Military personnel returning from wars in Afghanistan and Iraq show increasing rates of post-traumatic stress disorder (PTSD) and post-traumatic nightmares. Media coverage of these two vexing mental health conditions is also intensifying and raising public awareness about the need for more effective therapeutic options. With growing attention focused on patients with nightmares, sleep centers have an opportunity to engage these patients. Successfully doing so hinges on applying a standard of care for nightmare assessment and treatment through behavioral sleep medicine specialists.

MENTAL HEALTH VIEW OF NIGHTMARES

Traditionally, nightmares reflect emotional turmoil that needs venting through the process of dreaming. This psychological perspective fuels the entrenched and enduring focus on dream interpretation therapy as one of two core treatments for this potent sleep disrupter. The other primary approach known as exposure therapy is gaining ascendency in the mental health community because of the prevailing view that PTSD—the cause of the disturbing dreams—must be treated first. As the theory goes, the nightmares will resolve when their cause is treated. Yet, both these treatment paradigms (dream interpretation and exposure) trigger treatment avoidance among nightmare patients because of their fear of unmasking unpleasant mental health issues. Although this paradox creates an opening for nightmare patients to seek help outside of mental health facilities, it is rare for sleep medicine clinics to encounter patients seeking treatment exclusively for nightmares.

Read More…

Her car is racing at a terrifying speed through the streets of a large city, and something gruesome, something with giant eyeballs, is chasing her, closing in fast. It was a dream, of course, and after Emily Gurule, a 50-year-old high school teacher, related it to Dr. Barry Krakow, he did not ask her to unpack its symbolism. He simply told her to think of a new one. “In your mind, with thinking and picturing, take a few minutes, close your eyes, and I want you to change the dream any way you wish,” said Krakow, founder of the PTSD Sleep Clinic at the Maimonides Sleep Arts and Sciences center in Albuquerque and a leading researcher of nightmares. And so …

Read More…

This common sense perspective fits perfectly with our experiences in clinical practice and research investigations. To this day, we are not convinced that IRT is actually a therapy. We have long believed that IRT simply represents the formalization of a natural, working process of the human mind, and we’ve assumed the technique has probably been in operation for millennia. Why wouldn’t it seem logical or reasonable for people to imagine that their waking images influence their sleeping images? Dream research has shown that daytime reflections or even bedtime “preemptive” images may induce specific modes or content in dreams.

If there is a therapy aspect to IRT, it might be through the process of mastery. Consciously, patients feel empowered by IRT by taking control of something that previously felt like it was an uncontrollable and unconscious process. Perhaps even greater potency arises from the actual changes of “dream” content that IRT necessitates. We have speculated that these changes may have psychodynamic properties, that is, by encouraging the patient to intuit changes in their dreams, could it be that such changes reflect efforts to alter or resolve underlying conflicts? Although there are some patients who change their dreams entirely to something that appears to have no relationship to the original dream content, this approach is not the norm. Typically, patients retain some aspects of the disturbing dream, both in terms of content and apparent emotional states. For these reasons, we have stuck with Joseph Neidhardt’s original prescription, “change the nightmare anyway you wish.”

Summing up for those who support IRT, it seems to be a very natural use of the mind’s eye, and the mind’s eye is certainly a powerful gateway through which to understand and solve numerous problems experienced in the waking state. No doubt, many nightmare sufferers have been fortunate to have grasped this perspective and reversed their bad dreams rather easily, presumably because waking imagery work influences sleeping imagery.

For the Jungians who commented, apparently IRT is difficult to chew on, digest, and absorb. Somehow it’s a quick fix and superficial solution whose benefits are largely outweighed by the loss of insights from “inappropriate” alteration of the dream. To these psychoanalysts, may I be so presumptuous as to remind them that Freud originally theorized that “dreams were the guardian of sleep.” In other words, Freud must have believed that sleep was also a relevant factor in this equation. Why else would dreams allegedly protect sleep? To me, this construct implies that a brilliant psychoanalyst understood that sleep must be important; there is a context to dreams, they occur during sleep, and therefore the interpretation of dreams while valuable is not an exclusive proposition.

I certainly concur with the view that dream interpretation work is an asset to therapy, but it’s remarkable that more 75% of all chronic nightmare patients we’ve seen have previously completed more than a few sessions of psychotherapy of some type and yet reported minimal improvement in their nightmares. Arguably, many did not use dream interpretation work in their psychotherapy. Regardless, I’m a board-certified internist and sleep specialist and when a patient seeks help, my goal is help them sleep better.

Ask most of our IRT patients if they lost something by replacing their nightmares with a good night’s sleep, and we would predict most would be perplexed by the question. “Thanks for giving me back my sleep,” was the most common refrain from those who successfully conquered their disturbing dreams and nightmares. If asked to keep the nightmares or gain the sleep, we’ve seen a few cases where patients were so overwhelmed by the sudden disappearance of their bad dreams they immediately stopped IRT so the nightmares might return. In every one of these few cases, several months later the patient decided enough is enough, returned to IRT practice, and the bad dreams abated once again.

As Sarah Kershaw’s article described, we’ve seen a great deal of complexity to nightmare disturbances and related sleep problems in PTSD patients. In patients presenting to our sleep center with the problem of nightmares, at least 70% also have obstructive sleep apnea and up to 25% have leg movement problems. So, here’s a conundrum the Jungians will need to sort out. What about the sleep apnea patient who has severe nightmares that completely disappear once breathing is restored to normal with the artificial device known as PAP therapy (positive airway pressure)? Should we stop treatment with PAP therapy to insure the nightmare patient completes his or her 5 years of appropriate Jungian psychoanalysis to uncover the hidden meanings of nightmares? Or, since sleep apnea worsens heart disease, hypertension, and depression, would it be reasonable to continue with PAP therapy and just call the elimination of nightmares a “side-effect” of unknown clinical consequences.

What may seem ironic or not to Jungians is that I started my career in sleep medicine through the field of dream research, spending several years studying the field and presenting our nightmare treatment research to the Association for the Study of Dreams of which I am a current member. I also co-write a book with Dr. Neidhardt introducing IRT (Conquering Bad Dreams & Nightmares, 1992), but it also included a lengthy, detailed section on Dr. Neidhardt’s dream interpretation techniques to solve nightmare problems. So, I strongly endorse dream interpretation techniques, including Jungian work, and remain firmly convinced that dream interpretation therapies are vastly underrated and underused. Dr. Neidhardt, a psychiatrist now practicing in Santa Fe, taught me how dream interpretation work is an incredibly incisive technique for understanding emotional conflict and subsequent attempts at emotional processing to resolve such conflicts. I still use these techniques, but my clinical practice population steers me towards greater usage of IRT.

I must say it never occurred to me there was something mutually exclusive about IRT and dream interpretation work, although most people who share this view—patient or therapist—recognize they would not necessarily attempt both techniques at the same time on the same dream; however, I’m certain there are therapists who would have the skill to do just that if a patient were motivated to do so.

We known a lot more about sleep and dreams than we did 100 years ago, and what we know is that things that disrupt sleep cause mental and physical health problems, serious problems that clearly impact daytime functioning and quality of life. Having suffered from sleep problems for 35 years prior to successful treatment, I know first hand how much impairment can be caused by these nocturnal mischief-makers of which nightmares are only one—one that often runs with a pack. I would hope the Jungians would regroup and ask themselves whether they are on solid scientific footing when they would choose salvaging a nightmare disorder in favor of a good night’s sleep. The number of nightmare patients with undiagnosed physiological sleep disorders is not small. Overemphasizing the dream work increases the risk for missing these diagnoses, which will lead to no small amount of harm to these patients. Sleep is as precious as dreams, maybe more so.

Following a Script to Escape a Nightmare

The holidays are especially hard for Wolford, who has yet to be treated for his condition, but about 2,500 veterans receive treatment at the Guam Vets Center annually. 65% of them have undergone treatment specifically for Post-Traumatic Stress Disorder. Local Guam yoga therapist Debbie Purcell says she uses yoga as a form of therapy to treat patients with PTSD, and that she’s had great success with vets by getting them to focus on the breath.

Read More…

When Do Nightmares Become A Sleep Disorder?

One in 20 adults in the US complain of disturbing dreams, and more than twice that many children and adolescents also experience frequent nightmares, yet few chronic nightmare sufferers imagine that it is a treatable problem. We’ll talk about nightmares with leading sleep disorder specialist Dr. Barry Krakow.

Listen to the Interview

Imagery rehearsal therapy is a broad term for myriad cognitive-imagery treatments for chronic and potentially acute nightmare disorders. Several groups are researching specific brands of the therapy, and this modality is receiving substantial attention in two converging ways.

First, several review articles have argued that imagery rehearsal therapy (IRT) is now or is becoming a first-line treatment for chronic nightmare disorder (CNS Drugs 2006;20:567-90 and Sleep Med. Rev. 2006;10:19-31).

Second, media coverage of the rising rates of posttraumatic stress disorder (PTSD) in U.S. military personnel has raised public awareness of the interaction between chronic nightmares and traumatic exposure.

All IRT programs stress imagery rehearsal of consciously altered dream content. But they vary on the use of exposure therapy, which involves intense focus on the content of nightmares and the trauma event.

A recent report in this publication about an IRT program conducted at Yale University, New Haven, Conn., for Vietnam War veterans might have given the impression that the therapy requires a large exposure element, because “patients are asked to identify a repetitive nightmare related to a traumatic event” (“Revised Imagery Protocol May Help Some Vets,” April 2009, p. 10). However, that was not what my coinvestigators and I intended when we developed the most tested and widely published version of IRT ( JAMA 2001;286:537-45).

Since 2000, our continuing work at the Sleep & Human Health Institute, Albuquerque, has focused on a two-component IRT protocol, both of which eschew any substantive discussion of trauma or the traumatic content of nightmares (Behav. Sleep Med. 2006;4:45-70).

Each component targets a distinct but related problem in the nightmare sufferer. The first addresses nightmares as a “learned sleep disorder,” and the second addresses them as “the symptom of a damaged or malfunctioning imagery system.” The therapy comprises four 2-hour sessions for groups—or for individuals, just a few hours.

In the first two sessions, patients are encouraged to recognize the impact nightmares have on their sleep by discussing how nightmares promote learned insomnia. Then they are taught to recognize how nightmares can develop into a learned behavior. In the last two sessions, patients are encouraged to explore the human imagery system, monitor how this system operates, appreciate connections between daytime imagery and dreams, and then implement the specific steps of IRT—that is, selecting a nightmare, changing the nightmare into a new dream, and rehearsing the new dream.

We never discount patients’ perspectives on the triggering incidents that they perceive as the source of their nightmares, because trauma survivors often assume nightmares are an unalterable aspect of PTSD that may have purpose or meaning.

Nevertheless, they are taught that nightmares can be effectively treated as a distinct sleep disorder without any discussion or emphasis on previous traumatic events or nonsleep-related PTSD symptoms. As such, our brand of IRT seeks to minimize exposure elements; patients are instructed to avoid working with replaylike dreams of traumatic events.

Our treatment strategy focuses on the “nightmaring process” and not simply on nightmares. When individuals appreciate that nightmares might be a learned sleep pattern and they reestablish confidence in the use of their natural imagery skills, disturbing dreams and nightmares abate.

The dramatic potency of exposure therapy for PTSD proper is well recognized, but I remain skeptical of nightmare treatments that combine the two approaches (exposure and IRT). Nightmare patients are skittish about seeking treatment for this vexing problem; frequently express embarrassment or, worse distress, when discussing the problem; often drop out of treatment; and in so doing, reinforce avoidance behavior. The addition of exposure components to IRT can exacerbate these problems in some (certainly not all) nightmare patients; whereas other versions of IRT can— and have—achieved marked successes without major exposure elements.

On the related matter of sleep in PTSD, since 1997 my coinvestigators and I have published and presented data on the complexity of sleep disturbances in nightmare disorders, and we submit that disturbing dreams herald a deeply rooted sleep pathophysiology, often masquerading as classic psychiatric insomnia (Sleep Breath. 2002;6:189-202).

When we looked beyond insomnia and nightmares, we diagnosed extraordinarily high rates of obstructive sleep apnea (OSA) in more than 1,000 trauma survivors in clinical and research samples. At our clinic, we continue to document OSA rates of more than 80% in patients— most of whom have PTSD—who seek help for their nightmare complaints.

Anecdotally, this physiologic disorder of sleep respiration seems to play an undetermined role in the nightmaring process, perhaps through the effects of chronic sleep fragmentation and resultant sleep deprivation. This sleep fragmentation might compromise the natural human capacity for mental imagery, which in turn creates a vulnerability to onset and perpetuation of chronic nightmares.

Finally, in certain nightmare patients who are already suffering chronic and severe sleep fragmentation or deprivation from an occult and undiagnosed OSA condition, it is conceivable that exposure therapy produces an intolerable stress load that increases risk for worse outcomes.

Download PDF