Category: nervous system

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Are Nightmares Bad for Your Heart?

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John’s nightmares visit often, and when they wake him up, he can feel his heart racing and his palms sweating. He has been putting off therapy to address the trauma he knows is fueling his nightmares because it’s just so hard face it. What he doesn’t realize is that this avoidance not only disrupts his peace of mind, but also puts him at higher risk for a heart attack or stroke.

It’s well-known that nightmares can disrupt sleep and affect daytime mood, and that they are associated with a wide range of mental health diagnoses, including post-traumatic stress and increased risk of suicide. What is more recently becoming clear is that nightmares are bad for physical health as well — specifically an increased risk of cardiovascular disease. While I have long been advocating for increased awareness and treatment of nightmares, heart health is yet another reason to pay attention to nightmares. This post summarizes some of the key findings on the intricate relationship between cardiovascular health and nightmares from the past five years.

Nightmares and Increased Cardiovascular Risk

Several studies have shown that frequent nightmares are associated with an increased risk of cardiovascular problems. For instance Nadorff and colleagues (2020) found that those who experience persistent nightmares have a higher likelihood of developing cardiovascular disease. This study involved a large cohort of over 3,000 participants and utilized self-reported questionnaires to assess the frequency and intensity of nightmares, as well as the incidence of cardiovascular events. The key finding was that those with frequent nightmares had a significantly higher risk of experiencing cardiovascular events, such as heart attacks and strokes. The study suggests that the stress and anxiety associated with nightmares can lead to increased sympathetic nervous system activity, which, in turn, negatively affects heart health.

Heart Rate Variability (HRV) and Nightmares

HRV, a measure of autonomic nervous system function and cardiac health, has been a focal point in understanding the link between nightmares and cardiovascular health. A study by de Zambotti et al. (2021) included 200 participants and indicated that lower HRV is often observed in individuals with frequent nightmares. Participants underwent polysomnographic sleep studies along with HRV monitoring. The researchers found that decreased HRV, reflecting reduced parasympathetic activity and increased sympathetic dominance, is associated with poor sleep quality and higher nightmare frequency. This imbalance in autonomic function is a potential pathway through which nightmares contribute to cardiac stress and disease.

Nightmares, Sleep Apnea, and Cardiac Stress

Sleep apnea, a condition often co-occurring with nightmares, has also been linked to increased cardiac stress. A study by Basta et al. (2021) involved 150 patients diagnosed with obstructive sleep apnea (OSA) and examined the presence of frequent nightmares. The research utilized polysomnography to monitor sleep and assessed cardiac stress markers such as blood pressure and heart rate. The study showed that patients with both OSA and frequent nightmares exhibited significantly higher levels of cardiac stress markers compared to those without nightmares. The researchers suggest that the intermittent hypoxia and fragmented sleep characteristic of OSA, compounded by the psychological stress of nightmares, can exacerbate cardiovascular strain.

Psychological Stress, Nightmares, and Heart Health

Psychological factors play a crucial role in the relationship between nightmares and heart health. An analysis by Li et al. (2022) reviewed the interplay between psychological stress, nightmare frequency, and cardiovascular outcomes. This review included data from multiple studies, covering a combined participant pool of over 5,000 individuals. The review concluded that the chronic stress response induced by frequent nightmares can lead to hypertension and other cardiovascular issues. The persistent arousal and anxiety from nightmares activate the hypothalamic-pituitary-adrenal (HPA) axis, leading to prolonged cardiovascular strain. These findings were derived from a meta-analysis that consolidated results from various studies, providing a robust understanding of the link between psychological stress from nightmares and cardiovascular health.

Prospective Studies and Longitudinal Data

Longitudinal studies have provided further evidence of the impact of nightmares on long-term cardiac health. A notable study by Ohayon et al. (2021) followed a cohort of 4,500 individuals over ten years. Participants were regularly assessed for nightmare frequency, sleep quality, and cardiovascular health through clinical examinations and self-reported surveys. The study found that those with chronic nightmares had a significantly higher incidence of cardiac events, including heart attacks and strokes, compared to those without frequent nightmares. This study emphasizes the potential long-term cardiovascular risks associated with untreated sleep disturbances like nightmares.

Taken together, these recent studies underscore a significant link between nightmares and cardiac health, strongly supporting the notion that frequent nightmares can be a risk factor for heart disease. This relationship is mediated by mechanisms that include increased sympathetic nervous system activity, reduced HRV, and heightened psychological stress. Beyond the well-understood need to reduce stress to promote heart health, directly addressing nightmares using established dream therapy methods has the potential to mitigate some of these risks.

References

Basta, M., Lin, H. M., Peppard, P. E., & Young, T. (2021). Cardiovascular disease prevalence in patients with obstructive sleep apnea and frequent nightmares. Journal of Clinical Sleep Medicine, 17(1), 17-23. https://doi.org/10.5664/jcsm.8616

de Zambotti, M., Goldstone, A., Colrain, I. M., & Baker, F. C. (2021). Cardiac autonomic regulation during sleep and the relation with nightmares in women with PTSD. Psychosomatic Medicine, 83(3), 299-306. https://doi.org/10.1097/PSY.0000000000000895

Li, S. X., Lam, S. P., Yu, M. W., & Wing, Y. K. (2022). Nightmares and cardiovascular health: A review of recent evidence. Sleep Medicine Reviews, 58, 101453. https://doi.org/10.1016/j.smrv.2021.101453

Nadorff, M. R., Liu, X., & Germain, A. (2020). Nightmares and cardiovascular health: A longitudinal study. Sleep, 43(5), zsz247. https://doi.org/10.1093/sleep/zsz247

Ohayon, M. M., Carskadon, M. A., Guilleminault, C., & Vitiello, M. V. (2021). Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: Developing normative sleep values across the human lifespan. Sleep, 44(5), zsab012. https://doi.org/10.1093/sleep/zsab012

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Current Nightmare Treatment Research Roundup: Addressing Pre-Sleep States, Individual Differences and Co-Occuring Mental Illness

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Our state of mind and body prior to falling asleep can affect the way we dream, and this can be a target for treatment for those who experience frequent trauma-related nightmares. If you are someone who has trouble falling asleep because you can’t quiet your mind and body, you are also more likely to have disturbing dreams.

 

A recent study by Youngren and colleagues (2022) has replicated existing evidence that the time it takes to fall asleep (also called sleep onset latency or SOL) and pre-sleep cognition (such as worry or rumination) significantly increase nightmare frequency. Somatic arousal is also implicated, but the results are more complex – self-reported physiological arousal did not impact nightmare frequency. However increased arousal measured by the DREEM headband used to measure physiological aspects of sleep did significantly correlate with more nightmares. The subjective and measured arousal levels did not correlate; it seems participants were not reliable judges of their own physiological pre-sleep arousal.

 

The researchers tested a small sample of 15 male inpatient veterans who had experienced trauma and frequent nightmares. They were seeking to strengthen the evidence for their NIGHT-CAP (nightmare cognitive arousal processing) theory, which proposes that the longer it takes to fall asleep, the more time there is for negative pre-sleep worries to prime a person for negative dreams. However, while SOL and pre-sleep cognitions independently predicted nightmares, the interaction between the two was not significant.

 

The authors note the importance of their findings to clinicians because “current treatment options for post-trauma nightmares remain sparse and are less effective than treatments for other sleep disorders, such as insomnia.” The study results suggest that a bedtime ritual of calming the body and clearing the mind could potentially help reduce nightmares.

 

A complicated picture: How pre-sleep arousal affects dreaming

The effect of the body’s arousal level prior to sleep on subsequent dreams is not clear or linear, however. Another recent study (Dumser et al., 2023) highlights individual differences. In this study of 16 women with regular nightmares, fear of sleep was, when averaged, significantly linked with increased nightmare distress, but there were notable individual differences. Pre-sleep arousal also yielded highly individual effects on sleep and dreaming.

 

The authors concluded: “These findings highlight the crucial role of fear of sleep in the etiology of nightmares and sleep disturbances, while pointing to the importance of pursuing individual, personalised models that explain heterogeneity in the process of triggering nightmares.”

 

Nightmares and Psychiatric Illness: Co-occuring or Causal?

Nightmares are a cardinal symptom of post-traumatic stress injury and in this context, are becoming more frequently considered as a target for treatment. However, disturbed dreaming is also prevalent in other psychiatric disorders, notably depression, anxiety, suicidal ideation and borderline personality. Yet nightmares are rarely a target of treatment in these cases.

 

A recent systematic review of the effect of nightmare treatment on mental health issues (Sheaves, Rek & Freeman, 2023) highlights the scarcity of research in this area, but also some indication that treating nightmares has the potential to help with a variety of symptoms. They found treating nightmares particularly helpful with threat-based disorders, pointing to a causal relationship. Moderate reductions in PTSD, depression and anxiety were found as a result of nightmare treatment. There is also a surprising result from two pilot studies that nightmare treatment might prevent recovery from suicidal ideation, despite strong evidence linking nightmare frequency with subsequent suicide attempts.

 

This and all other areas of nightmare treatment are “greatly understudied” so firm conclusions could not be drawn from the existing evidence. The authors suggest it’s possible that rather than being causally related to many mental health problems, nightmares may instead share similar causes. In PTSD, however, the impact of nightmares on related symptoms is more clearly causal and also bi-directional.

 

I am offering a more comprehensive course for clinicians called The Nightmare Treatment Imperative. Learn why treating nightmares is both essential and surprisingly simplein this online course for mental health professionals, dreamworkers, and anyone who supports those with nightmares.

 

References

Dumser, B., Werner, G. G., Ehring, T., & Takano, K. (2022). Symptom dynamics among nightmare sufferers: An intensive longitudinal study. Journal of Sleep Research, e13776.

Sheaves, B., Rek, S., & Freeman, D. (2022). Nightmares and psychiatric symptoms: A systematic review of longitudinal, experimental, and clinical trial studies. Clinical Psychology Review, 102241.

Youngren, W. A., Hamilton, N. A., Preacher, K. J., & Babber, G. R. Testing the Nightmare Cognitive Arousal Processing Model. In press, Psychological Trauma: Theory, Research, Practice, and Policy.

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New study shows altered nervous system activity for those with frequent nightmares

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New study shows altered nervous system activity for those with frequent nightmares

In a recent paper on nightmares and the autonomic nervous system (ANS), I described how polyvagal theory might inform clinicians seeking to understand and treat those with frequent nightmares (Ellis, 2022). A new paper, desceribed below, offers further evidence that nightmares are implicated in alterations in the ANS.

 

A free talk on how to apply polyvagal theory to nightmares

For those interested in applying these ideas in clinical practice, consider joining me for the upcoming free presentation Nightmares: How Polyvagal Theory Informs Treatment. I am a guest of Jan Winhall’s free felt-sense polyvagal approach to trauma group hosted by the Polyvagal Institute on April 21.

 

Recent research corroborates the nightmare-ANS link

Tomacsek and colleages (2023) studied a group of 24 frequent nightmare sufferers and 30 control participants, examining heart rate and heart rate variability (HRV) at various sleep stages and in response to emotion-inducing pictures. Increased heart rate and reduced HRV indicate nervous system dysregulation, and are increasingly used as measures in emotion and sleep research (specifically to measure parasympathetic dysregulation).

 

The researchers found a significant difference in the heart rate of nightmare sufferers versus controls but only during the sleep portion of the study “suggesting autonomic dysregulation, specifically during sleep in nightmares.” The researchers also found reduced HRV in the nightmare group during the picture-viewing task, which was intended to create a nightmare-like experience during waking.

 

Dysregulation across sleeping and waking in severe cases

The researchers concluded that the extent of dysregulation during both sleeping and waking may depend on the intensity of disturbed dreaming. The participants in the study were frequent nightmare sufferers, but on the less severe end of the spectrum, with non-traumatic nightmares and no symptoms of posttraumatic stress disorder. Still, they found “trait-like autonomic changes during sleep and state-like autonomic responses to emotion-invoking pictures” and concluded that this indicates parasympathetic dysregulation is present in those who suffer from frequent nightmares. They suggested that ANS dysregulation would likely be more consistent across sleep and waking states in more severe cases.

 

As evidence such is this continues to corroborate a link between ANS dysregulation and nightmares, it will ideally lead to treatment protocols that take this information into account. One of the main tenets that polyvagal theory has brought to trauma treatment in general is the notion that attention to a felt sense of safety and to creating conditions that regulate the nervous system is essential to trauma recovery. My paper offers an articulation of ways to extend this polyvagal-informed approach to trauma treatment. Ideally, specific methods of instilling safety and ANS regulation would be considered an integral part of the treatment of nightmares.

 

Ellis LA (2022) Solving the nightmare mystery: the autonomic nervous system as missing link in the aetiology and treatment of nightmares. Dreaming. https://doi.org/10.1037/drm0000224

Tomacsek, V., Blaskovich, B., Király, A. et al. Altered parasympathetic activity during sleep and emotionally arousing wakefulness in frequent nightmare recallers. Eur Arch Psychiatry Clin Neurosci (2023). https://doi.org/10.1007/s00406-023-01573-2

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Dreams as a picture of the nervous system

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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 Clinics, 5(2), 241-248.

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Terror and excitement are not so far apart

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Nervous system hybrid states and how they show up in dreams 

Not all dreams are pure fight/flight, but much like our complex nervous systems they can express hybrid states. We are all familiar with the nightmares of being chased (flight response) or weighed down with helpless immobility (dorsal vagal response). These are fear-based dreams, but they take on a very different tone when imbued with a sense of safety.

At its most basic level safety allows for social engagement, a sense of being at home in the company of those we love and trust. There are also hybrid states, where how safe we feel can mediate how our nervous system responds. When we are immobilized with safety, this allows for stillness, intimacy and bonding. When we are activated with safety, this allows for excitement, sport and play.

The genius of the polyvagal theory developed by Dr. Stephen Porges is that it takes us beyond the simple categorization everyone rattles off without much thought – the well-known fight/flight/freeze paradigm. When naming and understanding our autonomic state, Porges puts safety first.

A neuroception of safety is automatic, not intellectual

What does Porges mean by safety? His polyvagal theory is referring not to literal safety, but rather, bodily-sensed safety. Many who experience activated nervous systems, fear responses and nightmares are not in any real, physical danger, but there is no way to convince them of this, at least not by simply saying so.  Porges’ model stresses the neuroception of safety, that full-body sense which happens automatically, beyond conscious control, that allows our system to relax and repair.

When we are not experiencing rejuvenating embodied safety (a ventral vagal state), our dreams come as nightmares, as being chased or in aggressive encounters (fight/flight) or as helplessness immobility (often called freeze, those this word is not quite accurate). When our bodies feel safe, we dream of social encounters, of intimacy, adventures and play. Our dreams depict how safe or endangered we feel. As such, they can be a doorway to shifting these states at a deep level.

Autonomic state shifts are common — our nervous systems are always working to balance the need for safety and self-protection with those of social engagement, healing, digestion and the achievement of homeostatic balance. When our system perceives threat, things like digesting food or making love are luxuries our bodies senses we can’t afford… whether or not this is actually true.

Our sense of safety or danger is not always accurate

How do our bodies get this wrong? Much of the mismatch comes from early programming, from chronic exposure to neglect or trauma that creates nervous system responses that are either too sharp, too dull or a mixture of both. Those with complex trauma histories, for example, can perceive danger where none exists, or be blithely unaware of actual threatening situations and walk into danger without knowing it. Our dreams can provide both clues and solutions as they reflect our unconscious ANS responses.

During typical sleep, we shift states many times, alternating periods of deep restorative sleep with progressively longer period of dream-rich rapid-eye movement (REM) sleep. In these state shifts, we are most likely to become aware of our dreams and to be awakened by those that are particularly intense. Nightmares can disrupt sleep and affect mood, but they can also open the door to autonomic state shifts that can be lasting.

If we approach our dreams with curiosity, and begin to cultivate mastery and degrees of lucidity, we may be able to shift our dreamscape from a pervasive sense of threat to one of safety, changing our whole experience of the dreaming. This is easier to do that one might think. One chronic nightmare sufferer I worked with was able to turn a face her pursuers and discovered they were far less threatening than expected, and this changed the nature of her dreams. The chase dreams still visit at times, but now they have taken on more of an adventurous feel, one of excitement rather than terror – a similar activated state, but with more of a sense of safety.

Hybrid states show us that the programming our nervous systems received early in life may be tenacious, but it is also malleable. Change is possible, and dreams are one pathway to understanding and altering our habitual responses.

For more on this topic, join Dr. Leslie Ellis for a workshop on Nightmares and The Nervous System October 13, from 9:30-noon (Pacific)

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Nightmares and the nervous system: How the content of your nightmares can guide recovery from disturbed dreaming

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The content of our dreams offers clues about the state of our nervous system. As we know from current research on recurrent dreams, these often depict being chased, feeling helpless or, if positive, represent ways of being socially engaged. Anyone familiar with the polyvagal theory will recognize these states as the some of the main expressions of different states of autonomic nervous system (ANS): being chased is fight/flight, helplessness is immobility and social engagement corresponds with the ventral vagal state the body enters when feeling safe.

A new wave of somatically-oriented trauma therapies has swept through the field of trauma treatment as a result of what we now know about the nervous system. I love that these new approaches view ANS responses as adaptive rather than pathological. I am also impressed at how neatly such constructs map onto dream content. Clinicians can use this information from dreams to inform diagnosis and treatment, and to map clinical progress. For example, when recurrent dreams change, this is can indicate clinical progress as it coincides with increased well-being.

My upcoming journal article, Solving the Nightmare Mystery: How Polyvagal Theory Updates Our Understanding of the Aetiology and Treatment of Nightmares, takes Porges’ polyvagal theory and the nervous system into account when considering the causes and treatment of nightmares; it is in the final stages of production for APA journal Dreaming. The article articulates both a theory and treatment approach that I will cover in more detail in my upcoming workshop on October 13 (participants will receive an advance copy). One of the practical take-aways is the matching of dream content with autonomic states. Here is an excerpt from my article:

“It is possible to map the hierarchy of threat responses onto the content of nightmares. Virtually all fear-based nightmares contain material that represents either an activated fight/flight response or a helpless immobilized response in the face of threat. A recent study to determine the main themes in nightmare content (n = 1216) points to a strong, though not perfect, correlation between most common nightmare themes and the polyvagal response hierarchy. In order, the most frequent nightmare themes identified by Schredl and Goritz (2018) were failure or helplessness (immobility), physical aggression (fight), accidents, being chased (flight), illness or death (immobility), and interpersonal conflict (fight).”

In my doctoral research, I conducted a related qualitative study (Ellis, 2016), looking at changes in recurrent nightmare content after treatment using a protocol that is a precursor to the Nightmare Relief protocol I now use and teach.  The recurrent nightmares of study participants changed after treatment toward more empowered responses, moving up the polyvagal hierarchy of threat responses — from immobility to flight to fight. Also, the dreams that came after treatment began to weave in current settings and characters from the dreamer’s life shifting away from a focus in past trauma. The progression of dream content from replicative and recurrent toward dreams with strange twists and temporal anomalies (ie more normal dreaming) often coincides with trauma recovery.

Relevant to polyvagal theory, I also noticed that the dreams post-treatment tended to move toward greater social engagement: “When dreamers were asked to rescript their dream endings, they almost invariably imagined ‘home.’ The quality of home is similar to Porges’ ventral vagal state: not necessarily a literal place (especially for those whose actual homes were unsafe), but rather a sense of safety in the company of trusted others.” This is a clue about how to help with nightmares – assisting dreamers to reimagine their dreams in ways that feel safer can shift them, and reduce the aversion nightmare sufferers tend to have toward sleep and dreams.

In my upcoming seminar, I will present the most salient aspects of this material and focus mainly on introducing the Nightmare Relief protocol. I will be able to offer more detail, clinical examples, demos and experiential practices than are covered in the academic paper. I would like those who take this workshop to be able to put these ideas into practice right away with clients who suffer from nightmares and disturbing dreams.

To sum up, I have arrived at the idea that the nervous system is deeply implicated in nightmare suffering, and that using newer embodied trauma treatment methods that instill a sense of safety and connection are the starting points for treatment. I have incorporated what I learned in my doctoral research, and also what I have learned from existing evidence-based treatment to develop an individualized, embodied approach to treatment. This is described in my paper and upcoming workshop. I do hope you’ll join me.

 

Workshop: Nightmares and the Nervous System: How to treat disturbed dreaming
October 13, 9:30 to noon Pacific
LIVE online via Zoom, recording available to registrants
Cost: 140 (plus GST) = $147 USD

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Nightmares and the nervous system: a new approach to treatment based on polyvagal theory

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At long last, my article that takes Porges’ polyvagal theory and the nervous system into account when considering the causes and treatment of nightmares, has been accepted for publication in the APA journal Dreaming. Although it could be many months before it is actually published, I am happy to share some of the main ideas and invite you to an online workshop on nightmare treatment based on this research. Those who sign up will receive an advance draft copy of the article, Solving the Nightmare Mystery: How Polyvagal Theory Updates our Understanding of the Aetiology and Treatment of Nightmares.

Here is the abstract: “Current theories about the aetiology of nightmares and mechanisms of action that account for their successful treatment have not yet taken the polyvagal theory (Porges, 2011) into consideration. While the polyvagal theory’s updated and multi-faceted view of the autonomic nervous system’s (ANS) response to threat has begun to transform the field of trauma treatment, most of these ideas have not yet been applied to nightmares and their treatment. This paper outlines how the theory may provide a missing link in understanding specific ways that trauma and adversity lead to chronic nightmares, and it offers a way to make sense of the heterogeneity of trauma-related symptoms and concomitant responses to nightmare treatments. A review of the literature demonstrates evidence of links between measures of ANS and physiological responses to nightmares. Content similarities between threat responses described by polyvagal theory and common nightmare themes provides an additional avenue for assessment and intervention. Theories of nightmare aetiology and treatment are evaluated with respect to polyvagal theory, and lastly, a proposed treatment protocol, Nightmare Relief, offers a polyvagal-informed, process-experiential approach to treating nightmares, with links to clinical examples.”

This sounds like quite a mouthful. In my upcoming seminar, I will present the most salient aspects of this material and focus mainly on introducing the Nightmare Relief protocol. I will be able to offer much more detail, clinical examples, demos and experiential practices than are covered in the academic paper. I would like those who take this workshop to be able to put these ideas into practice right away with clients who suffer from nightmares. Students of mine who have learned this way of working tell me it has stopped the nightmares of some of their clients.

What inspired me to spend the last couple of years on this enormous project? It stems from my experience as a trauma therapist, and many forces have converged to lead me to this focus on treating nightmares. In my 25 years working with posttraumatic stress injury and complex trauma, I have watched the practice of trauma treatment evolve, bringing more embodied practices and deep empathy into the work. I have enjoyed the move away from pathologizing stances toward a deeper understanding of the nervous system’s response to threat and ideas about how to help clients understand and befriend their bodies.

In the past few years, I completed a PhD with a focus on using focusing-oriented therapy, a gentle embodied approach to psychotherapy, for treating the nightmares of refugees. Encouraged by the results, I have continued to study nightmare treatment and was alarmed to discover two things: how few clinicians are versed in this important skill, and how imperative it is to treat nightmares. They are robustly linked to increased suicide risk, and associated not only with posttraumatic stress, but virtually all forms of mental health disturbance. The available treatments appear to work, but not necessarily for the most severe cases, and there is room to understand more about what works and why.

I have arrived at the idea that the nervous system is deeply implicated in nightmare suffering, and that using newer embodied trauma treatment methods that instill a sense of safety and connection are the starting points for treatment. I have incorporated what I learned in my doctoral research, and also what I have learned from existing evidence-based treatment to develop an individualized, embodied approach to treatment. This is described in my paper and upcoming workshop. I do hope you’ll join me.

Workshop: Nightmares and the Nervous System: How to treat disturbed dreaming
October 13, 9:30 to noon Pacific
LIVE online via Zoom, recording available to registrants
Cost: 140 (plus GST) = $147 USD

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Nightmares and the Nervous System: A new way to understand and treat nightmares

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In the world of trauma therapy, a paradigm shift has been taking place over the past decade or so, a marked shift toward embodied and somatic approaches to the understanding and healing of trauma. The polyvagal theory by Dr. Stephen Porges has led clinicians to consider that much of what was previously viewed as pathological behaviour can be seen as adaptive responses that our client’s autonomic nervous systems (ANS) have initiated as a means of protection and survival. This hopeful and non-shaming approach has changed the way trauma therapy is practiced for so many… yet the paradigm shift has not found its way into the treatment of nightmares. I feel that it’s high time for this to change because nightmares deserve clinical attention. They are a cardinal symptom of post-traumatic stress injury, and associated with complex trauma, anxiety, depression and many other mental health challenges. They have been strongly correlated with increased suicide risk.

I have been doing my best to help more clinical attention to nightmares and opportunities for training. I have spent the past several years developing a theory and treatment protocol for nightmares that takes the polyvagal theory into account. This work is the basis of a major article (now under review) and two online courses on nightmares, one for clinicians and one for the general public. I am consistently sending the message that nightmares are urgent messages from the body, attempts at trauma recovery and at getting the dreamer’s attention so they can attend to underlying sense of threat that haunts their nights. Nightmares are treatable, yet so often they are not treated. And in the   most serious cases, where they may lead to greater suicide risk, I believe treatment is imperative.

 

Nightmares reflect a nervous system that doesn’t feel safe

One of the most freeing aspects of Porges’ theory is the idea of ‘neuroception’, which is the internal sensing process which happens automatically, outside of conscious awareness, as our bodies pick up cues of threat and safety from the environment and react accordingly. The theory states that our autonomic responses happen in a specific order – first with activation to fight or flee from danger, and second with immobility or shutdown when fight or flight are not possible or advisable. Shutdown in the face of an overpowering aggressor may in fact be the wisest choice, though it is completely out of conscious control. Knowing this has helped rape survivors, for example, understand why they went limp and didn’t fight back, an action their own body deemed would put them in even greater danger. This knowledge reduces their sense of shame.

 

Nightmare content reflects the autonomic nervous system

Something interesting I noticed in working with nightmares over time is that the content of these dreams often reflects the various states ascribed to nervous system responses. The vast majority of fear-based nightmares depict scenes of being chased or running away (flight), of being faced with agression (fight) or of a sense of frozen hopelessness and inability to move (immobility). It is as though our dream content is describing our autonomic state. The beauty of this is that it is not static, but can shift and change in response to cues from the environment.

Porges has stated, quite simply, that when in comes to trauma and resulting ANS reactions, “safety is the treatment.” I have found that with frightening dreams, if you can instil a sense of safety in the dreamer, either within the dream itself, or after that fact in working with the dream material, it can shift even long-term recurrent nightmares, sometimes permanently. Too often I have seen that nightmare sufferers feel like victims of the terrifying dreams, thinking there is nothing they can do, making them fear sleep itself, which is ideally a balm and a time for deep rest and recovery.

 

Not all nightmares are the same

One thing that the polyvagal theory has helped me to understand is that there are two distinct responses to trauma and adversity – one is highly activated and the other is more dissociative. The pathway to safety and recovery from these two states is different, yet most nightmare treatments are applied as if they are all the same. When a person’s body reflects collapse or immobility, what the polyvagal theory states is that they are very far from being able to engage with someone who is trying to soothe or help them because they have turned inward and their social engagement system is shut down. Porges says the path back from this state is longer and more complicated and needs to pass back through the activated state most of us associate with trauma.

In either case, instilling a sense of safety and then of connection will help shift the dreamer’s state, and often, the memory of this stays with them when they next encounter the fear response within their dreams. This is why the popular nightmare treatment method of ‘rescripting’ or rewriting the content of one’s dreams can be so powerful. When we revise our dream narratives, we can add empowerment, help from others, a new way of seeing the situation that renders it less threatening… or anything that feels right to the dreamer.

In my work with dreams and nightmares, I always ask the dreamer to find and then embody any aspects of the dream they find helpful – and to imagine the dream forward to include such elements if the dream itself contains no such sources of support. When they experience a sense of power, of safety and of company in the face of their haunting dreams, these dreamers often hold on to it, and the potential for a helpful shift is available to them next time they have a similar dream. This brings hope and change to places that felt frozen in place, the beginning of a new and more empowering relationship to one’s embodied dreams.

 

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Dreaming with our hearts as well as our minds

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New research uncovers a brain-body network that creates our dreams

So much of the research into how and why we dream has focused on the brain rather than the body… with the possible exception of nightmares where physiological fear responses are clearly a part of the experience. My sense of dreaming has always been that it is deeply embodied, and dynamically responsive to both our thoughts and emotions in an intricate dance. This may indeed be the case as a team of Italian researchers propose activation of the brain-heart axis is a trigger for dreaming.

New research led by Mimmi Nardelli has uncovered what I have always suspected was there: a body-mind link that drives dreaming, a bi-directional link where the body affects our dreams, and our dreams affect our bodies. The research team at the University of Pisa performed a comprehensive analysis of physiological signals during dream-rich REM sleep with nine healthy dreamers tracking brain and nervous system dynamics associated with dream recall. They also looked at causal directions not just correlations. They concluded that “bodily changes play a crucial and causative role in conscious dream experience during REM sleep.”

Much of the physiological dream research conducted to date has focused on neural correlates of dreaming, but this study also examines its relationship with the central and autonomic nervous system using measures of heart rate variability and blood pressure, along with EEG (brain) signals. Heart rate variability is a reliable measure of the state of the autonomic nervous system, which governs the body’s responses to cues of threat and safety. Blood pressure can also indicate levels of sympathetic activation.

The authors of the study noted that previous studies of nervous system correlates focused on discriminating sleep stages – for example, several studies investigating heart rate variability dynamics found a shift from vagal to sympathetic activity during REM. According to the Polyvagal Theory developed by Stephen Porges, this would indicate a shift from a sense of safety to one in which the body mounts a response to threat. This study goes beyond study of sleep stages to uncover new information about the relationship between dreams and the body.

During the experiment, researchers woke participants up during REM sleep and asked about their dreams – did they recall one, and was it positive or negative? They captured physiological data from the minutes prior to awakening and compared instances of dream recall with those where no dream was recalled.

Dreams and emotions linked

Previous studies have shown that in dreaming, the right hemisphere of the brain, more associated with visuo-spatial functiong and non-conscious emotional perception, is more active during dreaming, while activity in the left frontal hemisphere, associated more with logic and executive functioning, decreases. These finding were supported in this study. With respect to heart rate variability, when a dream was recalled,  an overall increase in sympathetic activity, and parallel decrease in vagal activity, was observed. The authors speculate that these findings indicate emotional arousal during dreaming.

In their study of changes in the nervous system over time in relation to dreaming, the authors found evidence to support a long-standing ‘activation-synthesis’ theory by Hobson and McCarley (1977) that dreaming arises from sensorimotor information relayed from the brain stem to the cerebral cortex. The current study suggest this is only half true. They found a bi-directional influence – a dynamic interchange from body to brain and brain to body.

The researchers wrote: “Results from the heart-to-brain interaction analysis suggest that the interactions between CNS and ANS associated with dreaming experience are bidirectional and exhibit dynamic changes.” They are quick to point out the results are preliminary because the sample size was small and low in statistical power. However, the study points to something I have come to believe about dreams: that their images are a picture of our embodied emotional state that impacts us deeply – and that we can also impact our dreams and how they unfold. They respond to us and we to them.

 

References

Hobson, J. A. & McCarley, R. W. (1977). The brain as a dream state generator: an activation-synthesis hypothesis of the dream process, The American journal of psychiatry.

Nardelli, M., Catrambone, V., Grandi, G., Banfi, T. (2021). Activation of brain-heart axis during REM sleep: a trigger for dreaming. American Journal of Physiology – Regulatory, Integrative and Comparative Physiology. https://doi.org/abs/10.1152/ajpregu.00306.2020