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  • Writer's pictureV. Romanov

Hypnotherapy for Insomnia. Part II: A path to restful sleep

This is the second part of a longer article on the treatment of sleep disorders with hypnosis. The first part described the dangers and consequences of sleep deprivation and sleep deficit, and discussed various sleep disorders, their development, course and chronification. Special emphasis was placed on the most common sleep disorder, non-organic insomnia. The first part of the article can be found here.

Sleep disorders can be diverse, have both physical and psychological causes, and vary in their complexity, course and duration. It is therefore important to clarify the possible causes before starting treatment. The first step is to have a medical examination to rule out physical causes. It is always a good idea to discuss sleep problems with your doctor first. Tell your doctor in detail about your sleep problems, their duration, possible triggers and whether you have any other physical or mental complaints. The appropriate treatment may depend on the cause of the sleep disorder, which may be primarily an independent disorder or secondarily a symptom or consequence of an underlying disease or medication.

Sleep disorders should be treated causally, not symptomatically. This is all the more true because sleep medications are often prescribed without considering the causal relationship. For example, problems with falling asleep and staying asleep are typical symptoms of depression, so it makes more sense to treat the underlying illness rather than the sleep disorder itself, either psychotherapeutically or with medication. With treatment and the resulting improvement in depressive symptoms, sleep problems will also improve. However, treating the cause of sleep problems is not always possible. A symptomatic approach is indicated when the cause is difficult to treat, such as in the case of sleep apnoea, where in most cases a significant weight loss would lead to an improvement in sleep problems, but in many cases this is not feasible. It is also much more difficult to treat the cause of a sleep disorder when there are multiple causes or when the causes cannot be identified.

Depending on the severity of the symptoms and the nature of the cause, sleep problems can be treated with specific medications. Benzodiazepine and non-benzodiazepine hypnotics, antidepressants with sleep-regulating properties or even antipsychotics, which are usually used for treatment of severe mental illnesses, may be indicated, depending on the underlying condition or cause of the sleep problem. These drugs are used by doctors with caution and sometimes under strict control because many of them can have serious side effects and have a not inconsiderable potential for dependence, especially hypnotics, i.e. sleeping pills. It is for this reason that such sleeping pills are only approved in Germany for short-term treatment lasting a few weeks at a time.

Psychoeducation is an essential initial component of any insomnia treatment. It includes basic knowledge about the function of sleep, its normal and disturbed course, and explanation of sleep hygiene, i.e. simple rules and recommendations for everyday life that promote sleep, as well as information about what impedes sleep. Some people with sleep disorders have never heard of sleep hygiene and have never thought about it; others know most of the rules but do not follow them. In essence, it is also about dispelling patients' often false and fearful ideas about their sleep. They tend to associate their bed and bedroom environment not with sleep itself, but with activities that are incompatible with sleep, such as reading, working, problem solving, thinking, watching TV or using tablets and smartphones. It is therefore advisable to start by redesigning the bedroom and sleep environment to relieve the negative conditioning.

People are biologically attuned to wake up in the light and sleep in the dark. Therefore, the bedroom should be adequately darkened with curtains or blinds. Make sure there are no disturbing light sources such as computer screens or bright clocks in the sleeping area. Clocks are particularly disruptive to sleep because looking at the clock activates consciousness and triggers cognitive processes that can disrupt sleep. A lower room temperature also promotes sleep: many people make the mistake of going to sleep in rooms that are too warm. Especially in the cold season, it is a good idea to have the bedroom aired and the heating set at between 15 and 19°C. It is worth investing in a good bed, a suitable mattress, good quality sheets and pillows, bed linen and pyjamas. It is a good idea to visit one or more specialist shops for advice and to pick out the right bedding for you. A good night's sleep is worth almost any investment, as people spend more or less a third of their lives in bed.

The day determines the night. An active waking life with work, interests, exercise, pleasant social interactions, time with family and friends can contribute to restful sleep. It is good to avoid long periods of wakefulness in bed, and to abstain from caffeinated or other stimulating drinks in the afternoon. Smoking and alcohol also have a negative effect on sleep. The nicotine in tobacco is both stimulating and addictive, so the body is constantly exposed to the craving for nicotine, even during sleep. Alcohol, on the other hand, has a relaxing and sleep-promoting effect, but the effect does not last long enough and you may still wake up in the middle of the night. Especially for people with sleep disorders, alcohol can gradually lead to dependence because the dose needs to be increased to achieve the desired effect. In addition, alcohol - even in small doses for some people - has a negative influence on sleep stages and sleep quality. Eating a large meal just before going to bed also stresses the body and has a detrimental impact on sleep.

In the evening, about two to three hours before going to bed, you should avoid exercising and dim the lights in the house. The warm, dim light signals to the body that it is almost time for bed. Smartphones and tablets are now ubiquitous and often accompany their owners to bed. If you have trouble falling asleep or staying asleep, you should definitely avoid using these devices and preferably keep them in another room. For one thing, they encourage sleep-disturbing behaviour such as constantly scrolling through social networks, watching endless videos or series, checking work tasks, etc. All these activities are generally incompatible with sleep as they stimulate our cognitive processes, activate our senses and can also trigger emotions that raise blood pressure and heart rate, such as a late night work assignment from the boss. If you still can't give up using your smartphone, tablet or laptop in bed, the least you can do is activate the screen's night mode, which significantly reduces screen brightness and sets a warm colour palette to minimise the cold blue light from the screen, which has been shown to have a negative impact on sleep. If you're still not ready to give up reading and escape the daily grind, there's always the classic printed book.

Many of the rules of sleep hygiene involve abstinence and a little more organisation in everyday life. However, you should not live on the frugal side, but enjoy life. After all, it is not only your sleep that determines your day, but your day also determines your sleep. The German Society for Sleep Research and Sleep Medicine (Deutsche Gesellschaft für Schlafforschung und Schlafmedizin e. V.) has detailed information on sleep hygiene and the treatment of specific sleep disorders. Some of this information is also available in English.

Psychotherapeutic treatment approaches are mainly indicated for non-organic, i.e. psychologically caused, sleep disorders. In general, cognitive behavioural therapy is recommended as one of the most effective treatments for sleep onset and maintenance disorders. Particularly in primary insomnia, changing a patient's learned sleep-related behaviours and associated beliefs can significantly improve sleep. Each patient is a unique individual with a highly complex combination of beliefs, some of them deeply held, about oneself, the environment and life in general. These beliefs, or thought patterns, condition and shape our perception of events and determine our behaviour. We acquire them over the course of our lives, based on our experiences in dealing with the environment and ourselves. Some of these thought patterns can be dysfunctional, triggering unpleasant emotions and causing problematic or even destructive behaviour. Such thought patterns are usually referred to as thought errors or cognitive distortions. Here are some examples of such thoughts in relation to sleep:

  1. Selective perception: Focusing on negative aspects and ignoring positive ones. "Although I slept well the last four nights, I only remember the one night I slept badly."

  2. Black and white thinking: Seeing things only as "good" or "bad", without allowing for grey areas. "If I don't get at least 8 hours sleep tonight, tomorrow will be absolutely terrible."

  3. Catastrophise: The assumption that the worst will happen. "If I don't sleep tonight, I'll lose my job and never have a peaceful night's sleep again."

  4. Overgeneralisation: General rules are derived from a single negative event. "I couldn't fall asleep last night, this happens to me all the time, I'll never sleep well again."

  5. Perfectionism: The basic belief that everything must be perfect. "I can only fall asleep if everything is perfect (e.g. room temperature, bed linen, mattress)."

These and similar thought patterns can trigger negative feelings, fears and worries, effectively preventing sleep. In principle, however, such thought patterns can be applied to almost all areas of life and thus not only prevent restful sleep, but also negatively influence other aspects of existence. For example, cognitive distortions can be an important component of thinking in depression or of anxious rumination in phobias.

Many of our habitual thought processes run automatically, hidden from our conscious mind, and thus evade critical examination of their content. In particular, basic beliefs formed in childhood and adolescence can be particularly deeply embedded in the subconscious. Additional measures are needed to consciously formulate, adapt, reshape and replace such deeply held beliefs with new ones. The process of shaping and changing dysfunctional thought patterns is called cognitive restructuring. The combination of cognitive-behavioural therapy and hypnosis has proven to be particularly helpful, as the hypnotic trance makes hidden processes running in the background particularly accessible and facilitates the reception and storage of new formulations through the suggestible state. It is very helpful to tap into the unconscious mind's ability to work with metaphors and symbols.

Hypnosis allows and encourages indirect processing of thought content, which is particularly helpful for sleep disorders. Normally, it is beneficial to exert more effort in order to achieve a goal more quickly. Paradoxically, this normally beneficial strategy is counterproductive in sleep disorders and usually has the opposite effect, i.e. the more you try to fall asleep, the less successful you are. The use of suggestions and metaphors in hypnosis can indirectly influence the symptoms so that the patient does not fall back into the typical pattern of agonising over not being able to fall asleep. The combination of cognitive behavioural therapy and hypnosis produces a significant increase in improvement compared to 70% of patients treated with behavioural therapy alone.

Hypnotic suggestions can also be used to influence physical sleep processes, such as the release of the sleep hormone melatonin. The so-called sleep tree metaphor is used for this purpose. The patient can visit their sleeping tree in their mind's eye and examine its condition by looking at what the tree, its roots, branches and leaves need. There can also be a mental exchange between the tree and the patient. The process can be understood as an interaction with the subconscious, with the tree representing a sub-personality of the patient responsible for certain aspects of sleep. By taking care of the tree in his inner world, the patient takes care of himself. In this way, different metaphors can be constructed to effectively treat different aspects of the sleep disorder. Patients' depression and anxiety are also reduced by using these techniques.

People who suffer from sleep disorders are usually mentally and emotionally overstimulated both during the day and at night. It has therefore been found useful to supplement therapy with relaxation techniques such as progressive muscle relaxation or autogenic training. Self-hypnosis techniques can also be taught to patients so that they can use them independently for deep relaxation.

It has been shown that a systemic approach to therapy, which takes into account and seeks to improve as many aspects of the patient's daily life as possible, has a clear advantage over approaches that focus only on sleep-related symptoms. Coping with stress, increasing leisure activities, building and maintaining robust social relationships all lead to improved quality of life and, in combination with hypnotherapy and behavioural therapy, to improved and normalised sleep onset and sleep duration.

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