bio behavioral tools

1. Bio Behavioral Tools Ms Rae Tattenbaum, MSW, LCSW Director, Inner Act Center BCIA EEG Fellow Chair: AAPB Optimal Functioning Section Instructor, University of Hartford

2. Who? Consultant, Bio Behavioral Tools, Insomnia Programs Director, Inner Act Training programs that are technology based Training Programs enhance: Professional achievement Stress, anxiety and depression management Sleep Management

3. Objectives Define Bio Behavioral management (BBM) Cognitive Behavioral management and BBM Describe the tools and how used Issues in using them Provide an overview of utility of BBM in sleep disorders Involve participants in hands-on experience

4. Cognitive Therapy Based on the observation that people with insomnia have negative thoughts and beliefs about their condition and its consequences. Challenging these beliefs can decrease anxiety and arousal associated with insomnia. Cognitive restructuring focuses on catastrophic thinking and the belief that poor sleep will have devastating consequences. These beliefs are challenged with evidence collected by the patient of how often these horrible consequences have occurred (not often).

5. Cognitive-Behavioral Treatment of Insomnia

6. Progression of Transient to Chronic Insomnia (�Learned Insomnia�) Transient insomnia, if unaddressed, can become �learned insomnia� with chronic symptoms. A typical scenario involves a patient under duress. A patient who may be predisposed to insomnia during a stressful period would become frustrated trying to sleep. Frustration would build, until an overwhelming concern with sleep actually prevents sleep from occurring. [DSM-IV-TR, p. 599-B; Hauri, p. 19-B; ICD-10, p. 182; Spielman, pp. 543, 547] Evidence suggests that hyperarousal may be a key component of insomnia. Although patients with insomnia would be expected to demonstrate classic signs of sleep deprivation, patients with chronic insomnia may actually be less sleepy during the day than normal sleepers. Furthermore, while sleep-deprived patients are usually lethargic, patients with chronic insomnia are often tense and worried and exhibit an increase in metabolism, body temperature, and serum cortisol levels. [Hauri, pp. 17, 19-A; Vgontzas, pp. 3787, 3791] Spielman AJ, Caruso LS, Glovinsky PB. A behavioral perspective on insomnia treatment. Psychiatr Clin North Am. 1987;10:541-553. Hauri PJ. Psychological and psychiatric issues in the etiopathogenesis of insomnia. Prim Care Companion J Clin Psychiatry. 2002;4(suppl 1):17-20. American Psychiatric Association. Sleep disorders. In: Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed, Text Revision. Washington, DC: American Psychiatric Publishing, Inc; 2000:597-662. Vgontzas AN, Bixler EO, Lin HM, et al. Chronic insomnia is associated with nyctohemeral activation of the hypothalamic-pituitary-adrenal axis: clinical implications. J Clin Endocrinol Metab. 2001;86:3787-3794. World Health Organization. F50-F59: Behavioural syndromes associated with psychological disturbances and physical factors. The International Statistical Classification of Diseases and Related Health Problems, 10th revision: ICD-10. Geneva, Switzerland: World Health Organization; 1992:174-197.Transient insomnia, if unaddressed, can become �learned insomnia� with chronic symptoms. A typical scenario involves a patient under duress. A patient who may be predisposed to insomnia during a stressful period would become frustrated trying to sleep. Frustration would build, until an overwhelming concern with sleep actually prevents sleep from occurring. [DSM-IV-TR, p. 599-B; Hauri, p. 19-B; ICD-10, p. 182; Spielman, pp. 543, 547] Evidence suggests that hyperarousal may be a key component of insomnia. Although patients with insomnia would be expected to demonstrate classic signs of sleep deprivation, patients with chronic insomnia may actually be less sleepy during the day than normal sleepers. Furthermore, while sleep-deprived patients are usually lethargic, patients with chronic insomnia are often tense and worried and exhibit an increase in metabolism, body temperature, and serum cortisol levels. [Hauri, pp. 17, 19-A; Vgontzas, pp. 3787, 3791] Spielman AJ, Caruso LS, Glovinsky PB. A behavioral perspective on insomnia treatment. Psychiatr Clin North Am. 1987;10:541-553. Hauri PJ. Psychological and psychiatric issues in the etiopathogenesis of insomnia. Prim Care Companion J Clin Psychiatry. 2002;4(suppl 1):17-20. American Psychiatric Association. Sleep disorders. In: Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed, Text Revision. Washington, DC: American Psychiatric Publishing, Inc; 2000:597-662. Vgontzas AN, Bixler EO, Lin HM, et al. Chronic insomnia is associated with nyctohemeral activation of the hypothalamic-pituitary-adrenal axis: clinical implications. J Clin Endocrinol Metab. 2001;86:3787-3794. World Health Organization. F50-F59: Behavioural syndromes associated with psychological disturbances and physical factors. The International Statistical Classification of Diseases and Related Health Problems, 10th revision: ICD-10. Geneva, Switzerland: World Health Organization; 1992:174-197.

7. Behavior Changes Combination with pharmacotherapy appears to solidify treatment outcomes Inherent attitudes and values about cognitive behavior tools Compliance issue Mirroring professional�s expectations Routine similar to dieting/abstinence

8. Biobehavioral Management Just like re-teaching how to sleep relies on intrinsic ability, bio behavioral management re-teaches inherent ability to reduce arousal The techniques are selected and monitored by technology providing �feedback�. Any technique with which the patient is comfortable can be used

9. Distinctions Examples of relaxation techniques that you may be already using include progressive muscle relaxation, deep breathing and autogenic training. Using different forms of biofeedback such as Heart Rate Monitor or Neurofeedback. The technology helps select the best tool and monitors it�s effectiveness.

10. Biobehavioral Management The technique should: elicit the Relaxation Response allow direct, real-time feedback be easy to learn and practice in a short time period identify unprocessed feeling and events that become activated.

12. Biobehavioral Management Involves any or all of the following tools: Deep Relaxation Training Biofeedback techniques A specialized type of biofeedback, Neurofeedback

13. Progressive Muscle RelaxationJacobson Detect, attend to and systematically tense up and then release tension in various muscle groups. Client learns to distinguish sensations of tension and relaxation Tensing up muscles sets the stage for a relaxation.

14. Autogenics (Schultz) Thinking about physical sensations related to physical relaxation can often evoke relaxation Hypnosis is an inner ability that patients are permitted to unfold. Sequential program repeating suggestive phrases.

15. The Relaxation Response/ Herbert Benson�60s Counterbalancing mechanism to the stress response or a reversal of genetic and cellular stress response Changes the physical and emotional responses to stress metabolism decreases heart beats slower muscles relax breathing becomes slower blood pressure decreases nitrous oxide increases

16. The Relaxation Process Quiet place Close your eyes.� Breathe easily and normally, � Select a word: "calm", "peace" , "sunshine" or even "relax� In your mind, say your word to as you breathe out.� 10-15 minutes twice a day away from sleep time

18. Obstacles Intrusive thoughts Child in toy store Squatters taking up residence Neurophysiological response Passive observation Q and A Office Monitor Heart Tracing (HRV)

20. Balancing all systems The main difference in this state is that sustained positive emotions lead to the coherent state. Points to cover: Mind and emotions can be out of phase - give examples Breathing alone can calm emotions due to change in afferent patterns, put does not lead to positive feelingsThe main difference in this state is that sustained positive emotions lead to the coherent state. Points to cover: Mind and emotions can be out of phase - give examples Breathing alone can calm emotions due to change in afferent patterns, put does not lead to positive feelings

21. Coherence Balanced oscillatory activation of the sympathetic/parasympathetic �Centering� of the EEG to the alpha state which supports integration of diverse cortical and subcortical regions. Psycho-physiological state of safety with activation of the social engagement system increases permeability of interpersonal boundaries with spontaneous increase in expression�

22. Coherence Dissipation of pathologically stored excess energy in the system. Putting a system at its resonant frequency creates a portal for energy transfer e.g. hit a metal pipe on a rock and the kinetic energy leaves as a tone at the resonant frequency.) Turns off stress response (HPA axis). 23% reduction in cortisol after four weeks. McCraty

23. Changing Heart Rhythms � Emotions affect the heart rhythms. Our changing heart rhythms affect not only the heart but the signals sent to the brain affecting our capacity to perceive, learn, act, feel, and utilize and synthesize information. � Frustration causes the heart to speed up and slow down in a uncoordinated and inefficient way. � Incoherent, non-synchronous neural processing occurs. Brain function is restricted to the lower levels of the brain. � A feeling like Appreciation causes harmony in the heart rhythms. We can think clearly, manage our emotions, and creatively solve problems. Reaction speed increases. Changing Heart Rhythms � Emotions affect the heart rhythms. Our changing heart rhythms affect not only the heart but the signals sent to the brain affecting our capacity to perceive, learn, act, feel, and utilize and synthesize information. � Frustration causes the heart to speed up and slow down in a uncoordinated and inefficient way. � Incoherent, non-synchronous neural processing occurs. Brain function is restricted to the lower levels of the brain. � A feeling like Appreciation causes harmony in the heart rhythms. We can think clearly, manage our emotions, and creatively solve problems. Reaction speed increases.

24. Types of Neurofeedback Training Approaches QEEG (brain map) driven protocols Protocols designed to target specific EEG frequencies Systems that entrain and migrate the EEG frequencies Global, comprehensive, adaptive based on non-linear dynamics

25. Non-linear neurofeedback system applies a different principle Does not involve subjects practicing or thinking to perform a particular act Subconscious information processing Invokes the orienting response to interrupt faulty EEG patterns Non-traditional forms of Neurofeedback

26. Speaking to The Brain NeuroOptimal speaks the language of the brain The brain uses visual and auditory information offered by the software to reorganize itself and release old patterns of �stuckness� (worry, fear trauma anxiety, inattention, rage. The brain gets information about what it has just done. The brain uses this information to reorganize itself and when it does- a whole lot of issues drop away.

27. Effects Effortless transformation with unwanted effects. Concerns and fears drop away. The feeling of clarity and presence in their daily lives. Experiencing greater focus and awareness.

28. Neurofeedback with NeurOptimal? Two sensors are pasted one to each side of the scalp and referenced to sensors on same side ear lobe The sensors allow brain activity to be monitored EEG synchronized to music heard over headphones which play favorite music

30. Neurofeedback training sessions The software responds to shifts in attention, arousal, thoughts, feeling During the training session, the system detects increased variability in the EEG spectrum and briefly interrupts the music and the images on the screen There is a very brief interruptions in both the music and visual feedback As the EEG spectrum variability remains low the music and the images on the screen are continuous The interruption tells the CNS what it has just done-that something has just happened

33. Easy to implement for trainer Clients not required to actively participate Clients more readily participate in other aspects of program, eg visualization Clients appear to �buy into� the entire program Advantages of Non-linear Neurofeedback

34. Result table

35. The Influence of Sleep Drive, Circadian Rhythm and Arousal/Stress on Alertness Sleep load or drive begins to accumulate the moment wakefulness occurs. This drive is also called the homeostatic sleep process, a process which is correlated with cortical levels of extracellular adenosine. Sleep dissipates adenosine levels, as well as the drive for sleep. Incomplete dissipation of the homeostatic pressure for sleep occurs with sleep restriction/sleep deprivation. Circadian Rhythm: the timing of wakefulness onset is governed by the Suprachiasmatic nucleus (SCN) Light in the am anchors this timing. In addition to timing, the SCN provides an alerting drive that opposes the accumulating homeostatic sleep pressure across the day.- During the afternoon, this alerting drive backs off transiently, hence the �seista� period. At the time for sleep set by the clock, the alerting drive rapidly declines, leaving the unopposed homeostatic pressure to facilitate sleep onset. Sum = wake propensity Sleep load or drive begins to accumulate the moment wakefulness occurs. This drive is also called the homeostatic sleep process, a process which is correlated with cortical levels of extracellular adenosine. Sleep dissipates adenosine levels, as well as the drive for sleep. Incomplete dissipation of the homeostatic pressure for sleep occurs with sleep restriction/sleep deprivation. Circadian Rhythm: the timing of wakefulness onset is governed by the Suprachiasmatic nucleus (SCN) Light in the am anchors this timing. In addition to timing, the SCN provides an alerting drive that opposes the accumulating homeostatic sleep pressure across the day.- During the afternoon, this alerting drive backs off transiently, hence the �seista� period. At the time for sleep set by the clock, the alerting drive rapidly declines, leaving the unopposed homeostatic pressure to facilitate sleep onset. Sum = wake propensity

36. Chronic partial sleep loss is cumulative and attention, alertness and performance suffer The major brain control centers for executive function and cognition go offline without sufficient sleep There is very little �brain� left to respond to training protocols There is a major need for healthy sleep awareness underlying optimal performance NF training can improve sleep and, consequently, optimal function SUMMARY Conclusions, no notes Conclusions, no notes

37. Contact Rae Tattenbaum, MSW, LCSW Director Inner Act 10 North Main Street West Hartford, Conn 06107 Web Site: www.inner-act.com 860 561-5222