Category: Nightmare Relief

Are Nightmares Bad for Your Heart?

By Dr. Leslie EllisJuly 25, 2024

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

The Alarming Nightmare-Suicide Link: Review just published

By Dr. Leslie EllisJuly 5, 2024

In my continuing bid to get the word out about the alarming link between frequent nightmares and increased suicide risk, I wrote a review paper that was just published. In it, I cover the growing body of research documenting evidence of this strong connection. I also explore the potential mechanisms at work that make nightmare sufferers more prone to suicide, and discuss treatment and the need for more research.

Recently, I’ve had conversations with several psychotherapists who came across my writings on this topic. I have been consulting with some of them about clients who fit the typical profile of concern: a person suffering from posttraumatic stress who has nightmares almost every night, and has attempted suicide, or is in danger of doing so.

Much of my work involves keeping abreast of nightmare research, developing and honing a treatment protocol based on current evidence and my depth of clinical experience. I also share this information via my writing and courses, including an online course specifically covering nightmares and suicide, and what clinicians need to be aware of.

Here is the abstract and citation for the paper. Please share it with anyone who might benefit from knowing about this.

The Alarming Nightmare-Suicide Link: Evidence, Theories, and Implications for Treatment

A robust link has been established between frequent nightmares and increased risk of suicide, both in adult and adolescent populations. Yet nightmares remain vastly undertreated for a confluence of reasons: patients rarely talk about their nightmares, clinicians rarely ask about them, and too few clinicians are trained to treat disturbing dreams. Current clinical research shows that nightmares are not only associated with posttraumatic stress disorder (PTSD), but also are more prevalent in most psychiatric disorders. There are myriad reasons for clinicians to inquire about and treat nightmares: Patterns of disturbed dreaming, and content of nightmares can provide warning signs of suicide; dream content can aid in diagnosis, treatment, and assessment of response to treatment; and there are established, evidence-based treatments for nightmares that appear to reduce nightmare frequency and distress, as well as other symptoms of post-traumatic stress. Mechanisms of action remain unclear, and the range of treatment options could be expanded, so further research is needed. In the meantime, viable nightmare screening and treatment options currently exist that have the potential to mitigate suicide risk. This review summarizes the extant body of research in this clinical area.

Ellis, L. (2024). The Alarming Nightmare-Suicide Link: Evidence, Theories, and Implications for Treatment. SIS Journal of Projective Psychology & Mental Health, 31(2).

Trauma-Related Nightmare Type Linked to Higher Suicide Risk

By Dr. Leslie EllisApril 24, 2024

Adding to the robust literature linking nightmares to suicide risk, a new study offers an important distinction for clinicians: of the 3 nightmare types identified by researchers, only trauma-related nightmares are linked to a greater risk of suicide (Youngren et al., 2024). Idiopathic and complex nightmares (comorbid with sleep and breathing problems) do not lead to higher suicide risk.

The study is important for a couple of reasons. First, it supports the theory of differing nightmare types and their resulting effects on mental health. Second, it provides guidance for clinicians who treat trauma, nightmares, and suicidality. The study also found that those who suffer from trauma-related or complex nightmares are more likely to seek treatment than those who experience idiopathic nightmares.

The study used a sample of 3,543 veterans who had previously attempted suicide. The main goal of the study was to examine the relationship of nightmare type to both suicide reattempt and treatment utilization. Multiple logistical regression analysis showed that when controlling for anxiety and depression, only trauma-related nightmares significantly predicted suicide re-attempts.

The authors speculated that the difference in nightmare content for trauma-related nightmares may account for their greater links with suicide. Trauma-related nightmares tend to be more direct replication of traumatic events, and are more easily recalled than other types of nightmares. Therefore, those who have frequent trauma nightmares are more likely to re-experience their traumatic memories. This can lead to life-threatening despair on its own. And it can also create higher levels of distress that interfere with sleep. Insufficient and poor-quality sleep have been clearly linked to suicide, with or without nightmares.

The authors advocate for nightmare treatment: “Regardless of the mechanism, our findings support treating nightmares to potentially reduce suicide risk.” They note that although prior studies how shown that both psychotherapy and medication failed to reliably help with PTSD-related nightmares (e.g. Peppard et al., 2013; Raskine et al., 2013), the outcome picture is altered when nightmare type is considered. According to a Youngren (2021), when nightmares are divided by type: “trauma-related nightmares appeared to decrease after nightmare-specific therapies such as ERRT, whereas complex nightmares did not.”

This is good news for clinicians. Nightmares directly related to trauma are most highly linked to suicide risk and also appear to be the most amenable to treatment. More good news – although previous studies suggest nightmares are vastly undertreated, the current study shows that those with trauma-related nightmares are more likely to seek treatment than those who suffer from idiopathic (less dangerous) nightmares.

Also noteworthy: the term ‘complex nightmares’ to denote nightmares associated with sleep-disordered breathing (SDB) is a new one. Such nightmares can also be trauma-related, but are associated with poorer dream recall. More research is needed to understand the distinctions between these complex states and their implications for treatment.

Overall this important study is yet another reason for clinicians to ask about nightmares, especially for those patients with suicidal ideation or previous attempts. Another step is to determine whether the dreams depict memories of specific traumatic events. If so, nightmare treatment is not only warranted, but according these recent finding, may reduce both the nightmares and the risk of suicide.

Don’t miss our 1-hour seminar on critical information for therapists about nightmares and suicide, including current research and how to help. We are currently offering a 30% discount! Click here to avail the promo!!

References

Youngren, W. A., Bishop, T., Carr, M., Mattera, E., & Pigeon, W. (2024). Nightmare types and suicide. Dreaming, 34(1), 1.

Youngren, W., Balderas, J., & Farrell-Higgins, J. (2021). How sleep disordered breathing impacts posttrauma nightmares and rescripting therapies. Dreaming, 31(1), 20–31. https://doi.org/10.1037/ drm0000161

Sleep Paralysis… curse or blessing?

By Dr. Leslie EllisApril 2, 2024

A first encounter with sleep paralysis (SP) is usually terrifying. But for those who experience it often and learn to stay calm, it can be entryway to lucid dreaming and extraordinary states.

Ryan Hurd, a sleep paralysis expert, has experienced hundreds of episodes himself and offers a road map for those who experience it. The following is a summary of his book, Sleep Paralysis, A Guide to Hynagogic Visions & Visitors of the Night.

In Hurd’s initial encounter with SP at age 14, all he wanted to do was wake up from the nightmare: first a ring, then a menacing voice that said, ‘Darkness rules!’ A pervasive felt sense of evil. The strong feeling of being pushed down forcibly into sleep. He was left feeling crazy, haunted and reticent to talk about his experience. It was classic a SP episode, and it deeply influenced the course of his life. He later became both a dream researcher, lecturer and lifelong lucid dreamer.

Symptoms of Sleep Paralysis

Hurd said the symptoms of SP are “near universal” and “noted throughout history and across cultures.” An episode might include one or more of the following:

Inability to move;
a feeling of great weight on your chest, abdomen and/or throat;
hearing buzzing or crackling sounds, or voices;
difficulty breathing;
heart racing;
extreme fear;
out-of-body experience;
electrical current or shock;
seeing lots of spiders or insects;
sensing, seeing and/or bring touched by an apparition or presence;
full awareness and a sense that what is happening is very real.

Isolated SP is common – about 40% of people experience it at least once in their lifetime (and a full 75% of post-secondary students). Alarming as it is, SP is a normal part of sleep, not pathological or a sign of psychosis.* It happens most often from sleep deprivation or disrupted sleep cycles (ie shift work, jet lag, late-night partying). It is an intrusion of REM/dreaming during the transition from wake-to-sleep or sleep-to-wake. In essence, your dreams are being superimposed onto the waking state. This is why the visions that arise can feel so real.

Ways to Manage Sleep Paralysis

Most people who experience SP occasionally simply want the hellish experience to stop. Hurd has found the following series of responses to be the most helpful:

Identify to yourself that you are having an eposide of SP
Surrender, don’t fight it (or it intensifies)
Wiggle your toes or clench a fist to break the paralysis
Focus on calm, steady breathing
Wait patiently for the episode to end, usually after a minute or two

Some people experience multiple episodes of sleep paralysis, or have a series of false awakenings. If you are worried about falling asleep and back into another episode, Hurd suggests you wake up more fully before going back to sleep:

Expose your eyes to bright light for a least a minute
Get up and do 10 minute of exercise
Write about the encouter in your journal

Then go back to sleep! Do not make things worse with even more sleep deprivation. To prevent SP, good sleep hygiene is essential… things like sleeping and waking at the same time every day, sleeping in a cool, dark, quiet place that you feel safe in, avoiding caffeine, alcohol and strenuous exercise too close to bedtime.

Get to Know the ‘Stranger’

For those who have learned to relax and go with the SP experience, and are brave and curious about the presence that appears to them, Hurd suggests turning toward the apparition with openness and trust (with the caveat that not all of the figures that appear are benign). However, if it feels available to you and safe enough, he suggests you relax, trust, be curious, ask what the stranger wants. These actions can transform the presence into something helpful and healing.

He notes that many tales of hauntings and magical creatures may in fact stem from sleep paralysis. A major clue is the timing of the visitation – if the presence appears at the edges of sleep, it is likely a hypnagogic hallucination. Vampires, the legend of the Sea Hag, ghosts, out-of-body experiences and even alien abductions may be attributed to sleep paralysis. It can also be a doorway to lucid dreaming and deeply spiritual encounters.

Sleep Paralysis as a Doorway to Extraordinary States

Despite his initially terrifying experiences with SP, Hurd now sees these as a “blessing in disguise.” If you recognize the state you are in as SP, you are already dreaming while awake, and can use this to co-create the kinds of dreams you would like to have. He suggest that once you have come to terms with your personal beliefs and have learned to relax into an SP state, you can “focus on the kinds of dreams you want to have and watch them materialize around you.”

He describes how you can use SP as an entrée into out-of-body experiences, lucid dreaming, creativity and spiritual growth.

Hurd even suggests ways to encourage SP (and of course do the opposite if you want to prevent it): Sleep on your back; take a nap when you are sleep-deprived or have jet-lag; or wake up 2 hours before your usual time, and nap later. When you nap while sleep-deprived, there is pressure to make up for a lack of REM sleep, and this intrusion of REM can induce the mixed state of SP.

The key message in all of this is that the valence of the visions which appear to us in a hynagogic state are dependent on the degree of safety we feel. The more frightened we are, the more terrifying the images that visit. It is an example of how we co-create dreams. If we stay calm, we can engage with the dream state while maintaining lucid awareness. Hurd notes that those new to lucid dreaming often treat it as a “virtual playground’ and invite fantasy experiences like flying or sex. But deepening into the experience can lead to truly extraordinary visions and “even a taste of enlightenment.”

Reference:

Hurd, Ryan (2011). Sleep Paralysis, A Guide to Hynagogic Visions & Visitors of the Night. Los Altos, CA: Hyena Press.

*Symptoms of typical isolated sleep paralysis are not considered harmful – unless they include sleep apnea, narcolepsy or other parasomnias. If you have any concerns, consult a sleep medicine professional for diagnosis and treatment.

How Are You Dreaming? A Very Simple Question to Screen for Suicide Risk

By Dr. Leslie EllisDecember 11, 2023

Your dreams are an excellent barometer of your emotional life. And for those at risk for suicide, they can be a warning sign that is too often ignored. I have been calling for more clinicians to ask about dreams when their clients are dangerously depressed, and am pleased to see that others are joining the chorus.

Geoffroy (2023) wrote a letter to the journal, Bipolar Disorders suggesting that clinicians ask one simple question of their clients at risk for suicide: How are you dreaming? He states that dreams and their recent changes represent “a meaningful warning signal of the suicidal crisis.” This simple inquiry could help detect one of the foremost causes of death worldwide, particularly lethal in youth populations.

There is a clear and growing body of evidence to show that nightmares represent an independent risk factor for suicide, even when depression, post-traumatic stress and other risk factors are adjusted for. I have written a comprehensive review article of this evidence, now in press (Journal of Projective Psychology and Mental Health, 2024). Here is the abstract:

Some compelling evidence cited by Geoffroy in his letter includes a review by Akkaoui and colleagues (2020) which concluded that chronic nightmares affect up to 70% of patients with personality, mood or post-traumatic stress disorders. The researchers concluded: “Nightmares are overrepresented in mood and psychotic disorders… These findings emphasize major clinical and therapeutic implications.”

Changes in Nightmare Content Can Predict Suicide
Another recent study underscores the importance of tracking the dream content of those in crisis. Geoffroy (2022) offers some clarity about specific ways that nightmares escalate prior to a suicide attempt. The study of 40 patients hospitalized for suicidal crisis found that 80% had experienced changes in their dream lives prior to their crisis. Two-thirds experienced bad dreams, half had nightmares and 22% had dreams about suicide. The researchers also noted a progression in the way dreams changed, with bad dreams appearing 4 months’ prior, nightmares 3 months’ prior and suicidal scenarios 1.5 months’ prior to the suicidal crisis. They concluded: “Dream alterations and their progression can be readily assessed and may help to better identify prodromal signs of suicidal behaviors.”

Nightmares and suicide are clearly linked, and much more can be done to research, inquire into and treat nightmares as a way of reducing suicide risk. In my clinical experience treating trauma and nightmares over two decades, I see great benefit in treating these dreams. The content itself can point to areas of trauma that need to be metabolized and integrated, and when this is achieved, the nightmares tend to change or sometimes cease altogether. Also, when patients are taught simple ways to rescript their nightmares, this can provide a constructive alternative to rumination leading to suicidal thoughts. These dreamers say they feel empowered when they know they can do something about their nightmares, which increases hope and agency, and improves sleep quality. All of these factors can reduce suicide risk.

For those interested in learning more about nightmare treatment and the nightmare-suicide link, I have a range of online courses available covering these topics in detail at https://drleslieellis.com/products/

References

Akkaoui, M., Lejoyeux, M., d’Ortho, M. & Geoffroy, P. (2020). Nightmares in Patients with Major Depressive Disorder, Bipolar Disorder and Psychotic Disorders: A Systematic Review. Journal of Clinical Medicine, 9(12), 3990.

Ellis, L. A. (2024, in press). The Alarming Nightmare-Suicide Link: Evidence, Theories and Implications for Treatment. Journal of Projective Psychology and Mental Health, 31(2).

Geoffroy, P. A. (2023). How Are You Dreaming? A Very Simple Question to Screen for Suicide Risk. Bipolar Disorders, (25)4, 341.

Geoffroy, P., Borand, R., Ambar Akkaoui, M., Yung, S., Atoui, Y., Fontenoy, E., Maruani, J., & Lejoyeux, M. (2022). Bad dreams and nightmares preceding suicidal behaviors. The Journal of Clinical Psychiatry, 84(1), 22m14448.

To Sleep Better, We Need to Surrender to Our Dreams

By Dr. Leslie EllisJune 15, 2023

A podcast review by Dr. Leslie Ellis

The main reason people don’t sleep is that they have a bad relationship with dreaming. – Dr. Rubin Naimin

I was so inspired by a recent conversation between Nikos Patedakis and Dr. Rubin Naiman on the Dangerous Wisdom podcast, I want to share some of their surprising and inspiring ideas —such as how befriending dreams can be the key to getting a good night’s sleep.

Sleep and dreaming are a different, and wider form of consciousness than waking. Many with sleep troubles fear falling into sleep and dreams because it means letting go of our accustomed waking state and the sense of self that comes with it, according to Naiman, a psychologist, author, Fellow in the American Academy of Sleep Medicine and clinical assistant professor of medicine at the University of Arizona’s Andrew Weil Center for Integrative Medicine.

We need to change how we think about sleep

Naiman consults internationally about sleep and dreams and believes patients with sleep problems are thinking about sleep in the wrong way. “The statement, ‘I can’t sleep’ makes no sense… because the presumption is that the part of me that I call ‘I’, the waking self, should be able to sleep, and it can’t. That’s where people get stuck, they try leverage waking to get to sleep.” In fact, our very efforts to fall asleep tend to engage our waking selves more deeply.

So how does he suggest we descend into sleep then? It’s more of an accident than a deliberate effort, and it takes a willingness to descend into a different state where our sense of self and ego are not as central, and there is a greater breadth of consciousness available. Naiman said that over the previous few decades, our collective consciousness has shrunk, in part a product of spending more time narrowly focused, indoors, and looking at various screens rather than the natural world. So when we begin to fall asleep, and dreaming begins to widen our horizons, we may feel overwhelmed.

Naiman said: “Sleeping and dreaming both require a fundamental willingness to allow consciousness to expand, but this may be something many are not comfortable with. A contraction of consciousness allows for the kind of focus essential to survival in the waking, material world. The problem is that if we stay there, we think that’s all there is.” He goes on to lament the current epidemic of sleep loss, which he says is actually dream loss, and that attention to dreaming is a glaring omission in modern sleep medicine.

“The main reason people don’t sleep is that they have a bad relationship with dreaming.” Naiman cites evidence that when those with sleep troubles are first letting go into the kaleidoscope of dreams and a dissolution of waking consciousness, they react to that “as if it were a stampede coming from the horizon.”

Psychedelics as an appetizer for expanded consciousness

Dreaming is a different order of consciousness, one that is both feared and repressed, but also sought after. Because we are being deprived of the mind-expanding properties of dreaming, we hunger for it. Naiman says this may be why there is such a resurgence of interest in psychedelics: “We have forgotten how to expand consciousness through sleep and dreams, so it makes sense we are fascinated that a molecule or mushroom can do that. I’m not opposed to that, but these are the appetizers, not the main course.”

Patedakis views mind-altering substances as a bridge but not the final destination: “You need to learn what your mind can do. And then you need to learn how to do it within yourself.” Both speakers advise proceeding gradually into wider ways of seeing and being because plant medicine can bring overwhelm and disorientation to those not prepared for a direct experience of expanded consciousness. As a culture, we have been taught to fear or dismiss such things.

Academic focus on the material world ‘distorts and impoverishes’ our self-understanding

Naiman quotes Gary Schwartz and a group of scholars lamenting the nearly absolute dominance of the material over the subjective in academic study. This has “led to a severely distorted and impoverished understanding of ourselves and our place in nature.”

Even those who practice mindfulness and other potentially consciousness-shifting activities often do so to become better in their waking life. They want to know what their dream means so they can apply it to their personal situation, missing entirely that dreaming reflects a much larger perspective, one that takes us beyond ourselves into a wider, more spiritual realm.

Dreaming as antidepressant

Naiman also speaks of the psychological importance of dreaming. “It processes, sifts, digests and assimilates waking experience. If we are not dreaming, we’re not assimilating, and we’re not being nourished by our waking experiences.” This could explain the well-known link between dream loss and clinical depression. Ironically, the medications to treat depression erode dreaming even further because most antidepressants suppress REM sleep.

The answer to the epidemic of depression and sleep loss, according to Naiman, is not to medicate the problems but to turn toward our dream lives and allow them to help us become more comfortable with a wider sense of who we are. “If we have a better relationship with the dream world, we definitely sleep better,” says Naiman.

Expanding Liminal Space, Extending Sleep

Building a bridge between waking and sleeping by dwelling in the in-between, the gradual transformation inward as night falls, is a natural way to drift into sleep. “In nature, sleep actually starts when the sun goes down and there is a beautiful, gradual transformation of consciousness through dusk, and also again through dawn.” Naiman suggests that we surrender to the night and to the dark, allow it to naturally expand our consciousness, and view it neither as inferior nor applicable to waking life. In fact, sleep and dream life is the larger vessel in which the narrower consciousness of waking is contained.

Below are the links to both Nikos’ interview with Rubin Naiman, as well my conversation with Nikos on experiential approaches to dreams (which is referred to in this interview).

Rubin’s podcast episode: https://dangerous-wisdom.captivate.fm/episode/recovering-sleep-and-dreams

Rubin’s YouTube link: https://www.youtube.com/watch?v=X_E4tyFw-8c

Leslie’s podcast episode: https://dangerous-wisdom.captivate.fm/episode/attending-to-our-dreams-dialogue-with-dr-leslie-ellis

Leslie’s YouTube link: https://www.youtube.com/watch?v=7NyYEd3neIg

References

Naiman, R. (2017). Dreamless: the silent epidemic of REM sleep loss. Annals of the New York Academy of Sciences, 1406(1), 77-85.

For more on experiential dreamwork for clinicians, visit www.drleslieellis.com

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

By Dr. Leslie EllisJune 1, 2023

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.

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

By Dr. Leslie EllisApril 10, 2023

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

Nightmares exacerbate mental illness, but treatment helps

By Dr. Leslie EllisJanuary 7, 2023

In clinical settings, nightmares are rarely inquired about, and even less often treated directly. Evidence that this needs to change is mounting. On a more positive note, nightmare treatment research continues to advance – and a new method shows that adding sensory triggers can strengthen treatment effects.

Review finds nightmares may contribute broadly to mental illness

A recent review by Sheaves (2022) found that nightmares may contribute to the development of psychiatric illness rather than being merely a symptom. The paper concludes that nightmare treatment may be an avenue for reducing threat-based disorders in particular.

Thirty-five studies were assessed overall. Although most were not designed to test the effectiveness of nightmare treatment, the researchers were able to note moderate reductions in PTSD and depression post treatment, plus some reduction in anxiety and paranoia following direct treatment of nightmares. As well, while nightmares are known to increase suicide risk, two studies suggest nightmare treatment mitigates this risk.

The study has an interesting focus on network approaches to psychopathology — an interest in symptoms that account for comorbid diagnoses. For example, sleep disruption can lead to a variety of mental illnesses and thus is identified as a clinical priority.

Three Ways Nightmares Worsen Mental Health

The authors suggest nightmares generate anxiety and subsequent hyperarousal that may lead to more nightmares, a feedback loop that warrants greater clinical attention. Nightmares can also exacerbate negative mood due to their distressing content. And via yet another avenue, sleep disruption, nightmares can contribute to a range of mental health issues. While nightmares are typically associated with PTSD, half of patients with psychosis or dissociative disorders and a third of those with mood disorders also experience problematic nightmares.

This research adds to the growing base of evidence for the need to treat nightmares. The authors are suggesting here that nightmares may not be an isolated symptom, but a more of a global one, and also a causal factor in the exacerbation of many forms of mental illness. While it is difficult to tease apart what is causal and what is symptomatic, it’s clear that once nightmares become chronic, they tend to make matters worse in at least three ways: by creating anxiety that generates more nightmares, by disrupting sleep and the myriad repercussions from that, and also by adversely affecting mood, especially if the dreamer dwells on the negative content.

Nightmare treatments: Education, rescripting and now, music!

Nightmare treatment can also work along several avenues. Most treatments include some relaxation and educational components that can help assuage anxiety generated by nightmares. Sometimes simple things like letting dreamers know dream content is not literal and is often an intensified image of a situation that needs attention can bring a helpful shift in perspective. For example, dreaming of killing a parent who is angry might signify an empowered response, reflecting a desire to effectively stop the aggression. It does not indicate murderous intent!

Understanding metaphoric nature of dreams brings perspective

In my extensive work with nightmares, I see two main avenues of intervention. The first is to address the activation – in terms of the nervous system, to dissipate the sympathetic charge. Working with the dream material and making sense of it in terms of metaphor often brings a new perspective. If needed, offering information about the nature of dreaming itself often helps those whose dreams are filled with gruesome or horrific content to see that this is not reflective of their character or personality, but truly just the nature of dreaming during turbulent emotional times.

Once the dream feels more approachable, I work with the dreamer to find ways to dream it forward, first by finding allies or resources to draw upon, ideally from within the dream itself. Bolstered, the dreamers typically imagine a different way forward, one that feels better in their bodies. Often, elements of these more empowered dream stories find their way into subsequent dreams, rendering them less nightmarish. Often even recurrent nightmares change, and sometimes they simply stop.

Sound added to nightmare treatment a promising new avenue

Technological advances suggest that it is quite possible to intervene in a bad dream and shift its trajectory – from the outside as well as the inside. For example, a recent study showed that pairing a revised dream sequence with a specific sound (a piano chord), and then playing the sound every 10 seconds during the dream-rich REM phase of sleep, would help them recall the new and improved version of the dream. This worked!

Perogamvros and colleagues (2022) tried it on half of a 36-person sample. All were treated for nightmares for two weeks using Imagery Rehearsal Therapy and half had the sound added. While all experienced a reduction in nightmares, those with the addition of the piano music reported fewer nightmares and more positive dreams than the control group, and these significant shifts were still apparent three months later.

The researchers noted that it was not the sound itself, but the memory trigger that accounts for the difference. Other sounds, or smells may also work to remind the dreamer of the positive shifts they created during dream treatment. This is called ‘targeted memory activation’ (TMR), a method that has been shown to enhance memory consolidation during sleep.

For more on how to treat nightmares, we have a full-length course and a lecture on nightmares and the nervous system. Or check out my web site for many other posts on this topic.

Schwartz, S., Clerget, A., & Perogamvros, L. (2022). Enhancing imagery rehearsal therapy for nightmares with targeted memory reactivation. Current Biology, 32(22), 4808-4816.

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.

Nightmare Distress: How we experience dreams is more impactful than what we dream

By Dr. Leslie EllisNovember 14, 2022

‘Mary’, a client in my clinical practice, had frequent, bloody, violent dreams and came to love them. She once dreamt of being shot point-blank but did not find this disturbing. The feeling in the dream, and in processing it after, was peaceful, almost spiritual. Another dreamer dreamt of scenes of her family around the table simply eating dinner, yet these dreams struck terror into her heart and left her feeling upset for the entire day.

It is often the case that the emotions present in a dream are not congruent with the dream scenario. There are many reasons for this, and many implications for clinicians who ask about and work with dreams and nightmares. The main point is that emotion is a key element in the dream, possibly more important than the imagery itself.

Images in dreams can be highly dramatic, metaphorical and even fantastical. The key is what they evoke. So when asking your clients about their dreams, always inquire about the emotional landscape as well as the visual one. And also understand that dream responses are something we can work with and change.

The words of Victor Frankl (1985) come to mind here: ‘Between stimulus and response, there is a space. In that space is our power to choose our response.” We can’t change the fact that our dream forest, however beautiful, is steeped in terror (unless we become lucid, but that’s another topic). However, when we process such a dream with open curiosity, we can change how we feel about it after the fact, and over time, develop a better relationship to our dreams in general.

Mary, for example, had an intense and loving relationship to her dreams, though most of them depicted frightening or violent scenes. And as we worked with them, we discovered that these intense dreams were particularly powerful for engendering deep emotion and change. This is why, as a long-term dream therapist, I look at dream content from a not-knowing stance, never assuming a dream is as bad (or good) as it appears. Instead, I accompany the dreamer on a search for cues of safety and support, and from this place of relative comfort, the whole dream can look and feel very different from the first impression it may have made.

A recent study (Mathes et al., 2022) into nightmare distress confirms much of this clinical experience I describe. The researchers confirmed earlier findings that the level of distress a nightmare brings is significantly influenced by exposure to childhood trauma, and acutely stressful life events. However, violent dream content was less impactful for the 103 participants with frequent nightmares than the emotions they experienced in response to their dreams, a result they did not expect.

The study tracked 103 participants, 59 of whom experienced frequent nightmares, measuring dream recall, nightmare distress, levels of childhood trauma, dream emotions and violent content, and distress related to current life events. The notion that current stressors can bring nightmares, especially for those with a history of adversity, was supported and offers an explanation for the increase in nightmare frequency and distress during the worst of the global COVID pandemic, for example.

However, your response and your attitude towards such dreams can make a real difference to the level of distress they cause. A recent study by Schredl (2021) supports this idea. He found that attitudes toward nightmares and also levels of neuroticism impact how nightmares affect us. But while we can’t change our history of adversity or alter many of life’s stressors, we can change our attitudes and responses toward our dreams. The more we learn and understand about nightmares, and the more we can turn toward our dreams with calm curiosity, the less they are likely to cause distress.

The conclusion Mathes reached about nightmare distress is that “emotional appraisal has a substantial influence on nightmares. This suggests that dreamers can influence dream experiences due to their reappraisal during the dream and probably also in waking life.” My substantial clinical experience working with nightmares suggests that latter is true and may affect the former. In other words, if we befriend our dreams in waking life, we are also more likely to do so within the dreams themselves.

For example, in a few nightmare treatment sessions, I invited ‘Paula’, who experienced frequent recurring nightmares, to gather up any helpful elements she could find in her dreams. She then began to do this from within the dreams. Her nightmares were always harrowing chase scenes, but as she became more curious and comfortable with them, she developed superpowers within the dreams, such as the ability to fly away or disappear. More importantly her feelings around the dreams shifted from abject terror to a sense of adventure. And while the content of these recurring dreams still often begins in similar way, her response, both within and after the dream, has shifted to the point where she would no longer call these dreams nightmares.

References

Frankl, V. E. (1985). Man’s search for meaning. Simon and Schuster.

Mathes, J., Schuffelen, J., Gieselmann, A., & Pietrowsky, R. (2022). Nightmare distress is related to traumatic childhood experiences, critical life events and emotional appraisal of a dream rather than to its content. Journal of Sleep Research, e13779.

Schredl, M. (2021). Nightmare distress, beliefs about nightmares, and personality. Imagination, Cognition and Personality, 40, 177-188.