Even in the first hypnosis session, Daniel was able to relax extremely quickly, and he very soon reached a level approaching sleep. When asked for a special place, he immediately referred back to a time when he was playing tennis with his coach in Florida. In this situation, he felt extremely well and confident, and the way that he described the situation made it very obvious that he was enthusiastic about the playing against the coach. It was clear from his facial expression that the whole experience of playing against his tennis coach was exhilarating and gave him a huge amount of confidence. I then asked him for a relatively easy social situation, and he said that he wanted to rehearse meeting the ex-girlfriend on the street. It was indicated that we could reduce the sweating response by introducing this experience in imagination followed by the special place. This was repeated several times until he felt comfortable in this situation. He was also given the post hypnotic suggestion that he should carry out self hypnosis for 10 minutes every day, using the association word 'calm' for the induction.
When he came for his third session, Daniel said that he felt decidedly better in a number of social situations and, although he still felt hot, he did not get the excessive sweating which had always caused him distress. He went on to say that there had been other times when his symptoms had decreased in intensity and he therefore wanted to exercise caution before attributing it to the therapy. He was surprised that there was a very noticeable improvement at this early stage and it was pointed out to him that patients recover at different rates.
During the hypnosis, Daniel wanted to rehearse a potentially difficult situation at a house warming party involving approximately 200 guests. His anxiety level was reduced by alternating this difficult situation with the special place-again, this consisted of playing against his coach in Florida. This special place was used repeatedly during the course of the therapy and Daniel found this extremely helpful.
A week later, when Daniel came for his next session, he recognised one of the patients in the waiting room: under normal circumstances, this would have caused severe sweating, but, on this occasion, it did not cause him any distress. Although he acknowledged that there had been an improvement in the sweating response, he was reluctant to attribute this to the treatment. Again, he was concerned about the forthcoming house warming party and he wanted to go over this in the hypnosis. We rehearsed three possible scenarios: a sit down meal, a buffet supper, drinks and canapes. In addition, he was keen to envisage two further social events-a cocktail party at his brother's house and a quiz night at his synagogue.
When he came for his next treatment session, the fifth, he told me that he had coped extremely well with the three social events, but, despite this improvement, he was disappointed that he had experienced a further episode of sweating when meeting senior officials in Italy. Indeed, Daniel continued to be negative about his treatment and was reluctant to admit that the therapy was helpful.
He was keen to talk at some length about his relationship he had had with his father whom he described as a very powerful man. His father had died 13 years ago. Daniel gave a verbatim account of what it felt like to talk to clients on the telephone when his father was present: on many occasions, his father tapped him on the shoulder, admonished him and undermined his authority. He could distinctly remember how he felt when talking to the clients on the telephone and that this caused a feeling of heat: this heat which he had felt in relation to his father had now generalised to a number of difficult social situations. Daniel began to understand the source of his debilitating social anxiety.
In the sixth session, he reported that he had unexpectedly met his ex-girlfriend on the street: he was surprised to find, however, that he did not develop any symptoms whatsoever. Notably, he did not experience any feeling of heat or sweating. He had also coped very well at a restaurant in central London; however, despite his many improvements, he was reluctant to show any enthusiasm in case this was only of a temporary nature.
In the second half of the session, hypnotherapy was used where, once again, the special place involved Daniel playing tennis with his coach in Florida. Whenever this scene was introduced in the therapy, his face would light up and he would feel that he had been 'charged' with a tremendous feeling of confidence. We then rehearsed the forthcoming event in his synagogue as well as a rather prestigious dinner dance event in London; again, whenever he found the situation difficult, he was immediately returned to his special place.
A week later, he reported that not only he had coped very well at the synagogue, but he had also enjoyed the dinner dance, and this is despite the fact that there were over 300 guests and that the room was decidedly hot. Indeed, he felt comfortable conversing with many of the guests and was free of all his symptoms. However, when he met his ex-girlfriend again when going to the bank, this did produce a sweating response, and he commented that the surprise element was particularly potent in producing symptoms. In the second half of the session, we rehearsed a number of forthcoming social events in hypnosis: on this occasion, uncharacteristically, he was prepared to admit that his sweating had diminished significantly over the last year. This improvement was maintained during the next week; and, at the next session, the eighth, he was pleased to report that he had attended the synagogue and was able to cope with the whole of the service without developing any symptoms.
In the tenth session, there was a distinct turning point in his treatment: he now wanted to know why he had had to suffer from the hyperhidrosis all his life, and this was now of paramount importance to him. It was stressed that these symptoms were directly related to his relationship with his father, and that this would require further exploration. It was pointed out to him that, in subsequent sessions, he would need to analyse the feelings that he had toward his father; in particular, he should focus on those occasions when his father would appear unexpectedly. Indeed, it was explained to him that these sudden interruptions were inextricably linked to his severe sweating response on chance meetings in the present day.
During the next three sessions, Daniel preferred to talk out some of his problems in the workplace as he had now become much more competent in social situations. In the fourteenth session, Daniel accepted that he was now much calmer, but that sudden, unexpected encounters still produced some sweating though it was markedly diminished.
In the sixteenth session, he was delighted to be able to tell me that his tennis had improved and, while this was not the aim of his therapy, he felt that this was a very welcome bonus. In the seventeenth and eighteenth sessions, he reported that not only had his sweating response been highly reduced but that he also felt calmer in himself. When he began treatment, he had always needed to be accompanied when going to social events, but this was no longer necessary for him as he could now attend these on his own. He found that this was a difficult adjustment to make as he had always needed an escort in the past.
In the 19th session, Daniel described a trip to the Middle East which involved a busy itinerary, and he was pleased to report that he did not have any sweating whatsoever. Although the outside temperature was high, Daniel did not experience any sweating beyond that required for thermoregulation. Daniel remarked that he no longer had any sweating symptoms when making phone calls, but, although this was a most welcome improvement, again he found that this required a great deal of re-adjustment.
In the 20th session, his last, Daniel agreed that his sweating symptom was much reduced. In particular, he was delighted that he did not experience any symptoms when making telephone calls to clients and that he did not feel that someone was listening to what he was saying over his shoulder. He now understood the origin of his symptoms and that these were a direct result of his relationship with his father. It was pointed out to him that, in fact, the hyperhidrosis symptom came from early childhood at a time when was petrified of his father; indeed, his fear of authority figures had remained with him throughout his life. He now felt that he had recovered sufficiently to terminate the treatment at this stage.
In a follow-up interview on the telephone 7 months later, he said that, while there had been considerable imIn a follow-up interview on the telephone 7 months later, he said that, while there had been considerable improvement, the therapy had not been a complete success. However, in reality, it was clear that he had made a vast improvement: he was able to cope with prestigious social functions, he was able to go to these events on his own, he was able to speak on the telephone without any trepidation and he was no longer frightened of authority figures. But, most importantly, his sweating had been eliminated in all these social situations.
Physicians and surgeons have made strenuous efforts to control hyperhidrosis by medical and surgical means without paying any attention to or considering the psychological factors responsible for the symptom. The Introduction describes the many treatment approaches from topical application to the invasive procedures such as thoracic sympathectomy. It has been the experience of the senior author that patients who have had a sympathectomy feel that they are worse off than they were prior to the operation. The excessive sweating is a release mechanism for their social anxiety; but, after the sympathectomy, they are unable to express their fears in this way and this makes them feel extremely uncomfortable. In the present case study, the authors have drawn together both the sweating symptom and its causation. As a result, the patient learnt to cope with a whole series of social situations which had previously been impossible for him, and this, in turn, opened up a new series of behaviour patterns—for example, being able to go to social functions on his own. It should be emphasized that social anxiety is at the heart of all patients suffering from hyperhidrosis other than those who suffer from medical conditions such as phaeochromocytoma. Social anxiety is particularly responsive to hypnotherapy (Kraft & Wijesinghe, 1970), but it is important to combine this approach with psychodynamic psychotherapy, to establish the underlying causative factors and to ensure that the patient explores and works through these emotional traumas. psychotherapy. This case study demonstrates the efficacy of using a combination of hypnotherapy and psychodynamic psychotherapy.