Month: October 2022

Dreams as a picture of the nervous system

Dreams as a picture of the nervous system, and an avenue for state shifts

It’s beginning to dawn on me that not just nightmares, but all dreams can be seen as an expression of the nervous system. They are images direct from the body, far less filtered by our internal censor than waking thoughts — they are more image-based, more visceral and fluid. Spending time with our dream images in a calm and curious way can be inherently regulating, and I am beginning to suspect why this is so.

The late Ernest Hartmann, a celebrated dreamworker and researcher, said two things that I want to follow up on in this context. The first is, “The nightmare is the most useful dream.” This is not meant to dismiss the real distress and terror that our worst dreams can bring. It’s that nightmares represent an extreme state, and as such, one that we can learn the most from.

Linking nightmares and the nervous system

I’ve spent the last couple of years investigating the link between nightmares and the autonomic nervous system (ANS) through the lens of polyvagal theory. Although I think the implications of this for nightmare formation and treatment are still largely unexplored, I started this ball rolling with the recent publication of an article with the optimistic title, Solving the Nightmare Mystery in which I imply that the role of the nervous system is a missing link in our understanding of how to treat nightmares (Ellis, 2022).

I have been sitting with those who experience deeply disturbing dreams for many years now, one of the main things I do to help is facilitate the search for, and embodiment of, cues of safety that help alter their perception and experience of these dreams. They tell me this embodied process of dreaming their dreams forward (called ‘rescripting’ in modern nightmare treatment literature), changes how they hold the dream in their body. Typically, the memory remains, but the charge dissipates, after a successful session.

Nightmares are dramatic, and there is clear autonomic activation during sleep state shifts for those who experience them frequently. Nightmares are easily recalled and their impact is tangibly felt, as is the relief one experiences when they begin to fade or shift into a more benign form. This is useful because when a phenomenon is loud and colorful, we can more easily see it.

Dream images as nervous system state and shifts

However, in a recent class I teach on the clinical use of dreams, a dreamer brought an image of a dark, still woman in a tub that had sat so long the water had gone cold. Her impulse, in dreaming this forward, was to turn on the hot water faucet, to bring some warmth to the bath and to the woman’s body. Entering the dream further, she noticed the tub itself, and it was older, more ornate and beautiful than the one is her current bathroom, where the dream was set. Her own demeanor changed in this process or warming the bath, her face coloring and smiling as she described making the bath a sanctuary, adding scent and oil and dipping into the enjoyment of it. Later, she told me the shifts continued in the coming days: “I continued to experience “mini shifts” in the following days and was able to access and carry the felt sense of the warmth and beauty of the bath into many areas of my daily life. I noticed I feel more present when I bring a sense of aesthetics, in the form of a little beautifying and warming detail, when I have to tackle some of the mundane daily tasks and responsibilities, which were weighing me down lately.”

This entire dream process could be seen as an image of the nervous system as it shifted from a cold, immobilized (dorsal vagal) state, into one of connection and animation that was clearly visible on her face. Her fellow classmates remarked on the change, as her physiology demonstrated a clear shift into a state of social engagement and warmth (ventral vagal). This kind of shift is typical in working with dreams. The images from nightmares are clear representations of autonomic states. Activation or fight/flight – being chased or engaged in a battle – are some of the most prevalent nightmare themes. The leap I have made is simply that nightmares are the most obvious expression of what happens in all dreams. They are our bodies expressing in image and sensation our fluctuating internal state. They are doorway into its expression, particularly valuable for those who have trouble hearing what’s going inside.

Dreamwork as a way to metabolize and regulate emotion

This brings me to another of Hartmann’s famous statements: that dreams are a ‘picture-metaphors’ for our most salient emotional concerns. Sometimes our most pressing feelings are repressed, historic or fleeting enough that we don’t think about them during the day. But our dreams have an uncanny way of picturing what matters most, even if we have repressed it. Our bodies carry the charge of feelings and memories that are unmetabolized, and these find expression in our dreams.

My sense, which is shared with many dreamworkers and researchers, is that a purpose of dreaming about emotion is not to upset us but to help us process and shift such feelings. Sometimes, the dreams do this all on their own, like a nocturnal therapist, and sometimes it really helps to have another person process the dreams with us. One idea that attention to the nervous system and polyvagal theory has taught us is that we humans (and all mammals) function better together than alone. Sharing our dreams and bringing them into company and the light of day helps them do their job better. And more and more, I’m beginning to think that a large part of their job is expressing and regulating the state of our nervous system.

 

References

Ellis, L. A. (2022). Solving the nightmare mystery: The autonomic nervous system as missing link in the aetiology and treatment of nightmares. Dreaming.

Hartmann, E. (1999). The nightmare is the most useful dream. Sleep and Hypnosis, 1(4), 199-203.

Hartmann, E. (2010). The dream always makes new connections: the dream is a creation, not a replay. Sleep Medicine Clinics5(2), 241-248.

Nightmares Quadruple Adolescent Suicide Risk

Nightmares quadruple suicide risk in youth, yet overlooked by most clinicians

Scary dreams are common among children, and possibly it is for this reason that they are often overlooked by clinicians. In fact, frequent nightmares can indicate a life-threatening state. It has been well established that nightmares are robustly linked with higher suicide risk in adults, and a recent study has extended this to adolescents.

Children with frequent nightmares are twice as likely to consider suicide and four times more likely to attempt it than kids with fewer nightmares. It’s normal in childhood to have some nightmares, but frequent, chronic, distressing dreams indicate nightmare disorder, which warrants clinical attention, something too few nightmare sufferers receive.

 

Clinicians drastically underestimate nightmare prevalence

In a recent study, Corner and colleagues (2022) looked at reported rates of nightmare disorder among 806 child psychiatric outpatients, asking both children and their parents about prevalence of nightmares. The researchers found that parents reported 40 percent of these children had nightmares, while 56 percent of the children said they had experienced a nightmare the previous week. Of these children, just 12 (0.01%) had been diagnosed with nightmare disorder, and 16% were given a posttraumatic stress disorder (PTSD) diagnosis. It appears parents underestimate the prevalence of their childrens’ nightmares by a little, and clinicians underestimate by a lot – if they consider nightmares at all.

The researchers found that very few children in this sample with chronic nightmares had been identified, yet many families expressed desire for treatment for their children. Their conclusion: “We join with researchers of adult populations in calling for routine screening of nightmares.”

A recent systematic review of the prevalence of nightmares in youth found that in clinical populations, 27% to 57% reported nightmares in the previous week and 18% to 22% in the previous month (El Sabbagh et al., under review). By contrast, 1% to 11% of those without a clinical diagnosis reported having a nightmare in the previous week, and 25% to 35% in the past month. Clearly, nightmares are highly prevalent in those children with mental health concerns.

 

Childrens’ nightmares are highly prevalent, mostly undiagnosed, yet treatable

The hard part of this story is that so many of those with nightmare disorder are undetected and therefore untreated, despite the availability of effective therapies. For example, a recent study looked at treatment of childrens’ nightmares using a sample of 17 children aged 5 to 17. While the researchers were exploring some of the nuances of such treatment, the first important point is that the treatment was effective, with high effect sizes across the board.

The sample was too small to draw firm conclusions about the efficacy of the treatment used – five cognitive-based sessions, including psychoeducation and rewriting the nightmare. However, it does support the considerable evidence that nightmares are treatable.

In this particular study, Pangelinan and colleagues (2022) wanted to know which was reduced first during treatment: nightmare frequency or distress. Because the distress caused by nightmares is considered a driving force in recurrent dreams, the researchers expected distress to drop before frequency, but found the opposite to be the case. Yet both factors were steadily reduced over time, after an initial spike in the distress levels, possibly caused by focusing on the nightmares more than usual.

What makes nightmare treatment effective continues to be a bit of a puzzle and potentially many factors contribute to the success of treatment. I suggest, in my recent article on nightmares and the nervous system (Ellis, 2022), that it is a sense of safety at a physiological level that could underlie nightmare treatment success, and this can be achieved in many ways. Some of these factors are alluded to by Pagelinan: “The steady decline of nightmare frequency and distress over time supports the idea that nightmare treatment is not about an on-off switch of sorts but rather a process by which different skills that address efficacy, hope, relaxation, and sleep skills, in addition to the emotion processing of a nightmare through exposure and rescription, may be important in nightmare treatments.”

The main point here is that while there are many more things to understand about how to treat nightmares, we know enough already to make a real difference. The larger problem we currently face is lack of awareness that nightmares are so prevalent in the clinical population, and that they represent both risk and opportunity.

I am offering a more comprehensive course for clinicians called The Nightmare Treatment Imperative.  Learn why treating nightmares is both essential and surprisingly simple.

 

References

Cromer, L. D., Stimson, J. R., Rischard, M. E., & Buck, T. R. (2022). Nightmare prevalence in an outpatient pediatric psychiatry population: A brief report. Dreaming. Advance online publication. https://doi.org/10.1037/drm0000225

Ellis, L. A. (2022). Solving the nightmare mystery: The autonomic nervous system as missing link in the aetiology and treatment of nightmares. Dreaming.

Pangelinan, B., Rischard, M. E., & Cromer, L. D. (2022). Examining changes in nightmare distress and frequency across treatment in a child sample: Which improves first? International Journal of Dream Research15(2), 198-204.