A Randomized Controlled Trial Comparing Neurofeedback and Cognitive-Behavioral Therapy for Insomnia Patients: Pilot Study

Insomnia is a common disease that negatively affects patients both mentally and physically. While insomnia disorder is mainly characterized by hyperarousal, a few studies that have directly intervened with cortical arousal. This study was conducted to investigate the effect of a neurofeedback protocol for reducing cortical arousal on insomnia compared to cognitive-behavioral treatment for insomnia (CBT-I). Seventeen adults with insomnia, free of other psychiatric illnesses, were randomly assigned to neurofeedback or CBT-I. All participants completed questionnaires on insomnia [Insomnia Severity Index (ISI)], sleep quality [Pittsburgh Sleep Quality Index (PSQI)], and dysfunctional cognition [Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-16)]. The neurofeedback group showed decreases in beta waves and increases in theta and alpha waves in various areas of the electroencephalogram (EEG), indicating lowered cortical arousal. The ISI and PSQI scores were significantly decreased, and sleep efficiency and sleep satisfaction were increased compared to the pre-treatment scores in both groups. DBAS scores decreased only in the CBT-I group (NF p?=?0.173; CBT-I p?=?0.012). This study confirmed that neurofeedback training could alleviate the symptoms of insomnia by reducing cortical hyperarousal in patients, despite the limited effect in reducing cognitive dysfunction compared to CBT-I.

     

Specific EEG Sleep Pattern in the Prefrontal Cortex in Primary Insomnia

Objective

To assess the specific prefrontal activity in comparison to those in the other main cortical areas in primary insomnia patients and in good sleepers.

Methods

Fourteen primary insomnia patients and 11 good sleepers were included in the analysis. Participants completed one night of polysomnography in the sleep lab. Power spectra were calculated during the NREM (Non-rapid eyes movements) and the REM (Rapid eyes movements) sleep periods at prefrontal, occipital, temporal and central electrode positions.

Results

During the NREM sleep, the power spectra did not differ between groups in the prefrontal cortex; while primary insomnia patients exhibited a higher beta power spectrum and a lower delta power spectrum compared to good sleepers in other areas. During the REM sleep, the beta1 power spectrum was lower in the prefrontal cortex in primary insomnia patients compared to good sleepers; while no significant difference between groups was obtained for the other areas.

Conclusions

The present study shows a specific prefrontal sleep pattern during the whole sleep period. In addition, we suggest that primary insomnia patients displayed a dysfunction in the reactivation of the limbic system during the REM sleep and we give additional arguments in favor of a sleep-protection mechanism displayed by primary insomnia patients.     

Do chronic primary insomniacs have impaired heat loss when attempting sleep?

For good sleepers, distal skin temperatures (e.g., hands and feet) have been shown to increase when sleep is attempted. This process is said to reflect the body's action to lose heat from the core via the periphery. However, little is known regarding whether the same process occurs for insomniacs. It would be expected that insomniacs would have restricted heat loss due to anxiety when attempting sleep. The present study compared the finger skin temperature changes when sleep was attempted for 11 chronic primary insomniacs [mean age = 40.0 years (SD 13.3)] and 8 good sleepers [mean age = 38.6 years (SD 13.2)] in a 26-h constant routine protocol with the inclusion of multiple-sleep latency tests. Contrary to predictions, insomniacs demonstrated increases in finger skin temperature when attempting sleep that were significantly greater than those in good sleepers (P = 0.001), even though there was no significant differences in baseline finger temperature (P = 0.25). These significant increases occurred despite insomniacs reporting significantly greater sleep anticipatory anxiety (P < 0.0008). Interestingly, the core body temperature mesor of insomniacs (37.0 +/- 0.2 degrees C) was significantly higher than good sleepers (36.8 +/- 0.2 degrees C; P = 0.03). Whether insomniacs could have impaired heat loss that is masked by elevated heat production is discussed.     

Is daily routine important for sleep? An investigation of social rhythms in a clinical insomnia population

Social rhythms, also known as daily routines (e.g. exercise, of school or work, recreation, social activities), have been identified as potential time cues to help to regulate the biological clock. Past research has shown links between regularity and healthy sleep. This study examined the regularity and frequency of daytime activities in a clinical insomnia population and a good sleeper comparison group. Participants (N?=?69) prospectively monitored their sleep and daily activities for a 2-week period. Although participants with insomnia and good sleepers had similar levels of activity, relative to good sleepers, those with insomnia were less regular in their activities. Findings from this study add to the growing number of studies that highlight the relative importance of the regularity of daytime activities on sleep. Accordingly, future research should test treatment components that focus on regulating daytime activities, which would likely improve treatment outcomes.     

An Exploratory Study on the Effects of Tele-neurofeedback and Tele-biofeedback on Objective and Subjective Sleep in Patients with Primary Insomnia

Insomnia is a sleeping disorder, usually studied from a behavioural perspective, with a focus on somatic and cognitive arousal. Recent studies have suggested that an impairment of information processes due to the presence of cortical hyperarousal might interfere with normal sleep onset and/or consolidation. As such, a treatment modality focussing on CNS arousal, and thus influencing information processing, might be of interest. Seventien insomnia patients were randomly assigned to either a tele-neurofeedback (n = 9) or an electromyography tele-biofeedback (n = 8) protocol. Twelve healthy controls were used to compare baseline sleep measures. A polysomnography was performed pre and post treatment. Total Sleep Time (TST), was considered as our primary outcome variable. Sleep latency decreased pre to post treatment in both groups, but a significant improvement in TST was found only after the neurofeedback (NFB) protocol. Furthermore, sleep logs at home showed an overall improvement only in the neurofeedback group, whereas the sleep logs in the lab remained the same pre to post training. Only NFB training resulted in an increase in TST. The mixed results concerning perception of sleep might be related to methodological issues, such as the different locations of the training and sleep measurements.     

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.     

Sleep in the surgical intensive care unit: continuous polygraphic recording of sleep in nine patients receiving postoperative care.

Sleep was studied in nine patients for two to four days after major non-cardiac surgery by continuous polygraphic recording of electroencephalogram, electrooculogram, and electromyogram. Presumed optimal conditions for sleep were provided by a concerted effort by staff to offer constant pain relief and reduce environmental disturbance to a minimum. All patients were severely deprived of sleep compared with normal. The mean cumulative sleep time (stage 1 excluded) for the first two nights, daytime sleep included, was less than two hours a night. Stages 3 and 4 and rapid eye movement sleep were severely or completely suppressed. The sustained wakefulness could be attributed to pain and environmental disturbance to only minor degree. Sleep time as estimated by nursing staff was often grossly misjudged and consistently overestimated when compared with the parallel polygraphic recording. The grossly abnormal sleep pattern observed in these patients may suggest some fundamental disarrangement of the sleep-wake regulating mechanism.     

Diurnal sleep depth changes in the king penguin (<Emphasis Type="Italic">Aptenodytes patagonicus</Emphasis>)

Avian sleep quality depends on its depth (deeper sleep being of better quality). In king penguins (Aptenodytes patagonica), sleep may be disturbed by congeners passing in the sleeper's vicinity. As king penguin activity is increased in the morning, sleep disturbances are more likely to occur during this time period. One might therefore assume that afternoon sleepers (AS) sleep more profoundly than morning sleepers (MS). To test this hypothesis, we examined the diurnal variations in sleep depth of king penguins sleeping in resting sites adjacent to the colony of 'La Baie du Marin' (Crozet Archipelago). We measured the bodily tactile arousal threshold at the upper back level. The arousal threshold in AS was twice as high as in MS. This study demonstrates for the first time that sleep depth changes according to time of day in a diurnal wild bird. We postulate that diurnal sleep depth is increased due to decreased congener movements close to the sleeping penguin.     

Determinants of insomnia in relatively healthy elderly. A literature review

A review is presented based on the findings resulting from interview and questionnaire research concerning factors that determine insomnia in relatively healthy elderly. The investigated factors include modes of living, sleep wishes and personality aspects. During the period 1988-1997 18 published reports were found. Based on the findings it is difficult to claim that elderly persons with insomnia are characterized by inappropriate modes of living. There were, however, some (inconsistent) indications that tea consumption, smoking and lack of exercise predicted insomnia. There were also scarce indications for less realistic sleep expectations in bad than in good sleepers. More bad sleepers perceived their sleep as uncontrollable and unpredictable than than good sleepers. Bad sleepers had significantly higher scores for anxiety, neuroticism and depression than good sleepers. Anxiety as well as depression correlated positively with insomnia and negatively with sleep duration. Depression, anxiety or neuroticism often were better predictors of insomnia than health indicators such as perceived health and number of prescribed drugs. The findings suggest that insomnia in relatively healthy elderly is more tightly associated with psychological factors than with modes of living or health indicators. This has some consequences for therapy. In addition to advice concerning modes of living and sleep hygiene, one has to be alert for the possible presence of depression or anxiety. In that case depression or anxiety has to be treated, pharmacologically or nonpharmacologically.     

Bruxism and nocturnal groaning

Sleep bruxism (SB) is a sleep-related movement disorder, characterized by tooth grinding and/or clenching. The causes of SB range from psychosocial factors to an excessive sleep arousal response. Some studies showed that SB episodes during sleep are under the influences of transient activity of the brainstem arousal. Nocturnal groaning (NG) is a parasomnia characterized by an expiratory monotonous vocalization occurring during sleep, especially in REM sleep and during the second half of the night. The pathogenesis of NG remains still unclear and many hypotheses arose, ranging from the persistence of a vestigial ventilatory pattern rather than an expiratory upper airways' obstruction. Sleep microstructure fluctuation might modulate the NG, since the end of the NG episode usually is synchronized with a cortical arousal and an autonomic activation. Further studies should clarify the pathophysiology of SB and NG, especially when the two phenomena are associated.     

Neurofeedback for Insomnia: A Pilot Study of <Emphasis Type="Italic">Z</Emphasis>-Score SMR and Individualized Protocols

Insomnia is an epidemic in the US. Neurofeedback (NFB) is a little used, psychophysiological treatment with demonstrated usefulness for treating insomnia. Our objective was to assess whether two distinct Z-Score NFB protocols, a modified sensorimotor (SMR) protocol and a sequential, quantitative EEG (sQEEG)-guided, individually designed (IND) protocol, would alleviate sleep and associated daytime dysfunctions of participants with insomnia. Both protocols used instantaneous Z scores to determine reward condition administered when awake. Twelve adults with insomnia, free of other mental and uncontrolled physical illnesses, were randomly assigned to the SMR or IND group. Eight completed this randomized, parallel group, single-blind study. Both groups received fifteen 20-min sessions of Z-Score NFB. Pre-post assessments included sQEEG, mental health, quality of life, and insomnia status. ANOVA yielded significant post-treatment improvement for the combined group on all primary insomnia scores: Insomnia Severity Index (ISI p < .005), Pittsburgh Sleep Quality Inventory (PSQI p < .0001), PSQI Sleep Efficiency (p < .007), and Quality of Life Inventory (p < .02). Binomial tests of baseline EEGs indicated a significant proportion of excessively high levels of Delta and Beta power (p < .001) which were lowered post-treatment (paired z-tests p < .001). Baseline EEGs showed excessive sleepiness and hyperarousal, which improved post-treatment. Both Z-Score NFB groups improved in sleep and daytime functioning. Post-treatment, all participants were normal sleepers. Because there were no significant differences in the findings between the two groups, our future large scale studies will utilize the less burdensome to administer Z-Score SMR protocol.     

固本健脑安神方联合针灸对慢性失眠的治疗效果及对日间脑功能状态影响

摘要 目的：探讨固本健脑安神方联合针灸对慢性失眠的治疗效果及对日间脑功能状态影响。方法：选取我院于2021年1月份到2022年12月份期间收治的120例慢性失眠患者进行研究,根据患者就诊日期进行分组,其中60例奇数日期就诊的患者作为对照组（接受针灸治疗）,另外60例偶数日期就诊的患者作为观察组（接受固本健脑安神方联合针灸治疗）。对比两组愈显率、总有效率、匹兹堡睡眠质量指数（PSQI）量表评分、日间失眠症状反应量表（DISS）评分、过度觉醒量表（HAS）评分、不良反应发生率、生活质量评价量表（SF-36）评分。结果：（1）观察组愈显率为71.67%,对照组愈显率为53.33%,观察组明显高于对照组（P＜0.05）;观察组总有效率为95.00%,对照组总有效率为83.33%,观察组明显高于对照组（P＜0.05）。（2）治疗前,对两组睡眠时间、入睡时间、睡眠质量、睡眠效率、日间功能障碍、睡眠障碍、睡眠药物评分以及总分进行对比（P＞0.05）;治疗后,两组上述评分均出现不同程度的降低,且观察组比对照组低（P＜0.05）。（3）治疗前,对两组DISS评分及HAS评分进行对比（P＞0.05）;治疗后,两组上述评分均出现不同程度的降低,且观察组比对照组低（P＜0.05）。（4）经过治疗,观察组出现恶心呕吐、头痛头晕、口苦、疲乏无力、肝肾功能异常等不良反应的概率为6.67%,对照组为3.33%,两组比较（P＞0.05）。（5）治疗前,对两组生活质量评分进行对比无差异（P＞0.05）;治疗后,评分升高,且观察组比对照组高（P＜0.05）。结论：固本健脑安神方联合针灸治疗慢性失眠可明显提升愈显率和总有效率,改善睡眠障碍情况,提高日间脑功能状态,同时改善过度觉醒状态,促使患者生活质量得以提高,且安全性较高。     

Cross-sectional survey on risk factors for insomnia in Japanese female hospital nurses working rapidly rotating shift systems

A cross-sectional survey was carried out for the purpose of examining the association of work stress with insomnia among nurses working rotating shift systems. A self-administered questionnaire on sleep and mental health was distributed to 875 nurses at five hospitals in Japan. Out of the data from 785 (89.7%) respondents, those from 555 women engaged in rapidly and irregularly rotating shift systems as full-time nurses were examined. The prevalence of insomnia (29.2%) was three to four times higher than that in the general population. Among the insomniacs, 23% were current users of medically prescribed hypnotics. Multiple logistic analysis revealed that being 24 or less years old, working three or less night shifts per month, having six or less non-working days per month, receiving less support from colleagues and superiors, and taking care of severely ill patients were independent risk factors for insomnia. The number of hours of a night shift was found not associated with insomnia, taking the above variables into account. These results suggest that at least three factors, i.e., 1) young nurses not adapted to shiftwork, 2) the nurses requiring to remedy sleep deficits on non-working days, and 3) the work stress partly characteristic of nurses, have an adverse influence on their sleep.     

Metabolism during normal, fragmented, and recovery sleep.

Average metabolic data (O2 uptake and CO2 output) were obtained for each 3-min period during consecutive nights of normal, experimentally fragmented, and recovery sleep in a group of 12 normal young adult males. Naturally occurring arousals and awakenings resulted in a characteristic increase in metabolism on the baseline night. The placement of brief frequent experimental arousals on the following night resulted in significantly increased metabolism throughout the night and significantly decreased sleep restoration as measured by morning performance, mood, and alertness tests, even though total sleep time was minimally reduced. Metabolic variables were significantly decreased compared with baseline on the nondisturbed recovery night that followed the sleep fragmentation night. The data cannot be used to infer that increased metabolism during sleep causes nonrestorative sleep, but the direction and time course of metabolic change accompanying arousal are consistent with that hypothesis.     

Age-related reduction in the maximal capacity for sleep--implications for insomnia

Sleep changes markedly across the life span and complaints about insomnia are prevalent in older people [1]. Whether age-related alterations in sleep are due to modifications in social factors, circadian physiology, homeostatic drive, or the ability to sleep remains unresolved. We assessed habitual sleep duration at home and then quantified daytime sleep propensity, sleep duration, and sleep structure in an inpatient protocol that included extended sleep opportunities covering 2/3 of the circadian cycle (12 hr at night and 4 hr in the afternoon) for 3-7 days in 18 older and 35 younger healthy men and women. At baseline, older subjects had less daytime sleep propensity than did younger subjects. Total daily sleep duration, which was initially longer than habitual sleep duration, declined during the experiment to asymptotic values that were 1.5 hr shorter in older (7.4 +/- 0.4 SEM, hour) than in younger subjects (8.9 +/- 0.4). Rapid-eye-movement sleep and non-rapid-eye-movement sleep contributed about equally to this reduction. Thus, in the absence of social and circadian constraints, both daytime sleep propensity and the maximal capacity for sleep are reduced in older people. These data have important implications for understanding age-related insomnia.     

Insomnia: zolpidem extended-release for the treatment of sleep induction and sleep maintenance symptoms

Insomnia impairs daytime functioning or causes clinically significant daytime distress. The consequences of insomnia, if left untreated, may contribute to the risks of developing additional serious conditions, such as psychiatric illness, cardiovascular disease, or metabolic issues. Furthermore, some comorbidities associated with insomnia may be bidirectional in their causality because psychiatric and other medical problems can increase the risk for insomnia. Regardless of the serious consequences of inadequately treated insomnia, clinicians often do not inquire into their patients' sleep habits, and patients, in turn, are not forthcoming with details of their sleep difficulties. The continuing education of physicians and patients with regard to insomnia and currently available therapies for the treatment of insomnia is, therefore, essential. Insomnia may present as either a difficulty falling asleep, difficulty maintaining sleep, or waking too early without being able to return to sleep. Furthermore, these symptoms often change over time in an unpredictable manner. Therefore, when considering a sleep medication, one with efficacy for the treatment of multiple insomnia symptoms is recommended. A modified-release formulation of zolpidem, zolpidem extended-release, has been approved for the treatment of insomnia characterized by both difficulty in falling asleep and maintaining sleep. Here, we review studies supporting the use of zolpidem extended-release in the treatment of sleep-onset and sleep maintenance difficulties.     

Automatic analysis of sleep using two parameters based on principal component analysis of electroencephalography spectral data

A computer program for the analysis of a sleep electroencephalogram (EEG) is presented. The method relies on two steps. First, a spectral analysis is performed for signals recorded from one or more electrode locations. Then, two EEG parameters are obtained by storing the spectral activity in a multidimensional space, whose dimension is reduced using principal component analysis (PCA) techniques. The main advantage of these parameters is in describing the process of sleep on a continuous scale as a function of time. Validation of the method was performed with the data collected from 16 subjects (8 young volunteers and 8 elderly insomniacs). Results snowed that the parameters correlate highly with the hypnograms established by conventional visual scoring. This signal parametrisation, however, offers more information regarding the time course of sleep, since small variations within individual sleep stages as well as smooth transitions between stages are assessed. Finally, the concurrent use of both parameters provides an original way of considering sleep as a dynamic process evolving cyclically in a single plane.     

Sleep and sleepiness among Brazilian shift-working bus drivers

The aim of this study was to evaluate daytime and nighttime sleep, as well as daytime and nighttime sleepiness of professional shift-working bus drivers. Thirty-two licensed bus drivers were assessed by nocturnal and diurnal polysomnography (PSG) recording and multiple sleep latency testing (MSLT) sessions. Sleep length was shorter and sleep efficiency reduced during daytime sleep compared with nighttime sleep. Thirty-eight percent of the drivers had indices of obstructive apnea and hypopnea syndrome (>5/h sleep) during nighttime and daytime sleep; more drivers snored during daytime than nighttime sleep (50% vs. 35%, p < 0.05), and 38% of the drivers evidenced periodic leg movements. The MSLT revealed that 42 and 38% of the bus drivers met the criteria for sleepiness when the test was conducted during the day and night, respectively. The daytime as compared to nighttime sleep of shift-working bus drivers was shorter and more fragmented and was associated in many with evidence of excessive sleepiness. Respiratory disorder was a common finding among the professional shift-working bus drivers. All these sleep deficiencies may adversely affect on the job driving performance.     

The Difference Between Activity When in Bed and out of Bed. III. Nurses on Night Work

Eight nurses have been studied during rest days and three successive night shifts. Measurements of wrist activity have been made and used to assess the extent to which the pattern of daily activity changes between control (rest) days and days involving night work. One analysis considered wrist activity during time spent in bed; this appears to decrease in parallel with the amount of time in bed that is lost during night work but, when this effect is corrected for, there is greater activity during time spent in bed in the daytime compared with control days (when time in bed is during the night). The dichotomy of activity (between lower values during time spent in bed and higher values when out of bed) also decreases if time in bed is during the daytime while on night shifts. These changes in the amount of wrist activity and the dichotomy between activity in and out of bed are related to the changed quality and quantity of sleep that has been measured by self-report questionnaires and the sleep EEG. It is concluded that results from wrist actimetry can provide valuable information regarding the process of adjustment to night work, and that its convenience (to subject and experimenter), coupled with the new analytical approaches described here, make it a viable method for field studies. (Chronobiology International, 13(4), 273-282, 1996)     

Cumulative Association of Obstructive Sleep Apnea Severity and Short Sleep Duration with the Risk for Hypertension

Obstructive sleep apnea (OSA) and short sleep duration are individually associated with an increased risk for hypertension (HTN). The aim of this multicenter cross-sectional study was to test the hypothesis of a cumulative association of OSA severity and short sleep duration with the risk for prevalent HTN. Among 1,499 patients undergoing polysomnography for suspected OSA, 410 (27.3%) previously diagnosed as hypertensive and taking antihypertensive medication were considered as having HTN. Patients with total sleep time (TST) <6 h were considered to be short sleepers. Logistic regression procedures were performed to determine the independent association of HTN with OSA and sleep duration. Considering normal sleepers (TST ≥6 h) without OSA as the reference group, the odds ratio (OR) (95% confidence intervals) for having HTN was 2.51 (1.35–4.68) in normal sleepers with OSA and 4.37 (2.18–8.78) in short sleepers with OSA after adjustment for age, gender, obesity, diabetes, depression, current smoking, use of thyroid hormones, daytime sleepiness, poor sleep complaint, time in bed, sleep architecture and fragmentation, and study site. The risk for HTN appeared to present a cumulative association with OSA severity and short sleep duration (p<0.0001 for linear trend). The higher risk for HTN was observed in short sleepers with severe OSA (AHI ≥30) (OR, 4.29 [2.03–9.07]). In patients investigated for suspected OSA, sleep-disordered breathing severity and short sleep duration have a cumulative association with the risk for prevalent HTN. Further studies are required to determine whether interventions to optimize sleep may contribute to lower BP in patients with OSA.