Nightmares and PTSD

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Nightmares refer to complex dreams that cause high levels of anxiety or terror. In general, the content of nightmares revolves around imminent harm being caused to the individual (e.g., being chased, threatened, injured, etc.). When nightmares occur as a part of PTSD, they tend to involve the original threatening or horrifying set of circumstances that was involved during the traumatic event. For example, a rape survivor might experience disturbing dreams about the rape itself or some aspect of the experience that was particularly frightening.

Nightmares can occur multiple times in a given night, or one might experience them very rarely. Individuals may experience the same dream repeatedly, or they may experience different dreams with a similar theme. When individuals awaken from nightmares, they can typically remember them in detail. Upon awakening from a nightmare, individuals typically report feelings of alertness, fear, and anxiety. Nightmares occur almost exclusively during rapid eye movement (REM) sleep. Although REM sleep occurs on and off throughout the night, REM sleep periods become longer and dreaming tends to become more intense in the second half of the night. As a result, nightmares are more likely to occur during this time.

How common are nightmares?

The prevalence of nightmares varies by age group and by gender. Nightmares are reportedly first experienced between the ages of 3 and 6 years. From 10% to 50% of children between the ages of 3 and 5 have nightmares that are severe enough to cause their parents concern. This does not mean that children with nightmares necessarily have a psychological disorder. In fact, children who develop nightmares in the absence of traumatic events typically grow out of them as they get older. Approximately 50% of adults report having at least an occasional nightmare. Estimates suggest that between 6.9% and 8.1% of the adult population suffer from chronic nightmares.

Women report having nightmares more often than men do. Women report two to four nightmares for every one nightmare reported by men. It is unclear at this point whether men and women actually experience different rates of nightmares, or whether women are simply more likely to report them.

How are nightmares related to PTSD?

A person does not have to experience nightmares in order to have PTSD. However, nightmares are one of the most common of the ‘re-experiencing’ symptoms of PTSD, seen in approximately 60% of individuals with PTSD. A recent study of nightmares in female sexual assault survivors found that a higher frequency of nightmares was related to increased severity of PTSD symptoms. Little is known about the typical frequency or duration of nightmares in individuals with PTSD.

Are there any effective treatments for nightmares?

Yes. There are both psychological treatments (involving changing thoughts and behaviors) and psychopharmacological treatments (involving medicine) that have been found to be effective in reducing nightmares.

Psychological Treatment

In recent years, Barry Krakow and his colleagues at the University of New Mexico have conducted numerous studies regarding a promising psychological treatment for nightmares. This research group found positive results in applying this treatment to individuals suffering from nightmares in the context of PTSD. Krakow and colleagues found that crime victims and sexual assault survivors with PTSD who received this treatment showed fewer nightmares and better sleep quality after three group-treatment sessions. Another group of researchers applied the treatment to Vietnam combat veterans and found similarly promising results in a small pilot study.

The treatment studied at the University of New Mexico is called ‘Imagery Rehearsal Therapy’ and is classified as a cognitive-behavioral treatment. It does not involve the use of medications. In brief, the treatment involves helping the clients change the endings of their nightmares, while they are awake, so that the ending is no longer upsetting. The client is then instructed to rehearse the new, nonthreatening images associated with the changed dream. Imagery Rehearsal Therapy also typically involves other components designed to help clients with problems associated with nightmares, such as insomnia. For example, clients are taught basic strategies that may help them to improve the quality of their sleep, such as refraining from caffeine during the afternoon, having a consistent evening wind-down ritual, or refraining from watching TV in bed.

Psychologists who use cognitive-behavioral techniques may be familiar with Imagery Rehearsal Therapy, or may have access to research literature describing it.

Psychopharmacological Treatment

Researchers have also conducted studies of medications for the treatment of nightmares. However, it should be noted that the research findings in support of these treatments are more tentative than findings from studies of Imagery Rehearsal Therapy. Part of the reason for this is simply that fewer studies have been conducted with medications at this point in time. Also, the studies that have been conducted with medications have generally been small and have not included a comparison control group (that did not receive medication). This makes it difficult to know for sure whether the medication is responsible for reducing nightmares, or whether the patient’s belief or confidence that the medication will work was responsible for the positive changes (a.k.a., a placebo effect).

Some medications that have been studied for treatment of PTSD-related nightmares and may be effective in reducing nightmares include Topiramate, Prazosin, Nefazodone, Trazodone, and Gabapentin. Because medications typically have side effects, many patients choose to try a behavioral treatment first.

What happens if nightmares are left untreated?

Nightmares can be a chronic mental health problem for some individuals, but it is not yet clear why they plague some people and not others. One thing that is clear is that nightmares are common in the early phases after a traumatic experience. However, research suggests that most people who have PTSD symptoms (including nightmares) just after a trauma will recover without treatment. This typically occurs by about the third month after a trauma. However, if PTSD symptoms (including nightmares) have not decreased substantially by about the third month, these symptoms can become chronic. If you have been suffering from nightmares for more than 3 months, you are encouraged to contact a mental health professional and discuss with him or her the behavioral treatments described above.

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Syptoms of PTSD

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Symptoms of posttraumatic stress disorder (PTSD) can be terrifying. They may disrupt your life and make it hard to continue with your daily activities. It may be hard just to get through the day.

PTSD symptoms usually start soon after the traumatic event, but they may not happen until months or years later. They also may come and go over many years. If the symptoms last longer than 4 weeks, cause you great distress, or interfere with your work or home life, you probably have PTSD.

There are four types of symptoms: reliving the event, avoidance, numbing, and feeling keyed up.

Reliving the event (also called re-experiencing symptoms):

Bad memories of the traumatic event can come back at any time. You may feel the same fear and horror you did when the event took place. You may have nightmares. You even may feel like you’re going through the event again. This is called a flashback. Sometimes there is a trigger: a sound or sight that causes you to relive the event. Triggers might include:

  • Hearing a car backfire, which can bring back memories of gunfire and war for a combat veteran
  • Seeing a car accident, which can remind a crash survivor of his or her own accident
  • Seeing a news report of a sexual assault, which may bring back memories of assault for a woman who was raped

Avoiding situations that remind you of the event:

You may try to avoid situations or people that trigger memories of the traumatic event. You may even avoid talking or thinking about the event.

  • A person who was in an earthquake may avoid watching television shows or movies in which there are earthquakes
  • A person who was robbed at gunpoint while ordering at a hamburger drive-in may avoid fast-food restaurants
  • Some people may keep very busy or avoid seeking help. This keeps them from having to think or talk about the event.

Feeling numb:

You may find it hard to express your feelings. This is another way to avoid memories.

  • You may not have positive or loving feelings toward other people and may stay away from relationships
  • You may not be interested in activities you used to enjoy
  • You may forget about parts of the traumatic event or not be able to talk about them.

Feeling keyed up (also called hyperarousal):

You may be jittery, or always alert and on the lookout for danger. This is known as hyperarousal. It can cause you to:

  • Suddenly become angry or irritable
  • Have a hard time sleeping
  • Have trouble concentrating
  • Fear for your safety and always feel on guard
  • Be very startled when someone surprises you

What are other common problems?

People with PTSD may also have other problems. These include:

  • Drinking or drug problems
  • Feelings of hopelessness, shame, or despair
  • Employment problems
  • Relationships problems including divorce and violence
  • Physical symptoms

Dealing with PTSD symptoms

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1: Understanding the symptom.

The first thing to do is understand what happens to you and why. Ask professionals and do your own research from reliable sources about the symptom.

Understand something about what happens to your body when the symptom is triggered. For example, if you experience panic attacks, why do they happen? – what is the physical process which makes you feel so awful? – how can the physical reactions be controlled?

When you have information about why the symptom happens, then you have something to work with

2: Understand yourself.

When you have information about why a symptom happens, compare this to how you feel and how the symptom is triggered in your life. How does it start? – how does your body react? – what are you thinking? You may be surprised at the similarities.

3: Think of a plan.

When you know why something happens and the real effect it has on you, you are in a position to develop a coping plan.

Emphasis is on ONE THING AT A TIME! Don’t try to rush it!

A common reaction to many symptoms is to try and ‘get away’ from them. Perfectly natural. But you can not do that if you want to control them and reduce their impact on your life.

For example, if a symptom occurs and the trigger is being in a public place, you need to develop an awareness of what the REAL situation is rather than what you THINK it is. So, imagine the scenario in an objective way. Is there a REA L threat to you? Are people REALLY interested in you? Are people REALLY bothered if you are there or not? You HAVE as much right as anyone else to be there!

Another example may be flashbacks. Perhaps your reaction is to get away from them – forget them. But you know what they are so you can do something about them. They are pictures in your mind – they are NOT the REAL situation you are in. So instead of trying to shy away from them, what would happen if you looked at them from an objective viewpoint? Really looked at them? Rationalised why they are happening? Perhaps understanding that a picture is only a picture and can not harm you.

Whatever plan you develop for a symptom is flexible. You can change it to suit you at any time. The important thing is to have a plan in the first place.

On thing of note is that you may not be able to make the symptom go away forever. It may still be present in some form for a very long time. You will need to accept this, but your attitude to it is the key. If the symptom happens, try not to get stressed – just let it pass then carry on.

4: Using the plan.

It is important that you realise that things take time and persistence. There is no ‘magic. With a plan you are informed and ready.

The first few times you use your plan you may find it extremely difficult, and it may be disturbing. STOP! DO NOT force yourself.

Try it again, and again – small steps. Also, you may have ups and downs. One time your plan may work and a few tries later it becomes very disturbing or difficult. That is OK. Just keep trying it.

If your plan doesn’t work at all, reassess the information you have and think of another plan – KEEP IT SIMPLE!

Conclusion

Not everything works for everybody all the time. The important thing is to think about the things that you need to do and how to overcome symptoms that stop you doing them.

We could go in-depth, but the important thing is you understand the general principle.

Stigma of PTSD
Groundng and triggers
Grounding for flashbacks

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