Category: Nightmare Relief

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Nightmares Quadruple Adolescent Suicide Risk

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

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

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

 

Clinicians drastically underestimate nightmare prevalence

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

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

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

 

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

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

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

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

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

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

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

 

References

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

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

Pangelinan, B., Rischard, M. E., & Cromer, L. D. (2022). Examining changes in nightmare distress and frequency across treatment in a child sample: Which improves first? International Journal of Dream Research, 15(2), 198-204.

 

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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