Month: September 2021

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Dream Changes During the Pandemic Reflect Massive Collective Trauma

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A multinational study concludes that dreams are a reflection of massive collective trauma, and that dreams and dream recall must be integrated into approaches for improving mental health and health in general.

By Dr. Leslie Ellis

Since the beginning of the COVID-19 pandemic, the world has collectively been dreaming more, and our dreams have reflected the rise in stress levels, fear and uncertainty. A group of 23 researchers from 14 countries teamed up to take an in-depth look at how the pandemic has affected our dream recall and how this impacts health and mental health. They conclude that dreams are “an often-forgotten expression of the existential situation of individuals” and that they need to be integrated into how we understand and support mental health.

A recent multinational study of more than 19,000 adults explored the associations between dream recall frequency and related social, health and mental health factors, comparing data prior to and during the pandemic across four continents and 14 countries. Higher dream recall was linked with nightmares, sleep talking, recurrent disturbing thoughts and PTSD symptoms. As in previous studies, this one showed that women have been affected more than men, but also that those aged 55-64 had lower dream recall than younger people.

While the higher intensity of emotion during the pandemic has generated more dream recall — associated with more PTSD symptoms, problems with sleep maintenance, more nightmares and parasomnias — there is one interesting finding that bears further inquiry. Contrary to earlier studies, in the one, high dream recall was negatively associated with depression and anxiety. This could be because dreaming can help regulate the strong emotions people are experiencing in these turbulent times. However, the authors speculate that it could also be the result of the dream-dampening effect of anti-depressant medication. They said not enough specific data was collected to solve this riddle.

The study’s authors wrote: “The COVID-19 crisis has touched every person in the world in some way, whether it is related to becoming infected, suffering financially, through reduced social contacts, missed opportunities, or an inability to get required supplies and materials. It has become a communal trauma that has a profound impact on people around the world. One of the most difficult aspects of the pandemic is social isolation and confinement. Solitude goes against our inborn social instincts to form and maintain relationships as human beings and live in herd- or swarm-like alignments. Recent research has shown that the pandemic has led to increased anxiety levels, panic attacks, irrational fears, post-traumatic stress, depression, fatigue, reduced sleep quality, and sleep disturbances. Given the effects it has had on our everyday lives, perhaps it is unsurprising that COVID-19 has crept into our dreams.”

Earlier, smaller studies in various parts of the world (China, Italy, USA) have corroborated the findings that our dreams have been more intense and frequent during the pandemic, and that there are differences in how men and women have been dreaming. For example, a US study found that women with higher education were affected more than others, and several Italian studies showed that while all of us have experienced an increase in dream recall, women have been more affected.

“Since the pandemic has reportedly led to worsened mental health and higher levels of depression, anxiety, distress and symptoms of PTSD, heightened dream recall frequency might be an expression of the current mental health status,” according to the study authors. Women may be more affected as they have had to face more of the load – including increased childcare and health care responsibilities and greater job losses.

In their concluding comments, the authors called for more attention to dreams in mental health care and in general. “Dreams and dream activity are an often-forgotten expression of the existential situation of individuals. Based on our results, we assume that disruption in sleep patterns due to changes caused by the pandemic explains the increase in dream recall. Additionally, we propose that the observed increased dream recall frequency in our sample is an expression of the emotional intense and demanding experience of the current situation and could be an indicator that the pandemic is indeed turning into a collective trauma… Therefore, dreams and dream recall deserve more attention as potential support for coping with crisis situations, such as the COVID-19 pandemic and overall in supporting psychological wellbeing. Dreams and dream recall need to be accepted more and integrated into approaches for improving mental health and health in general.”

 

If you are a mental health professional interested in learning more about nightmares, parasomnias, and their treatment, sign up for my short, focused online course. Because I feel this material is important to disseminate, the course is always open, is self-paced, and discounted during the pandemic. Please ask your clients if they have nightmares, and let them know they are treatable.

 

Check out the Short Focused Course on Nightmare Treatment using THIS LINK. 

References

Fränkl E, Scarpelli S, Nadorff MR, Bjorvatn B, Bolstad CJ, Chan NY, Chung F, Dauvilliers Y, Espie CA, Inoue Y, Leger D, Macêdo T, Matsui K, Merikanto I, Morin CM, Mota-Rolim S, Partinen M, Penzel T, Plazzi G, Sieminski M, Wing YK, De Gennaro L, Holzinger B. How our Dreams Changed During the COVID-19 Pandemic: Effects and Correlates of Dream Recall Frequency – a Multinational Study on 19,355 Adults. Nat Sci Sleep. 2021;13:1573-1591
https://doi.org/10.2147/NSS.S324142

Iorio I, Sommantico M, Parrello S. Dreaming in the time of COVID-19: a quali-quantitative Italian study. Dreaming. 2020;30(3):199–215. doi:10.1037/drm0000142

Nielsen T. Infectious dreams. How the COVID-19 pandemic is changing our sleeping lives. Sci Am. 2020;323:31–35.

Pesonen A-K, Lipsanen J, Halonen R, et al. Pandemic dreams: network analysis of dream content during the COVID-19 lockdown. Front Psychol. 2020;11:2569. doi:10.3389/fpsyg.2020.573961

Scarpelli S, Alfonsi V, Mangiaruga A, et al. Pandemic nightmares: effects on dream activity of the COVID-19 lockdown in Italy. J Sleep Res. 2021;e13300. doi:10.1111/jsr.13300

Schredl M, Bulkeley K. Dreaming and the COVID-19 pandemic: a survey in a U.S. sample. Dreaming. 2020;30(3):189–198. doi:10.1037/drm0000146

 

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Sleep quality and PTSD: A bidirectional link

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If you want to effectively treat PTSD, it’s critical to address sleep issues, including nightmares. Currently, there is too little integration of sleep and trauma-focused therapies for the treatment of PTSD according to the authors of a comprehensive review of sleep disorders and PTSD. Weber and Wetter’s (2021) survey of the literature shows that intervening in sleep disturbances also helps daytime PTSD symptoms and may even offer a preventative effect.

 

Sleep problems, a core feature of PTSD, include nightmares, insomnia and nocturnal anxiety. The authors found little evidence for the long-term effectiveness of medication for insomnia and nightmares and called for a more complex and integrated approach to psychological treatment. They stress the importance of addressing sleep issues, noting that sleep problems and PTSD have a bidirectional link. Sleep issues can predispose a person to PTSD and perpetuate it.

 

“Interventions that enable people to sleep better are likely to be of particular therapeutic importance, as they may have immediate remedial effect on PTSD symptoms,” according to the authors. More than 90 percent of those with PTSD also have sleep problems that include post-traumatic nightmares, and difficulty falling and staying asleep. They can also ruminate at night, talk in their sleep, wake up disoriented and suffer from parasomnias.

 

PTSD associated with alterations in the nervous system and sleep architecture

There is much evidence to show that those with PTSD have low parasympathetic tone while awake and resting, and increased sympathetic activation during sleep, especially during REM when most dreaming occurs. It is now considered established that altered heart-rate variability (HRV), a measure often used to assess the state of the nervous system, increases the likelihood of developing PTSD after trauma.

 

The sleep patterns of those with PTSD differs in many measurable ways from normal, healthy sleep, indicating they sleep less deeply, and spend less time in restorative, regulating slow-wave sleep. Sleep spindles, bursts of brain activity that can be seen on EEG readouts during stage 2 non-REM sleep, are associated with memory consolidation and neuroplasticity. These are altered in those with PTSD sufferers. Similar disruptions in sleep spindle patterns were also found recently in those with nightmares associated with early childhood adversity – a finding that suggests trauma nightmares and so-called idiopathic nightmares (of unknown origin) may not be so easily differentiated (Nielsen et al. , 2019). REM sleep patterns are also altered in PTSD in ways that fragment this dream-rich phase of sleep that has been shown to help regulate emotion and attenuate fear and distress.

 

Sleep disturbances are linked to increased suicidality and self-harming behaviours. PTSD is also a risk factor for suicide. Weber and Wetter (2021) note that reciprocal influences of sleep, PTSD and suicide are well documented but not well understood. They do, however, cite a study that suggests “targeted treatment of sleep disorders and nightmares could contrubute to reducing the risk of suicidality in PTSD patients (Bishop et al., 2020).

 

Treatment of PSTD and Sleep Disorder Must Be Integrated

While PTSD treatment helps with insomnia and nightmares, and treatment of sleep problems helps with daytime PTSD symptoms, the two approaches are rarely integrated. The authors note several effective psychotherapeutic approaches to treating nightmares, including IRT, ERRT and EMDR. They also review pharmacological interventions, and the evidence is less favorable. They also studied the impact of sleep inteventions post-trauma as a way to prevent PTSD, and again the evidence was not conclusive.

 

In their conclusions, Webe and Wetter say there is “robust evidence” for psychotherapeutic inteventions and less evidence for medication as a treatment for PTSD. “Integrative concepts and optimized algorithms for sleep and daytime symptoms are needed.” These may also help reduce the risk of suicide, and in future, even prevent the development of PTSD following trauma.

 

References

Bishop T. M., Walsh P. G., Ashrafioun L., Lavigne J.E., Pigeon W. R. (2020). Sleep, suicide behaviors, and the protective role of sleep medicine. Sleep Medicine, 66, 264–70.

Nielsen T., Carr M., Picard-Deland C., Marquis L. P., Saint-Onge K., Blanchette-Carriere C., et al. (2019). Early childhood adversity associations with nightmare severity and sleep spindles. Sleep Medicine, 56, 57–65.

Weber, F. C. & Wetter, T. C. (2021). The many faces of sleep disorders in post-traumatic stress disorder: An update on clinical features and treatment. Neuropsychobiology, published online Seot. 2. DOI: 10.1159/000517329

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Nightmare Relief from a Single Phone Session

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A recent study showed that even one session of nightmare treatment can be enough to significantly reduce the frequency and distress of nightmares. Katharin Luth and two other German researchers studied this low-threshold intevention, stressing the need for easy access to treatment because so often, nightmares are both underdiagnosed and untreated.

In the study, 28 people were given a half-hour phone session that provided information on what causes nightmares, and then offered a short version of Imagery Rehearsal Therapy (IRT), which asks the dreamer to write down their nightmare, imagine a new ending or revised version and visualize this new version for 5-10 minutes a day.

After 8 weeks of self-practice, the participants were asked about the impact on their nightmares. Participants were either students or patients from a sleep laboratory, and there was no control group.  Follow-up calls determined that 64% of participants’ nightmare frequency was reduced, 29 percent were unchanged and 7 percent experienced an increase in nightmare frequency.

Results were very similar for nightmare distress, which was reduced significantly for 63% of participants and most (78%) reported little or no distress post treatment. Of the 28 participants, 17 decreased distress, 9 remained the same and 1 experienced an increase.

The researchers also asked participants about their subjective experience with the treatment, and found that 2 of the 28 thought the treatment itself was scary because the process began with imagining their nightmares. There were far more positive reports (19) and 3 found immediate relief, saying, “The dreams completely disappeared as if they were switched off.”

All but one person in the study found the process helpful or very helpful. Effect sizes (d=1.92) were very large, possibly because for every person in the study, this was the first time their nightmares were addressed by a professional. For some, the simple idea that nightmares could be treated was a revelation, and then, to have a tool that they could use on their own brought them a greater sense of safety.

The authors concluded, “Because of the simplicity and the effectiveness of this method, we stress the idea put forward by many dream researchers that such easily accessibly offers for nightmare treatment should be implemented in our health care system.”

Some further resources:

Help for nightmare sufferers (free PDF) CLICK HERE

If you are interested in learning more about nightmares and their treatment, sign up for my short, focused online course. Because I feel this material is important to disseminate, the course is always open, is self-paced, and currently discounted during the virus crisis. Please ask your clients if they have nightmares, and let them know they are treatable.Check out our Short Focused Course on Nightmare Treatment using THIS LINK.

Lüth, K., Schmitt, J. & Schredl, M. Conquering nightmares on the phone: one-session counseling using imagery rehearsal therapy. Somnologie (2021). https://doi.org/10.1007/s11818-021-00320-w

Are you a parent concerned about the frequency and intensity of your child’s bad dreams? Should you be concerned?
Learn more about Nightmare Relief for Everyone designed by nightmare expert Dr. Leslie Ellis, this self-paced user-friendly and accessible online course covers the very latest in science and research about what nightmares are, and what they’re not. Leslie offers some simple steps you can take to get some relief from nightmares and other nocturnal disturbances – both for yourself and for others, including your children.

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Veterans and dreams: Special considerations for treating moral injury and lucid nightmares

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Veterans and dreams: Special considerations for treating moral injury and lucid nightmares

By Dr. Leslie Ellis

Sometimes, traumatic injury is not just an overwhelming event, but one that constitutes a deep moral injury. This kind of trauma, more common among veterans, requires a uniquely sensitive approach. At the most recent conference for the International Association for the Study of Dreams (IASD, June 2021), keynote speaker Eduardo Duran, addressed the complexities of treating the moral injury many veterans suffer – where trauma is not just about what you have witnessed and experienced, but also about things you have done or failed to do in the context of battle, where the usual societal rules do not apply. Taking the life of another or failing to save someone’s life, for example, may lead to devastating moral injury.

 

An indigenous perspective on treating moral injury

Duran brings an indigenous perspective to the question of moral injury, and speaks of the importance of redressing balance. A moral injury refers to an act that weighs heavily on one’s conscience, characterized by profound guilt and shame. In his book, Healing the Soul Wound (2019), Duran writes of the indigenous teachings which say there is an agreement or contract made when one warrior takes the life of another. “Taking anything requires that a balancing act occur in order to harmonize the action. Everything in the universe seeks balance, and actions taken in any situation will either balance themselves unconsciously through the manifestation of symptoms, or will enhance human consciousness if understood from a psycho-spiritual perspective.”

At the IASD conference, Duran spoke of how in some indigenous tribes, taking the life of another indebted the warrior to the deceased soldier’s family for his lifetime. Often those who have taken a life dream of the deceased, both those whose lives they may have directly or indirectly taken, and they also dream of compatriots who lost their lives in battle. These dreams are a constant reminder that keeps their suffering alive, sometimes for decades, unless some kind of healing takes place. There is an understanding that while different rules apply during wartime, there is a need for balance and restitution upon returning to peace, and that these acts of atonement are as important for the agressor as they are for the victims of violence.

Practically speaking, this means that a soldier who has taken a life must make amends in some way to the person or the family and community whose life they have taken. This can be done through offerings, direct service, ceremony, therapy and ultimately, self-forgiveness. Duran said the pull toward suicide in such cases is may also be seen as an attempt to restore balance (a life for a life) but one that merely doubles down on losses. He calls suicide a desire for transformation, an important call, though not one to be taken literally.

In many indigenous traditions, suicide is a spirit that calls for transformation, which can lead to a spiritual rebirth, and a new life. Duran believes Western paradigms misinterpret this as suicidal ideation, as an impulse to take one’s own life in the physical realm. He said it’s crucial to not only treat PTSD symptoms, but also the deep moral injury that can lead to a desire for death. “A larger issue of soul separation is what is calling for a transforming event, such as we encounter in death. Therapeutic ceremony that allows for soul restoration is a must.”

 

Moral injury leads to higher suicide risk

A recent study (Battles et al., 2021) confirmed that suicide risk is higher among those veterans who have suffered a moral injury, which has symptoms in common with PTSD, but also a unique and complex presentation. The researchers found that those with strong guilt and shame, as well as comorbid psychiatric conditions, carried the highest suicide risk. The symptom picture differs from the flashbacks, nightmares and hypervigilance associated with PTSD. Moral injury and the shame associated with it bring depression, anxiety, loss of trust, and social alienation. The researchers concluded that while there is overlap between moral injury and PTSD, there are distinctive differences that need to be considered in treatment and prevention of suicide.

Another recent article addressing the impact of war on veterans found that the way they dream has unique characteristics. Miller, Ross and Harb (2021) studied the dreams of 54 veterans with PTSD and found that more than half of them were experiencing lucid nightmares of the most challenging variety. Participants were aware they were dreaming, but this did not lend them greater control over these distressing dreams. Instead, they reported feeling stuck, anxious and unable to wake themselves up from their distressing dreams.

Normally, lucid dreaming is associated with feelings of greater well-being, autonomy, assertiveness and confidence, but not in these cases. Although lucid dreaming has been studied as a treatment for traumatic nightmares, in these cases, the notion of taking control and achieving mastery over the dream content is not viewed as a promising pathway. The authors suggest that helping veterans who suffer from lucid nightmares to learn to distinguish these dreams from reality might be a useful focus of treatment.

In this and other recent studies, it is apparent that the treatment of veterans suffering from past-traumatic and/or moral injury is a complex business, and one that deserves further attention and study, especially because it may help reduce the high prevalence of suicide in this clinical population. It’s important for clinicians to understand that moral injury, and lucid nightmares are among the complex challenges in working with veterans, but they are treatable. There is hope.

If you are interested in learning more about nightmares and their treatment, sign up for my short, focused online course. Because I feel this material is important to disseminate, the course is always open, is self-paced, and currently discounted during the virus crisis. Please ask your clients if they have nightmares, and let them know they are treatable. Check out our Short Focused Course on Nightmare Treatment using THIS LINK.

 

References

Battles, A. R., Jinkerson, J., Kelley, M. L., & Mason, R. A. (2021). Structural examination of moral injury and PTSD and their associations with suicidal behavior among combat veterans. Journal of Community Engagement and Scholarship, 13(4).

Duran, E. (2019). Healing the soul wound: Trauma-informed counseling for indigenous communities. New York, NY: Teachers College Press, Columbia University.

Miller, K. E., Ross, R. J., & Harb, G. C. (2021). Lucid Dreams in Veterans with Posttraumatic Stress Disorder Include Nightmares. Dreaming, 31(2), 117-127.