The same people reported trouble falling asleep, night waking, nightmares, periodic limb movements, and poor sleep. In the daytime, they had more trouble with memory and concentration, felt sleepier and more fatigued, and reported lower quality of life than those with lower PTSD scores. The severity of their symptoms was correlated with sleep factors that promote excess arousal, Barry Krakow, M.D., and colleagues at Maimonides Sleep Arts and Sciences in Albuquerque, N.M., reported at the annual meeting of the Associated Professional Sleep Societies in June. Changes in the brain during sleep in people with PTSD may maintain or increase activity in arousal-promoting brain centers and reduce activity in sleep-promoting centers, Anne Germain, Ph.D., an associate professor of psychiatry at the University of Pittsburgh School of Medicine, told Psychiatric News.

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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.

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“Most people with PTSD have insomnia and nightmares. It’s almost a given,” said Dr. Barry Krakow of the Maimonides Sleep Center.

The effects are devastating for them and others.

“Parasomnia conditions, very disruptive sleep” are common, said Krakow. “They could actually act out their dreams and move around and hurt somebody.”

Krakow said he’s been treating people with sleeping problems for years, helping them with their nightmares. Recently he’s seen a growing problem.

“There clearly is a rise, or at least an awareness of PTSD that’s growing in the community,” Krakow said.

Friday he unveiled a new PTSD sleep clinic.

“We’re trying to emphasize for the PTSD patient,” said Krakow. “We’re going to work on all their sleep problems.”

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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

One month after the murderous rampage at Virginia Tech, should we expect a similar media frenzy to latch onto the community’s efforts at recovery? Obviously and regrettably not, as few journalists or media organizations know how or what to effectively broach when exploring the topic of recovery. Articles will appear here and there about various human interest stories, the availability of counseling, or with the media’s addiction to controversy, what the Scientologists are doing in Blacksburg. But, aside from rare instances when they cover in depth the work of an expert in the field of trauma recovery, most of what the mainstream media writes in this realm is useless.

Now at the one month mark’a critical milestone in trauma recovery’it is important to closely examine some aspects of recovery, including what is and isn’t normal and how to identify the risks that predict whether someone is heading in the wrong direction. First and foremost, from an economic and community perspective, it is useful to recognize that the vast majority of individuals directly impacted by the shootings (e.g. everyone on the campus or closely affiliated with the campus) need absolutely no interventions to recover from traumatic experiences. A large number of individuals probably need only to discuss their experiences with close friends and family members for a few days or weeks, and there are probably a sizeable number who probably need even less engagement and will do just fine.

Natural human resilience explains this process. It doesn’t mean that individuals are not scarred for life or that the imprint of the experience can be erased. Rather, it means that most humans have the ability to acknowledge terrible things, feel a wide range of distressing emotions, and then move on with their lives. Many in fact move up in a spiritual sense because the experience permits, encourages or forces them to take stock of their lives. Resilience should not be confused with callousness; resilience is the ability to engage a traumatic experience at a level that hurts but then move beyond that hurt to some form of reckoning’rational, emotional, or spiritual’that allows the individual to embrace the idea and feeling that ‘life goes on.’

How these resilient individuals negotiate this process takes various forms and steps, one of particular interest to the visual media is the desensitization caused by repeated exposure to the horrific images or assorted reminders of these images. This desensitization allows the person to dampen the emotional reaction to the trauma over the course of days or weeks. In this area, visual media are truly serving a valuable purpose for a very large number of survivors, although arguably most people would have recovered and coped fairly quickly with or without this added exposure.

Who then doesn’t recover quickly or recover to a reasonably healthy state? How do we identify and provide them the help they need? And, how do we match individuals with post-traumatic struggles with the best and most appropriate therapeutic interventions?

Sleep is a very useful marker to estimate when someone will recover fast, slowly, or poorly. Within days of traumatic events, most survivors describe unwanted sleeplessness, poor sleep quality, or nightmares, or a worsening of these symptoms if they already suffered from sleep disturbances. It is in fact logical to need less sleep or experience a lighter form of sleep (poor sleep quality), because adverse experiences raise a person’s threat level. A continuous threat assessment emerges after trauma, raising one’s level of alertness and vigilance to a state of hypervigilance. Consider how much more cautiously or safely you drive immediately after you suffer a very scary, near-miss with another car.

As your threat level rises, you want to reduce your vulnerability to future threats. The sensible thing is to avoid sleep, the most vulnerable state within the natural human life cycle. Sleep can be avoided in the extreme by not sleeping (insomnia), but one’s vulnerability can also be decreased by making sleep lighter (poor quality).

Nightmares play out in several ways in the recovery process. On the one hand, nightmares function acutely to remind you of events, thus insuring you keep your guard up; they also provide detailed information about what happened in ways that might stimulate you to reflect on all the circumstances surrounding the events and what you might do the next time to prevent something or respond in better ways. Nightmares also have direct therapeutic potential for some individuals by aiding their processing of emotional reactions to stressful events. It is extremely common for some survivors to report ‘instant replay’ like dreams following traumatizing experiences, but typically in a matter of days or weeks, the nightmares change in ways that become less threatening than these original, disturbing replay images.

Research indicates that a metamorphosis occurs within the dream material. At first, the dreams resemble the actual trauma. Then, they change, becoming more symbolic or metaphorical about what occurred. During this transformation, emotions within dreams change in ways that suggest dreams are helping survivors feel more comfortable with and adapt more to their responses to the traumatizing events.

What’s remarkable about sleep symptoms is that the more and the longer you have them, the more likely you are to suffer a poor recovery or no recovery at all. In technical terms, a person with these symptoms almost always suffers from other post-traumatic stress symptoms; and, after the first month if they are still present, an acute stress disorder is diagnosed. When these stress symptoms including some of the sleep symptoms persist at three months, the individual may meet diagnostic criteria for post-traumatic stress disorder (PTSD).

In my clinical and research experience, I have found that once sleep symptoms of any type persist beyond 4 to 6 weeks, the chances are much higher that the trauma survivor’s recovery will go slower and less smoothly unless proper treatment is provided. Proper treatment would not mean treating just these sleep symptoms, because most survivors who report sleep problems one month later would also report other types of post-trauma stress indicators such as: memories of the trauma while awake, easily startled, restless or jumpy feelings, emotional numbness, difficulties with memory and concentration, irritability, increased pessimism, feelings of isolation, and behavioral avoidance in which survivors distance themselves from circumstances, locations, or discussions that might trigger memories of the traumatic experiences. Undoubtedly, these other symptoms are also useful markers in recognizing individuals who are more susceptible to a slow or poor recovery.

Sleep symptoms are particularly vexing because sleep deprivation due to insomnia, compromised sleep quality, or nightmares worsens all other symptoms by triggering chronic, daytime fatigue or sleepiness that robs survivors of the energy they need to cope effectively and move toward a health recovery. In our work, we find that sleep treatments spark a lot of curiosity among trauma survivors. It’s not to say that sleep treatment is the best approach or that it should be the first approach. Rather, as physicians, we must recognize the ‘opening’ the patient offers and use that to initiate treatment with the hope of expanding services as needed to maximize recovery.

Trauma survivors can hear instructions about how to tackle sleep problems or how to use their dreams to help them recover; whereas, they may be less inclined in the early going to discuss the actual traumatic events. This reluctance also manifests as a disconcerting paradox in the mental health community. On the one hand, many researchers have developed state-of-the-art programs that dramatically increase rates of recovery from traumatizing events; and these treatments require that the person ‘re-live’ some of their experiences to either become desensitized to them or to work successfully through their emotional responses (usually both goals are achieved). These techniques are known as exposure therapy, and in the space of weekly sessions, given for about 2 to 4 months, they will often reduce PTSD symptoms to negligible levels or yield an outright cure.

The paradox is that a large proportion of community-based mental health professionals outside of academic centers are often unaware of these advanced yet now standardized techniques, have never received training to provide such therapies, or have their own reluctance about using them. Ironically, this reluctance mirrors that of those survivors who are skeptical, weary, or nervous about being ‘exposed’ to exposure therapy. Survivors and therapists alike have concerns about the ‘reexperiencing’ model and imagine it could just as easily worsen stress levels. However, exposure therapy is conducted in a controlled environment in which traumatic memories are divided up into much smaller units to make the process more digestible. The key element occurs when individuals allow themselves to reexperience the distressing emotions, and they do so by permitting themselves to feel feelings in their bodies instead of overanalyzing their feelings in their minds. In the simplest terms, trauma survivors who are recovering slowly or poorly often fear fear, so they engage in activities to avoid having to feel fear. Through exposure therapy, the fear is reexperienced, preferably in graduated doses over several weeks of work, and the individual gradually realizes they no longer have to fight with their traumatic memories or the distressing emotions triggered by these images.

Remarkably, it is this key part of the process that seems to generate reluctance among many therapists, even among those who have received training or education on exposure therapy. They apparently fear that the patient’s reaction to the therapy will lead the patient to feel overwhelmed, even though the technique when properly administered frequently leads the survivor to much healthier, richer, and controllable forms of emotional expression.

In our practice of sleep medicine, we are not trained and do not offer exposure therapy. Instead, we see many trauma survivors in research and clinical practice eager to start treatment by focusing on their insomnia, poor sleep quality and nightmares. In my new book, Sound Sleep, Sound Mind (October, Wiley & Sons), I detail a number of techniques to solve these problems, and the book was written with many of my most complex patients in mind, particularly trauma survivors who report some of the most severe sleep disturbances. In future posts, I’ll be discussing these techniques, and our website www.sleepdynamictherapy.com will also provide practical, interactive programs to lead you through many of the steps.