Getting rid of Nightmares that maintain Depression and PTSD


By David Joel Miller.

Then Come Nightmares.

Frequent nightmares play a major role in maintaining depression, PTSD, and other mental health problems. It is common for people to think that they need to cure the PTSD or Depression and then the nightmares will go away.  The opposite approach is more likely to be productive.

Most treatments for PTSD do not target the nightmares. There are treatments for nightmares available, some as brief as three sessions. These have been shown to help reduce nightmares and promote recovery from other problems.

Treatment for nightmares has been shown to reduce symptoms of PTSD and depression.

Children also suffer from nightmare related problems. Children who are fearful because of a family problem, moves, divorces or separation develop symptoms of mental illness. “Bad dreams” are the result of the child’s out of control fear and are at the root of many childhood attention or conduct disturbances. When the child gets a good nights sleep they behave, when they don’t sleep they don’t pay attention, and they don’t mind.

Nightmares are associated with high levels of anxiety. They are fear based.

Most people who have PTSD, depression, bipolar disorder or any other diagnosis also have a co-occurring anxiety problem. Now sometimes anxiety is good, it protects you from danger. But when the anxiety circuits do not turn off the anxiety gets to be the problem rather than the solution.

We also see lots of disturbing dreams in clients recovering from substance abuse problems. Substance abuse counselors report clients sharing about drug using dreams. We have some simple interventions around those issues, but not much research has been done in this area because substance abusers, people with Bipolar Disorder and people with psychosis are routinely excluded from research studies. I believe that the treatment for nightmares will work for anyone.

The solution is to tone down that fear circuit.

Before I describe a treatment method for reducing nightmares – a word of caution, working on nightmares, especially those that maintain PTSD, can be a painful process. It is best to work with a therapist or other professional person, and you need to make sure you have a strong support system in place in case you have difficulty coping.  For more on support systems see “How to develop a support system” or “How supportive is your support system?”

Taming nightmares involves three steps.

1. Learn relaxation methods.

Nightmares are fear based, and the fear persists after you awake. Sitting thinking about the scary part of the dream might reinforce the nightmare and result in memorizing your nightmare. Fear and relaxations are not compatible. The more you relax, the less fear you will have. As you get better at relaxing your fear shrinks and your dreams become less traumatic.

2. Learn sleep hygiene

Keeping regular bedtimes, reducing or eliminating caffeine especially in the hours before bedtime and other efforts to improve sleep naturally are helpful. It is important to allow plenty of time for sleep.

People who stay up late and get up early gradually become sleep deprived. Lack of sleep aggravates all sorts of mental health issues. Insufficient sleep increases the possibilities that you will be suddenly awakened and will remember the “bad dreams.”

During sleep the brain keeps working on our issues, memories are consolidated and thoughts organized. We only call dreams “nightmares” if we awake during the dream and have memories of it. Better sleep can result in fewer nightmares.

3. Begin treatment of the nightmares once you are relaxed and well rested.

The process of “reframing” nightmares makes them less scary and more manageable. Reframing or reprocessing is helpful for intrusive daytime thoughts as well as for nightmares.  The application of this to reducing or eliminating nightmares was described by Rhudy et al. in their 2010 article on CBT treatment for nightmares in trauma-exposed people, where they called it “ERRT” therapy.  Ben Furman has also described a similar approach for use with children.

Disclaimer- Rhudy et al.’s study, like most research in the mental health area, excluded substance abusers, people with mania or psychosis and probably screened out all people with Bipolar Disorders. The sample size was also low with about twenty people per group. There is so much overlap between substance abuse, bipolar disorder and PTSD in the clients I see these studies leave out exactly the people who most need new effective treatments. That said – the ideas appear to be fully appropriate for clients with co-occurring disorders.

Here is how it works:

To reprocess or reframe nightmares do the following things:

A. Write out as full a description of the nightmare as possible.

Getting it down on paper tames the story and makes it manageable. It also allows you to go back over it and add missing details. In step C you will be rewriting it with added insight.

Remember that it is a normal process for your brain to use your dreams to make sense of your experiences. In dreams, your brain will turn the experience around and examine it from all sides. Your brain may also play out multiple alternative endings for the event. It is not the dream that is the problem; it is the connection between the dream and fear that makes this a nightmare.

If you have several versions of the dream try to write them all down.

B. Read the nightmare story aloud.

Listen for the themes in the story. What are the fear messages? I think it is helpful to be able to read this to a therapist or other support person who can keep you from being overwhelmed and can provide some insight to things you may not immediately see. Just don’t make someone listen to your nightmare that is not emotionally able to hear the story.

C. Re-script the nightmare.

What is the expected ending? What is an alternative ending? Write out the story this time with a new less scary ending. Read the new version out loud. Has seeing a new possible ending tamed the fear?

Furman described a story, not sure where it originated, in which a grandmother applied the sort of approach to her grandson’s nightmare.

The child came to grandmother scared because of a nightmare.

“Grandma, ” he said, “I had a nightmare.”

“There are no such things as nightmares,” The grandmother said “Only goodmares. All dreams should have happy endings. The problem is you keep waking up before the end. What is a good ending that could have happened?”

In this story the child then works with his grandmother to find new happy endings for these scary dreams. The result – fewer scary dreams and less fear when bad dreams occurred.

Warring – in people with PTSD who were treated with re-scripting the fear declined first, anger later and the frequency and length of nightmares were the last thing to decline.

Talk to your care provider about this process. If you try this process, see if it works. Learn to relax more. Tame your sleep. Then tame your nightmares. If you have had success in changing your nightmares ending please share your success with the rest of us.

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For more about David Joel Miller and my work in the areas of mental health, substance abuse and Co-occurring disorders see the about the author page. For information about my other writing work beyond this blog check out my Google+ page or the Facebook author’s page, up under David Joel Miller. Posts to the “books, trainings and classes” category will tell you about those activities. If you are in the Fresno California area, information about my private practice is at counselorfresno.com. A list of books I have read and can recommend is over at Recommended Books

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18 thoughts on “Getting rid of Nightmares that maintain Depression and PTSD

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  6. All nightmares are caused by palpitations. 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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  7. Although German scientists Wilhelm Wundt thought that dreams were caused by stimulation of palpitations, abdominal distensions, urgent urinations and other objective things, he did not clearly indicate nightmares were caused by palpitations, and even did not give a satisfactory and convincing explanation to the reasons for nightmares. in addition, he did not have any mysterious insights, unlike the Freud’s mysterious theory of dream without scientific basis as well as Freud’s popularity due to capturing people’s curiosities, his correct opinions failed to receive wide attention. A paper published in Chinese Scientists 1996 proposed that nightmares were caused by palpitations, and the two most common nightmares were caused by the two most common reasons of palpitations. After giving satisfactory explanations to nightmares, someone from another country also published papers online in 2002, and proposed that nightmares were caused by palpitations(http://boards.straightdope.com/sdmb/archive/index.php?t-145666.html). However, he also did not give any further satisfactory explanation, so his correct opinions also failed to receive wide attention.

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    • 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)}.

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  8. I have PTSD from a car accident twenty years ago, and it’s still getting worse. I suffer from nightmares constantly (about anything except the accident) and I am on Amitriptyline to reduce the sleep paralysis which would otherwise happen around six times a night.

    Tried hypnotherapy and counselling, but my brain will not recollect the details to allow it to move from short to long term memory. Is CBT worth trying if there is physical damage/injury to the brain (my head made contact with the carriageway through the sunroof).

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    • CBT is certainly worth a try. The emphasis would be on control of current symptoms and how they are affecting your life. You also want to be sure that your physician has ruled out other physical or neurological problems. Six episodes of sleep paralysis and nightmares not related to the trauma make me think there are other issues, medical and psychological going on. Best wishes on your recovery.

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      • Hi David,

        Thank you so much for your reply. I was diagnosed at Papworth Sleep Clinic after an overnight EEG. He said that the connections weren’t right after the damage and that my brain does on wakening what it should do when I fall asleep. So when I wake, it takes the signal and throws it back and the brain keeps trying until after 5-10 seconds it accepts the connection and I can once more move and speak.

        He said the nightmares were my brain trying to find the accident in short term memory and put it into long term, but although I was fully conscious through the accident, when the car stopped, I thought I’d clipped the kerb as my brain went into protection mode, then I passed out.

        I take drugs to help me sleep but the sedative effect in the morning means I’m limited to what I can take. The night sweats are constant but vary in seriousness.

        I’m also easily startled and I have read that this is possibly hyper vigilance? I’m 38 now and have been unable to start a family as I barely have the energy to keep my job! That said, compared to others, I came off very lightly indeed! Thanks so much again.

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      • Your response very much sounds like Hyper Vigilance. That is treatable with therapy. You may well have “dissociated” around the time of impact which is one way your brain protects you from having to remember severe trauma. You may want to talk with your prescribing physician, I can’t help wondering if your meds may be making that sleep paralysis more pronounced. If you get meds from more than one doctor I would keep a list and show it to the other doctors., Sometimes meds interact. Since your nightmares have content about things other than the accident I would try to write them down immediately on awakening and talk them over with a counselor. There may be newer issues your brain is working on. Hope you find a way to have a happy life despite these challenges.

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  9. Thank you David. I only have the one doctor, and he prescribed the 20mg of Amitriptyline each night for the sleep paralysis. The only other medicine I’m on is birth control. I did try a counsellor, originally he said the nightmares were because I couldn’t come to terms with the accident, but after a few sessions, he said there was nothing further he could do as I had totally accepted it, but my brain couldn’t (or something similar).

    I did go through about 3 months of jotting the nightmares down, but sometimes it’s every 15-20 minutes I wake up, so I spend most of the night writing! Plus some of them are so….horrific (serial killers after me, members of family being blown up by bombs) that I try extremely hard to forgot them!

    I know there is no magic fix and the doctors believe the damage is more physical than physiological, but as research moves on, it’s always worth checking. Thank you again for your time, I do have a wonderful life, job and family, so happiness isn’t a concern for me at all. Onwards and upwards!

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