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Evidenced-Based Hypnotherapy for the Management of Sleep Disorders
Evidenced-Based Hypnotherapy for the Management of Sleep Disorders
There is a plethora of research suggesting that combining cognitive-behavioral therapy with hypnosis is effective for a variety of psychological, behavioral, and medical disorders. Yet, very little empirical research exists pertaining to the use of hypnotherapy as either a single or multitreatment modality for the management of sleep disorders. The existing literature is limited to a small subset of nonbiologic sleep disorders. The objectives of this paper are: to provide a review of the most common sleep disorders, with emphasis on insomnia disorders; discuss the cognitive-behavioral approaches to insomnia; and review the existing empirical literature on applications of hypnotherapy in the treatment of sleep disturbance. The overreaching goal is to educate clinicians on how to incorporate sleep therapy with hypnotherapy. There is an immediate need for research evaluating the efficacy of hypnotherapy in the management of sleep disturbance.
The objectives of this paper are: to provide a review of the most common sleep disorders, with emphasis on insomnia disorders; discuss the cognitive-behavioral approaches to insomnia treatment; and review the existing empirical literature on applications of hypnotherapy in the treatment of sleep disturbance. The overarching goal is to educate clinicians on how to combine sleep therapy with hypnotherapy. Examples of hypnotic scripts are provided to illustrate how to accomplish this objective. Many patients complain of sleep disturbance, with insomnia being the most common sleep complaint. However, there are many biologic-based sleep disorders that often mimic psychological/behavioral sleep disorders such as insomnia. For instance, patients with undiagnosed obstructive sleep apnea may complain of difficulty maintaining sleep and experiencing ruminative thoughts centering on lack of sleep. This report could easily lead to an insomnia diagnosis and treatment for insomnia. In this example, treatment most likely will fail because the difficulty with maintaining sleep arises from biologic factors. More specifically, the patient stops breathing during sleep because the pharyngeal airway has narrowed and collapsed, obstructing the patient's airway (the hallmark feature of obstructive sleep apnea), and the body awakens (an evolutionary adaptive response to protect the body) in order to restore breathing. Hypnotherapists must always maintain a conservative approach when treating sleep disturbance. If patients are treated for sleep disturbance and there is no improvement in sleep functioning, referral to a sleep disorder center for evaluation is mandatory. Although assessment options are available, a referral to a sleep specialist is strongly preferred ([ 9]; ).
Common Sleep Disorders
Several types of sleep disorders have been successfully treated utilizing hypnosis as either a single or multitreatment modality. These categories include excessive-sleepiness disorders (e.g., hypersomnia, obstructive sleep apnea), circadian-rhythm disorders (e.g., delayed sleep phase, jet lag), and parasomnia sleep disorders (e.g., somnambulism, sleep terrors, nightmares, REM-behavior sleep disorder). Generally, these sleep disorders result from biologic factors, and biologic sleep disorders are not amenable to hypnotic interventions. However, if psychological and/or behavioral issues are contributing factors then hypnotherapy may be efficacious, specifically in reducing arousal states.
Of the behavioral sleep disorders, the insomnia disorders have received the most attention, specifically regarding the etiology, assessment, and management of insomnia. Cognitive-behavioral techniques have been found to be the "gold standard" in maintaining long-term treatment gains. In order to treat insomnia, clinicians must be educated regarding the etiology and assessment of insomnia.
Insomnia is a complex, multifaceted complaint that may involve difficulty falling asleep, staying asleep, early morning awakenings (with an inability to return to sleep), and/or a complaint of nonrefreshing sleep that produces significant impairment ([ 1]; [ 2]; [ 6]; ). The most prominent feature of insomnia is the complaint of poor sleep, either in inadequate duration or quality, impacting quality of life, mood, energy, and daytime functioning (). An insomnia complaint almost always involves some type of increased arousal state.
The two most common types of insomnia disorders (not including insomnia associated with a medical disorder) are adjustment and psychophysiological sleep disorders. Adjustment sleep disorder is a condition in which an individual has experienced a significant life stressor(s), (such as the death of a loved one or being diagnosed with a life-threatening illness) that interferes with sleep. This type of sleep disturbance is more commonly associated with a transient sleep disturbance and generally abates within 1 month. However, when this type of transient insomnia does not attenuate over time, it can progress to chronic insomnia, often accompanied by depression. In comparison, psychophysiological insomnia is a sleep disorder that results from the presence of heightened arousal in which somatized tension and learned sleep preventing associations (e.g., nervousness, anxiety, ruminative thoughts) interfere with nocturnal sleep.
Patients' faulty beliefs and attitudes about sleep and sleep disturbance contribute to their continuing sleep problems ([ 6]). Many patients believe that 8 hours of continuous sleep each night is necessary to maintain daily functioning—yet there is wide variability in patients' nightly sleep patterns. There also appears to be no evidence that occasional loss of sleep has any lasting effect. Despite these facts, sleep disturbance often elicits anxiety about continued sleep disturbance, leaving patients lying in bed worrying about whether they will get to sleep or get enough sleep in the coming night and further maintaining that disturbance. Of course, the continuing use of maladaptive sleep behaviors, including an excessive amount of time in bed, napping, and an irregular sleep-wake cycle, will both maintain and possibly worsen sleep disturbances ().
Cognitive-behavioral Therapy for the Management of Insomnia
Management of insomnia using cognitive-behavioral treatment involves the same principles used in cognitive-behavioral therapy (CBT), except therapy is directed toward altering dysfunctional beliefs and attitudes about sleep () and replacing maladaptive behaviors with more adaptive "presleep and postsleep" cognitions and behaviors. However, the first step in treatment should begin with patient education. Educating the patient regarding CBT techniques is an essential requirement for managing insomnia. Patients need to learn how to recognize sleep problems, as well as how they and their provider team can help them.
The Multicomponent Approach
The clinician is also encouraged to use a multicomponent approach to treatment of sleep disorders. The multicomponent approach generally includes the four general approaches to behavioral treatment of sleep disorders: education (e.g., sleep hygiene behaviors), stimulus control and sleep restriction therapies (), and cognitive therapy (Figure 1). After a brief educational session, the patient initiates the behaviors at home. Subsequent clinic visits require evaluation of the success of these behaviors and discussion of specific barriers to achieving the goals of treatment. All four approaches require that patients monitor their sleep patterns as they initiate these changes while monitoring their sleep/rest/wake times using a sleep self-monitoring form (e.g., sleep diary) or other assessment instrument.  provide an example of an 8-week script of materials for the management of insomnia that includes hypnotic interventions for the treatment of insomnia but may be altered to treat other sleep disorders.
Patient contributors to sleep disturbance. Patients may also contribute to the initiation and maintenance of sleep disturbance. For instance, patients often lack knowledge about foods, drinks, medications, and physical activities with psychostimulant properties that can interfere with sleep. Further, patients may know little about stress reduction or relaxation techniques that may promote sleep onset. Patients may overuse over-the-counter or herbal remedies that were designed for short-term use only. These are examples of maladaptive behaviors that interfere with nocturnal sleep and are termed poor sleep hygiene behaviors (, ). Sleep hygiene refers to the organization of activities (e.g., presleep behaviors) that promote sleep and minimize sleep disturbance. Typically, it incorporates the following behaviors:
• Reduce the intake of nicotine, caffeine, and other stimulants
• Avoid stimulants (if taken) in the afternoon or evening
• Avoid alcohol near bedtime
• Keep a regular daytime schedule for work, rest, meals, treatment, exercise, and other daily activities
• Perform strenuous exercises early in the day rather than in the late afternoon or evening
Insomnia complaints can often be corrected by implementing these proper sleep hygiene behaviors. For instance, some patients are reluctant to avoid napping during the day, or they will unintentionally fall asleep during the day. This unintentional sleep is often a major contributor to the onset and maintenance of insomnia. The goal is to educate the patient so that they can eliminate behaviors that lead to sleep disturbance.
Adaptive Sleep Hygiene Behaviors
1. Keep a regular time for going to sleep and for waking up (even on weekends).
2. Create a bedtime routine—engage in quiet, calming activities.
3. The bedroom is for sleep and intimate activities only.
4. Don't lie down for bed until sleepy.
5. If you don't fall asleep within 15–20 minutes, get out of bed and go into another room and engage in a quiet nonstimulating activity until you are sleepy and then return to bed.
6. Sleep just long enough.
7. Regular exercise during the day can deepen sleep—it should be done 4–6 hours before bedtime.
8. Have a light bedtime snack—avoid heavy foods.
9. Reduce noise and light level.
10. Regulate room temperature.
11. Avoid stimulants—nicotine and food and drinks containing caffeine—4–6 hours before bedtime and includes chocolate, coffee, and sodas.
12. Avoid alcohol—helps you fall asleep but causes awakenings and poor sleep later.
13. Avoid daytime naps—limit naps to 20 minutes and avoid them after 3 pm.
The primary objective of stimulus control therapy is to train the patient, through a learning paradigm, to associate the bed with sleeping and sleeping with the bed. In addition, the patient learns to set their sleep/wake cycle. A general guideline is to educate patients about the bedroom environment. The bedroom is for sleep and intimate activities. It should be considered a safe haven and an environment that is conducive to sleep. To achieve these goals, the following behaviors are suggested:
• Go to bed only when sleepy.
• Pursue only sleep in bed. No other activity except sexual activity is permitted; in other words, reading, eating, watching television, or completing homework is not to be done in bed but in another area of the home.
• Get out of bed, if sleep does not come within 15 or 20 minutes of retiring at night, and engage in relaxing behavior, returning to bed only when sleepy (this may be repeated as often as needed throughout the night).
• Wake at the same time every day, regardless of the amount of sleep achieved during the night.
• Avoid daytime naps.
Sleep restriction generally involves creating a mild state of sleep deprivation with the goal of increasing "sleep pressure" (the need and drive to fall asleep) so that patients are able to fall asleep and to maintain (i.e., consolidate) their sleep. The overarching goal is to have the patient sleep continuously throughout the night. A general heuristic is that if your patient complains of difficulty falling asleep and reports lying awake in bed for greater than 30 minutes, suggest the patient go to bed during the time that they report falling asleep. For instance, if a patient reports going to bed at 10:00 pm but does not fall asleep until midnight, it is appropriate to suggest going to bed at midnight and not before midnight (unless patient cannot stay awake). The hypnotherapist is cautioned about utilizing sleep-restriction therapy without having formal training and experience in this technique. If the therapist does not have experience in sleep restriction, consultation with a sleep specialist is recommended.
In addition to sleep hygiene, stimulus-control therapy, and sleep-restriction therapy, a more general cognitive approach is implemented. For example, many patients who have difficulty sleeping begin to worry about their lack of sleep and the nightly struggle to achieve restful sleep. They may ruminate more about their sleep patterns than the current psychosocial stressors they are experiencing. They begin to develop cognitions that only amplify the problem. Sleep difficulties may be seen as a potential contributor to ongoing problems. They may become concerned, as one recent patient did, that lack of sleep will result in poor job performance, which will result inevitably in termination from employment and loss of the family's resources that will preclude his children (ages 5 and 12) from going to college and achieving successful careers. Patients may be challenged on the veracity of these statements and encouraged to produce alternative thoughts. They can then be encouraged to compare the veracity of the worried cognitions with the alternatives.
The objectives of implementing these types of cognitive strategies into hypnotic scripts are (a) to counter the irrational thoughts with rational affirmations, (b) to induce relaxation and deepening hypnotic techniques to increase time spent asleep, and (c) to assist the patient to decrease both daytime and nighttime heightened states of arousal and somatized tension.
Relationship Between Hypnosis and Sleep
A common misperception individuals may have is that patients are asleep when they are in a hypnotic trance. Although these states appear to be similar, sleep and hypnosis are distinctively different. Sleep is characterized by having perceptual disengagement and unresponsiveness to the environment (). A hypnotic trance can be described as a highly suggestible state of relaxation, which does not necessarily lead to sleep. Electroencephalographic (EEG) studies of brain waves have shown that hypnosis is characterized by waking patterns, which are distinctly different from sleep ([ 7]). Further, studies have shown that slow-rolling eye movements are not present during hypnotic trance induction but are seen during the transition from wake to Stage 1 sleep onset (), as well as during rapid eye movement (REM) sleep.
A Review of Hypnosis Literature
Hypnosis as a single-treatment modality has been used successfully to alleviate insomnia ([ 3]; [ 4]; [ 5]; ; ; , ; ; Spiegel & ; , ; ), nightmares, night terrors, and sleep walking ([ 8]). Hypnosis and self-hypnosis both offer rapid methods to manage anxiety and worry, facilitating deep relaxation, and controlling mental overactivity and decreasing physiological arousal, which are cardinal symptoms of insomnia (Bauer & McCanne; Hammond). Self-hypnosis is considered a voluntary relaxation technique (Dement & Vaughan) that is similar to meditation because it can ease the body and mind, preparing the body for sleep (Kryger).
Hypnosis in the Treatment of Insomnia
Clinical hypnosis is a safe and effective method of treating insomnia as it allows the clinician to gain access to the underlying problem (). Several trials as well as several reviews (; ; ; ) and meta-analyses (; ) have examined the efficacy of relaxation and hypnosis for treatment of insomnia (). A 1994 meta-analysis of 59 studies () reported that psychological interventions averaging 5 hours produced reliable changes in sleep-onset and time spent awake after an awakening. A 1996 National Institute of Health (NIH) consensus panel concluded that hypnosis and biofeedback produced significant changes in some aspects of sleep; however, it was unclear whether the magnitude of improvements in sleep onset and total sleep time were clinically significant ().
It is not surprising that studies have yielded conflicting findings. Clinicians trained in hypnotherapy should consult with a sleep professional when designing studies to ensure that the population is homogenous in terms of sleep disturbance. As discussed earlier, somatically based insomnias have been unamenable to hypnotic interventions (). In contrast, some psychological insomnias (i.e., precipitated by upset either prior to sleep onset or waking up after sleep onset and experiencing difficulty returning to sleep because of anxiety about not sleeping or losing sleep) are very amenable to hypnosis.
Relaxation training and hypnosis can be effective in treatment of late-life insomnia (). A randomized trial found that CBT (alone and in combination with pharmacologic therapy) was effective in reducing time awake after sleep onset in elderly patients (). Whereas drug therapy alone was also more effective than placebo, only those patients using the behavioral approach maintained treatment gains at follow-up. Although pharmacologic treatments produced somewhat faster sleep improvements in the short-term, behavioral approaches including hypnosis and relaxation training showed comparable effects in the intermediate term (4–8 weeks), and in the long-term (6–24 months), behavioral approaches including hypnosis and relaxation training showed more favorable outcomes than drug therapies ().
Relevance of Treating Sleep Disorders Using Hypnosis and Cognitive-Behavioral Therapy
It is widely agreed that effective treatment of insomnia must assume a multidisciplinary approach in which physiological, psychological, behavioral, and environmental interventions receive equal emphasis. Approximately 70% to 80% of patients treated with nonpharmacological interventions benefit from treatment (, ; , ; ). For patients with chronic primary insomnia, nonpharmacological treatments are likely to reduce sleep onset and/or wake after sleep onset to below 30 minutes with sleep quality and satisfaction scores significantly increasing (, , ; , ; ). Three treatments meet the American Psychological Association (APA) criteria for empirically supported behavioral treatments for insomnia: stimulus-control therapy, progressive muscle relaxation, and paradoxical intention. Three other treatments meet APA criteria for probably efficacious treatments: sleep restriction, biofeedback, and multifaceted CBT. CBT has been found to show significantly more long-lasting improvements following treatment than pharmacologic agents in treating chronic primary insomnias (). This improvement is primarily due to CBT because this therapy targets the underlying problem causing the sleep disturbance and is not a mere band-aid approach like pharmacological interventions. In addition, termination of pharmacological agents can cause a rebound of the initial sleep difficulties.
There is an overwhelming need for more empirically based research studies to demonstrate the efficacy of CBT and hypnosis in the treatment of insomnia disorders. CBT has been successfully used to treat insomnia, while hypnosis has been more effective with arousal disorders, but the empirical evidence demonstrating that hypnosis is efficacious in the treatment of sleep disturbance is lacking.
Implementation of CBT with Hypnosis
A comprehensive review of CBT implementation with sleep disorders is contained in the work of , and  provide a comprehensive review of hypnosis and CBT as a multitreatment approach for insomnia management. Figure 1 illustrates how to incorporate education regarding sleep hygiene, stimulus control therapy, sleep restriction strategies and cognitive therapy prior to hypnosis and how to implement these techniques into hypnotic scripts when appropriate. The clinician is strongly encouraged to educate the patient regarding these strategies/techniques before beginning hypnotherapy.
Although behavioral treatment approaches for sleep disturbance are initially more time-consuming and more expensive than medications, there are long-lasting benefits associated with behavioral treatments. For instance, over the course of total physician visits and prescriptions, it may be more cost effective for patients to engage in behavioral treatments. Current research findings support the use of behavioral approaches for treating nonbiologic (i.e., behavioral) sleep disorders such as insomnia because these approaches target and resolve the underlying problem(s) associated with sleep disturbance, whereas pharmaceutical agents are a band-aid approach to treatment. Emphasis must be placed on combining CBT and hypnotherapy as treatment approaches for sleep disorders.
In the meantime, it may be beneficial for hypnotherapists to gain specialty training in the evaluation and management of behavioral sleep disorders. This specialty training should teach clinicians how to incorporate sleep therapy treatment(s) into hypnotic scripts. Currently, the utilization of hypnosis as either a single- or multitreatment modality is limited to a very small subset of behavioral sleep disorders. There is an immediate need for more research evaluating the efficacy of hypnotherapy as single- or multitreatment modalities for management of sleep disorders. Once this efficacy is established, it will increase the demand and utilization of hypnotherapy as a valid treatment for nonbiologic sleep disorders.
The authors thank Stephanie Gutz, LCSW, for her comments on an earlier draft of this manuscript. John C. Hardie, Ph.D., wishes to acknowledge Lynne S. Wagner, Ph.D., for her clinical support, guidance, and supervision since August 2006, as well as her contributions to the final preparation of this manuscript.
Authors: Graci GM; Northwestern University, Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois, USA.Hardie JC
Source: The International journal of clinical and experimental hypnosis [Int J Clin Exp Hypn] 2007 Jul; Vol. 55 (3), pp. 288-302.
Publication Type: Journal Article; Review
Journal Info: Publisher: Routledge Country of Publication: England NLM ID: 0376166 Publication Model: Print Cited Medium: Print ISSN: 0020-7144 (Print) Linking ISSN: 00207144 NLM ISO Abbreviation: Int J Clin Exp Hypn Subsets: MEDLINE
Imprint Name(s): Publication: 2005- : London : Routledge
Original Publication: New York, Society for Clinical and Experimental Hypnosis.
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By GinaM. Graci and JohnC. Hardie
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