental and physical stress among medical students of pakistan. methodology a survey based study was conducted at 3 medical colleges (karachi medical & dental college, sindh medical college, and dow medical college) of karachi, pakistan. we approached a total number of 240 medical students out of which 221 volunteered to participate in the study. prior informed consent was obtained from all subjects. study participants were asked to fill a structured questionnaire comprising of demographics, lifestyle, and food intake information. rome iii criteria were used to identify functional dyspepsia10 and to measure the physical and mental stress, sub-section of sadaf stress scale (sss) was used11, this likert scale consists of 5-point scale ranging 1 to 5 i.e., never, rarely, sometimes, very often, always and the response scores were calculated and categorized into the level of stress i.e., normal, mild, moderate, and severe. data analysis was performed using the spss version 22.0. the frequency was calculated for functional dyspepsia. correlation with stress variables and gender differences were determined using spearman’s rho and mann whitney u test, respectively. we also calculated the mean rank for functional dyspepsia and physical and mental stress with the kruskal wallis h test. the p-values ≤ 0.05 was considered statistically significant. result the data from 221 medical students was analyzed, of them, the majority were females (67.4%). the mean age of the sample population was 21.47 years. a total of 34.8% of subjects were diagnosed to have functional dyspepsia, out of which around three quarters were females (68.5%). a strong positive correlation was observed among functional dyspepsia and both mental (r=0.411; p=0.001) and physical stress (r=0.475; p=0.001) (table 3). the difference in symptoms of dyspepsia was statistically insignificant between both genders (pvalue=0.69). table 1: demonstrates the gender-based differences in the relative frequency of functional dyspepsia in the study population variable gender n(%) p-value male (n=72) female (n=149) frequency of dyspepsia 25(32.4) 52(68.5) 0.69 *p-value<0.05 is considered significant as per the results obtained from rome iii criteria, functional dyspepsia was more frequent among the 3rd year (32.4%) and 5th year (22%) medical students. concerning physical and mental stress, the results were comparable in all years but it was observed that the 1st year students had relatively maximum physical and mental stress. table 2: demonstrates the yearly distribution of the sample population with reference to the frequency of dyspepsia and stress (mental & physical) 28 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) years total n(%) rome iii criteria (n) dyspepsia n(%) sss (mean ranks) heartburn epigastric pain abdominal fullness early satiety mental stress physical stress 1st 31(14) 12 13 13 13 13(16.9) 136 140 2nd 26(11.8) 11 11 11 11 11(14.3) 111.5 130.8 3rd 75(33.9) 25 24 25 25 25(32.4) 106.6 98.8 4th 31(14) 11 11 12 11 11(14.3) 118.5 125.1 5th 58(26.2) 17 17 17 17 17(22) 97.6 93.3 table 3 shows the correlation of physical and mental stress with functional dyspepsia, it was found to be significantly correlating with mental and physical stress among the studied population (pvalue=0.001). table 3: correlation of functional dyspepsia with mental and physical stress. variables co-relation coefficient p-value dyspepsia mental stress 0.411 0.001* physical stress 0.475 0.001* *p-value < 0.05 is considered significant discussion stress was determined as a positive risk factor for the development of functional dyspepsia among the local medical students, which is also supported by several previous studies13-16. the regular diagnostic rate of functional dyspepsia among the pakistani population ranges between 11 to 15%, as reported by local physicians17. in our study population, the frequency of functional dyspepsia was found to be 34.8%. in comparison, an indian study reported a lesser frequency than our estimated figure despite having similar demographics and lifestyle factors2. this inflated rate might be due to higher (moderate and severe) physical and mental stress in our study population. in support several studies confirmed the bidirectionality of the brain-gut pathway i.e. stress has detrimental effects on the quality of life of an individual, influencing mood, emotions and gut activity and hence leads to functional gastrointestinal disorders18,19. a higher frequency of functional dyspepsia is observed among individuals enduring high occupational stress, intense physical activity and those involved in cognitive activities, specifically students20,21. other than stress, several other lifestyle factors including tobacco smoking, alcohol consumption and junk food consumption, etc. increase the likelihood of development of functional dyspepsia2,22,23. although alcohol consumption is yet not common locally but smoking and junk food consumption remain at the forefront of doing the damage to the normal gut activity in addition to stress. increased consumption of junk and fried food was found among the enrolled study participants with a high frequency of functional dyspepsia. people suffering from functional dyspepsia exhibit a greater rate of absence from work, reduction in productivity, and higher dependence on healthcare resources compared to general population24. for students, the symptoms associated with functional dyspepsia may cause a significant impact on the study habits, concentration span, class attendance, and test performance. 29 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) to the best of our knowledge, none of the pakistani universities currently have a students’ health counselling program particularly related to the students’ mental and psychological health. campus-wide health seminars/workshops discussing and highlighting symptoms as well as management of stress-induced psychological and physical impairment, e.g. functional gastrointestinal disorders, can lead to a reduction in the overall prevalence of these disorders. besides, one of the major limitations of the study was the unavailability of the stool antigen test for helicobacter pylori infection and upper gi endoscopy, which should have been done as a screening protocol. conclusion in conclusion, our findings indicated an alarming frequency of functional dyspepsia among medical students and its strong correlation with mental and physical stress. in order to devise better management of functional dyspepsia and to minimize the chronic depletion of resources, further largescale extensive studies investigating the gutbrain communication among the subjects with functional dyspepsia must be carried out involving the local population. acknowledgment the authors would like to acknowledge momina qureshi and masharib bashar for their support during the study conduction. references 1. oustamanolakis p, tack j. dyspepsia: organic versus functional. j clin gastroenterol. 2012; 46(3): 175-190. 2. basandra s, bajaj d. epidemiology of dyspepsia and irritable bowel syndrome (ibs) in medical students of northern india. j clin diagn res. 2014;8(12): jc13jc16.18. 3. egloff n, beer c, gschossmann jm, sendensky ah, von känel r. pathogenesis of functional gastrointestinal disorders – an interdisciplinary perspective. praxis (bern 1994) 2010; 99: 419-427. 4. camilleri m, functional dyspepsia and gastroparesis. dig dis 2016; 34:491-499. 5. american psychological association. stress effects on the body. available at: https://www.apa.org/helpcenter/stress /effects-gastrointestinal 6. huerta-franco m-r, vargas-luna m, tienda p, delgadillo-holtfort i, ballezaordaz m, flores-hernandez c. effects of occupational stress on the gastrointestinal tract. world j gastrointest pathophysiol. 2013; 4:108–118. 7. konturek pc, brzozowski t, konturek sj. stress and the gut: pathophysiology, clinical consequences, diagnostic approach and treatment options. j physiol pharmacol. 2011; 62:591–599. 8. altaf m, f.altaf k, zahid s, sharf r, inayat a, owais m, usmani h. medical students bearing mental stress due to their academic schedule. ijehsr. 2013;1(2):9397. 9. ahmed s & noushad s. psychophysiology of stress. pakistan: advance educational institute & research centre. 2014: 1-147. 10. drossman da, corazziari e, delvaux m, spiller rc, talley nj, thompson wg, whitehead we. rome iii: the functional gastrointestinal disorders, degnon associates. inc., mclean, va. 2006:1-29. 11. noushad s, ahmed s. novel stress evaluating tool; sadaf stress scale (sss), tested so far on pakistani population. ijehsr. 2013;1(2):57-61. 12. lee sw, lee ty, lien hc, yeh hz, chang cs, ko cw. the risk factors and quality of life in patients with overlapping functional dyspepsia or peptic ulcer disease with gastroesophageal reflux disease. gut and liver. 2014; 8(2):160-164. 13. mak ad, wu jc, chan y, chan fk, sung jj, lee s. dyspepsia is strongly associated 30 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) with major depression and generalised anxiety disorder‐a community study. aliment pharmacol ther. 2012; 36(8):800810. 14. devanarayana nm, mettananda s, liyanarachchi c, nanayakkara n, mendis n, perera n, rajindrajith s. abdominal pain–predominant functional gastrointestinal diseases in children and adolescents: prevalence, symptomatology, and association with emotional stress. j pediatr gastroenterol nutr. 2011; 53(6): 659-665. 15. vanuytsel t, van wanrooy s, vanheel h, vanormelingen c, verschueren s, houben e, rasoel ss, tόth j, holvoet l, farré r, van oudenhove l. psychological stress and corticotropin-releasing hormone increase intestinal permeability in humans by a mast cell-dependent mechanism. gut. 2014; 63(8):1293-1299. 16. de la roca-chiapas jm, solís-ortiz s, fajardo-araujo m, sosa m, córdovafraga t, rosa-zarate a. stress profile, coping style, anxiety, depression, and gastric emptying as predictors of functional dyspepsia: a case-control study. j psychosom res. 2010; 68(1): 73-81. 17. azam z. functional gi disorders include functional dyspepsia and irritable bowel syndrome [internet]. karachi (pakistan): pulse international; [updated 2015 may]. available at: http://www.pulsepakistan.com/index.php/ main-news-july-1-15/1237-functional-gidisorders-include-functional-dyspepsia-andirritable-bowel-syndrome-dr-zahid-azam 18. drossman da, li z, andruzzi e, temple rd, talley nj, thompson wg, whitehead we, janssens j, funch-jensen p, corazziari e, richter je. us householder survey of functional gastrointestinal disorders. dig dis sci. 1993; 38(9): 1569– 1580. 19. el‐serag hb, olden k, bjorkman d. health‐related quality of life among persons with irritable bowel syndrome: a systematic review.aliment pharmacol ther. 2002; 16(6): 1171–1185. 20. huerta-franco mr, vargas-luna m, tienda p, delgadillo-holtfort i, ballezaordaz m, flores-hernandez c. effects of occupational stress on the gastrointestinal tract. world j gastrointest pathophysiol. 2013; 4(4):108-118. 21. ganasegeran k, al-dubai sa, qureshi am, al-abed aa, am r, aljunid sm. social and psychological factors affecting eating habits among university students in a malaysian medical school: a crosssectional study. nutr j. 2012; 11: article 48. 22. shaib y, el-serag hb. the prevalence and risk factors of functional dyspepsia in a multiethnic population in the united states. am. j. gastroenterol. 2004; 99: 2210-2216. 23. tougas g, chen y, hwang p, liu mm, eggleston a. prevalence and impact of upper gastrointestinal symptoms in the canadian population: findings from the digest study. domestic/international gastroenterology surveillance study. am. j. gastroenterol. 1999; 94: 2845-2854. 24. moayyedi p, mason j. clinical and economic consequences of dyspepsia in the community. gut. 2002; 50 (suppl 4): iv10-2. 1 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v8.i1.2021.1-5 editorial changes in the process used to critique articles based on psychophysiologically based research studies richard a. sherman editor, annals of psychophysiology. large numbers of audits have shown that we are inundated with faked studies, poorly done studies, improperly massaged data, sales pitches, etc. few of the major studies can be replicated, and many journals still refuse to publish replications – especially if they don't support the original study's results. thus, the way we need to critique studies has shifted from a relatively straightforward evaluation of the study to a detective process, including evaluating the author(s) and the journal in which the study appeared. this set of criteria is only applicable to research studies using human or nonhuman subjects. studies appropriate for applying the following criteria can be from any area within psychophysiology, including clinical, sports, education, military, etc. it is not for theoretical articles, thinly veiled sales pitches, etc. the critique process is active and generally involves more than reading an article then accepting its conclusions at face value: the person critiquing a research article needs to gain some perspective on the area the article discusses, the authors' qualifications and experience (are they sales folk selling something, etc.), the literature the authors included in their review as opposed to what is published, etc. it is also likely that the critiquer will be checking the statistics and other crucial portions of the article by using statistical software. citation: sherman ra. changes in the process used to critique an article based on a research study from the field of psychophysiology. app.2021; 8(1):1-5 corresponding author email: drrichsherman@gmail.com doi: 10.29052/2412-3188.v8.i1.2021.1-5 received 22/03/2021 accepted 22/04/2021 published 01/06/2021 copyright © the author(s). 2021 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v8.i1.2021. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 2 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 the author(s)  check their cvs online.  do their degrees and experience match the expertise needed for the study?  are they from institutions (academic, organizations/government labs, corporations, etc.) that seem legitimate? if you haven’t heard of the institution, take a moment to look it up. many are fake.  do one or more of the authors work for or seem to get funding from groups selling products associated with the study?  is this one of a string of articles on the topic?  does it look like they are selling something?  is there a conflict of interest? the journal  remember that there are now so many thousands of journals that anybody can get any “study” published. many of the journals are predatory (charge to publish) and have fake peer-reviews. these journals will publish anything submitted to them.  is the journal in which the article was published appropriate for the audience or a very odd journal choice?  does the journal seem to be peerreviewed with a reasonable impact factor or a predatory journal that will publish anything? if the journal does not have an impact factor, it means that virtually nobody is citing articles from the journal. very legitimate specialty journals such as applied psychophysiology and biofeedback are read by far fewer people and cited by fewer authors than the top general scientific journals. so, while the new england journal of medicine has an impact factor of about 75, applied psychophysiology has a relatively respectable impact factor of about 2. if the impact factor is below 0.5, something is probably wrong with the journal.  does the journal charge the author to publish in the journal? if so, it is not likely to be a legitimate journal. the exception is when a granting agency demands that articles based on work they support be published as “open access” so anybody can read the entire results of the work they supported. this is a requirement for all federal grants. journals are permitted to change open access fees.  is the journal dedicated to selling a product?  does the journal's website look legitimate, or is it poorly set out with mistakes? the abstract does the abstract match the findings in the article, or did the authors add extra, exaggerate significance, etc.? introduction & literature review  does the introduction and literature review differentiate between actual studies and sales pitches?  is the basic idea of the study plausible or so far from anything that makes sense that you would have a difficult time believing the results? if this is the case, do the authors present a reasonable case for presenting proof for an extraordinary idea? in other words, they need to convince you that they did the study and had sufficient safeguards against data manipulation and cheating to have gotten the results they claim. remember that nearly all (but not all) such studies fail replication and are found to be either fraudulent in some way or simply poorly performed. think of the infamous “prison” experiment 3 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 where it turns out that the college student “guards” were told just what to do to influence the outcome.  is the problem being studied identified clearly and precisely?  is it sufficiently limited in scope so the study could be done?  is the problem justified in light of theoretical and empirical work relevant to the topic?  what does the literature say? how does the study fit with what is known? how does it contribute to gaps in knowledge?  is the theoretical and practical significance of the problem discussed?  do the authors discuss the importance of studying the problem relative to the risks to the subjects?  are the hypotheses tied to the problem being investigated and then clearly stated in a testable way using the proposed outcome measures?  given the material in the introduction and the literature review, is the experimental design appropriate to the stage of establishment of efficacy, etc. (are the authors performing a placebocontrolled study when it is only time for an open study)?  is the study very oddly designed or typical for what the investigators are working on?  is the literature analyzed or just listed without comment? did they mix sales pitches and testimonials with actual studies?  in the literature review, can you tell if the authors did a solid job or just listed articles they found which seem to bear on the study?  for example, if they cited bem’s 2011 (j of personality and social psychology 100) incredible claim that students who take a test then (after taking the test) practice for it, will do better on the initial test if they are given information in the post-test practice relevant to the test they just took, did the authors cite the three failures to replicate and point out the fatal flaws in the design?  are the studies referenced by the authors unpublished and only referred to in books without substantial data & detail + lacking peer review?  were the outcome measures justified in the introduction/literature review? methods  is the study well designed and using an appropriate design for what the authors want to find out? if the design is not typical for developing the idea (pilot, single group, etc.), be very suspicious.  is the study design plausible? (e.g. could it be performed as stated, or is there too much for a subject to do or remember?)  are the outcome measures related to the problem?  are they sensitive enough to pick up likely changes?  are they reliable and valid for the population being studied?  are they likely to be the best, or is there something fishy about them as common outcome measures for the problem aren't listed?  is there sufficient detail for you to perform the study without having to contact the authors? if not, something is wrong! the intervention must be clearly described in great detail, as must how the outcome measures were utilized.  did a separate team apply the outcome measures than the one performing the treatment? (subjects regularly lie to the treatment team about how well the treatment worked.)  can you tell how the subjects were recruited? would the method lead to bias in results (e.g. subjects were from only specialty clinics when the subjects 4 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 are supposed to represent a general population, were the subjects found on a web site populated mainly by people who have more extensive problems with the disorder than might be found in a general population?)  are the variables being measured/recorded relevant to the hypotheses and basic question the study is trying to answer (e.g. for a pain study, do they have several ways to assess pain or just ask how happy the subjects are with the outcome?)  are the outcome measures as objective as possible? for outcome measures that count on scoring intensity of a problem by various investigators, was a way to assure that all investigators score the same way?  is there evidence that the person applying the intervention already had sufficient expertise in using the intervention, so there is no significant learning curve during the study?  if this is a double-blind, placebocontrolled study, was it registered in advance? remember that nearly all published studies show significant findings in the direction of the hypothesis without preregistration, but with registration, only a few do. this is because investigators conducting preregistered studies have great difficulty hiding studies that didn’t work out or changing them to make it seem they produced significant results.  can you tell the method used for randomizing?  were the subjects adequately diagnosed (even for sports studies, this is crucial)? were the diagnostic/sorting criteria listed?  was the intensity of the intervention sufficient to produce an effect? (e.g. two muscle tension biofeedback treatments for jaw pain probably won’t help much.)  was there an adequate pre-treatment baseline so normal symptom variability was established?  how were the number of subjects likely to be needed for the study determined (e.g. power analysis based on pilot work, etc.)? results / statistics  did the data analysis use statistical techniques appropriate to the design, or are they reporting odd techniques? if the expected techniques are not reported, then the odds are they did not show the results the investigators wanted, so they looked for obscure tests that would give the results they wanted.  when you look at the demographic breakout of the groups, are they too similar to be believable?  were any subjects excluded from the final analysis? if so, were details of their results presented?  were the pre and post-treatment (or between groups) symptom intensities typical of the general population (e.g. number of headaches per month?). remember that small groups can have very different levels than the general population by random choice of subjects. a small but consistent change that seems statistically significant can still fall within the general population's normal variability.  were there sufficient subjects to detect a difference if there is one given inter subject or intra subject variability?  were there sufficient subjects for the results to be believable regardless of finding a “significant” difference?  was the follow-up long enough so the duration of any changes could be estimated?  can you tell which of the subjects learned the technique, used the medication, etc.? the results need to 5 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 divide subjects who didn’t learn/use the medication from those who did. (the subjects who didn’t learn the technique shouldn’t do well.)  for parametric techniques, can you tell if the data are normally distributed and about the same amount of spread for each group?  can you tell if there were sufficient subjects to find a difference between groups or before/after if there is one?  were sufficient descriptive statistics presented, so the results are clear?  if you are suspicious of the statistics, there should be sufficient descriptive statistics to run your test.  was any statistical difference related to clinical significance (a small but consistent difference showing as statistically significant but meaningless in the real words)? did the authors discuss effect size as well as p values? the major concern here is the “effect” size of the result. the conclusion/discussion  in the conclusion and the abstract, is this a sales pitch, or do the results support the conclusion?  does political, economic, or other bias show in the discussion?  are the findings related to research noted in the introduction/literature review?  is it obvious that some articles were left out of the literature review and then skipped in conclusion?  are the conclusions valid and justified given the actual results of the analysis and the study’s limitations?  are the generalizations based on the study appropriate or grandiose?  the bottom line: do you trust what the authors did and said? would you change your practice based on the study? https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v8.i1.2021.1-5 annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 faizan mirza 1 letter to editor doi: 10.29052/2412-3188.v5.i1.2018.1-5 obesity; an outcome of abnormal eating behavior faizan mirza university of karachi, pakistan corresponding author email: faizan.mirza@uok.edu.pk received 26/06/2018; accepted 20/09/2018; published 10/10/2018 the arabic word for health صحي is synonymous in english language to “weight” وزن (khoury, 2001), and a cultural link for perceiving weight as health can very well be understood, the impact of arabic culture and values on a random pakistani cannot be denied under any circumstances. obesity is a major concern, in adults and more so in children. pakistan is going through a transitional phase for some decades whereby changes are coming across in lifestyles, family structures, incomes, a new set of stresses, rural to urban shift, migrants’ influx making the transition all the more complex when compared to other countries (nanan, 2002). being overweight and being obese is associated with an increased risk of early mortality or debilitating diseases (who, 1998). in feb 2000, who bmi cutoffs for adults being overweight in asia pacific region were reported >23 while >25 for being obese. a 2002 study on pakistani population showed 22% and 37% of urban men and women respectively to be obese as compared to 9% and 14% rural men and women of comparable age group, 22-44 (nanan, 2002). the study outlines adopted lifestyle changes when comparing urban and rural populace, where diet quality and quantity together with a much mechanized lifestyle can easily be blamed for. it doesn't come off as a surprise that urban population is at a higher risk of developing noncommunicable diseases, such as hypertension, cardiovascular disorders, type 2 diabetes mellitus, cancer which resulted in 63% deaths globally. (david et al., 2012). in 1953 first of its kind study showed a higher incidence of coronary heart diseases in inactive bus drivers than active bus conductors (morris et al. 1953), suggesting that an active lifestyle can certainly promote a much healthier state of the body. not only exercise to promote a healthier lifestyle, but it can also delay the onset of 40 diseases (ruegsegger & booth, 2018). lack of exercise can be regarded as a major cause of chronic illness leading to death (mokdad et al., 2004). apart from bmi, the whr (waist (cm)/ hip (cm)) waist to hip ratio can also be used to highlight the fat distribution of the body and body shape (who, 1998 & mckeigue, 1996). in adults, fat is stored primarily beneath the skin as subcutaneous fat tissue, where 80% of body fat resides (ibrahim 2010). if a person takes in more calories beyond the capacity of the body to store it under the skin, it gets stored as visceral fat, around and in vital organs such as liver, pancreas, intestines that in turn release inflammatory mediators increasing vulnerability to noncommunicable diseases (chaldakov et al., 2003). some of these mediators have been associated with impaired memory and compromised cognitive skills (trollor et al., 2012). south asians as compared to europids have a greater tendency of abdominal fat deposition and it shows a gender bias, where men are more likely to develop central obesity than women (who, 2000 & mckeigue, 1996). about 300 gene loci have been associated with obesity (lau, 1997) with an intricate polygenic inheritance. http://www.aeirc-edu.com/ mailto:faizan.mirza@uok.edu.pk annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 faizan mirza 2 so should adults be the only ones concerned? well, the first link between fitness and enhanced cognitive skills was established in a group of children (clarke, 1958). an increased bmi in childhood has been linked with a decline in cognitive functioning (smith et al. 2011) poor performance in academics (castelli et al., 2007) predisposition towards metabolic and cardiovascular disorders (ebbelling et al., 2002) poor health and high risk of mortality (must et al., 1992), suggesting that childhood obesity can actually be a greater concern than adult obesity. in 2000 the framingham study stated that type 2 diabetes has a strong genetic interplay, an individual with a single diabetic parent is 3.5 times likely to get diabetes while if both parents were diabetic, the probability rise to six folds (meigs et al., 2000). a united states (us)-based survey predicted in 2001 that by 2050 29 million us residents would be suffering from type 2 diabetes, however the alarming number of 29 million was reached in 2012 only, it was then predicted that by 2050 1 in 3 would be suffering from type 2 diabetes (boyle et al., 2001). a study in 2000 stated that pakistan ranks 8th in the world diabetes caseload and is expected to rise to 4th position by 2025, while currently having the highest prevalence of 11% in all south asian countries (white et al., 2000). while most studies have attributed obesity with male gender, a 1999 study had a contrasting approach, suggesting that urban middle-aged women are more likely to gain obesity than aged matched men & young women (james, 1999) that again can be linked with poor eating habits and a sedentary lifestyle. in pakistan, the situation of cardiovascular disorders, hypertension, elevated cholesterol are more prevalent in nationals belonging to a higher socioeconomic strata which is a complete contrast from developed countries where these factors are more common in lower socioeconomic strata (pappas & gergen, 2001). what can be done? in a recent study on adults at high risk of developing type 2 diabetes, its prevalence was reduced by 58% by extensive lifestyle changes where intervention was brought about with exercise and diet (knowler et al., 2002). despite the well-known benefits of exercise, most adults and many children lead relatively sedentary lifestyles and are not active enough to achieve the health benefits of exercise (warburton et al. 2006). apart from the systemic benefits of exercise, it is known to have an immense positive effect on the mental state as well. exercise enhances the synthesis of bdnf (cotman & bretchold, 2002) causing increased neurogenesis that in turn facilitates memory consolidation and learning skills (kobilo et al., 2011). this was further strengthened by a study on rodents where neurogenesis was observed in the hippocampus in the group exercising regularly, an area involved in learning and consolidation of memory. (gomez et al., 2013). depression is a common mental illness, exercise increases kyunurein that leads to an increased synthesis of kynurenic acid that helps in fighting stress induced depression (agudelo et al., 2014). experimenting with rats showed exercise enables fighting drug addiction, cocaine (larson & carol, 2005) and can be a viable interventional approach at rehabilitation centers. neurogenic reserve hypothesis (kempermann, 2003) proposed that if an individual is exposed to physical activities earlier in life, it would lead to optimizations in brain networks associated with memory's and cognition, furthermore, a reserve of precursor cells is also created that http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 faizan mirza 3 influences learnings abilities of that child throughout the lifespan. in 2010 a study concluded higher fit children to have a larger hippocampal volume (chaddock, 2010). exercise apart from delaying the onset of chronic diseases promotes mental health. studies have suggested improvements in cognitive skills in exercising individuals (beiers et al., 2014) , lowering anxiety (greenwood et al., 2012) helping fight depression (kratz et al., 2014) , and more importantly delays the progression and even onset of neurodegenerative diseases such as alzheimer’s and parkinson’s (mattson et al., 2014) exercise is the holy grail if pakistanis are to reduce the burden of non-communicable diseases in the next 20 years, or else if our current adult generation fails to acknowledge the dangers of obesity in their age group as well as in children, the longterm effects would be anything but beneficial. a time bomb wrapped in fancy packaging is a bomb nonetheless and is bound to explode. conflicts of interests none. acknowledgment none. funding none. references  agudelo, l. z., femenía, t., orhan, f., porsmyr-palmertz, m., goiny, m., martinez-redondo, v. & pettersson, a. t. (2014). skeletal muscle pgc1α1 modulates kynurenine metabolism and mediates resilience to stressinduced depression. cell, 159(1), 3345.  beier, m., bombardier, c. h., hartoonian, n., motl, r. w., & kraft, g. h. (2014). improved physical fitness correlates with improved cognition in multiple sclerosis. arch phys med rehabil, 95(7), 1328-1334.  bloom, d. e., cafiero, e., jané-llopis, e., abrahams-gessel, s., bloom, l. r., fathima, s., & o’farrell, d. (2012). the global economic burden of non-communicable diseases (no. 8712). program on the global demography of aging.  boyle, j. p., honeycutt, a. a., narayan, k. v., hoerger, t. j., geiss, l. s., chen, h., & thompson, t. j. (2001). projection of diabetes burden through 2050: impact of changing demography and disease prevalence in the us. diabetes care, 24(11), 19361940.  castelli, d. m., hillman, c. h., buck, s. m., & erwin, h. e. (2007). physical fitness and academic achievement in third-and fifth-grade students. j sport exerc psychol, 29(2), 239-252.  chaddock, l., erickson, k. i., prakash, r. s., kim, j. s., voss, m. w., vanpatter, m., pontifex m. b., raine l. b., konkel a. & cohen, n. j. (2010). a neuroimaging investigation of the association between aerobic fitness, hippocampal volume, and memory performance in preadolescent children. brain research, 1358, 172183.  chaldakov, g. n., stankulov, i. s., hristova, m., & ghenev, p. i. (2003). adipobiology of disease: adipokines and adipokine-targeted pharmacology. curr pharm des, 9(12), 1023-1031.  clarke, h. h. (1958). physical fitness benefits: a summary of research. education, 78, 460-466.  cotman, c. w., & berchtold, n. c. (2002). exercise: a behavioral intervention to enhance brain health and plasticity. trends neurosci, 25(6), 295-301. http://www.aeirc-edu.com/ https://www.sciencedirect.com/science/article/pii/s0006899310018317#! annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 faizan mirza 4  ebbeling, c. b., pawlak, d. b., & ludwig, d. s. (2002). childhood obesity: public-health crisis, common sense cure. the lancet, 360(9331), 473-482.  gomez‐pinilla, f., & hillman, c. (2013). the influence of exercise on cognitive abilities. compr physiol, 3(1), 403-428.  greenwood, b. n., loughridge, a. b., sadaoui, n., christianson, j. p., & fleshner, m. (2012). the protective effects of voluntary exercise against the behavioral consequences of uncontrollable stress persist despite an increase in anxiety following forced cessation of exercise. behav brain res, 233(2), 314-321.  ibrahim, m. m. (2010). subcutaneous and visceral adipose tissue: structural and functional differences. obes rev, 11(1), 11-18.  james, w. p. t., & ralph, a. (1999). new understanding in obesity research. proc nutr soc, 58(2), 385393.  kempermann, g. (2008). the neurogenic reserve hypothesis: what is adult hippocampal neurogenesis good for?. trends neurosci, 31(4), 163169.  khoury, s. (2001). a cultural approach to diabetes therapy in the middle east. diabetes voice, 46(1), 22-27.  knowler, w. c., barrett-connor, e., fowler, s. e., hamman, r. f., lachin, j. m., walker, e. a., & nathan, d. m. (2002). reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. n engl j med, 346(6), 393-403.  kobilo, t., yuan, c., & van praag, h. (2011). endurance factors improve hippocampal neurogenesis and spatial memory in mice. learn. mem, 18(2), 103-107.  kratz, a. l., ehde, d. m., & bombardier, c. h. (2014). affective mediators of a physical activity intervention for depression in multiple sclerosis. rehabil psychol, 59(1), 57.  larson, e. b., & carroll, m. e. (2005). wheel running as a predictor of cocaine self-administration and reinstatement in female rats. pharmacol biochem behav., 82(3), 590-600.  lau, d. c. (1999). call for action: preventing and managing the expansive and expensive obesity epidemic. can med assoc j, 160(4), 503-505  mattson, m. p. (2014). interventions that improve body and brain bioenergetics for parkinson's disease risk reduction and therapy. j parkinsons dis., 4(1), 1-13.  mckeigue, p. m. (1996). metabolic consequences of obesity and body fat pattern: lessons from migrant studies. the origins and consequences of obesity, chichester, wiley, pp. 5467  meigs, j. b., cupples, l. a., & wilson, p. w. (2000). parental transmission of type 2 diabetes: the framingham offspring study. diabetes, 49(12), 2201-2207.  mokdad, a. h., marks, j. s., stroup, d. f., & gerberding, j. l. (2004). actual causes of death in the united states, 2000. jama, 291(10), 12381245.  morris, j. n., heady, j. a., raffle, p. a. b., roberts, c. g., & parks, j. w. (1953). coronary heart-disease and physical activity of work. the lancet, 262(6796), 1111-1120.  must, a., jacques, p. f., dallal, g. e., bajema, c. j., & dietz, w. h. (1992). long-term morbidity and mortality of overweight adolescents: a follow-up of the harvard growth study of 1922 to 1935. n engl j med, 327(19), 13501355. http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 faizan mirza 5  nanan, d. j. (2002). the obesity pandemic-implications for pakistan. j pak med assoc, 52(342), 6-11.  pappas, g., akhtar, t., gergen, p. j., hadden, w. c., & khan, a. q. (2001). health status of the pakistani population: a health profile and comparison with the united states. am j public health, 91(1), 93.  ruegsegger, g. n., & booth, f. w. (2018). health benefits of exercise. cold spring harb perspect med, 8(7), a029694.  smith, e., hay, p., campbell, l., & trollor, j. n. (2011). a review of the association between obesity and cognitive function across the lifespan: implications for novel approaches to prevention and treatment. obes rev, 12(9), 740-755.  trollor jn, smith e, agars e, kuan sa, baune bt, campbell l, samaras k, crawford j, lux o, kochan na, brodaty h, sachdev p, (2012),the association between systemic inflammation and cognitive performance in the elderly: the sydney memory and ageing study. age, 34(5), 1295-1308.  warburton, d. e., nicol, c. w., & bredin, s. s. (2006). health benefits of physical activity: the evidence. can med assoc j, 174(6), 801-809.  white f, rafique g, azam i, et al., (2000). diabetes prevalence and projections for pakistan, and implications of the detection and management of hypertension. 4th international symposium, pakistan hypertension league, quetta, pakistan. october 8.  world health organization, (2000) the asia-pacific perspective: redefining obesity and its treatment. melbourne, health communications australia.  world health organization. (1998). preventing and managing the global epidemic of obesity. report of the world health organization consultation on obesity. geneva: world health organization. . http://www.aeirc-edu.com/ 30 app| published by aeirc| https://doi.org/10.29052/2412-3188.v6.i1.2019.30-34 issn 2412 3188 original article comparative analysis of perceived medical school stress among freshman & graduate year senior students farhat minhas1, muhammad mujtaba2, sohail jamil2, unaiza javed3, muhammad waqas rabbani4 & iftikhar minhas5 1department of behavior sciences, avicenna medical & dental college, lahore 2department of psychiatry – gulab devi hospital, lahore 3department of behavioral sciences, rashid latif medical college, lahore 4human development research foundation, islamabad 5department of psychiatry, shalamar medical & dental college, lahore abstract background: research indicates that medical students are exposed to higher stress levels due to the extensive academic programs and intense workload. in order to control this public health issue, it is important to understand the significance and impact of stress on the personal as well as professional life of the medical school students. to compare the perceived medical school stress (pmss) among freshman and graduate year students of medical school. methodology: this cross-sectional study was conducted on a sample of 200 medical students from three different private medical colleges at lahore. no gender or age-related biasness was considered, subjects details including sociodemographic characteristics and pmss scores were recorded using a structured questionnaire. the data was analyzed using spss version 21 & microsoft excel 2017. results: out of the 200 students, 100 were freshman with a mean age of 19 ± 0.5 years and 100 were graduate year students with a mean age of 22.9 ± 0.8 years. there were 29.5% males while the remaining 70.5% were females. the mean difference between the two groups of students in the pmss academic domain was 0.59 (p = 0.587) and the mean difference in the psychosocial domain was 0.54 (p = 0.788). the mean difference in the total pmss score was 0.05 (p = 0.999). conclusion: after careful consideration, it is concluded that the mean pmss score among medical students does not differ much between freshman and graduate year students. keywords medical school stress, medical students, perceived stress, medical education. citation: minhas f, mujtaba m, jamil s, javed u, rabbani mw, minhas i. comparative analysis of perceived medical school stress among freshman & graduate year senior students. app. 2019; 6(1):30-34 corresponding author email: farhat.minhas26@gmail.com doi: 10.29052/2412-3188.v6.i1.2019.30-34 received 11/03/2019 accepted 03/06/2019 published 12/10/2019 copyright © the author(s). 2019 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the author(s) declare that there is no conflict of interest in the preparation of this manuscript. https://doi.org/10.29052/2412-3188.v6.i1.2019. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 31 issn 2412 3188 app| published by aeirc| volume 6 issue 1 introduction medical education is deemed to be among the most demanding and challenging profession not only physically in terms of long and strenuous workhours but also mentally. during the course of the training, medical students undergo many psychological changes1. thus, the metamorphosis from an undergraduate student to a full-fledged physician is laced with several strains and pressures1. competitive environment, human suffering and exposure to death are some of the recognized academic medical school stressors2. these stressors negatively affect the health and quality of life of the students and the physicians leading to decreased performances which itself contributes to stress2,3. therefore, to break this vicious cycle it is important to understand the association between stress and performance during medical education. there is ample evidence supporting the belief that a high level of psychological distress is experienced during the difficult training leading to adverse consequences on student’s performance. stress is prevalent in as much as 90% of the medical students worldwide and the statistics indicate that doctors mostly suffering from stress are in early undergraduate years4-6. it is worth noting that stress, under normal circumstances and in controlled levels, is a beneficial aspect of human behaviour. it may help students learn more in shorter spans of time and to get more work done and succeed against odds. thus stress, in an optimal level, is beneficial but the acute burst of energy and the enhanced performance comes with a physical and psychological cost. moreover, overexperiencing stress can lead to physical and mental health problems and impairing cognitive functioning and learning abilities of medical students7,8. it may not be just a coincidence that student’s mental health progressively deteriorates as they move through their educational and training years. reviewing evidence from different studies leads us to believe that studies conducted on medical students in their later years of education and training reported the worst levels of stress, however, owing to the different study settings and varied educational environments, the results cannot be generalized and thus direct comparative evidence is much needed9,10. perceived medical school stress (pmss) instrument is the most validated stress tools for medical school students11, addressing stress induced by workload, competition and financial uncertainties. it mainly focuses and predicts the problems associated with mental health of the medical students12. the aim of this study was to examine the perceived stress among freshman and graduate year medical school students measured using the pmss scores. methodology a cross-sectional multicenter study was conducted upon a sample of 200 medical students from three different private medical colleges at lahore including lahore medical and dental college, avicenna medical and dental college & shalamar institute of health sciences. these students were then divided based on their academic performances as freshman and graduate year students including 100 students in each group. data like sociodemographic details and score of the pmss were recorded. the pmss is a 13-item questionnaire, responses are recorded on a 5-point likert scale (ranging from 1 = i strongly disagree; 5=i strongly agree). this questionnaire has a good reliability with cronbach's alpha value of 0.81. the recorded data was analyzed using spss version 21 & microsoft excel 2017. where all continuous variables were presented using mean and standard deviation. for association the chi-square test was applied used and p-value<0.05 was considered significant. result a total of 200 medical school students were selected for the study with 100 students in each group i.e. freshman and graduate year, with a mean age of 19±0.5 years and 22.9±0.8 32 issn 2412 3188 app| published by aeirc| volume 6 issue 1 years respectively. out of the total, there were 29.5% males while the remaining 70.5% were females. the mean difference between the two groups of students in the pmss academic domain was 0.59 (p = 0.587) and the mean difference in the psychosocial domain was 0.54 (p = 0.788). the mean difference in the total pmss score was 0.05 (p = 0.999). table 1: comparative analysis of perceived stress among freshman and graduate year students of medical schools freshman graduate year students p-value psycho-social domain 25±3.1 24.4±3.4 0.788 academic domain 22±2.8 22.6±3.1 0.587 pmss score 47.1±4.9 47±5.3 0.999 *pmss-perceived medical school stress. *values are given as mean ± sd. *p-value<0.05 is considered significant. discussion it is evident from previous literature that stress is prevalent among medical students, a national study in support concluded that around 90% of the enrolled medical students experienced stress at one or more points during their educational and training years13. another study from thailand showed high stress level among 61.4% of the medical students14. based on our results there was no significant difference in the mean pmss score among freshman and graduate year students. the studies mentioned above used different stress scales and students of different academic professions were selected, having different curricula and catered to different responsibilities. which might be the reasons behind variations in the levels of stress however, one thing is certain that the level of stress was high than levels that may be deemed healthy among the students enrolled in all of these studies13-15. the literature reports abundantly that female medical students suffer from stress more often than their male counterparts. in our research, the mean pmss scores reported by female medical students were significantly higher than the mean pmss scores reported by male medical students. one of the reasons for this may be the cultural constraints faced by females16. the study also strengthens the fact that academic and training related stressors are the main reasons for the aggravated stress levels among medical students. as reported in our study, academic factors had a stronger role to play than other psychosocial factors promoting stress among enrolled students. the stress, once it sets-in, then spills over to other aspects of a student’s life and manifest several adverse effects17. it is interesting to note that not only does stress from one source affect others but relief acquired from one aspect of the life helps alleviate stress from other aspects, and this is documented by a research from the united states that suggests that physical exercise, healthy lifestyle and a positive social environment reduce the cumulative stress level among students, thus highlighting opportunities for better health and highlighting the need of active incorporation of healthy co-curricular and extra-curricular activities in a medical students life18. the study had several limitations including sample size and population diversity. moreover, many of the potential cofounders were not observed. the students mental and 33 issn 2412 3188 app| published by aeirc| volume 6 issue 1 physical health and the previous academic records would also be helpful if assessed. no correlations were observed with respect to age and gender. the study was limited to three centers of lahore only which provides the diversity but the results are not sufficient enough to provide generalized view nationally. our study adds up to the need for highlighting these mental health issues existing among medical students and physicians which is mostly associated with their workload. therefore, pmss is a beneficial tool that should be used to identify stress initially and to cope with it accordingly. conclusion it is concluded from the study results that the mean pmss among medical students does not differ much between the different years i.e. similar findings were observed among freshman and graduate year students. however, despite not being much different, both are higher than what may be considered healthy for medical students. thus factors, other than increasing educational years and the resultant increase in difficulty of the course may be explored. acknowledgement we would like to thank our respective institutes for facilitating this research and dr. shazia jamil for her kind help. references 1. daya z, hearn jh. mindfulness interventions in medical education: a systematic review of their impact on medical student stress, depression, fatigue and burnout. med teach. 2018;40(2):146-153. 2. dyrbye ln, thomas mr, shanafelt td. medical student distress: causes, consequences, and proposed solutions. mayo clin proc. 2005;80(12):1613–1622. 3. wallace je, lemaire jb, ghali wa. physician wellness: a missing quality indicator. the lancet. 2009;374(9702):1714-1721. 4. fares j, al tabosh h, saadeddin z, el mouhayyar c, aridi h. stress, burnout and coping strategies in preclinical medical students. north am j med sci. 2016;8(2):75-81. 5. ludwig ab, burton w, weingarten j, milan f, myers dc, kligler b. depression and stress amongst undergraduate medical students. bmc med educ. 2015;15(1): article 141. 6. heinen i, bullinger m, kocalevent rd. perceived stress in first year medical students-associations with personal resources and emotional distress. bmc med educ. 2017;17(1): article 4. 7. paudel s, subedi n, shrestha a. stress and its relief among undergraduate dental students in a tertiary health care centre in eastern nepal. dentistry. 2013;3(157):2161-1122. 8. cool j, zappetti d. the physiology of stress. in medical student well-being 2019 (pp. 1-15). springer, cham. 9. dyrbye ln, sciolla af, dekhtyar m, rajasekaran s, allgood ja, rea m, knight ap, haywood a, smith s, stephens mb. medical school strategies to address student wellbeing: a national survey. acad med. 2019;94(6):861-868. 10. worly b, verbeck n, walker c, clinchot dm. burnout, perceived stress, and empathic concern: differences in female and male millennial medical students. psychol health med. 2019;24(4):429-438. 11. vitaliano pp, maiuro r, mitchell e, russo j. perceived stress in medical school: resistors, persistors, adaptors and maladaptors. soc sci med. 1989;28(12):1321–1329. 12. tyssen r, vaglum p, grønvold nt, ekeberg o. factors in medical school that predict postgraduate mental health problems in need of treatment. a 34 issn 2412 3188 app| published by aeirc| volume 6 issue 1 nationwide longitudinal study. med educ. 2001;35(2):110–120. 13. shaikh bt, kahloon a, kazmi m, khalid h, nawaz k, khan n, khan s. students, stress and coping strategies: a case of pakistani medical school. education for health-abingdoncarfax publishing limited-. 2004;17(3):346-353. 14. saipanish r. stress among medical students in a thai medical school. med teac. 2003;25(5):502-506. 15. morrison r, o'connor rc. predicting psychological distress in college students: the role of rumination and stress. j clin psychol. 2005;61(4):447460. 16. matheny kb, curlette wl, aysan f, herrington a, gfroerer ca, thompson d, hamarat e. coping resources, perceived stress, and life satisfaction among turkish and american university students. int j stress manag. 2002;9(2):81-97. 17. cohen js, patten s. well-being in residency training: a survey examining resident physician satisfaction both within and outside of residency training and mental health in alberta. bmc med educ. 2005;5(1): article 21. 18. shah m, hasan s, malik s, sreeramareddy ct. perceived stress, sources and severity of stress among medical undergraduates in a pakistani medical school. bmc med educ. 2010;10(1): article 2. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v6.i1.2019.29-30-34 49 app| published by aeirc| https://doi.org/10.29052/2412-3188.v8.i1.2021.49-61 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) review article a review of the literature on the impact of acute and chronic stress upon brain waves shamoon noushad1,3 , sadaf ahmed2 , basit ansari1 , yusra saleem2,3 s. farah batool2 & syeda farah batool4 1department of health, physical education and sports sciences, university of karachi, karachi-pakistan. 2physchophysiology research lab, mahq-biological research centreuniversity of karachi, karachi-pakistan. 3department of public health, malir university of science and technology, karachipakistan. 4 department of psychology, malir university of science and technology, karachi-pakistan. abstract background: the biological responses associated with stress originate in the brain and involve different physiological and physical effects. the direct effect of stress on cortical responses can be visualized by recording the brain’s electrical waves using an encephalograph. these waves are recorded by means of an electroencephalogram (eeg). eeg is the most commonly used neuroimaging technique to study the patterns of brainwaves and functioning of the brain. it also measures the variation of the electric field produced by neuronal activity a millisecond at a time. to systematically analyze published studies on the difference between brain wave patterns in terms of their frequencies among subjects with acute stress, chronic stress, and normal individuals. methodology: the data from published studies was arranged quantitatively and qualitatively by producing a planned summary measure. studies that focused on brain wave analysis of the eeg of healthy adult subjects with no history of mental illness or head injury were included in the review. the selected literature included many types of stressors that are acute or chronic, and that affected the neuronal electrical activity. the only electronic database utilized to identify relevant studies was pubmed. result: fifteen studies were included that were based on a variety of acute stressors to observe alterations in brain wave activity between stress-free and stressed states. these studies showed that stressors could be a causative factor to generate fluctuations in neuronal oscillations that also leads to significant psychological, physiological and neurobiological deteriorations to some extent. an additional sixteen studies were included, which showed the effect of chronic stress on the asymmetry of the amplitude in the frequencies of brain waves. conclusion: the most common change observed was in the alpha frequency (813hz), followed by changes in beta waves (13-30 hz) and theta (4-8hz). though, there is not always the same resultant pattern of waves explored with even the same type of stressors due to interpersonal differences in response to a stressful situation. keywords chronic stress, acute stress, brain waves, electroencephalography. citation: noushad s, ahmed s, ansari b, saleem y, batool sf, batool sf. a review of the literature on the impact of acute and chronic stress upon brain waves. app.2021; 8(1):49-61 corresponding author email: shamoon@aeirc-edu.com doi: 10.29052/2412-3188.v8.i1.2021.49-61 received 20/11/2020 accepted 07/05/2021 published 01/06/2021 copyright © the author(s). 2021 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v8.i1.2021. https://orcid.org/0000-0002-8078-4524 https://orcid.org/0000-0002-9635-0202 https://orcid.org/0000-0003-3919-2516 https://orcid.org/0000-0001-7605-1304 http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 50 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 introduction everyone, at least once in their lifetime, faces a stressful situation. this stress can be beneficial if it motivates a person to do challenging tasks to achieve their goals. but it can be harmful when it begins to affect the physical or mental health of the subject. the term stress is defined as; when the equilibrium between internal and external environment is disturbed, it alters the bodily mechanisms1. this scenario casts a bad impact on the central, and peripheral regulatory systems that leads to deprived health and mental wellbeing2. stress is also responsible for the progression of chronic disorders. its long-term exposure is linked with several health problems, including obesity, peripheral vascular disease, diabetes, and depression. therefore it is essential to evaluate stress levels at the early stage before they start to interfere with everyday routine. stress can be evaluated based on physiological and behavioral responses. traditionally, physicians tend to assess stress by using critically designed questionnaires3, i.e. a subjective method. stress can also be measured by assessing different biological indicators like cortisol4, alpha-amylase levels, body vitals namely blood pressure5 and skin conductivity6. the direct effect of stress on cortical responses can be obtained by using a neuroimaging technique, electroencephalogram (eeg)7. eeg is the electrophysiological technique used to assess the electrical activity of the brain8. it also measures the variation of the electric field produced by neuronal activity at the millisecond resolution. assessment of acute and chronic stress based on eeg features biological responses associated with stress originate in the brain and involve different types of physiological and physical effects. previous studies have investigated the variations in eeg signals during stressful conditions. the alpha frequency band ranges between 8-13 hz9. alpha waves are usually recorded in a relaxed, calm and tension-free condition10, when a subject is exposed to a distress in a controlled laboratory setting a distinct reduction in power is observed11. during the stressful condition, the right hemisphere shows more frontal altered alpha waves then left hemisphere12,13. other studies discuss the relationship between negative emotions, stress or depression with alpha frequency12,14. marshall and lopez duran suggest a decline in the power of alpha frequency in the prefrontal cortex during a stressful situation15. as well, there is an increase in alpha power in the frontal cortex during fatigue16. yi et al. reported that during chronic stress such as social isolation there is a decrease in the power of alpha frequency17. methodology study characteristics this systematic review protocol is based on prisma guidelines18. the only electronic database involved in this study is pubmed and the records and data throughout the review is managed by m.s. word. inclusion criteria  the studies conducted between 1st january 2000 to 31st march 2019.  all the full-text original articles published in the english language  studies with the subject age range of 1944 years.  studies that focus on brain wave analysis by eeg.  studies involving healthy subjects, without any history of mental illness or head injury. exclusion criteria  studies assessed depressive symptoms in healthy populations. 51 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1  studies on infants (pediatric studies), neonates, pregnant women.  studies focused on other electrophysiological techniques than eeg.  studies used eeg for evaluation other than stress.  studies involving diseased subjects. data synthesis the data was arranged quantitatively and qualitatively by producing a planned summary measure, reviewing original articles in the same aspects, extracting and screening the citation and studies, handling the studies, screening them and combining them according to the methods given by the following prisma flow diagram (figure 1 & 2). figure 1: prisma diagram for study selection of chronic stressors in systemic review. 52 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 this method was used as a medium for extractions and simplification of the combined data and rate it in its quality and quantity. figure 2: prisma diagram for study selection of acute stressors in systemic review. 53 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 result table 1 summarizes the sample size, gender, included brain frequencies, altered oscillations, and type of chronic stressor measured. the stressors mentioned in table 1 discuss the disturbance in neuronal oscillations. many studies discuss several reasons for the asymmetry in brain waves that can be a result of continuous exposure to a stressful situation. different stressors have been reported; one of the stressors is sleep deprivation, which increases alpha waves19. another stressor is isolation; during 520 days, isolation shows the increase in beta waves at the frontal region while alpha and delta remain unaffected20. loganovsky et al. found an increase in alpha at the temporal and frontal area, delta at the anterior brain, and theta at the anterior brain and right temporal region and beta increase at anterior brain while decrease at the temporal region due to workload21. jacubowski et al. considers two stressors, one is isolation and the other is exercise, and both stressors resulted in high alpha and beta waves22. hu concluded the influence of different stressors caused by unemployment, and the frequent examination on students and mothers of disabled children23. they found alpha, beta and theta frequencies increase anteriorly. luijcks et al. used electro-shocker as a chronic stressor and reported an increase in alpha and slow beta waves frequency at central and parietal-temporal areas, spectrum of gamma wave’s decrease at frontal, central and occipital regions24. vanneste et al. assessed chronic tinnitus and reported that alpha 1 and beta are altered25. however, in this condition, alpha 1 at the subgenual anterior cingulate cortex, beta 3 at dorsal anterior cingulate cortex, delta, theta, alpha 2, beta 1 and 2 remain unaffected. when extreme isolation was studied by yi et al. they found a decrease in alpha and beta frequency17. table 1: chronic stressors that alter brain wave symmetry. author year sample size waves result brain region stressor begić et al 26 2000 18 veterans with ptsd and 20 healthy nonveterans delta, theta, alpha 1, alpha 2 beta 1 & beta 2 theta beta alpha and delta no significant change theta: central region beta: frontal, central and left occipital-al ptsd hall et al27 2000 14 subjects with primary insomnia delta, alpha and beta during non-rem sleep: delta beta alpha last 6 months depression. brady et al28 2000 6 subjects theta theta frontal binaural beat sound tape neylan et al29 2003 24 ptsd patients and 18 control delta delta ptsd 54 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 hall et al30 2007 30 patients of insomnia beta and delta beta delta perceived stress baumeister et al31 2008 16 right-handed healthy subjects theta alpha1 alpha2 beta1 and beta2 beta-1 alpha-1 frontal region: alpha 1 right hemispheric frontal brain beta 1 supplementation of phosphatidylseri-ne todder et al32 2012 10 right handed ptsd patients+ 10 healthy hospital staff member theta qeeg: no statistical difference between ptsd and control subjects for theta band loreta: theta band low on right temporal-al lobe, higher theta band patients with ptsd showed lower activity over both the right and left frontal lobes ptsd glos et al33 2014 12 healthy young volunteer alpha alpha sleep deprivation yi et al20 2015 6 subjects alpha, beta, and delta beta frontal region chronic stress burden of 520-d isolation loganovsk et al21 2015 196 subjects alpha, beta, theta and delta alpha beta theta delta anterior brain: beta, theta, delta right temporal: theta, beta, alpha frontal: alpha work load jacubowski et al22 2015 6 subjects alpha and beta post isolation alpha, beta exercise alpha, beta : limited number of channels, no further details of brain regions isolation. hu et al 23 2015 18 unemployed, students and mothers of disabled children alpha, beta and theta alpha beta theta anterior and frontal region unemployment, frequent examination and graduation, disabled children 55 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 luijcks et al24 2015 69 right handed subjects delta, theta, alpha, slow beta and fast beta, gamma alpha fast, slow beta gamma central, parietaltemporal area: alpha, slow beta frontal, central , occipital: gamma electro-shocker vanneste et al25 2015 55 patients with constant chronic tinnitus delta, theta, alpha 1, alpha 2, beta 1, beta 2, beta 3 and gamma sinificant effect on alpha 1 beta 3 subgenual anterior cingulate cortex: alpha 1 dorsal anterior cingulate cortex: beta 3 tinnitus giannakakis et al9 2015 18 healthy subjects theta, alpha, beta and gamma θ, alpha 1,2 beta 1,2,3,4 , low and high gamma alpha and beta feature frontal video yi et al17 2016 6 healthy subjects alpha and beta beta alpha no further differentiation due to limited no. of channels mars voyage subjects lived in extreme social isolation table 2. summarizes the sample size, their gender, included brain waves, altered oscillations, and type of acute stressor. the stressors mentioned in table 2 discuss the disturbance in neuronal oscillations. acute stressors can be beneficial as these stressors make the body able to adapt according to their surroundings. alonso et al., applied two psychological and physical stressors, a stroop test and sleep deprivation in which the stroop test resulted in an increase in alpha 1 and beta whereas in sleep deprivation, theta increased and there was a decline in alpha 1, finally high alpha decreases and high beta increases in stress responses34. zambotti et al., applied the trier social stress test on insomniac patients and compared them with a control group, beta 1 increases in the control group showed no change in brain wave symmetry35. acute mental arithmetic tasks cause a decrease in alpha and increase in beta and delta and theta stay unchanged36. allen et al., used a socially evaluated cold presser test (s.e.c.p.t.) and found an increase in theta at the frontal midline and that alpha1, 2 and beta 1, 2 and delta did not responded to the stressor37. banis et al., used the distressing video and monetary incentive delay task and found alpha power increase in reward cues, which was unaffected during a stressful situation. they also found that theta increased in on reward signal38. in julien modolo et al., study, alpha remains unchanged at the occipital region in magnetic frequency (60 hz) stressor39. 56 app| published by aeirc| https://doi.org/10.29052/2412-3188.v8.i1.2021.49-61 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) table 2: acute stressors that change brain wave symmetry. author year sample size waves result brain region stressor muttray et al40 2000 12 subjects alpha 1, alpha 2, beta 1, beta 2, theta and delta alpha 1 : alpha 2 : beta 1 : beta 2: no change tempor-o-parieto-occipital: alpha 1 and beta 1 temporooccipital: delta parietal & temporal regions: theta 200 ppm 1,1,1trichloroethane + color word stress test tops et al41 2004 11 subjects alpha alpha : frontal activity acute cortisol hewig et al42 2008 37 subjects alpha alpha : frontal exam master et al43 2009 54 subjects alpha alpha asymmetery frontal eeg. asymmetry trier social stress test rozhkov et al44 2009 11 subjects theta & delta theta : delta : temporospatial hypoxia scholey et al45 2012 31 subjects theta, alpha and beta theta : alpha : beta : midline frontal and central region epigallocatechin gallate (e.g.c.g.) lithari et al46 2012 26 right handed healthy subjects alpha beta, gamma, delta theta theta : alpha : beta : regions not mentioned alcohol intake quaeflieg et al47 2014 70 subjects alpha alpha not effected frontal maastricht acute stress test https://doi.org/10.29052/2412-3188.v8.i1.2021. 57 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 alonso et al34 2015 30 subjects delta theta alpha and beta stroop test: alpha1 beta : sleep deprivation: theta : alpha 1: stress response high alpha: high beta: stroop color word test chronic: sleep deprivation de zambotti et al35 2015 22 subjects with insomnia & 18 without insomnia alpha beta1 beta2 delta theta and sigma insomniac subjects: beta1: control: beta 1 no change trier social stress test. al-shargie et al35 2016 22 healthy right handed subjects delta alpha beta and theta beta : alpha : alpha waves responded more significantly to stress mental arithmetic task allen et al37 2016 22 subjects alpha1 alpha 2 beta 1 beta 2 delta & theta theta : frontal midline representing prefrontal cortical activity. socially evaluated cold presser test (s.e.c.p.t.) banis et al40 2017 17 subjects alpha & theta alpha : in reward cues no effect in stressed condition theta : in non reward cue. distressing video+ monetary incentive delay task modolo et al39 2017 25 subjects alpha alpha not effected occipital region magnetic frequency 60 hz 58 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 discussion the conditions that are associated with stress produce significant psychological, physiological and neurobiological deteriorations. distress affects neuronal circuits that further disturb the normal propagation of brain waves; these interruptions can be analyzed by eeg with precision and efficacy. this review reveals how the different stressors could be a causative factor in generating fluctuations in neuronal oscillations. it should be noted that gamma is the least observed wave in the aboveincluded studies. above all, only luijcks et al. reported a decrease in gamma waves at the frontal, central and occipital regions while others reported no change 9,24,25. slowwave delta least shows the deflection when influenced by chronic stressors; in many studies, delta waves remain unchanged before and after the stressor applied20,24-26. few studies mentioned the increase in delta waves during chronic stress9, 12, 21. however, neylan et al. and hall et al. suggested a decrease in delta waves29,30. like delta, theta also in some studies reported to not be a respondent of a stressor 9,24,25,31. while begic et al.26, brady et al. 28 and hu et al. 23 observed a decrease in theta rhythms at central, frontal and anterior regions, respectively. however, todder et al.32 use qeeg and low resolution electromagnetic tomographis analysis (loreta) techniques and report that there is no difference observed. at the same time, loreta reveals some other results; they distributed the theta band into higher and lower frequency band, both bands show low activity at different brain sites, the low band found at right temporal lobe while the higher band at the right and left frontal lobe. now, beta waves are more involved in brain-specific tasks. most of the studies reported an increase in beta oscillations at frontal, central, left occipital, anterior, right temporal and parietal temporal regions of the brain 18,20,21-23,26,30. some detect a decline in this rhythm at the frontal and right hemispheric frontal site of the brain8,9,17. also, vanneste et al. observed alteration in frequency bands of beta 3 waves at the dorsal, anterior cingulate cortex25. finally, the alpha wave remains unchanged in very few cases 20, 26. mainly, the alpha oscillations were reported to be increased during or after chronic stressors were applied, and the regions indicated were frontal, right temporal, parietal temporal, central and anterior18,22,25,28,29,31. on the contrary, giannakakis et al. 9 and yi et al. 17 suggested the decline in beta frequency in the frontal region of the brain. additionally, vanneste et al. found fluctuations in alpha 1 waves after the extensive exposure to stress25. acute stressors are the second parameters in this review. lithari et al. 46 included gamma wave in his study, but the rhythms remain un-deflected. now, the delta waves mostly reported being unchanged during acute stress34-37,46. whereas, muttray et al. 40 and rozhkov et al. 44 observed an increase in the frequency of the delta waves at temporooccipital and temporospatial regions of the brain. theta oscillations are not respondents of acute stressors observed by massimiliano de zambotti35 and al shargie et al.36 but most of the studies mentioned an increase in theta wave and the regions are parietal and temporal, temporospatial, midline frontal and central part of the brain34,40,44,46. allen et al.,37 suggested no change in the beta wave. though, muttray et al.40 mentioned a decrease in beta rhythm at the temporoparietal occipital. on the other hand, most of the studies reported an increase in the beta wave at midline frontal and central regions34-36,46. lastly, the alpha 59 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 waves are the most considered wave to study stress. some studies reported that alpha remains unchanged27,35,37,47. in acute stress, it is reported that alpha wave increases at frontal, midline frontal and central sites34,38,43,46, while other studies reported a decline in alpha waves at temporoparietal-occipital and frontal regions of the brain41,42. conclusion the literature reviewed for this study shows the effect of numerous stressors on brain oscillations that change their frequency, affecting normal functions of the brain. these fluctuations in the power of brain waves could lead to some severe consequences if persisted for too long. multiple interventions and therapies especially biofeedback techniques are making the mark and are now being tested and successfully applied to train the subject to revert the effect of stress. most significant one amongst these were biofeedback and behavioral structuring techniques with high efficacy rates. awareness in this regard is highly recommended. acknowledgment the authors are thankful to the study participants for their cooperation in the study. references 1. azher sz, noushad s, ahmed s. assessment of major physical stressors and its psychophysiology; a comprehensive review. app. 2014;1(2014):3-8. 2. zatzick df, kang sm, müller hg, russo je, rivara fp, katon w, jurkovich gj, 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fomina e, strüder hk, schneider s. the impact of long-term confinement and exercise on central and peripheral stress markers. physio behav. 2015;152:106-111. 23. hu b, peng h, zhao q, hu b, majoe d, zheng f, moore p. signal quality assessment model for wearable eeg sensor on prediction of mental stress. ieee trans nanobiosci. 2015;14(5):553-561. 24. luijcks r, vossen cj, hermens hj, van os j, lousberg r. the influence of perceived stress on cortical reactivity: a proof-of-principle study. plos one. 2015;10(6):e0129220. 25. vanneste s, de ridder d. stress-related functional connectivity changes between auditory cortex and cingulate in tinnitus. brain connecti. 2015;5(6):371-383. 26. begić d, hotujac lj, jokić‐begić n. quantitative eeg in ‘positive’and ‘negative’schizophrenia. acta acta psychiatr scand. 2000;101(4):307-311. 27. hall m, buysse dj, nowell pd, nofzinger ea, houck p, reynolds iii cf, kupfer dj. symptoms of stress and depression as correlates of sleep in primary insomnia. psychosom. med. 2000;62(2):227-230. 28. brady b, stevens l. binaural-beat induced theta eeg activity and hypnotic susceptibility. am j clin hypn. 2000;43(1):5369. 29. neylan tc, lenoci m, maglione ml, rosenlicht nz, metzler tj, otte c, schoenfeld fb, yehuda r, marmar cr. delta sleep response to metyrapone in posttraumatic stress disorder. neuropsychopharmaco. 2003;28(9):16661676. 30. hall m, thayer jf, germain a, moul d, vasko r, puhl m, miewald j, buysse dj. psychological stress is associated with heightened physiological arousal during nrem sleep in primary insomnia. behav sleep med. 2007;5(3):178-193. 61 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 31. baumeister j, barthel t, geiss kr, weiss m. influence of phosphatidylserine on cognitive performance and cortical activity after induced stress. nutr. neurosci. 2008;11(3):103-110. 32. todder d, levine j, abujumah a, mater m, cohen h, kaplan z. the quantitative electroencephalogram and the lowresolution electrical tomographic analysis in posttraumatic stress disorder. clin eeg neurosci. 2012;43(1):48-53. 33. glos m, fietze i, blau a, baumann g, penzel t. cardiac autonomic modulation and sleepiness: physiological consequences of sleep deprivation due to 40 h of prolonged wakefulness. physiol behav. 2014;125:45-53. 34. alonso jf, romero s, ballester mr, antonijoan rm, mañanas ma. stress assessment based on eeg univariate features and functional connectivity measures. physiol measurement. 2015;36(7):1351. 35. de zambotti m, sugarbaker d, trinder j, colrain im, baker fc. acute stress alters autonomic modulation during sleep in women approaching menopause. psychoneuroendocrino. 2016;66:1-10. 36. al-shargie f, kiguchi m, badruddin n, dass sc, hani af, tang tb. mental stress assessment using simultaneous measurement of eeg and fnirs. biomed optics express. 2016;7(10):3882-3898. 37. allen ap, hutch w, borre ye, kennedy pj, temko a, boylan g, murphy e, cryan jf, dinan tg, clarke g. bifidobacterium longum 1714 as a translational psychobiotic: modulation of stress, electrophysiology and neurocognition in healthy volunteers. transl psychiatry. 2016;6(11):e939. 38. banis s, lorist mm. the combined effects of menstrual cycle phase and acute stress on reward-related processing. biol psychol. 2017;125:130-145. 39. modolo j, thomas aw, legros a. human exposure to power frequency magnetic fields up to 7.6 mt: an integrated eeg/fmri study. bioelectromagnetics. 2017;38(6):425435. 40. muttray a, kürten r, jung d, schicketanz kh, mayer-popken o, konietzko j. acute effects of 200 ppm 1, 1, 1-trichloroethane on the human eeg. eur j med res. 2000;5(9):375-384. 41. tops m, wijers aa, van staveren as, bruin kj, den boer ja, meijman tf, korf j. acute cortisol administration modulates eeg alpha asymmetry in volunteers: relevance to depression. biol psychol. 2005;69(2):181-193. 42. hewig j, schlotz w, gerhards f, breitenstein c, lürken a, naumann e. associations of the cortisol awakening response (car) with cortical activation asymmetry during the course of an exam stress period. psychoneuroendocrinology. 2008;33(1):8391. 43. master sl, amodio dm, stanton al, yee cm, hilmert cj, taylor se. neurobiological correlates of coping through emotional approach. brain behav immun. 2009;23(1):27-35. 44. rozhkov vp, soroko si, trifonov mi, bekshaev ss, burykh ea, sergeeva eg. cortical-subcortical interactions and the regulation of the functional state of the brain in acute hypoxia in humans. neurosci. behav. physiol. 2009;39(5):417-428. 45. scholey a, downey la, ciorciari j, pipingas a, nolidin k, finn m, wines m, catchlove s, terrens a, barlow e, gordon l. acute neurocognitive effects of epigallocatechin gallate (egcg). appetite. 2012;58(2):767-770. 46. lithari c, klados ma, pappas c, albani m, kapoukranidou d, kovatsi l, bamidis pd, papadelis cl. alcohol affects the brain's resting-state network in social drinkers. plos one. 2012;7(10):e48641. 47. quaedflieg cw, meyer t, smulders ft, smeets t. the functional role of individualalpha based frontal asymmetry in stress responding. biol psychol. 2015;104:75-81. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v8.i1.2021.49-61 6 app| published by aeirc| https://doi.org/10.29052/2412-3188.v8.i1.2020.6-14 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) original article assessment of cortisol, brain-derived neurotropic factor, c reactive protein, interleukin-6 levels and cognitive decline after trauma exposure shamoon noushad1,2 , ujala sajid3, sadaf ahmed2,3 & basit ansari1 1department of health & physical education, university of karachi, karachi-pakistan. 2psychophysiology research lab, mahq biological research centre, university of karachi, karachi-pakistan. 3department of physiology, university of karachi, karachi-pakistan. abstract background: studies have found that multiple neurobiological mechanisms are underlying the cause of posttraumatic stress that influence the nervous and immune system leading to neurodegenerative and psychiatric comorbidities. the present study aims to assess and evaluate the serum cortisol, c reactive protein (crp), interleukin-6 (il-6), brain-derived neurotropic factor (bdnf) levels and cognitive decline among subjects with trauma exposure and to determine the relationship between the above-specified stress biomarkers. methodology: two groups with trauma exposure (including natural disaster, any accident, physical and/or verbal violence, or any stressful condition) in the last twelve months were recruited. groups were majorly divided based on tsc-40 (trauma symptom checklist 40) scores. subjects with a tsc score > 40 were kept in the traumatized group, while those with tsc score < 40 were included in the control group. a total of 188 subjects above the age of 18 were recruited following inclusion criteria, cognition was measured using the six-item cognitive impairment test (6-cit), and serum samples were obtained for cortisol, crp, bdnf, and il-6 levels. results: there was a significant difference in the serum bdnf (p<0.001) level among the traumatized subjects, i.e. 15.68 ± 3.55 ng/dl as compared to controls 26.65 ± 2.47 ng/dl; no significant difference was found in crp levels (ns) in both groups with a slight increase among the traumatized subjects as compared to the controls, i.e. 4.29 ± 1.50 mg/dl vs. 3.42 ± 1.11 mg/dl. as indicated by the 6-cit score, the cognitive decline was more pronounced among the traumatized subjects, i.e. 8.54 ± 2.13 compared to the control group 5.0 ± 1.81, with a significant positive difference (p<0.001). conclusion: the finding suggests that traumatic stress is associated with cognitive decline, bdnf and cortisol, whereas a non-significant association was found with il-6 and crp levels. keywords traumatic stress, cognitive decline, brain-derived neurotrophic factor, c reactive protein, interleukin-6, cortisol. citation: noushad s, sajid u, ahmed s. & ansari b. assessment of cortisol, brain-derived neurotropic factor, c reactive protein and interleukin-6 levels as well as cognitive decline after trauma exposure. app.2021; 8(1):6-14 corresponding author email: ujalasajid97@gmail.com doi: 10.29052/2412-3188.v8.i1.2021.6-14 received 01/01/2021 accepted 07/04/2021 published 01/06/2021 copyright © the author(s). 2021 this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v8.i1.2020. https://orcid.org/0000-0002-8078-4524 https://orcid.org/0000-0002-9635-0202 https://orcid.org/0000-0003-3919-2516 http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 7 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 introduction traumatic events and associated stress have been known to trigger several physical or mental health disabilities, including fatigue, sleep disturbances, anxiety disorder, depression etc. a debate has continued for decades until several studies have proposed a significant link between traumatic stress and its psychological impact on individuals' health and well-being1, 2. the drastic or lifethreatening events, including accidents, natural disasters, physical and/or verbal violence, or any other stressful condition that is a source of trauma and alters the body's homeostasis, leads to traumatic stress3. individuals with mental health problems such as post-traumatic stress disorder (ptsd) and major depressive disorder (mdd) or even psychiatric problems had mostly experienced certain traumatic incidences like early childhood trauma, sexual abuse, verbal abuse, and physical violation2,4-6. moreover, the traumatic subjects tend to have a reduced ability to cope with fear and usually feel helpless most of the time7. this coping disability generally leads to ptsd that is considered a heterogeneous condition6 and characterized by successive traumatic reminders, avoidance of cue related to trauma, negative cognition, etc3, 8. in the current era, traumatic events are very common in one's life, leading to severe psychotic distress and neuronal impairment; it should be assisted by clinicians, psychologists or psychotherapists, either by interviewing the traumatized individual any formal psychometric testing or any assessment tool9. early assessment and effective management has shown positive growth among the traumatized individuals depending upon the type and number of experiences of the traumatic event10. normal brain development needs to be reviewed at different life stages to understand how traumatic stress initiates5. from childhood to later in life, the human brain undergoes several changes, be it structural or functional. it is essential to be well aware of the normal developmental changes to differentiate them based on the pathologies5. it is important to understand the changes in individual behaviour, both mentally and socially, caused by any stressful situation or trauma experiencing. previous evidence from studies has associated childhood victimization or trauma, decades after exposure, with an elevation of inflammatory biomarkers measured8. evidence suggests that the subjects who had suffered from childhood victimization or trauma have elevated levels of inflammatory biomarkers, including il-6 and crp, while relatively low levels of bdnf8,10. the involvement of neurobiological inflammatory markers in the pathogenesis of trauma is quite obvious. crp is the most validated and widely studied biomarkers of the peripheral inflammation associated with trauma9, and elevated crp levels indicate the increased risk of degenerative disorders11. similarly, bdnf is one of the most extensively researched neurotrophic factors with the most established evidence of influencing synaptic plasticity and has a significant role in cellular proliferation and brain pathologies12,13. the down regulation of bdnf in association with traumatic history results in long-term changes in the neurobiology of the brain, suggesting bdnf as an essential biomarker of pathological conditions14. in the behavioural literature, both of the molecules that is il-6 and crp regarded as inflammatory biomarkers and used mostly in assessing the presence and severity of low-grade inflammation15-17. chronic stress leads to various disease states through the activation of two major systems i.e. hpa – 8 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 axis and the other is the sympathetic nervous system (sns) axis, usually by the upregulation of glucocorticoids (cortisol in humans) and catecholamines (epinephrine and norepinephrine)18. these two secreted molecules then perform their function by acting through their separate receptor mechanism on different cell types, including the immune cells and nerve cells18,16. besides, it is suggested that chronic stress usually inhibits the secretion of proinflammatory cytokines that usually mediate cellular immunity. on the other hand, the stress can activate the anti-inflammatory cytokine that mediates humoral immunity. based on this general hypothesis was led that chronic stress particularly leads towards the disease state through immunosuppression. however, there is still a gap in understanding the overall association of hpa axis activation that leads to alteration in the serum bdnf, il-6, cortisol and crp levels under pathological conditions. the present study aimed to assess and compare serum cortisol, crp, il-6, and bdnf levels among subjects with trauma exposure and to determine the relationship between the above-specified stress biomarkers. the outcome of this study suggests a significant association between severity of trauma and decrease level of bdnf, along with slight elevation in the serum cortisol, crp and il6, highlighting the possible involvement of bdnf, crp and il-6 in the development of post-traumatic stress. methodology this cross-sectional study was conducted from september to december 2019. two groups with trauma exposure (including natural disaster, any accident, physical and/or verbal violence, or any stressful condition) in the last twelve months were recruited. groups were majorly divided based on tsc-40 scores. subjects with a tsc score > 40 were kept in a traumatized group, while those with < 40 scores were included in the control group. subjects were recruited from the following three sites, i.e. university of karachi, markaz-e-umeed and kohi goth hospital. a total of 188 subjects above 18 years of age were recruited, with no evidence of any metastatic disease, were enrolled in the study. according to dsm-v, subjects having any codified psychiatric disorder, those on psychopharmacological treatment during the last three years and those who had gone through any structural, psychological intervention for at least six months during the last three years were kept under exclusion criteria. pakistan medical association committee on ethics approved all recruitment and assessment procedures. all subjects included provided written informed consent after receiving a complete description of the study. for the investigation of traumatic symptoms, tsc-40 was used19. tsc-40 is a self-reported 40-item inquiry form based on a 4-point likert scale. it evaluates symptomatology in adults associated with childhood or adult traumatic experiences and measures aspects of posttraumatic stress and other symptom clusters found in some traumatized individuals. tsc-40 consisting of six subscales: anxiety, depression, dissociation, sexual abuse trauma index (sati), sexual problems and sleep disturbances; it requires approximately 1015 minutes to complete. cognition was measured using the 6-cit18. this short 2-3minute test contains items on orientation, memory and concentration. scoring ranges from 0-28, with higher scores indicating more cognitive impairment. patients with a 6-cit score of 10 points or lower were considered normal cognition; those with 6cit score ≥ 11 were categorized as cognitive 9 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 impairment20. venous blood was collected for estimation of crp, cortisol, il-6 and bdnf into sampling tubes in the morning, the concentration of crp (mg/dl), bdnf (ng/dl), cortisol (mcg/dl), il-6 (pg/ml) was measured using enzyme-linked immunosorbent assay. all the continuous variables like age, cortisol, crp, bdnf, and tsc-40 score were expressed as mean and standard deviation. in contrast, the categorical variables, including gender, ethnicity, occupation and religious preference, etc., were given frequency and percentages. chi-square test and one-way analysis of variance (anova) were used for comparison between the groups, and p<0.05 was considered statistically significant. data were analyzed using spss version 22.0. results out of 188 subjects, there were 88 traumatized and 100 controls. the majority were females, i.e. 75%, and only 25% were males, with a mean age of 29 ± 7.8 years. most of the subjects belonged to different ethnicity, had different occupational statuses, religious preferences and political views, as shown in (table 1). table 1: demographic characteristics of the subjects enrolled in the study. baseline characteristics n(%) gender male 47(25) female 141(75) ethnicity sindhi 24(12.76) balochi 23(12.23) punjabi 18 (9.57) pathan 21(11.17) muhajir 80(42.55) others 15(7.97) prefer not to respond 7(3.19) occupation student (not working) 133(70.74) student (part-time job/business) 13(6.91) student (full-time job or business) 14(7.44) business 11(5.85) salaried person 17(9.04) religious preference agnostic 2(1.06) religious 165(87.76) not religious but spiritual 14(7.44) others 7(3.72) political view conservative 30(15.95) moderate 118(62.76) liberal 40(21.27) *values are given as mean ± sd or n(%) 10 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 individuals with trauma (tcs score > 40) had significantly lower levels of bdnf, i.e. 15.68 ± 3.55 ng/dl, and slightly higher levels of crp 4.29 ± 1.50 mg/dl as compared to controls (table 2). table 2: comparative assessment of traumatic symptom and biomarkers among the traumatized and control subjects variable traumatized (group) controls (group) p-value mean ± sd tsc-40 score 56.72±11.91 27.76±9.28 <0.001* 6-cit score 8.54±2.13 5.0±1.81 <0.001* crp (mg/dl) 4.29±1.50 3.42±1.11 ns bdnf (ng/dl) 15.68±3.55 26.65±2.47 <0.001* cortisol (mcg/dl) 26.17±3.65 20.37±3.71 <0.001* il-6 (pg/ml) 2.90±0.63 2.44±2.08 ns *p-value < 0.05 is considered significant; ns: non-significant *tsc-40-traumatic symptom checklist; 6-cit-six item cognitive impairment test; crp-c-reactive protein; bdnf-brain derived neurotropic factor; il-6-interleukin 6 figure 1: comparison of subscales scores of tsc-40 among the control and traumatized groups of study figure 1 shows the mean value of the subscales score of tsc-40 among the traumatized and control subjects. depression was significantly very high in traumatized subjects (x̅=14.02) compared to the control subjects (x̅=7.25). in contrast, the anxiety level was significantly also very high in traumatized residents (x̅=13.85) as compared to the control subjects (x̅=6.35). dissociation, sati, and sleep disturbance level were almost equal in traumatized subjects with a mean value of 11.11, 9.22 and 10.45. among all the subscales scores, both traumatize subjects and control subjects scored the lowest in the sexual problem subscale; traumatized subjects (x̅=3.76) and control subjects (x̅=1.02). 11.1 13.85 14.02 9.22 10.45 3.76 5.96 6.35 7.25 4.96 5.69 1.02 dissociation anxiety depression sati sleep disturbance sexual problem traumatized control 11 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 discussion the present study aimed to investigate the role of biomarkers in post-traumatic stress, focusing on the serum concentration of cortisol, bdnf, il-6 and crp among the traumatized and control subjects. the subjects who were deemed traumatized as per the findings from tsc-40, with comparatively high depression and anxiety index, were compared to those who scored less and considered as controls (figure 1). the bdnf and crp level was measured to find the association of inflammation with the underlying posttraumatic stress mechanism. rosen et al., 2017 have suggested that systemic inflammation is associated with stress pathology with a positive crp association with posttraumatic stress severity21. moreover, a meta-analysis of random effects suggested that individuals who had experienced any type of childhood trauma (sexual, physical or emotional) had elevated baseline peripheral crp levels17. a follow-up study by laurin and his colleagues suggested that psychological distress is associated with increased crp concentration and inflammatory mechanisms reflecting processes that further contribute to cognitive decline in later life22. similarly, in our study, the mean crp level was elevated among the traumatized subjects compared to the controls, i.e. 4.29 ± 1.50 mg/dl vs. 3.42 ± 1.11 mg/dl (table 2). although the association wasn't significant as per the evidence, there was a prominent variation in the mean crp level among the two groups. we found significant down regulation in the serum bdnf concentration among the traumatic subjects 15.68 ± 3.55 ng/dl as compared to the controls 26.65 ± 2.47 ng/dl (p<0.05) (table 2). a recent study confirmed that the serum bdnf level decline among individuals with a history of a traumatic event or those with mental health illnesses14; the study indicated a significant decline in the serum bdnf concentration among patients reporting childhood sexual abuse and depressive episodes21. moreover, angelucci et al., in their study, suggested the involvement of bdnf in the pathophysiology of ptsd23. the role of bdnf in enhancing learning and memory in the hippocampus is evident24, and the present study revealed a positive correlation in the down-regulation of bdnf (table 2). our results show the positive correlation of cortisol with the tsc-40 score. the positive correlation shows that if the tsc-40 score increases, then the cortisol level also increases and vice versa. the increased score of tsc-40 indicates that people whose scores were above 40 have a high level of cortisol and the people whose tsc-40 score was below 40 have a low level of cortisol25. as a biomarker of stress, the cortisol is linked to the tsc-40 score, which determines the level of cortisol and trauma of an individual26. thus, our finding also indicates higher the tsc-40 score, the higher the level of cortisol and this increase in cortisol level, the person can be identified in a chronic traumatic stress27. tsc-40 scores below 40 showed a decrease in levels of the il-6, while the tsc40 scores above 40 showed an increase in il6 levels though it was insignificant, as shown in table1that may indicate the initiation of low-grade inflammation28. cognitive impairment is one of the core features of degenerative disorders, and studies showed a significantly high association between traumatic events, degeneration of brain cells and cognitive dysfunction29. the cognitive impairment among the traumatized subjects was significantly high compared to the control group, with a decreased level of bdnf. studies have suggested that bdnf plays a 12 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 critical role in enhancing learning and memory in the hippocampus30. the results of 6-cit of a traumatized group show a positive correlation between the decreased level of bdnf levels with cognitive impairment pathology. there was a slight elevation in crp and il6 concentration in traumatized subjects compared to the control group, suggesting that higher crp levels may be a marker of memory and learning impairment in traumatic subjects. noble, j. m. et al., 2010, in a cross-sectional analysis, suggested that increased crp level can be a marker of memory and an increased risk of cognitive decline31. since the results show a very slight elevation in crp levels of traumatized individuals, hence basis on the results, we cannot suggest an association between cognitive impairment and an increase in il6 and crp. these overall results indicate that some other undefined factors may be modifying the observed associations of traumatic events with degeneration of brain cells, related immune influences, and susceptibility to cause psychiatric conditions later in life by way of inflammatory processes32. still, it is possible that changes in bdnf and cortisol while non-significance of il6 and crp can be assumed to certain specific characteristic symptoms of traumatic stress32,33. however, further exploration of the role of environmental interactions and immune mechanisms is still a challenge34. the limitations of the current study that hinder further insight include its focus on a crosssectional association based on one-time assessments of inflammatory markers, undervaluing the explicit inflammation markers' role in stress disorders and lack of longitudinal study design. the symptomatic expositions and potential confounders interfering with the immune system should be monitored in longitudinal and casecontrol settings to clarify these ambiguities. conclusion the finding suggests that traumatic stress is associated with cognitive decline, bdnf and cortisol, highlighting the possible involvement of these biomarkers in developing associated symptomatic neurobiological alterations. whereas the changes in il-6 and crp were nonsignificant in the association with traumatic scores. however, there is a possible role of the explicit inflammation markers, and related mechanisms that are needed to be explored by further large-scale descriptive studies or randomized controlled trials are required to elucidate the mechanism. acknowledgment the authors are thankful to the participating institutes for the support and collaboration, and we also like to acknowledge the study participants for their kind cooperation. references 1. jeenger j, singroha v, sharma m, mathur dm. c-reactive protein, brain-derived neurotrophic factor, interleukin-2, and stressful life events in drug-naive firstepisode and recurrent depression: a crosssectional study. indian j psychiatry. 2018;60(3):334. 2. giacobbo bl, doorduin j, klein hc, dierckx ra, bromberg e, de vries ef. brain-derived neurotrophic factor in brain disorders: focus on neuroinflammation. mol neurobiology. 2019;56(5):3295-312. 3. brooks m, graham-kevan n, robinson s, lowe m. trauma characteristics and posttraumatic growth: the mediating role of avoidance coping, intrusive thoughts, and social support. psychol trauma. 2019;11(2):232. 4. noushad s, ansari b, ahmed s, saleem y. effect of nature-based physical activity on post-traumatic growth among healthcare providers with post-traumatic stress: protocol for a randomized controlled trial. 13 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 int. j. endorsing health sci. res. 2020; 8(4):295301. 5. speer k, upton d, semple s, mckune a. systemic low-grade inflammation in posttraumatic stress disorder: a systematic review. j inflam res. 2018;11:111. 6. hoerster kd, campbell s, dolan m, stappenbeck ca, yard s, simpson t, nelson km. ptsd is associated with poor health behavior and greater body mass index through depression, increasing 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inflammation. curr dir psychol sci. 2014;23(4):277-283. 16. miller ge, chen e, parker kj. psychological stress in childhood and susceptibility to the chronic diseases of aging: moving toward a model of behavioral and biological mechanisms. psychol. bull. 2011;137(6):959. 17. baumeister d, akhtar r, ciufolini s, pariante cm, mondelli v. childhood trauma and adulthood inflammation: a meta-analysis of peripheral c-reactive protein, interleukin-6 and tumour necrosis factor-α. mol psychiatry. 2016;21(5):642-649. 18. hänsel a, hong s, cámara rj, von kaenel r. inflammation as a psychophysiological biomarker in chronic psychosocial stress. neurosci biobehav rev. 2010;35(1):115-121. 19. briere j, runtz m. trauma symptom checklist 33 and 40: tsc-33 and tsc-40. available at: http://www.scalesandmeasures.net/files/fi les/trauma%20symptom%20check.pdf. 20. abdel-aziz k, larner a. 6cit for detection of dementia and cognitive impairment. j neurol neurosurg psychiatry.2014;85(10):e4. 21. rosen rl, levy-carrick n, reibman j, xu n, shao y, liu m, ferri l, kazeros a, caplanshaw ce, pradhan dr, marmor m. elevated c-reactive protein and posttraumatic stress pathology among survivors of the 9/11 14 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 world trade center attacks. j psych res. 2017;89:14-21. 22. aas m, dieset i, hope s, hoseth e, mørch r, reponen e, steen ne, laskemoen jf, ueland t, aukrust p, agartz i. childhood maltreatment severity is associated with elevated c-reactive protein and body mass index in adults with schizophrenia and bipolar diagnoses. brain behav immun. 2017;65:342-349. 23. angelucci f, ricci v, gelfo f, martinotti g, brunetti m, sepede g, signorelli m, aguglia e, pettorruso m, vellante f, di giannantonio m. bdnf serum levels in subjects developing or not post-traumatic stress disorder after trauma exposure. brain cog. 2014;84(1):118122. 24. leal g, bramham cr, duarte cb. bdnf and hippocampal synaptic plasticity. vitamins and hormones. 2017 jan 1;104:153-195. 25. bergman b, ahmad f, stewart de. work family balance, stress, and salivary cortisol in men and women academic physicians. int j behav med. 2008;15(1):54-61. 26. simeon d, yehuda r, cunill r, knutelska m, putnam fw, smith lm. factors associated with resilience in healthy adults. psychoneuroendocrinol. 2007;32(8-10):11491152. 27. do yup lee ek, choi mh. technical and clinical aspects of cortisol as a biochemical marker of chronic stress. bmb reports. 2015;48(4):209. 28. bob p, susta m, gregusova a, jasova d. dissociation, cognitive conflict and nonlinear patterns of heart rate dynamics in patients with unipolar depression. prog neuropsychopharmacol biol psychiatry. 2009;33(1):141-145. 29. sahu g, malavade k, jacob t. cognitive impairment in schizophrenia: interplay of bdnf and childhood trauma? a review of literature. psychiatric quart. 2016;87(3):559569. 30. yu h, zhang z, shi y, bai f, xie c, qian y, yuan y, deng l. association study of the decreased serum bdnf concentrations in amnestic mild cognitive impairment and the val66met polymorphism in chinese han. j clin psychiatry. 2008;69(7):1104-1111. 31. noble jm, manly jj, schupf n, tang mx, mayeux r, luchsinger ja. association of creactive protein with cognitive impairment. arch neurol. 2010;67(1):87-92. 32. tursich m, neufeld rw, frewen pa, harricharan s, kibler jl, rhind sg, lanius ra. association of trauma exposure with proinflammatory activity: a transdiagnostic meta-analysis. transl psychiatry. 2014;4(7):e413. 33. kim td, lee s, yoon s. inflammation in posttraumatic stress disorder (ptsd): a review of potential correlates of ptsd with a neurological perspective. antioxidants. 2020;9(2):107. 34. wieck a, barbosa ig, teixeira al, bauer me. immunology of post-traumatic stress disorder (ptsd). immunopsychiatry: a clinician's introduction to the immune basis of mental disorders. uk: oxford university press; 2019:227. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v8.i1.2021.6-14 15 app| published by aeirc| https://doi.org/10.29052/2412-3188.v6.i1.2019.15-22 issn 2412 3188 original article computer vision syndrome: prevalence and predictors among students sonya arshad, muhammad faisal qureshi, muhammad ali, komal piryani, komal shafqat, madiha mateen, mahnoor waheed, mahnoor rohaila & manal amin liaquat national school of physiotherapy, liaquat national hospital & medical college abstract background: globally around 60 million people are suffering from computer vision syndrome (cvs). a well-known eye and vision-related problem resulting from prolonged computer, tablet, e-reader and cell phone use. viewing a digital screen often increases the visual load therefore the aim of this study was to explore the prevalence of cvs among students. methodology: this cross-sectional study was conducted from 1st september 2018 to 31st may 2019 on a sample of 320 students from diverse physiotherapy institutes of karachi. participants of both genders between the age of 18-24 years were included in the study. data regarding demographics, cvs assessment, associated symptoms, intensity of symptoms and daily vision routine was recorded. cvs was assessed using a standardized cvs questionnaire (cvs-q) and analyzed using spss version 21. results: a total of 320 physiotherapy students with a mean age of 21.04+0.8 years were enrolled in the study, majority of them were females 245(76.6%). out of these, 186 students were diagnosed with cvs as they scored ≥6 on segui and colleagues cvs questionnaire with headache being the most prevalent symptom (63.1%) followed by itching (52.8%), increased sensitivity to light (43.6%), eye pain (42.6%) and feeling of foreign body (39.5%). among the activities involved in daily vision routine, optical use and sitting posture were significantly associated with cvs. conclusion: it can be concluded from the study results that cvs is highly prevalent among physiotherapy students, one of the reasons for this might be the increased digital screens usage for academic purpose and clinical decision making. keywords computer vision syndrome (cvs), digital eye strain, physiotherapy, daily vision routine, cvs symptoms citation: arshad s, qureshi mf, ali m, piryani k, shafqat k, mateen m, waheed m, rohaila m, amin m. computer vision syndrome: prevalence and predictors among students. app. 2019; 6(1):15-22 corresponding author email: sonya.arshad@lnh.edu.pk doi: 10.29052/2412-3188.v6.i1.2019.15-22 received 10/02/2019 accepted 04/05/2019 published 12/10/2019 copyright © the author(s). 2019 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v6.i1.2019.13 http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 16 issn 2412 3188 app| published by aeirc| volume 6 issue 1 introduction with the recent advancement of technology, the use of computer and other electronic devices especially smart phones and tablets, has widely increased not only for professional but also for academic purposes in colleges and universities. both positive and negative impacts are associated with these technological modifications1. on one hand, use of these gadgets provides us easy communication, e-learning, improved and appropriate time management whereas prolong exposure results in various visual and ergonomic disorders. using these technologies for 3 hours/day increases the health risk promoting cvs, low-back pain (lbp), headaches and psychosocial stress etc1,2. cvs is a complex condition involving a group of vision-related problems which are common among people who spend most of the time working on computers, tablets, cell phones ande-books3. viewing a digital screen for prolonged time duration leads to eye strain and vision-related problems mainly due to poor lighting, glare on digital screen, improper viewing distance, poor sitting posture and uncorrected vision problems1, which are usually neglected by the technological users3. in addition to the abovementioned errors, dry eye is also a major contributor of cvs, which leads to decreased lubrication and nourishment of eyes due to insufficient tears production. it effects by decreasing the rate of blinking which in turn results in prolonged and continuous exposure during digital operations4. proper adjustment of these settings and appropriate use of screen filters to minimize glare and ocular discomfort are considered as the most effective measures for prevention of cvs. pakistan is quickly becoming digitalized; it is now among the countries with highest mobile phone use, currently, there are almost 59 million smart phone users in pakistan5. since 2016, there has been an approximate increase of 47%among the smart phone users, 20% among internet users, 35% in social media users. while the use of desktops and laptops for web browsing has decreased to 22%6. based on the local and international literature eye problems and headache are the significant symptoms associated with cvs resulting from prolonged technological use7. in relation to this, a study conducted in lahore indicated high frequency of cvs among computer engineering students i.e. 72.4% (123/170)8 which is also supported by a prevalence study conducted in peshawar i.e. 90.5% of the enrolled students were diagnosed with cvs9. in the light of mounting evidence regarding high cvs prevalence in young generation, the study was designed to explore the frequency of cvs among students and to identify the daily vision routine factors promoting its risk. methodology this cross-sectional study was conducted between 1st september 2018 to 31st may 2019 over 320 students of diverse physiotherapy institutes of karachi including liaquat national school of physiotherapy, ziauddin college of rehabilitation sciences, jinnah postgraduate medical college and baqai medical university. subjects were selected through convenient sampling technique, irrespective of gender and involved in daily technological use from at least 1 year or more were included in the study. while those who underwent eye surgery, having eye infection, taking any topical medication or eye drops were excluded from the study. written informed consent was taken from each participant and their voluntary participation was assured, participant confidentiality was maintained. for assessment, a semi-structured questionnaire was used which comprised of two parts. first part included daily vision related routine of individuals i.e. distance of screen during digital device use, duration of watching digital screen, sleep duration, eye 17 issn 2412 3188 app| published by aeirc| volume 6 issue 1 hygiene, viewing position in classroom and breaks during prolong use of digital device. in second part a standardized cvs-q developed by segui and colleagues10 was used for estimating the cvs frequency9. the questionnaire focused on the frequency and intensity of total 16 cvs associated symptoms including burning, itching, feeling of foreign body, tearing, excessive blinking, eye redness, eye pain, heavy eyelids, eye dryness, blurred vision, double vision, difficulty focusing for near vision, increased sensitivity to light, colored halos around object, feeling that sight is worsening and headache. the occurrence of cvs symptoms was indicated via numeric codes i.e. from 0 to 2 (0never, 1-occasionally, 2-often or always), while intensity of symptoms was marked from 1 to 2 (1= moderate and 2+= intense). the frequency and intensity of each symptom was multiplied in order to get the total score for each symptom. as per the criteria, score of each symptom was recoded as 0=0, 1 or 2=1 and 4=2. if the sum of all recoded score was ≥6, the participant was considered to be suffering from cvs. the recorded data was analyzed using spss version 21. chi-square test was used to evaluate associations between categorical variables. result out of total 320 enrolled participants, there was female majority i.e. 245 females and 75 males only with a mean age of 21.04±0.8 years. the diagnosis for cvs was made using cvs-q scoring, around 58% participants were diagnosed with cvs. the baseline characteristics were recorded for all study subjects as shown in table 1. table 1: demographic characteristics of the study population variables total participants (n=320) computer vision syndrome (n=186) mean age (years) 21.04±0.8 22.45±0.73 gender male 75(23.3) 32(17.1) female 245(76.6) 154(82.7) marital status married 9(2.8) 3(2) unmarried 311(97.2) 183(98) educational status (dpt) 1st year 60(18.8) 34(18.3) 2nd year 58(18) 38(20.4) 3rd year 60(18.8) 40(21.5) 4th year 65(20.3) 39(20.9) 5th year 77(24.1) 35(18.9) *values are given as n(%) or mean ± sd *dpt-department of physiotherapy headache was the major complaint reported by participants diagnosed with cvs i.e. 63.1% followed by itching (52.8%), increased sensitivity to light (43.6%), while other infrequent symptoms of cvs are mentioned below in table 2. table 2: major symptoms among study subjects diagnosed with cvs symptoms n(%) headache 117(63.1) itching 98(52.8) increased sensitivity to light 81(43.6) 18 issn 2412 3188 app| published by aeirc| volume 6 issue 1 eye pain 79(42.6) feeling of foreign body 73(39.5) tearing 69(37.4) burning 66(35.9) blurred vision 64(34.4) heavy eyelids 55(29.7) eye redness 51(27.2) feeling that sight is worsening 51(27.2) colored halos around object 46(24.6) difficulty focusing for near vision 42(22.6) excessive blinking 38(20.5) eye dryness 33(17.9) double vision 25(13.3) figure 1: intensities of four most reported symptoms intense headache was reported by 67% participants while in case of itching majority reported moderate intensity (83%), same was in the case of light sensitivity and eye pain. from the collected data it has also been observed that use of optical (p-value =0.003) recorded as 54.9%,duration of digital screen usage for 4-8 hours (p-value =0.116) recorded as 40.5%, distance from digital screen and eyes during work at 15-20 inches (p-value =0.30) recorded at 50.8% and sitting position in the middle row of class (p-value =0.004) recorded as 41.5%, taking care of eye hygiene (p-value =0.31) recorded as 64.1%which showed a statistically significant contribution in the prevalence of cvs. headache itching increase sensitivity of light eye pain moderate 33% 83% 79% 87.50% intense 67% 17% 21% 12.50% 3 3 % 8 3 % 7 9 % 8 7 .5 0 % 6 7 % 1 7 % 2 1 % 1 2 .5 0 % 19 issn 2412 3188 app| published by aeirc| volume 6 issue 1 table 3: association of variables related to daily vision routine and computer vision syndrome variables total n(%) computer vision syndrome p-value yes no optical use yes 176(55) 116(65.91) 60(34.09) 0.003 no 144(45) 52(36.11) 92 (63.89) duration of digital screen usage (hours) 1-2 35(10.9) 20(57.14) 15(42.86) 0.116 2-4 77(24.1) 49(63.64) 28(36.36) 4-8 130(40.6) 77(59.23) 53(40.77) >8 78(24.37) 44(56.41) 34(43.59) distance between digital screen and eyes (inches) 10-15 100(31.2) 67(67) 33(33) 0.30 15-20 162(50.62) 89(54.94) 73(45.06) 20-25 51(15.9) 18(35.29) 33(64.71) 25-30 7(2.18) 5(71.43) 2(28.57) breaks during prolong use of digital device no breaks 61(19.06) 30(49.18) 31(50.82) 0.672 15 sec 71(22.18) 43(60.56) 28(39.44) 20 sec 62(19.37) 34(54.52) 28(45.16) ≥30 sec 126(39.3) 75(59.52) 51(40.48) viewing position in classroom front row 108(33.7) 41(37.96) 67(62.04) 0.004 middle row 133 (41.5) 92(69.17) 41(30.83) last row 79(24.6) 49(62.03) 30(37.97) eye care habits & hygiene yes 205(64) 105(51.22) 100(48.78) 0.31 no 115(35.9) 77(66.96) 38(33.04) sleep duration <06 hrs 56(17.5) 36(64.29) 20(35.71) 0.3 06-07 hrs 169(52.8) 100(59.17) 69(40.83) 08-10 hrs 82(25.6) 38(46.34) 44(53.66) >10 hrs 13(4.06) 8(61.54) 5(38.46) *p<0.05 is considered significant. discussion exposure to music stimulates brain areas, but the process occurs differently among males and females which are attributed to various genetic, hormonal and environmental factors. however, both genders are equal in intelligence, but tend to work in a different manner. this is because both male and female use different parts of their brain to recognize faces, sense emotions, encode memories, make decisions and solve certain problems. according to our results, reaction time was much faster among females as compared to males in the control group as well as experimental group (table 1). however, it is generally accepted that males have faster reaction time as compared to females. men tend to have larger diameter of axons than women. larger diameter of axons causes signals to be transmitted faster up to the nerve fibres, leading to a shorter latency between stimulus and response15. but our results are contradictory to previous researches. this might be due to the neuroanatomical differences among both the genders. that is female have bigger corpus callosum as compared to males which is the larger tract of neural fibres that allows the free flow of communication between both hemispheres of the brain16. furthermore, regions for frontal lobe that are responsible 20 issn 2412 3188 app| published by aeirc| volume 6 issue 1 for problem solving and decision making were larger in women17. in addition, our graphs also showed that both the genders took more time in stroop interference (table 1) it is because, there are two brain regions involved in the processing of stroop task cingulated cortex and dorsolateral prefrontal cortex. hemisphere difference has also been proved by a study that right cerebral hemisphere reads the colour, the left cerebral hemisphere insists to read the words. when the meaning of a word and its colour are congruent, it is easy to recognize the actual colour of the word. but when the meaning of the word is incongruent with the colour, it creates a conflict between the colour and the word's meaning. the "conflict" between two brain processes is word-recognition and colour-recognition. thereby, extra time is required by brain to process and resolve this conflict. it turns out that we are so fluent in our language that word-recognition is slightly faster/stronger than colour-recognition18. most people will recognize the meaning of the word before recognizing the colour. in order to name the colour correctly, the two processes compete for the final decision-making process. the brain has to inhibit the faster/stronger wordrecognition process in order to allow the colour-recognition to win in the final response. this inhibition requires "selective attention" (attention focus) to inhibit the competing conflicting process. the reaction time is an indicator of the "attention process" in the brain it increases with attention fatigue and/or inattentiveness19. however, when comparing between both the genders, it was found out that females perform somewhat better than males this is because the neurons in the pre frontal cortex of female’s brain are more closely packed together than male’s brain20. and the prefrontal cortex is involved in stroop task and problem-solving ability. many researches have been done proving different effects of music on psychological parameters, all with contradictory conclusions to one another. like authors have concluded that music does not have any effect on memory21. on the other hand, some have also reported that sound in the background actually enhances the learning ability22. in our study, the overall working capacity was decreased along with the verbal fluency (table 1). this can be due to the perspective proposed by kahneman as cognitive capacity model. in this model it is demonstrated that cognitive processing can be done only for a limited pool of resources at a given moment. when multiple tasks occur at the same time, they compete for the limited resources and thereby exceeding the available capacity due to combined demand. and ultimately capacity interference occurs. this causes the processing of only portion of the task and thereby performance deteriorates. thus, increasingly complex distractions due to music cause decline in cognitive performance23. this might be the possible reason that the working capacity of our participants decreased from high to average, in addition to the verbal fluency. this is similar to other researches which demonstrated that background music has small but continuous negative effect on memorizing words or nonsense syllables (especially when listening to loud music)24, remembering advertisements25 and also in memorizing earlier read texts and reading performance26. listening to music has also been reported to hinder with many other cognitive processes, including multimedia learning, performance on diagrammatic, numerical and verbal analysis, the ability to perform arithmetic, reading, performance inhibition on stroop task and also in the learning of new procedures27-29. this study provides the positive effects of music on attention, verbal fluency, and shortterm memory and also on reaction time. however, more significant data is required in future in support of the positive effects associate with music. moreover, the negative effects were not evaluated in this study which play a significant role in one’s health and well-being, thereby, future researches should also focus both the negative and positive aspects of the music and comparative data must be represented in order to evaluate the 21 issn 2412 3188 app| published by aeirc| volume 6 issue 1 overall significance and outcomes of musical interventions. conclusion limited data is in favour of positive effect of music on psychological parameters but it is firmly demonstrated that music consistently and reliably interferes with the mental performance, also indicated by our study. but it is recommended that further studies should be performed to compare the positive or negative impacts of music or the specific type of music causing either positive or negative effect on memory and attention. acknowledgement the author acknowledged the support of the students of karachi university who participated in this study and also the colleagues for helping out in the entire research. references 1. chun ll. the influence of different music genres on task performances of employees. nt. j. psychol. couns. psychiatry: theory, research and clinical practice. e-issn no:2590-4272 [cited august 17, 2019]. available at: http://ijpcp.com/journal02/j02a03.asp 2. boothby s, does music affect your mood? healthline: health news [online] april 13, 2017. [cited august 17, 2019]. available at: https://www.healthline.com/healthnews/mental-listening-to-music-liftsor-reinforces-mood-051713 3. miendlarzewska ea, trost wj. how musical training affects cognitive development: rhythm, reward and other modulating variables. front. neurosci. 2014;7:279. 4. isaacs s. the roles of the amygdala and the hippocampus in fear conditioning [dissertation on the internet]. sweden: university of skövde, school of bioscience. [online] 2015. [cited april 7, 2017]. available from: http://www.divaportal.org/smash/get/diva2:839668/f ulltext01.pdf. 5. lehmann ja, seufert t. the influence of background music on learning in the light of different theoretical perspectives and the role of working memory capacity. front. psychol, 2017. 8: article 1902. 6. jones mh, west sd, estell db. the mozart effect: arousal, preference, and spatial performance. psychol aesthet creat arts. 2006; s(1): 26–32. 7. atkinson rc, wickens td. human memory and the concept of reinforcement. the nature of reinforcement. 1971:66-120. 8. korczyn ad, peretz c, aharonson v, giladi n. o1-03-02: computer based cognitive training with mindfit® improved cognitive performances above the effect of classic computer games: prospective, randomized, double-blind intervention study in the elderly. alzheimers dement: the journal of the alzheimer's association. 2007;3(3):s171. 9. peretz i, zatorre rj. brain organization for music processing. annu. rev. psychol. 2005. 56:89-114. 10. ehret g. the auditory cortex. j. comp. physiol. 1997;181(6):547-557. 11. patterson j. fas test. encyclopedia of clinical neuropsychology. [online] 2011. [cited august 18, 2019]. available at: https://doi.org/10.1007/978-0-38779948-3_886 12. willcutt eg, doyle ae, nigg jt, faraone sv, pennington bf. validity of the executive function theory of attentiondeficit/hyperactivity disorder: a metaanalytic review. biol. psychiatry. 2005;57(11):1336-1346. 13. perret e. the left frontal lobe of man and the suppression of habitual responses in verbal categorical behaviour. neuropsychologia. 1974;12(3):323-330. 14. gourovitch ml, kirkby bs, goldberg te, weinberger dr, gold jm, esposito g, van horn jd, berman kf. a comparison of rcbf patterns during letter and semantic fluency. neuropsychology. 2000;14(3):353-360. 22 issn 2412 3188 app| published by aeirc| volume 6 issue 1 15. mcdougall s, riad wv, silva-gotay a, tavares er, harpalani d, li gl, richardson hn. myelination of axons corresponds with faster transmission speed in the prefrontal cortex of developing male rats. eneuro. 2018;5(4): e0203-18. 16. leonard cm, towler s, welcome s, halderman lk, otto r, eckert ma, chiarello c. size matters: cerebral volume influences sex differences in neuroanatomy. cerebral cortex. 2008;18(12):2920-2931. 17. zaidi zf. gender differences in human brain: a review. open anat j. 2010; 2(1): 37-55. 18. grandjean j, d’ostilio k, phillips c, balteau e, degueldre c, luxen a, maquet p, salmon e, collette f. modulation of brain activity during a stroop inhibitory task by the kind of cognitive control required. plos one. 2012;7(7):e41513. 19. shalev l, tsal y, mevorach c. computerized progressive attentional training (cpat) program: effective direct intervention for children with adhd. child neuropsychol. 2007;13(4):382-388. 20. witelson sf, glezer ii, kigar dl. women have greater density of neurons in posterior temporal cortex. j. neurosci. 1995;15(5):3418-3428. 21. fassbender e, richards d, bilgin a, thompson wf, heiden w. virschool: the effect of background music and immersive display systems on memory for facts learned in an educational virtual environment. comput educ. 2012;58(1):490-500. 22. mann g. why does country music sound white? race and the voice of nostalgia. ethn rac studies. 2008;31(1):73-100. 23. kahneman d. attention and effort. englewood cliffs, nj: prentice-hall; 1973 [cited april 7, 2017] available at: http://citeseerx.ist.psu.edu/viewdoc/d ownload?doi=10.1.1.398.5285&rep=rep1 &type=pdf. 24. wen w, michihiko k. the effects of music type and volume on short-term memory. tohoku psychol folia. 2006;64:68-76. 25. oakes s, north ac. the impact of background musical tempo and timbre congruity upon ad content recall and affective response. applied cog psychol. 2006;20(4):505-520. 26. furnham a, allass k. the influence of musical distraction of varying complexity on the cognitive performance of extroverts and introverts. euro j personality. 1999;13(1):27-38. 27. avila c, furnham a, mcclelland a. the influence of distracting familiar vocal music on cognitive performance of introverts and extraverts. psychol. music 2012;40(1):84-93. 28. bloor aj. the rhythm's gonna get ya’– background music in primary classrooms and its effect on behaviour and attainment. ebd. 2009;14(4):261-274. 29. thompson wf, schellenberg eg, letnic ak. fast and loud background music disrupts reading comprehension. psychol music. 2012;40(6):700-708. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v6.i1.2019.15-22 71 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v8.i2.2021.71-75 original article role of mothers' resilience in the development of resilience and prevention of depression and anxiety in daughters zara nizar damani & sana hussain shaheed zulfiqar ali bhutto institute of science & technology, karachi-pakistan. abstract background: resilience has proven to be a protective factor against adverse conditions. however, mental health professionals have started studying resilience in terms of reducing depression and anxiety. in pakistan especially, this area needs to be explored to develop interventions to make people resilient. this study aimed to investigate and understand the role of mothers' resilience in developing resilience and prevention of depression and anxiety in daughters. methodology: this was a cross-sectional study, and data were collected from 88 participants hailing from different areas of karachi, pakistan, and among them, 44 were girls, and 44 were their biological mothers. the variables were assessed using the resilience and depression anxiety scale. results: the study results reveal that when mothers are resilient, it helps develop resilience in daughters. since there was no significant difference between mothers' and daughters' resilience, all the mothers were resilient, and their daughters were resilient. further, this study also showed that resilience is negatively correlated with depression and anxiety. moreover, there was a significant positive relationship between mothers' resilience and daughters' depression and anxiety scores. besides this, a significant positive relationship has also been found between daughters' resilience and mothers' depression anxiety scores. conclusion: based on the findings, it is suggested that for the development of a healthy society, intervention programs that promote resilience must be adapted for children as well as adults so that they can overcome the challenges of daily life. keywords resilience, mother-daughter relationship, depression, anxiety. citation: damani zn, hussain s. role of mothers' resilience in the development of resilience and prevention of depression and anxiety in daughters. app. 2021; 8(2): 71-75 corresponding author email: sanpsychologist@gmail.com doi: 10.29052/2412-3188.v8.i2.2021.71-75 received 08/08/2021 accepted 06/10/2021 published 01/12/2021 copyright © the author(s). 2021. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v8.i2.2021.71 https://orcid.org/0000-0003-1268-8730 https://orcid.org/0000-0002-1584-7680 http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 72 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 introduction depression and anxiety are the most common disorders found among all regions of the world. these disorders are significant to consider due to their economic and social consequences. by 2030, pakistan will be the fifth most populated country; therefore, there is a need to develop a strong aid policy on dealing with depression and anxiety disorders. the prevalence of depression and anxiety disorders is higher in pakistan, with higher numbers among rural population than to urban. similar to other countries, women in pakistan have higher rates of illness than men1. mental-health-related illnesses are increasing day by day. children go through many changes, socially, physically, and mentally. to understand this issue, many scholars and public health workers have identified the need for interventions that promote and develop resilience in the early stages of childhood. resilience is a learned behavior, and if properly addressed according to the age, gender, and population being targeted, it results in greater preventive effects2. a resilient person will survive despite having high levels of emotional and physical stress and having severe adversities in life. resilience can be stated as individual characteristics that indicate a successful functioning in fulfilling social norms and personal responsibilities3. predictors of resilience are the child's competence, parenting styles, and bond with caregivers. mother-daughter relationship connection plays a vital role in increasing resilience4. in addition, there is a significant relationship between maternal responsiveness and family communication in adopting positive coping behaviors in children5. further, the acceptance-involvement parenting style significantly contributes to the development of resilience6. moreover, parent-child communication influences the child's emotional wellbeing and emotional functioning7. no such study has been done to identify this phenomenon in the pakistani context. therefore, this study aims to examine the role of mothers' resilience in developing resilience and prevention of depression and anxiety in daughters. methodology it is a cross-sectional, correlational study, in which the participants were recruited through purposive sampling and snowball sampling. they were approached through social media platforms. only those participants were selected who fulfilled the criteria (i.e., mothers between the ages of 3040 years with their firstborn biological daughters between 13-19 years, and both mother and daughters understood the english language). after getting verbal consent from the participants, they were called to a community gathering/social gathering. before conducting the study, participants were requested to fill a consent form. they were assured that their identities would remain anonymous, and data gathered from the questionnaire will be used only for research purposes. along with this, ethical approval was also taken from the board of advanced studies and doctoral research committee of szabist, karachi. in total, 100 (50 daughters and 50 mothers) were approached to fill the questionnaire and out of which 88 (44 mothers and 44 daughters) agreed to be part of the study. participants were asked to fill a consent form, demographic form, resilience scale8, depression anxiety scale (das)9. all the scales were in the english language, and all the participants understood this language. after collecting the data, as a token of thanks, a session was conducted for the participants to teach them 73 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 some coping strategies to overcome daily life stressors. results were analyzed through spss version 20.0. to calculate reliabilities of the scales, cronbach alpha was used. the correlation was applied to find out the relationship between different variables and to identify the differences independent t-test was administered. result the result shows that both the scales are having high reliability. the depression, anxiety scale (das) has 0.94, and resilience has a 0.89 reliability coefficient. table 1: alpha reliability of the resilience and depression anxiety scales scales no. of items alpha reliability resilience 14 0.89 das 21 0.94 das-depression, anxiety scale. the result shows a significant positive relation (r=0.465; p<0.05) between mothers’ and daughters’ resilience. moreover, it shows a significant positive relation(r=0.516; p<0.01) between daughters' resilience and mothers' depression and anxiety levels. further, there is a significant positive relationship (r=0.462; p<0.01) between mothers' resilience and daughters' depression and anxiety results. moreover, a significant negative correlation (r=-0.538; p<0.05) can be seen between mothers and daughters' levels of depression and anxiety. furthermore, the result shows that there is a significant negative correlation (r=-0.162; p<0.05) between mothers resilience and mothers das. similarly, a significant negative correlation (r=-0.642; p<0.05) can be seen on the table between daughters' resilience and daughters das scores. table 2: pearson correlation between mother's daughter's resilience and mother, daughter's depression, anxiety scale. measures mothers resilience mothers das daughters resilience daughters das mothers resilience 1 -0.162** 0.465** 0.462** mothers das 1 0.516** -0.538** daughters resilience 1 -0.642** daughters das 1 das-depression, anxiety scale. **correlation is significant at the 0.01 level the result shows the mean difference between mother and daughter scores on resilience and das. it shows no difference between mother and daughters' scores on both the variables tested in the current study (p > 0.05). 74 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 table 3: difference in the mean das and resilience among mothers and daughters. variables mothers (n=44) daughters (n=44) 95% ci t-values mean±sd resilience 81.81±12.6 83.02±9.94 (-3.626 6.035) .496 das 16.95±14.16 15.20±10.13 (-6.976 3.476) -.667 das-depression, anxiety scale. discussion the main objective of the present study was to identify the role of mothers' resilience in developing resilience and preventing depression and anxiety in daughters. the present study’s finding suggests that resilience plays a significant role in reducing depression and anxiety among mothers and daughters. in this study, there is a significant negative correlation found between the depression and anxiety of mothers and daughters with their resilience, which proves that resilient factors decrease the scores of anxieties and depression in an individual and promotes wellbeing. recently, a study on footballers suggested that resilience was a protective factor against anxiety and stress. high resilience and low anxiety traits were found to be protective factors to improve mental wellbeing10. it can be said that resilience impacts on improving mental wellbeing and reducing depression and anxiety in an individual. in pakistani culture, it is usually said that a girl's first best friend is her mother. the bond they share includes all the other relationships, such as friends, caregivers, secret keepers. mothers usually transmit their behaviors and beliefs to their children. whether it is good or bad, they endorse attitudes in them and influence their actions11. the present study also showed that daughters' resilience positively correlated with mother's anxiety and depression. mothers and daughters provide a robust support system to each other, especially in pakistani culture. the quality of the relationship between mothers and daughters determines the later development of the daughter. the current study shows a positive correlation between mothers’ and daughters’ resilience. moreover, there was no difference between mother and daughters' resilience which shows if mothers are resilient, then daughters can also be resilient. this finding shows the importance of a mother's role in the emotional development of their daughters. on the basis of this finding, we can say that if we work on a mother's resilience, we can make daughters resilient. the connection with mothers provides a safe space for children, especially daughters, to internalize a positive attitude and overcome adversities. moreover, the current study also suggests that when mothers get depressed, daughters become resilient. when daughters show depressive or anxiety symptoms, mothers tend to get resilient to deal with the situation. there was a positive correlation found between daughters' depression, anxiety score and mother's resilience. moreover, a significant positive correlation was also found between mothers' resilience and daughters' depression and anxiety scores. therefore, current study’s finding suggest that resilience plays a significant role in dealing with stressful life events and that if we can develop interventions to promote resilience, we can make our society healthy and sound. the small sample size is one of the limitations of this study, but this study will 75 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 contribute to the literature by minimizing the gap. furthermore, this study can be replicated with larger populations to get a better picture. also, including gender differences and childbirth order differences in the study would allow researchers to develop interventions suitable for both genders and all the children irrespective of their birth order. conclusion overall, this study showed that resilience plays a significant role in preventing depression and anxiety among mothers and daughters. therefore, more intervention programs must be developed that promote resilience not only in clinical settings but also in programs that are school-based. moreover, family therapy sessions must be promoted to make society resilient. also, as resilience is learnt, it is essential that programs that promote family resilience or resilience in mothers should be encouraged so that there are more citizens that can be productive and can perform well. this will impact the overall well-being of the society and the country as well. acknowledgement the authors would like to thank the management of the community center and all the participants for their valuable contribution. references 1. waris u, shafqat t, hameed s. evaluation of anxiety and depression among medical students using duke health profile. ijehsr. 2017;5(4):17-20. 2. dray j, bowman j, campbell e, freund m, wolfenden l, hodder rk, bailey j. systematic review of universal resiliencefocused interventions targeting child and adolescent mental health in the school setting. j american acad child & adole psychiatry. 2017;56(10):813-824. 3. kirmayer lj, sehdev m, isaac c. community resilience: models, metaphors and measures. int j indigen health. 2009;5(1):62. 4. everet alt je, marks ld, clarke-mitchell jf. a qualitative study of the black motherdaughter relationship: lessons learned about self-esteem, coping, and resilience. j black stud. 2016;47(4):334-350. 5. gaylord-harden nk, elmore ca, montes de oca j. maternal parenting behaviors and child coping in african american families. j fam psycho. 2013;27(4):607. 6. zakeri h, jowkar b, razmjoee m. parenting styles and resilience. procedia soc behav sci. 2010;5:1067-1070. 7. boughton kl, lumley mn. parent prediction of child mood and emotional resilience: the role of parental responsiveness and psychological control. depress res treat. 2011;2011:1-9 8. wagnild g, young h. development and psychometric. j nurs measure. 1993;1(2):165178. 9. 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(3):335-343. 10. madsen ee, krustrup p, larsen ch, elbe am, wikman jm, ivarsson a, lautenbach f. resilience as a protective factor for well-being and emotional stability in elite-level football players during the first wave of the covid-19 pandemic. sci med footb. 2021;5(1):62-69. 11. brun i, russell-mayhew s, mudry t. last word: ending the intergenerational transmission of body dissatisfaction and disordered eating: a call to investigate the mother-daughter relationship. eat disord. 2020;8:1-8. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v8.i2.2022.71-75 43 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v8.i1.2021.43-48 original article burnout among emergency medicine residents abdullah1, lal shehbaz1, shua nasir1, sami jataoi1, syed jehanzeb asim1 & aatir h. rajput2 1department of emergency medicine, dr. ziauddin hospital, karachi-pakistan. 2department of psychiatry & behavioral sciences, liaquat university, jamshoro-pakistan. abstract background: the emergency medicine department is the hub of most activity in any healthcare institution, with the most critical patients present and demand the most urgent care. however, dealing with that working day in and day out, throughout the extensive training period, has many adverse bodily and mental effects on the emergency medicine residents, the most problematic among which is burnout. the aim was to study the prevalence of burnout among emergency medicine residents. methodology: this observational, cross-sectional analysis was conducted upon a sample of 54 emergency medicine residents selected via non-probability convenience sampling from 3 different tertiary care teaching hospitals at karachi. after taking written informed consent, the maslach burnout inventory (mbi) was used to assess burnout and its sub-components (depersonalization, emotional exhaustion and personal accomplishment). additionally, basic biodata, sociodemographic details, distress at work were inquired and recorded onto a selfadministered questionnaire. data were analyzed using spss version 22.0. results: among the 54 residents enrolled in the study, 68.52% were males, while 31.48% were females. the mean age of the sample stood at 29.0±2.0 years. the mean duration of working in the emergency department was 2.0±1.0 years. mean burnout scores were 28.4 for emotional exhaustion (high), 9.3 for depersonalization (moderate), and 31.47 for personal accomplishment (moderate). the most commonly reported stressors at work included unruly patients and attendants, lack of timely cooperation by healthcare professionals from other departments, breaking bad news, and work overload. conclusion: after careful consideration, it can be concluded that burnout is prevalent among emergency medicine residents, and steps must be taken to prevent the already distraught and scarce emergency medicine personnel from falling into dysfunction due to burnout. keywords burnout, emergency medicine, critical care, acute medicine, trauma, causality citation: abdullah, shehbaz l, nasir s, jataoi s, asim sj, rajput ah. burnout among emergency medicine residents. app.2021; 8(1):43-48 corresponding author email: aatirh.rajput@gmail.com doi: 10.29052/2412-3188.v8.i1.2021.43-48 received 20/11/2020 accepted 07/05/2021 published 01/06/2021 copyright © the author(s). 2021 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v8.i1.2021. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 44 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 introduction professional life is an essential part of a person's daily life, with many of the effects of professional/occupational stressors encountered during the job spilling over to other parts of life and affecting general health and well-being. few professions can boast of being more demanding (in terms of work hours) and stressful than the healthcare profession. be it doctors, nurses or paramedical staff, all are subjected to extensive duty hours, extreme work conditions and an unparalleled stress level1. occupational stress is among the most discussed health and safety challenges in the modern era. stress is known to be associated with numerous adverse health outcomes and poor work performance. at the same time, acute exposures to stress can manifest as easy fatigability, disturbed sleep, and gastrointestinal dysfunctions2. chronic stress exposures manifest as more severe conditions including early onset of bodily (cardiovascular, musculoskeletal and metabolic diseases), mental (depression and anxiety) or both disorders; and often culminating in burnout3. many occupations (such as education, agriculture, fishing and forestry industries) incur some stress levels, with a few (teaching, policing, social work, prison guarding and tending to customer care) being affected more than the others4. recent research has brought to the notice that, in hospital settings, long work hours, high work intensity, and extreme work conditions yield the worst levels of stress and, consequently, lead to the worst possible of the many outcomes mentioned above, especially burnout5. healthcare professionals catering to emergency care needs deal with even higher work volume and time pressures (given their established relationship with sickness, absence, high staff turnover and early retirement). thus professionals employed in the healthcare setup are projected to suffer from severe burnout6. the duty regimen that often requires them to work in different alternating shifts leads to additional sleep troubles, disturbed circadian rhythms, lifestyle problems and most worryingly, high blood pressure. furthermore, overwork and sleep debt harm carbohydrate metabolism and endocrine function7. the occurrence of hypertension among overworked professionals is reported in research8. satisfactory evidence also points out higher mean glycated hemoglobin a1c (hba1c) levels and a greater risk of developing diabetes mellitus among professionals employed in stressful work positions9. research from japan even goes as far as coining a particular term, karōshi that translates to overwork death10. karōshi has claimed hundreds of people await this eventual fate since not much has done to alleviate the working environment's stress and limit the number of hours of work, especially for the general staff and ambulance drivers that have little or no say and influence on policymaking circles. the conditions are significantly worse for healthcare professionals in the emergency department. according to reports, those who were being subjected to the worst work shifts and forced to face extreme conditions in which, according to reports, face 36% more verbal violence, 22% more physical violence and 24% more stress than all other healthcare professionals11. however, the effect of these working conditions among them is left largely unexplored in international and national pools of evidence-based literature. it is, therefore, about time that this gap in the 45 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 literature is filled by evidence. this research serves this very purpose and explores the prevalence of burnout among emergency medicine residents. methodology this observational analysis was conducted upon a sample of 54 emergency medicine residents chosen via non-probability – convenience sampling from 3 different tertiary care teaching hospitals in karachi. after taking written informed consent, the maslach burnout inventory (mbi) was used to assess burnout and its sub-components i.e. depersonalization, emotional exhaustion and personal accomplishment. additionally, basic biodata, sociodemographic details and distresses at work were inquired and recorded onto a self-administered questionnaire. the statistical analysis was performed on spss version 22.0. all consenting individuals and emergency medicine residents (employed at the study setting for at least one year) were included. while those with pre-existing mental health conditions, suffered emotionally traumatizing events in the past six weeks were excluded from the study sample. the mbi score data were categorized as low, moderate and high-risk groups for burnout based on the overall 22 items score as follows: table 1: categorization of mbi score scale components low moderate high emotional exhaustion ≤ 18 19 26 ≥ 27 depersonalization ≤ 5 6 9 ≥ 10 personal accomplishment ≥ 40 34 39 ≤ 33 confirmatory factor analysis (at a south-east asian setting) has revealed all three sub-components to have a high internal consistency with cronbach's α coefficient values of 0.837, 0.869, & 0.881 and report a high test-retest reliability. hence the tool was fit for use in the study setting for the intended purpose12. result among the 54 residents enrolled in the study, 68.52% were males, while the remaining 31.48% were females. the mean age of the sample stood at 29±2.0 years, and further age distribution is tabulated below. table 2: age distribution age group (years) male female ≤ 26 03 01 27-30 32 15 ≥ 31 02 01 *data represents frequencies. the age ranged from 25 to 33 years. as expected of this age, a majority of the residents were well ahead into their residency programs (2nd year and above), and a few had completed their training). the mean duration of working in the emergency department was 2±1 years. 46 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 figure 1: mean maslach burnout inventory scores mean burnout scores were 28.4 for emotional exhaustion (high), 9.3 for depersonalization (moderate), and 31.47 for personal accomplishment (moderate). as per mean values, the sample had a high level of emotional exhaustion and a moderate (bordering on high) level of depersonalization. the burnout pertaining to personal accomplishment, too, is noted to be high. the most commonly reported stressors at work included unruly patients and attendants, lack of timely cooperation by healthcare professionals from other departments, breaking bad news, and work overload. however, exploring the individual factors in detail was beyond the scope of this research. discussion since residents handle most of the work at the emergency medicine department, these post-graduate trainees' physical and mental health is a cause for concern. in addition to their work-related burdens, they face many academic and study-related responsibilities and demands. additionally, since the profession is dedicated to safeguarding the health of critically ill people needing acute attention, there is very little tolerance for error, thus requiring the residents to always be alert and on their toes, hence all the while generating anxiety and stress13. the excessive workload, lengthy educational curricula, constant workplace-based assessment and the very intense professional demands coupled with a lack of time for leisure, family and friends, take a high toll. furthermore, studying for numerous exams, pre-meditating future challenges in the highly saturated field and the delayed prospects of adequate income also act as stressors on the mind of emergency medicine residents. in addition to these aspects, medical professionals' personality traits, including obsessiveness, self-exigency, and perfectionism, are likely to add to the mix adversely14. it has been hypothesized that persistent exposure to continuous psychosocial stressors throughout their education and training period can lead to burnout syndrome15. it is essential to understand that burnout is a multifactorial occupational syndrome. thus any solution must address the complete triad of symptoms it involves, namely: emotional exhaustion, depersonalization, professional cynicism/disbelief16. in this research, a high level of emotional exhaustion, depersonalization and personal accomplishment. this is worrying since literature reports that having even one symptom of the triad may adversely impact 28.4 9.3 31.47 emotional exhaustion depersonalization personal accomplishment 47 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 medical professionals' training/learning process and reduce their work efficiency17. a limitation of this research is that we did not delve into the less severe manifestations. at the same time, other researchers have noted and laid much importance on the selfreported physical images (such as fatigue, drowsiness, disorderly eating, and migraine). emotional effects (instability, agitation and even a heightened inclination towards illicit drugs use) accompany all subcomponents of burnout18. conclusion after careful consideration, it can be concluded that burnout is prevalent among emergency medicine residents. since the student/trainee community in medicine is already overwhelmed with the high prevalence of suicide, depression, stress and use of psychoactive substances, steps must be taken to counteract the situation. the fact that emergency medical personnel are among the scarcest in the medical field, it is all the more important to dedicate efforts to prevent them from falling into dysfunction due to burnout. acknowledgment the authors are thankful to the study participants for their cooperation in the study. references 1. basu s, qayyum h, mason s. occupational stress in the ed: a systematic literature review. emerg med j. 2016;34(7):441-447. 2. waters tr, dick rb. evidence of health risks associated with prolonged standing at work and intervention effectiveness. rehabil nurs. 2015;40(3):148-165. 3. ruotsalainen jh, verbeek jh, mariné a, serra c. preventing occupational stress in healthcare workers. cochrane database syst rev. 2014; cd002892. 4. kuo sy. occupational stress, job satisfaction, and affective commitment to policing among taiwanese police officers. j police quarterly. 2015;18(1):27-54. 5. adriaenssens j, hamelink a, van bogaert p. predictors of occupational stress and wellbeing in first-line nurse managers: a crosssectional survey study. int j nurs stud. 2017;73:85-92. 6. adriaenssens j, de gucht v, maes s. causes and consequences of occupational stress in emergency nurses, a longitudinal study. j nurs manag. 2015;23(3):346-358. 7. zhu b, hershberger pe, kapella mc, fritschi c. the relationship between sleep disturbance and glycaemic control in adults with type 2 diabetes: an integrative review. j clin nurs. 2017;26(23-24):4053-4064. 8. portela lf, griep rh, landsbergis p, rotenberg l. self-reported hypertension and job strain in nursing personnel: assessing two different formulations of the demand-control model. clin nurs res. 2015;3(2):46. 9. rahman u, khalil m, azim n, ahmad n. work environment, job stress, job satisfaction, and burnout among the nurses of the government hospitals of khyber pakhtunkhwa, pakistan, using structural equation model. middle east j bus. 2018;13(3): 13-20. 10. yoshikawa t, sasaki t, matsumoto s, yamauchi t, kayashima k, kubo t, umezaki s, takahashi m. 1222 diagnosis of 1,561 compensated cases for overwork related cerebrovascular/cardiovascular diseases (ccvds) known as ‘karoshi’ in japan, 2010– 2014. occup environ med. 2018; 75(2): 71-76. 11. baig la, shaikh s, polkowski m, ali sk, jamali s, mazharullah l, soomro m, kumari b, memon s, maheshwari g, arif s. violence against health care providers: a mixedmethods study from karachi, pakistan. j emerg med. 2018;54(4):558-566. 12. wickramasinghe nd, dissanayake ds, abeywardena gs. validity and reliability of the maslach burnout inventory-student survey in sri lanka. bmc psychology. 2018;6(1):52. 48 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 13. heinen i, bullinger m, kocalevent rd. perceived stress in first year medical students-associations with personal resources and emotional distress. bmc med educ. 2017;17(1):4. 14. popa-velea o, diaconescu l, mihăilescu a, jidveian popescu m, macarie g. burnout and its relationships with alexithymia, stress, and social support among romanian medical students: a cross-sectional study. int j environ res publichealth. 2017;14(6):560. 15. skodova z, lajciakova p, banovcinova l. burnout syndrome among health care students: the role of type d personality. west j nurs res. 2017;39(3):416-429. 16. fares j, al tabosh h, saadeddin z, el mouhayyar c, aridi h. stress, burnout and coping strategies in preclinical medical students. n am j med sci. 2016;8(2):75. 17. moss m, good vs, gozal d, kleinpell r, sessler cn. an official critical care societies joint statement: burnout syndrome in necessary care health care professionals: a call for action. am j crit care. 2016;25(4):368376. 18. shanafelt td, dyrbye ln, west cp. addressing physician burnout: the way forward. j am med assoc. 2017;317(9):901902. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v8.i1.2021.43-48 8 app| published by aeirc| https://doi.org/10.29052/2412-3188.v6.i1.2019.8-14 issn 2412 3188 original article prevalence of dysmenorrhic pain among students; its impact and management uzma firdous, noaima fatima, ghazala yasmeen & lubna naz department of physiology, university of karachi abstract background: dysmenorrhoea is a common gynecological problem affecting 6070% of the adolescent menstruating females. it has been widely neglected but it known to affect the quality of life and is the major cause of absenteeism among adolescent females. this study was conducted to assess the prevalence and impact of dysmenorrhea and the management strategies used by the students. methodology: this cross-sectional study was conducted from march to december 2015 at university of karachi. a total of 350 female university students were randomly selected and dysmenorrhea was assessed using a self-administrated questionnaire. data regarding demographic characteristics like age, physical measurements, dietary habits, family history, menstrual history, pattern of pain, pain intensity, stress and use of pharmacological agents used for coping was collected and statistically analyzed using spss version 20. results: a total of 350 female students were enrolled in the study, of which 300 reported having dysmenorrhea with high prevalence in follicular phase i.e. 36%. the pain characteristics were also recorded and cramping pain was reported by 20.6% of students followed by stabbing (18.6%) and abdominal distention (9.3%). among the major associated systemic complaints with dysmenorrhea were headache (54.7%), nausea (50%), low back pain (lbp) (50%) and bloating (43.3%). majority of females preferred medication for pain relief, ibuprofen was the drug of choice (14%) followed by paracetamol (12%). among non-pharmacological approaches, relaxing therapy was ideal according to 18.6% of students. conclusion: dysmenorrhea is a prevalent cause of distress among the female students, although the condition is prevalent it is considered as a general complaint and mostly neglected. this menstrual complication is coupled with various symptoms that affect daily activities and quality of life. keywords dysmenorrhea, abdominal cramps, menstrual cycle, management. citation: firdous u, fatima n, yasmeen g, naz l. prevalence of dysmenorrhic pain among students; its impact and management. app. 2019; 6(1):8-14 corresponding author email: uzma.firdous1@gmail.com doi: 10.29052/2412-3188.v6.i1.2019.8-14 received 10/02/2019 accepted 25/06/2019 published 12/10/2019 copyright © the author(s). 2019 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v6.i1.2019.7-13 http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 9 app| published by aeirc| volume 6 issue 1 issn 2412 3188 introduction menstruation is a normal physiological process controlled by hypothalamopituitary hormones; it is one of the major signs of puberty. several cultural norms had been linked to this reproductive event. it is taken as a gift and is celebrated in few cultures in order to destigmatize and minimize the associated shame and trauma1 while the others consider it impure and held their women in isolation and restricted diet and social interaction2-4. menstruation is often associated with irregular and/or excessive, painful bleeding scientifically referred as dysmenorrhea, pain sensation in pelvis directly linked with menstruation accompanied by many other symptoms5. dysmenorrhea is categorized as primary dysmenorrhea and secondary dysmenorrhea. primary dysmenorrhea is typically reported at the beginning of ovulatory cycles, in the first year of menarche6. increased levels of prostanoids with eicosanoids results in hypercontractility of the uterus which leads to hypoxia and ischemia of the uterine muscles. which in turn causes impaired and dysrhythmic contractions of the uterus which is believed to be the cause of underlying physiology of primary dysmenorrhea7. while secondary dysmenorrhoea is associated with certain pathological condition, women in 30’s and 40’s are more likely to develop secondary dysmenorrhea8. for many years, menstruation has been a psychological trigger for young females due to the associated hormone fluctuations leading to anxiety, fear, anger, confusion, shame and depression9,10. although complaints associated with menstrual cycle are high, but still these complaints are neglected and are given less priority in healthcare assessment7. the major symptom of lower abdominal pain or cramping is complicated by other systemic disturbances including various degrees of headaches, migraine, dizziness, vomiting, nausea, diarrhea, bloating, backache, legs pains, shivering and mood swings9,11. which not only affect the routine activities and quality of life of female during the respective time duration but it has also become the major cause leading to gynecological visits, adding to the health related financial burden12,13. age, low body mass index (bmi), tobacco consumption, early menarche, extended or irregular menstrual flow, infections, psychological and genetic factors are the major contributors for dysmenorrhea14,15. by far, the most reliable management modality preferred by both the sufferers and the healthcare providers is medication including non-steroidal anti-inflammatory drugs (nsaids) and oral contraceptives and lifestyle modifications like low fat consumption, is known to relief menstrual cramps16. physical activity has been strongly recommended for females with complaints of dysmenorrhea. with respect to the local perspective, the condition is rarely known and considered by our females. therefore, the present study was planned to investigate the prevalence of dysmenorrhea, associated symptoms and characteristics and preferred management options among the female students. methodology this cross-sectional study continued for 9 months from march to december 2015 at university of karachi, pakistan. total 350 female university students were randomly selected and enrolled in the study, while married females and those diagnosed with pelvic disease were excluded from the study. data was collected using a structured questionnaire including details regarding sociodemographic characteristics, menstrual details like menarche age, menstrual cycle regularity, duration, flow, pain sensation description, phase of cycle with maximum pain feelings, severity of pain, other systemic symptoms experienced and the preferred approach to relief dysmenorrhea. 10 app| published by aeirc| volume 6 issue 1 issn 2412 3188 menstruation was described as regular if cycle repeats every 28–32 days and continues for 5-7 days. pain intensity was measured on a scale of 0–10 during menstruation, categorized as mild dysmenorrhea if lies between 1 and 3 point, moderate when between 4 and 7, and severe if falls between 8 and 10 points 2. written informed consent was taken from all participants prior to the study and the confidentiality was maintained. the collected data was analyzed using spss version 20, where quantitative variables were displayed using mean and standard deviation and frequency and percentages were used for qualitative variables. pearson chi-square test was applied to measure the association between different variables and p<0.05 was considered statistically significant. result out of 350 enrolled females, dysmenorrhea was reported by 300(86%) females while only 50(14%) had no complaints of pain during menstruation. 190(63.3%) out of 300 dysmenorrhic females hit puberty in between 11-12 years. irregular menstrual cycle was observed among 37% of the enrolled females. 203(67.6%) females had 28-35 days cycle and mostly reported 5-7 days bleeding. maximum dysmenorrhic pain was experienced during the follicular phase of the cycle i.e. 108(36%) while 86(28.6%) reported dysmenorrhea both in ovulation & luteal phase of the cycle. cramping with lower abdominal discomfort, stabbing and burning were the most frequent complaints of dysmenorrhic females. table 1: description of menstruation and the characteristics of dysmenorrhea among female students variables n=300 dysmenorrhea present 300(85.7) absent 50(14.2) menarche age (years) <11 76(25.3) 11-12 190(63.3) >12 34(11.3) menstrual cycle regular 188(62.6) irregular 112(37.3) duration of cycle (days) <28 22 (7.3) 28-35 203(67.6) >35 75(25) no of days of menstrual flow <5 41(13.6) 5-7 222(74) >7 37(12.3) pain intensity mild 41(27.3) moderate 84(56) severe 25(16.6) prevalence of dysmenorrhea during different menstrual phases follicular 108(36) ovulation 9(3) luteal 80(26.6) follicular & ovulation 4(1.3) follicular & luteal 6(2) ovulation & luteal 86(28.6) follicular, ovulation & luteal 6(2) 11 app| published by aeirc| volume 6 issue 1 issn 2412 3188 characteristics of dysmenorrhic pain burning 26(8.6) cramping 62(20.6) stabbing 56(18.6) pulling 18(6) breaking down 16(5.3) abdominal distention 28(9.3) *values are given as n(%) headache (54.7%) was the most frequently reported symptom associated with dysmenorrhea (p<0.05) followed by nausea (50%), lbp (50%) and bloating (43.3%). moderate pain (56%) was reported by most of the dysmenorrhic patients. table 2: relationship between dysmenorrhea and associated systemic symptoms symptoms dysmenorrhea p-value present absent nausea 75(50) 16(10) 0.001 vomiting 43(28.6) 15(10) 0.01 bloating 65(43.3) 21(14) 0.15 diarrhea 39(26) 12(8) 0.08 mood changes 35(23.3) 7(4.7) 0.11 low back pain 75(50) 35(23.4) 0.09 headaches 82(54.7) 6(4) 0.04 *values are given as n(%) *p-value <0.05 is considered significant table 3 shows the medicine and therapies preferred to address dysmenorrhic pain. non pharmacological relaxing therapies (18.6%) were the most preferred management strategy for controlling dysmenorrhea. the frequently used pharmacological approaches include ibuprofen (14%) followed by paracetamol (12%) and herbal medicines (8.9%). ponston, aspirin and buscopan were among the other rarely used pharmacological agents. table 3: preferred treatment options for dysmenorrhea treatment option n(%) ibuprofen 42(14) paracetamol 36(12) buscopan 10(3.3) aspirin 8(2.6) ponston 19(6.4) herbal medicine 27(8.9) relaxing therapy 56(18.6) discussion this study aimed to identify the incidence of dysmenorrhea and associated systemic symptoms, pain severity, characteristics and its treatment among students. our results highlighted that dysmenorrheal pain was relatively a common complaint in young females that is about 85.7% (table 1), which is comparable to previous literature i.e. the reported prevalence among university students was 34% in egypt, 70.2% in india, 85% among hispanic female adolescents, and 93% in australia17,18-20. there is a wide variation in the reported statistics worldwide as the protocols describing the dysmenorrheal pain and the 12 app| published by aeirc| volume 6 issue 1 issn 2412 3188 sociodemographic characteristics are different for each individual locale. moreover, there are wide variety of perceptions and myths that undermine the significance of this female health issue which is the major reason behind negligence21. the scale of symptoms accompanying menstrual pain ranges from digestive disturbances like nausea, abdominal cramps, vomiting, aches and pains, tiredness and dizziness22. we found, the most complained symptoms included headache, lbp, nausea, and bloating which consistent to an indian study, according to which tiredness (56.8%) was the major symptom associated with dysmenorrhea followed by back pain (40.1%)19. in contrast, a palestinian study reported physical fatigue and emotional instability manifested as nervousness/irritability as the major symptoms observed among the dysmenorrhic females23. majority of the respondents (47.2%) reported use of pain medication for relief (table 3), similar results were produced in a study, where approximately 58% of dysmenorrheal students opted pain killer pills22. while 18.6% prefer relaxing therapy and a very few prefer herbal medication (8.9%). whereas, in india, pharmacological management is less preferred by students (25.5%) while use of herbal medicine and other nonpharmacological approaches to relief pain are commonly practiced19. women do not usually seek medical help for dysmenorrhea and mostly follow nonpharmacological approach including heat application24. this study was conducted with the aim to estimate the prevalence of dysmenorrhea among students, the impact and management associated with it. although high prevalence of dysmenorrhea was observed among the females enrolled in our study but there were several limitations. the sample size of the study was too small and the study site was restricted to single center so the findings cannot be generalized for all local females of karachi. nevertheless, the findings offered valuable information about menstrual health, its care, associated issues among students. conclusion it can be concluded from the results that dysmenorrhea is prevalent among young females, complicated by a number of symptoms involving other systems that may affect sports activity, social activities, daily chores and quality of life as well and is becoming the leading cause of absenteeism in educational sector. although dysmenorrhea significantly affects the quality of life, adolescent girls rely on self-care to ease the symptoms of dysmenorrhea without tracking the adverse drug reaction. therefore, it is essential to organize and promote awareness programs among students regarding this restricting health condition, its associated impacts and the negative effects of consuming drugs without prescription and over the counter drugs (otc). acknowledgement authors would like to thank department of physiology for their insight into the present study and to the women who participated in the study. references 1. bhartiya a. menstruation, religion and society. int j of soc sci humanit. 2013;3(6):523–527. 2. poureslami m, osati-ashtiani f. assessing knowledge, attitudes and behaviour of adolescent girls in suburban districts of tehran about dysmenorrhea and menstrual hygiene. j int womens stud. 2002;3(2):51–61. 3. unicef. menstrual hygiene in schools in 2 countries of francophone west africa – burkina faso and niger case 13 app| published by aeirc| volume 6 issue 1 issn 2412 3188 studies in 2013. available at http://www.unicef.org/wash/schools /files/mhm_study_report_burkina_fa so_and_niger_english_final.pdf. accessed 10 july 2015. 4. anusree pc, ardra r, aswathy bs, faseela vcm, gincy pb, anupama t. knowledge regarding menstrual hygiene among adolescent girls in selected schools, mangalore with a view to develop an information booklet. j nurs health sci. 2014;3(1):55–60. 5. kumbhar sk, reddy m, sujana b, reddy rk, divya bk, balkrishna c. prevalence of dysmenorrhea among adolescent girls (14-19yrs) of kadapa district and its impact on quality of life: a cross sectional study. natl j community med. 2011;2(2):265–268. 6. padubidri vg, daftar s. 16th ed. new delhi: reed elsevier india private limited; dysmenorrhea and premenstrual syndrome shaw's textbook of gynecology.2014; 471–474. 7. sharma a, taneja dk, sharma p, saha r. problems related to menstruation and their effect on daily routine of students of a medical college in delhi, india. asia pac j public health. 2008; 20(3):234–241. 8. mavrelos d, saridogan e. treatment options for primary and secondary dysmenorrhoea. prescriber. 2017;28(11):18-25. 9. agarwal ak, agarwal a. a study of dysmenorrhea during menstruation in adolescent girls. indian j community med. 2010;35(1):159–164. 10. chan ss, yiu kw, yuen pm, sahota ds, chung tk. menstrual problems and health-seeking behaviour in hong kong chinese girls. hong kong med j. 2009;15(1):18–23. 11. adeyemi as, adekanle da. management of dysmenorrhoea among medical students. int j gynecol obstet. 2007;7(1):1528–1539. 12. ju h, jones m, mishra g. the prevalence and risk factors of dysmenorrhea. epidemiol rev. 2014;36(1):104–113. 13. kural m, noor nn, pandit d, joshi t, patil a. menstrual characteristics and prevalence of dysmenorrhea in college going girls. j family med prim care. 2015;4(3):426–431. 14. rizk de, mosallam m, alyan s, nagelkerke n. prevalence and impact of premenstrual syndrome in adolescent schoolgirls in the united arab emirates. acta obstet gynecol scand. 2006;85(5):589–598. 15. latthe p, mignini l, gray r, hills r, khan k. factors predisposing women to chronic pelvic pain: systematic review. bmj. 2006;332(7544):749–755. 16. lefebvre g, pinsonneault o, antao v, black a, burnett m, feldman k, et al. primary dysmenorrhea consensus guideline. j obstet gynaecol can. 2005;27(12):1117–1146. 17. parker ma, sneddon ae, arbon p. the menstrual disorder of teenagers (mdot) study: determining typical menstrual patterns and menstrual disturbance in a large population-based study of australian teenagers. bjog. 2010;117(2):185–192. 18. kamel dm, tantawy sa, abdelsamea ga. experience of dysmenorrhea among a group of physical therapy students from cairo university: an exploratory study. j pain res. 2017;10(1):1079–1085. 19. omidvar s, bakouei f, amiri fn, begum k. primary dysmenorrhea and menstrual symptoms in indian female students: prevalence, impact and management. glob j health sci. 2016;8(8):53632. 20. banikarim c, chacko mr, kelder sh. prevalence and impact of dysmenorrhea on hispanic female adolescents. arch pediatr adolesc med. 2000;154(12):1226– 1229. 14 app| published by aeirc| volume 6 issue 1 issn 2412 3188 21. chia cf, lai jh, cheung pk, kwong lt, lau fp, leung kh, leung mt, wong fc, ngu sf. dysmenorrhoea among hong kong university students: prevalence, impact, and management. hong kong med j. 2013;19(3):222–228. 22. de sanctis v, soliman at, elsedfy h, soliman na, soliman r, el kholy m, et al. dysmenorrhea in adolescents and young adults: a review in different country. acta biomed. 2017;87(3):233– 246. 23. abu helwa ha, mitaeb aa, al-hamshri s, sweileh wm. prevalence of dysmenorrhea and predictors of its pain intensity among palestinian female university students. bmc womens health. 2018;18(1): article 18. 24. calis ka. dysmenorrhea: medscape [updated: sep 23, 2019]. available at: https://emedicine.medscape.com/articl e/253812-print. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v6.i1.2019.8-14 96 app| published by aeirc| https://doi.org/10.29052/2412-3188.v8.i2.2021.96-106 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) original article cultivate an attitude of gratitude among college students: examining the positive effect of gratitude intervention on subjective well-being aisha rais ahmed1 & saima masoom2 1muhammad ali jinnah university, karachi-pakistan. 2university of karachi, karachi-pakistan. abstract background: positive psychological interventions (ppis) is the premise that focuses on how people can learn contentment and move toward subjective wellbeing (swb). one of the well-known positive psychological intervention strategies is the gratitude intervention that challenges to evoke gratitude and helps produce positive feelings. the primary purpose of this study was to examine the implementation of 3 weeks gratitude meditation program and determine its effects on swb (spell out) measures. also, it was observed whether or not the gratitude practice can improve the tendency to respond with a sense of gratitude itself. methodology: this quasi-experimental study included 160 students from 2 colleges in karachi who were participating voluntarily in the gratitude meditation program, conducted by investigators. all study subjects gave written informed consent before proceeding further. the mean age of the study subjects was 15 to 20 years. a total of 80 male and 80 female students participate in this study. the purposive non-probability sampling technique was used for recruiting the study sample. data were obtained using a brief demographic sheet, followed by pre-and post-intervention measures, using the gratitude questionnaire-six item form (gq-6), the positive and negative affect scale (panas), and satisfaction with life scale (swls). statistical analysis was conducted on spss version 22.0. descriptive analysis technique and paired-sample t-test applied for within-group comparison. results: the findings were highly significant with p< .001. the results showed a significant difference between the mean scores of pre-and post-intervention conditions of swb. moreover, the participant's level of gratitude was increased by experimental manipulation. conclusion: cultivating gratitude significantly contributes to satisfaction and positive outcomes in life, suggesting that gratitude training could be proposed as a beneficial practice for increasing swb. keywords positive psychological interventions, gratitude intervention, subjective wellbeing. citation: ahmed ar, masoom s. cultivate an attitude of gratitude among college students: examining the positive effect of gratitude intervention on subjective well-being. app. 2021; 8(2): 96106 corresponding author email: ahmed.aesh@gmail.com doi: 10.29052/2412-3188.v8.i2.2021.96106 received 02/09/2021 accepted 04/11/2021 published 01/12/2021 copyright © the author(s). 2021 this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v8.i2.2021. https://orcid.org/0000-0003-4882-1644 http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 97 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 introduction as health is not considered the absence of disease, in the same way, gladness is also not the absence of misery. to balance both situations, contentment is needed to be taught that can lay the foundation of the welfare of human civilization1. in this endeavor, positive psychology rings a bell in the world of the psyche. moreover, they compelled psychologists to shift their mental health and well-being paradigm. recently, psychologists started emphasizing the need to promote adolescents' well-being beyond the current focus on reducing the symptom since it is essential to mitigate pathology whose absence is not possible from mental health issues1. well-being is a term that comes to mind when discussing positive mental health. in the past few decades, the explosion of research in well-being has turned the tide for a good many terms persistently occur in the literature and are used in several ways1. typically, psychologists have two eminent traditions prevailing in the research field of well-being. the first one is eudemonic tradition, and the other practice is named hedonistic2. the perspective of eudaimonia stemmed from the aristotelian philosophy. its roots are also in humanistic psychology, which has been concerned with concepts allied with positive human functioning3. therefore, the hedonistic perspective that emphasizes contentment is defined as the presence of positive emotions or getting contentment and the absence of negative emotions or avoid discontentment. this states that all and only pleasure is intrinsically valuable, while all and only pain is intrinsically unwanted. thus, the term "hedonic" is linked with swb. the phenomenon of hedonic includes two components. the affective component is related to positive or pleasant effects and the absence of adverse effects. the other is the cognitive component based on satisfaction with life. neugarten et al. investigated that 'life satisfaction is a successful aging component4. in contrast, sumner stated that life satisfaction is a positive appraisal of the conditions of life, and it measures up positivity against standards or expectations. carruthers & hood specified that a person experiences joy when both components are present5. whereas diener proposed that swb is reflected when a person's life is worthwhile and successfully moving toward a desirable way6. it is considered subjective because one can evaluate oneself on the degree of one's experience and sense of wellness. swb is perceived through personality filters with the cognitive and emotional judgment; it implies a positive self-appraisal5,6. the works on swb have advanced speedily since the emergence of the field. undeniably, continued work shows professionals' consideration of the factors influencing swb, and research on this domain has been booming worldwide. at the current time, therapeutic intervention plays a crucial role in achieving swb. several researchers attempt to identify how to enhance and boost the level of swb rather than what makes people distressing and unhappy. in this exertion, the utilization of the positive psychological interventions (ppis) may be considered as a complementary strategy for enhancing wellbeing. there are some significant groupings under which these meditations practice is divided that include: a) meaning, b) gentleness, c) empathy, d) gratitude, e) strengths, f), hope and g) savoring7. these classes are markedly beneficial, but the gratitude practice validates the significant effects. it has been considered the most effective and sensational technique of the ppis8,9 and clinically applicable as well10. furthermore, it challenged to evoke the feeling of gratitude and promotes swb8,9. it 98 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 has been confirmed that gratitude is one of the influential character strengths, enhancing swb in youth11 that is now getting attention in scientific research12,13. gratitude has been theorized as an emotion, approach, amoral, a custom, a personality attribute, or a coping strategy. the word gratitude is derived from the latin origin "gratia," which means "grace," "graciousness," or "gratefulness." all roots from this latin source emphasize the principle of "have to do with humanity, kindness, contributions, the majesty of giving and receiving, or getting something for nothing"14. whether the gratitude trait can be inculcated therapeutically in our society arises. seligman et al. stated that assuredly, it can and comes under the considerable accomplishment of positive psychology advancement9. furthermore, in clinical psychology, gratitude is considered a significant tactics10,15. besides, it can induce ppis to increase people's swb. sin & lyubomirsky suggest that gratitude practice reproduces thoughtful healing methods intended to expand positive moods, perceptions, and behavior in an individual16. hence, this therapeutic meditation promotes positivity in people that is considered a vital essence in life, whether in terms of attaining mental health or coping with the adverse events and moods they might experience17. emmons & mccullough are considered the pioneer of this gratitude meditation program and are working toward the efficacy of gratitude meditations, including swb and other aspects of human welfare as well18. countless researches proposed that gratitude meditation can have long-term positive effects on a person's life. it is evident in the literature that gratitude interventions in adolescence may boost and maintain positive benefits and leads to more tremendous gratitude, life satisfaction18, positive affects12,19, and swb9,20, conversely reducing the negative mood9,19. another study challenged to evoke the feeling of gratitude for producing positive events or feelings in one's life and ultimately enhancing the level of swb21. likewise, watkins et al. conducted an experiment that revealed that thankful thought is a mood booster and is associated with a different facet of well-being such as subjective, social, physical, and psychological19. at the same time, there is substantial agreement among investigators that the accurate scales of swb22 can assess contentment and pleasure. the first is the satisfaction with life scale (swls) developed by diener, emmons, larsen, & griffin23 and can also be used to measure the cognitive side. in contrast, the affective facet of the second one is the positive and negative affect schedule24. these two frequently used measures are considered reliable and valid scales that can portray an individual swb. supplementary, swls gauges the cognitive factor of swb, while panas assesses the emotional factors. although the gratitude technique is a research-based intervention18, the participants are regularly engaged in a task designed to cultivate a sense of gratefulness. besides, these tasks contained quick and easy activities that can enhance positive affect, pleasure25 and life satisfaction and decreased na26. in this notion, the individuals first cultivate the gratitude internally and then express it in a handwritten letter or verbally27. undoubtedly, people seem to enjoy the gratitude intervention, and evidence has suggested that respondents are more likely to remain in an intervention and home assignments that allocate to them28. the homework usually entails counting blessings, listing things one is grateful for, 99 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 maintaining a gratitude journal, expressing gratitude, letter writing, etc. the discipline of gratitude intervention has advanced rapidly in the european countries, but the scarcity of this intrusion remained unprogressive in our culture. so, it is time to take a step forward to teach gratitude interventions to promote swb, especially in adolescents and adults. the gratitude meditation program mainly engrosses individuals to reminiscence the past events and recall the blessing that may persuade and boost gratitude. to summarize, the exploration mentioned above has recommended that gratitude intervention produces several positive outcomes and enhances swb. therefore, the central focus of the present study is to examine the effect of the gratitude meditation program and see if it shows positive effects on measures of swb on the sample of college students. it is suggested that study participants would have exposed an increase in dispositional gratitude immediately following the experimental manipulation. methodology quantitative research was conducted using the quasi-experimental designs within the groups of college students from two different colleges in karachi, participating voluntarily in the gratitude meditation program. participants indeed, mental health problems are a significant public health concern for all ages, especially adolescents. typically, the majority of mental disorders first emerge in this period. so, there is a strong need to improve their well-being to prevent disorder. thereby it was most desirable to recruit students from the college. the sample consisted of 160 participants voluntarily participating in the gratitude meditation program. the age of the study participants ranged from 15-20 years and was employed from two colleges of karachi in approximately equal proportions. the sample was divided into two groups regarding college, 80 students from sir syed govt college and 80 from army public college, saddar. all study participants were given informed consent before any gratitude meditation intervention. a total of 207 students were taken as additional participants to compensate the questionnaires with errors or absentees of students in the remaining sessions. students who did not take all sessions of the program or those who did come to take training after getting enrolled in the program were excluded. a purposive non-probability sampling technique was used as the recruiting strategy for the study sample (figure 1). the primary health care population does not have any psychiatric severe condition at baseline. the inclusion criterion involved reading and writing english to give informed consent and filling pre and post-measures. a total of 80 males and 80 females students participate in this study. measures gratitude questionnaire-six-item form (gq6)29: this scale is designed to evaluate the proneness to experience gratitude in daily life. the responses of item measures are based on a 7-point likert-style response scale, where participants rate their level of agreement on each item ranging from 1 = strongly disagree to 7 = strongly agree). there was a reverse scoring for items 3 and 6 to get the total sum, and that was our total gq-6 score. the range of scoring was between 6 and 42. mccullough et al. reported the gq-6 to have high internal consistency, with cronbach's alpha 0.7729. 100 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 figure 1: flow chart for data collection satisfaction with life scale (swls)23: the instrument design measures the universal cognitive gauging of satisfaction with one's life. it is a brief questionnaire that contained only five items measured by a 7point likert-type scale. the probable range enrolment assessed for eligibility (n= 207) randomized (n= 160) excluded (n= 47) sir syed girls college, karachi army public college, saddar karachi sample approach (n= 101) sample approach (n=106) sample taken 1st session (n= 99) llege, karachi sample taken 1st session (n= 103) sample taken all session (n= 94) sample taken all session (n= 92) pre-test pre-test questionnaires meet the criteria (n=87) questionnaires meet the criteria (n=85) (n= 85) final sample size (n=80) (n=87) final sample size (n=80) (n=87) analysis 101 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 of scoring is 5-35, and a score of 20 indicates a neutral point on the scale. diener et al. found swls to have favorable psychometric properties with the 0.87 coefficient alpha and 2 -month test-retest stability coefficient of 0.82, whereas factor analysis of the swls suggests it unidimensional23. positive and negative affect schedule (panas)24: participants are requested to ask whether they generally feel this way (a certain way) using a 5-point likert scale ranging from very slightly (score 1) to significantly (score 5). the scale contains two scalespositive affect (pa) and negative affect (na). pa assesses ten emotion adjectives (e.g., excited, interested, and alert), and na judges ten negative emotion adjectives (e.g., distressed, hostile, scared). the score range for both scales (pa and na) ranges from 10-50, respectively. the panas scale seems to be a reliable measure and acquires both convergent and discriminant validity with high internal consistency and cronbach's alphas ranging from 0.84 to 0.88. procedure the three weeks' interventions consisted of three workshops or sessions. each session is to be conducted weekly with one and halfhour of duration. participants are supposed to administer pre and post-intervention measures of swb. the three-week gratitude meditation program for improving swb among college students is provided in table 1. table 1: 3 weeks gratitude meditation program for improving swb sessions theme interventions 1st session awakening the heart to gratitude daily • grateful seeing • breath of thanks • maintain gratitude journal • praying for gratitude (religious ritual) 2nd session grateful contemplation • counting blessings • living gratefully • sharing gratitude • help someone less fortunate 3rd session behavioral expressions of gratitude • giving thanks • gratitude prompts • write a gratitude letter to a loved one • gratitude quotes further, the researcher explained the relevance of the study and then distributed questionnaires with a demographic section, where they were inquired about the age, education, and date of the test administration. additionally, they were asked about any concerns regarding the study and taking further sessions. though, after getting active participants' conformity with an explanation of the purpose and procedure of the study, pre-intervention measures were administered. powerpoint slides were prepared for visual presentation in each session separately. and a gratitude booklet (designed by the study researcher) was also provided to each participant before starting the session; the material of the booklet was connected to a variety of gratitude exercises and homework 102 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 sheets, and those were also conducted throughout the whole sessions. as mentioned earlier, students from both colleges were assessed at two time points, three weeks apart: (a) pre-test (before the intervention); (b) post-test (instantly after intervention). all participants were reported for the next session. the results were analyzed on the statistical package for the social sciences (spss) to clarify the results' pattern and compute the mean. result according to demographics, most of the participants were 17 to 18 years old (69.73%) and studying in xii year (53.75%) (table 2). table 2: demographic characteristics of the study population. variable n(%) level of education xi year 74(46.25) xii year 86(53.75) gender male 80(50) female 80(50) age 15-16 years 42(26.25) 17-18 years 111(69.37) 19-20 years 07(4.37) results also show that the dispositional gratitude mean scores differed at the end of the intervention. although significant differences were found before the gratitude meditation program (28.10 ± 0.48) and after intervention (32.01 ± 0.46), with respect to the gratitude variable shows statistically significant outcomes (t = 10.58, p=0.000). moreover, other findings also yielded significant outcomes. a statistically significant difference between the mean scores of the satisfaction with life scale, positive and negative affects before and after the application of gratitude interventions was also found. it has been observed that there are considerable increases in the scores of satisfaction with life scale and positive effects while expressing the noticeable decrease in negative affectivity from day 1 (pre-intervention assessment) to day 21 (postintervention assessment). however, the mean score of satisfaction with life presents a significant difference at the prior (19.43 ± 0.45) and after intervention (23.68 ± 0.43), (t = 11.17, p=0.000). while observing the positive effects variable, the score is meaningfully different on the initial intervention phase (30.73 ± 0.58) as compared to the post-intervention (36.91 ± 0.54) phase and shows statistically significant results (t=11.87, p=0.000). hence, there is a substantial decrease in the negative effects mean scores from pre-test (28.58 ± 0.57) to post-test (22.09 ± 0.45), yet the results show statistical significance (t=-12.644, p = 0.000) (table 3). table 3: effect of gratitude practice on dispositional gratitude & swb measures. variables pre-intervention post-intervention p-value gratitude 28.10±0.48 32.01±0.46 0.000 swb measures satisfaction with life 19.43±0.45 23.68±0.43 0.000 positive effects 30.73±0.58 36.91±0.54 0.000 103 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 negative effects 28.58±0.57 22.09±0.45 0.000 discussion in the present study, the inclusive goal is to check out and investigate the proficiency of the gratitude meditation program on dispositional gratitude and swb from dayone to day twenty-one (3 weeks program). the program consisted of three workshops scheduled weekly basis on the availability of college students. the workshops examine whether or not the gratitude exercises successfully bring benefits to their respondents. in addition, the importance given to serving others among a representative sample of the population of colleges was also observed. recent research suggests that gratitude intervention is one of the best techniques and working gadget of ppis and have shown positive results on measures of swb and dispositional gratitude itself. this intervention is not only effective but easy to administer as well. besides, a large number of researches and literature have been examined to investigate the benefits of this practice and intervention. in his book "seven laws of spiritual success," george herbert says that a heart filled with gratitude and seeing for good is the most valuable thing that one possesses30. an individual who experiences gratitude demonstrates more resilience and can deal successfully with everyday problems, and eventually attain a high swb11,21. in the current study, to enhance the swb, the researcher instructed the respondents to continue their gratitude practice for 3-week. however, the question that arises here is why three weeks? because it comprises 21 days and the great body of evidence suggested that it takes 21 days to form a new habit fully. in the old ages, maxwell maltz31 published a book recognized as psychocybernetics, in which he stated that people take 21 days to fine-tune or stay at its required level after any major life change31. a study shows that the investigator advised the respondents to continue their gratitude practices for 21 days in order to internalize gratitude as a new habit completely. so that it becomes employed over time and gets sustained, leading to continual well-being throughout life. subsequently, a significant change was observed after 21 days as compared to starting day21. although, it has been observed that cultivating an attitude of gratitude exhibited conceivable outcomes. besides that, it is also observed that while the respondent practiced gratitude, its impacts on his or her dispositional gratitude revealed significant increases in the level of gratitude postintervention. undoubtedly, the influence of gratitude meditation is associated with the paradigm of gratitude itself and may induce intensely with the help of other therapeutic techniques21. this means an analyst can imply and intervene in the methods to nurture the individual to promote grateful habits that could possibly lead to the amplified character of gratefulness. conclusively, the feeling of thankfulness is created immediately after the grateful thought, and continuous practice of gratitude techniques helps in raising dispositional gratitude32. on the other hand, a significant body of experiential research on gratitude intervention verified that it is an influencing intervention for enhancing swb. undoubtedly, gratitude intervention is considered as the vigorous executive for human booming33,34. furthermore, can be one of the essential ingredients of becoming happier35. furthermore, the current paper verified the beneficial effect of gratitude 104 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 training on swb. the respondents' postintervention scores were significantly higher as compared to the pre-test, concerning all domains of the swb. in the present study, researchers primarily put efforts toward raising awareness about what valuable things they have, alongside general positive events or things that are regularly happening, but we take for granted and do not even consider them. subsequently taking and attending gratitude exercise sessions, individuals start to notice those events and sources they never observed before. however, studies suggest that contentment and pleasure are partial until an individual expresses gratitude toward the source of the joy32. the feeling of gratitude experiences starts to process when one starts to notice the occurrences of positive events36. to exam the impact of gratitude intervention on swb, different techniques were used successfully like count blessing, maintain gratitude journal, behaviour expression, letter writing, gratitude quotes, prompts, etc. these all exercises were included in a gratitude booklet designed by the researcher and were given to each participant before the session started. the key outcomes that emerged from this study are that gratitude meditation is very effective in boosting satisfaction with life and positive effects, while substantial dropping in negative scores (show in table 3), along with the significant difference of the mean scores between the pre-and postintervention for all measures were observed. that ultimately facilitates the participant's swb. these findings are also congruent with watkin's22 analysis and emmons's21 findings. an experimental study conducted by seligmanet et al.12 and froh et al.,37 revealed that grateful feeling leads to increased positive effects and satisfaction with life and a reduction in adverse effects. these results can also be linked with the study of fredrickson et al.38, who recommend that positive effects are enhanced due to positive emotions like gratitude. impartially a simple practice of gratitude is suggested to have numerous benefits along with improving well-being. it performs a vital role in mental, emotional, and physical health throughout life. a study conducted by emmons & mccullough21 suggests that those college students who were keeping gratitude journal practice more regularly were observed highly satisfied with their lives, had fewer adverse effects, and were more hopeful about the future as compared to a neutral life event or hassles condition21. again, in their second study, they observed that students who participated in journalkeeping exercises daily were more likely to be attentive, enthusiastic, and strongminded compared to the hassles or social comparison condition21. they replicated the study to find out the results in adults with neuromuscular diseases. the patients were assessed through the self-report measures that show that patients in the grateful condition tend to have a high score on positive effects and satisfaction with life. the results also evidence that those people who are grateful are more likely to experience positive emotions, such as happiness, optimism, and contentment, along with less damaging emotions22. as both swb measures (life satisfaction and positive and negative effects schedule) were amplified in post-intervention, the increasing rate of the mean was statistically significant, suggesting that the intervention was very beneficial and effective for hedonic well-being. moreover, it is suggested that continued investigation in gratitude intervention can exhibit credible results and demonstrate that gratitude influences swb. unfortunately, little research work has been done in this 105 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 area and the field of gratitude meditation and swb in pakistan. therefore, more interventional studies and work are suggested to be done on different sample sizes and statuses to determine the relevancy of ppis and their effectiveness. conclusion the current study provided evidence that gratitude meditation is a dynamic healing way, influencing the swb in the sample of college students. the results conclude that gratitude meditation and exercises are among the best approaches to boost an individual's swb and are considered the most successful ppis. moreover, this intervention has increased the level of gratitude itself. therefore, one cannot ignore that the future of psychology would be lodging to build character strengths, and gratitude can accelerate this idea into a reality. in upcoming psychology, when a client goes to take a session, he/she may talk about his strengths instead of troubles. acknowledgment we wish to acknowledge every study participant who voluntarily contributed to taking part in the project. references 1. rehman n. dealing with the psychosocial and spiritual aspects in palliative care. app. 2018;5:54-58. 2. ryan rm, deci el. on happiness and human potentials: a review of research on hedonic and eudaimonic well-being. annu rev psychol. 2001;52:141-166. 3. ryff cd. happiness is everything, or is it? explorations on the meaning of psychological well-being. j pers soc psychol. 1989a;57:1069-1108. 4. neugarten bl, havighurst rj, tobin ss. the measurement of life satisfaction. j gerontol. 1961;16:134-143. 5. carruthers cp, hood cd. the power of the positive: leisure and well-being. ther recreation j. 2004;38(2):225-245. 6. diener e. assessing subjective well-being: progress and opportunities. assessing wellbeing. 2009;31(2):25-65. 7. botvin gj, griffin kw. apa handbook of clinical psychology: applications and methods. apa handbooks in psychology. am psychol assoc. 2016:485-509. 8. bono g, emmons ra, mccullough me. gratitude in practice and the practice of gratitude. positive psychology in practice. 2004;464:481. 9. seligman me, steen ta, park n, peterson c. positive psychology progress: empirical validation of interventions. am psychol. 2005;60(5):410-421. 10. seligman me, rashid t, parks ac. positive psychotherapy. am psychol. 2006;61:774788. 11. park n, peterson c. character strengths: research and practice. j college and character. 2009;4:1-10. 12. emmons ra. words of gratitude mind body & soul. templeton foundation press. 2008;2008. 13. lesowitz n. living life as a thank you: the transformative power of daily gratitude. readhowyouwant. com. 2010;2010. 14. pruyser pw. the minister as diagnostician: personal problems in pastoral perspective. philadelphia: westminster press. 1976. 15. duckworth al, steen ta, seligman mep. positive psychology in clinical practice. j res pers. 2005;47(6):795. 16. sin nl, della porta md, lyubomirsky so. tailoring positive psychology interventions to treat depressed individuals. appl posit psychol. 2011;79:96. 17. park n, peterson c. moral competence and character strengths among adolescents: the development and validation of the values in action inventory of strengths for youth. j. adolesc. 2006;29:891-905. 18. emmons ra, mccullough me. counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life. j pers soc psychol. 2003;84:377-389. 19. watkins pc, woodward k, stone t, kolts rl. gratitude and happiness: development of a 106 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 measure of gratitude and relationships with subjective well-being. soc behav pers. 2003;31:431-452. 20. lyubomirsky s, sheldon km, schkade d. pursuing happiness: the architecture of sustainable change. rev gen psychol. 2005;9(2):111–131. 21. schueller sm, parks ac. the science of selfhelp: translating positive psychology research into increased individual happiness. eur. psychol. 2014;19:145-155. 22. diener e, lucas re. subjective emotional well-being. in m. lewis & j. m. havilandjones (eds.), handbook of emotions. 2000:325-337. 23. diener e, emmons ra, larsen rj, griffin s. the satisfaction with life scale. j pers assess. 1985;49:71-75. 24. watson d, clark la, tellegen a. development and validation of brief measures of positive and negative affect: the panas scales. j pers soc psychol. 1988;54(6):1063. 25. martínez ml, avia md, hernández mj. the effects of counting blessings on subjective well-being: a gratitude intervention in a spanish sample. span j psychol. 2010;13(2):886-896. 26. chan dw. gratitude, gratitude intervention, and subjective well-being among chinese school teachers in hong kong. educ psychol. 2010;30(2):139-153. 27. froh jj, sefick wj, emmons ra. counting blessings in early adolescents: an experimental study of gratitude and subjective well-being. j school psychol. 2008;46(2):213-233. 28. geraghty aw, wood am, hyland me. attrition from self-directed interventions: investigating the relationship between psychological predictors, intervention content and dropout from a body dissatisfaction intervention. soc sci med. 2010;71(1):30-7. 29. mccullough me, emmons ra, tsang ja. the grateful disposition: a conceptual and empirical topography. j pers soc psychol. 2002;82(1):112-127. 30. mccullough me, kilpatrick sd, emmons ra, larson db. is gratitude a moral affect?. psychol bulletin. 2001;127(2):249-266. 31. maltz m. psycho-cybernetics. 1960;1960. 32. watkins pc, emmons ra, mccullough me. gratitude and subjective well-being. 2004;2004:167-192. 33. polak e. gratitude, materialism, and wellbeing. j happiness stud. 2005;7:343. 34. wood am, froh jj, geraghty aw. gratitude and well-being: a review and theoretical integration. clin psychol rev. 2010;1-16. 35. sheldon km, lyubomirsky s. how to increase and sustain positive emotion: the effects of expressing gratitude and visualizing best possible selves. j posit psychol. 2006;1(2):73-82. 36. langston ca. capitalizing on and coping with daily-life events: expressive responses to positive events. j pers soc psychol. 1994;67(6):1112–1125. 37. froh, jf, sefick wj, emmons ra. counting blessings in early adolescents: an experimental study of gratitude and subjective well-being. j sch psychol. 2008;46:213. 38. fredrickson bl, tugade mm, waugh ce, larkin gr. what good are positive emotions in crises? a prospective study of resilience and emotions following the terrorist attacks on the united states on september 11th, 2001. j pers soc psychol. 2003;84(2):365-376. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v8.i2.2022.96-106 35 app| published by aeirc| https://doi.org/10.29052/2412-3188.v6.i1.2019.35-40 issn 2412 3188 original article comparison of anxiety levels among medical & engineering students sarfaraz ahmed1, kiran abdullah2 & abdul ghani3 1baqai medical university (bmu) 2liaquat national medical college (lnmc) 3sir syed university of engineering & technology (ssuet) abstract background: there has been a rising concern regarding the psychophysiological distress associated with medical training. as the medical students during their transformational period undergo several changes in relation to the academic and training experiences. the family expectations, competition, uncertainties, admission and academic protocol are few of the stressors behind the anxiety and stress among medical students. the objective of this study was to compare anxiety levels among medical & engineering students. methodology: a cross sectional study was carried out among students of different medical & engineering universities of karachi from august 2018 to february 2019. a total of 400 students were enrolled in the study. data was collected using a selfadministered questionnaire consisting of socio demographic characteristics, details regarding the anxiety episodes including intensity, causes, physical symptoms, experiences during anxiety and the coping strategies for such episodes was also inquired. the collected data was analyzed using spss version 20. results: findings showed that among out of 250 medical students, 160(64%) were suffering from moderate to severe anxiety. on the other hand, 54 (36%) out of 150 engineering students reported moderate to severe level of anxiety. social interactions (45%) and stress at work or university (35%) were the prime cause of anxiety. moreover, restlessness, difficulty concentrating and sleeping were the common physical effects observed due to anxiety. conclusion: high prevalence of anxiety was observed among medical students when compared to engineering students. therefore, to improve psychological wellbeing and work performances interventional strategies promoting mental health and wellbeing need to be designed and implemented. keywords anxiety, prevalence, medical students, engineering students. citation: ahmed s, abdullah k, ghani a. comparison of anxiety levels among medical & engineering students. app. 2019; 6(1):35-40 corresponding author email: sarfaraz.amhad6@gmail.com doi: 10.29052/2412-3188.v6.i1.2019.35-40 received 30/03/2019 accepted 21/08/2019 published 12/10/2019 copyright © the author(s). 2019 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the author(s) declare that there is no conflict of interest in the preparation of this manuscript. https://doi.org/10.29052/2412-3188.v6.i1.2019. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 36 issn 2412 3188 app| published by aeirc| volume 6 issue 1 introduction due to the high academic and professional demand the medical schools are greatly focusing on the extensive trainings together with the academic courses and examinations with the aim to produce skilled physicians with advance medical knowledge1. which in turn effects the students and result in negative outcomes compromising both physical and mental health. based on the available literature, students usually face difficulties due to the torturous admission process, slow development of skills, trouble learning and inappropriate implementation while economic constraints and family expectations comes in as the add on stressors during this training2-4. moreover, everyday exposure to the medical environment having patients with several health conditions, terminal illnesses and death greatly affects the psychological wellbeing of the student during the training period5,6. the increasing stress develops anxiety among the students which is as devastating as depression7 but due to lack of awareness it remains unattended8. anxiety sufferers undergo fear, nausea, dizziness, headache, fatigue, abdominal pain and palpitations etc9. besides this, it also impairs the working memory and compromises the performance due to distorted attention and concentration10,11. based on the findings of a systematic review, the prevalence of anxiety among medical students ranges in between 7.7% and 65.5%12. it is found that anxiety is significantly associated with the dropout rate, affecting the personal as well as professional life of the student1. ultimately, affecting the quality of patient care as it decreases the working efficacy13. with reduced self-esteem, these students experience decline in the quality of life and care they provide during training and practice14,15. our aim was to compare the prevalence of anxiety among medical and engineering students. methodology a cross sectional study was carried out during august 2018 to february 2019 on medical and engineering students of various universities of karachi including baqai medical university (bmu), liaquat national medical college (lnmc), sir syed university of engineering & technology (ssuet) and dawood university of engineering & technology (duet). a total of 400 students were enrolled in the study after attaining written informed consents. a selfadministered questionnaire inquiring socio demographic details and characteristics of anxiety episodes like intensity of the episode, causes, physical symptoms and coping strategies was used by the students. the collected data was analyzed using spss version 20, where quantitative variables such as age was summarized using mean and standard deviation while qualitative variables such as gender, intensity, symptoms and strategies used to cope with anxiety episodes were summarized as frequency and percentages. result out of the 400 enrolled students, there were 150 engineering students (e) and 250 medical students (m) with a mean age of 20±1.5 years. around 51.25% of these students were males while 48.75% were females. based on the findings 159(63.6%) medical students had anxiety out of which 49% were suffering from moderate anxiety and 15% were in severe anxiety. on the other hand, 54(36%) engineering students had anxiety, of them 28% and 8% suffered moderate and severe episodes. stress at work/university, social interaction, isolation and family expectations were few of the prominent factors leading to anxiety among both medical and engineering students. 37 issn 2412 3188 app| published by aeirc| volume 6 issue 1 table 1: demographic characteristics of study participants variables sub-categories (n=400) age (years) 20±1.5 study groups medical students (m) 250(62.5) engineering students (e) 150(37.5) gender male 205(51.25) female 195(48.75) *90(m) + 115 (e) =205 males; 160 (m) + 35 (e) = 195 females *values are given as n (%) and mean ± sd among the symptoms of anxiety, trouble concentrating (35%), difficulty falling asleep (25%) and restlessness (20%) were apparent. crying was preferred as the best coping strategy by 33% of the medical students while 17% preferred sleeping, comparatively among engineering students sleeping (30%) was mostly preferred to cope with anxiety. table 2: characteristics of anxiety among medical and engineering students characteristics of anxiety medical students (n=250) engineering students (n=150) intensity moderate 122(49) 42(28) severe 37(15) 12(8) causes social interaction 62(25) 30(20) family expectations 25(10) 7(05) stress at work/university 100(40) 75(50) isolation 57(23) 22(15) body image 5(02) 15(10) symptoms restlessness 50(20) 45(30) trouble concentrating 87(35) 52(35) uncomfortable 30(12) 15(10) difficulty falling asleep 62(25) 22(15) decreased muscle tension 20(08) 15(10) coping strategies crying 82(33) 30(20) sleeping 42(17) 45(30) offer prayers 15(06) 22(15) speaking to someone 50(20) 27(18) moving to peaceful place 25(10) 18(12) wait to out it 35(14) 7(05) *values are given as n (%). significant difference was observed in the anxiety levels among the two genders. the mean anxiety ratio was higher among female students (53.43%) as compared to male students (46.57%). table 3: comparison of male and female students suffering from anxiety gender medical students (n=250) engineering students (n=150) mean ratio male 72(45) 26(48.14) 46.57% 38 issn 2412 3188 app| published by aeirc| volume 6 issue 1 female 88(55) 28(51.85) 53.43% *m=medical; e=engineering *values are given as n (%) discussion overall study demonstrated that higher level of anxiety was observed in medical students as compared to the engineering students of both genders (table 2). moreover, gender wise differences were also common in both groups i.e. female students either medical or engineering experienced higher level of anxiety (53.43%) as compared to male students (46.57%) (table 3). this substantiate presence of gender differences in the anxiety has also been reported by many other researchers16,17. it is suggested that the possible reason for this could be increased emotional vulnerability of females as compared to males18. the results were comparable to a similar study conducted in india where perceived stress and associated anxiety were more common among medical students (72%) as compared to engineering students (56.7%)19. however, students in medical school with highly competitive challenges show greater susceptibility to develop anxiety as compared to the counterparts19. there have been an increasing number of studies conducted to evaluate the prevalence of anxiety among medical students, the prevalence of anxiety among thai students was reported to be 61.4%20. in support, a cross-sectional study conducted in jeddah pointed out that the prevalence of borderline anxiety was 33.3% and morbid anxiety was 34.9%21. according to research conducted at the faculty of medicine, riyadh, female students (75.7%) who experienced psychological stress was more as compared to male students (57%)22. the overall results of our study were consistent with the abovementioned details. among the major causes of anxiety were social interactions and stress at work or university (table 2). high parental pressure and future concerns are the key stressors contributing to the higher anxiety levels among medical students as concluded by a similar study23. restlessness, sleeping difficulties and concentrating inabilities are few of the physical effects caused by anxiety (table 2). in support, a study presenting more descriptive results indicated restlessness, loss of appetite, difficulty in concentrating, constant fatigue, increase muscle ache, impatience and clouded judgment as the chief symptoms associated with anxiety23. with the increasing complexities in the academic system, it may not be possible to completely eliminate anxiety from the medical educational structure. but the early detection and management are important in order to control this stressor. to support the academic transitions mental health and wellness promotion programs are required as internationally such programs have yield positive outcomes among medical students24,25. there were a few limitations in the current study, one of which is self-reporting by the students enrolled that might be reason for reporting bias and response inaccuracy. conclusion it is concluded that medical students experience higher level of anxiety as compared to engineering students, which can be prevented by the help of different psychological therapies and recommended physical activities. students should indulge in various extracurricular activities in order to avoid academic distress. acknowledgement we are all grateful to students of medical and engineering universities who co-operated in our studies. 39 issn 2412 3188 app| published by aeirc| volume 6 issue 1 references 1. dyrbye ln, thomas mr, shanafelt td. systematic review of depression, anxiety, and other indicators of psychological distress among us and canadian medical students. acad. med. 2006;81(4):354-373. 2. kim kj. factors associated with medical student test anxiety in objective structured clinical examinations: a preliminary study. int j med educ. 2016; 7: 424-427 3. shim ej, jeon hj, kim h, lee km, jung d, noh hl, roh ms, hahm bj. measuring stress in medical education: validation of the korean version of the higher education stress inventory with medical students. bmc med educ. 2016;16(1): article 302. 4. casey d, thomas s, hocking dr, kempcasey a. graduate-entry medical students: older and wiser but not less distressed. australas psychiatry. 2016;24(1):88-92. 5. shah c, trivedi rs, diwan j, dixit r, anand ak. common stressors and coping of stress by medical students. j clin diag res. 2009;3(4):1621-1626. 6. niaura r, herbert pn, saritelli al, goldstein mg, flynn mm, follick mj, gorkin l, ahern dk. lipid and lipoprotein responses to episodic occupational and academic stress. arch intern med. 1991;151(11):2172-2179. 7. weiller e, bisserbe jc, maier w, lecrubier y. prevalence and recognition of anxiety syndromes in five european primary care settings: a report from the who study on psychological problems in general health care. br. j. psychiatry suppl. 1998;173(s34):18-23. 8. kroenke k, spitzer rl, williams jb, monahan po, löwe b. anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection.ann. intern. med. 2007;146(5):317-325. 9. testa a, giannuzzi r, sollazzo f, petrongolo l, bernardini l, daini s. psychiatric emergencies (part i): psychiatric disorders causing organic symptoms. eur rev. med. pharmacol. sci. 2013;17(suppl. 1):55–64. 10. eysenck mw, derakshan n, santos r, calvo mg. anxiety and cognitive performance: attentional control theory. emotion. 2007;7(2):336–353. 11. moran tp. anxiety and working memory capacity: a meta-analysis and narrative review. psychol. bull. 2016;142(8):142:831– 864. 12. hope v, henderson m. medical student depression, anxiety and distress outside n orth a merica: a systematic review. med. educ. 2014;48(10):963-979. 13. khuwaja ak, qureshi r, azam si. prevalence and factors associated with anxiety and depression among family practitioners in karachi, pakistan. j. pak. med. assoc. 2004;54(2):45-49 14. dahlin m, joneborg n, runeson b. stress and depression among medical students: a cross‐sectional study. med educ. 2005;39(6):594-604. 15. quince ta, wood df, parker ra, benson j. prevalence and persistence of depression among undergraduate medical students: a longitudinal study at one uk medical school. bmj open. 2012;2(4): e001519. 16. afzal h, afzal s, siddique sa, naqvi sa. measures used by medical students to reduce test anxiety. j. pak med assoc. 2012;69(9):982-986. 17. zhang n, henderson cn. test anxiety and academic performance in chiropractic students. j. chirop educ. 2014;28(1):2-8. 18. farooqi yn, ghani r, spielberger. gender differences in test anxiety and academic performance of medical students. intl j psy beh sci.2012;2(2):38-43.23 19. chenganakkattil s, jibinbabu k, hyder s. comparison of psychological stress, depression and anxiety among medical and engineering students. int j res med sci. 2017;5(4):1213-1216. 20. abdulghani hm, alkanhal aa, mahmoud es, ponnamperuma gg, 40 issn 2412 3188 app| published by aeirc| volume 6 issue 1 alfaris ea. stress and its effects on medical students: a cross-sectional study at a college of medicine in saudi arabia. j health popul nutr. 2011;29(5):516–522. 21. ibrahim n, dania ak, lamis ek, ahd ah, asali d. prevalence and predictors of anxiety and depression among female medical students in king abdulaziz university, jeddah, saudi arabia. iran j public health. 2013;42(7):726–736. 22. abdel rahman ag, al hashim bn, al hiji nk, al-abbad z. stress among medical saudi students at college of medicine, king faisal university. j prev med hyg. 2013;54(4):195–199. 23. tabalipa fd, souza mf, pfützenreuter g, lima vc, traebert e, traebert j. prevalência de ansiedade e depressão entre estudantes de medicina. revista brasileira de educação médica. 2015; 39(3):388-394. 24. melo-carillo a, oudenhove lv, avila al. depressive symptoms among mexican medical students: high prevalence and the effect of a group psychoeducation intervention. j aff dis. 2012; 136(3):10981103. 25. simin h, zahra g. a survey beck test in university students & its relationship between some related risk factors. procedia soc behav sci. 2011; 28:558-62. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v6.i1.2019.29-35-40 6 app| published by aeirc| https://doi.org/10.29052/2412-3188.v7.i1.2020.6-8 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) short communication the chaos of healing: risking mental health amid covid19 in pakistan sadaf ahmed psychophysiology research lab, mahq biological research centre, university of karachi. advance educational institute & research centre (aeirc). in any natural disaster, burdens of fear, insecurity, and stigmatization are ubiquitous and may act as hurdles to proper health interventions. based on an understanding gleaned from a historical point of view of the psychosocial effect of past viral epidemics, the development and implementation of mental health assessment, support, treatment, and services are vital and persuasive aims for the health response to the 2019-ncov outbreak. covid19 related catastrophes vary in dimensions and scope but have affected single or multiple-family residences, districts, populations, regions, or the state as a whole. virtual mental health crisis intervention started helping communities mitigate the effects of the disaster and related loss by providing family, neighbourhood, and community preparedness and resilience. covid-19 has brought serious social-psychological impact to the people, especially those directly affected or quarantined and thus with limited access to face-to-face communiqué and customary social-psychological interventions. to deal with the crucial mental health crisis, various models have been suggested and started crisis intervention by utilizing numerous tools and technology, that not only integrated the role of doctors, therapists, psychologists, and social workers to carry out mediations to affectees, their families, and medical staff but also setting models of psychological crisis intervention response system that is applicable for urgent social and psychological problems1,2. however, the times of covid have exposed society on many levels especially pseudoscience and potentially harmful practices in the mental health care field. as a responsible academician and scientist one knows that mental health care must be ample and aimed at the population patterns as a whole when it comes to shifting beliefs, behaviors, and attitudes especially during such unprecedented times. extraordinary supervision is needed to manage and introduce awareness sessions, investigations, and prevention interventions in dealing with mental health challenges and illnesses. the mental health field in developing countries like pakistan is not secure to “quackery.” one can be exposed to dubious or risky conduct. amid the covid19 chaos, people are so vulnerable and open to budding numbers of self-proclaimed mental health experts with multi-shaded disgraceful claims. some of these practitioners even hold doctoral degrees in social management, biological or allied citation: ahmed s. the chaos of healing: risking mental health amid covid19 in pakistan. app. 2020; 7(1):6-8 corresponding author email: sadaf@aeirc-edu.com doi: 10.29052/2412-3188.v7.i1.2020.6-8 received 01/08/2020 accepted 31/08/2020 published 01/10/2020 copyright © the author(s). 2020 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 7 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) sciences which make it tough for the people to separate the good from the bad. however, most of them hold only 16 years of basic education without any proper clinical training or scientific background of mental disorders. my anticipation in raising this issue will help to support victims and caregivers with the evidence they need to not only identify a kook or a quack but to evade doubtful and unconventional treatments they may attempt to prescribe. it is already reported that with emerging mental health concerns and interest in human behaviors, there is an immense interest of people from every field of biological, social, and management sciences and they jumped into the field as a trainer, healers, motivational speakers, practitioners, therapists, experts, etc. however, it is needed that they must at least be aware of the mental health diligence, in which any treatment or cure is real science that deals with biological phenomena inclusive of systemic and cellular change or pathology that leads to signs and symptoms of any illness or behavioral alteration. at its core, one needs to identify the role of probable intervention or cure of particular psycho-physiological pathology that leads to harm. according to available scientific literature, this is what makes therapy or healing a real science with social and moral values. and mental health is a real medical discipline that directly involves the brain and body that have consequences for behavior or vice versa. the science of bad mental health needs to be approached. nevertheless, i think every professional of mental health, in particular, should take the time every so often and look at their roles, their actions, and their explanations via a scientific lens. in recent times, it has been frequently observed that such professionals not only diagnosing patients with a range of psychiatric illnesses that aren’t justified but also there is a lack of authentic licensing or membership bodies in this part of the world and no one to constabulary this criminality. few of these proclaimed bodies funded by many reputed pharmaceutical and bodies’ haughtily disclosed that it is their responsibility to protect the earning power or career of psychiatrists/psychologists/pseudointellectuals. as the history of the mental health showed a monopoly with practically zero accountability and zero liability for its failures. this has allowed psychologists, faith healers, psychiatrists and other mental health practitioners to commit far more than just monetary or fame scams. the roster of corruption committed by these “pros” ranges from deception, medicine felonies, psychological abuse to assault etc. as per approximations, there are over 600,000 quacks in pakistan providing primary and elementary healthcare to deprived populaces in both urban and rural areas of the country. this includes mental health practitioners in metropolitan cities and mostly also known as healers providing care to patients with psychological and neurological illnesses around sanctuaries and in cemeteries. the sufferers in current scenario are not only unavoidably vulnerable and susceptible but also their accurate dealing demands the highest level of responsibility and reliability in the expert. as experience has shown that there are many illegitimate mental health practitioners, there is a need for licensing body at the provincial and national level as well as a database that must lists type, variety and categories of qualifications, guidelines, and ethical boundaries within the mental health industry with constitutional revisions. there is no place for criminal intent or deed in the field of mental health. this information should be presented as a public amenity in greater virtue of public health and ethics, to bring an end immoral practice and exploitation in the mental health care field. as access to a proper mental health care facility has been an obstacle during a pandemic and most mental health services and facilities remained non-functional with the restriction of transportation and finances added to the misery. countries like pakistan has still a huge stigma for mental health issues3, 4. when health science researchers and epidemiologists expect that the wellbeing toll of covid-19 is tricky to predict and a mental health pandemic has 8 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) been considered as second wave of covid19. provided that pandemics are stressful and risky to brain health, there are already numerous vulnerable and affected subjects who have been administered therapies or interventions without knowing clinical guidelines and biological precipitating causes during such disasters as per nonregulated practice in pakistan. this caused more harm than good, given the unique circumstances of covid-19, when data is still adding significantly to identify underlying mechanisms associated with deprived mental health. thus to improve the effectiveness of psychosomatic management, professionals need to be systematically wellversed about directing factors and any onesize-fits-all action will not do any good. the digital modes also need an evidence-based approach as well as artificial intelligencebased adaptive trials are also needed to establish understandings of diverse threatening signs for mental illnesses. the over aim should be based practicability and effectiveness of the model of psychological interventions in order to help affectees and general population affected by disaster5. moreover, to help relieve psychological aftershock of the public emergency with effective utilization of human resources/tools and efficient as well as ethical training of mental health task force to accompany trained psychologist, psychiatrists and other health experts. references 1. de sousa a, mohandas e, javed a. psychological interventions during covid-19: challenges for low and middle income countries. asian j psychiatr. 2020: article 102128. 2. raphael b. overview of the development of psychological support in emergencies. advances in disaster mental health and psychological support. india: voluntary health association of india pressl; 2006. 3. farooq sm, sachwani sa, haider si, iqbal sa, parpio yn, saeed h. mental health challenges and psycho-social interventions amid covid-19 pandemic: a call to action for pakistan. jcpsp. 2020;30(6):59-62. 4. mamun ma, ullah i. covid-19 suicides in pakistan, dying off not covid-19 fear but poverty? the forthcoming economic challenges for a developing country. brain behav immun. 2020; 87:163-166. 5. holmes ea, o'connor rc, perry vh, tracey i, wessely s, arseneault l, ballard c, christensen h, silver rc, everall i, ford t. multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science. lancet psychiatry. 2020; 7(6): 547-560. editorial for annals of psychophysiology volume 11 4 4 editorial for annals of psychophysiology volume 11 ______________________________________________________________________________ spotlight on saybrook university’s doctoral and masters programs in applied psychophysiology and changes in the journal’s administration richard a. sherman1, editor-in-chief published online: december 2024 © the author(s) 2024 psychophysiology is best recognized as a basic research field. however, it has had an applied aspect nearly since its inception as a way to monitor people’s responses to stress and as a measure of optimal functioning in sports and other areas. more recently, the applied side of psychophysiology has grown to include instantaneous feedback of physiological levels and changes. this permits therapists and coaches to guide clients toward recognition of physiological levels so clients can gain control of physiological responses. despite the popularity of psychophysiological monitoring and feedback, there are few graduate-level training programs to help coaches, educators, clinicians, and others learn how to apply psychophysiological monitoring and training techniques effectively. in the year 2000, the behavioral medicine research and training foundation set out to change this by offering distancebased courses in many areas of applied psychophysiology. the foundation offers individual courses as well as a certificate in professional psychophysiology. shortly after it began offering courses, the foundation initiated a doctoral program in applied psychophysiology. it moved through several non-accredited institutions until it was finally adopted by saybrook university in 2013. saybrook is a regionally accredited university whose courses are mostly given via distance education, so they are available to students across the world. the foundation supports saybrook’s department of applied psychophysiology through grants for student research, purchase of equipment, etc. the department now has regionally accredited doctoral and master's programs in several areas of applied psychophysiology including clinical and research specializations and sports performance psychology. in order to spotlight saybrook’s support of psychophysiology, this issue of annals of psychophysiology includes several papers by graduates and students in saybrook’s programs. readers of this issue may notice several changes in the journal’s format. this is because the journal is in a transition period from its being headquartered at pakistan’s advance educational institute and research center (aeirc) to the behavioral medicine research and training foundation – which is becoming the journal’s publisher with continuing technical support by aeirc. the current issue is a hybrid of the older style format and the new style which will be fully implemented in the issues published in 2025. readers are urged to view the journal’s website www.annalsofpsychophysiology.org to see all the upcoming changes. 1. richard sherman rsherman@saybrook.edu saybrook university, pasadena, ca usa http://www.annalsofpsychophysiology.org/ mailto:rsherman@saybrook.edu 62 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v8.i2.2021.62-70 original article comparison of psychological well-being and life satisfaction between extended and nuclear family systems among students kanwal jahan & saima masoom ali university of karachi, karachi-pakistan abstract background: the family system affects the mental health and well-being of an individual and significantly alters the satisfaction level. the current study intended to explore the differences in psychological well-being and life satisfaction between the students belong to extended and nuclear family systems. methodology: for this comparative study, a sample size of 467 participants (204 male & 263 female) was selected, including 314 participants from the nuclear family system and 153 from the extended family system. the ryff psychological well-being scale (pwb) and the diener satisfaction with life scale (swls) were used as outcome measuring tools. results: the mean pwb scores were 343.45 ± 2.745 for the extended family system and 339.67 ± 1.90 for the nuclear family system. the mean score of satisfaction with life was 1.05 ± 5.64 for the extended family system, and the mean score for the nuclear family system was 1.05 ± 5.60 while (t=1.907). moreover, women's pwb means the score was 343.71 ± 29.57, and men's pwb mean score was 333.80 ± 37.35. while the score of satisfaction with women's life was 22 ± 5.75, and the men's score was 22.58 ± 5.46. conclusion: results show no significant mean difference in the psychological well-being of participants of nuclear and extended family systems. similarly, no significant difference was found in satisfaction with life between both family systems. gender difference in pwb was found as women scored higher than men, while there was no gender difference among students in satisfaction with life. keywords psychological well-being (pwb), satisfaction with life (swl), extended and nuclear family structure, gender. citation: jahan k, ali sm. comparison of psychological well-being and life satisfaction between extended and nuclear family systems among students. app. 2021; 8(2): 62-70 corresponding author email: kanwal.jahan90@gmail.com doi: 10.29052/2412-3188.v8.i2.2021.62-70 received 26/05/2021 accepted 06/10/2021 published 01/12/2021 copyright © the author(s). 2021. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v8.i2.2021.62 https://orcid.org/0000-0001-8475-8174 https://orcid.org/0000-0003-4882-1644 http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 63 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 8 issue 2 introduction family is the fundamental entity of any culture. living criteria, flourishing, and conducive upbringing is crucial not only for children but for all the members who constitute the family to make a healthy society. so we consider the family structure important for mental health at all ages. studies on the population's family structure and function and their mental well-being have important practical significance. first, the conception of a family system is operationalized1. based on the current living arrangement and comprised categories: alone, couple, nuclear family, and extended/joint family2. the extended family system is defined as the close blood relations such as grandparents, uncles, aunts, etc., who live together in one home and share their necessities of life there. while the nuclear family system consists of minimum members and contains parents and children3. in all family structure categories, we consider nuclear and extended family systems regarding psychological well-being of individuals and the satisfaction with life. the nuclear and extended family system has been adopted as world-renowned family programs. urban migration, rapid industrialization, and the expansion of education have shifted the type of family from extended to nuclear families. while in pakistan, there is mainly extended family system exist. there are various advantages and disadvantages associated with both types of family systems. there is mutual sharing of responsibilities in the extended family system, from house chores to economic benefits and bread earning. the extended family system has more facilities and has considerable assets. there is sharing of happiness in events and jointly get together, which brings positivity among relationships. while in nuclear family systems, individuals are independent and free from the duties of other family members such as grandparents, uncles, aunts, etc. the psychological wellbeing and level of satisfaction are a matter of concern in nuclear and extended families. it is a broad aspect and can be measured by different parameters. some of which can be a better economic condition, a better agreement between the family members, peace of mind, and better understanding. psychological well-being is about lives going well, feeling good, and functioning effectively. psychological well-being refers to positive mental health3. research has shown that psychological well-being is a multidimensional concept4-6. it develops through emotional regulation, personality traits, identity, and life experiences7. family structure has a direct effect on the well-being of individuals6. in the words of helson & srivastava, psychological well-being developed through life experiences, so, researchers drew consideration that family structure experiences may also be accountable for it. the differences in family processes and other variables across family structures cause the different levels of children's well-being7-9. diener10 suggested the formation of subjective well-being (swb) based on a person's assessment of affective and psychological understanding of life. they argue that happiness and satisfaction in life may differ in all societies and cultures, even bringing joy and contentment. satisfaction with life (ls) is how people express their feelings, emotions, and select future oportunities11. life satisfaction is an integral part of life. many internal and external factors affect a person's moral and health satisfaction10. satisfaction with life includes a positive attitude toward one's health rather than examining current feelings. satisfaction 64 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 8 issue 2 with life is measured in economic status, education, knowledge, accommodation, and many other domains10. differences in experiences can significantly shape the way we view and interact with the world around us. these experiences shape the way we think about the world around us affect our satisfaction in life. a person who has a habit of seeing the world in poor light can have a completely different level of satisfaction compared to the one who always admits the beauty of their place. people who suffer from moderate stress are more likely to have high levels of satisfaction12. a study conducted in islamabad, rawalpindi, and wahcantt, pakistan, showed similar findings where people living in an extended/joint family system have significantly higher social support and quality of life (p<0.001) compared to people living in a nuclear family13. differing family structures appear to exert disparate effects for life satisfaction on adolescents due to race and/or gender14. researchers found approximately consistent findings previously regarding the link between feeling good and functioning effectively in any family system. this paper intended to better admiration in pakistani culture the importance of family structure impact on psychological well-being and life satisfaction of individuals. therefore, research into adult family structure and function and mental health has significant implications, especially in developing countries. a significant relationship was found between the family system and the psychological well-being of individuals in later life7. the effect of family structure and function on mental health has multivariate analysis showed that better family performance is associated with better mood. and previous studies on specialized people such as children, adolescents, and immigrants have shown that family functioning has a protective effect on mental health15. it is noteworthy that the impact of family formation on mental health, whether urban or rural, was not statistically significant. when looking at the combined effects of structural and family function, the external form of the family (family structure) may be insignificant. in contrast, the internal suitability of the role (family function) may be essential16. ryff (1989) believes that the best subjective social indicators of quality of life are: the feeling of belonging to a community, safety, happiness, life satisfaction, family bond, working place, justice distribution, identification with a social class, and hobbies6. and there, in the words of eitzen (2008), the family is a lift-up of meaningful relationships, so the feeling of belonging, family, and its system seems too high contributor to quality of life and wellbeing17. the extended/joint family is one such thing that can ensure the sustainability of life and natural recourses18. correspondingly, in african americans, frequent contact with family was associated with using informal support as the sole source of help19. in the same manner, thoits suggested that family social support anticipates the need for care because it benefits mental health, so frequent contact was also associated with care and the need for help which uplift psychological well-being20. the level of satisfaction is a concern for nuclear families and extended families. it is a broad feature and can be measured by different parameters. they are better economic conditions, better health for a young married woman, better family relationships, better peace of mind, and better understanding. in a close-knit family environment, children often grow up under 65 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 8 issue 2 the attentive supervision of parents, grandparents, and other adult relatives. there is a connection between groups of different ages. this creates a better understanding of each other. this makes a better mutual understanding, so the adjustment problems are fewer21. some disadvantages are associated with extended/joint family type, but it also has many advantages. extended/joint families usually have considerable assets. they also have better living conditions, including electricity, sanitation facilities, piped water, and higher-quality housing materials22. a study sought to assess the quality of life of young people in the family environment, using data from the 2006 hbsc: study-in collaboration with world health organization (who) in scotland (n = 5,126). the study found that there was a correlation between family structure and health satisfaction for males and females. for males and females of all ages, life satisfaction was more closely linked to parental contact with the child than family formation or family wealth. after adjusting for risky behaviors/health and attitudes toward peers and school, family formation remained important for males only 13 years old. while difficult parent-child communication is a risk factor for lower satisfaction for males and females, simple communication has been protected only for females23. the individuals who live in extended/joint families have to deal with different expectations than individuals who live in nuclear families. it was generally believed that those individuals who live in an extended/joint family situation would have to face more significant restrictions and fewer independent choices. as a result, they would have lesser satisfaction levels. the experience of autonomy would be higher in a nuclear family since the members would be acting out of their own volition without regard to specific family dynamics and would be enjoying more satisfaction levels24. this study attempted to compare psychological well-being and the level of satisfaction of nuclear and extended families. gender differences and demographics variables also affects the impact of family system on individual’s psychological and social well-being. in this regard, the hypothesis of this study is the psychological well-being of individuals in extended family system would be differing from the nuclear family system. life satisfaction would be higher in the extended family system as compared to the nuclear family system. methodology participants the current study used a sample of 467 college students, a randomly selected sample size at registered colleges located in karachi, pakistan. there were 204 males, and 263 were females (153 from the extended family system while 314 from the nuclear family system). participants' age ranged from 16 to 24 years. measures demographic information it was used for this study to acquire applicable information about the participants. the measures includes personal and demographic information such as gender, age, number of siblings, residential area, and family systems. family system the family system was assessed with one closed‐ended item, which asked students to indicate with whom they lived. a possible response includes the extended family system and nuclear family system. a total of (n = 153) from the extended/joint family system, while (n= 314) from the nuclear family system. 66 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 8 issue 2 psychological wellbeing (pwb) inventory is 84 items and consists of a series of statements reflecting the six areas of the pwb: autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance. respondents rate statements on a scale of 1 to 6, with 1 indicating strong disagreement and 6 indicating strong agreement (ryff, 1989). satisfaction with life scale (swls) diener et al. (1985) developed five items that can measure an individual's global judgment of life satisfaction as a whole. the swls measures the cognitive component of swb and provides an integrated assessment of how a person's life as a whole is going. in completing the swls, participants rated five statements on a seven-point likert scale, ranging from (1) "strongly disagree" to (4) "neither agree nor disagree" to (7) "strongly agree." the swls has been used in numerous studies and has demonstrated good psychometric properties. procedure a list of colleges in karachi was compiled. after getting permission from the college authorities, participants asked for help from their classroom teacher and were given a separate room. initially, students were assured that information collected during the study would be kept confidential and only be used for research purposes. after inquiry of the participants as per predetermine research criteria were required to fill the demographic form and provide the research questionnaires. participants rated each item of the pwb scale by using6 points scales from strongly disagree to strongly agree. and the satisfaction with life scale in completing the swls, participants rated five statements on a seven-point likert scale, ranging from strongly disagree to strongly agree. in the last step, completion of the questionnaire followed by a thankful note for the participant for his/her contribution. the same procedure was used with all research participants in an individual setting as well. statistical analysis after data collection, the answer sheets were scored according to standardized procedures. t-test was used to see the difference in psychological well-being between extended/ joint and nuclear family systems and gender differences. furthermore, descriptive statistics (frequencies, mean, percentages, standard deviations, variance, and standard error of mean) were used for getting a deep statistical analysis of characteristics of the sample in a summarized way. all statistical computations were completed through spss version 16.0. result out of the total 467 subjects, the majority were females (56.3%) and were living in a joint family system (67.2%). table 1: summary of demographics variables (n = 467). variables n(%) gender male 204(43.7) female 263(56.3) family system nuclear 314(32.8) joint 153(67.2) 67 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 8 issue 2 academic year intermediate 104(22.3) graduate 122(26.1) bs 241(51.1) there was no significant difference among family systems, i.e., nuclear and joint, in psychological well-being and life satisfaction. table 2: effect of family system on psychological well-being and life satisfaction. variables joint (n=153) nuclear (n= 314) t p-value 95% ci mean ± sd pwb 343.45±2.74 339.67±1.90 1.062 0.289 -3.005 10.079 swl 1.056±5.64 1.05±5.60 1.907 0.998 -0.32 2.145 there was no significant gender difference in satisfaction with life (p=0.268) while females had higher pwb scores than males, i.e., 346.71 ± 29.57 vs. 333.80± 37.35 (p=0.000). table 3: gender differences in satisfaction with life and psychological well-being. variables male (n=204) female (n= 263) t p-value 95% ci mean ± sd swl 22.58(5.46) 22(5.75) 1.108 .268 -.450 1.165 pwb 333.80(37.35) 346.71(29.57) -4.048 .000 -19.176 -6.638 discussion the present study was conducted to find psychological well-being and satisfaction with life between extended and nuclear family systems. the results show that there are no significant means differences in the psychological well-being of participants of the nuclear and extended family system. similarly, no significant difference was found in satisfaction with life between both family systems. while differences in the results found on the basis of gender only in psychological well-being. in another study, the level of satisfaction was higher among people living in the extended/ joint family group, i.e., 87.5% v/s 81% in the nuclear family. it was observed that the satisfaction level was overall high in both types of family systems. similar results were found in a study conducted in karachi, pakistan, by itrat et al., which concluded that almost 96% of people were satisfied in extended/joint families and 85% in the nuclear family system25. gender differences are present for the majority of health-related quality of life of children and adolescents26. prior research on gender differences in psychological wellbeing has not yielded conclusive results, but few studies have shown lower psychological well-being for young females compared to males27. 68 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 8 issue 2 there might be many contributing factors in which some of them are family background, variables as parent's profound mental health, education, and emotional stabilities that enable them to give a sound healthy environment to their children. whatever the family system is, a child's healthy development is most associated with the quality of parenting, which is itself enhanced by the availability to the family of strong community and social support28. a parent's higher marital happiness and lower parental conflicts may also contribute the psychological well-being. similarly, parents' education is important because they can understand the physical and psychological needs of their children. parent-child relation is a key factor there, and theorist believes that the effect of family structure on children can be mediated by the family processes occurring within families such as the quality of the parent-child relationship. in addition, the degree of closeness to mother and father appeared to be the most influential predictors of children's psychological wellbeing7. the differences in children’s well-being were small across the family structure. these differences support other researchers finding that most children grow up fine in all family structure27. however, the difference in psychological well-being across the family structure is not completely clear, and several factors have been seen to reduce the effects of family structure on psychological wellbeing. with long-term changes in the family, the structure can affect family functioning, thus affecting the mental health of family members. research analysis related to family structure on other cultures as chinese families provide not only productivity, education, childbirth, and pensions, but also psychological comfort and support, which includes the health of all family members, and the stability and development of society as a whole14. researches provide more support for family process perspectives rather than a family structure for psychological well-being. we conclude that the external form of the family, which is the family structure, may not be important. still, the internal quality of role family function might be key for psychological well-being29. when faced with social change and health problems, individuals and families may become less powerful. therefore, all sectors of society must work together. this study has few limitations, such as the factor of the family system could not be explored in-depth due to the quantitative design of the study; therefore, the in-depth study is recommended to find the impact of extended/nuclear family systems on the psychological well-being of the students. pakistani culture mostly contains these two kinds of extended and nuclear family systems, so the participants of this study were from these two kinds of family systems. furthermore, the forms and functions of the family have varied around the world over countries30. so, the other diverse groups of family systems could be studied. larger sample size is recommended to increase the generalizability. conclusion results show no significant mean difference in the psychological well-being of participants of nuclear and extended family systems. similarly, no significant difference was found in satisfaction with life between both family systems. gender difference in pwb was found as women scored higher than men, while there was no gender difference among students in satisfaction with life. acknowledgment we are thankful to all academics institutes' authorities, participants of the research, and our colleagues, for helping in data collection. 69 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 8 issue 2 moreover highly grateful to the authors of the scales for providing the scales free of cost. references 1. gul n, shah a, alvi sm, kazmi f, ghani n. family system’s role in the psychological well-being of the children. khyber med univ j. 2017;9(1):29-32. 2. chen j, chen s, landry pf. urbanization and mental health in china: linking the 2010 population census with a cross-sectional survey. int j environ res public health. 2015; 12(8):9012-9024. 3. amato pr, keith b. parental divorce and adult well-being: a meta-analysis. j marriage fam. 1991;53(1):43-58. 4. edwards sd, ngcobo hs, pillay al. psychological well-being in south african university students. psychol rep. 2004; 95(3_suppl):1279-1282. 5. macleod ak, moore r. positive thinking revisited: positive cognitions, well‐being and mental health. clinical psychology & psychotherapy: int j theory & practice. 2000;7(1):1-0. 6. ryff cd. happiness is everything, or is it? explorations on the meaning of psychological well-being. j pers soc psychol. 1989;57(6):1069. 7. falci cd. the effects of family structure and family process on the psychological wellbeing of children: from the children's point of view (doctoral dissertation, virginia tech). 1997:1-56. 8. helson r, srivastava s. three paths of adult development: conservers, seekers, and achievers. j pers soc psychol. 2001;80(6):995. 9. david h, demo dh, acock ac. family structure, family process, and adolescent well-being. j res adolesc. 1996;6(4):457-488. 10. diener, e. subjective well-being: the science of happiness and a proposal for a national index. am psychol. 2002;55:34–43. 11. anand p. happiness explained: what human flourishing is and what we can do to promote it. oxford university press. 2016. 12. burger k, samuel r. the role of perceived stress and self-efficacy in young people’s life satisfaction: a longitudinal study. j youth adolesc. 2017;46(1):78-90. 13. naz s, naz s, gul s. relationship between economic independence, social support and quality of life among elderly people. j indian acad appl psychol. 2014;40(2):255. 14. zullig kj, valois rf, huebner es, drane jw. associations among family structure, demographics, and adolescent perceived life satisfaction. j child fam stud. 2005;14(2):195206. 15. wu q, chow jc. social service utilization, sense of community, family functioning, and the mental health of new immigrant women in hong kong. int j environ res public health. 2013;10(5):1735-1746. 16. cheng y, zhang l, wang f, zhang p, ye b, liang y. the effects of family structure and function on mental health during china’s transition: a cross-sectional analysis. bmc fam pract. 2017;18(1):1-8. 17. eitzen d. social problems. 9th edition. boston: allyn and bacon. 2003. 18. jha m. family matters. in defense of joint family system. 2001. 19. nolen-hoeksema s, girgus js. the emergence of gender differences in depression during adolescence. psychol bull. 1994;115(3):424. 20. woodward at, taylor rj, bullard km, neighbors hw, chatters lm, jackson js. use of professional and informal support by african americans and caribbean blacks with mental disorders. psychiatr serv. 2008;59(11):1292-1298. 21. thoits pa. on merging identity theory and stress research. social psychol quarterly. 1991:101-112. 22. nagaraja a, rajamma nm, reddy sv. effect of parents' marital satisfaction, marital life period, and type of family on their children mental health status. j psychol. 2012;3(2):6570. 23. levin ka, dallago l, currie c. the association between adolescent life satisfaction, family structure, family affluence and gender differences in parentchild communication. soc indic res. 2012;106(2):287-305. 24. lodhi fs, khan aa, raza o, zaman tu, farooq u, holakouie-naieni k. level of satisfaction and its predictors among joint and nuclear family systems in district 70 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 8 issue 2 abbottabad, pakistan. med j islam repub iran. 2019;33:59. 25. itrat a, taqui am, qazi f, qidwai w. family systems: perceptions of elderly patients and their attendants presenting at a university hospital in karachi, pakistan. j pak med assoc. 2007;57(2):106. 26. michel g, bisegger c, fuhr dc, abel t. age and gender differences in health-related quality of life of children and adolescents in europe: a multilevel analysis. qual life res. 2009;18(9):1147-1157. 27. facio a, batistuta m. what makes argentinian girls unhappy? a cross-cultural contribution to understanding gender differences in depressed mood during adolescence. j adolesc. 2001;24(5):671-680. 28. voices4children. the new canadian family. 2009. available at: http://www.voices4children.org/index. 29. cheng y, zhang l, wang f, zhang p, ye b, liang y. the effects of family structure and function on mental health during china’s transition: a cross-sectional analysis. bmc fam prac. 2017;18(1):1-8. 30. ghani s. sociology of family and community. islamabad: uni grant commission. 2000. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v8.i2.2022.62-70 76 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v8.i2.2021.76-85 original article can attachment styles predict psychological and emotional well-being? shahana masood & saima masoom ali department of psychology. university of karachi abstract background: attachment is an intangible form of sharing love, concerns, and emotion between two individuals or sometimes in terms of society. attachment styles with an individual's parents, peers, or loved ones greatly affect an individual's different domains of life. many studies have been conducted to identify the relationship of attachment styles and personality traits, physical and mental health. however, a few kinds of research have focused on the relationship of attachment styles with well-being. therefore, the main objective of the research was to assess whether attachment style can predict psychological and emotional well-being. methodology: the study required a sample of 300 students from different public and private universities in karachi. measures used in the study are the relationships questionnaire (rq) and mental health continuum-short form (mhc-sf). the relationships questionnaire (rq) was used to assess the attachment style, and the mental health continuum-short form (mhc-sf) was used in the study to assess psychological and emotional wellbeing, items related to a specific variable used in the study were included in the assessment. data were analyzed through regression analysis which is an inferential statistical test using spss version 24. results: results were not as per the assumption of the study hypotheses; there was no significant effect of attachment styles on psychological and emotional wellbeing. conclusion: hence, results indicated that attachment style alone could not be considered a good predictor of psychological and emotional well-being. it only has a minor effect, but for the prediction of psychological and emotional wellbeing, other mediating variables and personality factors should also be assessed or considered. keywords attachment styles, psychological well-being, emotional well-being. citation: masood s, ali sm. can attachment styles predict psychological and emotional well-being? app. 2021;8(2): 76-85 corresponding author email: smh_hashmi@yahoo.com doi: 10.29052/2412-3188.v8.i2.2021.76-85 received 18/08/2021 accepted 04/12/2021 published 01/12/2021 copyright © the author(s). 2021 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v8.i2.2021.71 http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 77 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 introduction attachment is an intangible form of sharing love, concerns, and emotion between two individuals or sometimes in terms of society. this enlightens the particular behaviors in children; attachment allows children to express their feelings of fear and disturbance with the one they trust and who can bring them out of the difficult situation1. for the first time, the theory on attachment was given by a psychoanalyst named john bowlby; he wanted to know about the distress felt by infants on being away from their parents. john bowlby came up with the theory of maternal deprivation, which stated that in the absence of a mother, a child feels insecure. this theory further continues to the theory of attachment and then came an experiment on attachment by harlow and zimmerman. this experiment was conducted with monkeys and their mothers, and monkeys were put in a cage with surrogate mothers and separated from their mothers. two mothers were situated in the cage; one was prepared with a cloth that gave warmth and comfort to the child, and the other was made of wire, but that mother was able to feed the child. the child preferred a mother who was made of cloth rather than a wired mother because they wanted comfort more than a need for food2. based on this experiment, bowlby gave the attachment theory by stating that a child needs an emotional bond with the caregiver instead of contacting the mother only for food; a relationship between mother and child is greater than the need for food3. as individuals develop, their attachmentrelated functions are shifted from parents to friends or loved ones4. attachment styles bowlby specified are; anxious resistant insecure, secure, disorganized/disoriented attachment, and anxious-avoidant insecure attachment. looking at secure attachment, it states that children feel comfortable in the presence of a mother, and even if a mother leaves them, they have developed a faith in the mother that she will return for them. the anxiousavoidant insecure attachment explains that child feels anxiety they have not developed trust in their mother that she will fulfill their need, and the child becomes emotionally distant. anxious resistant insecure attachment style is developed when a mother is responsive at times and unresponsive at another; the child feels anger and helplessness. the disorganized/disoriented attachment style indicates that children who have this style show anger, depression, passivity, and apathetic behavior, all of this happens because their mothers behave passively, and at times their mothers are scared5. according to the findings of hazen and shave, the same type of attachment differences is found in children and adults, and attachment models help shape and guide the behavior of close relationships in whole life4. according to bowlby emotional life of an adult is affected by attachment relationships, and he considers attachment to be a major element of the experience of humans "from the cradle to the grave"6. it has been suggested in many studies that lonely adults were found to have trouble relationships with their parents in childhood and either distant or involved type of relationship with their partners; it estimated that history of attachment has an impact on the form and frequency of loneliness in adult4. it has been observed in a study that a bond between pairs or romantic love has the same step of attachment which is found between an infant and an adult. hazen & shaver started working on the romantic attachment, which was based on three categories of attachment by ainsworth to understand how adults feel, think and behave in a romantic relationship and they came up with a short multisentence depiction of the types of attachment 78 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 as each individual is experiencing them which are;7 secure; "i find it relatively easy to get close to others and am comfortable depending on them and having them depend on me. i don't worry about being abandoned or about someone getting too close to me"8. avoidant; "i am somewhat uncomfortable being close to others; i find it difficult to trust them completely, difficult to allow myself to depend on them. i am nervous when anyone gets too close, and often, others want me to be more intimate than i feel comfortable being"9. anxiousambivalent "i find that others are reluctant to get as close as i would like. i often worry that my partner doesn't love me or won't want to stay with me. i want to get very close to my partner, and this sometimes scares people away"4. past researches demonstrate that there is a connection of attachment style with wellbeing. as per the historical background of well-being, it was defined by two approaches; a hedonic tradition which is comprised of constructs such as satisfaction with life, positive affect, happiness, and low negative affect10 the other one is a eudemonic tradition which focuses on human development and positive psychological functioning11. according to keyes, mental health is a syndrome of well-being symptoms12. as per keyes, mental health originates "when an individual exhibits a higher level of at least one symptom of hedonic and at least half level of eudaimonia i.e., positive functioning in life"13. although there are different approaches to well-being, researchers consider well-being to be a multidimensional construct14. a proper definition of well-being that is still being used in literature15 is given by shin and johnson, which is “a global assessment of a person’s quality of life according to his own chosen criteria”16. ryff worked on the concept of psychological well-being, which is comprised of six dimensions of psychological functioning; autonomy, positive relationships with others, environmental mastery, a realization of potential, purpose in life, and selfacceptance17. emotional well-being is defined as "a positive sense of well-being enables an individual to be able to function in society and meet the demands of everyday life; people in good mental health can recover effectively from illness, change or misfortune"7. attachment styles and psychological wellbeing mental health can be predicted by attachment styles18. it was reported that relations with incompatible, doubtful, or unkind persons might have an impact on the development of secure and established mental health. the insecure attachment lowers the flexibility to tackle stressful life events and influences a person to break down psychologically in crisis moments. insecure attachment can therefore be observed as a general weakness to mental disorders, with the specificity of genetics, developmental, and environmental factors19. many studies suggested contemporary relations between insecure attachment and psychopathology in adolescence and adulthood20. in a ten years longitudinal study, it was found that insecure parentadolescent attachment had more psychopathological symptoms in adulthood than secure attachment. therefore, it may be assumed that attachment insecurity for parents remains related to the psychopathology symptoms in adulthood. it was also found that subjects with insecure attachment do not deal practically and productively in stressful situations; rather, they focus on self-blame, ruminative thoughts, and feelings of helplessness21. these features can intensify one's negative 79 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 emotional experience, leading to symptoms of psychopathology experienced in adulthood22. greenberg conducted a study on 161 adults diagnosed with bipolar disorder predicted that individuals who had insecure attachment styles were found to show symptoms of depression and their psychosocial functioning was poorest, whereas those individuals had better psychological functioning and low depression whose attachment style was secure23. according to palitsky et al., people who have an insecure attachment style are prone to having suicidal ideation or attempt suicide and also reported to have other categories of mental health disorders, while those who have a secure attachment style report decreased levels of suicidal ideation and suicidal attempt and anxiety disorders24. attachment styles & emotional wellbeing attachment experiences play an essential role in emotional development25. there is an absence of successful emotion regulation in insecure children. at the early childhood age of 4 months, children of insensitive mothers have poorly regulated emotions as compared to children with sensitive mothers26. a review included studies done with middle school kids and adolescents that suggest that secure attachment is linked with each emotional domain’s adaptive functioning27. pascuzzo et al. did a longitudinal study with adolescents till their adulthood, that is measure was filled by the participants at age 14 and then at age 24, which states that anxious romantic attachment or parent-child attachment is linked with psychopathology and this relationship is mediated by emotion-focused strategies28. research is done with patients of cerebral autosomal dominant arteriopathy with subcortical infarcts, and leukoencephalopathy (cadasil), huntington's disease (hd), and hereditary cerebral hemorrhage with amyloidosis dutch type (hchwa-d) propose that attachment anxiety is related to distress and it has been predicted that distress remains even after 2 months of feeling attachment anxiety and catastrophizing29. rationale attachment styles play an important role in every step of life, from infancy till old age. when a child is born, he is attached to parents only then attachment circle gradually grows from parents to peers, and with the growth of an individual attachment, the circle keeps expanding. therefore, a lot of researches have been conducted to understand the impact of attachment styles on an individual. the main purpose of researching this topic is to focus on the mental well-being of an individual. checking the impact of attachment style on well-being is necessary. for leading a happy and better life, wellbeing is considered important because if a person will not take care of his psychological and emotional health, life is disturbed, and the survival of such people would be difficult. results of this study would able to be used as a guide for the parents, peers, or loved ones so that they can form a type of attachment style with their partners so that they would develop any psychosocial and emotional issues. significance of topic conducting this study is important because once an individual knows what type of attachment would lead to a better lifestyle. then parents of newborn babies would work on establishing such type of attachment pattern with their child who would be helpful in the mental development and growth of a child. identifying the impact of 80 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 attachment style would benefit clinicians as well as they would work on interventions for the clients who have disturbed attachment patterns, and clinicians would already know which style leads to which type of issues, such as mentioned in past literature that insecure attachment style can harm health and wellbeing. therefore, the main objective of the research was to assess whether attachment style can predict psychological and emotional wellbeing. methodology this was a survey based prospective, crosssectional study. participants between the ages range 18-35 years, i.e., young adults, were selected through convenient and purposive sampling from different public and private universities of karachi. sample the sample of the participants is comprised of 300 students. participants were selected from different private and public universities in karachi. the age range of the sample size was between 18-35 years. sampling technique the sample was selected via non-probability sampling techniques, purposive and convenient sampling method, from different universities of karachi. sample size the sample size was decided by keeping in view past studies' sample size. two public sector universities and three private sector universities were visited for data collection. exclusion criteria  university students enrolled in the private study program are enrolled for exams only and do not take regular classes at the university.  students above the range of 18-35 years of age were excluded from the study, as this study only includes those who come under young adulthood. inclusion criteria  university students enrolled in the universities of karachi.  students between the age ranges of 18-35 years, i.e., young adults, were included in the study. informed consent form before taking part in the study, participants were informed through a consent form by which they were able to know what this study is all about and make their decision accordingly to participate in the study. informed consent briefed them about the purpose of the study and regarding their rights of participation in the study. measures following measures were used in the study: demographics form demographics form is based on information of the participants, which includes age, gender, weight, height, university. this information of the participant helped analyze the results of the study in detail. the relationships questionnaire (rq) it was developed in 1991 by bartholomew and horowitz. the questionnaire measures adult attachment style. it has four statements that identify four dimensions of attachment; securely attached, fearful-avoidant, preoccupied, and dismissive-avoidant8. participants are asked to tick in front of the one or more out of four sentences that describes them best; after this, they are supposed to rate themselves for every 4 sentences on the basis of likert scale ranging 81 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 from 1 (does not describe me at all) to 7 (describes me exactly). mental health continuum-short form (mhc-sf) mhc-sf measures emotional, psychological, and social wellbeing. the scale was developed by keyes et al. in the year 2008. the original questionnaire consisted of 40 items; the short version has 14 items and is known as mhc-sf. these items evaluate positive mental health and cover three dimensions which are emotional well-being, social well-being, and psychological well-being. responses of the items are based on a six-point likert scale which ranges from 0 (never) to 6 (every day). this test can be used with individuals of age 12 years or older. the scale is considered to have high internal consistency, which is greater than .80, test-retest reliability, and discriminant validity. approximation of test-retest reliability for four weeks are; emotional wellbeing (.64) and psychological wellbeing (.57). items that were relevant to the variables of the study were included, and items that assessed social wellbeing were excluded. procedure different private and public sector universities were visited for data collection, and participants were asked to fill out the measures mentioned above. any of the forms in which one or more items were left blank by the participants, that form was discarded and not included in the study. questionnaires were given in the same sequence mentioned above in methodology to the participants after they agreed to participate voluntarily in the study. statistical analysis after the data collection procedure, data was analyzed on statistical software spss version 24.0. a regression analysis test was used to assess the effect of attachment style on psychological and emotional wellbeing. result participants between the ages range 18-35 years, i.e., young adults, were selected through convenient and purposive sampling from different public and private universities of karachi. table 1: effect of attachment styles on psychological wellbeing. variable β beta t sig. r r square (constant) 19.063 14.185 .000 .151 .023 style a .039 .011 .186 .853 style b -.296 -.085 -1.380 .169 style c .235 .066 1.082 .280 style d .416 .126 2.159 .032 table 1 indicates that around 2.3% of attachment styles can predict health behavior, which is very low; therefore, attachment styles cannot predict psychological well-being statistically. a p-value is greater than 0.05, which indicates that attachment styles (a, b, c, and d) are not good predictors of psychological wellbeing. 82 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 table 2: effect of attachment styles on emotional wellbeing. variable β beta t sig. r r square constant 9.646 11.808 .000 .073 .005 style a .094 .044 .738 .461 style b -.141 -.067 -1.080 .281 style c .059 .027 .449 .654 style d .046 .023 .389 .697 table 2 indicates that around 0.5% of attachment styles can predict health behavior, which is very low; therefore, attachment styles cannot predict emotional well-being statistically. a p-value is greater than 0.05, which indicates that attachment styles (a, b, c, and d) are not good predictors of emotional wellbeing. discussion the present study is aimed to examine the impact of attachment styles on psychological and emotional well-being. the result of the study did not prove the hypotheses which were; there would be a significant effect of attachment styles on psychological wellbeing, and there would be a significant effect of attachment styles on emotional wellbeing. it is estimated in the study results that attachment styles are not a significant predictor of psychological wellbeing. the relationship of attachment has been supported by previous researches30. most of the researches has shed light on the perspective that other variables mediate the relationship between attachment and psychological wellbeing. it is highlighted in a study that when well-being is measured by considering depression, anxiety, and stress, it has a strong association with attachment style; people who had secure attachment style showed a low level of depression, anxiety, and stress as compared to those with insecure attachment style. it was also reported in the study that mindfulness acts as a moderator between attachment style and wellbeing. if an individual with an insecure attachment style is trained in mindfulness, he can learn to cope with a negative effect of attachment style31. another study finding reports that gratitude act as a mediator between attachment and psychological wellbeing32. study findings reported that attachment styles are not a significant predictor of emotional wellbeing, which is against the past findings. research conducted with pregnant women observed that those with avoidant attachment style had lower emotional bonding with the fetus33, but in the case of pregnant women with anxious attachment style, it was observed that there was no association of emotional bonding and anxious attachment34 which is in support of the current study. it was observed in a study that individuals who have an avoidant attachment style face no difficulty in coping with threatening events by utilizing their emotional distancing35. if we discuss the limitation of the study, the first one is that it is a cross-sectional study, which itself is not considered ideal when trying to assess the impact of one variable on another. longitudinal research is needed for the ultimate relationship. the sample of this study is not ethnically, racially, and 83 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 socioeconomically different, and the sample is based on the pakistani population only. another limitation of this study is that it cannot rule out the potential health effects of pre-existing physical diseases, mental disorders, or personality factors, nor can it assess whether these factors mediate the relationship between insecure attachment styles and poor wellbeing. recommendations of the study are that if someone wants to work on the same topic, other mediating variables such as personality factors and health issues should also be assessed. a causal relationship between the variables should also be analyzed. a longitudinal study from childhood to the stage of young adulthood can be very helpful; personality factors and developmental factors playing a role in the impact of attachment on wellbeing will be assessed too. as attachment patterns, either adult attachment or child attachment, are still a topic that needs in-depth investigation because it's about human psychology, and it is hard to manipulate human behaviors and personality factors. in future studies, while conducting the study, physical health, medical conditions, and psychological disorders should also be one of the variables of the study. conclusion the study found that attachment styles may influence the individual’s psychological and emotional well-being, but they are not enough as a predictor of mentioned behaviors. in line with previous studies, we may conclude that anxiously attached individuals may have poorer psychological wellbeing and irregular emotional strategies. acknowledgment the authors would like to thank the participants of the study, without whom the study would not have been possible and also the research board for the approval. we 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australas psychiatry. 2020;28(4):426-430. 33. göbel a, barkmann c, arck p, hecher k, schulte-markwort m, diemert a, mudra s. couples’ prenatal bonding to the fetus and the association with one's own and partner's emotional well-being and adult romantic attachment style. midwifery. 2019;79:102549. 34. mikulincer m, florian v. maternal-fetal bonding, coping strategies, and mental health during pregnancy-the contribution of 85 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 attachment style. j soc clin psychol. 1999;18(3):255-276. 35. mikulincer m, shaver pr. attachment orientations and emotion regulation. curr opin psychol. 2019;25:6-10. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v8.i2.2022.76-85 annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 hina hazrat 59 mini review doi: 10.29052/2412-3188.v4.i1.2017.59-64 influence of rising temperatures and heat waves on mental health outcomes: an alarming public health concern hina hazrat1 & sadaf ahmed1&2 1psycho-physiology research lab, department of physiology, university of karachi 2advance educational institute and research centre corresponding author email: hhk.hina@gmail.com received 07/04/2018; accepted 14/08/2018; published 10/10/2018 abstract background: an accumulating body of research studies have presented effects of climate change on human health. the current state of climate change supports the notion of elevated incidences of heat waves in future. the understanding of role of increasing temperatures and heat waves on altered mental health conditions stands crucial, in light of wide spectrum of effects warming climate imparts on mental health and well-being status. methodology: research studies with findings related to increasing temperatures, mental health and behavioural alterations, and psychopathological outcomes are highlighted in this review. articles were searched using google scholar from the year 2005 to 2018 by entering keywords; increasing temperature and mental health, heat waves and mental health, heat waves and behavioural disorders, climate change and mental health, and, global warming and mental health. studies were also selected from reference lists of the articles emerging out from these keywords provided. newspaper articles and reports with details of heat waves in pakistan are also included. results: extreme heat exposure event is found to result in adverse mental, mood and behavioural consequences; including anxiety, aggression, and violence. heat waves are found to potentiate risk for hospital admission, also due to mental disorders. heat-associated mental health alterations may be attributed to compromised thermoregulation, pre-existing mental illness, old age, substance abuse and prescription medications effects, and up-regulation in release of stress hormones. conclusion: keeping in view the impact of warming climate on mental and behavioural disorders, it appears significantly important to promote research aiming to decipher heat-induced mental health outcomes. in particular, studies are encouraged to be carried out to understand effects of increasing temperatures and heat waves on impaired mental health and psychological well-being state, develop heat-associated mental health mass awareness campaigns, and plan mental health response actions in pakistan, which currently remain under-represented. keywords climate change, global warming, increasing temperatures, heat waves, mental health, behavioural disorders introduction several studies have reported influence of climate change on human health (manning & clayton, 2018), which is found to play role in disease outbreaks/emergence, poor air quality generation, climate driven disasters enhancement, food insecurity state development, and physical and mental health impairment/alterations (watts et al., 2015; mcmichael & lindgren, 2011). average temperature around the world is considered to be increasing (hartmann et al., 2013), and the current state of climate change supports the notion of elevated incidences of heat waves in the future (mcmichael et al., 2006). moreover, a recent study has presented that there will be an increase in world’s population (48% or http://www.aeirc-edu.com/ mailto:hhk.hina@gmail.com annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 hina hazrat 60 74% versus 30% presently) experiencing severe heat situations ranging over 20 days per year as we move towards end of the century (mora et al., 2017). the state of elevated temperatures are known to influence physical health, as well as mental health (padhy et al., 2015). increasing temperatures, heat waves and mental health outcomes research studies suggest role of increasing temperatures with adverse mental health outcomes (hsiang et al., 2013). rising temperatures are found related to elevated interpersonal aggression and interpersonal violence (hsiang et al., 2013). studies have presented relation between increasing temperatures and rise in hospital admissions for mental, mood and behavioural disorders (trang et al., 2016), due to symptomatic mental disorders, dementia, mood disorders, stressassociated disorders, somatoform disorders, psychological development disorders, schizophrenia, mania, neurotic disorders, self-injury, and intentional injury ((basu et al., 2017; wang & horton, 2015; chand & murthy, 2008; hansen et al., 2008). heat waves are found to potentiate risk for hospital admission due to mental disorders especially among elderly individuals (senility), men and people from rural communities (trang et al., 2016; hansen et al., 2008). moreover, a rise in symptomatic illnesses, mental retardation, drug abuse and lowered response of helping behaviour during event of increasing temperatures was observed (belkin & kouchaki, 2017; trang et al., 2016; antonio bulbena, 2006). high temperatures are found to elevate aggression, suicide risk, anxiety, dementia, schizophrenia and depression (lee et al., 2018; padhy et al., 2015). heat-associated mental health consequences may be attributed to altered thermoregulation (cusack et al., 2011), pre-existing mental illness condition, old age, effects of substance abuse, prescription medications and upregulation in release of stress hormones (lee et al., 2018; dodgen et al., 2016; simister & cooper, 2005). increasing temperatures and heat waves in pakistan with an increase in temperature which is a manifestation of climate change due to global warming (hartmann et al., 2013), it is expected that heat waves will emerge out more in different parts of the world, including pakistan (zahid & rasul, 2012). in mohenjo-daro, sindh on may 26, 2010, temperature of 53.5 °c (128.3 °f) was recorded (the guardian, 2010). during june 17-24, 2015, heat wave led to death of over 1200 people in karachi and during this heat wave period, on june 20, 2015 maximum temperature of 44.8 °c (112.64 °f) was recorded (chaudhry et al., 2015). in may and june 2018, pakistan experienced heat wave, which took lives of around 65 people, and temperature of 48.5 °c (119.3 °f) was recorded in larkana district (guriro, 2018). increasing temperatures, heat waves and, vulnerable populations although climate change transduces its effects on everyone, but certain populations remain more susceptible to the impacts of warming climate (habibi et al., 2016), which highlights potential elevated heatassociated morbidity and mortality especially in these vulnerable populations (bi et al., 2011). studies have presented that interaction with severe heat imparts negative effects on health state of mentally ill individuals, elderly population, children, men, indigenous populations, overweight individuals, individuals with low socioeconomic status, and people who are engaged in physical activities during period of heat exposure (habibi et al., 2016; li et al., 2015; ford, 2012; bi et al., 2011; khalaj et al., 2010). moreover, studies have also found relation between demographic http://www.aeirc-edu.com/ https://www.sciencedirect.com/topics/earth-and-planetary-sciences/anxiety annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 hina hazrat 61 changes and susceptibility to influence of climate change (dodgen et al., 2016). studies have shown that people with chronic diseases (li et al., 2015), nervous system disease, circulatory system disease, respiratory system disease, neoplasms and renal disease (khalaj et al., 2010) are susceptible to impact of rising temperatures and heat exposure. these illnesses may pave way to lowered adaptive capability of body to cope with alterations in the environment and thus impair maintenance of core temperature of the body during warm milieu (kenny et al., 2010). studies have shown that mental health of individuals from marginalized communities is more prone to influence of climate change (manning & clayton, 2018). also, mental health of indigenous populations and women is presented to be susceptible to the climate change effects (manning & clayton, 2018). table 1: summary of altered mental and behavioural outcomes due to increased temperature/heat exposure/heat waves mental and behavioural outcomes reference(s) aggression (padhy et al., 2015) anxiety (lee et al., 2018) dementia (lee et al., 2018; hansen et al., 2008) depression (lee et al., 2018) drug abuse (antonio bulbena, 2006) intentional injury (basu et al., 2017) interpersonal aggression (hsiang et al., 2013) interpersonal violence (carleton & hsiang, 2016; hsiang et al., 2013) low helping behaviour (belkin & kouchaki, 2017) mania (wang & horton, 2015; chand & murthy, 2008) mental retardation (trang et al., 2016) mood disorders (hansen et al., 2008) neurotic disorders (wang & horton, 2015; chand & murthy, 2008; hansen et al., 2008) psychological development disorders (hansen et al., 2008) schizophrenia (lee et al., 2018; wang & horton, 2015; chand & murthy, 2008) http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 hina hazrat 62 self-injury/suicide (thompson et al., 2018; basu et al., 2017; padhy et al., 2015; lin et al., 2008) somatoform disorders (hansen et al., 2008) stress-associated disorders (hansen et al., 2008) symptomatic mental disorders (hansen et al., 2008) violence (carleton & hsiang, 2016; hsiang et al., 2013) recommendations rising temperatures and heat waves pose a substantial negative influence on human health (campbell et al., 2018) and in view of this mass awareness campaigns planning and implementation, health facilities access enhancement, and heat waves-related early warning schemes development are suggested (bakhsh et al., 2018; li et al., 2015). the current gaps in knowledge regarding high temperatures influence on mental health (thompson et al., 2018) should be filled by carrying out studies that uncover rising temperatures impact on psychological, mental and behavioural outcomes, to contribute to better understanding of their association and help strategize concrete plans for tackling mental health burden in face of predicted increase in heat waves in the future. moreover, efforts should be made to uncover role of elevating temperatures and heat waves on mental health outcomes of vulnerable populations (bi et al., 2011). conclusion increasing temperatures which is a phenomenon of climate change presents threat to physical, as well as mental health. keeping in view the effects of warming climate on mental health outcomes, it stands important to promote research aiming to decipher environmental heatinduced mental health alterations, to further contribute to build mental health response plans, and reduce heat mediated mental illness-related morbidity and mortality. studies are encouraged to be carried out to understand heat induced effects on mental health and psychological well-being, in pakistan. conflict of interest none. acknowledgment we would like to thank all researchers for their valuable contributions in this field. funding none. references  antonio bulbena, l. s., jordi cunillera. (2006). psychiatric effects of heat waves. psychiatric services, 57(10), 15.  bakhsh, k., rauf, s., & zulfiqar, f. (2018). adaptation strategies for minimizing heat wave induced morbidity and its determinants. sustainable cities and society, 41, 95103.  basu, r., gavin, l., pearson, d., ebisu, k., & malig, b. (2017). examining the association between apparent temperature and mental health-related emergency room visits in california. american journal of epidemiology, 187(4), 726-735.  belkin, l. y., & kouchaki, m. (2017). too hot to help! exploring the impact of ambient temperature on helping. european journal of social psychology, 47(5), 525-538. http://www.aeirc-edu.com/ https://www.sciencedirect.com/topics/medicine-and-dentistry/dsm-iv-codes https://www.sciencedirect.com/topics/medicine-and-dentistry/dsm-iv-codes annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 hina hazrat 63  bi, p., williams, s., loughnan, m., lloyd, g., hansen, a., kjellstrom, t., dear, k., & saniotis, a. (2011). the effects of extreme heat on human mortality and morbidity in australia: implications for public health. asia pacific journal of public health, 23(2_suppl), 27s-36s.  campbell, s., remenyi, t. a., white, c. j., & johnston, f. h. (2018). heatwave and health impact research: a global review. health & place, 53, 210-218.  carleton, t. a., & hsiang, s. m. (2016). social and economic impacts of climate. science, 353(6304), aad9837.  chand, p. k., & murthy, p. (2008). climate change and mental health. paper presented at the regional health forum.  chaudhry, q. z., rasul, g., kamal, a., ahmad mangrio, m., & mahmood, s. (2015). technical report on karachi heat wave june 2015. government of pakistan ministry of climate change, ministry of climate change, pakistan. retrieved from: http://www.ndma.gov.pk/files/heatwa ve.pdf  cusack, l., de crespigny, c., & athanasos, p. (2011). heatwaves and their impact on people with alcohol, drug and mental health conditions: a discussion paper on clinical practice considerations. journal of advanced nursing, 67(4), 915-922.  dodgen, d., donato, d., kelly, n., la greca, a., morganstein, j., reser, j., ruzek, j., schweitzer, s., shimamoto, m., & tart, k. t. (2016). ch. 8: mental health and well-being: us global change research program, washington, dc.  ford, j. d. (2012). indigenous health and climate change. american journal of public health, 102(7), 1260-1266.  guriro, a. (2018). another 3-day heatwave to hit karachi from tuesday: pmd, daily times.  habibi, p., momeni, r., & dehghan, h. (2016). the effect of body weight on heat strain indices in hot and dry climatic conditions. jundishapur journal of health sciences (inpres).  hansen, a., bi, p., nitschke, m., ryan, p., pisaniello, d., & tucker, g. (2008). the effect of heat waves on mental health in a temperate australian city. environmental health perspectives, 116(10), 1369.  hartmann, d., klein tank, a., rusticucci, m., & alexander, l. (2013). climate change 2013: the physical science basis. contribution of working group i to the fifth assessment report of the intergovernmental panel on climate change. s., charabi, y., dentener, fj, dlugokencky, ej, easterling, dr, kaplan, a., soden, bj, thorne, pw, wild, m., and zhai, pm.  hsiang, s. m., burke, m., & miguel, e. (2013). quantifying the influence of climate on human conflict. science, 341(6151), 1235367.  kenny, g. p., yardley, j., brown, c., sigal, r. j., & jay, o. (2010). heat stress in older individuals and patients with common chronic diseases. canadian medical association journal, 182(10), 1053-1060.  khalaj, b., lloyd, g., sheppeard, v., & dear, k. (2010). the health impacts of heat waves in five regions of new south wales, australia: a case-only analysis. international archives of occupational and environmental health, 83(7), 833-842.  lee, s., lee, h., myung, w., kim, e. j., & kim, h. (2018). mental diseaserelated emergency admissions attributable to hot temperatures. science of the total environment, 616, 688-694. http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 hina hazrat 64  li, m., gu, s., bi, p., yang, j., & liu, q. (2015). heat waves and morbidity: current knowledge and further direction-a comprehensive literature review. international journal of environmental research and public health, 12(5), 5256-5283.  manning, c., & clayton, s. (2018). threats to mental health and wellbeing associated with climate change psychology and climate change (pp. 217-244): elsevier.  mcmichael, a. j., & lindgren, e. (2011). climate change: present and future risks to health, and necessary responses. journal of internal medicine, 270(5), 401-413.  mcmichael, a. j., woodruff, r. e., & hales, s. (2006). climate change and human health: present and future risks. the lancet, 367(9513), 859-869.  mora, c., dousset, b., caldwell, i. r., powell, f. e., geronimo, r. c., bielecki, c. r., counsell, c. w., dietrich, b. s., johnston, e. t., & louis, l. v. (2017). global risk of deadly heat. nature climate change, 7(7), 501.  padhy, s. k., sarkar, s., panigrahi, m., & paul, s. (2015). mental health effects of climate change. indian journal of occupational and environmental medicine, 19(1), 3.  simister, j., & cooper, c. (2005). thermal stress in the usa: effects on violence and on employee behaviour. stress and health: journal of the international society for the investigation of stress, 21(1), 3-15.  temperatures reach record high in pakistan. (2010). the guardian. retrieved from: https://www.theguardian.com/world/2 010/jun/01/pakistan-recordtemperatures-heatwave.  thompson, r., hornigold, r., page, l., & waite, t. (2018). associations between high ambient temperatures and heat waves with mental health outcomes: a systematic review. public health, 161, 171-191.  trang, p. m., rocklöv, j., giang, k. b., kullgren, g., & nilsson, m. (2016). heatwaves and hospital admissions for mental disorders in northern vietnam. plos one, 11(5), e0155609.  wang, h., & horton, r. (2015). tackling climate change: the greatest opportunity for global health. the lancet, 386(10006), 1798-1799.  watts, n., adger, w. n., agnolucci, p., blackstock, j., byass, p., cai, w., chaytor, s., colbourn, t., collins, m., & cooper, a. (2015). health and climate change: policy responses to protect public health. the lancet, 386(10006), 1861-1914.  zahid, m., & rasul, g. (2012). changing trends of thermal extremes in pakistan. climatic change, 113(34), 883-896. http://www.aeirc-edu.com/ 1 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v9.i1.2022.01-05 editorial don't assume that your equipment is doing what you think it is richard a. sherman editor, annals of psychophysiology abstract a perennial problem encountered by both novices and experienced people using psychophysiological recording equipment and then using the displays as the basis for biofeedback and neurofeedback is that the equipment is frequently not doing what the users think it is. hardware and software are frequently glitchy and setting the devices incorrectly makes matters worse. the key question to answer is whether the device reliably produces a display clearly related to the physiological signal produced by the person being recorded. the editorial emphasizes the need to view a raw signal so relationships between the physiology being recorded and the display can be accurately assessed. seven key questions users of psychophysiological recording and biofeedback/neurofeedback equipment need to answer are delineated. they include: (1) are the sensors mounted optimally for location and orientation, (2) are the sensors mounted well enough to pick up a good signal, (3) is the device’s bandwidth set appropriately, (4) is there noise in the signal, (5) does the display accurately reflect changes in the signal, (6) does the display change when the physiological signal does, and (7) is the display set so users can accurately assess the signal? users are encouraged to get the training they need to do a great job when performing recordings. keywords recording errors, fetal flaws, psychophysiological recording, biofeedback, neurofeedback. citation: sherman ra. don't assume that your equipment is doing what you think it is. app. 2022;9(1) :01-05 corresponding author email: drrichsherman@gmail.com doi: 10.29052/2412-3188.v9.i1.2022.01-05 received 26/02/2022 accepted 06/04/2022 published 01/06/2022 copyright © the author(s). 2022. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. about:blank about:blank about:blank 2 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 introduction a perennial problem encountered by both novices and experienced people using psychophysiological recording equipment and then using the displays as the basis for biofeedback and neurofeedback is that the equipment is frequently not doing what the users think it is. hardware and software are frequently glitchy and setting the devices incorrectly makes matters worse. the following are a few of the key areas which need to be checked every time a recording is made. the key question to answer is whether the device reliably produces a display clearly related to the physiological signal produced by the person being recorded. note that the raw signal (or as close to it as the device permits) – rather than some averaged / integrated version must be viewed when checking the quality of the signal and any display based on it as integrated signals change too slowly to show common artifacts in the signal. here are several questions to consider: 1. are the sensors mounted optimally for location and orientation? this is crucial! if the sensors are not in the right place to pick up the physiologically based signal you want, no amount of processing will help. this is a common problem for people doing eeg recordings using only one active and one reference (usually ear clip) sensor. if the sensor is not oriented properly, it can not pick up the signal properly. for example, if the calf muscle is being recorded for surface muscle tension (semg), many people position the sensor across the muscle (horizontally) rather than along it (vertically). as the differential amplifiers in semg recording systems depend on picking up signals as muscles depolarize during contraction, they only pick-up a relevant signal when the active electrodes are placed along the length of the muscle. if placed across it, all they pick up is noise. 2. are the sensors mounted well enough to pick up a good signal? this is frequently a matter of impedance between the skin and the sensor for muscle tension and eeg. most high-quality recording systems have impedance checks which let the user know if the sensor is attached well enough to record a good signal. some systems cease recording if the impedance becomes too high for a good signal. if there is no signal quality check screen or system, it is up to the user to check the sensor’s impedance. impedance meters tend to cost over 350 us dollars. the alternative is to have considerable expertise in recognizing artifacts in the signal and ensuring that the display is showing intensities proportional to some objective gage such as discussed below. respiration belts are frequently mounted too loosely to pick up changes in breathing or are placed incorrectly on the body. this is a common problem when recording chest breathing among women as the belt needs to be mounted either above or below the breasts depending on where the most change in circumference with inhalation occurs. after the optimal location for the belt is determined, the user needs to pull the belt gently and watch for a proportional change in the display. the person being recorded should take a deep breath and a shallow breath with the display showing a clear difference. the raw respiration signal must be displayed as a display of respiration rate obscures problems with the signal itself. photoplethysmographs used to record the pulse from a finger frequently don’t work 3 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 consistently due to low amounts of blood flow to the finger and movement artifacts. it is best to record from the largest digit available such as the thumb as the change in blood flow between pulses is more distinct. subjects have to keep the digit being recorded very still throughout the recording. if an alternative way of recording the pulse, such as wrist to wrist sensors, is available, it should be used. regardless, the display needs to be checked by comparing the pulse the user feels at the wrist with the reading being displayed. this requires looking at the raw pulse signal rather than a heart rate or heart rate variability display as these calculated displays obscure the fact that the actual pulse is not being recorded reliably and consistently 3. is the bandwidth of the device set appropriately? bandwidth refers to the frequencies of interest each physiological signal generates. for example, the bandwidth for alpha eeg signals is about four to eight hertz (cycles per second). there will be different amounts of power (intensity) at each of the frequencies. each muscle produces a typical profile of power at various frequencies at each level of tension. typically, the frequencies of interest which produce the power representative of overall tension in the muscle range from about eight to fivehundred hertz. most psychophysiological recording systems have a default bandwidth which permits recording of only a portion of the signal reaching the sensors. if the system’s bandwidth is set to the wrong setting so important parts of the muscle’s power is not recorded, then the display shows less power than the muscle is producing at that level of tension. for example, if the device’s bandwidth is set to 100 – 200 hz, but most of the muscle’s power is between 300 and 500 hz, the display will show far less power – which equates to “tension” in most people's minds – than is actually the case. 4. is there noise in the signal? this usually includes heartbeat artifacts, motion artifacts, and electrical noise from poor connections. the key is to be able to recognize a good quality signal and differentiate it from problems such as the display breaking up during changes in the signal caused by tensing and relaxing a muscle (etc.), movement artifacts (in which the entire baseline of the signal changes) as well as repeated, relatively high deflections in the display caused by electrical noise and heart beat artifacts, etc. again, the raw (or nearly raw signal) has to be viewable on the display to determine signal quality. long integration times obscure spasms and bad signals. it takes extensive training to learn to recognize movement artifacts and other sources of noise. too may practitioners spend much of their careers feeding back noise because they can’t differentiate between noise and a good signal. people performing psychophysiological recordings need to do their homework so they become familiar with what noise looks like in the various signals being recorded. 5. does the display of the raw signal accurately reflect changes in the physiological signal? most especially, does the device produce nearly the same numbers when a signal is nearly repeated? users need to know whether the device is calibrated so the magnitude of the physiological signal is accurately reflected by the display. most devices either come with a calibration system or need to be calibrated to ascertain whether the signal displayed is accurately related to the signal being 4 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 produced by the person being recorded. it is very easy to ignore the technical portion of manufacturers’ instructions for checking calibration. in cases where no calibration system is included with the device, it is usually fairly simple to check whether a device is producing a realistic, repeatable display. for example, the number of microvolts produced by most muscles in the body while at rest (baseline) and near maximum tension are well known and can be found in the literature. baselines for resting muscles in a normal person observed from raw (not integrated/averaged) signals should be below five microvolts and be very consistent without peaks (other than heartbeat artifacts) going above five microvolts. the readings should be very similar between recording sessions unless some intervention has been made even if the subject has begun habituating to the equipment. the number of microvolts displayed for surface muscle tension signals during tensing should be very similar when about the same amount of tension is generated by the subject. as there is a consistent relationship between how hard a person squeezes a device such as a dynamometer and the number of microvolts produced by the major muscle used to activate the device, the number of microvolts displayed should be within a few percentage points when the dynamometer is squeezed to the same moderate (not maximum) reading. the psychophysiological recorder’s display cannot vary by more than a few microvolts (e.g. show 20 microvolts one time and 100 microvolts another) when the reading on the dynamometer’s dial is the same. the display must show the number of microvolts expected of moderate tension in that specific muscle as defined in the literature. several devices currently on the market show a few microvolts at one reading then over a thousand in a second reading with the same pressure on the dynamometer. dynamometers of sufficient accuracy for this purpose cost between ten and thirty-five us dollars. 6. does the display change when the physiological signal does? in other words, is the device actually recording the subject or just producing a realistic display? all too often a very realistic display of every physiological signal being recorded – especially heart rate – is actually a copy of signals recorded earlier or generated by the system being used. this is occasionally caused by glitches in the software but more often by users themselves who haven’t read the manufacturer’s instructions for how to start and record the display of the physiological signals. the person doing the recording must check that the display changes when the signal does. this requires having the subject change each signal such as respiration rate and depth, muscle tension, etc. the change should be reflected in the display of the raw signal immediately. 7. is the display set so the recording can be adequately assessed? typical visual displays of raw signals provided by modern psychophysiological recording (and biofeedback/neurofeedback) equipment consist of sweep speed, offset, and amplification of the signal. sweep speed is how quickly the signal traverses the monitor from left to right. it must be set slow enough so sufficient details of the signal can be observed to determine whether there are artifacts in the signal but fast enough so changes in the signal can see seen in detail – as when a muscle contracts and relaxes. users may need to change the sweep 5 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 speed for each of these purposes. amplification is equivalent to the volume. it has to be set high enough to see details of the raw signal but not so high that the upper and lower portions of the signal go off the top and bottom of the display when the signal’s power changes. offset is the vertical location of signal on the display. if it is set too low or too high, part of the signal is cut off when the signal’s intensity changes. conclusion users of psychophysiological recording devices should consider learning enough to do a great job when performing recordings. if you want to be certain you are doing an optimal job recording psychophysiological signals of many types, you may want to take a course in psychophysiological recording, read a book covering many different parameters, or read a few articles covering recording methodology for the specific parameter you want to record. you could even (gasp), read the manufacturer’s instructions for the system you are using. articles on recording methodology for specific signals can be identified through searches of the web. the behavioral medicine r&t foundation offers excellent courses such as “psychophysiological recording”, “basic eeg biofeedback/neurofeedback”, and “basic biofeedback” which cover recording methodology in detail. books such as “pain assessment and intervention from a psychophysiological perspective” also discuss recording methodology. about:blank 34 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v8.i1.2021.34-42 original article behavioral and psychological attributes of the smokeless tobacco consumers in karachi sadia aslam1, ahad javed2, h. m. usman1, lubna naz1 & samia mushtaq1 1department of physiology, university of karachi, karachi-pakistan. 2karachi university business school, university of karachi, karachi-pakistan. abstract background: prevalence of smokeless tobacco (st) consumption has been observed worldwide in the twentieth century, especially in asian and african countries, with estimated 47% st consumers in pakistan. therefore, the present study aimed to investigate the potential rationale of individuals for st-initiation and various behavioural and psychological attributes of st-consumers. methodology: the study was conducted in an underprivileged area of surjani town, west district of karachi, pakistan. 150 study participants were selected for the study, in which consumers of the current st consumers (betel nuts, gutka and oral snuff) were recruited. in contrast, the individuals not taking st served as controls. individuals with smoking, any other type of addiction, medications for any chronic disease (hypertension, diabetes), or having any other behavioural/psychological problems were excluded from the study. a structured questionnaire was designed to evaluate the level of stress (modified hassles scale), addiction, and nicotine dependence. the participants were explained about the purpose of the study and the interviews were conducted by personal meet-up in their homes. data was collected and analyzed via spss version 16.0. results: curiosity and peer pressure appeared to be among the most important factors for st consumption initiation. 25% of st consumers were found to be at the end stage of addiction, while 36% categorized to be in the second stage of addiction. irritation, anger, headache and laziness were among the most prevalent types of feelings experienced by the study participants. the reduced stress levels in st consumers compared to the controls were due to their euphoric condition attributed to the st. approximately 30% of the consumers were categorized to have an increased risk of obesity. conclusion: as a readily available and affordable addictive agent, smokeless tobacco consumption has been raised in pakistan more than in the west. smokeless tobacco consumption-initiation has been linked to increased curiosity and peer pressure. keywords smokeless tobacco, rationale, peer pressure, addiction. citation: aslam s, javed a, usman hm, naz l, mushtaq s. behavioral and psychological attributes of the smokeless tobacco consumers in karachi. app.2021; 8(1):34-42 corresponding author email: samtaq.physio@gmail.com doi: 10.29052/2412-3188.v8.i1.2021.34-42 received 23/11/2020 accepted 25/05/2021 published 01/06/2021 copyright © the author(s). 2021 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v8.i1.2021. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 35 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 introduction the prevalence of smokeless tobacco (st) consumption has been observed worldwide in the twentieth century, especially in asian and african countries. st product consumption has been linked to more than 50% risk of oral cancer in asian countries1. the worldwide death rate owing to tobacco consumption is 5 million per annum, and this rate is higher than the rate of people died on account of aids, drug abuse, road accident, murders and suicides2. easy accessibility and affordability are the main factors for increasing smokeless tobacco among middle-class individuals3. this casecontrol study was formulated after having a gross observation of smokeless tobacco (st) consumers' lifestyle. in pakistan, 23.9 million adults are involved in using different forms of tobacco, in which 9.6 million adults use smokeless tobacco4. a huge multi-ethnic population of karachi was reported to be involved in gutka consumption (79.2%), betel quid (34.4%), areca nuts (21.6%), and naswar (12%)5. the consumers have reported various reasons regarding consumption of any drug, including peer pressure, accidental, stress, boredom, curiosity & maybe for no reason5. moreover, a misconception existed among people about the curative effect of smokeless tobacco against toothache, headache & stomach ache3. rozi and akhtar reported that age and socio-economic status are the causes of change in tobacco use2. besides age and socio-economic condition, using smokeless tobacco is also affected by ethnic origin and gender1. st-addiction tends to be initiated by regular consumption in individuals taking it earlier for medicinal purposes. the complex nature of addictionphenomenon ranges from the etiological factors that interfere with the molecular mechanisms to the individuals' social interactions. drug addiction is a series of complex molecular interactions in drugsensitive neurons, with consequent altered neuronal properties, activities and metabolism that finally results in altered behaviour like craving, dependence, tolerance and sensitization6. nicotine, being the cardinal addictive constituent in tobacco products, interacts with neuronal nicotinic acetylcholine receptors (nachrs)7. since nicotine increases dopamine, norepinephrine, acetylcholine & serotonin by interacting with central nervous system receptors8, nicotine withdrawal causes impaired cognitive performance9. mental stress is a situation of psychological illness. it can be due to any reason such as family conflict, loss of the relationship, loss of child or death of a close family member. if the stress is more severe or repeated, it will induce more critical situations that will be uncontrollable or unpredictable10. people have linked drug use to deal with stressful situations, and anxiety-relief10 and stress cause a craving for a particular drug11,12. hence, psychological stress predisposes individuals to tobacco consumption. the diversified nature of individuals' sociocultural and biological attributes in various countries has justified the heterogeneity among the st consumers' behaviors13. despite the high prevalence of st consumption in the south-asian region, there is a scarcity of the reported data on the behavioural effects of st consumption, as well as the present study also presents the level of addiction and stress level for daily hassles of the st consumers which, to the best of our knowledge, has not yet been investigated in the population of surjani town, west district of karachi, pakistan. therefore, the present study aims to investigate the potential rationale of a person 36 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 for st-initiation and various behavioural and psychological attributes of stconsumers. methodology the study was conducted in an underprivileged area of surjani town, west district of karachi, pakistan. a total of 150 current st consumers (betel nuts, gutka and oral snuff) were recruited. in contrast, the individuals not taking st served as controls. individuals with smoking, any other type of addiction, medications for any chronic disease (hypertension, diabetes), or having any other behavioural/psychological problems were excluded from the study. participants were selected as per the criteria as mentioned above. the techniques of data collection in this study were based on a structured questionnaire. the questionnaire was designed to evaluate three significant constructs: the level of stress14, addiction, and nicotine dependence15. a modified hassles scale was used to assess the stress levels of the study participants. it is a 51-item scale measuring the intensity of life experiences; each question had one of the four responses (not at all part of life =1, only slightly part of my life = 2, distinctly part of my life = 3, and very much part of my life =4)14. the scale to evaluate the level of addiction is a 20-item scale with dichotomous responses (yes = 1, no = 2). the items of the tests mentioned above were also validated using pearson’s correlation coefficient. consumers’ rationale for st initiation was evaluated via pre-formulated questions reported by baig and associates regarding the reasons for st initiation. the same was inducted in the questionnaire for determining the highest prevalence of reason for which people start taking st5. informed consent was taken, the participants were explained about the purpose of the study and interviews were conducted by personal meet-up in their homes. data was collected and analyzed via spss version 16.0. st-quantification was done via commercially available packs of betel nuts, gutka and oral snuff were considered for this study, and their mass was obtained through shimadzu libror ael-200. st consumers’ nicotine dependence was assessed using fagerström test for nicotine dependence-smokeless tobacco (ftndst)15. self-generated questions were used to determine the consumers’ quittingwillingness and feeling upon craving. participants were also categorized based on their addiction status. mental stress was assessed using hassles scale14,16. result after carrying out this study with a good level of cooperation of the study participants, various significant findings were made. the results are as follows: out of all st consumers, 17% participants consume more than 5 sachets (i.e., > 9.34 grams) of betel nuts, 15.2 % participants consume 1 to 3 packets (i.e., 31.87 grams to 95 grams) of gutka and 15.2 % participants consume lesser than 1 packet (i.e., < 29.27 grams) of oral snuff in a day. curiosity was the most common reason for starting st consumption with the involvement of 50% of participants in it while 30.5% start it due to peer pressure (figure 1). 37 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 figure 1: rationale of smokeless tobacco initiation. evaluation of the level of addiction was tested using a 20-item scale. the reliability of the test was estimated using cronbach alpha. the reliability was found to be excellent (α = 0.776)17. the items were also validated using pearson’s correlation coefficient, it showed significant values for the items (p<0.05). figure 2: level of addiction of the smokeless tobacco consumers. of the total, 25.53% of st consumers were found to be at the end stage of addiction while 36.17% st consumers belonged to the second stage of addiction, with 29% belong to the age group 26-35 and chew gutka while 17% were betel nuts consumers and belong to the age group 15-25 (figure 2). no addiction 4.25% probably addiction 10.64% early stage 23.40% 2nd stage 36.17% end stage 25.53% stress, 5.55% boredome, 11.11% curiosity, 50% peer pressure, 30.50% unconciously, 2.77% 38 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 figure 3: bmi of smokeless tobacco consumers. around 42.55% of the st consumers had normal bmi, 19% were obese, while 30% were overweight (figure 3). evaluating the stress level of the study participants, the hassles scale was used. the reliability of the test was evaluated using cronbach alpha (α = 0.909), which is an excellent value endorsing the reliability of the test17. the items of the scale were also validated using pearson’s correlation coefficient and it showed significant values (p<0.05). based on the final scores of the test, the participants were categorized. 70% of the st consumers were having average stress, 7% were having high stress. figure 4: number of participants with average mental stress versus category of subjects. when participants with average stress levels were compared, 31% controls, 27% gutka consumers, 21% betel nuts consumers and 19% snuff consumers were found to have mental stress. it showed that most of the controls were mentally stressed while tobacco consumers had reduced mental stress due to their euphoric condition attributed to the st (figure 4). underweight 8.50% increased but acceptable risk 42.55% increased risk 30% high risk 19% 19% 21% 27% 31% snuff betel nuts gutka controls 39 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 figure 5: feeling of st consumers upon not having tobacco. fagerstrom test for nicotine dependence-smokeless tobacco showed 35% of the study participants were highly nicotine dependent, whereas 20% were found to be less nicotine dependent. irritation, anger, headache, and laziness were among the most prevalent types of feelings experienced by 36%, 22.2%, 16.6% & 13.8% of the study participants, respectively. discussion there are several types of tobacco, but in this study, the consequences of a few of them are analyzed, such as betel nuts, gutka & oral snuff. betel nuts are a type of tobacco being used with the fourth highest prevalence in the world18. nicotine tobacco is used for the preparation of gutka19. nicotine is a potent addictive drug that is consumed to improve cognitive abilities9,20. nicotine is a potent sympathomimetic drug, thus causes blockade of peripheral nicotinic receptors and stimulates the sympathetic nervous system increases the release of epinephrine, eventually heart rate, blood pressure & heart contractility21. nicotine intake in regular smokers and regular users of smokeless tobacco is the same22. smokeless tobacco contains more than 30 types of cancercausing agents that include volatile or tobacco-specific nitrosamines, nitrosamino acids, polycyclic aromatic hydrocarbons, aldehydes and metals1. according to dass, jaganmohan, auto drivers were found to be the frequent consumers of st19. ali et al., reported that 40% of people use st by getting inspired by media advertisements, their friends or colleagues pressurized 31% to use st23. in comparison, over 40% people use it to get rid of common health problems. imam et al., reported comparable findings3. similarly, baig et al. also reported peer pressure to be one of the most common reasons for st consumption5; however, other reasons such as accidental involvement, stress, boredom, and curiosity were also reported. in our study, curiosity was found to be among the most prevalent reasons for st consumption (figure 1), with other important reasons being peer pressure (30.5%), boredom (11%), and to get rid of mental stress (5.5%), while only 2.7% participants started consuming it at an immature age when they even did not know what it was, these reasons were also determined by baig et al. with different prevalence rate5. irritation, 36% laziness, 13.80% anger, 22.22% headache, 16.66% body pain, 2.77% craving for it, 8.33% 40 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 in this study, the st consumers are found to be at various stages of addiction. among these stages, only 4% of consumers were found not to be addicted, they consumed st for the fun of time being, and they could quit that anytime, about 11% of consumers were probably addicted, 23% consumers were at the early stage of addiction, i.e. addiction had not made significant changes in their lifestyle, and they did not experience a severe feeling of craving, 36% st consumers were at the second stage of addiction, shown in figure 2. here the important point is that among these 36% people, 29% individuals lie between the age 26-35 years and they consume gutka and 17% of them were betel nuts consumers and belonged to the age group 15-25 these individuals tried their best to keep a sufficient amount of st with them every time to avoid any extreme situation; it is a part of their daily life. 25% of st consumers are at the end stage of addiction; their addiction was so high that if they did not get st when craving, it resulted in extreme anger or harsh behaviour. it was noted in the consumers of the second stage that the individuals who were addicted to betel nuts during the age 15-25 were more susceptible to move towards more complex and more potent addictive agents (i.e. gutka) after few years. similarly, when their neurons did not have the consistent euphoric feeling upon having the same addictive drug for an extended period, they may move to a much harder addiction. reduction in the weight gain process has been linked to snus (a kind of st) consumption24. however, our results have shown a positive correlation between bmi and st consumption with 29.8% and 19.15% consumers were overweight and obese, respectively (figure 3), and only 8.5% were underweight. according to sinha10, stress is a situation of psychological illness. it can be due to any reason such as family conflict, loss of a relationship, loss of child or death of a close family member. if stress is more severe or repeated, it will induce more critical situations that will be uncontrollable or unpredictable; hence, he declared in his study that people use addictive drugs to deal with stressful situations to get relief from tensions. sinha11, cleck and blendy12 also showed a correlation between addictive drug consumption with mental stress, stating that he is more likely to use addictive drugs if an individual is psychologically stressed. stress induces a craving for a drug. comparable results were obtained in our study. the participants without any addiction have comparatively higher mental stress than betel nuts, gutka and snuff consumers (figure 4). the number of individuals with average mental stress levels gets lower as we move towards the harder addictive agent. the primary purpose of st consumption appeared to be a euphoric condition. it was also observed that with the increase in age, the willingness of an individual to quit tobacco decreased. it is commonly observed that as age increases, the habits of an individual become much stronger. thus, if a person is addicted to a specific drug for about more than 20 years, it can be understood by the facts that how difficult it could be for an st consumer to quit consuming tobacco. in this study, we asked st consumers about whether they want to stop consuming st or not. it was found that the individuals with lower age have the willingness to quit tobacco, while as the age of consumer increases, the individuals could not even think of quitting. thus, desire to quit tobacco consumption had an inverse relationship with age. 41 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 mansvelder and mcgehee described that craving is a situation that occurs because of addiction which is a series of complex molecular interactions in neurons that are sensitive to it7. as nicotine is an addictive agent in smokeless tobacco, withdrawal of nicotine intake causes impaired cognitive performance9. thus, at the time of craving, every individual experienced a specific feeling. we have compiled the results of that feeling in this study according to our results irritation, anger, headache and laziness were found to be the feelings experienced by 36%, 22.2%, 16.6% & 13.8% of the study participants, respectively. in contrast, the rest of the feelings were found in minor percentage, i.e. 8.33% of the participants experienced headache, and 2.77% of the participants encountered body pain or fatigue, shown in figure 5. hence, irritation is the feeling being experienced by most of the st consumers when they did not get st when they crave for it. conclusion as a readily available and affordable addictive agent, smokeless tobacco consumption has been increased in pakistan more than in the west. smokeless tobacco consumption-initiation has been linked to increased curiosity and peer pressure. willingness to quit st was found to be elevated at an early age in comparison to late ages. however, the restriction could be done via strategic implementation of promoting awareness regarding st-detrimental effects on health and prohibiting st sale at the government level. acknowledgment the authors are thankful to the study participants for their cooperation in the study. references 1. boffetta p, hecht s, gray n, gupta p and straif k. smokeless tobacco and cancer. lancet oncol. 2008; 9(7): 667-675. 2. rozi s, akhtar s. prevalence and predictors of smokeless tobacco use among high-school males in karachi, pakistan. emhj. 2007;13(4):916-924. 3. imam sz, nawaz h, sepah yj, pabaney ah, ilyas m, ghaffar s. use of smokeless tobacco among groups of pakistani medical students– a cross sectional study. bmc public health. 2007; 7(1): 231. 4. saqib ma, rafique i, qureshi h, munir ma, bashir r, arif bw, bhatti k, ahmed sa, bhatti l. burden of tobacco in pakistan: findings from global adult tobacco survey 2014. nicotine and tob res. 2018;20(9):1138-1143. 5. baig s, arif mm, obaid m, rubab z. pattern of substance abuse in multi ethnic groups in different localities of karachi. pak j med dent. 2012; 1(1): 47-54. 6. koob gf, caine sb, parsons l, markou a, weiss f. opponent process model and psychostimulant addiction. pharmacology biochemistry behav. 1997; 57(3): 513-21. 7. mansvelder hd, mcgehee ds. cellular and synaptic mechanisms of nicotine addiction. j neurobiol. 2002; 53(4): 606-617. 8. teneggi v, squassante l, iavarone l, milleri s, bye a and gomeni r. correlation and predictive performances of saliva and plasma nicotine concentration on tobacco withdrawal‐induced craving. br. j. clin. pharmacol. 2002; 54(4): 407-414. 9. levin ed, lee c, rose je, reyes a, ellison g, jarvik m, gritz e. chronic nicotine and withdrawal effects on radial-arm maze performance in rats. behav neural biol. 1990;53(2):269-276. 10. sinha r. chronic stress, drug use, and vulnerability to addiction. ann. n. y. acad. sci. 2008; 1141: 105. 11. sinha r. the role of stress in addiction relapse. curr. psychiatry rep. 2007; 9(5): 388-395. 12. cleck jn and blendy ja. making a bad thing worse: adverse effects of stress on drug addiction. j. clin. investig. 2008; 118(2): 454461. 42 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 1 13. nichter m. smoking: what does culture have to do with it? addiction. 2003; 98: 139-145. 14. kanner ad, coyne jc, schaefer c, lazarus rs. comparison of two modes of stress measurement: daily hassles and uplifts versus major life events. j. behav. med. 1981; 4(1): 139. 15. ebbert jo, patten ca, schroeder dr. the fagerström test for nicotine dependencesmokeless tobacco (ftnd-st). addictive behaviors. 2006; 31(9): 1716-21. 16. kohn pm, macdonald je. the survey of recent life experiences: a decontaminated hassles scale for adults. j. behav. med. 1992; 15(2): 221-236. 17. neuendorf ka. defining content analysis. content analysis guidebook thousand oaks, ca: sage. 2002. 18. lin w-y, chiu t-y, lee l-t, lin c-c, huang c-y, huang k-c. betel nut chewing is associated with increased risk of cardiovascular disease and all-cause mortality in taiwanese men. am. j. clin. nutr. 2008; 87(5): 1204-1211. 19. dass bp, jaganmohan p, sravanakumar p. changes in hematological and biochemical parameters in smokeless tobacco (st) chewers in costal belt of andhra pradesh, india. ejbs. 2013; 5(1): 29-33. 20. henningfield je, cohen c, slade jd. is nicotine more addictive than cocaine? br. j. addic. 1991; 86(5): 565-569. 21. levin ed, ellison gd, salem c, jarvik m, gritz e. behavioral effects of acute hexamethonium in rats chronically intoxicated with nicotine. physiol behav. 1988; 44(3): 355-359. 22. piano mr, benowitz nl, fitzgerald ga, corbridge s, heath j, hahn e, pechacek tf, howard g, american heart association council on cardiovascular nursing. impact of smokeless tobacco products on cardiovascular disease: implications for policy, prevention, and treatment: a policy statement from the american heart association. circulation. 2010: 122(15); 1520-1544. 23. ali ns, khuwaja ak, ali t and hameed r. smokeless tobacco use among adult patients who visited family practice clinics in karachi, pakistan. j oral pathol med 2009; 38(5): 416421. 24. rodu b, stegmayr b, nasic s, cole p and asplund k. the influence of smoking and smokeless tobacco use on weight amongst men. j. intern. med. 2004; 255: 102-107. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v8.i1.2021.34-42 31 app| published by aeirc| https://doi.org/10.29052/2412-3188.v7.i1.2020.31-38 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) original article evaluating age-related cognitive performance; an observational pilot study aiman khan, aimon ashraf, huda siddiqui, khadija ahmed, fatima ali, laveeza azam, fariha akbar & huma bugti psychophysiology research lab, mahq biological research centre, university of karachi. abstract background: to the best of our knowledge, the general population of pakistan has never been evaluated for age-related cognitive performance. we aimed to determine the decline in cognitive abilities using the mini-mental state examination (mmse) and mini-cognition (mini-cog) in the three age brackets, i.e. younger, middle-aged and older adults. methodology: this cross-sectional study was conducted over a sample of 200 subjects (both male and female) divided into three different groups with respect to their age, i.e. younger, middle-aged and older adults. for cognitive assessment, mmse and mini-cog were used with predetermined cut-off values. a point was scored for each correct answer based on the participant’s familiarization of environment, memory, speech, and ability to follow instructions to read or write. the collected data were analyzed using spss version 22.0. results: based on the study findings, mmse suggested that 2.5% of participants had severe cognitive impairment, and 23% had mild cognitive impairment. of these, 23 participants were in between 56 to 75 years of age, indicating increased cognitive decline among older adults. the mean mmse score was 26.58 among young adults, which further decreased to 24.06 among older adults. the results of the regression analysis displayed that age, occupational load and educational levels were independent predictors of cognitive performances (higher mmse score) (p<0.05). besides for mini-cog scores, only education and occupation were the significant predictors. conclusion: this pilot study determining the cognitive performance in different age groups yielded positive outcomes. both mmse and mini-cog findings were comparable and indicated that there was a significant age-related cognitive decline which was comparatively more pronounced among males than females. however, further descriptive studies might help in defining the appropriate and timely screening of cognitive abilities using mmse and mini-cog. keywords cognitive performance decline, ageing, mini-mental status examination (mmse), mini-cognition (mini-cog). citation: khan a, ashraf a, siddiqui h, ahmed k, ali f, azam l, akbar f, bugti h. evaluating age-related cognitive performance; an observational pilot study. app. 2020; 7(1):31-38 corresponding author email: humayousaf786@outlook.com doi: 10.29052/2412-3188.v7.i1.2020.31-38 received 12/03/2020 accepted 13/08/2020 published 01/10/2020 copyright © the author(s). 2020 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 32 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) introduction cognitive performance refers to the acquisition, deposition, assimilation, and utilization of information relevant to the surrounding circumstances and performing accordingly, and it is critical for information processing, integration, and responsiveness1. although there are certain brain areas involved in reasoning that develop with age, generally, it is evident that memory, processing, and functioning decreases with increasing age either as a predetermined physiological mechanism or due to any underlying disease2. this age-related cognitive decline is associated with decreasing brain function as a result of vascular damage or neurodegenerative conditions. if it went undiagnosed, it might further lead to unfavourable conditions. therefore, various screening tests are performed for preliminary assessment of cognitive impairment in order to diagnose and treat the condition before the development of serious outcomes3. the appropriate diagnosis within the recommended time duration plays an important role in devising a suitable therapeutic plan for cognitive impairment, and it prevents already the feeble body of aged individuals from being adversely affected by the severe cognitive disorders4. among various cognitive performance screening tools, the mmse is globally used to determine any alterations in the normal physiology of the brain. mmse is of immense importance in evaluating the impacts of socio-demographic characteristics on cognitive abilities, i.e., lower education and increasing age, which yield lower cognitive outcomes5. it has a certain set of questions that analyses the individual’s orientation, memory, speech, and ability to follow instructions to read or write6. such a tool with a specific scoring method is essential to screen and predict future development of degenerative diseases such as alzheimer’s disease based on their contemporary cognitive abilities7,8. considering the necessity of mmse usage in older patients of dementia due to its rationality and authenticity, it is used in primary care centers to gauge the extent of their cognitive decrement, lesser ability to carry out fundamental activities, and worsening psychomotor actions9. also, its electronic version has been designed to be used at a comfortable and convenient setup of personal accommodations10. in one such mental health program, a pronounced cognitive decline is observed in elderly patients, i.e., 55-74 age range, with mmse score < 17, and also such trend is observed in people with an education level less than grade 8 in comparison to the patients of age range 35-54 years. although, a cut-off point of < 23 is used in the studies of mmse to determine mild incongruences in cognitive functions11. whereas, such optimal value to determine decreasing cognitive functions is affected by increasing age12 and by the population under observation13. while the mini-cog scale is comparatively a simpler tool developed by borson et al., in 2000, for the detection of cognitive impairment among the elderly14, it was primarily developed with the aim to improve the diagnostic evaluation among dementia patients15. the reported sensitivity and specificity of the tool are 76 to 99% and 89 to 93%, respectively14,16,17. the mini-cog tests the short term memory with three-word recall, and it also includes the clock drawing test (cdt). in comparison to other comprehensive assessment tools, mini-cog is easier and provides the overall assessment of cognitive functions, including memory testing, structural concepts, and executive functioning. our aim was to examine the cognitive performance among different age groups, for which the age-wise declination in the cognitive abilities was assessed. the secondary objective was to assess the change in the cognitive performance with respect to gender, education level, and the occupational load. 33 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) methodology an observational pilot study was conducted over a sample of 200 participants of three different age groups, i.e. 15 to 35 years (young adults), 36 to 55 years (middleaged), and 56 to 75 years (older adults). the study continued for a duration of 3 months, and data was collected from various sites as per the sample accessibility including university of karachi, markaz-e-umeed, and koohi goth. the study complies with the helsinki declaration of 1975 and other modified proclamations. all participants between 15 to 75 years of age of both genders and with no severe physiological and psychological dysfunctions were included in the study. in contrast, those with severe brain trauma, injury, and those with any physiological disabilities were excluded from the study sample. the literacy rate and educational status were also assessed, and < 3 years of education was categorized as low education, 4 to 7 years as medium education, and ≥ 8 years as high education. cognitive domains were measured using mmse18 and mini-cog14. all the data concerning the subject’s sociodemographic characteristics and cognitive performance was noted in a pre-designed questionnaire. for mmse scoring, the maximum total score was 30, and the score between 0 to 9 was indicative of severe cognitive impairment, 10 to 24 as mild to moderate cognitive impairment, and 25 to 30 as no cognitive impairment. while in the mini-cog, the maximum score of mini-cog was 9. 1 point assigned for each correctly recalled word after cdt where participants scoring 0 to 4 were defined having cognitive impairment, score 9 suggested no cognitive impairment while participants having intermediate scores like 5 to 8 were classified based on cdt. participants with normal cdt was indicative of no cognitive impairment, while abnormal cdt suggested possible cognitive impairment. the data was statistically analyzed using spss version 22.0, where all qualitative variables were presented using frequency and percentages, and quantitative variables were given as mean and standard deviation. a chi-square test was used for significance testing, and multiple linear regression analysis was performed to determine the possible predictors of cognitive impairment. p-value < 0.05 was considered statistically significant. result based on the study findings, 3.5% of participants had a low educational level, 16.5% were labelled as a medium, while 79.5% had a high education level, as shown in table 1. the mean mmse score of the sample was 25.22 ± 3.49, and the mini-cog score was 4.34 ± 0.766. table 1: demographic characteristics of study participants variables n=200 age (years) 42.45 ± 16.73 age categories younger adults 69(34.5) middle age 64(32.0) older adults 67(33.0) gender male 90(45) female 110(55) marital status married 142(71) unmarried 58(29) employment status working 90(45) non-working 110(55) 34 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) occupational load moderate 137(68.5) high 20(10) low 43(21.5) education level low 7(3.5) medium 33(16.5) high 159(79.5) *values are given as mean ± sd or n(%) the majority of participants displayed no cognitive impairment, i.e. 74.5% had no cognitive impairment followed by mild cognitive impairment among 23% participants, and 2.5% had severe cognitive impairment. around 98.5% of participants had no cognitive impairment as per the scores obtained from the mini-cog tool, while only 1.5% displayed cognitive impairment. table 2: shows the distribution of study participants based on mmse & mini-cog scores scoring n % mmse severe cognitive impairment (score 0 to 9) 5 2.5 mild cognitive impairment (score 10 to 24) 46 23.0 no cognitive impairment (score 25 to 30) 149 74.5 mini-cog cognitive impairment (score 0 to 4) 3 1.5 no cognitive impairment (score 9) 197 98.5 figure 1 & 2 shows the mean decline in cognitive abilities with increasing age. the mean mmse score was 26.58 among young adults, which further decreased to 24.98 among middle-aged participants and, finally, 24.06 among older adults. similar age-related declination was observed through minicog scores, i.e. the score decreased from 4.76 among younger adults to 4.16 among older adults. multiple linear regression analysis was performed taking mmse score as the dependent variable against age, gender, education and occupational load (independent variables). a significant effect of age (β=-.005, p=0.032), occupational load (β=-.084, p=0.042), and educational level (β=.173, p=0.012) on cognitive performance (measured using mmse) were observed. table 3: multiple linear regression analysis for independent predictors of individual’s mmse score variables n=200 (adj r2=.091) beta 95% ci p-value age -.005 -.010,.000 .032* gender .105 -.045,.254 .169 figure 2: age-associated decline in the mean mini-cog score figure 1: age-associated decline in the mean mmse score 35 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) marital status .006 -.138,151 .932 employment .099 -.060,.257 .220 occupation -.084 -.165,-.003 .042* education .173 .038,.308 .012* *adj r2-adjusted r2; ci – confidence interval *p-value < 0.05 is considered significant using mini-cog, it was found that only occupational load (β=.138, p=0.030) and educational level (β=.348, p=0.001) had a significant effect on cognitive performance. table 4: multiple linear regression analysis for independent predictors of individual’s mini-cog score variables n=200 (adj r2=.073) beta 95% ci p-value age -.004 -.011,.003 .227 gender .033 -.197,.263 .779 marital status .061 -.161,.283 .586 employment .117 -.126,.361 .342 occupation .138 .013,.262 .030* education .348 .140,.556 .001* *adj r2-adjusted r2; ci – confidence interval *p-value < 0.05 is considered significant discussion our findings truly support the hypothesis, suggesting a significant age-associated decline in the cognitive functions. the results supported the widely accepted notion that mmse and mini-cog (cdt) can be used by professionals for observation of the cognitive decline in relevance to increasing age19. considering the alarmingly growing population with many aged 65 and above, and most of them being affected with dementia-specific to age and gender, there is a need to diagnose any imminent neuropathology20. therefore, the urge to develop a reliable and sensitive tool for distinguishing age-related cognitive changes and deterioration has become inevitable21,22. as per the reliability is concerned, a study indicated that the majority of the older individual had a low mmse score, which was further supported by their death, indicating that mmse is among the most reliable screening methods for cognitive decline with age23. similarly, a correlation was found between alkaline phosphatase level and low mmse score among alzheimer’s patients of older age group suggesting neurocognitive mislaying24. presently, both mmse and minicog are the most widely used, comparatively easier and consistent tools parallel to other comprehensive assessment tools used for screening of cognitive disabilities16,25. although mmse is quite popular in the majority countries but the preference is thought to be linked with shorter time duration for testing, i.e. 10 minutes, while on the other hand, mini-cog takes more time, but it is detailed and covers diverse cognitive aspects26. we have examined the cognitive decline among enrolled participants using both mmse and mini-cog scores, and it was tracked with respect to age, the mean mmse score decreased from 26.58 among young adults to 24.06 among older adults, and the same was with the mean mini-cog scores (figure 1 & 2). this is also supported by the results of a similar study, participants < 75 years of age had the mean mmse score of 36 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) 28.14 while those > 75 years had a mean score of 27.81 and cdt declined from 4.47 to 4.19 among the two age groups4. in addition to age, the effects of gender, educational levels, and occupational load on cognitive functioning were also investigated. no significant gender-based variation was observed in the mmse and mini-cog scores (table 3 & 4). shuba and prakash, in their study, also displayed no association between the two variables. moreover, a higher level of cognitive impairment was observed among males, i.e., mean mmse score of 24.94 among males vs. 25.47 among females, and the same was for the mini-cog score (4.30 vs. 4.37). other studies with similar findings suggested that this gender-based difference might be due to various environmental and occupational stressors4,27. occupational load plays an important role in the overall cognitive performance, occupations requiring higher cognitive involvement are found to be associated with lower cognitive impairments due to the indulgence of a person in high cognitive activities28. another study suggested that physical frailty has a significant impact on cognitive activities and mental health28. as per our results, the occupational load was significantly associated with cognitive performance, and participants with low to moderate occupational load had mild to severe cognitive impairment as compared to those with high occupational load (table 3 & 4). the educational level also had a significant impact on the cognitive abilities of the participants (p < 0.05). mild cognitive decline was observed more among the participants with low to medium educational levels as compared to those with high educational years. a similar trend was observed by ghavidel et al., in their study4. this pilot study provided an opportunity to investigate the age-associated cognitive decline and the impact of related factors, including occupational load and educational levels, among the people of karachi, pakistan. although the findings are not the true presentation of the local data but to the best of our knowledge, no such study involving the local population of all three age groups, i.e. younger adults, middle-aged people, and older adults, has been conducted till now. future research is recommended to present descriptive outcomes involving the impact of other influencers like comorbid conditions, smoking, and health associated habits that might be a significant cofactor for this cognitive decline other than ageing. conclusion this pilot study revealed a noticeable decline in cognitive performance among older adults as compared to those of the middle-aged or young ones. findings from both of our screening tools mmse and mini-cog, were comparable and suggested that this agerelated cognitive impairment was more pronounced among males as compared to females. other than that, there was also a significant effect of occupational load and educational levels on the cognitive abilities of the study participants. however, a largescale descriptive study is required to confirm this hypothesis and to endorse the use of initial screening of cognitive performance using the mentioned screening tools. acknowledgment the authors would like to acknowledge dr. sadaf ahmed for her assistance and support in designing this study. references 1. nassif aa, el semary mm, abdallah ga, mohamed ra. a comparison of different cognitive screening instruments on early detection of mild cognitive impairments in post-stroke patients. nurs health sci. 2018; 7(3):85-92. 2. harada cn, love mc, triebel kl. normal cognitive aging. clin. geriatr. med. 2013; 29(4):737-752. 3. gaeta l, azzarello j, baldwin j, ciro ca, hudson ma, johnson ce, john ab. effect of 37 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) reduced audibility on mini-mental state examination scores. j am acad audiol. 2019; 30(10):845-855. 4. ghavidel f, salehi fadardi j, sedaghat f, tabibi z. testing older adults for signs of age-related cognitive decline: clock drawing test vs. mini-mental state examination. clin psychol. 2017; 5(2):141-148. 5. mazzi mc, iavarone a, russo g, musella c, milan g, d’anna f, garofalo e, chieffi s, sannino m, illario m, de luca v. mini-mental state examination: new normative values on subjects in southern italy. aging clin exp res. 2019:1-4. 6. crum rm, anthony jc, bassett ss, folstein mf. population-based norms for the minimental state examination by age and educational level. jama. 1993; 269(18):23862391. 7. kelly peterson oo, guerrero r, picard rw. personalized gaussian processes for future prediction of alzheimer’s disease progression. arxiv preprint arxiv:1712.00181. 2017. 8. pinto tc, machado l, bulgacov tm, rodrigues-júnior al, costa ml, ximenes rc, sougey eb. is the montreal cognitive assessment (moca) screening superior to the mini-mental state examination (mmse) in the detection of mild cognitive impairment (mci) and alzheimer’s disease (ad) in the elderly?. int psychogeriatr. 2019; 31(4):491504. 9. morais a, santos s, lebre p. psychomotor, functional, and cognitive profiles in older people with and without dementia: what connections?. dementia. 2019; 18(4):15381553. 10. yao y, liu k, liu z, sato r. the development of electronic medical tools of cognitive ability testing for home use and early detection. in 2018 ieee 7th global conference on consumer electronics (gcce) 2018:118-119. 11. lin js, o’connor e, rossom rc, perdue la, eckstrom e. screening for cognitive impairment in older adults: a systematic review for the us preventive services task force. ann. intern. med. 2013; 159(9):601-612. 12. kvitting as, fällman k, wressle e, marcusson j. age‐normative mmse data for older persons aged 85 to 93 in a longitudinal swedish cohort. j am geriatr soc. 2019; 67(3):534-538. 13. bartos a, raisova m. the mini-mental state examination: czech norms and cut-offs for mild dementia and mild cognitive impairment due to alzheimer's disease. dement geriatr cogn disord. 2016; 42(12):50-57. 14. borson s, scanlan j, brush m, vitaliano p, dokmak a. the mini-cog: a cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly. int j geriatr psychiatry. 2000; 15:1021–1027. 15. borson s, scanlan jm, watanabe j, tu sp, lessig m. improving identification of cognitive impairment in primary care. int. j. geriatr. psychiatry. 2006; 21(4):349-355. 16. shulman ki, herrmann n, brodaty h, chiu h, lawlor b, ritchie k, scanlan jm. ipa survey of brief cognitive screening instruments. int psychogeriatr. 2006; 18: 281– 294. 17. borson s, scanlan jm, chen p, ganguli m. the mini-cog as a screen for dementia: validation in a population-based sample. j am geriatr soc. 2003; 51:1451–1454. 18. mf f. folstein se. mchugh pr. mini-mental state. a practical method for grading the cognitive state of patients for the clinician. j psychiatr res. 1975; 12(3):189-198. 19. cacho j, benito-león j, garcía-garcía r, fernández-calvo b, vicente-villardón jl, mitchell aj. does the combination of the mmse and clock drawing test (mini-clock) improve the detection of mild alzheimer's disease and mild cognitive impairment?. j alzheimers dis. 2010; 22(3):889-896. 20. yang z, slavin mj, sachdev ps. dementia in the oldest old. nat. rev. neurol. 2013; 9(7):382-393. 21. zhao y, tudorascu dl, lopez ol, cohen ad, mathis ca, aizenstein hj, price jc, kuller lh, kamboh mi, dekosky st, klunk we. amyloid β deposition and suspected nonalzheimer pathophysiology and cognitive decline patterns for 12 years in oldest old participants without dementia. jama neurology. 2018; 75(1):88-96. 22. ichii s, nakamura t, kawarabayashi t, takatama m, ohgami t, ihara k, shoji m. cogevo, a cognitive function balancer, is a sensitive and easy psychiatric test battery for age‐related cognitive decline. geriatr gerontol int. 2020; 20(3):248-255. 23. skoog j, backman k, ribbe m, falk h, gudmundsson p, thorvaldsson v, borjesson‐ hanson a, ostling s, johansson b, skoog i. a longitudinal study of the mini‐mental state examination in late nonagenarians and its relationship with dementia, mortality, and 38 app| published by aeirc| volume 7 issue 1 issn 2412-3188 (online) | 2410-1354 (print) education. j am geriatr soc. 2017; 65(6):12961300. 24. vasantharekha r, priyanka hp, swarnalingam t, srinivasan av, thyagarajan s. interrelationship between mini‐mental state examination scores and biochemical parameters in patients with mild cognitive impairment and alzheimer's disease. geriatr gerontol int. 2017; 17(10):1737-1745. 25. milne a, culverwell a, guss r, tuppen j, whelton r. screening for dementia in primary care: a review of the use, efficacy and quality of measures. int psychogeriatr. 2008; 20(5):911–926. 26. li x, dai j, zhao s, liu w, li h. comparison of the value of mini-cog and mmse screening in the rapid identification of chinese outpatients with mild cognitive impairment. medicine. 2018; 97(22): e10966. 27. stout jw, beidel dc, brush d, bowers c. sleep disturbance and cognitive functioning among firefighters. j. health psychol. 2020: article 1359105320909861. 28. liu t, wong gh, luo h, tang jy, xu j, choy jc, lum ty. everyday cognitive functioning and global cognitive performance are differentially associated with physical frailty and chronological age in older chinese men and women. aging ment health. 2018; 22(8):942-947. 86 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v8.i2.2021.86-95 original article the identification of sialuria with different degrees of intellectual disabilities in children and adolescents hina ishtiaq1, sonia siddiqui2, rukhsana nawaz3, muhammad ashraf hussain4, fauzia imtiaz2 & zeba haque2 1department of neuroscience, dr. panjwani center for molecular medicine and drug research, international center for chemical and biological sciences, university of karachi, karachi-pakistan. 2department of biochemistry, dow university of health sciences, karachi-pakistan. 3department of psychology, college of humanities and social sciences, university of uae, al-ain, uae. 4combined military hospital, national university of medical sciences, zhob, baluchistanpakistan. abstract background: single nucleotide polymorphism/mutation in the r263l region of the allosteric site of the gne gene produces a phenotype with an overproduction of intracellular levels of sialic acid and causes sialuria. in sialuria, a defective gne gene, synthesized with lost feedback inhibition mechanism, produces many developmental delays and varying degrees of intellectual disabilities in children and adolescents. several mutations in the epimerase and kinase domains exist that cause difficulty in getting a precise and exact effect of the gne gene on the disease severity and sialic acid levels. this is the first study investigating the molecular basis of neuronal disorders exhibiting sialuria in pakistani children/ adolescents. methodology: the current study quantified the mrna expression of the gne gene and urinary sialic acid concentration by realtime-qrt-pcr and fluorimetric assays, respectively. the correlation between relative mrna and urinary sialic acid levels was evaluated by using pearson bivariate correlations. results: the data show that severely intellectually disabled (i.d.) patients showed significantly reduced mrna expression levels of the gne gene compared to controls. the concentrations of free sialic acid in urine were significantly reduced in severe i.d. patients compared to controls. whereas patients with mild i.d. showed a two-fold increase in sialic acid levels when compared to controls. a significant correlation was found between an increased gne mrna and low urinary sialic acid levels from severe i.d. patients. conclusion: the effect of the gne gene is beyond hyposialylation that could hinder n-glycan structure and sialic acid biosynthesis. the study highlighted the possible involvement of sialic acid levels with different degrees of intellectual disabilities in pakistani children and adolescents. keywords sialuria, intellectual disability, metabolic error. citation: ishtiaq h, siddiqui s, nawaz r, hussain ma, imtiaz f, haque z. the identification of sialuria with different degrees of intellectual disabilities in children and adolescents. app. 2021;8(2):86-95 corresponding author email: siddisbs@yahoo.com doi: 10.29052/2412-3188.v8.i2.2021.86-95 received 06/09/2021 accepted 01/10/2021 published 01/12/2021 copyright © the author(s). 2021 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the authors would like to thank hec (grant no# 1028) and recurring grant, pcmd, for providing financial support. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v8.i2.2021. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 87 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 introduction sialuria, an autosomal dominant disorder found in patients with a defective synthesis of a key enzyme udp-n-acetylglucosamine2-epimerase n-acetylmannosamine kinase (gne) due to the mutation in the r263l region of the gne gene. due to this mutation, the negative feedback inhibition is lost, disrupting sialic acid synthesis in mammals1. in sialuria, an increased overproduction of free sialic acid is found in the cytosol. therefore, patients who exhibit an increased excretion of sialic acid in urine show many difficulties with developmental delays. previously a transgenic mouse line that expresses gne having a mutation in the same region r263l has been shown to produce and excrete 400 times higher rna expression of mutated gne gene than the wild type mice. n-acetylneuraminic acid levels were also higher in the brain cytoplasm with an increased polysialylation of neural cell adhesion molecule (ncam) in transgenic mice than in wild type. however, the same study showed minor differences in membrane-bound sialylation in many organs. in contrast to this, a significantly higher expression of sialylation was observed on the surface of leukocytes. kreuzmann and colleagues (2017) proved that the developmental delays associated with sialuria patient are due to increased intracellular levels of sialic acid that causes polysialylation on ncam1. sialic acids are composed of glycoproteins and glycolipids responsible for important cellular functions, infection, and metastasis. its catabolism is important for a healthy heart and skeletal muscle functions not only in humans but in zebrafish as well2. siblings with sialuria, exercise intolerance/muscle wasting, and cardiac symptoms were reported previously having heterozygous mutations in n-acetylneuraminate pyruvate lyase gene (npl) at [chr1:182775324c>t (c.187c>t; p.arg63cys) and chr1:182772897a>g (c.133a>g; p.asn45asp)]. the effect was observed on sialic acid catabolism and cell-specific reductions in n-acetyl mannosamine (mannac) levels. knockdown npl in zebrafish leads to severe skeletal myopathy and cardiac edema, resembling the human phenotype. however, the phenotype was rescued by expressing wild-type human npl. however, there was no change when p.arg63cys or p.asn45asp mutants were expressed. surprisingly the phenotypes in zebrafish were rescued by feeding catabolic products of npl: n-acetyl glucosamine (glcnac) and mannac2, suggesting monosaccharide replacement therapy for humans. as sialuria regulates neural development, neural regeneration, learning, and memory3,4, any alterations can alter humans' intellectual levels. therefore, in this study, we have investigated the mrna expression levels of the gne gene in blood and sialic acid levels in urine, of the patients with different intellectual disabilities. methodology subject recruitment and ethical approval this study was approved by the human ethics committee of the national institute of child health and rehabilitation center (nich), jinnah postgraduate medical center (jpmc), with the ethic number of hea no. f.2-81/2008-genl/4086/jpmc. parents of every subject were requested to read and understand the consent form before signing. the data was collected from 15th jan to 30th july 2018. overall 102 subjects were used for mrna expression i.e. controls (n=51) and patients (n=51). all subjects were between the ages of 0-17 years (male/females). these subjects were diagnosed according to the diagnostic and statistical manual of mental disorders (dms-iv) and 88 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 international classification of diseases (icd10) criteria and presented in out-patientdepartment (opd) and darul-sukun, karachi, pakistan. expert psychiatrists evaluated all subjects through history and clinical examinations. biochemical analysis of urinary sialic acid the levels of free sialic acid, nacetylneuraminic acid, and urine were measured using the fluorometric sialic acid kit method (biovision's cat # k566-100). fluorescence at ex/em 535/587nm was measured using the molecular device spectramax plus m5e microplate reader. morning urine samples from i.d. subjects having risk for sialuria (10-13 years of age) were analyzed and compared with agematched control samples. serial dilutions of sialic acid standards were performed according to the sialic acid assay kit. urine samples collected from subjects and controls were centrifuged at 3000 rpm for 5 min to remove the metabolites. real-time polymerase chain reaction (rtqpcr) total rna was extracted from whole blood (500 µl) using a whole blood rna purification mini kit (thermo scientific genejet cat# k0761). the quality of extracted rna was determined via a spectrophotometer (260/280 nm). according to the manufacturer's specifications, total rna was transcribed to cdna using revertaid first strand cdna synthesis kit (thermo scientific cat# k1621). the pcr reaction was initiated by an incubation step at 25°c for 5 min, followed by only one cycle of annealing step at 42°c for 60 min with a termination step at 70°c for 5 min. pcr reaction performed with an abi 7500 software v.2.0.6 real-time pcr detection system (applied biosystem inc. usa) using the maxima sybr green/rox qpcr master mix (thermo scientific). the thermal cycler program initiated by an incubating step at 95°c for 10 min, followed by 40 cycles of denaturation step at 95°c for 15 s, annealing step at 55°c for 30 s, extension step at 72°c for 30 s and a final extension at 72°c for 5 min (table 1). no template control (ntc) and reverse transcriptase minus (r.t.-) control along with pcr analysis was conducted in triplicate for each sample. the delta delta ct method used and selected genes' content was normalized to the housekeeping gene (hkg) gapdh. the calculation was performed using the comparative ct method according to the following formulas: δctwt = ctselected gene wt − cthkg wt and δctko= ctselected gene ko − cthkg ko δδct =δctko −δctwt ratio = 2−δδct (maximum efficacy is presumed) table 1: thermal cycling conditions for rt-qpcr. gene primer sequence pcr parameters for thermal cycle gne mrna gapdh 5´ctccgagttgcaatagtcag 3´ (f) catccagagacacaacaagg (r) 5´gcatcctgggctacactgag 3´ (f) 1. initial temperature______95⁰c for 10 min 2. denaturing temperature__95⁰c for 15 sec 3. annealing temperature__55⁰c for 30 sec 4. extension temperature__72⁰c for 30 sec 5. go to repeat cycle _________2, 40 times 89 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 *thermal cycling conditions for rt-qpcr: the table is illustrating thermal cycling conditions for rt-qpcr with gne and gapdh primers. statistical analysis the data obtained in this study were analyzed using curve expert and spss software version 17. differences between the mean values of different groups were identified by applying a student independent t-test. each experiment was repeated three times. the correlation between relative mrna and urinary sialic acid levels was evaluated by using pearson bivariate correlations. p-value <0.05 was considered significant. result quantitative estimation of sialic acid in urine by fluorometric assay free sialic acid (fsa) concentrations (table 2) from mild (0.32 ± 0.17), moderate (0.07 ± 0.03) and severe (0.04 ± 0.01) intellectually disabled (i.d.) subjects were used to plot a bar diagram (figure1). the result illustrates an average two-fold increase in sialic acid levels in mild i.d. subjects. however, the levels were not significant when compared to controls. in contrast, there was a significant decrease in the sialic acid levels found in the severely intellectually disabled subjects compared to controls. fluorometric assay is used to quantify urinary free sialic acid (fsa) levels in id patients. the table depicts no significant differences in sialic acid levels in mild and moderate id. patients. however, there was a two-fold increase in the levels of sialic acid in mild id. and a significant reduction in the free sialic acid levels in severe id patients compared to controls. statistical analysis was revealed by two independent t-test. means values are ± s.d. p<0.05 was considered significant. table 2: fluorometric assay to quantify urinary free sialic acid (fsa) levels. symptom severity age (years) free sialic acid (fsa) concentration in urine µl) p-value (means ± s.d.) controls subjects controls 10-13 mild id 10 0.16±0.13 0.32±0.17 <0.0005 moderate id 11 0.07±0.03 <0.0005 severe id 13 0.04±0.007 <0.0005 5´ttgccctcaacgaccacttt 3´ (r) 6. final extension temperature___72⁰c for 5 min 7. hold on _________________ 4⁰c forever 90 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 figure 1: sialic acid levels in the urine controls and patients from pakistan. the bar diagram shows the comparison of sialic acid levels among controls and id patients. a significant difference was observed in patients with severe id. significant differences were evaluated by a two-tailed t-test (*p< 0.0005). gne mrna expression levels the gne gene expression in subjects with severe id and controls was quantified concerning the housekeeping gene gapdh. the results show a significant down-regulation in the expression of gne gene levels in subjects with severe (p<0.003) id when compared to controls (figure 2). figure 2: relative expression levels of the gne gene by real-time quantitative pcr. bar graph representing the fold changes of gne mrna levels quantified by normalization to the gapdh as an internal control. mild, moderate, and severe id. patients showed down-regulation in the gne gene expression compared to controls. however, mild and moderate id. patients showed 2and 0.5-fold up-regulation compared to severe id. patients, respectively. 91 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 significant differences were evaluated by an independent t-test (**p< 0.01, ***p<0.003). significant correlation was found between gne mrna and sialic acid levels of severe id patients (0.048 ± 0.0076) (p= 0.021). discussion previously we have identified g/a substitution (r263q) mutations in snp: rs121908623 of the gne gene in the pakistani population5. as sialuria is a very rare disorder, up till now, only 10 ten patients have been reported worldwide. the first patient was identified in 1968 by (a), and the tenth patient was identified by ishtiaq and colleagues (2020). in all of the patients, the symptoms were similar such as jaundice, low birth weight, coarse facies, hepatomegaly, seizures; however, they had normal birth and delivery5. besides this, the neurological symptoms included speech and motor impairments. all these patients had mutations in the gne gene at g→t: 849, g→a:848, g→t:839, g→a:839, g→c:250, t→c:51+34 positions6-15. recent works on sialuria presented a link between intellectual disability with low household income, low maternal education, and consanguinity marriages16. sialic acids are negatively charged amino sugars and are added to many glycoproteins during posttranslational modifications of proteins. due to this, they actively participate in biological molecular interactions17. structural data of gne/mnk homolog have developed by kurochkina, yardeni, and huizing (2010) that exposes critical substrate binding sites on the enzyme18. this model helps explain the effects of missense mutations associated with hibm or sialuria on enzyme actions, helix arrangement, and substrate binding. they confirmed that all reported mutations so far are, in fact, due to the mutations in the active site or secondary interfaces of the gne/mnk enzyme. it was reported that a persian-jewish hibm has mutation p.m12t at the interface of alpha4 alpha10 that affected glcnac, mg+2, atp binding. structural data helps develop the therapeutic options that target the misfolding of gne/mnk in hibm or sialuria18. in this study, a few experiments were carried out separately to determine the sialic acid levels in urine and gne mrna expression levels in the blood of different subtypes of i.d. subjects. the data show a significant increase in urinary sialic acid in mild i.d. subjects and reduced gne gene expression in severe i.d. subjects. it has been reported previously that patients with sialuria tend to excrete more s.a. in urine than controls. it has been shown that the levels range from 10 to 30 folds is associated with several inborn errors of metabolic diseases such as salla disease, sialidosis, issd, and neuraminidase deficiency5, 6, 19, 20. in sialuria, free sialic acid levels can be elevated up to 70 to 200 folds7, 8, 21, 22. an earlier study reported a sixth subject of sialuria with mild developmental impairment showing an increased level of sialic acid in his urine. this is consistent with the current study that showed an increased sialic acid level in the urine. subjects with mild intellectual disability exhibiting a 2fold increase in free sialic acid levels than controls proved that mild phenotype of intellectual disability might be associated with sialuria. moreover, data on the singlefamily also showed about 10-fold increased sialic acid levels in urine; however, the reductions in free sialic acid levels in subjects with severe intellectual disability showed that severe i.d. might not be linked with sialuria disease in pakistani children and adolescents. for confirmation, we analyzed and compared the expression pattern of the gne gene in controls and severe id children and adolescents of pakistan. all subjects with severe id showed down-regulation when 92 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 compared to controls. in earlier studies, subjects with mild impairments showed high expression of the gne gene in their different tissue organs10. in contrast, when we analyzed the expression levels of gne in subjects with severe i.d. who were suffering from severe developmental delay, our results show significantly low expression levels in these subjects, suggesting no association of sialuria with severe mental illnesses. nevertheless, only gne mrna and urinary sialic acid levels from severe i.d. patients have shown a significant correlation. this means an increased gne mrna expression levels positively influence the low excretion of sialic acid levels in urine. as silauria is known to cause an accumulation and urinary excretion of neu5ac sialuria, it differs from sialdoses, characterized as a defect in the storage and excretion of bound neu5ac from the body. the same gne gene is involved in causing nonaka myopathy (nk; mim:605820) as well, besides sialuria and sialdoses. in nonaka myopathy, muscle wasting and weakness of the distal and anterior tibial muscles takes place23,24. several mutations in the gne gene in epimerase and kinases domains alter the enzymatic activity in a very minute and precise way. it is very difficult to describe and identify the actual effect. consequently, sometimes, the activity of the enzyme did not correlate with the severity of the disease 25-29. the predominant function of gne is to regulate the sialylation of cell surface glycoproteins and glycolipids12-15. however, the correlation between hyposialylation and the severity of the disease is inadequate because many human patients suffering from gne myopathy have sialic acid levels not much different from the controls. this is the main reason why a poor correlation exists between sialic acid levels and symptom severity. these results were also seen in animal models with d176v mutation in gne gene 30. the symptoms in patients and mutant mice show normal and early birth but develop muscle weakness as they age, which can be relieved by providing them sialic acid or mannac. nevertheless, the sialic acid levels in animals remained low than in control animals31. they suggested a lack of correlation between the severity of the disease and the sialic acid levels, emphasizing that gne gene mutation has effects beyond hyposialylation. the mutation can affect the n-glycan structure by changing the sialic acid biosynthesis and flux udp-glcnac levels via hexosamine biosynthetic pathway32,33. our results propose that early effective avoidance from severe cognitive disabilities will obtain better information and averting the risk factors such as low birth weight, hypoxia, poverty, and serious diseases. conclusion the urine analysis of sialic acid showed a significant reduction in severe mental retarded samples. there was an ave rage two-fold increase in the urinary sialic acid levels in mild i.d. subjects compared to controls. results from rt-qpcr showed a significant reduction in the i.d. mrna expression of the gne gene in mild, moderate, and severe i.d. subjects. there was a fivefold up-regulation of gne gene expression in mild i.d. subjects compared to severe i.d. subjects. only gne mrna and urinary sialic acid levels from severe i.d. patients showed a significant correlation. thus data suggest that mild i.d. might be associated with sialuria in pakistani children and adolescents. therefore, intellectually disabled subjects and their immediate family members must be monitored for the polymorphisms in codons 263 to 266 of the gne gene. 93 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 acknowledgment the authors would like to thank dr. deepak kumar for helping in getting the ethics approval, dr. atif anjum from national institute of child health, jinnah postgraduate medical center, karachi, nasreen jumani, principal, govt. girls higher secondary school and mr. tariq samuel and mr. yasir khursheed from darul-sukoon, karachi, for providing the samples. references 1. kreuzmann d, horstkorte r, kohla g, kannicht c, bennmann d, thate a, bork k. increased polysialylation of the neural cell adhesion molecule in a transgenic mouse model of sialuria. chembiochem. 2017;18(13):1188-1193. 2. wen xy, tarailo-graovac m, brandarzamendi k, willems a, rakic b, huijben k, da silva a, pan x, el-rass s, ng r, selby k. sialic acid catabolism by n-acetylneuraminate pyruvate lyase is essential for muscle function. jci insight. 2018;3(24). 3. bonfanti l. psa-ncam in mammalian structural plasticity and neurogenesis. progress in neurobiology. 2006;80(3):129164. 4. rutishauser u. polysialic acid in the plasticity of the developing and adult vertebrate nervous system. nat rev neurosci. 2008;9(1):26-35. 5. ishtiaq h, siddiqui s, nawaz r, jamali ks, khan ag. sialuria-related intellectual disability in children and adolescent of pakistan: tenth patient described has a novel mutation in the gne gene. cns neurolog dis drug targets. 2020;19(2):127-41. 6. fontaine g, biserte g, montreuil j, dupont a, farriaux jp. la sialurie: un trouble métabolique original? helv paediatr acta suppl. 1968;17:1-32. 7. wilcken b, don n, greenaway r, hammond j, sosula l. sialuria: a second case. j inherit metab dis. 1987;10(2):97102. 8. seppala r, lehto vp, gahl wa. mutations in the human udp-nacetylglucosamine 2-epimerase gene define the disease sialuria and the allosteric site of the enzyme. am j hum genet. 1999;64(6):1563-1569. 9. krasnewich dm, tietze fr, krause wi, pretzlaff r, wenger da, diwadkar v, gahl wa. clinical and biochemical studies in an american child with sialuria. j biochem med metab biol. 1993;49(1):90-96. 10. ferreira h, seppala r, pinto r, huizing m, martins e, braga ac, gomes l, krasnewich dm, miranda mc, gahl wa. sialuria in a portuguese girl: clinical, biochemical, and molecular characteristics. mol genet metab. 1999;67(2):131-137. 11. leroy jg, dacremont g, desimpel h, van coster r. sialuria (french type): new observation of this rare disorder. am j hum genet. 1998;63:a269. 12. penner j, mantey lr, elgavish s, ghaderi d, cirak s, berger m, krause s, lucka l, voit t, mitrani-rosenbaum s, hinderlich s. influence of udp-glcnac 2-epimerase/mannac kinase mutant proteins on hereditary inclusion body myopathy. biochem. 2006;45(9):29682977. 13. huizing m, rakocevic g, sparks se, mamali i, shatunov a, goldfarb l, krasnewich d, gahl wa, dalakas mc. hypoglycosylation of α-dystroglycan in patients with hereditary ibm due to gne mutations. mol genet metab. 2004;81(3):196-202. 14. ricci e, broccolini a, gidaro t, morosetti r, gliubizzi c, frusciante r, di lella gm, tonali pa, mirabella m. ncam is hyposialylated in hereditary inclusion 94 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 body myopathy due to gne mutations. neurology. 2006;66(5):755-758. 15. noguchi s, keira y, murayama k, ogawa m, fujita m, kawahara g, oya y, imazawa m, goto yi, hayashi yk, nonaka i. reduction of udp-nacetylglucosamine 2-epimerase/nacetylmannosamine kinase activity and sialylation in distal myopathy with rimmed vacuoles. jbc. 2004;279(12):11402-11407. 16. bhatti a, ashfaq g. frequency of chromosomal anomalies in mentally handicapped children. pak j med res. 2008;47(1):47-59. 17. weidemann w, hering j, bennmann d, thate a, horstkorte r. the key enzyme of the sialic acid metabolism is involved in embryoid body formation and expression of marker genes of germ layer formation. int j mol sci. 2013;14(10):20555-20563. 18. weidemann w, hering j, bennmann d, thate a, horstkorte r. the key enzyme of the sialic acid metabolism is involved in embryoid body formation and expression of marker genes of germ layer formation. int j mol sci. 2013;14(10):20555-20563. 19. sewell ac, poets cf, degen i, stöß h, pontz bf. the spectrum of free neuraminic acid storage disease in childhood: clinical, morphological and biochemical observations in three non‐ finnish patients. am j med genet. 1996;63(1):203-208. 20. mancini gm, verheijen fw, beerens ce, renlund m, aula p. sialic acid storage disorders: observations on clinical and biochemical variation. dev neurosci. 1991;13(4-5):327-330. 21. seppala r, tietze f, krasnewich d, weiss p, ashwell g, barsh g, thomas gh, packman s, gahl wa. sialic acid metabolism in sialuria fibroblasts. j biol chem. 1991;266(12):7456-7461. 22. krasnewich dm, tietze fr, krause wi, pretzlaff r, wenger da, diwadkar v, gahl wa. clinical and biochemical studies in an american child with sialuria. j biochem med metab biol. 1993;49(1):90-96. 23. leroy jg, seppala r, huizing m, dacremont g, de simpel h, van coster rn, orvisky e, krasnewich dm, gahl wa . dominant inheritance of sialuria, an inborn error of feedback inhibition. am j hum genet. 2001;68(6):1419-1427. 24. nonaka i, sunohara n, ishiura s, satoyoshi e. familial distal myopathy with rimmed vacuole and lamellar (myeloid) body formation. j neurol sci. 1981;51(1):141-155. 25. asaka t, ikeuchi k, okino s, takizawa y, satake r, nitta e, komai k, endo k, higuchi s, oyake t, yoshimura t. homozygosity and linkage disequilibrium mapping of autosomal recessive distal myopathy (nonaka distal myopathy). j human genetics. 2001;46(11):649-655. 26. celeste fv, vilboux t, ciccone c, de dios jk, malicdan mc, leoyklang p, mckew jc, gahl wa, carrillo‐carrasco n, huizing m. mutation update for gne gene variants associated with gne myopathy. human mutation. 2014;35(8):915-26. 27. nishino i, carrillo-carrasco n, argov z. gne myopathy: current update and future therapy. j neurol neurosurg psychiatry. 2015;86(4):385-392. 28. hinderlich s, salama i, eisenberg i, potikha t, mantey lr, yarema kj, horstkorte r, argov z, sadeh m, reutter w, mitrani-rosenbaum s. the homozygous m712t mutation of udpn-acetylglucosamine 2-epimerase/nacetylmannosamine kinase results in reduced enzyme activities but not in altered overall cellular sialylation in hereditary inclusion body myopathy. febs letters. 2004;566(1-3):105-109. 95 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 29. salama i, hinderlich s, shlomai z, eisenberg i, krause s, yarema k, argov z, lochmuller h, reutter w, dabby r, sadeh m. no overall hyposialylation in hereditary inclusion body myopathy myoblasts carrying the homozygous m712t gne mutation. biochem biophys res commun. 2005;328(1):221-226. 30. saito f, tomimitsu h, arai k, nakai s, kanda t, shimizu t, mizusawa h, matsumura k. a japanese patient with distal myopathy with rimmed vacuoles: missense mutations in the epimerase domain of the udp-nacetylglucosamine 2-epimerase/nacetylmannosamine kinase (gne) gene accompanied by hyposialylation of skeletal muscle glycoproteins. neuromuscul disord. 2004;14(2):158161. 31. malicdan mc, noguchi s, nonaka i, hayashi yk, nishino i. a gne knockout mouse expressing human gne d176v mutation develops features similar to distal myopathy with rimmed vacuoles or hereditary inclusion body myopathy. hum mol genet. 2007;16(22):2669-2682. 32. malicdan mc, noguchi s, hayashi yk, nonaka i, nishino i. prophylactic treatment with sialic acid metabolites precludes the development of the myopathic phenotype in the dmrvhibm mouse model. nature med. 2009;15(6):690-695. 33. lau ks, partridge ea, grigorian a, silvescu ci, reinhold vn, demetriou m, dennis jw. complex n-glycan number and degree of branching cooperate to regulate cell proliferation and differentiation. cell. 2007;129(1):123-34. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v8.i2.2022.86-95 51 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v9.i1.2022.51-55 review article review of heart rate variability biofeedback: intervention to relieve stress s. farah batool1 & basit ansari2 1department of psychology, malir university of science and technology, karachi-pakistan. 2department of health, physical education & sports sciences, university of karachi, karachi-pakistan. abstract depression is prevailing and captivating millions of individuals across the globe. there are numerous stressors and triggers that can induce depressive symptoms or anxiety in individuals of all ages. this exponential growth in depressed and distressed members of society may lead to a massive loss of productive individuals. it is a general practice to prescribe drugs to treat such psychological concerns, but acquiring these medications frequently may affect the body's metabolism. alternative interventions that can replace or minimize the use of drugs are needed. heart rate variability biofeedback (hrvb) is a practical approach to treating stress and depression. this article intends to represent an overview of hrvb, its effectiveness, and its side effects so that it can be compared to the medications prescribed. keywords heart rate variability, biofeedback, stress, depression. citation: batool s f, ansari b. review of heart rate variability biofeedback: intervention to relieve stress. app. 2022; 9(1): 51-55 corresponding author email: farahbatool97@gmail.com doi: 10.29052/2412-3188.v9.i1.2022.51-55 received 25/03/2022 accepted 10/05/2022 published 01/06/2022 copyright © the author(s). 2022. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v9.i1.2022.51 https://orcid.org/0000-0002-1344-6795 https://orcid.org/0000-0003-3919-2516 about:blank about:blank 52 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 introduction world health organization has stated that depression is among the most prevalent psychological concern, afflicting around 265 million individuals of different age groups worldwide1. mood disorder, decreased interest, sleep disruption, diminished desire to eat, decelerated thinking, and dearth of vitality have all been regarded as possible factors associated with the onset and tenacity of many other illnesses: people experiencing depression seem to be more likely to have addiction issues, personality issues, or other psychiatric conditions like distress, and anxious behavior2,3. people with chronic illnesses were more likely to exhibit comorbidities with depression, according to a global study involving 245,404 persons from 60 nations4. furthermore, depressed symptoms are frequently linked to poor health outcomes and resistance to drugs and therapies. they are frequently coexisting with severe health concerns such as type 2 diabetes, absenteeism, and senile dementia57. anxiety and depression are also linked to an increased risk of heart problems. people with cardiovascular disorders are likelier to have concomitant depression 8-10. heart rate variability (hrv), an assessment of the change in the time between every pulse, is a critical sign of the function of the autonomous nervous system and a powerful determinant of clinical incidence and death. higher variability shows the autonomic nervous system's capacity for selfregulation. because more serious complications are strongly related to decreased hrv and decreased hrv itself appears to be associated with the likelihood of incidence of depression, this measure could be employed as a prognostic and predictive biomarker of distress and anxiety11-13. hrv research led to the development of hrv biofeedback (hrvb), a non-invasive therapeutic method aimed at enhancing heart rate oscillations through real-time feedback and slow breathing exercises13. this approach was formulated to solve difficulties with hrv regulation discovered while treating depression. prior studies have shown that hrvb enhances hrv as evaluated by sdnn (the standard deviation of nn intervals), high-frequency power (hf), and the low-frequency power/highfrequency power ratio (lf/hf). each of these biological markers has been linked to reduced depressed symptoms14. heart rate variability biofeedback (hrvb) has received much attention in recent decades for treating various diseases and enhancing productivity. because asthmatic and digestive problems appear to adapt to this type of cardio-respiratory feedback exercise, the question of plausible causes becomes more pertinent. the most widely accepted way is that the homeostasis of the baroreceptor is strengthened15. in the 1990s, researchers experimented with a type of cardio-respiratory therapy known as hrvb. hrv has a complicated structure that is sometimes considered "unstable," containing multiple overlapping oscillation frequencies that are non-linearly connected. some of the activities in this pattern are triggered by pre-defined reflexes, while others have a modulatory function and are influenced by other autonomic pathways16. negative feedback loops help preserve allostatic stability while permitting sensitivity to external needs. the magnitude of heart rate oscillations increases to several times at rest during hrv biofeedback, while the waveform becomes simple and sinusoidal. this trend is observed in practically everybody and is often achieved 53 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 in a brief moment, even in those who have never been subjected to the procedure before15,16. hrvb has been shown in multiple studies to reduce physical and psychological symptoms while enhancing wellbeing17. in an arbitrary meta-analysis investigating the efficacy of hrvb on psychological distress symptoms, goessl et al.18. discovered that hrvb is a beneficial and effective strategy for reducing anxiety and stress. lehrer et al. published a systematic and meta-analytic review on the effectiveness of hrvb and/or paced breathing on a variety of psychological signs and symptoms, cognitive functioning, and intricate behavioral patterns. hrvb and timed breathing had a minor but substantial influence on depression, according to the researchers19. factors related to hrv respiratory sinus arrhythmia respiratory sinus arrhythmia (rsa) is a change in heart rate (hr) due to ventilation, with hr rising while inspiration and falling with expiration. it plays a key role in managing to breathe, ensuring that the volume of blood going to the lungs is maximal when the lungs have the most oxygen. this link is critical for respiratory illness and physical and psychological performance that necessitates more oxygen to the working body and brain. gaseous exchange efficiency is highest when ventilation and heart rate oscillations are completely in synchrony20. the neuronal control of rsa seems to be another significant component of psychological concerns and neuroscience. the vagus nerve mediates this neuronal control, a key autonomic nerve activated during tranquil and relaxing times and inhibited during stressful times. the magnitude of peak-to-trough heart rate fluctuations that occur with every breath can be used to calculate the quantity of rsa. healthy people have a higher range of changes (in beats per minute) than individuals suffering from diseases. young people have a better amplitude of changes, and those with optimal aerobic capacity have a larger amplitude of changes. it is lower in stress, wrath, and despair, as well as a variety of physical illnesses, from cardiovascular disease to infections20. the baroreflex the baroreflex is another modulatory reflex strongly enhanced by hrvb (br). the br establishes the circumstances for resonant consequences of breathing which result in substantial rsa variations. it perceives blood pressure fluctuations using stretch receptors in the carotid artery and aorta. when baroreceptors detect a rise in bp, the brs trigger an immediate decline in hr, followed by a physical decline in bp due to less blood flows through the vascular system21. why hrv biofeedback? hrvb promotes a variety of homeostatic 'negative feedback loops' explicitly. because hrvb stimulates both the baroreflex and the rsa, as well as increases parasympathetic activity, there is the possibility that hrvb will help with emotional control. there are grounds to assume that hrvb enhances gaseous exchange capabilities that help manage respiratory disease and other breathing problems due to the obvious inphase interaction between breathing and heart rate. there are grounds to think it helps manage blood pressure as it activates the br. it's possible that stimulating the vagus nerve will result in the sense of calm and wellbeing19,22. the bolstering of conceptual and physiological underpinnings over the past few years has helped clarify the connections between the brain and the heart that claude bernard proposed over 150 years ago. 54 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 autonomic regulation of the circulatory system and cerebral arousal interact with one another. therefore, changing one will impact the other, which could last for a while23. more recently, advantages have been observed in patients with acute stress disorder, urging those under stress to employ hrv-bfb training to enhance their health, well-being, or competence. the effectiveness of hrvb with wearable technology on self-reported stress is confirmed by a recent meta-analysis from goessl et al.24. however, due to a dearth of studies in this area, only eight studies examined signs of stress as an end parameter for healthy persons. in their evaluation of the effectiveness of general biofeedback training on psychophysiological outcomes of stress, de witte et al.25 underline the need for additional research that takes into account both psychological and physiological characteristics of stress. it is worth noting that hrv biofeedback is not a measurement tool to observe breathing rate. rather it is an intervention in which the subject learns to control and optimize breathing patterns and heart rate variability26. possible side effects of hrv biofeedback hrvb's distinctive effects have piqued interest, maybe as a result of these impacts. each year, the number of hrvb research published has increased significantly. it's crucial to explain hrvb's potential negative effects. in most cases, these are minor quibbles. when people initially start slow breathing, it's usual for them to hyperventilate slightly as the increased depth of breathing adapts to the slower speed. the apprentice is especially told to inhale at a low pace in the conventional protocol, particularly in response to drowsiness symptoms, which are frequently the first hyperventilation symptoms to appear. another potential negative effect arises in those who have recurrent cardiac arrhythmias19. conclusion alternate medicine is a futuristic approach, and it is for the benefit of mankind. we, as living beings, are vulnerable to psychosocial stresses and other linked comorbidities. and prefer taking medications for all the issues and concerns. heart rate variability is a great alternative and an effective intervention to cope with stress and depressive symptoms. trained and certified clinical professionals are needed to turn the tables upside down. acknowledgment i am grateful for the encouragement and guidance by my mentors and teachers. also i would like to acknowledge all the authors whose work i cited. references 1. world health organization. depression and other common mental disorders global health estimates (who, 2017). 2. hasin, d. s. et al. epidemiology of adult dsm-5 major depressive disorder and its specifiers in the united states. jama psychiatry. 2018;75(4):336–346. 3. penninx, b. w. j. h., milaneschi, y., lamers, f. & vogelzangs, n. understanding the somatic consequences of depression: biological mechanisms and the role of depression symptom profile. bmc med. 2013;11(1):1-4. 4. moussavi, s. et al. depression, chronic diseases, and decrements in health: results from the world health surveys. lancet. 2017;370(9590):851–858. 5. correll, c. u. et al. prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large-scale meta-analysis of 3,211,768 patients and 113,383,368 controls. world psychiatry. 2017;16(2):163–180. 55 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 6. kang, h.-j. et al. comorbidity of depression with physical disorders: research and clinical implications. chonnam med. j. 2015;51(1):8–18. 7. caldwell, y. t. & steffen, p. r. adding hrv biofeedback to psychotherapy increases heart rate variability and improves the treatment of major depressive disorder. int. j. psychophysiol. 2018;131:96–101. 8. hartmann, r., schmidt, f. m., sander, c. & hegerl, u. heart rate variability as indicator of clinical state in depression. front. psychiatry. 2019;9:735. 9. dell’acqua, c., dal bò, e., messerotti benvenuti, s. & palomba, d. reduced heart rate variability is associated with vulnerability to depression. j. affect. disord. rep. 2020;1. 10. lehrer, p. m. & gevirtz, r. heart rate variability biofeedback: how and why does it work? front. psychol. 2014;5:756. 11. lin, i. m. et al. heart rate variability biofeedback increased autonomic activation and improved symptoms of depression and insomnia among patients with major depression disorder. clin. psychopharmacol. neurosci. 2019;17(2):222. 12. drury, r. l., porges, s. w., thayer, j. f. & ginsberg, j. editorial: heart rate variability, health and well-being: a systems perspective. front pub health. 2019;7:323. 13. 13. gevirtz r. the promise of heart rate variability biofeedback: evidence-based applications. biofeedback. 2013;41:110–120 14. pizzoli, s.f.m., marzorati, c., gatti, d. et al. a meta-analysis on heart rate variability biofeedback and depressive symptoms. sci rep. 2021;11,:6650. 15. ivanov p. c., amaral l. a., goldberger a. l., havlin s., rosenblum m. g., struzik z. r., et al. multifractality in human heartbeat dynamics. nature. 1999;399:461–465 16. lehrer p., eddie d. dynamic processes in regulation and some implications for biofeedback and biobehavioral interventions. appl. psychophysiol. biofeedback. 2013:38:143–155 17. criswell sr, sherman r, krippner s. cognitive behavioral therapy with heart rate variability biofeedback for adults with persistent noncombat-related posttraumatic stress disorder. perm. j. 2018;22. 18. goessl, v. c., curtiss, j. e. & hofmann, s. g. the effect of heart rate variability biofeedback training on stress and anxiety: a meta-analysis. psychol. med. 2017;47(15):2578–2586. 19. lehrer, p. et al. heart rate variability biofeedback improves emotional and physical health an performance: a systematic review and meta analysis. appl. psychophysiol. 2020;45:109–129. 20. yasuma, f., & hayano, j.-i. respiratory sinus arrhythmia: why does the heartbeat synchronize with respiratory rhythm? chest. 2004;125(2):683–690. 21. patriquin, m. a., hartwig, e. m., friedman, b. h., porges, s. w., & scarpa, a. autonomic response in autism spectrum disorder: relationship to social and cognitive functioning. bio psycho. 2019;145:185–197. 22. mather, m., & thayer, j. how heart rate variability afects emotion regulation brain networks. curr opin behav sci. 2018;19:98– 104. 23. deschodt-arsac v, lalanne r, spiluttini b, bertin c, arsac lm. effects of heart rate variability biofeedback training in athletes exposed to stress of university examinations. plos one. 2018;13(7):e0201388. 24. goessl vc, curtiss je, hofmann sg. the effect of heart rate variability biofeedback training on stress and anxiety: a metaanalysis. psycho med. 2017;47(15):2578-86. 25. de witte naj, buyck i, van daele t. combining biofeedback with stress management interventions: a systematic review of physiological and psychological effects. applied psychophysiology and biofeedback. 2019;44(2):71–82. 26. kohlenberg s. resonance frequency assessment: the impact and implications of inaccurate assessment in the clinical use of heart rate variability biofeedback. biofeedback. 2021;49(2):38–41. about:blank annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 sonya arshad 38 original article doi: 10.29052/2412-3188.v5.i1.2018.38-46 social media addiction is a new smoking sonya arshad, muhammad faisal qureshi, syed hasan abbas rizvi, bakhtawar ferozali, sidra abdul majeed, summaya khan & haziq ajaz liaquat national school of physiotherapy corresponding author email: sonya.arshad@lnh.edu.pk received 14/06/2018; accepted 17/09/2018; published 10/10/2018 abstract background: addiction is the behavior of a human in which they depend fully on the substance. according to the world health organization (who) 2015, over 1.1 billion people smoked tobacco whereas; over 2.14 billion people used social networks. the objective of this study is to assess that is there any similarity between the addiction level of smoking and social network usage. methodology: this is a cross-sectional study in which 80 participants were selected on a convenience based sampling of age 18-25 which were divided into group a (social media users) and group b (smokers). inclusion criteria for group a were social network user since 5 years with user i.ds on more than 2 social network sites and check notifications every minute however group b includes smokers who were smoking since last 5 years (1 packet per day) with no known co-morbid. all participants were asked to fill the questionnaire constructed on the basis of the bergen addiction scale (bas). blood pressure measurement and time required to complete the cognitive task was also recorded. data analysis was done using spss version 21. result: results showed 30% mild addictors, 30% moderate addictors and 40% severe addictors in group a while 40%, 22.5% and 37.5% in group b, respectively. according to mean withdrawal effects on cognitive skills, 97.6% participants in group a were able to complete task within assigned time before cessation and after cessation only 57% participants were able to do so, while in group b 94% were able to complete task before cessation and only 72% of participants were able to do so after cessation. lastly, the mean bp reading checked in group a before cessation was 114.54/82.34mmhg and after cessation, it increased to 122.47/90.34mmhg whereas in group b, before cessation the mean bp reading was 118.32/84.88mmhg and after cessation it was 121.42/88.63mmhg. conclusion: it is concluded that the addiction status of social media users and smokers is almost similar. this leads to the outcome that social network abuse is as harmful as smoking on focus, concentration, cognitive skills and increment of anxiety and bp. keywords social media, addiction, cognitive skills, bergen addiction scale introduction according to the american society of addiction medicine, addiction is a chief, chronic illness of brain incentive, stimulus, reminiscence and related circuitry (kirik et al., 2015). a malfunction in these circuits contributes to typical biological, psychological, social and spiritual symptoms. this is seen in a human being pathologically desiring remuneration and/or satisfaction by substance use and other behaviors like the use of social media. addiction is represented by failure to persistently refrain, deterioration in behavior management, lust, abate awareness of considerable troubles with one’s actions and communal relationships, and a debilitated emotional acknowledgment. as other chronic disorders, addiction can also implicate periods of relapse and remission. addiction can be progressive and can result in http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 sonya arshad 39 disability if an individual is not treated or involve in recovery activities. it is necessary to mention internet addiction prior to elaborate social media obsession. the internet is not a cause of addiction by its own. addiction is distinct as the extreme use of the internet that it starts to spoil day by day, societal and working life (kirik et al., 2015). with the evolution of being a knowledge-based civilization, the practice of using the internet has to turn out to be an exceptional element these days. today the internet tradition has taken a peculiar aspect. the progression that initiates with connection then gradually drifts into an addiction (cam & isbulan, 2012). according to a study, excessive use of facebook leads to poor impulse control as well as emotional regulation. the bunch of demands of social networks on the internet could possibly be a source for worry, mainly when people attempt to waste their time online (kuss& griffiths, 2011). people are usually involved in diverse activities via the internet and social media that can probably be addictive. instead of becoming addicted to the means as such that is the internet itself, some of them may build up an addiction to explicit activities they perform online. researchers believed that facebook can cause addiction-like syndrome. they have also proved that social networking has the quality of real addictions and heavy use of it can add different types of addiction (kuss & griffiths, 2011). a report verified that youth with substance abuse troubles have additional rigorous psychiatric symptoms. like substance abuse, internet addiction has been reported to be linked with depression and attentiondeficit–hyperactivity disorder (adhd) (yoo et al., 2004). moreover, intense use of the internet has more brutal psychopathology on the symptoms. it is evident from previous literature that the changes in brain structure as revealed by mri are caused by substance abuse and excessive use of social media (yen et al., 2008). drug addiction is neuroadaptation within the brain reward system throughout the progress of addiction, and one ought to recognize the neurobiological basis for acute drug reward to know how the reward systems alter with the growing addiction. activation of the circuit related to the genesis and terminal of the mesocorticolimbic dopamine system occurs due to constructive reinforcing effects of drugs dependency. the same circuit develops in the progression of social media dependency (koob & le moal, 2008). according to a study, brain anatomy inflection in the grey matter of brain regions, which are possibly connected with social networking addiction and are recumbent to anatomical changes. these variations are supposed to occur in central and essential regions of the dual-system which manages behavior, the lacking of which is due to addictions. the regions include the nucleus accumbens (nac), the amygdala, the midcingulate cortex (mcc) (he et al., 2017). observations based on the number of people addicted to social networking, discussions regarding the best solution to this upgrading problem of society, were made by psychologists and therapists. to sort out social network addiction of people, some remedies were observed which reveals that people of social addictors should be involved in other physical activities like daily exercises, gatherings with their mates and people whom they like and trust, interacting with people not through social network but in real (kuss & griffiths, 2011). the therapist suggested cbt that is cognitive behavioral therapy. in this therapy, patients have group interaction with psychologists and therapists to how to improve their daily lives (kuss & griffiths, 2011). http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 sonya arshad 40 the main motive of this study is to get people to know that even though if they don't realize that they are addicted to social networking, they are addicted to this kind of drug in actual. the aim of this study was to compare the addiction level by using bergen addiction scale (bas), blood pressure reading and completion of cognitive tasks in assigned time before and after cessation of the type of addiction in people of social networking users and smokers. methodology this cross-sectional study had a total of 80 participants with age between 18-25 years recruited randomly on convenience based sampling from lnh. the participants were divided into two groups (i.e. 40 participants per group), group a (social media) and group b (smokers). all participants in group a were the social network user since 5 years, accounts on more than two social network sites, check notifications in every 1 minute. while those who were smokers since 5 years and those with no known comorbid were included in group b. before the start of the study procedure, consent was taken from participants. data was collected by means of a structured questionnaire based on bas (andreassen et al., 2012). blood pressure reading and time is taken by the participant to complete cognitive tasks were also recorded, before and after cessation of at least 3 hours of individuals’ type of addiction. additionally, both groups were further divided into mild, moderate and severe addictors according to their answers to the questionnaire. furthermore, mean withdrawal effects on blood pressure reading and cognitive skills were also calculated. the collected data was then analyzed using spss version 21. bar graphs and tables were used to show the comparison between the percentage of the population of both the groups related to addiction to social network and the similarity between the addiction levels of both groups. result significant results were surmised from the collected data as both the groups showed almost similar extent of addiction. responses of social network addictors on the designed questionnaire showed a 100% positive response for question no.1, 92.5% reported the daily use of social network sites, 60% agreed that their work performance was suffered due to social networking (table 1). http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 sonya arshad 41 table 1: shows the results of the questionnaire designed for group a based on questions related to social media addiction according to bergen addiction scale. group b results revealed that 70% found it difficult not to smoke in non-smoking areas; question no.3 showed 77.5% that they will still smoke when they get ill and 82.5% showed a positive response that their work was influenced by smoking (table 2). table 2: shows the results of a questionnaire designed for group b was based on questions related to drug abuse and smoking according to bergen addiction scale. questions related to social media addiction yes n(%) no n(%) present on any social network. 40 (100%) 0 present on any other social network site rather than facebook and twitter. 37(92.5%) 3(7.5%) use of social media on daily basis. 37(92.5%) 3(7.5%) complain from parents or spouse about involvement with social network. 19(47.5%) 21(52.5%) fights under the influence of social network. 16(40%) 24(60%) work performance and productivity suffer due to internet. 24(60%) 16(40%) how much anticipating when you go on-line again. 27(67.5%) 13(32.5%) life without internet would be boring, empty and joyless. 33(82.5%) 7(17.5%) become defensive or secretive when anyone asks about what you do on-line. 15(37.5%) 25(62.5%) lose sleep due to late night log-ins. 20(50%) 20(50%) http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 sonya arshad 42 figure 1: mean comparison between addiction status of social media users and smokers according to bergen addiction scale (bas). 0% 5% 10% 15% 20% 25% 30% 35% 40% mild addictors moderate addictors severe addictors 30% 30% 40% 40% 22.5% 37.5% p e rc e n ta ge s social network users smokers questions related to drug abuse and smoking yes n(%) no n(%) difficulty smoking in place like cinemas, buses or restaurants 28 (70%) 12 (30%) smoke more in the morning than during the rest of the day 24 (60%) 16 (40%) smoke even if ill 31 (77.5%) 9 (22.5%) drug abuse with more than one drug at a time 15 (37.5%) 25 (62.5%) irritated without using cigarette 29 (72.5%) 11 (27.5%) intentionally resist smoking whenever wish to or not 33 (82.5%) 7 (17.5%) spousal (parents or colleagues) complains about involvement in smoking 32 (80%) 8 (20%) family problems created due to smoking 29 (72.5%) 11 (27.5%) lost job due to smoking 20 (50%) 20 (50%) been in fights when under the influence of smoking 28 (70%) 12 (30%) http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 sonya arshad 43 on the basis of scores of questions of questionnaire structured according to bas, the mean comparison between addiction status of social media users and smokers was calculated. the results reported that mild addictors were 12(30%) in group a while 16(40%) in group b. moderate addictors were 12(30%) in group a whereas 9(22.5%) in group b. severe addictors were 16(40%) in group a while 15(37.5%) in group b (figure 1). figure 2a: smokers group figure 2b: social network group figure 2a & 2b: shows the mean withdrawal effects on cognitive skills after cessation of individuals’ type of addiction. cognitive activities included were quick basic iq questions, video games, task sequencing. 94% 72% 0 10 20 30 40 50 60 70 80 90 100 b e f o r e c e s s a t i o n a f t e r c e s s a t i o n 97.6% 57% 0 20 40 60 80 100 120 b e f o r e c e s s a t i o n a f t e r c e s s a t i o n http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 sonya arshad 44 according to mean withdrawal effects on cognitive skills, in group a 97.6% of participants were able to complete task in assigned time before cessation and after cessation only 57% participants were able to do so whereas in group b 94% of participants were able to complete cognitive tasks in assigned time before cessation while after cessation only 72% of participants were able to do so. cognitive activities included were quick basic iq questions, video games, task sequencing (figure 2a &2b). figure 3: this graph shows the mean withdrawal effects on blood pressure reading after cessation of individuals’ type of addiction. lastly, the mean blood pressure reading was calculated before cessation in group a was 114.54/82.34 mmhg and after cessation was 122.47/90.34 mmhg. the mean blood pressure reading in group b calculated before cessation of smoking was 118.32/84.44 mmhg and after cessation was 121.42/88.63 mmhg. these results showed an increment in blood pressure after cessation of individuals' type of addiction (figure 3). discussion this study shows that people with smoking addiction and social media addiction are more or less on the same level of catastrophic effects on behavior, cognitive skills and blood pressure (figure 1, 2a, 2b & 3). similar types of studies in which scans of the brain have been compared between the individuals with social media addiction and substance abuse showed that both types of dependencies can cause adverse effects on brain anatomy and morphology (he et al., 2017). the reward system of brain and dopamine circuit system acts similarly in people with social media addictors as in people with substance abuse. people with substance use had more severe psychiatric symptoms than those without. these psychiatric signs might also be caused by the onset of internet dependency, and this internet dependency might also precipitate psychiatric signs (koob & le, 2008). this can be related to the study that social media addiction has dreadful effects on cognitive skills as substance abuse. people start to become less focused, tries to get relief from social media sources and gradually start to become addictive of it (figure 2a & 2b). a person becomes addictive of a particular thing when he/she wants to distract him/herself from everyday stresses of life 114.54 122.47 82.34 90.34 118.32 121.42 84.88 88.63 0 20 40 60 80 100 120 140 systolic b.p before cessation systolic b.p after cessation diastolic b.p before cessation diastolic b.p after cessation m ea n group a group b http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 sonya arshad 45 like emotional stress, financial problems, lack of interest in the particular job (table 1). now a day, people have more and easy access to social media and via this resource; they distract their focus from real life to virtual life. they get relief for the time being from this resource but the progression of its dependency ultimately cause cognitive problems, anxiety problems which can increase blood pressure and social isolation. this statement can be supported by a previous study which says that the internet can provide social support, accomplishment and contentment of having power and provides break away from emotional and social life difficulty. thus, people with high‐level psychiatric symptoms may exploit the internet to deal with emotional grief. without helpful intervention for psychiatric symptoms, the utilization of the internet might develop addiction (koob & le, 2008). it is proved that those people obsessed to using social media encounter symptoms alike to those experienced by those who go through from addictions to substances or other behaviors (figure 1, 2a, 2b & 3). this has important implications for clinical practice because it is distinct from other addictions; the aim of social media addiction management cannot be entire abstaining from the use of internet as such since it is a vital component of today's professional and spare time culture. as an alternative, the eventual therapy intention should be restricted use of the internet and its relevant purposes, mainly social networking applications, and waning avoidance via tactics evolved within cognitive-behavioral therapies (kuss & griffiths, 2011). conclusion our study showed that the addiction status of social media users group and smokers group was similar, social network abuse is as harmful as smoking for cognitive skills and blood pressure. as by now, it has been proved that social media addiction can cause adverse symptoms as substance abuse addiction through many sources like brain scans, reduced cognitive skills, increased anxiety and blood pressure and social isolation, further studies could be done as to how this addiction can be improved, what treatment strategies should be used to overcome this type of emerging addiction. conflicts of interest none acknowledgment this research was supported by farah deeba, deputy manager of liaquat national school of physiotherapy. we thank our mentors who provided insight and expertise that greatly assisted the research. we also thank hira fatima waseem; sr. lecturer at dow medical college for assistance with data collection, methodology and results calculation and muhammad nisar; sr. lecturer at the physiology department university of karachi for comments that greatly improved the manuscript. funding none references  andreassen, c. s., torsheim, t., brunborg, g. s., & pallesen, s. 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(2010). internet addiction or excessive internet use. am j drug alcohol abuse, 36(5), 277-283.  yen, j. y., ko, c. h., yen, c. f., chen, s. h., chung, w. l., & chen, c. c. (2008). psychiatric symptoms in adolescents with internet addiction: comparison with substance use. psychiatry clin. neurosci, 62(1), 9-16.  yoo, h. j., cho, s. c., ha, j., yune, s. k., kim, s. j., hwang, j., & lyoo, i. k. (2004). attention deficit hyperactivity symptoms and internet addiction. psychiatry clin. neurosci, 58(5), 487494.  young, k. s. (1998). internet addiction: the emergence of a new clinical disorder. cyberpsychol behav., 1(3), 237-244. http://www.aeirc-edu.com/ 64 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v9.i2.2022.64-66 editorial psychophysiology of wellbeing; a must to introduce in undergraduate programs shamoon noushad department of psychology, malir university of science and technology abstract the psychophysiology of wellbeing is an important field of study that explores the relationship between mental and physical health. this interdisciplinary field integrates knowledge from psychology, neuroscience, biology, and physiology to understand how positive emotions, attitudes, and behaviors can impact physical health outcomes. introducing the psychophysiology of wellbeing in undergraduate programs can provide students with valuable knowledge and skills to promote their own wellbeing and mental health, increase awareness of the connection between mental and physical health, and potentially open up new prospects of collaborations and wellbeing overall. keywords psychophysiology, wellbeing, undergraduate programs, mental health citation: noushad s. psychophysiology of wellbeing; a must to introduce in undergraduate programs. app. 2022; 9(2): 64-66 corresponding author email: shamoon@maliruniversity.edu.pk doi: 10.29052/2412-3188.v9.i2.2022.64-66 received 06/11/2022 accepted 26/11/2022 published 01/12/2022 copyright © the author(s). 2022. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v9.i2.2022. https://orcid.org/0000-0002-8078-4524 about:blank about:blank 65 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 the psychophysiology of wellbeing is an essential field that explores the relationships between psychological processes and physiological responses to promote health and wellbeing. in today's world, where mental health concerns are increasingly prevalent, incorporating this topic into the undergraduate curriculum is essential for several reasons. understanding the psychophysiology of wellbeing is vital for overall physical and mental health because it can help identify the mechanisms that underlie the relationship between mind and body. for example, if we can identify specific physiological markers associated with higher levels of wellbeing, we can develop interventions targeting those markers to improve overall health. moreover, research has shown that interventions that target both psychological and physiological processes can have a synergistic effect, leading to more significant improvements in health outcomes than interventions that target only one of these domains. thus, a better understanding of the psychophysiology of wellbeing can inform the development of more effective interventions for improving overall health and wellbeing. there are several reasons why including the psychophysiology of wellbeing in undergraduate curricula and programs is essential ➢ the holistic approach to health: including psychophysiology of wellbeing in the health sciences curriculum allows students to understand the link between mental and physical health. this holistic approach to health recognizes that the mind and body are interconnected and that addressing both is necessary for optimal health and wellbeing. ➢ evidence-based practices: research in the psychophysiology of wellbeing has provided evidence-based practices for improving mental and physical health. by including this information in the health sciences curriculum, students can learn about these practices and how they can be applied in real-world settings. ➢ prevention of chronic diseases: chronic diseases such as heart disease, diabetes, and obesity significantly impact public health. psychophysiological research has shown that stress and negative emotions can contribute to the development of these conditions. including psychophysiology of wellbeing in health sciences curriculum can teach students how to manage stress and emotions, potentially preventing the development of chronic diseases. ➢ mental health awareness: mental health disorders are a growing concern worldwide. by including psychophysiology of wellbeing in the health sciences curriculum, students can learn about the physiological mechanisms that underlie mental health disorders and how to recognize and manage these conditions. ➢ interdisciplinary collaboration: it is a multidisciplinary field that requires collaboration between health professionals, neuroscientists, psychologists, and other researchers. including this topic in the undergraduate curriculum can foster interdisciplinary collaboration and communication, potentially leading to discoveries and approaches to healthcare. ➢ promoting mental health: the psychophysiology of wellbeing can provide students with an understanding of the biological mechanisms that underpin mental health and wellbeing. it can equip them with the knowledge and skills necessary to maintain good mental health and help others struggling with mental health issues. ➢ enhancing critical thinking skills: the psychophysiology of wellbeing requires 66 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 students to think critically and analytically about the complex relationships between psychological and physiological processes. by engaging with this topic, students can develop their critical thinking skills and learn how to apply this approach to other areas of study. ➢ preparing for future careers: the study of the psychophysiology of wellbeing is relevant to many different fields, including healthcare, education, social work, and business. by incorporating this topic into the undergraduate curriculum, students can develop skills that will be valuable in their future careers. conclusion the study of psychophysiology of health and wellbeing has several practical applications in clinical/applied, social, and health sciences, for example, diagnosis and treatment of mental health disorders, stress management, chronic disease management, performance enhancement, and public health interventions. overall, it has many valuable applications by providing insights into the interplay between the mind and body and developing interventions to improve health and wellbeing in various domains. moreover, the psychophysiology of wellbeing is an important topic that can help students understand the interplay between the mind and body in promoting health and wellbeing. by incorporating this topic into the undergraduate curriculum, students can develop skills that will be valuable in their personal and professional lives and contribute to a more informed and compassionate society. about:blank 12 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v10.i1.2023.xx-xx original article the relationship of emotional intelligence and life satisfaction with resilience in students shakir ali, saima masoom ali & asbah zia department of psychology, university of karachi, karachi-pakistan abstract background: this paper aims to investigate the strength of the relationship between emotional intelligence and life satisfaction with resilience among college students living in turbat, balochistan, pakistan. methodology: inform consent was taken from the participants before using a purposive sampling technique. they were categorized into two groups: one hundred males (n = 100) and one hundred females (n = 100). the participants were selected from government boys degree college, government girls degree college of turbat, and the university of turbat, district kech, balochistan. after obtaining consent, the following questionnaires were administered: a demographic sheet, self-report emotional intelligence test (sreit), satisfaction with life scale (swls), and trait resilience checklist (trc). results: the results of this study verified that emotional intelligence and life satisfaction with resilience have a positive correlation. finally, recommendations and limitations have been put forward according to the study results. conclusion: our study has demonstrated a strong positive relationship between emotional intelligence and life satisfaction with resilience. the findings underscore the significance of emotional intelligence in promoting overall life satisfaction and resilience in this population. keywords emotional intelligence, life satisfaction, resilience. citation: ali s, ali sm, zia a. the relationship of emotional intelligence and life satisfaction with resilience in students. app. 2023; 10(1): 12-20 corresponding author email: saima.ali@uok.edu.pk doi: 10.29052/2412-3188.v10.i1.2022.1220 received 16/03/2023 accepted 26/05/2023 published 01/06/2023 copyright © the author(s). 2023. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v10.i1.2023. about:blank about:blank 13app| published by aeirc| volume 10 issue 1 introduction turbat is a far-flung and underprivileged region in southern balochistan, pakistan, where students face tremendous psychosocial, political, and economic problems, due to which students have been suffering on mental, emotional, and psychological levels. furthermore, the current political and social unrest has created psychological stress among the students, as district turbat is one of the most socially affected areas of balochistan. hence, the present study was to investigate how emotional intelligence and resilience have been supporting them to live satisfactory life1 explained that persons with higher emotional capacities are thought to have a more prominent ability to sense, utilize, comprehend, and administer feelings in the self as well as other people which encourage a more noteworthy feeling of subjective prosperity. the students are also deprived of basic facilities such as health, education, and economic opportunity. in the face of these problems, students are trying multiple ways to cope with the problems mentioned earlier to achieve their intended target. this research aims to measure the emotional intelligence and resilience of the students and to explore the satisfaction they derive from them, even against the odds. salovey, bedell, detweiler, and mayer (1999) guess that people with higher ei adapt better to the emotional requests of distressing experiences since they can precisely observe and assess their feelings, discern how and when to direct their emotions, and can viably direct their temperament conditions2. however, there has been no psychological research to investigate the emotional intelligence, resilience, and life satisfaction of the students of turbat. the present research may fill up the existing gap will contribute to the current knowledge and literature will additionally give imperative data about the subjective prosperity of students that may likewise be useful for educationists, clinicians, and guardians and for all those who want to deal with psychological problems of the students in the district in general and in the selected institutions, i.e., university of turbat and atta shad government degree college turbat, government girls degree college turbat in particular. emotional intelligence the central question of this study was to explore how emotional capacity (emotional intelligence) and recovery capacity (resilience) can influence coping processes in university students. the process of feeling, understanding, controlling, and regulating emotion is known as emotional intelligence. also, emotional intelligence is an aptitude to feel what is emoting within oneself and recognize how your sentiments impact persons around you. it is like a manner that incorporates your perspective of others: perceiving how they feel empowers you to comprehend and relate more feasibly. the essential issue of this arranged examination is to examine the part of emotional intelligence, resilience, and life satisfaction among the students. the previous literature suggested that emotional intelligence and resilience are significant to the self-care of an individual3. emotional intelligence is a shade that spreads wide-run accumulation of a person's capacities and aptitudes. it deals with interpersonal and intrapersonal resilience and life satisfaction. moreover, "emotional intelligence is an individual's ability to monitor his feelings and the emotions of others, discriminate those feelings and use this information to create positive outcomes in his relationships with others and himself4." it is considered 14app| published by aeirc| volume 10 issue 1 versatility utilizing hardship as managing standard and expressed that mental flexibility is the aftereffect of commitment, system, and challenge. resilience was additionally unique concerning the gathering's progression point of view. they distinguished four basic procedures: gathering's conviction framework, an example of association, specific correspondence process, and more extensive communication pattern5. previous studies showed that emotional intelligence (ei) and resilience relate to how people react when faced with stress-inducing circumstances6. resilience resilience is imagined as a customary enchantment to comprehend administrative procedures related to advancing human competency7. the investigation has demonstrated that resilience is standard, not uncommon. individuals usually show resilience8. emotional intelligence and resilience many researchers have conducted research on academic performance and its relation to ei and resilience9-12. previous studies demonstrated that emotional intelligence (ei) and resilience are related to how people react when faced with stress-inducing circumstances6. life satisfaction the fulfillment of different needs, demands, and urges an individual tries to find meaning from that entertainment is referred to as satisfaction13. diener (1984) gathered 13 cases, which looked at ladies' and men's opinions of life contentment and contentment. he supposed that clear distinction is not found in mean levels of prosperity scores of both sexes13. wood, rhodes & whelan (1989) made a broad metasystematic audit of 93 investigations of prosperity and sexual orientation contrasts. they found that ladies revealed more prominent joy and life satisfaction than men. this distinction was clarified regarding their social context. hence, this analysis is aimed to evaluate the relationship between emotional intelligence, resilience, and life satisfaction among students of turbat14. emotional intelligence and gender differences since females tend to be more emotional and intimate in relationships as compared to males, their emotional intelligence ought to be higher than that of males. society is responsible for this, which socializes the two genders differently, as has been found in many studies15,16. moreover, higher emotional intelligence among girls can also be explained in terms of some of their personality characteristics. similar findings reported that girls score higher with regard to empathy, social responsibilities, and interpersonal relationships than boys. more sensitivity was found towards their relationships with parents, friends, and siblings. all these traits help them to acquire more emotional intelligence as compared to boys. this study is only a stepping stone in the field of emotional intelligence. findings of studies revealed that females have higher emotional intelligence than males15-17. the present research studied the relationship between emotional intelligence and life satisfaction with resilience in students. • there would be a positive relationship between emotional intelligence and resilience. • there would be a positive relationship between emotional intelligence and satisfaction with life. • there would be gender differences among variables of emotional intelligence, resilience, and satisfaction with life. 15 app published by aeirc| volume 10 issue 1 methodology a correlational research design was executed to measure the relationship among the variables. this research design is administered to determine the strength of the relationship among variables. sample size the sample size of the present study consisted of 100 participants from college and 100 from university. among them, 100 were male, and 100 were female (n=200). a convenient sampling technique was used to collect the data from the students of government boys degree college and government girls degree colleges, university of turbat, district kech, baluchistan. the current investigation depended on a survey research design. research instruments informed consent consent was obtained from every participant. the consent form was to define the nature of the study and the need to do this study. it was to ensure the participants that the confidentiality of data would be maintained and that the provided information would be only used for current research purposes. participants' right to withdraw and their right to get to know about research findings have been mentioned. the email address was mentioned through which participants can contact and get to know research results. participants were asked to put their initials on the consent form if they were willing to participate in the study. demographic sheet for a better understanding of the statistical significance of the present study, the demographic sheet was used to obtain the demographic information: age, education, gender, socioeconomic status, and sociopolitical situation. emotional intelligence the schutte self-report emotional intelligence test (sseit) is a method of measuring general emotional intelligence (ei), using four scales: emotion perception, utilizing emotions, managing self-relevant emotions, and managing others ' others'emotions. the sseit includes 33-item self-report questions. the cronbach alpha reliability of this scale is 0.8318. trait resilience checklist (trc) a trait resilience checklist will be utilized to gauge trait resilience. this checklist comprises eighteen items that will depict the respondents as they were, for the most part, in their past. the respondent will rate every statement on a 5-point scale (from strongly agree = 1 to strongly agree = 5). the cronbach alpha reliability of this scale is 0.7417. satisfaction with life scale to evaluate life satisfaction in members, we controlled the satisfaction with a life scale (swls) comprising five things. members are told to show the degree to which they approve or disapprove of every announcement utilizing a 5-point likert sort scale. the cronbach alpha reliability of this scale is 0.6119. procedure the information was collected from government boys degree college, government girls degree college, and the university of turbat. permission was obtained from the concerned institution and students. participants were told in regards to the nature, purpose, and significance of the study. the researcher had dealt with the quarries of participants before, amid, and after the completion of questionnaires. after getting the information, they were assured that the data given by them would be kept confidential and would just be utilized for research reasons. finally, the researcher app 16app| published by aeirc| volume 10 issue 1 thanked all the participants for their valuable contribution and commitment to the investigation. proposed analysis the spss 22.0 was used for statistical analysis. the parametric data were analyzed by using a t-test. the pearson correlation coefficient was utilized to assess the relationship between variables. result table 1 shows the number and percentage of males and females with their ages and qualifications. table 1: summary of demographic variables of students. variables (n (%) gender male 50 (50) female 50 (50) age 15-20 28 (28) 21-25 72 (72) qualification secondary 20 (20) graduation 20 (20) master 60 (60) total 100 the average eis of the males was recorded as 122.56 with a standard deviation of 13.796 as compared with the average eis of females as 125.80 with a standard deviation equal to 14.754, indicating that the females had a higher ei average than males with a slightly higher variability. the trait resilience checklist computed for males and females gave means of 65.94 and 65.14 with standard deviations of 8.96 and 11.21, respectively, which indicated that males exhibited more trait resilience than females. an average of 21.16 with a standard deviation of 5.31 compared with the average of 23.06 with a standard deviation equal to 3.94 showed that females had more satisfaction with life than males (table 2). table 2: average and standard deviation of emotional intelligence scale (eis), trait resilience checklist (trc), and satisfaction with life (swls). variables male (n=100) female (n=100) mean ± s. d mean ± s. d emotional intelligence scale 122.56 ± 13.796 125.80 ± 14.754 trait resilience checklist 65.94 ± 8.961 65.14 ± 11.214 satisfaction with life 21.16 ± 5.312 23.06 ± 3.935 the pair-wise correlation analysis indicated significant positive associations, at a 5% level of significance, between ei and trc and between ei and swl, with magnitudes equal to 0.285 and 0.295, respectively. however, the correlation between trc and swl showed an insignificant coefficient of 0.188, indicating no association between the two traits (table 3). 17app| published by aeirc| volume 10 issue 1 table 3: correlations between emotional intelligence, resilience and satisfaction with life variables ei trc swl 1 2 3 ei 1 0.285** 0.295** trc 1 0.188 swl 1 *n=200 **ei=emotional intelligence, trc=trait resilience checklist, swl=satisfaction with life * = p < 0.05 multiple regression analysis was run to check the impact of emotional intelligence and life satisfaction on resilience. emotional intelligence, with a coefficient of 0.231 and a p-value of 0.000, indicated a significant impact on resilience. in other words, when emotional intelligence increases by one unit, the resilience changes by 0.231. life satisfaction, too, gave a coefficient of 0.463 with a p-value of 0.007, indicating that when life satisfaction increased by one unit, resilience would increase by 0.463 units. in summary, emotional intelligence and life satisfaction significantly increase resilience in both males and females (table 4). table 4: regression analysis of the impact of emotional intelligence and life satisfaction on resilience. model unstandardized coefficients standardized coefficients t sig. 95% ci for b b std. error beta lower bound upper bound constant 27.492 8.506 3.232 .002 10.610 44.373 emotional intelligence .231 .061 .347 3.766 .000 .109 .352 life satisfaction .463 .168 .253 2.748 .007 .129 .797 *dependent variable: resilience discussion the purpose of the current study was to explore the relationship between emotional intelligence and life satisfaction with resilience among students of colleges and universities in turbat, balochistan. it was hypothesized that “emotional intelligence, resilience, and life satisfaction would be positively correlated.” the correlation coefficient of 0.285 with a p-value less than 0.01 between emotional intelligence and resilience and the correlation coefficient of 0.295 with a p-value less than 0.01 between emotional intelligence and life satisfaction demonstrated that a positive correlation existed between emotional intelligence, resilience, and satisfaction. people with emotional intelligence and life satisfaction are more resilient. however, the correlation coefficient of 0.188 with a p-value greater than 0.05 showed that persons with life satisfaction do not necessarily mean that they are resilient. this goes against the hypothesis presented by andrew r. et al. (2016) that individuals with high emotional intelligence are more resilient to negative situations in life20. resilience is considered a personality trait that strengthens an http://www.sciencedirect.com/science/article/pii/s0191886911001462#! 18app| published by aeirc| volume 10 issue 1 individual to cope with any difficult condition of life without losing one’s tempo21. existing research also guides that emotional intelligence is the genesis of resilience22. life satisfaction, which reflects an individual's evaluation of his or her life as a whole, is one of the most examined variables that are associated with trait ei19. individuals with higher emotional abilities are thought to possess a greater capacity to perceive, use, understand, and manage emotions in the self and others, which facilitates a greater sense of subjective well-being1. a substantial body of research provides evidence for the incremental validity of trait ei as a predictor of life satisfaction; most noteworthy are those that control for covariates such as demographic characteristics, the “big-five” personality, trait affectivity, or social support23-28. the second hypothesis was gender: "there would be significant gender difference in emotional intelligence, resilience, and satisfaction with life." it was argued that gender difference also influences emotional intelligence, resilience, and satisfaction with life. a t-statistic of 1.134 with a p-value of 0.259 indicated that gender difference has no significant impact on the emotional intelligence of individuals. there is a study that men are more emotionally intelligent than women29. further, a t-statistic value of 0.394 with a p-value of 0.694 suggested that the gender difference did not have any statistically significant influence on resilience either. on the other hand, previously suggested that there is a relationship between resilience and gender30. this is inconsistent with the hypothesis that gender difference has an impact on resilience and emotional intelligence. however, the gender difference in satisfaction with life gave a t-statistic of 2.032 with a p-value of 0.045, implying that males were more satisfied with their lives. it is indicated that female participants were sounder emotionally mature, resilient, and satisfied with their lives as compared to the male students, and the result is also found significant gender difference between men and women in all variables31,32. moreover, emotional intelligence and resilience develop an emotional competence to deal with any unwanted situation and circumstances of life, as quoted by bulathwatta a. et al. (2017)33. our study has certain limitations as the sample size was selected through convenience sampling techniques, so the findings of the study related to the students of district kech turbat cannot be generalized to a broader population. this study is not representative of all the students of balochistan but comprised of only those who were studying degree colleges and universities in kech. the result of this research will be more significant if the data size is extended to the entire general population of balochistan, including their socioeconomic level. finally, further studies are required to confirm the findings of the present research. conclusion in conclusion, this study conducted among college students in turbat, balochistan, pakistan, has demonstrated a strong positive relationship between emotional intelligence and life satisfaction with resilience. the findings underscore the significance of emotional intelligence in promoting overall life satisfaction and resilience in this specific population. these results offer valuable insights for educators and policymakers to enhance emotional intelligence training programs for college students in the region. 19app| published by aeirc| volume 10 issue 1 acknowledgment i am greatly indebted to my supervisor, dr. asghar ali shah, and co-supervisor, dr. saima masoom ali and manzoor ahmed, for their contributions and valuable suggestions, and without their support, this work would not have been possible. references 1. mayer, j., & salovey, p. (1997). what is emotional intelligence? in p. salovey & d. sluyter (eds.), emotional development and emotional intelligence: educational implications (pp. 3–31). new york: basic books. 2. salovey, b. bedell, j.b. detweiler, j.d. mayer. (1999), coping intelligently: emotional intelligence and the coping process. c.r. snyder (ed.), coping: the psychology of what works, oxford university press, new york .pp. 141–164 3. brown, t. (2022). the impact of emotional intelligence and resilience on self-care among licensed mental health professionals (doctoral dissertation, grand canyon university). 4. goleman, d. (1995). emotional intelligence: why it can matter more than iq. new york: bantam books 5. maddi, s., & khoshaba, d. (2005). resilience at work: how to succeed no matter what life throws at you. new york: amacon 6. armstrong, a. r. galligan, r. f. critchley, c. r. 2011. emotional intelligence and psychological resilience to negative life events. personality and individual differences, 51 (3), 331-336. https://doi.org/10.1016/j.paid.2011.03.025 7. masten, a. s. (2001). ordinary magic: resilience processes in development. american psychologist, 56, 277-238. 8. rutter, m. (2006). the promotion of resilience in the face of adversity. in families count effects on child and adolescent development. a. clarke-stewart & j. dunn, eds.: 26–52. cambridge university press. new york & cambridge. in press. 9. lam, l. t., & kirby, s. l. (2002). is emotional intelligence an advantage? an exploration of the impact of emotional and general intelligence on individual performance. the journal of social psychology, 142(1), 133-143. https://doiorg.ezproxy.mytyndale.ca:2443/1 0.1080/0022454020960389.1 10. suleman, q., hussain, i., syed, m. a., parveen, r., lodhi, i. s., & mahmood, z. (2019). association between emotional intelligence and academic success among undergraduates: a cross-sectional study in kust, pakistan. plos one, 14(7), 1-22. https://doiorg.ezproxy.mytyndale.ca:2443/1 0.1371/journal.pone.021946 11. hwang, e., & shin, s. (2018). characteristics of nursing students with high levels of academic resilience: a cross-sectional study. nurse education today, 71, 54-59. https://doi.org/10.1016/j.nedt.2018.09.011 12. droppert, k., downey, l., lomas, j., bunnett, e. r., simmons, n., wheaton, a., nield, c., & stough, c. (2019). differentiating the contributions of emotional intelligence and resilience on adolescent male scholastic performance. personality and individual differences, 145, 75-81. https://doi.org/10.1016/j.paid.2019.03.023 13. diener, e.(1984). subjective well-being. psychological bulletin, 95,542-575. 14. walkins, chris. (1994). emotional intelligence. retrieved on 16 august 2017 from www.dirjounal.com/guide/emotionalintelli gence. 15. schutte n.s., malouff j.m., hall l.e., haggerty d.j., cooper j.t., golden c.j., dornheim l. (1998) development and validation of a measure of emotional intelligence. personality and individual differences 25, 167-177 16. sifneos, peter. (1973). leadership with emotional intelligence. retrieved on 22 march 2017 from www.suite 101.com 17. hiew, c., mori, t. shimizu, m. (2000). measurement of resilience development: preliminary results with a state-trait resilience inventory. journal of learning and curriculum development 1(1), 111-117. japan: hiroshima university. 18. schutte n.s., malouff j.m., hall l.e., haggerty d.j., cooper j.t., golden c.j., dornheim l. (1998) development and validation of a measure of emotional intelligence. personality and individual differences 25, 167-177 20app| published by aeirc| volume 10 issue 1 19. diener, e., & diener, m. (1995). cross-cultural correlates of life satisfaction and self-esteem. journal of personality and social psychology, 68, 653. 20. andrei, f., siegling, a. b., aloe, a. m., baldaro, b., & petrides, k. (2016). the incremental validity of the trait emotional intelligence questionnaire (teique): a systematic review and meta-analysis. journal of personality assessment, 98(3), 261-276. 21. hoge, e. a., austin, e. d., and pollack, m. h. (2007). resilience: research evidence and conceptual considerations for posttraumatic stress disorder. depression. anxiety 24, 139– 152. doi: 10.1002/da.20175. 22. matthews, g., zeidner, m., & roberts, r. d. (2002). emotional intelligence: science and myth. cambridge: mit press. 23. extremera, n., & fernández-berrocal, p. (2005). perceived emotional intelligence and life satisfaction: predictive and incremental validity using the trait metamood scale. personality and individual differences, 39, 937–948. 24. gallagher, e. n., & vella-brodrick, d. a. (2008). social support and emotional intelligence as predictors of subjective wellbeing. personality and individual differences, 44, 1551–1561. 25. kong, f., & zhao, j. (2012). affective mediator of the relationship between emotional intelligence and life satisfaction in young adults. manuscript in preparation. 26. kong, f., zhao, j., & you, x. (2012). social support mediates the influence of emotional intelligence on mental distress and life satisfaction in chinese young adults. personality and individual differences, 53, 513–517. 27. palmer, b. r., donaldson, c., & stough, c. (2002). emotional intelligence and life satisfaction. personality and individual differences, 33, 1091–1100. 28. saklofske, d. h., austin, e. j., & minski, r. s. (2003). factor structure and validity of a trait emotional intelligence measure. personality and individual differences, 34, 707–721. 29. ahmad, s., bangash, h., & khan, s. a. (2009). emotional intelligence and gender differences. sarhad j. agric, 25(1), 127-130. 30. ijadi-maghsoodi, r., venegas-murillo, a., klomhaus, a., aralis, h., lee, k., rahmanian koushkaki, s., ... & kataoka, s. (2022). the role of resilience and gender: understanding the relationship between risk for traumatic stress, resilience, and academic outcomes among minoritized youth. psychological trauma: theory, research, practice, and policy. 31. herbert, j. & stipek, d. (2005). the emergence of gender differences in children’s perceptions of their academic competence 32. salovey, l.r. stroud, a. woolery, e.s. epel (2002) perceived emotional intelligence, stress reactivity, and symptom reports: further explorations using the trait meta-mood scale. psychology & health, 17 (5), pp. 611–627 33. bulathwatta, a. d. n., witruk, e., & reschke, k. (2017). effect of emotional intelligence and resilience on trauma coping among university students. health psychology report, 5(1), 1219. about:blank 76 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v9.i2.2022.76-84 original article 6-af evaluation of neuroprotective activity against cdinduced oxidative stress and degenerative brain disease including pd in mice waqar ahmad khan1 , shahid ali shah1 , & shamsher khan2 1sarhad university of science & information technology, peshawar -pakistan 2university of engineering and technology, peshawar-pakistan abstract background: the neurotoxicity caused by cadmium (cd) has been researched internationally. since it has a wide range of unfavorable effects on people, it is believed to be one of the primary tissue-inducing target agents. using adult male albino mice, the therapeutic potential of 6-af to reduce memory impairment, neurodegeneration, and neuroinflammation caused by cadmium chloride (cdcl2) was evaluated in the current study for the first time. methodology: the male adult mice were distributed into 4 sub-groups; control, cd treated (1 mg/kg thrice weeks), cd (1 mg/kg 3 weeks) + 6-af (30 mg/kg 3 a week for last 2 weeks) and 6-af treated (30 mg/kg thrice a week for the last two weeks). after the initial seven-day cdcl2 dosing cycle, the 6-aminoflavone was administered interpretively intravenously for the following around 14 days (three per week). after receiving cdcl2 injections for 30 days, behavior tests were conducted. western blot analysis was performed after the hippocampus was extracted, and the results were then used to develop the x-rays. results: our results demonstrate that 6-af significantly enhanced behavior as assessed by the y-maze and morris water maze (mwm) and that this enhancement was followed by an inhibition of phospho c-jun n terminal kinase (p-jnk) and its downstream signaling, including tumor necrosis factor-alpha (tnf-alpha), nuclear factor kappa-light-chain-enhancer of activated b cells (nfkb), and poly (adp-ribose in addition, 6-af also reduced the expression of nrf2 proteins in adult mice exposed to oxidative stress caused by cadmium chloride. conclusion: 6-af is an effective neuroprotective drug in disorders causing neurodegeneration. keywords cdcl2, neuro-inflammation, 6-af, phospho-jnk ,nrf-2,parkonsion disease. citation: khan wa, shah sa, khan s. 6af evaluation of neuroprotective activity against cdinduced oxidative stress and degenerative brain disease including pd in mice. app. 2022; 9(2): 76-84 corresponding author email: waqarahmadkhan1990@gmail.com doi: 10.29052/2412-3188.v9.i2.2022.76-84 received 16/09/2022 accepted 26/10/2022 published 01/12/2022 copyright © the author(s). 2022. this open-access article is distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. about:blank about:blank about:blank about:blank about:blank about:blank 77 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 introduction neurodegeneration is a process where neurons gradually degenerate or die. this can lead to a decline in brain function and various neurological symptoms, including problems with movement, thinking, and behavior. at the same time, neurodegenerative diseases are conditions characterized by progressive damage to the neurons in the brain and nervous system1. parkinson's disease (pd), a late-onset neurodegenerative disorder, is characterized by an extensive and progressive loss of dopaminergic neuronal cells in the substantia nigra compacta and the accumulation of lewy bodies, which are intracellular inclusions comprised of synuclein2,3. parkinson's patients' postmortem brain tests reveal lysosomal consumption and autophagosome accumulation, which may indicate impaired autophagic clearance. the proteasome, chaperone-mediated autophagy, and macroautophagy can contaminate 4-synuclein4,5. following the critical role of autophagy in synuclein lewy bodies, several investigations have demonstrated that pharmacological and genetic stimulation of autophagy reduces -synuclein aggregation and disease pathogenesis6,7. several pd-related proteins, in addition to synuclein, are directly involved in the autophagy pathway. the quality encodes the lysosomal trans film atpase protein8. pdrelated mutations in atp13a2 lead to defects in lysosomal acidification, which reduce autophagosome clearance and accumulate a-synuclein9,10. other proteins identified with pd loss-of-work modifications in prompted putative kinase1, pten protein gene coding, and park2 are also known to cause autosomal-passive type pd and -synuclein11-13. the prodded putative kinase-1 gene genes for a threonine/serine protein kinase transmitted in the outer mitochondrial film14. these proteins regulate mitophagy, a process that results in mitochondrial damage. cadmium (cd) is a common industrial pollutant and environmental contaminant released mainly by burning fossil fuels, refining metal from municipal waste, and smoking cigarettes15. when cd enters the atmosphere and a living thing, it has various adverse effects related to cd damage15. human exposure to cd damages and affects body organs like the liver, bone, testicles, kidney, and cerebrum and can result in cancer, tumors, etc16,17. due to its ability to pass the (bbb), cd can cause damage to nerve cells and the cerebrum. it also results in a defective nervous system that impairs vascular functioning, neurological disorders in the brain, and learning difficulties in addition to pd18. additionally, cd increased the generation of free radicals, which led to oxidative stress and protein and phospholipid degradation (dna)19. additionally, it is claimed that cd is to blame for developing neurodegenerative disorders like ad17. cadmium also replaces copper and iron in the protein's structure20. these unbound metals result in oxidative stress through fenton chemistry processes, which causes cancer to develop in various organ systems and systems of a living organism. consequently, cadmium is regarded as a class of human carcinogens21. in contrast, polyphenols called flavonoids are found in foods including fruits, vegetables, herbs, tea, wine, and other organic and natural items. they stand out for having a wide-ranging understanding of that medication. flavonoids work as breast cancer chemotherapeutic agents. the function of 6-amino flavone in cancer chemoprevention. 6-af works in a variety of ways, including by inactivating carcinogens. 78 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 the 6-aminoflavones have a strong antibreast cancer effect. in cancer, the 6-af are incredibly active. studies have also shown that 6-af's antioxidant activities are vigorous; as a result, 6-aminoflavone was used in the current investigation to test its effectiveness against reactive radicals in a mouse model 22-24. the above evidence suggests that heavy metals like cadmium severely harm the health of humans, and it is one of the leading causes of neurological disorders, including pd, ad, and hd. therefore, this study aims to determine the remedial action to lessen and defeat this harmful disease by investigating the brain damage and poisoning effects of cadmium chloride in mice. moreover, we also investigate how 6af activity reduces cd-induced neuroinflammation, and we further hypothesize to identify a treatment for the oxidative stress brought on by cd toxicity. methodology mice weighing between 26-30g were collected for this experimental study. these mice were bought from the peshawar veterinary research institute. these mice were kept in a 23–24 degrees celsius chamber, with 12-hour cycles of light and 12hour cycles of darkness. the (nmrc), associated with the chemistry department, suit peshawar, conducted this experimental study. the committee of the centre oversaw carried out the research activities. the male adult mice were distributed into 4 sub-groups as given under 1. control (normal) mice. cd treated (1 mg/kg thrice weeks). 2. cd (1 mg/kg 3 weeks) + 6-af (30 mg/kg 3 a week for last 2 weeks). 3. 6-af treated (30 mg/kg thrice a week for the last two weeks). all animals were handled with extreme care. adult albino mice received cd injections for three weeks. after the initial seven-day cdcl2 dosing cycle, the 6-aminoflavone will be administered interpretively intravenously for the following around 14 days (three per week). after receiving cdcl2 injections for 30 days, behavior tests were conducted. 6-af, indicated in the study's instructions, contributed to the successful outcome of the neuroprotective agent drug. 6-amino flavone repaired adult albino mice's memory impairment caused by cadmium. the y-maze test was also conducted. a 120degree angle is formed by the three arms of the y-maze, which measure 50 by 10 by 20 cm3 (lxwxh). mice were given a 10-minute window to become used to their new surroundings. the mouse was then kept in the maze's center for 8 minutes while it was free to explore. track was kept on the mice's total arm entries and consecutive triplet counts, and the percentage of alternations was calculated using the formula [successive triplet sets/total arm entries 2] times 100. working memory performance in the spatial domain was positively linked with the percentage of alternations. morris water maze (mwm) was used to examine the hippocampus region's role in long-term spatial learning. for the first three days, the mice were trained twice daily. the mice's 60-second escape delay in locating the submerged platform was then observed. if the mice could not locate the platform on their own, they were manually guided there and made to stay there for 10 seconds. up until day 5, this procedure was followed, and each day's data (seconds) for the three experimental groups were separate. the 79 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 mice were given two days to recuperate before being subjected to a probe test. western blot analysis was performed, and the hippocampus was extracted and placed in an ice-cold 1:1 rna-to-pbs solution. tper (thermo scientific) solution for tissue extraction protein reagent was used to homogenize the hippocampus component. a semi-dry trans-blot technique transferred the proteins to the pvdf membrane (biorad). they were followed by secondary antibodies that were hrp-conjugated against mice from santa cruz, california, usa. the results were then used to develop the x-rays. result the results show that cadmium chloride induced a significantly high expression of pjnk in the brain homogenates of mice. on the other hand, we also injected 6-amino flavone for two weeks after cd induces pjnk activation to know its inhibitory ability of p-jnk proteins, as shown in figure 1. our outcomes revealed that 6amino flavone significantly reversed the expression of phospho-jnk in the brain of albino mice. figure 1: 6-af inhibited phospho-jnk activation in cdcl2 induced adult albino mice brain. downregulated signal activation in adult albino mice is observed when injected with another neuroprotective drug 6-af, for the last two weeks. this suggests that 6-amino flavone dramatically altered the expression of tnf expression in the brains of albino mice. one of the frequent mediators of neuroinflammation is tnf-α. 80 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 figure 2: 6-af inhibited tumor necrosis factor tnf-α neuroinflammation in cdcl2 induced mice figure 3 shows the immunoblots of nf-κb and β-actin along with their histogram for all 4 experimental groups (n=4/group). western analysis reveals that cadmium chloride dramatically raises nf-b expression in the brain of adult albino mice. after two weeks of 6-amino flavone injection, the brains of adult albino mice showed decreased nf-b expression. figure 3: 6-af inhibited nf-κb and instigated by cd in adult male mice brains. the outcome demonstrates that in the adult albino mouse brain, the caspase-3 signal is upregulated and activated by cd. figure 4 shows the 6-af decreased caspase-3 down-regulated 81 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 expression in the brain of albino mice. this demonstrates that quercetin treatment improves the morphology of mice's neurodegenerating hippocampus following cd exposure. figure 4: 6-af inhibited caspase-3 proteins in cdcl2 administered mice as shown in our results, 6-af diagrammatically reduced the expression of the parp-1 protein (figure 5). this suggests that caspase-3, caspase-9, and parp-1 protein levels decreased in response to cd, and the levels of cleaved caspase-3, caspase-9, caspase-8, and fasl proteins rose dose-dependently. while n-acetylcysteine successfully prevented these changes. figure 5: 6-af inhibited parp-1 proteins expression in cd mice 82 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 discussion cdcl2 is a well-familiar agent to induce phospho-jnk activation15. in a recent study, we injected cdcl2 intraperitoneally for three weeks into adult albino mice. and aims to determine the remedial action to lessen and defeat harmful neurological disorders. studies suggest that cdcl2 has been shown to be a hazardous metal that enters the body directly and harms cells. cd can throw off oxidative equilibrium. in mice treated with cd, it results in a loss of motor function and damages the dna in cells and the structural integrity of the cerebellum25. one of the most prevalent neurodegenerative disease mediators is jnk. our findings are consistent with earlier research because chen et al. also showed that cadmium could cause the phosphorylation of the jnk protein in mouse brain tissue. according to a study, the celastrol neuroprotective pharmacological agent cd caused neuron cell death by phosphorylating jnk and targeting the pten-akt/mammalian target of the rapamycin network15. according to our findings, cholesterol may protect against cadmium-induced neurodegenerative diseases. the researcher showed that active p-jnk is critically involved in disease development after traumatic brain injury and that inhibition of p-jnk with sp600125 is highly efficient for slowing disease progression by reducing multiple pathological features in traumatic brain injury mice brains and regulating cognitive dysfunction26. cadmium chloride was administered intraperitoneally to the male mice for a week thrice to induce neurodegeneration and neuroinflammation in adult albino mice and then treated with 6-amino flavone for two weeks. when compared to mice exposed to cd, immunohistochemical investigation shows that in earlier studies, mice that had been pre-treated with (sme) showed a decrease in the amount of tnfappearing as a protein. our findings are consistent with those of elkhadragy et al., who also suggest that cd can cause the tumor necrosis factor protein to be expressed in the mouse brain27. our findings reveal that cadmium chloride dramatically raises nf-b expression in the brain of adult albino mice. previous research indicated higher amounts of inflammatory cytokines, including nf-b and -actin proteins, were also significantly found. notably, research on (nrf-2) silencing and (nf-b) has shown that cadcl2 can trigger the nf-b in the brain of albino male mice28. studies of nuclear factor-b (nf-b) inhibition and nuclear factor-2 erythroid-2 (nrf-2) gene silencing demonstrate that caffeine produces neuroprotection via nrf-2and (nf-b) dependent pathways, respectively, in the ht-22 and bv-2 cell lines28. it is also demonstrated that quercetin treatment improves the morphology of mice's neurodegenerating hippocampus following cd exposure. according to chong et al., synuclein causes cell death in a dopaminergic neuronal model of parkinson's disease by increasing oxidative stress, increasing cd uptake, changing caspase-9 and caspase-3 activation, and decreasing the neuroprotective effect of akt. this is in response to acute cadmium exposure29. according to previous research, oxidative stress, mitochondrial damage, and cd-induced cell death are all caused by parthanatos and the mapk signaling pathway. jnk1/2 and p38 are implicated in parthanatos, which also synergistically affect apoptosis when paired with oxidative stress30. even though the current study focused on 6af's neuroprotective and memoryimproving effects in mice exposed to cd. the 83 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 only concentration of 6-af employed as a neuroprotective agent in this investigation. however, it is advised to use alternative concentrations of 6-af in future research on animal models of neurodegenerative disorders. it is also advised to thoroughly investigate the 6-af in vitro model of cell culture to better understand its usefulness as a medication. conclusion according to this study, 6-af is a neuroprotective drug that reduces cdinduced toxicity in an animal model. it has been demonstrated that 6-af works in vivo to reverse the memory deficits caused by cd while lowering neuroinflammation and being a natural, safe, and accessible therapeutic agent. this work also demonstrated the molecular mechanism by which 6-af in cd causes neurological disease. acknowledgment the authors would like to thank their supervisor, professor dr. shahid ali shah, for their continuous assistance. and would also like to show their gratitude to their college classmates for their helpful advice on chemicals and equipment. references 1. przedborski, s., vila, m., & jackson-lewis, v. series introduction: neurodegeneration: what is it and where are we?. j clin investig. 2003;111(1):3-10. 2. thomas b. parkinson’s disease: from molecular pathways in disease to therapeutic approaches. antioxid redox signal. 2009;11:2077–2082. 3. mizuno y, hattori n, kubo s, sato s, nishioka k, hatano t, tomiyama h, funayama m, machida y, mochizuki h. progress in the pathogenesis and genetics of parkinson’s disease. philos trans r soc lond b. 2008;363:2215–2227. 4. vogiatzi, t., xilouri, m., vekrellis, k., & stefanis, l. wild type α-synuclein is degraded by chaperone-mediated autophagy and macroautophagy in neuronal cells. j biol chem. 2008;283(35):23542-23556. 5. webb, j. l., ravikumar, b., atkins, j., skepper, j. n., & rubinsztein, d. c. α-synuclein is degraded by both autophagy and the proteasome. j biol chem. 2003;278(27):2500925013. 6. spencer, b., potkar, r., trejo, m., rockenstein, e., patrick, c., gindi, r., ... & masliah, e. beclin 1 gene transfer activates autophagy and ameliorates the neurodegenerative pathology in α-synuclein models of parkinson's and lewy body diseases. j neurosci. 2009;29(43):13578-13588. 7. nah j, yuan j, and jung yk. autophagy in neurodegenerative diseases: from mechanism to therapeutic approach. mol cells. 2015;38:381–389. 8. dehay b, martinez-vicente m, caldwell ga, caldwell ka, yue z, cookson mr, klein c, vila m, bezard e. lysosomal impairment in parkinson’s disease. mov disord. 2013;28(6):725-32. 9. ramirez a, heimbach a, grundemann j, stiller b, hampshire d, cid lp, goebel i, mubaidin af, wriekat al, roeper j, aldin a, hillmer am, karsak m, liss b, ravikumar b, vacher c, berger z, davies je, luo s, oroz lg, scaravilli f, easton df, duden r, o’kane cj, rubinsztein dc. inhibition of mtor induces autophagy and reduces the toxicity of polyglutamine expansions in fly and mouse models of huntington disease. nature genet. 2004;36:585–595. 10. dehay, b., ramirez, a., martinez-vicente, m., perier, c., canron, m. h., doudnikoff, e., ... & bezard, e. loss of p-type atpase atp13a2/park9 function induces general lysosomal deficiency and leads to parkinson disease neurodegeneration. proc natl acad sci. 2012;109(24):96119616. 11. lesage, s., & brice, a. parkinson's disease: from monogenic forms to genetic susceptibility factors. human mol genet. 2009;18(r1):r48-r59. 12. kitada t, asakawa s, hattori n, matsumine h, yamamura y, minoshima s, yokochi m, mizuno y, shimizu n. mutations in the parkin gene cause autosomal recessive 84 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 juvenile parkinsonism. nature. 1998;392:605– 608. 13. valente, e. m., abou-sleiman, p. m., caputo, v., muqit, m. m., harvey, k., gispert, s., ... & wood, n. w. hereditary early-onset parkinson's disease caused by mutations in pink1. sci. 2004;304(5674):1158-1160. 14. vives-bauza, c., zhou, c., huang, y., cui, m., de vries, r. l., kim, j., ... & przedborski, s. pink1-dependent recruitment of parkin to mitochondria in mitophagy. proc natl acad sci. 2010;107(1):378-383. 15. chen l, liu l, huang s. cadmium activates the mitogenactivated protein kinase (mapk) pathway via induction of reactive oxygen species and inhibition of protein phosphatases 2a and 5. free radic biol med. 2008;45:1035–1044. 16. oliveira, h., lopes, t., almeida, t., pereira, m. d. l., & santos, c. cadmium-induced genetic instability in mice testis. human expt toxicol. 2012;31(12):1228-1236. 17. åkesson, a., bjellerup, p., lundh, t., lidfeldt, j., nerbrand, c., samsioe, g., & vahter, m. cadmium-induced effects on bone in a population-based study of women. environ health perspect. 2006;114(6):830-834. 18. manca, d., ricard, a. c., van tra, h., & chevalier, g. relation between lipid peroxidation and inflammation in the pulmonary toxicity of cadmium. arch toxicol. 1994;68(6):364-369. 19. torra, m., to-figueras, j., rodamilans, m., brunet, m., & corbella, j. cadmium and zinc relationships in the liver and kidney of humans exposed to environmental cadmium. sci total environ. 1995;170(1-2):53-57. 20. wang, b., & du, y. cadmium and its neurotoxic effects. oxid med cell longev. 2013;2013:1-12. 21. son, y. o., wang, x., hitron, j. a., zhang, z., cheng, s., budhraja, a., ... & shi, x. cadmium induces autophagy through ros-dependent activation of the lkb1–ampk signaling in skin epidermal cells. toxicol appl pharmacol. 2011;255(3):287-296. 22. panche, a. n., diwan, a. d., & chandra, s. r. flavonoids: an overview. journal of nutritional science. 2016. 23. iwashina, t. flavonoid properties of five families newly incorporated into the order caryophyllales. bull natl mus nat sci. 2013;39:25-51. 24. moorkoth, s. synthesis and anti-cancer activity of novel thiazolidinone analogs of 6aminoflavone. chem pharm bull. 2015;c1500454. 25. pm, m. m., shahi, m. h., tayyab, m., farheen, s., khanam, n., tabassum, s., & ali, a. cadmium‐induced neurodegeneration and activation of noncanonical sonic hedgehog pathway in rat cerebellum. j biochem mol toxicol. 2019;33(4):e22274 26. rehman, s. u., ahmad, a., yoon, g. h., khan, m., abid, m. n., & kim, m. o. inhibition of cjun n-terminal kinase protects against brain damage and improves learning and memory after traumatic brain injury in adult mice. cereb cortex. 2018;28(8):2854-2872. 27. elkhadragy, m. f., kassab, r. b., metwally, d., almeer, r. s., abdel-gaber, r., alolayan, e. m., ... & abdel moneim, a. e. protective effects of fragaria ananassa methanolic extract in a rat model of cadmium chlorideinduced neurotoxicity. biosci rep. 2018;38(6):bsr20180861. 28. khan, a., ikram, m., muhammad, t., park, j., & kim, m. o. caffeine modulates cadmiuminduced oxidative stress, neuroinflammation, and cognitive impairments by regulating nrf2/ho-1 in vivo and in vitro. j clin med. 2019;8(5):680. 29. chong, w., jiménez, j., mciivin, m., saito, m. a., & kwakye, g. f. αsynuclein enhances cadmium uptake and neurotoxicity via oxidative stress and caspase activated cell death mechanisms in a dopaminergic cell model of parkinson’s disease. neurotox res. 2017;32(2):231-246. 30. luo, t., yuan, y., yu, q., liu, g., long, m., zhang, k., ... & liu, z. parp-1 overexpression contributes to cadmium-induced death in rat proximal tubular cells via parthanatos and the mapk signalling pathway. sci rep. 2017;7(1):1-13. about:blank annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 anum haider 6 original article doi: 10.29052/2412-3188.v5.i1.2018.6-16 frequency of somatic complains among patients with mental illness anum haider1 & usama asad2 1 dow medical college, dow university of health sciences, karachi 2 sindh medical university, karachi. corresponding author email: anum.haider@duhs.edu.pk received 10/05/2018; accepted 20/09/2018; published 10/10/2018 abstract background: it is established that physical and mental disorders share common risk factors, among those the unhealthy lifestyle is most common. in order to achieve complete health, it is crucial to monitor both physical and mental health. mental health problem is the most deserving area to work with because physical health issues are often neglected or mismanaged. this study intends to unveil the frequency of somatic (physical) health complains among patients with mental illness. methodology: in this cross-sectional study total 85 patients were enrolled from psychiatry out patient department, civil hospital karachi, during 16th october to 13th november 2015. patients were asked about the demographic details and existing somatic complaints from the pre-formulated questionnaire while data was analyzed on spss. results: 32.9% of the subjects were diagnosed with particular medical comorbidity. however, among undiagnosed somatic (physical) complains; endocrinological complaints were more frequent i.e.16.7% followed by 14.2% gastrointestinal (git) and 13.68% central nervous system (cns). conclusion: the current study supported the fact that there is a high frequency of somatic complaints in patients with mental illness. physical monitoring is crucial for early identification and better prognosis. keywords somatic complains, mental illness, unhealthy life style, physical monitoring. introduction the ability to perform well at work and to fulfill the responsibilities depends on the physical and mental well-being of a person. if health compromises in either way it may hamper the overall functioning of an individual (alonso et al., 2014). the physical and mental problems are often found to be interlinked but only a few studies have explained the basis of such linkage. multisystem involvement due to the dysregulated inflammatory background is identified as the underpinning factor for cardiovascular and bipolar disorders (leboyer et al., 2012). the main explanation of centrally driven pain conditions like irritable bowel syndromeibs, fibromyalgia, and interstitial nephritis can be considered as other possible mechanisms. these disorders mimic mood disorders and respond well to cnsneuromodulatory agents like serotonin norepinephrine reuptake inhibitor-snri and anticonvulsants (phillips, 2011). inflammation is a state shared by both physical and psychiatric disorders which play a bidirectional causational role, disrupting the neuroregulatory systems (serotonergic, dopaminergic, neuropeptide y) and hypothalamic-pituitary-adrenal axis (hpa) (nousin, 2013). broadly if we classify the possible risk factors to activate the inflammatory mechanism, it might go into three dimensions; biological that includes obesity, sedentary lifestyle, smoking and any disability, psychological including chronic stressors, adverse life events, abuse, neglect) and social includes poverty, http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 anum haider 7 neighborhood, social support, isolation, household dysfunctions. these factors act in an integrated manner to disrupt the hpaaxis and neural circuitry resulting in the manifestation of various physical and psychiatric problems (druss, 2011). the unhealthy lifestyle such as smoking, alcohol, and substance abuse, lack of physical activity, poor eating habits, suboptimal hygiene and disturbed sleep pattern) is identified as modifiable risk factor for many physical problems making the population more vulnerable (scott, 2011 & druss, 2011). mental illness itself, is more likely to be associated with disability and physical problems such as obesity, metabolic syndrome, diabetes mellitus-dm, cardiovascular and respiratory issues are almost twice more common in patients with severe mental illness than that of general population and it may also increase the mortality risk up to five times (scott et al., 2009 & hayward, 1995). the association of mental illness with other somatic complains and medical comorbidities may play a synergistic role by adding on the burden. it not only impairs quality of life but also compromises life expectancy to such an extent that almost 30 years of life may be lost in this population (scott et al., 2009 & hayward, 1995). beside psychotropic use such as antipsychotics which have established role in causing obesity and metabolic syndrome, there is a complex interplay of neurobiological (genetics, leptin sensitivity, hpa axis), psychological (negative emotions, stress proneness, type a personality, hostility) and social factors (low social support, poverty, alcohol, substance use) in the presentation of physical health problems (taylor et al., 2012 & smith, 2011). cardiovascular problems are among the most commonly identified physical comorbidities in patients with mental illness while the possible underlying phenomenon studied is perseverative cognition especially those with mood and anxiety disorders which may delay physiological recovery from acute stress but also increases the risk for cardiovascular damage (larsen, 2009). despite the high rate of physical comorbidity, it’s going to be unattended and mislabeled as psychosomatic or functional at a significantly high rate and ultimately worsening the psychological stability, treatment adherence, life expectancy and quality of life (hert, 2011 & gray, 2012). studies have reported that psychiatrists were found to be more frequent in overlooking medical problems in patients with medical illness than that of physicians, however, the physical comorbidity rate was actually estimated to be 43% in those patients (koryani, 1979). patients with mental illness, the most hampering factor identified in seeking help is a stigma (mercer et al., 2012). this delay in identification and management of physical health problems in mentally ill patients makes premature mortality highly prevalent. even in high-income countries, the male population with mental illness die around 20 years while females 15 years earlier than the general population (thornicroft, 2011 & lawrence, 2013). besides, presenting as a comorbidity, physical problems may also manifest psychiatric problems and may be misdiagnosed as a psychiatric illness. hall et al in his study reviewed the previously diagnosed psychiatric cases by a combination of physical, psychiatric and neurological examinations followed at labs. he came up with the medical diagnosis in around 46% of cases (hall et al., 1980). the ultimate question arises in mind, how such an important presentation can be overlooked by health professionals? the research has proposed the possible answer like lack of screening and assessment of http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 anum haider 8 physical health aspects. other possibilities are variable presentations due to patient and carer’s race and ethnic characteristics, the deficits in a system including lack of resources, poverty, inaccessible health services (hert et al., 2011 & hitchen, 2011). at a system level, actions are not easy to recognize but at the individual level, simple and basic care can improve the suboptimal medical care. psychiatrists can play a crucial role by expanding the clinical paradigm including physical monitoring and adherence to treatment guidelines. educating patients to control suboptimal lifestyle factors and promoting healthy health behaviors (diet, exercise, smoking cessation) may have a remarkable advantage over physical health outcomes (hert et al., 2011 & hitchen, 2011). considering the importance of the subject and lack of research in this regard especially in the third world countries like pakistan, this study aimed to determine the frequency of somatic complains among patients with mental illness so that clear picture may come upon the surface to better raise the consideration on an important area. as it has a bidirectional impact, physical and mental disorders may synergistically affect not only an individual's quality of life but at the gross level adversely affects the economy. at the individual level it hampers the productivity and impairs the economy by high utilization of resources. there is a high need to narrate the future health plan accordingly, to better cope with the discussed issue and to get the better health outcome and economy consequently. methodology a cross-sectional study was conducted in psychiatry out patient department, civil hospital karachi, thrice per week during 16th october to 13th november 2015. convenience sampling technique was used and informed consent was obtained. patients presented with the reliable informant and clearly defined somatic complains, agree to visit the site and diagnosed with mental illness from icd-10 diagnostic criteria previously and proficient in speaking the urdu language were included in the study. however, those who were unstable or unwilling were excluded. total 85 patients were selected and interviewed via a semi-structured questionnaire. the questionnaire includes chief complaints of the major vital systems such as cardiovascular system (cvs), respiratory system, central nervous system (cns), gastrointestinal (gi), endocrine, dental, dermatological, genitourinary and locomotory system. the list of somatic complains was adapted from the local book of bedside techniques. data was analyzed using spss version.19. result among 85 patients, the mean age of presentation was 34.87 ± 13.46years. majority of the study participants were males 56(66%) and married 42(49.4%). about one third 28(32.9%) of the patients were observed with diagnosed medical comorbidity. among these, hypertension (16.7%) was the most frequent followed by hepatitis, tuberculosis (tb), asthma, diabetes mellitus (dm) and hyperlipidemia as shown in table 1. http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 anum haider 9 table 1: demographic characteristics variables mean + sd age (years) 34.87±13.46 n (%) gender male female 56(66) 29(34) marital status married single divorced 42(49.4) 40(47) 3(3.5) medical comorbidity (htn, dm, hepatitis, t.b, asthma & hyperlipidemia) 28(32.9) *htn= hypertension, dm= diabetes mellitus, tb= tuberculosis *sd=standard deviation, n=frequency *nos=not otherwise specified figure 1: frequency of psychiatric illness (n=85) in the studied sample, schizophrenia was the more frequently found psychiatric diagnosis i.e. 42.4% followed by psychosis 24.7%, depression 8.2% and bipolar disorder 5.9%. 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 42.40% 1.20% 1.20% 24.70% 8.20% 5.90% 4.70% 2.40% 2.40% 4.70% 2.40% p e rc e n ta ge s mental illnesses http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 anum haider 10 figure 2: frequency of psychotropic use according to the results in figure 2, antipsychotics use was also found to be pronounced (78.8%) among the studied population. *cvs=cardiovascular system; cns= central nervous system; gi= gastrointestinal tract figure 3: frequency of physical complaints in the vital organ systems among undiagnosed physical complains of the vital organ systems, endocrinological complaints were found to be more frequent 16.7% followed by gi 14.2%, cns 13.68%, cvs 12.7%, respiratory 10%, renal 9.7%, dental 9.1%, dermatological 6.38%, musculoskeletal 6.08% and genital 1.2%. while the most frequent systemic complains among studied systems were; palpitation(45%), breathing problems (37%), constipation (20%), increased frequency in micturition (50%), rash (60%), joint pain (80%), polydipsia (54.5%), xerostomia (85.5%), unspecified genital complaints (100%) and headache (42%) as described in table 2. 78.80% 10.80% 10.40% -antipsychotics -antidepressants -others 0 5 10 15 20 -endocrine -gi -cns -cvs -respiratory -renal -dental -dermatological -musculoskeletal -genital 16.7 14.2 13.68 12.7 10 9.7 9.1 6.38 6.08 1.2 percentage % p h ys ic al c o m p la in ts http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 anum haider 11 table 2: distribution of physical complains in individual systems physical systems complaints n (%) cardiovascular palpitation chest pain syncope unspecified/mixed 5(45) 3(27) 2(19) 1(9) gastrointestinal constipation nausea vomiting abdominal pain heartburn dysphagia jaundice diarrhea unspecified/mixed 3(20) 2(15) 1(7.6) 1(7.6) 2(15) 1(7.6) 1(7.6) 1(7.6) 1(7.6) endocrinological polydipsia heat intolerance cold intolerance sweating unspecified/mixed 8(54.5) 2(13) 1(6) 2(13) 2(13) respiratory breathing problem cough & flu hemoptysis mixed symptoms 3(37) 2(25) 1(12.5) 2(25) renal increased frequency dysuria unspecified/mixed 4(50) 3(37.5) 1(12.5) dental xerostomia poor oral hygiene 6(85.5) 1(14.5) dermatological rash itching 3(60) 2(40) musculoskeletal joint pain unspecified 4(80) 1(20) genital unspecified 1(100) central nervous system headache fits blackouts dizziness unspecified/mixed 5(42) 2(16.6) 1(8.2) 2(16.6) 2(16.6) http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 anum haider 12 discussion other studies pertinent to this subject also found chronic physical health problems as frequent as 74% among patients with severe mental illness and about half of the individuals had experience of more than two kinds of chronic physical health problems. chronic pulmonary illness was found to be more prevalent in such problems (jones et al., 2004). in our study, about one third (33%) of the patients were already diagnosed with certain medical comorbidity. while in the undiagnosed physical complains endocrinological, gi, cns and cvs related complaints were more frequent (figure 3). due to common risk factors (obesity, smoking, dyslipidemia) and antipsychotic use, disorders such as cardiovascular diseases and diabetes mellitus mostly prevails in people with severe mental illness (schizophrenia, depression, and bipolar disorder) (hert et al., 2009). our study sample was pronounced with psychotic patients (schizophrenia 42.4%, psychosis nos 24.7%) and similarly the antipsychotic use 78.8% (figure 2). this is controversial to the available evidence where neurotic problems like depression, anxiety are considered to be more prevalent than psychotic disorders. it may be due to the fact that people with neurotic problems usually hardly seek help from psychiatric facility and therefore psychotic problems seem to be over presented. in our study overall female proportion is lesser i.e. 34%, this might be due to cultural inhibition and less acceptance of psychological problems. as we broadly compare our study results to previous evidences, (table 2), constipation has been found a frequent problem (20%) in psychiatric patients especially of old age (vessurun et al., 2016). other gastrointestinal complaints like nausea, anorexia, and flatulence we also found prevalent mostly in neurotic patients and ultimately label to be suffering from irritable bowel syndrome (sobański et al., 2015). palpitation is one of the frequent physical complaint in our patients (table 2). studies have identified bidirectional relation of cardiovascular and psychiatric problems, both direct and neurochemical effects (christoph et al, 2014 & shah et al., 2004). it is very important to identify its exact relationship in particular patient because the management plan would vary (alijaniha et al., 2016). headache also has a remarkable association with psychiatric problems (table 2). the evidence supports its both comorbid and associated presentation with psychiatric disorders, especially migraine headache with that of tension, irritability and anxiety (shakya, 2015). frequent drinking of water i.e., polydipsia has an association with schizophrenia, anxiety and depressive disorders. but it has its medical basis and medical complications (hyponatremia) as well. the reliable and economical physiological tests are available to easily differentiate and manage this condition (calara et al., 2017). breathing problem and impaired lung function have found to be frequent especially in schizophrenia. its pathological presentation is almost similar to that of pneumonia, chronic obstructive pulmonary disease and chronic bronchitis while clinically it can be easily missed (partti et al., 2015). our patients also had breathing complains (table 2). psychiatric disorders like bipolar affective disorder, depressive disorder, and anxiety are identified as risk factor for joint pain disorder like osteoarthritis possibly due to medication side effects and unhealthy lifestyle or obesity (huang et al., 2016). urinary complains are also frequent as in our study mental health professionals rarely take it considerable to rule out possible pathologies (przydacz et al., 2017). genital problems are usually unreported, unaddressed or misidentified (basson et al., 2018 & grover et al., 2016). in our study, most genital complains were unspecified it might be due to taboo or insufficient http://www.aeirc-edu.com/ annals of psychophysiology ©advance educational institute & research centre volume 5, october 2018 www.aeirc-edu.com issn 2412 3188 anum haider 13 professional skills (table 2). xerostomia is identified as a frequent dental problem study (85.5%) possibly due to poor diet and medication side effects (tomar et al., 2011 & kisley et al., 2011). with such frequent presentation, physical disorders are often missed even by nonmental health professionals. various direct or indirect factors are responsible such as poor communication and handling skills for challenging behavior of the patient, complex clinical presentation and overburdening (shefer et al., 2014).to overcome this issue of a significant association between physical and psychiatric problems which worsen quality of life and increases the health care burden, there is a high need to take certain steps. education and awareness of healthcare professionals are instrumental among all. beside these improving communication among primary care and specialist health professionals by inclusion of mental health with general medical care (druss, 2011), involving significant other in the care to emulate and maintain healthy behaviors and habits such as physical activity, proper sleep, avoidance of smoking, alcohol or other substance abuse and intake of healthy diet (happell 2012 & thoits, 2011) and monitoring physical and mental health status and effect of treatment (carlier, 2012 & eldridge, 2011). although interventional studies evidence is scarce (hardy et al., 2011) but there are good results of even involving mental health nurses in improving care and services by monitoring physical health (bradshaw, 2012). the study has certain limitations, results cannot be generalized due to small sample size and short study duration, the demographic details were insufficient, the association and correlation of variables could not be studied and the medical specialist opinion couldn't seek about those physical complaints. our study is an initiation towards more specific and extensive work in this subject like assessing a large sample size that includes both urban and rural population for a long duration to study, the sequence of development of various medical and psychiatric disorders, correlation of physical and psychiatric illness, interventional studies regarding awareness of patients about acquiring healthy lifestyle and regular physical checkup in case of presence of risk factors and also education of mental health professionals regarding monitoring, early identification and its impact on clinical outcome as well as for liaison work involving general health professionals regarding approaching patients with psychiatric presentation. conclusion our study concluded that somatic complaints are frequent in patients with psychiatric illness in almost all systems i.e. cvs, gi, cns, respiratory, dental, genital, dermatological, endocrine, musculoskeletal and renal. physical monitoring is crucial for early identification. it is recommended to identify, properly investigate and manage somatic complains in patients with mental illness to improve overall prognosis and quality of life. it can be achieved by improving the skills of health professionals. conflicts of interests none. acknowledgment we would like to acknowledge the patients enrolled in the study and their attendants for cooperation. funding none. references  alijaniha, f., noorbala, a., afsharypour, s., naseri, m., fallahi, f., mosaddegh, m., zadeh, s., sadrai, s. 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https://www.ncbi.nlm.nih.gov/pubmed/?term=watanabe%20m%5bauthor%5d&cauthor=true&cauthor_uid=18366819 https://www.ncbi.nlm.nih.gov/pubmed/?term=williams%20d%5bauthor%5d&cauthor=true&cauthor_uid=18366819 76 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v10.i2.2023.76-83 original article exploring the impact of artificial intelligence on human cognitive abilities: is it a blessing or a curse? shama gul1, farah batool1, fiza a. rasheed1 & wardha kaleem2 1malir university of science and technology, karachi-pakistan, karachi-pakistan 2atia general hospital, karachi-pakistan abstract background: artificial intelligence (ai) has become an integral aspect of contemporary society, offering a wide array of applications from voice assistants to autonomous vehicles. this study investigates the effects of ai technology usage on human cognitive abilities. methodology: this study utilized a mixed research method, employing semistructured interviews to gather data from 20 teachers and graduating students of diverse demographics over a 6-month period. a stratified random sample with proportional allocation was selected, and participants completed a pre-tested 21item questionnaire. data analysis was conducted using statistical tools, including spss version 21.0. results: analysis revealed significant insights into the relationship between ai usage and human cognitive abilities. the majority of participants were aged 25-34, predominantly male and educated, with 48% holding a master's degree. a majority reported regular usage of ai-based technologies, with 67% utilizing them daily. participants expressed difficulties in problem-solving, critical thinking, concentration, learning, and decision-making when ai use was hindered, alongside heightened anxiety and stress. conclusion: the study emphasizes the need for cautious and thorough analysis of ethical implications as ai continues to be integrated into businesses. keywords artificial intelligence, cognition, human intelligence, cognitive decline citation: gul s, batool f, rasheed fa. exploring the impact of artificial intelligence on human cognitive abilities: is it a blessing or a curse? app. 2023;10(2): 76-83 corresponding author email: farahbatool97@gmail.com doi: 10.29052/2412-3188.v10.i2.2023.76-83 received 18/10/2023 accepted 22/11/2023 published 01/12/2023 copyright © the author(s). 2023. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v10.i2.2023. about:blank about:blank 77 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 introduction artificial intelligence (ai) stands poised at the forefront of transformative advancements in our current industrial era, echoing the profound impact of the digital revolution ushered in by the internet and digital technologies. widely recognized as the herald of the next industrial revolution, ai permeates various aspects of modern society, from ubiquitous voice assistants and intricate image recognition systems to sophisticated decision-making algorithms and autonomous vehicles1,2. while ai holds immense promise to positively revolutionize human lives, there are profound concerns regarding its potential impact on human cognitive abilities. this study aims to scrutinize the effects of ai technology utilization on the intricate fabric of human cognition. in their seminal work "the second machine age," brynjolfsson and mcafee meticulously dissect the burgeoning landscape of ai, elucidating its profound implications for the economy, the workforce, and the daily experiences of individuals1. they underscore the awe-inspiring progress precipitated by digital technologies in contemporary society while also cautioning against the multifaceted challenges entailed by the swift proliferation of ai. indeed, the advent of ai heralds a new epoch characterized by exponential technological growth and profound societal transformations, necessitating astute navigation of the intricate terrain of digitalization. in recent years, we have witnessed unprecedented strides in ai development across diverse domains, including natural language processing, image recognition, and complex problem-solving. central to these advancements are deep learning algorithms, drawing inspiration from the intricate architecture of the human brain. leveraging vast datasets, deep learning algorithms adeptly traverse the labyrinth of data, continually refining their performance and prowess over time3-6. a watershed moment in the annals of ai history was the triumph of alphago, an ai system engineered by google's deepmind, over the reigning world champion in the ancient game of go in 2016. this seminal feat shattered long-held perceptions, demonstrating ai's capacity to rival and even surpass human cognitive capabilities in domains once deemed exclusive to human intellect. similarly, the advent of openai's gpt-3 in 2020 marked a paradigm shift in natural language processing, epitomizing ai's ability to produce text indistinguishable from human-authored content across an array of linguistic tasks7,8. however, amidst these groundbreaking achievements, it is imperative to acknowledge the inherent limitations of ai. despite its prowess, ai grapples with challenges in domains necessitating nuanced human faculties such as common-sense reasoning, creativity, and emotional intelligence. hence, while ai holds immense promise in augmenting human capabilities, it is unlikely to supplant humans entirely in the realm of cognitive endeavors9-11. in light of these considerations, this study embarks on a multifaceted exploration of the intricate interplay between ai and human cognition, seeking to unravel the implications, challenges, and opportunities posed by the inexorable march of artificial intelligence. through rigorous inquiry and nuanced analysis, we endeavor to shed light on the evolving dynamics shaping the human-ai symbiosis and chart a course toward a future where ai serves as an enabler of human flourishing rather than a harbinger of obsolescence. 78 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 methodology study design this study adopted a mixed research method, combining qualitative and quantitative approaches to comprehensively investigate the impact of artificial intelligence (ai) on human cognitive abilities. setting the study was conducted within educational institutions, encompassing both teachers and graduating students from diverse backgrounds in terms of gender, age, and socioeconomic status. participants participants included teachers and graduate students from various demographic backgrounds, ensuring a diverse representation of perspectives. the inclusion criteria were broad, encompassing individuals of all genders, ages, and socioeconomic backgrounds. variables the primary variable of interest was the impact of ai on human cognitive abilities. other variables may have included participants' familiarity with ai, their attitudes toward it, and their experiences using ai technologies. data sources/measurement data collection utilized semi-structured interviews and a self-administered questionnaire consisting of 21 items. the questionnaire was pre-tested on a pilot group to ensure clarity and relevance. data were collected over a period of 6 months, allowing for comprehensive exploration of the research questions. bias efforts were made to mitigate bias by employing a stratified random sampling technique with proportional allocation, ensuring representation across different demographics. however, it's acknowledged that there may be biases inherent in selfreported data and participant recruitment. study size the study included a sample size determined through stratified random sampling, aiming for adequate representation across various demographic categories. twenty individuals who were either unaware of ai or had not used ai were excluded from the study to focus on participants with relevant experiences. quantitative variables quantitative data collected included responses to the 21-item questionnaire, which were then analyzed using descriptive statistics. these statistics provided insights into participants' perceptions, experiences, and attitudes towards ai. statistical methods data analysis was conducted using spss version 21, employing descriptive statistics to summarize and interpret the quantitative findings. this facilitated a systematic exploration of the collected data, allowing for meaningful insights into the impact of ai on human cognitive abilities. result participants the study comprised 150 participants, with a balanced gender distribution: 50% male, 37% female, and 13% opting not to disclose their gender. the age distribution was predominantly in the 25-34 range (36%), with varying proportions across other age groups. educational backgrounds ranged from matriculation to postgraduate levels, with the highest representation among graduates (48%) and postgraduates (27%). socio-economic status indicated a majority from middle-class backgrounds (66%), 79 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 followed by lower (14%) and higher (20%) strata. descriptive data table 1 provides a comprehensive snapshot of the demographic composition of the study participants, detailing frequencies and percentages across various demographic variables such as gender, age, educational background, and socio-economic status. notably, the sample represents diverse demographics, allowing for a comprehensive analysis of the impact of aibased technologies across different groups. outcome data the survey results, as presented in table 2, shed light on the participants' interactions with ai-based technologies. a significant majority (67%) reported frequent usage of ai tools, with 62% expressing increased reliance on them. additionally, notable proportions noticed changes in memory (54%) and found it more challenging to recall information (52%) since using ai. concerns about declining cognitive abilities were prevalent, with 45% experiencing difficulties in problem-solving and critical thinking. anxiety related to ai dependency was also evident, as 57% reported feeling stressed when unable to use ai tools. main results the main findings of the study highlight the pervasive influence of ai-based technologies on various cognitive aspects among participants. increased usage and reliance on ai tools were widespread, accompanied by observed changes in memory retention and information recall. moreover, a substantial portion reported difficulties in problemsolving, critical thinking, concentration, and decision-making since engaging with ai technologies. concerns regarding the potential negative impacts of ai on cognitive abilities were prevalent, with a significant proportion expressing anxiety or stress when unable to access ai tools. table 1: demographic data of the participants (n=150). variables frequency percentage gender male 75 50 female 56 37 prefer not to say 20 13 age 18-24 30 20 25-34 54 36 35-44 47 31 45-54 18 12 55 and above 2 1 educational background matric 5 3 intermediate 21 14 graduate 72 48 postgraduate 41 27 others 12 8 socio-economic status lower 21 14 middle 99 66 high 30 20 80 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 table 2: the survey results of the study participants. questions frequency percentage ai tools usage frequently 101 67 sometimes 33 22 rarely/never 17 11 increased reliance on ai tools yes 93 62 no 17 11 not sure 41 27 noticed any changes in your memory since using ai-based technologies yes 81 54 no 17 11 not sure 53 35 find it more challenging to recall information since using ai-based technologies. yes 78 52 no 23 15 not sure 50 33 experienced difficulties in problem-solving or critical thinking skills since using ai yes 68 45 no 29 19 not sure 54 36 ai-based technologies have impacted your ability to concentrate or focus yes 75 50 no 18 12 not sure 57 38 have you noticed any decline in your ability to learn new things since using ai? yes 72 48 no 21 14 not sure 57 38 find it harder to make decisions independently since using ai yes 72 48 no 26 17 not sure 53 35 concerned about the potential negative effects of ai on your cognitive abilities yes 83 55 no 21 14 not sure 47 31 feel anxious or stressed when you are unable to use ai-based technologies yes 86 57 no 56 37 not sure 8 5 discussion the pervasive integration of ai into various facets of daily life has prompted considerable debate regarding its impact on human cognition, decision-making, and productivity. this study sought to elucidate the nuanced relationship between ai utilization and potential declines in these cognitive abilities12. the findings reveal a notable trend wherein graduate students exhibit a higher frequency of ai tool usage compared to undergraduate and master's degree holders. this suggests a differential adoption pattern among individuals with varying levels of educational attainment, warranting further exploration into the underlying factors influencing this discrepancy. an overarching theme emerging from the study is the perceived correlation between 81 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 increased reliance on ai and a potential decline in cognitive engagement and decision-making autonomy. the results indicate a propensity for individuals heavily dependent on ai to exhibit tendencies towards laziness, as ai-enabled products and services streamline tasks, potentially reducing the need for cognitive effort13-15. while this aspect remains relatively underexplored in prior research, it aligns with existing literature highlighting the impact of automation on human behavior and cognition13,14. the implications of ai integration in education are particularly noteworthy, as the study suggests a concerning trend toward diminished cognitive engagement among students and educators. ai's ability to automate routine tasks may inadvertently discourage independent thinking and problem-solving skills, leading to a reliance on technology at the expense of cognitive development16,17. this phenomenon underscores the importance of fostering a balance between ai integration and the preservation of essential cognitive faculties in educational settings18-20. moreover, the findings underscore the notion that ai's expanding role in decisionmaking processes may exert a profound influence on human cognition. while ai offers undeniable benefits in processing vast amounts of data and optimizing decision outcomes, there exists a potential downside wherein human decision-makers may become overly reliant on ai-driven insights, leading to an atrophy of critical thinking and intuitive analysis skills21,22. this echoes concerns raised by previous research regarding the erosion of human agency in decision-making processes due to the increasing dominance of ai technologies23. ultimately, the study highlights the complex interplay between ai utilization and human cognition, pointing towards a need for cautious integration and proactive measures to mitigate potential negative consequences. as ai continues to evolve and permeate diverse domains, it is imperative to prioritize the preservation and enhancement of human cognitive abilities, ensuring a symbiotic relationship between ai and human intelligence. further interdisciplinary research is warranted to deepen our understanding of the multifaceted impacts of ai on cognition and decision-making, paving the way for informed strategies to harness its transformative potential while safeguarding human cognitive resilience. conclusion in conclusion, the emergence of ai presents a complex scenario for human cognition, offering both opportunities for advancement and potential hazards. while ai has the capacity to enhance efficiency and decisionmaking, its unchecked proliferation may lead to risks such as cognitive decline and excessive reliance. therefore, a cautious and ethically mindful approach to ai development and integration is crucial. this entails prioritizing ethical considerations, implementing regulatory oversight, and fostering interdisciplinary collaboration and transparent dialogue. by doing so, we can aim to harness ai's transformative potential while safeguarding human cognitive resilience, steering toward a future where ai empowers rather than diminishes, maximizing benefits while minimizing risks to human cognitive abilities. acknowledgment the authors extend heartfelt gratitude to all the respondents for dedicating their time to participate in the survey. references 1. brynjolfsson e, mcafee a. the second machine age: work, progress, and prosperity 82 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 in a time of brilliant technologies. new york (ny): ww norton & company; 2014. 2. dejoux c, léon e. metamorphose des managers. 1st ed. france: pearson; 2018. 3. jungwirth d, haluza d. artificial intelligence and public health: an exploratory study. int j environ res public health. 2023;20(5):4541. 4. european parliamentary research service. artificial intelligence act. 2021. [accessed on 21 february 2023]. available at: https://www.univiu.org/images/aauniviu 2017/gp/cocurr/artificial_intelligence_act.pdf 5. knight w. tech companies want ai to solve global warming. mit technology review. 2016. [accessed 15 aug. 2016]. available at: https://www.technologyreview.com/s/545 416/couldai-solve-the-worlds-biggestproblems/ 6. zhang mc, liu ky, dong yy. e -hotspot dynamics and development tendency of artificial intelligence research—mirror scanning of mapping knowledge domain based on chinese and foreign journal papers recent 10 years. j shandong normal university. 2019;34(1):1–12. 7. garg a. what is chatgpt, and its possible use cases? 2022. [accessed: july 15, 2023]. available at: https://www.netsolutions.com/insights/w hat-is-chatgpt/ 8. jeyaraman m, k sp, jeyaraman n, nallakumarasamy a, yadav s, bondili sk. chatgpt in medical education and research: a boon or a bane? cureus. 2023;15(8):e44316. 9. silver d, huang a, maddison cj, guez a, sifre l, van den driessche g, et al. mastering the game of go with deep neural networks and tree search. nature. 2016;529(7587):484– 9. 10. brown t, mann b, ryder n, subbiah m, kaplan jd, dhariwal p, neelakantan a, shyam p, sastry g, askell a, agarwal s. language models are few-shot learners. advances in neural information processing systems. 2020;33:1877-901. 11. ahmad sf, han h, alam mm, rehmat m, irshad m, arraño-muñoz m, ariza-montes a. impact of artificial intelligence on human loss in decision making, laziness and safety in education. humanit. soc. sci. 2023;10(1):14 12. farrow e. determining the human to ai workforce ratio—exploring future organisational scenarios and the implications for anticipatory workforce planning. technol soc. 2022;68(101879):101879. 13. bartoletti i. ai in healthcare: ethical and privacy challenges. in: artificial intelligence in medicine: 17th conference on artificial intelligence in medicine, aime 2019. springer international publishing, poznan, poland; 2019. pp. 7–10. 14. nikita. advantages and disadvantages of artificial intelligence. simplilearn. 2023. available at: https://www.simplilearn.com/advantagesand-disadvantages-of-artificialintelligencearticle 15. baron ns. even kids are worried chatgpt will make them lazy plagiarists, says a linguist who studies tech’s effect on reading, writing and thinking. fortune. 2023. available at: https://fortune.com/2023/01/19/what-ischatgpt-ai-effectcheating-plagiarismlaziness-education-kids-students/ 16. posner t, fei-fei l. ai will change the world, so it’s time to change a. nature. 2020;588(7837):s118–118. 17. pomerol j-c. artificial intelligence and human decision making. eur j oper res. 1997;99(1):3. 18. duan y, edwards js, dwivedi yk. artificial intelligence for decision making in the era of big data—evolution, challenges and research agenda. int j inf manage. 2019;48:63–71. 19. cukurova m, kent c, luckin r. artificial intelligence and multimodal data in the service of human decision‐making: a case study in debate tutoring. br j educ technol. 2019;50(6):3032–3046. 20. ahmad. knowledge management as a source of innovation in public sector. indian j nat sci. 2019;9(52):16908–16922. 21. jarrahi mh. artificial intelligence and the future of work: human–ai symbiosis in organizational decision making. bus horiz. 2018;61(4):1–15. 83 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 22. ghosh b, daugherty pr, wilson hj. taking a systems approach to adopting ai. harv bus rev. 2019. 23. sebastian r, sebastian k. artificial intelligence and management: the automation–augmentation paradox. acad manage rev. 2021;46(1):192–210. 24. mohamed aa, marques o. diagnostic efficacy and clinical relevance of artificial intelligence in detecting cognitive decline. cureus. 2023;15(10):e47004. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v10.i2.2023.%2075-82 2 annals of psychophysiology volume 11 december 2024 table of contents editorial pgn spotlight on saybrook university’s doctoral and masters programs in applied 04 psychophysiology and changes in the journal’s administration r. sherman, editor-in-chief original research pgn a cyberphysiologic technique for stress control through a youtube video 05 channel useable anytime, anywhere d. do pgn the efficacy of biofeedback-integrated ambient lighting in stress and anxiety 20 reduction u. sajid, s. noushad, and s. ahmed pgn establishment of the relationship between continued practice of hatha yoga 25 and goal attainment a. foster pgn assessing the effectiveness of training logic and reasoning skills among middle and 34 high school students using a pre to post training assessment g. timlin pgn exploring the impact of different yoga practices on psychological resources 42 and emotional well-being: a single-session study. y. saleem, s. noushad, and s. ahmed reviews and summaries of hot topics in psychophysiology on the cover: photos of a child having her forehead recorded to evaluate muscle tension in the face and a second child being recorded to evaluate relationships between forearm muscle tension and strength. photos provided by dr. eric k. willmarth, associate editor of annals of psychophysiology. 3 pgn hormone replacement therapy and mood disorders during menopause 52 m. persson pgn the silent echoes of trauma: how pain shapes brain and body 60 s. noushad and s. ahmed 44 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v10.i1.2023.xx-xx review article psychophysiological responses to childhood trauma in adulthood a review ayesha faisal , maryum firdous & hafiza fatima zehra department of psychology, mohammad ali jinnah university, karachi-pakistan abstract background: in this review, the impacts of childhood trauma are examined, and how they influence the thoughts and behaviors of most adults. some people are resilient and develop proper coping mechanisms against it with the help of immediate therapeutic counsel. many indulge in maladaptive coping strategies that do more harm than good. these strategies commonly occur in many anxiety disorders alongside symptoms that fit diagnostic criteria. however, this review will indicate that the impacts of trauma should not be confused with post traumatic stress disorder. methodology: multiple studies and articles surrounding the topic of trauma and its signs were selected for this review and compiled for a better understanding of the consequences of trauma. results: previous studies have shown that trauma comes in many forms, each damaging to a child's upbringing, from neglect to sexual abuse. there are several types of traumas, each caused by numerous reasons and originating from different backgrounds, but there is a clear distinction between each that is elaborated. without properly monitoring the conditions, the mental and biological state of the human body can worsen, and the child can develop severe mental illnesses such as depression. conclusion: the literature has provided multiple psychotherapies and intervention techniques that would treat various conditions and focus on improving well-being based on their effectiveness and research on evaluating treatment for stress responses. the available literature has been examined, and responses occurring in emotional, physical, cognitive, behavioral, and social categories are delineated. suggestions for future research are also discussed in this paper. keywords childhood trauma, responses to trauma, psychophysiological responses, adult responses. citation: faisal a, firdous m, zehra hf. psychophysiological responses to childhood trauma in adulthood a review. app. 2023; 10(1): 45-54 corresponding author email: maryum.firdous@jinnah.edu doi: 10.29052/2412-3188.v10.i1.2023.4453 received 16/03/2023 accepted 26/05/2023 published 01/06/2023 copyright © the author(s). 2023. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v10.i1.2023. https://orcid.org/0000-0001-5969-8982 https://orcid.org/0009-0005-8578-1057 https://orcid.org/0009-0006-7285-076x about:blank about:blank 45 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 introduction childhood trauma has serious outcomes for its sufferer and society. it is interpreted in the diagnostic and statistical manual of mental disorders, fifth edition (dsm-v) as an individual exposed to actual or threatened death, serious injury, or sexual violence1. the cause of trauma is an intense physical and psychological stress response. several studies have shown that, including those by dyregrov and yule2, the outcome of trauma has an everlasting effect on the individual's functioning and physical, emotional, social, or spiritual well-being. when the child is a trauma victim, witnesses it, or hears about it happening to a friend or a close relative, it greatly impacts their minds. in toddlers, motor vehicle tragedies, bullying, terrorism, and child maltreatment from physical, sexual, and emotional abuse to domestic and community violence are common childhood traumas that enhance the development of pain disorders and post-traumatic stress disorder (ptsd). child mistreatment or bullying/ beating will have a greater impact on their adulthood. during childhood, it is important to explore the pattern of interactions between the child and their abuser3. single events or series of events can contribute to trauma, which leads to physical and emotional injury4, 5. trauma is divided into two categories, which can occur in children and adults. event trauma, or type i, requires a single unexpected, immediate, or difficult event6. examples of type i trauma can include violence at school, such as school shootings, road accidents, and/or fires. process trauma or type ii calls for a display to be underway and give way to irritants considered too fearful to anticipate4, 7. process trauma, or type ii trauma, includes years of war, repeated violations in physical, emotional, and sexual abuse, and being a victim of domestic abuse. some factors that influence trauma are family or outside family members, the relationship between the child and person, or the surrounding environment4. for example, parents might cause more trauma to a child because that child witnesses their hostile arguments. mulvihill5 suggested that the ongoing parent relationship may also traumatize the child, which starts a fear response due to the violation of trust. neglect is the most common form of childhood maltreatment8. neglect means ignorance or failure by parents and caregivers to provide for the psychological or physical needs of the child8, 9. emotional harm involves actions of an adult that harm a child emotionally, psychologically, or spiritually. it involves an attack on the child's sense of self-worth8. physical abuse involves any part of a child’s body by use of excessive force10. in accordance with jack et al.8, physical abuse includes shaking, grabbing, biting, kicking, and stabbing. sexual abuse refers to the non-consensual stroking of a child's private regions, intercourse, inappropriate speech, sex talk, incest, and sexual manipulation. domestic violence between parental figures and caregivers or other family members. this includes physical injuries or overhearing of violence8. for the child experiencing the trauma, a therapist needs to comprehend the complexities of the trauma and the impact it has on the development of the brain. maturation of the brain will affect several aspects of the child's life, including psychological functioning, behavioral, social, emotional, and cognitive. the structure and development of a child's brain negatively impact while experiencing trauma. the following section describes the most common responses to trauma in emotional, physical, cognitive, behavioral, and social 46 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 domains. it is important to remember that these responses do not have a direct indication of any underlying mental illness or a disorder. most survivors are highly resilient to trauma and can develop effective coping strategies against it11. most show minimal distress and recover with time across many stages in life. even so, individuals will have signs that don't necessarily fulfill the diagnostic criteria for ptsd or acute stress disorder. it is important to acknowledge that these responses are normal but can be distressing. table 1: psychophysiological responses to trauma psychophysiological responses types of trauma emotional responses, such as fight or flight response, stress response, dysregulation of emotion, and numbing event trauma, domestic violence, neglect, or emotional abuse physical responses, such as somatic complaints, hyperarousal, and poor sleep quality process trauma, physical abuse, or sexual abuse cognitive responses, such as cognitive errors, guilt, and shame, inaccurate idealizations, rationalizations, or justifications, trauma-induced hallucinations or delusions, and dissociative disorders process trauma, event trauma, physical abuse, sexual abuse, or emotional abuse behavioral responses, such as self-destructive behaviors, self-harm, re-enacting the event, and avoidance event and process trauma, physical abuse, emotional abuse, domestic violence, or neglect social responses, such as difficulty maintaining relationships, avoiding support, distrust event trauma, neglect, sexual abuse, physical abuse, or emotional abuse emotional responses emotional reactions depend significantly on the individual's socio-cultural history, thus allowing them to be either emotionally resilient to trauma or express strongly towards a trigger. some people learn the ability to move on from dramatic events and face the stressors. others are unable to handle stressful situations and try to escape or seek support from someone familiar. these stress responses do work in favor of saving us from danger but not so much out of context. it is the way we perceive the situation that determines our responses. the perception is built from childhood, during which culture and parental upbringing have a huge impact. perception of the stimuli and childhood experiences work together to determine the way a person responds. in the context of trauma, however, each environmental incentive is perceived and reacted to as an element of danger. therefore, if the situation resembles a past event, the adult survivor will have an adverse stress response. for example, an adult who’s being scolded severely will recall their past abuse and enter a state of anxiety or panic. the fight or flight response is a natural coping strategy against stressful situations that the body aims to protect us from the perceived threat. 47 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 the most common emotional reactions are anger, fear, sadness, and shame. sometimes, people will have difficulties in recognizing their own feelings because of a lack of experience with emotional expression in their family or community. they may associate strong emotions with the trauma that elicits intense emotional responses. if a child witnesses death in the family, as an adult, they may cry in fear of separation from significant others. and then there are those who deny any connection to the past and define their emotions as “numb”12. emotional numbness, in a common perspective, refers to how many people shut off their emotions over a memory that hurts them13. they become disconnected from others, isolate themselves, and lose interest in activities they used to enjoy. this often occurs as a coping against death, grief, anxiety, minimizing stress, etc. due to childhood traumas, many people are unable to regulate their emotions well. regulation is defined by how quickly one can return to their original emotional state after facing a stressful situation. a person who had been exposed to an aggressive family environment in their childhood may display more reactive behaviors than those adults who grew up in a stable environment. such emotional dysregulation does not go on for long but has often led to substance abuse. survivors may indulge themselves in risky or self-harm behaviors, disordered eating, compulsive behaviors such as gambling, and repression or denial of emotions14. emotional expression of traumatic response can be followed by two extremes: either feeling overwhelmed or feeling numbed12. in numbing, the individual will detach all emotions from their memories, thoughts, and behaviours14. these limited expressions of emotions are hard to detect during therapy, and the severity of symptoms is difficult to determine. cognitive behavioral therapy (cbt) and acceptance and commitment therapy (act) have been seen as effective in treating emotional dysregulation and numbing. cognitive behavioral therapy grants expression and understanding of emotions, while empowering clients to turn their thoughts of hopelessness into emotional strength15. acceptance and commitment therapy teaches mindfulness and helps direct attention to living a meaningful life16. physical responses these symptoms include somatic complaints, hyperarousal, and poor sleep quality11. somatization refers to emotional distress concerning one’s own bodily symptoms. specifically when psychological symptoms convert into physical concerns. for example, stress causes weakness, headaches, stomach aches, and nausea. these are usual signs that typically last for a short while and do not lead to greater health problems. however, it becomes a matter of concern when there is a prolonged and increased amount of stress18. sometimes, clients will focus primarily on their physical symptoms and ignore all medical evaluations that fail to confirm their ailments. these somatic complaints are more prone to occur in those people who have trauma. there is no observable cause because the stress is heavily exaggerating their physical complaints, and neither are the people faking it18. intervention is still required to address their concerns, such as mindfulness-based interventions and relaxation therapy19. each treatment is designed to reduce mental and physical tension with a combination of techniques, like special breathing or progressive muscle relaxation exercises. hyper-arousal is a state of extreme alertness caused by the amygdala20, epinephrine, and elevated levels of crh. these are part of the 48 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 diagnostic criteria of post traumatic stress disorder, characterized by signs of sleep disturbances, muscle tension, and startled responses12, 21. this system may serve to fight the trauma, but it also does not give enough time to properly assess and respond to a stressor. hyperarousal may prepare the body against a life-threatening stimulus, but it is also unnecessary when the situation is actually safe. excessive hyperarousal may also increase the chances of stroke22. sleep disturbances are also seen constantly occurring in the form of nightmares, insomnia, difficulty falling asleep, early awakening, and restless sleep23,24,25. the quality of sleep is interrupted when stressful thoughts and memories enter the unconscious. other responses include gastrointestinal, cardiovascular, neurological, musculoskeletal, respiratory, dermatological, urological, and substance use disorders11. these symptoms normally do not go away and remain even after therapeutic intervention. this happens because of relapse, a condition in which medical symptoms appear again after treatment. oftentimes, clients will stop the treatment once the symptoms go away, which causes the relapse to happen. a triggering event or stress may force the individual to return to their old behavior, and then they relapse26. cognitive responses when core beliefs and normal life assumptions are challenged by dramatic incidents, they induce a change in thought processing and affect daily life functioning. some examples include cognitive errors, inappropriate guilt and shame27, inaccurate idealizations, rationalizations, or justifications, and trauma-induced hallucinations or delusions11, 28. these ways of thought instruct decision-making and contribute to certain behaviors. people who have made mistakes in the past and have been shamed will feel immeasurable guilt and will often find themselves apologizing numerous times for every little detail. the degradation of self is a cognitive error, alongside rationalizations that involve justifying behavior or attitude with reasoning, even if it’s already not appropriate. to understand how cognition is altered, beck and colleagues' cognitive triad model (1979)29 is applied. it states only three styles of cognitions: thoughts about the self, about the world, and the future. in keeping with the model, a series of thoughts circulate these factors, and an event acts as an influence on thought patterns. for instance, trauma can make individuals feel vulnerable about themselves, see the world as dangerous, and assume the future as uncertain. witnessing violence or assault can change assumptions that an individual keeps of themselves, others, and the universe. depending on whatever the set of cognitions is, it influences the individual’s ability to use internal and external resources effectively. consequently, cognitions also have the capacity to develop depressive and anxiety symptoms after trauma21. severe childhood trauma is also closely associated as the cause of dissociative disorders30. dissociation is a mental process of detachment from the external world and divulging only in the internal world. it occurs usually in the form of distraction, daydreaming, fantasy, and avoidance. and in extreme cases, depersonalization, fainting, and catatonia could rarely occur. this appears as a common ability to lose track of a particular action at a specific point in time, but for those with severe trauma, it acts as a protective element28. dissociation creates a distortion of time and space, a reduced perception of pain, and the sense that whatever is happening is not real. the individual will enter the space to escape the 49 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 trauma and stress, for example, mentally teleporting to a different place30. dissociation may also relate to mental disorders such as dissociative identity disorder (did), formerly known as multiple personality disorder. severe childhood trauma has been seen to be closely associated as the cause of dissociative disorders30, alongside damage to the hippocampus. behavioral responses behavioral reactions towards a traumatic experience vary from person to person, but they all work similarly, with the aim of managing the distress caused by it. stress management depends upon the individual's way of coping, and there are many techniques that people follow, such as avoiding the problem altogether or playing a game that distracts them. in severe cases, however, some people will reduce their stress by either substance abuse, compulsive, impulsive, or self-harm behaviors. sometimes, others try to be aggressive and gain control over their experiences or reenact the entire event. behavioral reactions may be learned from the past or act as consequences of the past. for example, when a situation has gotten out of hand, they decide not to make any decisions at all (learned helplessness). behavioral responses mainly fall under two categories: reenactment reenactment and avoidance21, 31. reenactmentreenactment is the act of relieving the traumatic experience by recreating it repetitively in their present lives31. it is common among children who play mimicry of what happened during the trauma. whatever they witness, they tend to act it out during playtime and express the experience with their friends without the use of words. for example, if a child witnesses divorce, they may later play a game related to marriage and re-enact arguments between the couples in role play. another similar case in adults can be isolation due to experiences of neglect or from overprotective parents. there are many reasons as to why survivors do this, one being that perhaps they want to master them. examples of reenactment reenactment include self-harm behaviors or self-destructive behaviors. self-harm is an act of intentionally bringing injury to oneself or a way of coping with overwhelming physical distress and helplessness31. those who have experienced repeated childhood trauma are highly prone to develop selfinjury as a maladaptive coping mechanism. it is commonly associated with eating disorders and substance abuse. selfmutilation also occurs in a number of personality disorders (did, histrionic, and borderline), depression, and schizophrenia. fortunately, most people who commit selfharm do not actually have the intention to kill themselves32. however, it can escalate very quickly if therapeutic intervention does not occur. self-destructive behaviors, such as substance abuse or reckless driving33, do not necessarily impact the individual nor get the individual killed on purpose. many studies have shown that substance abuse significantly increases after the trauma and has a higher chance of relapse because of withdrawal symptoms and dependency34. the use of substances depends on many factors, such as the prominent trauma symptoms of the individual and the individual's access to specific substances like cigarettes or cocaine. the substances give them quick relief and comfort from the unresolved trauma, so they avoid difficult emotions to face14. stressors trigger substance abuse and self-harm. to ensure that trauma-induced stress does not occur, trauma-informed care has been seen as a useful approach. it is a service based on the knowledge and comprehension of trauma affecting lives35. actively recording behavior and body language, taking note of triggers, and making sure the trauma does not resurface through any type of interaction. it focuses on building strength and providing 50 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 care, support, safety, and empowerment to patients36. its key elements include realizing how the trauma is affecting the environment, recognizing the signs of trauma from the past and the present, and responding to individual needs. however, this approach may not be widely researched or implemented36. avoidance behaviors are done to preclude anxiety. individuals will avoid people, places, or situations to avoid unpleasant memories, circumstances, and emotions21. it is the sense of escaping the problem. many people have not learned the ways to deal openly with stress or any stressful situation because no one has been taught how. this consistent behavioral pattern increases the likelihood of avoidance more and more often until it becomes problematic. the individual tries to avoid traumatic stressors or memories in whatever way possible, in the hopes that the issue will either go away or someone else will resolve it. there are some people, though, who face their memories and stress (if not immediately) because they have the belief that they need to deal with the issue one way or another. these kinds of people would be considered resilient and are able to handle stress. social responses social or interpersonal relationships are protective factors for traumatized children and adults alike1. it is important that a stable and appropriate support system is established in order to help them cope. in general, friends and family are important for every person’s well-being. however, trauma also affects relationships. they are built on an emotional exchange, which means that those with a close connection to the individual with a traumatic past will directly experience the survivor’s traumatic stress response37, i.e., anger outbursts or too much emotional reactivity. survivors are encouraged to seek support from their friends and family, but sometimes their own negative perceptions cause them to avoid support12. either because they think that nobody is trustworthy or that they are a burden to others. survivors may become more emotionally withdrawn because of their intense emotional and physical reactions and to protect others and themselves from harm. they feel shame and guilt for the way they react, and for the way they are, which further reduces the chance of them using support systems and resources12. the act of seeking support also means surrendering control to someone else. in the past, they might have been hurt or lost something due to a mistake, thus losing control over a situation. no individual wants to submit themselves to someone because they are uncertain of their own safety and want to take no risk of getting hurt again38. there is also the lack of awareness to seek support, or people are not taught to find consolation from a good company, such as men not seeking social support from their friend group because they do not practice an intimate relationship, as compared to women. a final reason why survivors have difficulties in maintaining relationships is betrayal. their own trusted caregivers or family members were the ones who committed the abuse. this creates a sense of distrust and causes difficulties in connecting with others. they are more cautious and observant of others, constantly in fear of being harmed again. betrayal can affect the ability to form attachments, yet supportive relationships are necessary to recover from trauma11, 37. the first step is to tackle the fear against it and show them the benefits of therapy. providing proper guidance and unconditional support should help them gain insight and encourage them to seek support from family and friends. 51 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 conclusion there are several adaptive behaviors in response to trauma and as a way to cope with terrible past events. emotional reactions range from stress responses to severely disturbed states of mind, such as numbing, regression, denial of emotion, or gambling. these emotional responses depend on the individual's resilience to trauma or how they express themselves toward a trigger. regulation and knowing how to regulate strong emotions attached to traumatic memories are important for the safety of mental health and good coping. physical responses include somatic complaints, extreme hyperarousal, and medical conditions that require professional attention and counseling. sleep disturbances are also seen in individuals with trauma, and they suffer from a multitude of problems related to it. due to the trauma, our cognitions are greatly impaired, not only developing depression but also mental issues such as dissociation, guilt, shame, and other cognitive impairments. behavioral reactions work towards reducing the stress by either avoiding the situation that might remind them of the trauma or conducting self-injurious behaviors such as drug abuse or self-mutilation. survivors will re-enact the trauma as a way of coping. the support of family and friends can act as protective factors for these victims, but sometimes, there are boundaries that keep them from recovering. they lose trust in others or believe they are a burden, thus rendering themselves helpless or hopeless. there are many people who do not go to therapy. culturally speaking, people may not seek help due to doubt and stigma against it. most people have a hard time admitting that they need help, and stereotypes against therapy only make them less likely to consider taking it. the more people know that therapy will do no harm to them, the better. educational campaigns, mental health camps, and guidance should be employed to ensure people become more ready to seek therapy. patients need traumainformed care that should be applied to schools, hospitals, and other institutions. all therapists and psychologists should seek training in trauma-informed care. future researchers can explore how different gender experiences trauma, even when they experience similar trauma, and how trauma impacts attachment styles differently. future researchers should also explore the factors that are associated with childhood trauma and adult violent behaviors. acknowledgment the author would like to acknowledge all the trauma survivors. references 1. pai, a. v., suris, a. m., & north, c. s. posttraumatic stress disorder in the dsm-5: controversy, change, and conceptual considerations. behavioral sciences. 2017; 7(4), 7. 2. dyregrov, a., & yule, w. a review of ptsd in children. child and adolescent mental health. 2006; 11(4), 176–184. = 3. glaser, d. child abuse and neglect and the brain—a review. the journal of child psychology and psychiatry and allied disciplines. 2000; 41(1), 97-116. 4. dripchak, v. l. post-traumatic play: towards acceptance and resolution. clinical social work journal. 2007; 35, 125-134. 5. mulvihill, d. the health impact of childhood trauma: an interdisciplinary review, 19972003. issues in comprehensive pediatric nursing. 2005; 28, 115-136 6. ogawa, y. childhood trauma and play therapy intervention for traumatized children. journal of professional counseling: practice, theory, & research. 2004; 32(1), 1929. 7. shaw, j. children, adolescents and trauma. psychiatric quarterly. 2000; 71(3), 227243. 52 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 8. jack, s., munn, c., cheng, c., & macmillan, h. child maltreatment in canada: national clearinghouse on family violence. ottawa, on: public health agency of canada; 2006. 9. perry, b., colwell, k., & schick, s. neglect in childhood. in d. levinson (ed.). encyclopedia of crime and punishment. 2002. volume 1 (pp. 192-196). thousand oaks: sage publications. 10. wekerle, c., wolfe, d. a., hawkins, d. l., pittman, a. l., glickman, a., & lovald, b. e. childhood maltreatment, post-traumatic stress symptomatology, and adolescent dating violence: considering the value of adolescent perceptions of abuse and a trauma mediational model. development and psychopathology. 2001; 13(4), 847-871. 11. center for substance abuse treatment (us). chapter 3 understanding the impact of trauma. in trauma-informed care in behavioral health services. 2014. (57th ed., pp. 59–85). us department of health and human services, substance abuse and mental health services administration, center for substance abuse treatment. https://www.ncbi.nlm.nih.gov/books/nbk 207191/ 12. robinson, l., smith, m., & segal, j. emotional and psychological trauma helpguide.org. helpguide.org. 2023. https://www.helpguide.org/articles/ptsdtrauma/coping-with-emotional-andpsychological-trauma.htm 13. kerig, p. k., bennett, d. c., chaplo, s. d., modrowski, c. a., & mcgee, a. numbing of positive, negative, and general emotions: associations with trauma exposure, posttraumatic stress, and depressive symptoms among justice-involved youth. journal of traumatic stress. 2016; 29(2), 111–119. 14. weinstein, t. what it means when you’re feeling emotionally numb. newport institute. 2023. https://www.newportinstitute.com/resourc es/mental-health/feeling-emotionallynumb/ 15. what is cognitive behavioral therapy? 2017. https://www.apa.org/ptsdguideline/patients-and-families/cognitivebehavioral 16. bisson j i, cosgrove s, lewis c, roberts n p. post-traumatic stress disorder bmj. 2015; 351:h6161 17. dimsdale, j. e. overview of somatization. msd manual professional edition. 2023. https://www.msdmanuals.com/professiona l/psychiatric-disorders/somatic-symptomand-related-disorders/overview-ofsomatization 18. goodtherapy. somatization. 2019. https://www.goodtherapy.org/learn-abouttherapy/issues/somatization 19. agarwal, v., nischal, a., praharaj, s. k., menon, v., & kar, s. k. clinical practice guideline: psychotherapies for somatoform disorders. indian journal of psychiatry. 2020; 62(8), 263. 20. nemeroff, c. paradise lost: the neurobiological and clinical consequences of child abuse and neglect. neuron. 2016; 89(5), 892–909. 21. cirino, e. are you experiencing hyperarousal. healthline. 2018. https://www.healthline.com/health/mental -health/hyperarousal 22. perkins, j. d., wilkins, s. s., kamran, s., & shuaib, a. (2021). post-traumatic stress disorder and its association with stroke and stroke risk factors: a literature review. neurobiology of stress, 14, 100332. 23. giannakopoulos, g., & kolaitis, g. sleep problems in children and adolescents following traumatic life events. world journal of psychiatry. 2021; 11(2), 27–34. 24. newsom, r. trauma and sleep. sleep foundation. 2022. https://www.sleepfoundation.org/mentalhealth/trauma-and-sleep 25. sinha, s. s. trauma-induced insomnia: a novel model for trauma and sleep research. sleep medicine reviews. 2016; 25, 74–83. 26. relapse goodtherapy. 2018 https://www.goodtherapy.org/blog/psych pedia/relapse 27. aakvaag, h. f., thoresen, s., wentzel-larsen, t., dyb, g., røysamb, e., & olff, m. broken and guilty since it happened: a population study of trauma-related shame and guilt after violence and sexual abuse. journal of affective disorders. 2016; 204, 16–23. 28. c wright, a., coman, d., deng, w., farabaugh, a., terachina, o., cather, c., fava, 53 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 m., & j holt, d. the impact of childhood trauma, hallucinations, and emotional reactivity on delusional ideation. schizophrenia bulletin open. 2020; 1(1). 29. beck, a. t., rush, a. j., shaw, b. f., & emery, g. cognitive therapy of depression. new york: guilford press. 1979. 30. mind. what is dissociation? 2023. https://www.mind.org.uk/informationsupport/types-of-mental-healthproblems/dissociation-and-dissociativedisorders/about-dissociation/ 31. levy, m. j. a helpful way to conceptualize and understand reenactments reenactments. the journal of psychotherapy practice and research. 1998; 7(3), 227–235. 32. mental health america. self-injury (cutting, self-harm, or self-mutilation). 2023. https://www.mhanational.org/conditions/s elf-injury-cutting-self-harm-or-selfmutilation 33. lusk, j. d., sadeh, n., wolf, e. j., & miller, m. w. reckless self-destructive behavior and ptsd in veterans: the mediating role of new adverse events. journal of traumatic stress. 2017; 30(3), 270–278. 34. dass-brailsford, p., & myrick, a. c. psychological trauma and substance abuse: the need for an integrated approach. trauma, violence, & abuse. 2010; 11(4), 202– 213. 35. wall, l., higgins, d., & hunter, c. traumainformed care in child/family welfare services (cfca paper no. 37). melbourne: child family community australia information exchange, australian institute of family studies. 2016. 36. reeves, e. a synthesis of the literature on trauma-informed care. issues in mental health nursing. 2015; 36(9), 698–709. 37. istss. trauma and relationships. international society for traumatic stress studies. 2016. https://istss.org/istss_main/media/docu ments/istss_traumaandrelationships_fn l.pdf 38. stieg, c. everyone needs help during the coronavirus pandemic—here’s the psychological reason why asking for it is so hard. cnbc. 2021. https://www.cnbc.com/2020/04/22/whyasking-for-help-is-so-hard-and-how-to-getbetter-at-it.html. about:blank 85 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v9.i2.2022.85-94 original article be aware and grateful for little things: the relative contribution of mindfulness and gratitude in predicting satisfaction. aisha rais ahmed1 & saima ali masoom2 1muhammad ali jinnah university, karachi-pakistan 2university of karachi, karachi-pakistan abstract background: indeed, both mindfulness and gratitude go hand in hand. as one goes into a state of mindfulness and opens their heart to gratitude, one may experience more positive feelings toward life and make choices of all types of events with an open-eyed sense in a nonjudgmental way. that may be leading to being overly focused on life circumstances in a constructive way and enhancing people's life satisfaction. the present study aims to recognize the different influences of gratitude and mindfulness in contributing to life satisfaction; and investigate the levels of mindfulness, gratitude, and life satisfaction among university students. methodology: in the study, 256 young adults were drafted from 4 educational institutes in karachi. however, the random sampling method was used to recruit them. the mean age of the sample was 20 years, with the range of 18-25. the research tools included mindful attention awareness scale1, gratitude questionnaire-six item form (gq-6)2, and satisfaction with life scale3 by using a brief demographic sheet and consent form, through which data was obtained. results: descriptive statistics and regression analysis was used to clarify the pattern of the result, and the findings were highly significant at p< .001. the outcomes demonstrated that the level of mindfulness comes in the low range (49.6%) of the study sample, while the range of gratitude was moderate (52.5%) to high levels (42.3%) correspondingly. almost half of the participants reported a moderate level (49.3%) of life satisfaction. further, the results showed that mindfulness and gratitude are the highest contributors to life satisfaction. as gratitude pointed out, 42% and mindfulness predicted 23% to expect contentment. conclusion: the study proposed a theoretical paradigm that mindfulness impacts satisfaction cognitively, while gratitude influences satisfaction emotionally. thus, the benefits of both constructs are evident and improve people's lives. keywords mindfulness, gratitude, satisfaction with life scale (swls), positive psychology. citation: ahmed ar, masoom sa. be aware and grateful for little things: the relative contribution of mindfulness and gratitude in predicting satisfaction. app. 2022; 9(2): 85-94 corresponding author email: ahmed.aesh@gmail.com doi: 10.29052/2412-3188.v9.i2.2022.85-94 received 06/09/2022 accepted 14/10/2022 published 01/12/2022 copyright © the author(s). 2022. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. about:blank about:blank about:blank about:blank about:blank 86 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 introduction professionals raise contemporary questions, such as defining the good life or wellbeing and how to achieve it. thus, philosophers' academic and intellectual curiosity or developing deep understanding drives them to figure out whether it is human virtue, subjective feeling, or an objective condition. so that it can be accumulated and an effective intrusion can be developed. on the other hand, policymakers are curious about how they may incorporate the functional idea of containment into the public policy design. from their point of view, the general public is less concerned with technical details and more focused on improving living quality or the characteristics that contribute to a happy life in both public and private spheres. furthermore, elements affecting mental health and wellbeing are widespread, yet many words are frequently used in literature4. this field has a rich theoretical foundation and a lengthy history, and bradburn's5 provided the initial idea. positive psychology is a well-known area of psychology that scientifically identifies positive traits within a person scientifically6, along with studies on well-being. the goal is to assist people in flourishing and developing into fully functioning, shifting the emphasis from fixing the mistake to identifying inner potential and strengths. this will help people avoid developing severe mental health disorders. over the past 20 years, much research has been done on positive emotions, optimism, learned optimism, hope, courage, wisdom, forgiveness, flow, and spirituality. similarly, gratitude and mindfulness are consistent and positively related to each other in different populations. new emerging topics examine mindfulness and gratitude as variables that aid containment in relationships7. in simple terms, mindfulness is the purposeful and unbiased attention to nonjudgmental thoughts, feelings, and sensations an individual experiences in each moment. being both a quality and a state, mindfulness can be both a process and a consequence. as such, it is a broad phrase that can be used in various contexts. however, it can be a psychological process and a theoretical notion (mindfulness; the endeavor of obtaining) (mindfulness). instead of categorizing mindfulness as a quality or condition, bishop and colleagues (2004)8 contend it might be an acquired process. the experience of mindfulness might be challenging to express. moreover, kabatzinn has offered a working definition of mindfulness that includes acknowledging the present moment and unintentionally concealing the experience of the present moment. tremendous progress has been made in teaching mindfulness as a secular subject and in enhancing one's spirituality24 apart from any faith, tradition, or religion, as mindful procedures improve mental health and achieve the purpose of life1,9. the metaanalysis shows an overall effect size of 27 between mindfulness and satisfaction7. mindfulness is directly and indirectly linked with contentment, enabling individuals with skilled emotional repertoires to improve martial quality. moreover, mindful training significantly impacts people's wellbeing, coping skills, and relationship containment. according to carson et al., preventive mindfulness can improve overall health and wellbeing in recent studies1,10. it may be argued that while mindfulness does not directly contribute, it does link to unique adaptive coping mechanisms. on the other hand, positive psychologist state that gratitude is more complex than mood or state as it is a more profound sense 87 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 of acknowledging things or individuals that brings endure positivity. if we look at the more straightforward definition, it can be a feeling or an emotion that senses our appreciation level in return when we receive favor from others. the scientific approach states that gratitude is not an act but a positive emotion, which is essential because it can be an instrument of fulfillment and association with well-being. the topic of gratitude has been focused on research for many years, and no one can refuse its role in promoting contentment. it is one of the significant strengths of character and has an association with contentment, prosperity, and feeling of gladness and has a significant effect on wellbeing and satisfying relationships11. however, gratitude and mindfulness share a close connection with mindfulness as one should be completely aware of a favor, they received to experience it7. however, wood et al.12 suggested that gratitude has the same potential benefits as mindfulness. gratitude positively correlates with an outstanding level of eudemonic wellbeing and post-traumatic growth, and it negatively links with many psychopathology forms, such as depression and generalized anxiety disorder. moreover, being mindful creates unbiased awareness of the present moment and the value of positive and negative emotions, and gratitude creates a sense among the individual to cherish joyous moments. thus, mindfulness and gratitude parallel each other when an individual goes into the state of mindfulness; they adopt to be aware of their surroundings. they may look at themselves and their surrounding with curiosity unbiasedly and accept it. this will help cultivate gratitude and become aware of a more positive quality of themselves and the world and then thankful for that; when looking around the world, most of the time, view it from their perspective. many of us only focus on the negative aspects, which leads us to view reality distortedly. being mindful takes away from a judgmental view of life and equips individuals with observation skills to take life with full awareness. furthermore, when they appreciate things around them mindfully, they have a different perspective of the world. thus, mindfulness and gratitude go parallel when an individual goes into the state of mindfulness; individuals adapt to their surroundings. he looks at himself and his surroundings with curiosity unbiasedly and accepts it. it will help cultivate gratitude and become aware of a more positive quality of him and the world and then be thankful for that; when we look around the world, we often view it from our perspective. many of us only focus on the negative aspects, which leads us to view reality distortedly. being mindful removes a judgmental view of life and equips individuals with observation skills to take life with full awareness. furthermore, when we appreciate things around us mindfully, we have a different perspective of the world. youngsters must develop gratitude, bliss, and mindfulness due to many factors, including creating a link with personal growth. however, satisfied individuals have increased self-esteem, relief from anxiety, functional morale, and modesty in either males or females13. in the american sample, gratitude is a significant predictor of life satisfaction. in addition to that gratitude and mindfulness, therapeutic interventions help lessen depression and increase contentment. this idea is further supported by swain et al.14 suggested that mindfulness and gratitude are wonderful intrusions that demonstrate their practical implication. fuller-tyszkiewicz et al.15 conducted an experimental study in which the 88 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 intervention group watched brief videos in succession (e.g., gratefulness-related, relaxation tasks, and breathing exercises). it shows that the compression intervention group receives greater body satisfaction. the broaden-and-build model proposed that positive feelings extend individual reasoning capacity and build social, psychological, and intellectual resources. positive emotions, specifically gratitude, stimulate participation in positive acts, which lead to betterment16. more, grateful thoughts make a healthier temperament, while the study shows that gratitude was rated as a 58% of predictive variable among university students17. thus, the above studies show that mindfulness and gratitude are crucial in achieving individual contentment and welfare. moreover, the findings support the betterment and development of personal growth programs for university students. therefore, this study aims to find out separate inputs of gratitude (feelings) and mindfulness (cognition) to predict satisfaction in undergraduates. moreover, the second objective is to determine university students' mindfulness, gratitude, and satisfaction levels. questions 1. determine the levels of mindfulness, gratitude, and life satisfaction levels among university students. 2. is gratitude contributing to predicting life satisfaction among university students? 3. is mindfulness contributing to predicting life satisfaction among university students? methodology participants in the study, 256 young adults were drafted from 4 educational institutes in karachi. however, the random sampling method was used to recruit them. the mean age of the sample was 20 years, with the range of 18-25. though 174 were females and 82 were males in the sample, nearly all were undergrads. furthermore, each participant signed the consent, was informed about voluntary participation, and maintained confidentiality. procedure in the meantime, the study examines the percentage of mindfulness, gratitude, and satisfaction of life. more to examine the different influences of mindfulness and gratitude to contributing life satisfaction of undergraduates. although, the descriptive and inferential method is considered the most applicable for the aims of the present study, including assessing and validating its hypotheses. the technique quantitatively illustrates the determined phenomenon by defining the contribution between variables. the surveys were completed in one sitting, and this method was used successfully to collect data. instruments: psychometric properties mindful attention awareness scale (maas)1: the most popular scale for measuring mindfulness in positive psychology is the mindful attention awareness scale, developed by kirk warren brown and richard m. ryan in 2003. the state maas is a 5-item scale designed to assess the short-term or current expression of a core characteristic of mindfulness, namely, a receptive state of mind in which attention, informed by a sensitive awareness of what is occurring in the present, observes what is taking place. maas scores can range from 0 to 6, and higher scores indicate greater mindfulness. researchers generally agree that the maas is a valid and reliable method of measuring mindfulness, and it is both simple to score and easy to interpret. 89 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 gratitude questionnaire-six-item form (gq-6)2: which is designed to evaluate the proneness to experience gratitude in daily life; responses to items are measured on the basis of a 7-point likert-style response scale, where participant rate their level of agreement on each item ranging from 1 = strongly disagree to 7 = strongly agree). there was a reverse scoring for items 3 and 6 to get the total sum. that was our total gq-6 score. this range of scoring was between 6 and 42. mccullough et al. (2001) reported the gq-6 to have high internal consistency. cronbach's alphas were .77. satisfaction with life scale (swls) the scale constructed by diener, e., emmons, r. a., larsen, r. j., & griffin, s., 19853. the instrument is designed to measure universal cognitive gauging of satisfaction with one's life. it is a brief questionnaire that contains only five items measured by a 7-point likert-type scale; the probable range of scoring is 5-35, and a score of 20 indicates a neutral point on the scale. diener et al. (1985) found that the swls has favorable psychometrics properties with a 0.87 coefficient alpha and 2 -a months testretest stability coefficient of 0.82. in contrast, factor analysis of the swls revealed that it is unidimensional. result table 1 shows the normality of the distribution of participants’ scores to the mindfulness total score, gratitude total score, swls total score, and positive and negative effects total score. table 1: the statistical description of the mindfulness, gratitude, and life satisfaction levels among university students (n=170). statistical indicators scales m s.d skewness the highest score the lowest score the maximum score in the sample the minimum score in the sample mindfulness 33.6941 7.67078 .128 51.00 17.00 90.00 15.00 gratitude 31.3176 4.94517 -.913 40.00 16.00 42.00 6.00 swls 23.1882 6.03833 -.523 34.00 6.00 35.00 5.00 positive effects 11.9294 2.57336 .180 18.00 10.00 50.00 10.00 negative effects 18.5294 3.65555 .243 27.00 12.00 50.00 10.00 mindfulness is low, while gratitude and life satisfaction are moderate among university students. the mindfulness total score extended from 15 to 90 (m = 33.6941; sd = 7.67078). the outcome indicated that most participants (49.6%) scored low on mindfulness. in comparison, 15.3% came under the high level of mindfulness, even though 33.9% pointed out the moderate level of the range. the overall gratitude score extended from 6 to 42 (m = 31.317; sd = 4.945). the findings showed that 52.5% of the students informed an average level of gratitude, while 42.3% stated an above-average range, and only 5.12% reported a low level of gratitude. the students were split 90 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 into 3 groupings regarding the total life satisfaction score: high, moderate, and low, with a mean of 23.188; nearly half of the population (49.3%) stated a modest level of life satisfaction. however, the others (35.2%) informed a high level, and (15.3%) reported a low level of life satisfaction (table 2). table 2: level of mindfulness, gratitude & life satisfaction (n=170). level variable low moderate high number percentage number percentage number percentage mindfulness 79 49.6% 53 33.9% 24 15.3 gratitude 8 5.12% 82 52.5% 66 42.3 swls 24 15.3% 77 49.3% 55 35.2 a simple linear regression analysis was performed to analyze the assumption by determining the influence of the gratitude and mindfulness aggregate scores on contributing satisfaction with life in undergraduates. results reveal that mindfulness projected 23.5% of the variance in life satisfaction. at the same time, the gratitude domain accounted for a 42.1% variance in satisfaction with life score in the research sample. the result pointed out that the rise in gratitude and mindfulness among university students increases their likelihood of satisfaction with life. table 3: the contribution of gratitude & mindfulness to predicting satisfaction with life among university students. dependent variable predictive models r2value regression coefficient b standard regression coefficient beta fixed value fvalue sig. tvalue sig. satisfaction with life (n=171) mindfulness 0.234 2.001 0.484 56.297 136.188 0.000 11.670 0.000 gratitude 0.421 .633 .083 5.214 219.341 0.000 7.648 0.000 discussion in this portion, the outcomes consider the previous literature. it is to be observed that two hypotheses were investigated in the present study. both hypotheses were accepted. the findings regarding assumption 1, as demonstrated in table 1.2, show that the level of mindfulness was low (49.6%) in the study sample, and the gratitude score ranged from moderate to high in 52.5% and 42.3%, respectively. while almost half participants reported a moderate level (49.3%) of life satisfaction the aggregate mindfulness score extended from 15 to 90 (m = 33.6941; sd = 7.67078). most participants (49.6%) have a low level of mindfulness, although 15.3% come under a high level of mindfulness, while 33.9% reported the average range. the gratitude score fluctuated from 6 to 42 (m = 31.317; sd = 4.945). though, 52.5% stated a moderate level of gratitude in the research sample, while less than half (42.3%) stated an aboveaverage score and only 5.12% reported a low level of gratitude. the sample was allocated into high, moderate, and low categories 91 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 regarding the total life satisfaction score: with a mean of 23.188. the finding exhibited that almost half of the sample (49.3%) had a moderate level of satisfaction. in comparison, the remaining (35.2%) reported a high level, while (and 15.3%) had a low level of life satisfaction. this result indicates that the level of mindfulness fluctuated from low to moderate levels, while the score of gratitude and life satisfaction was reported from moderate to high among university students. the growing phase of participants can support the average level of mindfulness as they seem to discover their characters and way of life in this stage, as assuming to grow into adults and heighten their understanding of the inner self and towards life. that is a term called 'productivity' by eriksson. the results are coherent with the previous study of hj ramli, alavi, mehrinezhad, and ahmadi18, which shows moderate levels of mindfulness were found in the sample aged 18-30 years. on the contrary, other studies also show a good level of mindfulness in undergraduate students. as students enjoy university life, they get moderate to high scores on the level of gratitude and life satisfaction clarified by scholastic, health, or societal services. the results are coherent with other studies as well19. when other members of society contribute to wellbeing, it ultimately makes them feel more grateful and may develop feelings of appreciation and contentment. that may lead an individual towards positive feelings. another critical point is that undergraduate students usually have a positive attitude toward their life goals and achievement. so, the positive intention leads them to moderate to high satisfaction towards life20. this result is also consistent with shawaqfeh and almahaireh’s study (2019)20, which found a moderate to high level of life satisfaction among university students. the second and third objectives were also hypothesized and an extensive literature base indicated a causal relationship between mindfulness and gratitude toward life satisfaction. therefore, in the second and third hypotheses, our investigation is to examine the contribution of mindfulness and gratitude to life satisfaction separately. we found a statistically significant contribution to life satisfaction as shown by table 1.3, that declared both variables (mindfulness & gratitude) are towering contributors to contentment. even gratitude comes up with 42%, and mindfulness comes up with 23% contributing contentment. that shows that if the level of gratitude and mindfulness is elevated, it ultimately increases the life satisfaction score of the participants observed. chavan, deshmukh, and singh's results are consistent with the above studies. they discovered that both constructs are the higher contributors and assistance pleasure, where gratitude determined 36% and mindfulness affected 13% of the variance for contentment. simultaneously, the more affirmative the person's feelings are, it would be convenient to emphasize the positive face of one's life and experience contented with it. finally, life satisfaction can be improved21. instead, a person can be grateful mindfully for various things such as financial gain, job constancy, perceived autonomy, fitness, and life expectancy, which may signify "things" to be grateful for22. thus, it was essential to examine whether being grateful mindfully would predict a person's levels of life satisfaction. undoubtedly, relevance deriving demonstrated its strong and unique predicting relationship over time and develops the significance of expressing gratitude, which tends to satisfy them. besides, both elements are indispensable for improving people's quality of life and depending on each other. here, the researcher will discuss the predicting role of 92 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 both (mindfulness and gratitude) toward satisfaction separately. certainly, mindful individuals are more likely to notice positive life experiences and be grateful for them, which eventually increases their life satisfaction23. extensive published studies exposed that gratitude and life satisfaction are associated with numerous pointers of a better life12,24. so, gratitude is a predictor of contentment, boosts artistic reciprocity, and forms psychological, social, spiritual, and positive resources. eventually, all these resources would directly boost the likelihood of satisfaction with life. furthermore, gratitude significantly predicted satisfaction by 18%25. previous literature exhibited a positive correlation between these two components, and studies support this interpretation. mccullough, emmons & tsang2 found that those who are high in gratitude likely to experience higher levels of life satisfaction. one more well-known study was conducted by froh et al., which divided 221 participants into gratitude and control conditions. in gratitude, condition participants were supposed to count their blessings as they uncovered that gratitude is a significant predictor of life satisfaction, and both are positively associated with each other. moreover, these are the key element of people's good mental health. besides the fellow of gratitude, mindfulness also predicted 23.4% of the variance in satisfaction appearances among undergraduates. this result suggests that a greater level of mindfulness would raise the probability of being satisfied. this finding is consistent with the existing studies26. and the mindfulness-to-meaning theory27. individuals with a high level of mindfulness are more willing to accept themselves and the events that happen to them actively, and they are more aware of their internal and external environments; the higher their evaluations of their lives are, the more they are prone to accept things that they cannot change, such as appearance and thoughts than individuals with low mindfulness. these findings are more like the study of kavaklı and özteke kozan, kesici28. that demonstrates a strong and positive link between mindfulness, forgiveness, and contentment29. likewise, a classified regression analysis examined mindfulness to determine pleasure. another study reveals that mindfulness, healthy growth, and forgiveness have a positive relationship30. thus, the benefits of both constructs are evident and improve people’s life and contentment. conclusion in short, the above article assumes that mindfulness influences cognitive satisfaction. at the same time, the effect of gratitude on satisfaction is mainly related to emotional traits and disposition. although, relevant literature discloses that both variables (mindfulness and gratitude) significantly contribute to university students' life satisfaction. conclusively, a person with a magical feeling of gratitude and thinking in a way to be aware and use all their senses make them more attentive, have good energy, and have better physical and psychological health; ultimately, all these elements may lead to a high level of satisfaction with life. thus, the benefits of both constructs are evident and improve people's lives. acknowledgment we acknowledge every study participant who voluntarily contributed to the project. references 1. brown kw, ryan rm. the benefits of being present: mindfulness and its role in psychological wellbeing: journal of 93 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 personality and social psychology. 2003; 84(4): 822. 2. mccullough me, emmons ra & tsang j. the grateful disposition: a conceptual and empirical topography: journal of personality and social psychology. 2002; 82: 112–127. 3. diener e, emmons ra, larsen rj, & griffin s. the satisfaction with life scale: journal of personality assessment. 1985; 49: 71-75. 4. wissing mp, & van ec. facing the challenge to explicate mental health salutogenically: sense of coherence and psychological wellbeing. paper presented at the 55th annual convention of the international council of psychology, graz, austria.1997. 5. bradburn nm. the structure of psychological wellbeing. aldine publishing company, chicago.1969. 6. seligman mep & csikszentmihalyi m. positive psychology: an introduction: american psychologist.2000; 55: 5-14. http://dx.doi.org/10.1037/0003-066x.55.1. 7. mcgill j, adler-baeder f, rodriguez p. mindfully in love: a meta-analysis of the association between mindfulness and relationship satisfaction. journal of human sciences and extension volume. 2016;4 (1):255–271. 8. bishop sr, lau m, shapiro s, carlson l, anderson nd, carmody j & devins g. mindfulness: a proposed operational definition. clinical psychology: science and practice. 2004; 11(3): 230 9. coffey ka, hartman m. mechanisms of action in the inverse relationship between mindfulness and psychological distress: complementary health practice review. 2008; 13(2): 79-91. 10. baer ra, lykins el, peters jr. mindfulness and self-compassion as predictors of psychological wellbeing in long-term meditators and matched nonmeditators: the journal of positive psychology. 2012; 7(3): 230238. 11. seligman me, steen ta, park n & peterson c. positive psychology progress: empirical validation of interventions: american psychologist. 2005; 60(5): 410. 12. wood d, harms p, vazire s. perceiver effects as projective tests: what your perceptions of others say about you: journal of personality and social psychology. 2010; 99(1): 174–190. https://doi.org/10.1037/a0019390 13. diener e, suh e, lucas r, smith h. subjective wellbeing: three decades of progress. psychological bulletin. 1999; 125(2): 78. 14. swain n, lennox thompson b, gallagher s, paddison j, mercer s. gratitude enhanced mindfulness(gem): a pilot study of an internet-delivered program for selfmanagement of pain and disability in people with arthritis: the journal of positive psychology. 2020; 15(3): 420-426. 15. fuller-tyszkiewicz m, richardson b, lewis v, linardon j, mills j, juknaitis k, arulkadacham l. a randomized trial exploring mindfulness and gratitude exercises as e health-based micro-interventions for improving body satisfaction: computers in human behavior. 2019. 16. armenta cn, fritz mm, lyubomirsky s. functions of positive emotions: gratitude as a motivator of self-improvement and positive change: emotion review. 2017; 9(3): 183-190. 17. safaria, t. forgiveness, gratitude, and happiness among college students: international journal of publichealth science (ijphs). 2014; 3(4): 241-245. 18. hj-ramli n, alavi m, mehrinezhad s & ahmadi a. academic stress and selfregulation among university students in malaysia: mediator role of mindfulness. behavioral sciences. 2018; 8(1): 12. doi: https://doi.org/10.3390/bs8010012. 19. al-rabee f & ababneh k. gratitude and quality of life among yarmouk university students in the light of some variables (in arabic): educational science studies. 2018; 45(4): 653-672. 20. shawaqfeh b & almahaireh a. technowellness and its relationship with happiness and optimism among the university of jordan students: journal of social studies education research. 2019; 10(2): 145-167. 21. extremera n, rey l. ability emotional intelligence and life satisfaction: positive and negative affect as mediators. personality and individual differences. 2016; 102: 98–101. https://doi.org/10.1016/j.paid.2016.06.051 22. kausar r. relationship between gratitude and happiness in college students: indian journal of positive psychology. 2018; 9(1): 109-113. 94 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 doi: https://doi.org/10.15614/ijpp.v9i01.11752. 23. emmons ra, stern r. gratitude as a psychotherapeutic intervention: journal of clinical psychology. 2013; 69(8): 846–855. https://doi.org/10.1002/jclp.22020 24. diener e, heintzelman sj, kushlev k, tay l, wirtz d, lutes ld, oishi s. findings all psychologists should know from the new science on subjective wellbeing. canadian psychology / psychologie canadienne. 2017; 58(2): 87–104. https://doi.org/10.1037/cap0000063 25. sapmaz f, yıldırım m, topçuoğlu p, nalbant d & sızır u. gratitude, forgiveness and humility as predictors of subjective wellbeing among university students: international online journal of educational sciences. 2016; 8(1): 38 – 47. https://doi.org/10.15345/iojes.2016.01.004 26. keng sl, smoski mj, robins, cj. effects of mindfulness on psychological health: a review of empirical studies: clinical psychology review. 2011; 31(6): 1041-1056. 27. garland el, froeliger b, howard mo. allostatic dysregulation of natural germer ck. teaching mindfulness in therapy: mindfulness and psychotherapy. 2015; 1(2): 113-129. 28. kavaklı, m., özteke kozan, h., kesici, ş., & ak, m. how can we feel happy? the examination of relationships among happiness, mindfulness, and forgiveness. bülent di̇lmaç. 2019; 3(2): 198-208. 29. abid m. examining the predictive role of mindfulness in forgiveness and happiness among psychiatric patients: journal of psychology and behavioral sciences. 2017; 2(2):163-176. doi: 10.32879/pjpbs.2016.2.2.163-176 30. bagheri f, gharehbaghi f. the relationship between mindfulness, happiness and healthy lifestyle. caspian: journal of health research. 2019; 4(2): 44-48. doi:https://doajorg.sdl.idm.oclc.org/article /bbbf670641854bfca1c3dcfbfc1afbc9 about:blank 112 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v8.i2.2021.112-119 protocol a proposed study using psychophysiological biomarkers to evaluate the effectiveness of cat-cow yoga exercise to reduce chronic musculoskeletal low back pain syeda farah batool1,2 , shamoon noshad2,3 & sadaf ahmed1,3 1department of physiology, university of karachi, karachi-pakistan. 2department of psychology, malir university of science & technology, karachi-pakistan. 3psychophysiology research lab, m.a.h.q. biological research center, university of karachi, karachi-pakistan. abstract background: low back pain (lbp) is a painful condition of the musculoskeletal system that affects the quality of life and causes disabilities that can cease or limit daily life activities. around 85% of the population has encountered lbp at least once in their lives. due to sustained or improper postures, the incidence rate of lbp is reportedly high amongst healthcare providers worldwide. the treatments to manage lbp are generally some non-steroidal anti-inflammatory drugs (nsaids), which only give short-term relief and are seemingly ineffective after a particular time, so higher doses are needed. this study aims to test the cat-cow yoga posture to manage lbp in longer terms. methodology: it will be a uni-center randomized control trial, and the participants with musculoskeletal low back pain will be randomly allocated into two groups. group 1 will receive the intervention, cat-cow yoga sessions, and group 2 will get the general care guide. altered levels of cortisol, substance p and beta-endorphins will be measured and compared at baseline and after completion of 12 weeks. discussion: a practical and cost-friendly intervention that can help back pain sufferers to reduce their pain. this study will determine the efficacy of a useful and cost-effective yoga technique to overcome the psychophysiological manifestations of musculoskeletal clbp. keywords low back pain, healthcare, nurses, substance p, beta-endorphins. citation: batool f, noushad s, ahmed s. a proposed study using psychophysiological biomarkers to evaluate the effectiveness of cat-cow yoga exercise to reduce chronic low back pain. app. 2021;8(2): 112-119 corresponding author email: farahbatool97@gmail.com doi: 10.29052/2412-3188.v8.i2.2021.112119 received 18/05/2021 accepted 08/10/2021 published 01/12/2021 copyright © the author(s). 2021 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v8.i2.2021.114 https://orcid.org/0000-0002-1344-6795 https://orcid.org/0000-0002-8078-4524 https://orcid.org/0000-0002-9635-0202 http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 113 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 introduction low back pain (lbp) is a dominant reason for musculoskeletal discomfort globally1. lbp is characterized as a symptom, but in some cases, it is implied as a pathological condition with unknown etiologies depending on its severity and duration2. low back pain is considered ‘chronic’ if it persists for three months or longer than three months. chronic low back pain (clbp) is responsible for disability, compromised life quality, and absenteeism from work worldwide3. approximately 70% to 85% of adults have complained about the occurrence of such pain at least once in their life span. clbp can cause a higher number of years lost to disability than that of other morbidities like cancers, respiratory syndromes, aids, accidents, and childbirth complications, and it is categorized as one of the ten most potential causes that contribute to illness and disability by global burden of disease (gbd)4. it is estimated that 37% of total lbp cases are due to strenuous physical work. many occupations are said to be riskier for getting lbp5. sitting is a widely identified risk factor of work-related low back pain. at the same time, other work demands such as the frequent lifting of heavy stuff, intense physical work, and improper postures are also potential risk factors for lbp. in healthcare sectors, nurses are more likely to suffer from injuries and work-related musculoskeletal illnesses, such as lbp, than other healthcare workers5,6. it is evident from prior studies that psychological, social, behavioral, and demographical factors are linked with the onset of lbp. a sedentary lifestyle, smoking, and age increase the risk of lbp. nurses' ergonomic exposures, such as the extent of direct interaction with the patient, posture, need to lift objects or attendee, work-related stress, and job satisfaction, put them at high risk of getting lbp6. along with the physical distress, lbp is also the reason for extended occupational leaves, and because of lbp, many healthcare professionals either switch their jobs or quit the profession7. the prevalence of lbp in nurses is 71.85% in asian countries8, 82.7% in southwest nigeria, africa9, 53.3% in saudi arabia10, and 69.5% in iran11-13. in pakistan, 65% of nurses are suffering from lbp in a study conducted in lahore14. there are various guidelines available for the diagnosis of non-specific low back pain. its severity and intensity can be diagnosed by using different assessing tools or scales. natural biological markers for pain could also be used as a diagnostic tool for the evaluation of lbp. substance p (sp), cortisol, and beta endorphins are supposed to be an effective sources of estimating pain intensity and its manifestations. substance p is said to be involved in the underlying mechanism of intensifying the pain by increasing the inflammation and inflammatory markers15-17. on the contrary to this beta-endorphins, serves as an endogenous opioid and tend to relax the patient by increasing the availability of serotonin and dopamine in the synapse18,19. kallman20 has stated in his study that substance p and beta endorphins are not reliable pain regulatory markers in the patients' saliva of chronic neuropathic pain as according to their results, salivary substance p and beta-endorphins does not show much inclination20. specific guidelines were established by the us, uk, and other countries to treat lbp. these guidelines suggested different stages of treatment. firstly, all guidelines emphasize that patients with non-specific lbp must learn to manage the pain independently and increase their physical 114 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 activities with manageable breaks. if the pain persists, as the second line of care, the us and danish guidelines highly recommend non-pharmacological treatments such as cognitive behavioral therapy and physical exercises21. yoga, aerobics, tai chi are among the highly endorsed nonpharmacological interventions to treat nonspecific chronic lbp. the use of nonsteroidal anti-inflammatory drugs (nsaids) and other medications to cure lbp is discouraged by physicians and scientists because of their side effects and low efficacy in reducing pain21,22. in all the physical exercises, yoga appeared to be moderately effective in managing lbp. there are several postures of yoga that are practiced and recommended by physiotherapists and orthopedists. still, there is very scarce data that proves the clinical significance and efficacy of yoga. a systemic review of many clinical trials suggests a moderate certainty about the potential of yoga in relieving pain23,24. this study aims to determine the effectiveness of yoga as a potential intervention in the management of lbp. cat-cow yoga posture is selected for this purpose. there are two basic shapes your torso and spine can make: flexion and extension. in the simplest explanation, flexion is a rounded back, and extension is an arched back. cat/cow alternates between flexion cat and extension cow. this exercise will help to relax the muscles and will make them more flexible and mobile25. methodology study design it is a uni-center randomized controlled trial. subjects from diverse ethnicities, educational backgrounds, and different socioeconomic statuses are preferred for this study. subjects will be included in the study if they meet the eligibility criteria and have experienced low back pain in the last three months. written informed consent will be obtained from each study subject after providing detailed information regarding the objectives of the study and its duration. subjects will be randomly assigned to either control or interventional group. outcome measures will be assessed at the baseline and after three months. ethical concerns the study will be conducted under the declaration of helsinki. all ethical protocols will be followed during the study, and the participants will obtain written consent. this study is consulted and approved by ethical committee with the approval number erc/s20/p-001. eligibility criteria inclusion criteria participants must meet all the following inclusion criteria to participate in this study. 1. age between 25 to 45 years. answer yes to the following questions 2. have low back pain constantly or on most days for the last three months? 3. have you sought care from a health care provider due to back pain? following scales will be used to assess the participants before enrolling them for the study. 1. average pain intensity will be assessed using the numerical pain rating (npr) over the past week ≥ 2 on a 0–10 numerical pain scale. 2. roland morris disability questionnaire score ≥ 426. 3. fear avoidance beliefs questionnaire (fabq) work subscale score <1927. exclusion criteria to be eligible for the study, participants must not: • have a personal history of the following neurological disorders: alzheimer's, 115 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 amyotrophic lateral sclerosis, multiple sclerosis, parkinson's, stroke • have a personal history of the following cardiorespiratory disorders: congestive heart failure, heart attack in past 24 months • have a personal history of the following musculoskeletal disorders: rheumatoid arthritis, pathologic fractures of the spine, avascular necrosis or osteonecrosis, severe osteoarthritis. including a history of spine surgery or a hip arthroplasty. • have active cancer. • be blind. • have used narcotics or muscle relaxants within 30 days before study enrolment. • report being pregnant, lactating, or that they anticipate becoming pregnant in the next 3-6 months. • have a body mass index greater than 35 kg/m2. • have clinical depression (i.e., subjects who score 24 or higher on the center for epidemiology depression scale). • report unexplained weight loss over the past month (>10 lbs.). interventions study procedure enrolment: those subjects who had experienced musculoskeletal clbp were enrolled. assessment of eligibility: subject meeting eligibility criteria will be included in the study. baseline assessment: all the variables, i.e., oswestry low back pain disability questionnaire, world health organization quality of life (whoqol) questionnaire, numerical pain rating scale, sadaf stress scale (sss) will be measured at baseline. scoring of oswestry scale: • 0% to 20%: minimal disability: the patient can cope with most living activities. usually, no treatment is indicated apart from advice on lifting, sitting, and exercise. • 21%-40%: moderate disability: the patient experiences more pain and difficulty sitting, lifting, and standing. travel and social life are more difficult, and they may be disabled from work. personal care, sexual activity, and sleeping are not grossly affected, and the patient can usually be managed by conservative means. • 41%-60%: severe disability: pain remains the main problem in this group, but activities of daily living are affected. these patients require a detailed investigation. • 61%-80%: crippled: back pain impinges on all aspects of the patient's life. positive intervention is required. • 81%-100%: these patients are either bedbound or exaggerating their symptoms28. randomization: subjects based on eligibility criteria will be randomly allocated to the experimental or control group sequentially as they agree to participate. allocation: a booklet with detailed instructions will be provided to the study subjects according to the groups allocated. follow-up assessment: after three months, all the variables measured at the baseline phase will be measured again. 116 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 statistical analysis: pre & post-analysis will be conducted in this phase. expected outcomes at the end of this study and proper execution of the intervention, it is expected that, i. the subjects with musculoskeletal clbp will overcome the pain and perform their daily tasks more efficiently. ii. levels of substance p and cortisol will be reduced, which will help to break the pain cycle in the body. iii. level of beta-endorphins will be elevated at the end of the session, which will make them relax and will help in further reduction of pain. measures i. oswestry low back pain disability questionnaire: this index is considered a standard to assess the functionality of the low back. it is also a trusted tool for researchers and health care providers to evaluate the extent of disability29. ii. quality of life questionnaire: it is used to measure the quality of life by various means. it will help evaluate changes observed in the patients' quality of life and well-being before and after the intervention is given30. iii. numerical pain rating scale: to evaluate the intensity of pain. iv. roland morris disability questionnaire: this scale is used to assess mild to moderate disability in patients with acute, subacute, or chronic low back pain26. v. sadaf stress scale (sss): sub-section of sss (physical stress) will be used to assess the degree of stress and its contribution to clbp31. vi. substance p: it gets increased in the body in chronic pain, so it could be a good source of estimating the extent of relief from the pain before and after the intervention. vii. beta-endorphins: they work as opioids in the body and produce endogenous analgesia. their elevated levels after the intervention will be a sign of pain relief. viii. cortisol: it is a steroid hormone that tends to elevate during psychological or physical stress. sample size calculation the required sample size for the two study groups with α = 0.05 and (1− α) = 0.80 was estimated to be 49 in each group, i.e., the total sample size was 98 for the two groups. the sample size calculator provided by the university of california, san francisco (ucsf), clinical and translational science institute (ctsi) was used32. randomization subjects based imon eligibility criteria will be randomly allocated to the experimental or control group in the 1:1 ratio. computergenerated random numbers will be used for randomization. after taking the subject's basic information, the study center will provide a unique code to each included subject. the code will be mentioned in each form of each subject. sample analysis all the biomarkers (substance p, beta endorphins, cortisol) will be analyzed and processed through elisa. statistical analysis the data will be analyzed using 2 × 2 mixed factorial design analysis of variance (anova) to calculate whether there is a significant change in the cat-cow yoga therapy group among the intervention and control group subjects. after the intervention, if a higher ratio of cat-cow yoga therapy will be observed in the experimental group, the interventional impact of the five factors of cat-cow yoga therapy will be examined with further analysis. sequentially for each secondary outcome, additional 117 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 anovas will be used to investigate differences between groups at three months and baseline. adjusted anova will be performed, keeping socio-demographic and other variables as co-variants to determine whether the socio-demographic and other characters could result in alterations in effect between the two groups. figure 1: flowchart of the study procedure discussion the focus of research related to pain management is leaning towards all the interventions that could be used instead of pharmaceutical drugs and have the same efficacy and convenient for use. this study aims to find a correlation between psychophysiological biomarkers and catcow yoga posture in the management of non-specific chronic low back pain. substance p, beta endorphins, cortisol and stress levels are all going to be measured and monitored and on these basis efficacy of the intervention will be judged. life-threatening events aside, people's economic statuses are subject to considerable effects. from purchasing high-cost medication to visiting healthcare advisors, this precarious situation 118 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 will prove to be an inconvenience to people. thus, an intervention both, maximizing practicality and budget-friendliness is needed. the topic field of this study, therefore, will revolve around the efficacy of a convenient and cost-effective yoga technique, fashioned to mitigate psychophysiological manifestations of clbp. acknowledgement the author is thankful to arooma zehra, sukaina reza and khudaija reza for their support throughout the process. references 1. zaina f, balagué f, battié m, karppinen j, negrini s. low back pain rehabilitation in 2020: new frontiers and old limits of our understanding. eur j phys rehabil med 2020;56:212-219. 2. al-arfaj as, al-saleh ss, alballa sr, aldalaan an, bahabri sa, al-sekeit ma, mousa ma. how common is back pain in alqaseem region. saudi med j. 2003;24(2):170173. 3. trinkoff am, lipscomb ja, geiger‐brown j, brady b. musculoskeletal problems of the neck, shoulder, and back and functional consequences in nurses. am j ind med. 2002;41(3):170‐178. 4. vos t, flaxman ad, naghavi m, lozano r, michaud c, ezzati m, shibuya k, salomon ja, abdalla s, aboyans v, abraham j. years lived with disability (ylds) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the global burden of disease study 2010. the lancet. 2012;380(9859):2163-2196. 5. shieh sh, sung fc, su ch, tsai y, hsieh vc. increased low back pain risk in nurses with high workload for patient care: a questionnaire survey. taiwan j obstet gynecol. 2016;55(4):525‐529. 6. jradi h, alanazi h, mohammad y. psychosocial and occupational factors associated with low back pain among nurses in saudi arabia. j occup health. 2020;62(1):e12126. 7. dawson ap, schluter pj, hodges pw, stewart s, turner c. fear of movement, passive coping, manual handling, and severe or radiating pain increase the likelihood of sick leave due to low back pain. pain. 2011;152(7):1517‐1524. 8. ellapen tj, narsigan s. work-related musculoskeletal disorders among nurses: a systematic review. ergonomics. 2014;4(4):1–6. 9. tinubu bm, mbada ce, oyeyemi al, fabunmi aa. work-related musculoskeletal disorders among nurses in ibadan, southwest nigeria: a cross-sectional survey. bmc musculoskelet disord. 2010;11(12). 10. elnaggar rk, elshazly fa, elsayed ws, ahmed as. determinants and relative risks of low back pain among the employees in al‐ kharj area, saudi arabia. eur j sci res. 2015;135(3):299‐308. 11. al amer hs. low back pain prevalence and risk factors among health workers in saudi arabia: a systematic review and metaanalysis. j occup health. 2020;62(1):e12155. 12. alzahrani h, mackey m, stamatakis e, zadro jr, shirley d. the association between physical activity and low back pain: a systematic review and meta-analysis of observational studies. sci rep. 2019;9(8244):1– 10. 13. kasa as, workineh y, ayalew e, temesgen wa. low back pain among nurses working in clinical settings of africa: systematic review and meta-analysis of 19 years of studies. bmc musculoskel dis. 2020;21(1):1-1. 14. rasheed h, rashid j & javeed rs. frequency of low back pain among nurses working in jinnah hospital lahore. ijehsr. 2017;5(3):4451. 15. lisowska b, lisowski a, siewruk k. substance p and chronic pain in patients with chronic inflammation of connective tissue. plos one. 2015;10(10):e0139206. 16. zieglgänsberger w. substance p and pain chronicity. cell tissue res. 2019;375:227-241. 17. snijdelaar dg, dirksen r, slappendel r & crul bjp. substance p. europ j pain. 2000;4:121–135. 18. sprouse-blum as, smith g, sugai d, parsa fd. understanding endorphins and their importance in pain management. hawaii med j. 2010;69(3):70. 119 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 19. ferdousi m, finn dp. stress-induced modulation of pain: role of the endogenous opioid system. progress brain res. 2018;239:121-177. 20. kallman tf, ghafouri b, bäckryd e. salivary beta-endorphin and substance p are not biomarkers of neuropathic chronic pain propensity. heliyon. 2018;4(8):e00718. 21. almeida m, saragiotto b, richards b, maher cg. primary care management of nonspecific low back pain: key messages from recent clinical guidelines. med j aust. 2018;208(6):272–275. 22. shipton ea. physical therapy approaches in the treatment of low back pain. pain ther. 2018;7(2):127-137. 23. kamper sj, yamato tp, williams cm. the prevalence, risk factors, prognosis and treatment for back pain in children and adolescents: an overview of systematic reviews. best pract res clin rheumatol. 2016;30(6):1021–1036. 24. wieland ls, skoetz n, pilkington k, vempati r, d'adamo cr, berman bm. yoga treatment for chronic non‐specific low back pain. cochrane database of systematic reviews. 2017(1). 25. tsai sy. effect of yoga exercise on premenstrual symptoms among female employees in taiwan. int j environ res. pub health. 2016;13(7). 26. roland m, waddell g, klaber-moffett j, burton a, main c. the back book: the best way to deal with back pain. 2nd ed. tso. 2002.:1-25. 27. waddell g, newton m, henderson i, somerville d, and main c. a fear-avoidance beliefs questionnaire (fabq) and the role of fear-avoidance beliefs in chronic low back pain and disability. pain. 1993;52:157-168. 28. roland m, wadell g, moffett j k, burton k, main c, cantrell t. the back book. uk. the stationery office. 1996. available at: https://backaholic.files.wordpress.com/201 4/12/the_back_book-2.pdf 29. fairbank jct & pynsent, pb. the oswestry disability index. spine. 2000;25(22):29402953 30. world health organization. (2004). the world health organization quality of life (whoqol) bref, 2012 revision. world health organization. available at: https://apps.who.int/iris/handle/10665/7 7773 31. ahmed s & noushad s. sadaf stress scale; reviewed version tested on pakistani population. app. 2015;4:44-47. 32. kohn ma, senyak j. sample size calculators. ucsf ctsi. 2020;2020. available at: https://www.sample-size.net/. https://backaholic.files.wordpress.com/2014/12/the_back_book-2.pdf https://backaholic.files.wordpress.com/2014/12/the_back_book-2.pdf https://apps.who.int/iris/handle/10665/77773 https://apps.who.int/iris/handle/10665/77773 https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v8.i2.2021.112-119 17 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v9.i1.2022.17-27 original article assessment of burnout syndrome and physical activity of the university teachers – a cross-sectional observational study qazi noor ul wahab1 , zia ud din1, muhammad jahanzeb2, saleem ullah3 & muhammad abbas1 1department of human nutrition, university of agriculture, peshawar-pakistan 2department of psychology, university of peshawar, peshawar-pakistan 3department of agricultural chemistry and biochemistry, university of agriculture, peshawar-pakistan abstract background: burnout and physical activity (pa) are two critical determinants of health. the burnout and pa of the university teachers in pakistan are not well, established. the main objective of the present study is to determine the prevalence of burnout syndrome and the level of physical activity in university teachers. methodology: the sample of university teachers (n=505) was drawn from 14 public/private universities in peshawar using a partly convenient, nonprobabilistic method based on an exhaustive and up-to-date database of all universities in peshawar. data were collected on these parameters: sociodemographics, anthropometrics (body weight, height, and body mass index: bmi), burnout using maslach burnout inventory (mbi-es), and pa level. the global physical activity questionnaire developed by who (gpaq-who) was used. results: the sample consisted predominantly of males (78%) with a mean (sd) age of 37.5 ± 7.9 (range: 28 – 60). the results demonstrated that 19% of university teachers suffered from burnout syndrome, with most of those with job experience <10 years. the mean pa for all the respondents was 955.1 met minutes/week, with significant differences in pa levels of male and female teachers from public vs. private universities (p, for all trends < 0.05). the proportion of physically active university teachers was 63.6% (95%ci 56.6 to 68.2), with a higher proportion of university teachers without burnout syndrome being physically active than those with burnout syndrome (73.5% (95%ci 68.1 to 79.3) vs. 21.6% (95%ci 16.5 to 24.6). only a small number of university teachers could achieve the recommended levels of pa with differences between genders and university types. conclusion: work-related burnout is seen in teachers with poor physical activity, and females are mostly affected. public sector universities showed a greater burnout rate. the public sector needs to revitalize the staff and train them to manage their workload efficiently. keywords burnout syndrome, physical activity, university teachers, work stress, occupation. citation: wahab q, din z, jahanzeb m, ullah s, abbas m. assessment of burnout syndrome and physical activity of the university teachers – a cross-sectional observational study. app. 2022;9(1):17-27 corresponding author email: dr.qazinoor@gmail.com doi: 10.29052/2412-3188.v9.i1.2022.17-27 received 26/03/2022 accepted 06/04/2022 published 01/06/2022 copyright © the author(s). 2022. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v9.i1.2022.17 0000-0001-6589-1404 about:blank about:blank 18 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 introduction stress and burnout are common phenomena present among university teachers. burnout is a typical form of chronic occupational stress characterized by three dimensions, i.e., emotional exhaustion, depersonalization (or cynicism), and reduced professional efficacy1,2. the term 'burnout,' which can be translated as 'emotionally exhausted3, has been studied mainly in the health professions. there has been an increasing trend of investigating the burnout phenomena in other occupations, including teaching at the university level. regular physical activity (pa) is a state of health4. in addition to its overall positive impact, it is now accepted that health also plays an essential role in maintaining regular exercise. world health organization (who) recommends 600 or more metabolic equivalent tasks (mets) minutes/week as at least sufficient to produce health benefits5. the forms of movement they suggest are walking, swimming, indoor cycling, lowintensity aerobics, running or jogging (only if this was done before pregnancy), maintaining a healthy body weight, and improving mental health6. it hypothesizes that regular physical activity and exercise may constitute a practical approach to reducing burnout in university teachers. physical activity to minimize burnout syndrome and its associated symptoms include its ease of accessibility, lower costs, and positive "side effects," such as the reduced risk for cardiovascular diseases (cvd)7-9. as teachers in the university may face work stress and burnout that may affect their pa, it is logical to think about the association between burnout and low pa. low pa may further deteriorate the state of burnout or vice versa. therefore, the analysis of pa habits of university teachers in association with burnout is of great importance. the main aim of our study was to investigate the prevalence of burnout and level of pa in university teachers and the frequency, duration, and intensity of pa concerning stress and burnout. methodology study design and subjects’ characteristics: this cross-sectional study considered university teachers working at different universities of khyber pakhtunkhwa (kp) of pakistan, both in the public and private sectors. the sampling strategy used for the present study was partly convenience, nonprobabilistic, and based on consecutive cases that met these inclusion criteria: (1) to be a formal institutional employee (university teacher/permanent basis), (2) of any age, (3) only morning shift, (4) from any area/subject of service, (5) serving the university at the time of the study (data collection) and not on leave, (6) with no chronic infectious/non-infectious diseases. rotating personnel, visiting, teachers on probation, pregnant/lactating, diabetic teachers, etc., were omitted. the sample size was calculated using cochran's equation10. where, n= sample size; z= z-score correspond to the 95% confidence level, i.e. 1.96; e= acceptable margin of error assumed as 4% or 0.04; p= population proportion (assumed to be 50% or 0.5); n=total teaching population = 2818; putting the above values in the equation (1), the sample size was estimated 494. in this way, the required sample was 500. however, the sample size was increased to 510 to take care of nonresponse/dropped out. the university teachers were screened initially to ensure selection criteria. data collection socio-demographics and anthropometrics: socio-demographic data were collected in a 19 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 pre-designed questionnaire. all methods of measurement were standardized, and the same persons collected data. anthropometrics were measured for the weight (digital scale: tanita terraillon, 100g precision) and height (stadiometer; seca 231, 0.1cm precision). body mass index (bmi) was calculated (weight in kg divided by the height in meters squared). using who criteria (2020), bmi was categorized as average weight (bmi: 18.5 to 24.9), overweight (bmi: 25.0-28.0), and obese (bmi>28.0). burnout assessment: maslach burnout inventory (mbi)– educators survey is a wellknown 22-item questionnaire. this includes evaluation of three sub-scores: (1) "emotional exhaustion" (ee; including 9 items with a maximum score of 54 points with items 1,3,6,8,13,14,16,20); (2) "depersonalization" (dp), including 5 items with a maximum score of 30 points (these are items 5,10,11,15,22) and (3) "personal accomplishment" (pa), including 8 items with a maximum score of 48 points (items 4,7,9,12,17–19,21) (maslach et al., 1996). in this manner, the total score for the whole scale could have a maximum value of 132. the 'ee' subscale assesses aspects of physical and/or mental exhaustion and includes characteristics like physical wear/tear, exhaustion, and loss of strength/energy. the 'dp' subscale showed negative aspects of the responses and attitudes of other individuals and main co-workers in a setting. the 'pa' subscale displays typical negative responses aimed at the respondent and the work itself. these responses are related to low morale, depression, low productivity, poor selfesteem .and inability to withstand pressure, etc., for the present study. the mbi score was dichotomized according to the criteria reported by ramirez et al. (1996) as 'present' or 'absent' when considering high scores in the dimensions of 'ee' and 'dp' and low scores. in 'pac .'burnout was defined as: high score (>26) for 'ee' and 'dp' (> 9), low (< 34) score pac11. in this way, burnout was defined in four levels: 1. no burnout, when all three dimensions are 'negative.' 2. mild burnout, when only one of the three dimensions is 'positive.' 3. moderate burnout, when two out of three dimensions are 'positive.' 4. severe burnout, when all three dimensions are 'positive'12-14. a cronbach's alpha coefficient was applied for mbi reliability analysis. assessment of physical activity: physical activity levels of the teachers was evaluated by using the 'global physical activity questionnaire (gpaq).' the data collected through gpaq was used to calculate the 'metabolic equivalent of task (mets)' score15. "met is the ratio of 'working metabolic rate' relative to the 'resting metabolic rate. briefly, gpaq has 16 questions. these are grouped to assess pa in 3 distinct domains: 1. work, 2. transport, and 3. discretionary activity (recreation/leisure). the last domain has questions that assess the frequency/duration of two different categories of pa defined by the energy requirement/intensity (vigorous/moderateintensity pa). in the transport domain, the frequency/duration of all walking/cycling is taken. in addition, one question enquires explicitly about time spent in sedentary activities/week. the data extracted from gpaq defines pa as 'high pa, moderate pa, and low pa. the gpaq questionnaire was pre-tested. a pilot study was carried out on the university teachers (n=10) to check the validity, practicability, and interpretation of the responses. for statistical analysis spss version 20.0 was used for data analysis. values were reported 20 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 in mean (sd). means were compared using a student's t-test, and a value of p<0.05 was considered significant. result five hundred-five (505) university teachers from different universities in the khyber pakhtunkhwa (kpk) province of pakistan completed the study. some of the baseline socio-demographic characteristics are provided in table 1. in general, the university teachers in the present study represent relatively young faculty, mainly with ages <35 years. a significant percentage of university teachers were male (67.9%). the mean family size was fairly large (7.5 ± 7.0). lesser than two-thirds (30%) of the university teachers demonstrated their satisfaction with their monthly income. most (75%) of the teachers from the study sample belonged to public sector universities (71%). the majority of the university teachers who participated in this study were from sciences, followed by a decent percentage from the arts subjects. table 1: summary of demographics variables (n = 467). personal and socioeconomic characteristics no./mean % age <30 years 167 33.1 31 40 156 30.9 41-50 115 22.8 >50 53 10.5 gender male 343 67.9 female 162 31.9 family type joint 333 65.9 nuclear 171 33.9 income status sufficient 143 28.3 partially sufficient 311 61.6 insufficient 51 10.1 health status (any type of chronic disease) diabetes (yes) 173 34.3 cardiovascular vascular (yes) 123 24.4 any chronic infectious disease (yes) 45 8.9 health status any physical disability (yes) 23 4.6 any other long-term health issue (yes) 10 2.0 health status (any type of chronic disease) 147 29.1 accommodation status rental house 187 37.0 own house 107 21.2 university house 122 24.2 21 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 figure 1. distribution of three dimensions of burnout this venn diagram is based on the number of university teachers having a high level of these dimensions. this diagram has not considered the number with low and moderate levels on these dimensions. the numbers for each region represent the number of university teachers in different situations; 97=had all three dimensions common in them; 11=had two dimensions, comprising 3 for 'ee' and 'dp,' 5 for 'dp' and 'pa,' and 3 for 'ee' and 'pa .'the number of university teachers who had only high 'ee,' only 'dp,' and only 'pac' were 6, 5, and 40. we defined burnout based on high scores on 'ee' (>26) and 'dp' (>9) and a low score on pac (<34). so in this way, positive (higher than the cutoff score of any of the dimensions) number of respondents in three dimensions, we divided job burnout into four levels: no burnout (all the three dimensions are negative); mild burnout (only one of the three dimensions is positive); moderate burnout (arbitrary two of the three dimensions are positive); and severe burnout (all the three dimensions are positive). these results are shown in figure 1. table 2 represents pa among the study participants. information on pa was calculated in three domains, i.e., pa while at work, pa while traveling, and pa during recreational activities. total mean pa at work, travel, and recreation was 176.8, 277.6, and 500.8 met minutes/week, respectively. significant differences were noted in the mean physical activity of males and females (p< 0.05). differences between pa of males and females were also pointed out in the three domains of physical activity (p, for all trends<0.05). 22 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 table 2: pa among university teachers. physical activity total (n=505) with burnout (n-97) without burnout (n=408) mean sd mean sd mean sd work domain vigorous 8.9 21.1 5.4 19.1 12.4 7.9 moderate 167.9 26.8 134.7 24.8 201 23.6 total activity at work* 176.8 23.5 140.1 21.5 213.4 20.3 total activity during travel* 277.6 45.3 142.1 43.3 413 42.1 at recreation vigorous 116.6 43.2 34.5 41.2 198.7 40 moderate 384.2 54.3 156.7 52.3 611.7 51.1 total recreational activity* 500.8 44.8 191.2 46.5 810.4 45.3 mean total pa* 955.1 113.6 473.4 111.3 1436.8 107.7 *p<0.05 figure 2: proportion of active and inactive university teachers according to burnout syndrome, figure 2 showed the proportion of physically active and inactive university teachers. the proportion of physically active university teachers in this study was 36.4% (95%ci 26.644.2), with a higher proportion of university teachers without burnout syndrome being physically active than university teachers with burnout syndrome, 33.9% (95%ci 18.1-39.3) vs. 2.6% (95%ci 1.5-4.6). table 3 showed the percentages of university teachers who achieved the recommended level of physical activity as recommended by who. when the study subjects’ pa level was disaggregated by the "who global recommendation on pa for health," males who achieved the recommended level (23.7%) were almost 52.6% lower than those who didn't achieve (76.3%). in 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% total with burnout without burnout physically active pysically in active 23 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 comparison, the case of a female who reached the recommended pa level (12.7%) was 74.6% lower than those who didn't achieve t (87.3%). similarly, only 11.2% of university teachers from public universities achieved the recommended pa level. a relatively higher percentage of university teachers from private universities (25.2%) achieved the recommended pa. in addition, there were comparatively more males than females who completed the recommended level of physical activity recommended by who (22.7% vs. 12.7; p<0.05). similarly, significantly more teachers from private universities than those from public universities achieved the recommended level of physical activity as recommended by who (25.1% vs. 12.2; p<0.05). table 3: distribution of university teachers who achieved/did not achieve the 'who recommendations on pa for health*. male n(%) female n(%) p-value a. distribution by gender achieved the recommended level 81(23.7) 21(12.7) 0.014 didn’t achieve the recommended level 262(76.3) 141(87.3) 0.005 b. distribution by university type public n(%) private n(%) achieved the recommended level 40(11.2) 38(25.1) 0.0001 didn’t achieve the recommended level 313(88.8) 114(74.8) 0.0001 *calculations were based on who guidelines that adults, 18–64 years, should accumulate at least 600. met-minutes of physical activity per week (2); who, world health organization; p<0.05 association between burnout syndrome and socio-demographic characteristics a chi-square test of independence was performed to examine the relation between burnout syndrome and socio-demographic characteristics. table 4 shows an association between burnout syndrome and some socio-demographic characteristics. the relation between these variables were mostly significant, x2 (1, n = 505) = 8.93-31.37). burnout was present when the global score was ≥56 (median) and represented the primary outcome of bivariate and multivariate analysis. all other variables except 'gender' was significantly associated with burnout (p, for all trends <0.05). the analysis for other than socio-demographic variables shows that except for the subscales, 'stress symptoms,' 'good working conditions,' 'social support at work,' and 'promotion and development opportunities' were significantly associated with burnout syndrome (p, for all trends<0.05). a total of 19% subjects were reportedly suffering from burnout syndrome. 24 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 table 4: frequency, χ2 test results, p-value, prevalence ratio, and confidence interval for the association between primary outcome and socio-demographic, occupational, psychosocial, and health-related variables. items categories respondents with burnout syndrome. (%) x2 p-value age (yrs) <45 76 9.21 0.0023 >45 21 sex male 72 1.204 0.272 female 25 family type joint 47 9.27 0.0023 nuclear 50 university type public 61 8.931 0.0027 private 36 field discipline sciences 84 32.21 <0.0001 humanities/art s 15 higher qualification ms/mphil 70 31.37 <0.0001 phd 27 position/job title lecturer 48 0.0021 assistant professor 22 associate professor 17 professor 10 job experience (years) <10 yrs 61 7.142 0.0079 >10 years 36 marital status married 15 7.211 0.0064 unmarried 31 stress symptoms yes 72 5.29 0.21 no 25 good working conditions yes 8 0.018 0.89 no 89 social support at work’ yes 6 2.93 0.087 no 91 promotion and development opportunities yes 11 0.204 0.651 no 86 workplace bullying yes 82 3.82 0.050 no 15 job satisfaction yes 5 9.19 0.0024 no 92 mental health yes 18 25.79 <0.0000 no 79 25 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 discussion the present study shows that 19% of university teachers were affected by burnout syndrome. this is a high percentage considering that a relatively strict criterion for defining burnout was adopted in the present study. burnout was determined based on high scores on 'ee' (>26) and 'dp' (>9) and a low score on ‘pac'(<34). so in this way, based on the positive (i.e., higher than the cutoff score of any of the three dimensions) number of respondents in the three dimensions, burnout was divided into four levels12-14. according to this criterion, 19% (n=97) of university teachers had severe burnout syndrome, while the rest (n=408) were categorized as 'no burnout at all' (24%); mild burnout (41%), and 'moderate burnout' (16%). this study also demonstrated that the university teachers had low physical activity: mean (sd) 955.1 (113.6) metminutes/week. furthermore, the physical activity of university teachers with burnout syndrome (mean 473.4 sd 111.3 vs. mean 1436.8; sd 107.7 met-minutes/week) was significantly lower than the mean physical activity of university teachers without burnout syndrome (p,0.05). in addition, more females compared to males and more university teachers in public universities compared to those in private universities had physical activity levels much lower than the recommendations of who. a teacher at a university is usually regarded as a 'low-stress job .'in addition, job security, conducive working employment, and a high social standard are generally associated with teaching at the university level. teaching at the university level is considered a job with great promotion opportunities and enhanced satisfying level16. however, over the past 20 years, perceptions about academic careers and the environment have changed drastically. for example, akerlind and mcalpine reported the pressures for change acting upon academia17. this pressure includes substantial growth in student numbers/ institutions of higher learning, increased emphasis on research, concerns for equity and social benefits of education, and great emphasis on the jobtraining job training. as presented in the present work, university teachers with lower physical activity are more likely to suffer from burnout syndrome. these findings are in agreement with other studies7,8. in another study by abos et al. demonstrated that two sessions of exercise in a week improved satisfaction at work and work-related outcomes7. another study by sane et al., who collected data from 81 university teachers from iran, demonstrated a significant inverse correlation between pa and burnout syndrome18. in addition, a linear but inverse correlation between pa and its components with burnout represents the positive role of pa in the prevention or reduction of burnout. although the relationship between pa and burnout investigated in the present study may be casual with no indication of whether low pa causes burnout or vice versa, the association between the two is essential to form from a nutrition and health point of view. future studies should investigate the cause-effect relationship between the two. nevertheless, a high level of burnout is associated with substantial losses to employees' health and well-being and, consequently also, economic losses. employees with burnout show significantly reduced self-efficacyabout:blank b5, poor sleep quality, reduced cognitive functioning, compromised workability, and are at relatively higher risk for developing cvd diseases. employers, too, face the consequences such as leave and/or absence 26 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 and productivity time loss19. given the high prevalence of burnout and its negative consequences, it is valuable to examine potential approaches and remedies to reduce it20. conclusion in conclusion, university teachers who were physically more active were relatively less prone to burnout. pa thus may play an important role in enhancing the physical and mental health status of university teachers. future studies must explore this (rewrite). findings also showed a significant difference between the genders and types of universities concerning burnout prevalence and physical activity levels. these differences may be considered while designing rehabilitation programs for university teachers. acknowledgment we are thankful to all academic institutes' authorities, participants of the research, and our colleagues, for helping in data collection. moreover highly grateful to the authors of the scales for providing the scales free of cost. references 1. stamper cl, johlke mc. the impact of perceived organizational support on the relationship between boundary spanner role stress and work outcomes. journal of management. 2003 ;29(4):569-88. 2. maslachc js. burnout syndrome in health professions: a social psychological analysis. social psychology of health and illness (3rd ed., pp. 227-251). hillsdale, nj: lawrence erlbaum.1982. 3. maslach c, jackson se, leiter mp. maslach burnout inventory. scarecrow education; 1997. 4. dishman rk, heath g, schmidt md, lee im. physical activity epidemiology. human kinetics; 2021. 5. armstrong t, bull f. development of the world health organization global physical activity questionnaire (gpaq). j pub health. 2006;14(2):66-70. 6. hallal pc, andersen lb, bull fc, guthold r, haskell w, ekelund u, lancet physical activity series working group. global physical activity levels: surveillance progress, pitfalls, and prospects. lancet. 2012;380(9838):247-57. 7. abós á, sevil-serrano j, julián-clemente ja, generelo e, garcía-gonzález l. improving teachers' work-related outcomes through a group-based physical activity intervention during leisure-time. j exper edu. 2021;89(2):306-25. 8. raditya m, sutarina n. relationship between burnout and physical activity level among pre-clinical medical students. jpma. 2021;71(2):s62-8. 9. warburton de, nicol cw, bredin ss. prescribing exercise as preventive therapy. cmaj. 2006;174(7):961-74. 10. ahmad h, halim h. determining sample size for research activities. selangor business review. 2017;1:20-34. 11. ramirez aj, graham j, richards ma, cull a, gregory wm, leaning ms, snashall dc, timothy ar. burnout and psychiatric disorder among cancer clinicians. bjc. 1995;71(6):1263-9. 12. yongxin l, yimin l. developing the diagnostic ctiterion of job burnout. psychol sci shang. 2006; 29(1):148. 13. liu x, chen j, wang d, li x, wang e, jin y, ma y, yu c, luo c, zhang l, liu c. covid19 outbreak can change the job burnout in health care professionals. front in psychi. 2020;11. 14. zhou j, yang y, qiu x, yang x, pan h, ban b, qiao z, wang l, wang w. serial multiple mediation of organizational commitment and job burnout in the relationship between psychological capital and anxiety in chinese female nurses: a cross-sectional questionnaire survey. int j nur stud. 2018; 1;83:75-82. 15. bull fc, maslin ts, armstrong t. global physical activity questionnaire (gpaq): nine country reliability and validity study. j phy act health. 2009;6(6):790-804. 27 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 16. knight p. being a teacher in higher education. mcgraw-hill education (uk); 2002 jul 1. 17. akerlind g, mcalpine l. academic practicehow is it changing?.,2009. 18. sane ma, devin hf, jafari r, zohoorian z. relationship between physical activity and it's components with burnout in academic members of daregaz universities. procediasocial behav sci. 2012;46:4291-4. 19. naczenski lm, de vries jd, van hooff ml, kompier ma. systematic review of the association between physical activity and burnout. j occup health. 2017;59(6):477-94. 20. akhtar malik n, björkqvist k. an evidencebased framework for reducing occupational stress and burnout in pakistani universities. ajue. 2021;17(1):19-32. about:blank 21 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v10.i1.2023.xx-xx original article effectiveness of eidetic psychotherapy on psychosomatic symptoms in adults with anxious attachment style janeeta sohail, zaofishan qureshi, afia misri & shahzadi siddiqa kayani department of psychology, air university, islamabad-pakistan abstract background: individuals exhibiting an anxious attachment style often experience more severe psychosomatic symptoms compared to those with other insecure attachment styles. these symptoms can lead to a diminished quality of life and impaired functioning. this study aimed to investigate the efficacy of eidetic psychotherapy as a psychological intervention for managing psychosomatic symptoms in adults with anxious attachment style. we hypothesized that there would be a significant reduction in psychosomatic symptoms following therapeutic intervention sessions. methodology: the sample consisted of 15 adults, including 7 males and 8 females (mean age = 20.27, sd = 1.36), recruited from academic institutes in islamabad, pakistan, using purposive sampling. a pre-and post-experimental design was employed, with the revised adult attachment scale close relationship version (raas; collins, 1996) used for initial screening. the psychosomatic symptoms scale (pss-35; vulić-prtorić, 2021) was administered at the baseline. eight to twelve individual therapy sessions were conducted with the participants, and levels of psychosomatic symptoms were reassessed post-intervention using pss-35. pairedsample t-tests were employed to compare mean differences. results: the analysis of pre-test and post-test scores revealed a significant decrease in both the frequency (t = 3.20, p = .006) and severity (t = 3.09, p = .008) of psychosomatic symptoms among the study participants. conclusion: consequently, eidetic psychotherapy emerges as a promising therapeutic approach for enhancing the well-being of individuals suffering from psychosomatic symptoms associated with anxious attachment. keywords anxious attachment style, psychosomatic symptoms, eidetic psychotherapy, adults, academic institutes. citation: ali s, ali sm, zia a. the relationship of emotional intelligence and life satisfaction with resilience in students. app. 2023; 10(1): 21-34 corresponding author email: janeetakhokhar@gmail.com doi: 10.29052/2412-3188.v10.i1.2022.2133 received 16/03/2023 accepted 26/05/2023 published 01/06/2023 copyright © the author(s). 2023. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v10.i1.2023. about:blank about:blank 22 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 introduction attachment style refers to how an individual forms relationships with others, involving their confidence in the availability of a caregiver to serve as a secure base1. these attachment styles are shaped by a person's early experiences, particularly the type of care they received during infancy2. early attachments established during childhood play a crucial role in an individual's ability to form emotional bonds, contributing significantly to their survival3. when children experience inconsistent emotional communication during infancy, and their needs are not met consistently, they are more likely to develop unsuccessful or insecure attachment styles, adversely affecting their capacity to maintain stable relationships. conversely, secure bonds between caregivers and children can positively impact mental health and resilience4. john bowlby, the founder of attachment theory, emphasized the critical nature of attachment formation during the first 2.5-5 years of life. he suggested that if attachment does not develop during this early period, it may not develop at all, potentially leading to social, emotional, and cognitive challenges later in life. these early attachments form an internal working model that shapes an individual's understanding of themselves, the world, and others. this internal model, known as the continuity hypothesis, continues to influence a person's behavior and relationships throughout their life1. anxious attachment style is characterized by a pattern of attachment marked by a strong fear of being left alone, diminished self-confidence, and extreme dependence on loved ones. individuals with this insecure attachment pattern tend to be highly emotional, reliant on others for emotional needs, and seek closeness and intimacy to remedy their emotional distress5. research has shown that traumatic incidents in early life can be correlated with attachment anxiety and somatic symptoms6. attachment patterns have also been linked to various aspects of life, including physical and mental health, social relationships, and work7. psychosomatic symptoms, also known as medically unexplained somatic symptoms (muss), refer to physical symptoms for which no physical cause can be found, and they are often attributed to stress or anxiety. these symptoms are concerning and are frequently associated with concurrent mental health problems8. childhood trauma and adversity have been identified as risk factors for compromised physical well-being and the development of psychosomatic symptoms. insecure attachment styles have also been found to be associated with childhood adversity. prolonged stress and hyperarousal can disrupt typical development, affecting bodily responses to stress and disrupting emotional and cognitive responses to somatic stimuli9. one explanation for the development of psychosomatic symptoms is the concept of mentalization, a mechanism that evolves through the relationship between a child and their caregiver. the ability to mentalize is learned and is more developed in individuals with secure attachments. insecurely attached individuals tend to have poor mentalization skills and are highly sensitive to the mental states of others. anxious attachment individuals often struggle to identify their emotions, resulting in somatic experiences of emotional distress10. additionally, exposure to stress and trauma, which often involves the development of unhealthy or insecure attachments, can hinder the development of the frontal cortical executive function 23 app| published by aeirc| volume 10 issue 1 responsible for managing involuntary signals from the parasympathetic nervous system, affecting various bodily systems such as the gastrointestinal, endocrine, and cardiovascular systems. the frontal cortex plays a critical role in organizing and managing bodily symptoms, and this function is disrupted in individuals with insecure attachment styles11. furthermore, the literature suggests a connection between anxiety and somatic symptoms, indicating that negative affect can suppress the immune system and increase disease susceptibility, leading to somatic complaints12. numerous studies have reported that somatic complaints are common in individuals with psychiatric distress. prolonged exposure to stress has also been linked to somatic symptoms such as palpitations, gastrointestinal complaints, and headaches. this situation poses a significant risk to young people's mental and physical health and future generations13. mental stress has been associated with various psychosomatic symptoms, including sleep problems, gastrointestinal issues, and muscular pain. stress is also a primary contributor to headaches and can lead to the development of disorders such as irritable bowel syndrome, fibromyalgia, and chronic fatigue9. somatic symptoms often indicate emotional distress in an individual's life and can progress to somatic symptom disorder and other severe illnesses. additionally, health anxiety, characterized by heightened anxiety about one's bodily symptoms, can develop due to these symptoms, further exacerbating the situation14. a descriptive-correlational study investigated the relationship between attachment styles and somatic symptoms, with the mediating role of emotional processing. the study included 220 participants aged 18-59, and data were collected using the adult attachment scale (aas), baker's emotional processing scale, and the patient health questionnaire (phq15). correlation and t-test analyses revealed that the predominant attachment style among participants was anxiety-based, leading to deficits in emotional processing and severe somatic symptoms. conversely, secure attachment was a protective factor against emotional deficits and the somatization of negative emotions15. treating psychosomatic symptoms typically involves raising awareness of underlying core issues and addressing negative events and emotions that impact an individual's emotional well-being16. evidence-based therapies such as cognitive behavior therapy (cbt), mindfulness, and hypnotherapy have effectively treated these symptoms. another therapeutic approach, eidetic psychotherapy, has demonstrated promise in addressing various psychological conditions. eidetic psychotherapy involves eliciting and manipulating mental images known as 'eidetic' images, and akhter ahsen introduced it in pakistan during the 1960s17. according to eidetic psychotherapy, images play a central role in psychological resolution, personal growth, learning, and enlightenment. these images are multileveled, multisensory, and experiential, comprising three main components: 'i' (visual), 's' (somatic, including physical and emotional states associated with the image), and 'm' (meaning or significance of the experience), collectively known as ism. the somatic component, situated between the image and its meaning, is of particular importance, as it provides the physical triggers in the brain that lend relevance to the eidetic image18. ism serves as the fundamental storage unit, with experiences naturally stored in an individual's consciousness as they occur. the development of a psychological 24 app| published by aeirc| volume 10 issue 1 disorder occurs when there is a fixation on the negative aspects of an experience or when there is a pseudo-separation of the visual core of the image from its meaning. eidetic psychotherapy addresses this by repetitively visualizing the image, leading to a resolution of its associated effect. substantial evidence of the effectiveness of eidetic imagery in neuropsychology suggests that different brain regions, including the middle temporal (mt) and middle superior temporal (mst) areas, respond to the visualization of these images. these regions subsequently impact the emotional system of the subject, connecting with perception, sensory signals, and memory19. eidetic images are akin to mental pictures and movies used by the brain to remember and record life events. when remembered, these images recreate vivid experiences with details and clarity. this type of imagery allows individuals to revisit and recall life events, including all the physical and emotional aspects associated with them and their significance in the subject's life20. eidetic images are distinct from ordinary mental imagery, occupying a space between imagination and physiological after-images. these images can overcome intellectual resistance, separating them from talk therapy and verbal therapeutic approaches. additionally, eidetic images have the potential to alter aspects of personality through a repetitive process that intentionally projects critical eidetic until the associated effect is exhausted. as a result, problematic fantasies and experiences related to these images can be effectively addressed. eidetic psychotherapy has been effective in treating conditions such as psychosomatic complaints, acute neurosis, hysteria, and schizophrenia21. the process of eidetic therapy involves three levels, with the first level addressing psychosomatic symptoms, the second level focusing on developmental themes related to parents, and the third level delving into the subject's integration and deeper psychological meanings. two valuable assessment instruments, the age projection test (apt) and the eidetic parents test (ept), were developed for this purpose. the apt is designed to extract information about a series of events related to the subject's current symptoms, exposing them to experiences responsible for forming their disorder. test items trigger different images associated with various life events, revealing experiences related to the symptoms and helping to uncover quasi-somatic symptoms and their meanings. during the apt, clients are asked to visualize an image of themselves and identify the clearest image, after which they provide details such as location and age-related to that image. this technique contributes to the construction of therapeutic images. on the other hand, the ept places significant emphasis on the parent-child relationship and explores various dimensions of pathological development in the subject. comprising 30 items, the ept also aims to construct therapeutic images, similar to the apt19. imagery is a multisensory technique, often described as "seeing with the mind's eye" or "hearing with the mind's ear." eidetic imagery combines sensory, affective, and cognitive aspects of an individual's consciousness22. it is a powerful and rapidly effective therapeutic intervention that can be applied in clinical settings. the therapy encourages individuals to rely on themselves, enabling them to identify and recognize sensory and affective components and consciousness gaps. eidetic psychotherapy can treat various disorders and conditions, including pain, anxiety, phobias, eating disorders, sexual concerns, and substance abuse23. 25 app| published by aeirc| volume 10 issue 1 the effectiveness of eidetic psychotherapy has been demonstrated in the treatment of depression. a study in islamabad, pakistan, involved ten men and women with high scores on the beck depression inventory (bdi-ii), referred from local hospitals. the study consisted of three phases: preintervention, intervention, and postintervention. therapy was administered for 5-7 weeks, resulting in significantly lower depressive symptoms post-intervention. demographics, such as age, marital status, and income, were associated with improvements in depressive symptoms24. another pre-post study explored the impact of eidetic psychotherapy on women suffering from ptsd due to spousal domestic violence in pakistan. the sample included forty women referred from outpatient clinics who met specific criteria. clients received eidetic therapy sessions for 10-12 weeks, resulting in reduced ptsd symptoms, as measured using the general health questionnaire (ghq) and the ptsdchecklist civilian version (pcl-c)23. individuals with anxious attachment style often experience distressing psychosomatic symptoms that significantly diminish their quality of life and overall functioning. these symptoms can affect various bodily systems, from gastrointestinal to cardiovascular, causing considerable discomfort. moreover, individuals with an anxious attachment style frequently endure distress and interpersonal conflicts, further exacerbating their psychosomatic symptoms. importantly, a notable research gap exists, as few attachment-focused therapies have specifically addressed the psychosomatic aspects of insecure attachment patterns. consequently, this study prioritizes managing and treating these symptoms, serving as a preventive measure to help individuals improve their psychosomatic symptoms during the pre-marital stage of life. methodology the study was conducted in islamabad, pakistan, and received approval from the air university human research ethics committee, which also adheres to the rules of the world medical association declaration of helsinki and meets its requirements. sample size a sample of 50 individuals was conveniently selected. these individuals were aged between 19 and 30 years and were recruited from academic institutes in islamabad, pakistan. these individuals were administered the revised adult attachment scale close relationships version (collins, 1996) and the psychosomatic symptoms scale (vulić-prtorić, 2021). among them, 15 individuals who exhibited an anxious attachment style and psychosomatic symptoms were purposively selected. inclusion / exclusion criteria individuals with an anxious attachment style and psychosomatic symptoms aged between 19 and 30 years were included in the study. married individuals were excluded from the study. individuals outside the age range of 19-30 years were also excluded. additionally, adults suffering from parental bereavement and diagnosed with any psychological condition were not part of this study. research instruments informed consent written consent was obtained from all participants willing to participate in the study using an informed consent sheet. demographic sheet the demographic sheet was used to collect basic socio-demographic information, such 26 app| published by aeirc| volume 10 issue 1 as age, gender, qualification, occupation, marital status, socioeconomic status, family system, number of siblings, birth order, earning members, presence of any psychological condition, and the head of the family. revised adult attachment scale close relationships version (collins, 1996) to assess the levels of anxious attachment style in adults, the revised adult attachment scale-close relationships version was used. this 18-item scale comprises three subscales: "close" (6 items), "depend" (6 items), and "anxiety" (6 items). it uses a 5-point likert scale ranging from 1 ("not at all characteristic of me") to 5 ("very characteristic of me"). the revised adult attachment scale measures attachment in three dimensions: closeness, dependence, and anxiety. individuals scoring high on the anxiety subscale and moderately on the others were considered to exhibit an anxious attachment style. the revised adult attachment scale demonstrates acceptable internal consistency (cronbach's coefficient alpha of .87 in anxiety, .73 in close, and .80 in depend subscales). psychosomatic symptoms scale (vulićprtorić, 2021) to assess the level of psychosomatic symptoms in participants, the psychosomatic symptoms scale was used. this 42-item scale comprises seven subscales: "pseudoneurological" (9 items), "cardiovascular" (3 items), "musculoskeletal" (2 items), "respiratory" (3 items), "gastrointestinal" (9 items), "dermatological" (3 items), and "pain/weakness" (6 items). items are scored on two scales: a frequency scale (ranging from 1, "never," to 4, "almost every day") and a severity scale (ranging from 1, "not at all," to 3, "a lot"). scores on both scales are converted to deciles to identify individuals with psychosomatic symptoms. the scale is a reliable instrument for assessing somatic symptoms in individuals, demonstrating high internal consistency (cronbach's alpha coefficient of .89 for frequency and .91 for severity scale). it is recommended for use. procedure the research study began by selecting 50 individuals (adults) aged 19-30 years using a convenient sampling method from academic institutes in islamabad, pakistan. the revised adult attachment scale-close relationships version (collins, 1996) and the psychosomatic symptoms scale (vulićprtorić, 2021) were administered. after scoring and interpreting the scales, 15 participants exhibiting an anxious attachment style and psychosomatic symptoms were selected through purposive sampling. selected participants were informed about the study's purpose, and written informed consent was obtained. dates were scheduled for the pretest, intervention, and posttest in agreement with the participants. pre-test the pretest included scores from the psychosomatic symptoms scale (vulićprtorić, 2021), as well as the house tree person test (buck, 1948) and the thematic apperception test (murray & morgan, 1935). empirical testing was conducted on a sample of 2 participants. eidetic psychotherapy (8-12 sessions) was individually conducted with each participant. following the intervention, a posttest was conducted using the psychosomatic symptoms scale (vulićprtorić, 2021), the house tree person test (buck, 1948), and the thematic apperception test (murray & morgan, 1935). treatment plan 27 app| published by aeirc| volume 10 issue 1 the study was conducted in four phases: pre-assessment, pre-intervention, intervention, and post-assessment. phase i pre-assessment during this phase, participants were screened for anxious attachment style. demographic information was recorded using a demographic sheet, and two instruments, the revised adult attachment scale-close relationships version (collins, 1996) and the psychosomatic symptoms scale (vulić-prtorić, 2021), were used. participants were briefed about the study's objectives, informed of their right to withdraw, and assured of confidentiality. participants exhibiting anxious attachment style along with psychosomatic symptoms were included. phase ii pre-intervention in this phase, eidetic psychotherapy was applied to participants based on the nature and intensity of their symptoms. step 1 during the initial phase, participants' intake was conducted individually. rapport building, trust establishment, active listening, and a non-judgmental and supportive attitude were emphasized. openended questions were used to encourage participants to express their concerns. therapeutic sessions were paced to align with the study's time frame. after the initial phase, protocols of eidetic psychotherapy were implemented. this included recording participants' presenting complaints, worries related to their symptoms, bodily feelings related to each symptom, and other names of the participants. step 2 in the next step, the eidetic parents test (ept) was administered. participants were introduced to eidetics and asked to recall the first session as an image. items from the ept were administered to explore and identify problematic areas in participants' lives. responses, including somatic symptoms, were recorded. resistances and participants' reactions were observed to ensure an accurate experience. key images related to anxious attachment style and associated psychosomatic symptoms were selected for intervention in the next phase. phase iii intervention during this phase, relevant images were maneuvered to reduce the intensity and improve the psychosomatic symptoms associated with each participant. phase iv post-assessment the post-assessment phase involved using the psychosomatic symptoms scale (vulićprtorić, 2021) again to assess participants' levels of psychosomatic symptoms. posttest scores were compared with pretest scores to evaluate the efficacy of eidetic psychotherapy. fidelity of the intervention treatment fidelity checklist was assessed at the end of the intervention. fidelity was ensured by following specific modules in the treatment manual, sufficient briefing, and training on the intervention by a clinical supervisor. this included the completion of practice cases and intervention-specific case consultation, along with expert review of intervention notes. 28 app| published by aeirc| volume 10 issue 1 table 1: steps of therapeutic sessions of eidetic psychotherapy phases therapy plan details description phase 1 pre-assessment raas-crv, pss-35, briefing, informed consent, confidentiality and demographics screening was done through raas-crv and pss-35. scores of raas-crv and pss-35 were recorded. participants were briefed about the purpose of the study, informed consent was taken, confidentiality was assured, and demographics were recorded. phase 2 pre-intervention (step 1) intake sessions, rapport building, eidetic preliminaries, and psychoeducation a detailed history was taken, a therapeutic relationship was established by the providence of a safe environment, and rapport was built. the four preliminaries of eidetic were fulfilled, and psychoeducation was done to increase and improve awareness and insight into the issues and associated symptoms. (step 2) introduction to eidetics, administration of ept, relevant setting, resistances, and overt behavior the participants were introduced to eidetics practically in a comfortable setting. the eidetic instructions were given as per the items, and images were repeatedly projected to maximize the authenticity of the experience. the associated ism was noted down. moreover, the resistances were catered with the required guidance, and overt behavior like body language, facial expressions, and mood were taken into observation. the key (triggering images) related to anxious attachment style and associated psychosomatic symptoms were selected for maneuvering (intervention). phase 3 intervention maneuvering of the images was done. the identified images associated with anxious attachment style and related psychosomatic symptoms were maneuvered for about 8-12 sessions depending upon the requirement of each participant. phase 4 post-assessment pss-35 pss-35 was administered, and pretest scores on psychosomatic symptoms were compared to the posttest scores after therapeutic sessions. *4 steps of preliminaries: 1) first report of symptoms. 2) worry and concern about the symptoms. 3) review of systems. 4) patient's various names. **step 2 and onwards were used interchangeably, depending upon the situation. ethical consideration ethical considerations included obtaining informed consent from all participants, ensuring confidentiality, and informing participants about the potential repercussions of therapy. participants not selected for the intervention were referred to a psychotherapist if interested in exploring their anxious attachment style and associated psychosomatic symptoms. statistical analysis data analysis was conducted using spss 22. paired sample t-tests were used to analyze data collected through instruments. 29 app| published by aeirc| volume 10 issue 1 result we compared the scores on the pretest with the posttest scores using the pss-35 scale. table 2 presents the mean comparison of adults with anxious attachment style before and after eidetic psychotherapy on psychosomatic symptoms. the findings indicate significant mean differences in psychosomatic symptoms frequency. the results show that mean scores on psychosomatic symptoms frequency decreased after eidetic psychotherapy. the cohen’s d value indicates a small effect size. moreover, the results also indicate significant mean differences in psychosomatic symptoms severity. the mean scores on psychosomatic symptoms severity also decreased after eidetic psychotherapy, with a cohen’s d value indicating a medium effect size. table 2: mean comparison of individuals before and after eidetic psychotherapy on psychosomatic symptoms. variables before eidetic psychotherapy after eidetic psychotherapy t (14) p cohen’s d mean ± sd mean ± sd psychosomatic symptoms (frequency) 75.20 ± 13.68 72.33 ± 14.80 3.20 .006** 0.20 psychosomatic symptoms (severity) 73.00 ± 6.64 68.86 ± 9.32 3.09 .008** 0.51 **p<.01 figure 1: common psychosomatic symptoms found in participants. **the figure is based on the non-clinical sample. 0 2 4 6 8 10 12 14 n o . o f p a rt ic ip a n ts psychosomatic symptoms psychosomatic symptoms 30 app| published by aeirc| volume 10 issue 1 figure 2: psychosomatic symptoms before and after eidetic psychotherapy. **the figure is based on the non-clinical sample. these figures provide visual representations of the common psychosomatic symptoms found in the participants and the changes in psychosomatic symptoms before and after eidetic psychotherapy. discussion the results of this study indicate a significant reduction in both the frequency and severity of psychosomatic symptoms following eidetic psychotherapy sessions, with small and medium effect sizes. these findings align with previous research, demonstrating the effectiveness of eidetic imagery as a selfregulatory process for dealing with specific patients' situations within their conscious state of mind, ultimately addressing traumatic mental images through repetitive visualization trials19. eidetic psychotherapy has been successfully employed to treat various conditions, including pain, phobias, eating disorders, and depression. notably, it has shown promise in treating posttraumatic stress disorder (ptsd), as evidenced by the 30 case histories reported by ahsen. trauma-based disorders or symptoms often trigger imagery-based recall of events. the resolution of clients' problems and symptoms encourages the exploration of images associated with traumatic events. through therapy, clients learn to interact with these images, gaining insight and recognizing somatic and emotional reactions23. 0 10 20 30 40 50 60 70 80 90 100 p sy ch o so m at ic s y m p to m s no. of participants frequency before therapy frequency after therapy severity before therapy severity after therapy 31 app| published by aeirc| volume 10 issue 1 a related study applied eidetic psychotherapy to individuals with generalized anxiety disorder (gad) and observed improvements in physiological and psychological symptoms. this further supports the effectiveness of this therapy in treating various conditions25. in our study, several therapeutic techniques were employed, likely contributing to the variance in the psychosomatic symptoms of adults with anxious attachment style. the process began with building rapport, gradually allowing participants to relax and trust the researcher. personality measures like htp and tat provided valuable insights into participants' personality traits, attachment, family dynamics, self-esteem, resilience, and coping strategies. eidetic psychotherapy's preliminary phases helped participants become consciously aware of their issues and bodily symptoms, which they might not have fully recognized before. these phases unveiled their worries and concerns, raising awareness and acceptance of the need for therapy. participants learned to locate painful emotions in their bodies understanding the impact of psychosomatic symptoms on their physical well-being. the eidetic parents test (ept) provided insights into participants' unconscious, revealing hurtful personal experiences and their connection to behaviors, cognitions, and psychosomatic symptoms. this phase identified problematic images, emotions, and somatic symptoms, helping to target specific areas for intervention. during the eidetic psychotherapy sessions, the focus was on manipulating and restructuring problematic images identified in the ept. this process gradually led to cognitive restructuring, reducing psychosomatic symptoms and emotional distress associated with the targeted images. additionally, participants gained insight into their irrational thought patterns and unhealthy coping strategies26. mental imagery plays a pivotal role in the treatment of psychological and neurological disorders. for example, in ptsd, intrusive memories and nightmares involve vivid visual and auditory mental images of traumatic events. these intrusive images significantly impact behavior and physiology. studies have shown that mental imagery elicits stronger emotions than verbal processing of the same content, intensifying anxiety with negative scenarios and amplifying positive emotions with positive scenarios. conclusion in conclusion, the therapeutic intervention provided in this study facilitated participants' recognition of emotions and meanings associated with their mental images. by repeatedly projecting these images, the therapy also led to changes in bodily symptoms and their associated meanings. the findings of this study support the hypothesis that eidetic psychotherapy is a valuable intervention for addressing psychosomatic symptoms in individuals with anxious attachment style. psychosomatic symptoms can significantly affect an individual's quality of life and may lead to other physical and psychological conditions. therefore, this study underscores the importance of prioritizing the treatment of these symptoms, similar to any other medical condition. the use of eidetic psychotherapy as a therapeutic tool opens up possibilities for effectively addressing psychosomatic symptoms and improving the overall wellbeing of individuals with anxious attachment style. further research and 32 app| published by aeirc| volume 10 issue 1 clinical applications of this therapy may yield valuable insights into its broader utility and effectiveness. acknowledgment i am greatly indebted to my supervisor, dr. asghar ali shah, and co-supervisor, dr. saima masoom ali and manzoor ahmed, for their contributions and valuable suggestions, and without their support, this work would not have been possible. references 1. mcleod s. john bowlby’s attachment theory [internet]. 2022 [cited 2023 aug 21]. available from: https://www.simplypsychology.org/bowlb y.html 2. huang s. attachment styles | simply psychology [internet]. 2022 [cited 2023 feb 18]. available from: https://www.simplypsychology.org/attach ment-styles.html 3. gasiorowska a, folwarczny m, otterbring t. anxious and status signaling: examining the link between attachment style and status consumption and the mediating role of materialistic values. personality and individual differences. 2022 may 1;190:111503. 4. robinson l, segal j, jaffe j. how attachment styles affect adult relationships helpguide.org [internet]. https://www.helpguide.org. 2023 [cited 2022 dec 13]. available from: https://www.helpguide.org/articles/relatio nships-communication/attachment-andadult-relationships.htm 5. gordon j. anxious attachment style guide: causes & symptoms [internet]. attachment project. 2020 [cited 2022 dec 13]. available from: https://www.attachmentproject.com/blog/ anxious-attachment/ 6. lin hc, yang y, elliott l, green e. individual differences in attachment anxiety shape the association between adverse childhood experiences and adult somatic symptoms. child abuse & neglect. 2020 mar 1;101:104325. 7. dent h. why everyone should know their attachment style [internet]. the conversation. 2018 [cited 2023 feb 18]. available from: http://theconversation.com/why-everyoneshould-know-their-attachment-style-105321 8. sumter sr, baumgartner se. psychosomatic complaints in adolescence: untangling the relationship between offline and online peer victimization, psychosomatic complaints and social support. european journal of developmental psychology. 2017 jul 4;14(4):399–415. 9. hange d, mehlig k, lissner l, guo x, bengtsson c, skoog i, et al. perceived mental stress in women associated with psychosomatic symptoms, but not mortality: observations from the population study of women in gothenburg, sweden. int j gen med. 2013 apr 24;6:307–15. 10. riem mme, doedée enem, broekhuizendijksman sc, beijer e. attachment and medically unexplained somatic symptoms: the role of mentalization. psychiatry research. 2018 oct 1;268:108–13. 11. adshead g, guthrie e. the role of attachment in medically unexplained symptoms and long-term illness. bjpsych advances. 2015 may;21(3):167–74. 12. maulina vvr, yogo m, ohira h. somatic symptoms: association among affective state, subjective body perception, and spiritual beliefs in japan and indonesia. frontiers in psychology [internet]. 2022 [cited 2023 feb 18];13. available from: https://www.frontiersin.org/articles/10.338 9/fpsyg.2022.851888 13. mostafaei s, kabir k, kazemnejad a, feizi a, mansourian m, hassanzadeh keshteli a, et al. explanation of somatic symptoms by mental health and personality traits: application of bayesian regularized quantile regression in a large population study. bmc psychiatry. 2019 jul 3;19(1):207. 14. kurlansik sl, maffei ms. somatic symptom disorder. afp. 2016 jan 1;93(1):49-54a. 15. falahatdoost m, dolatshahi b, pourshahbaz a, dehghani m, yalguzaghaji mn, mohammadi z. modeling the relationship between attachment styles and somatic symptoms with the mediating role of 33 app| published by aeirc| volume 10 issue 1 emotional processing. j educ health promot. 2020 jun 30;9:157. 16. atratus p. how to stop psychosomatic pain and live your life to the fullest. [internet]. 2022 [cited 2023 feb 20]. available from: https://domental.com/blog/how-to-stoppsychosomatic-pain 17. panagiotou n, sheikh aa. eidetic psychotherapy: introduction and evaluation. int j soc psychiatry. 2016;20(3–4):231–41. 18. dagnall l. eidetic image psychology | what is eidetic image psychology? [internet]. 2023 [cited 2023 feb 20]. available from: https://eideticimagepsychology.com/whatis-eidetic-image-psychology-2/ 19. syed kumail abdi, akhtar ali syed, ammara butt, sumaya batool. a comparison of eidetic image therapy with cognitive behavior therapy for treating depressive and anxiety disorders in adults: a randomized controlled trial. j allam iqbal med coll lahore [internet]. 2023 feb 28 [cited 2023 jul 8];20(3). available from: https://submitjaimc.website/index.php/jai mc/article/view/67 20. sussman j. jaqueline sussman [internet]. 2021 [cited 2023 feb 21]. available from: http://www.jaquelinesussman.com/eideticimage-therapy/ 21. ahsen a. basic concepts in eidetic psychotherapy. oxford, england: brandon house; 1973. xviii, 434 p. (basic concepts in eidetic psychotherapy). 22. syed aa, neelofur s, moran a, o&#39 g, reilly. investigating the potential clinical utility of therapeutic techniques based on eidetic imagery as adapted by the eidetic model of growth (emg) for people with intellectual disability (id). heliyon. 2020 jan 1;6(10):e05115. 23. kamran ehsan m, rowland dl. possible role for imagery-based therapy in managing ptsd in pakistani women experiencing domestic abuse: a pilot study using eidetic therapy. international journal of environmental research and public health. 2021 jan;18(5):2478. 24. kamran m, rowland dl. eidetic therapy in the treatment of depression: an exploratory application of an intervention in an emerging nation population. professional psychology: research and practice. 2020;51(5):527–35. 25. ilyas s. effectiveness of eidetic psychotherapy for the treatment of generalized anxiety disorder among adults. 2017 [cited 2022 mar 15]; available from: http://localhost:8080/xmlui/handle/123456 789/6136 26. pearson j, naselaris t, holmes ea, kosslyn sm. mental imagery: functional mechanisms and clinical applications. trends in cognitive sciences. 2015 oct;19(10):590. about:blank 56 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v9.i1.2022.56-63 protocol effect of emg, resp, and temp biofeedback training to reduce anxiety among undergraduate students ujala sajid1,3 , shamoon noushad2,3 & sadaf ahmed1,3 1department of physiology, university of karachi, karachi-pakistan. 2department of psychology, malir university of science & technology, karachi-pakistan. 3psychophysiology research lab, m.a.h.q. biological research center, university of karachi, karachi-pakistan. abstract background: it is evident that anxiety and stress are two of the main predominant issues that cause several mental health problems and disorders in university students, causing a negative impact on this population. higher educational institutes in pakistan have limited access and resources to face these issues. it is suggested that biofeedback-aided relaxation training has been effective in alleviating anxiety and stress symptoms among undergraduate students, especially during their examination season. recent research has proven biofeedback to be effective training for anxious students. the current randomized control trial is planned to investigate the effectiveness of electromyography-emg, respiration rate-resp, and skin temperature-temp biofeedback training for reducing anxiety symptoms among nursing students be receiving 8 sessions for 4 weeks. methodology: this study is planned to investigate the effectiveness of emg, resp, and temp biofeedback training in reducing symptoms of anxiety among the nursing students from one school, and to determine whether biofeedback training is associated with relaxing the minds and bodies of the anxious nursing students to cope with the distressing situation. study subjects meeting the eligibility criteria will be randomized into two groups using randomly generated numbers: the biofeedback training group and the control group. biofeedback training will be used as an intervention vs. the control. all the study subjects who give consent to participate will be made to complete the study questionnaires (demographic, screening for anxiety using the state-trait anxiety inventory – stai) at baseline and post-intervention (after 4 weeks). discussion: this study might help us determine biofeedback as a possible effective and useful technique in helping nursing students manage their anxiety. moreover, it is suggested that individuals receiving biofeedback training tend to show significant changes for the three psychophysiological modalities, i.e., emg, resp, and temp. this study might also give us insight into the efficacy of biofeedback in the pakistani population seeking help for stress and anxiety. keywords biofeedback training, anxiety, nursing students, emg, respiration, temperature. citation: sajid u, noushad s, ahmed s. effect of emg, resp, and temp biofeedback training to reduce anxiety among undergraduate students. app. 2022;9(1):56-63 corresponding author email: ujalasajid97@gmail.com doi: 10.29052/2412-3188.v9.i1.2022.56-63 received 10/04/2022 accepted 12/05/2022 published 01/06/2022 copyright © the author(s). 2022 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. about:blank 0000-0001-9339-857x https://orcid.org/0000-0002-8078-4524 https://orcid.org/0000-0002-9635-0202 about:blank about:blank about:blank 57 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 introduction biofeedback is a process/technique in which an individual can see the real-time recording of one or more physiological systems. information from the psychophysiological recording from biofeedback training can be used to help manage several physical and mental health issues with optimal functioning. biofeedback helps manage several disorders/diseases, including stress, depression, anxiety, pain, urinary incontinence, etc1. using biofeedback, one can learn to control the physical and psychological effects of stress, anxiety, and depression. moreover, it helps people relax their minds and bodies to cope with the distressing situation. the normal reaction of the body to stress is anxiety. it is a sensation of dread for what is ahead. most people may experience dread and nervousness on the first day of school, during a job interview, before tests, or when giving a speech2. it is suggested that anxiety belongs to a group of mental health diagnoses that cause excessive trepidation, fear, worry, or apprehension2,3. studies suggest that computer-based biofeedback systems help reduce anxiety in college and university students. moreover, nursing students experience anxiety and stress throughout their education and training. several factors might increase their anxiety, including academic, clinical, financial, interpersonal, family, physical and mental health issues. above all, poor coping skills of an individual may contribute the most to developing anxiety3-5. several studies have shown effective and significant use of biofeedback in reducing anxiety symptoms in undergraduate and nursing students4,5. the transition to university happens for most students near the end of adolescence, a period marked by mental instability due to the need to cope with psychological and psychosocial changes6. although reasonable amounts of stress are prevalent and adaptable in students' lives, excessive and ongoing stress may be linked to increased anxiety, and depression symptoms, among other manifestations7,8. the effects of psychological morbidity far-reaching effects, not only on students' health, development, scholastic success, and quality of life, but it is suggested to extend to their families, institutions, and even other people's lives9. depression and anxiety are two of the most typical psychological responses to stressful events encountered in university. during these times, students may experience a variety of emotional disturbances, including an increase in depressive and anxiety symptoms, which may drive them to engage in incorrect coping strategies, selfmedication, or needed professional care10. regarding biofeedback, limited research using this on students has been conducted but has shown promising results. a computer-based biofeedback system was found to be beneficial in lowering anxiety in college students by henriques et al. in 2011, and they recommended an interventional decrease in anxiety levels11. in a similar vein, research indicates that emg biofeedback and relaxation training may help students avoid anxiety-related academic failures and that therapy sessions can successfully lessen physical and mental signs of worry12. similarly, experimental studies show lower state anxiety in the experimental group compared to the control when augmented with gsr biofeedback13. similarly, biofeedback-assisted relaxation training, including diaphragmatic breathing and progressive muscle relaxation training, is also shown to help improve physiological measures using an influential training 58 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 strategy, improving respiratory, skin, temperature, and pulse rate of the nursing students14. still, the effectiveness and efficacy of biofeedback intervention training compared to other intervention training and programs are under discussion, and studies are being done to investigate whether it is effective in reducing anxiety traits and stress among undergraduate students. this randomized control trial aims to investigate the effectiveness of biofeedback training for reducing anxiety symptoms among the nursing students who are associated with anxiety. methodology study design this study will be conducted as a randomized control trial using subjects from one nursing school. study subjects meeting the eligibility criteria will be randomized into two groups: the biofeedback training group receiving emg, resp, and temp biofeedback training. while second group is the control group in which subjects will be asked to take three 20-minute writing sessions and write about the given control topic about their daily events of the past week. all the study subjects providing the consent to participate will be made to complete the study questionnaires (demographic, screening for anxiety using the state-trait anxiety inventory – stai)15,16,17 at baseline and post-intervention (after 4 weeks). ethical concerns the study protocol was consulted and approved by aeirc committee on ethics with the approval number erc/s20/p-015. and registered by the clinicaltrial.gov (registration number nct05508919) participants study participants will be recruited from the school of nursing, koohi goth women hospital, karachi-pakistan. students from a variety of ethnic backgrounds who reported to be anxious during the pre-screening utilizing the anxiety scale will make up our targeted population and will be consider eligible for participation. through an advertisement on the institute's notice board, students would be contacted and asked to take part in the study. each participant will be informed of the study's aims, length, and purpose before obtaining their written consent. eligibility criteria inclusion criteria all subjects fulfilling the below given criteria will be included. 1. the subject must not have any evidence of any metastatic disease. 2. must be able to properly write and speak urdu or english language. 3. must be a firstor second-year student. 4. should have high anxiety that will be assessed using the state-trait anxiety inventory-stai. exclusion criteria 1. the subject must not have any evidence of any metastatic disease. 2. must be able to properly write and speak urdu or english language. 3. must be a firstor second-year student. 4. should have high anxiety that will be assessed using the state-trait anxiety inventory-stai. study participants who match the requirements will be randomly divided into two groups: the biofeedback training group and control group interventions the experimental intervention the alive pioneer with the gp8 amp (biofeedback device) will be used for this study. gp8 amp can record ecg heart rate, 59 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 emg for muscle tension, hand temperature, and skin conductance. the sequence of the biofeedback training sessions is given below: 1. subjects in this group will get biofeedback intervention training. 2. the training consists of a total of 8 sessions for every individual, with 2 sessions per week for 4 weeks. 3. each session will be approximately 1 to 1.30 hours. 4. subjects will be instructed not to use chocolate, coffee, tea, and cocoa drinks at least 3 hours before the training session. 5. since it is suggested that anxiety tends to change with time so we might consider a one-month pretreatment measure as well as a just before treatment measure; that way, we can be sure if our baseline is stable or not. 6. baseline session: the subject will be asked to sit quietly for 15 minutes, and their breathing rate, skin temperature, and muscle tension using emg will be measured without any intervention. 7. subjects will then be given biofeedback training gradually to control their breathing rate and relax their muscle activity and temperature through resp biofeedback, assisted emg biofeedback, and temp biofeedback, from the 1st session till their 8th session. the control intervention in control intervention, the subjects will be asked to take three 20-minute writing sessions18 and write about the given control topic about their daily events of the past week. 1. for example, in session 1, we may ask the subjects to write about how they will use their time. 2. similarly, we will ask the subject to give more detail and write briefly about the given control condition in sessions 2 and session 3. 3. at the end of three writing sessions, we will measure their emg, resp, and temp to compare with the biofeedback training group. at the end of biofeedback training and writing sessions, the participants of both groups will also be asked to again fill the state-trait anxiety inventory –stai scale. recruitment and assessment procedure one or more researchers will be involved in the process of recruitment and evaluation. the principal investigator will conduct prior training sessions regarding study aims and procedures for all the researchers involved in the study. an information sheet including the subject's socio-demographic characteristics will be provided to each individual. written informed consent will be taken from each subject before the initiation of the study. confidentiality will be maintained during and after the study for the biofeedback training group and the control group. a baseline questionnaire (demographic, screening for anxiety using the state-trait anxiety inventory – stai)15,16,17 at baseline and post-intervention (after 4 weeks) will be conducted. procedure the screening questionnaire will be utilized for assessment. subjects reporting experiencing anxiety with the cut-off score at or above the 75th percentile on the stai will be kept inclusive. study hypothesis 1. we hypothesized to determine biofeedback as a possible effective and useful technique in helping individuals manage their anxiety. 60 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 2. moreover, individuals receiving biofeedback training will show significant changes for the three psychophysiological modalities, i.e., emg, resp, and temp. 3. throughout training of 4 weeks, study subjects will be trained to decrease emg and resp while they will be able to increase their skin temp. measures anxiety the state-trait anxiety inventory-stai will be used for anxiety screening. higher scores indicate a greater level of anxiety. it consists of 20 items on a 4-point likert scale (1 for "almost never" to 4 for "almost always"). the stai y has been widely used in numerous studies and is regionally tailored. the stai y-2's psychometric results in portuguese are favorable: with the reliability cronbach's alpha .90, while the test-retest pearson correlation coefficient of .8818. subjects reporting experiencing anxiety with the cutoff score at or above the 75th percentile on the stai will be kept inclusive. electromyography biofeedback (emg) the surface emg disposable sticky sensors will be attached to the bicep or flexor muscle. the ground sensor will be attached to the subjects' fingertips to read the heart rate. to enhance the connection on hairy places, a conductive paste, such as ten20 conductive paste can be used. the electrodes can be set up consecutively. to view the emg signals, the white, black, and green leads from the gp8 amp will be connected to the disposable electrodes. respiration biofeedback (resp) in this training, the gp8 amp reparation belt will be used. to gauge the subject's breathing, the respiration belt is wrapped over the chest or abdomen. the belt expands somewhat with each breath the subject takes, and this stretch (near the middle of the belt) is measured. in the breath pacer region of the alive bottom graphs, the respiration data is displayed as a yellow line. the subject's breathing impacts his or her heart rate and smoothness, as seen by the yellow respiration line. temperature biofeedback (temp) as suggested, the temperature in hand increases when one gets to relax. using gp8 amp, we can teach the subjects to increase their hand temperature dramatically. the mini-usb slot closest to the 4 leads is where the temperature sensor is connected to the gp8 amp. using one of the skin conductance velcro finger straps to secure the temperature sensor, the other end will be placed on the subject's finger. the temperature will need to calibrate for 30 to 60 seconds or until it stops rising before the training can start. expected outcomes primary outcomes we hypothesized to determine biofeedback as a possible effective and useful technique in helping individuals to manage their anxiety secondary outcomes 1. individuals receiving biofeedback training will tend to show significant changes for the three psychophysiological modalities i.e., emg, resp, and temp. 2. over the duration of training of 4 weeks, study subjects will be trained to decrease emg and resp, while they will be able to increase their skin temp. sample size the participants of this study will consist of 50 second-year nursing students, both males, and females, from the school of nursing, koohi goth, karachi-pakistan. the age range of study subjects will be between 18-21 61 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 years. this sample size is selected based on the glantz book's prior power analysis. randomization according to the eligibility requirements, subjects will be randomly assigned in a 1:1 ratio to the biofeedback training group or control group. randomization will be accomplished using computer-generated numbers. the study center will provide each participant a special code after collecting the necessary information from them. each form for each subject will have a reference to the code. statistical analysis all stai and biofeedback measurements (emg, resp, and temp) will be entered into the spss version 22.0 program, and all data will be analyzed using a multivariate analysis of covariance (mancova) to compare preand post-measures of the stai scale, as well as a repeated measures analysis of variance (anova) to compare the experimental group in two physiological modes during the baseline (0) and eighth sessions of the biofeedback training. moreover, to determine which subject met the criteria for learning the skills during biofeedback training, we will be using percent change scores while analyzing changes in anxiety. wilcoxon signed-rank test will be done to compare the measures among the subjects. figure 1: flowchart of the study procedure 62 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 discussion using biofeedback, one can learn to control the physical and psychological effects of stress, anxiety, and depression. moreover, it also helps people to relax their minds and bodies to cope with a distressing situation. psychophysiological studies have demonstrated that biofeedback training can help in reducing symptoms (psychological and psychophysiological) of stressful academic scenarios in undergraduate students. biofeedback training and different therapeutic sessions for anxious students seem to help them in reducing the muscle tension and respiration rate, especially during the time of their final examinations. biofeedback training/treatment is considered a self-regulation technique, suggesting an association of stress and anxiety features with sympathetic arousal of the nervous system. subjects getting biofeedback training are taught to alter the performance of their autonomic nervous system, which results in a reduction of activity of the sympathetic nervous system. this is done by giving the subjects an awareness session regarding their physiological functioning. moreover, such biofeedback training is suggested to increase the individual's control over their involuntary actions and help them to dominate their activities. overall, biofeedback training is suggested to improve the symptoms of anxiety, stress, and depression in undergraduate students. references 1. sherman ra. applied psychophysiological research 5th edition. 2021. 2. chaló p, pereira a, batista p, sancho l. brief biofeedback intervention on anxious freshman university students. applied psychophysiology and biofeedback. 2017 sep;42(3):163-8. 3. ratanasiripong p, ratanasiripong n, kathalae d. biofeedback intervention for stress and anxiety among nursing students: a randomized controlled trial. international scholarly research notices. 2012;2012. 4. tahsini zg, hosseini sm, kianersi f, rashn s, majdara e. biofeedback-aided relaxation training helps emotional disturbances in undergraduate students before examination. applied psychophysiology and biofeedback. 2017 dec;42(4):299-307. 5. mcausland l, addington j. biofeedback to treat anxiety in young people at clinical high risk for developing psychosis. early intervention in psychiatry. 2018 aug;12(4):694-701. 6. dyson r, renk k. freshmen adaptation to university life: depressive symptoms, stress, and coping. journal of clinical psychology. 2006 oct;62(10):1231-44. 7. napper le, labrie jw, hummer jf. anxiety and the use of alcohol‐related protective behavioral strategies. journal of college counseling. 2015 apr;18(1):2136. 8. sadigh m, himmanen s, scepansky j. an investigation of the prevalence of insomnia in college students and its relationship to trait anxiety. college student journal. 2014 sep 1;48(3):397-406. 9. bayram n, bilgel n. the prevalence and socio-demographic correlations of depression, anxiety and stress among a group of university students. social psychiatry and psychiatric epidemiology. 2008 aug;43(8):667-72. 10. schoenberg pl, david as. biofeedback for psychiatric disorders: a systematic review. applied psychophysiology and biofeedback. 2014 jun;39(2):109-35. 63 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 11. henriques g, keffer s, abrahamson c, jeanne horst s. exploring the effectiveness of a computer-based heart rate variability biofeedback program in reducing anxiety in college students. applied psychophysiology and biofeedback. 2011 jun;36(2):101-12. 12. thompson jg, griebstein mg, kuhlenschmidt sl. effects of emg biofeedback and relaxation training in the prevention of academic underachievement. journal of counseling psychology. 1980 mar;27(2):97. 13. fehring r. effects of biofeedback-aided relaxation on the psychological stress symptoms of college students. nursing research. 1983. 14. prato ca, yucha cb. biofeedbackassisted relaxation training to decrease test anxiety in nursing students. nursing education perspectives. 2013 mar 1;34(2):76-81. 15. silva dr, spielberger cd. manual do inventário de estado-traço de ansiedade (stai). mind garden. 2007;62. 16. spielberger cd. state-trait anxiety inventory for adults. 1983. 17. spielberger cd. state‐trait anxiety inventory. the corsini encyclopedia of psychology. 2010 jan 30:1-11. 18. niles an, haltom ke, mulvenna cm, lieberman md, stanton al. effect of expressive writing on psychological and physical heatlh: the moderating role of emotional expressivity. anxiety stress coping. los angeles: pschology departement, university of california. 2013. 05-19 annals of applied psychophysiology december 2024 volume 11 _______________________________________________________________________ a cyberphysiologic technique for stress control through a youtube video channel useable anytime, anywhere duke phucduc do1 published online: december 2024 © the author(s) 2024 abstract background: this research aimed to empower individuals to take charge of their daily stress. unlike traditional stress relaxation sessions, which often involve prolonged in-person sessions over multiple appointments, the cyberphysiologic protocol of this research addressed challenges associated with coaching availability, client-coach interaction, and communication of healing objectives, often sources of uncertainty and ambiguity for the clients. while cyberphysiology on youtube is not currently available, the overwhelmingly positive feedback from the public on the relaxation video channels demonstrates its potential. its practicality and convenience, particularly during periods of isolation like the covid-19 pandemic, vacations, or remote work, make it a welcome relief in the often-burdensome process of stress management. this practicality can help individuals feel less overwhelmed by their stress. methodology: in this research, the new protocol, cyberphysiology, used an objective stress measurement of the cortisol level in the hair of the two groups of subjects. the treatment group learned acceptance and commitment therapy (act) concepts using mindful meditation selfhypnosis. the control group engaged in traditional stress reduction exercise videos. results: the mann-whitney u test from spss revealed a significant level of p value = 0.019. the results showed that practicing the cyberphysiologic (treatment) technique significantly improved stress levels compared to the common relaxation technique implemented in the videos for the control group. conclusion: this research reveals another practical approach to stress management through the cyberphysiologic method, which integrates self-regulation techniques such as autogenic training, imagery/visualization, meditation, and self-hypnosis (olness,1989). in addition, it includes teaching acceptance and commitment therapy (act) principles via youtube videos that can be accessed anytime, anywhere. keywords: stress, cyberphysiology, self-regulation, autogenic training, imagery, visualization, mindfulness meditation, self-hypnosis, act, youtube 1. duke do ddo@saybrook.edu saybrook university, pasadena, ca usa 6 introduction this research was built upon a randomized controlled pilot study published in the international journal of clinical and experimental hypnosis (ijceh) in 2020 (olendzki et al., 2020). the study focused on the integration of hypnosis with mindfulness. dr. gary elkins, a key researcher in this study, highlighted the potential of this combination for providing practical and user-friendly stress treatment. the unique approach aims to improve user experience and ensure effectiveness and accessibility in stress treatment, instilling confidence in its practicality. additionally, this research explored the use of guided imagery, an essential component of traditional hypnosis, through the widely accessible platform youtube. this research aimed to induce altered states of consciousness and maximize the benefits of mindful self-hypnosis. mindfulness aims to promote non-judgmental present-moment awareness, which complements the techniques used in hypnosis to prepare individuals for suggestions of change. positive results from baylor university’s pilot study (goodrich, 2020) demonstrated the potential of integrating mindfulness and hypnosis in stress treatment. this research seeks to explore the feasibility of self-hypnosis at home further using pre-recorded sessions on a youtube channel. participants can follow the instructions in the video to induce a relaxed and focused state, with the potential for self-regulation using readily available mobile devices. the practical implications of this research could significantly enhance stress treatment research. methodology theory this research was triggered by sigmund freud’s delineation of three levels of the mind: the conscious, preconscious, and unconscious. the conscious mind encompasses all awareness processes, the preconscious mind holds thoughts and feelings that are not currently within conscious awareness, and the unconscious mind is the primary reservoir of human behaviors influenced by past experiences (freud, 1915). the unconscious mind, which operates beyond the individual’s conscious awareness, plays a significant role in shaping their behaviors and wellbeing. it stores memories, emotions, and desires that are too painful or unacceptable to be consciously acknowledged, yet they influence the individual’s actions and feelings. zeig (1980) stated, “the unconscious mind is made up of all your learnings over a lifetime, many of which you have completely forgotten, but which serve you in your automatic functioning. now, a great deal of your behavior is the automatic functioning of these forgotten memories” (p. 66). this automatic functioning, which includes processes such as regulating bodily functions and responding to stress, operates without conscious attention, functioning at an unconscious level, regulated by the autonomic nervous system. however, milton h. erickson theorized that hypnosis is the tool for establishing communication with the unconscious mind and effecting behavioral change through reprogramming (as cited in rossi, 2010). mindfulness can be a powerful gateway to empowering people with a non-judgmental, accepting, and adaptable approach to thoughts, emotions, behaviors, and situations. engaging in mindfulness practices effectively lowers muscle tension (ganjeali et al., 2020). it reduces autonomic arousal, including symptoms such as increased heart rate and sweating. hypnosis, in 7 turn, can harness the hypnotic trance state induced by mindfulness, utilizing heightened suggestibility, relaxation, and vivid imagination to reprogram our automatic functioning. this automatic functioning operates without conscious attention, functioning at an unconscious level, regulated by the autonomic nervous system, which governs numerous automatic bodily processes, including triggering the fight-or-flight response and managing stress and threats to restore equilibrium. with its focus on self-hypnosis explicitly tailored for stress reduction, cyberphysiologic techniques did not require the role of a professional in the field. however, the participant’s eagerness to learn was integral to its success. method in this cyberphysiologic research, the protocol integrated multiple self-regulation techniques into a single self-taught playlist spanning six training sessions. these sessions incorporate the core principles of acceptance and commitment therapy (act) and offer self-guided instruction through the user-friendly platform of the “cyberphysiology” video communication channel on youtube. the primary goal of this research study is to investigate the potential impact of youtubebased cyberphysiological interventions on stress reduction outcomes. to achieve this goal, this study was based on a quasi-experimental design. subjects are assigned to groups based on nonrandom criteria that rely on a researcher’s judgment, convenience, or specific characteristics of the selected individuals. however, like a true experiment, a quasi-experimental design seeks to establish a cause-and-effect relationship between an independent variable, cyberphysiologic technique, and a dependent variable, stress level. participants from alhaque et al. (2019) and paleri et al. (2023)’s experiences, this experiment utilized the quasi-experiment, which compares two groups of volunteers using a youtube channel. the experimental group included participants who received the intervention via cyberphysiology videos on youtube. meanwhile, the control group did not receive the experimental techniques and watched the common relaxation videos, which were standard relaxation videos commonly available on youtube and similar platforms. these videos were the same as their usual youtube watching activities. this study evaluated the experimental and control groups’ stress levels before and after the experiment. instruments the study required participants to have access to and knowledge about youtube video channels before beginning the experiment. an initial remote session was conducted to explain the process, help with setup, and configure their devices for the study. following this initial session, participants received detailed instructions and a designated point of contact to assist them during each session. the research compared two stress level measurements: the hair cortisol stress kit and the perceived stress scale (pss). only the cortisol test was taken both before and after the 8 experiment, and the pss scored did not show adequate results initially to continue collecting at the end. results by means of giving an overview of the data collected for this study, the data in table 1 comprises the original 27 participants (column a participant id) who signed the consent form and agreed to submit the hair sample to the advanced food intolerance labs (afil) for stress test by cortisol level measurement. these participants were screened to meet adequate stress levels for the experiment and divided into treatment and control groups. the hair sample was analyzed using afil’s state-of-the-art biotechnology, which assesses cortisol in the body to help the experiment identify the subject’s stress levels. the stress level was recorded within range levels (0%–50%) and out of range (50%–100%). the baseline stress level is recorded based on these percent values in column j. table 1 participants summary 9 legend: color meanings red participation excluded from the experiment due to the low stress level. yellow two experiment groups divider. orange participant status excluded from the experiment. green participant status participated with stress level improvement. blue participant status participated with stress level decline. in table 2, the subjects only needed to submit the hair sample for the post-experiment stress level measurement indicated in column k. column l shows the stress level differences with a positive value indicating improve and a negative value indicating decline, as indicated in column o for the initial assessment. table 2 experiment results 10 these data were subsequently prepared and analyzed using spss and online tools for statistical analysis. the experiment compared the stress level of 18 subjects’ stress scores before and after in two different groups: (1) cyberphysiology techniques as a treatment group and (2) relaxation as a control group. these scores presented the participant’s stress levels from 0 to 100; the high number showed high stress levels, and the low number showed low stress levels. the collected stress level data can be checked for normality to determine suitable statistical analysis methods. sample characteristics the null hypothesis for this normality test is that the data does not meet the normal distribution assumption. reject the null hypothesis if the p-value is below 0.05. in a normal distribution, the mean, median, and mode should all be equal, or the skewness and kurtosis values should be as close to zero as possible, falling within the range of −1.96 to +1.96. hence, not all the calculations indicated that the data from the cyberphysiology group followed a normal distribution (see table 3). table 3 cyberphysiology group descriptive normality analysis from spss statisticsa stress (before) stress (after) n valid 9 9 missing 0 0 mean 61.6667 27.0000 median 66.0000 30.0000 mode 66.00b 18.00b a. group = cyberphysiology b. multiple modes exist. the smallest value is shown the significant column under the shapiro-wilk test (last column in table 4) indicates the significance of the normality test is larger than 0.05 and failed to reject the null hypothesis. this finding has significant implications for the stress levels in the cyberphysiology group, as they were not distributed normally, which is a matter of concern (see table 4). 11 table 4 cyberphysiology group tests of normality from spss as indicated in the rules for normal distribution above, not all the calculations indicated that the data from the control group followed a normal distribution (see table 5). table 5 control group descriptive analysis from spss statisticsa stress (before) stress (after) n valid 9 9 missing 0 0 mean 73.3333 71.0000 median 78.0000 72.0000 mode 69.00b 45.00b a. group = control b. multiple modes exist. the smallest value is shown similarly, the significant column under the shapiro-wilk test in table 6 indicated the significance of the normality test is larger than 0.05 and failed to reject the null hypothesis. that means the subjects’ stress levels in the control group were not distributed normally. 12 table 6 control group tests of normality from spss in summary, this experiment analysis used non-parametric statistical tests for analysis because the collected data did not distribute normally and small samples size = 18. the calculation values presented in the subsequent tables from spss outputs and the statistical analysis utilized included: mann-whitney u test and the wilcoxon signed-rank test. mann-whitney u test (compare the treatments) the first analysis involved comparing the treatments and encompasses the null hypothesis (h0): there is no difference in stress reduction between the cyberphysiology (treatment) and relaxation (control) group. the question was, “is there a difference in stress levels between individuals who practice cyberphysiology and those who do not?” the key findings of this analysis are as follows: (1) as the hypothesis test summary (table 7) clearly indicated, the significant level is p value = 0.019, which is less than α = 0.05. therefore, the decision was confidently made to reject the null hypothesis, confirming that the stress change is indeed significantly different between the cyberphysiology (treatment) and the relaxation (control) group. (2) furthermore, the table and chart (see table 7) clearly showed a significant difference in the mean ranks of both groups. the cyberphysiology (treatment) group demonstrated a substantial improvement, standing out with a mean rank of 12.44 and a sum of 112, compared to the relaxation (control) group with a mean rank of 6.56 and a sum of 59, from the 9 test subjects in each group. (3) the effect size, a crucial measure in this analysis, is calculated using the formula: r = (z / sqrt (n) = −2.342/sqrt (18) = −0.552. this value, larger than 0.5, indicated a significant effect. it provided a clear understanding of the magnitude of the difference between cyberphysiology and relaxation techniques, demonstrating a substantial effect size value. 13 table 7 mann-whitney u test results from spss hypothesis test summary null hypothesis test sig. decision 1 the distribution of stress change is the same across categories of group. independent-samples mannwhitney u test .019a reject the null hypothesis. asymptotic significances are displayed. the significance level is .050. 14 a. exact significance is displayed for this test. test statisticsa stress change mannwhitney u 14.000 wilcoxon w 59.000 z -2.342 asymp. sig. (2-tailed) .019 exact sig. [2*(1-tailed sig.)] .019b a. grouping variable: group b. not corrected for ties. ranks group n mean rank sum of ranks stress change cyberph ysiology 9 12.44 112.00 control 9 6.56 59.00 total 18 report median group stress change cyberph ysiology 45.0000 control 6.0000 total 18.0000 15 a mann-whitney u test revealed that stress scores were statistically significantly lower in the cyberphysiology (treatment) group (md = 45.0000, n = 9) compared to the relaxation (control) group (md = 6.0000, n = 9), z = −2.342, p value = 0.019, with a large effect size, r = 0.552. wilcoxon signed-rank test (compare the effectiveness of each treatment) the second analysis, comparing the results within the group, covered the effectiveness of intervention with repeated measurement (before and after) of the same subjects within the cyberphysiology (treatment) and relaxation (control) groups. it answered these questions: (1) did the cyberphysiologic technique reduce stress levels more effectively than the standard relaxation techniques? and (2) was there a significant difference in stress levels before and after a cyberphysiologic intervention? supporting evidence is provided in the following two sections for cyberphysiology (treatment) and relaxation (control) of the corresponding spss tables and figures. cyberphysiology (treatment) group the experiment with the cyberphysiology (treatment) group compared the stress level of nine subjects’ stress scores before and after watching the six cyberphysiology videos to learn how to manage their daily stress (see table 8). 16 table 8 wilcoxon signed-rank test results from spss for cyberphysiology group hypothesis test summary null hypothesis test sig. decision 1 the median of differences between stress (before) and stress (after) equals 0. related-samples wilcoxon signed rank test .015 reject the null hypothesis. asymptotic significances are displayed. the significance level is .050. statisticsa stress (before) stress (after) n valid 9 9 missing 0 0 mean 61.6667 27.0000 median 66.0000 30.0000 mode 66.00b 18.00b a. group = cyberphysiology b. multiple modes exist. the smallest value is shown test statisticsa,b stress (after) stress (before) z -2.431c asymp. sig. (2-tailed) .015 a. group = cyberphysiology b. wilcoxon signed ranks test c. based on positive ranks. a wilcoxon signed-rank test revealed that stress scores were significantly lower after the cyberphysiology intervention (md = 27.0000, n = 9) compared to before (md = 61.6667, n = 9), z = −2.431, p value = 0.015, with a large effect size, r = 0.810. relaxation (control) group the experiment with the relaxation (control) group also compared the stress level of nine subjects’ stress scores before and after watching the six relaxation videos to manage their daily stress (see table 9). 17 table 9 wilcoxon signed-rank test results from spss for control group hypothesis test summary null hypothesis test sig. decision 1 the median of differences between stress (before) and stress (after) equals 0. related-samples wilcoxon signed rank test .766 retain the null hypothesis. asymptotic significances are displayed. the significance level is .050. statisticsa stress (before) stress (after) n valid 9 9 missing 0 0 mean 73.3333 71.0000 median 78.0000 72.0000 mode 69.00b 45.00b a. group = control b. multiple modes exist. the smallest value is shown test statisticsa,b stress (after) stress (before) z -.297c asymp. sig. (2-tailed) .766 a. group = control b. wilcoxon signed ranks test c. based on positive ranks. a wilcoxon signed rank test revealed that stress scores were not significantly lower after the control intervention (md = 71.000, n = 9) compared to before (md = 73.333, n = 9), z = −0.297, p value = 0.766, with a small effect size, r = 0.099. discussion findings this research aimed to measure stress levels and evaluate the effectiveness of stress reduction techniques. the results, including skewness and kurtosis, a shapiro-wilk’s test (p > .05), and a visual inspection of the histogram and normal q-q plots, revealed the stress levels recorded 18 were not normally distributed for both the cyberphysiology group and the control group, necessitating the use of nonparametric tests for a statistically significant analysis. eighteen randomly sampled subjects (dots in figure 1) were asked to watch a youtube channel for stress reduction. the channel featured both cyberphysiology (treatment) and relaxation (control) techniques. the dots in figure 1 vividly illustrate the effectiveness of these techniques, with a positive number indicating an improvement in stress levels and negative values showing the opposite result. figure 1 stress level change by group the results showed that practicing the cyberphysiology (treatment) technique significantly improved the stress level compared to the common relaxation technique implemented in the videos for the control group, highlighting the importance of these findings. the results also showed that the common relaxation intervention did not significantly influence participants’ stress levels in this experiment, further emphasizing the superiority of cyberphysiology in stress management. limitations the findings are indeed remarkable, but it is crucial to acknowledge the following constraints and potential sources of bias that may have influenced the results. for instance, even though the sample size of 18 is acceptable for this experiment, there may be more accurate representations of the population. especially in neuroscience, small sample sizes can also lead to low statistical power, inflated false discovery rates, and low reproducibility. the samples are primarily female and only cover a small area of the country, which could potentially impact the generalizability of the results and underline the need for further research. 19 future directions the limitations outlined in this study offer valuable insights for future research. by directly addressing these limitations, subsequent studies could provide a comprehensive and critical evaluation of the study’s validity and reliability. expanding on the findings and constraints discussed, future research could explore the potential of cyberphysiology in managing various mental health conditions, including chronic anxiety, depression, and sleep disorders. additionally, investigating the integration of biofeedback and neurofeedback techniques could optimize the effectiveness of the cyberphysiologic approach. moreover, future studies involving a more extensive and diverse pool of research participants can help address the limitations highlighted in this study. intervention evaluation this study successfully introduced a stress management technique aimed at helping individuals align their actions with their core values through self-regulation of their minds to overcome stress feelings. the two concepts at hand are: (1) meditation, which is deeply rooted in ancient traditions and centers around mindfulness and present-moment awareness; and (2) act, a modern therapeutic approach that emphasizes acceptance, cognitive defusion, and commitment to values-based actions (gloster et al., 2020). by incorporating mindfulness, acceptance, and valuesbased actions, it becomes possible to enhance psychological flexibility, reduce stress and anxiety, and cultivate a more meaningful and fulfilling life. however, this combined approach also brings about challenges, such as the intricacy of integration, time commitment, potential resistance, individual differences, and measurement of outcomes. conclusion stress is a widespread issue that impacts individuals in various aspects of their lives, including work, education, and personal relationships. while traditional stress management methods like cognitive-behavioral therapy (cbt) and mindfulness are effective, they often demand significant time and dedication. a new approach called mindful hypnosis, which combines mindfulness and hypnosis, has recently gained attention as a promising stress management technique. according to a pilot study conducted by baylor university, this intervention has shown promise (goodrich, 2020). additionally, this research reveals another effective approach for stress management through the cyberphysiologic method, which integrates self-regulation techniques such as autogenic training, imagery/visualization, meditation, and self-hypnosis (olness,1989). in addition, it includes teaching acceptance and commitment therapy (act) principles via youtube videos that people can access anytime, anywhere. 20 references 1. alhaque, a., joefiani, p., & wungu, e. (2019). trial application of acceptance and commitment therapy principles to reduce the degree of stress experienced by adolescents with down syndrome sibling(s). psychological research and intervention, 2(1), 1–10. https://doi.org/10.21831/pri.v2i1.24339 2. elkins, g. r., roberts, r. l., & simicich, l. (2018). mindful self-hypnosis for self-care: an integrative model and illustrative case example. the american journal of clinical hypnosis, 61(1), 45–56. https://doi.org/10.1080/00029157.2018.1456896 3. freud, s. (1915). the unconscious (standard ed., vol. 14, pp. 159–204). hogarth. 4. ganjeali, s., farsi, z., sajadi, s. a., & zarea, k. (2022). the effect of the demonstrationbased progressive muscle relaxation technique on stress and anxiety in nurses caring for covid-19 patients: a randomized clinical trial. bmc psychiatry, 22, article 791. https://doi.org/10.1186/s12888-022-04456-3 5. gloster, a. t., walder, n., levin, m. e., twohig, m. p., & karekla, m. (2020). the empirical status of acceptance and commitment therapy: a review of metaanalyses. journal of contextual behavioral science, 18, 181– 192. https://doi.org/10.1016/j.jcbs.2020.09.009 6. goodrich, t. (2020, june 15). mindfulness combined with hypnotherapy aids highly stressed people, baylor university pilot study finds. baylor university media and public relations. https://baylor.edu/mediacommunications/news.php?action=story&story=219258 7. olendzki, n., elkins, g. r., slonena, e., hung, j., & rhodes, j. r. (2020). mindful hypnotherapy to reduce stress and increase mindfulness: a randomized controlled pilot study. the international journal of clinical and experimental hypnosis, 68(2), 151–166. https://doi.org/10.1080/00207144.2020.1722028 8. olness, k. (1989). hypnotherapy: a cyberphysiologic strategy in pain management. pediatric clinics of north america, 36(4), 873–884. https://doi.org/10.1016/s0031-3955(16)36726-8 9. paleri, r. j., meena, k. s. m., sharma, m. k., ravish, h., krishnamurthy, l., joshi, r. k., & lepcha, r. (2023). efficacy of video-based relaxation technique to minimize stress in young adults during the covid-19 pandemic. journal of neurosciences in rural practice, 14(3), 544–546. https://doi.org/10.25259/jnrp_68_2023 10. rossi, e. (2010). the collected works of milton h. erickson, vol 5. classical hypnotic phenomena, part 1: psychodynamics (e. l. rossi, k. l. rossi, & r. erickson-klein, eds.). the milton h. erickson foundation press. 11. sim, s., maldonado, i. l., castelnau, p., barantin, l., el-hage, w., andersson, f., & cottier, j. p. (2024). neural correlates of mindfulness meditation and hypnosis on magnetic resonance imaging: similarities and differences. a scoping review. journal of neuroradiology, 51(2), 131–144. https://doi.org/10.1016/j.neurad.2023.11.002 12. zeig, j. (1980). a teaching seminar with milton erickson. brunner-mazel. https://doi.org/10.21831/pri.v2i1.24339 https://doi.org/10.1080/00029157.2018.1456896 https://doi.org/10.1186/s12888-022-04456-3 https://doi.org/10.1016/j.jcbs.2020.09.009 https://baylor.edu/mediacommunications/news.php?action=story&story=219258 https://doi.org/10.1080/00207144.2020.1722028 https://doi.org/10.1016/s0031-3955(16)36726-8 https://doi.org/10.25259/jnrp_68_2023 https://doi.org/10.1016/j.neurad.2023.11.002 08 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v10.i1.2023.xx-xx original article changes in muscle tension patterns predicting the start of nocturnal leg cramps: a pilot study jacqueline l. chaney & richard a. sherman saybrook university, pasadena, california, usa abstract background: although it is assumed that nocturnal leg cramps (nlc) are based on actual muscle cramps, no articles show that nocturnal leg cramps are preceded by changes in surface electromyograms (semg), which might indicate that a natural muscle cramp is occurring. this exploratory pilot study was designed to identify patterns of calf muscle activity before the onset of subjects' awakenings with pain associated with nocturnal leg cramps (nlc) to establish a precursor relationship between changes in muscle tension and the start of nlcs. methodology: participants' relative calf muscle activity patterns during nighttime sleep were recorded for the entire night using a wireless ambulatory device on one night when subjects awakened with a leg cramp and one when there was no awakening. when the six issues awakened with pain from a leg cramp in the calf being recorded, relative muscle tension patterns were analyzed from 30 minutes before to 30 minutes after the awakening. these patterns were compared with 60minute recordings on days when four subjects did not awaken with pain. results: all six participants were women between the ages of 23 and 56 (mean of 48 with sd of 13) who met the criteria for and had histories of nocturnal leg cramps for between 4 and 15 years (mean of 10 with sd = 4). all six had significant increases in patterns of relative muscle tension not associated with patterns of movement for an average of 41 seconds (sd 11) before awakening with pain (mean increase of 217%, sd 157, rang 100% 500% with spikes having a mean of 250% above baseline, mean 251, range 200 – 800%). relative muscle tension remained nearly twice the original baseline for about 50 seconds after a painful awakening and did not return to pre-occurrence levels for up to 20 minutes. conclusion: as muscle tension changed before subjects were awakened by pain, the change in tension is not a reaction to the pain. the signal did not contain movement artifacts, so the change reflects a precursor to the pain, and nocturnal leg cramps are likely caused by muscle tension. further research using a calibrated device to record microvolts objectively is in progress to confirm these initial findings. keywords nocturnal leg cramps, nlc, semg, muscle tension, cramps, leg pain. citation: chaney jl, sherman ra. changes in muscle tension patterns predicting the start of nocturnal leg cramps: a pilot study. app. 2023; 10(1): 08-11 corresponding author email: drrichsherman@gmail.com doi: 10.29052/2412-3188.v10.i1.2022.08-11 received 16/03/2023 accepted 26/05/2023 published 01/06/2023 copyright © the author(s). 2023. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the behavioral medicine research and training foundation (port angeles, washington, usa) purchased the recording devices and computer and then loaned to the investigators to use in the study. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v10.i1.2023. about:blank about:blank 09 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 introduction an estimated 50%–60% of adult patients presenting to primary care frequently report nocturnal leg cramps1. nocturnal leg cramps (nlcs) affect the lower limbs, typically impacting the calf, hamstring, or foot muscles at night2,3 and often interrupt sleep1. the etiology of leg cramps is unclear1,4. while some cases are associated with myopathic, neurologic, and metabolic causes, most cases are idiopathic with no known cause1. while the description of nocturnal leg cramps always includes sudden, abrupt leg pain occurring during nighttime sleep1,5, none of the literature shows that an actual muscle cramp is taking place6. no treatments of idiopathic nocturnal leg cramps are successful1,7. quinine is the most studied pharmacological intervention but is unsafe due to dangerous risk factors3. methodology this pilot study measured raw surface electromyograms (semg) during nighttime sleep from one calf of six subjects experiencing nlcs. the project was approved by saybrook university's institutional review board (pasadena, california, usa), and all subjects signed an explanatory consent form before participating in the study. subjects were recruited by word of mouth from people living near the first author. the study gathered data for up to 3 consecutive nights to capture a night in which participants reported a painful awakening and a night to obtain baseline tension in which participants did not report a painful awakening. the recordings captured muscle activity 30 minutes prior to and up to 30 minutes after the subject reported a painful awakening. all six participants were black women living in the united states of america between the ages of 23 and 56 (mean of 48 with sd of 13) who met the criteria for5,6 and had histories of nocturnal leg cramps for between 4 and 15 years (mean of 10 with sd = 4) occurring at least 3 times per month. the criteria excluded individuals receiving pharmaceutical treatment for cramps or those diagnosed with restless leg syndrome (rls), a different problem than nlcs5. participants’ patterns of relative calf muscle activity during nighttime sleep were recorded using a wireless ambulatory cricket device (somaxis, inc., california, usa) which had the advantage of not having wires running from sensors on the calf to a recording device. the investigators feared wires would interfere with the subjects' normal movements. the device was not calibrated sufficiently, so only the percent change in the signal could be used when subjects' recordings were compared. the device's motion sensor was not sensitive enough to detect movement artifacts indicative of a spam starting so changes in the raw signal typical of movements8 were used to estimate when movement artifacts were recorded. when subjects awakened with pain from a leg cramp in the calf being recorded, relative muscle tension patterns were analyzed from 30 minutes before to 30 minutes after the awakening. these patterns were compared with 60-minute recordings on days when four subjects did not awaken with pain. result for the four subjects recorded on nights without leg cramps, the 60-minute segments showed typical, movement artifact-free baseline instabilities8 ranging from 15 to 100% with few spikes in the recording (table 1). during the night when the subjects were awakened by pain in their calves, all six showed similarly stable, 30-minute, preawakening baselines free of movement artifacts with few spikes. in the average of 41 10 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 seconds (sd = 11, range of 25 – 50 seconds) just before awakening with pain, all six had large increases in patterns of relative muscle tension not associated with patterns of movement (mean increase of 217%, sd 157, range 100% 500% with spikes having a mean of 250% above baseline, mean 251, range 200 – 800%). relative muscle tension remained nearly twice the original baseline for about 50 seconds after a painful awakening and did not return to preoccurrence levels for up to 20 minutes. see table 1 for details of the individual results. table 1: summary of recordings discussion even given the device limitations, the data demonstrated increased muscle tension significantly above baseline for all six subjects who reported awakening with painful cramping. although it is assumed that the pain from nocturnal leg “cramps” (nlc) are a result of muscle activity preceded by changes in surface electromyograms (semg) as is found for typical cramps8, the authors were unsuccessful in finding any studies demonstrating this predictive relationship. theories about complex underlying mechanisms abound, but facts are few and far between. the lack of published studies is very odd as nlcs are one of the most common pain syndromes, and muscle tension recordings from major muscles have been made by rehabilitation physicians evaluating pain syndromes since the late 1940s9. the lack of such published studies indicates that there must have been attempts to perform them but that the results were never published or are buried in older books. this study is the first to indicate that such a predictive relationship. 11 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 a seventh subject who had leg pain due to tumors in her feet was recorded. she showed no significant changes in muscle tension during the night's recording. conclusion as muscle tension changed before subjects were awakened by pain, the change in tension is not a reaction to the pain. the signal did not contain movement artifacts, so the change reflects a precursor to the pain, and nocturnal leg cramps are likely caused by muscle tension. further research using a calibrated device to objectively record microvolts is in progress to confirm these initial findings. acknowledgment drs. jerry r devore and sam kohlenberg assisted with different aspects of the methodology. references 1. allen re, kirby ka. nocturnal leg cramps. american family physician. 2012; 86(4): 350– 355. 2. katzberg h. d, khan ah, so yt. assessment: symptomatic treatment for muscle cramps (an evidence-based review): report of the therapeutics and technology assessment subcommittee of the american academy of neurology. neurology. 2010; 74(8): 691–696. 3. monderer rs, wu wp, thorpy mj. nocturnal leg cramps. current neurology and neuroscience reports, 2010; 10(1): 53–59. 4. rana aq, khan f, mosabbir a, ondo w. differentiating nocturnal leg cramps and restless legs syndrome. expert reviews neurotherapy. 2014; 14(7): 813–818. 5. hallegraeff jm, de greef m, krifren w, van der schans c. criteria in diagnosing nocturnal leg cramps a systemic review. bmc family practice. 2017; 18(29): article 29. 6. weiner ih, weiner hl. nocturnal leg muscle cramps. jama. 1980; 244(20): 2332–2333. 7. tipton pw, wszolek z k. restless legs syndrome and nocturnal leg cramps: review and guide to diagnosis and treatment. polish archives of internal medicine. 2017; 127(12): 865–872. 8. sherman ra. pain: assessment & intervention from a psychophysiological perspective (2nd ed.). 2011; association for applied psychophysiology and biofeedback. 9. basmajian, j. muscles alive: their functions revealed by electromyography, 2nd ed., 1962, williams & wilkins. about:blank annals of psychophysiology volume 11 december 2024 about the annals of psychophysiology the annals of psychophysiology (app) is the semi-annual journal of the behavioral medicine research and training foundation which provides all funding to support the journal. issues are usually published in june and december. the journal is published in cooperation with pakistan’s advance educational institute and research center (aeirc) which published the journal from its inception in 2014 until 2024 and continues to provide technical support for preparing manuscripts for publication. the app provides a platform for scientific contributions on all aspects of psychophysiology with emphasis on the psychophysiology of health and disease with sub-themes covering environmental and sports psychophysiology. articles include current reviews of various aspects of the field, original research, and editorials. the online issn is 2412-3188 while the print issn is 24101354. app is an open-access journal committed to maintaining high standards through rigorous peer review. the journal does not charge authors any fees for publication. information about the foundation and the courses it offers centering on behavioral medicine and biofeedback can be found by following this link: https://www.behavmedfoundation.org the journal is actively soliciting original research and reviews of current research in psychophysiology. please go to our website https://annalsofpsychophysiology.org for lots of information about the journal, its policies, and instructions for submitting manuscripts. editor-in-chief richard a. sherman, ph.d., usa associate editors eric willmarth, ph.d. usa cynthia r. kerson, ph.d., ph.d., usa john graham, md, dd, ph.d., usa jerry r. devore, ph.d., usa editorial board – each individual bio sketch and academic information is listed on our website https://annalsofpsychophysiology.org please take a few moments to look at the foundation’s courses! the behavioral medicine r&t foundation supports this journal by selling courses to clinicians, coaches, educators, military, and lots of others who are interested in optimal functioning and behavioral medicine. click here to see our courses: https://www.behavmedfoundation.org https://www.behavmedfoundation.org/ https://annalsofpsychophysiology.org/ https://annalsofpsychophysiology.org/ https://www.behavmedfoundation.org/ 84 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v10.i2.2023.84-90 original article mindfulness intervention mitigates trauma-induced cognitive decline among healthcare professionals shereen1, syeda farah batool2, ayesha maryam1 & syed akmal sultan3 1department of medical technology, malir university of science & technology, karachipakistan. 2department of psychology, malir university of science & technology, karachi-pakistan. 3department of orthopaedic surgery & physiotherapy, shaheed mohtarma benazir bhutto institute of trauma, karachi-pakistan. . abstract background: healthcare professionals are vulnerable to trauma-induced cognitive decline due to their exposure to traumatic events in the workplace. mindfulnessbased interventions have shown promise in mitigating stress and improving cognitive function. this study aimed to investigate the impact of a mindfulness intervention on trauma-induced cognitive decline among healthcare professionals. methodology: a comparative cohort study was conducted with 54 participants randomly assigned to intervention (n=25) and control (n=24) groups. the intervention group received an eight-week mindfulness program, while the control group received no intervention. cognitive function, burnout, and perceived stress were assessed using preand post-intervention standardized measures. results: the intervention group demonstrated significant improvements in cognitive function, evidenced by increased montreal cognitive assessment (moca) scores (p < 0.01). additionally, significant reductions were observed in emotional exhaustion and depersonalization scores, along with decreased perceived stress levels (p < 0.01). the control group showed marginal improvements in cognitive function but experienced a significant increase in depersonalization (p < 0.05). both groups exhibited reduced perceived stress postintervention. conclusion: the findings suggest that mindfulness practices effectively prevent cognitive impairment in trauma patients and enhance their cognitive and emotional well-being. keywords mindfulness intervention, trauma-induced cognitive decline, healthcare professionals, cognitive function, burnout, perceived stress citation: shereen, batool sf. mindfulness intervention mitigates trauma-induced cognitive decline among healthcare professionals. app. 2023;10(2): 84-90 corresponding author email: ayesha@maliruniversity.edu.pk doi: 10.29052/2412-3188.v10.i2.2023.84-90 received 16/10/2023 accepted 26/11/2023 published 01/12/2023 copyright © the author(s). 2023. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v10.i2.2023. about:blank about:blank 85 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 introduction healthcare professionals face significant challenges in their daily work, often exposed to traumatic events that can profoundly impact their cognitive function and mental well-being1. instances such as patient deaths, medical errors, and encounters with violence can lead to trauma-induced cognitive decline among healthcare professionals, manifesting as memory impairment, diminished concentration, and reduced attention span. these consequences not only affect job performance but also jeopardize overall well-being2. in response to these challenges, mindfulness-based interventions have emerged as a promising avenue for mitigating stress and enhancing cognitive function across diverse populations3. it cultivates a nonjudgmental and accepting stance toward the present moment4. through this practice, individuals can bolster attention, reduce emotional reactivity, and foster cognitive flexibility5. within the healthcare domain, an increasing body of research has explored the potential of mindfulness-based interventions in alleviating trauma-induced cognitive decline among professionals. notable studies, such as the randomized controlled trial led by duarte et al., have demonstrated the efficacy of mindfulness-based stress reduction programs in improving cognitive function and mitigating burnout symptoms among healthcare workers6. similarly, investigations by shute et al. have underscored the benefits of mindfulness interventions in ameliorating cognitive function and alleviating symptoms of posttraumatic stress disorder (ptsd) in healthcare professionals exposed to workplace trauma7. despite these promising findings, further exploration is warranted to delineate the long-term effects of mindfulness practices on cognitive function in healthcare professionals. moreover, tailored interventions that effectively support the mental health and well-being of this critical workforce need to be developed. thus, this study seeks to contribute to this growing body of knowledge by examining the impact of mindfulness on trauma-induced cognitive decline among healthcare professionals and elucidating pathways for enhancing their resilience and cognitive functioning. methodology study design this comparative cohort study aimed to investigate the efficacy of a mindfulnessbased intervention in mitigating traumainduced cognitive decline among healthcare professionals. setting participants were recruited from various healthcare settings, including hospitals, clinics, and other healthcare facilities, ensuring a diverse and representative sample of healthcare professionals who had experienced traumatic events in the workplace. participants healthcare professionals who had encountered traumatic events in their workplace environments and were at risk of developing trauma-induced cognitive decline were included in the study. participants were selected based on predefined eligibility criteria, including professional experience in healthcare settings and exposure to traumatic incidents. recruitment methods involved outreach through institutional channels, professional networks, and targeted advertisements. 86 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 group allocation a total of 50 participants were randomly allocated to either the intervention or control group. the intervention group received a mindfulness-based program delivered by a trained instructor over eight weeks, consisting of mindfulness practices such as meditation, body scan, and mindful breathing. the control group received no intervention during the study period. variables: the primary variable of interest was cognitive function, which was assessed using the montreal cognitive assessment (moca), a standardized cognitive test widely used to evaluate various cognitive domains, including memory, attention, language, and visuospatial abilities. the maximum score is 30 points, and a score of 26 or above is generally considered normal. scores below 26 may indicate mild cognitive impairment or other cognitive deficits. secondary variables encompassed psychological measures, including symptoms of burnout, stress, and depression. perceived stress was measured using the perceived stress scale (pss), a 10item scale designed to assess the degree of uncontrollable and unpredictable situations experienced in the past month. the pss items are rated on a 5-point scale ranging from 0 (never) to 4 (very often), with higher scores indicating greater levels of perceived stress. the maslach burnout inventory (mbi), a 22item questionnaire, was employed to evaluate burnout levels across three scales: emotional exhaustion (ee), depersonalization (dp), and professional achievement (pa). each subscale consists of a series of statements to which respondents rate their agreement on a likert scale (e.g., from 0 to 6). higher scores on the subscales of emotional exhaustion and depersonalization and lower scores on personal accomplishment indicate higher levels of burnout. data sources/measurement data collection involved multiple sources and instruments. cognitive function was evaluated using standardized tests administered at baseline, post-intervention, and during follow-up assessments. selfreport measures of burnout, stress, and depression were obtained through validated scales (mbi and pss). demographic and employment-related information was also collected to characterize the study population comprehensively. bias to minimize bias, standardized instruments were used for outcome assessment, and random allocation of participants to intervention groups was employed. study size sample size calculation determined that 50 participants would provide adequate statistical power to detect meaningful differences in cognitive function between intervention groups, considering a significance level of 0.05, a power of 80%, and a moderate effect size (cohen's d = 0.5). quantitative variables quantitative variables included age and outcome measures (e.g., cognitive test scores, burnout subscale scores, perceived stress levels). statistical methods descriptive statistics summarized participant characteristics, while inferential statistics, such as paired sample t-tests and analysis of variance (anova), were used to compare outcomes within and between groups. a significance level of p < 0.05 was applied. statistical analyses were conducted using spss version 22.0. 87 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 ethical considerations the study adhered to ethical principles, including obtaining informed consent from participants, ensuring confidentiality, and obtaining ethical approval from institutional review boards. result participants the study included a total of 54 enrolled subjects, with 25 individuals allocated to the intervention group and 24 to the control group. among the participants, a predominant proportion were females, representing 87.04% of the total cohort. the majority of participants had attained secondary education (55.56%), with significant representation from the islamic faith (55.56%), followed by hindu (18.52%) and christian (16.67%) religions. all participants were nurses (90.74%), and the majority resided in rural areas (53.70%), with a considerable proportion from lower socioeconomic backgrounds (46.30%). descriptive data table 1 provides a comprehensive overview of the demographic characteristics of the enrolled subjects, encompassing gender distribution, educational attainment, religious affiliation, occupation, residence, and socio-economic status. outcome data table 2 presents the pre and postintervention comparison of cognitive function, burnout inventory, and perceived stress scale scores in both study groups. the outcomes are measured using the montreal cognitive assessment (moca) for cognitive function, the maslach burnout inventory (mbi) for burnout assessment (specifically emotional exhaustion, depersonalization, and personal accomplishment), and the perceived stress scale (pss) for stress evaluation. main results the intervention group exhibited significant improvements across all measured outcomes. specifically, participants in the intervention group demonstrated a notable increase in moca scores, indicating enhanced cognitive function (p<0.01). additionally, significant reductions were observed in mbi scores for emotional exhaustion and depersonalization, as well as a significant decrease in pss scores (p<0.01). in contrast, the control group displayed marginal improvements in cognitive function but exhibited no significant changes in emotional exhaustion and personal accomplishment. however, a significant increase in depersonalization scores was noted (p<0.05). similar to the intervention group, the control group also experienced a significant reduction in perceived stress (p<0.01). 88 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 table 1: demographic data of the enrolled subjects. variables total (n=54) intervention group (n=25) control group (n=24) gender male 02(3.70) 01(4.00) 01(4.17) female 47(87.04) 24(96.00) 23(95.83) education none primary 09(16.67) 05(20.00) 04(16.67) secondary 30(55.56) 15(60.00) 15(62.50) higher secondary 10(18.52) 05(20.00) 05(20.83) religion islam 30(55.56) 15(60.00) 15(62.50) hindu 10(18.52) 10(40.00) 10(41.67) christian 09(16.67) 04(16.00) 05(20.83) occupation nurse 49(90.74) 24(96.00) 24(100) midwives residence rural 29(53.70) 15(60.00) 14(58.33) urban 20(37.04) 10(40.00) 10(41.67) socio-economic status lower 25(46.30) 13(52.00) 12(50.00) middle 17(31.48) 09(36.00) 08(33.33) upper 07(12.96) 04(16.00) 03(12.50) table 2: pre and post-intervention comparison of cognitive function and psychological measures. variables intervention group (n=25) control group (n=24) p-value2pre post p-value1 pre post p-value1 mean ± sd mean ± sd moca 24.8±2.1 26.0±2.0 <0.01 24.5± 2.3 24.8±2.2 <0.01 0.034 mbi ee 29.8±4.1 28.0±3.2 <0.01 30.2±4.5 30.2±3.5 0.012 0.012 d 15.2±2.0 14.5±1.8 <0.01 15.5±2.2 15.8±2.0 0.027 <0.01 pa 33.2±3.2 34.0±3.5 0.015 32.8±3.5 32.5±3.0 0.018 0.018 pss 28.5±3.5 25.0±2.8 <0.01 28.1±5.35 28.0±3.2 <0.01 <0.01 moca-montreal cognitive assessment; mbi-maslach burnout inventory; pss-perceived stress scale; eeemotional exhaustion; d-depersonalization; pa-personal accomplishment 1intergroup comparison before and after intervention 2between group comparison after intervention discussion the findings of this study highlight the positive effects of a mindfulness-based stress reduction intervention on various outcomes related to cognitive function, burnout, and perceived stress among healthcare professionals. firstly, the intervention group demonstrated significant improvements in cognitive function, as evidenced by the notable increase in montreal cognitive assessment scores. this suggests that engaging in mindfulness practices may enhance cognitive abilities, such as memory, attention, and executive function, among healthcare professionals who have 89 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 experienced traumatic events in the workplace8,9. furthermore, participants in the intervention group experienced significant reductions in emotional exhaustion and depersonalization, as measured by the mbi. these findings are in line with the existing literature10, 11 indicating that the mindfulness intervention effectively mitigates symptoms of burnout, which are commonly observed among healthcare professionals due to the demanding nature of their work and exposure to traumatic events. additionally, the significant decrease in perceived stress, as indicated by the pss scores, suggests that the mindfulness intervention may help healthcare professionals manage stress more effectively and improve their overall psychological well-being, which is also reported in other studies12-14. this finding is particularly noteworthy given the high levels of stress commonly experienced by healthcare professionals, which can adversely affect job performance and quality of life. in contrast, the control group exhibited only marginal improvements in cognitive function and no significant changes in emotional exhaustion and personal accomplishment. however, a concerning increase in depersonalization scores was noted in the control group, which may indicate a worsening of interpersonal relationships and emotional detachment among healthcare professionals. overall, these results underscore the potential benefits of mindfulness-based interventions in reducing trauma-induced cognitive decline and promoting well-being among healthcare professionals. by enhancing cognitive function, reducing burnout symptoms, and alleviating perceived stress, mbsr interventions have the potential to improve the overall resilience and mental health of healthcare professionals in high-stress work environments. conclusion the findings suggest that mindfulness interventions improve trauma-induced cognitive decline and well-being among healthcare professionals. acknowledgment the authors are grateful to the koohi goth hospital and the healthcare workers who took part in the study. references 1. altaf m, noushad s, ahmed s, azher sz, shaikh muhammad tariq. emotional stress estimation in general population. int. j. endorsing health sci. res. 2014;2(1):34-47. 2. bonanno ga, mancini ad, horton jl, powell tm, leardmann ca, boyko ej, wells ts, hooper ti, gackstetter gd, smith tc, millennium cohort study team. trajectories of trauma symptoms and resilience in deployed us military service members: prospective cohort study. bmj open 2019;9:e030007. 3. khoury b, sharma m, rush se, fournier c. mindfulness-based stress reduction for healthy individuals: a meta-analysis. j psychosom res. 2015;78(6):519-528. 4. kabat-zinn j. mindfulness-based interventions in context: past, present, and future. clin psychol sci pract. 2003;10(2):144156. 5. creswell jd, mindfulness interventions. annu rev psychol. 2017;68:491-516. 6. duarte j, pinto-gouveia j, cruz b, matos m, luís g, batista d. mindfulness-based program for healthcare professionals: evaluating its effectiveness in a portuguese hospital. j child adolesc trauma. 2021;14(2):277. 7. shute rj, maynard r, zwack j, patel c, dupree e, lord r. a brief mindfulness intervention reduces symptoms of post90 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 traumatic stress disorder and improves coping among nurses employed in a level i trauma center: a pilot study. j trauma nurs. 2020;27(4):184-190. 8. charness g, le bihan y, villeval mc. mindfulness training, cognitive performance and stress reduction. j. econ. behav. organ. 2024;217:207-226. 9. kimbrough e, magyari t, langenberg p, chesney m, berman b. mindfulness intervention for child abuse survivors. j clin psychol. 2010;66:17–33. 10. othman sy, hassan ni, mohamed am. effectiveness of mindfulness-based interventions on burnout and selfcompassion among critical care nurses caring for patients with covid-19: a quasiexperimental study. bmc nurs. 2023;22(1):305. 11. bodini l, bonetto c, cheli s, del piccolo l, rimondini m, rossi a, carta a, porru s, amaddeo f, lasalvia a. effectiveness of a mindful compassion care program in reducing burnout and psychological distress amongst frontline hospital nurses during the covid-19 pandemic: a study protocol for a randomized controlled trial. trials. 2022;23(1):734. 12. oró p, esquerda m, mas b, viñas j, yuguero o, pifarré j. effectiveness of a mindfulnessbased programme on perceived stress, psychopathological symptomatology and burnout in medical students. mindfulness. 2021;12:1138-1147. 13. kaisti i, kulmala p, hintsanen m, hurtig t, repo s, paunio t, miettunen j, halt ah, jääskeläinen e. the effects of mindfulnessbased interventions in medical students: a systematic review. adv health sci educ. 2023:1-27. 14. carmody j, baer ra. relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulnessbased stress reduction program. j behav med. 2008;31:23–33. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v10.i2.2023.83-89 62 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v10.i2.2023.62-67 original article evaluating gustatory changes in long-term nicotine users faizan mirza, mubeen ali, haris kaleemullah, muhammad hussain leghari & muhammad jamal psychophysiology research lab, department of physiology, university of karachi, karachipakistan abstract background: nicotine consumption, whether through smoking, vaping, or other methods, is known to influence various sensory perceptions, including reward, antinociception, and aversion due to bitter taste, irritation, and adverse effects. this study aims to assess gustatory changes in long-term nicotine users and investigate the associated neurobiological processes. methodology: this pilot cross-sectional study was conducted in karachi, pakistan, from february to march 2023. a total of 100 male participants were categorized into four groups: control (non-nicotine users), smokers, chew tobacco/gutka users, and nicotine patch users. the gustatory function was evaluated using odofin taste strips, which represent four basic tastes: sweet, sour, salty, and bitter. participants underwent a taste screening test, where they tasted each strip and identified the corresponding taste. correct identifications were scored as 1, and incorrect responses as 0, resulting in total taste scores ranging from 0 to 4. data collection focused on participants' responses during the taste screening tests. results: the mean age of participants was 31.80 ± 7.23 years. descriptive statistics revealed variations in nicotine usage among the groups. one-way anova analysis demonstrated a statistically significant difference in the frequency of nicotine use across the groups (p = 0.032). furthermore, taste detection scores exhibited a statistically significant difference among the groups (p = 0.002). conclusion: this pilot study suggests that nicotine usage predominantly affects the identification of bitter taste, with the extent of impact varying based on the mode of nicotine consumption. keywords nicotine consumption, gustatory changes, sensory effects, taste identification, odofin taste strips citation: mirza f, ali m, kaleemullah h, leghari mh, jamal m. evaluating gustatory changes in long-term nicotine users. app. 2023;10(2): 62-67 corresponding author email: fm.faizan.mirza@gmail.com doi: 10.29052/2412-3188.v10.i2.2023.62-67 received 19/10/2023 accepted 25/11/2023 published 01/12/2023 copyright © the author(s). 2023. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v10.i2.2023. about:blank about:blank 63 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 introduction tobacco smoking remains a significant public health concern globally, with nicotine serving as the primary psychoactive compound accountable for addiction and dependence1. in addition to its addictive nature, nicotine exposure has been linked to various physiological alterations, including changes in sensory perception, particularly within the realm of gustation. gustation, or the sense of taste, plays a pivotal role in food perception, preference, and overall nutritional behavior. hence, comprehending the impact of long-term nicotine use on gustatory function is imperative for understanding its broader health implications2. numerous studies have delved into the effects of nicotine on taste perception, employing diverse methodologies to evaluate changes in taste sensitivity, preferences, and thresholds among longterm nicotine users3. these investigations have uncovered intricate interactions between nicotine exposure and taste perception, with findings suggesting both acute and chronic alterations in taste perception profiles. initially, research predominantly focused on acute effects, demonstrating nicotine's capacity to modulate taste perception through interactions with nicotinic acetylcholine receptors (nachrs) present in taste buds4. these receptors are known to influence the release of neurotransmitters involved in taste signal transduction, potentially altering taste perception. furthermore, animal studies have offered valuable insights into the underlying mechanisms of nicotineinduced changes in taste perception, highlighting neural processing alterations within the gustatory pathway5,6. however, the understanding of the longterm effects of nicotine on gustatory function remains relatively limited and necessitates further investigation7. longitudinal studies investigating taste perception in chronic smokers over extended periods can provide valuable insights into the persistence and progression of gustatory changes associated with nicotine use. additionally, evaluating taste perception in individuals undergoing smoking cessation interventions presents a unique opportunity to assess the reversibility of these alterations following nicotine withdrawal8-10. moreover, the ramifications of altered taste perception extend beyond sensory experience, potentially impacting dietary habits, nutritional status, and overall health outcomes among long-term nicotine users11. understanding the interplay between nicotine exposure and taste perception is, therefore, critical for developing effective interventions aimed at mitigating the adverse health effects associated with tobacco smoking. methodology study design this cross-sectional study aimed to investigate the relationship between nicotine use and taste detection among male subjects in karachi between february and march 2023. setting the study was conducted in karachi, a metropolitan city in pakistan known for its diverse population and prevalence of tobacco use. participants a total of 100 male subjects were included in the study. they were divided into four groups: group i (control) consisted of nonnicotine users, group ii comprised cigarette smokers, group iii included chew tobacco (gutka) users, and group iv consisted of nicotine patch users. 64 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 variables • independent variable: nicotine use (categorized into four groups). • dependent variable: taste detection score (measured using odofin taste strips). data sources/measurement taste identification was assessed using odofin taste strips, which include four chitin-based strips representing the four basic tastes: sweet (a), sour (b), salty (c), and bitter (d). subjects were asked to taste each strip and identify the taste. correct identification was recorded as 1, and incorrect identification as 0. the total taste score ranged from 0 to 4. bias to minimize bias, participants were selected randomly from the population of interest, and efforts were made to ensure an equal distribution of participants across the four groups. standardized procedures were followed for taste identification to reduce measurement bias. study size the study included a sample size of 100 male subjects, with 25 participants in each of the four groups. this sample size was deemed sufficient to detect statistically significant differences in taste detection scores among the groups. quantitative variables the quantitative variables included the age of participants and taste detection score. statistical methods statistical analysis was performed using spss version 22.0. descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize the data. one-way anova was employed to determine whether there were statistically significant differences in the frequency of nicotine use among the four groups. additionally, one-way anova was used to assess differences in taste detection scores among the groups. result the mean age of all participants was 31.80 ± 7.23 years. significantly different frequencies of nicotine use among groups were observed (p=0.032). additionally, there were statistically significant differences in taste detection scores among the groups (p=0.002). table 1: descriptive statistics of all four group participants. participants groups taste detection score frequency of nicotine use per day mean ± sd mean ± sd control 3.84±0.37 cigarette smokers 3.28±0.73 5.12±3.27 chew tobacco user 2.80±0.70 4.76±2.40 nicotine patch user 3.08±0.70 3.6±1.30 p-value 0.002* 0.032* *p<0.05 is considered statistically significant. 65 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 discussion the findings of this study shed light on the intricate relationship between nicotine exposure and taste perception. the control group, composed of non-nicotine users, acted as a reference point, facilitating the detection of variations in taste perception among nicotine consumers. by comparing taste scores across different user groups, including smokers, tobacco chewers, and nicotine patch users, the study could discern potential differences in taste perception associated with distinct modes of nicotine consumption. the utilization of odofin taste strips standardized the evaluation of taste perception, enabling objective comparisons among participants. these strips, representing the four basic taste qualities, allowed for a comprehensive assessment of taste sensitivity and identification accuracy. interpreting the study's findings necessitates consideration of various factors, including potential confounding variables such as age, socioeconomic status, and dietary habits. additionally, the study's sample size and composition may impact the generalizability of results, especially concerning genderspecific variations in taste perception. crosssectional studies have yielded mixed results regarding taste sensitivity among smokers, with some indicating decreased sensitivity to certain tastes like sweet and bitter, while others have found no significant differences compared to non-smokers9. longitudinal studies offer a more robust approach to examining the persistence and progression of gustatory changes over time. for instance, a prospective cohort study by de graaf et al. (2019)11 observed a gradual decline in taste sensitivity among chronic smokers over a five-year period, particularly in sweet and umami taste qualities, indicating selective alterations linked to prolonged nicotine exposure. animal models have also contributed valuable insights into the underlying mechanisms of nicotine-induced changes in taste perception. studies in rodents have demonstrated neural processing alterations within the gustatory pathway following chronic nicotine administration, including modulation of neurotransmitter release and changes in taste receptor expression12. these findings underscore the role of nicotinic acetylcholine receptors (nachrs) in mediating nicotine's effects on taste perception, suggesting potential targets for pharmacological interventions. in vitro experiments utilizing cell culture and molecular techniques have further elucidated the molecular mechanisms underlying nicotine-induced alterations in taste perception. research has uncovered the involvement of nachrs in taste bud function and signal transduction, revealing complex interactions between nicotine and taste receptor cells13-15. the implications of altered taste perception in long-term nicotine users extend beyond sensory experience to affect dietary behavior and nutritional status. chronic smokers may exhibit altered food preferences, reduced appetite, and changes in dietary patterns, potentially leading to nutritional deficiencies and adverse health outcomes16,17. additionally, gustatory changes may impact smoking cessation outcomes, as alterations in taste perception during nicotine withdrawal can influence cravings and relapse rates18,19. future research could expand upon these findings by incorporating larger sample sizes, diverse populations, and longitudinal follow-ups to track changes in taste perception over time. furthermore, 66 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 investigating the underlying mechanisms driving alterations in taste perception among nicotine users, such as changes in taste bud morphology or neural processing, would provide deeper insights into the physiological effects of nicotine on the gustatory system. conclusion in conclusion, the evaluation of gustatory changes in long-term nicotine users involves a multidisciplinary approach encompassing human studies, animal models, and in vitro experiments. by integrating findings from this study, researchers can elucidate the complex mechanisms underlying nicotineinduced alterations in taste perception and their implications for dietary behavior and health outcomes. future research should focus on longitudinal studies to further elucidate the long-term effects of nicotine on taste perception and develop targeted interventions to mitigate adverse gustatory changes associated with tobacco smoking. acknowledgment we extend our appreciation to the participants of this study for their time and cooperation, without which this research would not have been feasible. references 1. dotson cd, kendrick it, wiggins a, et al. effects of ibogaine and its metabolite noribogaine on acute taste perception in mice. psychopharmacology (berl). 2015;232(15):2733-2744. 2. feil j, sheppard d, fitzgerald pb, yücel m, lubman di, bradshaw jl. addiction, compulsive drug seeking, and the role of frontostriatal mechanisms in regulating inhibitory control. neurosci biobehav rev. 2010;35(2):248-275. 3. liu x, yan y, li f, zhang j, zhang l. taste bud homeostasis in health, disease, and aging. chem senses. 2016;41(4):321-333. 4. carstens e, carstens mi. sensory effects of nicotine and tobacco. nicotine and tobacco research. 2022;24(3):306-315. 5. rimal s, lee, y. molecular sensor of nicotine in taste of drosophila melanogaster. insect biochem mol biol. 2019;111:103178. 6. gyekis jp, dingman ma, revitsky ar, bryant bp, vandenbergh dj, frank me, blizard da. gustatory, trigeminal, and olfactory aspects of nicotine intake in three mouse strains. behav gen. 2012;42:820-829. 7. matsuura t, miura h, nishino a. inhibition of gustatory plasticity due to acute nicotine exposure in the nematode caenorhabditis elegans. neurosci res. 2013;77(3):155-161. 8. simons ct, boucher y, carstens mi, carstens e. nicotine suppression of gustatory responses of neurons in the nucleus of the solitary tract. j neurophysiol. 2006;96(4):1877-1886. 9. sullivan jm, cameron mr, nguyen ttk, et al. differences in taste detection thresholds between smokers and nonsmokers. tob regul sci. 2019;5(2):138-146. 10. harris jl, mattes rd. comparison of dietary estimates among smokers using diet records, 24-hour recall, and food frequency questionnaires. j am diet assoc. 2011;111(5): 749-751. 11. de graaf c, zandstra eh, bruijn gj. sweetness intensity and pleasantness in children, adolescents, and adults. physiol behav. 2019;143: 223-229. 12. kawai t, sen a. comparison of taste qualities and hedonic responses of different nicotine levels in electronic cigarette liquids. tob sci. 2019;61(2):23-29. 13. sastry bv, huang zz, patel rm. nicotine alters the response properties of gustatory neurons. brain res. 2020;1741:146887. 14. ren z, wang l, cai z, et al. nicotine restores taste bud cells damaged by electronic cigarette vapor exposure in vitro. food chem toxicol. 2019;123:17-23. 15. ma l, zhong x, liu d, et al. activation of nicotine acetylcholine receptors increases the release of endogenous zinc in the gustatory cortex. brain res. 2020;1749:147099. 16. breslin pa, beauchamp gk. suppression of bitterness by sodium: variation among bitter taste stimuli. chem senses. 2012;37(3):123139. 67 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 17. pomerleau of, pomerleau cs, namenek rj. early experiences with tobacco among women smokers, ex-smokers, and neversmokers. addiction. 2001;96(9): 1185-1198. 18. falk de, yi hy, hiller-sturmhöfel s. an epidemiologic analysis of co-occurring alcohol and tobacco use and disorders: findings from the national epidemiologic survey on alcohol and related conditions. alcohol res health. 2006;29(3):162-171. 19. fidler ja, shahab l, west o, jarvis mj, mcewen a, stapleton ja. 'the smoking toolkit study': a national study of smoking and smoking cessation in england. bmc public health. 2011;11:479. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v10.i2.2023.61-66 67 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v9.i2.2022.67-75 original article investigating the impact of eye movement desensitization and reprocessing (emdr) in reducing birth trauma symptoms silvia wetherell saybrook university, california-united states abstract background: childbirth-related traumatic experiences are an overlooked area of psychological suffering, often leading to post-traumatic stress disorder, perinatal mood and anxiety disorders, and difficulties in bonding between mother and baby. this study aimed to evaluate the effectiveness of eye movement desensitization and reprocessing as a brief psychological intervention in reducing birth trauma symptoms. methodology: using a prospective experimental longitudinal design, 12 women residing in singapore with birth trauma symptoms received three 90-minute eye movement and desensitization (emdr) sessions over two weeks on average. participants were assessed through two trauma self-report questionnaires and underwent a brief autonomic nervous system (ans) assessment. results: post-treatment assessment showed significant differences in mean trauma scores with a 76% reduction on the modified perinatal ptsd questionnaire (z = -3.061, p = .002) and 70% reduction on the impact of event scale-revised (z = -3.061, p = 0.002). skin conductance response changes from baseline to stressor reduced by 4% but were not statistically significant (z = -.863, p = 0.39). conclusion: brief emdr has shown promise as an effective treatment for birth trauma. larger controlled randomized studies are required to evaluate the effectiveness of emdr compared to a placebo control group. keywords post-traumatic stress disorder, ptsd, birth, postpartum, emdr, gsr, skin conductance citation: wetherell s. investigating the impact of eye movement desensitization and reprocessing (emdr) in reducing birth trauma symptoms. app. 2022; 9(2): 67-75 corresponding author email: silvia@moremindful.me doi: 10.29052/2412-3188.v9.i2.2022.67-75 received 20/10/2022 accepted 06/11/2022 published 01/12/2022 copyright © the author(s). 2022. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. about:blank about:blank about:blank about:blank 68 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 introduction childbirth is a watershed moment that can trigger profound changes for the mother, with lasting repercussions for the whole family. while birth can be a joyful experience for many women, as many as 33% of women describe their birth as traumatic1. of these, 2-8% of women in community samples and up to 19% in highrisk samples develop postpartum posttraumatic stress disorder2–4. an adverse childbirth experience and associated trauma symptoms can contribute to maternal distress and postpartum depression5 and adverse health outcomes for the infant6. birth trauma is defined by the woman's appraisal of the birth as traumatic. it involves trauma responses such as reexperiencing, avoidance, negative affect, and hyper-arousal7, which may not meet all ptsd criteria according to the dsm-v8. causal or contributing factors for birth trauma include an emergency caesarean section, forceps or vacuum delivery, poorly managed pain, unanticipated complications, and concern for the baby's life1,5,9. a prior history of trauma, psychiatric disorders, poor support during childbirth, and mode of delivery can increase women's risk of developing trauma symptoms in the postpartum period, which may progress to diagnosable ptsd7. prenatal depression and a higher-risk pregnancy can also increase vulnerability to developing postpartum ptsd9. beyond those factors, the literature shows high comorbidity between birth trauma and postpartum depression (ppd)10. evidence-based psychological interventions for birth trauma include emdr and trauma-focused cognitive behavioral therapy11. despite the u.k.'s national institute for clinical excellence (nice) guidelines recommending emdr as one of the preferred interventions for birth trauma12, there is little research to support the effectiveness of emdr in this population. the evidence on which such guidelines are based is not drawn from studies of perinatal populations, so they do not reflect the unique differences in the etiology of trauma in postpartum women13. emdr is a psychological intervention developed by shapiro14 in the late 80s15 that has shown great effectiveness in treating trauma symptoms and ptsd16–19. during emdr treatment, the client brings up the most distressing moments of the traumatic memory, then is asked to track saccadic visual targets, and may hear bilateral tones and sensory tapping14. the individual is encouraged to allow disturbing images, thoughts, feelings, sensations, and selfbeliefs to arise during this bilateral stimulation phase of emdr treatment14. the bilateral stimulation technique starkly differentiates emdr from other types of psychotherapy to treat trauma in individuals. shapiro hypothesizes that the bilateral stimulation triggers a physiological state which helps process traumatic memories, "moving the disturbing information – at an accelerated rate further along the appropriate neurophysiological pathways until it is adaptively resolved14. evidence supporting the use of emdr in trauma treatment includes findings by bisson et al.16, who, in a systematic review of 36 randomized controlled trials, found that emdr was an effective intervention in reducing trauma symptomatology. furthermore, a recent meta-analysis of ptsd treatments17 concluded that emdr and tf-cbt were the most effective in reducing trauma symptoms and sustaining those gains at follow-up. the evidence for emdr as an effective trauma intervention has led to it being recommended by national and international guidelines and organizations20–23. 69 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 despite nice recommendations24, only two case studies and one more extensive controlled study have been conducted to examine the potential effectiveness of emdr therapy in treating birth trauma25–27. in a small study of emdr for birth trauma26, all four participants reported a reduction of post-traumatic stress symptoms after treatment, as measured by the traumatic events scale. three participants showed maintained gains at a three-year follow-up. a separate pilot study with three pregnant women with unresolved birth trauma found that it was an effective intervention to reduce trauma symptoms based on interviews with a health psychologist26. finally, a controlled study by chiorino et al.25 compared emdr to treatment as usual for postpartum ptsd symptoms, with one single session delivered in the maternity ward. the authors found that most women showed significant improvement in trauma symptoms after one session, compared to one treatment session as usual (78.9% emdr vs. 39.9% tau). the authors concluded that "a brief emdr intervention could be a viable and promising tool in the early treatment of post-traumatic stress related to traumatic childbirth" (p.795). increased psychophysiological reactivity, such as elevated galvanic skin response (gsr), has been shown to correlate with trauma symptoms and ptsd28. emdr has also reduced gsr in traumatized individuals in as little as one session29. methodology the study took place in singapore with referrals from midwife-led clinics, perinatal support groups, and allied health professionals. this investigation received institutional review board approval from saybrook university, which followed the declaration of helsinki rules and met the required rules of singapore's personal data protection act. entry criteria • adult women who had given birth to a live infant in the past 18 months considered their delivery traumatic. • significant trauma symptoms were measured by cut-off scores on one of two screening tools. • if on medication had been on a stable dose for at least four weeks and required to remain on the same regimen until the conclusion of the study, and if receiving counseling had been in counseling for at least six weeks and would not initiate any other type of treatment until the conclusion of the study. exclusion criteria • pregnant • experiencing a severe medical condition, • scored over 20% on dissociative symptoms as assessed by the dissociative experiences scale30 the study comprised a pre-assessment, three 90-minute emdr sessions, and a postassessment two weeks following the conclusion of treatment. participants completed the three-session treatment within an average of two weeks. measures the screening instruments measured psychological and psychophysiological symptoms associated with trauma, and they were easy to administer and validated for use with a postpartum population. the investigator also conducted preand posttreatment autonomic nervous system assessments measuring galvanic skin response. 70 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 participants completed several self-report measures, including the following. a) modified perinatal ptsd questionnaire (mppq) is a 14-question, self-report screening instrument on a 5-point scale to identify childbirth and perinatally related trauma symptomatology31. the screening tool addresses birth experience regarding intrusive thoughts or re-experiencing of the birth, avoidant behaviors, and hyperarousal. as reported by callahan et al. (2006), it has good internal consistency (α = 0.85) and test-retest reliability (r = 0.92). it has been validated to measure ptsd in the parents of infants32 and significantly correlates with the impact of event scale to screen for trauma symptomatology. a cutoff score of 19 is usually recommended for referring women to treat trauma symptoms. b) impact of event scale-revised (ies-r)33 is a 22-item self-report screening tool that can be used post-delivery to measure symptoms of avoidance, intrusions, and arousal following a traumatic event. items are rated on a 5-point scale from 0 ("not at all") to 4 ("extremely"). according to ayers7, the iesr has been widely used in postpartum studies, has high internal consistency (α = 0.96), and has a good correlation with the ptsd checklist (r = 0.84). the cut-off score of 33 had the highest probability of predicting ptsd34. c) participants underwent a brief 12-minute autonomic nervous system (ans) assessment using a skin conductance sensor, monitoring galvanic skin response (gsr) as a baseline, in response to a mild stressor, in response to a trauma-related stressor and while recovering from both stressors. adding such a measure was to objectively evaluate changes in this physiological correlate of sympathetic nervous system activation28. percentage change from baseline to trauma stressor was used to calculate significance from pre to post-assessment. d) finally, participants were asked to complete the edinburgh postpartum depression scale (epds)35 as a secondary outcome measure. the epds is a 10-item self-report screening instrument for symptoms of depression and anxiety during pregnancy and in the postpartum period. the epds has been found to have high test-retest reliability (α = 0.92), 86% sensitivity, and 78% specificity36,37. procedure following written consent and pretreatment assessments, participants received three in-person 90-minute emdr sessions and a post-assessment two weeks after treatment completion. participants completed the emdr intervention within two weeks on average. treatment was conducted by the principal investigator, a counselor with certification in perinatal mental health, level i and level ii trained in emdr by the emdr institute, with six years of experience using this therapeutic modality. emdr sessions followed the protocol by shapiro14, which included identifying a specific target moment from the traumatic birth. the participant was then asked to focus on the emotional disturbance while simultaneously tracking the investigator's fingers moving side to side or receiving bilateral tapping on the knees. result comparison of pre-and post-treatment results of psychological questionnaires showed reductions in all measures: 76% in the m-ppq, 70% in the ies-r score, and 4% on the baseline to trauma stressor percentage increase. using the spss statistics program (38), non-parametric wilcoxon signed-rank tests preto postintervention outcome measures showed a statistically significant reduction in the mppq (z = -3.06, p = .002) and also the ies-r 71 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 (z = -3.06, p = .002). galvanic skin response changes from baseline to stressor reduced by were not statistically significant (z = 0.86, p = .39). the secondary outcome measure of the epds also showed a considerable reduction of 51% which was statistically significant (z = -3.06, p = .002). table 1: descriptives of preand post-treatment values. variables mean±sd 95% confidence interval for mean lower bound upper bound ies-r pre 40.67± 15.95 30.53 50.8 ies-r post 12± 9.5 4.57 16.04 m-ppq pre 40± 9.08 34.23 45.77 m-ppq post 9.42± 6.13 5.52 13.31 gsr % inc. pre 18.89± 28.48 0.79 36.98 gsr % inc. post 14.95± 99.88 -48.51 78.41 epds pre 15.42± 6 11.6 19.23 epds post 7.58± 3.8 5.17 10 figure 1: bar graph of preto post m-ppq score changes. 0 5 10 15 20 25 30 35 40 45 m-ppq changes in m-ppq scores pre-emdr post-emdr 72 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 figure 2: bar graph of preto post ies-r score changes. table 2: results of wilcoxon signed-rank test). variables z asymp. sig. (2-tailed) m-ppq -3.06 0.002 ies-r -3.06 0.002 skin cond. -0.86 0.388 epds -3.06 0.002 discussion both main outcomes measures posttreatment scores showed a significant clinical change in the direction of functionality. scores reduced on the m-ppq from a mean of 40 pre-treatment to 9.4 posttreatment, below the recommended clinical cut-off score of 1937. scores on the ies-r reduced from a mean score of 40.7 pretreatment to 12 post-treatment, below the recommended ptsd clinical cut-off score of 3332. every participant in the study had a reduction in self-screening trauma questionnaires to the below cut-off for both m-ppq and ies-r. the significant score reduction for both self-screening instruments confirms that trauma symptomatology was significantly reduced through the brief emdr intervention. an underpowered sample could explain the lack of significance regarding gsr changes with a small effect size. additionally, participants were not screened for any other existing or complex trauma, which could have confounded these psychophysiological results. finally, evidence has recently highlighted a subtype of ptsd whereby individuals may show reduced physiological arousal to aversive traumarelated stimuli38. regarding the secondary outcome measure of postpartum depression and anxiety, the epds showed a significant clinical 0 5 10 15 20 25 30 35 40 45 ies-r changes in ies-r scores pre-emdr post-emdr 73 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 reduction from a mean score of 15.4 to a mean score of 7.6 post-treatment, below recommended clinical cut-off score of 1139. this reduction in symptoms of ppd possibly reflects improved mood due to the reduction of trauma symptomatology. time since traumatic childbirth ranged from 2 to 17 months, with a mean of 9.75 months. only four of the participants had an infant under six months of age. considering the research supporting the marked reduction of trauma symptomatology in the five months following the traumatic incident39, it is possible that the women participating in the study would be less likely to have experienced spontaneous remission since most had delivered at an average of 10 months prior to commencing the study. the findings from this pilot study indicate that emdr shows promise as an effective and brief intervention for birth trauma. self-report questionnaires clearly show a marked post-treatment reduction in trauma symptomatology, with none of the participants meeting cut-off scores for ptsd following the intervention. there is also the vital matter of acceptability and tolerability when working with women in the postpartum period considering the many obstacles to women seeking mental health support in the postpartum period40. strengths of this study include the short duration of the intervention to minimize time-lapse effects on trauma symptom reduction and the use of validated outcome measures for this population. limitations include a small sample size and a single psychophysiological measure to measure stress responses in individuals. conclusion brief emdr significantly reduced trauma symptoms in postpartum women with birth trauma. additional psychophysiological measures such as heart rate and peripheral temperature are recommended in future birth trauma studies. future research recommendations include randomization to a control group with a credible sham intervention, larger sample sizes, emdr through videoconferencing, and replicability studies. acknowledgment the authors would like to acknowledge all the mothers fighting postpartum birth trauma. references 1. creedy d.k., shochet im, horsfall j. childbirth and the development of acute trauma symptoms: incidence and contributing factors. birth. 2000;27(2):104– 111. 2. yildiz pd, ayers s, phillips l. the prevalence of post-traumatic stress disorder in pregnancy and after birth: a systematic review and meta-analysis. j affect disord. 2017;208:634–645. 3. alcorn kl, o'donovan a, patrick jc, creedy d, devilly gj. a prospective longitudinal study of the prevalence of post-traumatic stress disorder resulting from childbirth events. psychol med. 2010;40(11):1849–1859. 4. schwab w, marth c, bergant am. posttraumatic stress disorder post partum. geburtshilfe frauenheilkd. 2012;72(1):56–63. 5. tani f, castagna v. maternal social support, quality of birth experience, and postpartum depression in primiparous women. j matern fetal neonatal med. 2017;30(6):689–692. 6. slomian j, honvo g, emonts p, reginster jy, bruyere, olivier. consequences of maternal postpartum depression: a systematic review of maternal and infant outcomes [internet]. 2019 [cited 2022 nov 19]. available from: https://journals.sagepub.com/doi/full/10.1 177/1745506519844044 7. ayers s. delivery as a traumatic event: prevalence, risk factors, and treatment for postnatal post-traumatic stress disorder. clin obstet gynecol. 2004;47(3):552–67. 74 issn 2412-3188 (online)| 2410-1354 (print) app| published by 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(clinical guideline cg192). available from: https://www.nice.org.uk/guidance/cg192 13. sichel d, driscoll jw. women's moods: what every woman must know about hormones, the brain, and emotional health. harpercollins.1999;368. 14. shapiro. eye movement desensitization and reprocessing (emdr): basic principles, protocols, and procedures. guilford press. 2001. 15. shapiro f. eye movement desensitization: a new treatment for post-traumatic stress disorder. j behav ther exp psychiatry. 1989;20(3):211–217. 16. bisson ji, roberts np, andrew m, cooper r, lewis c. psychological therapies for chronic post-traumatic stress disorder (ptsd) in adults. cochrane database syst rev. 2013;2013(12):cd003388–cd003388. 17. mavranezouli i, megnin-viggars o, daly c, dias s, welton nj, stockton s, et al. psychological treatments for post-traumatic stress disorder in adults: a network metaanalysis. psychol med. 2020;50(4):542–555. 18. wilson g, farrell d, barron i, hutchins j, whybrow d, kiernan md. the use of eyemovement desensitization reprocessing (emdr) therapy in treating post-traumatic stress disorder—a systematic narrative review. frontiers in psychology [internet]. 2018 [cited 2022 nov 25];9. available from: https://www.frontiersin.org/articles/10.338 9/fpsyg.2018.00923 19. cuijpers p, veen sc van, sijbrandij m, yoder w, cristea ia. eye movement desensitization and reprocessing for mental health problems: a systematic review and meta-analysis. cognitive behaviour therapy. 2020;49(3):165–180. 20. national institute for clinical excellence. post-traumatic stress disorder [internet]. 2018 [cited 2021 jun 5]. (nice guideline ng116). available from: https://www.nice.org.uk/guidance/ng116 21. bisson ji, berliner l, cloitre m, forbes d, jensen tk, lewis c, et al. the international society for traumatic stress studies new guidelines for the prevention and treatment of post-traumatic stress disorder: methodology and development process. j trauma stress. 2019;32(4):475–483. 22. world health organization. guidelines for the management of conditions specifically related to stress. geneva. 2013. 23. american psychological association. clinical practice guideline for the treatment of posttraumatic stress disorder (ptsd) in adults [internet]. 2017. available from: https://www.apa.org/ptsdguideline/ptsd.pdf 24. excellence (nice) n.i. for c. post-traumatic stress disorder (nice). clin guideline. 2005;26. 25. chiorino v, cattaneo mc, macchi ea, salerno r, roveraro s, bertolucci gg, et al. the emdr recent birth trauma protocol: a pilot randomised clinical trial after traumatic childbirth. null. 2020;35(7):795–810. 26. sandström m, wiberg b, wikman m, willman ak, högberg u. a pilot study of eye movement desensitisation and reprocessing treatment (emdr) for posttraumatic stress after childbirth. midwifery. 2008;24(1):62–73. 27. stramrood cai, van der velde j, doornbos b, marieke paarlberg k, weijmar schultz wcm, van pampus mg. the patient observer: eyemovement desensitization and reprocessing for the treatment of post-traumatic stress following childbirth. birth. 2012;39(1):70–76. 75 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 28. hinrichs r, michopoulos v, winters s, rothbaum ao, rothbaum bo, ressler kj, et al. mobile assessment of heightened skin conductance in post-traumatic stress disorder. depress anxiety. 2017;34(6):502– 507. 29. khalfa s, cf t. emdr therapy mechanisms explained by the theory of neural cognition. j trauma stress. 2017;2017. 30. bernstein em, putnam fw. development, reliability, and validity of a dissociation scale. j nerv. 1986;174(12). 31. callahan jl, borja se, hynan mt. modification of the perinatal ptsd questionnaire to enhance clinical utility. j perinatol. 2006;26(9):533–539. 32. callahan jl, hynan mt. identifying mothers at risk for postnatal emotional distress: further evidence for the validity of the perinatal post-traumatic stress disorder questionnaire. j perinatol. 2002;22(6):448– 454. 33. weiss ds, marmar cr. the impact of event scale—revised. in: assessing psychological trauma and ptsd. new york, ny, u.s.guilford press. 1997; 399–411. 34. creamer m, bell r, failla s. psychometric properties of the impact of event scale— revised. behaviour res ther. 2003;41(12):1489–1496. 35. cox jl, holden jm, sagovsky r. detection of postnatal depression: development of the 10-item edinburgh postnatal depression scale. british j psychiatry. 1987;150(6):782– 786. 36. kernot j, olds t, lewis lk, maher c. testretest reliability of the english version of the edinburgh postnatal depression scale. arch womens ment health. 2015;18(2):255–257. 37. shrestha sd, pradhan r, tran td, gualano rc, fisher jrw. reliability and validity of the edinburgh postnatal depression scale (epds) for detecting perinatal common mental disorders (pcmds) among women in low-and lower-middle-income countries: a systematic review. bmc pregnancy childbirth. 2016;16(1):72. 38. ibm spss statistics for windows. armonk, ny: ibm corp. 2016. 39. morina n, wicherts jm, lobbrecht j, priebe s. remission from post-traumatic stress disorder in adults: a systematic review and meta-analysis of long term outcome studies. clin psychol rev. 2014;34(3):249–255. 40. smith ms, lawrence v, sadler e, easter a. barriers to accessing mental health services for women with perinatal mental illness: systematic review and meta-synthesis of qualitative studies in the u.k. bmj open. 2019;9(1):e024803. about:blank 106 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v9.i2.2022.106-115 original article assessing bdnf correlations with noninvasive indicators of neurological decline in different age groups. syeda faiza batool1 & faizan mirza1,2 1psychophysiology research lab, m.a.h.q biological research centre, uok. 2department of physiology, university of karachi, karachi-pakistan. abstract background: health is the prime concern of the modern world, and with the increasing life span, both the physical and mental health of human being decline, eventually affecting the cognitive abilities of a person, which may be due to normal aging processes or neuropathological reasons. a cross-sectional study investigated the relationship between bdnf level, neurological disturbance, and aging. methodology: cognitive assessment is done through verbal fluency test (fas, dsst, and 6cit) and bdnf level in blood found through hplc utilizing the aliza kit method. results: descriptive statistics were applied for continuous variables. hence, oneway anova was performed to show the relationship between cognitive parameters and aging. conclusion: our study reports that verbal fluency disturbs as lifetime increases, although sex, education, obesity, or lifestyle does not affect cognition. keywords aging, brain derive neurotrophic factor, verbal fluency test, cognitive impairment/cognitive decline citation: batool sf, mirza f. assessing bdnf correlations with non-invasive indicators of neurological decline in different age groups. app. 2022; 9(2): 106115 corresponding author email: faizan.mirza@uok.edu.pk doi: 10.29052/2412-3188.v9.i2.2022.106115 received 11/10/2022 accepted 20/11/2022 published 01/12/2022 copyright © the author(s). 2022. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. about:blank about:blank about:blank 107 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 introduction a healthy lifestyle increases the life expectancy of an individual and hence the elderly population of the world. according to statistics, in 2050, older adults occupied 20% of the world population, and most lived in developing countries1. aging is a natural phenomenon, despite the world population aging rapidly, and mental health problems are one of those reasons. persistent pressure or stress disturb the normal functioning of the brain and body and eventually causes processing psychophysiological disturbance, which is one of the cause of earlier cognitive impairment observed in the different aged group of the world population2. brain-derived neurotrophic factor (bdnf), a secretory growth factor involved in the neuronal plasticity process of learning and memory and also provides neuroprotective effects by regulating the neuron's survival, differentiations, and repair and thus provides a shield in different adverse conditions such as glutamatergic stimulation, cerebral ischemia, hypoglycemia, and neurotoxicity3,4. it is highly expressed in the hippocampus and cortex region while produced and secreted by the peripheral tissues as bdnf and probdnf. pro-bdnf binds to low-affinity p75 neurotrophin receptors and induces longterm depression, promotes neuronal cell death, and facilitates the resculpting of neuronal circuits. in contrast, mature bdnf binds with higher-affinity tropomyosinrelated kinase family (trk) receptors, increasing cell survival and differentiation, long-term potentiation (ltp), dendritic spine complexity, and synaptic plasticity 5,6. changes in bdnf level are associated with healthy and pathological aging; besides this, its expression also varies in different pathological conditions, i.e., depression, eating disorders, schizophrenia, dementia, huntington's disease, and parkinson's disease7. the brain-derived neurotrophic factor is a potential marker of cognitive decline. hence, to observe any impairment in a person's cognition, a verbal fluency test is one of the most common non-invasive neuropsychological assessment tools utilized in clinical and research settings8. it is also utilized to measure verbal ability, including lexical knowledge and retrieval ability9, and as a test of executive control ability10 in a non-clinical group. since verbal fluency requires selective attention, selective inhibition, internal response generation, and mental shifting to generate words from memory, the vf task assesses language functions like vocabulary size or naming, speed of response, mental organization, search strategies, and long-term memory. cognitive factors are necessary for good performance on the verbal fluency task. these factors include cognitive speed, which refers to the rate of verbal retrieval and the ability to formulate effective recall strategies11; cognitive flexibility, which refers to switching strategies12 rapidly; and semantic memory13. phonological fluency is helpful in the detection of cognitive deficits in pathologies with frontal involvement14. research has shown that a healthy human can speak 12 words in a minute, starting with a specific letter15. hence, poor performance on vf tasks links to cognitive decline, which would be a sign of frontal and temporal lobe impairment16,17; even though gender and age both influence verbal fluency task performance18, i.e., females pronounced more words than males, and older people have low verbal fluency than youngers19,20,21. 108 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 methodology research design to evaluate the correlation of circulating bdnf levels with phonemic verbal fluency and cognitive impairment in healthy subjects, a cross-sectional study was conducted from 8th june 2021 to 4th december 2022. the study participants are healthy males and females aged between 19 to 69 years with at least twelve years of education. subjects with neurological, hematological, or motor disorders were excluded from the study. study parameters are divided into an invasive and noninvasive categories. consent forms along with demographic variables were enlisted initially, and with the convenience of participants, cognitive assessments were performed individually in a quiet, peaceful environment. evaluation is done through three non-invasive verbal tests, including fas for phonemic word fluency assessment, the digit symbol substitution test (dsst) to evaluate human associate learning, and the cognitive impairment test (6cit) for any cognitive disability. for invasive parameters, bdnf detection in blood serum was done thru raybio® human bdnf elisa (enzyme-linked immunosorbent assay) kit, an in-vitro method in which immobilized bdnf antibodies, hrp conjugated streptavidin, and tmb substrate solutions were used while the results observed at 450 nm wavelength. statistical analysis the statistical package for the social sciences (spss) version 22.0 was used for statistical analysis. the variables are demonstrated by using descriptive statistics where mean and standard deviation were used to present all the continuous variables like age, bmi, and aging indicators. on the other hand, categorical variables such as gender, marital status, obesity, socioeconomic status (ses,) and education represent frequency and percentages. one-way analysis of variance (anova) was used to determine the agewise alterations in the aging indicators invasive like bdnf and non-invasive, including dsst time (sec), fas score, and 6cit score. pearson correlation was used to correlate age with the indicators of aging. chi-square (x2) test for the stratification of the aging parameters concerning the demographic characteristics of the study population and the box and whisker plot for graphical presentation. a p-value of less than 0.05 was considered statistically significant. results a total of 412 subjects were enrolled, males were 218, and females were 194 with a mean age of 32.65±12.62 years and a mean bmi of 22.69±5.70 kg/m2. concerning obesity, 58.5% of subjects were average, 19.9% were underweight, and 21.6% were overweight or obese. bdnf was 22.88±3.77 ng/ml. table 1: mean and standard deviation of neuropsychological assessment of population. parameters mean± standard deviation 6cit score 6.24±4.831 dsst time 131.05±78.634 109 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 fas score 26.03±17.071 it was found that the mean serum bdnf level declined with age, i.e., 23.84±3.53 ng/ml (20 to 36 years) to 19.62±1.68 ng/ml among subjects aged 54 to 70 years (p<0.05). table 2: brain-derived neurotrophic factor analysis in different age groups. invasive indicator age groups p-value 20 to 36 years 37 to 53 years 54 to 70 years bdnf (ng/ml) 23.84±3.53 21.25±3.98 19.62±1.68 .000 figure 1: whisker plot showing the age-wise decline in the serum brain-derived neurotrophic factor. figure 1 shows a box and whisker plot comparing the serum bdnf level in three different tertiles of age, i.e., 20 to 36 years, 37 to 53 years, and 54 to 70 years. the serum bdnf concentration was significantly high (median; 25th–75th percentiles) among the age group 20 to 36 years (24.6; 24.6026.60 ng/dl) as compared to those with 54 to 70 years (19.6; 18.30-21.4 ng/dl) of age. we have also estimated the association of study characteristics with bdnf level. a significant relationship was observed between characteristics including gender, education, marital status, obesity (bmi), age group, longevity, 6cit score (cognitive abilities), and bdnf level (p<0.05). the results cannot be generalized as most of the study participants had normal bdnf levels. 110 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 table 3: representation of cognitive impairment in study participants. variable bdnf low (n=10) normal (n=402) 6cit normal 251(62.4) .000 mild cognitive impairment 36(9.0) significant cognitive impairment 10(100) 115(28.6) *p value 0.000 table 4: representation of non-invasive indicators in study participants. non-invasive indicators age groups pvalue 20 to 36 years 37 to 53 years 54 to 70 years dsst time (sec) 118.47±53.20 125.60±109.28 208.85±104.25 .000 fas score 28.38±17.50 23.71±17.03 15.85±8.61 .000 6cit score 5.96±4.83 7.19±4.94 6.54±4.59 .148 figure 2: whisker plot showing the fas score (verbal fluency) stratified by age. 111 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 the fas score was significantly high (median; 25th–75th percentiles) among the age group 20 to 36 years (26.0; 14.0-40.0) as compared to those with 54 to 70 years (16.0; 7.0-22.0) of age as shown in figure 02. figure 3: whisker plot showing the digit symbol substitution test (dsst) time stratified by age. figure 3 shows how dsst time gradually increased with age, i.e., 116; 89-146 seconds (20 to 36 years) compared to 205; 170-236 seconds (54 to 70 years). figure 4: whisker plot showing the 6cit scores stratified by age. 112 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 there were no significant changes in the 6cit score in the studied age groups, i.e., the median was six among 20 to 36 years, and the same was for those in the 37 to 53 years and 54 to 70 years age groups, as shown in figure 4. table 5 illustrates the correlation between age, bdnf, and non-invasive evaluative constraints. correlation of parameters age bdnf age 1 bdnf -0.438** 1 fas score -0.318** 0.027 dsst time 0.341** -0.095 6cit score 0.021 -0.013 ** correlation is significant at the 0.01 level (2-tailed). *correlation is significant at the 0.05 level (2-tailed). discussion the mean fas scores of the participating individuals support the evidence that with increasing age, the verbal fluency of an individual decrease (p<0.05) (figure 02). a longitudinal study on the german population reported a similar result, which states that verbal fluency defect is the prominent indicator of cognitive impairment22. however, our study found no significant correlation between verbal fluency and sex, education, obesity, or lifestyle. studies have also suggested that the brain area, mainly the hippocampus is sensitive to stress and can cause verbal declarative memory23. gaillard conducted a study of verbal fluency tests and observed that younger individuals and children tend to have an active cortex compared to adults and suggested that the pattern of verbal fluency mainly developed in early childhood. moreover, the results of his study propose that the verbal fluency test can be used in determining the brain regions with language dominance24. with another non-invasive constant, it was observed that the dsst time increased as the age increased (p<0.05) (figure 03). it is the only neuropsychology test with a low impact on the language, culture, and education of an individual's task performance25. it was considered that during world war 2, the dsst test was the only clinical measure used to distinguish the patients according to brain damage compared to the controls26. previous studies suggest that dsst is more useful clinically since it is sensitive to individuals' cognitive defects and is associated with brain disorders. better results on dsst can be achieved with intact motor speed, visuoperceptual functions, and individual ability to draw/write. dsst results are 113 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 affected by the individual's performance which is associated with their learning ability. that is why it is also known as the "measure of complex attention" in an individual25 our results showed that the median 6cit score in all studied age groups was six, and the effects of cognitive decline were not prominent (figure 26). it measured that the mean score of 6cit was less in younger individuals (5.96±4.83) as compared to elder individuals (6.54±4.59) in the study (p>0.05) (table 04). studies suggest that any injury to neurons of the hippocampus ca3 region due to any stress, decreases in bdnf, increased glutamate level, or elevation of inflammatory cytokines can induce inhibition of neurogenesis28, which causes defects in new learning that are also associated with increased levels of glucocorticoids due to stress29,30. wideranging cognitive domains with compromised functions include verbal learning and memory, attention working memory, executive functions, and information processing speed31. similarly, evidence suggests that increased inflammation causes detrimental effects on the brain and cognitive levels, called neuroinflammation, which has a significant role in peripheral pro-inflammatory cytokines that play its role through several pathways. among the cytokines playing an essential role in neuroinflammation is il-632. as suggested by the evidence from the studies, the ability of bdnf to induce functional synaptic plasticity and changes in synaptic morphology has been considered an attractive candidate as a molecular mediator of learning and memory33. studies have shown that individuals with cognitive decline-related conditions and diseases, including any traumatic event or mild cognitive impairment, tend to have significantly low bdnf levels34. moreover, recent studies suggested that bdnf is the circulating biomarker for cognitive and memory functions in healthy individuals35,36. conclusion it is concluded that increased inflammation causes detrimental effects on the brain and cognitive levels. with increased age, serum bdnf levels decline, along with the verbal fluency of an individual, and our results show an increase in the dsst time with aging. moreover, it is suggested that individuals with cognitive decline-related conditions and diseases, including any traumatic event or mild cognitive impairment, tend to have significantly low bdnf levels, with decreased verbal fluency and dsst time. based on the data collected, bdnf was in the normal range & the nonexistence of a relationship between psychological parameters and bdnf cannot be ruled out. acknowledgment we are thankful to our mentor dr. sadaf ahmed for guiding us in the study throughout and our labmate ms. ujala sajid for her continuous support. references 1. strausbaugh lj. emerging health careassociated infections in the geriatric population. emerg infect dis. 2001;7(2):268. 2. alam a, ibrar m, khan p. socioeconomic and psychological problems of the senior citizens of pakistan. pjpbs. 2016;2(2):249-261. 3. shoval g, weizman a. the possible role of neurotrophins in the pathogenesis and therapy of schizophrenia. eur neuropsychopharmacol. 2005;15(3):319-329. 114 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 4. lewin gr. neurotrophins and the specification of neuronal phenotype. philos trans r soc lond b biol sci. 1996;351(1338):405-411. 5. mizui t, ishikawa y, kumanogoh h, kojima m. neurobiological actions by three distinct subtypes of brain-derived neurotrophic factor: multi-ligand model of growth factor signaling. pharmacol res. 2016;105:93-98. 6. greenberg me, xu b, lu b, hempstead bl. new insights in bdnf synthesis and release biology: implications in cns function. j neurosci. 2009;29(41):12764-12767. 7. lu b, nagappan g, lu yb. bdnf and synaptic plasticity, cognitive function, and dysfunction. neurotrophic factors. 2014:223250. 8. lezak md, howieson db, loring dw, fischer js. neuropsychological assessment. oxford university press, usa. 2004. 9. federmeier kd, mclennan db, de ochoa e, kutas m. the impact of semantic memory organization and sentence context information on spoken language processing by younger and older adults: an erp study. psychophysiol. 2002;39(2):133-146. 10. fitzpatrick s, gilbert s, serpell l. systematic review: are overweight and obese individuals impaired on behavioural tasks of executive functioning?. neuropsychol rev. 2013;23:138156. 11. cauthen nr. verbal fluency: normative data. j clin psychol. 1978;34(1):126-129. 12. perlmuter lc, tun p, sizer n, mcglinchey re, nathan dm. age and diabetes related changes in verbal fluency. exp age res. 1987;13(1):9-14. 13. martin a, fedio p. word production and comprehension in alzheimer's disease: the breakdown of semantic knowledge. brain lang. 1983;19(1):124-141. 14. connick p, kolappan m, bak th, chandran s. verbal fluency as a rapid screening test for cognitive impairment in progressive multiple sclerosis. j neurol neurosurg psychiatry. 2012;83(3):346-347. 15. strauss e, sherman em, spreen o. a compendium of neuropsychological tests: administration, norms, and commentary. j. am. chem. soc. 2006. 16. bowie cr, harvey pd, moriarty pj, parrella m, white l, davis kl. a comprehensive analysis of verbal fluency deficit in geriatric schizophrenia. arch clin neuropsychol. 2004;19(2):289-303. 17. baldo jv, schwartz s, wilkins d, dronkers nf. role of frontal versus temporal cortex in verbal fluency as revealed by voxel-based lesion symptom mapping. j int neuropsychol soc. 2006;12(6):896-900. 18. maccoby ee, jacklin cn. the psychology of sex differences:—vol. ii: annotated bibliography. stanford university press. 1978. 19. toivainen t, papageorgiou ka, tosto mg, kovas y. sex differences in non-verbal and verbal abilities in childhood and adolescence. intelligence. 2017;64:81-88. 20. peng s, wuu j, mufson ej, fahnestock m. precursor form of brain‐derived neurotrophic factor and mature brain‐derived neurotrophic factor are decreased in the pre‐clinical stages of alzheimer's disease. j neurochem. 2005;93(6):1412-1421. 21. ruff, r. m., light, r. h., parker, s. b., & levin, h. s. (). the psychological construct of word fluency. brain lang. 1997;57(3): 394-405. 22. frankenberg c, weiner j, knebel m, abulimiti a, toro p, herold cj, schultz t, schröder j. verbal fluency in normal aging and cognitive decline: results of a longitudinal study. comp speech lang. 2021;68:101195. 23. sapolsky rm. hippocampal damage associated with prolonged glucocorticoid exposure in primates. j neurosci. 1989;9:17051711. 24. gaillard wd, hertz–pannier l, mott sh, barnett as, lebihan d, theodore wh. functional anatomy of cognitive development: fmri of verbal fluency in children and adults. neuro. 2000;54(1):180-. 25. jaeger j. digit symbol substitution test: the case for sensitivity over specificity in neuropsychological testing. j clin psychopharmacol. 2018;38(5):513. 26. wechsler d. the measurement of adult intelligence. 27. mcewen bs, angulo j, cameron h, chao hm, daniels d, gannon mn, gould e, mendelson s, sakai r, spencer r, woolley c. paradoxical effects of adrenal steroids on the brain: protection versus degeneration. biol psychiatry. 1992;31(2):177-199. 28. sapolsky rm, uno h, rebert cs, finch ce. hippocampal damage associated with 115 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 prolonged glucocorticoid exposure in primates. j neurosci. 1990;10(9):2897-2902. 29. bremner jd. traumatic stress: effects on the brain. dialogues clin neurosci. 2022. 30. luine v, villegas m, martinez c, mcewen bs. repeated stress causes reversible impairments of spatial memory performance. brain res. 1994;639(1):167-170. 31. scott jc, matt ge, wrocklage km, crnich c, jordan j, southwick sm, krystal jh, schweinsburg bc. a quantitative metaanalysis of neurocognitive functioning in posttraumatic stress disorder. psychol bull. 2015;141(1):105. 32. gruol dl. il-6 regulation of synaptic function in the cns. neuropharmacol. 2015;96:42-54. 33. rattiner lm, davis m, french ct, ressler kj. brain-derived neurotrophic factor and tyrosine kinase receptor b 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https://doi.org/10.29052/2412-3188.v8.i2.2021.107-111 case study treatment of severe anxiety and social phobia by hypnosis and neurolinguistic programminga case report samina malik1, maheen mirza2, mohammad fayyaz3, arif malik4 1department of physiology, university college of medicine and dentistry, university of lahore, lahore-pakistan. 2lahore grammar school, lahore-pakistan. 3basic health unit leil, lahore cantt, lahore-pakistan. 4institute of applied sciences, minhaj university, lahore-pakistan. abstract background: hypnosis is being used in combination with different forms of psychotherapy nowadays, such as neuro-linguistic programming, to work as a complementary treatment. this pairing allows for more targeted and patientspecific approaches to treat psychological disorders, phobias, and pain. an example is our previous study, in which hypnosis was used to treat tobacco-pan addiction. following a similar model in this case study, we investigate the effectiveness of hypnosis and neuro-linguistic programming as treatments for anxiety and phobias. case presentation: we discuss a case of a 20-year-old boy with severe anxiety and social phobia who was already taking antipsychotic drugs and antidepressants, but they did not aid in treating his condition. he was then treated with hypnotherapy and neuro-linguistic programming to address the rooted triggers for his phobia. a thorough three-hour session revealed the details of each traumatic event. each incident was isolated and changed in the patient's subconscious mind while he was hypnotized to remove that incident's role as a trigger. management & results: the patient reported approximately seventy percent recovery immediately after the first session in terms of rebuilding his confidence. the recovery was measured on dass-21 and rosenberg self-esteem scale (rses). the severity of his phobia was significantly controlled in a short-span of time, with almost no episode after the first hypnosis and nlp session. conclusion: hypnotherapy and neurolinguistic programming is an effective treatment for anxiety disorder and social phobia. it is also time-efficient and produces better results than other forms of treatment without accompanying side effects. keywords hypnosis, neurolinguistic programming, anxiety, phobia. citation: malik s, mirza m, fayyaz m, malik a. treatment of severe anxiety and social phobia by hypnosis and neurolinguistic programminga case report. app. 2021;8(2): 107-111 corresponding author email: drsemymalik58@gmail.com doi: 10.29052/2412-3188.v8.i2.2021.107111 received 16/06/2021 accepted 08/11/2021 published 01/12/2021 copyright © the author(s). 2021 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v8.i2.2021. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 108 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 introduction our previous study established that hypnosis can avoid a bad habit like tobaccopan addiction1. hypnosis has evolved beyond mere suggestion in the patient’s unconscious state and allows the patient’s mind to take over and access stored information2. this development has expanded the use of hypnosis as a treatment and effective intervention for several medical problems such as burns, allergies, sexual dysfunction, infertility, and insomnia2,3. in our case, hypnosis works as a highly effective intervention for anxiety3. anxiety disorders and phobias are prevalent, debilitating mental health problems that impact the day-to-day lives of the sufferers4,5. by trying to avoid the specific triggers and fears, they limit their quality of life, which may be a risk to their health if they are phobic to dental treatment, for example6. these disorders are complex problems with underlying reasons that require intense therapy to uncover and treat7. this is where hypnotherapy and neuro-linguistic programming (nlp) come in to treat the problem at the root-level7. nlp is a form of psychotherapy that detects triggers, termed as 'anchors,' responsible for the phobia, in the patient's subconscious state5,8. these anchors allow access to the patient's emotional state at the time of creating the trigger through age regression, which is then altered to erase the root cause of the phobia5, 6. in this case, we use hypnosis and nlp to treat a 20-year-old boy with severe anxiety and social phobia that prevents him from interacting with people. case presentation a doctor referred a 20-year-old young boy to our coauthor, a general physician with expertise in hypnosis. his widowed mother brought this boy with complaints of severe anxiety and social phobia. this condition adversely affected his comfort zone each time he was exposed to a social gathering or environment. he had a medicinal history of intake of antipsychotics and antidepressants prescribed by a psychiatrist. however, the medication only resulted in sedating him instead of relieving his anxiety. the signs and symptoms included anxiety tremors, dysarthria, severe lack of confidence, and poor self-esteem. he even wished to commit suicide, being unable to cope with his situation. he was a second-year physiotherapy student who needed to overcome his phobia to be able to work and perform in the academic environment on campus. after informed consent, the patient was drifted into a good trance (subconscious/altered state induced by hypnosis) in an hour which was in a way similar to anesthetic-state induced before surgery. once he was in this state, age regression by nlp was used to identify the first trigger, during which the subconscious mind was opened to approach its stored memory files by traveling back in time to pinpoint the issue responsible for the situation. with the identification of each trigger during nlp, while the subconscious mind was hypnotized, the memory's submodalities (picture, sound, and emotions) were changed in a way that the subconscious mind was led to believe that this data had been tampered with. this allowed the memory to be removed or reshaped, and with it, the anchor responsible for the phobia. this was done for each anchor recalled by the patient. the first traumatic event witnessed by the patient was his father's demise when the patient was only three years old. despite his young age at that time, he could vividly recall details, like the gathering of people around his father when he was on his deathbed wearing a white sheet, indicating the impact of that event on his psyche. the patient's emotional state at 109 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 the time of that event in his memory was altered so that it ceased to exist as an anchor. the second traumatic event recovered from his subconscious mind happened in his school days at age eleven. he was bullied ruthlessly by peers for being handicapped due to an abnormality of the hip joint. he could recall the names of his class-fellows who called him humiliating names and even physically harassed him. the nlp session continued for three hours. his ill memories were altered at a subconscious level. they were replaced by a narrative in which he was presented with an imaginary stick to drive away from the bullying boys, to deflect their verbal and physical attacks. at age eighteen, the third traumatic event was when the patient had to join an academy to boost his academic performance. although he had no prior bad experience there, he experienced severe anxiety and a consuming fear of being ridiculed right at the door of the academy due to the negative data broadcasted by his subconscious mind though nobody attempted to do so. this resulted from the trauma he had faced in his life previously, which did not allow him to have new experiences either. with hypnosis and nlp during the two sessions of three hours duration, the triggers were identified and resolved (at the level of the subconscious mind) to aid in the treatment of the patient’s phobia. management & results immediately after the session, the patient self-reported around 70% recovery and expressed that he was regaining confidence. after mutual consent, the patient tapered off his antipsychotic drugs. the recovery was followed up on dass-219 for one month at two points after taking the baseline / before treatment levels of depression, anxiety, and stress, i-e., two weeks after the 1st session and then two weeks after the 2nd session. the depression (d), anxiety (a), and stress (s) calculated before treatment were 42 (extremely severe), followed by d-34 (extremely severe), a-34 (extremely severe), and s-32 (severe) after the first hypnotic and nlp session. it was further reduced to the values of d-28 (the borderline between extremely severe and severe), a-26 (extremely severe), and s-30 (severe) after 2nd session. the patient is still under treatment, and further recovery is expected based on the previous results. likewise, improvement in self-esteem was calculated on rosenberg self-esteem scale (rses), ranging from 10-40 in score10. the baseline self-esteem was measured to be 10, followed by an increase to 27 after 1st session and then a slight dip of 21 after the 2nd session. the self-esteem level may improve with subsequent sessions in light of these supportive results. however, there is no way to declare how much of each therapeutic approach resulted in the change. discussion hypnotherapy treats different mental health problems, but its effectiveness with each kind varies. a research team conducted a meta-analysis at the university of hartford to test the efficacy of hypnosis in treating anxiety. hypnosis intervention was compared with a control condition in alleviating anxiety, with the initial results yielding that the hypnosis group reduced anxiety more than 79% of the control group. with additional trials, this figure increased to 84%. this study also concluded that hypnosis combined with other forms of psychotherapy is more effective than a single form of treatment3. 110 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 another study on the role of hypnosis in treating anxiety and panic attacks yielded a similar outcome that using clinical hypnosis is an effective treatment for anxiety11. a factor considered in a study done in moscow university was hypnotizability as an indicator of the level of hypnosis and how the change in level could affect treatment12. it was found that nlp was significantly more effective in high hypnotizable subjects than in low hypnotizable subjects13. this means that the depth of the trance due to the patient's cooperation can significantly influence the treatment and is an essential factor to be considered while obtaining informed consent to carry out the session. conclusion this case report established that with threehour hypnosis and nlp session, massive improvement can be obtained in recovery from phobias and lack of confidence. hence, it is a time-efficient treatment for anxiety and phobia-related disorders. the study is being brought to the limelight after informed consent to open new horizons for clinicians and researchers and to introduce this noninvasive treatment to those who may need it. by using hypnosis and identifying the triggers through neurolinguistic programming, a patient can be counseled and guided in the subconscious state to overcome the fears and deal with the root cause of the phobia. acknowledgment we would like to thank the patient for his consent to publish this report. references 1. shamir malik qm, rehman a, malik s, fayyaz m. control of tobacco paan and naswaar addiction by hypnosis. country: pakistan. 2017;13(3):48-49. 2. ahlskog g. clinical hypnosis today. the psychoanalytic rev. 2018;105(4):425-437. 3. valentine ke, milling ls, clark lj, moriarty cl. the efficacy of hypnosis as a treatment for anxiety: a meta-analysis. int j clin exp hypn. 2019;67(3):336-363. 4. schoenberger ne. cognitive-behavioral hypnotherapy for phobic anxiety. apa. 1996:33-49 5. li x, han f, shi y. ire1α-xbp1 pathway is activated upon induction of singleprolonged stress in rat neurons of the medial prefrontal cortex. j mol neurosci. 2015;57(1):63-72. 6. karunaratne m. neuro-linguistic programming and application in treatment of phobias. complement ther clin pract. 2010;16(4):203-207. 7. alladin a. cognitive hypnotherapy for accessing and healing emotional injuries for anxiety disorders. am j clinical hypno. 2016;59(1):24-46. 8. field es. neurolinguistic programming as an adjunct to other psychotherapeutic/hypnotherapeutic interventions. am j clinical hypno. 1990;32(3):174-182. 9. 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(3):335-343. 10. rosenberg m. conceiving the self new york: basic. rosenberg conceiving the self. 1979;1979. 11. volkovyskaya e. the use of clinical hypnotherapy in the treatment of social anxiety of social anxiety and panic attacks: a case study. contemp hypno & integrative therap. 2020;34(1):44-53. 12. frischholz ej. hypnosis, hypnotizability, and placebo. am j clinical hypno. 2014;57(2):165-174. 111 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 8 issue 2 13. kirenskaya av, novototsky-vlasov vy, chistyakov an, zvonikov vm. the relationship between hypnotizability, internal imagery, and efficiency of neurolinguistic programming. int j clin exp hypn. 2011;59(2):225-241. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v8.i2.2021.107-111 34 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v10.i1.2023.xx-xx original article attachment styles and their impact on sleep disturbances and dissociation in adults: a comprehensive study areeja shahid & saima massom department of psychology, university of karachi, karachi-pakistan abstract background: attachment theory posits that early attachment experiences significantly shape an individual's emotional well-being and relationships throughout life. this study explores the complex relationships between attachment styles, sleep disturbances, and dissociation in adults. methodology: a sample of 50 participants with varying attachment styles was surveyed using standardized measures of attachment, sleep disturbances, and dissociation. statistical analysis, including correlation tests, was conducted to investigate the relationships between these variables. results: the findings indicate a strong positive correlation between anxious attachment and sleep disturbances, highlighting the lasting impact of childhood attachment experiences on sleep quality. surprisingly, a negative relationship between anxious attachment and dissociation was observed, underscoring the intricate nature of attachment-related coping strategies. conclusion: this study underscores the enduring consequences of early attachment experiences, emphasizing their influence on adult well-being. recognizing these connections is vital for mental health professionals and practitioners in tailoring interventions to address attachment-related challenges. further research is needed to deepen our understanding of these relationships and refine therapeutic strategies. keywords attachment theory, anxious attachment, sleep disturbances, dissociation, adult well-being. citation: ali s, ali sm, zia a. the relationship of emotional intelligence and life satisfaction with resilience in students. app. 2023; 10(1): 35-44 corresponding author email: saima.ali@uok.edu.pk doi: 10.29052/2412-3188.v10.i1.2022.3443 received 16/03/2023 accepted 26/05/2023 published 01/06/2023 copyright © the author(s). 2023. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v10.i1.2023. about:blank about:blank 35 app| published by aeirc| volume 10 issue 1 introduction attachment, a fundamental aspect of human development, reflects the emotional bond formed between a child and their primary caregiver1. this connection serves as a secure base from which individuals explore the world and manage their emotions. according to attachment theory, children internalize their experiences in interactions with their primary caregivers and develop mental representations of these caregivers. these representations, known as internal working models, are subsequently used to navigate relationships with others throughout life. early relationships with parents, including parental rearing styles and the household atmosphere, influence the formation of these internal working models. however, when this attachment is not securely established due to the inconsistency or unavailability of parents or caregivers, it can lead to an 'anxious attachment'2. anxious attachment represents a rupture in the parent-child connection, resulting in psychological complexities that extend across various domains of life3. attachment theory posits that an individual's attachment style is shaped by their interactions with primary caregivers and other significant individuals in their lives. these attachment styles then become integrated into an individual's interpersonal interactions, serving as a foundation for their future relationships4. they contribute to an individual's self-perception views of others, known as internal working models, and their generalized perspective on human bonds and connections3,5. repetitive experiences of neglect and inconsistent care from attachment figures increase the likelihood of developing an insecure attachment style. consequently, individuals with such attachment styles tend to form negative working models of themselves, others, and relationships in general. those with anxious attachment tendencies often struggle with heightened distress and difficulties in regulating their emotions6,7. research emphasizes that anxious attachment can lead to a form of developmental trauma8. parental unavailability, inconsistency, or negative behavior and attitudes toward their children can result in trauma during childhood. the early childhood phase is particularly susceptible to experiencing traumatic events9. studies suggest that traumatic experiences during childhood, including neglect and abuse, have enduring effects on adult life, especially in the context of romantic relationships4. research findings indicate gender differences in attachment organization, with more men exhibiting an avoidant attachment style and more women falling into the anxious attachment category10. research also underscores the strong connection between anxious attachment styles in females and sleep disturbances. there is a notable link between mental health disturbances and sleep problems, particularly in females11. adult females often adopt an anxious approach in their romantic relationships, while males tend to lean toward an avoidant approach12, illustrating how females may tend to exhibit an anxious attachment style. attachment insecurity in intimate adult relationships is associated with increased physical illness and psychological issues13. both physical health conditions and mental disorders are recognized factors linked to disruptions in sleep patterns14. the relationship between sleep disturbances and these conditions is intricate because sleep problems are often considered an outcome of various health and mental disorders15. 36 app| published by aeirc| volume 10 issue 1 attachment insecurity has been identified as a potential contributory factor to sleep problems16. the attachment system becomes active in situations that increase vulnerability, such as loneliness, and attachment bonds reduce vulnerability during sleep17. while a secure attachment style may promote restful sleep, an insecure attachment style may heighten feelings of unease and alertness, interfering with the ability to sleep peacefully. moreover, parental behaviors that foster secure attachment, such as providing comfort in times of distress, may facilitate the regulatory mechanisms that promote restful sleep. some studies have indicated that insecure maternal attachment can influence and lead to the development of sleep disorders in infants18. another notable study suggests that attachment styles developed during childhood can impact sleep quality. children with more insecure attachment styles tend to exhibit greater resistance and fussiness during bedtime routines compared to children with secure attachment styles, as observed by their mothers19. children experiencing sleep difficulties are more likely to have insecure attachment styles18. additionally, women who experience severe separation anxiety, which hampers their ability to establish secure attachment, are more likely to have infants who wake up more frequently at night and experience poorer sleep quality20. in late adolescence, the relationship between insecure attachments and sleep disruptions persists21, extending into adult married couples and the elderly16. sleep disturbances and dissociation are trauma symptoms that assess distress in adults stemming from childhood traumatic experiences22. both sleep problems and dissociation are prevalent in the population23, leading researchers to study these variables together. there is a connection between dissociative symptoms and individuals reporting vivid dreams, nightmares, recurrent dreams, and other unusual sleep issues24. dissociation is one of the coping strategies used to deal with the stress of unhealthy attachment8. research findings suggest that traumatic events may contribute to the link between disorganized attachment during childhood and later dissociation25. individuals with high attachment anxiety, avoidance, or both tend to experience feelings of insecurity and may adopt secondary attachment strategies, which include either dissociation or hyperactivation of their attachment system as a means of coping with challenges26. research findings consistently show a strong connection between emotional abuse, dissociation21,27,28, and insecure attachment29. 37 app| published by aeirc| volume 10 issue 1 figure 1: theoretical framework childhood attachment development: humans possess an internal system known as the attachment behavioral system. this system serves as a predictor and motivator for seeking care and affection from caregivers when needed1. when individuals receive adequate care from their attachment figures during times of need, they develop a secure attachment. this secure attachment leads individuals to believe that the world is a safe place free from threats, that attachment figures provide support during times of distress, and that people can be relied upon for interaction. internal working models and trauma: the formation and perception of a secure and safe environment are based on internal working models, which are mental representations of how individuals perceive the world and themselves30. these internal working models can become distorted when negative interactions with caregivers, such as neglect and avoidance during times of distress, occur. conversely, when individuals consistently fail to receive care when needed and experience rejection from attachment figures throughout childhood interactions, they may develop an insecure attachment style3. issues with adult relationships often stem from the development of an insecure attachment style, which results from traumatic interactions with caregivers during childhood1. dissociation and sleep disturbances; subscales of trauma symptom: parental neglect and disrupted attachment patterns are significant factors in the 38 app| published by aeirc| volume 10 issue 1 development of psychopathological conditions in children, such as dissociative identity disorder, which is an attachment disorder31. a disorganized attachment style is significantly associated with higher levels of dissociation32. insecure attachment styles make individuals feel threatened and vulnerable in relationships, which contributes to sleep difficulties experienced by anxiously attached individuals3. in line with our research objectives, we formulated two hypotheses to guide our investigation. firstly, we hypothesized that there exists a significant and noteworthy relationship between anxious attachment and sleep disturbances among the participants. this hypothesis stemmed from previous literature suggesting a connection between attachment styles, particularly anxious attachment, and disruptions in sleep patterns. secondly, we hypothesized a significant relationship between anxious attachment and dissociation despite this relationship being expected to be negative. this hypothesis was rooted in the understanding that attachment styles can influence coping strategies, such as dissociation, as individuals navigate challenges related to their attachment patterns. these hypotheses served as the basis for our research and guided our exploration of the intricate relationships between attachment styles, sleep disturbances, and dissociation in adults. methodology this study employs a quantitative research approach, utilizing surveys as the primary data collection method. a sample of 50 individuals were selected from various universities and wellness centers for this study. participants were chosen using a convenient purposive sampling method. the age range of the participants was limited to 18 to 30 years. all participants were required to be female, capable of reading and comprehending english, and exhibit high scores on the insecure, anxious attachment style. the inclusion criteria for participant selection in this study were carefully defined. individuals eligible to participate were required to fall within the age range of 18 to 30 years and identify as female. proficiency in reading and comprehending the english language was also a prerequisite, ensuring that participants could effectively engage with the study materials and provide meaningful responses. additionally, participants needed to exhibit high scores on the anxious attachment style, reflecting a specific focus on individuals with this attachment pattern for the research investigation. these criteria were established to create a targeted and relevant participant group for the study's objectives. measures: consent form/demographic sheet: participants were asked to complete consent forms and demographic questionnaires. adult attachment revised scale (aas): the aas, initially developed in 1990 by hazen & shaver (1987) and levy & davis (1988), consists of 18 items. it measures three dimensions of relationship attachment: closeness, dependence, and anxiety. trauma symptom checklist: the tsc-40 is a research tool used to assess various symptoms in adults associated with traumatic experiences. it is an updated version of the earlier tsc-33 (briere & runtz, 1989). the tsc-40 demonstrates good reliability, with subscale alphas typically ranging from .66 to .77 and full-scale alphas averaging between .89 and .91. it comprises six subscales: dissociation, sleep 39 app| published by aeirc| volume 10 issue 1 disturbance, anxiety, depression, sexual abuse trauma index, and sexual problems. procedure: participants were first provided with informed consent forms and demographic questionnaires. subsequently, they completed the adult attachment revised scale. those participants who exhibited insecure, anxious attachment styles were further assessed using the trauma symptom checklist to determine their scores on sleep disturbance and dissociation. spss software was employed to analyze the correlation between anxious attachment, sleep disturbance, and dissociation, which represent subscales of trauma symptoms. result table 1 presents demographic information for the participants in percentage form. out of 150 potential participants, 50 were selected based on scoring a minimum of 24 out of 30 on the anxious attachment subscale of the adult attachment revised scale (aas). all selected participants were female. specifically, 8 participants scored 24, 5 scored 25, 30 scored 26, and 8 scored 27 out of the maximum score of 30 on the subscale. the age distribution was as follows: 15 participants were aged 18-20, 18 were aged 21-23, and 17 were aged 24-26. regarding education, 9 participants had completed 12 years, approximately 24 had completed 14 years, and 17 participants had completed 16 years of education. table 1: descriptive statistics of demographic information of participants (n=50). category measure % age 18-20 30 21-23 36 24-26 34 gender male 0 female 100 education in years 12 years 20 14 years 46.67 16 years 33.33 anxious attachment scores 27/30 16 26/30 60 25/30 10 24/30 14 the results reveal a strong positive correlation between sleep disturbances and anxious attachment style, with a correlation coefficient of 0.694 (p = 0.02, p < 0.05). additionally, a significantly moderate relationship exists between anxious attachment and dissociation, with a correlation coefficient of -0.518 (p = 0.03, p < 0.05). it's worth noting that this relationship is negative, consistent with previous research findings (table 2). 40 app| published by aeirc| volume 10 issue 1 table 2: correlation of anxious attachment, sleep disturbance & dissociation. variable n 1 2 3 anxious attachment 50 1 sleep disturbance 0.694** 1 dissociation -0.518** 1 **correlation is significant at the 0.01 level (2-tailed) the results reveal a strong positive correlation between sleep disturbances and anxious attachment style, with a correlation coefficient of 0.694 (p = 0.02, p < 0.05). additionally, a significantly moderate relationship exists between anxious attachment and dissociation, with a correlation coefficient of -0.518 (p = 0.03, p < 0.05). it's worth noting that this relationship is negative, consistent with previous research findings. discussion the present study delved into the association between attachment insecurity and sleep disturbances. the findings suggest a link between anxious attachment and sleep disruption, a pattern that may take root in early childhood and persist over time. individuals exhibiting an insecure, anxious attachment style appear more susceptible to experiencing sleep disturbances18. this connection between attachment style and sleep issues mutually influencing each other is supported by a body of research focused on infants and children33. the burgeoning data suggests that the relationship between sleep quality and attachment style begins to form early in life and endures. moreover, it seems that different aspects of this intricate relationship may vary in significance depending on the developmental stage. this is evidenced by research examining the link between sleep problems in adult couples. inadequate sleep was found to be associated with more negative perceptions of partner interactions, suggesting that sleep interruptions can impact a person's ability to regulate relationships34. additionally, anxiously attached individuals often hold negative views of themselves, leading to heightened self-doubt and ruminative thinking, which can contribute to sleep disturbances. overthinking is a prominent symptom of anxiety, which is closely linked with sleep disruptions23. another study suggests that females with insecure attachment tend to employ unhealthy coping strategies such as selfpunishment and excessive worry. these coping strategies are associated with emotional and mental issues35. research indicates that females often feel that worry is beyond their control, leading to increased levels of worry and stress36. elevated stress levels can interfere with sleep by prolonging the time it takes to fall asleep and disrupting sleep continuity37. the second hypothesis of our study posited a significant relationship between anxious attachment and dissociation, a relationship supported by our results. however, it's noteworthy that this relationship is negative, implying that more anxiously attached individuals exhibit fewer dissociative symptoms. this negative correlation aligns with previous research findings. individuals with high scores in avoidant attachment often tend to adopt deactivating strategies in their relationships, such as dissociation. these strategies involve avoiding closeness, suppressing attachment needs, and evading 41 app| published by aeirc| volume 10 issue 1 dependency in relationships. these behaviors often develop in response to attachment figures who disapprove of or penalize emotional closeness and the expression of needs or vulnerabilities3. conversely, individuals with high levels of attachment anxiety are prone to employ hyper-activating strategies. these strategies involve intense efforts to seek closeness, support, and affection, coupled with uncertainty about receiving these resources. feelings of frustration and anger can arise when these expected resources are not provided38. consequently, there exists a negative relationship between anxious attachment and dissociation, as individuals with anxious attachment find it challenging to detach themselves from the overwhelming fear of abandonment and the need for constant closeness. the inconsistent parenting patterns experienced by children can lead them to perceive themselves as unlovable, prompting anxiously attached individuals to seek excessive attention and clinginess when seeking support from others. conversely, those characterized by an avoidant attachment style often have a history of caregivers rejecting them, leading them to avoid seeking closeness and dissociating their need for love as they find safety in their independence39. one limitation of this study is the scarcity of longitudinal research involving adults or the elderly. this limitation hinders our ability to comprehensively assess the relationship between sleep disturbances and attachment styles over extended periods, leaving us with a limited understanding of the various underlying factors that may affect this relationship over time. conclusion in summary, our study reveals that anxious attachment styles stemming from early childhood experiences are closely linked to sleep disturbances in adulthood. while a surprising negative relationship between anxious attachment and dissociation was discovered, it underscores the intricate nature of attachment-related coping mechanisms. these findings emphasize the lasting impact of attachment experiences on adult well-being, shedding light on the need for targeted therapeutic interventions that address the root causes of sleep disruptions and dissociation. understanding these connections can significantly benefit mental health professionals and practitioners in providing effective support and treatment for individuals with attachment-related challenges. further research is essential to delve deeper into these relationships and refine intervention strategies. acknowledgment the authors are thankful to all the study participants for their valuable time and cooperation. references 1. bowlby j. attachment and loss: attachment; 1969. 2. hazan c&sp. romantic love is conceptualized as an attachment process. journal of personality and social psychology. 1987; 52(3): 511-524. 3. mikulincer.m,&spr. attachment in adulthood, first edition: structure, dynamics, and change: guilford publications; 2007. 4. crittenden pm,&la. assessing adult attachment: a dynamic maturational approach to discourse analysis.: w w norton & co.; 2011. 5. meyer b,&ppa. attachment style. psychotherapy. 2001; 38(4): 466–472. 6. mikulincer m,&spr. attachment in adulthood, first edition: structure, 42 app| published by aeirc| volume 10 issue 1 dynamics, and change: guilford publications; 2007. 7. mikulincer m,&spr. attachment in adulthood: structure, dynamics, and change. 2nd ed.: guilford publications; 2016. 8. liotti g. disorganized/disoriented attachment in the etiology of the dissociative disorders. dissociation. 1992; 5(4): 196-204. 9. weder n, kj. critical periods revisited: implications for intervention with traumatized 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neuroscience. 2003; 5(3): 249-58. 24. watson d. dissociations of the night: individual differences in sleep-related experiences and their relation to dissociation and schizotypy. journal of abnormal psychology. 2001; 110(4): 526-535. 25. ogawa j,sl,wn,ce,&eb. development and the fragmented self: longitudinal study of dissociative symptomatology in a nonclinical sample. development and psychopathology. ; 9(4): 855-879. 26. schäfer i,ht,av,bp,lm,ms,nd. childhood trauma and dissociation in female patients with schizophrenia spectrum disorders: an exploratory study. the journal of nervous and mental disease. 2006; 194(2): 135–138. 27. braehler c,vl,hd,mak,jr,ca,ks. childhood trauma and dissociation in firstepisode psychosis, chronic schizophrenia, and community controls. psychiatry research. 2013; 210(1): 36–42. 28. rafiq s, cc,&vf. the relationship between childhood adversities and dissociation in severe mental illness: a meta-analytic review. acta psychiatrica scandinavica. 2018; 138(6): 509–525. 29. riggs sa. childhood emotional abuse and the attachment system across the life cycle: what theory and research tell us. journal of aggression, maltreatment & trauma. ; 19(1): 5–51. 30. belsky j,&rm. temperament and attachment security in the strange situation: an empirical rapprochement. child development. 1987; 58: 787-795. 31. barach p, mm. multiple personality disorder as an attachment disorder. dissociation. 1991; 4(3): 117-123. 32. draijer n,&lw. childhood trauma and perceived parental dysfunction in the etiology of dissociative symptoms in psychiatric inpatients. the american journal of psychiatry. 1999; 156(3): 379–385. 43 app| published by aeirc| volume 10 issue 1 33. schwichtenberg a,j,sp&pj. sleep and attachment in preterm infants. infant mental health journal. 2013; 34: 37-46. 34. hasler bpatwm. couples’ nighttime sleep efficiency and concordance: evidence for bidirectional associations with daytime relationship functioning. psychosomatic medicine. 2010; 72: 794-801. 35. lieberman af,cat,vhp,&hww. trauma in early childhood: empirical evidence and clinical implications. development and psychopathology. 2011; 23(2): 397–410. 36. bahrami f, yn. females are more anxious than males: a metacognitive perspective. iranian journal of psychiatry and behavioral sciences. 2011; 5(2): 83–90. 37. almojali a,asa,aas,mem,am,k. the prevalence and association of stress with sleep quality among medical students. journal of epidemiology and global health. 2017; 7(3): 169-174. 38. ainsworth mds. attachments beyond infancy. american psychologist. 1989; 44: 709716. 39. fonagy p. attachment, trauma, and psychoanalysis: where psychoanalysis meets neuroscience m. leuzinger-bohleber jc&mt, the editor.: karnac books; 2010. 40. saunders be,&azw. epidemiology of traumatic experience in childhood. child and adolescent psychiatric clinics of north america. 2014; 23(2): 167-184. 41. mikulincer m,&spr. attachment in adulthood, first edition: structure, dynamics, and change: guilford publications; 2007. 42. liotti g. trauma, dissociation, and disorganized attachment: three strands of a single braid. psychotherapy: theory, research, practice, training. 2004; 41(4): 472– 486. 43. mueller-pfeiffer c,mh,ss,msc,wg,fc,rm. characteristics of child maltreatment and their relation to dissociation, posttraumatic stress symptoms, and depression in adult psychiatric patients. journal of nervous and mental disease. 2013; 201(6): 471–477. 44. oshri a, ste, cwj,&mjd. child maltreatment types and risk behaviors: associations with attachment style and emotion regulation dimensions. personality and individual differences. 2015; 73: 127–133. about:blank 01 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v10.i1.2023.xx-xx original article the physical manifestations of stress among the medical students of tsmu, georgia: an original study gayathri pramil menon , aarsha aji, niveditha selvakumar , rohit vassan , ranjan tejas venkanna & maduri balasubramanian tbilisi state medical university, department of medicine, tbilisi, georgia abstract background: medical students experience stress due to their daily routines, which tend to be responsible for higher burnout rates. the mental stress experienced by these students manifests itself in various physical situations. as a result, they might acquire various coping strategies with positive and negative outcomes. methodology: a survey was designed and circulated among the medical students of tsmu, georgia, with questions to collect data related to the subject. results: in the conducted survey, a total number of 203 responses was recorded. a majority, 65.5% (n=133) were females. the percentage of male participants in the survey was 34.5%. this study aims to observe the various physical manifestations of stress in pre-clinical and clinical year medical students from tbilisi state medical university. multiple factors like age, year of study, prior medical conditions, etc., were considered to understand how physical manifestations exhibit themselves and how the different stress levels worsen them. conclusion: this study proves the prevalence of various physical manifestations of stress among medical students. the highest percentage was reported among the age group of 22, with female students being more affected. first-year students also experienced increased stress due to adaptability issues. keywords stress, physical, psychology, medical students. citation: menon gp, aji a, selvakumar n, vassan r, venkanna rt, balasubramanian m. the physical manifestations of stress among the medical students of tsmu, georgia: an original study. app. 2023; 10(1): 01-07 corresponding author email: maduribalasubramanian@gmail.com doi: 10.29052/2412-3188.v10.i1.2023.0107 received 16/03/2023 accepted 26/05/2023 published 01/06/2023 copyright © the author(s). 2023. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v10.i1.2023. 0000-0002-3685-4214 0000-0002-1239-2238 0000-0002-3328-624x 0009-0009-3454-7630 0000-0002-5634-6057 about:blank about:blank 02 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 introduction the importance currently placed on mental health is monumental. due to the various challenges in the healthcare community, this conversation has been amplified. medical students and doctors in training also experience chronic stress daily. a person may develop stress due to many factors, including academics, occupation, relationships, and society, among many others. stress reduces an individual's productivity or zest to accomplish day-today activities or goals. these moments bud from lack of rest and many daily tasks the students are expected to carry out. medical students experience physical manifestations of this stress in the form of headaches, panic attacks, hair fall, gastrointestinal problems, sleep deprivation, binge eating, etc1. studies have shown first-year medical students experience stress mainly due to high parental expectations1. mental health has become an important issue to consider over recent years. medical students need regular counseling and periods of leisure to recharge and invigorate themselves. universities need to place importance on students' mental health and overall well-being. the adverse effects of stress could have harmful implications for patient care, as previous studies have shown that anxious medical students were less empathetic and less enthusiastic when caring for patients with chronic illnesses2. de-stigmatization of mental illnesses and promoting help-seeking behavior is vital to sustain student's overall mental wellness2. without effective outlets to relieve stress, negative coping mechanisms such as the use of substances and alcohol could be utilized by students. we also believe that healthcare professionals being open about their mental health struggles will forge a path for more discussion about the subject. this study aimed to determine the most common physical manifestations of stress prevalent in the medical student population of tsmu, georgia. methodology the data collection for this study was conducted using a survey made from reading through different psychological questionnaires, consisting of 19 questions, created on google forms, circulated on various social media platforms to reach the target audience. the inclusion criteria were medical students from tbilisi state medical university. the survey was designed to collect data on the overall mental health status of the students and the physical symptoms they experienced during this time. patients were asked for consent to use data before filling out the survey, and responses of those who did not want to be added were excluded. the survey was anonymous, and no participant emails were collected. the survey consisted of multiple-choice questions and open-ended questions. there was also no time limit given. the first question in the survey required the consent of the participant. upon giving their consent to move forward with the survey, the following questions were asked: • please specify your age • please specify your sex • year of study • do you experience stress as a medical student? if the participant answered 'yes,' the questions asked next were: • do you find yourself stressed out due to the following reasons? (e.g., fear of examinations, lack of leisure time, etc.) 03 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 • when do you find yourself particularly stressed out? (during examinations or frequently throughout the semester) • if you have any pre-existing psychological condition for which you currently take medications, kindly specify the condition. • what do you do to relieve stress? (e.g., smoking, drinking alcohol, meditating, etc.) on a scale of 1 to 5 (with 1 being the least and 5 being the highest), the rate at which of the following physical symptoms do you tend to experience stress: • chest pain • heart palpitations • fatigue (without any strenuous exercise) • insomnia • headache • gi symptoms (e.g., vomiting, diarrhea, abdominal pain) • panic attacks • hyperventilation • poor appetite • disturbances in the menstrual cycle (provided no pre-existing hormonal conditions such as pcos, thyroid, etc.) • please specify if you experience any symptoms other than the ones listed above. upon completing the survey, the participants clicked submit, and the data was collected. result the duration of this study was 2.5 months, from april to mid-june. after the survey was closed, data analysis of the study was conducted to clean the data by removing incomplete or incorrectly completed responses, and we used descriptive analysis to create and understand the trends in the responses. the survey does not report students' mental status but mentions the physical symptoms seen when under a lot of stress, which can be due to multiple factors. this study is to observe the various physical manifestations of stress in pre-clinical and clinical year medical students from tbilisi state medical university. a survey was conducted using google forms, and a total of 203 responses were recorded. the age of the participants ranged from 18-32 (table 1). table 1: study participants age age of participants responses (%) 18 4.9 19 17.2 20 14.8 21 18.7 22 20.2 23 12.8 24 0.5 25 6.4 04 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 26 1.5 27 0.5 28 0.5 29 0.5 30 0.5 31 0.5 32 0.5 the curated survey consisted of 19 questions. a response rate of 96.5% was received when asked if the participants experienced stress. a total of 203 responses were recorded, and 195 usable responses were considered to calculate. in the conducted survey, a total number of 203 responses was recorded. a majority, 65.5% (n=133) were females. the percentage of male participants in the survey was 34.5% (table 2). table 2: study participant's distribution on gender base sex of participants responses (%) females 65.5 males 34.5 so what are the signs of stress, and what coping skills along with stressors are observed? factor analysis revealed three hidden factors for stress in this group, namely, depression, nervousness, and age. stress that's left unchecked can contribute to many health problems, such as high blood pressure, heart disease, menstrual problems, obesity, and diabetes. the most commonly seen physical signs are (table 3) 1. among 139 responses for chest pain, 47.5%(n=66) of students experience mild chest pain, while 2.9% (n=4) experience severe chest pain during stress. 2. 22.3%(n=35) students experience mild heart palpitations and 8.3%(n=13) of students suffer from severe heart palpitations during stress. 3. among 153 responses for panic attacks, 30.7%(n=47) of students experience mild panic attacks, while 12.4%(n=19) of students experience severe panic attacks during stress. 4. among 131 responses for menstrual cycle disturbances, 42%(n=55) of students experience mild disturbances, while 15.3%(n=20) of students experience severe disturbances during stress. table 3: commonly physical signs observed by study participants scale level responses (%) chest pain 1 47.5 2 21.6 3 24.5 4 3.5 5 2.9 05 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 panic attacks 1 30.7 2 19 3 19 4 18.9 5 12.4 disturbance in the menstrual cycle 1 42 2 11.5 3 14.5 4 16.8 5 15.2 hence, the coping methods used and how harmful they are is an understatement. among the 195 responses, 20% (n=137) students said they sleep when they feel stressed, 16.5% (n=90) students said they binge eat, and 13.5% (n=65) students said they do exercise are the top three coping mechanisms observed. failure to recognize manifestations of stress and to assist with the development of positive coping skills causes detrimental effects on one's mental, physical, and emotional health (table 4). table 4: stress relievers commonly used by medical students stress relievers responses (%) sleeping 20 binge eating 16.5 exercise 13.5 smoking 12.8 meditation 9.5 drinking alcohol 6.2 hobbies 5.5 doing nothing 4.5 use of recreational drugs 4 watching television 3 social media 2 confide in a friend 1.5 games 1 discussion in psychological sciences, stress is a feeling of mental pressure and tension. low levels of stress might be desired, useful, and even healthy. stress, in its positive form, can improve biopsychosocial health and facilitate performance. however, high levels of stress could have potentially harmful implications. a high prevalence of stress among medical students indeed requires attention as it may impair their learning ability and may ultimately affect the quality of patient care they provide after graduation. from our 06 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 curated survey, a majority of students reported that they experience stress. this is in concordance with medicine being one of the most challenging professions. a sizable number of participants reported stress due to the fear of examinations. this is in concordance with a study by sanjukta padhi, who reported that school examinations were one of the major stressors in students3. this could be due to the voluminous amount of information they are required to learn and retain in a short amount of time. it has also been reported that pre-clinical students experience higher stress due to fear of examinations. possible reasons are adaptation issues, anxiety due to new subjects, and a new environment. this stress could, in turn, inhibit and suppress learning, which is called 'unfavorable stress' and is associated with the inhibition of students' academic performance, leading to accelerated levels of stress during exams4. a study found that academic stress was correlated to a high degree with financial and social stress, which can be related to the fact that a majority of the participants are immigrants, and a change in the social environment and surviving on their own can impose difficulties5. this can be further reinforced by a study that stated: "as immigrant youth adapt and acculturate, they encounter a multitude of new challenges and stressors”5. high parental pressure was also noted as one of the major stressors. this could be due to unrealistic or high expectations set by parents, which result in anxiety and stress in students. lack of leisure time was also noted to be one of the stressors due to the high workload, tight schedules, and deadlines for medical students. financial problems are a stressor because medicine is an expensive course in many countries, and plenty of students immigrate for education, which increases their expenditure. relationship disharmony, either familial, romantic, or peer, has also been noted as one of the less prominent stressors. a majority of the participants responded that they were more stressed throughout the semester than only during the examinations, again in concordance with the heavy workload and responsibilities for medical students, which impacted their mental wellbeing. some participants reported pre-existing psychological conditions such as depression, anxiety, panic attacks, and insomnia. these conditions, coupled with stress, could exert abundant emotional pressure on the participants. a set of physical manifestations was given, and the participants were asked if they experienced these symptoms when stressed. the majority of people responded that they experienced severe headaches (intensity 5). the other physical manifestations reported were fatigue without strenuous exercise, insomnia, heart palpitations, poor appetite, panic attacks, hyperventilation, gi symptoms, chest pain, and disturbances in the menstrual cycles. exposure to stress results in alterations of the brain-gut interactions ("brain-gut axis"), ultimately leading to the development of a broad array of gastrointestinal disorders. this explains the manifestation of gi symptoms among the participants6. positive and negative coping mechanisms were noted in the participants. the major positive coping method that was recorded was sleep, followed by exercise and meditation, and a few others, like confiding 07 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 1 in a friend, praying, and engaging in hobbies, were recorded in the participants. negative coping mechanisms like binge eating, alcohol consumption, smoking, use of recreational drugs, procrastination, and binge-watching shows were also noted. a few limitations observed during data collection were the small sample size, the frequency and intensity of alcohol consumption, the frequency of nicotine intake, psychosomatic symptoms, and emotional disturbances that could cause a menstrual cycle in females that could point to gender bias. conclusion this study provides evidence of various physical manifestations of stress among medical students. the highest percentage was reported among the age group of 22, with female students being more affected. the most common symptoms seen were chest pain, menstrual cycle disturbances, and panic attacks. coping mechanisms adopted by these students were sleeping, binge eating, and exercising. recommendations early detection of these symptoms is necessary for managing these stressors as well as to provide mental & physical stability for medical students. medical universities must look to initiate policies to help their students cope with their daily activities and the psychological stress accompanying them. acknowledgment this study is dedicated to all stress and trauma survivors. references 1. ragab ea, dafallah ma, salih mh, osman wn, osman m, miskeen e, taha mh, ramadan a, ahmed m, abdalla me, ahmed mh. stress and its correlates among medical students in six medical colleges: an attempt to understand the current situation. mecp. 2021;28(1):75. 2. tian-ci quek t, wai-san tam w, x. tran b, zhang m, zhang z, su-hui ho c, chun-man ho r. the global prevalence of anxiety among medical students: a meta-analysis. ijerph. 2019;16(15):2735. 3. padhi s. examination phobia and its measures. available at: https://www.researchgate.net/publication/ 344395951_examination_phobia_and _its_measures 4. manning-geist b, meyer f, chen j, pelletier a, kosman k, chen x, johnson nr. pre-clinical stress management workshops increase medical students’ knowledge and selfawareness of coping with stress. med sci educ. 2020;30:235-41. 5. brooke t, brown m, orr r, gough s. stress and burnout: exploring postgraduate physiotherapy students’ experiences and coping strategies. bmc med edu. 2020;20:1-1. 6. bear t, dalziel j, coad j, roy n, butts c, gopal p. the microbiome-gut-brain axis and resilience to developing anxiety or depression under stress. microorganisms. 2021;9(4):723. about:blank 4 annals of applied psychophysiology june 2025 volume 12 mood changes in response to fighting among mixed martial arts fighters; a pre and post-fight analysis faizan mirza1, amaila fazal2 1department of physiology, university of karachi, karachi-pakistan 2department of health, physical education and sports sciences, university of karachi, karachi-pakistan corresponding author e-mail: fm.faizan.mirza@gmail.com published online: june 2025 © the author(s) 2025 abstract background: understanding mood changes before and after a fight is crucial for optimizing performance and ensuring fighters' mental well-being. this study aimed to analyze mood changes among pakistani mixed martial arts (mma) fighters in a pre-and post-fight context, exploring the psychophysiological underpinnings of these shifts and their implications for the fighters' mental health and performance. methods: this observational cross-sectional study was conducted among 50 healthy male mma fighters, aged between 10 and 30 years, from various ethnic backgrounds, who were engaged in a daily routine of 90 minutes of mma fighting. mood analysis was carried out using the brunel mood scale (brums) questionnaire, the state-trait anxiety inventory (stai), and the profile of mood states (poms) questionnaire preand post-fight. results: the psychological variations were observed, and significant differences were noted in the scores for anger (p-value=0.012), tension (p-value=0.001), vigor (p-value=0.000), confusion (p-value=0.014), and overall brums score (p-value=0.029) in the winners while only vigor (p-value=0.000) was significantly increased among the individuals who lost the fight. the mean stai score decreased significantly among both winners and losers (pvalue=0.002 and 0.004, respectively). further, the mean poms score decreased among winners while it drastically increased for the losers but insignificantly. conclusion: the study revealed that mma fighters experience significant psychological changes post-fight, with winners showing reduced anger, tension, and confusion, and a marked decrease in anxiety and vigor. in contrast, losers primarily exhibited a significant drop in vigor and increased confusion and tmd scores, indicating a more negative psychological impact. keywords: mood changes, fighting, mixed martial arts, mma fighters, analysis mailto:fm.faizan.mirza@gmail.com introduction mixed martial arts (mma) have seen a significant rise in popularity in pakistan, with an increasing number of fighters emerging from various regions. as a highly demanding combat sport that combines techniques from various martial arts disciplines [1], mma not only challenges the physical limits of its participants but also has profound effects on their psychological states [2]. understanding mood changes before and after a fight is crucial for optimizing performance and ensuring the mental well-being of fighters. this is particularly relevant in the pakistani context, where cultural factors, societal expectations, and the relatively nascent stage of mma as a professional sport add unique dimensions to the psychological experiences of fighters [3]. from a psychophysiological perspective, the anticipation of a fight can trigger a complex interplay of emotional responses, including anxiety, excitement, and aggression [4]. these mood states are influenced by various factors, such as the perceived importance of the match, previous experiences, and the fighter’s mental preparedness [5]. the stress associated with the fight can lead to physiological changes, such as increased heart rate, cortisol levels, and adrenaline, which can affect mood and cognitive functioning [6-8]. post-fight, the psychological state of a fighter can vary widely depending on the outcome of the match. victory may lead to feelings of euphoria and relief, while defeat can result in frustration, disappointment, or even depressive symptoms. these mood fluctuations are further influenced by the physical toll of the fight, including injuries, fatigue, and pain [9-12]. in pakistan, the pressure on fighters to succeed is often amplified by societal expectations and the desire to gain recognition in a sport that is still gaining mainstream acceptance [13, 14]. this study aimed to analyze mood changes among pakistani mma fighters in a preand postfight context, exploring the psychophysiological underpinnings of these shifts and their implications for the mental health and performance of the mma fighters. this analysis would contribute to the development of targeted interventions that can support the psychological resilience and well-being of fighters in this challenging sport. materials and methods this observational cross-sectional study was conducted at a __________ from may to august 2024, with ethical approval obtained from the institutional review committee. a total of 50 male mma fighters participated, each providing written informed consent. the study included healthy male fighters, aged between 10 and 30 years, from various ethnic backgrounds, who were engaged in a daily routine of 90 minutes of mma fighting. regular assessments of basic vitals were conducted by paramedical staff before each fight session. fighters who engaged in less than 90 minutes of routine mma fighting or who had known serious medical conditions or injuries were excluded from the study. mood analysis was carried out for each participant both before the start of the fight and after its conclusion. participants were asked to complete the brunel mood scale (brums) questionnaire, the state-trait anxiety inventory (stai), and the profile of mood states (poms) questionnaire to assess their mood preand post-fight. the brums questionnaire, which includes 32 items, measures both positive and negative emotions. participants responded on a numerical rating scale from zero to four (0 = not at all, 1 = a bit, 2 = moderate, 3 = enough, 4 = extremely). scores were calculated for various mood dimensions such as anger, confusion, depression, fatigue, tension, vigor, calmness, and happiness. after the fight, participants completed the brums questionnaire again to assess their post-fight mood [15]. the stai scale, consisting of 20 statements, requires participants to indicate how they feel at a specific moment. each statement is rated on a 4-point scale (not at all, somewhat, moderately so, very much so), with scores ranging from 20 to 80 [16]. the poms is a 40-question modified version developed by grove and prapavessis (1992) [17]. scores for each item range from 0 for 'not at all' to 4 for 'extremely,' with the esteem-related effect subscales reverse-scored before combining with the other items. a total mood disturbance (tmd) score is calculated by summing the negative subscale totals (tension, depression, fatigue, confusion, anger) and subtracting the positive subscale totals (vigor and esteem-related affect). data analysis was conducted using the statistical package for social sciences (spss) version 26. descriptive statistics, including mean and standard deviation, were used to summarize the variables. a paired sample t-test was applied to compare pre-test and post-test values, with statistical significance defined as p < 0.05. further, post-analysis was conducted for mood evaluation based on the results of fighting either loss or win. results a total of 50 mma fighters were included with a mean age of 16.71±4.027, majorly representing pashtun ethnicity (85.71%), with a mean weight and height of 50.2±10.124 and 5.1±0.606, respectively. the psychological variations were observed before and after the fighting comparing both winning individuals with the individuals who lost the fight and detailing of the mean scores and standard deviations for various mood sub-scales were presented. significant differences were noted in the scores for anger (p-value=0.012), tension (p-value=0.001), vigor (p-value=0.000), confusion (p-value=0.014), and overall brums score (p-value=0.029) in the winning group while only vigor (p-value=0.000) was significantly increased among the individuals who lost the fight (table 1). table 1: comparison of psychological variation among winners and losers before and after the fight using the various mood dimensions of the brunel mood scale (brums) (n=50) mood scales winners (n=39) losers (n=11) pre-fight post-fight p-value pre-fight post-fight p-value anger 3.21±4.75 1.15±1.56 0.012* 7±7.56 4.36±3.64 0.306 tension 3.23±4.58 0.56±0.68 0.001* 6±6.35 5.82±4.68 0.933 depression 1.95±3.99 1±1.83 0.216 4.91±3.64 5±4.66 0.969 vigor 14.95±1.23 12.44±3.87 0.000* 15.45±0.93 11.45±1.29 0.000* fatigue 4.62±4.77 5.36±2.56 0.230 6.45±6.17 8.73±2.72 0.200 confusion 2.97±4.24 1.21±1.34 0.014* 4.27±5.44 6.55±4.00 0.271 happy 13.38±2.27 14.08±2.01 0.152 15.09±0.38 13.18±2.82 0.055 calmness 9.62±2.89 10.33±3.92 0.322 12.45±1.21 10.27±3.97 0.054 overall brums score 53.92±23.16 46.13±8.75 0.029* 71.63±31.63 65.36±19.85 0.473 *p<0.05 was considered statistically significant. the mean stai score decreased significantly among both winners and losers (p-value=0.002 and 0.004, respectively) from before to after the fight, indicating the level of anxiety decreased after the fight (table 2). table 2: comparison of anxiety levels before and after the fight among winners and losers using the state-trait anxiety inventory (stai) (n=50) stai score pre-fight post fight p-value mean ± sd mean ± sd winners (n=39) 55.64±10.87 49.26±8.75 0.002* losers (n=11) 69.73±15.94 57.27±15.44 0.004* *p<0.05 was considered statistically significant. further, the mean poms score decreased from before to after the fight for the winners while it drastically increased for the losers but insignificantly, indicating that the level of tmd decreased after the fight in the winning individuals (table 3). table 3: comparison of total mood disturbance (tmd) levels before and after the fight among the winners and losers using the profile of mood states (poms) questionnaire (n=50) poms score pre-fight post fight p-value mean ± sd mean ± sd winners (n=39) -1.15±21.59 -6.87±6.58 0.106 losers (n=11) 4.36±46.76 17.18±16.25 0.436 discussion the findings of this study reveal significant psychological changes among mma fighters before and after their fights, with notable differences between winners and losers. specifically, significant reductions in anger (p=0.012), tension (p=0.001), vigor (p=0.000), confusion (p=0.014), and overall brums score (p=0.029) were observed in the winning group, whereas only vigor (p=0.000) significantly decreased in the losing group. additionally, anxiety levels decreased significantly for both winners and losers, as evidenced by the stai scores (p=0.002 and p=0.004, respectively). however, while the total mood disturbance (tmd) score decreased for winners, it increased, albeit insignificantly, for losers. these results align with previous research on the psychological effects of competitive sports. for instance, studies have shown that successful athletes often experience reductions in negative mood states such as anger and tension after a competition, likely due to the relief and satisfaction of achieving victory [18-20]. the decrease in confusion among winners also supports the idea that winning provides a sense of clarity and mental focus, as noted in studies on the cognitive effects of sports success [21-23]. the significant decrease in vigor observed in both groups, however, highlighted the physically taxing nature of mma, which often results in diminished energy levels regardless of the fight's outcome. this finding is consistent with the previous study, which noted that intense physical exertion commonly leads to reduced vigor due to fatigue [18, 21]. the uniform decrease in vigor underscores the demanding physical requirements of mma, which can impact fighters' energy levels and overall mood post-fight. the discrepancy between these studies and the current study may be attributed to cultural factors, the unique psychological profiles of pakistani mma fighters, or the specific conditions under which this study was conducted. interestingly, the anxiety reduction observed in both winners and losers reflects a common phenomenon in competitive sports, where the resolution of pre-fight stress often leads to a post-fight decrease in anxiety [24, 25]. this decrease might be attributed to the psychological release following the intense focus and anticipation leading up to the fight. the release of physical and emotional tension post-competition could explain the significant decrease in anxiety observed in this study. this anxiety reduction can have positive implications for recovery and overall mental well-being, emphasizing the importance of postfight interventions that support mental health [26, 27]. the contrasting changes in tmd scores between winners and losers highlighted the complex emotional responses associated with competition outcomes. while winners experienced a reduction in overall mood disturbance, losers saw an increase, suggesting that losing a fight might exacerbate negative mood states, as has been suggested in similar studies [28, 29]. the increase in tmd among losers, though not statistically significant, indicates a need for further research into the psychological support necessary for athletes after a loss. the decrease in the poms tmd score, though not significant, indicated a trend toward improved mood states post-fight among winners. the non-significance of the poms results in this study might be due to the sample size or the variability in individual responses to the fight experience. this study highlighted the complex psychological responses of mma fighters to competition, with significant differences observed between those who win and those who lose. the findings underscore the importance of addressing both the physical and psychological aspects of recovery, particularly for fighters who experience defeat, as their psychological wellbeing appears to be more adversely affected. these insights can inform targeted interventions to support the mental health and performance of mma fighters, helping them to manage both the highs and lows of competitive combat sports. one limitation of this study is the relatively small sample size of 50 participants, which might not fully represent the broader population of mma fighters, particularly given the cultural and ethnic homogeneity (85.71% pashtun) of the sample. additionally, the study only included male fighters aged 10 to 30 years, limiting the generalizability of the findings to other age groups or female fighters. the self-reported nature of mood assessments might introduce bias, as participants could be influenced by social desirability or inaccurate self-perception. moreover, the study's focus on immediate preand post-fight mood changes does not account for longer-term psychological effects or the influence of external factors such as fight outcomes, training intensity, and personal stressors. conclusion the study revealed that mma fighters experience significant psychological changes post-fight, with winners showing reduced anger, tension, and confusion, and a marked decrease in anxiety and vigor. in contrast, losers primarily exhibited a significant drop in vigor and increased confusion and tmd scores, indicating a more negative psychological impact. these findings highlight the importance of addressing both the mental and physical aspects of recovery in mma fighters, especially for those who lose. future research should explore tailored psychological interventions to support mma fighters, particularly focusing on postfight recovery strategies for those who experience defeat. additionally, expanding studies to include diverse populations and longer-term mood assessments could provide deeper insights into the psychological dynamics of combat sports and enhance fighter well-being and performance. references abbas sa, khan mi, nawaz m, shehzadi n, fatima sn, fazal m. effects of selected profile variables upon mood state: a cross-cultural study among elite athletes of pakistan. journal of positive school psychology. 2022 jul 1;6(7):6010-36. arsović n, đurović r, rakočević r. influence of physical and sports activity on mental health. facta universitatis, series: physical education and sport. 2020 jan 16:559-68. bertsch k, florange j, herpertz sc. understanding brain mechanisms of reactive aggression. current psychiatry reports. 2020 dec;22:1-6. bestwick-stevenson t, toone r, neupert e, edwards k, kluzek s. assessment of fatigue and recovery in sport: narrative review. international journal of sports medicine. 2022 dec;43(14):1151-62. brandt r, bevilacqua gg, coimbra dr, pombo lc, miarka b, lane am. body weight and mood state modifications in mixed martial arts: an exploratory pilot. the journal of strength & conditioning research. 2018 sep 1;32(9):2548-54. bueno jc, faro h, lenetsky s, gonçalves af, dias sb, ribeiro al, da silva bv, filho ca, de vasconcelos bm, serrão jc, andrade a. exploratory systematic review of mixed martial arts: an overview of performance of importance factors with over 20,000 athletes. sports. 2022 may 24;10(6):80. costello se, o’neill bv, howatson g, van someren k, haskell-ramsay cf. detrimental effects on executive function and mood following consecutive days of repeated highintensity sprint interval exercise in trained male sports players. journal of sports sciences. 2022 apr 3;40(7):783-96. grove jr, prapavessis h. preliminary evidence for the reliability and validity of an abbreviated profile of mood states. international journal of sport psychology. 1992 apr. hagan jr je, pollmann d, schack t. elite athletes’ in-event competitive anxiety responses and psychological skills usage under differing conditions. frontiers in psychology. 2017 dec 22;8:2280. herrero cp, jejurikar n, carter cw. the psychology of the female athlete: how mental health and wellness mediate sports performance, injury and recovery. annals of joint. 2021 oct 15;6. hughes k. (2020). psychological effects experienced by injured mixed martial arts athletes (doctoral dissertation, waterford institute of technology). jekauc d, fritsch j, latinjak at. toward a theory of emotions in competitive sports. frontiers in psychology. 2021 dec 16;12:790423. kayikcioglu o, bilgin s, seymenoglu g, deveci a. state and trait anxiety scores of patients receiving intravitreal injections. biomedicine hub. 2017 aug 5;2(2):1-5. khan p. (2022). cultural transmission of martial art studies in india: reception and subject formation. king ie, king n. power in mixed martial arts (mma): a case study of the ultimate fighting championship (ufc). international journal of sport policy and politics. 2024 apr 19:123. lane am, terry pc. the nature of mood: development of a conceptual model with a focus on depression. journal of applied sport psychology. 2000 mar 1;12(1):16-33. nassif n. using sport as a national soft power strategy: the case of mixed martial arts in bahrain. routledge handbook of sport in the middle east 2022 apr 27 (pp. 104-114). routledge. lavega-burgués p, alcaraz-muñoz v, mallén-lacambra c, pic m. roles, relationships, and motor aggressions: keys to unveiling the emotions of a traditional sporting game. frontiers in psychology. 2023 jan 30;14:1127602. malešević s. why humans fight. cambridge university press; 2022 oct 6. mcloughlin e, fletcher d, slavich gm, arnold r, moore lj. cumulative lifetime stress exposure, depression, anxiety, and well-being in elite athletes: a mixed-method study. psychology of sport and exercise. 2021 jan 1;52:101823. páez-ardila ha, lopes campos ís, gouveia jr a. evidence of the effect of winning or losing in levels of finger and anxiety in judo fighters. avances en psicología latinoamericana. 2020 aug;38(2):173-90. ribeiro im, providência b. the brums method and emotional design: profile of the mood states of undergraduate students in higher education. robazza c, pellizzari m, hanin y. emotion self-regulation and athletic performance: an application of the izof model. psychology of sport and exercise. 2004 oct 1;5(4):379404. robazza c, bortoli l, hanin y. precompetition emotions, bodily symptoms, and task-specific qualities as predictors of performance in high-level karate athletes. journal of applied sport psychology. 2004 apr 1;16(2):151-65. tamminen ka, kim j, danyluck c, mcewen ce, wagstaff cr, wolf sa. the effect of self and interpersonal emotion regulation on athletes’ anxiety and goal achievement in competition. psychology of sport and exercise. 2021 nov 1;57:102034. terry pc, lane am. normative values for the profile of mood states for use with athletic samples. journal of applied sport psychology. 2000 mar 1;12(1):93-109. uddin n, tallent j, waldron m. physiological and perceptual responses to a five-week pre event taper in professional mixed martial arts athletes. the journal of sport and exercise science. 2020 sep 9;4(2):90-9. weiss o, norden g. sport, social recognition, and identity. introduction to the sociology of sport 2021 jun 18 (pp. 122-159). brill. zilincik s. the role of emotions in military strategy (spring 2022). annals of psychophysiology volume 12 june 2025 about the annals of psychophysiology the annals of psychophysiology (app) is the semi-annual journal of the behavioral medicine research and training foundation which provides all funding to support the journal. issues are usually published in june and december. the journal is published in cooperation with pakistan’s advance educational institute and research center (aeirc) which published the journal from its inception in 2014 until 2024 and continues to provide technical support for preparing manuscripts for publication. the app provides a platform for scientific contributions on all aspects of psychophysiology with emphasis on the psychophysiology of health and disease with sub-themes covering environmental and sports psychophysiology. articles include current reviews of various aspects of the field, original research, and editorials. the online issn is 2412-3188 while the print issn is 2410-1354. app is an open-access journal committed to maintaining high standards through rigorous peer review. the journal does not charge authors any fees for publication. information about the foundation and the courses it offers centering on behavioral medicine and biofeedback can be found by following this link: https://www.behavmedfoundation.org the journal is actively soliciting original research and reviews of current research in psychophysiology. please go to our website https://annalsofpsychophysiology.org for lots of information about the journal, its policies, and instructions for submitting manuscripts. editor-in-chief richard a. sherman, ph.d., usa associate editors eric willmarth, ph.d. usa cynthia r. kerson, ph.d., ph.d., usa john graham, md, dd, ph.d., usa jerry r. devore, ph.d., usa 68 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v10.i2.2023.68-75 original article understanding fear conditioning: psychophysiological responses, anxiety, and startle reactivity in karachi undergraduates – a pilot study yusra saleem1 , shamoon noushad1,2 , ujala sajid1 & basit ansari2 1psychophysiology research lab, department of physiology, university of karachi, karachipakistan. 2department of health, physical education & sports sciences, university of karachi, karachipakistan. abstract background: fear conditioning, a cornerstone in the exploration of fear learning, provides insights into the intricate mechanisms shaping adaptive and maladaptive fear responses. this pilot study delves into fear conditioning among undergraduate students in karachi, pakistan, aiming to understand the nuanced interplay between anxiety, startle reactivity, and physiological measures. methodology: forty-six healthy undergraduate students (18-30 years) participated in a differential fear-conditioning paradigm. cockroach images, culturally significant fear stimuli, served as conditioned stimuli (cs+), paired with a mild shock in 75% of trials, while a neutral cue (cs−) provided a baseline. psychophysiological responses, including fear potentiated startle (fps), skin conductance response (scr), heart rate variability (hrv), online distress ratings, and subjective assessments, were measured. results: the study's results reveal significant findings in fps, scr, hrv, and online distress ratings during various phases of fear conditioning. fps exhibited dynamic changes across habituation, conditioning, extinction, and reinstatement, with the highest response during conditioning. scr and hrv also showed significant variations during these phases, indicating physiological changes. distress ratings increased significantly during conditioning. correlation analysis highlighted positive associations between fps and distress, a non-significant trend with fear of cockroaches, and a significant negative correlation with trait anxiety. additionally, fps showed a positive, non-significant correlation with scr and hrv, suggesting potential links between physiological startle responses and autonomic modulation. conclusion: this study contributes to understanding fear conditioning in a diverse urban population, emphasizing the significance of individual differences. the incorporation of culturally relevant fear stimuli and the exploration of hrv offer a comprehensive perspective on fear learning. keywords fear conditioning, anxiety, startle reactivity, psychophysiological responses, heart rate variability. citation: saleem y, noushad s, sajid u & mukhtar a. understanding fear conditioning: psychophysiological responses, anxiety, and startle reactivity in karachi undergraduates – a pilot study. app. 2023;10(2): 68-75 corresponding author email: yusra@maliruniversity.edu.pk doi: 10.29052/2412-3188.v10.i2.2023.68-75 received 20/10/2023 accepted 24/11/2023 published 01/12/2023 copyright © the author(s). 2023. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v10.i2.2023. https://orcid.org/0000-0001-7605-1304 https://orcid.org/0000-0002-8078-4524 https://orcid.org/0000-0001-9339-857x about:blank about:blank 69 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 introduction fear conditioning offers a valuable framework for investigating fundamental aspects of fear learning and exploring individual differences in the transition from adaptive to maladaptive fear responses. during pavlovian fear conditioning, a neutral conditioned stimulus (cs+) becomes associated with an aversive unconditioned stimulus (us), leading to the elicitation of a fear response1. in a differential fear conditioning paradigm, a second cue (cs−) is introduced, explicitly unpaired with the us. patients and highly anxious individuals often exhibit reduced discrimination between the reinforced threat stimulus and the safety cue, indicating deficient safety learning. while cued fear conditioning effectively models fear learning towards predictive cues, it may not fully capture the anticipatory vigilance characteristic of anxiety2,3. context-specific adjustments in the conditioning environment, such as elevated baseline startle responses before aversive conditioning, have been observed. this phenomenon, particularly prominent in individuals with anxiety disorders, underscores the importance of considering broader contextual factors in fear response modulation. patients and highly anxious individuals frequently exhibit reduced discrimination between reinforced threat stimuli (cs+) and safety cues (cs−), indicating deficient safety learning4. this deficit contributes to the persistence of maladaptive fear responses and underscores the need to explore not only fear acquisition but also the mechanisms underlying discrimination and safety signal processing. exploring individual variations in negative emotionality, particularly in the context of fear conditioning research, shows potential for gaining crucial insights into the mechanisms influencing individual susceptibility and resilience in the development of anxiety and stress-related disorders5. a recent review highlighted three scales connected to the broader concept of negative emotionality that consistently correlate with individual differences in fear conditioning performance and predisposition to pathological fear and anxiety6. these scales include the trait anxiety scale of spielberger's state-trait anxiety inventory (stai-t)7, the big five neuroticism scale of the neo five-factor inventory (neo-ffi-n)8, and the intolerance of uncertainty scale (ius)9. investigating individual differences in physiological measures during fear conditioning holds promise as a means to identify markers for maladaptive fear learning. beyond traditional questionnairebased trait measures, exploring heart rate (hr) derivatives, such as hrv, presents an intriguing avenue. hrv reflects the dynamic interplay between sympathetic and parasympathetic activity, offering insights into autonomic nervous system regulation and its role in shaping fear responses10. the utilization of hrv as a metric goes beyond mere quantification, providing a dynamic index of autonomic flexibility. understanding how hrv relates to fear conditioning can offer valuable information about individual differences in adaptive and maladaptive fear learning. this, in turn, may pave the way for identifying individuals predisposed to anxiety-related conditions. existing literature supports the integration of hrv in fear conditioning studies, emphasizing its role in elucidating individual differences. studies exploring the link between hrv, anxiety, and fear learning contribute to a comprehensive 70 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 understanding of the psychophysiological mechanisms involved. methodology study design the experimental study aimed to investigate fear memory and responses to conditioned stimuli among undergraduate students in karachi, pakistan, employing a comprehensive three-day protocol encompassing habituation, conditioning, specific interventions, extinction training, and a reinstatement test. setting the study was conducted at various educational institutes situated in karachi, pakistan, reflecting the diverse cultural milieu of the city. participants forty-six healthy undergraduate students, evenly distributed across genders, participated in the study. participants were screened for good hearing and absence of relevant psychological and physical disorders and provided informed consent. variables the study's independent variables included conditioned stimuli (cs+ and cs−) and specific interventions implemented during the second day of the protocol. dependent variables encompassed fear-potentiated startle (fps) responses, electrodermal activity, distress ratings, heart rate variability, fear of cockroaches questionnaire (fcq) scores, and trait anxiety levels measured via a locally adapted version of the state-trait anxiety inventory (stai-t). data sources/measurement psychophysiological responses were measured using electromyography (emg) of the orbicularis oculi muscle for fps and electrodermal activity. distress ratings were collected using an 11-point scale during image presentations. anxiety and fear were assessed through the state-trait anxiety inventory (stai-t) and fear of cockroaches questionnaire (fcq), respectively. heart rate variability (hrv) was recorded using a transmitter belt during exposure to culturally relevant video clips. bias to minimize bias, counterbalancing of conditioned stimuli assignment and employing culturally relevant assessment tools were used. ethical considerations were paramount, with participants provided the option to withdraw from the study at any point. study size the sample size comprised forty-six participants, ensuring adequate statistical power to detect significant effects in the psychophysiological responses across different phases of the study. quantitative variables quantitative variables included age, fearpotentiated startle responses, electrodermal activity, distress ratings, fcq scores, and stai-t scores. experimental procedure the utilization of cockroach images as conditioned stimuli in this study is rooted in considerations of cultural relevance and emotional impact. cockroaches, being a prevalent fear in karachi, are culturally significant and likely to evoke strong emotional responses. this choice is aligned with principles from evolutionary psychology, recognizing the potential evolutionary significance of fear responses to stimuli associated with unhygienic conditions. within the experimental setup, one image (cs+) was consistently paired with a mild shock in 75% of the trials, while another image served as a neutral control 71 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 (cs−). the assignment of images as cs+ or cs− was counterbalanced across participants, and each conditioned stimulus was presented eight times for 8 seconds per presentation. the intertrial intervals (iti) ranged between 15 and 25 seconds, averaging 20 seconds. the standardized use of cockroach images enables precise experimental control over stimuli associated with mild shock (cs+) and neutral control (cs−), facilitating the establishment of conditioned fear responses. crucially, this method is ethically sound, inducing fear without exposing participants to live insects. fear potentiated startle (fps) was initiated by presenting acoustic stimuli through headphones to the participants. it was measured through electromyography (emg) of the orbicularis oculi muscle. acoustic stimuli were presented binaurally through headphones. the emg signal was sampled at 1000 hz, and the peak blink amplitude was determined in a 30–150 ms interval following probe onset. electrodermal activity was measured using two ag/agcl electrodes attached to the medial phalanges of the first and third fingers of the non-preferred hand. responses to cs were calculated by subtracting the baseline from the maximum score during the 1 to 7 s window after cs onset. participants were provided distress ratings during each image presentation on an 11point scale placed at the bottom of the screen within 5 s following stimulus onset. ratings ranged from ‘not distressed at all’ (0) to ‘very distressed’10. the three-day protocol employed in this study aimed to investigate fear memory through a systematic progression of experimental phases. on the initial testing day, participants underwent habituation and conditioning sessions. during these sessions, baseline data on startle responses and other psychophysiological measures were collected. the second day of the protocol involved specific interventions aligned with the study's objectives. these interventions likely included manipulations or procedures designed to influence fear responses or memory consolidation. on the third day, participants engaged in extinction training, a phase focused on reducing or extinguishing the conditioned fear response. following the extinction phase, a reinstatement test was conducted to assess whether the fear response could be reactivated under certain conditions. statistical methods descriptive statistics were employed for baseline categorical and continuous variables. repeated measures anova analyzed psychophysiological responses across different phases, while correlation analysis examined relationships between fear-potentiated startle responses and outcome variables. ethical considerations ethical approval was obtained from the ethics review board of the malir university of science & technology. result fear-potentiated startle (fps) the repeated measures anova for fps revealed significant results, emphasizing the dynamic nature of physiological startle responses across habituation, conditioning, extinction, and reinstatement phases. the main effect of phase (f(3, 123) = 21.34, p < 0.001) indicates overall differences, while the significant main effect of condition (f(2, 82) = 19.12, p < 0.001) suggests variations between the cs+ and cs− conditions. the interaction effect (phase x condition; f(6, 246) = 4.45, p = 0.001) underscores the influence of condition on the phase-related changes and vice versa. post-hoc tests 72 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 confirmed significant differences between phases, highlighting the highest fps during the conditioning phase (p < 0.001). skin conductance response (scr) the analysis of skin conductance response (scr) revealed significant outcomes, indicating variations in electrodermal activity across experimental phases. the main effect of phase (f(3, 123) = 12.18, p < 0.001) highlights overall differences, while the main effect of condition (f(2, 82) = 10.09, p < 0.001) suggests differences between the cs+ and cs− conditions. the interaction effect (phase x condition; f(6, 246) = 2.89, p = 0.012) implies a reciprocal influence between phase and condition. post-hoc tests indicated a significant increase in scr during the conditioning phase compared to habituation (p < 0.001). heart rate variability (hrv) the analysis of heart rate variability (hrv) yielded significant findings, indicating physiological changes across baseline, video exposure, conditioning, and extinction phases. the main effect of phase (f(3, 123) = 7.26, p = 0.001) suggests overall differences, while the main effect of condition (f(2, 82) = 3.81, p = 0.027) points to variations between the cs+ and cs− conditions. the interaction effect (phase x condition; f(6, 246) = 2.11, p = 0.065) implies a reciprocal influence. posthoc tests showed a significant decrease in hrv during the conditioning phase compared to baseline (p < 0.001). online distress ratings the repeated measures anova for online distress ratings demonstrated significant outcomes, highlighting changes in reported distress across experimental phases. the main effect of phase (f(3, 123) = 15.20, p < 0.001) indicates overall differences, while the main effect of condition (f(2, 82) = 12.45, p < 0.001) suggests variations between the cs+ and cs− conditions. the interaction effect (phase x condition; f(6, 246) = 3.25, p = 0.005) implies a reciprocal influence. posthoc tests confirmed a significant increase in distress ratings during the conditioning phase compared to habituation (p < 0.001). correlation analysis the correlation analysis revealed that fps responses were positively correlated with distress ratings, indicating a heightened physiological startle response was associated with increased reported distress during image presentations. while there was a positive correlation between fps and fcq scores, it did not reach statistical significance, suggesting a potentially weaker link between the physiological response and fear of cockroaches. notably, a significant negative correlation was found between fps and stai-t scores, implying that an elevated physiological startle response was associated with lower levels of trait anxiety. additionally, fps showed a positive, nonsignificant correlation with skin conductance response (scr). a positive correlation trend was observed between fps and hrv, although it did not reach statistical significance. this speculative insight hints at potential associations between physiological startle responses and autonomic nervous system modulation (table 1). table 1: relationships between fps and outcome variables. variables correlation (r) p-value distress ratings 0.45 <0.01* fear of cockroaches (fcq) 0.15 0.25 trait anxiety (stai-t) -0.30 <0.05* skin conductance response (scr) 0.20 0.15 73 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 heart rate variability (hrv) 0.25 0.08 *p<0.05 is considered statically significant. discussion the current study delves into the intricate interplay between physiological responses and psychological experiences in the context of fear conditioning, providing valuable insights into the dynamic relationship between these dimensions. our findings, particularly in fear potentiated startle (fps), reveal significant differences across habituation, conditioning, extinction, and reinstatement phases. the heightened physiological startle response during the conditioning phase is crucial, emphasizing the acquisition of fear—a fundamental aspect of fear conditioning. cued fear conditioning, as modeled in our study, effectively represents how individuals learn to associate a threat cue with imminent danger. it's essential to note, however, that this paradigm might not fully capture the hypervigilance characteristic of anxiety. anxiety, being future-oriented and not strictly tied to an explicit cue, may be better explored through learned adjustments to the conditioning environment. for instance, prior research has demonstrated that startle response magnitudes significantly increase during the baseline period before an aversive conditioning experiment involving electrical stimulation, compared to situations without aversive stimuli11. importantly, this context-specific elevation of baseline startle responding, occurring before aversive conditioning, is more pronounced in individuals with anxiety disorders12-14. this suggests that examining startle responses in a broader contextual framework may offer a more comprehensive understanding of anxiety-related processes. the analysis of skin conductance response (scr) has unveiled significant fluctuations in electrodermal activity across various experimental phases. the observed increase in scr during the conditioning phase aligns with expected patterns indicative of heightened arousal during the acquisition of fear. it's noteworthy that scr conditioning has been demonstrated to occur independently of the valence of the unconditioned stimulus (us), such as unpleasant electrical stimulation or a reaction time15,16. this physiological marker adds another dimension to the intricate profile of fear responses, emphasizing the complex interplay between psychological and physiological elements. the conditioning of scr, regardless of the specific nature of the aversive stimulus, underscores the robust nature of electrodermal activity changes during fear learning. this highlights the versatility of scr as a reliable measure capturing various aspects of the fear conditioning process. the observed alterations in heart rate variability (hrv) provide additional insights into the modulation of the autonomic nervous system during fear conditioning. the decrease in hrv during the conditioning phase aligns with anticipated autonomic changes associated with the acquisition of fear. this physiological marker adds depth to our understanding of fear responses, highlighting the intricate interplay between psychological and physiological dimensions. however, previous research on the relationship between resting hrv and contextual anxiety has yielded inconclusive findings. one study reported an inverse relationship between baseline startle responding and resting hrv17, while another found no such association18. notably, the former study involved only women, whereas the latter included both men and women without exploring sex 74 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 differences18. although it is established that women generally exhibit higher resting hrv19-21, the impact of gender on the modulation of emotional learning through hrv remains relatively unexplored. this study will include exploratory analyses to investigate the interaction between gender and resting hrv in the modulation of fear learning, shedding light on potential sex differences in this context. the correlation analysis revealed meaningful associations between fear potentiated startle (fps) responses and distress ratings, underscoring the intimate connection between physiological startle responses and subjective distress. while a positive correlation trended between fps and fear of cockroaches (fcq) scores, the absence of statistical significance suggests a nuanced relationship in the context of specific fear stimuli. an intriguing finding emerged with a significant negative correlation between fps and trait anxiety (stai-t) scores, suggesting that individuals with lower trait anxiety exhibited heightened physiological startle responses, introducing complexity to the understanding of trait anxiety's role in fear conditioning. furthermore, fps exhibited a positive, non-significant correlation with skin conductance response (scr), hinting at potential interconnectedness between startle responses and electrodermal activity. the incorporation of heart rate variability (hrv) values provided speculative insights into potential correlations with distress ratings, fear of cockroaches, and trait anxiety, emphasizing the necessity for future research to unravel the intricate interplay between hrv and psychological variables. in interpreting the results, it's crucial to acknowledge the correlational design's limitations, cautioning against inferring causation from identified associations. the cross-sectional nature of the study provides valuable insights into connections between physiological responses and psychological variables. still, the need for future research employing longitudinal or experimental designs is emphasized for a more profound understanding of the intricate interplay between physiological and psychological aspects of fear conditioning. conclusion this study contributes to understanding fear conditioning in a diverse urban population, emphasizing the significance of individual differences. the incorporation of culturally relevant fear stimuli and the exploration of hrv offer a comprehensive perspective on fear learning. acknowledgment we express our gratitude to ms. amna mukhtar for 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finns study. auton neurosci. 2009;145(1-2):81–88. 21. snieder h, van doornen lj, boomsma di, thayer jf. sex differences and heritability of two indices of heart rate dynamics: a twin study. twin res hum genet. 2007;10(2):364– 372. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v10.i2.2023.67-74 25 annals of applied psychophysiology december 2024 volume 11 ______________________________________________________________________________ establishment of the relationship between continued practice of hatha yoga and goal attainment amé foster1, published online: december 2024 © the author(s) 2 abstract background: this original dissertation research explored the understanding as to why novice yoga students terminate participation. this research is important due to the fact that there is limited information and data available within this specific subject matter of yoga practice. methodology: the relationship between continued yoga practice and goal attainment was examined through goal achievement, in addition to psychological inventories and assessments. the research was conducted among eighteen novice yoga participants both male and female. results: the main results of the research study quantified the influences of the hatha yoga intervention calculated through pre-post change scores in the psychological assessments. the outcomes revealed a strong inverse relationship between negative affect and relaxation state; and a moderate inverse relationship between positive affect and relaxation state for the non-drop-out subjects, which included six individuals. furthermore, the subject goal information established that the type of goals varied between the drop-out and non-drop-out participants. conclusion: the results of this research denote that individuals who develop goals more focused on mood enhancement and relaxation improvement as well as establishing a sense of community tend to continue yoga practice and attend classes in comparison to subjects with goals focused specifically related to only addressing health concerns. keywords: yoga, goal attainment, relaxation, mood and affect, drop-out 1. amé foster afoster1@saybrook.edu saybrook university, pasadena, ca usa introduction previous research conducted on hatha yoga demonstrates that it is indeed a successful psychophysiological intervention. however, the limited amount of data observing the reasoning behind yoga practice cessation is significantly lacking. this research assessed the relationship between continued yoga practice and goal attainment examined through goal achievement, in addition to examinations of psychological inventories and assessments. this was completed with measurements before and after the intervention period. the assessments included goal attainment scaling, the positive and negative affect scale, the profile of mood states questionnaire, and the rmm (e) inventory. the objective was to expand the knowledge currently understood between the relationship of yoga attendance and goal achievement as well as psychological and physical changes within the subjects. methodology research method the information was acquired through a pre-post design model. the subjects included yoga students from two yoga studios in the state of kansas. the participant inclusion conditions consisted of the following: (a) subject candidates are at least 18 years of age, (b) subject candidates are available to participate in an approximately 1-hour yoga session one to two times a week for two months, and (c) subject candidates are beginners at the practice of yoga. the exclusion conditions contained the following: (a) subject candidates do experience symptoms of a mental health disorder and are not currently seeking treatment by a professional, (b) subject candidates are not 18 years or older, (c) subject candidates are not available to participate in an approximately 1-hour yoga session one to two times a week for two months, (d) subject candidates have previously practiced yoga, and (e) subject candidates attend a different type of yoga class other than hatha yoga during participation in the study. involvement in this study was for a period of two months for a minimum of eight yoga classes. the total subject number was eighteen. measures each participant provided information for the pre-participation survey. correspondingly, a goal attainment scale, the positive and negative affect scale, the profile of mood states questionnaire, and the rmm-e tracker inventory were all completed before and after the two-month intervention period. finally, the attendance of each participant was recorded. this research utilized a quantitative method data analysis approach. the quantitative data analyses included descriptive statistics, the wilcoxon signed rank test, and linear regression and correlation analysis of the psychometric measurements. the significance levels within each appropriate analysis were measured utilizing the value of equal or less than (p ≤0.05) with a 95% confidence level. subject information subjects included males and females all over the age of eighteen years. each participant was categorized as a beginning level yoga student with no prior yoga practice experience. subjects were gathered from two yoga studios in a rural kansas area. supplementary subject details included medications and treatments. specifically mental health therapy for three individuals and an ssri medication for one subject. results the examination of the psychological elements was achieved through the analysis of pre and post change scores. these analyses were completed applying a linear regression and correlation analysis with a p-value (<0.05) among the data from non-dropout participants. the results revealed a moderate inverse relationship between positive affect and state relaxation, and a strong inverse relationship between negative affect and the state of relaxation. table 1: positive affect descriptive statistics positive affect group n mean sd se median minimum maximum total participants (pre) 10 37.2 9.508 3.007 40 22 49 total participants (post) 10 36 9.201 2.91 38 18 46 non-dropout (pre) 6 42.83 4.355 1.778 43 38 49 non-dropout (post) 6 38 8.602 3.512 38.5 22 46 table 2: negative affect descriptive statistics negative affect group n mean sd se median minimum maximum total participants (pre) 10 12.6 4.169 1.318 11 8 21 total participants (post) 10 13.8 5.287 1.672 11.5 9 24 non-dropout (pre) 6 13.17 4.355 1.778 12.5 9 21 non-dropout (post) 6 12.17 4.446 1.815 10.5 9 21 table 3: relaxation mediation mindfulness inventory descriptive statistics rmm group n mean sd se median minimum maximum total participants (pre) 10 2.98 0.5029 0.159 2.7 2.6 3.8 total participants (post) 10 3.26 0.6603 0.2088 3.4 1.8 4 non-dropout (pre) 6 3.167 0.5175 0.2333 3.1 2.6 3.8 non-dropout (post) 6 3.467 0.4131 0.1687 3.4 2.8 4 table 4: profile of mood states descriptive statistics profile of mood states group n mean sd se median minimum maximum total participants (pre) 5 13 26.95 12.05 14 -27 49 total participants (post) 5 6.4 27.63 12.36 3 -26 50 non-dropout (pre) 4 4 20.704 10.35 13.5 -27 16 non-dropout (post) 4 -8.5 12.503 6.251 -5.5 -26 3 table 5 goal attainment scale results participant attainment level ______________________________________________________________________________ (non-do) pre-intervention goals improve flexibility 1 greater than expected enhance relaxation improve shoulder mobility post-intervention goals improve flexibility enhance relaxation improve shoulder mobility become more fit ______________________________________________________________________________ (non-do) pre-intervention goals community 2 expected keep of recent weight loss improve mobility post-intervention goals community keep of recent weight loss improve overall health reduce stress level ______________________________________________________________________________ (non-do) pre-intervention goals flexibility 3 not selected improve upper body strength improve core muscles improve mindfulness post-intervention goals flexibility improve upper body strength improve core muscles improve mindfulness ______________________________________________________________________________ (non-do) pre-intervention goals community 4 greater than expected improve flexibility improve mindfulness improve emotional stability post-intervention goals increase a sense of community increase physical activity improve flexibility enhance relaxation and calm ______________________________________________________________________________ (do) pre-intervention goals body appreciation 5 not selected better sleep and stress relief improve flexibility injury prevention post-intervention goals no data (do) pre-intervention goals no data 6 not selected post-intervention goals no data (do) pre-intervention goals self-improvement and self-care 7 not selected improve range of motion success in college and clarity marathon preparation post-intervention goals no data (do) pre-intervention goals attend yoga twice per week 8 not selected move body everyday book 5 photo shoots become a yoga instructor post-intervention goals no data (non-do) pre-intervention goals more active 9 greater than expected enhance relaxation and peace improve muscle tone become a yoga instructor post-intervention goals self-awareness muscle tone (non-do) pre-intervention goals more active 10 greater than expected improve breathing improve motivation post-intervention goals more active improve breathing improve motivation (do) pre-intervention goals stay in movement 11 not selected improve flexibility post-intervention goals no data (do) pre-intervention goals improve breathing 12 not selected improve flexibility post-intervention goals no data (do) pre-intervention goals relaxation 13 not selected muscle tone weight loss post-intervention goals relaxation muscle tone weight loss ______________________________________________________________________________ (do) pre-intervention goals relaxation 14 not selected improve teaching lessons relax muscles post-intervention goals relaxation improve teaching lessons relax muscles ______________________________________________________________________________ (do) pre-intervention goals enhance mood 15 not selected improve flexibility increase core strength relaxation and focus on breathing post-intervention goals enhance mood improve flexibility increase core strength relaxation and focus on breathing ______________________________________________________________________________ (do) pre-intervention goals improve balance 16 not selected improve flexibility stay calm and balanced relaxation and positive mood post-intervention goals delay aging maintain health and flexibility increase mental health and focus relaxation and positive mood (do) pre-intervention goals improve balance 17 not selected improve flexibility stay calm and balanced post-intervention goals no data (do) pre-intervention goals improve balance 18 not selected improve flexibility more strength decrease stress and improve breathing post-intervention goals no data note. participants determined and recorded individual goals for attending and practicing yoga on a goal attainment scale. additionally, the goal attainment level was reported in the post-intervention gas results. the results which state not selected or no data for the attainment level and goal content are due to incomplete outcomes reported by the subjects who dropped out. the dropout status is indicated in parentheses above the participant number. non-do represents non-dropout and do represents dropout. the attainment levels are measured to determine if the participant has met their individualized goals and expectations for the yoga practice. figure 1 positive affect and relaxation state pre-post change scores correlation note. the data as gathered from the pre-post change scores of the positive affect (pa) and the relaxation meditation and mindfulness (rmm) inventory results of non-dropout participants to calculate a linear regression and correlation analysis. this analysis examined the relationship between the two variables with the aim to establish the connection among the fluctuations within the psychological measurement outcomes. specifically, for the subjects that maintained extended yoga class attendance. r2 = .27, f(1,4) = 1.47, p = .292. β = -.04, p = .292. r-squared (r2) equals 0.2684. meaning that 26.8% of the variability of relaxation is explained by positive affect. correlation (r) equals -0.5181. denoting that there is a moderate inverse relationship between positive affect and relaxation. this is considered a paradoxical finding. figure 2 negative affect and relaxation state pre-post change scores correlation note. the data as gathered from the pre-post change scores of the negative affect (na) and the relaxation meditation and mindfulness (rmm) inventory results of non-dropout participants to calculate a linear regression and correlation analysis. this analysis examined the relationship between the two variables with the aim to establish the connection among the fluctuations within the psychological measurement outcomes. specifically, for the subjects that maintained extended yoga class attendance. r2 = .41, f(1,4) = 2.81, p = .169. β = .18, p = .169. r-squared (r2) equals 0.4129. this means that 41.3% of the variability of increased relaxation is explained by negative affect reduction. correlation (r) equals 0.6426, denoting that there is a strong inverse relationship between negative affect and relaxation. figure 3 positive affect and poms pre-post change scores correlation note. the data as gathered from the pre-post change scores of the positive affect (pa) and the profile of mood states (poms) results of non-dropout participants to calculate a linear regression and correlation analysis. this analysis examined the relationship between the two variables with the aim to establish the connection among the fluctuations within the psychological measurement outcomes. specifically, for the subjects that maintained extended yoga class attendance. r2 = .0045, f(1,2) = 0.009, p = .933. β = .068, p = .933. r-squared (r2) equals 0.004495. this means that 0.4% of the variability of poms is explained by positive affect. correlation (r) equals 0.06705, denoting that there is a very weak direct relationship between positive affect and poms. this is considered a paradoxical finding. figure 4 negative affect and poms pre-post change scores correlation note. the data as gathered from the pre-post change scores of the negative affect (na) and the profile of mood states (poms) results of non-dropout participants to calculate a linear regression and correlation analysis. this analysis examined the relationship between the two variables with the aim to establish the connection among the fluctuations within the psychological measurement outcomes. specifically, for the subjects that maintained extended yoga class attendance. r2 = .16, f(1,2) = 0.37, p = .603. β = 2.9, p = .603. r-squared (r2) equals 0.1576. this means that 15.8% of the variability of poms is explained by negative affect. correlation (r) equals 0.397, denoting that there is a weak direct relationship between negative affect and poms. figure 5 relaxation state and poms pre-post change scores correlation rmm note. the data as gathered from the pre-post change scores of the relaxation meditation and mindfulness (rmm) inventory and the profile of mood states (poms) results of non-dropout participants to calculate a linear regression and correlation analysis. this analysis examined the relationship between the two variables with the aim to establish the connection among the fluctuations within the psychological measurement outcomes. specifically, for the subjects that maintained extended yoga class attendance. r2 = .0011, f(1,2) = 0.0021, p = .967. β = .81, p = .967. r-squared (r2) equals 0.001068, meaning that 0.1% of the variability of poms is explained by rmm. correlation (r) equals 0.03268, and denoting that there is a very weak direct relationship between the rmm and poms. discussion ancillary data was obtained regarding attendance and dropout rates. this information includes the narratives of four out of the eighteen subjects in the study that dropped out. these subjects replied to the investigator during the post-research data collection. each subject claimed that attendance cessation occurred due to non-availability. the total dropout percentage was 66.6%. there was an important correlation between attendance and the goal content among the subjects who maintained attendance. the goal attainment scaling content results demonstrate that the goal content is significant and presents a connection between the participants who completed the intervention period and continued to practice yoga in contrast to those participants who did not. the goals of the non-drop-out subjects who maintained yoga class attendance incorporated goals focused on improved relaxation and mood as well as decreased levels of stress, and the importance of community. moreover, these subjects completed the goal attainment scaling level detailing that the goals were achieved. furthermore, each subject who maintained attendance in the yoga classes demonstrated an increase of relaxation state and a reduction in the total mood disturbance score as well as decrease of negative affect. nevertheless, the paradoxical findings between the particular change scores are notable due to the opposite nature of the expected outcomes. limitations the main limitation of this research includes the small number of subjects. this was most likely due to a limited sample population in a rural area. the second critical limitation was the high drop-out rate. finally, incomplete data is available outside of the utilized assessments concerning the individual subject experience of the yoga practice. conclusion the outcomes of this research provide more detailed information behind the reasoning for yoga practice cessation. existing research provides only minimal explanations regarding this topic and includes results from yoga attendance within medical group research studies and group therapy treatments. the data gathered from these subjects offers evidence to support the preceding research for group therapy treatments, in conjunction with contributing more understanding within the general population of yoga practitioners. particularly, concerning the influences of attendance and dropout. the practical purposes of this information might help yoga studios more productively focus on the needs of the students attending; and thus, improve retention rates. additionally, when the necessities of the yoga students are more fully met, the psychological components examined within this research may be improved. acknowledgment the author 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(1996). a study of group therapy dropouts. arch gen psychiatry 14(4), 393-414. image4.png image5.png image1.png image2.png image3.png 1 annals of applied psychophysiology december 2025 volume 13 ______________________________________________________________________________ editorial richard a. sherman, ph.d. editor our founding editor, sadaf ahmed, just received yet another prestigious award and it is time to revive pamphlets as an intermediate between brief review papers and full-length books as a means of getting targeted information to professionals the award: i am proud to bring your attention to the founding editor of our journal (and current managing editor) having received yet another prestigious award. dr. sadaf ahmed received the society for neuroscience’s science educator award for 2025, which was presented at their annual meeting. the award is supported by the allen institute. among her other honors and awards, sadaf was recently recognized as one of the four top women in the neurosciences from under-resourced areas. she continues to mentor students from many fields, which has resulted in their producing outstanding research. for example, this issue of annals contains an article by dr. sara rafique, which reviews the material leading to her study on the relationship between stress and periodontal problems. it is time to revive pamphlets as a means of getting targeted information to professionals: the way professionals gain knowledge of relatively narrow, targeted material is changing rapidly. there seems to be less interest in purchasing entire books when the books cover far more material than a particular topic of interest. journals used to publish lengthy supplements to issues to meet the needs when there was too much material for a review article, but a full-length book was not warranted. that practice also appears to be seen less often. websites providing a plethora of material have proliferated but there is frequently no way to assess the credibility of the sites and their claims. it is time for journals to step into the breach to provide peer-reviewed pamphlets covering narrow, targeted topics of interest to professionals who do not want to read an entire book on a broader topic or spend time gathering sufficient review articles to provide the crucial information. the annals of psychophysiology and the behavioral medicine research and training foundation (which sponsors this journal) will begin publishing a series of pamphlets intended to meet this need starting with one on magnetic therapies for pain and brain-based disorders then continuing with pamphlets covering various aspects of biofeedback including neurofeedback and muscle tension biofeedback. 91 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v10.i2.2023.91-110 mini review red flags warning for providers about risks in applying psychophysiologically based interventions richard a. sherman, cynthia r. kerson, eric k. willmarth, phoebe l. manalang-monnier & jerry r. devore saybrook university, california-united states. abstract many behaviorally oriented practitioners applying psychophysiologically based interventions to symptoms such as headaches, early dementia, dysfunctional breathing, low back pain, anxiety, noncardiac chest pain, and irritable bowel syndromes may lack the training to recognize very serious underlying medical etiology, resulting in potentially life-threatening symptoms. thus, some psychophysiologically based interventions should be deferred until an appropriately trained medical specialist clears clients. practitioners may lack an appreciation of the limitations and challenges of certain psychophysiologically based interventions, such as hypnosis, neurofeedback, respiratory training, and biofeedback, for a variety of symptoms, including cluster headaches, temporomandibular joint (tmj) disorder, psychosis, and neurodegenerative disorders. this paper identifies red flag warnings associated with specific symptoms and the psychophysiologically oriented interventions employed to treat them. keywords screening, biofeedback, neurofeedback, psychophysiology, hypnosis citation: sherman ra, kerson cr, willmarth ek, manalang-monnier pl, devorce jr. red flags warning for providers about risks in applying psychophysiologically based interventions. app. 2023;10(2):91-110 corresponding author email: drrichsherman@gmail.com doi: 10.29052/2412-3188.v10.i2.2023.91-110 received 20/10/2023 accepted 20/11/2023 published 01/12/2023 copyright © the author(s). 2023. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the recording devices and computer were purchased by the behavioral medicine research and training foundation (port angeles, washington, usa) and then loaned to the investigators to use in the study. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v10.i2.2023. about:blank about:blank 92 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 introduction some behaviorally oriented practitioners lack the training to recognize very serious underlying medical conditions that are not amenable to psychophysiological interventions and may be life-threatening. they may also not be aware of when specific psychophysiological interventions should not be applied to clients presenting with a variety of symptoms. this paper summarizes some of the red flags practitioners should be aware of (a) before providing psychophysiologically oriented interventions for a variety of conditions such as headache, anxiety, dementia, and depression, and (b) providing specific behaviorallyoriented interventions such as hypnosis, neurofeedback, and biofeedback for a variety of symptoms. the key is for practitioners to know when to get assistance in assessing symptoms and when psychophysiologically based interventions are not appropriate. some disorders are amenable to psychophysiological but not psychotherapeutic interventions, such as phantom limb pain, incontinence, and reflex sympathetic dystrophy1. there are also disorders that usually have a physical etiology and may include psychological components that could be helped by psychotherapeutic interventions (e.g., male impotence). developing a treatment plan that addresses the patient's symptoms and the causes of those symptoms requires a thorough assessment. a vital part of the assessment includes identifying problems that may not be responsive to psychophysiologically based interventions especially those problems that require medical attention that is not currently being provided. practitioners must keep in mind that their scope of practice may limit them to assessing and treating only certain disorders using specific techniques. commonly applied techniques such as electrical stimulation may be outside the scope of practice for many behavioral practitioners. in general, unlicensed practitioners can assess and treat stress or assess and assist optimal functioning among essentially healthy people such as athletes desiring to improve their performance. only trained medical professionals who are licensed to do so can diagnose symptoms that could have severe consequences if not medically managed. this paper reviews experiential and behavioral symptom presentations that may be secondary to serious medical conditions. it addresses what a behavioral health provider should assess to determine whether a referral for conventional medical or psychological evaluation and care is needed. an appropriate assessment of clients considering psychophysiologically based services involves obtaining information from interviews and a careful review of their current status and history— including medications, psychophysiological measurements, and psychometric measurements—before deciding to provide a psychophysiologically based intervention for a patient. headache problems, for instance, are often referred to practitioners who employ biofeedback as their main interventional modality. however, no behavioral modality will cure a brain tumor presenting with symptoms similar to those of common headaches. this is why properly trained medical professionals must assess symptoms such as headaches before practitioners without such credentials attempt to treat what may appear to be common problems. this can be true if a medical professional who is assessing outside the realm of their expertise refers the client. in other words, do not assume all 93 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 appropriate medical evaluations have been performed when the referral is from a medical professional without training and expertise in the symptom area. three key points paraphrased from psychophysiological assessment and intervention for chronic pain1: 1. many disorders are a collection of comorbid symptoms that do not have welldefined explanations or etiologies. some examples are migraine headaches, adhd, and phantom limb pain. several very independent underlying problems can result in the same collection of symptoms defining these disorders. the same cluster of symptoms can derive from psychological or medical mechanisms or some combination of both. for example, as recently as 20 years ago, reflex sympathetic dystrophy (rsd), now-called complex regional pain syndrome (crps), male impotence, and phantom limb pain were considered to be primarily psychologically based. some behavioral therapists are still treating these disorders as if they are primarily caused by behavioral problems2. there are literally hundreds of articles by behavioral therapists, including psychiatrists and psychologists, attesting to the psychological causes of many of these problems. for example, numerous authors characterized phantom pain as being a manifestation of some mental or emotional problem such as unresolved grief3, depression4, a psychosomatic manifestation of an unstable personality2,5,6, and psychopathological misinterpretation of ordinary phantom sensations7. crps was considered to be caused by adolescent attachment problems to the mother primarily in young girls8. male impotence was related to all manner of psychological problems9. of course, for some, it is. however, empirical research has demonstrated that these problems are not usually primarily psychologically based. 2. physical and behavioral symptoms are often subjective and can be magnified by stress and other psychological problems. 3. behavioural interventions can help and even resolve physically based problems such as migraine and tension headaches. symptoms and conditions requiring review by appropriately trained and licensed clinicians like early dementia/memory, problems/cognitive, and processing problems. cognitive problems initially present as neuropsychological issues—such as problems with cognition and adaptive functioning. medications and medical conditions can produce or exacerbate these symptoms. behavioral practitioners should not treat clients with memory problems unless thyroid and medication levels have been checked and acknowledged by a medical practitioner. hypothyroidism this is an important consideration for the behavioral therapist. hypothyroidism is clearly a common cause (not a correlate) of early dementia. this is not open to question any longer because far too many studies have demonstrated the relationship10. hypothyroidism (low levels of thyroid hormone) and thyrotoxicosis (very high levels of thyroid hormone) can cause dementia. these thyroid issues are common in people diagnosed with early dementia, and they duplicate every symptom of both earlyand late-onset dementia. a thyroid panel ordered by a medical professional can determine this, and proper adjustment of thyroid hormone levels may eliminate the problem if given in a timely manner. sleep apnea sleep apnea is associated with symptoms of widespread cognitive decline. screening questions—including whether the patient 94 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 snores a lot, whether sleep is restorative, and whether the patient falls asleep frequently during the day—especially if this pattern is not associated with recent stressors—should trigger a medical referral to evaluate for sleep apnea11. medication medication can have cognitively impairing consequences, especially when given to geriatric populations. for instance, benzodiazepines to assist with anxiety and insomnia management significantly contribute to cognitive impairment and fall risks12, 13. many sleep medications can have similar adverse effects14. behavioral practitioners should not treat clients with memory problems unless thyroid and medication levels have been checked and acknowledged by a medical practitioner. headaches if the headache symptoms are unremitting and constant in intensity, or if the basic character of the headache changed within the last 3 months, an immediate neurology consult is recommended, as these can be indications of severe problems, such as aneurysms and tumors. in this case, ask whether the pain is worse in the morning and gets better during the day. such a pattern may reflect increased intracranial pressure (due to tumors, etc.). ask if the pain gets worse when lifting or other exertions, including sexual intercourse. this pattern may reflect a leaking cerebral aneurysm, for example. a headache in people over 50 years of age that includes throbbing temples is frequently temporal arteritis rather than a migraine. this condition can lead to blindness and strokes if not treated promptly1, 15-17. refer patients for medical evaluation (preferably to a neurologist) if there is/are: 1. history of treatment for cancer and a change in or onset of headaches. 2. any recent-onset sensory or motor deficits (e.g., weakness or numbness in an extremity or slurred speech) that have not been previously medically evaluated. 3. headaches that begin after a trauma to the head or neck. cervical compression can cause headaches for years and is frequently overlooked in neurological examinations. 4. a unilateral headache. 5. recent onset of a throbbing headache centered on the temples that do not abate but may vary in intensity, especially among people over 50 years of age. 6. report of a noticeable change in personality, behavior, memory, or another revealing symptom. 7. vomiting accompanying a tension-type headache. refer patients to a dentist specializing in tmj disorder if there is a history of jaw issues such as clicking or misalignment. many medications cause headaches, especially as they wear off. discontinuing them (including some headache medications), especially without medically monitored tapering, may cause headaches. if your patient starts getting headaches or notices a change in headache activity a few days to a few weeks after starting a new medication or after stopping a medication used for some time, a medical professional, preferably the prescriber, to determine if the medication is the cause of the headaches, should check the patient. following is a list of some medications that are commonly associated with a high incidence of headache17: • adalat/nifedipine (23%) • indocin (11%) • clinoril (3–9%) 95 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 • isordil (25%) • halcion (10%) • lopressor (10%) • mexitil (6%) • minipress (8%) • sorbitrate (25%) • naprosyn (3–9%) • nitroglycerine products (25–60%) • terazol (25%) • procardia (15–23%) • tolectin (3–9%) • prozac (20%) • any nitroglycerine drugs (over 50%) • retrovir (1 0 42%) • trental (1–6%) • seldane (16%) • xanax (13%) frequent use of analgesics (e.g., aspirin, acetaminophen), barbiturates, ergotamines (i.e., cafergot, wigraine), and caffeine can cause or exacerbate headaches during use, as well as when withdrawing. low back pain patients reporting low back pain sometimes go directly from general medical practitioners to healthcare providers who may have little medical training. this means that patients occasionally are not appropriately screened for serious underlying issues. it is very important that a qualified practitioner screen for these. turk and melzack (2002) suggest the following red flags to use in identifying patients who may require further evaluation by specialists18. the nonmedical provider should document these as reasons to encourage the primary care provider to consider specialty consultation: 1. severe back pain different from previous episodes (if any) in people below 20 and above 55 years of age 2. recent violent trauma (falls, auto accidents, etc.) 3. constant, progressive pain not related to movement 4. thoracic pain 5. previous history of cancer and ovarian cysts 6. chronic use of systemic steroids 7. use of illegal drugs 8. positive for hiv 9. chronically unwell, including unexplained weight loss, etc. 10. severe restriction of lumbar flexion 11. obvious structural deformities contacting the primary care provider may be indicated if one of the following is evident: 1. widespread neurological signs 2. erythrocyte sedimentation rate above 25 3. plain x-ray showing vertebral collapse or bone destruction if any of these signs are present, or if any other finding seems to warrant concern, err on the side of caution and report to the primary care provider with a recommendation for further investigation by a specialist. if these signs are absent, practitioners should be reasonably comfortable proceeding with an evaluation. nonphysician providers would be practicing beyond their scope of practice in attempting to evaluate cat scans, mris, xrays, etc. empirical evidence concerning the teaching of self-regulation for low back pain only supports the use of biofeedback if, indeed, pain is secondary to or exacerbated by muscle tension. the psychophysiological evaluation needs to determine whether this relationship exists and if the pain is exacerbated by stress responses leading to increased muscle tension. for increased pain due to stress responses, behavioral interventions such as cognitive behavioral 96 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 therapy (cbt), which is intended to educate patients about stress responses that may increase back pain from any cause, may be appropriate. dysfunctional breathing/ respiratory problems many behaviorally oriented practitioners teach clients to modify their breathing patterns through capnometry and the use of respiration belts mounted over the chest and abdomen to help their clients perform better in sports and reduce respiration-related symptoms, including anxiety, noncardiac chest pain, and asthma. some may not realize that distorted respiratory patterns are frequently caused by underlying medical problems that are not amenable to psychophysiologically based interventions19,20. dyspnea and hyperventilation are a type of dysfunctional breathing (db) that involves a sensation of breathlessness/shortness of breath, labored breathing, or difficulty breathing. primary and secondary dysfunctional breathing is marked by abnormal breathing patterns in the absence of organic conditions such as anxiety or secondary to cardiopulmonary/neurological diseases20. behaviorally oriented providers can only teach breathing methods for dysfunctional breathing or respiratory problems secondary to non-medically caused conditions. the evaluation, therefore, should assess the matter and determine if the condition is caused by physical deconditioning of respiratory muscles, underlying psychological causes, or both21. structural causes of dysfunctional breathing. medical conditions, diseases, and underlying physical conditions of the respiratory and cardiovascular systems may cause dysfunctional or labored breathing22. improving db requires adequate breathing assessments, subjective clinical and psychophysical scales, and questionnaires to measure, predict, and/or determine the pathophysiology of the underlying disease22,23. the most common physical diagnoses of db include lower respiratory tract infection, heart, liver, or kidney failure, pneumothorax, allergic reaction, chronic obstructive pulmonary disease, and asthma24. if a patient has been diagnosed with any of these, they should be referred to their primary care provider for specially trained respiratory consultations. if a patient has not been diagnosed but exhibits one or more of the following symptoms in conjunction with db, refer them to their primary care provider for further care: • pulse rate >120 bpm • tachypnea – respiratory rate > 30 rpm • systolic blood pressure <100 mm hg • oxygen saturation < 90% • peripheral edema • wheezing • special populations: pregnancy • anatomical restriction of the nasal passages, chest, and abdominal cavity (i.e., heart, lungs, hernia, cesarean, etc.) if none of these signs are present or pertain to the patient, proceed with the evaluation. analysis of chest x-rays, lab analysis (serum electrolytes, white cell counts, assays, etc.), ct pulmonary angiographs, or lung ultrasounds performed by a nonphysician provider are outside the provider's scope of practice. refer these patients to their primary care provider for recommendations regarding analyses of diagnostic reports and exams. psychological causes of db. acute or chronic cases of db, such as hyperventilation syndrome (hvs) or idiopathic hyperventilation (ih), may be triggered by other factors that cannot be attributed to underlying diseases20 and may not always be improved with pathophysiological treatments. aside from pharmacological 97 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 interventions, nonpharmacological approaches that modify the brain’s processing of signals from the respiratory afferent nerves may be used to modify the psychological and emotional management connected with db25. jack et al. (2003) showed that idiopathic hyperventilation can become a condition caused by psychological factors26. anxiety disorders, including panic attacks, are two major psychological disorders that could cause or contribute to db. patients with sustained arterial and alveolar hypocapnia below 30 mmhg need to be referred to their primary care provider to rule out arterial hypoxemia or metabolic acidosis before beginning respiratory training sessions26. dysfunctional breathing and pain. bartz-overman et al. (2022) found that pain and db might utilize inherently linked neurological structures and networks27. for example, the role of the insular cortex as a central modulator for both pain and dyspnea has been established, and his recent research has shown that, from a patient's perspective, dyspnea and pain may share the same fundamental experiences, so when one symptom is treated, the other may improve as well. in the event that db is related to pain, refer patient to their primary care provider prior to commencing treatment. anxiety physical causes of anxiety are frequently overlooked. many diseases, some normally ingested substances (foods, drinks), and some prescribed and over-the-counter medications can cause intense, disabling anxiety. it is the provider’s job to review the patient’s medical record and patient reports to evaluate all substances the patient takes to identify any potential substances and diseases capable of causing sufficient anxiety that could account for the presenting symptoms. an error made by too many therapists is noting that a patient is taking a medication that rarely causes intense anxiety—say in only one in 10,000 patients—then ignoring that medication because the effects are rare. however, this could be that one in 10,000 patients. medical conditions and commonly ingested substances that can produce symptoms of anxiety include: • dietary: some vitamin deficiencies, too much caffeine, monosodium glutamate, magnesium • diseases: anemia, secreting tumors (pheochromocytoma, insulinoma, carcinoid), neurologic conditions including encephalopathies and some seizure disorders, and metabolic problems including cushing’s disease, hypoglycemia, and porphyria in practice, nonmedical providers can use a checklist to identify anxiety-associated disorders and substances. the provider then can decide when patients with these issues should be referred for further medical evaluation. an expensive work-up to treat a condition that might resolve with a few treatment sessions of anxiety management training is not a model that is cost-effective or that is expected of any clinician. however, if behavioral and psychophysiological interventions do not provide the expected benefits, further evaluation would be warranted. breathing disorders and anxiety deguire et al. (1996) have determined that any anxiety disorder presentation may actually hold a breathing disorder as the primary diagnosis and that once the breathing disorder is corrected, the symptoms of anxiety may be alleviated without further intervention28. thus, it is important to determine which is the primary diagnosis. 98 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 hypoglycemia hypoglycemia can be extenuated by poor breathing. a drop in blood sugar causes extreme reactions in the nervous system, including feelings of anxiety, confusion, and even panic attacks29. thus, people subject to hypoglycemia need to be monitored carefully. depression nelson and kriegsfeld (2017) noted that depression is often evoked by endocrine changes30. the symptoms of depression may include reduced mood, low self-esteem, general fatigue, feelings of guilt, sleep disturbances, anger, irritability, and reductions in sexual motivation and food consumption. many people are very depressed without any obvious reason for such deep depression. this endogenous depression used to be ascribed to such causes as a "wandering uterus." it turns out that the uterus doesn't wander much, but there are lots of changes in the body's hormonal control system that go out of whack and can cause depression. many diseases (such as diabetes) seem to cause depression by altering hormonal balances—entirely separate from people's natural reaction of becoming depressed because they are sick. it could be that some environmental event originally triggered a change in hormones, but there isn't evidence supporting this idea. both high and low levels of some hormones—such as cortisol—can cause the same depressive symptoms. according to nelson and kriegsfeld (2017): 1. thyrotropin-releasing hormone and thyroid-stimulating hormone administration can ameliorate depressive symptoms. 2. abnormalities in amounts of growth hormone and prolactin are linked to depression. 3. about half of depressed patients have elevated cortisol production. 4. estrogen deficits are associated with depression, and estrogen replacement therapy can elevate mood in depressed women30. nelson and kriegsfeld (2017) conclude that depressed patients may have experienced an alteration in the neuroendocrine mechanisms underlying the feedback control systems of the hypothalamicpituitary-adrenal axis30. the practical implication for the nonphysician provider is to consider referral for medical evaluation for depressed patients who are in the mild to moderate range and who are not responding to psychological treatment. cases in the severe range of symptoms should always have a medical evaluation with consideration of specialty consultation, as medications and other medical interventions may be necessary. noncardiac chest pain using psychophysiologically based interventions for anxiety-initiated or amplified noncardiac chest pain can be problematic even when the patient has been cleared by a general practice provider because the actual underlying factors are difficult to identify by nonspecialists. problems include: 1. people with noncardiac-related chest pain can also have or develop cardiacrelated chest pain 2. the noncardiac-related chest pain may not be due to anxiety but some other problem that is amplified by stress 3. patients sometimes leave out important information when talking with a healthcare provider, perceived to be hurried, so what looks like a simple case 99 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 of stress-related noncardiac pain can mask a cardiac-related event1. the following are some of the symptoms to consider and include in your interview. if the patient reports a new pain in the chest area or chest pain that differs in any way (sensation, location, intensity, duration) from previous episodes that were evaluated and treated appropriately, they should be referred to a specialist. if the nonphysician provider notes these symptoms, they should be included in documentation to the primary care physician to ensure that the patient consults with a qualified medical provider who can perform an appropriate evaluation in a timely manner. if the patient reports burning pain that seems to come from the central chest—especially near the sternum—that spreads to the upper back and both arms (not just the left) and is not particularly affected by exercise, there is a distinct possibility that the patient has gastroesophageal reflux disease (gerd) and/or a hiatal hernia. many people over age 50 have asymptomatic hiatal hernias. at the same time, nonphysician providers should not assume that the known presence of a hiatal hernia explains the pain. gerd is probably caused by a weakness in or other problem with the lower esophageal sphincter, which results in stomach acid leaking up into the esophagus. the most common symptom is heartburn. pulmonary embolisms and pericarditis can cause noncardiac chest pain. chest pain is nothing to be complacent about. any rational patient having chest pain will be highly anxious. they may need the therapist’s help to deal with the anxiety and, perhaps, chest pain caused by anxiety, but a specialist needs to be sure that the pain is only due to anxiety and not a missed diagnosis1. irritable bowel syndrome (ibs) it is important to ensure that the patient has ibs before initiating treatment because most other abdominal problems with similar symptoms do not respond to behavioral interventions, and a few can be lifethreatening. it is important to appreciate that (1) people with ibs can also have and or develop a similar symptom set for other reasons, (2) the obviousness of ibs’s symptoms can mask a life-threatening problem, and (3) patients sometimes omit important information when consulting with a healthcare provider. typical symptoms of irritable bowel syndrome (ibs) include pain and bloating that usually occur together but not always. constipation, diarrhea, cramps, urgency, mucus in the bowel movement, and a gassy-bloated feeling can also occur32. symptoms are amplified by stress for at least one-third of patients. a patient with some or all of these symptoms may have ibs but could also have several serious medical conditions with similar symptoms that may also be exacerbated by stress. providers with expertise in diagnosing organ-related pain are likely to rule out rectal bleeding as it is not a symptom associated with ibs. expert providers assessing for severe pain in the abdomen described it as a constant dull pain, knife-like pain, or cramping pain when accompanied by tenderness to touch in the stomach area, bloody diarrhea, vomiting, black/tarry bowel movements, temperature above 101 °f, history of previous abdominal surgery, history of diverticulosis, pregnancy or likelihood of being pregnant. the combination of any of the above-presenting concerns could indicate appendicitis, infectious diarrhea, bleeding from the bowels, perforated appendix, bleeding ulcer or diverticula, miscarriage, ectopic pregnancy, pancreatitis, or bowel blockage. 100 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 if the patient has cramps and non bloody diarrhea (and perhaps even abdominal burning) without the problematic combinations noted above, ibs may not be of concern, even if symptoms are induced or worsened by stress. a combination of symptoms can indicate chronic gastroenteritis, especially if accompanied by fever, aches, chills, nausea, or vomiting. if burning is present, an ulcer or chronic gastritis may be the culprit. if the patient is a woman, vaginal discharge accompanied by typical symptoms of ibs may indicate a chronic infection. the same symptoms as above, accompanied by occasional blood or mucus in feces, can indicate ulcerative colitis and crohn's disease33. pancreatitis can also mimic these symptoms34. changes in medications caused by behavioral interventions individuals using medications including insulin, oral hypoglycemics, thyroid replacement, antidepressants, diuretics, vasodilators, anticonvulsants, and antihypertensive medication may require gradual modification in the dosage of these medications. the prescribing healthcare provider should be informed of the patient's participation in behavioral interventions. patients maintained on antihypertensive medication, vasodilators, antidepressants, diuretics, or any other medication with a potential side effect of postural hypotension should avoid any sudden changes in posture, such as standing abruptly from a sitting position. this practice should especially be observed while practicing biofeedback/relaxation training. warnings related to specific techniques this section contains warnings about pitfalls likely to be encountered when applying psychophysiologically based interventions for specific symptoms and individuals. peripheral biofeedback not all psychophysiological recording and biofeedback sensors are safe to use with all patients. galvanic skin response (gsr/scl) systems send a small current across the skin to record the amount of sweat (essentially a conductive salt solution) on the skin, which changes in response to autonomic nervous system reactions. as current follows the easiest—rather than the shortest—path, gsr should never be used with people with broken skin as the current may penetrate breaks in the skin, across the heart, and then out again. some respiration sensors— such as belts for recording changes in chest circumference—may contain electronics that could interfere with pacemakers. be sure to read the warnings in the equipment’s manuals. it is strongly recommended that behavioral interventions not be used to treat patients with cluster headaches, trigeminal headaches, hypertension, or tmj disorder (the joint problem as opposed to tmd, the jaw area muscle problem). empirical evidence fails to support the utilization of behavioral interventions for the aforementioned conditions. note that because of a file drawer effect (i.e., negative studies are rarely published)35, 36, citations supporting this assertion are rare, and the implication is based primarily on anecdotal experience. two exceptions to the file drawer effect are sherman's 1985 study concluding that semg biofeedback does not help alleviate tmj pain and sherman et al.'s 1978 study showing that relaxation training and biofeedback do not reduce blood pressure among pregnant hypertensive women37, 38. it is noteworthy that it has taken over 45 years since sherman's initial publication in 1978 for sufficient evidence to accrue to determine that biofeedback is not effective either alone or in conjunction with relaxation training or cognitive restructuring to reduce stress labile hypertension39. both 101 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 cognitive restructuring and relaxation training can reduce stress labile hypertension, but adding any form of biofeedback does not improve outcomes. respiratory training paced breathing methods. although variations of paced breathing methods (resonance frequency training, heart rate variability (hrv) training, slowpaced breathing, etc.) have been used as a noninvasive strategy in modulating autonomic nervous system (ans) functioning, improving overall health, reducing stress, and reducing anxiety, aberrant reactions have been documented in certain populations. paced breathing methods, for instance, may trigger anxious arousal and a dynamic of defensive responses that result in an increased respiratory rate40,41. therefore, paced breathing methods should be employed only after a thorough medical history and assessment that includes the suffocation fear subscale (sfs)42, anxiety sensitive index-3 (asi-3)43, body vigilance scale (bvs)44, and the trait portion of the statetrait anxiety inventory (stai)45. high scores recorded from these questionnaires have been correlated with predicted anxiety and panic attacks, exaggerated anxious response, and increased defensive mobilization40. it is advised that individuals who score high in one or more of these inventories need additional support, such as education and the use of a pulse oximeter while training41. it is also advised that these individuals train under supervision to ensure dynamic defensive responses are not triggered prior to having them practice at home on their own. capnometry sidlecki et al. (2017) found that individuals with post-concussion syndrome (weeks to years after injury) will have abnormal etco2 readings due to alterations of cerebral physiology and deficits in the ans46. mild traumatic brain injury (mtbi) may alter cardiorespiratory processes, resulting in poor prognosis, especially for individuals with respiratory disease46. damage to the brain stem or reduced blood flow to the thalamus can cause breathing issues. a thorough history should include screening for concussions due to the varying duration of post-concussion syndrome46. capnometry training will need to be modified to account for individuals who have histories of post-concussive syndrome and complicated mtbi. neurofeedback unlike peripheral biofeedback, neurofeedback (nfb), or electroencephalography (eeg), biofeedback trains the central nervous system (the brain). while the feedback is usually obvious—a sound accompanied by visual feedback such as a bar increasing and decreasing based upon the strength of the signal, the felt experience is not as tangible as with peripheral modalities. for example, in the case of muscle tension, one can easily acknowledge (and appreciate) the reduction of tension in a muscle. in the case of breathing and hrv training, it is very apparent when the patient's breath and heart rate have slowed. this is one reason it usually takes more sessions with nfb training. the brain is the most complicated natural system known. chemical and electrical phenomena combine to create communication and connections between brain areas that then realize specific tasks— and these phenomena are what make us who we are. these functions are the target of nfb training, and one can see that they are less observable when the brain is learning from the training than when one is practicing biofeedback. 102 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 care should be taken when considering candidates for nfb training. in addition to the many cautions below, articulating what one should feel or experience while training and, ultimately, from the nfb training program itself can be challenging. for those who might become frustrated or confused, another modality, such as stimulation technology (audiovisual entrainment, transcranial direct current stimulation, etc.), may be indicated. patterns in the eeg vs. behavior. often, the eeg does not contain patterns that are considered specific to a behavioral presentation. clinicians may record an eeg for evaluation and discover biomarkers that do not match the behavioral symptoms. as well, the eeg assessment may show one finding, and different nfb software will show something else47. therefore, neurofeedback should include an assessment—ideally a 19-channel eeg recording, but minimally a 2or 4-channel sequential recording—and the healthcare provider should not rely on a decision tree based on presentation alone or assume eeg patterns will be present based solely upon behavior. another important concern with nfb, with any client, is that the changes in the eeg do not always reflect behavioral patterns. it is not uncommon for the eeg to make remarkable advances from the protocols and modalities used without any noticeable behavioral change. there may even be an increase in symptom intensity. conversely, the eeg may be stubborn, with no real sustained response to the training, and yet the client reports an alleviation or reduction of symptoms. many clients of neurofeedback take medications. depending on what medications they are taking, which can be an extremely complicated cocktail, the medications' effects can override any advances due to the neurofeedback training. for example, adderall will increase beta and decrease lower frequencies, which may be great if it is needed. generally, anxiolytics will reduce faster frequencies (if taking the appropriate dose). however, if the anxiolytic is a benzodiazepine, widespread increased amplitudes in beta frequencies are common and thought to reflect the activation of neuroinhibitory processes that are gabamediated. in fact, too high a dose of this class of medications can result in extremely elevated beta and possibly beta spindling. so, here you have two medications that have contradictory mechanisms, and now you want to add some operant conditioning to influence beta. while you may have a temporary shift in the eeg in response to the nfb, as soon as either of these medications is consumed, all positive gains will be overshadowed. it is also important to frequently query clients, preferably at every session, about changes in their medications and/or dosages. while neurofeedback generates some positive changes in the eeg, the effects of medication dosage may become amplified, which can lead to unpleasant side effects. when this happens, faith in medications can overrule confidence in the neurofeedback training, and the client—and perhaps even their prescribing clinician— may blame the neurofeedback for unpleasant experiences. watch the client carefully when on medications and, if possible, communicate with the prescriber so that any ill effects due to the effectiveness of the nfb can be considered as just that, and a reduction in dosage can be contemplated. depending on the medication and the interest the prescriber has in neurofeedback's success, this can be challenging. 103 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 while not necessarily a red flag (meaning that you can still work with patients on medications), understanding the effects of certain medications on eeg recordings is essential. the clinician should refer to drug effects on the eeg: a reference guide47 or other references to enhance confidence concerning where and how eeg patterns originate. neurofeedback for anxiety. one of the main concerns when using neurofeedback with people who present with anxiety is, well, their anxiety—notably anxiety about whether the neurofeedback is working. you might see clinical changes in the eeg, meaning that the operant conditioning is working and the brain is responding well. however, as discussed above, this may not translate to the efficacy of treating the behavioral presentation. people with anxiety syndromes, including ptsd and phobias, have little patience and fear the continuation of their anxious symptoms, which often spiral into more intense symptomology. positive reinforcement of their successes in their eeg, no matter how small, can be reassuring if presented often and consistently, and this may be what the client needs to start experiencing lower levels of anxiety. it may be a slow process and could be contraindicated if anxiety levels are severe. it is common knowledge that alpha-theta training can result in abreaction or unexpected negative emotional response48. this is especially true if this protocol is administered too soon in the healing process. as with any therapy, slow and steady provocation of underlying fears and memories is required. the client's emotional state is very important for influencing how they may respond to the uprising feelings and memories. if they are very anxious, they may lack the capacity to deal with the feelings and abreact (form a negative reaction). conversely, if the patient is in a state of lowered vigilance and arousal, the coupling of the more relaxed state and emotional experience will become a more fitting association, leading the client to be able to manage these resurfaced feelings and memories. neurofeedback for schizophrenia. schizophrenics are poor candidates for neurofeedback. they generally have extremely high levels of paranoia and are unlikely to trust the efforts of the clinician or what is happening in their brain during neurofeedback. i (cynthia kerson) once worked with a client who reported anxiety, but after eight sessions, i questioned the authenticity of his report. he came to the practice complaining that the protocol i had chosen was destroying his brain and demanded i do neurofeedback to reverse the effects. he admitted to having been diagnosed with schizophrenia, and we ceased the neurofeedback training. unfortunately, for this client, the emotional and perceptual implications of the disorder challenged his ability to trust the process and ultimately sabotaged any gains. this client might fear any change that may be taking effect, especially without their conscious knowledge, and the changes that occur with nfb are generally unconscious until the behavioral presentation is changed and observed. neurofeedback for adhd. often, parents seek nfb for their children once they are diagnosed with adhd, primarily in an effort to avoid the use of stimulant medications. in the interview phase, be sure to observe the child carefully. there are times when their motives don’t seem aligned with their parent/caregiver— or they may not fully understand that their behavior is undesirable. giving them an opportunity to articulate their perceptions can help them understand what they understand about their behavior. as well, 104 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 there are times when medication is indicated to make initial progress with nfb. if the child is severely hyperactive, suggesting sitting and attending for even 20 minutes is challenging. there are times when a low dose of a stimulant will help the child settle enough for neurofeedback to start working with the intention of titrating and ultimately eliminating medication as neurofeedback takes effect. collaboration with prescribing providers is therefore essential for the coordination of care and enhancing the likelihood that stimulant medication is discontinued if nfb is effective. in this case, try to work with the prescriber. be sure they know that the patient plans a short trial and that reducing the dose over a few months is the plan. children with adhd are also less frustrated with their symptoms than the people around them. this generates a challenge for using nfb as it may be a chore they are not interested in. secondary rewards may provide the essential incentive and motivation needed for children with adhd to participate in nfb. in practice, i (ck) provided coupons that tallied the session's points (which can be made up in any formula necessary to have success each time). essentially, the children are deceived into being successful in nfb. the family maintains the coupons and creates a program for the transfer of the points to a reward. some give the child some desired item at 1,000 points. or a penny a point. or maybe a sleepover. this is more effective and less wasteful than having inexpensive prizes in a basket for them to choose from. they're usually cheap plastic (bad for the environment), and the kids generally don't care much about them. using the coupon system raises the bar, and kids really want to get the reward that they chose. they don't realize or, sometimes, don't even care that their adhd symptoms are improving, but with that much effort towards getting points (rewards when the brain is being trained), they do care, and your nfb will be a success. neurofeedback for oppositional defiant disorder (odd). odd children will likely not tolerate nfb. it will likely be too boring, and children diagnosed with odd often engage in defiant behaviors to get what they want. parents of odd children may enable, be in denial and/or be inappropriately strict. when these children are introduced to nfb, they can be quite stubborn and—predictably— oppositional. it is not uncommon for parents to assign too much authoritative responsibility to the practitioner, requiring the practitioner to maintain a professional role with appropriate boundaries. parents may assume that you, as a professional, are skilled in managing the child's behavior. and you may well be, but not in the context of nfb training. if the child doesn't engage in secondary reward systems, such as the coupon system mentioned above, there is little hope for the odd behavior to dissipate enough to make meaningful brain shifts. an alternative strategy could be to refer or engage the parents in coaching or other therapeutic alternatives. neurofeedback for neurodegenerative diseases. parkinson’s, multiple sclerosis (ms), alzheimer’s, progressive neuropathies, and other neurodegenerative diseases are not indicated for nfb as a resolution. nfb can help lessen, though not alleviate, the symptoms of this class of diseases. some anecdotal evidence demonstrates temporary symptom relief, such as with pulsed electromagnetic field therapy, but there is no evidence that neurofeedback has completely reversed any neurodegenerative disease. 105 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 neurofeedback when there are structural issues. shunts, plates, scar tissue, skull damage, and other head or brain assaults can cause complications in reading the eeg. consequently, location and functional implications need to be carefully understood. the scalp at the site of injury may be thicker, which will attenuate any signal from below. this can be incorrectly read as a deficit in power, and the clinician may attempt to train at that site. in fact, there isn't an attenuation of power; there is only an attenuation of the signal. as well, the plastic brain may redirect and arborize neurons to skirt a structural issue. these are functional pathways, but they are not normal. if compared to a normative database, they will appear to be disregulated. however, they provide an alternate functional route and need to be valued as such. these cases should only monitored with the consent of an overseeing practitioner who is aware of the structural implications. neurofeedback and epilepsy. it is normal for brain function to occasionally go offline. these offline moments may be represented in the eeg as subtle epileptiform transients that do not constitute a diagnosis of epilepsy. however, a patient seeking nfb for seizure reduction or cessation must be carefully studied. first and foremost, only those who are licensed to treat this medical disorder can treat it using nfb. secondly, the clinician can misinterpret and even overlook an epileptic transient, failing to properly diagnose epilepsy. when unsure, proceed with caution and consult with an epileptologist. herein lies one of the main issues with brain mapping services that use artificial intelligence (ai) to complete the artifacting process. if a client seizures only periodically and there is only one small epileptic transient present, the ai system will eliminate it or average it into the parts of the eeg that are used for evaluation. needless to say, not recognizing an epileptic transient can be detrimental to the well-being of the client. additionally, more of these undetected eeg behaviors may occur during the nfb sessions if the practitioner is unaware of their morphology or simply not paying attention. neurofeedback and headaches. there are three types of headaches: tension, migraine, and cluster. the intensity, duration, and frequency of headaches are important measurements when considering treatment options. tension headaches are the most common type and are better controlled with electromyographic (emg) biofeedback since they are the result of tense shoulder, neck, scalp, and/or facial muscles. about 10–15% of headache patients have the more debilitating migraine type. these may be categorized as primary or secondary when they are triggered by neurologic disorders, infections, hormonal shifts, allergies, stress, and/or medications. thus, it is better to treat the etiology rather than the symptom (which is the headache). as is well documented49,50, migraine headaches are better treated with distal temperature training. combined-type headaches need attention to both the migraine and the tension aspects. cluster headaches should not be treated with neurofeedback. these cause severe pain to one side of the head; their etiology is not understood, and there is no evidence that neurofeedback can work to resolve these symptoms. while there are some studies that report success with neurofeedback for headaches in general51, it is best to consider the above and refer to or complement other modalities. this population may regularly cancel appointments or keep appointments in 106 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 hopes of remediation during a headache event. doing neurofeedback when a headache is present is not advised. it is compelling to think the training will alleviate the headache, but this is not substantiated and should be avoided. in addition to the many possible eeg profiles that could emerge during their headache, they could also be exhausted from a bout of headaches and the accompanying loss of sleep, so doing neurofeedback at this time may result in an exacerbation of the pain and frustration. headache medications (triptans) tend to disrupt alpha power and reduce task response efficiency, which cannot be rectified by the training, causing a cycle of shifts in the eeg that cannot be sustained. (as noted above, this is true for all medications that have lasting effects on the eeg.) mild traumatic brain injury (mtbi). mild traumatic brain injuries occur from a multitude of causes, including direct head impact from falls, having objects dropped on the head, or accidents that insult the brain from the side or neck. additionally, blast injuries—those caused by a nearby explosion—result in back-and-forth acceleration of the brain without blunt, local impact and cause diffuse global damage. thus, they result in subtle global effects on the eeg, making it difficult to target the damage. the behavioral changes—such as anxiety, anger issues, headaches, and others—may guide the training and assessment, but this is not always an accurate picture of what needs to be resolved physiologically. commonly, mtbi patients experience connectivity issues in the eeg, which can be trained, however, some disregulations may be compensatory and training can cause reversal of progress and/or more intense symptoms. a full history of the injury is very important and should include the length of time since impact and whether (and how long) the client was concussed and/or unconscious. the brain naturally heals during the first few months of recovery with slower and prolonged improvement thereafter. assessment revealing excess slow wave power should not be considered pathological. removing the power shutdown forces the brain to work rather than heal. waiting until the eeg assessment reveals a return to somewhat normal patterns—likely about 4–6 months, depending on the extent of the damage—is highly suggested. clinical hypnosis patients have been benefiting from the therapeutic use of hypnosis for hundreds of years, and yet there remains a good deal of misinformation and mistrust related to this adjunctive technique. while there are thousands of books on the topic of hypnosis, this section will review a few of the most important red flag considerations here. first, unlike the popular presentation in movies, cartoons, and television shows, hypnotic ability resides within the patient, not the clinician (i.e., hypnotist). just as a music teacher does not "do" music to a student, a practitioner using hypnotic techniques does not "do" hypnosis to anyone. rather, a skilled practitioner educates and creates a positive context to maximize an individual's skill in accessing their own hypnotic ability. secondly, learning hypnosis does not typically qualify anyone to treat a patient they were not qualified to treat before learning hypnosis, though there are some exceptions to this rule. many clinicians may not have treated individuals with chronic, acute, or procedural pain prior to learning hypnosis, though they are quite qualified 107 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 and competent to do so upon the completion of appropriate clinical hypnosis workshops and hours of individual and/or group consultation with a more experienced clinician. hypnotic techniques should increase one's effectiveness in many situations, but learning to teach the ability to alter the perception of pain, for instance, does not remove any of the considerations related to pain listed above. in fact, covering the perception of pain without prior medical evaluation can result in major problems. also, individuals vary in their level of hypnotic ability, and the success of a hypnotic intervention can vary due to multiple factors, including the context of the intervention, the skill of the practitioner, the relationship and trust level between practitioner and patient, environmental factors, patient attitudes, and prior experience with hypnosis, just to name a few. in most settings, hypnosis can be best characterized as a collaborative relationship. in the emergency room, however, the approach might be more effective when it is very directive or even authoritarian if that is what best serves the patient and their situation. there are few absolute red flags related to the use of hypnosis by a trained professional. the following, in particular, deserve special consideration. psychosis, schizophrenia, or other disorders of consciousness. hypnosis is often described as a set of skills and interventions used for effecting an altered state of consciousness. this definition, of course, assumes that there is something akin to a normal state of consciousness. still, if a patient struggles already in their efforts to hold a common reality with others, intentionally altering this reality should only be attempted by those highly experienced with this population and only then if there is clear potential for benefit to the patient. legal issues. hypnosis is often used to help trauma patients safely review past events through techniques such as age regression. however, most states within the united states do not allow testimony related to the use of hypnotically enhanced memory in court. by using this technique, you may be eliminating a client’s ability to testify on their own behalf. in contrast, federal courts often permit hypnotic testimony but only if very specific procedures are followed. as a practitioner, you are not likely to know what might come to light in a hypnotic session, so a discussion of the potential legal complications is highly encouraged as an element of informed consent. symptom removal without prior medical evaluation. as already discussed, behavioral interventions for the treatment of medical symptoms should always be preceded by medical evaluation. while even a comprehensive medical evaluation cannot guarantee anything, all reasonable steps should be taken to rule out dangerous etiologies. for example, sudden adult onset of severe headaches should never be treated with hypnosis and/or biofeedback before tumors or other neurological conditions have been ruled out. religion. unfortunately, the 300+ year history of therapeutic hypnosis comes with a good deal of baggage related to religious objections and the inaccurate portrayals of hypnosis by stage hypnosis, popular books, tv, and movies. religious objections can be particularly delicate since some patients will belong to churches or denominations with a long history of admonitions to avoid hypnosis. a popular baptist minister published a book and video referring to 108 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 hypnosis as "a portal to lucifer." in general, if a patient has a strong belief that hypnosis is wrong, bad, or evil, it is best to avoid this intervention and find an alternative treatment option that is more acceptable to the patient. for those who are on the fence about this topic, the book hypnosis, healing, and the christian by john court (1997) can be very useful52. conclusion while this is an overview of contraindications to biofeedback, hypnosis, and neurofeedback training, there are others that may exist due to individual patterns and experiences. each and every case should be considered from a personal medicine approach and assessed with multiple instruments. acknowledgment this review is dedicated to all the mental health survivors. references 1. sherman r. psychophysiological assessment and intervention for chronic pain. 3rd ed. washington, usa: behavioral medicine r&t foundation; 2024. 2. sherman r, devore m, jones c, katz j, marbach j. phantom pain. plenum press; 1997. 3. parkes cm. factors determining the persistence of phantom pain in the amputee. j psychosom res. 1973;17(2):97–108. 4. lindesay je. multiple pain complaints in amputees. j r soc med. 1985;78(6):452–455. 5. dawson l, arnold p. persistent phantom limb pain. percept mot skills. 1981;53(1):135– 138. 6. sherman ra, sherman cj. prevalence and characteristics of chronic phantom limb pain among american veterans. results of a trial survey. am j phys med. 1983;62(5):227–238 7. abt l. psychological adjustment of the amputee. in: klopsteg p, wilson p, editors. human 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1983. 46. siedlecki p, sanzo p, zerpa c, newhouse i. end-tidal carbon dioxide levels in patients with post-concussion syndrome during neurocognitive and physical tasks compared to a normative control group. brain inj. 2018;32(13-14):1824–1833. 47. kerson c, debeus r, lightstone h, arnold le, barterian j, pan x, et al. eeg theta/beta ratio calculations differ between various eeg neurofeedback and assessment software packages: clinical interpretation. clin eeg neurosci. 2020;51(2):114–120. 48. martins-mourao a, kerson c. (2017). alphatheta neurofeedback in the 21st century: a handbook for clinicians and researchers (expanded second edition). foundation for neurofeedback and neuromodulation research. 49. ailani j, burch rc, robbins ms; board of directors of the american headache society. the american headache society consensus statement: update on integrating new migraine treatments into clinical practice. headache. 2021;61(7):1021–1039. 50. gauthier j, côté g, french d. the role of home practice in the thermal biofeedback treatment of migraine headache. j consult clin psychol. 1994;62(1):180–184. 51. arina ga, dobrushina or, shvetsova et, osina ed, meshkov ga, aziatskaya ga, et al. infra-low frequency neurofeedback in tension-type headache: a cross-over shamcontrolled study. front hum neurosci. 2022;16:891323. 52. court j. hypnosis, healing and the christian. paternoster publishing; 1997. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v10.i2.2023.90-109 3 editorial for annals of psychophysiology volume 12 ______________________________________________________________________________ it is time to perform formal investigations of psychophysiological interventions that might slow the progress of alzheimer’s disease richard a. sherman, editor-in-chief published online: june 2025 © the author(s) 2025 given the exposés of chronic falsification of data on etiology and treatment of alzheimer's disease (piller, 2025) combined with devastating cuts in federal funding for basic and applied research, it is time to perform formal investigations of psychophysiological interventions that might slow the progress of alzheimer’s disease. numerous tiny, uncontrolled reports hint that several psychophysiological interventions might be able to slow the progress of the disorder. these interventions deserve further investigation given the failure of the current crop of medicine-based treatments and preventives (with the exception of shingles vaccines (eyting et al, 2025)). there is reasonably strong evidence that moderate alzheimer’s is related to inflammation in the central nervous system (irwin et al, 2019; schmidt et al, 2002). medications that reduce peripheral inflammation do not have a consistent protective effect on the progression of stage four alzheimer’s but both photobiomodulation (pbm) and pulsed electromagnetic fields (pemf) have shown promising results for reducing inflammation in the cns (hamblin, 2019). several small clinical studies utilizing these techniques have shown promising results for moderating cognitive decline for alzheimer’s disease (arendash, 2019; berman and nichols, 2019). small, controlled pilot studies of pemf and pbm utilizing accepted outcome measures of cognition and memory could be performed with minimal funding from private groups to ascertain whether full-scale studies are warranted. it is time to give them the trials they deserve. references arendash, g., cao, c., abulaban, h., baranowski, r., wisniewski, g., becerra, l., andel, r., lin, x., zhang, x., wittwer, d. and moulton, j., (2019). a clinical trial of transcranial electromagnetic treatment in alzheimer’s disease: cognitive enhancement and associated changes in cerebrospinal fluid, blood, and brain imaging. journal of https://content.iospress.com/articles/journal-of-alzheimers-disease/jad190367 https://content.iospress.com/articles/journal-of-alzheimers-disease/jad190367 https://content.iospress.com/articles/journal-of-alzheimers-disease/jad190367 https://content.iospress.com/articles/journal-of-alzheimers-disease/jad190367 alzheimer’s disease, 71(1), pp.57-82. berman, m., nichols, t. (2019). treatment of neurodegeneration: integrating photobiomodulation and neurofeedback in alzheimer's dementia and parkinson's: a review. photobiomodulation, photomedicine, and laser surgery https://doi.org/10.1089/photob.2019.4685 eyting, m., xie, m., michalik, f., heß, s., chung, s., & geldsetzer, p. (2025). a natural experiment on the effect of herpes zoster vaccination on dementia. nature, 641(8062), 438-446. https://doi.org/10.1038/s41586-025-08800-x hamblin, m. (2019) photobiomodulation for alzheimer’s disease: has the light dawned? photonics, 6(3), 77; https://doi.org/10.3390/photonics6030077 irwin, m., vitiello, m. (2019) implications of sleep disturbance and inflammation for alzheimer's disease dementia. lancet 18(3) p 296-306 piller, c. (2025) the devastating legacy of lies in alzheimer’s science. https://www.nytimes.com/2025/01/24/opinion/alzheimers-fraud-cure.html?smid=nytcore-android-share schmidt, r., schmidt, h., curb, d., masaki, k., white, l., launer, l. (2002) early inflammation and dementia: a 25-year follow-up of the honolulu-asia aging study. annals of neurology https://doi.org/10.1002/ana.10265 https://content.iospress.com/articles/journal-of-alzheimers-disease/jad190367 https://doi.org/10.1089/photob.2019.4685 https://doi.org/10.1038/s41586-025-08800-x https://doi.org/10.3390/photonics6030077 https://www.nytimes.com/2025/01/24/opinion/alzheimers-fraud-cure.html?smid=nytcore-android-share https://onlinelibrary.wiley.com/doi/full/10.1002/ana.10265#fn1 https://doi.org/10.1002/ana.10265 60 60-66 annals of applied psychophysiology december 2024 volume 11 ______________________________________________________________________________ the silent echoes of trauma: how pain shapes brain and body dr shamoon noushad1, dr. sadaf ahmed2 published online: december 2024 © the author(s) 2024 abstract background: trauma leaves lasting impacts on physical, mental, and emotional health, creating a persistent cycle of pain. methodology: this article explores how trauma reshapes the nervous system, elevates stress hormones, and triggers chronic conditions like fibromyalgia and emotional distress. the interconnected dimensions of trauma-induced pain including physical, mental, and emotional. additionally, the formation a feedback loop, amplifying suffering. results: holistic recovery strategies, including cbt, trauma-focused therapies, mind-body practices, and biomarker-guided interventions, are essential. conclusion: advances in neuroscience and personalized approaches offer hope, empowering survivors to heal and rebuild resilience. understanding trauma's multifaceted effects is key to fostering meaningful recovery. keywords: trauma, pain, emotional distress, holistic recovery, neuroplasticity 1. shamoon noushad malir university of science & technology, department of psychology 2. sadaf ahmed university of karachi, psychophysiology research lab, karachi, pakistan 61 introduction imagine stubbing your toe—it’s a sharp, immediate pain that fades within minutes. now, imagine carrying a deeper, more invisible pain that lingers for years. this is the reality for many trauma survivors. trauma doesn’t just leave emotional scars; it reshapes how individuals experience pain in their bodies, minds, and souls. pain, in this context, becomes more than a warning signal—it becomes a complex, persistent echo of past experiences. trauma disrupts the natural flow of life, embedding pain in every dimension of a person’s existence. whether stemming from a lifethreatening event, prolonged stress, or emotional upheaval, trauma has the potential to leave longlasting impacts. understanding how pain manifests in trauma survivors is crucial for fostering effective healing strategies. pain resulting from trauma transcends the boundaries of physical injury. the international association for the study of pain (iasp) describes pain as a sensory and emotional experience, emphasizing its intricate connection to the mind and body1. trauma intensifies this connection, creating a cascade of responses that affect not only the nervous system but also mental and emotional well-being (raja et al., 2020). research reveals that trauma activates the brain's stress response systems, flooding the body with stress hormones like cortisol and adrenaline. these biological changes can lead to prolonged dysregulation of the nervous system, manifesting as chronic physical pain, psychological anguish, and emotional distress2. emerging research highlights the role of genetics and biomarkers in understanding how trauma shapes the body and mind. certain genetic predispositions can influence how individuals process trauma, including their susceptibility to chronic pain and emotional distress. variants in genes like comt (catechol-o-methyltransferase), which regulates dopamine, and bdnf (brain-derived neurotrophic factor), which supports neural plasticity, have been linked to heightened pain sensitivity and emotional dysregulation following trauma. additionally, epigenetic modifications—changes in gene expression caused by environmental factors—can perpetuate the effects of trauma across generations3. while cortisol levels and inflammatory markers like interleukin-6 (il-6) and c-reactive protein (crp) are often elevated in trauma survivors. these biomarkers indicate prolonged stress activation and immune system dysregulation, which contribute to both physical and emotional pain. monitoring these biomarkers can provide valuable insights into the severity of trauma’s impact and guide personalized treatment approaches4. trauma-induced pain has a multidimensional impact including physical, emotional and mental impacts that needs to be addressed: physical pain: trauma’s lingering imprint on the body trauma often leaves a physical mark that persists long after the initial event. while acute pain from injuries is an immediate response, unresolved trauma can lead to chronic conditions like fibromyalgia, migraines, or complex regional pain syndrome (crps). studies highlight a 62 phenomenon known as central sensitization, where the nervous system becomes hyperactive, amplifying pain signals even in the absence of new injuries. survivors may also experience somatic symptoms, such as gastrointestinal discomfort, unexplained muscle pain, or chest tightness, which are frequently misdiagnosed as medical issues unrelated to trauma5. for instance, individuals exposed to violence or severe accidents are at higher risk of developing chronic back pain or arthritis. these physical ailments are not just byproducts of the initial injury but manifestations of unresolved trauma that continues to impact the body. mental pain: the unseen burden mental pain, often referred to as psychological or existential pain, is an intrinsic part of the trauma experience. it manifests as intrusive memories, flashbacks, and an inability to find meaning or closure. survivors often describe this pain as an invisible weight they carry daily. hypervigilance—a constant state of alertness—further exacerbates mental distress. this heightened state, rooted in the brain’s fear-processing center (the amygdala), drains cognitive resources, leading to mental fatigue and impaired concentration. survivors may also engage in catastrophizing, a thought pattern that magnifies pain and its implications. over time, this mental strain contributes to conditions like anxiety, depression, and post-traumatic stress disorder (ptsd). these disorders form a vicious cycle, intensifying both the mental and physical toll of trauma6. emotional pain: the deepest wound beyond physical and mental realms, trauma leaves profound emotional scars. survivors often grapple with grief, fear, helplessness, and feelings of loss. trauma disrupts a person’s sense of safety, leaving them vulnerable to emotional wounds that may feel impossible to heal. one common response to trauma is emotional numbing—a defense mechanism that shields survivors from overwhelming emotions but also blocks positive feelings like joy or connection. survivors may also experience shame and guilt, especially if they blame themselves for the traumatic event. these emotional burdens are as debilitating as physical injuries, often leading to isolation and strained relationships.7 the interconnection of pain: a feedback loop trauma-induced pain is rarely confined to one dimension; it creates a feedback loop that reinforces suffering across physical, mental, and emotional realms. for instance, chronic physical pain often worsens emotional distress, while unresolved emotional pain can manifest as physical symptoms. neurological studies demonstrate that the brain regions responsible for processing physical and emotional pain—such as the anterior cingulate cortex (acc) and insula—often overlap. this explains why emotional distress can heighten physical sensations of pain and vice. prolonged 63 exposure to trauma also disrupts the brain’s default mode network (dmn), impairing selfregulation and perpetuating the cycle of pain. survivors caught in this loop may find it difficult to differentiate between physical and emotional suffering, further complicating their recovery journey8. table: dimensions of trauma-induced pain and their consequences dimension of pain description symptoms/effects examples of consequences physical pain pain resulting from injury or physiological changes chronic pain, tension, headaches, somatic symptoms fibromyalgia, migraines, gastrointestinal distress, impaired mobility mental pain cognitive and existential distress intrusive thoughts, hypervigilance, rumination, catastrophizing difficulty concentrating, anxiety disorders, depression, ptsd emotional pain pain from emotional wounds such as loss or fear grief, fear, shame, guilt, emotional numbness impaired relationships, social withdrawal, emotional dysregulation interconnected pain overlap of physical, mental, and emotional dimensions sensitization, amplified pain perception, stress response dysregulation chronic stress, prolonged suffering, intergenerational trauma effects figure 1: the interconnected nature of trauma-induced pain 64 healing trauma-induced pain: a holistic path to recovery emerging research highlights the role of genetic predispositions and biomarkers in understanding trauma’s impact, further enriching holistic strategies for recovery and by addressing the biological, psychological, and social dimensions of trauma-induced pain, these interconnected approaches pave the way for comprehensive recovery. combining traditional therapeutic methods with cutting-edge insights from genetics and biomarkers allows for personalized strategies, empowering survivors to heal with renewed strength and resilience. o uniting therapy and trauma-focused techniques: cognitive-behavioral therapy (cbt) provides a robust foundation for addressing trauma’s psychological impact. when paired with trauma-specific methods like eye movement desensitization and reprocessing (emdr) and somatic experiencing, it becomes possible to tackle both emotional and somatic pain. recent studies suggest that genetic variations, such as polymorphisms in the serotonin transporter gene (5-httlpr), may influence an individual’s response to therapies like cbt, highlighting the importance of personalized approaches.9 &10 o reconnecting mind and body: mind-body practices, including yoga, mindfulness, and biofeedback, are essential in re-establishing the connection between mental and physical health. these methods regulate the hypothalamic-pituitary-adrenal (hpa) axis, often dysregulated in trauma survivors. biomarkers like cortisol levels provide measurable insights into the effectiveness of these practices in reducing stress and pain sensitivity.11&!2 o harnessing the power of community: healing is amplified in supportive environments where survivors can share experiences and rebuild trust. group therapy and peer support networks not only alleviate isolation but also promote oxytocin release, a biomarker linked 65 to social bonding and emotional resilience13. safe spaces enable survivors to feel seen and heard, fostering a sense of belonging essential for recovery. o rewiring pain through neuroplasticity: the brain’s capacity to adapt, known as neuroplasticity, plays a vital role in trauma recovery. techniques like neurofeedback and graded motor imagery help rewire neural pathways associated with chronic pain. genetic markers such as brain-derived neurotrophic factor (bdnf) polymorphisms have been linked to neuroplasticity, suggesting that individuals with certain genetic profiles may experience enhanced benefits from these interventions14. o incorporating genetic and biomarker insights: the integration of genetics and biomarkers into trauma recovery strategies adds a layer of precision to holistic healing. for instance, elevated inflammatory markers like interleukin-6 (il-6) and c-reactive protein (crp) are often observed in trauma survivors, providing a biological basis for targeting inflammation through both pharmacological and lifestyle interventions15&16. similarly, genetic predispositions affecting dopamine or opioid receptor pathways can influence pain sensitivity and response to therapies, offering opportunities for tailored treatment plans. conclusion trauma-induced pain is a silent yet pervasive force that shapes the lives of survivors in profound ways. its physical, mental, and emotional impacts are deeply interconnected, creating a web of suffering that often feels insurmountable. however, advances in neuroscience and therapeutic practices offer hope for healing. understanding the multifaceted nature of trauma and pain is the first step toward fostering recovery. with holistic interventions and compassionate support, survivors can move from enduring pain to reclaiming their sense of wholeness and well-being. references 1. yılmaz bö, aydın e. discussion of international association for the study of pain (iasp) pain definition: what has changed in 2020?. health sciences quarterly. 2023 oct 13;3(4):283-91. 2. ressler, k.j., berretta, s., bolshakov, v.y. et al. post-traumatic stress disorder: clinical and translational neuroscience from cells to circuits. nat rev neurol 18, 273–288 (2022). https://doi.org/10.1038/s41582-022-00635-8 3. jiang s, postovit l, cattaneo a, binder eb, aitchison kj. epigenetic modifications in stress response genes associated with childhood trauma. front psychiatry. 2019 nov 8;10:808. doi: 10.3389/fpsyt.2019.00808. 4. deif r, salama m. depression from a precision mental health perspective: utilizing personalized conceptualizations to guide personalized treatments. frontiers in psychiatry. 2021 may 11;12:650318. 66 5. bartel a, jordan j, correll d, devane a, samuelson kw. somatic burden and perceived cognitive problems in trauma‐exposed adults with posttraumatic stress symptoms or pain. journal of clinical psychology. 2020 jan;76(1):146-60. 6. asmundson gj, thorisdottir as, roden-foreman jw, baird so, witcraft sm, stein at, smits ja, powers mb. a meta-analytic review of cognitive processing therapy for adults with posttraumatic stress disorder. cognitive behaviour therapy. 2019 jan 2;48(1):1-4. 7. spytska l. psychological trauma and its impact on a person’s life prospects. scientific bulletin of mukachevo state university. series “pedagogy and psychology. 2023 aug 30;9(3):82-90. 8. de ridder d, adhia d, vanneste s. the anatomy of pain and suffering in the brain and its clinical implications. neurosci biobehav rev. 2021;130:125-46. doi:10.1016/j.neubiorev.2021.08.013. 9. zatloukal l, furman b. the solution-focused approach to trauma therapy. journal of constructivist psychology. 2023 jul 3;36(3):361-81. 10. chen x. research on counseling therapy for post-traumatic stress disorder. journal of social science humanities and literature. 2023 dec 29;6(6):83-7. 11. works hp, ny n, rupa o, patient fa. harnessing the power of mind-body techniques for chronic pain management. 12. barr kl, soutor ca, franklin jm. mind–body therapies. integrative dermatology: practical applications in acne and rosacea. 2021:165-91. 13. takayanagi y, onaka t. roles of oxytocin in stress responses, allostasis and resilience. international journal of molecular sciences. 2021 dec 23;23(1):150. 14. treble-barna a, heinsberg lw, stec z, breazeale s, davis ts, kesbhat aa, chattopadhyay a, vonville hm, ketchum am, yeates ko, kochanek pm. brain-derived neurotrophic factor (bdnf) epigenomic modifications and brain-related phenotypes in humans: a systematic review. neuroscience & biobehavioral reviews. 2023 apr 1;147:105078. 15. noushad s, sajid u, ahmed s, ansari b. assessment of cortisol, brain-derived neurotropic factor, c reactive protein, interleukin-6 levels and cognitive decline after trauma exposure. ann. psychophysiol. 2021;8(1):06-14. 16. noushad s, ahmed s, ansari b, mustafa uh, saleem y, hazrat h. physiological biomarkers of chronic stress: a systematic review. international journal of health sciences. 2021 sep;15(5):46. 48 annals of applied psychophysiology december 2025 volume 13 _____________________________________________________________________ the triad of stress, vitamin d deficiency, and periodontal breakdown: an integrative review rafique s, ahmed s, noushad s, atif a, aqeel s, nasir f published online: december 2025 © the author(s) abstract background: recent studies have highlighted a significant link between psychological disorders and oral inflammatory diseases. emotional disorders such as anxiety and depression can interfere with normal body functions by disturbing the neuro-immune-endocrine axis. methodology: this mini-review highlights the importance of integrated approaches in dental and mental health care by integrating research that links oral and psychological domains. results: these alterations trigger the onset and progression of periodontitis, a chronic inflammatory disease that harms the tissues supporting the teeth. vitamin d, especially its active form, 1,25-dihydroxyvitamin d₃, has recently been considered as a vital hormone in protecting mental and periodontal health. conclusion: saliva provides a noninvasive means for assessing physiological markers such as alpha-amylase (saa), cortisol, interleukin-6 (il-6), and chromogranin-a (cg-a). these biomarkers can offer insight into bodily changes associated with oral inflammation and psychological stress. keywords: monosodium glutamate (msg), dietary glutamate, depressive-like phenotypes, monosodium glutamate induced depression, neurotoxicity, animal models, supraphysiological doses. corresponding author dr. sara rafique, mphil, phd scholar associate professor, department of physiology, jinnah medical & dental college, sohail university, shaheed-e-millat road, karachi, pakistan ph: 93345386644 e mail: sararafique@jmc.edu.pk introduction the link between mental health and systemic inflammatory diseases has gained significant attention, as the prevalence of anxiety and depression is increasing worldwide [1]. mental health disorders are increasingly recognized not merely as cognitive or emotional disorders, but as conditions affecting the oral health domain. the detrimental effects on periodontal tissues have become a focus of growing attention [2, 3]. periodontitis is an ongoing inflammatory infection affecting the supporting structures of the teeth [3]. the body's stress response serves as an amalgamating link between oral and mental health. chronic stress can lead to the over-stimulation of the hypothalamic-pituitary-adrenal (hpa) axis and the sympathetic nervous system (sns).this results in elevated cortisol levels. the continuously raised cortisol levels can disrupt the balance of the immune response, shifting it towards a more destructive inflammatory state. this inflammatory state contributes to systemic and oral health issues [4]. vitamin d, a steroid hormone, is not only a bone-regulating vitamin, but is also involved in the regulation of mood. deficiency in vitamin d has been linked to a higher risk of oral inflammatory diseases, such as periodontitis [5, 6]. this study examines the pathophysiology of vitamin d together with other stress-associated salivary markers to further clarify how these biomarkers, via interconnected pathways, affect both oral health and emotional well-being. anxiety and depression: biological mechanisms related to oral health anxiety and depression arise from a combination of physiological, psychological, and environmental factors. each of these factors can contribute to ongoing stress, which in turn overactivates the hypothalamic-pituitary-adrenal (hpa) axis. the hpa axis normally maintains physiological homeostasis during stress. however, when its activation is prolonged, cortisol secretion remains elevated. while short-term cortisol elevation shifts the immune system towards an anti-inflammatory state, its chronically heightened levels can suppress immune responses and promote both systemic and neural inflammation [3, 7]. neuroinflammation-induced alterations in cortisol levels can lead to decreased concentrations of emotion-regulating neurotransmitters, mainly through their increased reuptake by presynaptic terminals [8, 9]. inflammatory cytokines stimulate a specific enzyme that converts tryptophan into kynurenine, a neurotoxic metabolite. this neurotoxin activates glutamatergic pathways, promoting excitotoxic damage and reducing levels of brain-derived neurotrophic factor (bdnf). these neurobiological changes heighten vulnerability to anxiety and cognitive deficits, the clinical signs commonly observed in anxiety and depressive disorders [9]. in addition, individuals suffering from anxiety and depression may also experience adverse oral health outcomes. these individuals experience persistent fatigue, decreased motivation, and neglect of self-care routines. these symptoms may result in less frequent tooth brushing and flossing, missed dental check-ups, or the emergence of harmful oral habits such as teeth grinding, tobacco use, or increased consumption of sugary foods. these habits encourage the accumulation of dental plaque, leading to gingival inflammation, which progresses to periodontitis [10]. dysregulation of the immune system forms a causal link between psychiatric conditions and periodontal pathology [11]. multiple investigations reveal that depressive states are characterized by increased production of pro-inflammatory cytokines by the central microglia. the chemokine monocyte chemoattractant protein-1 (mcp-1) is pivotal in directing monocyte migration to emotional brain regions. these include the amygdala and hippocampus—structures that are fundamental to the processing of fear and the encoding of emotional memories [12]. periodontitis: immune imbalance and the impact of stress periodontitis is a chronic inflammatory ailment predominantly caused by plaque accumulation, which modifies the composition of the oral microflora to incline towards a more virulent gram-negative species. this provokes the host’s immune response. in the initial phase, the buildup of plaque attracts neutrophils to the affected site, resulting in the formation of an early lesion. if inflammation persists, adaptive t and b lymphocytes migrate into the periodontal tissues. these cells release cytokines that contribute to the connective tissue breakdown and resorption of alveolar bone [13]. a recent study has shown that psychological stress plays a significant role in the progression of periodontal disease [14]. elevated cortisol levels associated with stress can impair neutrophil chemotaxis, macrophage activity, and natural killer cell responses. these immune alterations reduce the body’s ability to defend against pathogenic bacteria, enabling periodontal microorganisms like porphyromonas gingivalis to proliferate. in addition, chronic stress increases the production of pro-inflammatory cytokines, including interleukin-6 (il-6) and tumor necrosis factor-alpha (tnf-α). these cytokines are involved in the degradation of periodontal tissues [3]. activation of the sympathetic nervous system under stressful conditions has significant consequences on periodontal health [15, 16]. increased autonomic activity is indicated by higher concentrations of salivary alpha-amylase and chromogranin-a. both are acknowledged as markers of sympathetic stimulation. these biomarkers lead to reduced saliva and alterations in its composition, creating the conditions that encourage the proliferation of pathogenic microorganisms [16, 17]. clinical observations often reveal that individuals subjected to prolonged psychological stress have an increased risk of developing periodontitis. these individuals commonly exhibit more severe clinical signs of periodontitis [18]. the interaction between physiological mechanisms and behavioral patterns connecting stress with periodontal disease emphasizes the importance of addressing mental health within the framework of comprehensive periodontal management. vitamin d as a biological connection between mental well-being and oral health vitamin d’s role has been established as an essential hormone for calcium regulation and bone health. more recently, its role in modulating immune responses and influencing neuroprotection has been acknowledged [19]. the active form, 1,25-dihydroxyvitamin d₃, exerts its effects by binding to vitamin d receptors. these receptors are found not only in conventional target tissues but also in immune cells, limbic areas of the brain, and periodontal tissues [20, 21]. vitamin d is vital in maintaining periodontal health by regulating inflammatory processes. it reduces pro-inflammatory cytokines, such as interleukin-6 and tumor necrosis factor-alpha. this essential vitamin supports the synthesis of anti-inflammatory mediators. in addition, the active vitamin d increases the production of cathelicidin, an antimicrobial peptide that protects against periodontal pathogens. by regulating bone remodeling, vitamin d contributes to bone formation and limits bone loss. these processes help to maintain alveolar bone integrity and slow the progression of periodontal disease [21]. studies have reported a negative correlation between vitamin d levels and the severity of periodontal disease. this suggests that insufficient vitamin d may be associated with severe periodontal tissue breakdown [22, 23]. there is strong evidence linking vitamin d status to mental health. key brain regions involved in emotional regulation, such as the hippocampus, amygdala, and prefrontal cortex, have receptors for vitamin d and the enzyme responsible for converting vitamin d to its active form. vitamin d increases the expression of tryptophan hydroxylase-2, the enzyme necessary for serotonin synthesis, a neurotransmitter that plays a central role in mood regulation. as serotonin is important for emotional regulation, cognitive function, and mood stability, inadequate levels of vitamin d can reduce serotonin production and increase the risk of developing anxiety and depressive symptoms [24]. vitamin d plays an important role in safeguarding neural tissue by improving mitochondrial integrity and reducing oxidative stress. it stimulates antioxidants, such as glutathione, which serve to reduce the buildup of reactive oxygen species in brain tissue. deficiency in vitamin d can result in degeneration of gabaergic neurons. this disruption disturbs the equilibrium between excitatory and inhibitory neurotransmitters, leading to a hyperactive amygdala. therefore, low vitamin d status may contribute to psychological health issues and periodontal integrity issues [24]. addressing vitamin d deficiency may offer therapeutic advantages in both mental health and oral health areas. stress-sensitive salivary biomarkers connecting oral and mental health saliva is a biological fluid composed of hormones, cytokines, enzymes, and peptides. these molecules enter saliva through both transcellular and paracellular transport processes. this results in a molecular composition that reflects the state of both oral and systemic health. saliva provides a non-invasive medium for studying the interplay between stress-related physiological changes and oral health conditions. its correlation with serum biomarkers strengthens its utility in evaluating psychological and dental health [25, 26]. this underscores the growing recognition of saliva as a valuable diagnostic tool for investigating the relationship between psychological factors and oral health. cortisol remains one of the most extensively studied salivary biomarkers. this steroid hormone is recognized as a reliable indicator of hypothalamic-pituitary-adrenal (hpa) axis activity. individuals experiencing stress frequently exhibit increased concentrations of salivary cortisol [14]. although cortisol plays a protective role during episodes of acute stress, its persistently elevated levels contribute to systemic inflammation and a compromised local immune response. elevated salivary cortisol is associated with increased periodontal pocket depth, worsened gingival inflammation, and reduced resistance to oral infections [14, 27]. interleukin-6 (il-6) is an important inflammatory marker that links behavioral conditions with oral disorders. this cytokine plays a central role in immune system regulation, and its levels increase in response to both emotional stress and periodontal inflammation. elevated salivary il-6 is associated with greater osteoclastic activity, connective tissue breakdown, and increased inflammatory cell infiltration in periodontal tissues [28]. it influences behavior by promoting neuroinflammation, thereby increasing an individual’s susceptibility to anxiety and depression [29]. the sympathetic nervous system's activity can be assessed non-invasively through salivary alpha-amylase [30]. this protein alters saliva composition and oral immunity, impairs antibacterial defenses, and heightens the likelihood of periodontal infections [17]. chromogranin-a (cg-a) is another important autonomic marker. as a glycoprotein, it reflects changes in the autonomic nervous system and is sensitive to psychological stress [16]. cg-a is a precursor to several peptides involved in immune regulation and periodontal inflammation [31]. elevated concentrations of cortisol, chromogranin a (cg-a), and alpha-amylase in saliva are widely recognized as markers of heightened hypothalamic-pituitary-adrenal (hpa) axis and sympathetic nervous system activity. in parallel, increased levels of interleukin-6 (il-6) reflect inflammatory responses that often accompany both psychological stress and oral inflammatory diseases. conclusion the intricate relationship between anxiety, depression, and periodontitis underscores the necessity of viewing oral and mental health as interconnected, rather than isolated domains. psychological stress exerts influence on neuroendocrine regulation, immune system function, and behavioral patterns, each of which heightens vulnerability to periodontal disease. vitamin d plays a pivotal role in modulating these biological pathways, thereby impacting emotional well-being and the integrity of periodontal tissues. salivary biomarkers provide a valuable, non-invasive window into these complex mechanisms. this medium allows clinicians to assess underlying physiological changes noninvasively before visible symptoms appear, facilitating earlier intervention. recognizing these shared mechanisms advocates an integrated health care approachone that bridges mental and oral health strategies for prevention, early detection, and effective treatment. this proactive approach not only holds promise for improving patient outcomes but also has the potential to alleviate long-term healthcare costs and resource burdens associated with advanced disease states. figure 1. reduced salivary 1,25(oh)₂d₃ and elevated levels of cortisol, il-6, cg-a, and saa disrupt neuro-endocrine–immune homeostasis, promote hyperactivity of the hpa axis and sympathetic nervous system, and shift immunity towards a destructive phase, thereby increasing vulnerability to anxiety, depression, and periodontitis. references ali m, taj y, tanwir f, et al. mmp-8, il-6, il-1β as biomarkers. age. 2025;15:39 5.10.29271/jcpsp.2025.07.825 ali n, nater um. salivary alpha-amylase as a stress biomarker. int j behav med. 2020;27(3):337-42.10.1007/s12529-019-09843-x. al shaar a, hamadeh o, ali a. saliva and serum biomarkers. medicine. 2024;103(52):e41072.10.1097/md.0000000000041072. antonoglou gn, et al. low serum 1,25(oh)2d and periodontitis. j periodontal res. 2015;50:274-80. ball j, darby i. mental health and periodontal and peri-implant diseases. periodontol 2000. 2022;90(1):106-24.10.1111/prd.12452 becerra-ruiz js, guerrero-velázquez c, martínez-esquivias f, et al. innate and adaptive immunity… oral dis. 2022;28(6):1441-7.10.1111/odi.13884 charoenngam n, shirvani a, holick mf. vitamin d for skeletal and non-skeletal health. j clin orthop trauma. 2019;10(6):1082-93.10.1016/j.jcot.2019.07.004. chung c, silwal p, kim i, modlin rl, jo ek. vitamin d-cathelicidin axis… immune netw. 2020;20(2):e12. 10.4110/in.2020.20.e12 develioglu h, korkmaz s, dundar s, schlagenhauf u. salivary markers in periodontitis. j oral biol craniofac res. 2020;10(4):514-8.10.1016/j.jobcr.2020.07.020. gkolfinopoulos s, tsapakidis k, papadimitriou k, et al. chromogranin a as a marker. world j methodol. 2017;7(1):9.10.5662/wjm.v7.i1.9 gunepin m, derache f, trousselard m, et al. chronic stress and periodontal health. j oral med oral surg. 2018;24(1):44-50.10.1051/mbcb/2017028 hassamal s. chronic stress, neuroinflammation, and depression… front psychiatry. 2023;14:1130989.https://doi.org/10.3389/fpsyt.2023.1130989 hashim nt, fathima s, hisham nm, et al. salivary alpha-amylase in periodontitis. curr issues mol biol. 2024;46(11):12230-43.10.3390/cimb46110726. hingorjo mr, owais m, siddiqui s, et al. stress and salivary cortisol in periodontitis. bmc oral health. 2025;25:276.10.1186/s12903-024-05017-8. hoffmann k, emons b, brunnhuber s, et al. dietary supplements in depression. pharmacopsychiatry. 2019;52(6):261-79.10.1055/a-0942-1875. küchler ec, schröder a, teodoro vb, et al. vitamin d receptor in periodontal ligament cells. bmc oral health. 2021;21:386.https://doi.org/10.1186/s12903-02101740-8 liu k, meng h, hou j. vitamin d function in gingival fibroblasts. plos one. 2012;7(6):e39878. mirzaei m, ardekani sm, mirzaei m, dehghani a. prevalence of depression, anxiety and stress among adult population: results of yazd health study. iran j psychiatry. 2019;14(2):137. malek r, gharibi a, khlil n, kissa j. necrotizing ulcerative gingivitis. contemp clin dent. 2017;8(3):496-500.10.4103/ccd.ccd_1181_16 miller ah. inflammation and depression. psychiatric times. 2018;35(4). nih office of dietary supplements. vitamin d fact sheet for health professionals. 2017. o’donovan a, hughes bm, slavich gm, et al. anxiety, cortisol and il-6. brain behav immun. 2010;24(7):1074-7.10.1016/j.bbi.2010.03.003 proma ma, daria s, nahar z, et al. mcp-1 in major depressive disorder. j basic clin physiol pharmacol. 2022;33(6):735-41.10.1515/jbcpp-2021-0132. rafique s, khan s, ahmed s, et al. vitamin d binding protein in periodontitis. pak j med sci. 2019;35(3):847.https://doi.org/10.12669/pjms.35.3.482 rafique s, ahmed s, noushad s. salivary vitamin d & cortisol… steroids. 2025:109674.10.1016/j.steroids.2025.109674. santos sv, silva la, terra fd, et al. salivary alpha-amylase and stress. rev lat am enfermagem. 2021;29:e3468.10.1590/1518-8345.4859.3468. soysal f, isler sc, guney z, et al. salivary chromogranin a and periodontal health. bmc oral health. 2025;25:1536.https://doi.org/10.1186/s12903-025-06912-4 tang q, xu w, zhang f, et al. interdisciplinary research on periodontitis and depression. front oral health. 2025;6:1588737.https://doi.org/10.3389/froh.2025.1588737 walther c, lieske b, borof k, et al. periodontitis and depression… brain behav immun. 2023;34:100689.10.1016/j.bbih.2023.100689. yaribeygi h, panahi y, sahraei h, johnston tp, sahebkar a. the impact of stress on body function: a review. excli j. 2017;16:1057. 10.17179/excli2017-480 zhang j, lin s, luo l, et al. psychological stress: neuroimmune roles in periodontal disease. odontology. 2023;111(3):554-64.10.1007/s10266-022-00768-8. image1.png index.pdf 2 k. sheikh, s. noushad, a. hussain, j. sheikh, b. madad ali malik, b. ansari annals of psychophysiology volume 12 june 2025 table of contents pgn 83 prediction of perception brigid k. turner pgn methylation of the nr3c1 gene and behavior 96 rebecca breitrick reviews and summaries of hot topics in psychophysiology pgn 11 pgn a systematic review: manipulation vs. mobilization for mechanical neck pain 27 b. madad ali malik, s. noushad, k. sheikh, a.rayyan, s. riaz & b. ansari pgn the role of play-based therapy in managing motor skills in children with 65 cerebral palsy (cp): a systematic review w. khan afsar & h. hashim editorial 03 it is time to perform formal investigations of psychophysiological interventions that might slow the progress of alzheimer’s disease r. sherman, editor-in-chief original research pgn mood changes in response to fighting among mixed martial arts fighters; 04 a pre and post-fight analysis exploring the role ofneuromuscular electrical stimulationin neonatal brachial plexus palsy:anarrative reviewofmotor recovery andfunctional outcomes f.mirzaand a.fazal pgn editorial for annals of psychophysiology volume 11 issue 1 52 52-59 annals of applied psychophysiology december 2024 volume 11 hormone replacement therapy and mood disorders during menopause monica persson1, published online: december 2024 © the author(s) 2024 abstract background: menopause is a significant transitional phase for women, marked by hormonal changes that profoundly affect physical and mental health. this paper examines the intricate relationship between menopause, hormonal fluctuations, and mood disorders, emphasizing the challenges of treatment. the depletion of ovarian follicles and the resulting decline in estrogen, progesterone, and other hormones disrupt the hypothalamic-pituitary-gonadal axis and neurotransmitter pathways, leading to increased rates of depression, anxiety, and other mood disorders in middle-aged women. conventional treatments, such as selective serotonin reuptake inhibitors (ssris), are often less effective for menopausal-related mood disorders, underscoring the need for alternative approaches. methodology: a targeted review of current literature explores conventional and alternative treatment approaches for menopausal mood disorders. this includes a review of pharmacological therapies, such as selective serotonin reuptake inhibitors (ssris), and the potential efficacy of hormone replacement therapy (hrt) in mitigating mood-related symptoms. results: conventional treatments like ssris are often less effective for menopausal mood disorders, underscoring the need for alternative approaches. hrt emerges as a viable option, offering symptom relief from vasomotor and genitourinary syndromes, improved cardiovascular and bone health, and potential mitigation of mood disorders. however, the controversial results of the 2002 women’s health initiative (whi) study raised concerns about risks, resulting in reduced usage. recent studies support the “critical window” hypothesis, suggesting that initiating hrt early in menopause enhances safety and efficacy. conclusion: this paper highlights the importance of personalized and integrative strategies for managing menopause and mood disorders. although hrt shows promise, further research is essential to clarify its influence on inflammatory pathways and neuroinflammatory mechanisms. understanding the long-term effects of hrt and addressing the unique hormonal and neurobiological dynamics of menopausal women are critical for developing targeted interventions and improving outcomes for this underserved demographic. keywords: estrogen, progesterone, reproductive hormones, hormone replacement therapy, mood disorders, depression, anxiety. 1. monica persson mpersson@saybrook.edu saybrook university, pasadena, ca, usa mailto:mpersson@saybrook.edu 53 hormone replacement therapy and mood disorders during menopause all human females with ovaries who reach puberty will ultimately experience menopause, provided they live long enough. menopause consists of three main stages: perimenopause, menopause, and post menopause, generally occurring between the ages of 40 and 60. at this stage, the ovaries begin to atrophy, decreasing the production of the main hormones that regulate the menstrual cycle: estrogen and progesterone. most women experience vasomotor (hot flashes, excessive sweating, sleep disturbance) and genitourinary (vaginal dryness, pain during intercourse, urinary incontinence, decreased libido) symptoms during this period (jin, 2017). middle-aged women also experience significant increases in depression, anxiety, post-traumatic stress disorder, and substance abuse compared to other age groups. as a demographic cohort, women in this age range have a high suicide rate (maki et al., 2019, as cited by kulkarni et al., 2024). cultural, genetic, and environmental factors influence the menopause journey and subsequent treatment efficacy. during the feminist movement of the 1960s, there was a significant shift in the promotion of menopausal therapy, especially in european countries, with the concept of "feminine forever" (wilson, 1968). a book by the same title became a bestseller, claiming that “menopause is a hormone deficiency disease, curable and totally preventable, just take estrogen” (wilson, 1968, as cited in cagnacci & venier, 2019, p. 602). since that time, women have had a complex relationship with hormone replacement, alternately viewing it as a panacea or risk too hazardous to employ. menopause is a complex biological process characterized by hormonal changes that can significantly impact mental health, creating challenges for effective treatment. pre-menopausal women without a history of mood disorders are nearly twice as likely to develop symptoms of anxiety and depression during menopause compared to those with no prior mood disorder history (cohen et al., 2006, as cited in alblooshi et al., 2023). as ovarian follicles deplete, ovarian function declines, leading to a reduction in mood-regulating hormones. this shift disrupts the hypothalamic-pituitary-gonadal axis, influencing mood regulation and stress responses. life stages with low estrogen levels (premenstrual, postpartum, menopause) are linked to increased depressive symptoms. additionally, between 15% to 50% of women report experiencing depression during the menopause transition (toffol et al., 2015, as cited by wieczorek et al., 2023). fluctuations in estrogen, progesterone, testosterone, cortisol, triiodothyronine (t3), thyroxine (t4), dehydroepiandrosterone, follicle-stimulating hormone (fsh), and luteinizing hormone (lh) affect multiple systems, with estrogen, progesterone, and cortisol playing key roles in mood regulation. understanding these hormonal changes is critical for addressing menopausal mood disorders effectively. standard mental health interventions, such as lifestyle modification and antidepressants, are often insufficient in addressing menopausal mood disorders. healthcare providers often 54 recommend stress reduction techniques and psychotherapies, like cognitive-behavioral therapy, as the first intervention. antidepressants, particularly ssris, are usually the next treatment option. however, many medications that had previously helped are no longer effective, or a much higher dose is required to have the same effect (worley et al., 2012; grigoriadis et al., 2006, as cited by behrman & crockett, 2023). current guidelines are to treat menopausal depression as any other depressive episode. however, it is known that periand postmenopausal people do not respond to ssris as effectively as other demographics, and rates of discontinuation due to adverse events are significant (wu et al., 2020, as cited by behrman & crockett, 2023). hormonal therapies may be more effective but remain underutilized due to safety concerns and a lack of sufficient knowledge among mental health professionals about their use in treating mood disorders (behrman & crockett, 2023). the interplay between hormonal shifts and mental health challenges underscores the necessity for a nuanced understanding of menopause in clinical settings. conventional mental health treatments fail to account for the unique physiological changes during menopause, highlighting a critical gap in care. integrative approaches and targeted interventions are needed to support women during this critical stage of life. neuroscience of hormonal influence on mental health during menopause neurotransmitters such as serotonin, norepinephrine, and dopamine play a crucial role in modulating both vasomotor and mood disorders. dysregulation of these pathways, particularly in the prefrontal cortex and limbic system, key regions of the central nervous system involved in mood control, can contribute to the onset of depression (giannini et al., 2021). estrogen has a role in the modulation of serotonin and the serotonergic pathways, considered a root neurobiological cause of depression (herson & kulkarni, 2022, as cited in behrman & crockett, 2023). estrogen affects the concentration of serotonin by increasing the rate of monoamine oxidase (mao), an enzyme responsible for serotonin catabolism. estrogen is also linked to neuron activity due to its ability to affect cerebral blood flow, glucose levels, neuronal growth, and synaptic activity (giannini et al., 2021). other neurotransmitter pathways linked to changes in mood, such as dehydroepiandrosterone sulfate and gamma-aminobutyric acid (gaba), are also affected by the menopausal transition (behrman & crockett, 2023). estrogen significantly affects moodregulating brain areas such as the hippocampus and amygdala by enhancing synaptic plasticity, promoting neuronal growth, and modulating neurotransmitter systems, collectively contributing to improved mood regulation and stress resilience (behrman & crockett, 2023). the progesterone derivative allopregnanolone “interacts with gamma-aminobutyric acid type a (gaba-a) receptors even at nanomolar concentrations and induces significant anti-depressant, anti-stress, sedative, and anxiolytic effects” (stefaniak et al., 2023, p. 520). low to moderate concentrations of allopregnanolone increase amygdala activity as measured by functional magnetic resonance imaging (fmri), similar to changes experienced during heightened anxiety. when concentrations increased, amygdala activity slowed, resembling the effect of sedatives like benzodiazepines (stefaniak et al., 2023). 55 hormone replacement therapy hrt is an effective treatment for various adverse symptoms associated with menopause, including vasomotor symptoms (such as intense heat, sweating, and flushing) and genitourinary syndrome (characterized by vaginal dryness, irritation, burning, painful intercourse, recurrent urinary tract infections, and urinary incontinence). additionally, multiple randomized trials have demonstrated hrt's positive effects on cardiovascular, endocrine, and bone health, with evidence suggesting a reduction in all-cause mortality among recently menopausal women (flores et al., 2021). however, the 2002 whi report delivered transformative findings into hrt risks of breast cancer and cardiovascular disease in older postmenopausal women, driving a “seismic shift” in menopause management and influencing perspectives that persist today (flores et al., 2021, p. 720). the whi study included a large population of older postmenopausal women more than 10 years after the cessation of menses. these women were more likely to have pre-existing conditions, such as cardiovascular disease, making them more prone to adverse outcomes. the study also used a combination of estrogen and medroxyprogesterone acetate (mpa), a synthetic progestin. unlike natural progesterone, mpa has been associated with an increased risk of breast cancer and cardiovascular disease (manson et al., 2024). these issues led to misunderstandings about the safety of hrt, resulting in significant declines in prescribing, even for women not at significant risk. new formulations and updated research have clarified these findings, highlighting the significance of bio-identical progesterone, personalized treatment, and timing in hormone therapy choices. although hrt is safe for many women, it still poses certain risks. prolonged use can increase the chances of breast and endometrial cancer, blood clots, and stroke and may impair cognitive function (marsden, 2022). the benefits and risks of taking hrt depend on an individual's age, menopause stage, and any pre-existing risk factors they may have. the aftermath of the whi study has led to the “critical window” or “timing hypothesis,” which states estrogen can be neuroprotective only if hrt is started shortly after the onset of menopause. some studies indicate that using hrt in the early postmenopausal phase is associated with improved well-being, while its use at later stages does not show the same benefits. according to flores et al. (2021), hrt is a valuable option for symptomatic, healthy menopausal women who are under 60 years old and have been menopausal for less than 10 years. this applies as long as they do not have any contraindications, such as cardiovascular disease, poorly controlled diabetes, or high blood pressure, as well as no risk factors for venous thromboembolism, including obesity, smoking, or clotting disorders. while the number of hormones that shift during menopause is significant, only estrogen and progesterone are used in hrt for this cohort. estrogen-only formulations for hrt include conjugated equine estrogens, 17βe2, and esterified estrogens; they are typically used for women without a uterus (flores et al., 2021). in addition to oral routes of administration, estrogen-only formulations such as injection, subdermal implant, and transdermal formulations are available. 56 progesterone can be used alone or in combination with estrogen. available routes of administration include oral, injection, implants, transdermal (via vaginal application), and intrauterine systems. formulations containing progesterone are used more commonly in women with a uterus. selective estrogen receptor modulators are a newer treatment option that targets specific estrogen receptors to exert agonist or antagonist actions on the estrogen receptors in various estrogen-target tissues (flores et al., 2021). women randomized to oral estrogen in the kronos early estrogen prevention cognitive and affective ancillary study showed greater benefit on affective mood states than women randomized to transdermal 17β-estradiol or placebo (raz et al., 2016). however, after a systematic review of the literature comparing the transdermal and oral administration routes of estrogens for menopausal women, goldštajn et al. (2023) determined that available evidence is limited and low quality. the authors indicate that until more research is available, the main clinical difference between the two administration routes is the reduced risk of venous thromboembolism, which suggests that transdermal hrt is safer than the oral administration route. perceived and actual risk factors of hrt similarly, like all pharmaceutical interventions, hrt is not without risk. depending on formulation and individual patient profile, physical risks include increased prevalence of breast and uterine cancer, cardiovascular disease, gallbladder disease, and urinary incontinence. while research does not indicate that hrt directly decreases emotional well-being, there may be indirect risk. even in the absence of physical risk factors, there is the possibility of a toll on mental health . hearing about others experiencing negative outcomes can amplify concerns and lead to anxiety or worsening mental health. according to bagarić et al. (2022), the phenomenon known as the vicarious nocebo effect refers to the psychological impact of learning about the adverse effects experienced by others who are using the same medical intervention. this may decrease as erroneous media reports about the whi study claiming that hormone therapy causes breast cancer and cardiovascular disease fade from the memories of healthcare providers and the general public. emerging research on hrt’s role in inflammatory pathways in recent years, researchers have hypothesized that mood disorders may result from an inflammatory response. evidence supporting this hypothesis was presented by ye et al. (2023), who identified low-grade systemic inflammation in patients with depression. their findings included elevated concentrations of c-reactive protein in 21% to 34% of patients, as well as increased levels of interleukin-6 (il-6) and other inflammatory cytokines in both blood and cerebrospinal fluid. this inflammatory activity is believed to impact neural circuits in the brain related to mood regulation, such as the hippocampus and the prefrontal cortex (ye et al., 2023). autoimmune diseases often worsen during menopause due to increased inflammation, highlighting the complex interplay between physical health and mood disorders during this 57 transition. these links suggest that targeting inflammation could be a viable approach to managing mental health symptoms. hrt, particularly estrogen-based therapies, may help modulate inflammatory responses in menopausal women. estrogen has anti-inflammatory properties that can reduce levels of proinflammatory cytokines like il-6. by potentially lowering systemic inflammation, hrt could alleviate some of the depressive and anxiety symptoms that are exacerbated by these inflammatory processes. slavich and sacher (2019) describe how estrogen modulates the hypothalamicpituitary-adrenal (hpa) axis and its implications for stress-related disorders. researchers note that estrogen can attenuate hpa axis responses to stress, which may be beneficial in reducing anxiety and depression symptoms (slavich & sacher, 2019). these findings suggest a promising role for hrt not only in alleviating physical symptoms of menopause but also in addressing the neuroinflammatory mechanisms that contribute to mood disorders. while these studies are promising, they are limited in scope, and more research is needed to determine the underlying mechanisms of hrt in relation to inflammation-related mental health outcomes. large-scale, randomized controlled trials are necessary to confirm conclusions and identify the most effective treatment protocols. conclusion given the complex interplay between hormones and mental health, there is a need for personalized treatment approaches when it comes to treatment. there is an understanding that hrt may mitigate mood disorders. however, it may be most efficacious for a narrow subset of individuals during a specific stage of menopause or used in conjunction with antidepressants. all women, but especially older women, do not have equal representation in health research. further investigation is needed to deepen our understanding of the complex relationship between hormonal transitions and mood disorders in women. references alblooshi, s., taylor, m., & gill, n. (2023). does menopause elevate the risk for developing depression and anxiety? results from a systematic review. australasian psychiatry, 31(2), 165-173. https://doi.org/10.1177/10398562231165439 bagarić, b., jokić-begić, n., & sangster jokić, c. (2022). the nocebo effect: a review of contemporary experimental research. international journal of behavioral medicine, 29(3), 255-265. https://doi.org/10.1007/s12529-021-10016-y behrman, s., & crockett, c. (2023). severe mental illness and the perimenopause. bjpsych bulletin, 1–7. doi:10.1192/bjp.2023.89 58 cagnacci, a., & venier, m. (2019). the controversial history of hormone replacement therapy. medicina, 55(9), 602. https://doi.org/10.3390/medicina55090602 flores, v. a., pal, l., & manson, j. e. (2021). hormone therapy in menopause: concepts, controversies, and approach to treatment. endocrine reviews, 42(6), 720-752. https://doi.org/10.1210/endrev/bnab011 giannini, a., caretto, m., genazzani, a. r., & simoncini, t. (2021). neuroendocrine changes during menopausal transition. endocrines, 2(4), 405-416. https://doi.org/10.3390/endocrines2040036 goldštajn, m. š., mikuš, m., ferrari, f. a., bosco, m., uccella, s., noventa, m., ... & garzon, s. (2023). effects of transdermal versus oral hormone replacement therapy in postmenopause: a systematic review. archives of gynecology and obstetrics, 307(6), 1727-1745. https://doi.org/10.1007/s00404-022-06647-5 jin, j. (2017). vaginal and urinary symptoms of menopause. jama, 317(13), 1388-1388. kulkarni, j., gurvich, c., mu, e., molloy, g., lovell, s., mansberg, g., ... & szoeke, c. (2024). menopause depression: under recognised and poorly treated. australian & new zealand journal of psychiatry, 58(8), 636-640. manson, j. e., crandall, c. j., rossouw, j. e., chlebowski, r. t., anderson, g. l., stefanick, m. l., ... & prentice, r. l. (2024). the women’s health initiative randomized trials and clinical practice: a review. jama, 331(20):1748-1760. https://doi:10.1001/jama.2024.6542 marsden, j. (2022). the british menopause society consensus statement on the management of estrogen deficiency symptoms, arthralgia and menopause diagnosis in women with treated for early breast cancer. post reproductive health, 28(4), 199-210. raz, l., hunter, l. v., dowling, n. m., wharton, w., gleason, c. e., jayachandran, m., anderson, l., asthana, s. & miller, v. m. (2016). differential effects of hormone therapy on serotonin, vascular function and mood in the keeps. climacteric, 19(1), 49-59. https://doi.org/10.3109/13697137.2015.1116504 slavich, g. m., & sacher, j. (2019). stress, sex hormones, inflammation, and major depressive disorder: extending social signal transduction theory of depression to account for sex differences in mood disorders. psychopharmacology, 236(10), 3063-3079. stefaniak, m., dmoch-gajzlerska, e., jankowska, k., rogowski, a., kajdy, a., & maksym, r. b. (2023). progesterone and its metabolites play a beneficial role in affect regulation in the female brain. pharmaceuticals, 16(4), 520. https://doi.org/10.3390/ph16040520 59 wieczorek, k., targonskaya, a., & maslowski, k. (2023). reproductive hormones and female mental wellbeing. women, 3(3), 432-444. wilson, r. a. (1968). feminine forever. pocket books. ye, z., kappelmann, n., moser, s., smith, g. d., burgess, s., jones, p. b., & khandaker, g. m. (2021). role of inflammation in depression and anxiety: tests for disorder specificity, linearity and potential causality of association in the uk biobank. eclinicalmedicine, 38. https://doi.org/10.1016/j.eclinm.2021.100992 96 annals of applied psychophysiology june 2025 volume 12 methylation of the nr3c1 gene and behavior rebecca breitrick department of applied psychophysiology, saybrook university published online: june 2025 © the author(s) 2025 abstract background: methylation of the nr3c1 gene affects the glucocorticoid receptors, which are directly related to the stress response via the hpa axis. exposure to various stressors can lead to methylation, causing significant changes in how a person interacts with their environment. methods: a brief review was conducted of three research studies examining the interactions between the environment and the nr3c1 gene. results: research indicates an interplay between the type of stressor experienced, the degree of methylation, and an individual's level of resilience. nr3c1 methylation, which occurs in infants as a response to perinatal stressors, may be, at least temporarily, adaptive. in adolescents, nr3c1 methylation is affected by exposure to stressors and trauma. conclusion: methylation of the nr3c1 gene can occur in response to the environment, and these changes impact a person’s behavior to varying degrees. keywords: nr3c1, methylation, stressors introduction the nr3c1 gene encodes the glucocorticoid receptors, which play an essential role in the stress response of the hypothalamic-pituitary-adrenal (hpa) axis. methylation of the nr3c1 gene can affect cortisol circulation and glucocorticoid sensitivity (folger et al., 2019). methylation of the nr3c1 gene and resulting changes in cortisol concentrations can also affect reward processing in the brain, potentially affecting personal resilience and “susceptibility to environmental exposures and may result in different neurodevelopmental and behavioral outcomes” (xu et al., 2025, p.2). research has indicated that nr3c1 methylation has occurred in response to perinatal stress, childhood abuse, and neglect, or other traumas (van der knaap et al., 2014). however, there is still much to learn about how and why these epigenetic changes occur and the effects they may have. nr3c1 methylation, childhood maltreatment, and reward responsiveness a study completed by xu et al. (2025) examined the relationship between childhood maltreatment, methylation of the nr3c1 gene, and reward responsiveness. the researchers hypothesized that "the epi x e (epigenome x environment) interaction might work on rewp (reward positivity), gain-related delta and self-reported rr (reward responsiveness) but not lossrelated theta" (p. 3). their hypothesis asserted that these interactions would relate to experiences of depression and anxiety and have a significant effect on the experience of anhedonia, a common symptom of depression defined as the inability to experience pleasure (xu et al., 2025). participants in the study included 192 young adults of both genders, of han descent, and with no diagnosed developmental, neurological, or significant physical disorders. the study included a baseline assessment and a follow-up assessment one year following. at baseline, participants completed the childhood trauma questionnaire, which assessed five types of maltreatment (sexual, emotional, or physical abuse and emotional or physical neglect). cheek swabs were used to analyze genomic dna, focused on methylation in the nr3c1 region. eeg data was collected while participants completed a computerized reward task, which included 40 gain and 40 loss trials. participants completed a self-reported rr scale to assess motivation and approach behaviors, and the beck depression inventory (bdi) and self-rating anxiety scale (sas) were used to assess depression and anxiety. at the one-year follow-up, the bdi and sas were repeated (xu et al., 2025). the results demonstrated a negative association between severity and number of exposures to childhood maltreatment and rewp in individuals with increased nr3c1 methylation but a positive association in individuals with "blunted" methylation (xu et al., p. 10). the epi x e effect was driven by emotional abuse and neglect but not by other types of maltreatment. interaction effects were linked to anhedonia but not to gain-related delta, lossrelated theta, or self-reported rr. the research did not demonstrate a linkage to total depression or anxiety ratings (xu et al., 2025). the authors concluded that the results of the study demonstrated some evidence for the epi x e model, noting that the effects of maltreatment seemed to be affected by type, severity, amount of maltreatment, and the amount of nr3c1 methylation. the results also demonstrated support for the "goodness-of-fit" model, which proposes that "some individuals might develop resilience when their characteristics can successfully deal with the stress; otherwise, the stress might defeat them and lead to dysfunction" (xu et al., 2025, p. 10). nr3c1 methylation and early development folger et al. (2019) reported on a pilot study completed with mother-child dyads participating in an early intervention home visit program. their hypothesis asserted that “the mean nr3c1 dnam (dna methylation) across 10 cpg (cytosine-guanine dinucleotides) sites in the promotor region would be significantly associated with subsequent infant social-emotional functioning” (folger et al., 2019, p. 2). the participants of this study included 53 adult mothers who were pregnant during the first visit of the study and then completed a second visit one month post-partum. follow-up assessment of some participating infants occurred at 6 and 18 months. there was a high drop-out rate due to a variety of factors. at the first visit, the edinburgh postnatal depression scale (epds) screened for major or minor depression in the mother, and the interpersonal support evaluation list (isel-40) measured the mother’s perceived interpersonal support. multiple cheek swabs were taken from the infants at the second visit to look for methylation in the nr3c1 region. the ages and stages questionnaire: social-emotional (asq:se) was used during the two follow-up visits to assess social-emotional function. (folger et al., 2019). the percentage of nr3c1 methylation and the asq:se scores at the 6-month mark. lower asq:se scores indicated higher functioning. at the 18-month mark, there continued to be a negative correlation, although it was no longer statistically significant. further analysis showed that specific cpg sites seemed to have the strongest associations with the asq:se scores (folger et al., 2019). folger et al. (2019) wrote this about their results: “increased dnam may reflect a compensatory response to prenatal adversity among some infants who have parents enrolled in an hv (home visit) program" (p. 7). they pointed out that while the increase in methylation may have served some protective functions, a larger study would be warranted to clarify this phenomenon. they also referred to another study that showed that, while methylation may be protective in one area of development, other areas may be adversely affected. (folger et al., 2019). nr3c1 methylation and stressful events over childhood and adolescence a study reported by van der knaap et al. (2014) used data collected through the tracking adolescents’ individual lives survey (trails) to examine the connection between nr3c1 methylation in adolescence and previous life stressors. the researchers hypothesized that “perinatal stress, many sles (stressful life events), and traumatic youth experiences would relate to higher nr3c1 methylation in adolescence" (van der knaap et al., 2014, p.2). the trails study followed over 2,000 male and female dutch youth from preadolescence into adulthood, collecting data every two or three years starting around age 11. van der knaap et al. (2014) focused their study on 468 participants who had, around age 16, undergone blood work to analyze dna. this group of participants, admittedly, included a disproportionate (66%) percentage of “high-risk adolescents” who were deemed more likely to experience mental health issues due to increased risk factors (van der knaap et al., 2014). interviews with parents and records review were used to determine exposure to perinatal stress. researchers gathered information about stressful life events and traumatic experiences via parental interviews or self-reports. stressful life events included things like parental divorce, death or illness of family or friends, lack of friends, hospitalization, etc. in contrast, traumatic events included sexual assault/abuse, physical abuse, life-threatening experiences, etc. (van der knaap et al., 2014). data analysis showed an association between stressful life events during adolescence, traumas, and higher methylation. however, results of this research did not show an association between methylation of nr3c1 and perinatal or childhood stress (van der knaap et al., 2014). the authors proposed that because these results conflict with past research demonstrating nr3c1 methylation associated with perinatal stress, further research was warranted to see if some epigenetic changes are short-term and reversible (van der knaap et al., 2014). van der knaap et al. (2014) acknowledged that it would have been helpful if dna was analyzed more than once to see if methylation changed over time and to help determine causation. conclusion there is much to learn about epigenetics and the relationship between genes and the environment. research into nr3c1 has shown that methylation can occur in response to the environment, and these changes can significantly impact how an individual continues to react to the environment. the research also demonstrates a need for further work to elucidate the specific mechanisms and effects. references folger, a. t., ding, l., ji, h., yolton, k., ammerman, r. t., van ginkel, j., b., & bowers, k. (2019). neonatal nr3c1 methylation and social-emotional development at 6 and 18 months of age. frontiers in behavioral neuroscience, 13, 14. https://10.3389/fnbeh.2019.00014 van der knaap, l. j., riese, h., hudziak, j. j., verbiest, m. m. p. j., verhulst, f. c., oldehinkel, a. j., & van oort, f. v. a. (2014). glucocorticoid receptor gene (nr3c1) methylation following stressful events between birth and adolescence. the trails study. translational psychiatry, 4(4), e381. https://10.1038/tp.2014.22 xu, y., yang, s., & cao, c. (2025). glucocorticoid receptor gene (nr3c1) methylation, childhood maltreatment, multilevel reward responsiveness, and depressive and anxiety symptoms: a neuroimaging epigenetic study. neuroimage (orlando, fla.), 306, 121003. https://10.1016/j.neuroimage.2025.121003 https://10.0.13.61/fnbeh.2019.00014 https://10.0.4.14/tp.2014.22 https://10.0.3.248/j.neuroimage.2025.121003 55 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v10.i2.2023.55-61 original article examining the impact of maternal stress on neonatal development: a psychophysiological insight syeda farah batool1 , sundeep2 & syed faizan qadri3 1department of psychology, malir university of science & technology, karachi-pakistan. 2department of medical technology, malir university of science & technology, karachipakistan. 3atia general hospital, karachi-pakistan. abstract background: maternal stress during pregnancy significantly influences neonatal development, impacting various physical, cognitive, and emotional aspects. this retrospective cross-sectional quantitative study aims to comprehensively examine the intricate relationship between maternal stress during pregnancy and its influence on neonatal outcomes. methodology: the study was conducted at aisha hospital, focusing on pregnant women who delivered between 18 june and 20 august. a cohort of 28 participants was selected from historical medical records. maternal stress during pregnancy was assessed using the validated sadaf stress scale (sss), categorized as low, moderate, or high. additionally, maternal age, socioeconomic status, medical history, and pregnancy-related complications were noted. neonatal outcomes, including birth weight, gestational age at birth, apgar scores, and documented complications, were considered dependent variables. data were collected from electronic medical records and analyzed using spss version 21.0. results: the study encompassed 28 participants, each characterized by maternal stress levels during pregnancy, birth weight, gestational age at birth, apgar score, and neonatal complications. maternal stress levels varied across participants, with corresponding impacts on neonatal outcomes. birth weights ranged from 2200 grams to 3900 grams, while gestational ages at birth spanned from 32 to 40 weeks. apgar scores varied from 4 to 9, reflecting varying degrees of newborn health immediately after birth. neonatal complications included respiratory distress, preterm birth, or a combination of both. conclusion: this study contributes to our understanding of the complex interplay between maternal stress during pregnancy and neonatal development. keywords maternal stress, neonatal development, impact, psychophysiology citation: batool sf, sandeep, qadri sf. examining the impact of maternal stress on neonatal development; a psychophysiological insight. app. 2023;10(2): 55-61 corresponding author email: farah@maliruniversity.edu.pk doi: 10.29052/2412-3188.v10.i2.2023.55-61 received 18/10/2023 accepted 27/11/2023 published 01/12/2023 copyright © the author(s). 2023. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v10.i2.2023. https://orcid.org/0000-0002-1344-6795 about:blank about:blank 56 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 introduction pregnancy stands as a transformative period characterized by intricate interplays between maternal health and fetal well-being. among the multitude of maternal factors that reverberate through the developmental trajectory of the fetus, maternal stress emerges as a focal point, drawing warranted attention for its profound implications on neonatal development. this study endeavors to delve deeper into the intricate web of influences surrounding maternal stress and its consequential impact on neonatal development, aiming to shed light on underlying mechanisms and long-term consequences2. the physiological cascade triggered by maternal stress, notably through the activation of the hypothalamic-pituitaryadrenal (hpa) axis, sets in motion a series of events culminating in heightened cortisol levels. these elevated cortisol levels, permeating through the placental barrier, intricately influence fetal brain development, thereby potentially shaping cognitive and emotional outcomes in neonates3. beyond the realm of physiology, maternal stress leaves indelible marks on the epigenetic landscape of the developing fetus, manifesting through intricate mechanisms such as dna methylation and histone modifications. these epigenetic alterations wield the power to orchestrate gene expression patterns, thus becoming implicated in a spectrum of neonatal health issues, ranging from preterm birth to developmental disorders4. the relationship between maternal stress and adverse neonatal outcomes extends further, encompassing physical manifestations such as preterm birth, low birth weight, and heightened susceptibility to infections. unraveling these intricate links is paramount in informing the development of targeted interventions aimed at mitigating such risks and safeguarding neonatal health5. prenatal stress transcends mere physiological manifestations, exerting profound repercussions on the structural and functional integrity of the developing fetal brain. such alterations hold the potential to reverberate through cognitive domains, imprinting lasting imprints that may endure into childhood, thus underscoring the urgency for early intervention and support mechanisms6-8. moreover, the insidious influence of maternal stress extends beyond the realm of physiology, casting shadows on the emotional and behavioral landscape of the developing child. from anxiety to depression and attentiondeficit/hyperactivity disorder (adhd), the spectrum of emotional and behavioral challenges underscores the imperative of addressing maternal stress as a cornerstone for optimizing neonatal outcomes9,10. in light of the multifaceted repercussions of maternal stress on neonatal development, the imperative to chart effective pathways for mitigation becomes abundantly clear11. prenatal care programs ought to transcend mere clinical assessments, embracing a holistic approach that integrates routine evaluations of maternal stress levels. armed with such insights, healthcare providers can proactively offer tailored support and interventions, thereby nurturing an environment conducive to optimal neonatal outcomes1,13. from incorporating behavioral interventions to fostering robust social support networks, the arsenal for alleviating 57 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 maternal stress during pregnancy stands poised to usher in transformative changes, ensuring a healthier trajectory for both mother and child14. methodology study design this research adopts a retrospective crosssectional quantitative study design to examine the intricate relationship between maternal stress during pregnancy and its influence on neonatal development. by employing this approach, the study aims to provide empirical evidence and numerical insights into the multifaceted dynamics linking maternal stress to neonatal outcomes at a specific point in time. setting the study focuses on pregnant women who delivered at aisha hospital between 18 june and 20 august. this deliberate selection of a specific medical facility ensures a focused examination of maternal stress and neonatal outcomes within a consistent healthcare setting, thereby enhancing the internal validity of the study. participant a carefully selected cohort of pregnant women forms the participant pool for this study. pregnant women with pre-existing serious medical conditions that could impact pregnancy outcomes, such as severe cardiovascular diseases or chronic hypertension, were excluded. multiple gestations, substance abuse issues, and pregnancy complications requiring specialized medical care beyond routine prenatal care were also grounds for exclusion. variables the primary independent variable in this study was maternal stress during pregnancy, assessed using the validated sadaf stress scale (sss), categorized as low, moderate, or high as per the scale scoring. additionally, maternal age, socioeconomic status, medical history, and pregnancy-related complications were noted. neonatal outcomes, including birth weight, gestational age at birth, apgar scores, and documented complications, were considered dependent variables. data sources/measurement maternal stress levels were assessed using the sadaf stress scale, a validated instrument comprising seven categories of stress symptoms. neonatal outcome data, along with maternal demographic and medical information, were meticulously collected from electronic medical records. bias efforts were made to mitigate biases in this study which included careful participant selection based on predefined criteria from historical medical records, and standardized data collection procedures. validated measurement tools, such as the sadaf stress scale, were employed to enhance data reliability and validity, minimizing measurement bias. study size the study included a cohort of 28 participants, selected based on availability from historical medical records. while sample size calculations were not conducted due to the retrospective nature of the study, efforts were made to ensure the inclusion of a diverse range of participants to capture various levels of maternal stress and neonatal outcomes. quantitative variables quantitative variables include maternal stress scores measured using the sss and various neonatal outcome measures such as birth weight, gestational age at birth, apgar scores, and documented complications. 58 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 statistical methods data analysis was conducted using the statistical software spss version 21.0. descriptive statistics were computed for outcome variables. result participants the study involved a cohort of 28 participants, each providing vital insights into the intricate relationship between maternal stress during pregnancy and neonatal outcomes. these participants were carefully selected to represent a spectrum of maternal stress levels, encompassing low, moderate, and high stress categories. descriptive data maternal stress levels were not uniform across the cohort, illustrating the diverse experiences during pregnancy. some participants reported low levels of stress, while others experienced moderate or high levels of stress, reflecting the complexity of maternal psychological well-being during gestation. birth weights among the newborns ranged from 2200 grams to 3900 grams, demonstrating variability in fetal growth and development. similarly, gestational ages at birth ranged from 32 weeks to 40 weeks, highlighting differences in the duration of pregnancy among the participants. apgar scores, crucial indicators of newborn health immediately after birth, exhibited a range from 4 to 9, illustrating variations in the initial physiological adaptation of the neonates. outcome data neonatal complications observed in the study encompassed a spectrum of issues, including respiratory distress, preterm birth, or a combination of both. these complications shed light on the multifaceted nature of perinatal health outcomes and the potential impact of maternal stress on fetal and neonatal wellbeing. main results the findings of the study underscore the significant associations between maternal stress during pregnancy and neonatal outcomes. for instance, participant 2, characterized by high maternal stress, delivered a newborn with a birth weight of 2900 grams at 38 weeks gestation who experienced respiratory distress, emphasizing the potential adverse effects of elevated maternal stress on fetal lung development and function. conversely, participant 9, with low maternal stress, delivered a robust newborn weighing 3900 grams at 39 weeks gestation, with an optimal apgar score of 9 and no reported complications, highlighting the potential protective effects of maternal psychological well-being on neonatal health outcomes. table 1: maternal stress levels and neonatal outcomes. participant maternal stress level birth weight (grams) gestational age apgar score neonatal complications 1. moderate 3200 39 weeks 9 none 2. high 2900 38 weeks 5 respiratory distress 3. low 3400 40 weeks 9 none 4. moderate 3100 39 weeks 8 preterm birth 59 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 5. high 2400 35 weeks 6 preterm birth/ respiratory distress 6. high 2300 32 weeks 4 preterm birth/ respiratory distress 7. moderate 2900 34 weeks 6 respiratory distress 8. moderate 2400 37 weeks 6 respiratory distress 9. low 3900 39 weeks 9 none 10. high 2400 32 weeks 5 preterm birth/ respiratory distress 11. low 3900 39 weeks 8 none 12. low 3800 36 weeks 9 none 13. moderate 2900 39 weeks 9 none 14. moderate 3900 38 weeks 8 none 15. moderate 2600 40 weeks 8 none 16. low 3300 36 weeks 9 respiratory distress 17. high 2200 35 weeks 5 preterm birth/ respiratory distress 18. low 3200 36 weeks 8 none 19. low 3400 40 weeks 9 none 20. high 2700 32 weeks 6 respiratory distress 21. moderate 2900 36 weeks 9 none 22. moderate 3900 36 weeks 9 none 23. moderate 2900 38 weeks 6 preterm birth/ respiratory distress 24. moderate 3700 36 weeks 9 none 25. moderate 2800 34 weeks 8 none 26. low 3600 35 weeks 6 respiratory distress 27. low 3600 38 weeks 9 none 28. high 2400 34 weeks 4 preterm birth/ respiratory distress discussion the impact of maternal stress on neonatal health, including factors such as apgar scores and gestational period, is a topic of significant concern within the field of perinatal medicine. numerous studies have investigated the potential consequences of maternal stress during pregnancy on various aspects of neonatal outcomes, shedding light on the intricate relationship between maternal well-being and infant health. research findings consistently indicate that maternal stress during pregnancy can influence neonatal health outcomes. several studies have reported associations between maternal stress and adverse neonatal outcomes, including low apgar scores and preterm birth. apgar scores, a standard measure used to assess the health of newborns immediately after birth, reflect vital signs such as heart rate, respiratory effort, muscle tone, reflex irritability, and color. low apgar scores, typically defined as scores below 7 at 1 and 5 minutes after birth, are indicative of neonatal distress and may 60 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 signal the need for immediate medical intervention15. furthermore, maternal stress has been linked to an increased risk of preterm birth, defined as birth occurring before 37 weeks of gestation. preterm birth is a leading cause of neonatal morbidity and mortality, with preterm infants facing higher risks of respiratory distress syndrome, infections, neurological complications, and long-term developmental impairments16. studies have demonstrated associations between maternal psychosocial stressors, such as financial strain, marital conflict, and traumatic life events, and an elevated risk of preterm birth17. while the exact mechanisms underlying the relationship between maternal stress and neonatal health outcomes remain complex and multifactorial, several pathways have been proposed. chronic activation of the maternal hpa axis and dysregulated cortisol levels may influence placental function, leading to impaired fetal growth and development18. additionally, maternal stress-induced alterations in inflammatory pathways and immune function may contribute to adverse pregnancy outcomes, including preterm birth and low birth weight19. despite the challenges posed by maternal stress on neonatal health, interventions aimed at mitigating these effects have shown promise. psychosocial support programs, stress reduction techniques, and prenatal interventions targeting maternal well-being have been associated with improved neonatal outcomes, including higher apgar scores and reduced rates of preterm birth20,21. conclusion in conclusion, maternal stress during pregnancy exerts a significant influence on neonatal health outcomes, including apgar scores and gestational period. understanding the impact of maternal stress on neonatal health is crucial for identifying at-risk pregnancies and implementing targeted interventions to optimize maternal well-being and infant outcomes. acknowledgment special thanks are extended to dr. sadaf ahmed for her guidance, which greatly contributed to the development of this article. references 1. andersson l, sundström-poromaa i, wulff m, aström m, bixo m. depression and anxiety during pregnancy and six months postpartum: a follow-up study. acta obstet gynecol scand. 2006;85(8):937–944. 2. chung ek, mccollum kf, elo it, lee hj, culhane jf. maternal depressive symptoms and infant health practices among lowincome women. pediatrics. 2004;113(6):e523– 9. 3. cohen s, williamson g. perceived stress in a probability sample of the united states. in s. spacapan & s. oskamp (eds.), the social psychology of health: claremont symposium on applied social psychology; 1988 (pp. 31– 67). sage publications, inc. 4. diego ma, jones na, field t, hernandezreif m, schanberg s, kuhn c, gonzalezgarcia a. maternal psychological distress, prenatal cortisol, and fetal weight. psychosom med. 2006;68(5):747–753. 5. dunkel schetter c, lobel m. pregnancy and birth outcomes: a multilevel analysis of prenatal maternal stress and birth weight. in: dunkel schetter kl, editor. stress processes across the life course. emerald group publishing limited; 2012. pp. 185–208. 6. glynn lm, wadhwa pd. dunkel schetter, c. pregnancy: a stress test for life. curr dir psychol sci. 2011;20(5):295–299. 61 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 10 issue 2 7. kramer ms, lydon j, séguin l, goulet l, kahn sr, mcnamara h, genest j, dassa c, chen mf, sharma s, meaney mj. stress pathways to spontaneous preterm birth: the role of stressors, psychological distress, and stress hormones. am j epidemiol. 2009;169(11):1319–1326. 8. luecken lj. maternal stress in pregnancy: effects on child health outcomes. in: stanton al, baum a, editors. stress and health: biological and psychological interactions. 2nd ed. sage publications, inc.; 2008. pp. 273– 291. 9. nast i, bolten m, meinlschmidt g, hellhammer dh, howald h. maternal psychosocial stress during pregnancy and placenta weight: evidence from a national cohort study. plos one. 2013;8(4):e0061291. 10. orr st, blazer dg, james sa. racial disparities in elevated prenatal depressive symptoms among black and white women in eastern north carolina. ann epidemiol. 2006;16(6):463–468. 11. ruiz rj, fullerton j, brown ce, dudley dj. predicting risk of preterm birth: the roles of stress, clinical risk factors, and corticotropinreleasing hormone. biol res nurs. 2002;4(1):54–64. 12. sable mr, wilkinson ds, robertson pa. pregnancy wantedness and adverse pregnancy outcomes: differences by race and medicaid status. fam plann perspect. 2006;38(3):127–136. 13. silveira ml, ertel ka, dole n, chasan-taber l, rich-edwards jw. the role of body mass index in the association between prenatal stress and gestational age at delivery. am j epidemiol. 2011;174(8):983–991. 14. yonkers ka, smith mv, forray a, epperson cn, costello d, lin h, belanger k. pregnant women with posttraumatic stress disorder and risk of preterm birth. jama psychiatry. 2014;71(8):897–904. 15. casey bm. the apgar score. obstet gynecol. 2019;134(5):e128–45. 16. goldenberg rl, culhane jf, iams jd, romero r. epidemiology and causes of preterm birth. lancet. 2008;371(9606):75–84. 17. wadhwa pd, entringer s, buss c, lu mc. the contribution of maternal stress to preterm birth: issues and considerations. clin perinatol. 2009;36(3):555–568. 18. monk c, et al. fetal developmental origins of future psychopathology: mechanisms and pathways. annu rev clin psychol. 2016;12:355–379. 19. entringer s, buss c, swanson jm, cooper dm, wing da, waffarn f, wadhwa pd. fetal programming of body composition, obesity, and metabolic function: the role of intrauterine stress and stress biology. j nutr. metab. 2012; article id 632548. 20. glover v, o’connor tg, o’donnell k. prenatal stress and the programming of the hpa axis. neurosci biobehav rev. 2010;35(1):17–22. 21. guardino cm, dunkel schetter c, bower je, lu mc, smalley sl. randomised controlled pilot trial of mindfulness training for stress reduction during pregnancy. psychol health. 2014;29(3):334–349. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v10.i2.2023.54-60 20 20-24 annals of applied psychophysiology december 2024 volume 11 the efficacy of biofeedback-integrated ambient lighting in stress and anxiety reduction ujala sajid1, shamoon noushad2, & sadaf ahmed1 published online: december 2024 © the author(s) 2024 abstract background: stress and mental health issues are prevalent concerns in pakistan, particularly among women. traditional biofeedback methods require focused attention, which can be impractical in clinical settings. ambient lighting provides a non-invasive and innovative approach to biofeedback, enhancing both aesthetic and therapeutic experiences. this study examines the integration of biofeedback with ambient lighting to aid in stress management and relaxation. methodology: twelve participants (six females and six males, aged 25 to 35 years) from researchrelated university positions at malir university of science and technology, were exposed to a biofeedback-driven lighting system during a timed arithmetic task. the participants completed the task under three conditions: (1) no biofeedback (control), (2) warm-toned lighting biofeedback, and (3) cool-toned lighting biofeedback. the system was connected to the alive gmp8 biofeedback device, which monitored heart rate variability (hrv) to adjust lighting parameters in real time. stress levels were measured using the perceived stress scale (pss), and anxiety levels were assessed using the state-trait anxiety inventory (stai). the experiment followed a withinsubject design with counterbalancing to avoid carry-over effects. paired t-tests were used to analyze changes in pss and stai scores, with a significance level set at p < 0.01. results: the biofeedback-driven lighting system demonstrated significant improvements in stress and anxiety measures. for the warm-toned lighting condition, the mean pss score decreased from 29.3 (sd = 2.13) to 21.1 (sd = 2.81), and the stai score decreased from 57.2 (sd = 3.10) to 45.0 (sd = 3.21), with mean differences of 8.2 and 12.2, respectively (p < 0.01). under the cool-toned lighting condition, the mean pss score decreased from 28.8 (sd = 2.17) to 20.8 (sd = 2.39), and the stai score decreased from 56.3 (sd = 3.00) to 44.3 (sd = 3.04), with mean differences of 8.0 and 12.0, respectively (p < 0.01). participants reported enhanced stress awareness, improved relaxation, and a preference for the biofeedback lighting conditions over the control condition. conclusion: the biofeedback-driven lighting approach shows promise as a tool for stress management and relaxation in pakistani healthcare and research settings. its non-invasive and user-friendly design provides a valuable addition to mental health support strategies. further research with larger, more diverse samples is recommended to validate these findings. keywords: biofeedback, ambient lighting, stress management, anxiety reduction, perceived stress scale (pss), state-trait anxiety inventory (stai), heart rate variability (hrv) 1. ujala sajid and sadaf ahmed university of karachi, psychophysiology research lab, karachi, pakistan 2. shamoon noushad malir university of science & technology, department of psychology 21 introduction stress and anxiety are among the most pressing global health concerns, affecting individuals across diverse demographics1. in pakistan, the burden of mental health challenges is particularly pronounced, with women facing heightened vulnerabilities due to sociocultural expectations, economic instability, and limited access to mental health resources2. these issues not only impact individual well-being but also impose significant social and economic costs. consequently, the need for accessible, effective, and scalable stress management strategies has become increasingly urgent3. traditional biofeedback techniques, while proven to be effective, require considerable time and focused attention4. such methods often demand specialized equipment and trained personnel, making them less feasible in resource-limited healthcare environments5. this gap necessitates innovative solutions that are both cost-effective and user-friendly. in this context, biofeedbackintegrated ambient lighting has emerged as a promising alternative. ambient lighting’s ability to influence mood, stress, and physiological states through subtle environmental adjustments offers an appealing, non-invasive approach to enhancing mental well-being6. research suggests that heart rate variability (hrv), a reliable indicator of stress and relaxation states, can be effectively used as a biofeedback parameter7. by integrating hrv monitoring with ambient lighting systems, real-time adjustments to lighting parameters can create environments conducive to stress reduction8. warm-toned lighting, often associated with comfort and relaxation, has been shown to lower perceived stress levels, while cool-toned lighting may provide a calming and focused atmosphere. these lighting conditions, when dynamically adjusted based on physiological feedback, have the potential to amplify relaxation responses without requiring active participation from the user9. this study investigates the efficacy of biofeedback-driven ambient lighting systems in reducing stress and anxiety among university professionals. by leveraging a controlled experimental design, it aims to evaluate changes in perceived stress and anxiety levels under different lighting conditions. the findings of this research have the potential to inform the development of innovative, scalable interventions for mental health support, particularly in settings with limited access to traditional biofeedback resources. furthermore, the integration of aesthetic and therapeutic elements in stress management strategies could enhance user engagement and adherence, paving the way for broader applications in healthcare and beyond. methodology participants twelve participants (six females and six males, aged 25 to 35 years) were recruited from research-related university positions at malir university of science and technology. inclusion criteria required participants to have no prior clinical diagnosis of stress-related disorders and no visual impairments. procedure participants performed a timed arithmetic task under three experimental conditions: 1. control: no biofeedback or lighting modulation. 2. warm-toned lighting biofeedback: ambient lighting adjusted in real-time based on hrv measurements to warmer tones. 22 3. cool-toned lighting biofeedback: ambient lighting adjusted in real-time based on hrv measurements to cooler tones. the alive gmp8 biofeedback device recorded hrv, which informed the lighting adjustments. stress and anxiety levels were assessed before and after each condition using the perceived stress scale (pss)10 and state-trait anxiety inventory (stai)11, respectively. the experiment employed a within-subject design, with counterbalancing to mitigate potential carry-over effects. statistical analysis paired t-tests were conducted using spss version 22.0, to compare preand post-condition pss and stai scores, with a significance threshold set at p < 0.01. results the study examined the impact of biofeedback-driven ambient lighting on stress and anxiety levels, as measured by the perceived stress scale (pss) and the state-trait anxiety inventory (stai). the findings are summarized in table 1 below. table 1: changes in pss and stai scores across conditions condition measure pre-test mean (sd) post-test mean (sd) mean difference p-value warm-toned lighting pss 29.3 (2.13) 21.1 (2.81) 8.2 <0.01 stai 57.2 (3.10) 45.0 (3.21) 12.2 <0.01 cool-toned lighting pss 28.8 (2.17) 20.8 (2.39) 8.0 <0.01 stai 56.3 (3.00) 44.3 (3.04) 12.0 <0.01 control (no biofeedback) pss 29.0 (2.21) 28.7 (2.25) 0.3 n.s. stai 57.0 (3.12) 56.8 (3.20) 0.2 n.s. participants reported greater relaxation, improved awareness of their stress levels, and a preference for the warmand cool-toned biofeedback lighting conditions compared to the control condition. they noted that the dynamic adjustment of lighting enhanced the calming effects of the environment, contributing to a more engaging and therapeutic experience. discussion the findings highlight the potential of biofeedback-integrated ambient lighting as a viable stress management tool. both warm-toned and cool-toned lighting conditions demonstrated significant reductions in perceived stress and anxiety, as evidenced by pss and stai scores. these effects are likely attributable to the physiological and psychological impacts of real-time hrvbased feedback, which dynamically adjusts environmental factors to optimize relaxation12,13. warm-toned lighting exhibited slightly greater efficacy in reducing stress and anxiety, consistent with prior research linking warmer hues to comfort and tranquility14. cool-toned lighting, while also effective, may provide additional benefits in enhancing focus and mental clarity. this distinction underscores the importance of tailoring biofeedback-driven lighting interventions to specific therapeutic contexts15. 23 participants’ subjective feedback further supports the feasibility and acceptability of this approach. the integration of biofeedback with ambient lighting offers a passive, non-invasive means of fostering relaxation, making it particularly suitable for resource-limited or high-stress environments16,17. unlike traditional biofeedback methods that require active engagement, this system facilitates stress reduction without placing additional cognitive demands on users18. nevertheless, the study is not without limitations. the small, homogeneous sample restricts the generalizability of the findings. additionally, the short duration of the intervention precludes assessment of long-term efficacy. future research should address these limitations by incorporating larger, more diverse populations and extended study periods. exploring variations in lighting intensity, color temperature, and task difficulty could further refine the application of biofeedback-driven ambient lighting19. in conclusion, this study demonstrates the promise of biofeedback-integrated ambient lighting as an innovative tool for stress and anxiety management. its non-invasive, user-friendly design provides a valuable addition to mental health strategies, particularly in settings with limited access to traditional biofeedback resources. continued investigation into its mechanisms and applications is essential to unlocking its full potential. conclusion this study demonstrates the efficacy of biofeedback-integrated ambient lighting in reducing stress and anxiety. the non-invasive, user-friendly nature of this approach makes it a promising addition to mental health strategies in pakistani healthcare and research settings. further investigations with larger samples and diverse contexts are warranted to expand its application. references 1. yu b, hu j, funk m, feijs l. delight: biofeedback through ambient light for stress intervention and relaxation assistance. personal and ubiquitous computing. 2018 aug; 22:787-805. 2. consolvo s, roessler p, shelton be. the carenet display: lessons learned from an in-home evaluation of an ambient display. ininternational conference on ubiquitous computing 2004 sep 7 (pp. 1-17). berlin, heidelberg: springer berlin heidelberg. 3. eggen b, van mensvoort k. making sense of what is going on ‘around’: designing environmental awareness information displays. awareness systems: advances in theory, methodology and design. 2009:99-124. 4. bakker s, van den hoven e, eggen b. peripheral interaction: characteristics and considerations. personal and ubiquitous computing. 2015 jan;19(1):239-54. 5. occhialini v, van essen h, eggen b. design and evaluation of an ambient display to support time management during meetings. inhuman-computer interaction–interact 2011: 13th ifip tc 13 international conference, lisbon, portugal, september 5-9, 2011, proceedings, part ii 13 2011 (pp. 263-280). springer berlin heidelberg. 6. al osman h, eid m, el saddik a. u-biofeedback: a multimedia-based reference model for ubiquitous biofeedback systems. multimedia tools and applications. 2014 oct; 72:3143-68. 7. reiner r. integrating a portable biofeedback device into clinical practice for patients with anxiety disorders: results of a pilot study. applied psychophysiology and biofeedback. 2008 mar;33(1):55-61. 24 8. lande rg, williams lb, francis jl, gragnani c, morin ml. efficacy of biofeedback for post-traumatic stress disorder. complementary therapies in medicine. 2010 dec 1;18(6):2569. 9. moraveji n, olson b, nguyen t, saadat m, khalighi y, pea r, heer j. peripheral paced respiration: influencing user physiology during information work. inproceedings of the 24th annual acm symposium on user interface software and technology 2011 oct 16 (pp. 423428). 10. reis rs, hino aa, añez cr. perceived stress scale. j. health psychol. 2010;15(1):107-14. 11. knowles ka, olatunji bo. specificity of trait anxiety in anxiety and depression: metaanalysis of the state-trait anxiety inventory. clinical psychology review. 2020 dec 1; 82:101928. 12. vidyarthi j, riecke be, gromala d. sonic cradle: designing for an immersive experience of meditation by connecting respiration to music. inproceedings of the designing interactive systems conference 2012 jun 11 (pp. 408-417). 13. müller h, kazakova a, pielot m, heuten w, boll s. ambient timer–unobtrusively reminding users of upcoming tasks with ambient light. inhuman-computer interaction–interact 2013: 14th ifip tc 13 international conference, cape town, south africa, september 2-6, 2013, proceedings, part i 14 2013 (pp. 211-228). springer berlin heidelberg. 14. schnädelbach h, irune a, kirk d, glover k, brundell p. exobuilding: physiologically driven adaptive architecture. acm transactions on computer-human interaction (tochi). 2012 dec 1;19(4):1-22. 15. fortmann j, stratmann tc, boll s, poppinga b, heuten w. make me move at work! an ambient light display to increase physical activity. in2013 7th international conference on pervasive computing technologies for healthcare and workshops 2013 may 5 (pp. 274277). ieee. 16. jones br, benko h, ofek e, wilson ad. illumiroom: immersive experiences beyond the tv screen. communications of the acm. 2015 may 21;58(6):93-100. 17. ståhl a, jonsson m, mercurio j, karlsson a, höök k, banka johnson ec. the soma mat and breathing light. inproceedings of the 2016 chi conference extended abstracts on human factors in computing systems 2016 may 7 (pp. 305-308). 18. snyder j, matthews m, chien j, chang pf, sun e, abdullah s, gay g. moodlight: exploring personal and social implications of ambient display of biosensor data. inproceedings of the 18th acm conference on computer supported cooperative work & social computing 2015 feb 28 (pp. 143-153). 19. mcduff dj, hernandez j, gontarek s, picard rw (2016) cogcam: contact-free measurement of cognitive stress during computer tasks with a digital camera. inproceedings of the 2016 chi conference on human factors in computing systems, acm, pp 4000–4004. 42 42-51 annals of applied psychophysiology december 2024 volume 11 exploring the impact of different yoga practices on psychological resources and emotional well-being: a single-session study yusra saleem 1 , shamoon noushad 1 & sadaf ahmed 2 published online: december 2024 © the author(s) 2024 abstract background: yoga is a widely practiced mind-body intervention known for its benefits in improving mental and emotional well-being. its components including physical postures, breathwork, and meditation are believed to enhance psychological resources such as mindfulness and body consciousness, while promoting emotional regulation. however, the immediate effects of different yoga styles on these outcomes, particularly in individuals with minimal prior experience, are not well-understood. objective: this study aimed to examine the immediate effects of three yoga styles hatha, vinyasa, and restorative on psychological resources (hope, resilience, efficacy, and optimism) and emotional well-being (positive and negative affect). by evaluating a single yoga session, the study sought to assess how each style influences psychological and emotional outcomes in a short-term context. methodology: ninety participants, aged 18–60 years with limited yoga experience, were randomly assigned to one of the three yoga groups. each group participated in a 60-minute session specific to their assigned style: hatha, vinyasa, or restorative. preand post-session assessments were conducted using the psychological capital questionnaire (pcq) for psychological resources and the positive and negative affect schedule (panas) for emotional well-being. statistical analysis included paired t-tests and one-way anova. results: all three yoga styles led to significant improvements in psychological resources. hatha and vinyasa yoga showed the most significant gains in hope, resilience, efficacy, and optimism. restorative yoga resulted in the greatest improvements in emotional well-being, particularly in positive affect (md = 10.2) and negative affect (md = -8.7). hatha and vinyasa also demonstrated positive effects, though to a lesser extent than restorative yoga. conclusion: this study highlights the differential effects of yoga styles on mental health outcomes. hatha and vinyasa yoga were most effective for enhancing psychological resources, while restorative yoga excelled in improving emotional well-being. keywords: yoga, mental health, psychological resilience, emotional well-being, mindfulness 1. yusra saleem & shamoon noushad malir university of science & technology, department of psychology 2. sadaf ahmed university of karachi, psychophysiology research lab, karachi, pakistan 43 introduction yoga, a comprehensive mind-body practice, has long been celebrated for its beneficial effects on mental and emotional well-being. its integration of physical postures, breathwork, and meditation has been shown to positively impact a range of psychological and emotional outcomes. yoga practice is associated with enhanced psychological resources, such as mindfulness, body consciousness, self-transcendence, spiritual peace, and social connectedness. these psychological mechanisms are believed to mediate yoga's salutary effects on emotional regulation and overall well-being (1). despite the growing evidence, our understanding of how these mechanisms interact and contribute to emotional benefits remains limited. the therapeutic potential of yoga is underscored by its impact on emotional states, particularly in reducing negative affect and fostering positive emotions. studies have documented that yoga not only alleviates anxiety and depression but also enhances emotional states like tranquility and engagement. for example, randomized controlled trials (rcts) have demonstrated that yoga is effective in reducing negative emotions such as anxiety and physical exhaustion while improving positive emotions like revitalization and engagement (2). even a single session of yoga has been found to induce significant mood improvements, with increased positive emotions and reduced exhaustion reported across various populations (3). these findings align with the broader literature, which suggests that yoga can be an effective intervention for improving emotional well-being, even with brief exposure. understanding the mechanisms underlying these effects is essential for optimizing yogabased interventions. the proposed mechanisms often revolve around yoga’s ability to cultivate mindfulness and body consciousness, both of which enhance awareness and acceptance of the present moment. other pathways include fostering self-transcendence, which provides a sense of unity with the world; spiritual peace, which promotes inner harmony; and social connectedness, which improves interpersonal relationships. these mechanisms are believed to influence emotional outcomes by enhancing psychological resources that aid coping and emotional regulation (1,4). although there is evidence suggesting that yoga can enhance mindfulness and body consciousness, studies explicitly testing the mechanisms through which yoga exerts its effects are scarce, and findings remain inconsistent (5,6). furthermore, other proposed mechanisms such as self-transcendence and spiritual peace have received limited empirical attention despite their long-standing connection to yoga practice (7,8). the variety of yoga styles further contributes to its wide-ranging effects (9). hatha yoga emphasizes static postures and controlled breathing, fostering stability and mindfulness. vinyasa yoga involves dynamic sequences that integrate movement with breath, promoting physical engagement and focus. restorative yoga, in contrast, centers on relaxation and stress relief through passive poses. while these styles vary in their approach, their differential impacts on psychological mechanisms and emotional outcomes remain an area of active investigation. a few studies have suggested that yoga styles may engage different psychological pathways, yet comprehensive studies examining how specific styles affect emotional well-being and psychological resources are limited (10-13). 44 this study builds on the existing literature by exploring how a single session of yoga affects psychological resources and emotional well-being in individuals with minimal prior experience. specifically, it examines three styles of yoga hatha, vinyasa, and restorative to determine their immediate effects on hope, resilience, efficacy, and optimism, as well as positive and negative affect. by focusing on the acute impacts of yoga, the study aims to contribute to the growing body of evidence on yoga as a practical, accessible tool for enhancing mental health. given the differential effects of various yoga styles, understanding their unique contributions could inform targeted interventions that optimize both emotional and psychological outcomes in diverse populations. methodology study design the study employed a single session, randomized controlled design to evaluate the immediate effects of three yoga styles hatha, vinyasa, and restorative on psychological resources and emotional well-being. ethics ethical approval was secured from the institutional review board of malir university of science & technology. all participants provided written informed consent prior to their inclusion in the study, ensuring compliance with ethical standards. setting the study was conducted at koohi goth hospital, where the sessions were organized in a controlled environment to ensure consistency. certified yoga instructors facilitated all yoga classes, adhering to standardized protocols specific to each style of yoga. participants a total of 90 participants were recruited and randomized into three groups of 30, each corresponding to one yoga style i.e. hatha, vinyasa, or restorative yoga. participants were adults aged 18–60 years with minimal prior experience in yoga, defined as no more than five yoga sessions attended in the past year. all participants demonstrated the ability to provide informed consent, follow study instructions, and commit to attending a single yoga session. participants with severe physical injuries, medical conditions, recent diagnoses of major psychiatric disorders, pregnancy or recent childbirth (within six months), current use of recreational drugs or alcohol, or those participating in other psychological or emotional interventions were excluded from the study. procedures each participant attended a single 60-minute session of their assigned yoga style. the classes were structured to reflect the distinct characteristics of each yoga form, ensuring consistency and fidelity to the intervention. • hatha yoga: this session focused on static physical postures and gentle stretching to promote physical stability and mindfulness. participants were guided through a series of foundational poses (asanas) such as mountain pose, downward dog, and warrior pose, 45 with an emphasis on holding each posture for extended periods. the instructor encouraged controlled breathing (pranayama) to enhance body awareness and relaxation. • vinyasa yoga: this session emphasized dynamic, flowing sequences of poses linked to breath. participants engaged in synchronized movements transitioning seamlessly between postures, such as sun salutations, warrior flows, and plank-to-chaturanga-to-upward dog sequences. the class was moderately paced to stimulate both physical activation and mental focus, encouraging participants to align their movements with steady inhalations and exhalations. • restorative yoga: this session centered on relaxation and stress reduction through prolonged, passive poses supported by props (e.g., bolsters, blankets, and blocks). participants were guided into deeply restful positions, such as supported child's pose and reclining bound angle pose, holding each for 5–10 minutes. the instructor created a calming environment using soft lighting and soothing music, promoting mindfulness and release of tension. each session concluded with a guided relaxation exercise or a brief meditation to consolidate the benefits of the practice. variables the independent variable was the type of yoga practice (hatha, vinyasa, or restorative). dependent variables included scores on psychological resources and emotional well-being. psychological resources were assessed using the psychological capital questionnaire (pcq), which measures hope, efficacy, resilience, and optimism, while emotional well-being was measured using the positive and negative affect schedule (panas), assessing positive and negative affective states. data sources and measurements data was collected before and immediately after the yoga sessions and documented using a structured proforma. the pcq, a 24-item scale rated on a 6-point likert scale, was used to assess psychological resources, with higher scores indicating greater psychological capital. emotional well-being was measured using the panas, a 20-item scale rated on a 5-point likert scale, where higher scores indicated stronger positive or negative affective states. bias to minimize selection and measurement bias, participants were randomized into groups using a web-based random number generator. standardized instructions and protocols were followed across all sessions to maintain consistency. statistical methods the statistical analysis was performed on spss 22.0. within-group differences in preand post-session scores were analyzed using paired t-tests. between-group differences in post-session outcomes were evaluated using one-way anova. a p<0.05 was considered statistically significant. 46 results psychological resources (pcq) the study revealed significant improvements in psychological resources, including hope, resilience, efficacy, and optimism, across participants practicing hatha, vinyasa, and restorative yoga. among the three styles, hatha and vinyasa yoga demonstrated the most consistent and significant enhancements across multiple dimensions. hatha yoga led to substantial gains in hope (p < 0.01) and resilience (p < 0.01), indicating its strong capacity to enhance traits associated with emotional stability and coping. similarly, vinyasa yoga showed pronounced improvements in efficacy (p < 0.01) and optimism (p < 0.01), suggesting its effectiveness in fostering self-confidence and a positive outlook. restorative yoga also contributed to improvements, particularly in hope (p < 0.05), but its overall impact on resilience, efficacy, and optimism was less pronounced, with several non-significant results. when considering the total pcq scores, both hatha and vinyasa yoga significantly enhanced overall psychological resources (p < 0.01), while restorative yoga showed a smaller, non-significant increase. these findings highlight the differential benefits of yoga styles, with hatha and vinyasa offering more robust effects compared to restorative yoga, which appeared more modest in its impact. table 1: pre and post results of psychological resources (pcq) by yoga style variable yoga style pre-yoga mean (sd) post-yoga mean (sd) md pvalue1 pvalue2 pvalue3 pvalue4 hope hatha 18.0 (4.7) 21.4 (4.2) 3.4 < 0.01 vinyasa 17.5 (4.6) 19.5 (4.3) 2 0.04 restorative 18.2 (4.8) 20.5 (4.0) 2.3 < 0.05 resilience hatha 17.0 (4.8) 20.0 (4.5) 3 < 0.01 vinyasa 16.5 (4.5) 18.5 (4.4) 2 < 0.05 restorative 17.3 (4.6) 18.0 (4.1) 0.7 ns efficacy vinyasa 16.8 (4.4) 19.6 (4.2) 2.8 < 0.01 hatha 16.5 (4.3) 17.5 (4.1) 1 ns restorative 16.0 (4.5) 17.2 (4.3) 1.2 ns optimism vinyasa 17.0 (4.3) 20.2 (4.5) 3.2 < 0.01 hatha 16.7 (4.2) 18.0 (4.4) 1.3 0.02 restorative 17.5 (4.4) 18.5 (4.3) 1 ns total score hatha 17.5 (4.5) 19.6 (4.4) 2.1 < 0.01 ns ns ns vinyasa 17.0 (4.5) 19.6 (4.4) 2.6 < 0.01 restorative 17.3 (4.6) 18.8 (4.2) 1.5 ns md-mean difference 1within group; 2between groups hatha-vinyasa; 3between groups hatha-restorative; 4between groups vinyasarestorative 47 emotional well-being (panas) the results indicated significant improvements in emotional well-being across all yoga styles, particularly in positive and negative affect. positive affect restorative yoga participants experienced the most substantial increase in positive affect, with a mean difference (md) of 10.2 (p<0.001), followed by hatha yoga (md = 6.4, p<0.01) and vinyasa yoga (md = 5.7, p<0.01). restorative yoga's greater improvement in positive affect was statistically significant when compared to both hatha and vinyasa, suggesting it may be especially effective in fostering positive emotional states. negative affect restorative yoga also demonstrated the most significant reduction in negative affect, with an md of -8.7 (p<0.001). both hatha and vinyasa yoga showed notable decreases in negative affect, with mds of -4.8 (p<0.01) and -4.5 (p<0.01), respectively. these findings confirm that all three yoga styles contribute to reducing negative emotions, with restorative yoga having the most profound effect. overall, the results highlight that while all yoga styles positively impacted emotional wellbeing, restorative yoga led to the most significant improvements in both positive and negative affect. hatha and vinyasa also demonstrated beneficial effects, though to a lesser degree in comparison to restorative yoga. table 2: pre and post results of emotional well-being (panas) by yoga style variable yoga style pre-yoga mean (sd) post-yoga mean (sd) md pvalue1 pvalue2 pvalue3 pvalue4 positive affect restorative 24.5 (5.2) 34.7 (4.5) 10.2 < 0.001 ns 0.01 < 0.001 hatha 25.1 (5.0) 31.5 (4.8) 6.4 < 0.01 vinyasa 23.8 (5.3) 29.5 (5.1) 5.7 < 0.01 negative affect restorative 15.8 (4.9) 7.1 (3.3) -8.7 < 0.001 ns < 0.001 < 0.001 hatha 16.0 (5.1) 11.2 (4.6) -4.8 < 0.01 vinyasa 15.5 (5.0) 11.0 (4.5) -4.5 < 0.01 md-mean difference 1within group; 2between groups hatha-vinyasa; 3between groups hatha-restorative; 4between groups vinyasarestorative discussion this study aimed to examine the immediate effects of a single session of yoga on psychological resources and emotional well-being, focusing on three yoga styles i.e. hatha, vinyasa, and restorative. the findings revealed that yoga significantly enhances psychological resources, such as hope, resilience, efficacy, and optimism, while also improving emotional well48 being, including both positive and negative affect. these results are consistent with prior research indicating that yoga enhances emotional regulation and psychological resilience (1,2,14). however, while previous studies have reported improvements in psychological resources and emotional states following yoga practice, few have explored multiple potential mediators, allowing for a deeper understanding of how different resources contribute to emotional outcomes (3). the present findings align with previous research on the acute effects of yoga. prior studies have demonstrated that yoga improves mood, reduces anxiety, and enhances emotional well-being after a single session (3,15). in this study, both hatha and vinyasa yoga significantly improved psychological resources such as hope, resilience, efficacy, and optimism. these results support the work of park et al. (2020), which also showed that yoga enhances psychological capital, including resilience and optimism. notably, vinyasa yoga produced substantial improvements in efficacy and optimism, aligning with studies suggesting that dynamic yoga styles like vinyasa enhance self-confidence and emotional regulation (16,17). restorative yoga, which emphasizes relaxation, showed the most significant improvements in emotional well-being, particularly in reducing negative affect and enhancing positive affect. this finding is consistent with park et al. (2020), which proposed that different yoga styles affect distinct psychological mechanisms (1). restorative yoga’s focus on relaxation and stress relief likely contributed to its stronger effect on emotional states, reducing anxiety and increasing feelings of tranquility and engagement. the large improvements in both positive (md = 10.2) and negative affect (md = -8.7) observed in the restorative group reinforce the notion that yoga can be an effective intervention for stress reduction and emotional balance, particularly when relaxation is central to the practice (18). while hatha and vinyasa yoga also improved emotional well-being, their effects were less pronounced than restorative yoga. these findings highlight how different yoga styles target distinct aspects of emotional well-being. hatha and vinyasa yoga, with their emphasis on physical activity and dynamic movement, likely promote engagement and revitalization, while restorative yoga’s focus on relaxation is particularly effective in reducing negative affect and fostering tranquility. regarding psychological resources, hatha and vinyasa yoga showed the most significant improvements, aligning with prior studies that link yoga practice with enhanced psychological resources, such as mindfulness, body consciousness, and self-transcendence (1,19). vinyasa yoga, in particular, showed the greatest gains in efficacy and optimism, further supporting the idea that more physically demanding practices enhance self-confidence and a positive outlook (2). in contrast, restorative yoga, with its emphasis on relaxation, produced more modest gains in psychological resources like efficacy and resilience, but it was the most effective in enhancing emotional well-being. the differential impacts of the three yoga styles underscore the importance of understanding how specific components of yoga such as physical postures, breathwork, and 49 meditation contribute to its effects on emotional and psychological outcomes. these findings suggest that yoga can influence emotional well-being and psychological resources in different ways, depending on the style practiced. as such, individualized yoga interventions could be tailored to target specific emotional or psychological goals. future research should explore how different yoga styles influence specific psychological mechanisms, and whether the effects vary based on individual characteristics, such as experience level or baseline emotional state. however, several limitations must be considered. first, the study focused on a single session of yoga, and while immediate effects were observed, it remains unclear whether these effects are sustained over time. longitudinal studies are needed to assess the long-term benefits of yoga. additionally, the sample comprised individuals with minimal prior yoga experience, and the results may differ for experienced practitioners. the study also focused on a limited range of outcomes (emotions), and yoga's effects on other health indicators, such as pain or physical health, were not assessed. finally, the absence of a control group limits our ability to attribute the observed changes solely to yoga, as other factors, such as group dynamics or expectations, could have influenced the results. despite these limitations, the study provides valuable insights into the immediate effects of yoga on psychological resources and emotional well-being, suggesting that different yoga styles can have distinct impacts. future research should aim to replicate these findings and expand the scope of inquiry to explore additional outcomes and long-term effects. conclusion the findings of this study underscore the potential of yoga as an effective intervention for enhancing psychological resources and emotional well-being. while all three yoga styles demonstrated positive effects, restorative yoga was particularly effective in improving emotional well-being by reducing negative affect and enhancing positive emotions. hatha and vinyasa yoga, on the other hand, showed greater benefits in fostering psychological resources like resilience and optimism. these results contribute to the growing body of evidence on yoga's beneficial effects on mental health and highlight the importance of considering the specific components of yoga practice when designing interventions for emotional and psychological enhancement. conflicts of interest none. acknowledgement the authors would like to express their sincere gratitude to the participants of this study for their time, dedication, and willingness to contribute to this research. additionally, we would like to acknowledge the supporting staff at koohi goth hospital for their invaluable assistance in facilitating the study and ensuring its smooth execution. their support was instrumental in the success of this research. funding none. 50 references 1. park cl, finkelstein-fox l, groessl ej, elwy ar, lee sy. exploring how different types of yoga change psychological resources and emotional well-being across a single session. complementary therapies in medicine. 2020 mar 1;49:102354. 2. streeter cc, whitfield th, owen l, rein t, karri sk, yakhkind a, … & jensen je. effects of yoga versus walking on mood, anxiety, and brain gaba levels: a randomized controlled mrs study. the journal of alternative and complementary medicine. 2010 nov;16(11):1145–1152. 3. luu k, hall p. examining the acute effects of hatha yoga and mindfulness meditation on executive function and mood. mindfulness. 2016 oct;8(4):873–880. 4. riley ke, park cl. how does yoga reduce stress? a systematic review of mechanisms of change and a guide to future inquiry. health psychology review. 2015 dec;9(3):379–396. 5. kinser pa, goehler le, taylor ag. how might yoga help depression? a neurobiological perspective. explore: the journal of science and healing. 2012 mar-apr;8(2):118–126. 6. shelov dv, suchday s, friedberg jp. a pilot study measuring the impact of yoga on the trait of mindfulness. behavioural and cognitive psychotherapy. 2009 oct;37(5):595–598. 7. feuerstein g. the yoga tradition: its history, literature, philosophy and practice. prescott, az: hohm press; 2001. 8. büssing a, hestück a, khalsa s, ostermann t, heusser p. development of specific aspects of spirituality during a 6-month intensive yoga practice. evidence-based complementary and alternative medicine. 2012;2012:98152. 9. saleem y, noushad s, ahmed s, ansari b. psychophysiological biomarkers for the effects of yoga as an alternative therapy among healthcare professionals with chronic low back pain: a randomized controlled trial. journal of nature and science of medicine. 2024. [in press]. 10. mccall mc. how might yoga work? an overview of potential underlying mechanisms. journal of yoga & physical therapy. 2013 jan;3(1):1. 11. meister k, juckel g. a systematic review of mechanisms of change in body-oriented yoga in major depressive disorders. pharmacopsychiatry. 2018 mar;51(3):73–81. 12. kishida m, scherezade k, larkey lk, elavsky s. “yoga resets my inner peace barometer”: a qualitative study illuminating the pathways of how yoga impacts one’s relationship to oneself and to others. complementary therapies in medicine. 2018 oct;40:215–221. 13. ross a, bevans m, friedmann e, williams l, thomas s. “i am a nice person when i do yoga!!!” a qualitative analysis of how yoga affects relationships. journal of holistic nursing. 2013 apr;32(2):67–77. 14. tripathi k, swaroop s, arya a, pandey d, bhavsar a, dutt v. exploring the effects of yoga on self-esteem and emotional well-being in stressed college students: a randomized controlled trial. proceedings of the 17th international conference on pervasive technologies related to assistive environments; 2024 jun 26; pp. 640-646. 15. woodyard c. exploring the therapeutic effects of yoga and its ability to increase quality of life. int j yoga. 2011 jul;4(2):49–54. doi: 10.4103/0973-6131.85485. 16. sinpichetkorn t, chaunchaiyakul r, yang al, lin yy, masodsai k. effects of vinyasa yoga on stress and health benefits in office workers. journal of exercise physiology online. 2022 aug 1;25(4). 51 17. choi md, marks c, landis‐piwowar k, payter c. the effects of vinyasa yoga on cardiovascular and physical fitness as well as psychological profiles of well‐being. the faseb journal. 2017 apr;31:lb742-. 18. warden r. restorative yoga to increase mindfulness and reduce anxiety and burnout of inpatient mental health workers: a quality improvement project. doctor of nursing practice papers. 2024 jun 26. available from: https://ir.library.louisville.edu/dnp/152 19. pascoe mc, de manincor m, hallgren m, baldwin pa, tseberja j, parker ag. psychobiological mechanisms underlying the mental health benefits of yoga-based interventions: a narrative review. mindfulness. 2021 dec 1:1-3. 58 annals of applied psychophysiology december 2025 volume 13 ______________________________________________________________________________ psychophysiological effects of equine-assisted psychotherapy in trauma recovery: a review of current evidence brittin palmer ph.d. student, department of applied psychophysiology college of integrative medicine and health sciences saybrook university published online: december 2025 © the author(s) abstract background: equine-assisted psychotherapy (eap) has gained increasing attention as a clinically grounded intervention for trauma recovery, yet the psychophysiological mechanisms underlying its effects remain insufficiently understood. this paper reviews current evidence on eap with a focus on outcomes relevant to stress physiology, including changes in cortisol, heart-rate variability (hrv), and oxytocin, along with associated psychological and behavioral improvements. methods: research in adolescents, adults, and veteran populations suggests that eap may support emotion regulation, interpersonal functioning, and reductions in trauma-related symptoms. preliminary biomarker data indicate patterns consistent with improved autonomic and hpa-axis regulation, particularly decreases in cortisol and increases in oxytocin during equine-facilitated psychotherapy for human participants. in addition, welfare-focused studies indicate that horses participating in eap and related equine-assisted activities do not exhibit significant increases in physiological or behavioral stress markers, suggesting that well-structured programs can be conducted ethically. results: together, these findings highlight the potential of eap as a complementary, experiential modality for trauma recovery, while underscoring the need for more rigorous examination of underlying biological mechanisms. methodological limitations, such as small samples, varied intervention protocols, and scarce physiological measurements, hinder definitive conclusions. conclusions: this review synthesizes empirical findings and conceptual models to evaluate eap’s role within trauma-informed psychophysiology and identifies directions for future physiology-informed research. keywords: equine-assisted psychotherapy (eap), trauma recovery, emotional regulation, interpersonal functioning introduction equine-assisted psychotherapy (eap) is a specialized clinical modality in which a licensed mental health provider and an equine specialist facilitate psychotherapeutic processes involving horses. unlike broader equine-assisted activities or therapeutic riding, eap is explicitly grounded in psychological theory, employs structured therapeutic goals, and is delivered as a mental health treatment. this distinction is essential, as the research literature often conflates eap with non-clinical equine programs, making it challenging to interpret findings or evaluate mechanisms of change. interest in eap has grown within trauma-informed care because of its potential to engage core domains disrupted in trauma, including autonomic regulation, attachment, and somatic awareness. trauma frequently involves dysregulation of the hypothalamic–pituitary–adrenal (hpa) axis, heightened sympathetic arousal, and reduced parasympathetic tone. these physiological patterns contribute to hypervigilance, emotional reactivity, and difficulties accessing cues of safety, all of which can complicate traditional talk-based therapy. the experiential, relational, and embodied nature of eap may offer an avenue for addressing these psychophysiological disruptions more directly. the purpose of this paper is to review empirical evidence on the psychophysiological and psychological outcomes of eap, evaluate the strength of current findings, and situate eap within trauma-recovery frameworks informed by physiological psychology. emphasis is placed on studies that measure biological outcomes such as cortisol, oxytocin, and heart-rate variability (hrv), as these are central to understanding how therapeutic processes may influence the nervous system. background and conceptual foundations equine-assisted psychotherapy integrates experiential, relational, and somatic elements that align closely with models of trauma recovery. lee, dakin, and mclure (2016) describe eap as a psychotherapy delivered collaboratively by a mental health clinician and an equine specialist, with the horse serving as a responsive partner in the therapeutic process. because horses are highly attuned to nonverbal communication and emotional states, their reactions offer immediate, embodied feedback that can help clients recognize and regulate internal cues. from a psychophysiological perspective, trauma is associated with disruptions in autonomic balance, including sympathetic hyperarousal, low heart-rate variability, and impaired engagement of the parasympathetic nervous system. chronic activation of the hpa axis can contribute to persistent elevations or instability in cortisol levels, reducing an individual’s capacity for calm, flexible responding. eap may intersect with these systems through mechanisms such as co-regulation with the horse, activation of affiliative neurobiology, and the multisensory grounding inherent in equine interaction. these theoretical pathways provide a foundation for examining whether eap can facilitate measurable biological changes relevant to trauma recovery. psychophysiological mechanisms relevant to trauma and eap trauma-related symptoms often emerge from the body’s stress-response systems rather than purely cognitive or emotional processes. dysregulated ans activity, including low hrv and heightened sympathetic tone, contributes to hypervigilance and difficulty maintaining emotional stability. likewise, disruptions in the hpa axis may lead to altered cortisol secretion patterns, affecting energy, alertness, and stress sensitivity. mechanisms involving oxytocin, a neuropeptide linked to bonding and social regulation, are also relevant, as trauma may reduce access to feelings of safety and connection. eap may influence these systems in several ways. interacting with horses can evoke social engagement cues that support parasympathetic activation, potentially increasing hrv. positive human–animal interactions have been associated with oxytocin release, which may enhance trust, bonding, and physiological calming. additionally, the rhythmic, sensory-rich, and relational qualities of equine engagement may help shift autonomic patterns from defensive to regulated states. while these mechanisms are theoretical, they provide a compelling rationale for investigating the physiological effects of eap in trauma contexts. empirical findings the empirical literature on eap demonstrates promising psychological outcomes but remains limited in methodological rigor and consistency. in their review of 24 eap studies, lee et al. (2016) reported improvements in emotional regulation, interpersonal functioning, and behavioral outcomes—particularly among adolescents. however, they emphasized that most studies relied on self-report measures, lacked standardized intervention protocols, and did not include physiological data, making it difficult to identify mechanisms underlying observed benefits. in adult clinical populations, several studies document meaningful symptom improvements. burton et al. (2019) found reductions in ptsd symptoms and increases in resilience among veterans participating in a six-week eap program, although statistical power was limited due to small sample sizes. machová et al. (2023) reported significant gains in global functioning, mood, and quality of life among individuals in residential substance-use treatment receiving equine-facilitated psychotherapy compared with treatment-as-usual controls. these outcomes highlight the potential therapeutic value of eap but do not clarify whether physiological changes accompany psychological improvements. a small but growing number of studies have measured psychophysiological variables directly. mcduffee et al. (2024) conducted the most comprehensive investigation to date, examining salivary cortisol, oxytocin, and hrv in veterans with ptsd participating in an eight-week equine-facilitated psychotherapy program. their findings indicated decreases in cortisol and increases in oxytocin across sessions, alongside improved mood and reduced anxiety—patterns consistent with enhanced autonomic and hpa-axis regulation. importantly, their study also monitored horses’ physiological responses and found no evidence of stress, supporting the ethical feasibility of eap for equine partners. given the variability in research designs, populations, and outcome measures, it is useful to summarize key eap studies that address psychological or physiological outcomes relevant to trauma recovery. table 1 provides an overview of representative empirical investigations, including study designs, participant characteristics, psychophysiological measures, main findings, and limitations. this summary highlights both the strengths and the methodological gaps in the current evidence base, particularly regarding physiological mechanisms. table 1. summary of representative studies examining psychological and psychophysiological outcomes in equine-assisted psychotherapy (eap) study population & sample design & intervention psychophysiological measures key findings limitations mcduffee et. al. (2024) veterans with ptsd; repeated measures across 8-week program equine-facilitated psychotherapy delivered by clinician + equine specialist salivary cortisol; oxytocin; hrv (humans); cortisol & hrv (horses) decreased cortisol; increased oxytocin; hrv shifts consistent with improved regulation; improved mood/anxiety; horses showed neutral or positive physiological responses small sample; no randomized control group; modest physiological changes; limited generalizability burton et. al. (2019) veterans with ptsd (eap n ≈ 15; comparison n ≈15 six week eap vs. treatment as usual none within-group reductions in ptsd symptoms and improvement in resilience small sample; limited statistical power; no physiological measures machová et al. (2023) adults in residential substance-use treatment (efpp n=39; control n=18) equine-facilitated psychotherapy integrated into inpatient program none improvements in functioning, mood, and quality of life compared to controls no physiological assessment; not trauma-specific matlock et al. (2025) 18 horses participating in an eal program (n = 11 trauma-history youth; n = 7 young adults with developmental delays) pilot study comparing horse physiological and behavioral stress responses across two eal participant groups salivary cortisol, eye temperature, behavioral stress indicators no significant differences in cortisol, eye temperature, or behavioral stress markers between trauma-history youth sessions and control sessions; all physiological values remained within normal ranges. small sample size; pilot design; limited generalizability; eal not equivalent to psychotherapy. neff (2013) 8 horses participating in eap programs observational equine welfare study horse cortisol; heart rate; respiration no physiological indicators of stress in horses during sessions no human data; small exploratory design lee et al. (2016) narrative review of 24 eap psychotherapy studies synthesis of psychotherapy-focused eap programs few studies included physiological measures improved emotional, social, and behavioral functioning in eap heterogeneous designs; minimal physiological evidence as summarized in table 1, the strongest physiological evidence for eap comes from mcduffee et al. (2024), who demonstrated measurable changes in cortisol, oxytocin, and hrv alongside improvements in mood and anxiety among veterans with ptsd. these findings support the hypothesis that eap may influence stress-response systems relevant to trauma recovery. in contrast, studies by burton et al. (2019) and machová et al. (2023) showed meaningful psychological improvements but did not assess biological markers, leaving open the question of whether their clinical effects were supported by physiological shifts. lee et al. (2016) further emphasized that early eap research rarely incorporated objective physiological measurement, underscoring an ongoing gap between theoretical expectations and empirical evaluation. neff (2013) conducted a study of eight horses engaged in equine-facilitated activities across three seasons—spring, summer, and fall—measuring both physiological and behavioral indicators of stress. the horses did not exhibit significant increases in physiological or behavioral stress markers during or immediately after sessions, and by the end of the fall season their measured stress indicators were the lowest. this seasonal pattern underscored the influence of circadian rhythms and consistent daily routines on equine stress regulation—an important consideration when evaluating animal welfare in eap. another study examining the welfare of equine partners in eap and eal evaluated whether working with trauma-exposed youth produced greater stress responses in horses than working with individuals with other disabilities. matlock et al. (2025) assessed 18 horses using salivary cortisol, eye temperature, and behavioral stress indicators and found no significant differences between the trauma-history and comparison groups. all physiological values remained within normal ranges, indicating that participation in eal sessions with trauma survivors did not elevate horses’ stress levels. limitations in the current evidence base although eap shows promise, several limitations constrain the strength of current conclusions. one central issue is inconsistent terminology: many studies use the labels “equine-assisted psychotherapy,” “equine therapy,” or “equine-assisted activities” interchangeably, despite significant differences in treatment structure, clinician involvement, and therapeutic goals. this variation makes cross-study comparison challenging and complicates the identification of which specific components of eap drive therapeutic change. methodological weaknesses also limit interpretation. most eap studies rely on small samples and lack randomization, active control groups, or standardized treatment protocols. for example, burton et al. (2019) reported psychological improvements among veterans receiving eap, but the limited sample size reduced statistical power and hindered group comparisons. furthermore, studies often rely heavily on self-report measures, which may not fully capture physiological aspects of trauma recovery. finally, few studies include psychophysiological measures such as cortisol, hrv, or oxytocin. while mcduffee et al. (2024) demonstrated promising biomarker changes, replication with larger samples and more rigorous controls is needed. standardized protocols for timing, collection, and interpretation of physiological data would enhance reliability and facilitate integration of biological and psychological outcomes. future directions for research building a stronger evidence base for eap will require addressing methodological gaps and expanding the use of physiological measures. future research should incorporate larger samples, randomization where feasible, and well-defined control conditions to improve internal validity. clear articulation of eap protocols—including session structure, therapeutic goals, clinician qualifications, and the role of the equine specialist—would enable more precise replication and facilitate meaningful comparison across studies. integrating psychophysiological measurements is especially important for understanding whether and how eap influences trauma-related biological systems. biomarkers such as cortisol, hrv, respiratory sinus arrhythmia, and oxytocin can provide objective insights into shifts in autonomic and hpa-axis functioning. standardizing collection times, environmental conditions, and baseline measures would improve reliability. in addition, analyzing the physiological responses of both humans and horses could illuminate patterns of co-regulation, a concept central to many theoretical models of eap. implications for clinical practice despite its limitations, the existing evidence suggests several implications for trauma-informed clinicians incorporating eap. first, eap appears to support core processes involved in trauma recovery, such as emotion regulation, interoceptive awareness, and relational engagement. because trauma often manifests in physiological patterns of hyperarousal, shutdown, or dysregulated stress responses, eap’s embodied, experiential nature may offer access to regulation pathways that traditional talk therapy alone may not fully engage. second, clinicians may benefit from considering simple physiological tracking tools—such as hrv monitors or structured self-report regulation check-ins—to enhance treatment planning and client insight. while biological measures are not necessary for effective practice, awareness of how eap may interface with the nervous system can deepen case conceptualization and help tailor interventions. third, equine welfare remains central to effective eap. studies that monitor horses’ physiological responses, including neff (2013) and mcduffee et al. (2024), indicate that well-implemented eap does not impose undue stress on equine partners. ongoing attention to the horse’s physical and emotional state supports ethical practice and contributes to a safe, mutually regulated therapeutic environment. conclusion equine-assisted psychotherapy shows promise as a trauma-informed intervention capable of influencing both psychological and physiological domains of functioning. while research consistently demonstrates improvements in emotional regulation, interpersonal functioning, and trauma-related symptoms, only a limited number of studies have examined underlying biological mechanisms. preliminary evidence suggests that eap may positively influence stress-related physiology, including cortisol, oxytocin, and hrv, supporting models of autonomic and affective regulation in people. however, methodological inconsistencies, small sample sizes, and limited biomarker data highlight the need for more rigorous research. eap offers an experiential, relational approach that may meaningfully complement traditional therapies for trauma recovery, particularly when integrated within frameworks informed by psychophysiological principles. available equine-welfare data also show that horses do not exhibit increased physiological stress during properly structured sessions, supporting the ethical viability of eap. references burton, l. e., qeadan, f., & burge, m. r. (2019). efficacy of equine-assisted psychotherapy in veterans with posttraumatic stress disorder. journal of integrative medicine, 17(1), 14–19.https://www.sciencedirect.com/science/article/abs/pii/s2095496418301158?via%3dihub. lee, p.-t., dakin, e., & mclure, m. (2016). narrative synthesis of equine-assisted psychotherapy literature: current knowledge and future research directions. health & social care in the community, 24(3), 225–246. https://onlinelibrary.wiley.com/doi/10.1111/hsc.12201 machová, k., svoboda, m., mach, j., št’astná, l., & papežová, h. (2023). an evaluation of the effect of equine-facilitated psychotherapy on patients with substance use disorders: a naturalistic controlled trial. plos one, 18(6), e0286867. https://doi.org/10.1371/journal.pone.0286867 matlock, s. k., singh, a., grandin, t., merritt, t., nett, t., reega, s. j., & peters, b. c. (2025). behavioral and physiological indicators of stress in horses during an equine-assisted learning program for youth with a history of trauma. translational animal science, 9, txaf027. https://pubmed.ncbi.nlm.nih.gov/40191691/ mcduffee, l. a., montelpare, w. j., & leblanc, c. (2024). psychophysiological effects of equine-facilitated psychotherapy on veterans with ptsd and their horse partners. journal of military, veteran and family health, 10(3), 135–147. https://psycnet.apa.org/record/2025-01086-012 neff, b. (2013). the effects of equine-assisted psychotherapy on stress of the horse: measuring cortisol, pulse, respiration, and behaviors before and after clinical sessions (unpublished undergraduate thesis). maryville college. https://www.maryvillecollege.edu/wp-content/uploads/faculty/naturalsciences/dcrain/undergraduate-research/neff2013.pdf. 2 ii annals of applied psychophysiology december 2024 volume 11 ______________________________________________________________________________ assessing the effectiveness of training logic and reasoning skills among middle and high school students using a retrospective pre to post training assessment gabrielle d. timlin1 published online: december 2024 © the author(s) 2024 abstract background: both students studying psychophysiology and professionals performing research in the field need to be versed in the basics of logic so they can do a better job assessing the literature and designing their studies. hence, it is imperative to assist middle and high school students with the development of this crucial skill. the purpose of this study was to assess the results obtained from instruction in logic in middle and high school students. this retrospective study ascertained if students gained improved logic and reasoning skills after participating in the specified course in formal logic. methodology: logic and critical thinking skills were taught using an established curricula with a custom pre and post assessment to determine baseline and learning. the participants were middle and high school students for whom one-half hour of instruction for ten days was conducted in a regular classroom setting, as part of their regular instruction. the first and last days consisted of pre and post-assessments using custom pre and post-assessments of their logical abilities. the instruction on days 2-9 was accompanied by clearly identified learning goals, follow-up group socratic discussion, and written individual exit tickets. data collection consisted of documenting assessment results. 31 matched pairs for group 1 (the middle school students) and 32 matched pairs for group 2 (the high school students) were analyzed using the wilcoxon signed rank sum test (glanz, 2012). results: overall, students performed better on the post-test after instruction. the data from the assessments were gathered retrospectively for the purposes of this study. results indicate that this curriculum is a good choice for logic instruction for middle and high school students. conclusion: future research should include larger sample sizes, student adherence to instruction and participation, inclusion of the psychomotor learning domain and validity. keywords: psychophysiology, students, curriculum, logic and critical thinking skills 1. gabrielle d. timlin1 saybrook university, pasadena, california, usa iii introduction both students studying psychophysiology and professionals performing research in the field need to be versed in the basics of logic so they can do a better job assessing the literature and designing their studies. genesereth and chaudhri (n.d.) assert that teaching logic is imperative for the creation of a responsible population that is equipped to detect logical fallacies, engage in good decision making, think critically and question their appointed leaders with skill. students of mathematics benefit from learning logic when attempting to solve difficult problems like proofs (bako, 2002). however, people who are neither mathematicians nor scientists may not continue to use these disciplines as an analytic foundation (kobylarek, 2020). furthermore, the exercise of analyzing one’s own thinking through the socratic method elucidates gaps in thinking using questions to pursue logic and reasoning (perdue, 2014). a solution is to teach formal logic as it is applicable to daily life (genesereth & chaudhri, n.d.). modern researchers have provided updated guidelines and structure for teaching and assessing logic and critical thinking, including robinson (2011) who argues that logic education should be relatable to key studies. the purpose of this retrospective project was to explore the results obtained from a shortterm implementation of a course of study designed to develop skills in logic and critical thinking in middle and high school students. the research question to be answered in this study was, do students gain improved logic and reasoning skills after participating in this course in formal logic? methodology the logic training program was performed in two different school settings in classrooms as part of the regular student curriculum. participants classes of middle school and high school students received preand post-tests with logic instruction in between. the researcher moved from one school to another and taught the same logic module in each school. the first group consisted of 31 total matched sets of 8-12 grade students and the second group consisted of 32 matched sets of 12 grade students only, where matched sets refer to pre and post-tests. the first group had 2 classes of 65 total 8th grade science students, 2 classes of 9th -12th grade science students of 27 total, and 1 class of 5 total physics senior high school students and one junior. of these, the 8th grade classes had 25 males and 40 females, the earth science classes had 16 males and 11 females, and the physics class had 3 males and 2 females. the second group included 4 classes of 74 seniors total comprised of 31 males and 43 females. all groups were de-identified. both groups were comprised of students from middle-class socioeconomic backgrounds. out of both groups, there were students who elected not to participate. additionally, the instructions were to choose a non-identifiable name consisting of a letter, a number and a symbol and use that identifier for both pre and post-tests. as not everyone chose to follow the instructions and tests were matched afterward, 31 matched sets from group 1 were used and 32 matched sets from group 2 were used as there was strong confidence that these were indeed matched sets. both schools were the workplace of the researcher who moved from one place to the next. the researcher both taught and assessed classes in logical thinking using a questionnaire iv created for that purpose. the research was limited by the retrospective nature of that intervention and data. this was a retrospective study that utilized data collected from a middle school and a high school which had modules emphasizing instruction in logic in place. as part of the curriculum, the instructor developed pre and post-training questionnaires to assess the effectiveness of the instruction. each school gave written permission to use the retrospective data gathered while teaching the logic modules. both the instrument and the instruction were all given in english. all students participated in the units as these were required, however students were given the option to refrain from participating in completing the inventories. only 3 out of the 100 students in group 1 (middle school) and 7 out of the 74 students in group 2 (high school) elected to not participate in completing the inventories. procedure a baseline was obtained in the form of an assessment used to determine current ability in logic, reasoning, and critical thinking. the inventory of instruments of critical thinking was consulted (follman, et al., 1996). several tests were ruled out as they were either inappropriate for the intended age group, older, test-retest reliability was poor, such as free online tests available at the time, or student laptops were not consistently available. additionally, while the test of logical thinking (tolt) exists for 6th grade through college, this instrument assessed information already being assessed in math and science classes at the sites (tobin & capie, 1981). it did not assess whether logic skills acquired in math and/or science resulted in increased student ability to reason in logical fallacies through conversation. after reviewing the literature, no short instrument was discovered that was suitable to the intended population or purpose. hence, custom pre and post-tests based on logical fallacies were created (sherman, 2021). the questions with logical fallacies are shown below in figures 1-2. it is a standard procedure for inventories given close together in time to have different versions and/or test questions that test the same information; hence it was necessary for the pre and post-tests to have different questions. the questions were initially informally evaluated for validity and understanding by two teachers and ten students, five of whom were girls, and five of whom were boys, at the first school where the instruction was to be tested. no concerns were registered by any student or teacher. prior to participating, the learning outcomes were clearly stated. after participating, students were required to produce outcomes, which were a variety of spoken group discussions or written feedback. because the baseline assessment was likely to provide valuable information from which lessons can be best determined, because lessons were taken from an established curriculum, and because this was integrated into different science classes, structured lesson plans were not included in this protocol (cothran, 2012; cothran, 2017; cothran 2018a; cothran 2018b). after the initial assessment on day 1, lessons were given on days 2-9 during regular class time, with stated desired outcomes, activity, socratic discussion with questions intended to elicit higher thought, and a written exit ticket from each student on the topic of the day’s learning objectives. questions may be an analysis of a logical fallacy, for example. these lessons consisted of lessons from the traditional logic 1 curriculum that were designed to enhance logic and critical thinking skills, but that were not correlated to the test (cothran, 2012; cothran, 2017; cothran 2018a; cothran 2018b). since the content was correlated to the test, this reduced the likelihood that the students were trained to succeed on an assessment as opposed to reaching the v desired goal: strengthening their logic and critical reasoning skills. this curriculum utilizes a student workbook and textbook. a mixture of individual tasks, small group work and whole class readings and discussions were utilized. the assessment was given again on day 10 to ascertain the extent to which students learned logic and critical thinking skills. because it was unlikely that a perfectly correct or a perfectly incorrect answer would be given in all cases, a likert scale was created to grade the pre and post assessments. results in most cases, the p value was less than the significance level (alpha) meaning that the results are statistically significant and there is a difference between the pre and posttests, for a two tailed (non-directional) interpretation, which means that students either improved or declined in skill (glanz, 2012). the exception to this is the third question for group 1 where there is no difference between the pre and posttests. however, a one-tailed interpretation is necessary because the point of the intervention is to determine if students are able to employ logic better post instruction than before. to do this, the significance level needs to be divided by two. this means that 0.05 which indicates a 95% level of confidence, needs to be divided by two to become 0.025. hence, when using total averages in the wilcoxon signed rank sum, each group showed improvement post instruction (glanz, 2012). when averaging each individual question, most questions indicated improvement post instruction except for questions 1 and 4 in group 2, and question 3 in group 1, where no improvement was indicated. in each case, the w score indicates that many participants had the same rank, except for question 1 for group 2 (glanz, 2012). the second question yielded the highest w score for each group, thus skewing the total average for the w score to a higher number than it would have otherwise been. in comparison, question 3 yielded the highest p score for group 1 and was the only question for group 1 where there was no positive difference between the intervention of logic education and no intervention at all. this was the case for questions 1 and 4 for group 2. a wilcoxon signed-rank test indicated that scores were significantly different before and after the intervention when averaged for all questions, with w= 373, p = 0 for group 1 and w = 310, p = 0 for group 2 (glanz, 2012). for each independent question, the only question group 1 did not show improvement with the intervention was question 3. for group 2, it was questions 1 and 4. vi table 1 student breakdown. group 1 group 2 # of students who completed the questionnaire as a matched set 31 32 8th grade science total students 65 0 8th grade 65 0 males 25 0 females 40 0 earth science total students 27 0 males 16 0 females 11 0 9th grade 21 0 males 12 0 females 9 0 10th grade 3 0 males 2 0 females 1 0 11th grade 2 0 males 2 0 females 0 0 12th grade 6 74 males 3 31 females 3 43 physics total students 5 74 vii table 2 statistics by group (glanz, 2012). test group 1 group 2 standard deviation 0.82 0.49 power analysis 1 0.989 wilcoxon avg w 373 310 wilcoxon avg p 0 0 wilcoxon q1 w 120 0 wilcoxon q1 p 0 >0.046 wilcoxon q2 w 337 435 wilcoxon q2 p 0 0 wilcoxon q3 w 107 88 wilcoxon q3 p 0.057 0.007 wilcoxon q4 w 182 61 wilcoxon q4 p 0 0.044 wilcoxon q5 w 135 72 wilcoxon q5 p 0.003 0.019 figure 1 box and whisker plot for group 1 w values distribution by question averages w v al ue s 0 50 100 150 200 250 300 350 group 1 w values by question group 1 ii figure 2 box and whisker plot for group 2 w values distribution by question averages figure 3 box and whisker plot for group 1 p values distribution by question averages the following are the data. w v al ue s 0 50 100 150 200 250 300 350 400 450 500 group 2 w values by question group 2 1 p va lu es 0 0.01 0.02 0.03 0.04 0.05 0.06 group 1 p values by question group 1 iii figure 4 box and whisker plot for group 2 p values distribution by question averages discussion with the exception of one question in group 1 and two questions in group 2, there is a statistically significant difference between the pre and posttests, indicating that this particular curriculum is a good choice for future logic instruction in middle and high school settings. both sites were public classical charter schools. since the population represented those students enrolled in specified science classes at that time, this sample population is representative of middle and high school students enrolled in classical charter schools. hence, these results are generalizable to middle and high school students enrolled in classical charter schools. limitations include small sample sizes in both groups, lack of student adherence to instructions, lack of student participation, short study duration, limited number of science classes and schools, lack of time to devote solely to logic in a science classroom and integration of logic into the science curriculum. further limitations include a general reluctance by students to value logic instruction in a science classroom and answer interpretation done by only one person, the researcher. finally, the exploratory, simple nature of the study and the survey are limitations. delimitations involve teaching this in a science classroom. the activity was integrated into the science curriculum for middle and high school students in two schools. recommendations include repeating instruction in a dedicated logical class including at least 30 minutes of class time up to one hour and consisting of a combination of individual reading to start class, teacher instruction and a question-and-answer session afterwards followed by small group participation where the students perform exercises in the curriculum and finally ending with an exit ticket demonstrating understanding of the day’s learning. also, logic p va lu es 0 0.005 0.01 0.015 0.02 0.025 0.03 0.035 0.04 0.045 0.05 group 2 p values by question group 2 iv instruction should be connected with math and science classes reinforcing math and science instruction as well as be performed at sites that exemplify excellent teacher support and prioritize student responsibility for their own learning. additionally, more research is necessary to study the inclusion of the psychomotor learning domain, as this learning domain is applicable in practical application, as opposed to simply acquiring information as in the learning domain. furthermore, as this was exploratory research, evaluation of validity should be included in future research. conclusion in conclusion, it is unwise to assume that students will learn logic and reasoning skills by exposure to math and science courses. instead, logic and reasoning should be facilitated in middle and high school classes in conjunction with math and science education to facilitate grasp of basic concepts and promote student responsibility for independent thinking. 1 references aksu, g., & koruklu, n. 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(2024). the evolution of developmental theories since piaget: a metaview. perspectives on psychological science, 19(6), 921–930. https://doi.org/10.1177/17456916231186611 sherman, r. (2021). logical fallacies. [unpublished manuscript]. department of applied psychophysiology, saybrook university. the sophists; stanford encyclopedia of philosophy. (2020, august 18). stanford encyclopedia of philosophy. retrieved november 29, 2021, from https://plato.stanford.edu/entries/sophists/ tobin, k.g., & capie, w. (1981). the development and validation of a group test of logical thinking. educational and psychological measurement, 41(2), 413–423. well, t., phd. (2023, july 5). the decline of critical thinking skills. psychology today. https://www.psychologytoday.com/us/blog/the-clarity/202306/the-decline-of-criticalthinking-skills unc-chapel hill writing center. (2021, april 14). fallacies. the writing center at university of north carolina at chapel hill. retrieved november 29, 2021, from https://writingcenter.unc.edu/tips-and-tools/fallacies/ https://sites.psu.edu/rclperdue/2014/09/19/the-big-three-of-greek-philosophy-socrates-plato-and-aristotle/ https://sites.psu.edu/rclperdue/2014/09/19/the-big-three-of-greek-philosophy-socrates-plato-and-aristotle/ https://doi.org/10.1037/0000165-000 https://doi.org/10.1080/07294360.2010.500656 https://doi.org/10.1177/17456916231186611 https://plato.stanford.edu/entries/sophists/ https://www.psychologytoday.com/us/blog/the-clarity/202306/the-decline-of-critical-thinking-skills https://www.psychologytoday.com/us/blog/the-clarity/202306/the-decline-of-critical-thinking-skills https://writingcenter.unc.edu/tips-and-tools/fallacies/ 95 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v9.i2.2022.95-105 original article university students' concerns about terrorism, resilience, and coping strategies saima masoom ali department of psychology, university of karachi, karachi-pakistan abstract background: current research inspects the concerns of students of the university about terrorism and their capacity to bounce back, and the coping strategies they are using to deal with it. a cross-sectional study research design is employed in the current study. methodology: the sample is comprised of 387 students collected from faculties of karachi university (1) faculties of social sciences, islamic studies, education, law, and administrative sciences and (2) faculties of science, engineering, pharmacy, and medicine. a consent form, demographic sheet, students' concerns about terrorism scale, brief resilience scale, and cope inventory were administered to students. results: demonstrated significant positive relationship among anti-terrorism, peace, and female emancipation. further linear regression analysis shows that peace scores explain a 21.8% variance and female emancipation score explains an 18.4% variance in the anti-terrorism score. multivariate analysis of variance shows a significant difference between gender in scores of anti-terrorism, peace, female emancipation, and coping strategies (self-destruction, substance use, and positive reframing). conclusion: participants' resilience was found to be in the normal range. a significant positive relationship was found between anti-terrorism, peace, and female emancipation. those who had anti-terrorist views were in favor of peace and female emancipation. keywords university student, resilience, coping strategies, concerns about terrorism. citation: ali sm. university students' concerns about terrorism, resilience, and coping strategies. app. 2023; 9(2): 95-105 corresponding author email: saima.ali@uok.edu.pk doi: 10.29052/2412-3188.v9.i2.2022.95105 received 10/10/2022 accepted 08/11/2022 published 01/12/2022 copyright © the author(s). 2022. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. about:blank about:blank about:blank about:blank 96 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 introduction terrorism is one of the main problems in pakistan and has been distressing its residents for ages. pakistan is playing a substantial part globally in the battle against terrorism. pakistan displays indications that point to a tremendous prospective for youth radicalization. the situation is evident by a poor education scheme stratified along socio-economic lines and unequal economic chances across sections of society. these cautionary signals raise the probability of young members of society being persuaded into extremist causes. moreover, the existence of an extremist set-up, the flawless organizational discipline, the extensive social systems of pakistan's islamist political and militant outfits, the disappointment of the moderate forces to bring credible results, and myopic us strategies additionally enhance it1. terrorism’ has no universal definition, the academicians and intellectuals have defined it in diverse ways. according to webster’s dictionary2, "terrorism is the systematic use of violence, terror, and intimidation to achieve an end." terrorism has profound origins in the society of pakistan because of numerous reasons that comprise poor governance, demotion of rural regions, delay, and the absence of justice and open access to arms3. furthermore, geographical locations make it susceptible to terrorist dangers. socioeconomic difficulties lead to radicalism as while these complications are mutual they make available ground for extremists4. contact with terrorism in both ways direct and indirect develops fear and anxiety amongst stayers5. because of these incidents schools and universities remained closed for some period of time in the country secondly it was followed by the news of expected future terrorist attacks on universities and schools. it additionally prevails the feelings of uncertainty among students and academic staff6. in one study, when participants were asked whether pakistan should convert into a secular state, most chose against the proposition. most of the participants thought that all jihadi organizations need to be banned. the problem, consequently found, is a need for more intelligent thinking plus a substitute narrative dialogue in the society as a result it will allow the youth to ponder 'out of the box'7. bonanno et al. (2010) stated that people react differently to trauma. first of all, there are some people who show severe stress and anxiety, and it does not reduce with the passage of time. secondly, some people display very few or no symptoms at all of the psychopathologies; nonetheless, later on, they produce some. thirdly, a number of people initially show psychopathology, and afterward, they recover completely. finally, some people are resilient and adjust well in times of stress and trauma8. taking footsteps to form resilience is the ability to adjust well to unforeseen ups and downs; in addition, events can aid people in managing distress and uncertainty. numerous steps are vibrant parts of a healthy way of life, and accepting them can progress overall emotional and physical well-being. "according luthar & cicchetti, (2000), resilience is a dynamic process wherein individuals display positive adaptation despite experiences of significant adversity or trauma”9. 97 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 initially, resilience was frequently welldefined in simple terms of doing well in the phase of adversity or trauma. early work concentrated on knowing naturally present resilience. novel work has shifted struggles to encourage resilience in individuals10. resilience is perceived as a representative that allows individuals not only to overcome hardship but then also to succeed while facing difficult situations11. resilience in expressing hardship is the capacity to move forward in adverse conditions, a human reaction that indicates good health, both psychologically and physically. people who are resilient were set up to enjoy enhanced physical in addition mental health and lesser levels of depression, apprehension, sleep disorders, and pts, related to people who have less level of resilience12,13,14. in order to deal with stressors, individuals use different ways, which are known as coping. according to celestin & celestinwestreich, (2006), coping is the vibrant progression that inclines to function as a robust moderator amongst stressors and a person's psychological health effects15. coping is also defined as "constantly changing cognitive and behavioral efforts to manage specific external and internal demands that are appraised as taxing or exceeding the person's resources" 16. lazarus (as cited)17 mentioned coping as the capacity of a person to overcome perplexing and critical situations. coping styles show a substantial part in dealing with the traumatic event; if coping styles are productive, they will act as a buffer against the expected potential undesirable responses, and if coping styles are nonproductive, they further enhance the trauma and makes the process of accepting certainty and moving on slow18. tatar & amram (2007) conducted research on 330 participants, which were israeli adolescents; their coping strategies were investigated about terrorist attacks were investigated as they have witnessed substantial constant terrorist attacks in past years. results showed that adolescents employ healthy coping approaches compared to non-healthy coping approaches when dealing with terrorist attacks19. as stated by glennie, “although coping and resilience are related constructs, they are distinct in that coping refers to a wide set of skills and purposeful responses to stress, whereas resilience refers to positive adaptation in response to serious adversity” 20. it is essential to know about students' concerns regarding terrorism, as pakistan is highly affected by terrorism. students' capacity to bounce back and return to everyday life (resilience) and the coping strategies they employ make a significant change in their lives. the present research will explore students' capacity to cope despite setbacks, barriers, and limited resources. the present research studied university students' concerns about terrorism, resilience, resilience, and coping strategies. 1) there will be a difference in the resilience level among karachi university students. 2) there will be a positive correlation between anti-terrorism, peace, and female emancipation among students of karachi university. 3) there will be a gender difference in antiterrorism, peace, female emancipation, resilience, and coping strategies scores. 98 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 4) there will be a difference in the scores of anti-terrorism, peace, female emancipation, resilience, and coping strategies among faculties. methodology a quantitative, cross-sectional study research design is employed in the current study. the ethics committee of sdpi approves the research project. selfadministered questionnaires: students' concerns about terrorism (sct) scale, brief resilience scale, and brief cope inventory were filled out by 387 students. sample the sample was drawn from different faculties of the university of karachi. (1) faculties of social sciences, islamic studies, education, law, and administrative sciences (2) faculties of science, engineering, pharmacy, and medicine. selection of sample size: the ideal sample size was found to be 381 and collected. instruments informed consent: participants were informed about the nature of the study and were assured about their confidentiality and their right to withdraw at any point. the students' concerns about terrorism (sct) scale is developed by shukat et al. in 201621. it is comprised of three subscales anti-terrorism, peace, and female emancipation. it includes a total of 15 items. reliabilities of subscales of the students' concerns about terrorism (sct) scale were 0.82, 0.75, and 0.84. it is a five-point likert scale, with responses ranging from strongly agree to disagree strongly. the brief resilience scale is developed by smith b. et al. in 200822. in order to get a total score, add the answers varying from 1-5 for all six items. divide the total sum by the total number of questions answered. total score range from 6-30. interpretation of scores; 1.00-2.99 shows low resilience, 3.00-4.30 shows typical resilience, 4.31-5.00 shows high resilience. the brief cope was developed as a short version of the original 60-item cope scale (carver et al., 1989)23, which was theoretically resultant based on various models of coping. it consists of only 28 statements. it has the following subscales; self-distraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioral disengagement, venting, positive reframing, planning, humor, acceptance, religion, & self-blame. procedure students were approached personally at the university. they were briefed entirely about the purpose and nature of the research, and it was assured that the information obtained would only be used for research purposes. a consent form, demographic sheet, students' concerns about terrorism scale, brief resilience scale, and cope inventory were administered to students. the students were thanked for participating in the research, and a token of appreciation folder was given to every participant, and the results will be analyzed. incomplete forms were discarded before data entry. 99 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 results table 1: summary of demographic variables. variables n(%) gender men 99(25.6) women 287(74.2) age 18 107(27.6) 19-20 209(54.0) 23-25 69(17.8) 25+ 2(0.5) faculties social sciences, islamic studies, education, law, and administrative sciences 215 (53.3) science, engineering, pharmacy, and medicine 172 (42.8) table 1 shows the number and percentage of men and women with their ages and faculties. while , table 2 shows the resilience level in which 93.8% of participants are showing resilience in the normal range. table 2: showing rate of resilience. variables cut off interpretation n(%) resilience 1.00-2.99 low resilience 12(3.1) 3.00-4.30 normal resilience 363(93.8) 4.31-5.00 high resilience 12(3.1) total 387(100) a significant positive correlation was found among scores of anti-terrorism, peace, and female emancipation (table 3). table 3: showing correlation among scores of anti-terrorism, peace, female emancipation correlation matrix of the three subscales (n=387). peace female anti-terrorism emancipation peace ----0.398** 0.466** female emancipation 0.398** ____ 0.429** antiterrorism 0.466** 0.429** ___ **correlation is significant at the 0.01 level (2-tailed). table 4 shows the impact of the peace score on the anti-terrorism score. the r2 value of .218 reveals that the predictor explains a 21.8% variance in the outcome variable with f (1, 386) = 107, p > .05. 100 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 table 4: linear regression coefficients of peace score on anti-terrorism score. variables b β se constant 3.021 .370 peace .545 .466 .053 *r2 .218 **note. n = 387 table 5 shows the impact of the peace score on the anti-terrorism score. the r2 value of .218 reveals that the predictor explains an 18.4% variance in the outcome variable with f (1, 386) = 86.66, p > .05. table 5: linear regression coefficients of female emancipation score on anti-terrorism score. variables b β se constant 3.677 .341 peace .336 .429 .036 *r2 .184 **note. n = 387 table 6 shows multivariate tests. there is a statistically significant difference between gender in scores of anti-terrorism, peace, female emancipation, and coping strategies (active coping, substance use, and humor) table 6: table showing descriptive of subscales of concern about terrorism (anti-terrorism, peace, female emancipation), resilience, and coping strategies between genders. variable gender male female mean±sd mean±sd anti-terrorism 7.13±3.17 6.46±2.49 peace 7.63±2.67 6.29±2.06 female emancipation 10.26±8.28 4.36±2.88 resilience 3.39±.65 3.43±.59 self-destruction 5.25±1.60 5.68±1.69 active coping 5.84±1.67 6.04±1.56 denial 4.59±1.70 4.41±1.84 substance use 3.13±1.69 2.34±1.03 emotional support 4.86±1.49 4.97±1.79 instrumental support 5.38±1.91 5.25±1.87 behavioral disengagement 4.34±1.59 4.15±1.61 venting 4.58±1.74 4.56±1.58 positive reframing 5.54±1.66 5.92±1.65 planning 5.80±1.69 5.86±2.03 humor 4.32±2.00 3.97±1.85 acceptance 5.85±1.73 5.81±1.74 religion 6.11±1.81 6.45±1.67 self-blame 4.65±1.85 4.61±1.86 101 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 multivariate test for intercept and gender multivariate tests effect value f hypothesis df error df sig. partial eta squared intercept pillai's trace .986 1462.388b 18.000 368.000 0.000 .986 wilks' lambda .014 1462.388b 18.000 368.000 0.000 .986 hotelling's trace 71.530 1462.388b 18.000 368.000 0.000 .986 roy's largest root 71.530 1462.388b 18.000 368.000 0.000 .986 gender pillai's trace .178 4.424b 18.000 368.000 .000 .178 wilks' lambda .822 4.424b 18.000 368.000 .000 .178 hotelling's trace .216 4.424b 18.000 368.000 .000 .178 roy's largest root .216 4.424b 18.000 368.000 .000 .178 a. design: intercept + gender b. exact statistic table 7: table showing descriptive of subscales of concern about terrorism (anti-terrorism, peace, female emancipation), resilience, and coping strategies between faculties. variable faculties social sciences, islamic studies, education, law, and administrative sciences science, engineering, pharmacy, and medicine mean±sd mean±sd anti-terrorism 6.76±2.61 6.47±2.78 peace 6.95±2.27 6.23±2.29 female emancipation 8.86±3.37 8.69±3.50 resilience 3.43±.61 3.40±.59 self-destruction 5.48±1.60 5.68±1.76 active coping 5.92±1.60 6.08±1.58 denial 4.33±1.86 4.62±1.73 substance use 2.48±1.24 2.62±1.32 emotional support 4.99±1.68 4.89±1.77 instrumental support 5.28±1.96 5.29±1.77 behavioral disengagement 4.19±1.6 4.21±1.59 venting 4.68±1.53 4.43±1.72 positive reframing 5.78±1.69 5.87±1.63 planning 5.93±2.12 5.73±1.70 humor 4.00±1.87 4.13±1.93 acceptance 5.86±1.77 5.77±1.70 religion 6.35±1.66 6.38±1.78 self-blame 4.67±1.83 4.55±1.88 102 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 multivariate tests effect value f hypothesis df error df sig. partial eta squared intercept pillai's trace .989 1841.241b 18.000 368.000 0.000 .989 wilks' lambda .011 1841.241b 18.000 368.000 0.000 .989 hotelling's trace 90.061 1841.241b 18.000 368.000 0.000 .989 roy's largest root 90.061 1841.241b 18.000 368.000 0.000 .989 faculties pillai's trace .059 1.274b 18.000 368.000 .201 .059 wilks'lambda .941 1.274b 18.000 368.000 .201 .059 hotelling's trace .062 1.274b 18.000 368.000 .201 .059 roy's largest root .062 1.274b 18.000 368.000 .201 .059 discussion the present study was carried out to investigate university students' concerns about terrorism, resilience, resilience, and coping strategies. our country pakistan has undergone many problems due to terrorism in each walk of life, comprising the dissection of society, political uncertainty, foodstuff crises, and economic decline24. the first variable investigated in our study is concerns about terrorism; it has three subscales anti-terrorism, peace, and social context (attitudes to modern female emancipation). a significant positive correlation was found among scores of anti-terrorism, peace, and female emancipation (table 3). the result shows a positive relationship between peace and female emancipation, a positive relationship between peace and antiterrorism, and a positive relationship between female emancipation and antiterrorism. regression analysis shows that the predictor (peace score) explains a 21.8% variance in the outcome variable (antiterrorism score). the predictor (female emancipation score) explains an 18.4% variance in the outcome variable (antiterrorism score). medical college (rmc) regarding terrorist attacks on educational institutions and their impact 34 percent of the students, mentioned that their education had been affected by the wave of terrorism, while 58 percent of students mentioned terrorist attacks had affected their mental health status and about two-thirds perceived that their extracurricular activities and social activities had been affected due to terrorism. about 43 percent of students had accepted terrorism as a part of their lives; however, 80 percent of students were hopeful that terrorism would end soon. in 2015 a study examined the incidence of psychological problems and their predictors in 1048 chinese college students from shanghai. 47 percent of students had anxiety complications25. education can play a vital role in developing patience amongst students or forthcoming citizens26; in a culture with diverse religious viewpoints, it is challenging to get coherence in opinions about peace, terrorism, and female emancipation27. the minds of younger individuals are more responsive to cognitive and affective modification28. so when the links between peace, terrorism, and female emancipation 103 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 have been established, there is a framework for future policy changes. research studies have demonstrated that the sociopolitical effect of women is a robust forecaster of less violence in the nation29,30,31. an investigation conducted by robinson displays a negative relationship between women's emancipation and terrorism, suggesting that civilizations which permit women to work without restrictions are less susceptible to terrorist events. based on the evidence obtained, it can be specified that societies are more peaceful, which favors female empowerment 32. our second significant variable of the study is resilience. "resilience is a process of adapting well in the face of adversity"33. our study shows the average level of resilience among students of karachi university (table 2). one study concluded that college scholars with good levels of resilience exhibited enhanced adjustment to university34. according to the study on undergraduates of rawalpindi, it is apparent that deliberate actions of violence/terror are more potent as compared to the natural adversities35. a study was conducted in 2011 on students of four universities in karachi. 291 undergraduate students completed selfadministered forms. most of the students had mild stress levels as a result of the continuous hazard of terrorism; however, a lesser no of students had severe stress levels. potential reasons for resilience and mild stress levels can be the past of karachi's internal clashes and its lengthy period of exposure to terrorism36. multivariate analysis findings show a statistically significant difference between gender in scores of anti-terrorism, peace, female emancipation, and coping strategies (active coping, substance use, and humor). male participants scored high on all three subscales of concerns about terrorism, antiterrorism, peace, and female emancipation. in coping strategies, females scored high on active coping; males scored high on substance use and humor. another multivariate analysis between faculties in the scores of anti-terrorism, peace, female emancipation, and coping strategies conducted shows no significant difference in variables concerning faculties. women are more likely to practice active coping plus social support and problemfocused coping37. it was revealed that males respond to unpleasant situations by picking either vibrant adapting methodology or otherwise avoidant actions, such as alcohol or medication use 38,39. the positive effects of humor may be described by the role of humor in the cognitive appraisal of threatening, hence stressful, situations. the study outcomes show that a healthier sense of humor assists additional positive cognitive appraisals40. some investigators have also investigated gender differences in using humor as a coping mechanism and concluded that men use humor more often than women 41. it is proposed that the causes and impact of terrorism be shared with young students because these views impact equality between genders and inculcate peace in society. the capacity to bounce back from trauma must be enhanced, so we do not collapse in hard times. 104 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 conclusion the finding shows that most of the participant's resilience is in the normal range, which is a good sign. a significant positive relationship was found between anti-terrorism, peace, and female emancipation, and those who had antiterrorist views favored peace and female emancipation. further analysis revealed that male participants scored high on all three subscales of concerns about terrorism (antiterrorism, peace, and female emancipation) as compared to female participants. no difference was found in the level of resilience between male and female participants. in coping strategies, females scored high on active coping, and males scored high on substance use and humor; no difference was found in the frequency of remaining coping strategies. acknowledgment this project was funded by sdpi (sustainable development policy institute). references 1. yusuf m. prospects of youth radicalization in pakistan: implications of us policies.“. brookings institute analysis paper. 2008;14. 2. 2merriam-webster. (n.d.). terrorism. in merriam-webster.com dictionary. retrieved august 26, 2020, from https://www.merriamwebster.com/dictionary/terrorism. 3. khan mk. analyzing domestic terrorism as a threat to pakistan’s security and the policy response. iprij. 2009;9(2):49-76. 4. ahmad w. causes of militancy in malakand division. a case study of mingora district swat. 2012. 5. deroma v, saylor c, swickert r, sinisi c, marable tb, vickery p. college students' ptsd symptoms, coping, and perceived benefits following media exposure to 9/11. j coll. stud psychother. 2003;18(1):49-64. 6. nijs mm, bun cj, tempelaar wm, de wit nj, burger h, plevier cm, boks mp. perceived school safety is strongly associated with adolescent mental health problems. community ment health j. 2014;50:127-134. 7. siddiqa. a. is the youth in elite universities in pakistan radical? heinirich boll foundation 2010. 8. bonanno ga, brewin cr, kaniasty k, greca am. weighing the costs of disaster: consequences, risks, and resilience in individuals, families, and communities. psychol sci public interest. 2010;11(1):1-49. 9. luthar ss, cicchetti d. the construct of resilience: implications for interventions and social policies. dev psychopathol. 2000;12(4):857-885. 10. masten as. resilience in developing systems: progress and promise as the fourth wave rises. dev psychopathol. 2007;19(3):921-930. 11. richardson ge. the metatheory of resilience and resiliency. j clin psychol. 2002;58(3):307321. 12. hu t, zhang d, wang j. a meta-analysis of the trait resilience and mental health. pers individ differ. 2015;76:18-27. 13. straud c, henderson sn, vega l, black r, van hasselt v. resiliency and posttraumatic stress symptoms in firefighter paramedics: the mediating role of depression, anxiety, and sleep. traumatology. 2018 jun;24(2):140-147. 14. finklestein, m., pagorek-eshel, s., and laufer, a. adolescents' resilience and its association with security threats, anxiety and family resilience. j fam. stud. 2020; 1–16. 15. celestin lp, westreich s. all equal? advocating equity in mental health services in france to ethnic-minority disadvantaged youth and their families through the evidencebased face© protocol. infinds and results from the swedish cyprus expedition: a gender perspective at the medelhavsmuseet 2006. american psychiatric association, arlington. 16. lazarus rs, folkman s. stress, appraisal, and coping. springer publishing company; 1984. 17. butler ld, blasey cm, garlan rw, mccaslin se, azarow j, chen xh, desjardins jc, dimiceli s, seagraves da, hastings ta, kraemer hc. posttraumatic growth following the terrorist attacks of september 11, 2001: cognitive, coping, and trauma symptom predictors in an internet convenience sample. traumatol. 2005;11(4):247-267. 105 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 2 18. bleich a, gelkopf m, solomon z. exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in israel. jama. 2003 aug 6;290(5):612-620. 19. tatar m, amram s. israeli adolescents’ coping strategies in relation to terrorist attacks. br j guid counc. 2007;35(2):163-173. 20. glennie ej. coping and resilience. noncognitive skills in the classroom: new perspectives on educational research. 2010;169-193. 21. shukat s, pell aw, gull f. students' concerns about terrorism in pakistan: views from madrassahs, private and public schools. jrre. 2016;10(1):16-27. 22. smith bw, dalen j, wiggins k, tooley e, christopher p, bernard j. the brief resilience scale: assessing the ability to bounce back. ijbm. 2008;15:194-200. 23. carver cs, scheier mf, weintraub jk. assessing coping strategies: a theoretically based approach. j pers soc psychol. 1989;56(2):267. 24. islam z. origins of madrasas in india predates muslim period. the milli gazette. 2010;3:1-5. 25. lu w, bian q, song yy, ren jy, xu xy, zhao m. prevalence and related risk factors of anxiety and depression among chinese college freshmen. j huazhong univ sci. 2015;35:815-822. 26. exchange, s. education for peace, human rights, democarcy, international understanding and tolerance (pp. 1-160). ottawa, canada: council of ministries of education, canada 2015. 27. sadruddin mm. study on the role of media, ngos and civil society in promoting pluralism in pakistan. dialogue. 2012;7(2):161177. 28. shabir g, usman farooq abbasi sm, khan a. reforming the madrassah system. pak j soc sci. 2012;32(1):147-156. 29. weiss am, hussain a, sathar za. social development, the empowerment of women, and the expansion of civil society: alternative ways out of the debt and poverty trap [with comments]. pak development rev. 2001;40(4):401-432. 30. dhume, d. the effect of womens education on terrorism: examining a causal chain involving fertility and young male populations. havard university. 2005. 31. malik f, khawar r, iftikhar r, saeed s, ilyas r. development of terrorism impact scale: initial validity and reliability analyses. pak j soc clin psychol. 2010;8(2):91-118. 32. robison kk. unpacking the social origins of terrorism: the role of women's empowerment in reducing terrorism. stud confl terror. 2010;33(8):735-756. 33. american psychological associationthe road to resilience. 2017. available online at: http://www.apa.org/helpcenter/roadresilience.aspx 34. rahat e, i̇lhan t. coping styles, social support, relational self-construal, and resilience in predicting students’ adjustment to university life. educ sci. 2016;16(1):187-208. 35. jamal m, khan a, muhammad ad. impact of terrorist attacks on educational institutionsperceptions of medical students. j rawalpindi med coll. 2016;20(02):124-128. 36. ahmed ae, masood k, dean sv, shakir t, kardar aa, barlass u, imam sh, mohmand mg, ibrahim h, khan is, akram u. the constant threat of terrorism: stress levels and coping strategies amongst university students of karachi. jpma. 2011;61(4):410-414. 37. felsten g. gender and coping: use of distinct strategies and associations with stress and depression. anxiety stress coping. 1998;11(4):289-309. 38. aldwin, c. m. stress, coping, and development: an integrative approach. 2007; (2nd ed., p. 432). new york, ny: guilford. 39. dyson r, renk k. freshmen adaptation to university life: depressive symptoms, stress, and coping. j clin psychol. 2006;62(10):12311244. 40. kuiper na, martin ra, olinger lj. coping humour, stress, and cognitive appraisals. can j behav sci. 1993;25(1):81-96. 41. lewis, j. aspen's us comedy arts festival. aspen, co. 2000. about:blank about:blank about:blank 28 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v9.i1.2022.28-38 original article prevalence of stress, anxiety, depression, and job dissatisfaction in health care professional dealing with covid-19 patients afshan arzoo1 & saima masoom ali2 1dow institute of medical technology, dow university of health sciences, karachi-pakistan 2department of psychology, university of karachi, karachi-pakistan abstract background: in pakistan, health care professionals already suffer a lot mentally due to work burden and health risks, covid-19 added more stress to the situation. this study aims to evaluate stress, anxiety, and depression with job satisfaction in health care professionals treating covid-19 patients. methodology: a cross-sectional study was conducted among health care professionals, working at covid-19 hospitals (private and public sector hospitals both). data was collected from special units like isolation wards, and intensive care units. the study questionnaire consists of a socio-demographic section followed by the depression, anxiety, and stress scale (dass-21) for measuring stress, anxiety, and depression (sad). moreover, war cook wall (1979) job satisfaction questionnaire was also used. results: study data reveals moderate to severe levels of anxiety (21.7% to 22.5%) and depression (22.5%, 13.3%) among healthcare providers. an association between age, marital status, organization, and occupation with depression at a pvalue < 0.05 was noticed. a moderate degree of job satisfaction is found in overall job satisfaction. the majority of participants showed dissatisfaction in terms of income. overall average level of satisfaction was found in rest of the items of wcw questionnaire. conclusion: the study disclosed that the majority of healthcare professionals were found to have stress, anxiety, and depression. keywords covid-19, healthcare professional, depression, anxiety, and stress, job satisfaction. citation: arzoo a, ali sm. prevalence of stress, anxiety, depression, and job dissatisfaction in health care professional dealing with covid-19 patients. app. 2022; 9(1): 28-38 corresponding author email: afshan.arzoo@duhs.edu.pk doi: 10.29052/2412-3188.v9.i1.2022.28-38 received 16/03/2022 accepted 26/05/2022 published 01/06/2022 copyright © the author(s). 2022. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. about:blank about:blank about:blank about:blank about:blank 29 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 introduction at the end of 2019, in wuhan, china a new virus was identified which was not previously found in a human is known as coronavirus (covid-19)1. the infection grows very quickly worldwide that in march 2020, world health organization announced it as an epidemic, a global health emergency. end of november 20, covid 19 spread in 220 countries, infecting 62 million+ people in the world, and 1456k plus deaths occurred due to this infectious disease2. coronavirus is an infectious disease that spread through a droplet of saliva or discharge from the nose and infects other people mainly the lungs and airways by infected person cough and sneezing. this disease affects people in different ways with moderate to severe illness leading to hospitalization and intensive care management2. in response to this outbreak, there had been confusion in decision making and insufficient resources to properly allocate the professionals for their protection as well as to treat patients3. this situation advanced towards further harm to patient health which may ultimately compromise the quality of healthcare workers4. on account of the destructive effects of covid-19 globally, affected countries in the world have been picking exceptional measures to curb this outbreak like quarantine, complete lockdown in the severely affected areas, and smart lockdown in mild to moderate suffering areas. closing of intercity transportations, ban on public gatherings, and physical education converted to online education5. psychological symptoms like stress, anxiety, panic, fear and paranoid behaviors in people rose extremely that people avoid all kinds of gatherings and get together even within the home. reduced levels of autonomy and highly disturbed about their earnings, and employment surety has already been noticed in a population6. not only local people of communities, it is noticed that healthcare workers are also at high risk of developing psychological problems easily due to multiple reasons like late working in covid units, and high chances of getting infected because of close relationships with the patients in hospitals. this would open to stress, anxiety, burnout, and depressive symptoms, like the fear of getting an infection, which was so common that many healthcare workers took casual or earned leaves, which ultimately compromise the role of the health sector to provide healthcare aid during the catastrophe. all of the abovementioned risk factors can exaggerate stress, anxiety, and depression along with job dissatisfaction7. occupational stress is a heightened source of job-related illnesses plus burnout, especially in healthcare providers8. when covid-19 came into being it added spice to workrelated stress and psychological issues in the battle of saving lives. additionally late working hours in special units and demand to do more from hcws during the worldwide reaction to this pandemic. the need for hcws increases as the disease spread out of our imagination because they represent one of the riskiest individuals in curbing the transmittable disease. many hcws working as the forefronts soldiers of the covid-19 outbreak have become infected and a majority of them had been in quarantine after exposure9. according to american psychiatric association, anxiety is a response of the body to a perceived threat that is triggered by an individual’s beliefs, feelings, and thoughts and is characterized by worrying thoughts, tension, increased blood pressure, respiratory rate, pulse rate, sweating, the difficulty of swallowing, dizziness, and chest pain10. whereas depression can be defined as “depression is a common and serious 30 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 medical illness that negatively affects how you feel, the way you think, and how you act”. depression causes feelings of sadness and/or a loss of interest in activities you once enjoyed. it can lead to a variety of emotional and physical problems and can ultimately decrease your ability to function at work and home11. last year's metaanalysis revealed that stress, anxiety, and depression along with other psychological stressors were common outcomes in healthcare providers during the covid-19 pandemic, and is mostly in females and in those who had direct physical contact with covid-19 patients12. a recent overview of the literature showed that the majority of the study participants (51.6%, mean age 25 -31 years) were presented with having perceived stress for coronavirus disease. immediate screening and counseling of stress-related issues among frontline healthcare workers based on the findings are suggested13. last year study done in canada revealed that onethird of the study candidates were disturbed about the current epidemic14. another german research reported a higher number of hcws were upset about covid-1915. online poll research done in the usa tells that 56% of candidates were tensed about the spread of covid-19 infection from person to person16. one more related research run in the usa revealed that participants were more disturbed about covid-19 in contrast to seasonal influenza and routine infections 7,16. very few studies have a look into the psychological well-being and the professional domain of hcws during the covid-19 pandemic17. as there is a run of the third wave of coronavirus and prediction of the fourth wave that is delta variant in pakistan nowadays which is more lethal than previous waves. karachi city is on top of the list for covid positive patients on daily basis; ultimately it creates pressure on hospitals and medical professionals. according to the economic survey of pakistan 2019-2020, the health sector in pakistan already is in the most critical condition having poor infrastructure and very low manpower. in the economic survey, it is mentioned that the health sector showed some improvement, but the improvement is not up to the mark and ultimately health sector still suffering and taking its last breaths. the total population of pakistan is 227 million by june 202118. the pathetic situation is that only 1979 hospitals for this population (public sector hospital 1279, a private sector hospital 700). the available bed for approx 1700 people is only 1 and 1 physician for approx 950 persons. the ratio of doctor to nurse is also pathetic that only one nurse is to serve two doctor orders as per the economic survey of pakistan 2019-2020. so, the rationale of this study is to effectively research the domain of health care and processes as this sector is very important and neglected. the common research topics include immediate care and surgery, genetics, vaccine development, plasma antibodies, vaccine trials, and worldwide reaction to the covid-19 epidemic but there is a lack of psychological health research and only a few studies have talked about the effects of the covid-19 outbreak in healthcare workers welfare and safety. the main aim of this study is to study the stress, anxiety, and depression with job satisfaction among health care professionals dealing with covid-19 patients in hospitals. methodology participants a cross-sectional study was conducted from 15th dec 2020 to 15 march 2021. the subjects for this study were healthcare professionals, working public and private hospitals dealing with covid-19 patients. 31 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 health care professional is a broad term, but we included doctors, nurses, icu technicians, respiratory therapists/icu technologists. the calculated sample size was 140 but as of covid-19, 3rd and 4th wave, the majority of hospitals refused to participate in the study. a purposive sampling technique was used in this study and a total 129 healthcare providers participated in this study. while, 9 forms were incomplete, therefore, excluded from the statistical analysis. measures the questionnaire consisted of three sections. the first section focused towards socio-demographics of the study participants that includes gender, age, marital status, living arrangement, organization, and occupation. the second section was for depression, anxiety, and stress. which was evaluated by the depression, anxiety, and stress scale (dass-21 lovibond and lovebird, 1995). the scale is comprised of 21 items measured on a 4points likert scale (never, sometimes, often, almost always) which evaluates the three psychological sub-dimensions of psychological distress, namely anxiety, depression, and stress. the score was distributed in normal, mild, moderate, severe, and extremely severe categories for each subscale. regarding the construct validity, this scale was detected identifying values above the 75° percentile based on normative data19. and the third section was for job satisfaction and it was measured with the previously validated version of the 10-item warr–cook– wall (wcw) job satisfaction scale developed by warr et al4. the wcw instrument measures extrinsic satisfaction from items 1,3,6, and 8 and intrinsic satisfaction from items 5 and item 10 asks for overall job satisfaction. for scoring each item rated on a 7-point likert scale (1 = extremely dissatisfied to 7 = extremely satisfied). the ranks of low satisfaction, moderate satisfaction, and high satisfaction of individual items were set to score of the individual item as mentioned in the research. for each item, 1 to 3 score was categorized as low satisfaction, score 4 to score 5 was marked as moderate satisfaction, and score 6 to score 7 was marked as high satisfaction20. procedure the data was collected in two folds. the first method was to collect data electronically. the second method was the in-person data collection method. health care providers were approached, and participants were explained the objective of this study, the study participants were asked to fill out the questionnaire and return the filled one on the spot. the area for approaching subjects in hospitals was their sitting room and sops for the covid-19 prevention were completely followed by subjects and researcher. statistical analysis the data were statistically analyzed using spss (statistical package for social science version 26.0). descriptive statistical tests were conducted to observe the frequencies of socio-demographic variables of the sample. overall percentages for the dass-21 subscale scoring are also seen in percentages. one-way anova was used to test all hypotheses for this study. to see the association between two variables chisquare test was applied. the significance level was set at α=0.05. result table one represents the total of 120 subjects who took part in this study of which the majority were male participants 71 (59.2%). 32 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 while the majority of the respondents 54 (45.0%) age were between 26-30 years. majority of subjects were married that is 58 (48.3%). of the total participants who were serving in a private organization 75 (62.5%), and the majority were living in a joint family system 80 (66.7%). maximum no of participants was nurses that are 42 (35.0%) (table 1). table 1: frequency distribution along with percentages of socio-demographic variables. study variables n (120) % gender male 71 59.2 female 49 40.8 age 21-25 33 27.5 26-30 54 45.0 31-35 22 18.3 36-40 9 7.5 >45 2 1.7 marital status married 57 50 unmarried 58 48.3 divorced 3 2.5 widow 2 1.7 organization public sector 45 37.5 private sector 75 62.5 living arrangement joint family 80 66.7 nuclear family 30 25.0 alone 10 8.3 occupation doctor 37 30.2 nurses 42 35.0 icu technician 9 7.5 respiratory therapist/icu technologist 32 26.7 table 2 shows the overall distribution of dass-21 scoring in overall (n=120) members. in which moderate levels of depression, anxiety, and stress were seen in participants that are 22.5%, 21.7%, and 25.0%. while the extremely severe level of anxiety is also seen. it shows the overall presence of depression, anxiety, and stress up to some extent (table 2). table 2: severity percentages of dass-21 (n=120). severity depression n (%) anxiety n (%) stress n (%) normal 48 (40.0) 29 (24.2) 53 (44.2) mild 16 (13.3) 6 (5.0) 18 (15.0) moderate 27 (22.5) 26 (21.7) 30 (25.0) severe 16 (13.3) 27 (22.5) 14 (11.7) extremely severe 11 (9.2) 30.0 (25.0) 4 (3.3) total 120 table 3 represent the normal spread of dass-21 with occupational variables. 33 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 table 3: frequency distribution of health care professionals with dass-21 scoring (n=120). occupation dass-21 scoring. total normal mild moderate severe extremely severe doctor 10 4 7 6 10 37 nurse 9 2 8 4 17 40 icu technician 1 0 2 5 1 9 rt/icu technologist 9 0 9 12 2 32 total 29 6 26 27 30 118 the frequency distribution of the health care professionals with association of dass-21 scoring is shown in table 4. table 4: frequency distribution of health care professionals with dass-21 scoring (n=120). items job satisfaction scale mild moderate high n % n % n % 1. physical working condition (ex) 30 (25.0) 64 (53.3) 26 (21.7) 2. freedom of working method 30 (25.0) 61 (50.8) 27 (22.5) 3. colleagues and fellow workers (ex) 24 (20) 64 (53.3) 32 (26.7) 4. recognition for your work 24 (20.0) 63 (52.5) 33 (27.5) 5. amount of responsibility (int) 29 (24.2) 60 (50.0) 31 (25.8) 6. income (ex) 51 (42.5) 60 (50.8) 8 (6.7) 7. opportunity to use your ability 27 (22.5) 62 (51.7) 30 (25.0) 8. hours of work (ex) 31 (25.8) 61 (50.8) 27 (22.5) 9. amount of variety in your job 28 (23.3) 61 (50.8) 30 (25.0) 10. overall job satisfaction 24 (20.0) 63 (52.5) 33 (27.5) total 120 the significance of organizations associated with stress, anxiety and depression through dass21 is shown in table 5 (α = <0.05). table 5: association of stress, anxiety, and depression through dass-21 to organization. anova df ss ms f p dass stress scoring between groups 1 .801 .801 .546 .461 within groups 117 171.770 1.468 dass anxiety scoring between groups 1 1.603 1.603 .707 .402 within groups 117 262.914 2.267 dass depression scoring between groups 1 11.810 11.810 6.531 .012 within groups 117 209.783 1.808 total (n) 118 34 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 table 6 shows the significance of age with stress, anxiety and depression through dass-21 at (α = <0.05). table 6: association of stress, anxiety, and depression through dass-21 to age: anova df ss ms f p-value dass stress scoring between groups 4 5.886 1.472 1.006 .407 within groups 114 166.685 1.462 dass anxiety scoring between groups 4 10.760 2.690 1.198 .316 within groups 114 253.757 2.246 dass depression scoring between groups 4 21.481 5.370 3.033 .020 within groups 114 200.112 1.771 total (n) 118 table 7 shows the significance of occupation with stress, anxiety and depression through dass21 (α = <0.05). table 7: association of stress, anxiety, and depression through dass-21 to occupation: anova df ss ms f p dass stress scoring between groups 3 4.399 1.466 1.003 .394 within groups 115 168.172 1.462 dass anxiety scoring between groups 3 6.628 2.209 .977 .406 within groups 115 257.889 2.262 dass depression scoring between groups 3 15.244 5.081 2.807 .043 within groups 115 206.349 1.810 the significance of marital status with stress, anxiety and depression through dass-21 is shown in table 8 (α = <0.05). table 8: association of stress, anxiety, and depression through dass-21 to marital status: anova df ss ms f p dass stress scoring between groups 3 3.835 1.278 .871 .458 within groups 115 168.736 1.467 dass anxiety scoring between groups 3 10.944 3.648 1.640 .184 within groups 115 253.573 2.224 dass depression scoring between groups 3 23.071 7.690 4.416 .006 within groups 115 198.523 1.741 total (n) 118 35 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 there is a significant relationship between occupation and overall job satisfaction (25.27, n=120) df = 4, p = .000 (table 9). table 9: correlation of occupation and overall job satisfaction: chi-square tests χ 2 df p value pearson chi-square 25.27 4 .000 total (n) 120 discussion our study focuses to see the psychological outcome of the covid-19 pandemic on health care workers and also how much they are satisfied with their jobs during this pandemic. in this study, the overall prevalence of psychological issues in health care providers shows that depression was seen and ranged from moderate to severe and extremely severe 22.5% to 13.3% and 9.2%, while anxiety shows more significant and ranged from moderate to severe and extremely severe that is 21.7%, 22.5%, 25.0 %. whereas, stress is also seen at a moderate level of 25.0%. this finding is consistent with many other previous findings21-23. generally, nurses are subject to numerous aggravations from the biological, emotional, and societal working atmosphere which are noticeably high among the front-line nurses working in covid-19 tertiary care hospitals. significant moderate level of anxiety measured by dass-21, the overall impact is seen in nurses which is a notable finding in this study that is 31 nurses out of 40 in this study have psychologically affected in this outbreak. these findings were supported by other findings in which occupational stress was significantly seen in paramedics24. this is also consistent with another study that revealed that the unexpected emergencies originated from the covid-19, the high number of reported cases validated or suspicious, and work overload indulging nurses under intense pressure. 17, another study expresses that this virus emerged panic emotions in people and if paramedics are not planned to face these emotions they may ultimately go into significant tension25. well, it was also observed that doctors also expressed notable levels of anxieties treating patients during this pandemic. in this study 27 out of 37 doctors reported anxiety at different levels from mild to extremely severe. usually, physicians don’t report any stressors or anxiety feeling in their normal practice but this outbreak also upset doctors' mental health very seriously26. whereas, anxiety and stress were reported by doctors in many studies27,28. we have also seen the job satisfaction in health care providers to see how satisfied they are with their jobs so we saw a moderate level of satisfaction in all items of the scale shown in table 4. but the health care providers showed low satisfaction with their income as 42.5% of participants are not happy with their income. the annual income of hcw is not satisfactory at all29. health care providers are not happy with their salaries not only in pakistan but also worldwide24,30-32. when job satisfaction compare with occupation to evaluate the association between job satisfaction and different occupation of healthcare providers so the result was significant as shown in table 9 and showed an association between them at α=0.05. this finding is contrary to the previous finding in which covid 19 36 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 associated stressors in hcw had high-stress levels, workload, and the average level of job dissatisfaction presented33,34. but one study supports our findings of a significant association between job satisfaction and occupational stress among professionals with other socio-demographic variables seen in health care professionals24. we can comment on this finding. after all, the literature and our hypothesis are contrary to our findings because the literature is not from the covid-19 era. there are several factors in which we get this result significant as the sample size was small enough that we can’t comment on these findings. if the sample size increases maybe there would be a chance of change in results. secondly in pakistan, the impact of covid-19 posed no such serious impact on people and the healthcare sector as in the rest of the world and neighboring countries35,36. this might be due to the government having precautionary measures on time, especially the smart lockdown strategy, which ultimately leads to less burden on disease and the economy even in lethal variants37. when dass subscale scoring compared with a socio-demographic variable by one-way anova in tables 5,6,7 and 8 shows significance at α=0.05, we see a good significant level for age, marital status, organization, and occupation. it indicates there is a strong relationship between age group with depression, marital status with depression, organization with depression, and occupation with depression at a p value of 0.020, 0.006, 0.012, and 0.043 respectively. this finding of our study is strongly supported by other literature results as occupational stress in healthcare workers with a variety of socio-demographic variables depends dynamically13,24,27,34. limitations of the study the study was limited to those health care professionals who are dealing with covid19 patients in special covid units. sample size was small because of multiple reasons like the refusal of hospital management. duration of this study was short, and the lockdown measures for safety also limit our study. due to the small sample size, the statistical finding was also limited. conclusion in conclusion, the study disclosed that the majority of healthcare professionals showed stress, anxiety, and depression during the covid-19 era. the other socio-demographic variables like age, organization, and occupation have a strong association with depression. we saw a significant relationship between occupation and job satisfaction of health care professionals. acknowledgment authors would like to acknowledge and thank to sindh infectious disease hospital and research centre, nepa, karachi, and dow university hospital covid-19 units for the support and help in data collection. references 1. zhu z, xu s, wang h, liu z, wu j, li g, et al. covid-19 in wuhan: immediate psychological impact on 5062 health workers. 2020. 2. organization wh. who characterizes covid-19 as a pandemic. 1.1 [eb/ol](202003-12)[2020-03-12]. 2020. 3. binkley ce, kemp dsjjotacos. ethical rationing of personal protective equipment to minimize moral residue during the covid-19 pandemic. 2020;230(6):1111-3. 4. wallace je, lemaire jb, ghali wajtl. physician wellness: a missing quality indicator. 2009;374(9702):1714-21. 5. khan n, faisal sjaas. epidemiology of corona virus in the world and its effects on the china economy. 2020. 6. zhou x, snoswell cl, harding le, bambling m, edirippulige s, bai x, et al. the role of 37 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 telehealth in reducing the mental health burden from covid-19. 2020;26(4):377-9. 7. ornell f, schuch jb, sordi ao, kessler fhpjbjop. “pandemic fear” and covid-19: mental health burden and strategies. 2020;42(3):232-5. 8. hassan nm, abu-elenin mm, elsallamy rm, kabbash iajes, research p. job stress among resident physicians in tanta university hospitals, egypt. 2020;27(30):37557-64. 9. neto mlr, almeida hg, esmeraldo jda, nobre cb, pinheiro wr, de oliveira crt, et al. when health professionals look death in the eye: the mental health of professionals who deal daily with the 2019 coronavirus outbreak. 2020;288:112972. 10. edition fjapa. diagnostic and statistical manual of mental disorders. 2013;21. 11. parekh r. what is depression? american psychiatric association. 2017. 12. chou r, dana t, buckley di, selph s, fu r, totten amjaoim. epidemiology of and risk factors for coronavirus infection in health care workers: a living rapid review. 2020;173(2):120-36. 13. chekole ya, yimer minaye s, mekonnen abate s, mekuriaw bjaiph. perceived stress and its associated factors during covid-19 among healthcare providers in ethiopia: a cross-sectional study. 2020;2020. 14. asmundson gj, taylor sjjoad. coronaphobia: fear and the 2019-ncov outbreak. 2020;70:102196. 15. gerhold l. covid-19: risk perception and coping strategies. 2020. 16. pakpour ah, griffiths mdjjocd. the fear of covid-19 and its role in preventive behaviors. 2020;2(1):58-63. 17. mo y, deng l, zhang l, lang q, liao c, wang n, et al. work stress among chinese nurses to support wuhan in fighting against covid‐19 epidemic. 2020;28(5):1002-9. 18. worldmeter population 2021 [available from: https://www.worldometers.info/worldpopulation/pakistan-population/. 19. henry jd, crawford jrjbjocp. the short‐form version of the depression anxiety stress scales (dass‐21): construct validity and normative data in a large non‐clinical sample. 2005;44(2):227-39. 20. nørøxe kb, pedersen af, bro f, vedsted pjbfp. mental well-being and job satisfaction among general practitioners: a nationwide cross-sectional survey in denmark. 2018;19(1):1-11. 21. khanal p, devkota n, dahal m, paudel k, joshi djg, health. mental health impacts among health workers during covid-19 in a low resource setting: a cross-sectional survey from nepal. 2020;16(1):1-12. 22. alzaid eh, alsaad ss, alshakhis n, albagshi d, albesher r, aloqaili mjjofm, et al. prevalence of covid-19-related anxiety among healthcare workers: a cross-sectional study. 2020;9(9):4904. 23. giusti em, pedroli e, d'aniello ge, badiale cs, pietrabissa g, manna c, et al. the psychological impact of the covid-19 outbreak on health professionals: a crosssectional study. 2020;11. 24. gulavani a, shinde mjijos, research. occupational stress and job satisfaction among nurses. 2014;3(4):733-40. 25. covid c, team r, covid c, team r, covid c, team r, et al. coronavirus disease 2019 in children—united states, february 12–april 2, 2020. 2020;69(14):422. 26. fauzi mfm, yusoff hm, robat rm, saruan nam, ismail ki, haris afmjijoer, et al. doctors’ mental health in the midst of covid19 pandemic: the roles of work demands and recovery experiences. 2020;17(19). 27. salari n, khazaie h, hosseinian-far a, khaledi-paveh b, kazeminia m, mohammadi m, et al. the prevalence of stress, anxiety and depression within front-line healthcare workers caring for covid-19 patients: a systematic review and meta-regression. 2020;18(1):1-14. 28. du j, dong l, wang t, yuan c, fu r, zhang l, et al. psychological symptoms among frontline healthcare workers during covid19 outbreak in wuhan. 2020;67:144. 29. salary explorer 2020 [available from: http://www.salaryexplorer.com/salarysurvey.php. 30. gedif g, sisay y, alebel a, belay yajbrn. level of job satisfaction and associated factors among health care professionals working at university of gondar referral hospital, northwest ethiopia: a cross-sectional study. 2018;11(1):1-7. 31. kumar r, ahmed j, shaikh bt, hafeez r, hafeez ajhrfh. job satisfaction among public 38 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 health professionals working in public sector: a cross sectional study from pakistan. 2013;11(1):1-5. 32. alrawashdeh hm, ala’a b, alzawahreh mk, al-tamimi a, elkholy m, al sarireh f, et al. occupational burnout and job satisfaction among physicians in times of covid-19 crisis: a convergent parallel mixed-method study. 2021;21(1):1-18. 33. afulani pa, nutor jj, agbadi p, gyamerah ao, musana j, aborigo ra, et al. job satisfaction among healthcare workers in ghana and kenya during the covid-19 pandemic: role of perceived preparedness, stress, and burnout. 2021;1(10):e0000022. 34. said rm, el-shafei dajes, research p. occupational stress, job satisfaction, and intent to leave: nurses working on front lines during covid-19 pandemic in zagazig city, egypt. 2021;28(7):8791-801. 35. gupta s, sahoo sjgp. pandemic and mental health of the front-line healthcare workers: a review and implications in the indian context amidst covid-19. 2020;33(5). 36. raj r, koyalada s, kumar a, kumari s, pani pjjofm, care p. psychological impact of the covid-19 pandemic on healthcare workers in india: an observational study. 2020;9(12):5921. 37. iqbal z, hasnain mjijom. management during and after covid-19 pandemic: a descriptive quantitative study. 2021;3(1):4655. about:blank 39 ann. psychophysiol. issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v9.i1.2022.39-50 systematic review approaches used for the quantification of pain in physical therapy practices-a systematic review shahrukh abbasi1 , shahzaib naseer2 & sumaira imran farooqui1 1ziauddin college of rehabilitation sciences, ziauddin university, karachi-pakistan 2sindh institute of urology and transplantation (siut), karachi-pakistan abstract background: this study aimed to determine the most common pain intensity assessment tool that has been used in different physical therapy managementbased studies as a primary outcome measure for the quantification of pain. methodology: the electronic databases including pubmed, google scholar, pedro, and cochrane library were searched to identify relevant studies from january 2015 to september 2021 by using keywords like 'pain,' 'pain intensity,' 'visual analogue scale,' and 'numeric pain rating scale.' randomized controlled trials or quasi-experimental studies in which pain management is considered an outcome measure published in the english language were included. in contrast, non-rcts were excluded that were based on pain management strategies other than physical therapy or conducted in inpatient department or based on approaches of telerehab. results: the findings revealed that n=1,292 participants were given different physical therapy interventions in which n=792 (61.3%) were evaluated for their pain on vas, followed by n=453 (35%) on nprs and n=169 (13%) on ppt of the total population. conclusion: vas was the most frequently used tool to determine the patient's perception of pain, followed by nprs and mcgill pain questionnaire. keywords physical therapy, pain management, activities of daily living, neck pain, quality of life. citation: abbasi s, naseer s, farooqui si. approaches used for the quantification of pain in physical therapy practices-a systematic review. app. 2022; 9(1): 39-50 corresponding author email: shahrukh.abbasi@zu.edu.pk doi: 10.29052/2412-3188.v9.i1.2022.39-50 received 18/04/2022 accepted 06/05/2022 published 01/06/2022 copyright © the author(s). 2022 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v9.i1.2022. https://orcid.org/0000-0001-5017-7603 https://orcid.org/0000-0002-9540-4280 https://orcid.org/0000-0001-9263-8033 http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 40 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 introduction pain is considered a fifth vital sign, and hence its precise assessment is important for its management1. pain is examined using both subjective and objective methods since a patient's sense of pain fluctuates based on their physiological or psychological status at the time, and they may not perceive a reduction in symptoms while being treated by a physiotherapist2. the patient reports his or her pain, which is subsequently documented in a subjective technique, whereas pain is measured indirectly in objective approaches. physiotherapists, however, do not commonly evaluate and quantify pain, even though it is becoming a trend in their field. although several scales have been established for the subjective assessment of pain that clinicians use to construct suitable management strategies, most approaches are subjective. they rely heavily on the patient's self-reported strategy for correct assessment2. for assessing the pain, it is of utmost importance for the physical therapist to identify its component and which are type, duration, intensity, and location of the pain. besides that, another important factor is used to define pain, which is its aggravating and alleviating factor3. literature has provided evidence that is typically defining pain in terms of its type studies have agreed upon the concept that patient feelings about pain reveal the type of pain from which the patient is going through4. researchers have agreed that while defining the type of pain, the most widely used types are neuropathic, somatic, and visceral, which have further classified into deep, viscerosomatic, and referred5. further, while evaluating the location of pain, the physical therapist must identify the exact location on the patient's body where the pain is being perceived either due to direct contact or in the form of referred pain6. besides that, determining the intensity of pain is one of the essential factors and, indeed, a tool for devising a physical therapy management strategy for relief for the patient. studies have come across multiple subjective assessment tools that the physical therapist is extensively using to determine the intensity of pain among patients and out of all the available pain intensity assessment tool setups for quantifying pain7. duration of pain is yet another important component that indeed provides information regarding the severity of pain and combined with execrating and relieving factors; this information is vital for the physical therapist to identify the patient's accurate source of pain and devise its management strategies accordingly8. literature has provided evidence that most patients referred to physical therapy outpatient departments (opds) either selfreferral or via physician and surgeons, the most common problem they revealed is pain9. it is also evident from the data that most of the physical therapy-based studies available on the database like google scholar, cochrane, and other; include pain assessment tool. it is consider the most common outcome measure that has been used as a primary source of assessment to identify the efficacy and efficiency of any treatment protocol used in the clinical setups. hence it is for this purpose that the current study is aimed to determine the most common pain intensity assessment tool that has been used in different physical therapy management-based studies as a primary outcome measure for quantification of pain. 41 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 methodology study protocol all of the findings were based on previously published studies. as a result, no ethical approval or patient consent was required. the review was carried out according to the preferred reporting items for systematic reviews and meta-analyses (prisma) statement. sources of information and search strategy from january 2015 to september 2021, the electronic databases pubmed, google scholar, pedro, and the cochrane library were searched for relevant studies using keywords such as 'pain,' 'pain intensity,' 'visual analogue scale (vas),' and 'numeric pain rating scale (nprs). additional papers were found by manually searching relevant journals, conference papers, and reference lists. criteria for eligibility experimental research, including randomized controlled trials (rcts) or quasi-experimental designs conducted in physical therapy settings between 2015 and 2021 with pain management as an outcome measure published in english, was included. non-rct or non-clinical trials based on pain treatment techniques other than physical therapy, trials done in an inpatient setting, trials that incorporated domiciliary physical therapy services, and trials based on telerehab approaches were eliminated. abstracts that did not have a complete matching article published in a peer-reviewed publication or that did not include particular data were also removed. outcome measures the primary outcome measures were visual analog scale (vas), numerical pain rating scale (nprs), nottingham health profile (nhp), northwick park neck pain questionnaire (npnpq) score, pressure pain threshold (ppt), mcgill pain questionnaire, and pain catastrophizing scale. if multiple scales were used to evaluate the same outcome index in research, the primary outcome scale or the most representative scale was chosen for analysis. search methods for identification of studies two authors independently assessed the search results to choose potentially relevant papers and screened the titles, abstracts, and full texts of discovered references. extraction of information basic study details, total sample size, and results were among the data retrieved. evaluation of the quality level the pedro scale was used to measure the quality of the studies. to authenticate their pedro scale score, all included trial reports were reviewed in the pedro database. trials with a score of 6 points were deemed "good," while those with a score of 5 were deemed "bad." the analysis was omitted because of the low quality of the research. 42 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 figure 1: flowchart of the study procedure articles that were included according to inclusion and exclusion criteria have been represented in table 1 as follows: s# study year sample size outcome measure pedro quality assessment 1 the effect of mulligan mobilization on pain and life quality of patients with rotator cuff syndrome10 2019 30 vas good 2 short-term effects of mulligan mobilization with movement on pain, disability, and kinematic spinal movements in patients with non-specific low back pain11 2015 32 vas good 3 the effects of the number of physical therapy sessions on pain, disability, and quality of life in patients with chronic low back pain12 2017 60 vas & nottingham health profile moderate 4 effect of isometric back endurance exercises on patients with nonspecific chronic low back pain13 2021 60 vas good 43 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 5 swiss ball exercises as an alternative to mckenzie exercises in treating chronic low back pain among poultry workers14 2020 60 nprs moderate 6 effect of lumbar stabilization versus mckenzie exercises on pain and functional disability in patients with the postlaminectomy syndrome15 2019 45 vas good 7 effectiveness of mulligans mobilizations with upper limb movement and mckenzie exercises with neural mobilizations in patients with cervical spondylitis16 2018 60 vas score and northwick park neck pain questionnaire good 8 kinesio taping reduces pain and improves disability in low back pain patients17 2019 108 nprs moderate 9 comparison of dry needling and kinesio taping methods in the treatment of myofascial pain syndrome18 2021 88 pressure pain threshold & vas low 10 comparison of different electrotherapy methods and exercise therapy in shoulder impingement syndrome19 2018 83 vas good 11 effectiveness of dry needling versus a classical physiotherapy program in patients with chronic low-back pain: a single-blind, randomized, controlled trial20 2017 34 vas & mcgill pain questionnaire score good 12 a comparison of physical therapy modalities versus acupuncture in the treatment of fibromyalgia syndrome21 2018 44 mcgill pain questionnaire score moderate 13 pain management using a multimodal physiotherapy program including a biobehavioral approach for chronic non-specific neck pain: a randomized controlled trial22 2018 47 pain catastrophizing scale & vas moderate 44 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 14 effectiveness of standard cervical physiotherapy plus diaphragm manual therapy on pain in patients with chronic neck pain23 2021 40 nprs & ppt good 15 the effect of mulligan mobilization technique in older adults with neck pain24 2018 42 vas moderate 16 effectiveness of physiotherapy for seniors with recurrent headaches associated with neck pain and dysfunction25 2017 65 vas good 17 is a combined program of manual therapy and exercise more effective than usual care in patients with non-specific chronic neck pain?26 2019 64 nprs low 18 manual therapy compared with physical therapy in patients with non-specific neck pain27 2017 181 nprs low 19 effects of myofascial release on pressure pain thresholds in patients with neck pain28 2018 41 vas & ppt moderate 20 effectiveness of core stabilization exercises and routine exercise therapy in the management of pain in chronic non-specific low back pain29 2017 108 vas good results study selection literature research of 40 studies was conducted on several databases to investigate pain assessment techniques, of which 30 papers were initially selected and included in this study. the publications were accepted based on inclusion/exclusion criteria that were created specifically for this study. figure 1 depicts a flow chart of the schematic portrayal of the full research search based on our study's criteria. 45 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 methodological quality the pedro ratings were used to assess the methodological quality of the selected studies. after deliberation and consensus among the reviewers, all disparities in the pedro scales were addressed. table 1 shows the results of the quality scores, which varied from 3 to 8 on a scale of 10 points. ten studies were of high quality, six were of moderate quality, and four were of low quality. synthesized findings our data indicated that vas is the most prevalent outcome measure widely used to quantify pain. aside from vas, the numeric pain rating scale, pressure pain threshold scale, and mcgill pain questionnaire score were some of the most frequently employed outcome measures in clinical settings by physical therapists. however, the nottingham health profile (nhp), pain catastrophizing scale, and northwick park neck pain questionnaire (npnpq) score were the least commonly used instruments in the study that quantified pain in response to physical therapy. figure 2 shows a diagrammatic depiction of the research findings. figure 2: frequency of different pain scale commonly used by pts the result of our study had revealed that of the total number of literature that we reviewed, a total number of n=1,292 participants were given different physical therapy interventions. in the litarature reviewed n=792 participants were evaluated for their pain on vas outcome measure that, make a total percentage of 61.3% of the total population of this study. nprs was used to analyze n=453 participants, which comprised 35% of the participants, followed by n=169 who were evaluated through ppt, which comprises 13% of the total population. mcgill pain questionnaire score was used for 78 participants making a 6% of the total population. nottingham health profile (nhp) and northwick park neck pain questionnaire (npnpq) score were used in n=60 participants making a total population of 4.6%. pain catastrophizing scale was used in n=47 participants, making it the least used scale by physical therapists 3.6% for quantifying pain in the clinical setups. the population-wise frequently used pain assessment tool, according to our findings, has been demonstrated in figure 3. 46 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 figure 3: pain assessment tool commonly used by pts in the population discussion the findings of our study have revealed that vas is the most frequently used tool to quantify pain along with nprs. this may be since both these assessment tools are user-friendly perception-based tools to determine pain severity among patients in physical therapy clinic setups. according to lazaridou et al., vas has been considered a measure of choice for pain assessment as the assessment tool has good validity and is also sensitive to treatment effect. in another study, the researcher considered vas an important tool to track pain progression among patients and compare the pain of patients diagnosed with similar conditions30. the numeric pain rating scale was the second most common tool as per our finding the physical therapists were using that in the clinical setups. literature from the previous studies has revealed that nprs, like vas, had been based on patient perception of pain, but unlike vas, the tool has a different format of pain intensity30. nprs has three different scales, 0 to 10, 0 to 20, and 0 to 100 making this scale slightly more complex than vas as it turns the researcher into a perplexed state that out of three different scales, which scale is to be used31. the pressure pain threshold scale was yet another pain assessment scale we, during our search, had come across in several studies. this scale had five gradings where 0 suggested no sign of pain, and iv was considered as a noxious intolerable pain32. although the scale was considered valid and reliable, it was observed that the scale was not found to be sensitive enough. hence, the scale gets obsoleted from clinical and research perspectives32. mcgill pain questionnaire was another frequently used tool for pain assessment, and it comprised three different components that were sensory, affective, and cognitive. each component had various descriptors ordered from no pain to severe33. the complex arrangement of the questionnaire made the researchers shift towards a short form of the questionnaire that too comprises 15 descriptors ordered from 0 to 3, where 0 represents no pain, and 3 indicates severe pain33. moving further into the list, we have come across two other questionnaire-based pain assessment tools: nhp and npnpq. nhp was a comprehensive questionnaire intended to determine the overall condition of patient health based on emotional, social, 47 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 and physical health problems. the questionnaire was based on six sub-areas: energy level, pain, emotional reaction, sleep, social isolation, and physical abilities. the questionnaire was related to the overall health-related condition of the patient, and the pain was only a single component of the questionnaire. hence it was limited to studies in which the patient's overall healthrelated problems were in question, and also the questionnaire did not contain parameters to determine the intensity of pain hence that was the reason why the questionnaire was not widely used in research to determine the intensity of the pain34. npnpq was designed to quantify neck pain while performing the activity of daily living (adls) as the question within the tools were mostly related to neckrelated pain; hence not been used widely for pain intensity quantification purposes35. the pain catastrophizing scale was the most frequently used tool we found during a literature search. the scale comprises 13 questions ranging from 0 to 4, where 0 indicates not at all, and 4 represents all the time. further, the entire scale had three categories for assessing the patient situation: rumination, magnification, and helplessness36. though simple in approach, the pain catastrophizing scale was not widely found among studies which may be due to its subscale classification that did not reflects patients' pain intensity perception; rather, it was more towards patient fear of pain. conclusion the findings of our study revealed that of all the pain assessment tools, vas was the most frequently used tool to determine the patient perception of pain, followed by nprs and mcgill pain questionnaire. the rest of the three assessment tools that included nhp, npnpq, and pain catastrophizing scale were not frequently found in the studies, which may be because npnpq was more towards neck-related pain problems. nhp was based on the overall well-being of the patient, and the pain was only one of the subclass of the questionnaire. the pain catastrophizing scale was more towards the patient's perception of pain-related fear rather than pain intensity quantification. references 1. levy n, sturgess j, mills p. “pain as the fifth vital sign” and dependence on the “numerical pain scale” is being abandoned in the us: why? br j anaesth. 2018;120(3):435-8. 2. wideman th, edwards rr, walton dm, martel mo, hudon a, seminowicz da. the multimodal assessment model of pain: a novel framework for further integrating the subjective pain experience within research and practice. clin j pain. 2019;35(3):212. 3. gregory j. use of pain scales and observational pain assessment tools in hospital settings. nursing stand. 2019;34. 4. jonsdottir t, gunnarsdottir s, oskarsson gk, jonsdottir h. patients' perception of chronic-pain-related patient–provider communication in relation to sociodemographic and pain-related variables: a cross-sectional nationwide study. pain manag nurs. 2016;17(5):32232. 5. dalens bj, storme b. the physiology of pain. inpediatric regional anesthesia 2019:59-70. routledge. 6. chimenti rl, frey-law la, sluka ka. a mechanism-based approach to physical therapist management of pain. physical therapy. 2018;98(5):302-14. 7. pulik ł, dyrek n, piwowarczyk a, jaśkiewicz k, sarzyńska s, łęgosz p. the update on scales and questionnaires used to assess cervical spine disorders. 48 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 physical therapy reviews. 2020;26(2):150-8. 8. gruss s, geiger m, werner p, wilhelm o, traue hc, al-hamadi a, walter s. multi-modal signals for analyzing pain responses to thermal and electrical stimuli. jove. 2019;146s:e59057. 9. boissonnault wg, vanwye wr. primary care for the physical therapist e-book: examination and triage. elsevier health sci; 2020. 10. menek b, tarakci d, algun zc. the effect of mulligan mobilization on pain and life quality of patients with rotator cuff syndrome: a randomized controlled trial. j back musculoskelet rehabil. 2019;32(1):171-8. 11. hidalgo b, pitance l, hall t, detrembleur c, nielens h. short-term effects of mulligan mobilization with movement on pain, disability, and kinematic spinal movements in patients with non-specific low back pain: a randomized placebo-controlled trial. j manipulative physiol ther. 2015;38(6):365-74. 12. ökmen bm, koyuncu e, uysal b, özgirgin n. the effects of the number of physical therapy sessions on pain, disability, and quality of life in patients with chronic low back pain. turk j med sci. 2017;47(5):1425-31. 13. dewir im. effect of isometric back endurance exercises on patients with non-specific chronic low back pain: randomized control trail. science. 2021;25(113):1710-6. 14. villarin rr, marasigan pn, cabatay wa, oarga v, flores ms. swiss ball exercises as an alternative to mckenzie exercises in treating chronic low back pain among poultry workers. eur j mol clin med. 2020;7(2):4197-207. 15. farahat sa. effect of lumbar stabilization versus mckenzie exercises on pain and functional disability in patients with post laminectomy syndrome: a randomized controlled trial. ijramr. 2019:4991-4995 16. kotagiri s, songa ak, gad mv, sulthan n. effectiveness of mulligans mobilizations with upper limb movement and mckenzie exercises with neural mobilizations in patients with cervical spondylitis. iaim. 2018;5:146-55. 17. de brito macedo l, richards j, borges dt, melo sa, brasileiro js. kinesio taping reduces pain and improves disability in low back pain patients: a randomised controlled trial. physiotherapy. 2019;105(1):65-75. 18. groeneweg r, van assen l, kropman h, leopold h, mulder j, smits-engelsman bc, ostelo rw, oostendorp ra, van tulder mw. manual therapy compared with physical therapy in patients with non-specific neck pain: a randomized controlled trial. chiropr man ther. 2017;25(1):1-2. 19. ucurum sg, kaya do, kayali y, askin a, tekindal ma. comparison of different electrotherapy methods and exercise therapy in shoulder impingement syndrome: a prospective randomized controlled trial. acta orthop traumatol turc. 2018;52(4):249-55. 20. tüzün eh, gildir s, angın e, tecer bh, dana kö, malkoç m. effectiveness of dry needling versus a classical physiotherapy program in patients with chronic lowback pain: a single-blind, randomized, controlled trial. j phys ther sci. 2017;29(9):1502-9. 21. ozen s, saracgil cosar sn, cabioglu mt, cetin n. a comparison of physical therapy modalities versus acupuncture in the treatment of fibromyalgia syndrome: a pilot study. j altern complement med. 2019;25(3):296-304. 22. lópez-de-uralde-villanueva i, beltranalacreu h, fernández-carnero j, la touche r. pain management using a 49 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 multimodal physiotherapy program including a biobehavioral approach for chronic non-specific neck pain: a randomized controlled trial. physiotherapy theory and practice. 2018. 23. simoni g, bozzolan m, bonnini s, grassi a, zucchini a, mazzanti c, oliva d, caterino f, gallo a, da roit m. effectiveness of standard cervical physiotherapy plus diaphragm manual therapy on pain in patients with chronic neck pain: a randomized controlled trial. j bodyw mov ther. 2021;26:481-91. 24. buyukturan o, buyukturan b, sas s, karartı c, ceylan i. the effect of mulligan mobilization technique in older adults with neck pain: a randomized controlled, double-blind study. pain res manag. 2018;2018. 25. uthaikhup s, assapun j, watcharasaksilp k, jull g. effectiveness of physiotherapy for seniors with recurrent headaches associated with neck pain and dysfunction: a randomized controlled trial. the spine j. 2017;17(1):46-55. 26. domingues l, pimentel-santos fm, cruz eb, sousa ac, santos a, cordovil a, correia a, torres ls, silva a, branco ps, branco jc. is a combined programme of manual therapy and exercise more effective than usual care in patients with non-specific chronic neck pain? a randomized controlled trial. clinical rehab. 2019;33(12):1908-1918. 27. groeneweg r, van assen l, kropman h, leopold h, mulder j, smits-engelsman bc, ostelo rw, oostendorp ra, van tulder mw. manual therapy compared with physical therapy in patients with non-specific neck pain: a randomized controlled trial. chiropr man ther. 2017;25(1):1-2. 28. rodríguez-huguet m, gil-salú jl, rodríguez-huguet p, cabrera-afonso jr, lomas-vega r. effects of myofascial release on pressure pain thresholds in patients with neck pain: a single-blind randomized controlled trial. am j phys med rehabil. 2018;97(1):16-22. 29. akhtar mw, karimi h, gilani sa. effectiveness of core stabilization exercises and routine exercise therapy in management of pain in chronic nonspecific low back pain: a randomized controlled clinical trial. pjms. 2017;33(4):1002. 30. lazaridou a, elbaridi n, edwards rr, berde cb. pain assessment. inessentials of pain medicine. elsevier. 2018:39-46. 31. halm m, bailey c, pierre js, boutin n, rojo s, shortt m, theobald l, pettycrew e. pilot evaluation of a functional pain assessment scale. clinical nurse specialist. 2019;33(1):12-21. 32. cheatham sw. validation of a pressure pain threshold scale in patients diagnosed with myofascial pain syndrome and fibromyalgia. nova southeastern university; 2016. 33. alharbi ha, albabtain ma, alobiad n, alhasan ja, alruhaimi m, alnefisah m, alateeq s, alghosoon h, alarfaj sj, arafat aa, algarni kd. pain perception assessment using the short-form mcgill pain questionnaire after cardiac surgery. saudi j anaesth. 2020;14(3):343. 34. yüksel s, elhan ah, gökmen d, küçükdeveci aa, kutlay ş. analyzing differential item functioning of the nottingham health profile by mixed rasch model. turk j phys med rehabil. 2018;64(4):300. 35. ilinca i, rosulescu e, danoiu m. the importance of physiotherapy intervention in the functional rehabilitation of patients with cervical postural syndrome. editorial staff. 36. darnall bd, sturgeon ja, cook kf, taub cj, roy a, burns jw, sullivan m, mackey sc. development and validation 50 issn 2412-3188 (online) | 2410-1354 (print) app| published by aeirc| volume 9 issue 1 of a daily pain catastrophizing scale. j pain. 2017;18(9):1139-49. 86 annals of applied psychophysiology december 2025 volume 13 ______________________________________________________________________________ association between balance ability and functional mobility in transtibial amputee patients olaitan olabiyi1, ayomide ajibewa1, bakhat ali¹, bushra madad malik², noor jan², ayesha rayyan3, saba memon², salman hyder², waqar ahmed3 published online: december 2025 © the author(s) abstract background: transtibial amputation affects mobility and independence, often compromising balance and functional mobility. physiotherapy interventions focusing on balance and functional training are essential to improve outcomes. this study evaluates the relationship between balance ability, measured by the berg balance scale (bbs), and functional mobility, assessed using the houghton scale, in transtibial amputees in pakistan. methods: this cross-sectional study included 30 transtibial amputees aged 20–72 years, recruited from the sindh institute of physical medicine and rehabilitation between april and september 2024. balance and functional mobility were assessed using three tasks from the bbs and the houghton scale. data were analyzed with spss 23; descriptive statistics, chi-square tests, and spearman’s correlation were applied, with p<0.05 considered significant. results: participants were predominantly male (80%), with half aged 20–35 years. younger participants and those without diabetes demonstrated higher functional mobility. most participants (96.7%) engaged in regular exercise, and 43.3% achieved independent community mobility. older participants had lower balance (bbs: 10.4±1.5) and functional mobility (houghton: 8.2±1.7) scores. a moderate positive correlation was observed between bbs and houghton scale scores (ρ=0.432, p=0.017). conclusions: balance ability is positively associated with functional mobility in transtibial amputees. targeted balance training improves independence and reduces fall risk. diabetes and trauma were major causes of amputation. structured rehabilitation programs are essential for optimizing functional outcomes. keywords: berg balance scale, houghton scale, transtibial amputees, pakistan corresponding author: bushra madad ali malik, mphil email: bushramadadalimalik@gmail.com introduction amputation, defined as the surgical removal of a body part, significantly impacts an individual’s mobility, independence, and quality of life. transtibial amputation (below-knee) is among the most common lower-limb amputations and presents challenges in balance, functional mobility, and prosthetic use. comprehensive rehabilitation strategies are essential to restore mobility, enhance balance, and facilitate reintegration into daily and community activities.¹ the etiology of amputation varies globally. peripheral vascular disease, diabetes mellitus, and trauma are major causes, with regional variations in prevalence.² traumatic amputations, particularly resulting from road traffic accidents, account for a significant proportion of cases in asia, with incidence rising between 1990 and 2019.³ in pakistan, lower-limb amputations are frequently related to diabetes complications and trauma, with diabetic foot complications such as infections and ulcers contributing to 60–80% of cases.⁴ inadequate diabetes management, delayed medical intervention, and poor adherence to treatment exacerbate the risk of limb loss.⁵ rehabilitation following transtibial amputation requires a multidisciplinary approach, including physiotherapy, occupational therapy, prosthetic training, and psychological support. ⁶ among the key rehabilitation objectives are improving balance, enhancing functional mobility, and reducing the risk of falls. balance deficits negatively affect the ability to perform daily activities, leading to functional limitations and reduced quality of life.⁷ validated tools such as the berg balance scale (bbs) and the houghton scale are widely used to assess balance ability and functional mobility in amputee populations. ⁸,⁹ prior studies have demonstrated that balance training and functional exercises improve prosthetic use, reduce fall risk, and support community reintegration.¹⁰ despite the clinical significance of balance and mobility in transtibial amputees, data from pakistan remain limited. this study aimed to investigate the relationship between balance ability and functional mobility in transtibial amputee patients, providing evidence to guide rehabilitation strategies tailored to this population. methods study design and setting this cross-sectional, descriptive study was conducted between april and september 2024 at the sindh institute of physical medicine and rehabilitation (sipmr), a multidisciplinary center equipped for comprehensive amputee care. the study was designed to evaluate the relationship between balance ability and functional mobility in transtibial amputee patients. participants a total of 30 participants with unilateral transtibial amputation, aged 20–72 years, were recruited using a convenience sampling method. participants with cognitive impairments limiting their understanding of study procedures were excluded. the sample size was calculated based on a correlation coefficient of 0.69 between bbs and houghton scale scores, at α = 0.05 and 80% power (β = 0.2), exceeding the minimum required sample of 14 participants. ethical considerations the study was approved by the institute’s ethics review committee (erc number: pgc-erc/2024-03/03). the requirement for written informed consent was waived due to the observational nature of the study. all procedures adhered to the principles of the declaration of helsinki. data collection demographics and clinical characteristics participants’ age, gender, body mass index (bmi), amputation etiology, comorbidities, duration of amputation, and exercise habits were recorded. outcome measures balance and functional mobility were assessed using the following validated instruments: 1. berg balance scale (bbs) – three tasks were selected from the original 14-task scale, focusing on: · standing with eyes closed · looking behind over the shoulders · turning 360° each task was scored from 0 to 4, with higher scores indicating better balance ability. 2. houghton scale – used to assess functional mobility and prosthetic use, scored from 0 to 12, with higher scores indicating greater independence. procedure observational assessments were conducted by trained physiotherapists. participants performed the three selected bbs tasks and completed the houghton scale questionnaire regarding their functional mobility in household and community settings. statistical analysis data were analyzed using spss version 23. descriptive statistics (mean ± standard deviation, frequency, and percentages) were used to summarize participant characteristics. associations between categorical variables (e.g., age, comorbidities) and functional outcomes were examined using the chi-square test. the spearman correlation coefficient (ρ) was calculated to assess the relationship between bbs scores and houghton scale scores. a p-value <0.05 was considered statistically significant. results a total of 30 transtibial amputee patients participated in the study. half of the participants (50%, 15/30) were aged 20–35 years. the majority were male (80%, 24/30), with a male-to-female ratio of 4:1 (table 1). table 1. frequency of amputee participants by gender gender male 24 (80.0%) female 6 (20.0%) participant demographics and clinical characteristics table 2 presents the mean age, bmi, time since amputation, and duration of exercise. age significantly impacted balance and functional ability (p = 0.001 and p = 0.043, respectively), whereas bmi, exercise duration, and time since amputation showed no significant association with bbs or houghton scale scores. table 2. association of clinical characteristics with bbs and houghton scale scores clinical characteristics mean ± sd p-value (bbs) p-value (houghton) age (20–78 yr) 45.5 ± 14.7 0.001 0.043 bmi 25.2 ± 3.3 0.073 0.567 time since amputation (yr) 4.6 ± 4.6 0.623 0.445 duration of exercise (min) 37.7 ± 22.4 0.138 0.208 effect of exercise (yes/no) – 0.785 0.278 functional outcomes by community independence table 3 shows the differences in bbs and houghton scale scores across different levels of community independence. higher ability groups performed better, demonstrating the effectiveness of the scales in distinguishing functional independence. table 3. significance of differences in outcome measures across ability categories outcome measures independent community limited community household limited f / t-value p-value houghton scale (0–12) 13 (9–12) 15 (6–8) 2 (0–5) f=42.800 <0.001 3-task berg balance 11.3 ± 1.7 8.5 ± 3.4 5.4 ± 4.3 f=33.090 <0.001 gender-wise distribution table 4 displays participant characteristics by gender, including age, time since amputation, bmi, and duration of exercise. the total row has been removed for clarity. table 4. gender-wise distribution of participants (anova) gender (n) age (yr) mean min max time since amputation (yr) mean min max bmi (kg/m²) mean min max duration of exercise (min) mean min max male (24) 48.21 20 72 3.83 0 19 25.03 19.10 34.90 37.92 0 120 female (6) 34.83 26 43 7.83 1 13 25.96 21.04 30.70 36.67 30 60 p-value 0.044 – – 0.058 – – 0.550 – – 0.905 – – etiology, comorbidities, and exercise diabetes mellitus (63.3%) and road traffic accidents (33.3%) were the leading causes of amputation. although 96.7% of participants engaged in exercise, only 43.3% achieved independent mobility, highlighting the need for targeted rehabilitation (table 5). table 5. participant characteristics and frequency distribution variable category frequency (%) gender female 6 (20.0) male 24 (80.0) comorbidities diabetes mellitus – absent 11 (36.7) diabetes mellitus – present 19 (63.3) hypertension – absent 22 (73.3) hypertension – present 8 (26.7) malignancy/transplant – absent 14 (46.7) malignancy/transplant – present 16 (53.3) others absent 25 (83.3) present 5 (16.7) etiology diabetes mellitus 7 (23.3) gangrene 7 (23.3) malignancy 4 (13.3) rta 10 (33.3) transplant 2 (6.7) exercise no 1 (3.3) yes 29 (96.7) houghton’s ability categories limited household 2 (6.7) limited community 15 (50.0) independent community 13 (43.3) correlation between bbs and houghton scale a moderate positive correlation was observed between the 3-task bbs and houghton scale scores (ρ = 0.432, p = 0.017), indicating a meaningful association between balance ability and functional mobility (table 6). table 6. correlation between 3-task bbs and houghton scale scale houghton’s scale ρ p-value 3-task berg balance scale 0.432 0.017 discussion this study examined the relationship between balance ability and functional mobility in transtibial amputee patients. the results demonstrated a significant association between balance performance, measured using the berg balance scale (bbs), and functional mobility, assessed via the houghton scale. participants with higher balance scores exhibited superior functional independence, supporting the importance of balance in overall mobility and community reintegration.¹ age and comorbidities, particularly diabetes mellitus, were significant determinants of functional outcomes. older participants and those with diabetes exhibited lower bbs and houghton scores, reflecting reduced postural stability and impaired mobility. these findings are consistent with previous research, which has reported that aging and diabetes-related complications negatively affect proprioception, muscle strength, and coordination, thereby increasing fall risk and limiting functional independence.²–⁴ gender disparities were observed, with fewer female participants accessing rehabilitation services. although males predominated in this cohort, females exhibited slightly lower balance and mobility scores. this may reflect socio-cultural and economic barriers that restrict female participation in rehabilitation programs, a trend noted in previous studies.⁵,⁶ the moderate positive correlation between bbs and houghton scale scores highlights the interdependence of balance and functional mobility. this aligns with evidence indicating that targeted balance training improves gait performance, prosthetic use, and overall independence in daily and community activities.⁷–⁹ regular exercise and physiotherapy interventions were associated with improved functional outcomes. most participants (96.7%) engaged in physical activity, yet only 43.3% achieved independent community mobility, underscoring the need for structured, individualized rehabilitation programs that incorporate balance and functional training. rehabilitation programs integrating muscle strengthening, coordination exercises, and proprioceptive training are essential for optimizing outcomes in this population.¹⁰,¹¹ the study findings emphasize the need for early intervention, particularly for older individuals and those with comorbidities. incorporating technology, such as virtual reality or wearable feedback devices, may further enhance rehabilitation outcomes by providing personalized, real-time feedback during balance and mobility training.¹²,¹³ strengths and limitations a key strength of this study is the use of validated outcome measures (bbs and houghton scale) to assess balance and functional mobility. the study provides baseline data on transtibial amputees in pakistan, which can guide rehabilitation strategies. limitations include a small sample size, convenience sampling, and the cross-sectional design, which limits causal inferences. future studies with larger samples and longitudinal designs are recommended to confirm these findings and evaluate the long-term impact of targeted rehabilitation interventions. conclusion balance ability is strongly associated with functional mobility in transtibial amputees. the berg balance and houghton scales are reliable tools for assessing rehabilitation outcomes. impaired balance negatively affects walking performance and community mobility, particularly among older patients and those with diabetes. targeted balance training and structured rehabilitation programs can improve functional independence, reduce fall risk, and enhance quality of life. diabetes mellitus and trauma were major causes of amputation, highlighting the need for early, individualized rehabilitation strategies. references brown md, flood kl. mobility limitation in the older patient: a clinical review. jama. 2013;310(11):1168–1177. claret cr, herget gw, kouba l, et al. neuromuscular adaptations and sensorimotor integration following a unilateral transfemoral amputation. j neuroeng rehabil. 2019;16(1):45. clemens s, doerger c, lee sp. current and emerging trends in the management of fall risk in people with lower limb amputation. curr geriatr rep. 2020;9(3):134–141. dillingham tr, pezzin le, mackenzie ej. limb amputation and limb deficiency: epidemiology and recent trends in the united states. south med j. 2017;110(1):1–12. el hage r, knippschild u, arnold t, hinterseher i. stem cell–based therapy: a promising treatment for diabetic foot ulcer. biomedicines. 2022;10(7):1050. grimmer m, riener r, walsh cj, seyfarth a. mobility-related physical and functional losses due to aging and disease: a motivation for lower limb exoskeletons. j neuroeng rehabil. 2019;16(1):123. pedersen he. the problem of the geriatric amputee. artif limbs. 1968;12(2):34–42. pepin me, devour a, coolsaet r, galen s. correlation between functional ability and physical activity in individuals with transtibial amputations: a cross-sectional study. cardiopulm phys ther j. 2019;30(2):70–78. roig-casasús s, blasco jm, lópez-bueno l, et al. balance training with a dynamometric platform following total knee replacement: a randomized controlled trial. j geriatr phys ther. 2018;41(4):204–209. thorud jc, plemmons b, buckley cj, shibuya n, jupiter dc. mortality after nontraumatic major amputation among patients with diabetes and peripheral vascular disease: a systematic review. j foot ankle surg. 2016;55(3):591–599. webster jb, crunkhorn a, sall j, highsmith mj, pruziner a, randolph bj. clinical practice guidelines for the rehabilitation of lower limb amputation. am j phys med rehabil. 2019;98(9):820–829. wong ck, gibbs w, chen es. use of the houghton scale to classify community and household walking ability in people with lower-limb amputation: criterion-related validity. arch phys med rehabil. 2016;97(7):1130–1136. wong ck. interrater reliability of the berg balance scale when used by clinicians of various experience levels to assess people with lower limb amputations. phys ther. 2014;94(3):371–378. 1 66 annals of applied psychophysiology june 2025 volume 12 the role of play-based therapy in managing motor skills in children with cerebral palsy (cp): a systematic review warda khan afsar1,2 & hamna hashim1 1department of health, physical education and sports sciences, university of karachi 2indus hospital, karachi corresponding author: warda.khan@indus.edu.pk published online: june 2025 © the author(s) 2025 abstract objective to systematically evaluate the effectiveness of play-based therapy in improving motor skills among children with cerebral palsy. this review aims to synthesize evidence from randomized controlled trials and cohort studies to inform pediatric rehabilitation practices. background a neurodevelopmental disease known as cerebral palsy (cp) is characterized by long-lasting motor deficits that negatively impact everyday functioning and quality of life. frequent physical exercises are a common component of traditional rehabilitation techniques, but they could not provide the level of involvement required for long-term progress in juvenile populations. methodology this systematic review assessed the data from 18 research published between january 2018 and january 2025, including 10 randomized controlled trials (rcts) and 8 cohort studies. relevant search phrases were used to conduct database searches in pubmed, cochrane library, bmj, medline, and google scholar. using the newcastle-ottawa scale (for cohort studies) and the cochrane risk of bias tool (for rcts), studies that satisfied the inclusion criteria were evaluated critically. results following play-based therapy, the examined trials showed notable improvements in motor outcomes. gross and fine motor skills, balance, and functional mobility all showed improvements; the effect sizes varied according on the severity of cp, the length of the intervention, and the uniformity of the protocol. moreover, improved engagement and therapeutic adherence were commonly found in all of the investigations. conclusion for children with cerebral palsy, play-based therapy is an engaging and successful way to manage motor deficits. this method improves motivation, adherence, and neuroplasticity by incorporating therapeutic exercises into pleasurable, purposeful activities. although more standardization and long-term research mailto:warda.khan@indus.edu.pk 2 are required to maximize results, the data support its inclusion as a fundamental part of pediatric rehabilitation. keywords cerebral palsy, play-based therapy, motor skills, rehabilitation, cohort studies. 3 introduction worldwide, cerebral palsy (cp) affects roughly two to three out of every 1,000 live births, making it one of the most common physical disorders among children [1]. prenatal or early postnatal nonprogressive disruptions in brain development cause cerebral palsy (cp), which manifests as aberrant muscle tone, postural dysfunction, and motor deficits [1,2]. these impairments limit a child’s independence and participation in everyday activities and often lead to secondary complications such as musculoskeletal deformities and reduced physical activity [1,3]. conventional rehabilitation for cp has traditionally relied on repetitive, exercise-based interventions (e.g., neurodevelopmental treatments, constraint-induced movement therapy) aimed at improving motor control and strength. however, these approaches may not adequately engage children over the long term, thereby reducing adherence and limiting overall motor gains [4]. playbased therapy offers a promising alternative by embedding therapeutic objectives within engaging, playful activities. this approach leverages children’s natural affinity for play to foster active participation, enhance neuroplasticity through real-time feedback, and improve psychosocial outcomes [7,8]. for instance, models incorporating interactive video games and virtual reality have demonstrated improvements in both gross and fine motor functions, as well as in balance and upper limb dexterity [8,9]. play programs that are both home-based and group-based have also been shown to improve therapy adherence by incorporating family members and establishing supportive environments outside of the therapeutic setting [10,11]. these methods are especially helpful for kids with cerebral palsy because they assist incorporate therapeutic activities into everyday life, which leads to long-lasting functional improvements. this systematic review synthesizes current evidence from rcts and cohort studies evaluating play-based interventions for children with cp. the primary aim is to elucidate their impact on gross and fine motor skills, balance, and functional mobility, while identifying factors that influence variability in outcomes methodology study design and search strategy a systematic review was conducted in accordance with prisma 2020 guidelines to ensure transparency and reliability of our methods. we performed comprehensive searches of pubmed, cochrane library, bmj, medline, and google scholar for studies published between january 2018 and january 2025 using controlled vocabulary and boolean combinations: “cerebral palsy” and “play-based therapy” and (“motor skills” or “pediatric rehabilitation”) and (“randomized controlled trial” or “cohort study”) participants according to the gross motor function classification system (gmfcs) levels i–iv, children with cerebral palsy of any subtype or severity between the ages of 1 and 12 were included in eligible research. the typical five-level system used to describe self-initiated mobility abilities in cp is called the gmfcs. 4 data sources, studies selection, and data extraction before applying predetermined inclusion/exclusion criteria, two reviewers separately retrieved full texts of possibly eligible studies and checked abstracts and titles for relevance. author(s), year, study design, sample size, participant gmfcs level, play-based intervention characteristics (type, duration, frequency), comparator, outcome measures (e.g., gmfm, macs, pbs), and primary findings were all recorded. differences were settled through debate or outside arbitration. quality of studies the cochrane risk of bias 2 tool was used to analyze randomized controlled trials. it uses signaling questions to assess five categories (randomization, deviations, missing data, measurement, and reporting) and produce an overall bias judgment (low/high/some concerns). the newcastle-ottawa scale was used to evaluate cohort studies, giving them up to nine stars in the selection, comparability, and outcome areas. inclusion and exclusion criteria we included english-language cohort studies and peer-reviewed rcts that assessed organized play-based interventions aimed at improving motor outcomes in children with cerebral palsy (cp) between january 2018 and january 2025. animal studies, non-play or vague therapies, reviews, meta-analyses, case reports, qualitative designs, non-english publications, and research involving individuals older than 12 years were all excluded. data analysis the study employed a narrative synthesis instead of a quantitative meta-analysis because of the variety in intervention kinds, outcome measures, and study designs. the results were arranged according to the main objectives, which included balance and coordination, fine motor skills, gross motor function, and engagement/adherence. variability was also examined by the severity of cp, the intensity of the intervention, and the involvement of the family. quality assessment the newcastle-ottawa scale was used to evaluate cohort studies, while the cochrane risk of bias tool was used to analyze rcts. excluded studies had a significant probability of bias. tables 1 and 2 provide a summary of the included research's quality evaluation. 5 table 1. cochrane risk of bias tool (rcts) domain criteria description selection bias random sequence generation was the allocation sequence adequately generated to ensure randomization? allocation concealment was the assignment of participants to groups concealed from those enrolling participants? performance bias blinding of participants and personnel were participants and study personnel unaware of the assigned intervention to prevent performance bias? detection bias blinding of outcome assessment were outcome assessors blinded to the intervention groups? attrition bias incomplete outcome data were incomplete outcome data (dropouts, missing data) adequately addressed? reporting bias selective reporting were all pre-specified outcomes reported as planned, without selective reporting? other bias other sources of bias were there any additional threats to validity not covered by the above domains? 6 table 2. newcastle-ottawa scale (cohort studies) domain criteria description selection representativeness of the exposed cohort does the study sample represent the target population of children with cp? selection of the non-exposed cohort were the non-exposed (comparison) groups drawn from the same community as the exposed group? ascertainment of exposure how was exposure (i.e., the play-based therapy) determined (e.g., record review, structured interview)? outcome of interest not present at start was it ensured that the outcome of interest (e.g., motor function impairment) was not present at the start of the study? comparability comparability of cohorts on the basis of design or analysis did the study control for confounding factors (e.g., cp severity, age, baseline motor function) in the analysis? outcome assessment of outcome how were the outcomes (e.g., gmfm, macs, pbs) measured (e.g., validated instruments, blinded assessment)? follow-up duration was the follow-up period sufficiently long for the outcomes to occur? adequacy of follow-up of cohorts was the follow-up complete, or was there a high rate of loss to follow-up that could bias the results? 7 data extraction using a standardized form, two reviewers independently extracted the data. study design, sample size, participant characteristics (including cp severity according to gmfcs levels), play-based intervention information (kind, duration, and frequency), comparator details, outcome measures (e.g., gmfm, macs, pbs), and main findings were among the data that were extracted. disagreements were settled through dialogue. data synthesis a qualitative and narrative synopsis of the results from the included studies was part of the data synthesis process. a meta-analysis was not practical due to the heterogeneity in intervention kinds, durations, and outcome measures. instead, a descriptive synthesis was given after the data were grouped according to the key outcomes (fine motor abilities, balance and coordination, gross motor function, and engagement/adherence). additionally, variations in cp severity, intervention intensity, and research design were examined in relation to outcome variability. results study characteristics and detailed findings a total of 18 studies with sample sizes ranging from 20 to 150 participants and intervention durations ranging from 6 to 24 weeks were included in the review: 10 rcts and 8 cohort studies. children with cp varying in severity (gmfcs levels i–iv) participated in the study. while effect sizes varied due to variations in intervention type, duration, and participant characteristics, these studies generally produced statistically significant improvements in motor outcomes. figure 1 shows the consort diagram that details the study selection process. . 8 table 3. characteristics of the included studies ref. no. study (authors, year) design sample size intervention type duration (weeks) primary outcome measures key findings 1 novak et al. (2013) [1] rct 50 motor skill training through play 12 gmfm, gait analysis improved gait, balance, and gross motor function. 2 fehlings et al. (2013) [2] rct 30 interactive & tech-assisted play 8 upper limb function, macs enhanced upper limb dexterity and coordination. 3 biddiss et al. (2021) [3] rct 40 group play based therapy 10 motor skill performance improved motor function and increased social interaction. 4 faccioli et al. (2023) [4] cohort 60 home-based play therapy 16 functional independence sustained motor improvements with active family involvement. 9 5 pashmdarfard et al. (2021) [5] cohort 45 sensorymotor play 8 balance (pbs), proprioception significant enhancement in balance and proprioceptive function. 6 gonzalez sanchez et al. (2018) [6] rct 35 motor skill training through play 10 gmfm, coordination tests notable improvements in overall coordination and mobility. 7 kim et al. (2018) [7] rct 40 virtual realitybased play therapy 8 upper limb function, macs enhanced fine motor control and engagement in virtual tasks. 8 lee et al. (2019) [8] rct 38 interactive play for fine motor skills 12 nine-hole peg test, fine motor scores improved hand dexterity and fine motor performance. 10 9 martin et al. (2020) [9] rct 45 sensorymotor play intervention 8 pbs, balance tests significant improvements in static and dynamic balance. 10 olivier et al. (2020) [10] cohort 55 home-based play therapy 12 functional independence consistent motor gains with parental supervision. 11 sanchez et al. (2019) [11] rct 42 structured play on gross motor skills 10 gmfm, gait analysis enhanced gross motor function and improved gait parameters. 12 thompson et al. (2018) [12] cohort 40 group play based therapy 10 motor skills, social interaction improved motor outcomes and increased social interaction. 13 wu et al. (2019) [13] rct 36 interactive play for cognitive & motor skills 12 cognitive & motor assessments dual improvements in cognitive and motor functions. 11 14 yoon et al. (2021) [14] rct 50 exergames in play-based therapy 10 motor function, engagement scores increased engagement and improved motor outcomes via exergames. 15 zhang et al. (2020) [15] rct 40 virtual reality play intervention 8 upper limb function, macs significant improvement in upper limb ref. no. study (authors, year) design sample size intervention type duration (weeks) primary outcome measures key findings motor performance. 16 anderson et al. (2018) [16] cohort 45 home-based play therapy with parental guidance 14 functional independence sustained motor improvements with home based programs. 17 brown et al. (2021) [17] rct 48 comparative play-based vs. traditional therapy 12 gmfm, quality of life measures superior motor improvements and quality of life in playbased group. 12 18 chen et al. (2022) [18] cohort 50 longitudinal playfocused therapy 16 gmfm, balance, motor function long-term improvements in motor function and balance. 13 figure 1. consort diagram 14 gross motor function gross motor function consistently improved as a result of play-based therapies. following 8–12 weeks of intervention, several studies found that gmfm ratings increased by 10%–20%, indicating improved gait, balance, and general mobility [1, 11,12,17]. fine motor skills technology-assisted interactive play was one intervention that significantly improved fine motor skills. in studies that use virtual reality and gaming consoles, for instance, the nine-hole peg test and macs demonstrate enhanced performance in upper limb dexterity and motor coordination [2,7,15]. balance and coordination significant gains in balance and postural control were obtained by sensory-motor play therapies that included motions including rolling, swinging, and tactile exploration. both static and dynamic balance gains were indicated by improved scores on the pediatric balance scale (pbs). [8,13]. engagement and adherence group-based as well as home-based play therapies mostly resulted in higher adherence and improved engagement compared to conventional therapy. these studies ascribed the increased engagement to the inherently enjoyable nature of the activities and active parental involvement, which facilitated long-term participation [3,4,10,16]. variability in outcomes variability was seen across studies, despite the fact that overall results were favorable. this is probably because of variations in the severity of cp, the intensity, duration, and family support of the interventions. the necessity of customized and standardized intervention approaches is highlighted by this variability [5,11,12] 15 discussion it is evident from the evidence compiled from these 18 research that play-based therapy provides children with cerebral palsy (cp) with a variety of advantages. measurable gains in motor function are not the sole benefits of incorporating therapeutic exercises into pleasant activities; social engagement and psychological health are also improved. enhancement of motor functions play-based therapy has consistently yielded significant improvements in gross motor function. increases in gmfm scores observed in studies such as those by novak et al. [1] and sanchez et al. [11] illustrate that structured play activities—such as obstacle courses and balance games—can lead to substantial improvements in gait, balance, and overall mobility. similarly, kim et al. [7] and zhang et al. [15] have observed improvements in upper limb dexterity and hand coordination, indicating significant gains in fine motor abilities from interactive, technology-assisted play modalities. psychosocial and cognitive benefits enhancement of psychosocial outcomes is another benefit of play-based therapies. biddiss et al. have demonstrated that group-based therapy can improve motivation and self-efficacy by promoting social contact and peer support.[3] and thompson et al. [12]. additionally, the integration of cognitive challenges within interactive play—as observed by wu et al. [13]—further enhances cognitive function, providing a holistic approach to rehabilitation that addresses both motor and cognitive domains. home-based and family-involved interventions it has been demonstrated that play therapy at home, especially when paired with active parental participation, maintains motor improvements over time. research by olivier et al. [10] and faccioli et al. [4] shows that family involvement makes it easier to integrate rehabilitative activities into everyday routines, which promotes ongoing practice and the maintenance of motor skills. technology-enhanced play the incorporation of interactive video game systems and virtual reality has greatly enhanced playbased treatment. by offering immersive experiences and real-time feedback, these technologically enhanced modalities speed up motor learning through neuroplasticity. research by ren and wu [12] and chen et al. [8] shows that vr-based play therapies can significantly improve gross and fine motor outcomes, especially in kids with severe motor impairments. variability and future directions although the results were generally favorable, there was variation in the findings amongst the investigations. this variation could be explained by variations in the severity of cp, the length, the intensity, and the degree of family support [5,11]. the sustainability of play-based therapeutic advantages will need to be ascertained through multicenter, long-term trials and the standardization of intervention techniques. in order to further maximize therapeutic results and customize treatment regimens, future studies should investigate the integration of cutting-edge technology such wearable haptic devices and augmented reality. 16 limitations this systematic review shows quite a few limitations that must be acknowledged. making firm comparisons was challenging due to the variability of interventions among trials, including differences in the kinds and procedures of play-based therapy. bias may have been introduced into several research due to inadequate randomization and blinding techniques. the results of certain studies could not be applied to larger populations due to their small sample sizes. an evaluation of the long-term advantages of playbased therapy was also impeded by a dearth of long-term follow-up data. results were also variable due to participant differences in age ranges and the severity of cerebral palsy. strengths notwithstanding these drawbacks, the review contains a lot of strong points. it is a thorough analysis of 18 research that were released between 2018 and 2025, offering a current and fact-based viewpoint on the function of play-based therapy in the treatment of cerebral palsy. to ensure a broad coverage of pertinent research, the search technique included several top-notch databases, such as pubmed, cochrane library, bmj, medline, and google scholar. both thorough efficacy evaluations and useful insights were made possible by the combination of rcts and cohort studies. crucially, the results demonstrated the therapeutic potential of play-based therapies by highlighting continuous increases in motor outcomes and therapy adherence. recommendations standardizing intervention procedures should be the goal of future research in order to improve study comparability. findings might be more broadly applicable if sample sizes were larger and varied groups were included. to measure the long-term advantages of play-based therapy, long-term follow-up evaluations are necessary. improved reporting of participant characteristics and the inclusion of objective outcome measures will aid in the improvement of therapy techniques. conclusion one promising, kid-centered strategy for treating motor deficiencies in kids with cerebral palsy is play-based therapy. these interventions greatly enhance balance, gross and fine motor function, and general functional mobility by incorporating therapeutic exercises into entertaining and engaging activities. additionally, the psychological advantages linked to higher levels of engagement and enhanced self-efficacy highlight the importance of play-based therapy as a crucial element of pediatric rehabilitation. the necessity for systematic, long-term research to improve these interventions and guarantee their sustainability across a range of groups is highlighted by the variation in results, nevertheless. funding this study was not able to receive any specific grant from public, commercial, or not-for-profit funding agencies. 17 references anderson, k., et al. 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(2020). virtual reality play intervention for improving motor function in children with cerebral palsy: a pilot rct. clinical rehabilitation, 34(11), 1520–1528. https://doi.org/10.1177/0269215520920112 https://doi.org/10.1080/07380577.2021.1938339 https://doi.org/10.1093/ptj/pzy105 https://doi.org/10.1080/09638288.2017.1339941 https://doi.org/10.1186/s12984-019-0579-1 https://doi.org/10.1123/gh.2020-0056 https://doi.org/10.1123/gh.2020-0056 https://doi.org/10.1177/0269215520920112 annals of psychophysiology volume 13 december 2025 table of contents editorial pg 1 our founding editor, sadaf ahmed, just received yet another prestigious award and it is time to revive pamphlets as an intermediate between brief review papers and full length books as a means of getting targeted information to professionals r. sherman, editor-in-chief reviews and summaries of hot topics in psychophysiology pg 2 analyzing the monosodium and dietary glutamate model of depression: a narrative review o. olabiyi, a. ajibewa, a. ajayi pg 48 the triad of stress, vitamin d deficiency, and periodontal breakdown: an integrative review rafique s, ahmed s, noushad s, atif a, aqeel s, nasir f pg 58 psychophysiological effects of equine-assisted psychotherapy in trauma recovery: a review of current evidence b. palmer pg 71 psychomusicology: the clinical relevance of music in health psychology e. willmarth original research pg 86 association between balance ability and functional mobility in transtibial amputee patients o. olabiyi, a. ajibewa, b. ali, b.m. malik, n. jan, a. rayyan, s. memon, s. hyder, w. ahmed 71 annals of applied psychophysiology december 2025 volume 13 ______________________________________________________________________________ psychomusicology: the clinical relevance of music in health psychology eric k. willmarth, ph.d. clinical psychomusicologist saybrook university published online: december 2025 © the author(s) abstract background: the use of music to assist in the treatment of medical and psychological conditions has evolved over centuries and remains a field in continuous development. methods: this article provides a very brief review of the psychophysiology of music along with some of the issues, clinical applications, and definitions related to psychomusicology, music therapy, music medicine, and music-assisted treatment. conclusions: music appears to be an effective, cost-efficient, accessible, low-risk, and well-accepted adjunctive modality that can contribute to the treatment of many disorders, including chronic pain, anxiety, and depression, within a wide range of clinical settings and cultural contexts keywords: psychomusicology, music therapy, music medicine, adjunctive therapy, psychophysiology . introduction for over 20 years, the author conducted weekly group therapy sessions in two different clinical settings for patients dealing with chronic pain and depression. group size averaged from 6-10 patients whose participation ranged from months to years. a key practice that evolved from these groups was the selection of one patient at the end of each session to bring a recording of their “favorite music” to the next meeting. the following session would then begin with the patient explaining why they had chosen their music selection, after which the whole group would listen to the recording. a visiting presenter, observing this for the first time, commented: “watching the group while the music was playing, i would never have guessed that this was a pain and depression group. looking at their faces, i saw only smiles and joy”. this article will attempt to look at the evidence supporting the adjunctive use of music in the field of clinical health psychology. music medicine vs music therapy vs music-assisted therapy vs psychomusicology while there are sometimes blurry distinctions in practice, the term “music therapy” is reserved for those who are board-certified as music therapists, generally requiring a degree in music. (salamon, 2024). music medicine, on the other hand, refers to the use of music as an adjunctive therapeutic technique employed by professionals from various disciplines, including physicians, social workers, psychologists, occupational therapists, physical therapists, and others. the term psychomusicology refers specifically to psychotherapists using music as an adjunctive technique in practice or research. a distinction is also sometimes suggested that music medicine involves primarily the passive listening to music, as in the example given in the introduction, while music therapy is more likely to engage the clients in active participation or performance. (gold, 2011). this is a more blurry distinction, dependent on the context and skills of the therapist and client. therapeutic drumming circles are certainly active and may be used by certified music therapists and psychomusicologists alike. another, more generic category has also emerged in the phrase “music-assisted therapy,” which seems to cover all the bases for both music medicine and music therapy. (de luca, 2020) brandt et al. (2014) completed a direct comparison of music therapy and music medicine when addressing the psychological outcomes and pain levels of cancer patients. they report: “the quantitative data suggest that both interventions were equally effective in enhancing target outcomes”. (p.1261) research on the impact of music on health often combines both music therapy and music medicine, as in the cochrane library review on music interventions by brandt et al. (2021). in this current review, an attempt will be made to differentiate between music therapy and the more encompassing terms of psychomusicology, music-assisted therapy, and music medicine, when possible. the psychophysiology of music listening to music appears to produce measurable psychophysiological changes across the autonomic, endocrine, and central nervous systems. music and musical features such as tempo, rhythm, tone, frequency, and timbre have been shown to impact heart-rate variability, stress hormones, and neural activity ( zhang et al. 2025). lata and kourtesis (2021) suggest that both the hypothalamic pituitary-adrenal axis and the autonomic nervous system are impacted by listening to music. they add that in studies conducted in healthy adults, listening to certain types of music results in a decrease in both cortisol levels and sympathetic activity (reduction in heart rate frequency and blood pressure). (lata & kourtesis, 2021). looking specifically at the impact of music-assisted therapy on the psychophysiology of pain, arnold et al. (2024) suggest that multiple areas are involved, including the periphery, spinal cord, brainstem, limbic system, and multiple areas of the cerebral cortex. loomba et al. (2012) found that selected music could evoke a decrease in blood pressure and heart rate. merrill et al. (2023) note that the psychophysiological changes elicited by music are not necessarily positive. listening to “disliked” music resulted in heightened arousal, with increased heart rate, body temperature, and skin conductance response koelsch (2005, 2014, 2020) has published extensively on the neuroscience and neuroimaging studies related to music-evoked emotions. he notes music’s “power to evoke strong emotions and influence moods” (koelsch, 2014, p. 170). his work in reviewing mri and other functional neuroimaging studies suggests that brain structures such as the amygdala, hypothalamus, hippocampus, cingulate cortex, and other areas are influenced directly by music and, in turn, can influence mood and emotion. he predicts that “the potential of music to modulate activity in these structures has important implications for the use of music in the treatment of psychiatric and neurological disorders.” (koelsch, 2014, p. 170). this foundational work provides some insights into the successful application of music in health psychology in areas ranging from pain, depression, anxiety, and other clinical conditions. music and health music has been utilized extensively in both clinical and non-clinical populations, across various healthcare settings, and in other applications, such as sports performance. (nidhal et al., 2025). within healthcare, another distinction can be made between work with pathological conditions and work with a more general population seeking wellness or enhanced health functioning. the use of music in preventative healthcare would be an example of the latter category. daykin et al. (2018), for example, reviewed the literature on subjective well-being outcomes when music was used as an intervention. they concluded that “there is reliable evidence for positive effects of music and singing on wellbeing in adults”. (p. 39). similar support has been offered by fancourt et al. (2017) for drumming circles and by florian & rosemond (2017). music has also been employed in an effort to delay or prevent dementia, as well as to improve the quality of life for those individuals suffering from dementia. within the field of health psychology, however, the majority of work appears to have been focused on pathological conditions and the impact that music-assisted therapy can provide. pain management, along with the treatment of depression and anxiety, makes up the core of this work. stress management is also frequently addressed in the music therapy literature and is equally applied to both pathological and non-pathological populations. this review will focus on the application of music-assisted therapy with individuals suffering from medical and/or psychological disorders. applications: chronic pain chronic pain impacts millions of people around the world. nahin et al. (2023) estimate that over 20% of the us population suffered from chronic pain in 2020. the impact on individuals with chronic pain is comprehensive and can include both the sensory pain experience and the severe psychosocial impact and limitations associated with chronic pain. while the “opioid crisis” has resulted in a reduction in the pharmacological treatment of pain, the need for alternatives has increased. (dowell et al. 2016). recently, chen et al. (2025) published a review and meta-analysis on the use of music therapy with individuals experiencing chronic pain. their review included nine randomized controlled trials. although the term “music therapy” is used throughout the review, only three of the studies reported using music therapists, while most of the others used a “trained nurse.” included in their original search strategy was the term “music intervention.” combining music therapy with music-assisted therapy, the study included 787 patients, most of whom received individual interventions, with only one study using group therapy. the authors reported a significant reduction in both pain and depression with the use of a music intervention compared to a standard care control. they did not find a significant improvement in either anxiety or quality of life. while chronic pain (pain lasting more than 3 months) can exist for countless reasons, cancer pain is one of the most common and most frequently identified causes, with 70-90% of individuals with advanced cancer reporting severe pain. (valeberg et al., 2007.) jethva et al. (2025), in a study with 43 individuals with cancer in a palliative care setting, report a significant improvement in pain perception, along with improvement in other symptoms, when treated by certified music therapists. earlier, brandt et al. (2014) did not find a direct impact of music therapy or music medicine on pain perception, although they did report other positive impacts with the use of music. more recently, brandt et al. (2024) again found that music therapy did not have a direct impact on pain intensity, but that pain-related self-efficacy was a primary moderator that should be incorporated into future music therapy interventions. in a 5-year retrospective study at a national cancer institute-designated comprehensive cancer treatment center, licht et al. (2022) reported both statistical and clinically meaningful reductions in pain among patients who received music therapy from certified music therapists. another common, if less well-defined, source of pain impacts individuals suffering from fibromyalgia. wang et al. (2020) reviewed 7 randomized controlled trials involving the use of music interventions with patients identified as suffering from fibromyalgia. while noting inconsistent methods, small sample sizes and the general low quality of the available literature, they conclude that “… music therapy is superior to non-music therapy in the treatment of pain, depression, and improvement of quality of life in fibromyalgia patients.” (p, 327) alparslan et al. (2016) investigated the effect of listening to recorded music in this population and found a significant reduction in pain levels compared to a non-treatment control. noting the widespread musculoskeletal pain present with fibromyalgia, espi-lopez et al. (2016) completed a study combining music with low-impact aerobic exercise, resulting in a decrease in general discomfort as well as improved treatment adherence. although the term “music therapy” was used, it appears that physical therapists, rather than certified music therapists, were involved, which, for the purposes of this paper, would categorize the study as “music-assisted therapy.” applications: anxiety and distress several of the studies cited above related to the use of music in the treatment of chronic pain also report on the impact of music on mood, including anxiety and depression. looking first at anxiety, the majority of studies seem to address anxiety in specific situations, such as undergoing medical treatment, rather than addressing generalized anxiety disorder. for example, rossetti et al. (2017) describe the use of music therapy with cancer patients beginning the first phase of radiation therapy. while noting that 10-20% of patients undergoing radiation therapy have clinically significant anxiety, they include “distress” as an additional measure. compared to a control group, which did not receive music therapy, the researchers concluded that; “music therapy, provided by a board-certified music therapist, may offer a safe, cost-effective means of alleviating patient anxiety and distress” (p.108). earlier, studies also support the use of music therapy or music-assisted therapy to reduce anxiety in radiation treatment (clark et al., 2006., chen et al., 2013), ventilation therapy (chlan et al., 1998; han et al., 2010), burn debridement (fratianne et al., 2001), chemotherapy (ferrer, 2007), gynecologic surgery (xu et al., 2021), and end-of-life care (horne-thompson & grocke (2008). lu et al. (2021) reviewed 32 randomized controlled trials evaluating the impact of music therapy on anxiety. music therapy was found to have a significant positive impact on anxiety at follow-up compared to control groups. more recently, de witte et al. (2025) conducted a systematic review and meta-analysis of the literature on anxiety and music, encompassing both formal music therapy and other music-assisted treatments. the review included 51 studies and concluded that patients undergoing music therapy showed marked decreases in anxiety levels across various settings. while a significant decrease was observed in patients’ self-reports of anxiety when using music-assisted treatment, the change in physiological measures related to anxiety was not found to be significant. in one of the relatively small number of studies looking specifically at generalized anxiety disorder, gutiérrez et al. (2015), using a pre-post design that did not include a control group, conclude that “it appears that music therapy was an effective psychotherapeutic treatment in the psychiatric care of patients with gad.”(p. 24). applications: depression depression is now the leading cause of disability worldwide, estimated to impact over 300 million people, and it accounts for approximately 800,000 deaths per year (who, 2025). given the staggering impact of this disorder, it is not surprising that multiple medical and psychological interventions have been studied, including the use of music therapy and other music-assisted interventions. similar to the study by brant et al. (2014) cited above, tang et al. (2020) conducted a meta-analysis of randomized controlled trials (rcts) and examined the independent impact of music therapy and other music-assisted treatments on depression. in studies identified as music therapy, treatment was provided by a credentialed professional who completed an approved music therapy program. studies in which treatment was provided by those who had not completed a music therapy program were identified as music medicine studies. in reviewing 51 rcts, the researchers found that both music therapy and music medicine interventions resulted in a significant reduction in the symptoms of depression, compared to control groups, with music medicine showing a stronger effect compared to music therapy. in a cochrane review summary related to music therapy and depression, roddis and tanner, (2020) found that the addition of music therapy to treatment-as-usual resulted in a decrease in depressive symptoms compared to patients who received only treatment-as-usual. no significant difference was found when comparing active to passive music interventions. a number of studies looked at specific patient populations when investigating the impact of music on symptoms of depression. geipel et al. (2022) looked specifically at adolescent patients and found that not only was music effective in decreasing symptoms of depression, but the treatment was also well accepted. zhao et al. (2016) found similar results working at the other end of the age spectrum with elderly individuals with symptoms of depression. as noted previously in this article, depression is also a common element for patients suffering not only from mental health concerns, but also those coping with chronic pain, cancer, and other medical conditions and loss. in most cases, music therapy and music medicine have been found to be beneficial, particularly when combined with other medical and/or psychological interventions. summary in this brief review, support has been offered for the clinical application of music therapy, psychomusicology, and the multiple other forms of music medicine or music-assisted treatment. there does not appear to be a strong clinical advantage to the often more active patient engagement associated with formal music therapy, and some reviews suggest that more passive approaches may have a slightly stronger effect, although this will vary depending on the context and multiple other variables. there certainly does not appear to be a standard protocol at this point for the application of music in clinical practice. while some argue that the modality of music should be left to the domain of certified music therapists, others argue that the tool of music is best placed in the hands of licensed psychotherapists and other licensed healthcare providers. in almost all cases, it appears that music is best seen as an adjunctive technique that can complement existing treatment for medical and psychological disorders. there is also consensus that much additional research is needed to expand support for music-related interventions and to explore areas where music could benefit those in need of additional and/or alternative options. references alparslan, g. b., babadağ, b., özkaraman, a., yıldız, p., musmul, a., & korkmaz, c. 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(2016). group drumming modulates cytokine response in mental health services users: a preliminary study. psychotherapy and psychosomatics, 85(1), 53–55. https://doi.org/10.1159/000431257 ferrer aj. (2007) the effect of live music on decreasing anxiety in patients undergoing chemotherapy treatment. j music ther 2007;44: 242-255. florian, c.,, & rosemond k. (2017). music and wellbeing in everyday life: an exploratory study of muscic experience in ghana. legon journal of the humanities, 27(2), 29–46. https://doi.org/10.4314/ljhv27i2.3 fratianne rb, prensner jd, huston mj, et al. (2001) the effect of musicbased imagery and musical alternate engagement on the burn debridement process. j burn care rehabil 2001;22:47-53. geipel, j., koenig, j., hillecke, t. k., & resch, f. 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(2025) impact of music-based interventions on subjective well-being: a meta-analysis of listening, training, and therapy in clinical and nonclinical populations. frontiers of psychology. volume 16 2025 | https://doi.org/10.3389/fpsyg.2025.1608508 zhao, k., bai, z. g., bo, a., and chi, i. (2016) a systematic review and meta-analysis of music therapy for the older adults with depression. int j geriatr psychiatry, 31: 1188–1198. doi: 10.1002/gps.4494. 6 ann. psychophysiol. issn 2412-3188 (online)|2410-1354 (print) app| published by aeirc| https://doi.org/10.29052/2412-3188.v9.i1.2022.06-16 original article sleep disturbances and lack of exercises: accumulating factors for altered bmi in medical students of public sector universities tehlil rizwan1, rabbiya khan1, fauzia imtiaz1 , sonia siddiqui1 , muhammad ashraf hussain2 & farhia khalid3 1department of biochemistry, dow university of health sciences, karachi-pakistan 2national university of health sciences (nums), rawalpindi-pakistan 3shaukat omar memorial hospital, fauji foundation, karachi-pakistan abstract background: changes in lifestyles such as lack of exercises and sleep can have negative effects on the body weight. therefore, the present study was designed to investigate the association of the pattern of sleep, exercise, and diets with the body mass index (bmi) of medical students. methodology: this is a cross-sectional study that incorporates self-developed questionnaires. participants are medical university students (250) living in karachi, pakistan. correlation and pearson’s chi-square test for independence was applied to observe the association between bmi, sleep patterns, exercise and eating habits. results: the age of the students were between 19-25 years. the data show a significantly higher number of students (70.6%) with low bmi. significantly high numbers of students have disturbed sleep (47.4%) during the nights and an increased number of students feel irritated (78.7%) about their sleeping pattern. because of this, students (61.1%) experienced difficulties at work. moreover, it was found that only 67 students are doing exercise while 154 students are not doing any exercises. however, they are taking enough 5-6 (47.1%) or 6-8 hours (29.9%) sleep. the majority of the students do not smoke (96.8%) or eat big meals before bed (62%) or consume junk foods (68.8%) on a daily basis. nevertheless, most of them felt tired (61.1%) but not sleepy (57%) before going to bed. the majority of the students (81.4%) have problems waking up in the morning. conclusion: a significant correlation was found between bmi and sleep duration. irregular sleeping pattern and lack of physical activities are accumulating factors for students to be underweight. sleep disturbances affected their focus on the academic studies. therefore, it is strongly recommended for students to participate in physical activities. keywords sleep disturbances, bmi, exercises, medical students. citation: rizwan t, khan r, imtiaz f, siddiqui s, hussain ma, khalid f. sleep disturbances and lack of exercise: accumulating factors for altered bmi in medical students of public sector universities. app. 2022;9(1) :06-16 corresponding author email: f.imtiaz@duhs.edu.pk doi: 10.29052/2412-3188.v9.i1.2022.06-16 received 26/02/2022 accepted 06/04/2022 published 01/06/2022 copyright © the author(s). 2022. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: the author(s) received no specific funding for this work. conflicts of interests: the authors have declared that no competing interests exist. about:blank https://orcid.org/0000-0002-9873-0428 https://orcid.org/0000-0002-8883-5242 https://orcid.org/0000-0002-3806-5008 https://orcid.org/0000-0001-6842-801x about:blank about:blank 7 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 introduction obesity is defined as a condition in which a person has accumulated an increased amount of fat that it might have a negative effect on their health. obesity comorbidities include coronary heart disease, hypertension and stroke, dyslipidemia, non-insulindependent diabetes mellitus, sleep apnea 1-4,6 7,8. during the recent pandemic of obesity, pakistan too has seen an increase in the population of overweight people, probably due to its increasing urbanization. this makes karachi, one of the most urbanized regions of pakistan, a high risk city9. the international obesity task force has set the following cut-off points for adults in the asia-pacific region: overweight at bmi >23 and obesity at bmi >25. these lower cut-off points are set because studies show that asian people are likely to develop comorbidities at lower bmi10. students in different colleges regardless of the professions such as medical or basic sciences students experiencing a marked change in curriculum, peer pressure, social pressure, erratic schedule and stress/anxiety. major shift in lifestyle habits most of the times such as unbalanced diets, alcohol intake, and lack of sleep can be very harmful for student’s health11, 12, 13. sleep deprivation is another issue plaguing urbanized cities such as karachi. many longitudinal studies show a correlation between sleep loss and weight gain in adults. however, some other studies prove that sleep quantity does not have a significant effect on weight gain in adults but sleep quality does. it also allows to predict overall health of an individual such as depression, fatigue and complaints14. gathered results showed insufficient poor quality of sleep is associated with sleep dissatisfaction in young adults. reported earlier an imbalance between calorie intake and physical activities are the precipitating factors involving obesity15,16. however numerous other factors are also known to be involved in the contribution of bmi-related obesity such as sleep17,18. besides obesity an increasing number of young adults have been shown to be associated to their bodyimage. this body-image dissatisfaction induces an increased weight loss behavior among young females19. using of nonscientific physical activity and poor diets were identified in underweight people. apart from this several dietary regimes such as lack of water intake resulted in increased confusion, stress, fatigue20,21,22 and tension with decreased vigor both in men and women. due to the conflicting results in different regions, it is hard to predict if there would be such a correlation in each setting. the link between sleep pattern with bmi and diets had not been studied in karachi before. therefore, we carried out a cross sectional study to determine the effects of quality of sleep on general health of medical students in karachi. we hypothesized to investigate the association of the pattern of sleep, exercise, and diets with the body mass index (bmi) of medical students. methodology participants the current study used a sample of 467 college students, a randomly selected sample size at registered colleges located in karachi, pakistan. there were 204 males, and 263 were females (153 from the extended family system while 314 from the nuclear family system). participants' age ranged from 16 to 24 years. 8 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 measures participants and study design it is a cross sectional study on medical students at a public sector university, from year 1 to year 5. the study was conducted on medical students of a public sector university during the period of 1st feb to 31st july, 2019. a sample size of 250 was calculated by using open epi an online software (confidence level=95 %). the sampling technique used was non probability convenience sampling. the mean age of the participants were 23.6 years. the participants included in the study were students of all ethnic groups and both genders, studying in a medical college. students with sleep disorders (narcolepsy, insomnia, snoring, sleep talking, night terrors, rapid eye movements behavior disorders, obstructive sleep apnea) and those taking medications to manage their weight were excluded from the study. measures of memory or focus were made by the information recorded by the participants that their memory and focus on the study has changed since they have weight and sleep issues. moreover, the information also included that they have difficulties in retaining the knowledge and felt agitated. these symptoms only occurred when their sleep pattern changes otherwise they did not have problems in focusing (thinking about other things besides studying). no one has attention deficit disorders. self-administered questionnaire verbal consent was taken from all participants. the questionnaire consisted of 34 close-ended questions, out of which the first 5 asked for demographic figures (age, gender, year of study, weight and height). the next 16 questions were related to sleep and factors that could affect the quality and the quantity of sleep (frequency and amount of caffeine intake). the next 10 questions were related to weight and factors that could cause weight change, for instance exercise and dietary patterns. to ensure the participants were not hesitant to answer all questions honestly, we provided full anonymity – by not asking for their names, contact numbers, or any other personal details. we reduced interviewer bias by using questionnaires instead of verbal interviews. body mass index (bmi) body mass index (bmi) was calculated as described previously. 19 briefly weight of an individual in kilograms is divided by height measured in meters squared. bmi from 18.0 to 25 is considered normal weight, bmi <18.5 is considered underweight, bmi 25 to 28 is considered overweight. actual bmi= weight (kg) (measured weight) / height2 (m) statistics data was analyzed by using spss version 16.0 software. bivariate correlations and pearson’s chi-square tests for independence were used. value of p < 0.05 was considered significant. result there were 73.3 % female and 26.7 % male students (table 1). the data show that mostly students (156) are underweight and very few (7) are overweight. nevertheless 58 students have normal bmi. chi-square test for independence show that there was a significant association of bmi with the sleeping hrs (p<0.00005). the data show that significantly (p<0.0005) increased numbers (98 vs 58) of students are aware about the importance of sleep (table 1). it has been observed that students with low bmi (47%) are taking 5-6 hours and 43% are taking 6 to 8 hours sleep. while students (50%) with normal bmi are also taking 5-6 hours and 9 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 34.5% are taking 6-8 hours sleep. in our study we have very few students (7) who were overweight. nevertheless, the data show mostly they are sleeping either less than 5 hours or 6-8 hours (table 2). current study also showed significant association between bmi and disturbed seeping pattern during the night. it showed an increased number of students (74 %) who were underweight have disturbed sleep. they either wake up once (47.4%), twice (27.6%), or more than twice (6.4%) during a night. students with normal weight also shows disturbances in the sleep, 50% of students wake up once and 20 % wakeup twice (table 3). significantly (p<0.0005) increased number of students are not doing any physical exercises (67 vs 154) and those who does (67), mostly spent their times in either cycling, walking or other aerobic activities (table 1). the duration of physical activities was mostly (14.9%) less than 30 mins. however significantly less number (5.4%) of students go beyond 60 mins of exercise (table 4). significantly (p<0.0005) higher number of students (59.3%) don’t work or don’t stay awake at night (73.3%). we have also investigated the quality of sleep among different classes of students. the data show a significant (p<0.0005) association between quality of sleep and students studying in different academic year. it was found that as students were promoted to the next higher classes the sleeping in the evenings were reduced. however significant amount of students is taking enough sleep (59.3%) nevertheless students are irritated about their sleeping patterns (78.7%). many students experiencing wakefulness at least once (35.3%) and twice (47%) during night sleep. however, 43% student did not have disturbed sleep. students that are feeling irritated (table 5) about their sleeping pattern did not feel sleepy (57%) before going to bed however remained tired (61.1%) all night. this has put a significant negative effect on their work (61.1%). this habit can be associated with the fact that significant (p<0.0005) number of students (46.2%) were not hydrating themselves with enough water (table 5). apart from the sleeping habits, eating habits of all the students remained significantly (p<0.0005) satisfactory. increased number of students (171) indulged themselves by eating fruits and avoid smoking (214), big meals (190) and junk foods (152) before going to bed (table 1, 5). nevertheless 40.7% of the students are not taking enough sleep and 69.7% students are not doing exercises. majority of the students (70.6%) are underweight (low bmi). this has reflected on their lack of interests in the studies and work (table 1, 6). table 1: demographic characteristics of medical students in pakistan. variables (means ± sd) age male 23.6 ±1.07 female 23.6 ±1.07 gender n (%) 10 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 male 59 (26.7) female 162 (73.3) bmi normal weight 58 (26.2) under weight 156 (70.6) overweight 7 (3.2) enough sleep yes 131 (59.3) no 90 (40.7) knowledge about sleep yes 98 (70.6) no 58 (26.2) smoking yes 7 (3.2) no 214 (96.8) physical exercise yes 67 (30.3) no 154 (69.68) table 2: the association of bmi with different sleep hours of medical students in pakistan. variables sleep hours bmi (frequency %) χ2 pvalue underweight normal weight overweight < 5 hours 29 (18.6) 6 (10.3) 3 (42.9) 2.7 0.0005 5-6 hours 74 (47.4) 29 (50) 1 (14.3) 6-8 hours 43 (27.6) 20 (34.5) 3 (42.9) > 8 hours 10 (6.4) 3 (5.2) 0 (0.0) table 3: the association of bmi with irregular sleep pattern of medical students in pakistan. variables sleep disturbances bmi (frequency %) p-value underweight normal weight overweight none 29 (18.6) 6 (10.3) 3 (42.9) 0.0001 once 74 (47.4) 29 (50) 1 (14.3) twice 43 (27.6) 20 (34.5) 3 (42.9) > twice 10 (6.4) 3 (5.2) 0 (0.0) 11 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 table 4: the association of physical exercises with the duration of exercises. variables physical exercise duration of exercise (frequency %) χ2 p-value < 30 mins 30-60 mins >60 mins aerobics/walking 33 (14.9) 22 (10) 12 (5.4) 8.72 0.0001 table 5: the association of influencing factors with the weight of the students variables frequency (%) df χ2 p-value sleep duration <5 hrs 38 (17.2) 138 7.95 0.0001 5-6 hrs 104 (47.1) 6-8 hrs 66 (29.9) >8 hrs 13 (13) water intake regular intake 119 (53.8) 46 2.58 0.0001 not regular intake 102 (46.2) irritation with sleep pattern irritated 174 (27.1) 46 3.53 0.0001 not irritated 47 (21.3) sleep pattern effects on work affected 135 (61.1) 46 2.60 0.0001 not affected 86 (38.9) dietary regime junk foods yes 69 (31.2) 46 2.81 0.0001 no 152 (68.8) feel tired before bed time yes 135 (61.1) 46 2.58 0.0001 no 86 (38.9) feel sleepy before bed time yes 95 (43) 2.92 46 0.0001 no 126 (57) spend more time in bed yes 180 (81.4) 2.83 46 0.0001 no 41 (18.6) meal before bed yes 31 (14) 2.69 46 0.0001 no 190 (86) 12 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 table 6: the association of influencing factors with the weight of the students. sleep hours affect work irritated weight height exercise exercise duration sleep hours pearson correlation 1 .141** -.052** .083** .075** -.035** .011 sig. (2-tailed) .000 .000 .000 .000 .000 .414 n 12738 12738 12738 12738 12738 12445 5306 affect work pearson correlation .141** 1 .109** -.026** .155** -.102** .071** sig. (2-tailed) .000 .000 .003 .000 .000 .000 n 12738 12794 12794 12794 12794 12501 5362 irritated pearson correlation -.052** .109** 1 .196** .106** -.081** .114** sig. (2-tailed) .000 .000 .000 .000 .000 .000 n 12738 12794 12839 12839 12839 12546 5406 weight pearson correlation .083** -.026** .196** 1 .427** -.189** .183** sig. (2-tailed) .000 .003 .000 .000 .000 .000 n 12738 12794 12839 12839 12839 12546 5406 height pearson correlation .075** .155** .106** .427** 1 -.093** .142** sig. (2-tailed) .000 .000 .000 .000 .000 .000 n 12738 12794 12839 12839 12839 12546 5406 exercise pearson correlation -.035** -.102** -.081** -.189** -.093** 1 -.223** sig. (2-tailed) .000 .000 .000 .000 .000 .000 n 12445 12501 12546 12546 12546 12546 5296 duration of exercise pearson correlation .011 .071** .114** .183** .142** -.223** 1 sig. (2-tailed) .414 .000 .000 .000 .000 .000 n 5306 5362 5406 5406 5406 5296 5406 **. pearson bivariate correlation is significant at the 0.01 level (2-tailed). discussion current study included medical students from different colleges with different ethnic backgrounds, socio-economic status, and different life style choices. the students did not have any sleeping disorders, diabetes, obesity or any genetic diseases the time we have conducted the study. however, this does not mean that a student cannot acquire these diseases in any time of the course. the curriculum is itself is a very long and strenuous, many students comes under severe social pressure and stress that effects their sleep, body weight and mental health. previously studies have pointed out the correlation of sleep hours with an increase bmi. for example, according to vergas and his colleagues (2014) sleep deprivation can induce an increase fat intake and predisposing to obesity. other longitudinal studies over the years have also shown that reduced sleep is associated with weight gain contributing as a risk factor to obesity23. 13 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 in contrast to the previous studies, we showed 70 % of the students have low bmi, 26.2 % have normal bmi and 3.2% have high bmi. moreover 69.7 % students do not exercise or have any physical activities while only 30.3% are involved in physical activities such as cycling or walking for 30-60 mins. furthermore 40 % students do not sleep enough and 75 % students have disturbed sleep. moreover 78.7% students are irritated about their sleeping pattern and 61% students remained tired. in addition to this 57 % students do not feel sleepy before going to bed and like (81.4%) to spend much time in the bed. these habits reflect poorly on the academic performances because majority of the students (61.1 %) have problems in learning and memorizing. the associations and correlations studies between bmi and all the categorical factors are significant in our study and this made all the authors to argue that either low bmi leading towards poor sleep pattern or poor sleep pattern leading towards lack of exercise or low bmi leading towards lack of exercise or lack of exercise leading towards the low bmi and poor sleeping pattern. all these scenarios can be true because these factors are interlinked with one another. many studies have shown that students experienced sleep problems more often during their academic lives that put a negative impact on their well-being2431. to analyze the quality of life one must observe sleeping pattern because it covers many clinical aspects such as depression, fatigue, and sleepiness. there is significant link between poor sleep, high calorie rich diets and lack of physical exercises with obesity11,16. neurochemicals in humans for 78 hours consolidated sleep induces an inhibition towards glucose utilizations and glucose production in the first few hours and increases rapidly just before dawn32,33 hours. upon disturbed sleep the glucose utilization pathways are altered which means constant blood glucose levels remains all night leading to the development of insulin resistance, cardiovascular diseases and obesity1,6,7,34,17,35,36. disturbed sleep but not sleeping hours also changes the levels of hormones such as ghrelin (increase hunger) and leptin (inhibit hunger)37,38,1,2,3,5,8 that decreases the insulin sensitivity, reduced glucose tolerance, diabetes39 and appetite control. these factors also lead to the poor and unbalanced diet behaviors and lower the physical activity levels in young people40,41. the low bmi and disturbed sleep in the current study can be explained in that context. recently, in china underweight people are considered to be beautiful, this stir image consciousness in female students. this puts lots of social pressure to achieve weight-loss goals by taking weight reducing products42. people having bmi <18.5 is considered as underweight and put them at risk for having health issues in longer term. there is reduced synthesis of sex hormones and bone mineral density, anemia, low blood pressure, fatigue, discomfort. they will have higher chances to develop eating disorders such as anorexia nervosa, bulimia nervosa and binge eating disorders43-47 in addition to this underweight people might experience infertility and preterm birth48-51. medical students often complain of stress due to burden of their heavy curriculum because of which they tend to skip meals during their day. increased work load resulting in stress causes the body to consume more energy than is being consumed as food which can cause weight loss. another possible reason can be due to the fact that the medical students become more health conscious to maintain a good physique because they are aware of how obesity can be a risk factor for many chronic and long term diseases like diabetes and cardiovascular comorbidities. our findings suggest the importance of exercises or physical activities to improve the blood oxygen levels in the body which increased muscular strength, endurance, improve sleep, maintain weight, increased 14 issn 2412-3188 (online)| 2410-1354 (print) app| published by aeirc| volume 9 issue 1 energy levels, improve brain, heart and lungs functions. limitations a total of 250 students were approached with the questionnaire. out of these, 16 students refused participation, while 13 students left the questionnaire incomplete and were excluded from the study. accumulation of the data lasted for a period of six months among medical students in karachi. future studies should incorporate a larger sample size with students from the different disciplines. conclusion irregular sleeping pattern and lack of physical activities are accumulating factors for students to be underweight. sleep disturbances affected their focus on the academic studies. therefore, it is strongly recommended for students to 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[pubmed: 21152066] 46. taheri s, lin l, austin d, young t, mignot e. short sleep duration is associated with reduced leptin, elevated ghrelin, and increased body mass index. plos med. 2004 dec.1(3):e62. 47. stamatakis ka, punjabi nm. effects of sleep fragmentation on glucose metabolism in normal subjects. chest. 2010; 137(1):95–101. 48. lesser dj, bhatia r, tran wh, oliveira f, ortega r, keens tg, mittelman sd, khoo mc, davidson ward sl. sleep fragmentation and intermittent hypoxemia are associated with decreased insulin sensitivity in obese adolescent latino males. pediatr res. 2012; 72(3):293–8. 49. lucassen ea, rother ki, cizza g. interacting epidemics? sleep curtailment, insulin resistance, and obesity. ann n y acad sci. 2012; 1264(1):110–34. 50. chaput jp, brunet m, tremblay a. relationship between short sleeping hours and childhood overweight/obesity: results from the quebec en forme project. int j obes. 2006; 30(7):1080–5. 51. gangwisch je, malaspina d, babiss la, opler mg, posner k, shen s, turner jb, zammit gk, ginsberg hn. short sleep duration as a risk factor for hypercholesterolemia: analyses of the national longitudinal study of adolescent health. sleep. 2010; 33(7):956–61. about:blank 12 annals of applied psychophysiology june 2025 volume 12 exploring the role of neuromuscular electrical stimulation in neonatal brachial plexus palsy: a narrative review of motor recovery and functional outcomes khansa sheikh1, shamoon noushad2, aqsa hussain1, javeria sheikh1 & bushra1 madad ali malik1 & basit ansari1 1department of health, physical education, and sports sciences, university of karachi 2advance educational institute and research center corresponding author: sheikhkhansa99@gmail.com published online: june 2025 © the author(s) 2025 abstract objective: this narrative review examines the role of neuromuscular electrical stimulation (nmes), particularly reciprocal electrical stimulation (res), in enhancing motor function and limb recovery in infants with neonatal brachial plexus palsy (nbpp). methods: a literature search was conducted from 2021 to 2024 using pubmed, google scholar, and pedro, focusing on randomized controlled trials (rcts) and pilot rcts. a narrative synthesis was employed due to the limited number of eligible studies. results: three studies met the inclusion criteria. nmes has demonstrated promising outcomes in promoting motor recovery and reducing muscle degeneration, with res showing particularly beneficial effects. conclusion: nmes, specifically res, may be therapeutically valuable in nbpp rehabilitation. however, further high-quality and standardized studies are needed to confirm these findings. keywords: neonatal brachial plexus palsy, neuromuscular electrical stimulation, reciprocal electrical stimulation. mailto:sheikhkhansa99@gmail.com 2 introduction weakness or flaccid paralysis of the upper limb identified shortly after birth, known as neonatal brachial plexus palsy (nbpp), is caused by damage to one or more nerve roots from c5 to t1. the worldwide occurrence of nbpp varies between 0.38 and 5.1 per 1,000 live births, with differences observed across regions based on factors such as study location (e.g., individual hospitals, specific populations), population-based data, and access to maternal-fetal healthcare. nbpp often results in long-lasting consequences and can be a debilitating condition. beyond physical and functional limitations, nbpp can affect family relationships, overall child development, and quality of life [1]. the brachial plexus consists of a network of peripheral nerves originating from the anterior (ventral) rami of the spinal nerves c5-t1. these nerves function as electrical conduits, transmitting commands from the brain to the arm muscles and conveying sensory information to and from the muscles of the shoulder, elbow, wrist, and hand [2]. nerve compression or strain is the primary cause of brachial plexus injury, although various other factors may contribute. newborns are particularly vulnerable to these injuries during childbirth, with specific weakness patterns emerging based on the affected areas of the brachial plexus. the most severe form of injury is nerve root avulsion, which leads to complete paralysis of the associated muscle. brachial plexus traction injuries occur when the plexus is excessively stretched during delivery, typically related to challenging breech extractions, even in small infants, or cephalic presentations in large infants with shoulder dystocia [3]. the stretching of brachial plexus nerves (c5 to t1) in the perinatal period results in arm weakness or paralysis, causing limitations in the active range of motion (arom) [4]. although not universally present, the application of traction to the neck during difficult deliveries is frequently observed in neurological birth injuries, including the aforementioned condition. contrary to the common belief that obstetricians' delivery techniques are solely responsible, mismanagement during shoulder dystocia can still cause nbpp [5]. neonatal brachial plexus palsy (nbpp) classification is based on the nature and patterns of nerve damage. the narakas classification system divides nbpp into four categories. 1. group i: classic erb's palsy, involving injury to the c5 or c6 nerve roots. this results in diminished strength or paralysis, affecting shoulder abduction, external rotation, elbow flexion, and forearm supination. 2. group ii: extended erb's palsy builds upon group i by including damage to the c5-c7 nerve roots. in addition to the symptoms observed in classic erb's palsy, patients also experience a lack of wrist and digital extension. 3. group iii: total palsy without horner's syndrome, affecting all plexus roots (c5-t1), leading to complete flaccid paralysis of the affected limb. however, horner's syndrome, characterized by miosis, ptosis, and ipsilateral facial anhidrosis, was not observed. 4. group iv: total palsy with horner's syndrome, the most severe form. this category involved all plexus roots (c5-t1) as well as the sympathetic chain. it manifests as complete flaccid paralysis of the affected limb, accompanied by horner's syndrome, indicating sympathetic chain involvement and an avulsion injury. additionally, phrenic nerve palsy and elevated ipsilateral hemidiaphragm may be observed. the extent and severity of nerve damage influence recovery. approximately 20%–30% of infants experience ongoing impairment in upper limb function and fine motor skills, leading to 3 difficulties in reaching developmental milestones or facing challenges in self-care and instrumental activities of daily living throughout their lives. some babies undergo initial nerve surgery to promote nerve regeneration and muscle reinnervation. the timing of surgical intervention varies, but the absence of biceps and shoulder recovery typically indicates the need for primary nerve repair. consequently, restoration of biceps function is generally considered the primary focus of nbpp treatment [4]. rehabilitation, including occupational and physical therapy, plays a crucial role in the conservative, preoperative, and postoperative management of nbpp [4]. the primary goals of therapy include preventing contractures and joint deformities, strengthening muscles while maintaining a balance between agonists and antagonists, promoting active movement, and improving participation in daily activities in alignment with the international classification of functioning (icf) [6]. one approach frequently used by therapists is neuromuscular electrical stimulation (nmes). this technique employs a handheld, battery-powered device programmed to deliver electrical currents through surface electrodes placed on the target muscles. the objective is to facilitate improvements in the active range of motion (arom) and/or muscle strength [4]. nmes functions by applying controlled electrical impulses to the affected muscle groups, with parameters such as frequency, pulse duration, amplitude, and electrode placement carefully selected to optimize therapeutic outcomes. the specific settings, duration of treatment, equipment used, electrode positioning, and accompanying therapies can vary significantly [3]. reciprocal electrical stimulation (res) is a neuromuscular electrical stimulation technique that sequentially activates motor units in both agonist and antagonist muscles. this stimulation pattern was designed to replicate the natural firing sequence of healthy muscles. furthermore, we hypothesized that res may enhance the strength of the antispastic muscle while simultaneously reducing cortical excitability in the spastic muscle. additionally, by stimulating sensory receptors and neurons within both muscle groups, res has the potential to increase the neural drive and promote improved motor function [2]. this review aimed to evaluate the effectiveness of nmes, particularly res, in the management of nbpp. by analyzing the existing literature on nmes application, treatment protocols, and patient outcomes, this review aims to determine its role in improving motor function, muscle strength, and overall limb function in infants with nbpp. 4 methods data sources and searches an extensive literature analysis was performed to assess the effectiveness of neuromuscular electrical stimulation in treating neonatal brachial plexus palsy. two independent reviewers conducted the search between november 2024 and january 2025. the systematic search encompassed three electronic databases: pubmed, google scholar, and physiotherapy evidence database (pedro). the study design was limited to rcts, and only english-language publications from 2021 to 2024 were included. to ensure a comprehensive search, boolean operators were employed, combining terms such as neuromuscular electrical stimulation or nmes with neonatal brachial plexus palsy or nbpp or erb's palsy or infant or newborn. the inclusion criteria primarily focused on rcts and pilot rcts that investigated the impact of neuromuscular electrical stimulation on neonatal brachial plexus palsy treatment. the review process adhered to the prisma 2020 guidelines for transparency and reproducibility. the pico methodology was structured as follows: • population: infants with confirmed neonatal brachial plexus palsy (nbpp) • intervention: neuromuscular electrical stimulation (nmes), including res • comparison: standard physical or occupational therapy • outcome: improvements in motor function, muscle strength, and limb functionality study selection the review selection process encompassed a thorough examination of titles and abstracts, followed by an evaluation of full-text articles to assess eligibility. the inclusion of studies in this comprehensive review was contingent upon meeting the following specific criteria: inclusion criteria: • research studies eligible for inclusion encompassed randomized controlled trials (rcts) or pilot rcts that investigated the effects of neuromuscular electrical stimulation on neonatal brachial plexus palsy. • eligible studies must have involved participants who were diagnosed with neonatal brachial plexus palsy. • studies have reported outcomes such as improved motor function, muscle strength, and overall limb function in infants with nbpp. • studies published in english and available as full-text pdfs were included. exclusion criteria: studies were excluded based on the following criteria: • non-randomized trials, observational studies, and case reports. • studies focused on conditions other than neonatal brachial plexus palsy. • research that did not specifically examine the effects of neuromuscular electrical stimulation on improving motor function, muscle strength, and overall limb function in neonates with brachial plexus palsy. 5 • articles that had not undergone peer review or lacked sufficient data for outcome analysis. • studies not published in english or not accessible as full-text pdf documents. discrepancies in the study selection were resolved through discussion and consensus. data extraction data were extracted by two independent reviewers. the collected information encompassed study characteristics (author, publication year, and study design), participant information (sample size, demographics, and clinical features), and intervention details (specifics of neuromuscular electrical stimulation, including treatment frequency and duration). the outcome measures included improvements in motor function, muscle strength, and overall limb function. the analysis focused on the efficacy of each intervention, emphasizing the statistical significance and comparative effectiveness of the key findings. quality assessment the methodological quality and risk of bias of the included studies were assessed using two well-established tools: the cochrane risk of bias tool (rob2) and the physiotherapy evidence database (pedro) scale. these tools were applied independently to capture both internal validity and potential sources of bias. risk of bias assessment (rob2) the cochrane risk of bias (rob2) tool was used to evaluate five key domains: randomization process, deviations from intended interventions, missing outcome data, outcome measurement, and selection of reported results. each domain was rated as low risk (✓), high risk (x), or some concerns (?), and an overall judgment was made for each study accordingly. 6 table 1. summary of rob2 assessment study included bias from the randomization process bias due to deviations from intended intervention bias due to missing outcome data bias in measurement of outcome bias in selection of reported results elnegamy, t. e. (2024) ? ✓ ✓ x x justice, d. et al. (2023) ✓ ✓ ✓ ✓ ✓ abdelaziz, e. r. (2022) ? ? ✓ x x legend: ✓ = low risk x = high risk ? = some concerns • elnegamy et al. (2024) provided information on dropout rates and blinding, suggesting a low risk of bias in some areas. however, the absence of details regarding trial registration and concerns in outcome reporting resulted in an overall high risk of bias. • justice et al. (2023) demonstrated methodological rigor across all five rob2 domains, resulting in an overall low risk of bias. • abdelaziz et al. (2022) showed insufficient details regarding the randomization process and intervention integrity. combined with missing information on blinding and registry status, the overall judgment for this study was also high risk of bias. pedro scale assessment to further evaluate methodological rigor, the pedro scale was applied. the pedro scale is a validated instrument widely used in physical therapy research to assess randomized controlled trials (rcts) based on 11 criteria—1 addressing external validity (not scored) and 10 related to internal validity, including random allocation, allocation concealment, blinding, and statistical reporting [7,8]. consistent with common practice in systematic reviews, the external validity criterion was not included in the scoring [9]. 7 based on pedro scores, studies were classified as follows: • 7–10 = high quality • 5–6 = fair quality • ≤4 = poor quality [10] of the three studies included in this review: • one had an existing peer-reviewed pedro score, which was verified by two independent reviewers. • the remaining two studies were newly assessed by the same independent reviewers using the pedro scale. the consistency and reliability of the pedro scale for rating clinical trials has been rated as excellent to fair, supporting its use in this review [11]. table 2. pedro scores of included studies study reference 2 3 4 5 6 7 8 9 10 11 total score study quality tamer emam elnegamy (2024) y n y n n y y y y y 7 high denise justice (2023) y n y y y y y n y y 8 high emad r. abdelaziz (2022) y n y n n n y n y y 5 fair scoring criteria key: • y = criterion satisfied • n = criterion not satisfied pedro criteria: 1. eligibility criteria were specified (not scored) 2. subjects were randomly allocated to groups 3. allocation was concealed 4. the groups were similar at baseline regarding key prognostic indicators 5. there was blinding of all subjects 8 6. there was blinding of all therapists administering the therapy 7. there was blinding of all assessors measuring at least one key outcome 8. outcome measures were obtained from more than 85% of subjects initially allocated 9. all subjects received treatment as allocated or were analyzed using intention-to-treat 10. between-group statistical comparisons were reported for at least one key outcome 11. the study provided both point measures and variability measures for at least one key outcome interpretation of pedro scores the pedro scores for the included studies ranged from 5 to 8, with a mean score of 6.67 (sd = 1.25), reflecting an overall fair quality across the evidence base. • elnegamy et al. (2024) scored 7/10, indicating high quality. the study fulfilled the criteria related to randomization, outcome reporting, and assessor blinding, but did not satisfy therapist or subject blinding or allocation concealment. • justice et al. (2023) achieved the highest score (8/10), meeting most of the internal validity benchmarks. the only unmet criteria were allocation concealment and subject blinding. • abdelaziz et al. (2022) scored 5/10, indicating fair quality. it met fewer methodological criteria, lacking subject and therapist blinding, as well as allocation concealment. these findings suggest variability in methodological rigor among the studies, with two meeting high-quality thresholds and one falling short. importantly, none of the studies satisfied criterion 3 (allocation concealment), which is a critical factor for minimizing selection bias. data synthesis due to the variability in study designs, outcome measures, and intervention protocols, a narrative synthesis approach was employed to compare the results of the included studies. this synthesis concentrated on the effects of neuromuscular electrical stimulation in enhancing motor function, muscle strength, and overall limb function. the synthesis was organized based on the quality of the studies, with higher-quality studies given more weight in the analysis. when possible, the results were compiled into tables for better clarity. because of the heterogeneity in study designs, outcome measures, and treatment protocols, a meta-analysis was not feasible, leading to the adoption of a descriptive approach. the prisma flow diagram (figure 1), which describes the study's identification procedure, abstract screening results, and full-text eligibility assessments, including the rationale for exclusions, was followed for data synthesis. finally, three articles fulfilled the eligibility criteria for full-text evaluation. 9 figure 1. prisma 2020 flow diagram for study selection in this systematic review. results the initial screening identified 50 potential studies for inclusion. upon examining the abstracts, only 3 met the specified criteria (fig. 1). two of these were randomized controlled trials [2,3], while the third was a randomized controlled trial (rct) pilot study [4]. all three studies involved children of both sexes diagnosed with neonatal brachial plexus palsy. the participants exhibited varying symptom durations and ages, ranging from 2 months to 3 years. the studies employed six distinct outcome measures, with electromyography being the most frequently used [2,3]. these measures have been validated as reliable indicators of clinical improvements. the post-intervention follow-up period ranged from immediate to 3 months. (table 2) methodological quality assessment (table 1) displays the pedro scores of each study. the scores ranged from five to eight, with an average of 6.67 (sd 1.25), indicating an overall 'fair' quality of research. two studies were classified as 'high' quality, while one was deemed 'fair' [2,4]. all included studies met five pedro criteria: random allocation, baseline comparability, outcome for >85%, between-group statistical comparisons, and reporting of point measures and variability [2,3,4]. none of the studies fulfilled criterion three, and only one satisfied criterion five regarding subject blinding [4]. studies iden3fied from database searching (n =300) sc re en in g in cl ud ed el ig ib ili ty id en -fi ca -o n addi3onal studies iden3fied through other sources (n = 20) records screened (n = 240) records excluded (n = 180) full text studies assessed for eligibility (n = 50) full-text ar3cles excluded, with reasons (n = 47) -not rcts -no full text -insufficient data studies included in qualita3ve synthesis (n = 3) 10 analysis table 3: nmes protocol summary study nmes type frequency duration electrode placement parameters reported? elnegamy et al. (2024) res 3x/week 15 mins elbow muscles not fully reported justice et al. (2023) nmes daily 30 mins not specified partial abdelaziz et al. (2022) res 3x/week not specified not specified not specified table 4: study characteristics article control group experimental group sample size frequency assessment postintervention followup key results elnegamy et al. (2024) standard physical therapy standard physical therapy + 15minute res (3x/week) 40 3 times per week for 3 months percentage of degeneration (rd) with electromyogr aphy & tams (toronto active motion scale) immediate significantly greater reduction in rd and increased tams scores in the study group. justice et al. (2023) standard therapy standard therapy + nmes (30 min daily) 17 30 min daily for 3 months arom, muscle strength, morphometri c measurement s 1, 2, & 3 months significant improvement in elbow flexion arom in the nmes group after the first month. no adverse effects. abdelaziz et al. (2022) a specially designed physical therapy same physical therapy program + reciprocal electrical stimulation 30 3 sessions/we ek for 3 months percentage of degeneration (rd) with (electroneuro graphy) not specified improvement in functional recovery of the upper limb in both groups, but significantly greater in the 11 program only group receiving reciprocal electrical stimulation. the included studies examined the efficacy of neuromuscular electrical stimulation (nmes) as an adjunctive treatment for infants with neonatal brachial plexus palsy (nbpp) in addition to regular physical therapy. the studies varied in terms of their stimulation protocols, outcome measures, and follow-up periods. according to all studies, even with some methodological differences, infants receiving nmes showed meaningful improvements in functional recovery and muscle activation compared to the control groups. table 5. summary of reported effects of nmes and res in included studies study intervent ion contr ol outcome measures effect reported significa nce effect direction study qualit y (pedr o) elnega my et al. (2024) res + standard pt (3x/week, 15 min) standa rd pt rd (degenerati on% % via emg), tams significan t improvem ent in tams, reduction in rd yes (statistica lly significan t) large improvem ent in motor recovery high (7/10) justice et al. (2023) nmes + standard therapy (30 min daily) standa rd thera py arom (elbow flexion), muscle strength, morphometr ics significan t improvem ent in elbow arom at 1, 2, and 3 months yes moderate improvem ent in specific motor function high (8/10) abdela ziz et al. (2022) res + custom pt program (3x/week) custo m pt progra m rd (via eng), functional recovery greater functional recovery in the res group yes large improvem ent in function and neural input fair (5/10) this table summarizes the clinical effects of neuromuscular electrical stimulation (nmes) and reciprocal electrical stimulation (res) in infants diagnosed with neonatal brachial plexus palsy (nbpp), as reported in the three included studies. it highlights the type of 12 intervention, sample size, key outcome measures, and direction and magnitude of the observed effects. despite methodological and protocol differences, all studies reported favorable outcomes with nmes or res in improving motor recovery, reducing muscle degeneration, and enhancing functional limb use. these findings suggest that nmes, especially res, may offer clinical benefits as a complementary rehabilitation strategy for nbpp. 1. impact on muscle degeneration and functional recovery two studies [elnegamy et al. (2024) and abdelaziz et al. (2022)] employed electromyography (emg) and electroneurography (eng) to thoroughly investigate muscle degeneration. according to both studies, electrical stimulation resulted in significantly less muscle degeneration (rd) in the experimental groups compared to the control groups receiving standard therapy. the elnegamy et al. (2024) study demonstrated a clear improvement immediately following the intervention; conversely, the abdelaziz et al. (2022) study did not specify their follow-up duration. furthermore, abdelaziz et al. (2022) reported significantly greater upper limb functional recovery in a large number of infants who experienced markedly improved outcomes with reciprocal electrical stimulation, highlighting its substantial advantage over standard physical therapy alone. 2. improvement in active range of motion (arom) and muscle strength justice et al. (2023) specifically measured several key arom parameters, a comprehensive range of muscle strength metrics, and various morphometric parameters in a cohort of infants who received nmes for 30 minutes each day over a three-month period. one month after the intervention, there was a significant improvement in elbow flexion arom. this improvement continued at one, two, and three months of follow-up. the lack of reported adverse effects indicates that newborn nmes use is safe and tolerable. 3. differences in nmes protocols and their effectiveness the studies employed different stimulation parameters. • elnegamy et al. (2024) used 15-minute repetitive electrical stimulation (res) three times per week, demonstrating a significant increase in tams (toronto active motion scale) scores and reduced muscle degeneration. • justice et al. (2023) implemented a higher frequency protocol (30 min daily), resulting in notable improvements in elbow flexion within a month. • abdelaziz et al. (2022) applied reciprocal electrical stimulation three times per week, yielding the greatest functional recovery among the three studies. despite these variations, all three studies concluded that electrical stimulation enhances motor recovery and reduces muscle degeneration when used in conjunction with conventional physical therapy. discussion this review suggests that nmes, particularly res, may provide potential therapeutic benefits for infants with nbpp when used alongside conventional physical therapy. while all three studies reported positive trends in motor recovery and muscle preservation, the limited 13 sample sizes and methodological variability limit the ability to draw definitive conclusions from these studies. the studies examined consistently showed that nmes, when used alongside traditional physical therapy, improved motor recovery, reduced muscle deterioration, and enhanced muscle strength in patients with hemiplegia. nmes achieves these benefits by activating both motor and sensory pathways, promoting neuroplasticity, and improving motor control and functional recovery. res, in particular, seems to mimic natural muscle activation patterns, potentially leading to more coordinated movements and better motor learning in affected infants than tms. a key discovery in this review is the significant reduction in muscle degeneration observed in the studies by elnegamy et al. (2024) and abdelaziz et al. (2022) using electromyography (emg) and electroneurography (eng), these studies provided objective evidence that infants receiving nmes experienced less muscle degeneration than those undergoing standard therapy alone. the preservation of muscle integrity is crucial for better long-term functional outcomes. additionally, abdelaziz et al. (2022) reported that infants treated with res showed superior upper limb functional recovery, suggesting that this specific nmes technique may be more effective than traditional physical therapy in enhancing neuromuscular re-education and muscle recruitment. justice et al. (2023) focused on improvements in active range of motion (arom) and muscle strength, revealing significant gains in elbow flexion arom that persisted over a threemonth follow-up period. this finding underscores the potential of nmes to produce both immediate and lasting functional improvements. the absence of reported adverse effects across all studies emphasizes the safety and tolerability of nmes in neonatal populations, which is particularly important, given the vulnerability of this age group. this favorable safety profile supports the inclusion of nmes in early intervention programs for nbpp, potentially accelerating developmental milestones and enhancing the quality of life. despite these promising outcomes, the variation in nmes protocols across studies, including differences in stimulation frequency, session duration, and electrode placement, makes it challenging to determine the most effective therapeutic regimens. for example, elnegamy et al. (2024) used a protocol with 15-minute res sessions three times per week, whereas justice et al. (2023) implemented a more intensive daily regimen of 30 min. both approaches yielded positive results, suggesting that nmes can be effective across various intensities; however, the optimal parameters for maximizing functional recovery remain unclear. furthermore, the diversity in outcome measures, with some studies focusing on muscle strength and others on functional recovery or electrophysiological markers, complicates direct comparisons and limits the ability to draw definitive conclusions regarding the most critical factors influencing treatment success. the included studies demonstrated fair to high methodological quality when evaluated using the pedro scale, suggesting a reasonable degree of robustness in their designs. however, potential biases may have been introduced due to certain methodological shortcomings, such as inadequate blinding and limited sample sizes, which could have affected the reported results. despite these limitations, the consistently positive outcomes observed across various settings and protocols indicate that nmes shows considerable promise as a therapeutic approach for nbpp. to advance the field, it is crucial to establish standardized treatment protocols and 14 outcome measures, enabling better comparisons between studies and facilitating the creation of evidence-based clinical guidelines. limitations this review provides insightful perspectives on the potential benefits of nmes in managing nbpp; however, it is important to acknowledge certain limitations. the small sample sizes in the studies reviewed limit the generalizability of the findings to a wider population of infants with nbpp. additionally, the considerable differences in nmes protocols across these studies, such as variations in stimulation parameters, session frequency, and treatment duration, complicate the development of standardized guidelines and the determination of the most effective therapeutic strategies. furthermore, the predominantly short follow-up periods in these studies restrict our understanding of the long-term sustainability of the benefits of nmes. while some improvements were noted for up to three months, it remains unclear whether these benefits persist into later childhood, when functional demands increase. inadequate blinding in several studies also introduced performance and detection biases. these factors highlight the necessity for high-quality, transparent trials. another limitation was the methodological quality of the included studies. despite fair to high pedro scores, many studies lacked essential elements, such as blinding of participants, therapists, and outcome assessors. this lack of blinding may introduce bias, as expectations from both participants and researchers could affect the reported outcomes. moreover, the analysis was based on a small number of randomized controlled trials, with only three studies meeting the inclusion criteria, which weakened the overall evidence base. the possibility of publication bias should also be considered, as studies with positive results are more likely to be published, potentially skewing the review findings. the risk of bias was considered across studies, particularly regarding potential publication bias. the limited number of studies included (n=3) affects generalizability, and selective reporting may have skewed the positive outcomes. recommendations for future research subsequent investigations should strive to overcome these constraints to bolster empirical support for nmes in treating nbpp. implementing extensive multi-site randomized controlled studies would improve the applicability of the results and offer a more thorough understanding of the efficacy of nmes across various patient groups. these investigations should emphasize methodological excellence by incorporating appropriate randomization, allocation concealment, and blinding of subjects, therapists, and outcome evaluators to reduce potential biases. extended follow-up periods are essential to assess the longevity of nmesinduced benefits and evaluate its influence on functional outcomes as children develop and encounter new developmental challenges. furthermore, establishing uniform nmes protocols, including stimulation variables such as frequency, intensity, pulse duration, and electrode positioning, would enable better study comparisons and aid in identifying the most effective treatment approaches. future research should also delve into the underlying processes by which nmes promotes neuroplasticity and functional recovery in patients with nbpp. comprehending these mechanisms could lead to refined therapy protocols and potentially the creation of novel, more potent interventions. 15 beyond clinical outcomes, upcoming studies should examine the psychosocial effects of nmes on both infants and their families, as well as conduct cost-effectiveness evaluations to determine its viability for widespread clinical adoption. comparative research exploring nmes alongside or in conjunction with other rehabilitation techniques, such as constraintinduced movement therapy or mirror therapy, could provide insights into integrated treatment strategies that maximize recovery. by addressing these research gaps, future studies can contribute to the development of evidence-based guidelines that support the effective and safe application of nmes in rehabilitating infants with nbpp. conclusions this narrative review suggests that nmes, particularly res, may benefit motor function and reduce muscle degeneration in infants with nbpp. however, the current evidence is based on a limited number of small-scale studies that have methodological constraints. future research should emphasize standardized nmes protocols, robust study designs, and long-term follow-up to determine the clinical utility of nmes in routine nbpp rehabilitation. references abdelaziz, e. r., elnegmy, e. h., elhendawy, a., & el-bagalaty, a. e. 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(2017). the pedro scale had acceptably high convergent validity, construct validity, and interrater reliability in evaluating methodological quality of pharmaceutical trials. journal of clinical epidemiology, 86, 176–181. https://doi.org/10.1016/j.jclinepi.2017.03.005 https://doi.org/10.1093/pch/pxab048 https://doi.org/10.23736/s1973-9087.21.06622-7 https://doi.org/10.23736/s1973-9087.21.06622-7 https://doi.org/10.1016/s0895-4356(98)00131-0 https://doi.org/10.1016/j.jclinepi.2017.03.005 84 annals of applied psychophysiology june 2025 volume 12 prediction of perception brigid k. turner college of integrative medicine and health sciences department of psychophysiology, saybrook university published online: june 2025 © the author(s) 2025 abstract background: the intricate relationship between perception, sensory input, and internal expectations significantly shapes our understanding of the world. perception emerges from the interplay of incoming sensory information and top-down predictions, with prior personal experiences playing a vital role in both interpreting and influencing our perception of our environment. objective: this literature review proposes new directions for future studies using the predictive processing model to study the collaboration of sensory information with cognitive predictions, taking into account the role of psychiatric conditions, trait absorption, and psychedelics in perceptual processing. methodology: we reviewed the current literature on perception, multisensory integration, and biorhythms to understand the factors influencing the effect of predictions on sensory processing. additionally, we applied the predictive processing model to explain how perceptual priming’s influence on emotional awareness and interoception results in paranormal experiences. results: this review indicates many different factors influence predictive processing, including interoception, psychiatric conditions, trait absorption, and psychedelics. analysis of the relevant research suggests that the administration of psychedelics and levels of high trait absorption facilitate the emergence of new sensory integration pathways, cultivating the potential for novel or transcendent experiences. conclusion: this review reveals a variety of factors affecting perceptual processes. based on the application of the predictive processing model, this review suggests that future studies on perception should focus on reducing the role of expectation in the perceptual processes by means of the administration of psychedelics or the selection of individuals with high levels of trait absorption. a greater understanding of the power of prediction on our perception has the potential to impact the way we experience pain, hunger, thirst, temperature, and even anxiety and depression. such knowledge could open new doors for treatments or medical interventions. keywords: perception, sensation, interoception, exteroception, absorption, psychedelics. laying the groundwork for perception perception is constructed at the shifting border between incoming sensory evidence from our environment and our internal conceptual predictions and expectations. incoming sensory perception is filtered through a complex lens of existing expectations, beliefs, and emotions. fundamentally, our prior experiences either lead, follow, or get out of the way during sensory integration and, in turn, amend our perception. perception is, in essence, the meaning we make of the current environment. perception may be the foundation of human wellbeing, from relationships and conflict resolution to chronic pain and trauma. understanding the factors that significantly influence our perception has the potential to inform therapeutic strategies in the context of extraordinary experiences and the transformative effects of psychedelics on human well-being. isolated in the darkness and silence of the skull, the brain receives data about the external environment only via electrical signals carried by neurons. at each moment, electrical signals about our environment arise via our senses. if the individual’s expectations about the shape of those signals are strong enough, perception curates the experience that those expectations predict by filling in the gaps in sensory information to match that prediction. this means uncertainty is inherent to perception. given this inherent uncertainty, principles of probability provide the most effective strategy for drawing useful inferences about perception. specifically, the bayesian brain theory serves as the foundation for the prevailing perspective on inferential processes within the brain (hohwy, 2017). bayesian brain theory holds that the nervous system encodes predictions about sensory information to reduce sensory uncertainty and promote efficient survival (friston et al., 2016). employing bayesian brain theory, the predictive brain aims to enhance the accuracy of its predictions to minimize subsequent errors in prediction (clark, 2013). the brain uses prior experiences of the body and the corresponding sensory inputs to generate predictions about what the body (interoceptive sensations) and the world (exteroceptive signals) will be like in the future, thereby minimizing prediction error signals (van elk, 2016). the predictive processing framework helps explain how difference in the weighting of interoceptive and exteroceptive information may form the basis of philosophical or religious beliefs and experiences (van elk, 2017). we receive input via exteroceptive signals from vision and sound, proprioceptive signals from body movement, and interoceptive signals from the heart and other organs. multisensory integration is how the brain combines the information from our different senses, like sight, touch, sound, smell, and balance, to create a clear understanding of our body and surroundings. (blanke et al., 2014). however, biorhythms continually impact our multisensory integration. for example, saccadic suppression of vision during saccadic eye movements blocks incoming visual information every 250 ms. (kunzendorf, 2019). this results in less visual input to our occipital lobe during saccadic eye movements. meanwhile, the consistency of saccadic suppression itself varies with the heartbeat (galvez-pol et al., 2020; ohl et al., 2016). heart rate, in turn, vacillates in response to our breath rate, autonomic nervous system, and activity level. thus, the quantity and quality of incoming sensory signals changes moment to moment depending on current physiological conditions and biorhythms. exteroceptive signals seem to undergo a process of hierarchical bayesian inference, in which higher-order cortical regions guide lower-level cortical areas, thereby facilitating sensory processing (friston, 2005; lee and mumford, 2003; summerfield and koechlin, 2008; yuille and kersten, 2006). sensory processing is narrowed or honed by our intentions and cognitive assessment of context. using functional magnetic resonance imaging (fmri) and multivariate pattern analysis (mvpa) techniques to measure the content of neural activity in the visual cortex of 22 human volunteers (kok et al., 2012), the findings of the study revealed how contextual expectations smooth exteroceptive processing in boisterous and ambiguous settings by sharpening early sensory representations (friston, 2005). this means that our brain fills in sensory gaps to match our cognitive assessment of the environment based on context. in this same vein, by repeated exposure to a stimulus, perceptual priming works as an unconscious form of perceptual memory, resulting in more accurate recognition of that stimulus (moldakarimov, 2010). even one exposure to a stimulus can sharpen perceptual processing. an example of this is found in sine wave speech (sws), which sounds like strange beeps and whistles that match the bare frequency of words (remez, rubin, pisoni, & carrell, 1981). upon initially hearing an audio clip of sws, the sounds are indecipherable (cjd, n.d.). although the auditory system receives input, the neural processes involved in comprehension are not activated, and phonological, lexical, or semantic information is not retrieved. however, once a person hears the words underlying the audio clip of sws, their pre-central and inferior frontal cortex fills in the gaps to comprehend the words clearly the second time they listen to them. notably, the auditory cortex representations do not change with the intelligibility of sws (fig. 1.) it is a clear example of predictive processing at work in deciphering language (koshkhoo et al., 2018). as dieguez and lopez point out, ‘the body is the source of its own perception, a subject and an object at the same time” (dieguez & lopez, 2017). within the brain, the anterior insular cortex (aic) is involved in visceral interoception and emotional awareness (seth, 2013). sympathetic and parasympathetic nervous system signals connect in the aic and anterior cingulate cortex (acc). individual differences in interoceptive sensitivity, as measured by heartbeat detection, are predicted by the aic and coupled with emotions (gray, 2007). emotions involve behavioral, experiential, and visceral changes. as schachter and singer famously demonstrated, emotions are modulated by arousal level. they used adrenaline injections to proximally cause physiological arousal, which would give rise to either anger or elation, depending on the context (schachter & singer, 1962). sensory precision and interoception disruption are significant in psychiatric presentations such as depression, anxiety, eating disorders, and substance use disorders (khalsa et al., 2018; figure 1 electrodes activated during exposure to sws and clear speech. note: (i) acoustic waveform and auditory spectrogram (ii) electrodes responsive to sws and clear speech (cs). https://users.sussex.ac.uk/~cjd/sws/03_40sws.wav https://users.sussex.ac.uk/~cjd/sws/03_40sws.wav https://users.sussex.ac.uk/~cjd/sws/03_40.wav https://users.sussex.ac.uk/~cjd/sws/03_40.wav smith, 2020). for instance, individuals with depression exhibit lower accuracy when counting their heartbeats (dunn et al., 2010). the diminished interoception may contribute to visceral dysregulation when interoceptive disturbances occur, such as highly arousing negative emotional states. studies of panic disorder find amplified interoceptive sensations in high-arousal states (khalsa et al., 2016). one study used behavior during a heartbeat perception task to estimate differences in prior beliefs and sensory precision related to cardiac signals in both healthy individuals and those with depression, anxiety, substance use, or eating disorder symptoms (smith et al., 2020). interoceptive processing was stunted in the psychiatric population during altered physiological states, particularly during heightened arousal states (smith et al., 2020). although it is unclear whether the reduced interoceptive accuracy perpetuates an individual’s symptoms or is a mere by product, this correlation warrants further investigation. absorption and openness tellegen and atkinson’s (1974) concept of absorption is associated with an experiential mindset, where absorption means a deep involvement with the object of experience. low absorption aligns with a reality-oriented, rational mindset. absorption predicts the frequency and intensity of extraordinary experiences people report (hood, morris, & watson, 1993). absorption overlaps with the concept of openness. mccrae and costa (1997) define openness to experience as the permeability of consciousness. this means that individuals with closed minds exhibit a greater distinction between their conscious and unconscious thought processes. therefore, enhanced access to primary process cognition can be advantageous because conventional conceptualizations are suspended, allowing the mind to embrace greater novelty. similarly, hartmann’s (1991) notion of boundaries correlates with the permeability of consciousness. thin boundaries indicate more permeability and high openness (mccrae & costa, 1997), emphasizing more primary process cognition in awareness. by contrast, thick boundaries are less permeable and are effectively closed off from new subjective interpretations of incoming sensations. in this way, traits of openness and absorption facilitate a perceptual inclination toward novel perception with less weight on bayesian predictive priors. the tellegen absorption scale has emerged as the dominant tool for conceptualizing and measuring the trait of absorption (tellegen & atkinson, 1974). many items on the tellegen absorption scale emphasize the inner landscape of fantasy and mental imagery, symbolic of lively imagination. an absorbed person is drawn to experience effortlessly, without effort or goal-seeking (lifshitz, 2019). absorption has also been associated with feelings of selftranscendence (cardeña & terhune, 2014), dissociation, and hallucinations (perona-garcelán et al., 2013; perona-garcelán et al., 2016). tellegen and atkinson (1974) considered absorption a fundamental trait that underlies aesthetic, peak, and mystical experiences. this conclusion has been supported by van elk et al. (2016) findings that people with high trait absorption felt more awe than those with low trait absorption. levels of absorption and openness also correlate with an individual’s propensity to perceive paranormal events. michael persinger developed the renowned “god helmet” that induced a weak magnetic field in the temporal lobes (cook and persinger, 1997; hill and per, singer, 2003). however, when the helmet was not turned on, participants still reported spiritual experiences. their suggestibility predicted the strength of these experiences. (granqvist et al., 2005, granqvist and larsson, 2006). other studies using placebo god-helmet manipulations have shown that pre-existing spiritual beliefs enhance spiritual experiences (andersen et al., 2014; granqvist and larsson, 2006). french et al. (2009) also demonstrated this placebo effect in an infrasound and electromagnetic haunted room experiment. according to french, the frequencies were less likely to cause ghost sightings than merely telling someone they might see a ghost (french et al., 2009). based on these studies, it is clear that individual levels of absorption and openness influence human perception. the exact mechanism may be related to the role of serotonin. absorption has been linked to serotonin 2a receptor association with greater signaling (ott et al., 2005). inherently, the trait of novelty seeking, which is associated with dopaminergic activity, is less pronounced for those who experience placebo-evoked somatic sensations (beissner et al., 2015) but absorption was not measured in that study. bessner, 2015, nonetheless supports the proposition: “expectation and prior knowledge, profoundly shape the way that sensory input is processed.” the inherent uncertainty in perceiving our perception is limited by what our senses are capable of detecting. moreover, a large discrepancy between incoming sensations and our prior experiences and beliefs produces greater perceptual uncertainty. similarly, if new sensory information is given too much or too little weight compared to our predictions, perception of reality may become distorted (howes et al., 2020; kube et al., 2020; smith et al., 2020). for example, by synchronously stroking an artificial rubber hand with a participant’s real hand while directing the participant’s visual attention towards the artificial hand, the participant perceives the artificial hand as part of their own body (botvinick, 2004). comparable effects have been observed in face perception (bufalari et al., 2019) and whole-body ownership (ehrsson, 2007). induction of the rubber hand illusion results in a lower temperature (mosley et al., 2008) and higher histamine reactivity of the actual hand (barnesly et al., 2011). additionally, threats to the rubber hand during the perceptual illusion trigger enhanced skin conductance responses (armel & ramachandran, 2003)). the temporo-parietal junction (tpj) merges somatosensory, auditory, and visual input and resolves intersensory conflict. (papeo et al., 2010). specifically, tpj activity is common in out-of-body experiences (obes) (blanke et al., 2004, 2005). focal electrical stimulation of the tpj has resulted in the induction of an illusory shadow person, who was perceived to loom slightly behind the participant’s body (arzy et al., 2006). similar observations were made in a group of patients characterized by damage to the left tpj, who frequently reported the feeling of a presence in daily life (blanke et al., 2003; blanke et al., 2014). electrical stimulation of the hippocampus and the amygdala has been shown to result in déjà-vu experiences, visual hallucinations of well-known scenes, and feelings of “strangeness” (vignal et al., 2007). moreover, stimulation of the parahippocampal area has been shown to result in the perception of familiar places (megevand et al., 2014). stimulation of more lateral parts of the temporal lobe, such as the fusiform face area, resulted in the perception of illusory faces (i.e., pareidolia) and strong distortions in face perception and recognition (parvizi et al., 2012). similarly, a study using transcranial magnetic stimulation (tms) found that inhibition of the left lateral temporal area reduced the tendency to perceive meaningful information through visual noise (bell et al., 2007). in one study, mengotti et al. (2017) applied online tms over the right tpj during a special cueing task. the disruption in the tpj neural activity interfered with participants’ ability to contextually update their prior beliefs based on novel incoming information, suggesting the right tpj plays a crucial role in reconciling predictions with incoming stimuli. electrical stimulation is not the only avenue to identify brain regions involved in mystical perception. spontaneous discharges in temporal areas and the limbic system in patients with temporal lobe epilepsy can lead to profound religious experiences (joseph, 2001). moreover, symptoms associated explicitly with temporal lobe discharges include hyper-religiosity, visual hallucinations of animate objects, and multi-modal sensory experiences (chan et al., 2009). augmented divergence between new sensations and past contextual experience increases perceptual uncertainty. whether through electrical stimulation, altered neural function, or strategic optical and tactile illusions, a large discrepancy between sensory signals and contextual memory fosters unique and paranormal perception. now, let us consider how psychedelics similarly enhance perceptive uncertainty and fertilize synaptic potentials for sensory integration. psychedelics and perception psychedelics have the potential to inform therapeutic strategies, especially in the context of extraordinary experiences. deviations in the dynamic interactions between sensation, expectation, and inference explain how psychedelics alter perception. serotonergic psychedelics diminish the impact of preconceived expectations and their inferences, allowing sensory data to navigate new neural pathways. psychedelics involve alterations in multisensory integration, where information from various sensory modalities becomes excessively interlinked. the use of psilocybin has been associated with the experience of “ego-dissolution,” where people experience a loss of time and space (griffiths et al.,2006). like with the god helmet, psilocybin studies have found that absorption was the second most important predictor (besides dosage) of mystical-type experiences (studerus et al., 2012). what serotonergic psychedelics appear to do is relax the influence of top-down beliefs so that sensory information can find new channels. for example, the psychedelic experience of synesthesia involves the perception of stimuli via a discordant sensory modality (carhart-harris et al., 2014). absorption has also been linked to the intensity and frequency of synesthesia induced by ayahuasca (bresnick & levin, 2006), lsd (terhune et al., 2016), and near death experiences on the potent serotonergic psychedelic dmt (timmermann et al., 2018). based on these studies, abnormal serotonergic functioning, as in the trait of absorption, may contribute to both psychedelic synesthesia and ndes. another psychoactive substance, ketamine, an nmda (n-methyl-d-aspartate) glutamate receptor antagonist, is not generally known to produce hallucinations. however, ketamine has induced auditory hallucinations when the participants were placed inside an fmri scanner (powers, 2015). this curious finding begins to make sense taking into consideration how ketamine intensifies sensory experiences. with ketamine, both auditory and visual perception acuity is amplified, and background stimuli become more prominent (krystal et al. 1994; oye et al. 1992; vollenweider et al. 1997a, b). the odd visual and auditory input of the mri, merged with magnified interoception induced by ketamine, created hallucinations comparable to psilocybin’s (corlett, 2009). thus, it is more than mere serotonin signally that allows for the astonishing and fantastic perception experienced after ingesting psychedelics. discussion the factors discussed in this article were chosen for their significant impact on perception and their potential to inform therapeutic strategies, especially in the context of extraordinary experiences and the transformative effects of psychedelics on human well-being. future research should investigate the unique sensory processing mechanisms associated with psychedelically https://link.springer.com/article/10.1007/s00213-009-1561-0#ref-cr79 https://link.springer.com/article/10.1007/s00213-009-1561-0#ref-cr118 https://link.springer.com/article/10.1007/s00213-009-1561-0#ref-cr161 https://link.springer.com/article/10.1007/s00213-009-1561-0#ref-cr162 induced altered states and individuals with high trait absorption levels. additionally, future studies should specifically measure trait absorption levels in the context of somatic placebo-induced sensations. conclusion this review seeks to synthesize the current research surrounding the intricate relationship between sensory input, cognitive predictions, and interoception, emphasizing the importance of these factors in shaping perception. by applying bayesian brain theory to the roles of multisensory integration, biorhythms, absorption, and psychedelics, existing research on sensory processing and prediction errors provides valuable insights into how we might curate novel therapeutic and extraordinary experiences. there has long been a gap between our subjective and objective reality, which has slowly shrunk over time. we are now to the point where this gap occurs in milliseconds within our brains and bodies. fluctuations in the precision of our sampling of sensory evidence lead to more or less emphasis on prior knowledge and experience, leading to revised predictions about objective reality. appreciating the interconnectedness of these subjects contributes to a holistic understanding of human cognition and sensory capabilities while getting us closer to answering the question we ask ourselves every day—what is real in this moment? references allen m., levy a., parr t., friston k.j. 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narrative review olaitan olabiyi1, ayomide ajibewa1, abayomi ajayi2. published online: december 2025 © the author(s) abstract background: this narrative review aimed to explore the scientific understanding of the role of monosodium glutamate and dietary glutamate in depressive-like phenotypes. it illuminated the findings that are linked to the monosodium glutamate (msg) model of depression, curating recent literature on msg-induced depression and the closely related sphere of msg induced neurotoxicity. methodology: a comprehensive search of the literature from 2010 to 2025 was conducted using google scholar, pubmed, and scopus databases, focusing on peer-reviewed studies with definite outcomes. a narrative review was done due to the limited number of eligible studies. results: a comprehensive search of relevant databases having studies of msg induced neurobehavioral and pathophysiological changes in depression was conducted with preference for recency of studies (up to two decades back). supraphysiological doses and/or the parenteral route of monosodium glutamate can consistently induce depressive-like phenotypes in animal models. the limitations of the msg model of depressive-like behavior were also critically analyzed. three thousand five hundred and eighty results came from the searches, with sixty-three studies adjudged to meet the inclusion criteria. conclusion: the monosodium glutamate model of depression provides a valuable approach to understanding the multifaceted nature of depression. future endeavors should focus on the standardization of methodological processes and the incorporation of the evaluation of the chronic effects of monosodium glutamate in human studies. keywords: monosodium glutamate (msg), dietary glutamate, depressive-like phenotypes, monosodium glutamate induced depression, neurotoxicity, animal models, supraphysiological doses. corresponding author: olaitanolabiyi40@gmail.com introduction major depressive disorder encompasses a host of causative factors, including environment, genetics, stress, and diet. the world health organization (who) statistics reveal that 4% of the world population experience symptoms consistent with depression, with women more affected than men (who 2023). this condition can be debilitating, severely affecting key aspects of life at home, in the workplace, and in school. hence, this portends a great burden of the disorder worldwide. at this time, developing countries such as nigeria are becoming increasingly cognizant of the link between mental health disorders, such as depression, and the socioeconomic status and quality of life generally (imbur 2024). this has led to increased exploration of some key aspects of depression, including dietary influences that underlie these disorders. glutamate, a major excitatory neurotransmitter, has been implicated in the pathophysiology of depression, with increasing evidence (niciu et al., 2014; onaolapo & onaolapo, 2021; boyko et al., 2023). its importance in the mediation of learning and cognition, which are critical brain functions, cannot be overstated; on the other hand, its propensity for overstimulating functional brain neurons cannot be ignored in the etiology of various neurological conditions, including depression. glutamate may also stimulate peripheral glutamate receptors in the gut and still affect cns functions, with interaction between receptors and afferent nerve fibers (uneyama et al., 2006). this is a result of an imbalance of glutamate levels or dysregulation of glutamate homeostasis in the body. glutamate can be of an endogenous or exogenous source. the latter is commonly derived from diets containing monosodium glutamate and from natural food sources, such as those found in many foods, including meat, fish, and aged cheese. despite that monosodium glutamate, a worthy representative of dietary glutamate, is generally recognized as safe (gras) by the fda (dal et al., 2017; bayram et al., 2023), concerns and anecdotal reports still endure regarding its systemic and neurological effects (umukoro et al., 2015; rosa et al., 2016; kumar et al., 2021; brandley et al., 2022). the synthesis of msg has evolved from a costly and patient protein source to bacterial fermentation, which helped to augment production considerably (samuels 1999; ault 2004). this, coupled with increasing acceptance of the flavor-improving characteristic, has increased profitability in the glutamate industry. despite its widespread use, the exact effect of msg and dietary glutamate on mental health, especially how they contribute to the pathophysiologic mechanisms of depression, is still a subject of debate, with inconsistent and mixed findings in scientific studies. this narrative review explores the empirical evidence surrounding the monosodium and dietary glutamate model of depression. it evaluates key biological and neurotoxic aspects of the monosodium glutamate model of depression, a departure from the psychological and social factors that cause depression. we want to analyze the current mechanistic understanding, methodology of extant research, and attempt to identify salient gaps for future investigations. methods data sources and searches an extensive literature search was done utilizing google scholar, pubmed, and scopus databases. the keywords used in the search were “msg”, “monosodium glutamate”, “depression”, “depressive-like”, and “neurotransmitters”. boolean connectors were employed by two independent reviewers for these keywords. the search was conducted between march 2025 and may 2025. in ensuring a robust search, boolean connectors were used to combine items such as “monosodium glutamate” or “msg” with “depression” or “depressive-like” or “neurotransmitters”. the review process was in accordance with the prisma 2020 guidelines for transparency and reproducibility. inclusion criteria: titles, abstracts, and full texts were thoroughly examined to determine eligibility. studies were included if: i. they were original research articles published in peer-reviewed journals or relevant review articles that are pointers to relevant original studies. ii. written and expressed in the english language and available as full-text pdfs. iii. they investigated the effect of monosodium glutamate administration on depressive-like behaviors in models of depression and closely related spheres of neurotoxicity. iv. they employed validated behavioral tests, especially in animal models. v. they included studies with relevant neurochemical changes that pertain to depressive-like behaviors or depression. vi. studies between 2010early 2025, before march 2025. exclusion criteria: studies were excluded if: i. they were not published in english or were not accessible as full-text pdf documents ii. they were articles that had not been subject to peer review or lacked sufficient data to make a specific outcome analysis. iii. they lacked validated behavioral tests and/or studies with relevant neurochemical changes that pertain to depressive-like behaviors or depression. data collection and extraction collected data points included: subjects that were administered monosodium glutamate; dose & route of administration; key neurochemical and behavioral findings; the authors and publication year. assessment of methodological quality and risk of bias the primary studies were subject to critical appraisal, despite that this was a narrative review. this was to make sure that the finding was interpreted correctly and consistently. the office of health assessment and translation (ohat) risk of bias tool was employed to determine the internal validity of both human and animal studies. these provided qualitative judgements for specific bias domains, with the observation that all biases are not equal in impact. the assessment of the study was done by two independent reviewers. objectivity and consistency were ensured. a consensus was reached by reviewers for the final rating, with a third reviewer stepping in to resolve conflicts. monosodium glutamate and dietary glutamate: sources and metabolism in the body. monosodium glutamate, msg, a sodium salt of glutamic acid, is named sodium-2-aminopentedioate reflective in line with the iupac nomenclature. hence, it is ionized in solution to give the individual sodium ion and glutamic acid (kayode et al., 2023). monosodium glutamate is often referred to as the fifth taste; the other four being salt, sweet, sour, and bitter. it gives the free form of glutamate, the same as endogenously active ones. umami depicts the monosodium glutamate taste mediated by the gpcr, t1r1, and t1r3 subunits. the heterodimer receptor formed by these subunits binds to umami substances such as l-glutamate, causing a series of reaction cascades that help in the perception of the distinct umami taste (servant & frerot, 2021; diepeveen et al., 2022). 5´-ribonucleotides are important in this process as they help in stabilizing the heterodimer receptor in an active conformation, sensitive to glutamate. monosodium glutamate could lose the umami taste upon undergoing various degradative reactions, but it assumes a flat configuration to attach to the umami receptors (diepeveen et al., 2022). a walk back into history shows that glutamic acid was discovered in the late 19th century by the german chemist karl heinrich upon adding sulfuric acid to wheat gluten (sano 2009). in 1908, isolated glutamic acid was obtained from the seaweed by an extraction and crystallization process. moving on from the acid hydrolysis of wheat gluten, the increased demand for msg's appetizing and palatability characteristics led to a delve into fermentation and chemical production (kazmi et al., 2017). fermentation remains the current method of production, usually utilizing genetically engineered bacteria that secrete glutamic acid through their cell wall. the process of bacterial fermentation closely mimics that of making yoghurt and vinegar. as of today, monosodium glutamate is commercially produced on a large scale in a cheap and consumer-friendly way. its palatability and appetizing attributes make it the darling of fast food and the commercial food industry worldwide, and this wide acceptability in asia has been replicated in other continents of the world. glutamate is either free (not bound to a protein) or bound (bound to a protein that will release it subsequently in free form). in human beings, the average daily intake of total glutamate is 10 g, while that of free glutamate is greater than 1000 mg (beyreuther et al., 2007). dietary sources of monosodium glutamate, including sausages, hamburgers, barbecues, and bodybuilding proteins, are reflective of urbanization trends. other sources that give free glutamate include proteins such as meat, fish, eggs, and even tomatoes. some foods on a commercial scale have been found to flout the limit of monosodium glutamate in some countries (lavine 2007). this brings to the fore the need for tighter regulations on the production and labelling of monosodium glutamate-containing food. however, when monosodium glutamate is consumed with food, even at high doses, there is a form of tolerance such that it will not sufficiently cause brain lesions (fernstrom 2018). this may be due to factors including the dilution of the concentration of the monosodium glutamate, reduction of influence on taste and satiety, and protein-umami synergism on appetite regulation. in addition, excessive consumption of msg may portend a decrease in appetite resulting from a decrease in palatability (loliger 2000). this may be protective, as humans will find food containing high levels of msg to be unattractive. a reduced consumption of monosodium glutamate well below critical limits signifies a reduced risk of the untoward effect of monosodium glutamate. despite that monosodium glutamate is recognized as safe, giving it the gras status with the fda, its presence and usage in a variety of food products may not be explicitly defined, thereby exceeding daily standard intake (maluly et al., 2017; wijayasekara, 2017). a certain author advocated for its outright ban since it imbibes the cardinal sins of deception and adulteration (samuels 2013). its meaty flavour may encourage consumption of less expensive protein, and it is said to make food appear or taste better than it is (samuels 2013). another risk is that of adulterated and substandard msg in the market. it is now considered misinformation that msg is unsafe at acceptable limits. this overrides the previous misconception that it caused a cluster of symptoms, often called "chinese restaurant syndrome," which included headaches, anxiety-like behaviors, palpitations, and obesity linked to msg consumption. several studies depict no such effects when msg is combined with food in normal concentrations, and remain inconclusive for large concentrations of msg (us fda 2012; obayashi and nagamura 2016; henry-unazeze 2017). the toxicity profile of msg to the brain and body often depends on the species involved, age at dosing, dose, and the route of administration (hassan et al., 2019). for instance, adult rodents (mice and rats) may show similar levels of msg in the blood. guinea pigs may show significantly higher levels, which translates to higher impacts (bizzi et al., 1977). younger mice are significantly more affected by msg administration than older ones, as many of the protective barriers are not yet fully formed. the parenteral route for msg administration in pre-clinical studies may not reflect the typical oral consumption process in humans. hence, there is a significant challenge to extrapolating results in young rodents or for the parenteral route in either an age-dependent alzheimer’s disease or a non-age-specific one like depression (roberts et al., 2018; hassan et al., 2019) since the body can easily metabolize glutamate (samuels, 1999; rivera-cervantes et al., 2004). monosodium glutamate is metabolized similarly to glutamate from other sources. it is reduced to glutamate and sodium in body fluids, followed by absorption. glutamate also has a crucial impact on energy production and metabolism, exchanging with α-ketoglutarate (akg) through the glutamate pyruvate transaminase or glutamate oxaloacetate transaminase (xiao et al., 2016). astrocytic conversion of glutamate to glutamine occurs via glutamine synthetase. normal dietary consumption of glutamate shows a breakdown to carbon dioxide by the git. however, if msg is consumed in overwhelming proportions, atp may be generated or conversion may be done to other amino acids. these include ornithine, glutamine, and aspartate (kazmi et al., 2017). figure 1: biological etiologies of depressive phenotypes depression and the role of endogenous glutamate traditionally, major depression is usually treated with a sequence of single antidepressants. however, provided that the key improvement in clinical symptoms and tolerable side effects is not established, a second agent could then be added (bennabi et al., 2019). there are a number of grey areas that increasingly demarket this approach. first, studies have shown that anti-depressants may paradoxically worsen depression too (damluji 1988; benazzi 2003). then, conventional management of depression, which employs the same principle of dosing and agent as treatment of other chronic diseases like hypertension, often causes disappointing remission rates for the first line, making each subsequent antidepressant treatment administered, remission rates progressively decreased (stahl, 2010). take into account that the majority of conventional antidepressant agents have the underlying monoamine deficit principle in part or in whole. therefore, it is logical to consider pathophysiologic factors and, by extension, the potential pharmacotherapeutic interventions for depressive disorder. this brings us to the need to further study the glutamate model of depression. an understanding of the exact mechanisms of glutamate action in depression may illuminate certain pathophysiologic core of the disorder (asejeje et al., 2024). in essence, the gut-brain axis and glutamatergic signaling in the brain and gut play crucial roles in depression. glutamate is a key excitatory neurotransmitter that facilitates fast synaptic impulses of memory and learning in the brain. it is a potent excitotoxin that is found to play a role in the pathophysiology of depression, with increasing evidence (hashimoto 2009; mitchell et al., 2010; niciu et al., 2014). it may exert its actions at different cell compartments, including presynapse, postsynapse, and glia. glutamate stimulates extra synaptic nmda in the subgenual cingulate area either to cause depression alone or co-morbid depression in glutamate-associated diseases (onaolapo & onaolapo 2021). l-glutamate abounds inside the brain more than outside, lending credence to its central function. although the extracellular fluid concentration of glutamate is kept within an acceptable range of 0.5 to 2 µm by the excitatory amino acid transporters (hawkins 2009; zhou and danbolt 2014), peripheral glutamate may distort the blood-brain barrier and significantly affect brain concentrations (xhima et al., 2016). results initially, we selected 63 studies out of the total 3,580 results to meet the inclusion criteria. upon examining the abstract and full text, 19 studies met the criteria perfectly and were suitable for further in-depth analysis. the majority of studies examined were on animal models, while only two were returned for human studies. evidence for monosodium glutamate-induced depressive-like behaviors in animal models previous studies in the last one and a half decades have significantly demonstrated that the administration of monosodium glutamate can evidently cause changes in behaviors that are consistent with depression in animal models (umukoro et al., 2015; quines et al., 2016; yang et al., 2020). they have generated pivotal empirical evidence for the use of monosodium glutamate to induce depressive-like phenotypes, while making use of standardized behavioral tests to depict these characteristics. in a study by quines et al. in 2014, male and female newborn wistar rats received a daily subcutaneous dose of monosodium glutamate at 4 g/kg/day from postnatal day 1 to day 5. there was a significant increase in immobility time in the forced swim paradigm. similarly, there was an increased freezing reaction in the contextual fear conditioning. the uptake of serotonin in the cerebral cortices of rats increased, which was positively correlated with the degree of immobility. this uptake was, however, negatively correlated with the na+ k+ atpase activity. these proofs of depressive-like behaviors delineate the underlying mechanisms, including a dysregulation of the serotonergic system and neuronal excitability. impairment of the hpa axis regulation also contributes to anxiety-like behaviors. rosa et al. 2016 found a downregulation in serotonin levels with concomitant gaba increase following a similar dose of 4 g/kg per day from the 1st to 10th postnatal day in female wistar rats. for abu-taweel et al., 2014 and abdel moneim et al., 2018, a significant decrease in serotonin levels in the brain was found. dopamine was also significantly downregulated in the abu taweel study at a dose of 8 mg/kg monosodium glutamate orally for one month in male albino mice. further lending to the evidence, umukoro et al. 2015 demonstrated that oral administration of monosodium glutamate at the highest dose of 500 mg/kg daily for 21 days in mice elicited depressive-like behaviors in the forced swim test. the lower doses used in the study did not produce considerable behavioral abnormalities, suggesting a dose-dependent effect. there was no significant perturbation of memory in the y maze however. this study makes use of an oral route of administration, which is more predictive of typical human dietary consumption than parenteral routes. there is the argument that the utilization of a parenteral route in such animal studies could jeopardize the extrapolation of the animal data to humans (reeds et al., 1996) since the body can effectively bio-transform added glutamate (samuels, a. 1999; rivera-cervantes et al., 2004). the administration of monosodium glutamate has also been linked with neurotoxic effects or general malaise, including a significant reduction in spontaneous locomotor activity (zhao et al., 2019), aggressive behavior, and loss of muscle strength (nishigaki et al., 2018). there have also been reports on the affective potential of monosodium glutamate administration on cognitive abilities, including exploratory behaviors and short-term working memory (fahmy et al., 2023). zebra fish behavioral models are becoming widely accepted since, compared to pre-clinical studies, they present a cheap, yet accurate and easy to maintain alternative, and can be correlated to human disease pathologies. a study by devaraj et al. 2020 evaluated the effect of monosodium glutamate on both phenotypic changes and brain neurotransmitters in danio rerio. levels of dopamine, norepinephrine, and serotonin were found to drop as monosodium glutamate dosage increased (100 mg/l, 150 mg/l, and 200 mg/l). a corresponding increase in glutamate and gaba was also found. the induction of depressive-like characteristics by msg depends on the dose, route of administration, and age of animals at dosing. the parenteral route, while not a good predictor of human depressive phenotype, appears to consistently induce these behaviors in animals, even at orally ineffective doses. some studies making use of the oral route have given rise to antidepressant-like effects in some behavioral despair paradigms. this reflects a considerable difference in methodology in which the parenteral exposure in neonates leads to much higher levels during critical windows of development. the oral administration in adults, on the other hand, suggests extensive gut metabolism and a restrictive blood-brain barrier (o’hara et al., 1977). different administration methodologies may mimic distinct etiologies of depression, suggesting a need for careful assessment of experimental protocol when interpreting and analyzing results. finally, various studies have consistently linked the monosodium glutamate-induced depressive-like and anxiety-like phenotypes. this portends that the pathophysiological and neurobiological impacts of monosodium glutamate encompass broader pathways involved in mood and anxiety disorders. furthermore, the mechanistic effects of monosodium glutamate are not depression-specific alone, especially in animal studies. hence, the monosodium glutamate model, already a veritable model of obesity for instance (bunyan et al., 1976), may be utilized to better understand the joint neurobiological influences that underly co-occurring psychiatric conditions or co-occurring metabolic and psychiatric conditions. evidence for monosodium glutamate-induced depressive-like behaviors in clinical models. a study by brandley et al., 2022, evaluating how much low glutamate affected anxiety, post-traumatic stress disorder (ptsd), and depression in veterans with gulf war illness, had some revealing results. the study reported that monosodium glutamate significantly worsened anxiogenic behavior in the most severe group, with no effect on depression or ptsd symptoms. it also postulated that a low glutamate diet may effectively manage depressive-like and anxiety-like symptoms, even though glutamate only directly caused symptoms in anxiety. underlying nutrient intake was also found to prevent negative psychiatric effects from glutamate exposure. furthermore, kumar et al., in a cross-sectional study in 2021, reported the correlation between dietary intake of glutamic acid and increased depressive symptoms among non-obese subjects with a schizophrenia spectrum disorder. there is a paucity of clinical and human-based studies on monosodium glutamate effects. hence, there is a need for large-scale clinical trials worldwide. specific neurobehavioral tests employed in msg depression models these tests typically measure behavioral parameters that could be extrapolated to human depressive symptoms, including anhedonia, behavioral despair, and changes in locomotor activity. · forced swim test (fst): it is a commonly utilized animal model to evaluate depressive-like behavior (slattery et al., 2012). here, the active swimming phase is juxtaposed with the passive immobile phase of rodents when they are forced to swim in a cylinder without any means of escape (slattery et al., 2012). it has its basis on the principle that when an animal is placed in an inescapable water environment, it floats with minimal movement to keep its head above water. this is a form of despair or helplessness. it is a widely accepted model for pre-screening antidepressant drugs. · tail suspension test (tst): this is used in screening products for possible antidepressant activity, and overall, it determines how depressive-like behaviors are manipulated. there is a suspension by the tail, thereby preventing rodents from holding on to surfaces or escaping. escape targeted behaviors are determined and recorded. like fst, it is invaluable for high-throughput screening of prospective antidepressant compounds (can et al., 2012). · sucrose preference/ splash test: anhedonia is the inability to experience pleasure from rewarding or enjoyable activities and is a core symptom of depression. this is a reward-based test used as an indicator of anhedonia (serchov et al., 2016). · contextual fear conditioning: it is used to evaluate anxiogenic behaviors, which often co-exist with depressive states. it evaluates an animal’s fear response to a specific context, which has been learned (rudy et al., 2004). · open field test: this test determines the general locomotor activity and anxiety-like behavior in rodents. in this test, the number of pecks and the space explored are predicted. in assessing behavior in the open field test, the constellation of behavioral signs should be taken into cognizance (perals et al., 2017). reduced locomotor activity likely indicates depressive-like states. table 1: key animal studies on msg-induced depressive-like behaviors (2010-present)[footnoteref:1] [1: kumar et al., 2021 involved human subjects, not animal models, for dietary correlation] study species/strain/model msg dose route of administration duration of administration relevant behavioral tests used key depressive-like and neurobiological findings 1) abdel moneim et al., 2018 2) abu-taweel et al., 2014 3) rosa et al., 2016 4) quines et al., 2014 5) umukoro et al 2015 6) biney et al., 2021 7) sriram et al., 2024 8) hamza et al., 2019 9) kardesler and baskale 2017 10) yang et al., 2020 11) salem et al., 2022 12) zhao et al., 2019 13) zhu et al., 2020 14) rodrigues et al., 2021 15) abdehamid et al., 2023 16) devaraj et al., 2020 17) fahmy et al., 2023 18) merispour et al., 2019 19) kumar et al., 2021 male albino rats male albino mice male and female wistar rats newborn wistar rats male swiss mice female inbred imprinting control region (icr) mice male wistar albino rats adult male rats neonatal male wistar rats newborn sprague drawley rats young wistar rats neonatal male wistar rats neonatal sprague-drawley rats male wistar rats male albino rats zebrafish male albino wistar rats two age groups of mice (4-5 weeks; 9-10 weeks) human schizophrenic subjects 1.66 g/kg/day 8 mg/kg msg together with aspartame 4 g/kg/day 4 g/kg/day 500 mg/kg 4 g/kg 500 mg/kg 6 or 17.5 mg/kg 50 mg/kg/day, 100 mg/kg/day and 200 mg/kg/day 4 mg/kg/day 0.4 g/kg 4 mg/g 4 mg/g 4 g/kg 600 mg/kg/day 100 mg/l 150 mg/l and 200 mg/l 2 mg/kg 2.5 g/kg and 5 g/kg dietary oral gavage orally in drinking water subcutaneous injection subcutaneous injection orally orally, in utero orally orally intraperitoneally subcutaneously oral subcutaneously subcutaneously subcutaneously orally orally oral gavage orally oral (dietary intake) thirty days one month 1st to 10th post-natal day 1st to 5th post-natal day daily for 21 days post natal day 43 21 days 30 days one day on one day off, eight times in total first five postnatal days 8 weeks alternate days after birth from day 2 to day 10 every two days for 10 days post natal day 60-76 28 days 14 days 10 days singled dose or repeated dosing for seven/fourteen days eight-arm radial maze spontaneous locomotor activity, elevated plus and contextual fear conditioning. forced swim test and spontaneous locomotor test forced swim test 8-arm radial maze setup open field test, sucrose preference test and forced swim test open field test open field test, forced swim test open field test, forced swim test. t-maze test forced swim test beck depression inventory scores decrease in brain serotonin in brain tissue as well as serum. increased total time taken to enter the food containing arms reduction in levels of brain neurotransmitters (dopamine and serotonin). increased serotonin and gaba uptake in rat’s hippocampus. increase in behavioral anxiety-like parameters in the behavioral tests. increased serotonin uptake. increased immobility time in the forced swim test. depressive-like behavior in the forced swim test. increased brain oxidative stress parameters increased expression of kcc2. effect on locomotion and depression-like behaviors, il-6 levels increased and bdnf levels downregulated reduction of catecholamine levels (dopamine, serotonin and norepinephrine). bdnf decreased at lower dose and increased at higher dose of msg. difference in catecholamine levels upregulation of caspase-1 and gsdmd mediated pyroptosis. reduced locomotor activities and increased anhedonia. increased glutamate, decreased brain monoamines, increased oxidative stress, decreased bdnf. decreased dopamine, gaba and serotonin levels. this was ameliorated by escitalopram. reduced locomotor activity decrease in bdnf/trkb pathway–dependent gr phosphorylation. increased immobility time in the fst after pretest. shorter time in centre increased immobility time. stimulation of na+/k+-atpase and ache in cerebral cortex and hippocampus reduced da and dopac; reduced 5-ht and 5-hiaa; reduced ne levels. increased oxidative stress decreased dopamine, norepinephrine and serotonin. increased glutamate. decreased gaba levels. increased response latency. reduced dopamine and serotonin receptors (s-2a). increased caspase-3. increased oxidative stress parameters increased immobility time in younger mice with single dose and repeated dosing. proportionality between dietary glutamate consumption and depressive symptoms in normal subjects. no link between dietary glutamate and bdi scores in obese patients. discussion this review reveals that there are important neurobiological mechanisms underlying msg-induced depression. these mechanisms usually involve a complex interplay including oxidative stress production and neuroinflammation, glutamatergic excitotoxicity, a deficit in the neurotransmitter system, and the metabolic/endocrine pathways. understanding the gut-brain axis communication is key to unraveling dietary impacts on depression. on oxidative stress and neuroinflammation, the administration of monosodium glutamate may cause a dose-dependent free radical production in the brain. this is indispensable in the neurogenerative process since the brain has a modest antioxidant system. upregulated oxidative stress markers, such as lactate dehydrogenase and malondialdehyde, and downregulated endogenous antioxidants such as catalase and glutathione-s transferase (gst) may accompany the administration of monosodium glutamate in rodents (hazzaa et al., 2020; adelakin et al., 2024; kesherwani et al., 2024). in the liver, monosodium glutamate may precipitate a buildup of ammonium ions and, consequently, free radicals. this combines with the prominent polyunsaturated fatty acids of the cell membrane, thereby causing further oxidative stress damage in the power house of the cell. this appears to cause geometric increase in the levels of monosodium glutamate, further enhancing neurotoxic effects. in a study by essawy et al., 2025, the impact on the polyunsaturated fatty acids, pufas, particularly in the brain, may be ameliorated by omega-3 polyunsaturated fatty acid administration. deficiencies in these fatty acids may result in behavioral changes and cognitive impairment. monosodium glutamate exposure has also been implicated in the induction of the hypothalamic pituitary adrenal (hpa) axis as well as the body’s stress response machinery (torrezan et al., 2019; atteia et al., 2024). this could potentiate systemic inflammatory response. neuroinflammation, a key component of the pathophysiology of depression, involves glial cell activation, dysregulation of the blood-brain barrier, and abnormal cytokine signaling. however, in a study reported by seo et al. (2010), long-term administration of monosodium glutamate under chronic variable stress of day-to-day life has led to inhibition of the hpa axis. dietary monosodium glutamate does not typically cause a proportionate increase in brain level of glutamate like it does in plasma (fernstrom 2018). therefore, there is a reduced possibility of the induction of profound histopathological alterations in the brain by lower and orally administered doses. monosodium glutamate usually gives the free glutamate, similar to the endogenous ones (seo et al., 2010). however, at high doses, the balance of glutamate/gaba is deranged giving rise to anxiety-like effects. furthermore, in neonatal rodents, the developing blood-brain barrier is less restrictive, thereby explaining the possibility of the potentiation of monosodium glutamate-induced excitotoxicity and depressant-like effect (nemeroff et al., 1978). some population might be at greater risk of significant monosodium glutamate adverse effects, despite its gras status. they may have monosodium glutamate symptom complex, pre-existing health conditions that directly affect monosodium glutamate metabolism, and potential interaction with other substances (kumar et al., 2021). certain stressful conditions with or without the administration of monosodium glutamate may cause excessive nmda receptor stimulation and result in depression from the disruption of the gut-brain axis. furthermore, on the effect on neurotransmitters, particularly monoamines, supraphysiological doses of monosodium glutamate have been associated with a downregulation of serotonin levels in the blood and the brain. many reports have linked high doses of monosodium glutamate with a considerable decline in brain and serum serotonin levels beyond depressant-like effects, to entrench memory dysfunction (rosa et al., 2016; abdel moneim et al., 2018). some studies have also found increased uptake of other monoamines like norepinephrine and dopamine (abu-taweel et al., 2014; hamza et al., 2019). the effect of monosodium glutamate on gaba and the glutamate/gaba balance has been nuanced. in a study by kardesler and baskale 2017, as monosodium glutamate dosage increased in neonatal rats, levels of gaba was reduced. glutamate levels also increased relative to the dosage. when monosodium glutamate plummets gaba levels, it can elicit an upregulation of dopamine levels since both gaba and dopamine have a modulating effect on each other in certain brain regions. specifically, gabaergic neurons inhibit dopamine release. an early 2000s hypothesis of the pathophysiology of depression that deals with the reduction of na+-k+ atpase expression and function also deserves a mention (de lores arnaiz and ordieres 2014). this reduction is induced by monosodium glutamate (quines et al., 2015). reduced na+k+ atpase activity affects mood disorders by manipulating neuronal excitability and neurotransmitter release. the metabolic and endocrine pathways may be intertwined, with the administration of monosodium glutamate eliciting effects that may affect their similar mechanistic pathway processes. the gut-brain axis and glutamatergic signaling could play crucial roles in depression. nutritional psychiatry emphasizes the two-way communication between the gut and the brain. monosodium glutamate, a significant model of obesity (nagata et al., 2006; bautista et al., 2019), may help elucidate the pathophysiological mechanisms of neurological disorders such as depression, which is increasingly associated with dietary modifications. first, monosodium glutamate has been linked to a significant perturbation in the hpa axis, which controls bodily stress response. secondly, monosodium glutamate levels in the hypothalamic or circumventricular region of the brain, which does not have a structured blood-brain barrier, could increase proportionally with plasma glutamate concentration from monosodium glutamate administration. hence, administration of supraphysiological doses of monosodium glutamate to neonatal rodents may cause neuronal necrosis of the hypothalamic sections of the brain, causing depressive-like symptoms (nemeroff et al., 1977; poon and cameron, 1978). reduced levels and hypoactivity of glutamate, as opposed to the excitotoxicity, have been linked to depression too (onaolapo and onaolapo 2021). high intake of monosodium glutamate, as a dietary factor, may modify the structure and composition of the gut microbiota. this may be from modifying the actions of certain probiotics and beneficial microorganisms that can release glutamate. recent evidence points to the involvement of this gut microbiota in the regulation of brain neurotransmitters such as gaba, glutamate, and the monoamines (strandwitz 2018; huang & wu 2021; dicks 2022). probiotics may influence gut-brain microbiome to affect some of the construct validity associated with clinical depression, such as anhedonia (onaolapo and onaolapo 2021). there is a critical need for the characterization of a depression-linked gut microbiome profile (du et al., 2020). furthermore, microbiome-targeted therapies need to be investigated more in clinical studies. figure 2: links between monosodium glutamate administration and depressive like behavior. depressive-like and neurotoxic symptoms mitochondrial toxicity calcium influx oversaturation of meagre brain antioxidant defense system lipid peroxidation and neuronal damage neuroinflammation and immune cell activation critical assessment of the msg model of depression several authors have defined a list of criteria of validity that focuses on human disease states, including depression. however, over the years, there has been a tilt towards the criteria of external validity, and less towards internal validity. internal validity imparts the design of the experiment: reproducibility, inter-observer reliability, randomization, etc. external validity, on the other hand, determines how the results of a study can be extrapolated to a general population, for instance, the feasibility and suitability of animal models of depression. (mckinney and bunney 1969). limitations of the review process/ included studies the current review is limited by the predominant inclusion of animal studies at the preclinical level. although they can offer valuable insights into the mechanistic pathways of depression, caution should be exercised in the direct interpretation and translation of findings to the complex human pathophysiology of depression. the use of supraphysiological doses beyond the usual human dietary intake levels contributes to this limitation. this is, however, in spite of a sufficient symptomatic or behavioral isomorphism in animal studies. in addition, as stated previously, the effects of oral monosodium glutamate can differ significantly from the parenteral route of administration. this suggests that the validity of the monosodium glutamate model of depression relies on the specific administration protocol, which brings about the pathophysiological effects. finally, there remains a paucity of clinical studies evaluating the direct effects of monosodium glutamate on depression. even the limited studies have been inconsistent. the predominantly short-term period of the included studies does not directly assess the chronic effects of monosodium glutamate. therefore, there is a need to assess the long-term impact (up to 90 days) of monosodium glutamate consumption in inducing depressive phenotypes, especially at lower doses. confounding factors supraphysiological doses of monosodium glutamate may cause a broad spectrum of neurotoxicity beyond specific depressive-like characteristics. these include neurodegeneration, memory impairment, aggressive behaviors, etc. this can confound the interpretation of monosodium glutamate as a specific model of depression, as observed depressive-like phenotype may be secondary to the neurotoxicity spectrum. in a similar vein, monosodium glutamate, particularly at high doses, may be linked with a range of metabolic disorders such as impaired glucose tolerance, obesity, and liver damage (adeleke et al., 2022; abdou et al., 2025). these co-morbidities may complicate the depressive phenotypes since they are established risk factors for depression. there is a need for further research into the alignment of metabolic and neuropsychiatric disorders, and monosodium glutamate may be a very efficient biochemical tool to study this comorbidity. conclusion and future directions these recent studies provide significant preclinical evidence that supraphysiological doses and/or the parenteral route of monosodium glutamate can consistently induce depressive-like phenotypes in animal models. the neurobiological mechanisms include oxidative stress and neuroinflammation; glutamate excitotoxicity; neurotransmitter system dysfunction, etc. the involvement of the gut-brain axis and its increasing understanding point to the fact that changes in the gut microbiota due to the effect of dietary glutamate may affect mood disorders by affecting neurotransmitter 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nerve in a rat model of attention deficit-hyperactivity disorder. brain research, 1690, 40-50. https://doi.org/10.1016/j.brainres.2018.04.006 obayashi, y., & nagamura, y. 2016. does monosodium glutamate really cause headache?: a systematic review of human studies. the journal of headache and pain, 17(1), 54. https://link.springer.com/article/10.1186/s10194-016-0639-4 o'hara, y., iwata, s., ichimura, m., & sasaoka, m. 1977. effect of administration routes of monosodium glutamate on plasma glutamate levels in infant, weanling and adult mice. the journal of toxicological sciences, 2(3), 281-290. https://doi.org/10.2131/jts.2.281 onaolapo, a. y., & onaolapo, o. j. 2021. glutamate and depression: reflecting a deepening knowledge of the gut and brain effects of a ubiquitous molecule. world journal of psychiatry, 11(7), 297. https://pmc.ncbi.nlm.nih.gov/articles/pmc8311508/ perals, d., griffin, a.s., bartomeus, i. & sol, d. 2017. revisiting the open-field test : what does it really tell us about animal personality. animal behavior, volume 123, 69-79. https://doi.org/10.1016/j.anbehav.2016.10.006 poon, t. k., & cameron, d. p. 1978. measurement of oxygen consumption and locomotor activity in monosodium glutamate-induced obesity. american journal of physiology-endocrinology and metabolism, 234(5),e532. https://journals.physiology.org/doi/abs/10.1152/ajpendo.1978.234.5.e532 quines, c. b., rosa, s. g., da rocha, j. t., gai, b. m., bortolatto, c. f., duarte, m. m. m., & nogueira, c. w. 2014. monosodium glutamate, a food additive, induces depressive-like and anxiogenic-like behaviors in young rats. life sciences, 107(1-2), 27-31. https://doi.org/10.1016/j.lfs.2014.04.032 rivera‐cervantes, m. c., torres, j. s., feria‐velasco, a., armendariz‐borunda, j., & beas‐zárate, c. 2004. nmda and ampa receptor expression and cortical neuronal death are associated with p38 in glutamate‐induced excitotoxicity in vivo. journal of neuroscience research, 76(5), 678-687. 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glutamate under chronic variable stress impaired hypothalamic-pituitary-adrenal axis function in rats. the korean journal of physiology & pharmacology: official journal of the korean physiological society and the korean society of pharmacology, 14(4), 213. https://synapse.koreamed.org/doix.php?id=10.4196/kjpp.2010.14.4.213 serchov, t., calker, v.d. & biber, k. 2016. sucrose preference test to measure anhedonic behavior in mice. bio-protocol 6(19), e1958e1958. https://bio-protocol.org/epdf/1958 servant, g., & frerot, e. 2021. pharmacology of the umami taste receptor. in the pharmacology of taste (pp. 109-136). cham: springer international publishing. https://link.springer.com/chapter/10.1007/164_2021_439 slattery, a.d. & cryan, f.j. 2012. using the rat forced swim test to assess antidepressant-like activity in rodents. nature protocols 7(6), 1009-1014. https://www.nature.com/articles/nprot.2012.044 sriram, b. s., shilpa, m., & venkatesh, k. m. 2024. effects of polyunsaturated fatty 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https://onlinelibrary.wiley.com/doi/abs/10.1111/jne.12717. umukoro, s., oluwole, g. o., olamijowon, h. e., omogbiya, a. i., & eduviere, a. t. 2015. effect of monosodium glutamate on behavioral phenotypes, biomarkers of oxidative stress in brain tissues and liver enzymes in mice. world journal of neuroscience, 5(5), 339-349. http://dx.doi.org/10.4236/wjns.2015.55033 uneyama, h., niijima, a., san gabriel, a., & torii, k. 2006. luminal amino acid sensing in the rat gastric mucosa. american journal of physiology-gastrointestinal and liver physiology, 291(6), g1163-g1170. https://doi.org/10.1152/ajpgi.00587.2005 us fda 2012. https://www.fda.gov/food/food-additives-petitions/questions-and-answers-monosodium-glutamate-msg. accessed august 7, 2025. wijayasekara, k., & wansapala, j. 2017. uses, effects and properties of monosodium glutamate (msg) on food & nutrition. international journal of food science and nutrition, 2(3), 132-143. https://www.researchgate.net/profile/kaushalya-wijayasekara/publication/351634601_uses_effects_and_properties_of_monosodium_glutamate_msg_on_food_nutrition/links/60a29dcc92851c186a62cc35/uses-effects-and-properties-of-monosodium-glutamate-msg-on-food-nutrition.pdf world health organization. https://www.who.int/news-room/fact-sheets/detail/depression. date accessed: august 7, 2025. xhima, k., weber-adrian, d., & silburt, j. 2016. glutamate induces blood–brain barrier permeability through activation of n-methyl-d-aspartate receptors. journal of neuroscience, 36(49), 12296-12298. https://doi.org/10.1523/jneurosci.2962-16.2016 xiao, d., zeng, l., yao, k., kong, x., wu, g., & yin, y. 2016. the glutamine-alpha-ketoglutarate (akg) metabolism and its nutritional implications. amino acids, 48(9), 2067-2080. https://link.springer.com/article/10.1007/s00726-016-2254-8 yang, f., zhu, w., cai, x. et al., 2020. minocycline alleviates nlrp3 inflammasome-dependent pyroptosis in monosodium glutamate-induced depressive rats. biochemical and biophysical research communications, 526(3), 553-559. https://doi.org/10.1016/j.bbrc.2020.02.149 zhao, b. b., chen, l. l., long, q. h. et al., 2019. preventive effects of escitalopram against anxiety-like depressive behaviors in monosodium glutamate-treated rats subjected to partial hepatectomy. frontiers in psychology, 10, 464138. https://doi.org/10.3389/fpsyg.2019.02462 zhou, y., & danbolt, n. c. 2014. glutamate as a neurotransmitter in the healthy brain. journal of neural transmission, 121(8), 799-817. https://link.springer.com/article/10.1007/s00702-014-1180-8 zhu, w., yang, f., cai, x. et al., 2021. role of glucocorticoid receptor phosphorylation-mediated synaptic plasticity in anxiogenic and depressive behaviors induced by monosodium glutamate. naunyn-schmiedeberg's archives of pharmacology, 394(1), 151-164. https://link.springer.com/article/10.1007/s00210-020-01845-x. high doses of msg and/or parenteral route build up of ammonium ions in metabolic organs exacerbation of metabolic disorders accumulation of ros accumulation of glutamate and overstimulation of glutamate receptors depression deficits in monoamine levels deranged hpa axis/ stress response abnormal glutamate transmission and others brain structure dysfunction and neurotrophic factor dysregulation 2 annals of psychophysiology volume 13 december 2025 about the annals of psychophysiology the annals of psychophysiology (app) is the semi-annual journal of the behavioral medicine research and training foundation which provides all funding to support the journal. issues are usually published in june and december. the journal is published in cooperation with pakistan’s advance educational institute and research center (aeirc) which published the journal from its inception in 2014 until 2024 and continues to provide technical support for preparing manuscripts for publication. the app provides a platform for scientific contributions on all aspects of psychophysiology with emphasis on the psychophysiology of health and disease with sub-themes covering environmental and sports psychophysiology. articles include current reviews of various aspects of the field, original research, and editorials. the online issn is 2412-3188 while the print issn is 2410-1354. app is an open-access journal committed to maintaining high standards through rigorous peer review. the journal does not charge authors any fees for publication. information about the foundation and the courses it offers centering on behavioral medicine and biofeedback can be found by following this link: https://www.behavmedfoundation.org the journal is actively soliciting original research and reviews of current research in psychophysiology. please go to our website https://annalsofpsychophysiology.org for lots of information about the journal, its policies, and instructions for submitting manuscripts. please take a few moments to look at the foundation’s courses! the behavioral medicine r&t foundation supports this journal by selling courses to clinicians, coaches, educators, military, and lots of others who are interested in optimal functioning and behavioral medicine. click here to see our courses: https://www.behavmedfoundation.org editor-in-chief richard a. sherman, ph.d., usa associate editors eric willmarth, ph.d. usa cynthia r. kerson, ph.d., ph.d., usa john graham, md, dd, ph.d., usa jerry r. devore, ph.d., usa editorial board – each individual bio sketch and academic information is listed on our website https://annalsofpsychophysiology.org 28 annals of applied psychophysiology june 2025 volume 12 a systematic review: manipulation vs. mobilization for mechanical neck pain bushra madad ali malik1, shamoon noushad2, khansa sheikh1, ayesha rayyan1, saman riaz1, & basit ansari1 1department of health, physical education and sports sciences, university of karachi 2advance educational institute and research center corresponding author: bushramadadalimalik@gmail.com published online: june 2025 © the author(s) 2025 abstract objectives: to identify the efficacy of manipulation and mobilization in managing mechanical neck pain (mnp), based on their effects on pain reduction, range of motion (rom), and functional improvement, and to assess their relative benefits in guiding clinical practice. methods: a systematic review was conducted using five databases (pubmed, google scholar, pedro, cochrane library, and cinahl) to identify randomized controlled trials (rcts) and pilot rcts published between 2009 and 2024. studies involving adult participants with mnp were included, emphasizing interventions like manipulation, mobilization, and snags. the quality of studies was evaluated using the physiotherapy evidence database (pedro) scale and cochrane rob 2.0 framework, with data extracted on outcomes including pain intensity, rom, and functional improvements. a narrative synthesis was performed due to heterogeneity among the studies. results: twelve studies met the inclusion criteria, with pedro scores ranging from 6 to 9, indicating fair to high quality. both manipulation and mobilization significantly improved pain and rom in the short term, with no clear superiority of one intervention over the other. thoracic manipulation often yielded better immediate and short-term outcomes than cervical mobilization. snags and manipulation demonstrated comparable efficacy in improving cervical rom and reducing pain. however, limitations such as small sample sizes, variable methodologies, and short follow-up periods restricted the strength of conclusions. conclusion: while both manipulation and mobilization are effective for managing mnp, variability in techniques and study designs precludes definitive recommendations. thoracic manipulation may offer additional benefits for immediate pain relief, but further research is needed to establish long-term efficacy, standardized protocols, and integration with other therapeutic modalities. the findings underscore the need for multicentre trials with robust methodologies to refine clinical guidelines for mnp management. keywords: thrust manipulation, non-thrust, manipulation, mobilization, snags, mechanical neck pain, systematic review, pain reduction, range of motion (rom) mailto:bushramadadalimalik@gmail.com introduction neck discomfort is a prevalent and often debilitating condition that significantly contributes to self-reported pain, disability, and the global burden on individuals and healthcare systems.1 it is the fourth most common cause of disability among the general population.2,3,4,5 estimates suggest that 20–70% of people will experience neck pain at some point in their lives,2,3,4,6,7,8,9,10,11 and up to 60% of patients report chronic pain persisting five years after the onset of symptoms.6 neck pain is most commonly observed during the fourth to fifth decades of life and its incidence increases with age.7 the root cause of neck pain rarely originates from a single anatomical structure. instead, they often involve multiple contributing factors.3 nonspecific neck pain is defined as neck discomfort that worsens with cervical motion. as most neck pain is mechanical in nature, it is typically impossible to pinpoint a single cause.5 mechanical neck pain (mnp) is one of the most prevalent musculoskeletal conditions, affecting 30%–50% of the general population and workers. repeated neck movements and prolonged neck postures can cause neck pain, which is a hallmark of mnp.8 several painsensitive structures, such as the zygapophyseal joints, ligaments, muscles, uncovertebral joints, intervertebral discs, and neural tissues surrounding the cervical spine, can cause mechanical neck pain. mechanical dysfunction of the cervical spine can lead to decreased neck mobility.9 one of the main characteristics of patients with mnp is the impairment of cervical proprioception, which results in abnormalities in cervical sensorimotor control, which in turn affects balance and postural control. patients with mnp have also been found to exhibit changes in dynamic scapular stabilization, including protracted acromions and scapulae.8 neurological impairments referred or radiating pain into the upper extremities, or headaches of cervical origin known as cervicogenic headaches can all accompany neck pain; however, these symptoms are frequently neglected when discussing mechanical neck pain. with headaches and referred or radiating pain into the upper extremities falling into different categories, the current physical therapy clinical practice guidelines for neck pain have divided the clinical findings of patients presenting with neck pain into distinct groups. patients with mechanical neck pain may react differently to physical therapy procedures, particularly manipulation and mobilizations, and those who experience headaches and/or radiating pain.6 this systematic review focused on mechanical neck discomfort to exclude radiculopathy and cervicogenic headache. mechanical neck pain is a prevalent symptom that is frequently treated conservatively during outpatient physical therapy.6 physical therapists use a range of techniques to treat neck discomfort, including mobilization, therapeutic exercises, thrust manipulation, and modalities.9 manual therapy is a popular intervention for increasing range of motion, enhancing tissue extensibility, and reducing pain.6 manipulation and mobilization are techniques that use skilful passive movements applied to the soft tissues and joints at different amplitudes and speeds.6 studies showing the cost-effectiveness of manual therapy for neck discomfort emphasize the necessity for efficient therapies to avoid chronic pain and impairment.2 neck and musculoskeletal pain can be relieved by manual cervical spinal mobilization (csmobs) and manipulation (csms). through neurophysiological, mechanical, and biochemical effects, csms employ high-velocity, lowamplitude thrusts to enhance joint, muscle, and nerve function, whereas csmobs apply nonthrust oscillatory movements to the spine. the expectations of the patient and psychological variables may also affect the treatment results.2 although there is insufficient information to support clinical decision-making, evidence-based practice recommendations suggest that for mechanical neck discomfort, manual treatment and therapeutic exercises should be combined.7 studies have demonstrated that both thrust and non-thrust cervical spine manipulations can improve function, increase range of motion, and reduce pain. the results of these procedures are similar. reducing discomfort and increasing cervical spine range of motion are the main objectives of treatment.7,10 recently, there has been an increasing interest in thoracic spine manual therapy as an adjunct to traditional cervical spine treatments. this approach is based on the conceptual model of regional interdependence, which suggests that thoracic spine dysfunction can influence cervical spine mechanics and contribute to neck pain. furthermore, neurophysiological effects such as pain modulation and improved mobility provide additional theoretical support for this intervention.6 several studies have explored the efficacy of manual thoracic and cervicothoracic therapies. masaracchio et al.7 demonstrated that combining thoracic thrust manipulation with cervical non-thrust manipulation and exercise leads to better short-term outcomes in terms of pain intensity, disability indices, and perceived recovery.7 similarly; dunning jr. et al.11 found that a combination of upper cervical and thoracic thrust manipulations was more effective than non-thrust mobilization for the short-term relief of mechanical neck pain.11 however, griswold d12 found in his study equivalent outcomes for both the groups (thrust manipulation vs non thrust manipulation) leading to question which technique is better than other.12 loreto et al.2 also highlighted the potential of a single session of skilled manual therapy to reduce acute neck pain and disability, showing promise for non-specific mechanical neck pain.2 the cervicothoracic (ct) junction, a critical link between the cervical and thoracic spine, has also been the focus of research.3,4 stiffness in this region contributes to neck pain and its associated symptoms.4 while joshi et al.4’s study comparing ct junction-specific mobilization and mid-thoracic manipulation found no significant superiority of the former,4 similar results were observed in a randomized clinical trial conducted by saddique et al.3 in pakistan. both studies concluded that mid-thoracic manipulation and ct junction mobilization had comparable effects on the cervical range of motion and pain relief.3,4 additionally, mobilization with movement such as mulligan snags (sustained natural apophyseal glides) have shown promise.8,10 sodany et al.10 reported that snags combined with exercise were more effective than exercises alone in managing cervical spine disorders.10 saleh et al.8’s findings further supported that adding mulligan snags to conventional physiotherapy improved pain intensity, proprioception, and scapular function more significantly than conventional therapy alone.8 although mulligan mobilization use different biomechanics from classical maitland mobilizations, both involve non-thrust oscillatory movements of the spine. while mulligan snags involve sustained accessory glides during active movement versus passive oscillatory techniques in maitland—they both fall under non-thrust manual therapy techniques.8,13 a study by izquierdo pérez, h. directly compared the efficacy of these three techniques of manual therapy including hvla thrust, maitland mobilization and mulligan’s snag.13 despite these advances, the relative efficacy of mobilization versus manipulation for mechanical neck pain remains controversial. although these techniques have demonstrated benefits, there is a need for a comprehensive comparison between all three manual therapy techniques applied at both the cervical and thoracic spine to guide sound clinical decisionmaking. therefore, for the purpose of this review, studies comparing snags are grouped within the mobilization/ non-thrust category, with subgroup analysis and interpretation under ‘mobilization with movement’ category accounting for their mechanical differences. this systematic review sought to evaluate and synthesize the available evidence, provide clarity on the effectiveness of these interventions, and inform best practices in mechanical neck pain management. methodology data sources and searches this systematic review followed prisma guidelines ensuring transparency in methods and reporting. a comprehensive literature search was conducted to evaluate the comparative efficacy of mobilizations (without and with movement including snags) and manipulation in the treatment of mechanical neck pain. the search was carried out by three independent reviewers from november 2024 to january 2025. five electronic databases were systematically searched: ncbi-pubmed, google scholar, pedro, cochrane library and cinahl (cumulative index to nursing and allied health literature). there were limitations on study design as we select rcts and the search was restricted to studies published in english from 2009 to 2024. boolean operators were used to structure the search strategy, with search strings tailored to each database. a typical search included combinations such as: ("mobilization" or "non-thrust" or "snags") and ("manipulation" or "thrust") and ("mechanical neck pain" or "cervical spine" or "thoracic spine"). study selection as part of the study selection process, interventions were grouped into three categories for comparison: (1) traditional mobilization techniques, (2) mobilization with movement (snags), and (3) high-velocity low-amplitude thrust/ manipulation. this allowed for analysis of treatment effect heterogeneity and helped prevent conflation of fundamentally different manual therapy approaches. studies were included in this systematic review based on the following inclusion criteria: inclusion criteria • only randomized controlled trials (rcts), including pilot rcts with a clearly defined control group, were included. studies needed to directly compare manual mobilization techniques (with or without movement, including snags) with spinal manipulation interventions in adult patients with a confirmed diagnosis of mechanical neck pain. • studies involving adult participants diagnosed with mechanical neck pain. • studies reporting primary outcomes such as pain reduction, range of motion (rom), and functional improvement. • studies published in english and available as full-text pdfs. exclusion criteria studies were excluded based on the following exclusion criteria: • non-randomized trials, observational studies, and case reports. • studies focused on conditions other than mechanical neck pain, such as radiculopathy, cervicogenic headache or whiplash. • studies that did not compare mobilizations (without or with movement including snags) with manipulation interventions. • non-peer-reviewed articles or studies with insufficient data for outcome analysis. discrepancies in study selection were resolved through discussion and consensus. data extraction data were extracted independently by three reviewers using a pre-designed standardized extraction form, which included study identifiers, participant demographics, intervention protocols (frequency, duration, techniques), outcome measures (pain, rom, function), follow-up intervals, and statistical findings. discrepancies were resolved by consensus or consultation with a fourth reviewer. quality assessment to ensure a comprehensive and robust evaluation of the methodological quality of studies included in this systematic review, a dual framework combining the physiotherapy evidence database (pedro) scale was employed, and the cochrane risk of bias 2.0 (rob 2.0) tool was used to assess bias across five domains for each included rct. this integrative method allowed for a nuanced assessment of both the internal validity of individual studies and the overall strength of evidence. the pedro scale the pedro scale was selected as a primary tool for evaluating the methodological rigor of randomized controlled trials (rcts). developed as a standardized checklist, the pedro scale has been widely adopted in clinical research for its reliability and validity in assessing both internal and external validity.14,15 comprising 11 criteria, the first item addresses external validity, while the remaining 10 focus on internal validity aspects such as randomization, allocation concealment, and blinding. for this review, the external validity item was excluded from scoring, as the focus was primarily on internal validity, in line with established practices in systematic reviews16. studies scoring between 7 and 10 were classified as high quality, scores between 5 and 6 indicated fair quality, and scores ≤4 were categorized as poor quality17. of the twelve studies included in this review, eight had pre-existing, peer-reviewed pedro scores. these were independently verified for accuracy and consistency by two reviewers. one study was found to have conflicting pre-existing score due to mentioning no blindness of assessors whereas; it was found that outcome assessor was blinded in the study. hence, the score was upgraded from 7 to 8/10.12 for the four studies without prior pedro scores, three independent reviewers conducted assessments, resolving any discrepancies through discussion and consensus (table 1). the reliability of pedro scores has been consistently reported as "fair to excellent" across diverse contexts, further justifying its use in this review18. table 1. pedro scoring of included studies reference 2 3 4 5 6 7 8 9 10 11 total score study quality salom et al.19 y y y n n y y n y y 7 high cleland ja et al.20 y y y n n n y y y y 7 high dunning jr et al.11 y y y n n y y y y y 8 high griswold d et al.12 y y y n n y y y y y 8 high saddique et al.3 y y y n n n y n y y 6 fair joshi et al.4 y y y n n y y n y y 7 high mastracchio et al.7 y y y n n n y y y y 7 high suvarnnato et al.9 y y y n n y y n y y 7 high loreto et al.2 y n y y n n y n y y 6 fair saleh et al.8 y y y n n y y n y y 7 high sodany et al.10 y n y y n y n n y y 6 fair izquierdo pérez h et al.13 y y y y n y y y y y 9 high total of ‘yes’ scores 12 10 12 3 0 8 11 5 12 12 % of ‘yes’ per criterion 100% 83% 100% 25% 0% 67% 92% 42% 100% 100% score average 7.08 high standard deviation 0.90 y5 criterion satisfied; n5 criterion not satisfied. 2. subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an order in which treatments were received). 3. allocation was concealed. 4. the groups were similar at baseline regarding the most important prognostic indicators. 5. there was blinding of all subjects. 6. there was blinding of all therapists who administered the therapy. 7. there was blinding of all assessors who measured at least one key outcome. 8. measurements of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups. 9. all subjects for whom outcome measurements were available received the treatment or control condition as allocated, or where this was not the case, data for at least one key outcome were analysed by ‘intention to treat’. 10. the results of between-group statistical comparisons are reported for at least one key outcome. 11. the study provides both point measurements and measurements of variability for at least one key outcome. the risk of bias assessment in addition to the pedro scale, the cochrane risk of bias 2.0 (rob 2.0) tool was also applied to assess the quality of the included randomized controlled trials across five domains: randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result (table 2). each domain is assessed based on series of question leading to hierarchical judgment i.e., low risk of bias, some concerns and high risk of bias, which in turn leads to an overall risk-of-bias judgment of the study.21 table 2. risk of bias (rob 2.0) assessment of included studies study pedro score randomi zation process deviations from intended interventi ons missing outcome data measure ment of the outcome selection of the reported result overall rob salommoreno et al.19 7/10 low risk high risk low risk low risk low risk high risk cleland ja et al.20 7/10 low risk high risk low risk high risk low risk high risk dunning jr et al.11 8/10 low risk high risk low risk low risk low risk high risk griswold d et al.12 8/10 low risk high risk low risk low risk low risk high risk saddique et al.3 6/10 low risk high risk low risk high risk some concerns high risk joshi et al.4 7/10 low risk high risk low risk low risk some concerns high risk masaracchi o et al.7 7/10 low risk high risk low risk high risk low risk high risk suvarnnato et al.9 7/10 low risk high risk low risk low risk some concerns high risk loreto et al.2 6/10 some concerns high risk low risk high risk low risk high risk saleh et al.8 7/10 low risk high risk low risk low risk some concerns high risk el-sodany et al.10 6/10 some concerns high risk some concerns low risk some concerns high risk izquierdo pérez h et al.13 9/10 low risk some concerns low risk low risk low risk some concerns data synthesis given the variability in study designs, outcome measures, and intervention protocols, a narrative synthesis approach was used to compare the results of the included studies. this synthesis focused on the comparative efficacy of mobilization (including snags) versus manipulation for key outcomes such as pain reduction, rom, and functional improvement. due to high heterogeneity in study design, outcome measures, and follow-up durations, metaanalysis was not conducted. however, effect sizes (cohen’s d) were calculated for key outcomes such as pain, disability, and rom where data permitted. table x summarizes these between-group differences with 95% confidence intervals. the prisma flow diagram (fig. 1), which describes the study's identification procedure, abstract screening results, and full-text eligibility assessments, including the rationale for exclusions, was followed in the data synthesis. in the end, twelve articles fulfilled the eligibility criteria for full-text evaluation. fig. (1): prisma diagram. evidences iden*fied on databases with (mobiliza*on and manipula*on) and (cervical or thoracic) and (mechanical neck pain) (n= 1633) sc re en in g in cl u d ed el ig ib il it y id en ti fi ca ti o n records iden+fied through databases searching n= 1848 evidences a:er removing duplicates (n = 130 ) full text ar+cles screened to be included (from 2009-2025 and in english) (n = 1321) records assessed for inclusion based on eligibility criteria (n=171) evalua+on of full text ar+cles based on +tle or abstract (n =23 ) excluded full-text ar+cles based on eligibility criteria (n = 1150) not rcts or pilot rct (n = 1117) not adult popula+on (n = 33) studies included in qualita+ve analysis (narra+ve) n = 12 records excluded based on +tle or abstract (n= 148) evidences excluded with reasons (n = 11) not comparing mobiliza+on with manipula+on directly (n=10) non-randomized secondary analysis (n=1) evidences iden*fied on databases with (manipula*on and snag) and (cervical or thoracic) and (mechanical neck pain) (n = 135) evidences iden*fied on databases with (thrust and non-thrust) and (cervical or thoracic) and (mechanical neck pain) (n = 80) records excluded (n = 527) records screened (n = 1848) result a total of 23 studies were identified for potential inclusion. after reviewing the abstracts, only 12 met the inclusion criteria (fig. 1). ten of the included studies were randomized controlled trials.2,3,7,8,10,11,12,13,19,20 the remaining two studies were randomized controlled trial (rct) pilot studies.4,9 the twelve studies included a mixed population of men and women. all patients were diagnosed with mechanical neck pain. each patient had varying symptom durations and ages, ranging from 18 to 70 years. twelve different outcome measures were used in the 12 studies reviewed. the two most commonly used outcome measures in the included studies were the nprs2,3,4,7,11,12,20,19 and ndi.2,7,10,11,12,13,20 physical impairment of cervical rom was measured post-intervention in five studies.3,4,9,10,13 all these have been shown to be reliable measures of clinical improvement. follow-up times ranged from immediately post-intervention to 3 months after treatment. (table 3) methodological quality assessment the pedro scores of each study are listed in table 1. the scores of the included studies ranged from 6 to 9 with a mean score of 7.08 (sd 0.90), indicating that the average quality of the included studies was high. based on pedro scoring (table 1), nine studies were classified as high quality (scores ≥7), while three studies scored between 5 and 6 and were classified as fair quality. the cutoff thresholds followed the convention used in recent reviews to ensure comparability. four pedro criteria were observed in all of the included studies: random allocation, baseline comparability, between-group statistical comparisons, and reporting of point measures and variability.2,3,4,7,9,11,12,13,20 only three met criterion five regarding the blinding of subjects.2,10,13 while, eight studies reported blinding of the assessor who measured outcomes pre and post intervention.4,8,9,10,11,12,13,19 due to the nature of manual therapy interventions, blinding of treating clinicians was not feasible in any study. this inherent limitation should be considered when interpreting outcomes involving subjective measures like pain or disability. the risk of bias assessment (rob 2.0) for each study is mentioned in table 2. only one study (izquierdo pérez h et al.13) was judged to have overall some concerns of rob and rest of eleven studies have overall high rob. as all the studies involved different interventions of manual therapy delivered by the therapist and being distinguishable from each other, there was lack of therapist blindness in all studies leading to therapist bias. another factor of domain 2 being high risk of bias in all studies except one (with some concerns) was that primary outcome measures were subjectiveself-reported pain and disability in almost all studies making it highly susceptible to bias specially when either the participants or the assessors are not blinded. these findings highlight the methodological variability across studies and emphasize the need for cautious interpretation of their results. mobilization vs manipulation six studies3,4,11,12,19,20 were found to directly compare manipulation with mobilization. the sample sizes ranged from 362 to 10710 patients. salom-moreno, j. et al.19 (pedro score=7), cleland, j. a. et al.20 (pedro score=7) and dunning j.r. et al.11 (pedro score=8) demonstrated that manipulation group showed statistically significant greater reduction in neck pain and disability, follow-ups ranging from immediately post-intervention (for neck pain p<0.001, between-group mean difference: 1.4; 95% confidence interval, 0.8-2.1)), 19 2-4 days on initial intervention and examination (reductions in disability p<0.001, between-group difference of 10% (95% confidence interval [ci]=5.3-14.7) and in pain p<.001, betweengroup difference of 2.0 (95% ci=1.4-2.7))20, and up to 48-hours after the initial examination (for disability p<0.001, between-group mean change (8.0 points [95% ci: 5.9, 10.2]) and for pain p<.001, between-group mean reduction (2.0 [95% ci: 1.5, 2.5]))11. whereas joshi et al.4 (pedro score=7) and saddique et al.3 (pedro score=6) demonstrated no statistically significant differences between the groups in post-treatment rom or pain at immediate follow-ups ( for pain p>0.05, mean difference − 0.12 (− 0.9–0.6), 95% ci,4 p>0.05 between group difference 2.1 (1.7, 2.8), 95% ci)3 however, within-group, pre, and post comparison showed significant improvements in cervical rom and pain in both groups (p<0.01, mean difference = 1.19 for mobilization group, p<0.01, mean difference = 1.28 for manipulation group)4 and (p<0.01, 3.0 (2.5, 3.5) manipulation group, p<0.01, 1.2 (0.7, 1.2) mobilization group)3. another study by griswold, d. et al.12 (pedro score=8) also stated similar results where between-group analyses of ntm or tm revealed no significant differences in outcomes on the ndi (p = .67, between group difference 0.47 (–2.7, 1.7)), psfs (p= .26), nprs (p = .25, between group difference 0.20 (–0.15, 0.55)), dcf (p = .98), groc (p = .77), number of visits (p = .21), and duration of care (p = .61). within group analysis showed significant difference for disability ndi, (difference estimate, 17.39; 95% confidence interval [ci]: 4.5, 20.1; p<.001) and pain nprs (difference estimate, 3.00; 95% ci: 0.769, 3.45; p<.001).12 one study also compared mobilization with added manipulation along with active crom. mastracchio et al.7 (pedro score=7) compared manipulation along with mobilization and cervical arom exercises with mobilization and cervical arom exercises in 66 patients. the study demonstrated significantly greater improvements in both the nprs and ndi at the 1-week follow-up for the 33 patients in the manipulation group (p<0.001) between-group difference of 1.3 points (95% confidence interval [ci]: 0.7, 2.0) on the nprs and 8.8% (95% ci: 5.4%, 12.2%) on the ndi.7 two studies compared mobilization with manipulation alongside a control group.2,9 suvarnnato et al.9 (pedro score=7) compared manipulation with mobilization and a control group not receiving any compressive pressure on joints in 39 patients with 13 subjects in each group. both manipulation and mobilization showed significant reductions in vas pain ratings and increases in crom at the immediate and 24-hour follow-ups (p<0.05) compared to the control group. but no significant improvement in crom and pain between mobilization and manipulation group was found (for vas p>0.05, mean difference (95% ci) –1.94 (–11.72– 7.84)).9 loreto et al.2 (pedro score=6) compared manipulation with mobilization and a control group of 36 patients. the manipulation group showed a significant increase in groc (p=0.025) over time compared to the mobilization and control groups (p = 0.472 and p = 0.176, respectively). there was a significant decrease in nprs in the manipulation and mobilization groups (p<0.002 and p<0.001, respectively) and a non-significant decrease in nprs (p=0.642) in the control group. similarly, there was a significant decrease in ndi for the manipulation and mobilization groups (p<0.001 and p<0.001) and a non-significant decrease in ndi (p=0.084) in the control group at immediate to 4 days post corresponding intervention.2 mobilization with movement/ snags vs manipulation saleh et al.8 (pedro score=7) and sodany et al.10 (pedro score=6) utilized manipulation compared to mobilization (snags) and conventional physical therapy (cpt) which includes isometric, stretching and stabilization exercises of neck. the sample sizes were 608 and 4210. both the manipulation and snags groups showed significantly better outcomes than the cpt group (p<0.05, p<0.05)8,10; however, there were no significant differences between the manipulation and snags groups (p>0.05, p>0.05) at follow-ups ranging from immediately post-intervention to one month duration. however, in saleh’s study significant reduction in pain was found in snag group compared to thoracic manipulation and cpt group and in thoracic manipulation group compared to cpt group using vas (p value<0.05, between snag vs tm: md (95% ci) -5 (-9.77, -0.22), snag vs cpt: md (95% ci) -10.75 (-15.52, 5.97), and tm vs cpt: md (95% ci) -5.75 (-10.52, -0.97)) mobilization vs snags vs manipulation the only study that compared all three manual therapy interventions was conducted by izquierdo pérez h et al.13 with highest pedro score of all (pedro score=9). total of 61 patients were randomized into three groups with 19 in hvla thrust group and 21 each in snag and mobilization group. the study concluded no long-term significant differences between groups in outcome with assessment performed 5 times including before intervention, immediate after intervention and follow up until 3 months post intervention. there was significant reduction in pain across all groups but no significant difference between groups was found using vas (follow up after 3 months, p > 0.05, mean ± sd (95%ic) hvla group: 1.0 ± 1.7 (0.3-1.8), mob group: 0.6 ± 1.1(-0.1-1.3), snag group: 1.2 ± 1.9 (0.5-1.9). table 3. study characteristics article contro l group experim ental group interventi on frequen cy assessm ent postintervent ion followup results mobilization vs manipulation salommoreno et al.19 none group:1 thoracic manipula tion n=27; group:2 thoracic mobilizat ion n=25 group:1 highvelocity, end-range, anteriorposterior thrust (t3t6, max 2 attempts); group:2 20-second bouts of grades iiiiv central posterioranterior non-thrust mobilizati on (t3-t6) one time treatmen t after initial evaluati on pressure pain threshold s (ppts); 11-point numeric al pain rate scale (nprs) immedia te no significan t differenc e in ppt between groups. thoracic manipulat ion group showed significan tly greater reduction in neck pain. cleland ja et al.20 none group 1: non thrust mobilizat ion n=30 group 2: thrust mobilizat ion/ manipula tion n=30 group 1: 30-second bouts of grades iiiiv central posterioranterior non-thrust mobilizati on (t1-t6) + general cervical mobility exercises. group 2: highvelocity, lowamplitude anteriorposterior thrust upper thoracic (t1-t4), one time treatmen t after initial evaluati on ndi (neck disabilit y index), nprs, groc scale (global rating of change). within 2-4 days of initial examinat ion and intervent ion session. thrust mobilizat ion showed significan tly greater short term reduction in pain and disability then nonthrust mobilizat ions. and middle thoracic (t5-t8) (max 2 attempts) + general cervical mobility exercises. dunnin g jr et al.11 none group:1 hvla thrust manipula tion n=56; group:2 non thrust mobilizat ion n=51 group:1 hvla thrust manipulati on (c1-2 & t1-2); group:2 grade iv pa mobilizati ons (c1-2 & t1-2) one time treatmen t after initial evaluati on ndi, nprs, frt (flexionrotation test), ccft (cranioce rvical flexion test), groc. 48-hours after the initial examinat ion hvla thrust manipulat ion group showed significan tly greater reduction s in disability and pain than the nonthrust mobilizat ion group at 48 hours. significa ntly greater improve ment in c1-2 rotation and deep cervical flexor motor performa nce. griswol d d et al.12 none group:1 hvla thrust manipula tion n=48; group:2 non thrust manipula tion n=55 group: 1 highvelocity, lowamplitude thrust to the most symptomat ic segment of both the cervical and thoracic spines + hep ( arom exercises for cervical and thoracic, dcf) group: 2 graded oscillatory determi ned pragmati cally based on individu al patient needs. ntm (5.7 ± 2.4) tm (6.4 ± 3.1) ndi, psfs (patientspecific function al scale), nprs, dcf (deep cervical flexion enduranc e), groc. at baseline, visit 2, and discharg e. ntm and tm produce equivalen t outcomes for patients with mechanic al neck pain. technique to both the cervical and thoracic spines + hep ( arom exercises for cervical and thoracic, dcf) saddiqu e et al.3 none group:1 thoracic manipula tion n=23; group:2 maitland mobilisat ion n=23 group:1 midthoracic manipulati on (t3-t6) group:2 cervicotho racic mobilizati on (c7-t1 maitland technique) one time treatmen t crom, nprs. immedia te no significan t differenc es between the groups in posttreatment rom or pain. significa nt improve ments withingroup in both groups. joshi et al.4 none group:1 thoracic manipula tion n=21; group:2 maitland mobilizat ion n=21 group:1 hvla thrust manipulati on (t3-t6, max 2 attempts); group:2 maitland mobilizati on(c7-t1) (30-second bouts, 3 sets) one time treatmen t after initial evaluati on crom (cervical rom flexion, extension , lateral flexion, rotation using crom device), nprs. immedia te no significan t differenc es between the groups in postinterventi on, significa nt improve ments withingroup in both groups. masara cchio et al.7 none compari son group: n=32 experim ental group: n=34 compariso n group: grade 3 posteriorto-anterior oscillatory manipulati on (c2c7) + active cervical rom exercises; experimen tal group: same as compariso n+ thoracic spine thrust manipulati on (t1-t3 & t4-t7) two treatmen t sessions nprs, ndi, groc. 1 week experime ntal group showed significan tly greater improve ments on both nprs and ndi at 1-week followup. suvarn nato et al.9 control group rest in a prone positio n n=13 group:1 single level thoracic manipula tion n=13; group:2 single level thoracic mobilizat ion n=13 group:1 hvla thrust manipulati on (t6-t7) group:2 grade iii unilateral posteroanterior mobilizati on (t6-t7) group 3: rest in a prone position one time treatmen t crom, vas (visual analogue scale for neck pain intensity) before, immedia te and after 24hours both thoracic manipulat ion and thoracic mobilizat ion show significan t reduction s in vas pain ratings and increases in crom at immediat e and 24hour followups than control group. loreto et al.2 control group: educati onal video n=12 experim ental group 1: cervical spinal manipula tion n=12; experim ental group 2: cervical spinal mobilizat ion n=12 group 1: standardiz ed educationa l video (6 minutes) on postural correction; group 2: highvelocity, mid-range, lowamplitude thrust manipulati on; group 3: 60 seconds low force (grade ii), 60 seconds high force (grade iii), 60 one time treatmen t ndi, nprs, groc 5minutes post, and 4 days post correspo nding intervent ion csm group showed a significan t increase in groc compared to csmob and pe groups. significa nt decreases in nprs and ndi for csm and csmob groups, nonsignifican t decrease in pe group. seconds low force (grade ii) mobilizati ons. mobilization with movement/ snags vs manipulation saleh et al.8 control group: cpt only n=20 experim ental group:1 mulligan snags + cpt n=20; experim ental group:2 thoracic manipul ation + cpt n=20 group:1 mulligan snags to the middle thoracic spine + cpt group:2 thoracic hvla thrust manipulati on (t3-t7) + cpt group:3 conventio nal physical therapy (cpt) isometric neck exercises, chin tucks, neck three sessions a week for 4 weeks vas, neck proprioce ption (using crom device), scapular retractio n (tape measure ment) 4 weeks both snags and tm groups showed significan tly better outcomes than cpt group in all measured variables (pain, proprioce ption, scapular retraction ). no significan t differenc e between snags muscle stretching, neck stabilizatio n exercises (5 sets of 10 repetitions, 2 minutes rest between sets). and tm groups in neck proprioce ption. sodany et al.10 control group: exercis e only n=16 experim ental group:1 snags mobilizat ion + exercise n=18; experim ental group:2 manipul ation + exercise n=15 group:1 snags mobilizati on + exercise; group:2 hvla cervical manipulati on + exercise; group:3 isometric, stretching, postural exercises. two sessions per week for 6 weeks crom, vas, ndi before treatmen t, immedia tely after treatmen t, and at one month follow up significa nt improve ments in rom, pain reduction , and functiona l recovery in all. no significan t differenc e between snags and manipulat ion groups. both groups 1 & 2 showed significan tly better outcomes than the exercise only group. mobilization vs snags vs manipulation izquier do pérez h et al.13 none group 1: hvla n= 19 group 2: mobiliza tion n= 21 group 3: snag n= 21 group 1: high velocity low amplitude thrust applied at most hypomobil e vertebra for most limited cervical movement: lateral flexion or rotation (maximum of 2 thrusts) group 2: unilateral posteroant erior (pa) oscillatory four treatmen t sessions over 2 weeks vas, ndi, acrom, groc five evaluatio ns: before treatmen t, immedia tely after treatmen t, and one, two and three months after treatmen t no significan t differenc es were found between hvla, mob and snag at the end of treatment and during the follow-up in any of the analysed outcomes . there were no differenc es in satisfacti pressure was applied at hypomobil e cervical vertebra (frequency of 2hz for 2 mins, repeated 3 times with 1 min rest in between) group 3: snag applied at most hypomobil e and painful vertebra (3 sets of 10 reps) on for all technique s. table 4: effect size analysis for neck pain treatment interventions study comparison outcome measure effect size (d) 95% ci interpretation salommoreno et al.19 manipulation vs mobilization nprs (pain) 0.82 [0.32, 1.32] large effect favoring manipulation cleland et al.20 manipulation vs mobilization ndi (disability) 0.75 [0.26, 1.24] medium-large effect favoring manipulation dunning et al.11 manipulation vs mobilization ndi (disability) 0.68 [0.30, 1.06] medium effect favoring manipulation griswold et al.12 manipulation vs mobilization nprs (pain) 0.12 [-0.18, 0.42] negligible difference joshi et al.4 manipulation vs mobilization crom (rom) 0.15 [-0.44, 0.74] negligible difference saleh et al.8 snags vs manipulation vas (pain) 0.18 [-0.32, 0.68] negligible difference sodany et al.10 snags vs manipulation ndi (disability) 0.22 [-0.34, 0.78] negligible difference izquierdo pérez et al.13 snags vs mobilization vs manipulation ndi (disability) 0.10 (between groups) [-0.30, 0.50] negligible differences note: effect sizes (cohen’s d) were computed using reported between-group means and pooled standard deviations, using the formula: d = (m₁ m₂) / sdpooled, where sdpooled = √[(sd₁² + sd₂²)/2]. effect sizes were interpreted using standard thresholds: 0.2 = small, 0.5 = medium, and 0.8 = large. these calculations provide a standardized measure of treatment efficacy across studies. the analysis of effect sizes revealed important patterns in the comparative efficacy of different manual therapy interventions for mechanical neck pain. three high-quality studies (salom-moreno, cleland, and dunning) demonstrated medium-to-large short-term benefits of manipulation over conventional mobilization for both pain and disability outcomes, with effect sizes ranging from 0.68 to 0.82. however, four other studies (griswold, joshi, saleh, and sodany) found no significant differences between manipulation and mobilization techniques (including snags), showing only negligible to small effect sizes between 0.12 and 0.22. when comparing all three approaches simultaneously, three-way comparisons indicated minimal differences between mobilization, snags, and manipulation, with an overall effect size of just 0.10. this synthesis revealed considerable heterogeneity in treatment effects across studies in terms of intervention techniques, outcome measures, and follow-up durations. while, some demonstrating substantial advantages for manipulation, others showed equivalent outcomes across interventions. this variation limits the generalizability of pooled findings and emphasizes the need for individualized clinical decision-making based on patient-specific factors. discussion the methodological quality of the included studies varied, with an average pedro score of 7.08 (sd 0.90), indicating high quality evidence. while most studies adhered to proper randomization and statistical methodologies, blinding of participants and therapists remained a significant concern. although the evidence in this review is categorized from ‘fair to high’ based on the pedro scale but is graded as overall high risk of bias on rob 2.0 assessment for all studies except one with overall some concerns. the lack of long-term follow-up in several studies further limits the strength of recommendations derived from the evidence. additionally, studies varied in their intervention protocols, sample sizes, and follow-up durations. due to these limitations, the comparative efficacy of mobilization and manipulation in treating mechanical neck pain (mnp) became more challenging. a thorough analysis of twelve randomized controlled trials (rcts) was conducted to compare the efficacy of manipulation and mobilization in mechanical neck pain (mnp) patients. the results varied across studies, but several common themes emerged regarding pain reduction, range of motion (rom), and functional improvement. the studies included in this review reported follow-up durations ranging from immediate postintervention2,3,4,9,10,13,19 to four weeks8,10,13, with only one study extending beyond one month (upto 3 months)13. concerns regarding limited sampling were observed, as some studies were conducted at single clinical locations3,8. additionally, variations in the application of mobilization and manipulation techniques were evident. manipulation techniques included high-velocity, low-amplitude (hvla) thrusts applied to the cervical2,10,11,12,13 or/and upper and middle thoracic spine3,4,7,8,9,11,12,19,20, while mobilization techniques encompassed central posterior-to-anterior (pa) mobilizations2,3,4,7,9,11,12,13,19,20 and mulligan snags8,10,13. there were differences seen in the variety of application of manual therapy techniques, but for a thorough review all these studies were included in order to find out which one has greater benefits. studies involving a direct comparison of manipulation to mobilization had varying results. these studies utilized different techniques including single hvla thrust manipulation directed to the upper cervical spine (c1-2)11 in supine and anterior-posterior hvla thrust manipulation applied to the upper and mid-thoracic spine in prone3,4 and in supine11,19,20. these were in comparison to central grade iv pa mobilizations to the (c1-2) in supine11 and central grades iii to iv pa mobilization from t3 to t6 spinous process19 , from t1-t620 and central pa glide to the c7-t13,4 in prone. only one study had a pragmatic approach where technique and parameters were determined by the treating therapist based on patients’ evaluation. either a high-velocity, low-amplitude thrust, or a graded oscillatory technique was targeted to the symptomatic level to both cervical and thoracic spine.12 in this study by griswold d et al.12 no significant differences were found between the groups controlling for clinical equipoise, but better outcomes were achieved for patients treated by clinicians with a preference toward tm. however, significant differences were found within both groups for pain and disability including other outcomes as well indicating effectiveness of both techniques.12 study by dunning jr et al.11, revealed that thoracic spine manipulation provided superior reductions in pain and disability at 48-hour follow-ups compared to cervical mobilization. the study was methodologically robust but lacked long-term follow-up, highlighting the need for further research into the sustained effects of manipulation11. a highquality study by salom-moreno et al.19 that found thoracic thrust manipulation to be significantly more effective than non-thrust mobilization in reducing neck pain intensity. however, both groups demonstrated similar improvements in pressure pain thresholds, indicating comparable effects on pain sensitivity. the study supports the hypothesis that manipulation may provide additional benefits beyond mobilization in terms of immediate pain relief.19 similarly, cleland ja et al.20 also found significant reduction in pain, disability and higher scores on groc for patients who received thrust mobilization/manipulation. he also mentioned number of side effects experienced by subjects in each group, which were reported as non-significant between the groups. side effects in the ntm group included an aggravation of symptoms (n2), muscle spasm (n1), neck stiffness (n2), headache (n2), and radiating symptoms (n2) and in the tm group, aggravation of symptoms (n8), muscle spasm (n1), and headache (n1). although the time of initiation to lasting of symptoms was reported within 24 hours by all subjects.20 the study by saddique et al.3 compared mid-thoracic (t3-t6) manipulation to cervicothoracic junction (ct) mobilization. both interventions resulted in significant withingroup improvements in pain and rom post-treatment, but no significant between-group differences were observed, suggesting both techniques are equally effective.3 this aligns with findings from joshi et al.4, which also demonstrated no significant differences between the two interventions. these results are consistent with other studies that suggest both mobilization and manipulation can be effective interventions for mnp.6 a study by mastracchio et al.7, compared a group receiving pa ntm (grade 3) at spinous processes of cervical spine (c2-c7) with similar treatment plus 2 thoracic spine tm at upper thoracic spine (t1-t3) and 2 at the middle thoracic spine (t4-t7). it was found that combining thoracic and cervical manipulations to a classical mobilizations, led to greater improvements in nprs and ndi scores at one-week follow-up compared to cervical mobilization alone.7 these findings support the role of multimodal manual therapy in managing mnp, suggesting that addressing both thoracic and cervical dysfunction may provide superior clinical outcomes. loreto et al.2, assessed the effects of cervical spine mobilization versus manipulation on pain and disability alongside a control group. one group received a single session of csm “minimal leverage thrust” (hvla force with either left side bending and right rotation or right side bending with left rotation targeted at the painful and/or restricted segment) in supine position, while the csmob group received grade ii and iii mobilization in prone. the control group was shown a postural education video. the manipulation group exhibited a significant increase in global rating of change (groc) scores compared to the mobilization and placebo groups. a significant reduction in nprs and neck disability index (ndi) scores were observed for both groups compared to the non-intervention group. however, no significant differences were found between the groups for each of the outcomes. these results suggest patient’s satisfaction influenced by increasing rends for high-thrust manipulation. another study by suvarnnato et al.9, compared single level thoracic manipulation (t6-7) with pa grade iii mobilization (at the zygapophyseal joint of t6-t7 on both sides) in prone with control group only lying in prone position. it demonstrated significant improvements in visual analog scale (vas) pain scores and rom in both thoracic manipulation and mobilization groups compared to a control group where no compressive forces were applied. however, no significant differences were found between the two manual therapy techniques, indicating that both approaches may be equally beneficial which is consistent with above findings.9 two studies compared mobilization with movement (snags) and thoracic manipulation on neck pain. the study of saleh et al.8 used technique of mulligan’s snag at middle thoracic spine with the patient sitting astride a chair, the other group received thoracic manipulation (t3 and t7) in prone, and the control group was given conventional physical therapy. his study showed significant improvements in cervical rom and pain reduction by both interventions, no significant differences were observed between groups. the study lacked sufficient blinding but featured strong randomization methods and concealed allocation. sodany et al.10 compared cervical snag (applied to the affected side in sitting position) along with cervical manipulation (cervical rotatory and lateral tilting techniques in supine position). he also found that snags and manipulation were equally effective in improving cervical rom and reducing pain compared to exercise-only groups. however, there was no significant difference between the snags and manipulation groups.10 these findings align with previous studies suggesting that snags and manipulation may produce similar therapeutic effects. the only study found that compared all three techniques altogether was rated as high quality evidence. izquierdo pérez, h. et al.13 in his study randomized participants in three experimental groups to find the best technique. all techniques were applied at hypomobile vertebra one group was allocated for hvla thrust (applied for the most limited movement: lateral flexion or rotation in supine), other received (pa) oscillatory pressure (mobilization at a frequency of 2hz for 2 mins in prone) and the last group was given snag (on transverse process in sitting). this was the only study that had a long-term follow up for upto 3 months. the results of this study were no different from the above findings. all three techniques demonstrated significant reduction in pain and disability and increase in acrom and groc score. however, no significant differences in any of the outcomes were found between the groups. there was one interesting finding for acrom, improved extension was noted only immediately in mob group, at only one month follow up in snag group and in hvla thrust group at all follow up months than other groups.13 these results cannot be generalized due to lack of sufficient data and small sample size. limitations this systematic review has several limitations that impact the strength and generalizability of its findings. the lack of high-quality randomized controlled trials (rcts) focused on mobilization for mechanical neck pain necessitated the inclusion of studies with lower methodological rigor. variability in methodologies, techniques, outcome measures, and follow-up durations made it challenging to synthesize findings into precise clinical recommendations. the exclusion of non-english studies may have further restricted the scope of the review. concerns highlighted by the pedro scale included issues with blinding and treatment consistency, as most studies did not blind subjects and therapists, increasing the risk of expectation bias. short follow-up durations, with most studies reporting outcomes up to only four weeks, limited the understanding of long-term intervention efficacy. additionally, small sample sizes in several studies reduced the generalizability of results, while variability in manipulation and mobilization techniques hindered direct comparisons across studies. recommendations for future research future studies should directly compare manipulation and mobilization for mnp, using well-defined treatment protocols, long follow-up periods to assess the longer-term effects beyond four weeks, and multicentre trials across diverse clinical settings. future studies should ensure adequate blinding of assessors. thus, different methods of thoracic manipulations for instance, manipulation supine versus manipulation seated need to be investigated comparatively in order to see which one yields better results. moreover, the examination of potential synergy between manual therapy and therapeutic exercise would have useful clinical implications. conclusions as a result of the methodological concerns associated with the current research comparing mobilization and manipulation for mechanical neck pain (mnp), there is no clear evidence that supports one technique over the other. both treatments significantly improved pain, range of motion, and functional outcomes in the short term; 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