Most of us experience occasional nightmares, waking up after dreams of being chased, confronting intruders, or other scenarios that leave us feeling scared or anxious.
But trauma can supercharge nightmares, as Christine So observed when she worked at a Department of Veterans Affairs Medical Center in Philadelphia.
Many of the veterans she worked with had post-traumatic stress disorder. Nightmares regularly jarred them awake.
One of her clients had witnessed the death of a close friend in combat. Night after night, he relived the moment his friend was killed—reexperiencing the feelings of helplessness, grief, and fear for his own safety, says So, an assistant professor in Washington State University’s Department of Psychology.
Another client repeatedly dreamed that he was a mouse being chased by a large snake.
Besides combat veterans, trauma-related nightmares are common for survivors of abuse, accidents, conflict, and natural disasters like wildfires. About 70 percent of people treated for PTSD report experiencing nightmares. And when the dreams are sensory nightmares, they feel like they are back in the moment of the original trauma.
“No one is immune to experiencing a traumatic event,” says So, who is board-certified in behavioral sleep medicine. “Anyone can be susceptible to developing PTSD, and sleep problems are a huge issue for people experiencing PTSD.”
Last year, she published a review of studies about nightmare interventions with researchers affiliated with VA health care systems in Birmingham, Alabama, and Minneapolis, Minnesota. Their work is part of ongoing efforts to raise awareness of trauma-related nightmares, understand the causes, and provide relief for people who experience them.
So recently began offering psychotherapy for sleep disruptions at the WSU Psychology Clinic. The community mental health center serves residents of the greater Palouse region, including veterans. Services are provided by advanced clinical psychology doctoral students under So’s supervision.
Most dreams, including nightmares, occur during the rapid eye movement (REM) stage of sleep. People’s closed eyes move rapidly while their arms and legs are temporarily immobilized to prevent them from acting out their dreams. Heart rate, blood pressure, brain activity, and breathing increase, according to Harvard Health.
Important cognitive functions take place during REM sleep, such as brain development in infants and protection against dementia in older adults. REM sleep is also associated with memory consolidation, emotional processing, and creative problem-solving.
Waking up during REM sleep interrupts those functions and hampers sleep routines.
“Nightmares can make people fearful of going back to sleep because they’re scared that they will have another nightmare,” So says. “They start to dread bedtime. Disrupted sleep has a ton of health consequences, including worsening physical and mental health.”
Nightmares are also a strong predictor of suicidal thoughts. And even after people are successfully treated for PTSD symptoms, their nightmares can linger, she says.
Standard nightmare treatment involves imagery rehearsal therapy. Clients write out their nightmares in detail, then work with a therapist to rescript the nightmare into a less distressing dream that they rehearse over and over.
“Our brains process and consolidate information while we sleep,” So says. “If you constantly wake up for nightmares, that process is interrupted. By rehearsing a new, less disturbing version of the nightmare, you feed your brain something that’s easier to process and consolidate. And then hopefully, you will be able to sleep through the night.”
In addition, prazosin is sometimes prescribed for nightmares. A blood pressure medication, the drug reduces the adrenaline effect of a rapid heart rate and higher blood pressure. Pioneering work on the use of prazosin to reduce nightmares took place in the VA Puget Sound Health Care System.
Perplexingly, the treatments work well for some people, but not others, So says. That’s led to conflicting recommendations for treating nightmares.
The American Academy of Sleep Medicine identifies imagery rehearsal therapy as the only recommended treatment for PTSD-related nightmares. Meanwhile, clinical practice guidelines from the Department of Veterans Affairs/Department of Defense say there isn’t enough evidence to recommend for or against the therapy. The VA/DoD guidelines do recommend prescribing prazosin for nightmares but say the evidence of its effectiveness is weak.
More research is needed to unlock effective treatment, So says.
“We really don’t understand what contributes to nightmares,” she says. “Some people speculate it’s an overactivation of the sympathetic nervous system. Others say it has to do with emotional dysregulation, which is difficulty in managing intense emotions.”
In the meantime, trauma-related nightmares are a reality for many, including those who don’t seek out help.
“Providers don’t regularly ask about nightmares in primary care and mental health settings,” So says. “It’s easy for nightmares to fall through the cracks.”