NIGHTMARES

3 TYPES OF DISTURBING DREAMS

• Nightmares: Frightening dreams that wake the dreamer from REM sleep

• Anxiety Dreams: Disturbing and anxiety provoking dreams that do not actually wake the dreamer

• Post Traumatic Nightmare: Recurring disturbing dream that repeats an actual traumatic experience

NIGHTMARE FACTS

• Almost everyone has had a nightmare in their lifetime

• More common in times of stress or transition

• More common in trauma survivors (PTSD)

• Greatest incidence is with young children ages 3-6

• 5-10% of adults report regular nightmares

NIGHTMARE FACTS• Can be associated with medications or physical causes

• Substance abuse and substance withdrawal can lead to nightmares

• Fever, sickness, sleeping position, etc

• Tend to occur later in the sleep cycle, when periods of REM cycles are longer

NIGHTMARE THEMES

• Most common theme is feeling helpless in the face of threat

OTHER COMMON THEMES• Being chased or attacked

• Being injured or paralyzed in some way

• Sensing something dangerous or ominous

• Death, health concerns

• Falling

FACTORS THAT LEAD TO NIGHTMARE DISTRESS

• People often believe they are prophetic and point to something bad that will happen

• They are more realistic, vivid, and impactful than regular dreams

• The perceived lack of control in the nightmare

• They have a very anxiety producing and disturbing storyline (dream of being buried alive in a coffin, for example)

POST TRAUMATIC NIGHTMARES (PTN)

• Associated with a traumatic event:

• DSM: “(1) The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2) the persons response involved intense fear, helplessness or horror”

POST TRAUMATIC NIGHTMARE

• Threatening or frightening dreams that awaken a dreamer and may be marked by any intense negative emotions, such as fear, anger or sadness. They cause significant distress and may occur several times a week

POST TRAUMATIC NIGHTMARES

• Have an obvious precipitating event

• However, not all nightmares following a traumatic event are a direct replay of the event (can be symbolic or indirectly related to the event)

• Usually about 50% who experience traumatic event (PTSD patients) have Post traumatic nightmares

POST TRAUMATIC NIGHTMARES

• More likely if the person was vulnerable to stress when the event occurred

• Other precipitating factors include poor attachment and poor coping skills

• For most, PTN tend to fade over time and remit.

PTN

• Different from “ordinary” nightmares in that there is associated physiological arousal: waking up with a scream or in terror, acting out, or sleep walking episode.

• Can occur in REM sleep as well as stage 2 sleep

TREATMENT OF NIGHTMARES

• Storyline Alteration Methods

• Face and Conquer Methods

• Children’s nightmares

• Imagery Rehearsal Therapy (PTN)

STORYLINE ALTERATION

• Techniques that provide ways in which the anxiety producing storyline or ending is altered in some way.

• Most helpful where the client is very fearful about the nightmare

1. STEPS IN STORYLINE ALTERATION

• Have client repeat dream first in the third person, then in first person, present tense, until they feel comfortable

• Can reflect on any meaning or interpretation of the dream

• Have the dreamer identify how they would change the storyline to make the nightmare less frightening.

1. STORYLINE ALTERATION CONTINUED

• Have the dreamer run through and practice the new storyline

• Have the dream run through and experience the new storyline in a relaxed state before going to sleep

• Dreamer makes the suggest to his/her unconscious, that the desired alteration will be incorporated into the nightmare if it occurs again.

2. RE-WRITING NIGHTMARE

• Similar to storyline alteration, but here the story is ACTUALLY rewritten by the dreamer.

• Usually as homework assignment

STEPS:1. Recall and summarize the nightmare

2. Choose which actions are positive and valuable, and which are negative

3. Choose a point in the dream where you want to change a negative aspect

1. As the dream ego, you can change your involvement or how you are (being active vs passive, different time or place, powerful vs afraid, etc).

STEPS CONT…..

4. Sit comfortably with pen and paper (or computer) and re-write the dream with the dream ego going through the same scenes but using the new, more creative attitudes

5. Read through new scenario and make statement to summarize what the dream ego is doing/feeling.

FACE AND CONQUER METHOD

• Dreamer is instructed to face or to confront and conquer the feared object of the dream

• Based on Senoi system of dream control (Senoi were a tribe of people living on the Malaysian peninsula)

• Useful when the nightmare involves being chased or attacked

The technique is often done by having the therapist take the dreamer

through the method as a form of guided fantasy

FACE AND CONQUER STEPS• If the dreamer is the victim of any aggressive action or

attack, they should fight back with all their might, even to the death

• Dreamer can call on “helpers” to assist her in fighting back

• Any dream figure that is aggressive or refused to help is to be considered an enemy

FACE AND CONQUER STEPS

• After the dreamer has confronted and subdued the aggressor, they can force it to give them a gift

• Prior to going to sleep, the dreamer can rehearse the dream

IMAGERY REHEARSAL THERAPY

• Developed in the early 90’s and adapted by Krakow in 2004 for use with trauma survivors.

• It does not explore the meaning of the dream, but works to change the content of the dream

• Clients are first educated about dreams and trauma, then instructed how to do IRT

• Meta-analysis (2012) found large effects on nightmare frequency, sleep quality, and PTSD symptoms. Effects sustained at 6-12 follow-up

IRT STEPS• Select disturbing dream, preferably one of lesser intensity and not a

re-enactment of the trauma.

• Change the nightmare “any way you wish”

• Create written narrative of the dream in rescripted form

• Rehearse the new dream for a few minutes every day

• Continue this each day until symptoms are reduced

• Work with no more than 1-2 dreams per week.

Clients can change the dream at any point they wish, or they can change the ending. Research has found

that the best results are when the dream is rescprited with a positive feeling tone and increased mastery.

http://www.nightmaretreatment.com/

Website for IRT And Nightmare Treatment