Nightmares After Trauma

How nightmares in PTSD differ from regular nightmares

Posted Mar 30, 2016

PTSD is a psychological disorder that may develop after a traumatic experience, and it is characterized by one symptom that is particularly unique, called “re-experiencing”, or more commonly, "flashbacks". This is when the memory of a trauma is involuntarily recalled, usually triggered by cues in the environment that are somehow associated to the trauma. These intrusive trauma memories can be remarkably vivid, overwhelmingly emotional, and are experienced as if they were really happening right then and there.

Re-experiencing also occurs in the form of posttraumatic nightmares, considered a “hallmark” of the disorder (Ross, Ball, Sullivan, & Caroff, 1989). Posttraumatic nightmares are generally defined as threatening or frightening dreams that awaken a dreamer and may be marked by any intense negative emotion, such as fear, anger, or even sadness. These nightmares cause significant distress (both during the dream, and after awakening) and may occur several times a week. One study of sexual assault survivors with PTSD found a nightmare frequency of greater than five per week (Krakow et al., 2002).

In general, posttraumatic nightmares are more intense than regular dreams and are similar to waking flashback memories; they contain replays of the actual traumatic event and more scenes of death and violence than normal dreams (Esposito, Benitez, Barza, & Mellman, 1999). At least 50% of PTSD patients suffer from re-experiencing nightmares that incorporate clear elements or even contain exact replications of a traumatic event (termed "replicative nightmares"). Another 20-25% of PTSD patients experience posttraumatic nightmares that are not an exact replay of a trauma memory, but are still often symbolically or indirectly related to the traumatic event (Wilmer, 1996).

One study examined patients 40 years after a traumatic event and found that patients with replicative nightmares had worse symptoms than patients with non-replicative nightmares (Schreuder, Kleijn, and Rooijmans, 2000). Another study found that trauma survivors who develop PTSD have more replicative nightmares than trauma survivors who do not develop PTSD (Wittmann et al., 2006). Thus, it seems that replicative nightmares are correlated with the development and severity of PTSD.

The question remains whether posttraumatic nightmares may be adaptive over time; if they are, we would expect them to become less distressful over time as symptoms improve (Phelps, Forbes, & Creamer, 2008). Even in the general population, having recurrent dreams (see previous post) is associated with higher levels of distress and lower psychological well-being (Zadra, O'Brien, & Donderi, 1997). It seems that recurrent bad dreams or nightmares are revealing some unresolved conflict that keeps replaying during sleep. However, the cessation of a recurrent dream is associated with increased psychological well-being, suggesting that successful resolution or adaptation to the conflict has occurred and the nightmare is no longer necessary (Zadra, 1996). Unfortunately, in some cases replicative nightmares may persist decades after a trauma.

That being said, targeted treatment of nightmares in PTSD is associated with relief from all symptoms. One recent treatment approach focuses on integrating trauma memories through a waking visualization technique called Visual Kinesthetic Dissociation. In this technique, therapists ask their patients to mentally replay a trauma memory in a variety of 'safe' ways, i.e., as a black-and-white film they are watching in a movie theater, or even further, to imagine watching themselves in a movie theater watching a film of the trauma memory (in black and white, or backwards, in slow motion, etc.) (Gray & Liotta, 2012). This procedure may allow the activation and integration of emotional memories while keeping the emotions and distress at a safe distance.

Research on this technique is currently actively recruiting participants, for more information see