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When Dr. Lazarus sees patients who are motivated and have no other medical or psychological problems, they typically have significant improvement in keeping the bed dry after only 1 to 3 visits!
Bedwetting, medically known as nocturnal enuresis (NE), is a common pediatric problem that can follow children into their early teens. Bedwetting can have a significant impact on a child or adolescent’s life. He may feel sad, ashamed, and embarrassed. She may worry that she might have an accident while sleeping at a friend’s home or while away at overnight camp. Some “feel like babies” because they still have to wear pull-ups at night.
Nocturnal enuresis may be due to:
Before considering medical hypnosis for treatment, your child should be evaluated by his or her primary care clinician, including having a urinalysis.
When other biological causes have been eliminated, it is not clear why bedwetting occurs and it may simply be an unconscious habit that some children develop.
If the parent wants the child to be dry, and the problem doesn’t bother the child, then the child is not yet ready for this, or any other, type of treatment.
There is often a family history for nocturnal enuresis (NE). If one parent has had NE, then there is a 44% chance that the child will. If both parents had NE, then there is a 78% chance that the child will also have NE.
It is important to realize that just because the parents used to have NE, this does not mean that the child will not benefit from medical hypnosis. Medical hypnosis techniques to control bedwetting have been effective for many, many children whose parents had NE.1
The prevalence of bedwetting reveals that 15% of 5-year-olds, 10% of 6-year-olds, 5% of 10-year-olds, and 1 out of every 100 15-year-olds is still wetting the bed at night. Sadly, many children are so embarrassed by this problem that they don’t even want to mention it to their primary care clinician!
In general, Dr. Lazarus doesn’t consider this to be a problem until children are around 8 years old. This is the typical age at which it starts to bother children. Of course, there are younger children who are motivated to become dry at night, and older children who still don’t care about it.
Medical hypnosis has been found to be effective in treating nocturnal enuresis, even after traditional approaches, including the bedwetting alarm, medication, drinking less before bedtime, and having someone wake the child during the night, have failed.
The largest study regarding the use of medical hypnosis for bedwetting was a series of 257 children conducted by Dan Kohen, MD, (1984).
Most had previously tried the bedwetting alarm or bedwetting medication.
After learning medical hypnosis, 45% were completely dry, defined as 30 nights in a row and 1 year later without relapse.
An additional 32% were dry more than 50% of the time. Importantly, it was found that successful patients usually demonstrated improvement after only 2 or 3 visits.
Unsuccessful children were either not motivated or had parents who were too involved.3
Karen Olness, MD, (1975) taught self-hypnosis (SH) to 40 children with nocturnal enuresis (NE). Thirty-one were dry, usually within the first month.4
Stanton (1979) had a similar series of 28 children: 20 were dry within 1-3 visits, 15 of those were still dry 1 year later.5
Before Dr. Lazarus sees patients, he screens them by talking with the parent first, over the telephone, for about 20 minutes, at no charge. He is mainly interested in knowing the following:
Dr. Lazarus then meets with the parent(s), alone, for about 2 and ½ hours. During this comprehensive initial consultation, Dr. Lazarus obtains a complete history, including not only the problem, but also school, sports, hobbies, families, pets, and other issues. He then outlines his approach, so that the parents understand what we do, how we do it, when we do it, and why we do it. Dr. Lazarus explains, “We are all on Team Jane,” or “Team John,” and wants the parents to understand every step of the process.
Then he sends an introductory letter to the patient. This allows the patient to develop positive expectations and positive rapport before even meeting with Dr. Lazarus.
Four initial patient visits are set up, usually around a week apart from one another. The first visit is around 2 and ½ hours, depending on the age and cognitive level of the child.
As you know, most therapists meet for 50 minutes, once a week, for weeks, months, or years. Dr. Lazarus finds the problem with this is it seems that half the time you’re doing “catch-up,” and half the time you’re doing “crisis intervention.” This may include, “My brother did this, my friend said that, my teacher did this…”. Not that those things aren’t important. But they take away from the task at hand, There is no question we accomplish a lot more in one visit of 150 minutes than we could ever hope to accomplish in 3, 4, or even 5 visits of 50 minutes each.
Homework is always assigned, and Dr. Lazarus cautions the parents about mentioning this to the child before they meet, as most kids won’t want to do this! He has a very special way of introducing the homework, which he goes over in detail at the initial parent visit.
Patients are guided through their first clinical hypnosis experience (also known as medical hypnosis, visualization, guided imagery, guided meditation) in which Dr. Lazarus teaches them an empowering experience, in their minds, to teach their brain to talk with their bladders so that they will be dry at night. For more on what medical hypnosis is, click here.
Homework is assigned.
At the end of this visit, Dr. Lazarus meets with the patients and parents together, to discuss how best to move forward together.
At the second visit, the homework is reviewed, and the patient’s self-hypnosis skills are practiced and enhanced, because learning this process is like any other skill that needs to be learned and practiced.
Dr. Lazarus tells his patients, “I’m your coach, and I’m going to teach you some powerful skills to help you keep the bed dry at night. And, just like any other skill that needs to be learned and practiced, like kicking a soccer ball, or playing the piano:
At the end of this visit, a little more homework is assigned.
At the third visit, the homework is reviewed, then patients are taught advanced methods of self-hypnosis.
Again, homework is assigned.
At the fourth visit, the homework is reviewed and the patient’s self-hypnosis skills are practiced and refined.
At the end of this visit, Dr. Lazarus meets with the patient and parents together to reassess how things are going.
Typically, there is significant improvement after only 1 to 3 visits.
Now, Dr. Lazarus cannot guarantee results, of course. With biobehavioral work, one never knows how quickly individuals will improve. But when everyone follows the program, things usually get better pretty quickly.
And, what’s exciting is that, rather than simply taking a temporary pill, patients learn a lifetime skill. And they’ll be able to use this skill in the future in ways they are not even aware of, yet!
What a wonderful opportunity parents will be providing for their child.
Furthermore, when patients are able to gain to control over their bodies and life challenges, their self-confidence and self-esteem blossom (see testimonials).
Dr. Lazarus is a board certified pediatrician. He received his training in pediatrics at Stanford University Medical Center. He wrote the chapter on nocturnal enuresis, or bedwetting, for a recent pediatric hypnosis textbook.
He has also had the privilege of teaching workshops on this subject at the last few meetings of the International Society of Hypnosis, where he taught clinicians from around the world how to use these techniques to help their patients attain dry nights.
Dr. Lazarus combines more than 25 years in general pediatrics with a 20-year medical hypnosis practice.
Dr. Lazarus has also developed a new bedwetting video to help families manage bed wetting in children and adolescents. View the Keeping the Bed Dry video at its dedicated website and help your child control the bed wetting problem with the use of self-hypnosis.
The most common approaches in the treatment of nocturnal enuresis, or bedwetting, include medication (most commonly desmopressin, also known as ddAVP) and the bedwetting alarm.
It is important to note that these alternatives to hypnotherapy give the message that the patient relies on an external locus of control instead of an internal locus of control. This means that the patient learns to be dependent on someone else, or something else, rather than on his or her own internal resources.
Medical hypnosis teaches internal locus of control so the child feels empowered and in control!
In 1993, Banerjee, et al, compared hypnotherapy with imipramine. After 3 months, both the hypnotherapy and medicated groups were about 75% improved. At this time, the imipramine was stopped and the self-hypnosis group was encouraged to continue doing the hypnosis exercise. Six months later, only 24% of the imipramine group participants were still doing well compared with 68% of the hypnotherapy group.6 Imipramine is a medication that used to be used commonly to treat nocturnal enuresis. In general, this medication is no longer used due to side effects.
Lister-Sharp et al (1997) found that the use of most medications provided one more dry night per week during treatment, and most patients relapsed after the medication was discontinued.7
Hjalmas et al’s study (1998) of 399 children using DDVAP for one year revealed that 37% were dry on or off the medication, and they concluded that this was probably due to spontaneous cure, meaning that the children had become dry on their own, having nothing to do with the medication.8
Imipramine is a tricyclic antidepressant. One of its side effects is urinary retention. That is why it used to be used for bedwetting. As it happens, a more serious side effect is a cardiac arrhythmia! So, my question is: Why would you treat a non-life-threatening condition with a potentially life-threatening medication?
Bedwetting alarms and buzzer treatment systems may take up to six months to work, and we have all heard stories of the alarm waking everyone in the household…except the patient! In addition, for this approach to work, both the child and the parents must be very motivated, and it requires a great deal of parental involvement and supervision.9
Vermandel et al. studied 34 patients with NE in 2005, all of whom had had prior treatment, including medication. All had undergone cystometry, a very invasive procedure. They used bladder training, oxybutynin (a medication that can help for daytime accidents but not night-time accidents), and a bedwetting alarm. They concluded that nighttime dryness is obtained mainly from increase in arousal sensitivity, and not from medication or the alarm.10
To date, there has been only one study comparing hypnotherapy to the bedwetting alarm. Patients in the hypnosis group who were motivated, experienced success more quickly than those using the alarm.11
Previous research has documented a strong placebo effect for medication in the treatment of NE. This ranges from 59% at four and eight weeks to 37% long-term (Rombis, Triantafyllidid, et al, 2005; Humphreys and Reinberg, 2005; Smellie et al, 1996). The strong placebo response for NE can actually be an indicator that hypnosis would be an effective treatment. It supports the value of the power of the mind over the body in resolving this issue.12-14
References:
1. Lawless MR, McElderry DH. Nocturnal enuresis: current concepts. Pediatr Rev. 2001;22:339 – 407.
2. Caldwell PHY ,Deshpande AV ,Gontard AV. Management of nocturnal enuresis. BMJ 2013;347:f6259.
3. Kohen, D.P., Olness, K.N., Colwell, S., & Heimel, A. 1984. The use of relaxation/mental imagery (self hypnosis) in the management of 505 pediatric behavioral encounters. J Dev Behav Pediatr, 1: 21-25.
4. Olness K. 1975. The use of self-hypnosis in the treatment of childhood nocturnal enuresis. A report on forty patients. Clin Pediatr (Phila) Mar;14(3):273–279.
5. Stanton, HE. 1979. Short-term Treatment of Enuresis. Am J Clin 22:103-107.
6. Banerjee, S., A. Srivastav, and B. M. Palan. 1993. Hypnosis and self-hypnosis in the management of nocturnal enuresis: a comparative study with imipramine therapy. Am J Clin Hypn 36:113-119.
7. Lister-Sharp, D., et al. (1997). A systematic review of the effectiveness of interventions for managing childhood nocturnal enuresis. Research Report. York: University of York.
8. Hjalmas, A. et al. Nocturnal Enerusis : An International Evidence Based Management Strategy. The Journal of Urology 2004;171:2545-61
9. Glazener CMA, Evans JHC, Peto RE. Alarm interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD002911. DOI: 10.1002/14651858.CD002911.pub2.
10. Vermandel, A., de Wachter, S., and Wyndaele, J-J. (2005). Refractory monosymptomatic nocturnal enuresis: A combined stepwise approach in childhood and follow-up into adolescence, with attention to the clinical value of normalizing bladder capacity. BJU International 96: 629-633
11. Seabrook, J., Gorodzinsky, F., Freedman, S. 2005. Treatment of primary nocturnal enuresis: A randomized clinical trial comparing hypnotherapy and alarm therapy. Pediatr Child Health 10(10): 609-610. (Personal communication – Drs. Gorodinsky and Freeman, 2013)
12. Rombis, V., Triantafyllidis, A., Balaxis, E., Kalaitzis, C, and Touloupidis, S. (2005). Nocturnal Enuresis in Children: A four-year experience in outpatient clinics of pediatric urology. Folia Medica, XLVII.
13. Humphreys, M. R., and Reinberg, Y. E. (2005). Contemporary and emerging drug treatments for urinary incontinence in children. Paediatr Drugs 7:151-162.
14. Smellie, J. M., V. S. McGrigor, S. R. Meadow, S. J. Rose, and M. F. Douglas. 1996. Nocturnal enuresis: a placebo controlled trial of two antidepressant drugs. Arch Dis Child 75:62-66.
13. Glazener CMA, Evans JHC. Desmopressin for nocturnal enuresis in children. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.: CD002112. DOI: 10.1002/14651858.CD002112.
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