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IntroductionNightmares and fear of sleeping alone are

common in children but may become develop-mentally inappropriate and more problematic,warranting clinical intervention. Behaviouralapproaches such as the operant reinforcement ofappropriate nighttime behaviour and not reinforcinganxious/ avoidant behaviours have been shown tobe effective in such cases1. Nocturnal anxiety inchildren has also been managed through cognitivebehavioural programmes that combine exposure,cognitive restructuring, relaxation and incentiveprogrammes2. Yet another technique that has beenreported to be effective in the treatment of childhoodphobias is emotive imagery3 and refers to imagerythat produces positive feelings (for example, self-assertion, pride, affection) and other similar anxietyinhibiting responses. It is considered to be a formof systematic desensitization because the childengages in emotive imagery while anxietyprovoking items are gradually introduced. Thistypically involves the therapist helping the child todevelop a story about the child’s favourite heroeshelping them to be brave or fight back when thefeared object is presented4. The child may beencouraged to pretend to be some hero and take ontheir characteristics (for example, courage or specialpowers). Emotive imagery has been specificallyrecommended for managing nighttime fears.5,6 It hasbeen assumed that emotive imagery may beparticularly useful in treating anxiety where thephobic object is imaginary, such as monsters andghosts and conventional invivo exposure is notpossible7.

The present case study highlights the processof psychotherapy for a six year old boy reporting

with fear of ghosts.

Case ReportT, a six year old boy studying in Grade 2 from

urban background, was brought by his mother forcomplaints of nightmares about ghosts, not goingto sleep with lights off as he feared ghosts may comesince last one year. The child also reported fear ofbeing left alone at nighttime and refusal to sleepalone owing to this fear of ghosts. There were nocomplaints regarding child’s affect, other anxietydisorders or any other psychiatric/ neurologicalillness. T reported high levels of anxiety (increasedheart rate) and cognitions (that is, ruminations thatghosts do exist; they will come and harm him/ hisfamily). He also reportedly experienced frequentnightmares involving ghosts chasing, attacking,hurting him/ his family members. However, hedenied ever seeing any ghosts.Baseline Assessments

The initial assessment comprised of psychiatricinterviewing and detail work up. Visual AnalogueScale (VAS) was used as an outcome measure,which is a ten point equidistant scale ranging from0 to 9 where 0 stands for no problem and 9 standsfor maximum problem. Patient himself and hisparents reported the severity of the problem on VASevery alternate day during the course of treatment.

Based on the parental reporting and interviewsessions the goal of the present interventionprogramme was outlined so to enable the patient toovercome his presenting problems and deal withthe underlying cognitive factors associated with hissymptoms. The three goals that were set included(a) to decrease his nocturnal fear of ghosts, (b) todecrease the frequency of nightmares and (c) to be

Case Report

Psychotherapeutic Management ofNight-time Fears

S. Malhotra1, G. Rajender2, M.S. Bhatia3

1Department of Clinical Psychology, CNBC Hospital & MAMC, Delhi,2Department of Psychiatry, Mahatma Gandhi Medical College, Jaipur,

3Department of Psychiatry, UCMS & GTB Hospital, Delhi

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Delhi Psychiatry Journal 2012; 15:(1) © Delhi Psychiatric Society 229

able to sleep with lights off.Since the child himself requested his mother

to help him get rid of his fear of ghosts and hadgood cognitive abilities, cognitive restructuring wasused along with emotive imagery.

Since the fearful stimuli elicited emotions inthe child, they were reinforcers in terms of operantconditioning. Since being alone in the dark triggeredfear and anxiety, the alleviation of that anxietyreinforced avoidance behaviour. His avoidancebehaviour may have also been reinforced by hisparents always accompanying him whenever hewanted them to be with him and not being left alone.Thus, ongoing experiences were the maintainingfactors for continuing behavioural problems. Management

Psychotherapeutic intervention was givenduring a total of eight sessions, each lasting forapproximately one hour spread over a period ofthree weeks. After the initial session which focusedon assessment and diagnosis of the patient, all othersessions were so planned that after every sessionthe child and his family members were given a fewassignments involving therapeutic techniques thatwere to be followed and monitored at home.

The first intervention session focussed on goalsetting, but cognitive restructuring and emotiveimagery were also introduced. Next few sessionsfocussed on the development of emotive imagerytechniques. Appropriate reinforcements andrelaxation were also introduced. The cognitiverestructuring sessions, focussed on altering T’sbeliefs about existence of ghosts so that theybecome less threatening to him. In this process ofcognitive restructuring, T himself came up with thesupposed origin of his fear- watching of horrorshows on television. This made the process ofcognitive restructuring easier as the child himselfhad come up with this supposed origin. Emotiveimagery was also used along side and the child wasencouraged to pretend himself to be like hisfavourite cartoon character (that was supposed tohave special powers to fight with and defeat ghosts).However, care was taken to ensure that the childdid not over pretend this cartoon role as this wouldhave led to further behavioural problems. All hisefforts were consistently reinforced.Outcome and Discussion

Both child’s and parents’ ratings on VAS during

the course of treatment revealed marked decreasein child’s fear (Pre-intervention score of 8 and postintervention the score was 2). He made significantprogress during the course of intervention sessions.The present case study illustrates the effective useof emotive imagery and cognitive restricting in thetreatment of nocturnal anxiety and fear of ghosts ina child as young as six years of age. The rationalefor using emotive imagery in this case includedprevious evidence of its effectiveness in treatmentof childhood phobias3 and nocturnal anxieties4. Themost remarkable aspect about this case study wasthe way the child himself wanted treatment of his“ghost fear” and his active participation throughoutthe treatment. Emotive imagery along withcognitive techniques seems to have considerablepotential as an effective technique in working withchildren in managing their anxieties and fears.

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