Treatments for Chronic Nightmares

Relatively few people have chronic nightmares (perhaps around 5%). Few people with nightmares consult a professional about them. Just how few is hard to tell, but Michael Schredl reported on a German study in 2013 that 8% of his sample sought help for chronic nightmares. However, even in sleep clinics, clinicians rarely ask about nightmares, though Barry Krakow reported around 16% of patients in the sleep clinic also had nightmares. Furthermore, many medical and mental health professionals don’t know how to treat nightmares, which is not surprising given that nightmares has only recently become a popular research topic.

There are cognitive and pharmacological (drug) treatments with the potential to rid one of persistent nightmares. However, there is not enough research to conclusively determine which method is the best under which circumstances. Clinical judgment and caveat emptor are required.

This post discusses some of the treatment options and provides bibliographical references for further information. This post is a bit technical and may be of greater interest to mental health professionals than the general reader.

Reminder. This site does not provide medical or regulated advice. This post discusses early stage research. It is recommended to consult a medical doctor or psychologist for advice on medical and mental health matters, respectively.

Stimulants, such as Caffeine

I had chronic nightmares for several years, though I had/have no waking anxiety or distress in that period. If you’ve never experienced or read about this, then you probably don’t know what it’s like to have chronic nightmares. You go to bed at night, not knowing what kind of oneiric war zone you are about to enter. A nightmare, unlike a simple “bad dream”, takes a turn for the dramatically worse. Graphic murders, war killings, blood, gore, plane crashes, drownings, explosions, death of loved ones, etc. I was not merely apprised of such “facts”; I experienced rich, realistic imagery of events unfolding, as if they were true. I have never liked horror movies or even drama — maybe that made me more susceptible – who knows? So, I eventually delved into the sparse literature on nightmares. I systematically measured potentially relevant variables and performed experiments on myself.

A biopsychologist colleague, Professor Julie Carrier, of the Université de Montréal, who specializes in sleep research, suggested I curtail my caffeine intake. I switched to decaf coffee, then dropped coffee but kept regular tea, switched to decaf tea, etc. The less caffeine I took in, the less likely I was to have a nightmare. Alas, I found I needed to completely wean myself from caffeine in order to drive the likelihood of a nightmare to near zero. Even decaffeinated tea and white chocolate would lead me to nightmares. (Incidentally, chocolate does not necessarily contain caffeine. It contains a related stimulant.) I was grateful to be able to control the nightmares, but disappointed to be deprived of caffeine. But such is life. Then they returned without caffeine. Eventually, I found a solution. Because this is a case study, one can’t infer causation at this point. I’ll return to my case near at the end of this post.

Psychotherapies for Nightmares

Here I discuss two psychotherapies for nightmares: (a) Imagery rehearsal therapy and (b) acceptance and commitment therapy.

Imagery Rehearsal Therapy is a promising approach to reducing nightmare frequency. It involves

1. selecting a nightmare to modify,
2. documenting this nightmare, imagining a different, more positive outcome (i.e., imagining how the nightmare might have been a neutral or positive dream),
3. rehearsing the modified scenario.

The idea is to train your mind to generate better outcomes for dreams. This is not unreasonable given that dreams are the product of higher brain areas (they are not merely the interpretation of low-level sensory output/imagery). When approaching or experiencing a nightmare, one is supposed to try to steer the dream into a more constructive direction. (See also “lucid dreaming”.) This technique is often helpful; but it does not work for everyone or all of the time for those who get the hang of it.

This type of therapy can be self-applied. (In Cognitive Productivity, I talk about how to use psychological principles to transform yourself with knowledge resources, rather than to just become familiar with the knowledge. The technical term I coined for this is “meta-effectiveness”.)

ACT suggests a different approach to nightmares. An ACT psychotherapist might also try some of the cognitive techniques referenced in the bibliography, including imagery rehearsal therapy. However, she would typically also help the client accept the nightmares. For, as temporarily unpleasant (and downright terrifying) a nightmare may be, it is ultimately just an experience. Inescapably, being human is to experience displeasure and pain. That doesn’t make the experience awful or unbearable. Paradoxically, by accepting unpleasant feelings, those feelings might actually become less frequent and less intense. But ACT doesn’t directly seek to remove pain. ACT is about accepting experience—good or bad,—choosing a valued direction and moving on.

Without therapy (or a coach, or a friend who masters this, Buddhism or stoicism), obtaining the mindset sought by ACT is more challenging than some of the other types psychological frameworks. This is true not just for accepting nightmares, but all types of acceptance and commitment. In chapter 15 of Cognitive Productivity, I briefly discuss ACT in relation to meta-effectiveness.

Medical Treatments for Chronic Nightmares in PTSD

Medical treatments for nightmares in PTSD patients are currently being investigated. Norepinephrine (NE) and epinephrine (adrenaline) are hormones and neurotransmitters underlying stress responses, including “fight or flight” responses. They are prominent in the sympathetic nervous system and in the central nervous system. Here are some reasons to believe medications that block NE or adrenaline receptors might be helpful for controlling nightmares.

1. Medications that block norepinephrine (NE) receptors are helpful in controlling sympathetic nervous system symptoms of anxiety (e.g., increased heart rate and perspiration). That’s why NE blockers are sometimes used to decrease anxiety for high-stakes public performance.

2. Lower levels of norepinephrine are normally seen in REM sleep, where dreams are most likely to occur. However, higher levels of norepinephrine are often seen in PTSD dreaming.

Indeed, there is empirical research to support this hypothesis. For instance, research suggests Prazosin, an alpha–1 adrenergic receptor blocker, may be effective in treating nightmares in PTSD. The same goes for Propranolol, which is a non-selective beta-adrenergic blocker. Both of these medications are already commonly in use for other conditions.

More research is required to assess the potential effectiveness and optimal doses of these blockers in the treatment of nightmares.

Given my recent posts on rumination and emotion, it is noteworthy that a paper recently reported that “Beta-blockers May Reduce Intrusive Thoughts in Newly Diagnosed Cancer Patients”. The perturbance theory of emotion emphasizes insistent motivators – motivators that have a propensity to engage attention. (This theory was originally developed by Aaron Sloman, based on Herbert A. Simon’s theory. I suggested the name “perturbance” in the early 1990s and have contributed to the development of this theory). What I mean is that it’s interesting that nightmares involve a very intense emotion, and very insistent motivators (a state of “perturbance”). I won’t elaborate more on this here because it would take far too long. (I’m currently co-authoring a paper in which I explain the role of “perturbance” in more detail. And you can check out Cognitive Productivity for more information on perturbance, insistence and leveraging related concepts.)

Back to ACT and Beyond

mySleepButton does not currently address nightmares. However, mySleepButton is best used in a mindset of acceptance. If the app describes something for which you conjure an unpleasant image, try to accept the feeling that comes with the image. You could give then give the image a neutral or pleasant meaning. When the next item is spoken, repeat the process. Let your mind wander from one disconnected image to another. The goal of mySleepButton isn’t to run away from your concerns. Nevertheless, we recognize that, when lying in bed, it is normally not helpful to indulge in entertaining daytime concerns and worries. With mySleepButton you are to let your mind entertain a dreamy parade of imagery.

If you suffer from chronic nightmares, it is recommended to receive professional help from a qualified therapist. You might wish to ask your therapist to comment on the psychological treatments mentioned above and in the references below. For an excellent, accessible introduction to ACT, check out Russ Harris’s book, The Happiness Trap. (Also available as an e-book). Or check out Stoicism, a related framework.

I mentioned above that I’d return to my own experience with nightmares. I have extensive data about my various ABA… experiments on myself. I no longer have nightmares. I’m able to drink several cups of coffee a day, even having some late in the afternoon. One cannot infer causation from such a case study, so I won’t mention the manipulations here. However, I have found the study illuminating. With a study a research runs on himself, he can perform manipulations that he can’t perform on others. I have a couple more tests to run on myself, then I will likely publish a report on the matter. Sleep researchers may contact me for more information on the case study.

References

NB: Most of the work on Prazosin’s effects on nightmares has been done by Raskind and colleagues. That line of research will hopefully be researched by independent labs.

• Broese, M., Riemann, D., Hein, L., & Nissen, C. (2012). α-Adrenergic receptor function, arousal and sleep: Mechanisms and therapeutic implications.. Pharmacopsychiatry, 45(06), 209–216.

• Cukor, J., Spitalnick, J., Difede, J., Rizzo, A., & Rothbaum, B. O. (2009). Emerging treatments for PTSD. Clinical Psychology Review, 29(8), 715–726.

• Friedman, M. J. (1991). Biological Approaches to the Diagnosis and Treatment of Post-Traumatic Stress Disorder. Journal of Traumatic Stress, 4(1), 67–91.

• Hansen, K., Höfling, V., Kröner-Borowik, T., Stangier, U., & Steil, R. (2013). Efficacy of psychological interventions aiming to reduce chronic nightmares: A meta-analysis. Clinical Psychology Review, 33(1), 146–155.

• Harris, R. (2013). The Happiness Trap. Exisle Publishing.

• Krakow, B., & Zadra, A. (2006). Clinical management of chronic nightmares: imagery rehearsal therapy. Behavioral Sleep Medicine, 4(1), 45–70.

• Mellman, T. A. , Bustamante, V. , Fins, A. I. , Pigeon, W. R. and Nolan, B. REM Sleep and the Early Development of Posttraumatic Stress Disorder,” American Journal of Psychiatry, 159 (2002): 1696–1701.

• Nadorff, M. R., Lambdin, K. K., & Germain, A. (2014). Pharmacological and non-pharmacological treatments for nightmare disorder. International Review of Psychiatry, 26(2), 225–236.

• Pagel, J. F., & Helfter, P. (2003). Drug induced nightmares? An etiology based review. Human Psychopharmacology: Clinical and Experimental, 18(1), 59–67.

• Raskind, M. A., Peskind, E. R., & Kanter, E. D. (2003). Reduction of nightmares and other PTSD symptoms in combat veterans by prazosin: a placebo-controlled study. American Journal of Psychiatry. 160(2), 371–373.

• Raskind, M. A., Peskind, E. R., Hoff, D. J., Hart, K. L., Holmes, H. A., Warren, D., et al. (2007). A Parallel Group Placebo Controlled Study of Prazosin for Trauma Nightmares and Sleep Disturbance in Combat Veterans with Post-Traumatic Stress Disorder. Biological Psychiatry, 61(8), 928–934.

• Schredl, M. (2013). Seeking professional help for nightmares: a representative study. The European Journal of Psychiatry.

• Sheffield, Carrie. (2013) Want An Unconquerable Mind? Try Stoic Philosophy. Forbes Magazine.

• Spoormaker, V. I., & Montgomery, P. (2008). Disturbed sleep in post-traumatic stress disorder: Secondary symptom or core feature? Sleep Medicine Reviews, 12(3), 169–184.

• Spoormaker, V. I., Schredl, M., & Bout, J. V. D. (2006). Nightmares: from anxiety symptom to sleep disorder. Sleep Medicine Reviews, 10(1), 19–31.

Revisions

2015–05–11. Some minor revisions, including deleting dangling text about “relied upon”.