Category: Trauma

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Trauma-Related Nightmare Type Linked to Higher Suicide Risk

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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

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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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What Can You Do About Your Nightmares? Ideas from a trauma expert

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There is a lot you can do, and some compelling reasons why you should take action to quell your nightmares, especially if you suffer from post-traumatic stress injury

Tom is awakened with a start by the sound of his own screams. Several nights a week in his dreams, he revisits the burning building, and hears terrified voices from inside, above the roar of the flames. The building has been deemed unsafe, he can only watch in frozen terror as the heavy beams start to fall and the building collapses. This is not an actual memory, but a condensation of all the times in his career as a firefighter that he arrived on the scene too late to save someone. Now, these memories haunt his dreams, and bring a deep sense of despair. What most people do not realize is that you do not need to simply suffer them; there is something you can do about nightmares.

Not all nightmares are a cause for concern

Nightmares plague almost all of us at different times in our lives. For the most part, this is not a problem, even though such dreams can be distressing. But if your nightmares cause significant distress, wreak havoc on sleep and adversely affect how you function during the day, it is really important to do something about your nightmares. About 5% of the general population and 30% of those with some form of mental illness fall into this category.

Researchers have established a clear link between nightmares and suicide, so if you have both suicidal thoughts and nightmares, you need to take action. Fortunately, what many people don’t realize is that there are many effective treatments for nightmares and they involve fairly simple steps. (If your therapist does not have training in nightmare treatment, some accessible online resources are listed below.)

Talking about your nightmares helps

Too few people talk about their nightmares; there is a tendency to think this wouldn’t help. Or that those you tell will judge you. Neither is true, and it really helps to talk about nightmares. Nadorff has studied nightmares extensively and concludes that “nightmares are a robust and modifiable predictor of increased suicidality and poor psychiatric outcomes” (2015, Journal of Clinical Sleep Medicine).

The good news is that nightmare treatment appears to work for many people. The research has raised many questions about what exactly is working and why, but it seems that almost anything that researchers have tried has the potential to make a difference. It may be that simply knowing nightmares can be treated opens the doorway to change.

Nightmare rescripting is the common denominator

There are many elements that have been incorporated into nightmare treatments. One of the most common is called nightmare rescripting. This is simply the process of coming up with a new ending to your nightmare. In the well-researched treatment modality called Imagery Rehearsal Therapy, people are asked to change their nightmare in any way they want, and then to imagine this new version a number of times before going to sleep. The research has shown this to be very helpful for many kinds of nightmare sufferers, from veterans to rape victims.

There are many variations on this treatment, and all appear to be helpful. I found in my practice that teaching clients to imagine a new ending to their nightmares is something they can do on their own, at home right when they wake up from a frightening dream. This gives them a constructive action to take, a way of calming down. They tell me it gives them a sense of control over their distressing dreams and takes away some of the fear of going to sleep. What is also good about such nightmare treatments is that they can not only help reduce nightmare frequency and distress, but they also reduce daytime symptoms of posttraumatic stress injury – things like flashbacks and a tendency to avoid situations that can trigger them. The other good news about most of the nightmare treatments studies is that treatment is quick, can make a difference in a session or two, and even if doesn’t help as much as you would like, the studies reported few if any adverse effects.

What to do when you wake up from a nightmare

When you are jolted out of sleep by a nightmare, your body will likely be quite amped up. So take a few minutes to let your heart rate and breathing slow down. Remind yourself gently that this was just a dream, and that it is not happening now, real as it may have seemed a few moments ago. Take a few long, deep breaths, extending the exhale to calm your nervous system. Calm your emotions by picturing in detail one of your favorite places or imagining someone you love deeply and amplifying the feelings you have about them. Look around the room for something comforting and to remind yourself you are safe in your bedroom, not back in the dream.

Once you feel calmer and better, go back to your nightmare images, just the very last part of the dream that woke you up, and allow the dream to play forward from there in any way you want. It does not have to come to a tidy resolution, although it might. Just let the dream play forward to find a better stopping place. Keep your breath slow and regular. What most people find is that this simple practice changes the dream for the better and gives the dreamer a greater sense of control and safety.

Nightmare changes can indicate trauma recovery

When I have treated patients with nightmares in a similar way to what is described above, I found that all of them experienced some kinds of changes in their dream life. Sometimes the nightmares stop altogether, but more commonly, they begin to change and start to look more like normal dreams – they are a bit stranger, more a of mix of past and present, and less of a direct replay of a trauma memory. This is an indication that the process of healing has begun.

When a traumatic event has not been metabolized, it can come back in the form of recurrent dreams that either represent or replicate the actual trauma event. The more the dreams of the trauma begin to weave in elements from current life, the closer the dreamer is to having integrated their trauma. The nightmares may not stop right away, but if they shift and start to feel more like normal dreams rather than repeated replays, this is a good sign.

Resist the urge to avoid treating nightmares

Both therapists and those who suffer from nightmares might be tempted to back away from conversations about their alarming content. But if you are suffering from the same kinds of terrifying dreams most nights, it is a mistake to think not talking about it will help in some way. It does not. Talking about it helps, even when the subject matter is intense.

Philosopher Eugene Gendlin said it this way: “What is true is already so. Owning up to it doesn’t make it worse. Not being open about it doesn’t make it go away… People can stand what is true for they are already enduring it.”

Current research has shown that even with the most unbearable trauma, such as those who were inmates of Auschwitz, it is better for survivors to talk about their dreams than try to bury them. A Polish researcher, Wojciech Owczarski, studied 500 dreams of 127 former inmates and found that only 10 percent are still suffering from recurrent dreams that replicate their trauma. He found that all the dreams had “therapeutic potential” either on their own or with the help of a therapist.

To wrap up, there are many reasons to talk about your nightmares, to rescript them, and to seek treatment if they cause you significant distress. These challenging dreams can be seen as your own body’s attempt to integrate the trauma you have suffered, but to realize this helpful effect, you must work with the dreams rather than avoiding them.

 

As a small gift to those who suffer from nightmares, I have made a free 7-minute self help video, dedicated to first responders and front-line workers. For those clinicians who want more information on treating nightmares, consider taking my online course: Nightmare Treatment Imperative.

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Dreaming in Times of Collective Crisis: A nocturnal perspective on Ukraine

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Recently I dreamt I was standing on a rocky, mountainous ridge, the stone an iron colour, like dust mixed with blood. I am looking for a way down, and all the options seem treacherous. Suddenly, the ground begins to split under my feet, a massive slice of it neatly dropping away. It feels as if this has destabilized everything around me, as if the earth’s crust has suddenly lost its integrity. I am left in a state of expectant waiting-for-disaster and not sure what form this will take. To me this dream clearly speaks to the devastation I feel as I watch, with the rest of the world, as the horrifying events of the Russian invasion of Ukraine unfold.

Like the recent global coronavirus pandemic, the war in Ukraine is an event that affects us all. It has destabilized the world and divided countries along ideological lines, which has the frightening potential of leading to a much larger war. The pandemic clearly infiltrated the world’s dreams, increasing dream recall and disturbed dreaming, and introducing themes related to health, loss of freedom, invisible threats and death. A number of studies have documented this global phenomenon, lending support for the continuity hypothesis that suggests that waking-life concerns find their way into our dreams. The same holds true for the way war now unfolding is infiltrating our collective dreaming.

In a recent and poignant session with one of my dream classes, I wanted to take a moment to acknowledge the harrowing events in Ukraine. I shared my dream and the personal nature of the war for me. Half my ancestry is a mix of Ukrainian, Russian and Polish. The borders have changed so much in the areas where my mother’s family originated that the same area was at times Russian, Ukrainian or Polish. The epicenter, according to my ’23 and Me’ ancestry test, is at Lviv, now part of Ukraine, part of the area that is being systematically reduced to rubble.

My dream of the ground splitting under my feet feels like a direct response and an apt metaphor for what is happening in Ukraine. This war feels very close to home, destabilizing and so much bigger than me. Others in the dream group, and in other dream circles I tend, have been reporting similar themes: dreams of invasion, of violence and displacement.

One poignant example was a recent dream offered by Theresa, her in-laws having immigrated over 50 years ago from what is now the Ukraine, Germans fleeing from the Russians. Recounting the dream, she said, “I am at my mother’s house. Looking out from the second-floor deck (of my current home), I see the new neighbour with his teenage sons looking towards me. They have torn down the fence and stripped my mother’s backyard of all its’ bushes and flowers. One tree remains, an apple, with only the trunk left standing. Now I find myself in my mother’s basement, the neighbour there with his boys, though younger in age. The room is wild, toys spread chaotically everywhere. I ask the one boy to clean up his mess and he defiantly refuses. I go upstairs to ask his father, the neighbour, and my husband, for help. By the time we return to the room, the toys are cleaned up and the other children confirm the young defiant one has helped…”

Many in the group could relate to the themes of invasion, destruction and utter disrespect of boundaries in the dream. There was a collective sense of grief, sadness and frustration expressed. However, the dreamer is given the last word in this dream process and Theresa said she ultimately saw this dream as one of reconciliation, the coming together of warring parts that have entered the foundation of her mother’s home; an invitation to have all take part in the commitment to a better way.

Recounting the dream brought deep and surprising emotion for the dreamer. Theresa said that her dream invited process at the collective as well as personal level, speaking to the situation in the Ukraine, and her life. She recognized the dream was showing her the power of our own ‘sacred motherland’ and at another level, the strength of the archetypal divine feminine to stand loving and firm while holding chaos and destruction. She felt the dream was hopeful in that her call for help was answered by the two adult men, as well as the children. One apple tree was left standing, the potential for regrowth still present. (The biblical symbolism of the garden of Eden is not lost on us.)

When I had my dream of the ground splitting, or when someone brings a dream of invasion and destruction, I wonder, as I am wont to ask, what is helpful about such dreams?

For the dream groups I am hosting, discussing dreams in times of crisis gives us a venue to feel and express our concerns and the deep emotion that has been stimulated by world events. We can hold each other in our grief and sorrow. Many of us have been given an image or a metaphor for our deep unexpressed feelings. This does not solve the larger problems, but it does make us feel less alone with them and it prompts action, in whatever ways we can offer help.

That world events can infiltrate our dreams makes sense because intense emotion is the fodder of dreams. World crises are changing our dreams collectively, demonstrating how we are all in this together. Information travels fast, and no longer do massive humanitarian crises take place in secret. My hope is the increasingly collective nature of world events can begin to sow the seeds of peace.

Near the close of the dream group, one member, through her tears, spoke in response to Theresa’ dream, “The devastation image was so immediate and resonant of Ukraine, and then Theresa brought such compassion to it. If we are going to dream our mutual dream of the human race forward, this is what will lead us.”

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REM Rebound: Managing intensification of dreaming when sleep deprivation or substance use stops

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When you end a period of sleep deprivation or substance use, your dreams return, sometimes with a vengeance. Dr. Leslie Ellis explains how to understand and manage REM rebound.

While the global pandemic has been identified as a big factor in the recent increase and intensification of dreaming, a phenomenon called REM rebound may be the mechanism at work in some cases. REM sleep is so important that following a period of REM deprivation, our bodies will automatically make up for what it has missed. REM rebound is characterised by intense dreaming and a structural shift in the normal sleep cycle.

Sleep rhythm will return to normal once we have made up our REM sleep debt. This can take days or weeks depending on why, how long and how severely the sleep cycle has been disrupted. There is much in the literature about how to manage sleep problems associated with REM rebound, but very little in the way of help with what to do about all those troublesome dreams. Read on for some simple suggestions from a clinical dream and nightmare expert.

 

What is REM rebound?

First, we need a basic understanding of rapid-eye-movement (REM) sleep. This is the sleep stage most associated with dreaming. In a typical night, we have 4-5 REM sleep periods that gradually increase in length over the course of the night. In total, we spend about 90 minutes or more in REM sleep during a typical 8-hour night of sleep, with most of our REM concentrated toward morning. If we become deprived of REM, our bodies will drop into REM immediately upon falling asleep instead of moving through the progressively-deepening cycles of non-REM sleep that typically start our night. This is REM rebound, a natural increase in REM to make up for what was missed, often due to sleep deprivation or the kind of stress that leads to restless, broken sleep.

There is considerable research to support the notion that REM sleep and dreaming help to regulate emotional reactivity and to reframe negative experiences. REM sleep affects hormonal balance and sleep homeostasis. To return to the normal, restorative sleep patterns so important to all aspects of our health, we may need to go through a period of intense dreaming to allow our sleep rhythm to reset itself. My suggestion is to befriend this process. A first step is to understand that even our most frightening nightmares are trying to help us by balancing our emotional state and taking the charge out of challenging past and current life situations. We can work with them, not against them. More on this later.

 

Substance Use and REM Rebound

The most common cause of REM rebound is sleep deprivation, especially very early awakening that cuts off the second half of our sleep. REM rebound also happens when a person stops taking a substance that suppresses REM sleep. These include many commonly-used substances like antidepressants, alcohol, cannabis and benzodiazepines. Paradoxically, many of these substances are used to promote sleep – and while they can help you fall asleep, they disrupt normal sleep architecture, ultimately making the situation worse. (Newer sleep aids like zolpidem do not cause this problem.)

Sleep is critical to our emotional and physical health. Insufficient or poor-quality sleep is associated with poor emotional regulation, diminished ability to consolidate memory, a higher risk of psychiatric illnesses (depression, anxiety, PTSD), obesity, heart disease and stroke as well as increased risk of workplace and vehicle accidents. Clearly, getting a good night’s sleep is critical to all aspects of our health. Getting sufficient REM is intrinsic to this process.

The best way to overcome REM rebound is simple, yet it can also be a challenge for those with chronic difficulty sleeping well. You simply need to get enough good-quality sleep to make up the REM that your body requires. There are plenty of resources available on good sleep hygiene: things like a calming bedtime routine, limiting screen time, caffeine and alcohol before bed, and getting enough exercise are well documented and can help.

However, for some people, the intensely disturbing flood of dream imagery following the cessation of substance use can make it tempting to go back to taking the antidepressant medication or addictive substance they want to stop using. For those in this category, part of the answer is to befriend your dreams, especially those that have returned with great intensity following a period of silence. If you have intense, frequent and disturbing nightmares during the REM rebound period, making friends with these dreams may seem like an impossible task, but it’s not. Few people realize that nightmares are both treatable, and in many ways, also helpful in the emotional recovery process.

 

Changing Your Relationship With Your Dreams

Dreams and nightmares have been shown to temper emotional intensity. Studies suggest that when we dream about a disturbing scenario, we generally feel better about it than we did before. The big problem with nightmares is that they can be so intense, they wake the dreamer up, so they disrupt sleep rather than helping. A simple solution is to imagine the dream forward; just let it continue from where it left off until you get to a place that feels like more of a resolution. It doesn’t even have to be a triumphant solution, just one that carries the dream forward.

In my experience, this simple process can effectively stop or change a nightmare immediately. It can also take a few tries, and in some cases might require professional help. If you have PTSD or a history of trauma, a professional trained in working with nightmares can make the difference. There are many studies on a version of this method called Imagery Rehearsal Therapy (IRT) that show it often helps, and when it doesn’t, it causes no adverse effects. In other words, it’s worth a try.

In general, getting to know more about your dream world and what it’s trying to tell you will set you up for a more positive relationship with your dreams. I have written extensively about this, and will post a list of resources in the references below. My main message, having worked for decades with the dreams of those recovering from trauma and addiction, is that your dreams are trying to help you, not hurt you. Dream lovers welcome the flood of nocturnal images that characterize a REM rebound. If you are someone who has stopped the use of a REM-suppressant substance, for whatever reason, be prepared for the dreams that will come to you, and find a way to welcome them. Also know that the condition is temporary and if you can stay the course, your normal sleep rhythm will return.

 

Dr. Leslie Ellis is the author of A Clinician’s Guide to Dream Therapy, and an expert in dreamwork and nightmare treatment. Her web site (www.drleslieellis.com) contains many resources about how to work with dreams and nightmares.

 

Resources:

There Are No Bad Dreams – a Ted-like talk about nightmares.

Nightmare relief, free PDF: What you can do about nightmares

For clinicians: A Short Focused Course on Nightmare Treatment

Live Oct. 13 (and recorded) Live workshop on Nightmares and the Nervous System

Blog post: Whether and how to work with traumatic nightmares

Blog post: Whether and how to work with traumatic nightmares

 

Selected references for this article:

Ellis, L. (2019). A clinician’s guide to dream therapy: Implementing simple and effective dreamwork. New York: Routledge.

Feriante J, Singh S. (2020). REM Rebound Effect. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560713/

Krakow, B. and Zadra, A. (2006). Clinical management of chronic nightmares: Imagery Rehearsal Therapy. Behavioural Sleep Medicine, 4(1), 45-70.