What is the connection between sleep and neurofeedback training?
Is there a relationship between adequate sleep and neurofeedback efficacy?  How does one manage the myriad complaints and presentations that accompany insomnia, and know when to refer out?
Are there techniques, other than or in addition to neurofeedback, that actually work?  What is the State of the Science of Insomnia, according to the NIH?

One rationale for alleviating sleep disturbance in this population is that left unmanaged poor sleep will undermine the effectiveness of neurofeedback training. Additionally, you will learn enough to manage even your difficult insomnia clients rather than needing to refer out.

Time permitting, also presented will be a discussion on the management of Insomnia today as reflected in the recent NIH Statement on State of the Science.


What is insomnia?
The most common sleep complaint in adults is insomnia, generally defined as the subjective sense that sleep is difficult to initiate or maintain, or that sleep itself is non-refreshing. Prevalence studies have shown that nearly one-half of the adult population experiences insomnia (30-50% acute problem, 10-15% as a chronic problem). Many sufferers report daytime consequences similar to those associated with chronic sleep deprivation: fatigue, performance decrements and mood disturbances. The daytime impairments result in poor quality of life, decreased productivity, higher accident rate and increased morbidity with augmented use of medical facilities. These findings present an obvious cause for concern in society.

Treatment: Where possible, treatment should be addressed toward correction of the underlying cause, particularly when there are associated medical/psychiatric issues. Simple changes in routine, living situation and food intake may be effective. In all cases, education regarding the mechanics of sleep, i.e., sleep promoting and interfering behaviors, is important.

Specific treatment regimens are generally implemented in accordance with the time-course of symptoms. Transient insomnia, lasting a few days to a couple of weeks is usually associated with transmeridian travel, a brief illness or stressful event (next day exam or presentation) and hypnotics can be used as the main therapy. The most effective are the newer medications with similar chemical structure or agonist like compounds to the benzodiazepine class. Short term insomnia, lasting several weeks to a month is usually associated with more traumatic life events that can be negative (death of a loved one, divorce or sudden hospitalization) or positive (marriage, job promotion, birth of a child). Although hypnotic therapy is indicated over the short term, behavioral therapies and education are important to prevent the development of chronic insomnia. The longer insomnia persists, the more complex are the causes and treatment.

Long term or chronic insomnia may last months to years. There are well-recognized effective behavioral treatments available to address the symptoms of chronic insomnia: sleep restriction, cognitive therapy, relaxation therapies, stimulus control and neuro/biofeedback feedback, generally referred to as cognitive-behavioral therapy (CBT). These therapies have common modes of action and relieve insomnia by either reducing emotional/somatic arousal (cognitive and relaxation therapy, stimulus control, neuro/biofeedback) or improving sleep efficiency (sleep restriction). CBT is typically employed during an 8-10 week program and has been recently shown to be the most beneficial treatment regimen for chronic insomnia by the NIH, with long-term efficacy. The longest controlled trial of any hypnotic is one year and given the chronic persistent nature of insomnia it is unclear of the long-term role of these medications. While recent advances in hypnotic selectivity have provided improved medications, when withdrawn treatment effects are reduced or lost completely. Consequently, hypnotics should not be viewed as the sole source of treatment particularly in the case of chronic insomnia. Rather, medication should be utilized as reinforcement for the educational and behavioral techniques.


NIH Statement on State of the Science
1. Acknowledges for the first time that Insomnia, while comorbid with many other disorders, particularly psychiatric disorders, is a distinct and independent disorder requiring separate, simultaneous management.
2. This statement recognizes the paucity of data on long-term consequences of insomnia and the long-term effects of current therapies.
3. Supports the finding that CBT is the most efficacious therapy at present, particularly in long-term gains, although there is some very new evidence to suggest that newer benzodiazepine-like agonists may be effective for up to one year.
4. Calls for significantly increased and broadened research agenda, including head-to-head comparisons between hypnotics with a CBT group.


What is the relationship of sleep disturbance to neurofeedback efficacy?
Clearly, the brain that is not restored by sleep is less apt to perform well under normal circumstances. Since NF efficacy is thought to be dependent upon brain plasticity, and brain plasticity requires normal functional capacities, sleep-deprivation adversely impacts brain plasticity.