Wednesday, August 3, 2022

Guided self treat­ment for PTSD re­lat­ed nightmares 

There is no hid­ing the im­pact that PTSD has on sleep. Night­mares and sleep dis­turbances are part of the cri­te­ria for PTSD symp­toms in the DSM. Re­search has shown  that 97% of com­bat vet­er­ans suf­fer from sleep dis­tur­bances, with over 90% of those  dis­tur­bances in­clud­ing night­mares. It may sound nat­ur­al for sol­diers of war to dream  about the dis­tress­ing events that they wit­nessed, but in the gen­er­al pop­u­la­tion (you  and me) in­di­vid­u­als with PTSD have a 67% rate of night­mares and sleep dis­tur­bances.  In fact, a third of in­di­vid­u­als with de­pres­sion and per­son­al­i­ty dis­or­ders can have night mares and sleep dis­tur­bances with­out PTSD.  

In re­search­ing the cause, ef­fect, and treat­ment of night­mares, sci­en­tists found that night­mares in PTSD aren’t as sim­ple as they sound. Night­mares don’t sim­ply re­play  the trau­ma in the head of the sur­vivor dur­ing sleep. These night­mares may also portray real-time or cur­rent fears of threats in the in­di­vid­ual, and can resur­face af­ter res­olu­tion (as is of­ten seen in sex­u­al trau­ma). It has also been found that in­di­vid­u­als with night­mares have a five-fold in­crease risk for sui­cide. This is not great news for those suf­fer­ing from PTSD re­lat­ed night­mares. One can be left search­ing for the an­swer to a good night’s sleep.  

There is a med­ica­tion that has been proven ef­fec­tive in PTSD night­mares, but it may not be for every­one. Pra­zosin has shown ef­fec­tive­ness in treat­ment of PTSD nightmares and is a first line treat­ment in many ar­eas. This med­ica­tion may have side ef­fects that pre­vent an in­di­vid­ual from re­ceiv­ing the re­quired dose, how­ev­er. Oth­er first-line treat­ments in­clude cer­tain types of an­ti­de­pres­sants as well as CBT ther­a­py. What’s impor­tant to rec­og­nize is that no sin­gle treat­ment ap­pears to be the cure for night­mares.  One treat­ment, how­ev­er, does al­low for some sig­nif­i­cant re­lief with­out the need for long-term use. This is es­pe­cial­ly help­ful in cas­es of re­cur­rence of nightmares af­ter they have been gone for a time.  


Im­agery Re­hearsal Ther­a­py (IRT) is a form of guid­ed self treat­ment for night­mares. The  pro­to­col is easy to fol­low and al­lows for a ther­a­pist to as­sist if re­quired with­out the require­ment of their pres­ence through­out the process. IRT is (in sum­ma­ry) a rewrit­ing of  a night­mare, but chang­ing small de­tails or set­tings, to de­crease the in­ten­si­ty of the  night­mare. Any­one who has seen Har­ry Pot­ter movies, specif­i­cal­ly the Bog­gart scene in Pris­on­er of Azk­a­ban, may un­der­stand how a sim­ple change to our dark­est fears can not only ease the fear, but may be quite com­i­cal. IRT works in this way. Af­ter a pe­ri­od of ed­u­ca­tion and learn­ing from a ther­a­pist to a suf­fer­er of night mares, the pro­to­col be­gins by se­lect­ing a night­mare that one feels com­fort­able work ing with. This may be the most in­tense night­mare, the scari­est, more real, or the eas­iest to cope with—de­pend­ing on where the com­fort lies. Once a night­mare is se­lect­ed,  the in­di­vid­ual must write out every de­tail. This can be the hard­est part of IRT, and should be done with the sup­port of a ther­a­pist. Then a por­tion of the dream is se­lected (the mon­ster, the fear, the set­ting) and rewrit­ten. This rewrit­ten night­mare is then visu­al­ized and re­hearsed dai­ly (or reg­u­lar­ly). The night­mare should start to change with re­peat­ed prac­tice. 

Sleep Hy­giene  

IRT does not work alone, how­ev­er, just as night­mares do not come with­out oth­er sleep dis­rup­tions. The na­ture of night­mares may lead some­one into in­som­nia over time, as it be­comes hard­er to fall asleep. Anx­i­ety may start to build and the en­tire cy­cle of sleep ing be­comes dys­reg­u­lat­ed. There is a sim­ple an­swer to set­ting one up for a good night of sleep, how­ev­er. These prac­tices can be used to com­bat in­som­nia and anx­i­ety re­lat­ed to night­mares. These prac­tices, called sleep hy­giene prac­tices, can range from sim­ple to re­stric­tive based on what is need­ed by the in­di­vid­ual.  

Sim­ple prac­tices in­clude stop­ping caf­feine and oth­er stim­u­lants be­fore evening  time. Some in­di­vid­u­als find that a morn­ing cup of cof­fee is where their caf­feine in­take  needs to stop, while oth­ers may be able to drink so­das into the af­ter­noon. Re­mem­bering to as­sess for stim­u­lants in dai­ly OTC med­ica­tions can be im­por­tant for this as well (think de­con­ges­tants). Stim­u­lus con­trol is an­oth­er sim­ple prac­tice. This in­volves us­ing  the bed as a place only for sleep­ing. Ly­ing awake at night in bed can lead to anx­i­ety  and even frus­tra­tion or anger. Leav­ing the bed for awhile un­til tired al­lows your body  to use the stim­u­lus (the bed) to sig­nal sleep. This prac­tice should also be used dur­ing  the day. Pre­vent read­ing, watch­ing tv, or work­ing in bed. Oth­er sim­ple prac­tices include only go­ing to bed when you are tired, try­ing to stick to a bed­time rou­tine (bath, yoga, bed), or turn­ing off elec­tron­ic ap­pli­ances (like TVs).  

When sleep has be­come very dis­rupt­ed or anx­i­ety pro­vok­ing, a more rigid practice may be re­quired. Sleep re­stric­tion may help get things back on track with a re­set.  Sleep re­stric­tion in­volves de­creas­ing the amount of sleep time by 15-20 min­utes to in crease the per­cent­age of bed­time sleep­ing. This works by find­ing the right amount of  sleep­ing (in min­utes or hours) for ef­fi­cien­cy. In sleep re­stric­tion, it is also im­por­tant to  get out of bed when you are awake for more than 15 min­utes. It is also es­sen­tial to keep a di­ary or log of sleep vs. awake time and how the pro­to­col is af­fect­ing one  through­out the day.  

Putting it all to­geth­er 

So, how does this treat night­mares? By putting it all to­geth­er, of course! Set­ting the stage for sleep­ing while sup­port­ing the cir­ca­di­an rhythm is just step one. Keep caffeine lim­it­ed and set a time to cut off all stim­u­lants. Turn off elec­tron­ics at bed­time (true rec­om­men­da­tions are hours be­fore bed due to blue light emis­sions). Make sure that your bed is as com­fort­able as you can get it, and turn the ther­mo­stat down. It is said that 68 de­grees is the per­fect sleep­ing tem­per­a­ture, but this is sub­jec­tive to each per­son and their bed­ding of choice. Con­sid­er white noise or lo-fi if it is not too dis­ruptive or if si­lence makes you anx­ious. Make the room dark and set your­self up for sleep with re­lax­ation tech­niques. Use your bed only for sleep (or in­ti­ma­cy). Go to bed when you are tired, and get out of bed when you are awake longer than 20 minutes. Prac­tice IRT and re­hearse your dream im­agery at least once a day when pos­si­ble.  If all else fails, sleep re­stric­tion can help you get more on track to sup­ple­ment the above prac­tices. Reg­u­lar ther­a­py can also help you to process trau­ma or dif­fi­cul­ties dur­ing hours that you are awake, de­creas­ing sleep dis­rup­tion. A rac­ing mind can make set­ting the stage for sleep dif­fi­cult. Here’s to a full night's sleep!

Guided self treat­ment for PTSD re­lat­ed nightmares 
August 3, 2022
Rachel Humphries
LPC-A, Paramedic