A New Look at an Old Workhorse A Pilot Study of Z Score Sensorimotor amp Individualized Neurofeedback See full text at Hammer BU Colbert AP Brown KA and Ilioi E C 2011 Neurofeedback for Insomnia A Pilot Study of ZScore SMR and Individualized Protocols Appl ID: 703839
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Slide1
Neurofeedback for Insomnia
A New Look at an Old Workhorse: A Pilot Study of
Z
-Score Sensorimotor & Individualized Neurofeedback
See full text at: Hammer, B.U., Colbert, A.P., Brown, K.A. and Ilioi, E. C. (2011). Neurofeedback for Insomnia: A Pilot Study of Z-Score SMR and Individualized Protocols. Appl.
Psychophysiol
Biofeedback, DOI 10.1007/s10484-011-9165-y
Email: barbhammer37@yahoo.comSlide2
Barbara U. Hammer, Ph.D., Agatha P. Colbert, MD
,
Kimberly A. Brown, MSOM, Helfgott Research Institute, National College of Natural Medicine, Portland, OR, Elena C. Ilioi, Psychology Honours, McGill University, Montreal, Quebec, Canada
The authors are grateful to the Helfgott Research Institute of the National College of Natural Medicine in Portland, Oregon for its generous support of this research. We are especially appreciative of the help from Mark L. Smith and Nancy Wigton on the design of the protocols, William Gregory and Heather Jaskirat Wild for her assistance
with the
data analysis, and the generous support of our research assistants, Sean E. Griffith and Tineke Malus. We thank all those who participated in this study, including those who took the time to complete the telephone screening and the extended screening sessions but who were not offered the opportunity to continue and to receive treatment.
Slide3
Insomnia Definition
Primary Insomnia (DSM 307.44)
:
Complaints of Difficulty Falling Asleep, Staying Asleep or Awakening too early, or Non-restorative Sleep which occurs for at least one month and:
1. Causes significant distress or impairment in social, occupational, or other important areas of functioning.
2. Does not occur exclusively during the course of Narcolepsy, Breathing-Related Disorder, Circadian Rhythm Sleep Disorder or a
Parasomnia
.
3. Does not occur exclusively during the course of another mental disorder.
4. Is not due to the direct physiological effects of a substance or general medical condition
.
Slide4
2005 NIH Conference on Insomnia declared Insomnia
an
Epidemic:20-30% of adults in the U.S. suffer from Insomnia\
Insomnia associated
with
increased
Illness, accidents, healthcare utilization, and industrial expenses
Costs estimated at $14-80 billion annually
Pharmacotherapy limited due to negative
side effectsSlide5
Psychological treatments
highest co-morbidity
Insomnia
persists despite psychotherapy for
depression
or
anxiety
Cognitive
Behavior Therap
y
—
demonstrated
70% efficacy , effectiveness, efficiency for
treatment of
Insomnia but seldom used
difficult to
administer requiring specialized training/many sessions
Challenges remain primarily in service delivery system.
Internet based program promising
Neurofeedback
SMR
from Sterman 1960’s to Hauri (1980’s
)=cats to humans, improved
sleep
Theta
benefitted tense insomniacs
Individualized
studied hereSlide6
Peter Hauri (9/2008):
SMR
Neurofeedback in 1980’s used Analog Equipment not feasible for general clinical use
:
Too Expensive
Too Cumbersome
Too Time consuming
Time
to revisit SMR for Insomnia with Digital equipment and new training methods
.
Slide7
Pilot Study Overview
:
IRB approved 8/2008
Purpose
–Compare treatment effects of
Z score NFB
SMR & sequential, quantitative EEG (sQEEG) guided Individually Designed (IND) protocols for Rx of Insomnia.
Methods
–
Eight completed single-blind study
.
Intervention
–Fifteen 20-minute
sessions
Z-Score
NFB.
Pre-treatment Screening—Medical History Questionnaire
Psychiatric Diagnostic Screening Inventory (PDSQ)
plus:
Pre-post measures
–
Insomnia
Severity Index (ISI
)
Pittsburgh Sleep Quality Index (PSQI
)
Psychopathology (MMPI-2-RF)
Clinical Interview Satisfaction/Happiness Quality of Life Index (QOLI)
sQEEGSlide8
PARTICIPANTS:
25+
Telephone Screening –unpaid, recruited over 4 months
Exclusions
—use of sleep aids, psychotropic meds,
meds that impact sleep, mental disorders, physical
disorders that
could
interfere
,
prior
NFB
,
enrolled
in another sleep
study
,
pregnant or shift worker
12
Selected/Met DSM 307.44 criteria
2 Declined to
start due to
personal/extraneous reasons
2 Dropped
out due to personal/external
reasons >8 visitsSlide9Slide10
Sleep Measures
ISI=
Insomnia Severity Index--
Perceived
Severity
of Symptoms
+ Daytime
Dysfunctions for past 1-2
weeks
PSQI=Pittsburgh Sleep Quality Inventory--
General Sleep Disturbance
+ Daytime
Dysfunctions for
past
1
month
Daily Sleep
Diaries=
from
Screening Visits to Post Testing--
recordings of bedtime, rising time, estimated latency, WASO, TST, Sleep Quality 1-10, adverse events or unusual
circumstances
Actiwatch=
72
hours pre and post treatmentSlide11
Measures of Daytime Functioning
MMPI-2
RF
-
Most
widely researched, used measure of psychopathology. Newest version
Psychiatric Diagnostic
Screening-
Questionnaire-
PDSQ—Guide to depth clinical interview to confirm absent Dx
Quality of Life Index-QOLI—
Measures positive
mental health=daytime
function
Slide12
Objective Physiological Measures
sQEEG=Quantitative
Electroencephalogram
Profiles
the brain’s electrical functioning
in direct comparison
with normative
database (NeuroGuide).
Like
other direct physiological measures, such as blood sugar, lipids or liver enzymes, the EEG
has
demonstrated high
reliability
Actiwatch
-
Numerous technical difficulties invalidated useSlide13
sQEEG—EEG General Screening
Records several minutes at 4 scalp sites in
5 runs for total of 19 of 10/20 sites
Records overall synchrony measures
between
each set of 4 sites
BrainMaster Certified
Calibration tested EEG
amplifier
for
NFB/QEEGSlide14
NFB=Operant Conditioning to Norm
Training to Norm =Normalizing physiological process
via self-regulating brainwave distribution
Based on Principles of Learning via
Operant Conditioning
Z-Score
NFB designed to use Live, Instantaneous record as basis of ReinforcementSlide15
Experimental Groups
Group 1—
Z-Score Individualized Protocol (IND) = Normalized 4 highest abnormal site(s) (HAS4) via reward of correct enhancement or inhibition of variables > ±1.96
Z
, at increasingly larger percentage of normal
Z
scores. Modified PZOKUL.
Group 2—
Z
-Score SMR Protocol (SMR) =
Training at Cz and C4, LE, reward production of SMR (12-15Hz) & inhibition of excessive theta & high beta, & all other amplitudes & connectivity measures within normal. Modified PZOKUL .
General Training Procedure =
I
nitial % of all variables in the normal range =50% raised as % Time >80
Z
scores normal. When % variables >80,
Z
score limit was reduced as far as possible.
Slide16Slide17
Success of Training
All subjects reached training goal of 80% correct within normal range for 80% of the training time.
Four of 5 in SMR improved SMR Z-scores (toward 0) at training sites ANOVA Age, sex, PDSQ, Group not significant covariates.
Groups combined for all measures.
Pre-Post Significant Changes
Significant improvement on all primary sleep measures. See Table 2 & 3, Figs 2 & 3
Sleep Efficiency above diagnostic cutoff Post treatment
WASO significantly improved in half.
QOLI significantly improved
MMPI clinical improvement
sQEEG significant lowering of Delta (sleepiness) & Beta (arousal) Table 4
Six month Follow-up
Six of 8 responded
Five of 6 remained free of insomnia, one returned to baseline, 3 improved from baseline
Slide18Slide19Slide20Slide21Slide22Slide23Slide24
Actiwatch—
72 Hour data pre-post with Multiple Technical
Difficulties Prevented Analysis
Click sound inaudible
Possibly defective
recording hardware
Possibly defective
recording software
Vender suggested corrections via
Sleep Log
questionable
User
errors discovered
too late
to re-trainSlide25
Adverse
Events
None
reported
__________________________
Two drop-outs
Unexpected life-style changes
(trauma induced) interfering
with treatment scheduleSlide26
Conclusions
:
Baseline EEGs showed both excessive sleepiness and hyperarousal, which significantly improved post-treatment.
Both NFB protocols provided significant improvement in self reported
sleep,
daytime
functioning, mental health, and sQEEG.
SMR treatment
at
least as effective as IND,
and
significantly less burdensome to administer
.Slide27
Discussion
Data replicates early
SMR studies with new equipment and advanced software/training
designs
Z score NFB possibly effective
at 8
Rx
sessions (160”) training time, possibly faster than traditional NFB & CBT
3) SMR at least as
effective
as
Individually designed protocol based on
sQEEG
4) Participants
improved on ALL self-report sleep
measures, quality of life, and mental healthSlide28
Discussion
(
continued)
All Participants became normal sleepers, relatively quickly
6)
Safe, well-tolerated,
non-pharmacological, Non-Invasive
7) SMR easily practiced clinicallySlide29
Limitations
:
Small Sample Size
Regression toward Mean
Lack of Control group
Single Blind
Design
Lack of useful Actiwatch/objective
sleep measure
Lack of EEG connectivity measures in
IND
Slide30
I love sleep. My life has the tendency to fall apart when I'm awake, you know?
Ernest Hemingway