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Post-Traumatic Stress Disorder

Ending the Nightmares

New research provides hope for veterans dealing with nightmares due to trauma.

"I still get nightmares. In fact, I get them so often I should be used to them by now. I'm not. No one ever really gets used to nightmares." — Mark Z. Danielewski, House of Leaves.

Everyone experiences nightmares once in a while and an estimated 2 to 8 percent of adults report problems with recurring nightmares that can keep them from getting a good night's sleep. Frequent nightmares are usually related to emotional issues stemming from personal crises or other life problems that won't leave us alone when we are trying to sleep.

For people dealing with trauma especially, frequent nightmares and disturbed sleep is usually one of the hallmarks of post-traumatic stress disorder (PTSD). Not only do nightmares serve to reinforce existing PTSD symptoms, but severe nightmares can also "re-traumatize" people who find themselves re-experiencing their original trauma due to what they are experiencing at night. Over the past two decades, researchers have been taking a closer look at how nightmares and insomnia can be treated in people with PTSD. This includes developing specialized treatment programs aimed at helping trauma victims work through their nightmares, and learning to sleep comfortably at night.

One of the first of these treatment programs is Imagery Rehearsal Therapy (IRT). Developed in the 1990s by Barry Krakow, director of the Maimonides International Nightmare Treatment Center in Albuquerque, N.M., IRT is designed to follow three easy steps:

  • Jot down a description of a recent nightmare. If this nightmare is too upsetting, pick another.
  • Think of a way to change the nightmare. In developing IRT, Krakow recommends leaving this open-ended, so that clients can decide for themselves how the nightmare should end.
  • Set aside a few minutes each day to imagine this altered version of the nightmare. Paint a mental picture that can boost the likelihood of the nightmare being changed in a positive way.

While Krakow recommends that IRT be carried out with the assistance of a qualified professional, people suffering from recurring nightmares can try it on their own. If the nightmares are part of a more serious problem such as PTSD however, working with a therapist is advisable. While many clients suffering from frequent nightmares may have difficulty believing that such a simple method could help them, IRT has a good track record for success and can be used in addition to broader therapy methods such as cognitive-behaviour therapy.

A second treatment program specifically developed for nightmares is Exposure, Relaxation, and Rescripting Therapy (ERRT). First developed by Joanne Davis of the University of Tulsa, ERRT is more comprehensive than IRT and is primarily intended for PTSD patients suffering from recurring nightmares. Along with psychoeducation on PTSD and nightmares, people undergoing ERRT are trained in sleep hygiene and treatment to alter sleep habits that can lead to insomnia. They also receive relaxation training and exposure to nightmare content, identifying the major themes of the nightmare content, rescripting the nightmare with a more positive ending, and rehearsing the rescripted version.

Overall, researchers have found that these approaches tend to have long-lasting benefits for nightmare sufferers and work better than medications such as prazosin. Structured therapy also appears to work better than self-help methods.

But what about military veterans? Studies of veterans returning from deployment in Iraq and Afghanistan can experience a wide range of PTSD symptoms, including nightmares. Surveys of veterans of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) report that more than half of all participants report their sleep as being "bad" or "very bad" though few report any problems before being deployed. Veterans with PTSD tend to be especially resistant to many of the regular treatment approaches for dealing with posttraumatic stress though there are still relatively few studies looking at nightmares specifically.

A new pilot study published in the journal Psychological Trauma: Research Practice and Policy provides a direct test of ERRT in treating nightmares in returning veterans. Conducted by Joanne Davis and Katherine Miller of the University of Tulsa along with Noelle E. Balliett of the Veterans Administration Puget Sound Health Care System in Tacoma, Washington, their pilot project examines 19 veterans dealing with PTSD symptoms and reporting nightmares.

For the purpose of the study, "nightmare" is defined as a dream that involves "negative emotion of sufficient intensity to cause awakening." While dozens of applicants volunteered to be in the research project, only 19 were selected of whom all but one continued to the end of the study. The average age of the 13 men and five women in the study was 56.6 and nearly 80 percent met formal DSM criteria for PTSD. Almost all of the participants were also receiving treatment for depression or anxiety.

The study began with comprehensive interviews and testing for all participants with psychometric tests of PTSD symptoms, depression, and sleep quality. They also received specialized testing looking at nightmare content and insomnia. Afterward, they all attended ERRT sessions for 90 minutes a week for four weeks. The sessions were either conducted individually or in smaller groups. The sessions focused on relaxation training, nightmare rescripting, exposure to nightmare content they found especially distressing, and rehearsal with deep breathing exercises. Participants were instructed to rehearse again just before going to bed and to practice the skills learned on a regular basis. All participants were also given a patient manual that included mindfulness exercises to help with depression.

Results showed that ERRT was effective in curbing nightmares and improving sleep quality in traumatized veterans. Fifty percent of the participants reported no nightmares at all by the time of the final treatment session while most of the remaining subjects reported fewer nightmares and reduced insomnia. Exposure therapy with participants becoming desensitized to the nightmare images that reinforced their anxiety appeared to be especially useful.

So, why is this kind of therapy so effective in reducing nightmares? Part of the benefit of being able to re-script nightmares and learning to regulate emotions is that it allows veterans to take back control over this part of their lives. Also, through repeated exposures, the things they had been dreaming about become less frightening. ERRT is specifically designed to focus on particularly vivid nightmares, especially nightmares in which veterans relive traumatic events in their lives.

While ERRT works well for controlling nightmares, it isn't intended to treat other PTSD symptoms such as depression, flashbacks, and other symptoms. To address these issues, additional treatment is still needed. Still, helping veterans regain control over their dreams and improve their sleep can also help them cope with daytime distress and most of the participants in the study reported some improvement in depression as a result. All of which demonstrates that ERRT can be effective in combination with broader cognitive behavioural therapy treatment.

Even though this is just a pilot study with a small number of participants, the benefits of ERRT for helping veterans deal with nightmares seem clear enough. While more research is needed, including larger studies with more participants, the sheer number of returning veterans reporting PTSD symptoms, including nightmares, demonstrates the value of this kind of treatment. Getting a good night's sleep is vital for emotional and physical health and veterans deserve whatever help we can provide for them.