Nightmares and PTSD
Nightmares are one of the hallmark symptoms of posttraumatic stress disorder (PTSD), though post-traumatic nightmares may exist independently and do not equate to a diagnosis of PTSD. Post-traumatic nightmares may be described as lengthy, detailed dreams in which the story line evokes intense fear, anxiety or other negative emotions. Many patients report that these nightmares involve trying to avoid or cope with some horrific danger that closely resembles a specific traumatic event.
Not surprisingly, nightmares can significantly interfere with sleep. Individuals with post-traumatic nightmares may actively avoid sleep for fear that they will experience a nightmare, leading to the development or exacerbation of other problems. I encourage providers to ask patients who have been exposed to trauma whether they have experienced nightmares. For those who have recurrent nightmares, especially regarding a specific trauma, nightmare treatment should be considered.
Treatment for Nightmares
Imagery rehearsal therapy (IRT) is a cognitive-behavioral therapy created to reduce the frequency and intensity of nightmares. Initially, the provider completes a detailed assessment regarding the nightmares. Generally, the content, frequency and intensity of the dreams are noted. Many clinicians will also assess information regarding the emotions evoked and the associated trauma history.
Over the course of several sessions, the provider assists the patient as they develop new, non-threatening endings (or details) for the nightmare of focus. The revised dreams (without the nightmare ending) are rehearsed regularly. In time, the nightmares change and they become dreams without the distressing affect. Clinicians should monitor nightmare content over time to assess treatment efficacy.
It is important that the provider carefully assess the patient’s history, symptoms and PTSD treatment plan in order to determine when imagery rehearsal therapy may be most effective. Many patients respond well to evidence-based treatment for PTSD, and cognitive-behavioral treatments will often alleviate the most distressing symptoms, including nightmares. For others, such as some with co-morbid disorders or those whose nightmares persist, IRT may be best used following PTSD treatment.
There are several variations of IRT, related to the number of sessions, duration of treatment, and the degree to which exposure therapy is included in the protocol. I encourage you to learn more about them if you find that your patients may benefit from this treatment. IRT is recommended as it can provide results quickly, giving relief to military patients, and building trust that mental health providers can help people achieve symptom resolution in other areas.
The Dream EZ mobile app developed by the Defense Health Agency is a free app based on IRT and helps users rewrite bad dreams to reduce the frequency and intensity of nightmares. The app enables users to:
- Write and log a description of the nightmare
- Track when and how often the nightmare occurs
- Practice visualization techniques to rewrite the dream’s plot and ending
- Record a new version of the dream, which can be played over and over before bedtime
O’Reilly was a contracted clinical psychologist and evidence-based practice subject matter expert at the Psychological Health Center of Excellence. Her specialties include the consequences of traumatic exposure and gender studies
The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.