Author’s Note: Patricia T. Spangler, Ph.D is a Clinical Research Psychologist at the Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD.
PTSD Nightmares and Sleep Disturbance and Their Treatment
The increased prevalence of posttraumatic stress disorder (PTSD) among military personnel and veterans over the past decade has highlighted the challenges therapists face in treating the disorder in all patients—civilians as well as service members and veterans. Two signature symptoms of PTSD are nightmares and sleep disturbance. These symptoms occur in approximately 50% to 70% of individuals with PTSD (Spoormaker & Montgomery, 2008). Nightmares engender a fear of sleep and thus contribute to trauma-related sleep disturbance. The consequent build-up of sleep debt contributes to deficits in cognitive functioning and memory, emotional lability, and impaired motor function. Sleep-related intrusions predict reactivation of PTSD symptoms (Boe, Holgersen, & Holen, 2010; Picchioni et al., 2010) and may play a role in the development of comorbid anxiety, depression, and suicidality (Bernert & Joiner, 2007; Sjostrom, Hetta, & Waern, 2009). Given these considerations, specifically targeting nightmares may be an essential component of treatment for therapists to consider in working with individuals with PTSD.
Great strides have been made over the past decade in investigating PTSD treatments. Yet despite evidence of the role nightmares and sleep disturbance play in PTSD, these symptoms are not targeted by most evidence-based psychotherapies and often are refractory following treatment (Spoormaker & Montgomery, 2008; Krakow et al., 2002). Prolonged exposure and cognitive processing therapy have been found efficacious for waking PTSD symptoms (McLean & Foa, 2011; Monson et al., 2005) but do not target nightmares. Imagery rehearsal therapy (IRT; Krakow & Zadra, 2010), does target trauma-related nightmares and can be an effective tool for many patients (Casement & Swanson, 2012). However, with IRT the focus is on rescripting the nightmare; processing nightmare content is avoided. Such avoidance may reinforce fear of nightmares and misses the opportunity to process traumatic content.
Nightmare Deconstruction and Reprocessing
A newly adapted treatment, Nightmare Deconstruction and Reprocessing (NDR), has potential as a therapeutic tool for treating trauma-related nightmares. NDR combines exposure and emotional processing to reduce fear response; meaning-making and reprocessing to address grief, loss, guilt, shame, and moral injury; challenge of maladaptive beliefs to assist with reconsolidation of nightmare images and trauma memories; and rescripting nightmare content to facilitate mastery over the nightmares and waking life changes.
The first session consists of psychoeducation on PTSD, nightmares, sleep, and mental health; an overview of the model; assessing motivation for change; and practicing stress reduction techniques for use in session and for returning to sleep after a nightmare. In the second session, therapist and patient work collaboratively through three stages (adapted from Hill, 2004): (1) deconstruction and exposure, (2) meaning making and reprocessing, and (3) changes to the nightmare and in waking life.
The model was originally designed to progress through all three stages in one 75- to 90-minute session, which is repeated for several sessions as needed. It can be adapted so that deconstruction and exposure are covered in a 45- to 50-minute session, progressing to meaning making, reprocessing, and changing the nightmare in subsequent sessions. Following is a detailed description of the NDR stages using a de-identified case example* from a recent pilot trial (Spangler, Bowers, & Hill, 2012).
Case Example of NDR*
The participant, Rafa, was a 25-year-old Hispanic male U.S. Army veteran who was an undergraduate student at a large mid-Atlantic university. While serving in an infantry unit during his two tours in Afghanistan, he was exposed extensively to combat situations (firefights, mortar fire, and sniper fire). Since separating from the military, Rafa had experienced several periods of depression during which nightmare frequency and intensity increased. He had lost interest in his usual activities and felt irritable toward and isolated from family members, friends, and fellow students. He nevertheless was high functioning, with a good academic record and plans to graduate within the year. He was screened for exclusion criteria (psychotic symptoms, traumatic brain injury, suicidality, severe substance abuse or dependence, and prescription for Prazosin), and he signed the informed consent. Outcome measures included the Clinician Administered PTSD Scale and Attitudes toward Dreams Scale. Other measures were the Session Evaluation Scale from the Helping Skills Measure and a daily sleep and dream diary.
Treatment consisted of six 75- to 100- min sessions over 3 weeks. The first session consisted of psychoeducation about nightmares and sleep disturbance in PTSD and an overview of NDR. I asked Rafa if he had recurrent nightmares or different nightmares with similar themes. Understanding an individual’s nightmare pattern provides direction on how to proceed with the model. If, for example, a patient has recurrent, highly distressing nightmares that are a re-experiencing of a traumatic event, the therapist can ask for a less distressing dream to begin with, help the patient to become comfortable with deconstruction and gain mastery over the dreams, and then work with more distressing nightmares in subsequent sessions.
Rafa had multiple distressing dreams with military themes and content. I asked him to think about a dream to discuss in our next session. I also explained that if deconstruction of the images became too intense, we could pause and use relaxation techniques to help calm and center him. Because deconstructing nightmare imagery can be distressing, it is important to describe NDR beforehand and assess the individual’s motivation for engaging in the treatment. Rafa seemed highly motivated, explaining that he wanted help with his disturbing dreams and was curious about the study.
In the next session, we worked through the NDR stages. Stage 1, which typically lasts 30-45 min, focuses on deconstructing 3 to 5 key nightmare images. This stage gives the patient the opportunity for detailed examination of nightmare images and serves an exposure function, which helps to extinguish the fear of nightmares. I asked Rafa to describe his nightmare in the first person, present tense (e.g., “In the dream, I’m walking around base”), in order to facilitate his re-experiencing the emotions in the nightmare. Rafa described the following dream (edited for brevity):
I’m a police officer in civilian clothes. There are 3 others with us…. One is a woman…. We search a building [for] children being held in a gymnasium. The rest of the hallway is dark and looks like a hospital…We find bathtubs full of dead bodies and body parts....SWAT comes in, but it’s a trap. I get into a firefight… I need a better weapon. As I search, I realize I’m on my bed.
I asked Rafa to pick 4 or 5 key images, and he named the civilian clothes, his female partner, the dead bodies, the SWAT team, and his weapon. The therapist can collaborate on this if the individual has difficulty identifying key images. Naming the images in chronological order helps to contextualize them and confirm the sequence of events. We deconstructed each image in order using the DRAW steps: (1) Describe the image in as much detail as possible, (2) Re-experience feelings experienced with that image, (3) Associate to that image from past experiences, and (4) identify current Waking life triggers related to that image. Although not the first image, the SWAT team is provided as an example because it was the most intense image. To encourage a detailed description, I asked Rafa to describe the image as if I had no idea what a SWAT team does. He described them as heavily armed, dressed all in black, and moving stealthily through the building. The emotions he re-experienced related to the image were surprise and extreme vulnerability. He associated to several combat experiences during which his unit was surprised. He had no specific waking life trigger events, but rather a pervasive wariness and dislike of being surprised. Rafa was able to deconstruct the images without using relaxation techniques.
At this point, a summary of all deconstructed images helps the individual to begin making meaning of the nightmare, the focus of the next stage. Rafa’s summary detailed how his civilian clothes felt inappropriate because he was on a mission. He was uncomfortable with his female partner because he felt he had to protect her rather than focus on the mission. The image of the bodies was distressing, but not horrifying, and was a reflection of what he had seen in combat and an omen of upcoming events in the nightmare. The SWAT team was the most emotionally intense image and reminded him of his distress at being surprised in combat situations. The weapon he carried was inadequate and contributed to his feeling vulnerable.
By the end of Stage 1, patients typically have a more nuanced understanding of the dream than they did at the start of Stage 1. Thus, Stage 2 begins with the therapist asking what the nightmare means based on the work done during deconstruction. Meaning making and reprocessing in this stage build on increased understanding by processing grief and loss, evaluating fear and anxiety, and challenging negative self-image related to guilt or moral injury. This is a two-step process: (1) collaborating with the patient in constructing a meaning of the nightmare and (2) guiding the patient through reprocessing his or her thoughts and feelings and, if necessary, challenging maladaptive beliefs and assumptions. The meaning may be related to current waking life issues, early life experiences, and/or existential issues. Typically, meaning making centers on the image causing the most distress. Reprocessing the image sets the stage for making changes to the nightmare. Depending on the patient’s level of understanding, this stage takes 20-30 min and may require circling back to deconstructing the images.
Rafa’s understanding of the nightmare at the end of Stage 1 was that it reflected his extreme discomfort with being surprised and related it to his unit being caught off guard and feeling the need to be more vigilant. This meaning made sense in that it focused on the most intense image, but it did not reflect any understanding of how Rafa’s trauma history reflected his changed view of himself and his relationships since separating from the military. He viewed his female partner as needing protection, but was uncertain because of her role as a unit member. He felt unprepared for and overwhelmed by the SWAT team, which challenged his self-image as vigilant and physically superior and made him feel helpless. We discussed his feelings of helplessness and vulnerability and looked for instances in his waking life that could challenge those feelings. This reprocessing led Rafa to a fuller meaning of the dream and deeper understanding of himself. Elements of the nightmare made him feel conflicted about his roles as both protector and warrior. Indeed, he said that he felt like both a sheepdog and a wolf, and he was uncertain about how those roles were transferrable to the civilian world.
The goal is this stage is to help the patient to gain mastery over the nightmares and begin to reconsolidate the traumatic images into long-term memory. There are three key components to this stage: (1) detailed description of changes to the nightmare images based on the work done in the first two stages, (2) emotional engagement with the new images through behavioral rehearsal of changes to the nightmare both in session and before going to bed, and (3) making changes in waking life based on the meaning made and changes to the nightmare.
I asked Rafa how he would change the dream based on his new understanding. He said he would change the woman to a man so that he would not feel so protective and vulnerable, he would better arm himself, and they would be able to find the children being held hostage. As we rehearsed the changed dream sequence twice, I encouraged Rafa to focus on the feelings evoked by the new images. Rehearsal is repeated several times until the patient is fully engaged with the new images and comfortable with behavioral rehearsal. Practicing in session also provides a model for the homework of rehearsing the new images before bed.
In subsequent sessions, any new dream images or themes are deconstructed as before. During meaning making and reprocessing, the focus is on the new images and what the patient believes these changes might mean. New changes to the dream are made based on the patient’s understanding of the changed images.
It may take several sessions of working with nightmares before the patient is ready to transition to waking life changes. These changes should be based on the meaning making, reprocessing, and changes made to the nightmare. Waking life changes might include: (1) specific behaviors, such as more interaction with a spouse or activities that help the individual feel less marginalized; (2) conducting a ritual to honor the dream, such as listening to a lost buddy’s favorite song; and (3) continuing to work on the dream through journaling or talking with others.
Rafa brought a different nightmare to each session. His nightmares had several themes, including distress at being surprised and vulnerable, the presence of family or other civilians in military situation, and isolation from family and friends. We worked on the images in these nightmares over the remaining 4 sessions.
Post-treatment measures indicated that Rafa’s PTSD symptoms decreased, he responded well to NDR, he maintained a very strong positive attitude toward dreams, and his sleep quality and duration remained good. The improvements on PTSD symptoms, as indicated by the decrease in CAPS score from 47 to 38, reflected a change from diagnosable PTSD to a subclinical level, including marked changes in avoidance and hypervigilance symptoms. These results indicate that NDR may be a useful alternative treatment for PTSD nightmares and sleep disturbance as well as addressing waking life symptoms.
* The participant described herein consented to the use of de-identified personal information in this article.
Cite This Article
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