PTSD and nightmares
My sleeping life has been marred by nightmares for as long as I can remember. At my worst, I’ve experienced nightmares seven days a week. I’ve kicked, thrashed, screamed, and cried at my partner in my sleep. I slept inconsistently, waking frequently. Despite spending eight to ten hours in bed each night, I never felt well-rested. Some nights, I had such bad night sweats I woke up looking like I had just hopped out of the shower.
Of all my mental health symptoms, my nightmares are the hardest to manage and most severely impact my waking life. Not only does my lack of a good night’s rest increase my overall vulnerabilities (I’m more likely to get depressed and anxious when overtired) but it makes it incredibly difficult for me to hold down a consistent routine.
Unfortunately, my experience is a common one. Some studies show as many as 80 per cent of those who suffer from PTSD also experience nightmares (often several times per week). In addition, PTSD-related nightmares come with deeper sleep disturbances than average nightmares including decreased total sleep time, an increase in duration and number of times waking throughout the night, increased rapid eye movement (REM) activity, decreased ability to sleep deeply, and increased leg movements during REM and non-REM sleep. People with PTSD are also more likely to experience disordered breathing during sleep, sleep movement disorders, and report feeling daytime fatigue. All of these sleep disruptions can have an intense impact on a person with PTSD’s daily life and compound existing mental health symptoms.
Initially, I attempted to treat my nightmares through common sense and DIY fixes: I read up on maintaining good sleep hygiene (ie. not falling asleep to Law & Order SVU, avoiding caffeine, etc.), I got real into binaural beats and delta waves, listened to YouTube sleep hypnosis and meditation tracks, and napped in small intervals during the day when I could (for some reason, my nightmares don’t seem to happen when I can sense daylight behind my eyelids). But, even with my adjustments and experimentations, my nightmares and poor sleep habits continued.
Though I personally haven’t experienced many of these treatments, there is some research suggesting specific therapeutic treatments may be helpful in treating PTSD-related nightmares. The first I’ll discuss is Image Rehearsal Therapy (IRT), a modified cognitive behavioural therapy (CBT) that involves reimagining nightmares through a few simple steps:
Write down the narrative or central elements of a nightmare upon waking (use pens and paper—phones create excessive light stimulation). Later, once you’re fully awake, rework your notes into paragraphs that tackle what happened, incorporating the most frightening aspects of the dream.
On a separate piece of paper, reimagine and rewrite the nightmare with a positive ending.
Before falling asleep, say to yourself: “If or when I have the beginnings of the same bad dream, I will be able to INSTEAD have this much better dream with a positive outcome.” From there, imagine the details of the rewritten dream from beginning to end. Repeat the above statement once more, before you allow yourself to fall asleep.
Ideally, with practice, those using IRT will be able to “redream” nightmares to reduce the amount and severity of fear they face each night, until they’re experiencing fewer nightmares in general. This therapy reminds me quite a bit of Peter A. Levine’s Somatic Experiencing therapy, a technique that’s worked well for me when it comes to dealing with PTSD flashbacks.
Another treatment that’s demonstrating efficacy in improving PTSD-related nightmares is Exposure, Relaxation, and Rescription Therapy (ERRT). ERRT is a multi-pronged approach to nightmare management that includes trauma and nightmare education, progressive muscle relaxation, rescripting nightmares to address traumatic themes (likely similar to IRT), and diaphragmatic breathing. In a 2015 study, 50 per cent of veterans who had participated in ERRT therapy weren’t experiencing any nightmares at a two month post-treatment assessment.
There’s also been evidence that Eye Movement Desensitization Reprocessing (EMDR), a trauma treatment, can improve nightmares in PTSD sufferers. EMDR works by stimulating neural mechanisms that are similar to those we experience during REM sleep. A therapist will encourage their patient to revisit traumatic memories or experiences, while having the patient’s eyes follow the therapist’s fingers as they move from side-to-side in the patient’s field of vision. This process helps the brain sort through information and provide insight and integration of traumatic memories. By reintegrating trauma in a patient’s waking life, that same memory loses some of its negative power, making the patient less likely to re-experience the trauma in the form of a nightmare. I’ve always been very curious about the efficacy of EMDR, but have never practiced it. If anyone has (or knows of Toronto-based EMDR practitioners) please leave a comment or send me an email.
Of course, in addition to therapeutic treatments, there are pharmacological options to relieve PTSD-related nightmares. There have been several positive studies on the effects of using Prazosin, a medication primarily used to treat high blood pressure, to treat nightmares in people with PTSD. It’s believed Prazosin helps with nightmares by blocking a receptor in the brain that deals with norepinephrine, a chemical in the body that acts as a neurotransmitter and stress hormone. Like any medication, it comes with its side effects—namely, dizziness—and its drawbacks. A 2018 study of “clinically stable” veterans found that Prazosin wasn’t as effective as other studies had noted.
I was prescribed Prazosin seven months ago and take it daily. I only have nightmares about half of the time, I sleep more consistently, and never wake through the night. I still need to spend a lot of time in bed, but I wake up feeling much more well-rested. It’s not a perfect fix though—when I do have nightmares, I still sleep-cry and scream, and my night sweats haven’t ceased. And, while Prazosin keeps me asleep throughout the night, it also prevents me from waking up from a nightmare, effectively trapping me in it. Unfortunately, sometimes the best you can hope for in mental health treatment is an improvement, not a cure.
Mad History
This issue: Sigmund Freud and dream analysis
T’was only a matter of time before this lunatic made his way into my Mad History section. Sigmund Freud, father of psychoanalysis, proponent of therapeutic cocaine use, and a man who sexualized young children, was also the pioneer of dream analysis. In his book, The Interpretation of Dreams, Freud states it is, “possible to interpret dreams…every dream reveals itself as a psychical structure which has a meaning and which can be inserted at an assignable point in the mental activities of waking life.” In fact, Freud believed that dreams were integral tools for self-analysis as they allowed inroads into the patient’s subconscious.
To this day, psychologists remain divided over the use of dreams in treatment. Some believe dreams are simply random brain activity that occurs when we’re sleeping. Others have posited that dream analysis can still prove useful in the therapeutic process. Most agree that dream analysis has little empirical or scientific evidence to back it up.
In Freud’s opinion, most symbolism in dreams relates to sex: Dreaming about the number three? You must have penises on the brain. Dreaming about a church? You’ve got to be thinking about vaginas. Fruit? Breasts! Your teeth falling out? Why, it’s merely a fear of castration. Freud’s “universal dream symbols” underline exactly what’s wrong with dream interpretation: there is no way to measure the accuracy of symbolic interpretation or to account for the analyzer’s biases and inconsistencies.
Recommended Reading
Dora: An Analysis of a Case of Hysteria
By: Sigmund Freud
I feel like a lot of people shit on Freud without ever having read any of his work. So, read Dora, a case study about a young girl who was brought to Freud, unspeaking, after her father’s mistress’s husband (bear with me), Herr K, assaulted her—a charge Herr K denied (despite evidence he’d been “grooming” Dora), and Dora’s father disbelieved. Chances are, like me, you’ll find Freud’s insights into Dora’s situation misogynistic, puzzling, and infuriating but at least the next time he comes up in passing, you’ll have some concrete criticisms to direct his way.
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