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Hypnosis and Parasomnia

January 2002

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Gerard Kennedy

RMIT University

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A review of hypnosis in the treatment of parasomnias: Nightmare, sleepwalking and sleep

terror disorders.

Kennedy, G. A. (2002) A review of hypnosis in the treatment of parasomnias: Nightmares, sleepwalking and

sleep terror disorders. Australian Journal of Clinical and Experimental Hypnosis, 30(2), 99-155

Gerard A. Kennedy

Running Head: Hypnosis for treating parasomnias

Department of Psychology, Victoria University, PO Box 14428 Melbourne City MC 8001

Australia

Gerard.Kennedy@vu.edu.au

Abstract

Hypnosis was used to treat patients with the primary parasomnias; nightmare, sleepwalking

and sleep terror disorders. The results for the patient with nightmare disorder suggested that

the effective element in decreasing the frequency of nightmares was the specific hypnotic

suggestion to alter the nightmare content. The generalised effects of increased relaxation and

improved sleep also contributed to therapeutic efficacy. Two other patients, with

sleepwalking and sleep terror disorders were also treated. In both the cases the effective

element in decreasing the frequency of these parasomnias appeared to be the generalised

effects of hypnosis. The data supports the observations of other authors who have suggested

the general lowering of tonic levels due to the anxiolytic effects of relaxation employed

during hypnosis is responsible for reducing the incidence of these disorders. In conclusion,

hypnosis is a relatively simple, non-invasive, inexpensive, and effective means of treating

nightmare, sleepwalking and sleep terror disorders.

INTRODUCTION

Was it a vision, or a waking dream? Fled is that music:- Do I wake or sleep?

John Keats 1795-1821

Parasomnias are disorders characterised by the occurrence of abnormal physiological and

behavioural events in association with specific stages of sleep and/or during transitional

stages of sleep (Mahowald & Rosen, 1990). In contrast to dyssomnias (disorders of initiation,

maintenance and/or timing of the sleep), parasomnias do not involve abnormalities of the

mechanisms generating or timing sleep. Parasomnias involve the inappropriate activation of

the autonomic nervous system or cognitive processes during various stages of sleep. Different

parasomnias occur at specific stages during sleep, during transitions from one sleep stage to

another, and/or at the sleep-wake or wake-sleep transitions. Most individuals suffering from

parasomnias present with complaints of unusual behaviour during sleep rather than

complaints of insomnia or excessive daytime sleepiness (Mahowald & Rosen, 1990).

However, in some cases excessive daytime sleepiness may result from awakenings caused by

parasomnia events during sleep.

Sleepwalking, nightmares and sleep terror are the most easily identifiable parasomnias.

Surveys suggest that nightmares, sleepwalking and sleep terror occur more frequently than

indicated by case study reports in the literature. A survey of 1006 households in the Los

Angeles area found that 11% of the subjects experienced nightmares and 2.5% sleepwalking

(Bixler, Kales, Soldatos, Kales & Healy, 1979). Belicki and Belicki (1982) found that 443

undergraduate students reported having more than five nightmares a year. Wood and Bootzin

(1990) found that 47% of 220 under graduates who kept dreams records over a two-week

period, reported at least one nightmare during the study. The estimated annual frequency of

nightmares from this study was 23.6%, which is 2.5 times the average suggested by other

retrospective studies.

It is important that parasomnias are correctly diagnosed and that effective treatment is given

if the behaviours associated with sleep are potentially injurious, violent or disruptive to the

patient or other people. Parasomnias can be organised into categories based on a number of

diagnostic criteria. These criteria are: (1) primary sleep phenomena and (2) symptoms of

organic systems that are manifested during sleep or associated transitional states (Mahowald

& Rosen, 1990). The classification system shown in Table 1 is based on clinical phenomena.

Mahowald and Rosen’s (1990) clinical approach to the classification of parasomnias differs

from that of the American Psychiatric Association’s Diagnostic and Statistical Manual

(DSM-IV) and that of the Association of Sleep Disorders Centers (Diagnostic Classification

of Sleep and Arousal Disorders). The advantage of Mahowald and Rosen’s (1990) system is

that it allows differential diagnosis of unusual sleep-related phenomenon and also points to

the therapeutic implications of diagnosis.

Insert Table 1. About Here

Primary sleep parasomnias are classified on the basis of whether events occur during non-

rapid-eye movement sleep (NREM), rapid-eye-movement sleep (REM) or occur during any

stage of sleep (miscellaneous). NREM and REM primary sleep parasomnias tend to occur

only during these sleep stages, while miscellaneous parasomnias may occur during any stage

of sleep (Mahowald & Rosen, 1990). Secondary sleep parasomnias are undesirable or

troublesome motor, behavioural or physiological events that occur during sleep. Secondary

sleep parasomnias result from the activity of bodily systems and can be classified according

to the organ system responsible for genesis.

Sleepwalking Disorder

During quiet sleepwalking the individual rises from bed and quietly walks about with their

eyes open. The person may walk towards a stimulus such as a light or noise or may walk

aimlessly from room to room. Children often walk into their parent’s bedroom. The person is

usually able to find their way around large obstacles. Occasionally, children and adults may

perform inappropriate behaviours during quiet sleepwalking (e.g. urinating on the floor).

Sleepwalking is very common in children with about 15% (mostly boys) having episodes (cf.

< 5% of adults) (Kales & Kales, 1974). The causes of sleepwalking vary according to the age

of the subject (Berlin & Qayyum, 1986). A study by Klackenberg (1982) of 212 children,

aged 6-16 in Sweden, found that the incidence of quiet sleepwalking was 40%. The study

also indicated an annual prevalence of 6-17% with only 2-3% having more than one episode

per month. In 33% of the children sleepwalking persisted for 5 years and in 12% it persisted

for more than 10 years.

In children, sleepwalking is usually benign and self-limiting, beginning at about age seven,

generally before age 10, and ceasing before age 15. Sleepwalking episodes usually last only a

few minutes and rarely extend beyond 10 minutes in duration. Sleepwalkers are difficult to

communicate with and if left alone often return to bed. When awakened, they have little

memory of anything that happened during the episode. Kales, Paulson, Jacobson, and Kales

(1966) found that few sleepwalking incidents were related to specific traumatic events.

Sleepwalking generally occurs about one or two hours after falling asleep. Sleepwalking

often begins with a burst of high voltage, slow frequency EEG activity and is related to

arousal from stage 3/4 NREM sleep (Kales et al, 1966; Broughton, 1968).

There is often a family history of sleepwalking (Vela-Bueno, Soldatos & Julius, 1987). Kales,

Soldatos, Bixler, Ladda, Charney, Weber & Schweitzer (1980) found that 96% of 52 patients

referred to a sleep research center reported one or more family member with a history of

sleepwalking. A Japanese study showed that sleepwalking was more common in 37 children

whose parents had also been sleepwalkers as children than in children with no family history

of this disorder (Abe, Amatoni & Oda, 1984).

Sleepwalking can be caused by the use of particular medications (Nadel, 1981). Barbiturates

and monamine oxidase inhibitor antidepressants, suppress all REM sleep, and tricyclic

antidepressants also reduce REM sleep. By altering the stages of sleep these drugs may

influence the frequency of sleepwalking (Kales, Tan, Preston & Allen, 1970; Kupfer &

Bowers, 1972). Flemenbaum (1976) administered a questionnaire to 30 medical and 106

psychiatric patients to determine the frequency of frightening dreams. In both groups roughly

equal numbers had dreams, but 28% of the psychiatric patients compared with 14% of the

medical patients had frightening dreams. The difference between the two groups was even

greater when patients who were taking psychotropic medication (antipsychotic or tricyclic

antidepressants) in a single dose at bedtime were compared with medical patients.

Sleepwalking, frightening dreams, confusion and physiological arousal were significantly

more frequent in psychiatric patients compared with hospitalised patients receiving no

medication. Huapaya (1979) reported seven cases of sleepwalking that were apparently the

result of the use of antipsychotic and antidepressant drugs in patients with long-standing

psychiatric problems. Sleepwalking and sleep terror have also been reported in children and

adolescents with febrile illnesses (Karacan, Wolff, Williams, Hursch & Webb, 1968; Kales,

Kales, Soldatos, Chamberlin & Martin, 1979).

Sleepwalkers tend to move in confused and clumsy manner, but gradually they manifest

better co-ordination, avoiding objects and often going to the bathroom (Kales & Kales, 1974).

In most cases sleepwalkers do not suffer any harm, but occasionally they may injure

themselves and have been know to injure others (Hartmann, 1983; Oswald & Evans, 1985).

Luchins, Sherwood, Gillin, Mendelson and Wyatt (1978) observed a 40-year old women in a

sleep laboratory, who had been acquitted of killing her daughter while sleepwalking. The

women had been diagnosed and hospitalised for schizophrenia prior to the filicide. Four years

after she was acquitted and released from hospital she was administered the same drug that

she had been taking when the filicide occurred. She was observed to sleepwalk on three of

the four nights she took the drug. Sleepwalking occurred during stage 4 sleep in the first half

of night.

Sleep Terror Disorder

Sleep terror disorder consists of nocturnal episodes of extreme terror and panic that occur

early in the sleep period in stage 3 or 4 sleep (Kales et al, 1982; Hartmann, 1984). Sleep

terror, has not received as much attention as nightmares because it is not as common.

Broughton (1968) found that sleep terror occurred during sudden and intense arousal from

slow-wave sleep with an EEG pattern similar to the awake pattern. Sleep terror episodes

usually only last a few minutes and there is little or no recall of the episode. Two thirds of

sleep terror episodes occurred during the first NREM sleep period in six subjects monitored

during 100 sessions (Fisher, Kahn, Edwards & Davis, 1973). Sleep terror usually begins

before the age of 10 and is usually outgrown during adolescence (Kales & Kales, 1974).

Sleep terror episodes may occur as often as three times a week (Kales, Soldatos, Caldwell,

Charney, Markel & Cadieux, 1980).

Sleep terrors are distinguishable from nightmares in terms of clinical features and sleep-

laboratory findings. Sleep terror includes more vocalisations, motility, and autonomic

discharge and usually more fear and anxiety than nightmares. Sleep terror occurs during sleep

stages 3 and 4, whereas nightmares occur during REM sleep (Kales et al, 1982; Hartmann,

1984; Vela-Bueno et al, 1987). Sleep terror and sleepwalking have similar clinical

characteristics (Hartmann, Greenwald & Brune, 1982; Kales, Cadieux, Soldatos & Kales,

1982; Oswald & Evans, 1985; Vela-Bueno et al, 1987). Kales, Soldatos, Caldwell, Charney

and Martin (1980) investigated sleep terror and sleepwalking in 40 adults and found that

sleep terror was often accompanied by sleepwalking and that the two sleep disorders seemed

related to genetic and developmental factors. Halstrom (1972) traced a family history of sleep

terror through three generations. When onset of these sleep disorders occurs after age 10, they

are likely to persist in adulthood, episodes are more frequent, and the time of onset is often

associated with major life stressors.

Mahowald and Rosen (1990) proposed a model for understanding the determinants and

manifestations of partial arousals from sleep. When a period of deep NREM sleep terminates

there is a transition that leads to one of three possible state changes: (1) beginning the next

sleep cycle by switching to different sleep stages; (2) continue arousal until full awakening;

or (3) become ‘trapped’ - unable to completely get out of deep sleep, unable to arouse fully,

and unable to move into the next sleep cycle.

There are three main factors that determine the occurrence of observable partial arousals.

These factors are: (1) tonic sleep factors; (2) phasic sleep factors; and (3) the behavioural

response to the arousal (Mahowald & Rosen, 1990). The tonic factors that occur throughout

the sleep period determine the underlying sleep pattern and arousal threshold. These include:

(1) genetic; (2) developmental; (3) sleep deprivation; (4) chaotic sleep/wake scheduling; (5)

drugs; and (6) psychological factors.

The most important tonic factors appear to be genetic and developmental. Partial arousals are

most common in young children because deep sleep is deeper and longer than it is in older

children. Phasic sleep factors (intermittent occurrence during the sleep cycle) can also cause

the disruption of sleep (Mahowald & Rosen, 1990). In some individuals who are predisposed

to partial arousals due to one of the tonic sleep factors listed above, a partial arousal can be

precipitated by any strategically timed phasic sleep factor. Phasic sleep factors include both

endogenous and exogenous factors. Endogenous factors may be both spontaneous and

pathologic in nature. Pathologic phasic factors are: (1) obstructive sleep apnoea; (2)

gastroesophageal reflux; (3) seizures; (4) fever; (5) periodic movements; and (6)

psychological. Exogenous factors are: (1) stimulation such as auditory, tactile or visual; and

(2) drugs.

In many individuals arousals appear to be spontaneous. This is evidenced by the fact that

sleepwalking can be induced in children by standing them up during slow wave sleep (Kales

et al, 1966; Broughton, 1968). Similarly, sleep terror can be triggered in susceptible

individuals by auditory stimulation during slow wave sleep. Both these observations suggest

that these behaviours are not the result of ongoing complex mental activity during sleep

(Fisher, Byrne, Edwards & Kahn, 1970; Fisher, Kahn Edwards, Davis & Fine, 1973). The

behavioural responses to the arousal is the clinically observed behaviour that occurs during

the partial arousal, and will be determined by developmental or psychological factors, as well

as by drugs. Tonic sleep factors, phasic sleep factors and the behavioural response to the

arousal interact to determine the frequency, duration and severity of the partial arousal.

Mahowald and Rosen’s (1990) model allows a framework for understanding the factors

contributing to partial arousals and in addition may point to the preferred treatment when the

diagnosis has been confirmed. Differential diagnosis of partial arousals excludes nocturnal

seizures, anxiety dreams (nightmares), behaviour disorders and dissociated states (Schenck,

Milner, Hurwitz, Bundlie & Mahowald 1989). Individuals with these conditions may show

unusual nocturnal behaviour that is indistinguishable from the disorders of partial arousal.

The important factor in the differential diagnosis of unusual nocturnal behaviour is a detailed

history that in most cases allows the correct diagnosis to be established. In obtaining a

detailed history the important facts include: (1) the timing of the event during the sleep cycle;

(2) a detailed description of the event; (3) the level of consciousness before during and after

the arousal; (4) daytime symptoms of sleepiness; (5) injury associated with the arousal; (6)

memory for the event; and (7) personal/family history of partial arousal disorder (Mahowald

& Rosen, 1990).

In the treatment of partial arousals it is important to confirm that a correct diagnosis has been

made. Patients, particularly children should be given reassurance that in most cases the

arousal is benign and self-limiting in nature. Patients should be given practical advice about

basic safety precautions that can be taken. For example, the bedroom should be cleared of

obstacles and any windows should be locked or otherwise secured. In some cases it may be

advisable to fit deadlocks or alarms to outside doors. Patients should be warned that sleep

deprivation should be avoided because it may precipitate partial arousals. They should also be

instructed to make the sleep/wake cycle as regular as possible. People living with the patient

should be advised not to intervene during arousals as this may prolong the event. In most

cases the sufferer is best left alone and any observer should just ensure that no injury occurs.

In cases where the arousals are dangerous or disruptive to the patient or to others, and no

obvious precipitant can be identified, symptomatic treatment is needed. Two successful

interventions for partial arousals have been described: pharmacological therapy

(benzodiazepines & tricyclic antidepressants) (Fisher, Kahn & Edwards, 1973; Kavey,

Whyte, Resor & Gidro-Frank, 1987; Guilleminault, 1989) and hypnosis with relaxation and

mental imagery (Pesikoff & Davis, 1971; Reid, Ahmed & Levie, 1981; Gardner & Olness,

1981). Valium, which tends to suppress slow-wave sleep, has been shown to reduce the

incidence of sleep terror episodes (Kales et al, 1982). The main problem with drug therapy

for partial arousals is the long-term nature of the disorder and the adverse effects chronic

drug usage may have on learning and behaviour (Weissbluth, 1984). Teaching patients

relaxation and mental imagery offers an alternative and allows the use of self-regulation

techniques to control previously uncontrolled nighttime behaviours. The mechanism(s)

resulting in reduced frequency of partial arousals after pharmacological and/or hypnotic

treatment are not well understood. It is possible that these treatments change underlying tonic

sleep factors resulting in a higher arousal threshold and fewer arousals. It is also possible that

the treatments (particularly hypnosis) cause a change in the behavioural response to the

arousal.

Nightmare Disorder (Dream Anxiety Attacks)

Dream anxiety attacks are frightening dreams (nightmares) that are accompanied by moderate

levels of autonomic activity (tachycardia, tachypnea, diaphoresis) and arousal (Association of

Sleep Disorders Centers, 1979). In comparison to sleep terror, the level of autonomic

activation is considerably less and recollection of the dream content is usually fairly

complete. Dream anxiety attacks do not occur at sleep onset and are not associated with

feelings of oppression or paralysis as may be experienced with sleep paralysis and

hypnogogic hallucinations.

Fisher Byrne, Edwards and Kahn (1970) recorded EEG, electroculogram (EOG), heart rate,

conversations with subjects, other vocalisations, and ratings of anxiety of 38 subjects with

nightmare disorder. Subjects were allowed to sleep undisturbed each night until

spontaneously awakening with anxiety. Subjects were interviewed on awakening to examine

the nature of the nightmare experience. Three types of nightmares were identified. Fifty

major stage 4 nightmares (sleep terror) were observed in seven subjects, 22 REM anxiety

dreams in 11 subjects, and seven subjects awoke spontaneously during stage 2 sleep.

Hartmann, Russ, Olfield, Sivan and Cooper (1987) found that 12 subjects remembered

having nightmares before they were 5 years old and that the frequency decreased between the

ages of seven to 11 years. Generally, nightmares do not become a matter of concern unless

they are recurrent, disrupt sleep and are anxiogenic (Erman, 1987).

Nightmares always occur during REM (dream sleep) and more often in the latter half of the

sleep period (Hartmann, 1984). Therefore, drugs that influence REM sleep may influence the

occurrence of nightmares. In addition to EEG activity during nightmares, the underlying

biological processes probably involve changes in the levels of brain neurotransmitters.

Parkinson’s patients frequently report nightmares and vivid dreams. L-Dopa, a form of the

neurotransmitter dopamine, counteracts the symptoms of Parkinson’s disease. Patients who

are more susceptible to nightmares report increased frequency of nightmares after small doses

of L-Dopa (Hartmann, Skoff, Russ & Oldfield, 1978; Hartmann et al, 1987).

During a nightmare there are signs of intense anxiety, evidenced by sweating, dilated pupils

and difficulty breathing. Dunn and Barrett (1988) found that scores on The Manifest Anxiety

Scale of 79 college students who experienced frequent nightmares, on were not significantly

different to the scores of students who did not experience nightmares. Individuals who

experience nightmares are more easily aroused and usually recall the content, which is more

lengthy and detailed than in sleep terror. Nightmares with frightening or unpleasant content

usually occur during REM sleep (Kales & Kales, 1974). Major life events have been

associated with the onset of nightmares and mental stress increases the frequency of attacks

(Celucci & Lawrence, 1978b; Kales Soldatos, Bixler, Ladda, Charney, Weber & Schweitzer,

1980; Garfield, 1987).

Earlier studies have shown that subjects who suffer frequent nightmares in REM sleep

showed many schizophrenic characteristics (Hartmann, 1965; Hartmann & Russ, 1979).

Psychiatric interviews revealed considerable psychopathology in them and in their family

histories. The mean scores of eight men were two standard deviations above normal on the

MMPI depression scale, and the scores of 12 women were two standard deviations above

normal on the psychopathic deviate and mania scales. In Hersen’s (1971) study, hospital

patients with psychotic disorders were divided into groups according to the frequency of

reported nightmares. Patients with more manifest anxiety and concern about death reported

more frequent nightmares. Jones (1951) reported that more frequent nightmare attacks tended

to accompany the development of hysteria and insanity, but his observations were based on

patients confined to psychiatric institutions.

Hartmann et al (1987) compared 12 lifelong nightmare sufferers with 12 subjects who had

vivid dreams, but no nightmares. Subjects who suffered nightmares scored significantly

higher on the psychosis scale of the MMPI. These subjects were also more likely to have

relatives who experienced nightmares and who required psychiatric admissions. In general,

nightmare sufferers were more sensitive and open people, tended to show some features of

the schizophrenic spectrum of disorders, and were more artistic with more manifest creative

tendencies and interests (Hartmann, Falke, Russ & Oldfield, 1981; Hartmann, Russ, Van Der

Kolk, Falke & Oldfield, 1981; Belicki & Belicki, 1986).

Studies have found that fear of death is often present in nightmares. In Feldman and Herson

(1967) study five percent of the subjects experienced nightmares frequently, and 86% had at

least one nightmare per year. Women scored higher than men on a 10-item Death Scale, but

subjects of both sexes with more frequent nightmares, expressed significantly more concern

about death. Feelings of helplessness and being threatened were common themes reported by

those experiencing frequent nightmares. Women reported these themes twice as often as men.

The final stage of women’s nightmare experiences was often escape from danger by

awakening (Feldman & Hyman, 1968).

Lester (1968) examined fear of death as a feature of nightmares by asking 304 college

students to estimate the frequency of dreams and nightmares and to complete a Fear of Death

Scale. Subjects with the poorest memory for dreams reported fear of death less often. Lester

(1968) suggested that type of question asked and subject’s memory of dreams overstated the

prominence of fear of death in the nightmares of frequent sufferers. In a later study of 170

students, the frequency of nightmares was found to be associated more with fears of others

dying rather than fear of one’s own death (Lester, 1969).

Surveys of war veterans indicate that combat personnel report nightmares more frequently

than non-combat personnel (Kramer, Schoen & Kinney, 1987; Kramer & Kinney, 1988). A

study of 529 World War II and Korean War combat veterans in a mixed medical and

psychiatric outpatient clinic showed that 32% had frequent nightmares, a higher rate than

expected from general population data (Van Der Kolk, Blitz, Burr, Sherry & Hartmann,

1984). The nightmares of veterans were found to occur earlier in sleep, usually reflected

actual events, and were more commonly associated with gross bodily movement. The MMPI

profiles were abnormally high and Rorschach protocols revealed evidence of thought disorder

in many veterans.

Some research has suggested that anxiety is associated with nightmares (Celucci &

Lawrence, 1978b). Haynes and Mooney (1975) explored the sleep patterns, anxiety levels,

and physiological arousal of college students experiencing nightmares in three questionnaire

studies. In the first study, 248 students who experienced nightmares did not differ in sleep

patterns from students who had no nightmares. The second study examined the relationship

between anxiety and the frequency of nightmares. It was found that scores on the Manifest

Anxiety Scale were positively related to the frequency of nightmares. This suggested that

anxiety influenced the frequency of nightmares. It was hypothesised that nightmares may

have an anxiety-reducing role, facilitating the extinction of anxiety and physical arousal. To

test this hypothesis, implosive therapy was used with four female students who experienced

frequent nightmares. Haynes and Mooney (1975) found that the therapy reduced the

frequency and intensity of nightmares experienced by the four subjects.

Psychological factors have been given a major role in the development and persistence of

nightmares (Kales, Soldatos, Caldwell, Charney, Kales, Markel & Cadieux, 1980).

Behavioural therapy has been shown to be beneficial for some adults who suffer recurrent

nightmares (Geer & Silverman, 1967; Shorkey & Himle, 1974; Schindler, 1980). Similarly,

systematic desensitisation has been shown to reduce the frequency and intensity of nightmare

experiences (Celucci & Lawrence, 1978a). Miller and DiPilato (1983) studied 32 nightmare

sufferers randomly assigned to a relaxation group, a systematic desensitisation group and a

waiting list group (control). In both treatment groups there was a significant decrease in the

frequency, but not the intensity of nightmares. Subsequent treatment of the waiting list group

also significantly reduced the frequency of nightmare attacks.

Pharmacotherapy has been shown to be effective in reducing the frequency and intensity of

some parasomnias. This effect probably operates via drug effects in altering sleep phases and

REM sleep (Hartmann, 1966, 1984). Nightmares occur during REM sleep, thus anti-anxiety

agents such as diazepam (Valium) and antidepressants that suppress REM sleep have helped

patients with frequent nightmares (Erman, 1987, Kales, Tan, Preston & Allen, 1970).

However, drug withdrawal may lead to REM-rebound and temporarily increase the

occurrence of nightmares (Kales, Soldatos & Kales, 1987). Beta-adrenergic blocker drugs

like propranol, prescribed for some heart patients, may increase the frequency of nightmares.

Reserpine a drug that prevents the intraneuronal storage of the neurotransmitters dopamine

and norepinephrine, also increases the frequency of nightmares (Hartmann, 1966, 1984).

Conclusions

In general, parasomnias such as nightmares, sleep terror and sleepwalking are better

understood than they were when Jones (1951) described them. Increased understanding of

parasomnias has largely been due to objective studies that have been performed using

polysomnography. Polysomnographic studies have allowed the behavioural disturbances

observed in parasomnias to be correlated with the underlying physiological states. However,

clinical understanding of sleep-associated phenomena remains relatively poor because often

those suffering from these conditions do not come to the attention of relevant medical

authorities.

Hypnosis and the Treatment of Nightmare Disorder

In the literature on sleep there are numerous references to theories about the function of

dreams (e.g. Hobson 1988; Bootzin, Kihlstrom & Schacter, 1990; Ellman & Antrobus, 1991).

However, there is very little literature on nightmares (Hartmann, 1984), and even less on

recurring nightmares. Repetitive nightmares may occur frequently with either the same or

differing themes. Recurrent nightmares have been reported and discussed as a definitive

feature of PTSD (Ross, Ball, Sullivan & Caroff, 1989). There are fewer reports of repetitive

nightmares featuring in non-traumatic conditions such as the anxiety and depressive

disorders. The only diagnosis other than PTSD for which nightmares are considered a

diagnostic feature is Nightmare Disorder (DSM-IV, 1994).

The lack of attention that recurrent nightmares have received may be due to the tendency for

clinicians the view nightmares as secondary symptoms of other underlying psychopathology.

Given that this is the case, the underlying disorder becomes the focus of treatment rather than

the nightmares (Eccles, Wilde & Marshall, 1988). Psychoanalytic practitioners may also view

nightmares as a useful source of information to aid in diagnosing and understanding the

patient’s psychopathology. In cases where nightmares cause severe sleep disturbance,

patients may be prescribed sedative medications. There are very few accounts of

psychotherapy being routinely used to directly address recurrent nightmares (Halliday, 1982;

Miller & DiPilato, 1983; Brylowski, 1990; Kellner, Neidhardt, Krakow & Pathak, 1992,).

The focus on nightmares as symptomatic of underlying psychopathology (which may be

correct in some cases) has probably led to needlessly prolonged distress in some patients.

Recurrent nightmares can cause fatigue from loss of sleep due to fear, and anxiety and

depression may increase as a results of the effect nightmares have on the patient’s waking

life. Patients may see the continuation of nightmares as evidence that psychotherapy is not

proving to be effective and this, in turn, can lead to further demoralisation (Frank & Frank,

1991).

Hypnosis is one direct method that has been effectively employed to allow patients to either

terminate or control recurrent nightmares (Kingsbury, 1993). There are a number of possible

mechanisms via which the hypnotic treatment of recurrent nightmares may have some impact

on other related problems in the cluster of “symptoms” that make up the diagnosed

psychopathology. For example, the successful treatment of any aspect of what patients

believe are related problems may lead to increased expectation that the overall therapy will be

helpful in addressing other problem areas. Furthermore, the successful treatment of a problem

may have an impact on other important areas of functioning. A treatment that leads to the

termination or control of recurrent nightmares may lead to significantly improved sleep and

hence higher daytime levels of energy and concentration. A further benefit of treating

nightmares directly is that this conforms to the patient’s view of what the problem really is.

Most patients are not able to understand that each symptom may be part of a set caused by

some central psychopathology or condition. The reflection of the patient’s understanding has

been held as an essential factor in demonstrating empathy and establishing a therapeutic

relationship (Rogers, 1957).

The proposed use of hypnosis as a treatment for recurrent nightmares may be questioned,

given that its differential effectiveness in altering dreams has not been clearly established.

However, there are a number of factors that suggest that hypnosis may be useful for treating

recurrent nightmares (Kingsbury, 1993). In the hypnotic state, the nightmare content is more

involving for the patient than under normal psychotherapy. Therefore, the patient has greater

access to the emotional state the nightmare produces and this appears to be therapeutically

useful (Gilligan, 1988). Furthermore, the hypnotic induction may mark a separate state from

normal consciousness and may heighten the expectation that this state has the power to effect

direct changes in what may otherwise be seemingly non-volitional behaviour (Combs &

Freedman, 1990; van der Hart, 1993). Research and theory support the link between hypnosis

and dreams via proposed dissociative mechanisms (Gabel, 1989, 1990). Finally, the available

literature indicates that hypnosis can be effectively used to either terminate or control the

content of recurrent nightmares (Tart, 1966; Moss, 1973; Marks, 1978; Seif, 1985;

Kingsbury, 1993).

A variety of interventions have been shown to alter dreams and their content (Arkin &

Antrobus, 1991; Walker & Johnson, 1974). However, there has been very little research on

the effect hypnosis has on subsequent dreaming. Research that has been carried out may

provide some ideas for therapeutic interventions, but in general its clinical significance has

been limited. Much of the earlier research examining the effects of hypnosis on dreams has

been carried out on populations of university students rather than on patients suffering

recurrent nightmares. The main aim of these studies has been to determine whether or not

specific dream content can be produced via hypnosis.

Tart and Dick (1970) studied the conscious control of dreaming in 13 highly hypnotisable

subjects during two nights in the laboratory. Before subjects went to sleep each night they

were hypnotised and instructed to dream about a stimulus narrative in every stage 1-REM

dream of the night. A second stimulus narrative was used for the other night in a

counterbalanced order. Dream reports were obtained from stage 1-REM awakenings. With

the exception of one subject, all subjects showed some effects, with two to four elements of

the stimulus narratives reported as appearing in dreams. Thematic analysis of subjects dream

reports showed that eight of the 13 subjects reported at least one dream in which the stimulus

narrative was a dominant organiser of content. The number of stimulus narrative elements

appearing in the dream reports was positively correlated with hypnotisability. The

correlations were positive for factors of hypnotisability characterising ability to function in an

altered state of consciousness and negative for compulsive, inhibitory aspects of

hypnotisability. Hypnosis was helpful, but not necessary to achieve deliberate control of

dream content. Such control has important therapeutic ramifications, particularly in assisting

those with recurrent nightmares to control or diminish the effects.

Barber, Walker and Hahn (1973) examined the effects of hypnotic induction and types of

suggestion on sleep mentation in 73 subjects. Just prior to sleep each night, half the subjects

were exposed to a hypnotic induction and half were not, and all subjects were given either

authoritative, permissive, or no suggestions to think and dream that night on a specific topic.

Subjects reported their thoughts and dreams when awakened at sleep onset and during REM

and NREM periods. The content of the dreams were affected by an interaction between

hypnotic induction and types of suggestions, and the hypnotic induction increased the number

of nocturnal thoughts that pertained to the specific topic. The findings of this study suggest,

as did the findings of the earlier study by Tart and Dick (1970) that hypnosis can be used to

effectively alter dreams and therefore might be useful for altering nightmare content.

A study by Belicki & Belicki (1986) examined the relationships between nightmare

frequency and hypnotic ability, vividness of visual imagery and tendency to become absorbed

in fantasy-like experiences. The subjects were 841 undergraduate university students who

participated in group tests of hypnotisability, after which they estimated the number of

nightmares that they had experienced in the previous year. In addition, 406 of the subjects

completed Mark’s Vividness of Visual Imagery Questionnaire, and Rotenberg and Bower’s

Absorption Scale. A total of 76% of the subjects reported experiencing at least one nightmare

in the previous year and 8.3% reported experiencing one or more nightmares per month.

Individuals with frequent nightmares scored higher on hypnotisability, vividness of visual

imagery and absorption.

Some research has focused on the relationship between nightmare frequency and

psychopathology. Belicki and Belicki’s (1986) study examined the relationship of nightmares

with more general personality (or cognitive) styles. Hartmann et al (1981) observed increased

creativity in nightmare sufferers. Other studies have associated hypnotic ability with “fear-

proneness”. Positive correlations have been observed between hypnotic ability and phobias

(Frankel & Orne, 1976) and posttraumatic stress disorder (Stutman & Bliss, 1985). Increased

frequency of nightmares in highly hypnotisable subjects may be an indication of

predisposition towards fear-based syndromes. However, it in not clear how relevant these

observations are in relation to people in the general population who suffer nightmares.

Belicki, Altray and Hill (1985) observed that nightmares are not always anxiety dreams, but

can be primarily characterised by other dysphoric emotions, such as grief. Hartmann (1984)

argued that patients with PTSD are quite different from those that present with nightmares

that do not stem from a known traumatic incident.

The main source of information about the hypnotic treatment of recurrent nightmares are the

few available published case studies and anecdotal clinical notes. The problem with case

studies and clinical notes is that the amount of information given is often limited and may not

be very useful. In most of these reports only rarely is there any attempt to present a number of

similar cases in a coherent fashion and generalisations made are more often than not, poorly

transferable from one case to another. Nevertheless, case studies and clinical notes are

heuristically valuable in that they do suggest possible hypnotic treatment strategies.

Clinical Studies of the Hypnotic Treatment of Nightmare Disorder

The available clinical literature suggests there are a number of different strategies for treating

recurrent nightmares that replay the patient’s actual experiences (these strategies would be

equally applicable to nightmares based on real non-traumatic or imagined experiences).

These types of nightmares are can be indicative of traumatic experiences in recent adult life.

This type of recurrent nightmare has been more frequently reported in the literature, probably

due to the clear traumatic aetiology. One reported strategy involves transforming the

nightmare while the patient is reliving or replaying it under hypnosis (Eichelman, 1985;

Gilligan, 1988). In this technique new elements may introduced into the nightmare or

frightening elements in the nightmare may be altered to appear more benign. Regardless of

whether a new element is introduced separately, or made by changing something that occurs

within the nightmare, the goal of this strategy is to change the patient’s reality so that it can

be coped with more easily.

The reported case studies indicate that this technique can be used to achieve the desired goal

in a stable manner even though it alters a reality that the patient may know to be factual. In

such cases a helpful friend or parent may be introduced into a nightmare to provide support,

or a threatening weapon may be transformed into some harmless object. Some therapists may

be concerned about the fact the technique involves altering the patient’s recall of a factual

event rather than helping the patient to gain mastery over the nightmare content. However,

this strategy has been reported to be highly effective in practice. Erikson (1959), in work on

revivification of nightmares alluded to the fact that the technique was designed not to alter

the true memory occurring within the nightmare but to add fantasy elements that help the

patient cope with the frightening nightmare content.

Another strategy that has been reported in the literature involves having the patient re-expose

themselves to the content of the nightmare, but in a manner that allows them acquire mastery

of the nightmare content. The patient can be taught how to interrupt the nightmare, first in the

treatment setting under hypnosis and then later at home (Gorton, 1988). A further method is

based on desensitisation or flooding where there is repeated exposure to the nightmare while

the person is hypnotised. A variation of this technique allows the patient to have more felt-

control by having them place the nightmare on a television or movie screen. In this method

the hypnotised patient has control of the imagery via an imaginary remote-control. A further

variation re-exposes the patient to the nightmare in progressively less involving contexts

(Kingsbury, 1988). Bishay (1985), who used a non-hypnotic treatment, and Kingsbury (1988,

1992) a hypnotic treatment for nightmares both suggested that gaining felt self-efficacy was

an important therapeutic factor in eliminating recurrent nightmares.

Helping the patient to solve a nightmare in some manner is another way to eliminate

recurrent nightmares. In this context, the recurrent nightmare can be viewed as an unfinished

story that is interrupted at some point by the patient waking. Waking may be the only way the

patient can escape from extremely frightening nightmares. The patient can be guided past the

usual point of waking in the nightmare while in the hypnotic state and helped to discover the

benign or successful ending. Thus, the patient is assisted by the hypnotherapist to complete

the nightmare in a manner that is not fear inducing (Kingsbury, 1993). This method appears

to fit within the beliefs of many patients who view themselves as escaping their nightmares

before some horrible event befalls them. The completion of the otherwise unfinished

nightmare can be a method of utilising the patient’s beliefs and reframing them to allow a

sense of felt mastery (Watzlawick, 1978).

Some methods of treating recurrent nightmares are based on psychoanalysis but use hypnosis

as a means of helping the patients retrieve and process material from nightmare episodes. In

such treatments the patient may be asked to experience the nightmare under hypnosis and

then the material discovered is dealt with in regular therapy. Arluck (1964) successfully

treated a women with nightmare disorder using hypnoanalysis. Similarly, Moss (1973) used

hypnosymbolism analysis to facilitate a male inmate with nightmare disorder re-dreaming his

nightmares. The material uncovered during these psychotherapy sessions was then used to

make his nightmare more benign. Gorton (1988) treated a 57-year old women who presented

with obsessional worries, insomnia and lifelong nightmares. Gorton (1988) employed a

combination of psychodynamic psychotherapy, paradoxical re-experiencing of the

nightmares, and posthypnotic suggestion to treat the women over a period of 10 months.

According to Gorton (1988) the treatment allowed the patient to take control of her symptoms

by means of the paradoxical use of trance within a narcissistic transference that lead to the

emergence of central issues related to early childhood trauma and a series of losses of self-

objects. Finally, it was stated that an underlying ambivalent relationship with these lost self-

objects and a wish/fear dilemma with regard to death itself was then amenable to

psychotherapeutic intervention. The critical factor was having the patient practice self-

hypnosis at home to re-experience nightmares and understand the content.

The major criticism of methods that employ a combination of analytical or psychoanalytical

therapy with hypnosis to treat nightmare disorder is that they may take a long time to give the

patient any relief from the frightening nightmares. This is apparent from Gorton’s (1988)

report that stated the therapy was conducted over a 10-month period. Other hypnotic methods

of relieving nightmare sufferers reported above may be helpful even after one session.

Therefore, a case could be made for using hypnosis for the direct treatment of nightmare

disorder within any given psychological approach to therapy for other related and/or causal

issues.

Miller and DiPilato (1983) found that relaxation was just as effective as systematic

desensitisation and that both were superior to waiting list control condition in alleviating

nightmare sufferers. Their data suggests that therapies aimed at anxiety reduction in general

are effective in reducing the frequency of nightmares. This suggests that reduction of arousal

may be an important element in reducing the occurrence of nightmares, and that nightmares

are not necessarily enmeshed in a web of psychopathology. Therefore, hypnosis can be

employed in promoting a more relaxed sleep within the context of a given therapeutic

regimen. Korth (1964) used hypnosis with suggestions of restful, relaxed sleep and

confidence, to effectively treat a women experiencing nightmares about examinations.

Cooperman and Schafer (1983) reported treating a 56-year old female with nightmare

disorder. The patient reported the content of her nightmares centred on the loss of her family.

Hypnotic fantasy visits with her deceased husband and children were successfully used to

alleviate the nightmares. Eichelman (1985) used hypnosis with two Vietnam veterans who

had PTSD with recurring nightmares. In his work, hypnosis was used to modify the content

and outcome of the nightmares so that they took on a more benign character. The two

veterans reported a significant reduction in the intensity and frequency of their nightmares.

Jencks and Brazza (1986) used hypnosis with adult subjects to promote self-confrontation in

order to resolve nightmare content. Similarly, Kingsbury (1993) employed hypnosis with

three adults female patients. Two subjects (35 & 44 years old) had no psychopathology while

the third 26-year old patient was suffering from depression with suicidal ideation. In the

treatments, hypnosis was used to view the traumatic event in the nightmare as an observer

and thereby reinterpret the result in a more realistic manner. Marks (1978) treated a women

with nightmare disorder by employing hypnotic suggestions for the rehearsal of the

nightmare in the waking state. Seif (1985) used hypnosis to treat a man who was suffering

nightmare disorder. The man was constrained by his life situation and a high degree of

conformity to what others wanted him to do. The hypnotic treatment included suggestions

that the man was free to be himself and that he did not have to please anyone.

In summary, the use of hypnosis to treat nightmare disorder in reported studies appears to be

in most cases successful in that nightmares are either eliminated totally or at least altered to

some extent so that patients learn to cope better with the content. A variety of strategies have

been reported with some authors suggesting that the therapeutic element might centre around

reduced arousal. Other authors have suggested that cognitive elements may be important

because patients suffering from nightmares can reinterpret or directly alter nightmare content

so that it can be coped with. Finally, the use of hypnosis as an aid to uncovering material or

reinterpreting material within the context of more traditional psychotherapeutic approaches

also has its advocates. In examining the literature it is clear perhaps the best approach to

alleviating nightmare disorder in the short-term is an individualised and direct approach using

hypnosis. In the longer-term patients with nightmare disorder that is treated directly with

hypnosis may still require ongoing psychotherapy to assist with other symptomatology that

may or may not be causally related to nightmare disorder. The short-term alleviation of

frightening nightmares via hypnosis may help the patient to gain confidence and function at a

higher level and this, in turn, may help produce therapeutic gains.

Hypnotic Treatment of Sleepwalking & Sleep Terror Disorders

Broughton’s (1968) studies of parasomnias suggested that non-specific and chronic repressed

mental conflict associated with anxiety may result in physiological changes that alter the

individual’s arousal response during sleep and at the transitions to and from sleep. Broughton

proposed that sleepwalking and sleep terror are primarily disorders of arousal rather than

disorders of sleep per se and that they may be triggered by external stimuli. Fisher, Kahn,

Edwards and Davis (1973) have shown that this hypothesis was correct, because they were

able to demonstrate that night terror can be triggered in sleeping patients by sounding a

buzzer.

Clinical Studies of the Hypnotic Treatment of Sleepwalking and Sleep Terror Disorders

Koe (1989) noted that Broughton’s work on parasomnias suggested a possible alternative

application for using hypnosis in the treatment of sleep terror. Koe (1989) hypothesised that

limiting the perception of external stimulation at night through post-hypnotic suggestion

might reduce the occurrence of sleep terror episodes. In Koe’s (1989) case study of the

hypnotic treatment of sleep terror disorder, the patient was a 16-year old boy who had proven

resistant to other forms of treatment. Tranquillisers such as diazepam, behaviour modification

and psychotherapy all had little or no effect on the intensity and frequency of the patient’s

sleep terror episodes. The patient’s mother reported that there were only two nights when he

had not experienced sleep terror since the age of seven. The sleep terror episodes usually

began each night with repetitive, terrified, screaming and involved leaping out of bed and

running around the room. The patient was often observed to have more than one episode per

night and sometimes became violent, breaking his mothers nose on one occasion, smashing a

window while trying to run through it on another occasion, and frequently destroying objects

in his room. The patient’s diagnosis of sleep terror disorder was confirmed in a sleep research

laboratory. The patient was able to state that his night terror was a fear of dying in his sleep

but was not able to say how he came to have this fear.

The patient was highly embarrassed by his condition, and thus according to Koe (1989),

highly motivated to change. In the treating this patient, Koe (1989) used systematic relaxation

as a hypnotic induction and his patient achieved a depth of seven on the Long Stanford Scale

of Hypnotic Depth, indicating a deep state of hypnosis. While the patient was hypnotised, he

was given the suggestion that he was in a deep sleep, deep sleep - in the stage of sleep in

which he normally experienced sleep terror. He was then told that a sleep terror episode was

beginning. Koe observed that the patient’s respiration rate accelerated and he began to toss

and turn, but remained in a prone position, giving the appearance being asleep. After several

minutes of increased autonomic activity had passed, Koe tapped his pencil on his desk. The

patient responded to this stimulus by screaming and immediately jumping up and running

into the wall of the room. This episode of sleep terror induced under hypnosis lasted about 15

seconds.

The manner in which Koe’s patient responded to the pencil tap, suggested that external

sounds might be triggering his sleep terror episodes. When the patient returned on the

following week, Koe again hypnotised him and gave the post-hypnotic suggestion that he

would gradually become less and less aware of outside sounds and sensations while asleep.

During the subsequent week only three episodes of sleep terror where reported and only one

further episode in the following two weeks.

Koe (1989) wished to confirm that the post-hypnotic suggestions were in fact causal in the

reduction of the frequency of the sleep terror episodes. In order to achieve this aim he asked

the subject for permission to again hypnotise him and remove the suggestions. However, the

patient would not permit the removal of the post-hypnotic suggestions because he was so

pleased with the treatments effect. Therefore, Koe was unable to determine whether or not the

sleep terror episodes could be made to resume and thus was not able to establish the validity

of the hypnotic treatment. A follow-up three months later found that the patient was no longer

experiencing sleep terror and that he remained very pleased with the effect of the hypnotic

treatment.

According to Hurwitz, Mahowald, Schenck, Schutler and Bundlie (1991) hypnosis is an

underrated modality of therapy for individuals suffering automatised, embarrassing, and

occasionally dangerous behaviours associated with sleepwalking and sleep terror. Hurwitz

(1986) and Hurwitz and Mahowald (1988) reported the successful use of hypnosis for the

treatment of individuals with sleepwalking and sleep terror disorders. A fuller report of

subjects from these two studies and additional subjects is provided in Hurwitz et al’s, (1991)

paper. In this study hypnosis was introduced as a method of enhancing self-control. Hypnotic

trance was usually induced with the commonly used technique of suggesting eye closure

during upward gaze and subsequent relaxation and sensations of floating. Patient’s were then

asked to visualise themselves in a pleasant, comfortable scene where they would find a screen

on which they could watch a time-lapse film of themselves sleeping quietly and peacefully

through an entire night. The initial induction in the office was often recorded on

audiocassette, lasted about 20 minutes, and constituted instruction for self-hypnosis. Post-

hypnotic suggestions included suggestions for security and anxiety reduction (e.g. “your

unconscious mind even during sleep can be aware that you are safe and secure), restful sleep

with minimal movement, and the instruction that suggestions be reiterated during self-

hypnotic practice at home. The patients were instructed to practice self-hypnosis two times

each day, and that one of these sessions should be carried out just prior to retiring at night.

Follow-up sessions were scheduled for reinforcement of the hypnotic treatment and subjects

were encouraged to report their experiences by telephone. Patients were treated during one or

up to six sessions at varying intervals over a period of time.

There were a total of 27 patients (19 men and eight women) aged between 18-51 years old.

Eight had a primary diagnosis of sleepwalking disorder and four sleep terror disorder. The

other 15 patients were diagnosed with both sleepwalking and sleep terror disorders. Twenty-

two of the patients reported bruises and lacerations as a result of frequent nocturnal arousals.

The frequency of episodes ranged from one to 45 per month. Past psychiatric conditions were

noted in 45% of the patients. Three patients had history of depression, four had histories of

drug and alcohol abuse but were in long standing remission, one patient had a history of

generalised anxiety disorder, six phobic disorders, two adjustment disorder and two attention

deficit disorder. However, at the time of treatment only one patient had an active DSM-III

axis-I psychiatric disorder. This patient had panic disorder and she was later found to have a

prolapsed mitral valve. Thirteen of the patients had no psychiatric history and showed no

signs of psychiatric disorder at the time of the study. Eighteen patients had a family history of

parasomnia disorders. Polysomnographic studies on 17 of the patients revealed no evidence

of seizure, REM sleep behaviour disorder or other disorders that might present as sleep

terror/sleepwalking parasomnias. Eight of these patients showed a high number of arousals

from sleep during the sleep study. The number of arousals shown by these individuals was in

excess of what might have been expected as a first night effect in the sleep laboratory.

The hypnotically based treatment was helpful in 20 of the 27 patients with sleepwalking and

sleep terror disorders. The patients were followed up at substantial intervals to determine the

effectiveness of the treatment. Five patients reported complete remission, but most

emphasised the benefit derived from increased control of frenzied and ambulatory behaviours

rather than the complete elimination of the arousals. They were often aware of having

awakened, occasionally at the bedside, but perceived immediate awareness of the arousals

and returned to sleep. Six of the subjects did not continue to use self-hypnosis. The wives of

two of these patients reported that they knew that if their husbands did use self-hypnosis

when under stress it reduced their aberrant nocturnal behaviour markedly.

Dillahunt (1971) treated an adult male with sleepwalking disorder. The treatment consisted of

hypnosis with suggestions for calm sleep. Dillahunt (1973) also reported a successful single

session treatment of a middle-aged female sleepwalker. He used hypnotic suggestions that

somnambulism, like hypnotic trance is subject to self-regulation. Taboada (1975) treated a

seven-year old boy suffering acute onset of sleep terrors with one hypnotherapeutic session

that resulted in a complete remission that was maintained for 18 months. Eliseo (1975)

reported the amelioration of sleepwalking in a 19-year old man after seven sessions of

hypnotherapy. He used suggestions for sleeping calmly and immediate wakefulness if the

patent’s feet should touch the floor during sleep.

Reid (1975) described the successful treatment of four of six 17-21 year old military trainees

with serious sleepwalking using Dillahunts (1973) technique. Follow-up was limited to the

brief period of their military training, but the four trainees reported no further sleepwalking

during this period. Later, Reid, Ahmed and Levie (1981) conducted a blind crossover study

designed to evaluate specialised hypnotherapy for the treatment of severe sleepwalking

disorder. The subjects were free from significant psychiatric illness. It was hypothesised that

subjects suffering from otherwise uncomplicated sleepwalking disorder would show a decline

in sleepwalking episodes following a course of hypnotherapy designed to impart arousal cues

that were inconsistent with sleepwalking behaviour. Furthermore, it was also proposed that

improvement would be greater using the specialised hypnotic treatment than simple

hypnotherapy that involved suggestion alone.

Subjects were randomly assigned to either active (7 males & 2 females) or a suggestion only

group (3 males & 1 female). Groups were unequal because a lottery like assignment

procedure was employed. The design was a single-blind, rater-blind, modified cross-over

procedure. Every subject in the active group improved at the end of the three-week study

period. In the suggestion only group two subjects improved dramatically but the other two

showed no improvement. The two subjects that showed improvement elected to cross-over

into the active treatment, but showed no further improvement. One subject from the active

group elected to cross-over into the suggestion only treatment in order to make further gains,

but his symptoms remained the same. At a three month follow-up, only one subject from the

active group showed pre-treatment levels of sleepwalking. The two subjects from the

suggestion only group also remained stable with fewer sleepwalking episodes reported

compared with the pre-treatment period. The results indicated that a relatively simple, non-

invasive, inexpensive procedure could be used to alleviate sleepwalking disorder in adults. In

conclusion, a few subjects reported waking beside the bed early in the treatment phase.

However, it was more usual for the therapeutic result to generalise through some mechanism

that is not clear so that there was no sleepwalking and subsequent awakening.

Gutnik and Reid (1982) stated that 50% of the sleepwalking cases they treated responded to

hypnotic treatment in a positive manner. They used hypnosis to treat adults with sleepwalking

disorder and employed suggestions for calm sleep and alertness if the patient’s feet touched

the floor during sleep. Reid, Haffke and Chu (1984) treated 5 adults 28-56 years old with

intractable sleepwalking disorder. However, in this group of subjects, hypnosis and

psychotherapy were not effective, but some subjects responded to treatment with diazepam.

Pai (1946) reported his experiences of treating 1853 wartime neurotic male patients at the

Maudsley Hospital in London. Sleepwalking and other unusual nocturnal activities were

observed in 117 of these men. Most were differentially diagnosed with sleepwalking that was

elaborated to include anxiety, hysterical dissociation, post-infective, and hysteromalingering

states. Treatment for many included resolution of stressors and time-limited heavy sedation.

Hypnosis was used to aid understanding and treat those with hysterical-dissociative

underpinnings. Pai (1946) reported that hypnosis was helpful in resolving sleepwalking in

some of his patients.

Kramer (1988) used hypnosis to treat sleep terror disorder in a 10-year old boy. The boy

experienced his first night terror episode at the age of four. The onset of his sleep terror

episodes were usually about 20 minutes after falling asleep and their frequency was on

average four times per week. Six months prior to the onset of the sleep terror episodes the

boy had reportedly watched a horror movie about werewolves after which the content of his

sleep terror became feelings and vague images that he was turning into a werewolf. At the

time he presented for treatment the frequency of his sleep terror episodes had dropped to

about two each week. The content at this time was vaguely related to images of being

physically mutilated or hurt by someone. He was amnestic for each sleep terror episode.

The boy was treated using hypnosis and was able to enter a deep trance rapidly. The

induction consisted of a finger lowering technique, in which the middle two fingers were

raised and he was asked to watch his fingers as they “go to sleep”. On completion of the

induction, he was given an explanation of the nature of sleep, stage by stage. The regularity

and continual movement of cycles of sleep were emphasised. He was also given direct

suggestions for not dropping too quickly into an extremely deep stage of sleep. A follow up

session was planned and took place one week later. In the interim, he had one night terror

episode of comparatively low intensity to those experienced previously. The suggestions for

dropping off to sleep gradually and having rotating cycles of sleep were reinforced in the

second session and he had not had a recurrence at the two-year follow-up. Continued

psychotherapy was recommended for the patient, but the hypnotic treatment had allowed a

rapid resolution of the sleep terror episodes and the patient was able to get more restful sleep.

Taboada (1975) treated a seven-year old boy with persistent sleep terror disorder and found

that hypnosis was successful in alleviating the symptoms. Taboada used guided imagery to

desensitise the boy to the content of the sleep terror. Gardner and Olness (1981) treated an

11-year old boy for sleepwalking disorder using hypnotic suggestions for calm sleep. The

treatment was successful and sleepwalking episodes were largely eliminated. Gardner and

Olness (1981) treated sleepwalking and sleep terror disorders in children using hypnosis and

also taught self-hypnosis techniques to the children. Mason (1987) used hypnosis to promote

calm sleep in a five-year old girl with sleep terror. Guilleminault (1987) reported the

successful treatment of three adolescents, two whose parasomnias responded to the

adjunctive use of hypnosis. He suggested that children and adolescents with sleepwalking and

sleep terror disorders should be treated with a combination of psychotherapy, hypnosis and

relaxation techniques. Kohen, Mahowald and Rosen (1992) used imipramine briefly, in

conjunction with hypnosis to establish symptom control in four children aged 8-11 years old

with sleep terror disorder. A further seven children 21 months to 16 years old with sleep

terror were treated using hypnosis without concurrent medication. In general, hypnosis was

successful in decreasing the intensity and frequency of the sleep terror episodes.

In a large study Guilleminault, Moscovitch and Leger (1995) treated 28 adolescent and adult

patients with sleepwalking disorder with associated violence and a further 12 patients with

sleepwalking disorder without violence. All patients had been sleepwalking since childhood.

Patient’s age, timing of sleepwalking, sleep state preceding sleepwalking episodes and

associated sleep pathologies were similar in both groups. Increased levels of daytime stress

were associated with more frequent sleepwalking episodes. Temporal lobe lesions were found

only in the violent group. The treatment included pharmacological agents, psychotherapy,

hypnosis and treatment for sleep apnoea in some cases. It was concluded that

pharmacotherapy was the main factor responsible for reduced frequency of sleepwalking

episodes and also of reduced sleep associated violence. However, subjects that discontinued

pharmacotherapy, but maintained psychotherapy and hypnotic treatment also showed less

frequent episodes of sleepwalking and nocturnal violence.

Nugent, Carden and Montgomery (1984) reported that hypnosis was successfully used to

treat sleepwalking in adults subjects. Treatment included suggestions for calm sleep and

alertness should the patient’s feet touch the floor during the sleep state. Reid and Gutnik

(1980) employed hypnosis to suggest calm relaxed sleep. This technique proved beneficial to

the male patient who had otherwise intractable sleepwalking. Zach (1990) used hypnosis to

successfully treat adult subjects with sleepwalking disorder. Schenck and Mahowald (1995)

treated two females aged 17 and 46 years for pre-menstrual sleep terror and injurious

sleepwalking disorders using hypnosis. Both patients responded positively to calming

hypnosis applied just prior to bedtime although the 46-year old women was also given

clonazepam (.25 mg).

In summary, the available studies of hypnosis as a treatment for sleepwalking and night terror

episodes show that in most cases hypnosis can be used directly to either completely alleviate

or reduce the frequency and intensity of these problematic behaviours. Further studies are

required because it is not clear which aspect of hypnosis is important in successful treatments

of sleepwalking and sleep terror. Some authors have suggested that the general lowering of

tonic levels due to the anxiolytic effects of relaxation employed during hypnosis might

reduce the incidence of these disorders. However, others suggest that the individualised use

of hypnosis with suggested imagery and cognitive strategies may reinforce the acceptance of

the modality as well as its efficacy in altering behaviour. Although it is not clear how

hypnosis exerts an effect on sleepwalking and sleep terror episodes, it nevertheless represents

a relatively simple, non-invasive, inexpensive, and effective means of treating these

potentially dangerous disorders.

Aims of the Study

The aim of the case studies reported here was to apply hypnotic treatments based on ideas

derived from the literature to patients with accurately diagnosed primary parasomnias and to

follow-up the treatments to assess efficacy.

METHOD

Subjects

Subjects were selected on an opportunistic basis from among patients presenting at an

insomnia clinic at a major public hospital in Melbourne. During the period allocated for the

study three patients presented with clearly diagnosable primary parasomnias.

Procedure

Patients were interviewed and a detailed history of their past and present sleep difficulties

was obtained during the first session. In all cases, additional information was obtained from

the physicians’ referral letters. Each patient was requested to keep a sleep-diary and complete

a sleep-log over the following two-week period. The information obtained from the sleep-

diary and logs was subsequently used to clarify the diagnoses. Patients were also asked to

have other people living with them to record any unusual nocturnal behaviour that occurred

during the pre-treatment, treatment and post-treatment periods. However, two of the patients

were living alone at the time of the study. In two female patients the original presenting sleep

difficulty was confirmed. One of these two female patients had nightmare disorder and the

other patient sleepwalking disorder. The 30-year old patient with sleepwalking disorder was

also given an overnight diagnostic polysomnographic examination in the sleep laboratory.

However, on the particular night that the patient was examined she did not show any

behaviour consistent with sleepwalking behaviour. The 37-year old patient with nightmare

disorder was not examined in the sleep laboratory because her symptoms were consistent

with the diagnosis of nightmare disorder. The third patient was a 33- year old male who

reported symptoms consistent with sleep terror disorder. This diagnosis was confirmed by an

overnight diagnostic polysomnographic sleep study and visual observation in the laboratory

and was consistent with his reported history. The treatment protocols for each patient were

based on ideas derived from the available literature detailing the use of hypnosis for the

treatment of the primary parasomnias; nightmare, sleepwalking and sleep terror disorders.

RESULTS

Case Study 1: The Hypnotic Treatment of Nightmare Disorder

Patient

SB was a 37-year old female Keyboard Operator

Initial Interview & Patient History

During this initial interview the patient reported a history of recurring nightmares with the

theme of being chased by a masked man who intended killing her. The nightmares had begun

two years previously and coincided with a separation from her husband. The frequency of the

nightmares was three to four nights per week. The patient who now lived alone found it

difficult to return to sleep after experiencing the nightmares and as a result was suffering

from excessive daytime tiredness. The daytime tiredness was affecting her work performance

and also her social life. The patient had undertaken psychotherapy to determine the cause of

the nightmares, but this had not been helpful in alleviating the nightmare condition. The

patient was referred for treatment by her physician after requesting medication for insomnia.

The patient had no other medical conditions and was reported to be in good health by her

physician.

The nature of the nightmare the patients reported was as follows: She hears a noise and

realises that someone, a man, is breaking into her flat. She flees out the back door of the flat,

but the man who is large and dressed in all black clothing chases her. She can see that the

man is carrying a large knife and is terrified that he is going to kill her. She never sees the

man’s face because he is wearing a black stocking mask. The nightmare always begins the

same way and she runs but cannot to get away from the man. Eventually, she is exhausted

and cannot run any further her heart is pounding as the man approaches threateningly with

the knife raised. At this point she screams but no one is there to help her. She really feels that

she is going to be killed and awakens frightened and shaking. After several minutes she turns

on the light and checks all the doors and windows to make sure that they are locked. Her

hearing is hypersensitive and she finds it difficult to return to sleep after the nightmare

episode even though she is aware that it was just a dream and that her flat is secure.

During the interview the patient presented a pleasant women who was embarrassed by her

condition. She had no memory of having nightmares as a child and believed that her present

circumstances were the causal factor. These circumstances revolved mainly around the fact

that she was recently separated from her husband of 10 years and that for the first time in her

life she was living alone. She expressed concerns about security and recounted examples of

crimes committed against women who were living alone that had been reported in the local

newspapers. In following up on these concerns, she was able to rationalise that such events

were random, and that she was living in a group of flats that were very secure. The patient

had no history of psychopathology and there were no indications of psychopathology evident

during the initial interview. The presenting problem was recurring nightmares and insomnia

due to the sleep disturbance caused by the nightmares. The content of the nightmares did not

seem to be causing any daytime problems, apart from the fact that she was sensitive to issues

of personal security to a degree that could have been characterised as over concern. The

patient was requested to keep a sleep diary and complete a sleep log over the following two

weeks.

Treatment Program

Session 1 (2 weeks later)

The frequency of nightmare episodes was confirmed by the diary and sleep log that were

completed during the two weeks since the last session. Nightmares had occurred on three

nights during one week and four nights the following week. The theme of the nightmares was

almost identical on each occasion and was consistent with the nightmare the patient outlined

during the initial interview.

Rationale for the use of hypnosis: Given that she was suffering from insomnia due to inability

to sleep soundly after having been awakened by recurring nightmares and that her physician

had not recommended sedative medication, it was suggested that hypnosis might be a useful

treatment. It was proposed that hypnosis might allow the patient to have control over her own

dream content and that hypnosis could also be used to promote sleeping calmly and soundly

each night.

Explanation of hypnosis: Hypnosis was explained as a state of consciousness different to the

normal waking state. It was also explained that the role of the hypnotherapist was to assist the

patient to enter hypnosis, to guide the patient while under hypnosis and to ensure that the

patient was safely brought out of hypnosis.

Assessment of hypnotisability: There were no contraindications for hypnosis. The Creative

Imagination Scale (Wilson & Barber, 1973) was used to introduce the patient to hypnotic

phenomena and indicated that she was highly hypnotisable.

Session 2 (1 week later)

The patient reported experiencing only two nightmares during the intervening week. The

theme of these three nightmares was the same as that reported previously.

Hypnosis: The induction and deepening procedure were tape-recorded and the patient was

instructed to play the tape each night just prior to bedtime. The induction consisted of the

Speigel eye-roll technique followed by suggestions for progressive relaxation of all the

muscles in the body and sensations of floating. When the patient achieved a deep level of

trance, it was suggested to her that since it was her nightmare she could control the outcome

in anyway she wished. It was suggested that she could bring other people into the nightmare

to help her or that she could use her intelligence to either escape or trap the man who was

chasing her. For example, it was suggested that if she ran in a different direction to the one in

which she usually ran that she would come to deserted carnival (like Luna Park) with a hall

of mirrors (cf.. Kingsbury, 1993). If she lured the man into the hall of mirrors he would be

confused by all the images of her and she could escape locking the door behind her.

It was then suggested that she replay her nightmare as if it was on a TV screen and make a

change to the ending that allowed her to have complete control. At the end of the session the

patient was asked to report what changes she had made to the nightmare ending. She reported

that she enjoyed changing the ending of the dream and that she had lured the pursuer to a hall

of mirrors at Luna Park and had locked him inside. She then reported that she had called the

police and that he had been taken away and locked up.

The patient was instructed to use the techniques on the tape recording as a guide for

practising self-hypnosis.

Session 3 (1 week later)

The patient reported that for the first few nights after the hypnosis session she had no

nightmares and felt a lot more relaxed during both the day and at night. However, as the week

went by she experienced the nightmare on one night. The nightmare was not as intense as it

had been before and she noted that she had a feeling of control and that she was able to

change the nightmare so that the man who chased her was not able to catch her. The patient

listened to the taped hypnosis session each night and reported no further nightmares during

that week.

Hypnosis: A further session of hypnosis was tape-recorded. The induction and deepening

procedure used was essentially the same as that used in the previous session. However,

suggestions for coping with any difficulties and setbacks in the progress of treatment

implementation were included towards the end of the tape.

Session 4 (1 week later)

The patient reported that she had experienced no further nightmares with the theme that had

troubled her for the past two years. However, she reported having some dreams that made her

anxious but that she was able to cope with these by employing similar techniques to the ones

she had used to make the original nightmare harmless.

Hypnosis: A similar session of hypnosis was carried out to the last one except that there were

suggestions for general well-being and coping with difficulties made towards the end of the

session. This session was also tape-recorded. The patient was encouraged to practice self-

hypnosis each day and to use the tapes of the hypnosis sessions. This was the last scheduled

treatment session and it was mutually agreed that there was no need for any further sessions

at this stage. It was agreed that the patient would contact the clinic again if she found that her

nightmares returned.

Treatment Follow-up

During the three months after treatment ended follow-up telephone calls were made every

two weeks. The patient reported that she had not experienced any nightmares with the

original theme during this period. Nevertheless, she did have some dreams that with

frightening themes but the intensity of these was much less than the original nightmare. The

patient reported that she had continued to use the hypnosis tapes and practice self-hypnosis

and that this was also helping her to feel more relaxed and cope better with her life situation

and work-related stress.

Case study 2: The Hypnotic Treatment of Sleepwalking Disorder

Patient

CH was a 30-year old female Solicitor.

Initial Interview & Patient History

The patient sought advice from her physician regarding her sleepwalking behaviour. She was

given a medical examination and was found to be in excellent physical health. She was

subsequently referred to the insomnia clinic for further investigation. The physician’s referral

letter gave no indications of any other medical or psychiatric conditions and concluded that

the patients might have parasomnia. Sedative medication was suggested, but the patient was

unwilling to take medication at that stage.

During this interview the patient presented as a well groomed, pleasant and intelligent young

women. There were no indications of psychopathology and no psychological concerns or

issues which might have been contributory to the patient’s episodes of nocturnal arousal. The

patient was referred for an overnight diagnostic test in the sleep laboratory. The subsequent

report from the overnight diagnostic test indicated that on the test night the patient had a

normal nights sleep and no sleepwalking behaviour was observed. Further nights of testing

could have been performed but this was unwarranted at this stage because the diagnosis was

consistent with sleepwalking disorder. An examination of the patient and her overnight sleep

record by a respiratory medicine specialist revealed no respiratory conditions that might have

been responsible for triggering the sleepwalking episodes.

The patient reported having sleepwalking episodes for as long as she could remember. Her

parents also confirmed that she had usually had at least one or two episodes of sleepwalking

each week throughout her childhood. The patient was not disturbed by her sleepwalking

because she rarely ventured far from her bed and usually had no memory of the episodes in

the morning. In most instances she returned to bed and went quietly back to sleep. Sometimes

she thrashed about while in bed rather than leaving the bed and wandering around. The

patient noted that she tended to experience more episodes of sleepwalking when she had been

mentally or physically activated or aroused just prior to going to bed.

The patient was involved in basketball and karate and often trained or played in the evening.

When she returned on these nights, she retired to bed soon after arriving home. On these

nights she often had episodes of sleepwalking. Similarly, when she worked in the evening

preparing material for the next day she often experienced sleepwalking episodes on these

nights. The episodes were brief (1-5 minutes) and usually occurred only once per night and

on average three times per week. The patient had never previously been concerned by her

sleepwalking because she had no associated nightmares or sleep terror, no memory of the

events and had never harmed herself or anyone else during the episodes. The reason the

patient gave for presenting at this stage of her life was that her partner’s sleep was being

disturbed by her sitting up in bed and moving around or getting out of bed a walking around

the room. A recent event where she thrashed about in bed had resulted in her partner

sustaining a black-eye. Her partner was understanding of her condition and was used to her

nocturnal wandering, but the patient felt that she should try to do something about the

behaviour because of the injury she had caused her partner.

The patient was informed that hypnosis might be a helpful in minimising her episodes of

sleepwalking. The patient agreed that she would be willing to try this in preference to taking

sedative medication. The patient was asked, with the assistance of her partner, to keep a sleep

diary and sleep log during the two weeks that followed.

Treatment Program

Session 1 (2 weeks later)

The data from the sleep dairy and sleep logs confirmed that during the 14 day period the

patient was observed to sleepwalk or thrash about in bed on six nights. On the nights when

sleepwalking episodes occurred there was a positive correlation with the level of physical

and/or mental activity the patient engaged in prior to retiring in the evening. The patient had

previously noted that her sleepwalking was worse on nights that she played sport or worked

in the evenings.

Rationale for the use of hypnosis: Given that the patient showed no other symptomatology,

that she was seeking treatment of her sleepwalking disorder for the sake of her partner’s sleep

and that she was unwilling to consider sedative medication, hypnosis was suggested as a

treatment for her condition.

Explanation of hypnosis: Hypnosis was explained as a state of consciousness different to that

of the normal waking state. It was further explained that the role of the hypnotherapist was to

assist the patient to enter hypnosis, to guide the patient whilst under hypnosis and to ensure

that the patient was safely brought out of hypnosis.

Assessment of hypnotisability: There were no contraindications for hypnosis and The

Creative Imagination Scale (Wilson & Barber, 1973) indicated that the patient was

moderately to highly hypnotisable.

Session 2 (1 week later)

The patient reported that she had one sleepwalking episode during the week. This episode

was noted by her partner and she was amnestic for the event.

Hypnosis: The induction and deepening procedure were tape-recorded and the patient was

instructed to use the tape each night just prior to bedtime. The induction consisted of

progressive muscular relaxation with suggestions for slipping more and more deeply into a

hypnotic trance. When a deep level of trance was achieved, suggestions were given for

sleeping very calmly and that if she should get out of bed as soon as her feet touched the floor

she would wake up immediately and be fully alert but return to bed and quickly return to

sleep (cf.. Eliseo, 1975; Reid, 1975; Hurwitz et al, 1991). The patient was also encouraged to

use self-hypnosis in the evening to assist her to be more relaxed prior to retiring.

The patient was instructed, if possible, to avoid vigorous sporting activity (karate &

basketball) late in the evenings as it was noted previously that there was a positive correlation

between the level of activity in the evening and sleepwalking episodes. If the patient could

not avoid playing sport or working late in the evening she was instructed to allow herself

sufficient time to relax before going to bed. During this time it was suggested that she might

use the recorded tape from the hypnosis session, practice self-hypnosis or sit quietly and

listen to some relaxing music.

Session 3 (1 week later)

The patient reported that she had not experienced any episodes of sleepwalking during the

intervening week. This was also confirmed by her partner who was not disturbed by her

activity on any night.

Hypnosis: The induction and deepening procedure used in this session were similar to that

used in the previous session.

Session 4 (1 week later)

The patient reported no nocturnal arousal during the week and again this was confirmed by

her partner.

Hypnosis: The induction and deepening procedure was identical to that used in the previous

sessions except that additional suggestions for calm, deeply relaxed sleep were added towards

the end of the tape recorded session. This was the last treatment session scheduled and as the

patient had experienced very few sleepwalking episodes since the treatment began it was

agreed that no further session were required at this stage.

Treatment Follow-up

The patient was followed-up over a five-month period by telephone calls every three weeks.

During this period there was a marked decrease in the frequency of sleepwalking episodes

from three per week to about one episode every three weeks. The patient also reported that

when she did not allow herself sufficient time to relax in the evening after sport or work

activities before retiring she was more likely to sleepwalk or move about in bed. The patient

reported that if she used the hypnosis tapes, self-hypnosis or relaxed for some time after

playing sport or working in the evening she generally did not have a sleepwalking episode.

Case Study 3: The Hypnotic Treatment of Sleep Terror Disorder

Patient

GS was 33-year old male Secondary School Teacher

Initial Interview & Patient History

The patient was referred by his physician for episodes of nocturnal arousal. The physician’s

referral letter stated that the patient complained of waking in terror on one or two nights per

week and that a physical examination had not revealed any medical condition that might

account for these episodes of arousal. The physician noted that the patient appeared to be

highly distressed by the recent breakdown of his marriage and the subsequent separation from

his wife and children.

The patient presented as an agitated individual with little insight into the problems that were

troubling him with regards to his marital separation, issues related to his parents, his present

career and earlier professional sporting career. In addition, he was overly focused on various

somatic complaints, taht he believed stemmed from his sleep disturbance. The patient was

referred on for counselling for his relationship difficulties because it was not possible to

address these issues fully within the context of the insomnia clinic.

The patient reported a history of sleep terror episodes that had begun at about the age of 12.

His parents were able to confirm that the sleep terror episodes had begun when he was 12

years old and that on average he experienced one to two episodes each week, with some

weeks where there were none. At the time he presented for treatment he was experiencing

one to two sleep terror episodes per week. These episodes were described as occasions were

he screamed out in a terrified manner and often jumped up from his bed and ran into another

room. Sometimes if he woke shortly after an episode he had a vague feeling that someone

was coming into his room to harm him but otherwise he had no recall of the episodes. When

he was 16 years old during one of these sleep terror episodes he had jumped through his

bedroom window, shattering the glass and landing on the front lawn. During this incident he

sustained only minor cuts and abrasions but was fearful of hurting himself more severely in

the future. Attempts to calm him during episodes of nocturnal arousal, either by his parents or

his wife while they were living together, were met with resistance and if he woke on these

occasions he was confused and disoriented. In the more recent months since he separated

from his wife he had experienced one or two episodes of the arousals each week. After most

episodes of sleep terror the patient reported waking usually confused and disoriented and then

having difficulty returning to sleep. What had prompted him to seek help was the fact that he

had smashed an internal glass door at his parent’s house while experiencing a sleep terror

episode.

The patient was referred for overnight diagnostic testing and observation in the sleep

laboratory. The results of the tests and observation of the patient confirmed the diagnosis of

sleep terror disorder. During the diagnostic test the patient aroused with terrified screaming

early in the night from stage 3/4 sleep. Attempts by the sleep laboratory technicians to calm

the patient were met with resistance and when he finally woke he was confused and

distressed. At this point, which was early in the night, the patient wanted to leave, but was

eventually convinced to stay for the rest of the night. Sleep during the rest of the night was

characterised by frequent awakenings but no further sleep terror episodes. Subsequent

examination of the patient’s sleep record and a physical examination by a respiratory

specialist revealed no respiratory anomalies that might have triggered the sleep terror

episodes.

The patient was requested to complete a sleep diary and sleep log during the two weeks until

the next session.

Treatment Program

Session 1 (2 weeks later)

The sleep diary and log showed that the patient had experienced four sleep terror episodes

that he was aware of during the two-week period since the initial interview.

Rationale for the use of hypnosis: The patient’s diagnosis of night terror was confirmed by

the diagnostic tests and observations conducted in the sleep laboratory. Medical examination

by the attending respiratory medicine specialist revealed no respiratory events that might be

acting as triggers for the sleep terror episodes. The patient was unwilling to take medication

that had been suggested by the respiratory physician and therefore hypnosis was suggested as

treatment that might allow him to sleep more calmly and soundly each night.

Explanation of hypnosis: Hypnosis was explained as a state of consciousness different to the

normal waking state. It was also explained that role of the hypnotherapist was to assist the

patient to enter hypnosis, to guide the patient whilst under hypnosis and to ensure that the

patient was brought safely out of hypnosis.

Assessment of hypnotisability: There were no contraindications for hypnosis and The

Creative Imagination Scale (Wilson & Barber, 1973) indicated that the patient was low to

moderately hypnotisable.

Session 2 (1 week later)

The patient reported being aware of experiencing two sleep terror episodes during the week.

After each event the patient awoke in a confused state and had considerable difficulty

returning to sleep.

Hypnosis: The induction and deepening procedure were tape-recorded and the patient was

instructed to play the tape each night just prior to bedtime. The induction procedure consisted

of progressive muscular relaxation with suggestions for sinking deeper and deeper into a

hypnotic trance. Despite showing only a low to moderate degree of hypnotisability on The

Creative Imagination Scale the patent achieved a deep level of trance. Suggestions were

given for sleeping very calmly and not dropping into deep sleep too quickly. It was further

suggested that patient would cycle through all the stages of sleep very calmly. It was also

suggested that if he should find his feet on the floor he would wake immediately, be fully

alert and return to bed and fall asleep rapidly (cf.. Kramer, 1988). The patient was also

instructed to use the techniques worked through in the tape recording to practice self-

hypnosis each day.

Session 3 (2 weeks later)

The patient reported that he was aware of experiencing one episode of sleep terror after

which he awakened and was not able to return to sleep.

Hypnosis: A further session of hypnosis was recorded which reiterated the same suggestions

as were given in session two. The induction and deepening procedure used was essentially

the same as that used in the previous session. Suggestions for coping with any difficulties and

setbacks in the progress of treatment implementation were included towards the end of the

tape.

Session 4 (1 weeks later)

The patient reported no experiences of sleep terror that he was aware of during the last week.

Hypnosis: This session followed the same format as the previous session with reinforcement

of the suggestions for calm sleep, not dropping into deep sleep too quickly and for alertness if

his feet touched the floor.

Session 5 (1 week later)

The patient reported no episodes of sleep terror that he was aware of during the week.

Hypnosis: The hypnosis session followed essentially the same format as that of the last

session.

Treatment Follow-up

The patient was followed up at intervals of three weeks over a six-month period. The follow-

up indicated that the intensity and the frequency of sleep terror episode dropped dramatically.

The pre-treatment level had been one to two episodes per week. During the follow-up period

frequency of sleep terror episodes was approximately one every three weeks. The patient

reported that he tended to experience episodes when he was agitated about his marital

situation or work, particularly if he did not use the hypnosis tape or self-hypnosis techniques

that he had been taught.

DISCUSSION

Hypnotic Treatment of Nightmare Disorder

Nightmares are frightening dreams accompanied by moderate levels of autonomic activity

and arousal and in contrast with sleep terror, the level of autonomic activation observed in

nightmares, is less and usually results in a complete awakening. Recall of nightmare content

is usually reasonably complete. Studies indicate that many people remember having

nightmares at an early age, but that the frequency of nightmares declines between the ages of

seven to 11 years old (Hartmann et al, 1987). Nightmares usually do not become a matter of

concern unless they are recurrent, disrupt sleep, or are anxiogenic (Erman, 1987).

In the present study, the case of SB presented a classic example of an individual suffering

from nightmare disorder. This patient was troubled by recurrent nightmares over a period of

two years. Nightmares are often caused by traumatic events in the life of the individual.

These events can be real traumatic events, as in the case of war veterans where nightmares

have been discussed as a definitive feature of PTSD (Ross et al, 1989). There are fewer

reports of repetitive nightmares featuring in non-traumatic conditions such as the anxiety and

depressive disorders. However, many people experience transient nightmares in association

with life events that cause high levels of stress (Celucci & Lawrence, 1978b; Kales et al,

1980; Garfield, 1987). Individuals under conditions of acute stress (e.g. examinations) may

experience nightmares , but these usually abate when the acute stress is resolved. However, in

some individuals nightmares may continue over a more extended period of time and come to

constitute nightmare disorder. Whether the threatening situation that caused the nightmares to

begin was real or was simply perceived as real makes little difference. For the patient SB in

this study the anxiety resulting from having to live alone after the separation from her

husband, coupled with her tendency towards over concern about issues of personal security

lead to the development of recurrent nightmares. Psychological factors are believed to play a

major role in the development and persistence of nightmares (Kales et al, 1980) and research

has suggested that anxiety is associated with nightmares (Celucci & Lawrence, 1978b).

The fear that resulted from the recurrent nightmares in SB’s case lead to secondary symptoms

that were centred around sleep deprivation. SB was unable to return to sleep on three to four

nights per week and experienced chronic insomnia. The insomnia caused by SB’s persistent

fear following the nightmare episodes resulted in considerable daytime somnambulance.

Daytime tiredness was interfering with SB’s work performance, social life and probably

reduced her ability to cope with her general life situation. It was the inability to sleep

following nightmare episodes rather than the nightmares themselves that lead SB to seek

medical treatment.

Nightmares can be treated with sedative hypnotic drugs derived from the benzodiapines and

brand names include medications such as Normison and Valium. However, drug treatment is

only warranted if the nightmares cause very severe sleep disturbance. In the case of SB her

sleep disturbance was judged by her physician not to be severe enough warrant treatment

with sedative hypnotic drugs. In cases such as that of SB, where nightmares are chronic, but

do not severely disrupt the patient’s daytime performance the prescription of sedative

hypnotic cannot be justified. Although sedative drugs can relieve the suffering caused by

recurrent nightmares they can exacerbate daytime somnambulance due to the hangover

effects. In addition, short-term usage is recommended and longer-term use often results in

chronic dependency.

There is a tendency for clinicians to focus on nightmares as symptomatic of underlying

psychopathology, which in many cases is a correct assumption to make. There are a variety

of reasons for why clinicians focus on treating other symptomology rather than directly

addressing nightmares. One reason is that historically, dreams have been viewed as a

valuable source of information in psychoanalytic approaches to the treatment of

psychopathology. Prior to seeking medical treatment, SB underwent lengthy a course of

psychotherapy in which the content of her nightmares was explored in relation to her

childhood and her marital separation. However, psychotherapy did not alleviate the suffering

that the nightmares were causing SB. The focus on nightmares as symptomatic of underlying

psychopathology can in fact needlessly prolong patients’ distress. Distress can be worsened

by fatigue due sleep loss, and anxiety and depression can increase as a result of nightmare

themes intruding into patient’s waking cognitions. Patients may interpret the persistence of

nightmares as evidence that psychotherapy is ineffective and be further demoralised (Frank &

Frank, 1991). In SB’s case these factors, particularly sleep deprivation, were affecting her

ability to cope with daily tasks at work and home.

Behavioural therapies, systematic desensitisation and relaxation training have been shown to

be effective in reducing the intensity and frequency of recurrent nightmares (Geer &

Silverman, 1967; Shorkey & Himle, 1974; Celucci & Lawrence, 1978a; Schindler, 1980;

Miller and DiPilato, 1983). Hypnosis has also been used to directly treat nightmare disorder

in children and adults (Marks, 1978; Moss, 1973; Seif, 1985; Tart, 1966; Kingsbury, 1993). A

number of mechanism through which hypnotic treatment may exert an effect have been

outlined. Under hypnosis nightmare content is more involving for the patient than under

normal psychotherapy giving the patient greater access to the emotional state associated with

the nightmare which is therapeutically useful (Gilligan, 1988). The hypnotic induction marks

a separate state from normal consciousness and heightens the expectation that it has the

power to change what seems to be non-volitional behaviour (Combs & Freedman, 1990; van

der Hart, 1993). Research and theory support a link between hypnosis and dreams via

proposed dissociative mechanisms (Gabel, 1989, 1990). Finally, the available clinical

literature indicates that hypnosis can be effectively used to either terminate or control the

content of recurrent nightmares (Kingsbury, 1993; Marks, 1978; Moss, 1973; Seif, 1985;

Tart, 1966).

With respect to the hypnotic treatment used in the case of SB there are several elements

mentioned above which were central to treatment. The technique used to treat SB was based

on one reported by Kingsbury (1993). In this technique the patient (SB) was hypnotised and

instructed that if she wished, she could change any detail of her nightmare. For example, she

could include other people who would help her in the nightmare in some way, or she could

use her intelligence to fool the person chasing her and therefore gain the advantage. After

giving SB examples of how she could make changes to the nightmare, she was asked to

replay the nightmare on a movie or TV screen which she could control. This method was

employed so that SB would be somewhat removed from the nightmare and thus feel safe and

in control of the situation. The patient was told that she could make changes to the nightmare

content as she viewed it on the screen. She was given the following example to illustrate the

kind of changes she could make to have control over the outcome of the nightmare. “You run

in a different direction to the one in which you usually run when being chased and eventually

end up in a place like Luna Park with a hall of mirrors. Inside the hall of mirrors the man that

is chasing you is confused by all the images of you and this allows you to escape. When you

escape you lock the man inside the hall of mirrors and know you are safe from harm.” Later

SB reported that she had enjoyed making changes based on the above story which resulted in

a safe ending for her nightmare. Subsequently, in her own home she was asked use the tape

recordings of the hypnosis session and to practice altering the nightmare content. She was

also encouraged to do the same thing under self-hypnosis. The technique adapted from

Kingsbury (1993) engages the patient to make cognitive changes to the nightmare by editing

it in way that makes it less threatening. The technique uses the projection of the nightmare on

some kind screen as a way of safely distancing the patient from it so it is viewed from an

observers perspective and in a controlled manner. In replaying the dream, there is also the

element of looking at the dream from an observers view point rather than as a participant.

This may afford the patient more insight into the fact they can actually have control over

some or all the elements in the nightmare. Having felt-control has been reported to be an

important factor in having mastery over nightmares (Watzlawick, 1978; Gorton, 1988).

In the present study SB was able to make changes to her nightmare under hypnosis so that it

was transformed in manner that allowed her to feel safe. The generalisation of the changes

from the hypnotic session to her home setting was relatively rapid with few nightmares

experienced at the level of intensity she had previously reported. It appeared that once the

patient gained insight into the fact she had the power to change the nightmare outcome, the

apparent hold of the nightmare was broken.

There were also other non-specific benefits of hypnosis and the acquisition of self-hypnosis

which are difficult to quantify given that this was a case study. These benefits seemed to flow

from the fact that associated with the hypnosis and self-hypnosis, were effects which were

best described as generalised relaxation effects. That is, the patient felt more relaxed both

during the day and at night. These effects could also have been due the fact that, concomitant

with the decline in nightmare frequency, there was also an improvement in sleep and

consequently energy levels. Increased levels of energy and concentration probably allowed

SB to cope more effectively with the challenges of the altered circumstances of her life and

work-related pressures. The effects of relaxation should not be under estimated in the

hypnotic treatment as relaxation processes without trance have been show to be effective in

decreasing the intensity and frequency of nightmares (Miller & DiPilato, 1983). However,

the advantage of hypnotic treatment over simple relaxation techniques is that additional

cognitive processes designed to alter nightmare content and outcome can also be

simultaneously introduced to allow the patient to have some degree of control almost

immediately. The effect of giving a person who has suffered very frightening nightmare even

a small degree of control should not be underestimated. In SB’s case it was apparent after the

first therapeutic session of hypnosis that she had gained a sense that she could control

nightmare content and outcome. This small gain, for the long suffering patient like SB, can be

a major boost for their moral and can increase self-confidence, which may, in turn, lead to

further therapeutic gain.

In summary, hypnotic treatments designed to treat recurrent nightmares are best

conceptualised in terms of the specific and the general effects hypnosis has on the patient.

Specific effects are those that result from direct hypnotic suggestion/instruction to the patent

involving transforming the nightmare (Eichelman, 1985; Gilligan, 1988), changing the

ending of the nightmare, interrupting the nightmare (Gorton, 1988), acquiring mastery of the

nightmare, exposure in less involving contexts (desensitisation) (Kingsbury, 1993), using

controlled imagery (Kingsbury, 1993), solving the nightmare (Kingsbury, 1993), and

reframeing the nightmare and incorporating it in some way (Watzlawick, 1978). General

effects of hypnosis which may not necessarily stem from direct instruction include; increased

feelings of relaxation, unconscious processing of material, improved cognitive function,

improved sleep and the secondary effects which might flow from this.

In conclusion, involving the patient in directly editing or making cognitive changes to

projected imagery of recurrent nightmare scripts can play an important role in hypnotic

techniques designed to treat nightmare disorder. The inclusion of cognitive processing is not

necessary because non-specific hypnotic-relaxation techniques are also effective. However,

generalised techniques without specific focus may take longer to be effective. Techniques

designed to focus specifically on the content and make changes seem to allow very rapid

treatment of the nightmare disorder. In addition, once a patient has these skills they can be

deployed to deal with other anxiety provoking dreams or nightmares which may arise at some

future time. In the case of SB, she found that she was able to use the general technique of

editing the nightmare to change other anxiety provoking dreams. Therefore, based on the

literature and the results of the case study of SB, direct hypnotic treatment employing

techniques designed to quickly alter nightmare content is a highly appropriate approach to the

treatment of nightmare disorder. A further factor which appeared to be critical was having the

patient practice hypnosis/self-hypnosis at home to re-experience nightmares and learn to

make the content more benign.

Hypnotic Treatment of Sleepwalking & Sleep Terror Disorders

It is important that parasomnias like sleepwalking and sleep terror disorders are correctly

diagnosed and that effective treatment is given if the associated behaviours are potentially

injurious, violent or disruptive to either the patient or other individuals. Sleepwalkers are

usually difficult to communicate with and if left alone often return to bed. When awakened,

they have little memory of anything that happened during the episode. Kales et al, (1966)

found that few sleepwalking incidents were related to specific traumatic events. Sleepwalking

generally occurs about an hour or two after falling asleep. In most cases, sleepwalking begins

with a burst of high voltage, slow frequency EEG activity, and is related to arousal from stage

3/4 NREM sleep (Kales et al, 1966; Broughton, 1968).

In the case of CH the primary diagnosis was sleepwalking disorder. This patient had a long

history of sleepwalking behaviour which began in childhood. The patient sought medical

treatment for her sleepwalking disorder because it was disrupting her partners sleep. The

patient herself was not aware of sleepwalking on most occasion and this is entirely consistent

with the diagnosis of sleepwalking disorder. The patient CH was offered medical treatment

for her sleepwalking in the form of sedative medication, but she was not willing to commence

drug therapy. The main problem with drug therapy for sleepwalking is the long-term nature

of the disorder and the adverse effects chronic drug usage may have on behaviour and

learning (Weissbluth, 1984).

Studies have shown that patients with sleepwalking disorder can learn to self-regulate

previously uncontrolled nocturnal behaviours by teaching them techniques such as relaxation

and mental imagery and self-hypnosis. Reid et al, (1981) compared hypnosis designed to

impart arousal cues inconsistent with sleepwalking behaviour to non-specific hypnotic

treatment. They found that both treatments were effective, but that the specialised technique

was superior. Reid et al’s study showed that a relatively simple, non-invasive, inexpensive

procedure could be used to alleviate sleepwalking disorder in adults. They found that a few

subjects reported waking beside the bed early in the treatment phase which was consistent

with what was expected in accordance with the post-hypnotic suggestions. Nevertheless, it

was more usual for the therapeutic result to generalise through some mechanism which was

not clear so that there was no sleepwalking and subsequent awakening.

The hypnotic treatment employed with the patient CH incorporated three main ideas which

been reported in the literature, relaxation, posthypnotic suggestions for calm sound sleep and

for alertness if the feet touched the floor during the night. The hypnotic treatment was

designed to promote relaxation in CH in the evenings before she retired to bed. CH had

previously reported that there was a positive correlation of her arousal level in the evening

and with the frequency of her sleepwalking episodes. When CH played sport or worked late

in the evening the likelihood of her having a sleepwalking episode was increased. Therefore,

it was also suggested that she avoid playing sport or working too late in the evenings or if she

could not avoid these activities to take time to relax before retiring to bed. Methods of

relaxing included using taped hypnosis sessions, practising self-hypnosis or simply listening

to some relaxing music. The second part of the hypnotic treatment incorporated post-hypnotic

suggestions for calm, sound sleep and alertness if the feet touched the floor during the night.

In line with what other researcher (e.g. Reid et al, 1981) have reported in the case of CH the

most effective element in the hypnotic treatment was not the post-hypnotic suggestions for

alertness if the feet touched the floor during sleep, but the reduced levels of tonic arousal

produced via the relaxation elements included in hypnosis sessions, the taped hypnosis

sessions and in self-hypnosis/relaxation practised in vivo. This conclusion was partly based

on the feedback CH gave about the correlation between high levels of mental and/or physical

activity and episodes of sleepwalking. CH who was heavily into sport found that on evenings

when she played sport late there was an increased likelihood of sleepwalking. Similarly,

when CH worked late at her office or at home on demanding mental tasks there was also an

increased chance of her sleepwalking. Mahowald and Rosen’s (1990) model of factors which

are likely to influence the frequency and intensity of parasomnias like sleepwalking includes

tonic arousal. Therefore, treatments which are likely to alter the level of tonic arousal

(i.e.lower it) are more likely to be helpful in stopping sleepwalking. The was probably no

specific factor which was central to the decrease in the frequency of sleepwalking episodes.

The factors most likely to have decreased the level of sleepwalking are twofold. Firstly, the

instruction to reduce activity in the evening and make sure that CH was sufficiently relaxed

before going to bed (behavioural change) and secondly the use of hypnosis tapes and self-

hypnosis in the evening prior to bedtime to lower tonic arousal levels. Thus, the main effect

from the hypnotic treatment was probably increased relaxation.

Sleep terror disorder is best described as nocturnal episodes of extreme terror and panic

which occur early in sleep when the person is in stage 3/4 deep NREM sleep (Hartmann,

1984; Kales et al, 1982). Sleep terror disorder is not as common as nightmare disorder.

Episodes of sleep terror usually last only a few minutes and the subject has little or no recall

of the event. Sleep terror disorder can be distinguished from nightmare disorder by clinical

features and sleep-laboratory findings. Sleep terror and sleepwalking have similar clinical

characteristics and many individuals experience both (Hartmann et al, 1982; Kales et al,

1982; Oswald & Evans, 1985; Vela-Bueno et al, 1987). Sleep terror disorder frequently

begins before the age of 10 and usually abates during adolescence (Kales & Kales, 1974).

In the present study the patient GS showed a history of symtomatology which was consistent

with a diagnosis of sleep terror. This diagnosis was subsequently confirmed by an overnight

polysomnographic sleep study. During the early part of the night when the patient was in

deep NREM sleep he aroused in a state of extreme terror. The attempts made by the sleep

laboratory technicians to comfort GS were met with resistance which is a typical reaction of

patients experiencing a sleep terror episode. Eventually, when GS awoke he was confused

disorientated and had to be convinced to remain in the sleep laboratory for the rest of the

night. The patient had no detailed recall of the mental processes that had lead to this episode

of sleep terror. However, he was able to state that he had a vague feeling that someone was

entering the room to get him.

Sleep terror can be triggered in susceptible individuals by auditory stimulation during slow

wave sleep (Fisher et al, 1970; Fisher et al, 1973). In many individuals and in the majority of

children arousals appear to be spontaneous. This is evidenced by the fact that sleepwalking

can be induced readily in children by standing them up during slow wave sleep (Kales et al,

1966; Broughton, 1968). Similarly, sleep terror can be triggered in susceptible individuals by

auditory stimulation during slow wave sleep. Both these observations suggest that these

behaviours are not the result of ongoing complex mental activity during sleep (Fisher, Byrne,

Edwards & Kahn, 1970; Fisher, Kahn Edwards, Davis & Fine, 1973).

The induction and deepening procedure used to treat GS consisted of progressive muscular

relaxation with suggestions for sinking deeper and deeper into a hypnotic trance. When the

patient was in trance he was given suggestions for sleeping calmly and not dropping too

quickly into deep sleep. It was also suggested that he would cycle through all the stages of

sleep very calmly. Finally it was suggested that he would wake and be alert should his feet

touch the floor during the night and that after this he would return to bed and fall asleep

rapidly. These suggestions were modelled on suggestions used by Kramer (1988) in his case

study report of hypnotic treatment of a 10 year old boy with persistent sleep terror disorder.

The patient GS was assessed as low to moderately hypnotisable using The Creative

Imagination Scale. However, GS was able to achieve a deep level of trance during the formal

induction for treatment of his sleep terror disorder. During the subsequent weeks GS reported

that the frequency of his sleep terror episodes declined so that during the follow-up period he

reported very few episodes of night terror. There were no occasions where GS reported being

awakened during a night terror episode. This observation is further supported by the fact that

on the few occasion where he did experience sleep terror after the commencement of the

hypnotic treatment program, when he awakened during the episode he was confused and

disorientated. Therefore, post-hypnotic suggestions for alertness if his feet touched the floor

during a sleep terror episode were not the effective element in the hypnotic treatment

program. Over the period of treatment sleep terror episodes declined markedly in frequency

and also to some extent in intensity. Patients in Hurwitz et al’s (1991) study were given

similar post-hypnotic suggestions for calm sleep and wakefulness if their feet touched the

floor during a sleep terror episode. However, these authors reported that there was a

generalised effect with less intense and frequent sleep terror episodes reported. Few patients

actually reported being alerted during an episode. Some patients reported complete remission,

but most emphasised the benefit derived from increased control of frenzied and ambulatory

behaviours rather than the complete elimination of the arousals. Six of the subjects did not

continue to use self-hypnosis. The wives of two of these patients reported that if their

husbands used self-hypnosis when under stress it reduced their aberrant nocturnal behaviours

markedly. The patient GS reported that he was more likely to experience sleep terror episodes

when he did not use the taped hypnosis sessions or self-hypnosis.

When onset of these sleep disorders occurs after age 10, they are likely to persist in

adulthood, episodes are more frequent, the time of their onset is often associated with major

life stress events, and they seem to be related to psychological factors. The patient GS was

distressed by psychological factors which seemed to mostly stem from his background and

current marital problems. Since the break down of his marriage he had reported more

frequent episodes of night terror. The patients psychological problems in combination with

his poor sleep habits and insomnia were probably interacting to cause increased arousal

during the night. Mahowald and Rosen (1990) proposed a model for understanding the

determinants and manifestations of sleep terror. Their model suggests that at the end of a

period of deep NREM sleep the individual suffering sleep terror may become ‘caught’ -

unable to completely get out of deep sleep, unable to arouse fully, and unable to move into

the next sleep cycle. Factors which determine the occurrence of partial arousals are: (1) tonic

sleep factors; (2) phasic sleep factors; and (3) the behavioural response to the arousal

(Mahowald & Rosen, 1990). The tonic factors which occur throughout the sleep period

determine the individual’s underlying sleep pattern and arousal threshold. In the case of GS

three factors which may have increased his level of tonic arousal were; sleep deprivation,

chaotic sleep/wake scheduling, and psychological problems.

The mechanism underlying the decrease in the intensity and frequency of sleep terror

episodes after hypnotic treatment are not well understood. However, it is possible that the

main factor contributing to the success of hypnotic treatments is a change in underlying tonic

sleep factors resulting in a higher arousal threshold and hence fewer arousals. Therefore, the

non-specific general factors in hypnosis which lead to the patient being more relaxed may be

important. In other studies (e.g. Hurwitz et al, 1991) the hypnotic treatment effect was

reported to generalise so that patients had few and/or less intense sleep terror episodes. In the

present study there was no evidence that specific post-hypnotic suggestions had any effect on

sleep terror as the patient did not report being alerted when experiencing a sleep terror

episode. In fact GS noted that when he did not use the hypnosis tapes or practice self-

hypnosis he was more likely to have sleep terror episodes. Research has shown that

relaxation training can decrease the occurrence sleep terror episodes. Therefore, the elements

of hypnosis that lower tonic arousal during sleep may be important therapeutic element in the

treatment.

In conclusion, studies of sleepwalking and sleep terror episodes employing hypnotically

based treatments indicate that in many cases this form of treatment may be used to directly to

either eliminate or reduce the intensity and frequency of these problematic behaviours.

Further studies of hypnotic treatments for these disorders are required because it is not clear

which aspect of hypnosis is important in successful treatments of sleepwalking and sleep

terror. The present cases studies of CH and GS support the observations of other authors (e.g.

Hurwitz, 1991) that suggest the general lowering of tonic levels due to the anxiolytic effects

of relaxation employed during hypnosis might reduce the incidence of these disorders.

However, others authors (e.g. Koe, 1989; Kingsbury, 1993) have suggested that the

individualised use of hypnosis with suggested imagery and a cognitive strategies may

reinforce the acceptance of the modality as well as its efficacy in altering sleepwalking and

sleep terror behaviours. Although it is not really clear how hypnosis exerts an effect on

sleepwalking and sleep terror episodes, it is nevertheless is a relatively simple, non-invasive,

inexpensive, and effective means of treating these potentially dangerous disorders.

ACKNOWLEDGMENTS

I wish to thank Susan Hook, for her optimistic encouragement and expert advice during the

course of this project. I would also like to thank my fellow ASH members; John Redman, Dr.

John White and Dr. Allison Weber who also provided support and valuable comment on this

project.

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Table 1. Mahowald & Rosen’s (1990) Classification of Parasomnias

Primary sleep parasomnias

A. NREM parasomnias

1. Sleep starts

2. Disorders of arousal (Sleep Terror & Sleepwalking Disorders (DSM-IV))

3. Sleep drunkenness

B. REM parasomnias

1. Dream anxiety attacks (Nightmare Disorder (DSM-IV))

2. Hypnogogic hallucinations and/or sleep paralysis

3. REM sleep behaviour disorder

C. Non-sleep stage specific parasomnias

1. Bruxism

2. Enuresis

3. Rhythmic movement disorder

4. Periodic movements of sleep

5. Posttraumatic stress disorder

6. Somniloquy (sleeptalking)

Secondary sleep parasomnias

A. Central nervous system

1. Seizures

2. Headaches

B. Cardiopulmonary

1. Sleep-related arrhythmias

2. Nocturnal asthma

3. Miscellaneous

4. Sleep apnoea

C. Gastrointestinal

1. Gastroesophageal reflux

2. Diffuse oesophageal spasm

D. Miscellaneous

1. Panic attacks

2. Nocturnal muscle cramps

3. Psychogenic dissociative states

ResearchGate has not been able to resolve any citations for this publication.

Case report: Treatment of intractable sleepwalking

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Jan 1980

An adult male with chronic destructive, virtually intractable sleepwalking symptoms was treated with a hypnotic conditioning paradigm as part of a larger study. He did not respond adequately, and some months later low h.s. doses of diazepam were instituted. The response was dramatic, positive, and has lasted almost one year. There has been no indication of relapse or of tolerance to the diazepam. The authors hypothesize that the medication helps to stabilize and normalize sleep patterns. There is no evidence to indicate that the antianxiety potential of the drug is addressing the sleepwalking symptom.

Cellucci, A. J. & Lawrence, P. S. (1978). The efficacy of systematic desensitization in reducing nightmares. Journal of Behavior Therapy and Experimental Psychiatry, 9, 109-114.

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Jun 1978
J BEHAV THER EXP PSY

The effectiveness of systematic desensitization in ameliorating nightmares was evaluated in a controlled study. Twenty-nine subjects were assigned to either systematic desensitization, a nightmare discussion placebo, or continuous self-recording. The placebo treatment did not differ from desensitization in terms of rated logicalness and potential effectiveness. However, the desensitization group showed a significantly greater reduction in the frequency of nightmares as well as a decrease in rated intensity. Moreover the desensitization subjects also had a significantly greater decrease in reported fear and state anxiety. Related research on nightmares is noted and future research needs are discussed.

A psychophysiological study of nightmares and night terrors

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Jan 1974

Principles and Practice of Sleep Medicine

Article

Jan 1994

Sleepwalking and night terrors

Article

Jan 1989

C. Guilleminault

Sleep disorders: Disorders of arousal? Enuresis somnambulism and nightmares in confu-sional states of arousal not in "dreaming sleep"

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Jan 1968

Roger James Broughton

Night terror in adults through three generations

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Aug 1972
ACTA PSYCHIAT SCAND

Symbol, story, and ceremony: Using metaphor in individual and family therapy.

Article

Jan 1990

Since the authors were inspired by the life and work of Milton H. Erickson and Gregory Bateson, they begin, in Section I on "Fundamentals," with overviews of Ericksonian psychotherapy and the Batesonian perspective. Then they show how to use metaphor in six basic therapeutic strategies: developing a relationship, gathering information, suggesting ideas, accessing and utilizing resources, reframing, and facilitating new patterns of thoughts, feelings, and behavior. In Section II, "How to Construct Metaphors," readers will find a compendium of practical exercises designed to develop flexibility, creativity, and confidence in thinking metaphorically. Specific guidelines are offered to help therapists develop strategies for creating symbols, stories, and ceremonies. In Section III, "The Therapeutic Interaction," the authors give their ideas on how to set up a context in which to work metaphorically and how to deliver metaphors effectively. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Dreams and dissociation theory: Speculations on beneficial aspects of their linkage

Article

Mar 1990

Stewart Gabel

Reviews psychological attempts to understand dreams from a dissociative perspective. Characteristics of several dream theories are discussed, and it is argued that dreams as now understood in some psychoanalytic and nonpsychoanalytic orientations may also be understood within the framework of dissociation theory. The study of dreams may be enriched by or contribute to greater development of dissociation theory in many areas, including developmental psychology and psychobiology, brain–behavior relationships, and learning theory. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Parasomnias: Sleepwalking, Night Terrors, and Nightmares

Article

Jul 1987

Discusses the evaluation and treatment of parasomnias. Characteristics of parasomnias are described, along with causative factors and differential diagnosis. Sleepwalking and night terrors are considered to be disorders involving impaired arousal, occur during slow-wave sleep, and are more common in children than adults. Nightmares occur during REM sleep, and recall is usually more vivid than sleepwalking or night terrors. Suggested treatment for sleepwalking or night terrors in children involves protection from self-injury. Treatment for nightmares involves reassurances that nightmares are a normal part of childhood and will be outgrown. It is noted that parasomnias in adults usually reflect underlying psychopathology. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

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