sleep and awake states per se, but rather are undesirable ... episode, when she awoke from a dream. ... than having to be on medication the rest of my life.
Sleep. 18(7):608-609
© 1995 American Sleep Disorders Association and Sleep Research Society
Short Note Elimination of a Rhythmic Movement Disorder with Hypnosis-A Case Report Carl Rosenberg Department of Neurology, Case Western Reserve University, University Hospitals of Cleveland, Cleveland, Ohio, U.S.A.
Summary: The following describes a case of rhythmic movement disorder successfully treated with hypnosis. Hypnosis and its use in sleep disorders are discussed, and it is hypothesized that hypnosis is an effective intervention in disorders that occur at the interface between waking and sleep. Key Words: Hypnosis-Parasomnia-Rhythmic movement disorder-Sleep disorders.
Parasomnias are defined as "clinical disorders that are not abnormalities of the processes responsible for sleep and awake states per se, but rather are undesirable physical phenomena that occur predominantly during sleep"(1). The following describes a case of "rocking", a rhythmic movement disorder persisting into adulthood and treated with hypnosis.
to feed the child and rock whenever she returned to bed. The result was that she and her husband would sleep in separate bedrooms. The patient was healthy with no other medical complaints. She did not smoke or drink, had no allergies and was not on any medications. There was no family history of illness, sleep disorders or parasomnias, and she had no other sleep complaints. The results of the patient's examination were entirely normal.
PRESENT ATION The patient was a 26-year-old woman who presented in May 1993 with a complaint of rocking in bed. She reported a long history of rocking beginning as an infant in her crib. As a child, she recalled rocking while trying to fall asleep. When she awoke during the night, she would rock to fall back to sleep. She thought she had grown out of this by late adolescence and believed that her rocking had disappeared. In 1991 the patient married. Her husband complained that her rocking had not stopped. The motion itself was a "to and fro" rocking with movement primarily above the waist. This rocking seemingly kept him from falling asleep and awakened him intermit·· tently throughout the night. The patient's rocking did not persist as sleep progressed. Furthermore, the problem became particularly acute when she was breastfeeding their first child. She would frequently awaken
INTERVENTION
The initiation of therapy was delayed by 11 months to allow the patient to complete breast-feeding. She returned in April 1994. Both she and her husband continued to be distressed by the "rocking". We decided to use hypnosis rather than a pharmacological approach because she was actively trying to become pregnant. In July she began hypnosis, which was intitated by using "coin fixation". She was a good subject and rapidly learned to induce a trance. Initial imagery was of watching a television set on which the program was one of her sleeping beside her husband and not rocking at any time throughout the night. We used the television image because it gave her more control, namely the ability to turn the television off. She was instructed to perform her hypnosis prior to going to bed each night and encouraged to practice it at least once a day. Accepted for publication April 1995. She returned 2 weeks later. She had been able to Address correspondence and reprint requests to Carl Rosenberg, M.D., Department of Neurology, Case Western Reserve University, advance her imagery to seeing herself in bed next to University Hospitals of Cleveland, Cleveland, OH 44106, U.S.A. her husband, as opposed to a picture on a television 608
.1
609
HYPNOSIS AND RHYTHMIC MO VEMENT DISORDER set. She was better able to monitor her rocking behavior with this behavioral intervention. She felt that her rocking had almost disappeared; she recalled only one episode, when she awoke from a dream. She had spent a weekend sleeping in the same bed as her husband and had not woken him once. We reinforced her imagery and scheduled a return visit in 3 weeks. The patient did not return but sent the following letter, dated August 18, 1994: ... I'm writing to tell you that I don't think I need to reschedule because I am happy to report that my husband sleeps with me every night and I haven't woke him up, not even once, since I began my self-hypnosis "exercise" at bedtime (isn't that incredible?). Secondly, I would like to thank you for your help in this "rocking" problem and let you know that it has made a significant difference in my marriage already. I admit, at first I thought the whole idea was rather corny, but I figured I really had nothing to lose by trying and that ANYTHING was better than having to be on medication the rest of my life.
Three months later a follow-up phone call revealed that the rocking remained in remission with only two occurrences over that time. DISCUSSION
The International Classification of Sleep Disorders defines "Rhythmic Movement Disorder" as "a group of stereotyped, repetitive movements involving large muscles, usually of the head and neck, which typically occur immediately prior to sleep onset and are sustained into light sleep (1). The patient described above meets these criteria: There were rhythmic body movements occurring during drowsiness, the movement was of a "body-rolling" type and it began very early in life. The differential diagnosis includes epilepsy and periodic movement disorder, but the history was not compatible with epilepsy. Her events involved the whole body with no alteration of consciousness and no amnesia related to event. Although the events where stereotypic, they could be interrupted by merely arousing the patient. The history is equally poor for a periodic movement disorder. The movements occurred at the initiation of sleep and then disappeared, and they were a constant rocking as opposed to a periodic
jerk. There were no indications of any psychological trauma or problems which could have precipitated the movements. Finally, it is highly unlikely that epilepsy or periodic movement disorder would respond to solely behavioral therapy. Once hypnosis has been determined to be useful, the process involves induction of an hypnotic trance, intervention during the trance, and resolution. Hypnosis has been used successfully in treating a variety of sleep disorders, including parasomnias, sleep terrors in children (2,3) and disorders of arousal in adults, such as sleep terrors and sleepwalking (4). A priori one would not expect a disorder involving sleep to respond to hypnosis, which is a cognitive and behavioral therapy performed in the waking state. It is curious that disorders of arousal and rhythmic movement disorders both respond to hypnotic intervention. One feature that all of these disorders have in common is that they exist at the interface between waking and sleep. Hypnosis appears to be most effective in dealing with the symptoms that are more on the waking side of the transition state. As stated earlier, the movements in rhythmic movement disorder disappear as sleep progresses. Hurwitz et al. attributed the efficacy ofhypnosis in the disorders of arousal to "increased control of frenzied and ambulatory behaviors rather than in the elimination of arousals. They (patients) were often aware of having awakened, occasionally at the bedside, but perceived immediate awareness of the arousal and returned to sleep"(5). REFERENCES I. Diagnostic Classification Steering Committee, Thorpy MJ, chairman. International classification ofsleep disorders: diagnostic and coding manual. Rochester, MN: American Sleep Disorders Association, 1990: 141. 2. Koe GG. Hypnotic treatment of sleep terror disorder: a case report. Am J Clin Hypnosis 1989;32(1):36-40. 3. Kohen DP, Mahowald MW, Rosen GM. Sleep-terror disorder in children: the role of self-hypnosis in management. Am J Clin Hypnosis. 1992;34(4):233-44. 4. Hurwitz TD, Mahowald MW, Schenck CH. A retrospective outcome study and review of hypnosis as treatment of adults with sleepwalking and sleep terror. J Nerv Ment Dis 1991;179(4):22833.
Sleep, Vol. 18, No.7, 1995
