Sleep and neurofeedback

Come Sleep! O Sleep, the certain knot of peace, 
The baiting-place of wit, the balm of woe, 
The poor man's wealth, the prisoner's release, 
Th' indifferent judge between the high and low. 
With shield of proof shield me from out the prease 
Of those fierce darts despair at me doth throw: 
O make in me those civil wars to cease; 
I will good tribute pay, if thou do so. 
Take thou of me smooth pillows, sweetest bed, 
A chamber deaf to noise and blind to light, 
A rosy garland and a weary head: 
And if these things, as being thine by right, 
Move not thy heavy grace, thou shalt in me, 
Livelier than elsewhere, Stella's image see.
-Sir Philip Sidney

The importance of sleep

Sleep is an important function of all living creatures, everyone in the animal kingdom has some variation of a sleep wake cycle. However why is sleep so important in humans? Research has shown that sleep has many functions.

Sleep helps us to consolidate what we have learned into memory through acquisition (information introduced to our brain), consolidation (the process of memorizing the information in the brain), and recall (information being brought up in any mental state). Those who have impaired sleep, can have impacts on memory and learning (Healthy Sleep, 2007).

Another example of the importance of sleep is its impact on mood. Having a good night sleep can lead to feeling energized, motivated, and content. In the reverse, impaired sleep or insomnia can lead to irritability, increased stress, or even the development of a mood disorder (Get Sleep, 2008).

Sleep also has an impact on body restoration. Certain hormones are released during sleep that is responsible for tissue repair and muscle growth. Another restorative factor sleep can assist in cognitive functioning, which may impact in learning and memory. Recent research has also found the importance of sleep on Neuroplasticity.

We previously believed in the idea that if we don’t use certain neurons through practice our brain loses the capacity to use it in the future (use or lose it principle). We now know that it isn’t true, as our brain has what is called Neuroplasticity, which the brain’s ability to form new neurological connections. We do this in everyday life, from learning something new (even if it is small), to sleep, to psychotherapy. We are making new neurological connections without realizing it! Proper sleep helps strengthen and these newer neurlogical connections.

Conditions that effect sleep

Knowing that sleep is very important and its impact that it can have on our brain, mind, and body, what happens when certain conditions impair sleep?

Mental Health CONDITIONS

There are several mental health conditions that can impact sleep. Anxiety, for example, can severely impact sleep. During the first part of the pandemic, many people were experiencing fear, uncertainty, stress, and many other emotions that naturally turned into anxiety. When one is feeling anxious their mind can race, especially while laying in bed trying to fall asleep. As a result of the anxiety, many individuals struggled to get enough sleep which could also further impact their mood.

Another symptom of anxiety that impacts sleep is hyperarousal, the state of being excessively alert. Therefore, when one is trying to sleep while also experiencing hyperarousal, they may be quick to awaken from even the smallest of stimuli (hearing a small thud from the apartment above, for example) and ready to react. 

Certain types of anxiety can also lead to nightmares. Post-Traumatic Stress Disorder and other anxiety and stress disorders can cause night terrors and nightmares that can impact a person’s relationship to sleep. Due to the fear of having night terrors or nightmares, one can also experience anticipatory anxiety.

Depression is another mental health condition that can impact sleep. Depression can impair sleep as well as sleep can impact depression. Due to this relationship, it can be difficult to know which condition caused which symptom. Depression is characterized by experiencing sleep-related symptoms of insomnia, hypersomnia, as well as having abnormal levels of Serotonin, a neurotransmitter that is important for regulation of sleep as well as other bodily functions. 

Medical conditions

There are also several medical conditions that impact sleep. In fact, there are several sleep disorders that can be treated with medication or devices, such as Sleep Apnea, a disorder that is related to breathing disruptions, and Narcolepsy, a sleep disorder related to regulation of the sleep-wake cycle. These are just a few types of sleep disorders, however there are many more conditions that fall under the umbrella of sleep disorders. There are also several chronic medical conditions that impact sleep.

Inflammatory chronic conditions such as, Arthritis, Fibromyalgia, and Inflammatory Bowel Diseases, can impair one’s sleep leading to the symptom of fatigue. Sleep disturbances can be a result of pain impacting one’s sleep, as pain is common in areas of inflammation. When someone is experiencing pain it can lead to mood dysregulation resulting in sleep disturbance conjointly with the the physical discomfort. Furthermore, research has shown that sleep disturbance can result in higher levels of C-Reactive Protein (CRP), a marker of inflammation, suggesting that sleep impairment and inflammation are directly correlated. 

Much like the aforementioned inflammatory conditions as well as cancer can impact one’s immunity. Our immune system is very important in our ability to fight off infections, and for those with a compromised immune system, contraction of infections can be regular occurrence or fear of contraction. Research has also found that sleep impacts immunity; when one has impaired sleep their immune system has difficulty fighting off infections. This also can further compound an already compromised immune system, leading to increased infections and overall feeling of being unwell, increased inflammation, and the cyclical nature of impaired sleep. (Simpson & Dinges, 2007).

Sleep Hygiene

Sleep hygiene is defined by the healthy habits one practices on a regular basis to promote restful sleep. The Sleep Foundation lists some great steps to improve sleep hygiene that is summarized below.

Setting a consistent sleep schedule

  • Go to bed and wake up at the same time everyday, regardless of weekend day
  • If you want to change your bedtime/wake up routine, make changes gradually
  • Try not to take as many naps; if you do take naps, have short 10-20 minute naps in the early afternoon

Have a bed time routine

  • Having a consistent bedtime routine can prep your mind for bedtime
  • Take 30 minutes to wind down before going to bed by doing something relaxing and not stimulating
  • Refrain form using electronics 30-60 minutes before bed, as the screens can be overstimulating to your brain
  • If you haven’t fallen asleep within 20 minutes of lying in your bed, get out of bed, do something relaxing, and then try again

Have healthy daily habits

  • Try and get some sunlight exposure to promote healthy circadian rhythm
  • Build a exercise/movement routine that is right for your ability
  • Limit smoking and alcohol consumption
  • Skipping on caffeinated beverages in the afternoon and evening
  • Try to eat and drink 2 hours before bed (be mindful of heaving/spicy meals); if you need to eat or drink something before bed try to make it small to not wake you up in the middle of the night
  • Regulate activity in bed to only sleep and sex

Having a restful and Relaxing environment

  • Having a bedpillow, and sheets that matches your comfort needs
  • Have a cool and dark sleeping environment
  • Have devices that block or drown out noise (i.e. ear plugs, noise cancelling machines, etc.) to not wake you in the middle of the night

Neurofeedback as a treatment strategy for sleep impairment

Now we know why sleep is important, what can affect sleep, and how we can improve sleep with proper sleep hygiene. But what if sleep hygiene isn’t enough to get a good night’s rest and there are more underlying issues that impact sleep. Therapy can be very helpful if the underlying symptom of sleep impairment originates from a mental health condition. However if there is a neurological reason for sleep challenges (either from mental health or medical conditions) a treatment strategy must address the neurological source of the disturbance. 

Neurofeedback is a form of biofeedback that encourages healthy neurological connections through the use of training one’s brain to effectively operate in specific conditions. Therefore, in regards to sleep, Neurofeedback training promotes healthy brain activity during the sleep state by regulating one’s brainwaves. 

In some cases, sleep and brain activity can be effected by the situation. In one study looking at college students with sleep onset insomnia, they found that poor sleepers had difficulty regulating their alpha brainwave. This suggested the use of neuro-regulating therapies to promote neuroflexibility (Buckelew et. al., 2013).

In another study that focused on the Central Nervous System, researchers studied the effects of electromyography tele-biofeedback versus tele-neurofeedback in subjects with insomnia. They found that not only does neurofeedback improved the amount of sleep in subjects, but also the efficacy of remote neurofeedback (Cortoos, 2010).

As previously mentioned, chronic health conditions can impact sleep, such as fibromyalgia, a condition where a patient experiences pain throughout their body and experience several other symptoms (including sleep disturbance and fatigue). In a study that researched the efficacy of neurofeedback in patients with fibromyalgia, researchers found that neurofeedback protocols that focused on alpha brainwave and sensorimotor rhythm regulation in an 8-week program produced significant results. Patients experienced sleep improvement and pain severity reduction (Wu, Fang, et al., 2021).

Neurofeedback is an evidence-based treatment strategy that does not utilize pharmaceutical intervention to treat sleep problems. In some cases, neurofeedback conjoint with behavioral modifications can drastically improve, if not alleviate, symptoms of fatigue due to sleep impairment.


Anxiety and Sleep, Suni, E., Sleep Foundation (March 2022).

Buckelew et. al, Neuroflexibility and Sleep Onset Insomnia Among College Students: Implications for Neurotherapy, Journal of Neurotherapy (2013). doi

Cortoos, A., De Valck, E., Arns, M. et al. An Exploratory Study on the Effects of Tele-neurofeedback and Tele-biofeedback on Objective and Subjective Sleep in Patients with Primary InsomniaAppl Psychophysiol Biofeedback 35, 125–134 (2010).

Get Sleep– Harvard Medical School

Gorgoni et. al., Is Sleep Essential for Neural Plasticity in Humans, and How Does It Affect Motor and Cognitive Recovery?. Hindawi, 2013. doi: 10.1155/2013/103949

Healthy Sleep– Harvard Medical School

Sleep Disorders, Rehman, A., Sleep Foundation (December 2020)

Sleep and Inflammation, Simpson & Dinges, Wiley (December 2007)

Yu-Lin Wu, Su-Chen Fang, Shih-Ching Chen, Chen-Jei Tai, Pei-Shan Tsai, Effects of Neurofeedback on Fibromyalgia: A Randomized Controlled Trial. Pain Management Nursing, Volume 22, Issue 6 (2021).

This month’s blog post was written by Aarti S. Felder, MA, LCPC, BCN, our Chronic Illness Specialist and Board Certified in Neurofeedback Therapist.

Attention Deficit Hyperactivity Disorder

What is Adhd?

Attention Deficit Hyperactivity Disorder is a complex neurodevelopmental disorder that is characterized by low production of dopamine in the prefrontal cortex.  The prefrontal cortex is in charge of what we call executive functions; planning, organizing, decision-making–all of the directing parts of the brain. Emotional regulation and reward pathways in the brain are also affected by individuals with ADHD. The diagnosis is further broken down into three different presentations: primarily inattentive, primarily hyperactive, or the combined type. Here’s a list of some of the symptoms to look for:

The inattentive symptoms (previously referred to as ADD) in the Diagnostic and Statistical Manual 5th edition (DSM-5) are:

  • Often fails to pay close attention to details or makes careless mistakes in schoolwork, at work, etc.
  • Often has trouble holding attention on tasks or activities (e.g., easily distracted)
  • Often does not seem to listen when spoken to directly
  • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, gets side-tracked)
  • Often has trouble organizing tasks and activities; has trouble finishing tasks
  • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time
  • Often loses things necessary for tasks and activities (e.g., school materials, wallet, phone, keys).
  • Often forgetful in daily activities
  • Often distracted by stimuli (e.g., sounds, movement)

The hyperactive/impulsive symptoms in the DSM-5 are:

  • Often fidgets with or taps hands/feet or squirms in seat
  • Often leaves seat in situations when remaining seated is expected (e.g., leaves place in the classroom, in meetings, etc.).
  • Often runs about or climbs in situations where it is inappropriate. In adolescents or adults, this may manifest as feeling restless
  • Often unable to play or engage in leisure activities quietly
  • Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to remain still for any extended time without significant discomfort; others may say that the person is restless, fidgety, or difficult to keep up with).
  • Often talks excessively
  • Often completes other people’s sentences or blurts out an answer before a question has been completed
  • Often has difficulty waiting for their turn (e.g., while waiting in line, while speaking in conversations).
  • Often interrupts or intrudes on others. For adolescents and adults, may intrude into or take over what others are doing (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission)

The combined type is diagnosed by the presence of an even mix of the symptoms. There are other criteria for this diagnosis which include symptoms lasting for a specific duration and having an impact on various domains of an individual’s life.

What are the Statistics

Approximately 5% of children and adolescents are affected by ADHD globally. In the U.S. 6.1 million children (9.4%) between the ages of 2 and 17 are estimated to be diagnosed with ADHD, with boys more likely to be diagnosed than girls (11.7% compared to 5.7%). The difference in the diagnosis of girls and boys is often due to the presenting symptoms and socialization of children. Girls are more often diagnosed with the inattentive presentation which is often missed in a classroom setting where most referrals for ADHD testing occur. 

While ADHD is considered a childhood disorder, 139.84 million adults have persistent ADHD with childhood onset (2.58% of the global population) and 366.33 million adults have symptomatic ADHD regardless of onset (6.76% of the global population) as of 2020. Because ADHD affects brain development, it manifests in all aspects of life and can significantly impair educational achievement, relationships (romantic, familial, friendships), employment, finances, etc. There are many common symptoms of ADHD (inattention, inability to focus, poor time management, weak impulse control, exaggerated emotions, hyperfocus) which are often seen as character flaws or bad parenting when the underlying cause is due to an individual’s specific brain functioning. This is also seen in difficulty with emotional processing.

Emotional dysregulation

One aspect of ADHD that has been recognized as a symptom for diagnosis in Europe and noted in research for at least two decades but is still not considered in the Diagnostic and Statistical Manual version 5, has been the emotional component of ADHD. About 70% of adults with ADHD report emotional dysregulation (ED), which has led to the term, DESR, or deficient emotional self-regulation, popping up in ADHD research, and other mental health conditions in which emotional dysfunction is a major component. This refers to a deficiency in the four components of self-regulation. These four components are the ability to inhibit behavior triggered by strong emotions, the ability to self-soothe and regulate strong emotions, the ability to refocus from events that cause strong emotion, and the ability to organize emotional responses. This emotional dysregulation greatly impacts a person’s ability to recognize and control the emotions that they are feeling which can lead to issues connecting with others, putting feelings aside to focus on something, and processing a difficult situation. This can be seen in rejection sensitive dysphoria. 

Rejection sensitive dysphoria (RSD) is a common manifestation of emotional dysregulation that is defined by an extreme emotional sensitivity and pain that is triggered by the idea that someone is being rejected or criticized by important people in their life or by the idea of failing to meet an expectation. While RSD is not caused by a trauma, the pain from it can be felt as a traumatic experience. When these feelings are internalized, they can imitate a mood disorder, and often leads to misdiagnosis of a major mood disorder. When these feelings are externalized, they can be like a sudden rage at the person or situation causing the pain. This can be a devastating ordeal that can lead to feelings of alienation. 

Comorbidities with adhd

People with ADHD often have other co-occurring mental health conditions. According to the CDC almost 64% of children with ADHD have at least one other mental health condition: 52% have behavioral health or conduct problems, 33% have anxiety disorders, 17% have depression, 14% have been diagnosed with autism spectrum disorder, and 1% have Tourette syndrome. 

In adults as many as 80% of people with ADHD have at least one co-occurring mental health condition. It is estimated that rates of comorbid bipolar disorder in adults with ADHD are between 5.1% and 47.1%, about one-fifth to one-half of adults with ADHD have major depressive disorder/dysthymia, about 50% of individuals with ADHD have some type of anxiety disorder, personality disorders are present in more than 50% of adults with ADHD, and research shows that 25% to 40% of adults with substance use disorder also have ADHD. Having multiple mental health conditions can make it harder to identify the source of a condition and the best way to approach treatment. When talking about ADHD, we expect it to present as primarily hyperactive/impulsive and this can also lead to issues in beginning treatment. Women and girls are often misdiagnosed or underdiagnosed in ADHD because they primarily present in the inattentive type. The classroom setting is most often where ADHD is first noticed, but with the inattentive type it is often less disruptive to the classroom so is less likely to get someone referred for treatment. Also in female students the behaviors that would often get male students categorized as ADHD get labeled as “airheaded” or a “chatterbox” or “flighty.”  They also are socialized to behave in ways that more easily mask their symptoms, such as spending more time on school work, which can lead to other problems when they are unable to manage emotionally or socially in the ways they are expected to. This can be stigmatizing when they are unable to perform the way they are expected to and can lead to perfectionism, social withdrawal, low self-esteem, and negative self-talk. 

The future of adhd

In current ADHD research there is looking into changing the name to better reflect the complex of the condition. One proposed future name is variable attention stimulus trait (VAST). This name comes from Edward Hallowell, M.D., John Ratey, M.D. who are leading researchers and wrote the book ADHD 2.0. Other areas of research are looking into better understanding the emotional aspects of the condition.

Treatment for adhd

When approaching treatment for ADHD, medication is the most well known and most stigmatized. It is an important treatment approach, because when people are on the right dosage of medication it greatly improves their lives. RSD can be greatly improved by medication management. 

Another treatment approach is ADHD/executive functioning coaching. This is a behavioral training that focuses on finding ways to deal with/externalize the executive functioning skills that are lacking. 

Therapy is another approach that helps build coping strategies, builds greater understanding of the areas in which a person is struggling, and can help a person learn ways of dealing with the emotional issues of ADHD.

Neurofeedback is another treatment that has been proven effective for ADHD. Neurofeedback, or EEG Biofeedback, is a technique that uses operant conditioning to train the brain to be more efficient (and is a service that we provide).

As we continue to learn more about ADHD and how to improve the quality of life of people who have the condition, we will continue to approach it by looking at the strengths that can be found in it. Here at TriWellness we can help. 


The Prevalence of Adult Attention-Deficit Hyperactivity Disorder: A Global Systematic Review and Meta-Analysis

Emotion Dysregulation in Attention Deficit Hyperactivity Disorder

Emotion Dysregulation in Adults with Attention Deficit Hyperactivity Disorder: a Meta-Analysis

Attention Deficit Hyperactivity Disorder (ADHD)

Data and Statistics About ADHD

Adult ADHD and Comorbid Disorders: Clinical Implications of a Dimensional Approach

Does the Continuous Performance Test Predict ADHD Symptoms Severity and ADHD Presentation in Adults?


This month’s blog post was written Jessie Duncan, MA, LPC, a specialist in Chronic Illness and Neurological Treatment modalities.