What Dreams May Come: Treating the Nightmares of PTSD


David Rijckaert (III) [Public domain], via Wikimedia Commons

A standard part of any psychiatric evaluation involves inquiring about a patient’s sleep.  Hidden in the answers that follow the basic question of, “How are you sleeping?” are the clues that are needed to  diagnose what is ailing the patient seeking help from me.

For those with depression, they typically report early morning awakening (i.e. they wake 3-4 hours earlier than needed) and are not able to return to sleep. Those with anxiety disorders often complain of not being able to fall asleep (initial insomnia), they toss and turn for hours, their minds “racing” with anxious thoughts and worries. For those with mania they report that they can’t sleep at all for their energized and overcharged bodies simply have no need for sleep.

My patients with PTSD often report an amalgamation of all of the above in addition to a specific complaint–nightmares.

Nightmares–those threatening or scary dreams that leave you crying out in your sleep, thrashing around in your bed or waking up in a blind panic, soaked in sweat and with your heart pounding in your throat.

Nightmares–a very common complaint for those living with PTSD. Some studies reporting up to 80%, of those with PTSD, experience nightmares that have them reliving or re-experiencing the traumatic event for months or years after the actual event took place.

Nightmares are not only commonly experienced by those living with PTSD but they occur frequently too, sometimes several times a week so their impact on the lives of those living with PTSD can be profound.

The differences in sleep amongst those with PTSD related nightmares (compared with those who do not have PTSD) are tangible, they have:

-increased phasic R (REM) sleep activity

-decreased total sleep time

-increased number and duration of nocturnal awakenings

-decreased slow wave sleep (or deep sleep)

-increased periodic leg movements during both REM and NREM sleep

In short, their sleep is less efficient and associated with a higher incidence of other sleep related breathing disorders

Treating Nightmares

Clinically, this translates to the sad stories I hear all too often: People turn to alcohol or illicit drugs to “escape” the nightmares or their chronically poor sleep quality leads to other problems such as depression and anxiety. Others start to fear sleep or simply don’t function that well—they lose jobs, are irritable and short tempered with their loved ones, feel tired and lack energy. The nightmares and poor quality sleep chips away at their lives over weeks, months and years.

As a psychiatrist, there is a certain amount of dread associated with learning that your patient is experiencing nightmares for the very simple fact that nightmares related to PTSD can be very hard to treat.

The first approach is to treat the underlying condition i.e. the PTSD.  I offer the patient evidence based psychotherapies and, if necessary, medications that I know work for PTSD and hope that, with time, the frequency and intensity of the nightmares will start to decrease as the underlying PTSD is treated.

But often times, despite PTSD treatment, patients still complain of nightmares. What can I offer them then?

A Psychotherapeutic Option

Image Rehearsal Therapy (IRT) is one option:

-          IRT is a modified CBT technique that utilizes recalling the nightmare, writing it down and changing the theme. i.e. change the storyline to a more positive one

-          The patient rehearses the rewritten dream scenario so that they can displace the unwanted content when the dream recurs (they do this by practicing 10-20mins per day)

-          In controlled studies, IRT has been shown to inhibit the original nightmare by providing a cognitive shift that refutes the original premise of the nightmare

Though it is a well tolerated treatment, the issue remains that a patient has to be willing and able to commit to IRT for it to work.

This leaves a need for alternative options for patients who are unable to commit to this type of treatment.

A Medication for Nightmares

Recently, hope has been offered in new research published about the medication- Prazosin

Prazosin is an alpha adrenergic receptor antagonist (traditionally used as an antihypertensive agent). It acts to reduce the level of activating neurochemicals in the brain and, via this action, is thought to damp down neurological pathways which are overstimulated in people with PTSD.

Whilst clinically psychiatrists have been using prazosin for the treatment of PTSD related nightmares for years, the fact remains we still need more evidence, from controlled trials, to support its efficacy.  A small randomized controlled trial of prazosin for sleep and PTSD has, recently, made a much needed contribution to that evidence base.

In a 15 week trial involving 67 active duty soldiers with PTSD, the drug was titrated up based on the participant nightmare response over 6 weeks.  Prazosin was found to be effective in improving trauma related nightmares and sleep quality and, in turn, associated with reduced PTSD symptoms and an improvement in global functioning.

This is encouraging, and increases the enthusiasm with which I will recommend this treatment to my patients with PTSD.

Still, the profound effect nightmares have on the quality of life of those living with PTSD highlights that more needs to be done to expand the array of options available to clinicians, like me, to help these patients.

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11 Responses to What Dreams May Come: Treating the Nightmares of PTSD

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  2. Tonny says:

    Suffering from PDSS, A few minutes ago I woke from a horrible dream, a dream my adoptive Grandparents, whom have pasted, were physically and mentally abusing to me. I was in my late teen years, and sleeping on the sofa. I remember I was so tired, I passed out, and couldn’t physically get up. I had been hit so hard by my grandfathers hand on the right side of my head I had a ringing in my ear that wouldn’t go away, later this progressed in to tinnitus, I was told I would someday loose all hearing in my ear. But back to the story at hand. As I was resting/sleeping both were taking turns picking at me, saying horrible things like “get up, and get out!” Get up and do something. My grandmother picking mentally, and my grandfather picking physically, the only power I had was to lay there lifeless, and focus on the buzzing sounds in my ear. After a few hours of this treatment, in my dream, I finally got up, and started fighting back, yelling at my grandmother “why!”, and with my grandfather things turned physical………..I always knew to not provoke him, but I had enough. I knew I might end up on the street but after trying to reason with both of them, which never worked. The physical attack started again, in reality I would ball up, and hope they would run out of energy, so it would stop, and I would get the usual apologies for my grandmothers behavior, and ignored by my grandfather, who would go sit and read the bible out loud. Though out my teen years this story was repeated, it wasn’t a good childhood, but it was better than living with my mother. So when I left home I didn’t look back, very few visits, and keeping them short and sweet. My Grandparents have since passed. In a conscious state I’ve moved on with my life, but these many stories of abuse find their way in to my dreams. I wake up crying, remembering the feelings like it just happen, like I am still that teenager with no hope, or protection form the world. This post speaks to me on a conscious level volumes, but my main point is what can I do about these dreams that haunt me? I wake up with the dreams in my head several times a month. I’ worked toward understanding, and accepting this part of my past while awake, but while sleeping the demons come out. Is there anything I can do? Thank you for any help you may have to offer. Sincerely, T.

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    • Shaili Jain, MD says:

      I am sorry to hear of your situation and your distress. I would suggest checking out this website for more information, self help tools and other suggestions for resources. http://www.ptsd.va.gov/public/index.asp

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    • Tonny says:

      I have Afib, 133 bpm at rest. Three procedures: 2 Cardioversion no success. One Ablation no success. Now the Cardio wants to do another ablation, more inside the heart, and a new type focused on the outside. Also, diagnosed with Multiple Sclerosis, and all that comes with it. But as Dora says on Finding Nemo……..Just keep swimming, just keep swimming……..

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  3. sgroclkc says:

    There are two main types of scary phenomenons in sleep(nightmare and sleep paralysis) that are caused by two main scary symptoms of cardiovascular disease {palpitation and fainting (syncope)}. Persons who palpitation is easy to occur are easy to have nightmare, drugs can cause nightmare because drugs can cause palpitation. Females are easier to have nightmare than males, because palpitation is easier occur to females than to males. Women have a huge amount of nightmares during pregnancy because women experience more palpitations in pregnancy. Physical factors that contribute to bad dreams include fever as also sleep because fever causes an increase in the heart rate, When palpitations occurs, people will have two most common feelings: one is tachycardia cause a feeling of seeming to be chasing ; the other is bradycardia or premature beat cause the feeling of heart suspension or heart sinking. Therefore, people in sleep accordingly will have the two most common nightmares : one is dream of being chased (occasionally hunting other people) ; the other is dream of flying in the air or dream of falling down. If transient cerebral ischemia or fainting occuring during the day may result in some very terrible dizziness, palpitations, feelings of chest pressure, dim vision, tinnitus and a variety of neurological symptoms. As a result, all the people who are prone to cerebral ischemia or fainting frail corporeity, excessive fear, taking the quinidine which may lead to low blood pressure, as well as a excessive high pillow ors, error in sleeping style which may lead to the aggrieved neck, pressed blood stream. when they sleep in deep night, they will have the extraordinary corresponding horrible dreams, in the dreams, they do some kind of terrible Belial pressuring them or being hunted down, but they can not cry out or escape, which are called nightmare in iatrology. Vague terrors in light sleep, which is known as sleep paralysis. Sometimes people was just woken up with the cerebral ischemia or fainting, be cause the vision continuing for a few minutes and dyskinesia have not yet concluded, which will cause psychological illusion that people struggle to wake up but fail to do it. For instance, a place in country, there is a “haunted” bed which makes people have nightmares every night and it is this fact that the pillow in the bed is too high. Another example, sleeping pills are the treatment of nightmare of being chased of neurasthenia, due to the nightmare of being chased of such patients is caused by tachycardia, and sleeping pills can lead to slower heartbeat, moreover slower heartbeat sometimes leads to sleep paralysis or fainting for people of low blood pressure. Therefore, treating a nightmare with sleeping pills at times is not only invalid, but also it will instead increase the patient’s state of the disease.

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  4. John Owens says:

    Tony, I am almost in the exact same boat and would be interested to see if you have had any resolution My email is rarewineguy@gmail.com if you don’t mind sharing. Thanks

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    • Tonny says:

      John, I’m sorry but I have no answers. I just try to meditate and keep thinking positive thoughts. FaceBook: Spiritual Networks
      Community, Pure Positive Energy,
      Buddha Bless You. These are some great pages to follow. No matter your beliefs, they open your mind, and your heart to thinking outside the box. I cannot take antidepressants, due to the side effects. But I do take Buspirone and Diazepam for my anxiety for day to day living. I take two Buspirone (20 mg) before bed, it helps. I have no answers, but I continue to search. I try to think like this, there is a positive and a negative, everyone has their ups and downs, finding a center between the two you will find peace. Peace is all we can hope for in this life, and its worth more than silver or gold. Peace out my friend.

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      • Tonny says:

        John, I’m sorry but I have no answers. I just try to meditate and keep thinking positive thoughts. FaceBook: Spiritual Networks
        Community, Pure Positive Energy,
        Buddha Bless You. These are some great pages to follow. No matter your beliefs, they open your mind, and your heart to thinking outside the box. I cannot take antidepressants, due to the side effects. But I do take Buspirone and Diazepam for my anxiety for day to day living. I take two Buspirone (20 mg) before bed, it helps. I have no answers, but I continue to search. I try to think like this, there is a positive and a negative, everyone has their ups and downs, finding a center between the two you will find peace. Peace is all we can hope for in this life, and its worth more than silver or gold.
        Also, Pandora Radio look up: Tibetan Serenity, listen to it, let it take your mind away from the pain, listen to it as often as you can, fall asleep with it playing.
        Stop listening to aggressive music, or watching dramatic tv, movies, etc.
        Surround yourself with positive thoughts and people, and become a giving person, you will receive more back than you will know.
        I know I started with “I have no answers” and I don’t but I do suggest you take to heart this message, and try……….Dude, all we can do is try!
        Peace out my friend,

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  5. Paty Layton says:

    I am desperately seeking help to stop the dreams and nightmares that plague my sleep every time I fall asleep. i was married to a man for 14 years, who was increasingly emotionally, physically and sexually abusive. while we both were addicted to many drugs and alcohol. I divorced that man. He went to prison. A year later I met my new husband. We got sober together, and have spent 15 years helping others with similar problems. Yet I dream of my ex husband. I dream of trying to get back with that man. Even though I know what he is. These nightmares always have new situations. I found a way to still love him. I know he is mortally dangerous to me. I love my husband. he thinks that dreams are not real. They sure feel real to ne, I cant shut them off. Can anyone help ? I feel this wont end until I am dead.

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  6. Andy says:

    Is it possible to not remember the dream? I don’t remember but I feel real pain, the pain I felt when I was laying in a heap with my body broken and medic working on me. There is a hole and my artery is severed and I know this because I was conscious. But I don’t see anything in my dream, I just feel. Then when it gets too intense I wake up and the pain lingers before relieving and I’m left panicked. Is this common? I just spoke to my Dr asking for help as its been 15 months since this little incident, I never divulged this info.

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    • Shaili Jain, MD says:

      yes, it is possible to not remember the dream and just experience the emotions associated with the incidentn

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