Self-Hypnosis for Sleep Disturbances in Menopausal Women

Abstract

Poor sleep is one of the most frequent health concerns among menopausal women. All stages of sleep can be impacted by the menopause transition. Negative outcomes of poor sleep are multidimensional and include poor physical, psychological, cognition, and social outcomes. Hypnosis is a nonpharmacological treatment for poor sleep and hot flashes in menopausal women. The goal of hypnosis is to educate and train subjects to perform self-hypnosis to alleviate the underlying symptom. The use of hypnosis as a treatment for poor sleep has shown benefits for both acute and chronic insomnia. Initial findings from the National Center for Complementary and Integrative Health (NCCIH) Hypnosis Intervention for Sleep in Menopause: Examination of Optimal Dose and Method of Delivery randomized control trial of 90 women were presented. Results showed that program and treatment satisfaction were high in all groups, adherence to daily practice met or exceeded adherence benchmarks. There were significant reduction of poor sleep quality in all groups with a significant increase in minutes slept in all groups. The majority of women also showed clinical improvements of duration. There were clinically meaningful improvements in reducing the perception of poor sleep quality in 50%–77% of women across time. Overall, the use of self-hypnosis as a treatment program for sleep problems related to menopause was acceptable for women. Data further support that hypnosis is a promising technique to improve sleep in menopausal women with sleep and hot flashes. Further research is ongoing on self-hypnosis delivery and implementation into wider populations of women using clear definition and control groups.

Background

Problems with poor sleep increase during menopause transition.¹ Approximately 28%–63% of women report sleep problems during menopause and postmenopausal transitions. The underlying cause can be multifaceted and complex. One common symptom that contributes to poor sleep during menopause transition is hot flashes. By definition, hot flashes are sudden transient and recurrent sensation of moderate-to-intense heat that usually begins in the upper body² with ∼80% of women experiencing hot flashes during perimenopause and 90% when menopause is induced by surgery. Sleep disturbances have been noted to be one of the main reasons women seek treatment for hot flashes.

Research findings suggest that all stages of sleep are impacted during menopause.³ Types of common sleep disorders in women with and without hot flashes include insomnia, sleep disordered breathing, restless leg syndrome, and circadian disruptions.⁴ There are both pharmacological and nonpharmacological treatment options; however, there are problems with the over use and abuse of prescription of sleep medications in women in this population. In the 2013 Dawn by the Substance Abuse and Mental Health Services Administration report, females aged ≥45 years accounted for the majority of emergency room visits from prescription reactions to sleep medications.⁵ The reason many women seek treatment is due to the negative impact of poor sleep. Negative outcomes of poor sleep are multidimensional and include poor physical, psychological, cognition, and social outcomes. Physical outcomes include daytime sleepiness, fatigue, and decreased immune function. Psychological outcomes include impaired cognitive process, depression/anxiety, and memory deficits.⁶

Identifying a Hypnosis Intervention

Despite widespread prevalence, there are few available effective and accessible nonpharmacological interventions to manage poor sleep in women during the menopausal transition. Uses of hypnosis have been found to be efficacious for women with hot flashes.⁷ The traditional model of hypnosis delivery is conducted by a trained provider and consists of two components. First is the induction initial phase of focus, relaxation, and concentration. Second is providing suggestions-directed words toward specific goals (relaxation/symptom alteration).^8,9 The mechanism of action continues to be developed but thought to be a mixture of neurological mechanisms but largely remains unknown.

Hypnosis is defined as a state of consciousness involving focused attention and reduced peripheral awareness characterized by a capacity for response to suggestion.¹⁰ The goal of hypnosis is to educate and train subjects to perform self-hypnosis to alleviate the underlying symptom. The following are the standard accepted definitions that constitute the process of hypnosis. Other important definitions include:

• (1)Hypnotic induction: A procedure designed to induce hypnosis.¹⁰
• (2)Hypnotizability: An individual's ability to experience suggested alterations in physiology, sensations, emotions, thoughts, or behavior during hypnosis.¹⁰
• (3)Hypnotherapy: The use of hypnosis for treatment of a medical or psychological disorder or concern.¹⁰
• (4)Self-hypnosis: Training subjects to be able to do hypnosis on their own. The goal for hypnosis training should be self-hypnosis.¹⁰

Research on Hypnosis for Sleep

The use of hypnosis as a treatment for poor sleep has shown benefits for both acute and chronic insomnia (inability to fall asleep, stay asleep, and feel rested).¹¹ Researchers suggest hypnosis can help treat hyperarousal (overactive mind and body) and it is suggested that hypnosis is best when coupled with cognitive behavioral therapy (sleep hygiene) for maximum benefit. The hypnotic relaxation or induction includes deepening suggestions such as imagery of a dolphin swimming down to the ocean floor.

In one study that used polysomnography to determine impact of hypnosis on sleep patterns, the researchers found that slow wave sleep increased by 57% among high-hypnotizable participants.^12,13 The study used progressive mental imagery of hypnosis suggestions and found a reduction in number of nighttime awakenings (sleep disturbances), reduction in the time to fall asleep (sleep latency), and an increase in deep sleep phase (slow wave sleep).¹² When the study was replicated in an older population that included elderly women, there was a noted increase in slow wave sleep using this type of deepening hypnotic suggestion.¹³ These findings coupled with the significant increase in global sleep quality in menopausal women with hot flashes were the premise of an intervention study to test the efficacy and delivery of hypnosis for sleep problems in postmenopausal women with hot flashes.

Self-Hypnosis for Sleep in Menopausal Women

Hypnosis Intervention for Sleep in Menopause: Examination of Optimal Dose and Method of Delivery (National Center for Complementary and Integrative Health [NCCIH]; Gary Elkin-Principle Investigator) was a randomized control trial of 90 postmenopausal women that tested four delivery schedules to determine which one is more effective. The groups were randomized into one of four groups including five in-person sessions (n = 23), three in-person sessions (n = 20), five phone calls with self-hypnosis (n = 23), and three phone calls with self-hypnosis (n = 23). Subjects were followed for 8 weeks. Measures of sleep included Pittsburgh Sleep Quality Index,¹⁴ Epworth Sleepiness Scale,¹⁵ Insomnia Severity Index,¹⁶ sleep environment assessment, wrist actigraphy (Respironics), and nighttime sleep diary. Other outcomes included satisfaction and adherence with the intervention, menopausal symptom severity, hot flash dairy, and pain.

Overview of Findings for Sleep Outcomes

Initial findings were presented during the conference; the results of all primary and secondary outcomes are pending final analysis (planned submission fall 2019). Initial demographics included postmenopausal women aged 41–65 years mainly Caucasian, from south central Texas area. Overall program and treatment satisfaction were high in all groups with no group differences. The use of hypnosis for sleep improvement was moderate to high with no group differences. In-person and phone-delivered methods rated high in both groups. Self-delivery rated high regarding ease of delivery. Adverse event-only one hypnosis related to suggestion during session that included water and fish.

Adherence to daily practice (seven times per week) met or exceeded adherence benchmarks with no differences in at-home practice between groups. The highest ratings of adherence were in five phone calls and home groups. For menopausal symptom severity (e.g., hot flashes, night sweats, and mood), reduction in overall severity of scores across all groups was noted with clinically meaningful improvements.

Sleep outcomes were as follows. There were significant reduction of poor sleep quality in all groups with a significant increase in minutes slept in all groups with largest sustained decrease in three phone calls/self-hypnosis groups at week 8 using actigraphy findings. The majority of women also showed clinical improvements of duration based on analysis of sleep diary entries. There were noted clinically meaningful improvements in reducing the perception of poor sleep quality (bothersomeness) in 50%–77% of women across time. The largest effect size was noted in the five phone calls treatment group.

Conclusions

Overall, the use of self-hypnosis as a treatment program for sleep problems related to menopause was acceptable for women. Phone delivery with self-hypnosis is just as effective as doing in-person sessions, suggesting that intervention can be more widely accessed and valuable. Data further support that hypnosis is a promising technique to improve sleep in menopausal women with sleep and hot flashes. Further research is ongoing on self-hypnosis delivery and implementation into wider populations of women using clear definition and control groups. The use of hypnosis to treat symptoms clusters such as pain, hot flashes, and sleep is needed along with better integration as a treatment into practice settings.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

National Institutes of Health; National Center for Complementary and Integrative Health 1R34AT008246-01.