Direct psychological therapies for nightmares: A review

The mechanisms of action underlying the efficacy of psychological nightmare treatments: A systematic review and thematic analysis of discussed hypotheses

Studies of psychotherapeutic treatments for nightmares have yielded support for their effectiveness. However, no consensus exists to explain how they work. This study combines a systematic review with a qualitative thematic analysis to identify and categorize the existing proposed mechanisms of action (MAs) of nightmare treatments. The systematic review allowed for a great number of scholarly publications on supported psychological treatments for nightmares to be identified. Characteristics of the study and citations regarding potential MAs were extracted using a standardized coding grid. Then, thematic analysis allowed citations to be grouped under six different categories of possible MAs according to their similarities and differences. Results reveal that an increased sense of mastery was the most often cited hypothesis to explain the efficacy of nightmare psychotherapies. Other mechanisms included emotional processing leading to modification of the fear structure, modification of beliefs, restoration of sleep functions, decreased arousal, and prevention of avoidance. An illustration of the different variables involved in the treatment of nightmares is proposed. Different avenues for operationalization of these MAs are put forth to enable future research on nightmare treatments to measure and link them to efficacy measures, and test the implications of the illustration.

Prevalence and correlates of disturbed dreaming in children

Relatively little is known about nightmares and other forms of disturbed dreaming in children. This article reviews the literature on the prevalence and correlates of nightmares in children and highlights key methodological issues in the field. Results show that regardless of how they are defined and measured, nightmares affect a significant proportion of children of all ages and there is some evidence to suggest that nightmare frequency may peak around the age of 10. Gender differences in nightmare frequency, with girls reporting more nightmares than do boys, tend to appear between the ages of 10 and 15. Although nightmares are associated with a range of psychosocial difficulties (e.g., stress, behavioural problems), elevated anxiety and concomitant sleep-related disorders (e.g., sleepwalking) are among the most robust correlates of nightmares. Very few studies have examined nightmare treatment in children, but promising results have been obtained with imagery rehearsal therapy. Overall, research in the field has been hampered by inconsistent definitions for nightmares, by extensive variability in questionnaire items used to measure nightmare frequency, and by a lack of awareness of how using parents versus children as respondents may impact results. Longitudinal studies are needed to better understand how nightmares and their correlates evolve during childhood and adolescence, to delineate their clinical significance, and to develop effective and age-appropriate treatment strategies.

Nightmare frequency, nightmare distress, and psychopathology in female victims of childhood maltreatment

This study investigated the relationships between a history of childhood maltreatment, the frequency of disturbing dreams, their associated distress, and the presence of psychopathology in 352 female undergraduate volunteers. Participants completed questionnaires assessing dream recall, bad dream and nightmare frequency, nightmare distress, psychological well-being, and history of childhood trauma. Four groups were investigated based on the type and severity of childhood maltreatments experienced. Women reporting more severe forms of maltreatment reported higher frequencies of disturbing dreams, higher levels of nightmare distress, and greater psychopathology. Results showed that nightmare distress explains frequency of disturbed dreaming beyond the effect of psychopathology and childhood trauma. The results highlight the importance of assessing waking distress associated with disturbing dreams independently from their actual incidence.

The role of cognitions in imagery rescripting for posttraumatic nightmares

Despite growing support for the use of imagery rescripting to treat posttraumatic nightmares (PTNMs), its underlying mechanisms have not been examined. This secondary data analysis piloted the proposal that modification of posttraumatic cognitions is a mechanism of change when using a manualized PTNM imagery rescripting intervention. Significant linear reductions in posttraumatic cognitions were observed from baseline through 6-month follow-up evaluations. Change in total negative cognitions was significantly correlated with change in posttraumatic stress disorder symptoms. Initial amount of change in subscale scores also predicted the amount of distal change observed at the 6-month follow-up. These findings provide preliminary evidence that trauma-related cognitions may improve over time as a result of imagery rescripting.

Multi-component treatment for posttraumatic nightmares in Vietnam veterans: two case studies

Posttraumatic nightmares (PTNMs) are trauma-related distressing dreams that cause a person to wake up. PTNMs can be a devastating addition to the clinical picture of posttraumatic stress disorder (PTSD), because they can result in increased levels of PTSD symptoms and overall distress and decreased sleep; they are also often resistant to typical PTSD treatments. While specialized treatments have been developed and empirically examined in the civilian population, these treatments have not been thoroughly explored with the Veteran population, despite the fact that 50%-88% of Vietnam Veterans experience chronic PTNMs. This article presents two case reports involving Vietnam Veterans. These reports describe the initial investigation of a variant of a treatment that has been successful in treating chronic PTNMs in the civilian population and has been modified to meet the needs of the Veteran population. Analyses revealed that both Veterans reported moderate reductions in sleep disturbances over the course of treatment, as well as clinically significant reductions in PTSD and depressive symptoms across assessments. These preliminary findings provide encouraging data that warrant further study. Limitations and future research are discussed.

Treatment of Delayed Post-Traumatic Stress Disorder Following Sexual Abuse: A Case Example

Recent advances have been made in the treatment of post-traumatic stress disorder (PTSD). Cognitive behavioural techniques have been reported in controlled trials to be very effective in reducing arousal symptoms associated with post-traumatic stress disorder, such as sleep disturbance, hypervigilance, intrusive thoughts and flashbacks. It remains unclear from the literature, however, how well these treatment modalities can alleviate post-traumatic stress disorder where the predominant clinical features are associated with depersonalization and dissociative states. Depersonalization is evident in a significant proportion of individuals presenting with PTSD and yet does not appear to be amenable to exposure based therapies. A case study presented suggests methods through which depersonalization may be addressed within the therapeutic context.

Long Term Reduction of Nightmares with Imagery Rehearsal Treatment

An eighteen month follow-up of chronic nightmare sufferers treated with imagery rehearsal, a cognitive-behavioral method, demonstrated significant and clinically meaningful decreases in nightmare frequency. Sixty-eight percent of subjects decreased their nightmares below criteria for a “Chronic Nightmare Disorder”. Significant improvement was also noted for sleep quality and daytime anxiety. The findings support the theory that nightmares may be clinically conceptualized as a primary sleep disorder in some chronic sufferers.

Imagery rehearsal therapy for frequent nightmares in children

This study examined the applicability of imagery rehearsal therapy (IRT) to children with frequent nightmares. Eleven boys and 9 girls aged 9 to 11, with moderate to severe primary nightmares (1 or more per week for 6 months) and without posttraumatic stress disorder, were randomly divided into an imagery rehearsal treatment group (n = 9) or a waiting-list (n = 11) group. ANCOVA with repeated measures revealed that, following a baseline period, IRT reduced the frequency of nightmares (p < .04; eta(2) = 0.22) in the treated group compared to the waiting-list group. This reduction was maintained over a 9-month follow-up. The effects of IRT on post-nightmare state distress could not be assessed due to low nightmare incidences. However, retrospective trait nightmare distress was not significantly reduced. Future research is needed to validate this simple approach for nightmare reduction and to evaluate its potential for the reduction of the associated nightmare distress.

Physiological-emotional reactivity to nightmare-related imagery in trauma-exposed persons with chronic nightmares

Script-driven imagery was used to assess nightmare imagery-evoked physiological-emotional reactivity (heart rate, skin conductance, facial electromyogram, subjective ratings) in trauma-exposed persons suffering from chronic nightmares. Goals were to determine the efficacy of nightmare imagery to evoke physiological-emotional reactivity, correlates (mental health, nightmare characteristics) of reactivity, and consequences (sleep and health problems) of reactivity. Nightmare imagery resulted in significant reactivity relative to control imagery. No mental health variable (posttraumatic stress disorder status, depressive symptoms, dissociation) or nightmare characteristic (months experienced, frequency, similarity to trauma) was associated with reactivity level. However, nightmare imagery-evoked autonomic responses were associated with greater sleep disturbance and reported health symptoms, even when nightmare frequency was controlled. These results suggest nightmare-related autonomic reactions may contribute to sleep and health disturbance.

Lucid dreaming treatment for nightmares: a pilot study

BACKGROUND

The goal of this pilot study was to evaluate the effects of the cognitive-restructuring technique 'lucid dreaming treatment' (LDT) on chronic nightmares. Becoming lucid (realizing that one is dreaming) during a nightmare allows one to alter the nightmare storyline during the nightmare itself.

METHODS

After having filled out a sleep and a posttraumatic stress disorder questionnaire, 23 nightmare sufferers were randomly divided into 3 groups; 8 participants received one 2-hour individual LDT session, 8 participants received one 2-hour group LDT session, and 7 participants were placed on the waiting list. LDT consisted of exposure, mastery, and lucidity exercises. Participants filled out the same questionnaires 12 weeks after the intervention (follow-up).

RESULTS

At follow-up the nightmare frequency of both treatment groups had decreased. There were no significant changes in sleep quality and posttraumatic stress disorder symptom severity. Lucidity was not necessary for a reduction in nightmare frequency.

CONCLUSIONS

LDT seems effective in reducing nightmare frequency, although the primary therapeutic component (i.e. exposure, mastery, or lucidity) remains unclear.

Habituelle Stressverarbeitung, Befindlichkeit und Verhalten nach Alpträumen

Zusammenfassung. Theoretischer Hintergrund: Das Auftreten von Alpträumen und der Umgang mit ihnen wird auch durch Persönlichkeitsvariablen und kognitive Stile bestimmt. Fragestellung: Gibt es einen Zusammenhang zwischen der habituellen Stressverarbeitung und den Effekten von Alpträumen? Methode: Es wurden Unterschiede in der habituellen Stressverarbeitung zwischen 30 gelegentlichen und 30 häufigen Alpträumern überprüft. Über einen Zeitraum von vier Wochen wurden prospektiv die Befindlichkeit und Verhaltenseffekte nach Alpträumen untersucht. Die habituelle Stressverarbeitung wurde mit dem Stressverarbeitungsfragebogen (SVF), die Befindlichkeit mit der Befindlichkeitsskalierung anhand von Kategorien und Eigenschaftswörtern (BSKE) und die Verhaltenseffekte von Alpträumen mit einem selbstentwickelten Fragebogen erhoben. Ergebnisse: Häufige Alpträumer berichteten ein höheres Ausmaß an stresserhöhenden Bewältigungsstrategien und weniger stresserniedrigende Bewältigungsstrategien im Vergleich zu gelegentlichen Alpträumern. Es zeigten sich Zusammenhänge zwischen Stressverarbeitungsfaktoren und negativer Befindlichkeit sowie Verhaltenseffekten von Alpträumen. Schlussfolgerungen: Ungünstige Stressverarbeitungsstrategien stehen im Zusammenhang mit einem häufigeren Auftreten von Alpträumen und den Verhaltensweisen nach Alpträumen.

Clinical management of chronic nightmares: imagery rehearsal therapy

Problems with nightmares are reported by a sizable proportion of individuals with a history of trauma and by approximately 5% to 8% of the general population. Chronic nightmares may represent a primary sleep disorder rather than a symptom of a psychiatric disorder, and direct targeting of nightmares is a feasible clinical approach to the problem. Of the treatments proposed, imagery rehearsal therapy (IRT) has received the most empirical support. An up-to-date account of this cognitive-imagery approach shows how to treat nightmares during 4 roughly 2-hr sessions. The main points covered in each therapy session and their underlying rationale are presented. Dismantling protocols are suggested to discern active ingredients of IRT and to develop flexible applications based on patients' needs.

Variety and intensity of emotions in nightmares and bad dreams

Nightmares are usually defined as frightening dreams that awaken the sleeper. This study uses the waking criterion to distinguish between nightmares and bad dreams and investigated the variety and intensity of emotions reported in each form of disturbing dream. Ninety participants recorded their dreams for 4 consecutive weeks and, for each dream recalled, noted the emotions present and their intensities on a 9-point scale. Thirty-six participants reported at least one nightmare and one bad dream over the 4 weeks covered by the log, while 29 reported having had at least one bad dream but no nightmares. Nightmares were rated as being significantly (p < 0.001) more intense than bad dreams. Thirty percent of nightmares and 51% of bad dreams contained primary emotions other than fear. The findings support the claim that awakening can serve as an indirect measure of nightmare intensity and raise important implications for the operational definition of nightmares.

Nightmares: personality dimensions and psychopathological attributes

In this article, in an attempt to integrate recent findings with existing knowledge, we provide an overview of issues related to nightmares that could be useful as a guide to clinical work. After defining what should be considered as a nightmare, we look into the relationship of nightmares with issues such as normal development and maturation, as well as culture. Issues of stress and personality are then discussed in their relation to situational and chronic nightmares. State and trait factors are further elaborated on as we explore the relationship of nightmares and psychopathology. A brief review of organic and pharmacological causes of nightmares follows before we embark on a discussion of issues that relate nightmares to psychological trauma. Some final remarks on treatment conclude our review.

Nightmare frequency in sexual assault survivors with PTSD

Sexual assault survivors with post-traumatic stress disorder (PTSD) were assessed for frequency of nightmares, measured retrospectively on the Nightmare Frequency Questionnaire (NFQ) and prospectively on nightmare dream logs (NLOG). Retrospective frequency was extremely high, averaging occurrences every other night and an estimated number of nightmares greater than five per week. Test-retest reliability data on the NFQ yielded weighted kappa coefficients of .85 (95% CI, .74-.95) for nights and .90 (95% CI, .83-.97) for nightmares. Correlations between retrospective and prospective nightmare frequencies ranged between .53 (P = .001) for nights and .63 (P = .001) for nightmares. Correlations between frequency and distress measures (anxiety, depression, post-traumatic stress) yielded coefficients ranging from (r = .28-.53). Compared with intrusive, cumbersome and time-consuming prospective measurements, the NFQ appears reliable, convenient, and equally useful in assessing nightmare frequency in a group of sexual assault survivors. Nightmare frequency, prevalence, distress and impairment are discussed.

Treatment of chronic nightmares in adjudicated adolescent girls in a residential facility

PURPOSE

To evaluate imagery rehearsal therapy for the treatment of chronic nightmares in a sample of adolescent girls.

METHODS

Adolescent girls ranging in age from 13 to 18 years were recruited from the Wyoming Girls School in Sheridan, Wyoming (treatment group, n = 9; control group, n = 10). These girls had previously suffered a high prevalence of unwanted sexual experiences in childhood and adolescence, and thus many suffered from nightmares, sleep complaints, and posttraumatic stress symptoms. Imagery rehearsal therapy was provided in a 1-day (6-h) workshop. Imagery rehearsal consists of three steps, all of which are performed in the waking state: (a) select a nightmare, (b) "change the nightmare any way you wish," and (c) rehearse the images of the new version ("new dream") 5 to 20 min each day. Control participants received no intervention.

RESULTS

At baseline, these girls had been suffering from nightmares, on average, for 4.5 years, and they reported experiencing 20 nightmares per month, which occurred at a frequency of at least one bad dream every other night. At 3 months, self-reported, retrospectively assessed nightmare frequency measured in nights per month decreased 57% (p =.01, d = 1.4) and measured in nightmares per month decreased 71% (p =.01, d = 1.7) in the treatment group, compared with no significant changes in the control group. No significant changes were noted for sleep and posttraumatic stress disorder measures in either group.

CONCLUSION

Imagery rehearsal therapy was an effective treatment option for chronic nightmares in this adjudicated adolescent population.

Children of traumatized and exiled refugee families: resilience and vulnerability. A case study report

This paper focuses on the main problems and outcomes of two children of a traumatized refugee family who have been in Britain since 1993. Their parents witnessed near death experiences and physical assaults, and suffered losses and a wide range of physical problems; the father manifests post traumatic stress disorder (PTSD) symptoms. The children have been exposed regularly to episodic rage and violent behaviour by their father, and have developed separation problems and psychosomatic complaints. Their mother has coped better and is very resilient in her care and approach to problems. This report acknowledges the negative experience of trauma, but also the sources of resilience of parents, children's adjustment and cultural differences in coping styles. Refugee experiences devastate individual well-being and coping mechanisms if there is no hope, support and faith in one's own potential. Protective and risk factors that may affect the manifestation of trauma symptoms are highlighted. A variety of treatment approaches are required for both adult and child victims of multiple trauma. A wide range of techniques, such as group therapy, behaviour and cognitive therapy, and desensitization and relaxation training, can help sufferers to enhance their coping skills and deal effectively with devastating life events.

Treatment of combat-related nightmares using imagery rehearsal: a pilot study

Posttraumatic nightmares are a hallmark of PTSD and distinct from general nightmares as they are often repetitive and faithful representations of the traumatic event. This paper presents data from a pilot study that examined the use of Imagery Rehearsal in treating combat-related nightmares of 12 Vietnam veterans with PTSD. Three treatment groups, comprising 4 veterans in each, completed standardised treatment across 6 sessions. Treatment effects were investigated using nightmare diaries and established instruments, including the IES-R, BDI, BAI, and SCL-90-R. The data demonstrate significant reductions in nightmares targeted, and improvements in PTSD and comorbid symptomatology. The paper recommends that, on the basis of the promising preliminary data, a randomised control trial be established to assess imagery ability and attitude toward nightmares.

A retrospective study on improvements in nightmares and post-traumatic stress disorder following treatment for co-morbid sleep-disordered breathing

OBJECTIVE

To assess the impact of treatment for co-morbid sleep-disordered breathing (SDB) on patients with nightmares and post-traumatic stress.

METHODS

Twenty-three chronic nightmare sufferers (15 with post-traumatic stress disorder, PTSD) who also suffered co-morbid SDB (obstructive sleep apnea, OSA, n=16; upper airway resistance syndrome, UARS, n=7) completed a telephone interview, on average, 21 months after having been offered treatment for SDB at a university sleep disorders clinic.

RESULTS

At follow-up, 14 reported maintaining treatment (Treatment Group) and 9 reported discontinuing treatment (No-Treatment Group). More patients in the Treatment Group reported improvement in sleep (93% vs. 33%) and in daytime well being (93% vs. 33%) compared with those in the No-Treatment group. The Treatment Group reported a median improvement in nightmares of 85% compared with a median 10% worsening in the No-Treatment Group. In the PTSD subset (n=15), nine in the Treatment Group reported a median 75% improvement in PTSD symptoms whereas six in the No-Treatment Group reported a median 43% worsening.

CONCLUSION

In this small sample of patients, treatment of SDB was associated with improvements in nightmares and PTSD. Relationships between nightmares, PTSD and SDB are discussed.

A controlled study of imagery rehearsal for chronic nightmares in sexual assault survivors with PTSD: a preliminary report

Imagery-rehearsal therapy for chronic nightmares was assessed in a randomized, controlled study of sexual assault survivors with posttraumatic stress disorder (PTSD). Nightmares, sleep quality, and PTSD were assessed at baseline for 169 women, who were randomized into two groups: treatment (n = 87) and wait-list control (n = 82). Treatment consisted of two 3-hr sessions and one 1-hr session conducted over 5 weeks. Of 169 participants, 91 women (Treatment, n = 43, Control, n = 48) completed a 3-month follow-up and 78 did not. At follow-up, nightmare frequency and PTSD severity decreased and sleep quality improved in the treatment group with small to minimal changes in the control group. Treatment effects were moderate to high (Cohen's d ranged from 0.57 to 1.26). Notwithstanding the large dropout rate, imagery-rehearsal therapy is an effective treatment for chronic nightmares in sexual assault survivors with PTSD and is associated with improvement in sleep quality and decreases in PTSD severity.

Short-term treatment of a Central American torture survivor

The short-term treatment of a Honduran torture survivor is recounted. Torture--the "counter-therapy of the State" (Ritterman 1987, p. 43)--involves intentional physical and psychological destruction of human beings. The socio-political context in which the traumatic events occurred is described, as are the theoretical and ethical assumptions underlying the work. Treatment of victims of organized violence is a formidable challenge. Obstacles and advantages of short-term psychotherapy and use of the therapist's emotional reactions to understand survivors' experiences are emphasized.

Imagery rehearsal treatment for chronic nightmares

Fifty-eight chronic nightmare sufferers were randomly assigned to two groups: treatment (n = 39) and wait-list control (n = 19). Treated Ss were taught a cognitive-behavioral technique called imagery rehearsal in which they learned in a waking state to change a nightmare and then to visualize the new set of images. Subjects were assessed pre-treatment and 3 months followup for nightmare frequency, self-rated distress and subjective sleep quality. Compared to controls, the treatment group showed significant and clinically meaningful decreases in nightmares. Treated Ss decreased nightmares as measured in nights/week (mean = -2.0, SD = 1.7, P = 0.0001) and actual number of nightmares (mean = -4.2, SD = 4.5, P = 0.0001). Significant improvement in self-rated sleep quality occurred in those treated compared with controls (P = 0.004); and, reduction in nightmares was a significant predictor of improvement in sleep (r = 0.55, P = 0.0001). These preliminary results lend support to the theory that, for some chronic sufferers, nightmares may be conceptualized as a primary sleep disorder which can be effectively and inexpensively treated with cognitive-behavioral therapy.

Imagery rehearsal treatment of chronic nightmares: with a thirty month follow-up

Nightmare frequency and self-rated distress were assessed retrospectively in two groups of chronic nightmare sufferers 30 months after treatment. In the initial phase, the image group (N = 9) learned a cognitive-behavioral technique (imagery rehearsal) for the treatment of nightmares. They were taught in one group session to: (1) record a nightmare; (2) change it (usually to something positive); and (3) rehearse the new images daily. The record group (N = 10) recorded nightmares during the first month only and learned imagery rehearsal subsequent to 3-month follow-up measurements. At 3 months and at 30 months, both groups had significantly fewer nightmares, but only the rehearsal group had less total distress. The results support the theory that nightmares are a primary sleep disorder rather than a symptom of an underlying psychiatric problem.

Brief hypnotic treatment of repetitive nightmares

Little attention has been paid to repetitive nightmares and their direct treatment. Hypnosis appears to be a treatment of choice for these nightmares, and techniques for hypnotic treatment may be based upon whether the nightmare mirrors an actual experience of the patient. A new technique that reframes the waking point as the interrupted middle rather than the end of the dream, which then allows a benign completion, is presented, with case histories.

Treatment of recurrent nightmares by the dream reorganization approach

Dream reorganization is introduced as a new theoretical and treatment approach to the alleviation of recurrent nightmares, derived from the principles of the Seligman and Yellen (1987) theory of dream construction. The cognitive-behavioral dream reorganization treatment package consists of two treatment components. Systematic desensitization with coping self-statements is employed to alter the emotional episode by counterconditioning a relaxation response to anxiety-evoking nightmare content. Guided rehearsal of mastery endings to dream content hierarchy items is added to modify the secondary visual stimuli associated with recurrent nightmares. The dream reorganization approach is presented in the case of a 10-year-old male with a fear of sleeping alone due to recurrent nightmares. Following treatment, the client reported 100% reduction in nightmares and demonstrated 100% reduction in night time arrival in the parents' room. The present report provides a theoretical rationale for dream reorganization, and future directions for research in the treatment of recurrent nightmares.