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ABSTRACT

The Impact of Nightmare Treatment on Posttraumatic Stress Disorder

 Barry Krakow, MD., Associate Research Professor of Emergency Medicine and Psychiatry at the University of New Mexico Health Sciences Center, Albuquerque, New Mexico, Medical Director, UNM Sleep Research. 

Chronic nightmares in sexual assault survivors are often associated with posttraumatic stress disorder (PTSD). As such, they are typically viewed as part of a psychiatric process or disorder that takes precedence over the problem of disturbing dreams. In other words, from a therapeutic perspective, since disturbing dreams emanate from traumatic exposure, the goal of the therapist would be to concentrate on the necessary therapies to resolve the distress associated with that trauma. If nightmares happen to be one symptom or manifestation of that distress, then it would be expected that psychotherapy, e.g. dynamic or cognitive-behavioral, would eventually reduce distress and consequently reduce bad dreams.
From the perspective of dream therapy, working on the nightmares through interpretive techniques may reveal important insights to the client and, further, may provide a direct means for resolving emotional conflicts and distress regarding the trauma. Indeed, there are many published and anecdotal case reports describing a kind of "metamorphosis" which takes in the dream narratives of clients who are resolving their traumatic experiences. Some of these patients report spontaneous alterations in their dream narratives while others have been reported the same process while in therapy. The prevailing view in this scenario is that dream work, whether aided by the dream therapist or occurring naturally through the mind's innate capacity for recovery, progresses in through a pattern of "changing." And, this pattern of change appears to be associated with a healthier and possibly faster trauma recovery process. Although this approach has not been scientifically investigated through controlled studies, it has been described and utilized by so many therapists and clinicians that it is likely to have some validity. Moreover, the reverse has also been noted by both therapists and researchers, that is, patients who demonstrate a pattern of fixed images in their dreams wherein traumatic events constantly recur in a mode that feels like a replay or reenactment of the trauma often appear to have greater difficulty in engaging the recovery process. Some of these individuals have developed blocks to such a degree that they no longer report any daytime imagery, while continuing to suffer from chronic nightmares.
Our program of "New Dream Therapy" which utilizes imagery rehearsal in the treatment of chronic nightmares emphasizes that nightmares, in the waking state, can be altered or changed and then rehearsed, again in the waking state, with the result of decreased disturbing dreams. In our previous work, we have demonstrated that not only does New Dream Therapy reduce disturbing dreams in PTSD patients, but that it also is associated with reductions in PTSD distress as well. This presentation will focus on the final data from a four year NIMH funded study based on a controlled evaluation of imagery rehearsal. Participants were randomized into treatment and wait-list controls and data was obtained at baseline and six-month follow-ups. More than 100 women completed the study and the findings demonstrate substantial changes in nightmares and PTSD symptoms with treatment. However, the results must be interpreted in the light of a drop-out rate of nearly fifty percent, a not uncommon finding in sexual violence treatment research.

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