The use of EEG theata biofeedback in the treatment of a patient with sleep-onset insomnia

In this report, the treatment of a 42-year-old female with a complaint of chronic sleep-onset insomnia is described. Following the unsuccessful use of relaxation training, treatment consisted of 11 sessions of EEG theta rhythm (4–7 Hz) biofeedback. Theta density and five sleep indices were monitored throughout baseline, placebo, and treatment sessions. A significant increase in theta density was accompanied by reports of a decrease in sleep latency and an increase in total sleep time. This improvement was maintained after withdrawal of medication and at 3-month follow-up.Appreciation is expressed to Dr. R. Muir, for medical supervision of the patient, and to Mr. D. F. Peck and Dr. J. I. Evans, for their comments on earlier drafts of this paper.     

Biofeedback and progressive relaxation treatment of sleep-onset insomnia

Previous research suggests that self-defined insomniacs are distinguished from normals by high levels of anxiety and physiological arousal, which might be mitigated by muscle relaxation. This study assessed the relative effects of frontal EMG biofeedback, progressive relaxation, and a placebo set of relaxation exercises on the sleep of 18 onset insomniacs. Each subject was trained in one of these three methods for six half-hour sessions and slept in the laboratory for two consecutive nights before and after training. The experimental groups demonstrated significant decreases in physiological activity during training while changes in the control group were minimal. Reductions in sleep-onset time were: biofeedback group, 29.66 minutes; progressive relaxation group, 22.92 minutes; control group, 2.79 minutes. The experimental groups improved significantly(p<.05) more than the control group, but did not differ from each other. No significant relationships between physiological levels and sleep-onset time were found, which suggests that muscle relaxation alone was not responsible for subjects' improvements. Since 20 minutes of daily practice were required to achieve an approximate 30-minute decrease in sleep-onset time, the practical utility of the methods is questioned.Portions of this paper were presented at the 15th Annual Meeting of the Association for the Psychophysiological Study of Sleep, Edinburgh, July, 1975, and at the 6th Annual Meeting, Biofeedback Research Society, Monterey, California, February, 1975.     

The treatment of psychophysiologic insomnia with biofeedback: A replication study

To replicate a previous study, 16 psychophysiological insomniacs were randomly assigned to either Theta feedback or sensorimotor rhythm (SMR) feedback. Evaluations by home sleep logs and by 3 nights in the laboratory were done before biofeedback, immediately after biofeedback, and 9 months later. Results from this study replicate previous findings. Both Theta and SMR feedback seemed effective treatments of insomnia according to home sleep logs. According to evaluations at the sleep laboratory, tense and anxious insomniacs benefited only from Theta feedback but not from SMR feedback, while those who were relaxed at intake but still could not sleep benefited only from SMR but not from Theta feedback.This research was supported by Grant No. MH24268 from NIMH. The authors would like to thank Michael Sateia, Elaine Olmstead, Molly Oldfield, and Boyd Hayes for their assistance with this paper.     

Simultaneous biofeedback of heart rate and frontal EMG as a pretraining for the control of EEG theta activity

Following one base-line session, 20 normal subjects received four half hour sessions consisting of simultaneous feedback of heart rate and frontalis muscle (pretraining). Ten subjects received contingent (CF), the other ten noncontingent feedback (NCF). Subjects were asked to lower heart rate and frontal muscle tension (EMG). Heart rate within sessions decreased up to 19 bpm, with a mean of 4 bpm for the CF group. There was only a weak decrease over sessions, however, because of the strong habituation effect. The following events accompanied the heart rate decrease: (1) an increase of the variability of the heart rate, (2) a decrease of the variance of the EMG, (3) an increased correlation between heart rate slowing and EMG decrease, and (4) an increasing subjective experience of control of heart rate and EMG. After pretraining, subjects received eight sessions of auditory feedback of their frontal EEG theta activity (four sessions with CF and four sessions with NCF in balanced order). There was a weak increase of theta for the CF condition over sessions, but a decrease within the sessions. Pretraining on heart rate and frontal EMG control had no influence on the performance during theta training. It was hypothesized that control of heart rate slowing and theta control involve different mechanisms.     

A comparison of relaxation techniques with electrosleep therapy for chronic,sleep-onset insomnia

Two methods of relaxation therapy, electromyograph biofeedback and autogenic training, were compared to a nonrelaxation treatment, electrosleep therapy, in reducing sleep latency among 22 chronic, sleep-onset insomniacs. While none of the electrosleep patients improved on all-night laboratory electroencephalographic sleep records or daily home sleep logs, approximately one-half of the relaxation-treated patients showed marked improvement, which was sustained over a 1-month follow-up period. Although some sleep and treatment variables differentiated relaxation therapy responders from nonresponders, external stress appeared to be the most salient factor. Successful and unsuccessful patients could not be differentiated on any of the psychological variables studied.     

The use of melatonin for the treatment of insomnia

The pineal product melatonin is involved in the regulation of the sleep/wake cycle in humans. In blind individuals and in people travelling through time zones, melatonin rhythms are sometimes unsynchronized with the diel cycle, and nocturnal sleep may be disturbed. Low or distorted melatonin rhythms have repeatedly been reported in middle aged and elderly insomniacs. Melatonin administration effectively synchronized the sleep wake cycle in blind individuals and in subjects suffering from jet lag and advanced sleep onset in subjects suffering from delayed sleep phase syndrome. In elderly insomniacs, melatonin replacement therapy significantly decreased sleep latency, and/or increased sleep efficiency and decreased wake time after sleep onset. In addition, melatonin substitution facilitated benzodiazepine discontinuation in chronic users. These data show an association between melatonin rhythm disturbances and difficulties to promote or maintain sleep at night. Specific melatonin formulations may be useful to treat circadian-rhythm-related sleep disorders and age-related insomnia.     

The use of temperature biofeedback in the treatment of chronic pain due to causalgia.

A patient with chronic pain due to a reflex sympathetic dystrophy in his hand and arm was successfully treated with temperature biofeedback after several months of conservative standard medical care brought little relief. Over the 18 treatment sessions the patient learned to emit a reliable handwarming response of 1 to 1.5 degrees C. Coincident with his learning, the pain in his hand and arm decreased markedly and remained absent at 1-year follow-up.     

EMG and EEG biofeedback training in the treatment of a 10-year-old hyperactive boy with a developmental reading disorder

The serial application of electromyographic (EMG) and sensorimotor (SMR) biofeedback training was attempted with a 10-year-old boy presenting a triad of symptoms: an attention deficit disorder with hyperactivity, developmental reading disorder, and ocular instability. Symptom elimination was achieved, for all three aspects of the triad, following the procedure of first conditioning a decrease in EMG-monitored muscle tension and then conditioning increases in the amplitude of sensorimotor rhythm over the Rolandic cortex. The learned reduction of monitored EMG levels was accompanied by a reduction in the child's motoric activity level to below that which had been achieved by past administration of Ritalin. In addition, the attention deficit disorder with hyperactivity was no longer diagnosable following the EMG biofeedback training. The learned increase in the amplitude of monitored SMR was accompanied by remediation of the developmental reading disorder and the ocular instability. These results remained unchanged, as ascertained by follow-ups conducted over a 24-month period subsequent to the termination of biofeedback training.     

Meta-analysis of benzodiazepine use in the treatment of insomnia

OBJECTIVE: To systematically review the benefits and risks associated with the use of benzodiazepines to treat insomnia in adults. DATA SOURCES: MEDLINE and the Cochrane Controlled Trials Registry were searched for English-language articles published from 1966 to December 1998 that described randomized controlled trials of benzodiazepines for the treatment of insomnia. Key words included "benzodiazepines" (exploded), "randomized controlled trial" and "insomnia." Bibliographies of relevant articles were reviewed for additional studies and manufacturers of benzodiazepines were asked to submit additional randomized controlled trial reports not in the literature. STUDY SELECTION: Articles were considered for the meta-analysis if they were randomized controlled trials involving patients with insomnia and compared a benzodiazepine with placebo or another active agent. Of the 89 trials originally identified, 45 met our criteria, representing a total of 2672 patients. DATA EXTRACTION: Data were extracted regarding the participants, the setting, details of the intervention, the outcomes (including adverse effects) and the methodologic quality of the studies. DATA SYNTHESIS: The meta-analyses of sleep records indicated that, when compared with placebo, benzodiazepines decreased sleep latency by 4.2 minutes (non-significant; 95% confidence interval (CI -0.7 to 9.2) and significantly increased total sleep duration by 61.8 minutes (95% CI 37.4 to 86.2). Patient-reported outcomes were more optimistic for sleep latency; those randomized to benzodiazepine treatment estimated a sleep latency decrease of 14.3 minutes (95% CI 10.6 to 18.0). Although more patients receiving benzodiazepine treatment reported adverse effects, especially daytime drowsiness and dizziness or light-headedness (common odds ratio 1.8, 95% CI 1.4 to 2.4), dropout rates for the benzodiazepine and placebo groups were similar. Cognitive function decline including memory impairment was reported in several of the studies. Zopiclone was not found to be superior to benzodiazepines on any of the outcome measures examined. INTERPRETATION: The use of benzodiazepines in the treatment of insomnia is associated with an increase in sleep duration, but this is countered by a number of adverse effects. Additional studies evaluating the efficacy of nonpharmacological interventions would be valuable.     

The use of temperature biofeedback in the treatment of chronic pain due to causalgia

A patient with chronic pain due to a reflex sympathetic dystrophy in his hand and arm was successfully treated with temperature biofeedback after several months of conservative standard medical care brought little relief. Over the 18 treatment sessions the patient learned to emit a reliable handwarming response of 1 to 1.5°C. Coincident with his learning, the pain in his hand and arm decreased markedly and remained absent at 1-year follow-up.The author wishes to acknowledge the assistance of Dr. Kit S. Mays and the staff of the Pain Clinic of the University of Tennessee Center for the Health Sciences.     

The use of EMG biofeedback with insulin-dependent diabetic patients

A recent report on the use of EMG biofeedback with an insulin-dependent diabetic is discussed. An examination of the role of EMG biofeedback in the management of carbohydrate metabolism is presented. While still an empirical question, it is concluded that EMG biofeedback will prove most useful in cases where a demonstrable relationship between stress and carbohydrate metabolism is evidenced.     

The effects of various mental tasks on appearance of frontal midline theta activity in EEG.

A distinct theta rhythm of EEG in the frontal midline area during performance of mental tasks has been called Fm theta. One of the characteristics of Fm theta is individual differences in its appearance. The effects of various mental tasks and its repetition on appearance of Fm theta were investigated. Adding, correcting wrong words, short-term memory (STM) and counting cubes were imposed 6 times on 7 male students who didn't generate Fm theta at the previous experiment. Counting cubes evoked more Fm theta than the other three mental tasks. In every task the first trial showed little Fm theta, and the appearance time of Fm theta was enhanced by repetition. Type I of Spielberger's State-Trait Anxiety Inventory (STAI-I) demonstrated a higher state anxiety level of the subjects at the first trial. It may be concluded that the amount of Fm theta corresponds to the level in concentration of attention.     

Electromyographic biofeedback treatment of a woman with chronic dysphagia

In this case report, a 25-year-old female with chronic dysphagia spastica(difficulty swallowing because of constriction of the throat muscles) was treated with 20 sessions of frontal electromyographic(EMG) biofeedback and home-relaxation practice. The subject monitored on a 10-point scale her difficulty swallowing during meals for 2 months prior to treatment, during treatment, and after treatment. There was a significant decrease in reported difficulty swallowing associated with frontalis EMG feedback. Improvement was maintained at a 6-month follow-up.     

Increase of slow periodic modulation of EEG in a patient with Alzheimer's disease.

The recently described slow oscillations of amplitude of theta and alpha waves of the EEG (with a frequency below 0.08 Hz) in healthy subjects are attributed to the autonomic nervous system with control at the brain stem level. In the present pilot study, the slow brain rhythms were analyzed in a patient with Alzheimer's disease and were compared to a healthy subject. Dynamic analysis of the EEG was performed using time-frequency mapping which gives simultaneous time and frequency representation of the brain signal. This method comprises a transform of the filtered EEG signal into its analytic form and application of the Wigner distribution modified by time and frequency smoothing. It has been shown that the envelope of both theta and alpha activities oscillates at 0.04 Hz and 0.07 Hz in the healthy subject and at 0.03 Hz and 0.06 Hz in a patient with Alzheimer's disease. The amplitude of the slow oscillations of theta activity was substantially higher in the patient with Alzheimer's disease as compared with the healthy subject. It is being proposed that the increase of slow brain rhythms in the patient with Alzheimer's disease reflects an abnormal activity of the autonomic nervous system. However, the underlying pathophysiological mechanisms need to be further studied.     

The use and utility of EMG biofeedback with chronic schizophrenic patients

This study examined the efficacy of muscle relaxation training via electromyographic (EMG) biofeedback from the frontalis and forearm extensor muscles of schizophrenic inpatients. Thirty chronically hospitalized patients were randomly assigned to one of three conditions: EMG biofeedback from the forearm extensor and frontalis muscles, progressive relaxation, and a control group. Treatment consisted of one session of orientation and baseline, and six sessions of training. The results indicated that the schizophrenic patients receiving EMG training had significantly lower EMG recordings than the progressive relaxation group, which, in turn, was significantly lower than the control group. Analyses of covariance on the Tension-Anxiety scale from the Profile of Mood States revealed no significant effects, while finger-tapping rates were significantly improved only for the arm receiving feedback training in the EMG group. On the Nurses Observation Scale for Inpatient Evaluation the biofeedback group significantly improved on the Social Competence and Social Interest factors.We would like to express our appreciation for the contributions the following people made to this project: Drs. Barry Smith, Robert Steele, Agnes Hartfield, Jeffrey Barth, Althea Wagman, and the late Harold Weiner; Earl Downs and the participating staff at Springfield State Hospital Center; and Robert Kline and Michael Kelley, who performed the data analyses. This research was supported in part by a grant from the Computer Science Center at the University of Maryland.     

The use and utility of EMG biofeedback with chronic schizophrenic patients

This study examined the efficacy of muscle relaxation training via electromyographic (EMG) biofeedback from the frontalis and forearm extensor muscles of schizophrenic inpatients. Thirty chronically hospitalized patients were randomly assigned to one of three conditions: EMG biofeedback from the forearm extensor and frontalis muscles, progressive relaxation, and a control group. Treatment consisted of one session of orientation and baseline, and six sessions of training. The results indicated that the schizophrenic patients receiving EMG training had significantly lower EMG recordings than the progressive relaxation group, which, in turn, was significantly lower than the control group. Analyses of covariance on the Tension-Anxiety scale from the Profile of Mood States revealed no significant effects, while finger-tapping rates were significantly improved only for the arm receiving feedback training in the EMG group. On the Nurses Observation Scale for Inpatient Evaluation the biofeedback group significantly improved on the Social Competence and Social Interest factors.     

High-dose zolpidem abuse in a patient with insomnia comorbid with major depressive disorder

Sleep and Biological Rhythms - A 39-year-old married woman was referred to a psychiatry outpatient clinic for treatment of major depressive disorder (MDD). The dose of zolpidem she had been taking...