Guided Self Treatment for PTSD Related Nightmares

There is no hiding the impact that PTSD has on sleep. Nightmares and sleep disturbances are part of the criteria for PTSD symptoms in the DSM. Research has shown that 97% of combat veterans suffer from sleep disturbances, with over 90% of those disturbances including nightmares. It may sound natural for soldiers of war to dream about the distressing events that they witnessed, but in the general population (you and me), individuals with PTSD have a 67% rate of nightmares and sleep disturbances. In fact, a third of individuals with depression and personality disorders can have nightmares and sleep disturbances without PTSD. In researching the cause, effect, and treatment of nightmares, scientists found that nightmares in PTSD aren’t as simple as they sound. Nightmares don’t simply replay the trauma in the head of the survivor during sleep. These nightmares may also portray real-time or current fears of threats in the individual, and can resurface after resolution (as is often seen in sexual trauma). It has also been found that individuals with nightmares have a five-fold increase risk for suicide. This is not great news for those suffering from PTSD related nightmares. One can be left searching for the answer to a good night’s sleep. There is a medication that has been proven effective in PTSD nightmares, but it may not be for everyone. Prazosin has shown effectiveness in treatment of PTSD nightmares and is a first line treatment in many areas. This medication may have side effects that prevent an individual from receiving the required dose, however. Other first line treatments include certain types of antidepressants as well as CBT therapy. What’s important to recognize is that no single treatment appears to be the cure for nightmares. One treatment, however, does allow for some significant relief without the need for long-term use. This is especially helpful in cases of recurrence of nightmares after they have been gone for a time. 
 IMAGERY REHEARSAL THERAPY  Imagery Rehearsal Therapy (IRT) is a form of guided self treatment for nightmares. The protocol is easy to follow and allows for a therapist to assist if required without the requirement of their presence throughout the process. IRT is (in summary) a rewriting of a nightmare, but changing small details or settings, to decrease the intensity of the nightmare. Anyone who has seen Harry Potter movies, specifically the Boggart scene in Prisoner of Azkaban, may understand how a simple change to our darkest fears can not only ease the fear, but may be quite comical. IRT works in this way. After a period of education, and learning from a therapist to a sufferer of night- mares, the protocol begins by selecting a nightmare that one feels comfortable working with. This may be the most intense nightmare, the scariest, more real, or the easiest to cope with—depending on where the comfort lies. Once a nightmare is selected, the individual must write out every detail. This can be the hardest part of IRT, and should be done with the support of a therapist. Then a portion of the dream is selected (the monster, the fear, the setting) and rewrittenThis rewritten nightmare is then visualized and rehearsed daily (or regularly). The nightmare should start to change with repeated practice. 
Sleep Hygiene  IRT does not work alone, however, just as nightmares do not come without other sleep disruptions. The nature of nightmares may lead someone into insomnia over time, as it becomes harder to fall asleep. Anxiety may start to build and the entire cycle of sleeping becomes dysregulated. There is a simple answer to setting one up for a good night of sleep, however. These practices can be used to combat insomnia and anxiety related to nightmares. These practices, called sleep hygiene practices, can range from simple to restrictive based on what is needed by the individual. Simple practices include stopping caffeine and other stimulants before evening time. Some individuals find that a morning cup of coffee is where their caffeine intake needs to stop, while others may be able to drink sodas into the afternoon. Remembering to assess for stimulants in daily OTC medications can be important for this as well (think decongestants). Stimulus control is another simple practice. This involves using the bed as a place only for sleeping. Lying awake at night in bed can lead to anxiety and even frustration or anger. Leaving the bed for awhile until tired allows your body to use the stimulus (the bed) to signal sleep. This practice should also be used during the day. Prevent reading, watching tv, or working in bed. Other simple practices include only going to bed when you are tired, trying to stick to a bedtime routine (bath, yoga, bed), or turning off electronic appliances (like TVs). When sleep has become very disrupted or anxiety provoking, a more rigid practice may be required. Sleep restriction may help get things back on track with a reset. Sleep restriction involves decreasing the amount of sleep time by 15-20 minutes to increase the percentage of bedtime sleeping. This works by finding the right amount of sleeping (in minutes or hours) for efficiency. In sleep restriction, it is also important to get out of bed when you are awake for more than 15 minutes. It is also essential to keep a diary or log of sleep vs. awake time and how the protocol is affecting one throughout the day. 
 Putting it all together  So, how does this treat nightmares? By putting it all together, of course! Setting the stage for sleeping while supporting the circadian rhythm is just step one. Keep caf- feine limited and set a time to cut off all stimulants. Turn off electronics at bedtime (true recommendations are hours before bed due to blue light emissions). Make sure that your bed is as comfortable as you can get it, and turn the thermostat down. It is said that 68 degrees is the perfect sleeping temperature, but this is subjective to each person and their bedding of choice. Consider white noise or lo-fi if it is not too disruptive or if silence makes you anxious. Make the room dark and set yourself up for sleep with relaxation techniques. Use your bed only for sleep (or intimacy). Go to bed when you are tired, and get out of bed when you are awake longer than 20 minutes. Practice IRT and rehearse your dream imagery at least once a day when possible. If all else fails, sleep restriction can help you get more on track to supplement the above practices. Regular therapy can also help you to process trauma or difficulties during hours that you are awake, decreasing sleep disruption. A racing mind can make setting the stage for sleep difficult. Here’s to a full night's sleep!