AAPB White Paper
Insomnia Treatment in Baltimore, MD
Sonia Ancoli-Israel, Ph.D.

Insomnia is a very prevalent complaint among Americans. Surveys have indicated that about one-third of adults experience occasional or chronic insomnia.The most frequently experienced problem of insomniacs is waking up feeling tired. Insomnia however has other serious consequences such as memory problems, relationship problems, difficulty concentrating and daytime fatigue and sleepiness.

Insomnia can be transient or chronic. Transient insomnia lasts less than two weeks. This type of insomnia is usually not seen by the practitioner since it resolves by itself. If a patient has episodic transient insomnia, i.e., repetitive episodes of transient insomnia, then the patient may seek help from the clinician. Chronic insomnia refers to continuing difficulty with sleep and is most likely to be seen by the clinician.

Insomnia is not a sleep disorder. Rather, insomnia is a complaint of trouble falling asleep, trouble staying asleep or both. This complaint can be caused by many different factors, including medical illness (e.g., pain, arthritis, nocturia, heart failure), pharmacology (e.g., any drug with depressing or stimulating side-effects including alcohol), psychiatric illness (e.g., affective disorder, anxiety disorder, schizophrenia), circadian rhythm disturbances (e.g., advanced or delayed sleep phase), sleep disorders (e.g., sleep disordered breathing or periodic limb movements in sleep) and behavioral problems.

Behavioral causes of insomnia include excess muscular tension, anxiety, mental stress and physical stress. One of the most common forms of insomnia is psychophysiological insomnia. Psychophysiological insomnia is caused by increased cognitive activation which prohibits sleep. Patients usually have a transient anxiety provoking situation which causes sleep difficulty on the first night. On the second night, the patient feels he has to get to sleep, and the harder he tries, the tenser he gets and the more difficult it is to fall asleep. After several nights of difficulty sleeping, the patient develops conditioned arousal to his bedroom and bed as well as performance anxiety about falling asleep.

Poor sleep hygiene is another major contributing factor to insomnia. Poor sleep hygiene includes irregular sleep schedules, excessive napping, caffeine and alcohol use, mental stimulation near bedtime and negative sleep associations (paying bills in bed; watching scary movies or the news in bed; reading murder mysteries in bed).

The recommended treatment for insomnia is behavioral treatment. This would include teaching good sleep hygiene techniques in conjunction with a behavioral treatment. Behavioral treatments include stimulus-control therapy, sleep restriction therapy, and relaxation therapy. Biofeedback is one of the forms of behavioral treatment that has been shown to improve the sleep of insomniacs.

Several types of biofeedback training treatments have been studied. Frontal electromyogram (EMG) biofeedback had been used in insomniacs with muscular tension. Theta EEG training has been used to improve relaxation and promote sleep. Sensorimotor rhythm (SMR) EEG training has been used to increase or strengthen 12-14 cycle per second sleep spindle activity.

The major conclusion that can be drawn from the different biofeedback studies is that different types of biofeedback are effective for different types of insomnia. Relaxation training (with EMG or temperature feedback) is most effective with psychophysiological insomniacs who are tense. SMR feedback is most effective with psychophysiological insomniacs who are already relaxed. Theta EEG feedback is also most effective with psychophysiological insomniacs who are anxious.

In conclusion, insomnia is a complaint that is very prevalent and has debilitating effects. Behavioral treatments can be very effective for chronic psychophysiologic insomnia. Biofeedback can be used as an adjunctive treatment with insomniacs, when the appropriate type of feedback is matched to the appropriate insomniac group.

Ancoli-Israel, S., Seifert, A.R. and Lemon, M. Thermal biofeedback and periodic movements in sleep: Patients' subjective reports and a case study. Biofeedback and Self-Regulation. 11:177-88, 1986.

Barowsky, E.I., Moskowitz, J. and Zweig, J.B. Biofeedback for disorders of initiating and maintaining sleep. Annals New York Academy of Science. 602:97-103, 1990.

Besner, H.F. A comparison of selected biofeedback techniques in treating chronic onset insomnia. Nova University, Ft. Lauderdale, Florida: Unpublished doctoral dissertation, 1975.

Coursey, R. Frankel, B. and Gaarder, K. EMG biofeedback and autogenic training as relaxation techniques for chronic sleep-onset insomnia. Biofeedback and Self-Regulation. 1:353, 1976.

Hauri, P. Biofeedback techniques in the treatment of chronic insomnia. In: Williams, and Karacan, I. (eds.) Sleep Disorders: Diagnosis and Treatment. John Wiley & Sons, Inc. 1978, pp. 145-59.

Hauri, P. Treating psychophysiologic insomnia with biofeedback. Archives of General Psychiatry. 38:752-58, 1981

Hauri, P.J., Percy, L., Hellekson, C., Hartmann, E. and Russ, D. The treatment of psychophysiologic insomnia with biofeedback: A replication study. Biofeedback and Self-Regulation. 7:223-35, 1982.