Category: Trauma therapy

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Dream changes help clinicians predict suicidal behaviors

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There is a well-established link between frequent nightmares and a greater risk of suicide, but until now, there has been no sense of specifically what to watch for in a client’s dream life to signal that their risk is escalating. However, a group of researchers has just published an article on how dreams change prior to suicide attempts.

I have long been suggesting that clinicians ask about nightmares and offer treatment if warranted. This recent study underscores the importance of asking about dreams – and offers some clarity about specific ways that nightmares escalate prior to a suicide attempt.

The naturalistic study collected dream information from 40 patients that were hospitalized for suicidal crisis, and found that 80 percent of them had experienced changes in their dream lives prior to this crisis. Two-thirds experienced bad dreams, half had nightmares and 22 percent had dreams about suicide.

The researchers also noted a progression in the way dreams changed prior to the suicidal crisis, with bad dreams appearing 4 months’ prior, nightmares 3 months’ prior and suicidal scenarios 1.5 months’ prior. They concluded: “Dream alterations and their progression can be readily assessed and may help to better identify prodromal signs of suicidal behaviors.”

The researchers studied the differences in those whose dream lives changes prior to their suicidal crisis versus those whose dreams stayed much the same, and found that those with altered dreaming had more of a family history of insomnia. Virtually all had symptoms of depression and altered sleep quality prior to their hospitalization.

The bottom line is that when you ask clients about their dream lives, you can also be alert to any changes. An increase in bad dreams that escalates to more frequent nightmares is an important change that may predict a suicidal crisis. Content of the dreams might provide some clues as well, though they are not going to dream about suicide specifically in most cases.

The other important consideration in your treatment of those who dream and sleep disturbance is escalating is that you can treat these as symptoms, not just as warning signs, and you may be able help them course-correct through direct attention to their nightmares. In other words, dream changes are not just diagnostic, but also avenues for treatment that may reduce suicide risk.

For more about what you can do to treat nightmares, I am offering a time-limited nightmare treatment course bundle, an in-depth online training for clinicians which includes a workshop on nightmares and the nervous system. You can check it out here.

References

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), 1

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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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Treating Trauma and Addiction with the Felt Sense Polyvagal Model: A Bottom-Up Approach

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A timely and compassionate book on treating trauma and addiction using the Felt Sense Polyvagal Model.

Just at a time when the wider world is waking up to a more compassionate and inclusive way of understanding trauma and addiction, a timely book that addresses these issues in personal, historical, embodied and practical ways has arrived. In Treating Trauma and Addiction with the Felt Sense Polyvagal Model: A Bottom-Up Approach (Routledge, 2021), author and psychotherapist Jan Winhall both demystifies and depathologizes addiction. She does so by demonstrating in theory and with compelling case studies how addictive behaviours are in fact resourceful attempts to regulate a body that has been thrown out of homeostatic balance by traumatic experience.

Winhall’s new book incorporates both focusing and the polyvagal theory to create a treatment model for that is both effective and humane. It’s a model to help those afflicted with addictions and other effects of trauma understand their own physiological and emotional responses, and begin to take steps toward change that are both self-compassionate and doable.

Winhall explains how addiction is a propeller of neurophysiological state change, and in doing so, she solves the mystery of addictive behavior that puzzled her so much as a young therapist. She begins her book with the compelling story of her first women’s group and the mystery of their deeply self-harming behaviors. At the time, she simply couldn’t understand why this fascinating group of young incest survivors would engage in such self-destructive acts. Rejecting the idea that they were simply damaged, broken and ‘borderline’, Winhall went on a decades-long hunt for a more compassionate understanding of how to help these women heal.

A consistent thread through the book is Jan’s story of her own development as a trauma therapist, and it illustrates the evolution of ideas about the etiology and treatment of trauma over the past 40 years. Early influences include Bass and Davis’ The Courage to Heal, and Judith Herman’s classic, Trauma and Recovery. Add to this mix a deep understanding of Eugene Gendlin’s focusing, which brings a way to listen to the body in a way that assumes it knows the way forward. Stir in a healthy grounding in Dan Siegel’s interpersonal neurobiology, Bowlby’s attachment theory, the compassionate views of Gabor Mate, the relational wisdom of Harville Hendrix and Helen LaKelly Hunt, and finally, the updated understanding of the nervous system’s response to threat and connection as proposed in Stephen Porges’ polyvagal theory.

When you combine all of these embodied, compassionate approaches to working with trauma and addiction, what emerges is a model that stands in stark contrast to the medicalized version which pathologizes those who have already suffered so greatly. As Jan so aptly demonstrates, those who have suffered trauma and subsequently engage in a range of addictive behaviours are not broken, but in fact, doing their best to manage their pain and overwhelming emotions in the ways that are most available to them. It reframes their stories from tales of illness to journeys of triumph and liberation.

Winhall’s definition of addiction is a simple and non-judgmental one: “It helps you in the short term, hurts you in the long term, and you can’t stop doing it.” However, the historic view of addictions is not so kind. Winhall leads the reader through a history lesson that shows how the war on drugs, and the controversial evolution of the ‘disease model’ of addiction has led to racist and pathologizing ways of viewing addictive behaviour. It has also prompted many resilient trauma survivors to view their own attempts at self-regulation as shameful and bad, an attitude that hampers their recovery.

The Felt Sense Polyvagal Model

Over her many years of working with those who have suffered from trauma, and with a naturally compassionate and inquiring approach, Winhall has developed a model that makes sense of addictive responses that alleviates blame and shame, and replaces it with ways that clients can make sense of their own shifting states. Through a clear, graphic diagram of the physiological states described by Porges’ polyvagal theory, and guidance on how to map one’s unique pattern of experiences onto this chart, clients can begin the make sense of their own behaviours. They are then offering tools to help them decide how to take systematic and doable steps toward changing those behaviours that are most hurtful in the long term into more healthful ways of managing intense states.

Winhall has included both a detailed model for clinicians and a simplified one for clients in the book as a visual aid for understanding patterns of behaviour that can readily be reframed from addictive to adaptive. In addition, she offers a detailed Embodied Assessment and Treatment Tool (EATT) and a comprehensive list of focusing-oriented strategies that can be tailored to particular clients and their unique challenges. There is also a version for couples, and a lovely case study of how these tools led a couple struggling with the impact of childhood sexual abuse toward deeper connection, understanding and mutual compassion in the face of the painful experience of sex addiction.

Focusing and Thinking at the Edge

Focusing, developed by Eugene Gendlin, is another thread that runs through this book, and is a foundational practice for Winhall. She takes us back to her first meeting with ‘Gene’, as he is affectionately called, and the ways in which his conception of the felt sense brought all of the pieces of the puzzle together for her. She writes, “The felt sense contains the whole of our experiencing, including content and process, thinking and feeling: the sweet spot of integration.”

Winhall’s book not only contains a primer on focusing concepts and their rich underlying philosophy, but also practical examples and many places in the book that invite the reader to pause, check inside, and engage in the material in a focusing-oriented way. In this way, the book is an example of what it describes, a personal journey into the heart of addiction and trauma that invites an embodied response to the material, not just an intellectual one.

In travelling this journey that Winhall takes you on, weaving historical and factual information with personal vignettes, and poignant case studies told with the mastery of a novelist, there is another enduring theme that emerges: one of consilience. What we see, over the course of this immersive journey, is how all of these ideas are related, how they are often different ways of saying the same thing. This makes sense: we are all human beings, sharing the same basic emotions and responses, and Winhall helps us see how we are truly all in this together. Addiction and responses to trauma are not something ‘out there’ that only ill and damaged people engage in. Rather, we are all ‘shaky beings’ (to use Gendlin’s phrase) that are doing our best to self-regulate, to engage in life, and if needed, to liberate ourselves from patterns of behaviour that were brilliant solutions at the time, and may need updating.

The FSPM teaches us all how to identify our autonomic states, to feel into them in the moment and to understand what drives them. It teaches us how to deepen into our own experience and to subsequently guide others into this inner terrain in ways that feel safe and respectful. It moves us from a medical model to one of both self and co-regulation, from framing responses to trauma as acts of triumph and courage rather than freakish acts of self destruction.

This book reads like a story that begins and ends with Winhall’s first women’s group, and her lifelong drive to understand and help these women heal. She offers the example of Bridgette, who was convinced she was a ‘freak’ because of the times she would awaken from a dissociated state to find she had taken a razor to her own vagina. Winhall speaks of how she knew, even before she had fully articulated her model, to ground and connect Bridgette and to ‘validate and celebrate’ her body’s response to trauma, to see it as a way to release the pain and shift away from an unbearable state.

Jan writes, “As I explain this new way of understanding, her face opens. She looks around and see the women in the group riveted by her journey. It is their journey too. Looking incredulous, her jaw drops, and she lights up. Bridgette moves from feeling like a disordered person to a hero who made it through living hell. It is a moment of liberation, a profound shift that changes everything. These moments of liberation, arising out of a system that shames and pathologizes, are the heart of transformational healing. I pause here inside. These are the moments that I live for in the work.”

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Does Your Child Wake Up Screaming? How to understand and treat night terrors

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I used to dread going to bed when we lived in my lovely heritage apartment in Vancouver. Every night, about two hours after falling asleep, I would be startled awake by the most blood-curdling, agonizing screaming from the woman next door. Her window faced ours, and she sounded as though she was being murdered in her sleep almost every night. I wondered why no one would wake her up or help her. I have since learned that this would not have done much good as she was having night terrors.

So many people I’ve spoken with about this have suffered the same thing with their children. Night terrors are fairly common in very young children, affecting 20-40% of children under age 3, and 3-14% of school age children, but just 2% of adults (APA 2013). In a typical episode, parents will put their child quietly to bed only to hear them thrashing and screaming in terror about three hours later. The kids were hard to fully wake up, disoriented and confused, often with little or no memory of the incident in the morning.

Night terrors are often mistaken for nightmares. At a recent talk I gave about nightmares, most of the questions were actually about night terrors – from desperate parents wanting to know if there was something they could do about them. I treat nightmares, not night terrors, but I did some investigation, and there are a few things to know and to do that can help. First and foremost, know that they are generally benign and kids usually grow out of them.

Who Has Night Terrors?

Before I get into some of the ways you can help your child with their night terrors, it helps to understand what they are, who has them and why. A thorough survey of the literature suggests that although the exact cause is not well understood, genetic, developmental, environmental, psychological and organic factors can all play a part.

Night terrors most common in early childhood. A longitudinal study (Petit et al., 2015) of 1,940 children from Quebec found that 34% of children aged 18 months experience night terrors, 13% at age 5, and 5% at age 13. A recent review (Leung et al., 2020) found the peak may be later, at age 5-7 years. Either way, sleep terrors typically start at a very young age and stop at adolescence. It’s rare that the condition continues into adulthood – although for some it can switch to sleepwalking.

Sleep terrors are more common under a number of conditions that can be controlled, at least to some degree, such as: sleep deprivation, going to bed with a full bladder, emotional stress, anxiety (including separation anxiety), bullying, a noisy sleeping environment and excessive alcohol or caffeine. Other factors associated with this parasomnia include: febrile illness (unexplained fever), ADHD, autism, epilepsy, sleep apnea and PTSD. Some medications, especially those that are sedative, can lead to night terrors because they increase the duration of non-REM, the deep sleep stage in which these episodes occur.

It bears repeating the while night terrors are very distressing and can disrupt sleep for both children and their parents, they are not considered dangerous. They warrant clinical attention only if they are severe enough to disrupt daytime functioning. If you are considering consulting a doctor, keep a sleep diary and track BEARS. Not the big furry animal, but the 5-item assessment tool for children with sleep problems (Owens & Dalzell, 2005):

  • B: bedtime issues
  • E: excessive daytime sleepiness
  • A: night awakenings
  • R: regularity and duration of sleep
  • S: snoring

What Are Night Terrors?

In a typical episode, the child will sit bolt upright or even jump out of bed, heart racing, screaming in terror. They may speak, but what they say will be confused and incoherent because although they appear to be awake, they are in a hybrid sleep-wake state. They will be difficult to wake fully because these episodes occur during very deep (slow-wave) sleep. It’s best not to wake them up during an episode, and typically they won’t recall a thing in the morning.

Night terrors are distinguished from nightmares because they happen in the first half of the night associated with the deeper (stage 3 and 4) of non-REM sleep, while nightmares mainly occur in the second half, and are associated more with REM sleep and dreaming. Nightmares are clearly recalled in vivid detail, and those who have them tend not to thrash around and scream.

Night terrors are much more common in children. When they continue into adulthood, they look a bit different. While two-thirds of children have no recollection after episodes of night terrors or sleepwalking, the same proportion of adults do recall at least one experience and remember their episodes about half the time (Castelnovo, et al., 2021). For adults, night terrors appear to be more of a dissociative experience, and can be accompanied by hallucinations.

What you can do about night terrors

While none of the suggestions below work all the time, there are a number of things you can try to reduce or even eliminate night terrors. Excellent sleep hygiene (such as regular bedtimes; limiting screen time, no food and drink before bed, especially sugar and caffeine; dark, cool quiet bedroom; and wind-down rituals like story time) can all help reduce night terrors. Parents can also do their best to limit stresses on kids who have night terrors – things like bullying and separation anxiety might be addressed. Interestingly, psychological factors are found to be mostly associated with night terrors in teens and adults, but not children.

Wake-up treatment. One treatment that has met with some success is to wake a person up about half an hour before they would typically have an episode. If you do this for two weeks, it can break the cycle and stop it from recurring. In some cases, however, the episodes simply start occurring later in the night.

Co-sleeping. One interesting paper (Boyden, Pott & Starks, 2018) suggests that sleeping with your child stops night terrors, especially with very young children. The authors say that evolution did not design humans to sleep alone when very young and that “night terrors are the result of an environmental mismatch between evolved behaviour and the modern cultural practice of solitary sleeping.” This solution has not been empirically tested, but anecdotally, it appears to work for many.

The bottom line is that while night terrors can seem extreme, they are usually benign and your child will experience them less and less over time. There are a number of things you can try, such as good sleep hygiene, limiting stress, waking them prior to an episode and co-sleeping. To all those exhausted parents reading this, I hope it has been of some help.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Davey, M. (2009). Kids that go bump in the night. Australian Family Physician, 30, 290- 294.

Ekambaram, V., & Maski, K. (2017). Non- rapid eye movement arousal parasomnias in children. Pediatric Annals, 46, e327-e331. doi:10.3928/19382359-20170814-01

Golbin, A.Z., Guseva, V.E., & Shepovalnikov, A.N. (2013). Unusual behaviors in sleep as “compensatory” reactions aimed at normalizing the sleep–wake cycle. Human Physiology, 39, 635-641. doi:10.1134/ S0362119713060042

Ivanenko, A., & Johnson, K.P. (2016). Sleep disorders. In M.K. Dulcan (Ed.), Dulcan’s textbook of child and adolescent psychiatry (2nd ed.). Arlington, VA: American Psychiatric Publishing.

Laberge, L., Tremblay, R.E., Vitaro, F., & Montplaisir, J. (2000). Development of parasomnias from childhood to early adoles- cence. Pediatrics, 106, 67-74. doi:10.1542/ peds.106.1.67

Leung, A. K. C., Leung, A. A. M., Wong, A. H. C., & Lun Hon, K. (2020). Sleep terrors: an updated review. Current Pediatric Reviews, 16(3), 176-182.

Murphy, P.J., Frei, M.G., & Papolos, D. (2014). Alterations in skin temperature and sleep in the fear of harm phenotype of pediatric bi- polar disorder. Journal of Clinical Medicine, 3, 959-971. doi:10.3390/jcm3030959

Nguyen, B.H., Pérusse, D., Paquet, J., Petit, D., Boivin, M., Tremblay, R.E., & Montplaisir, J. (2008). Sleep terrors in children: A prospective study of twins. Pediatrics, 122, e1164- e1167. doi:10.1542/peds.2008-1303

Petit, D., Pennestri, M.H., Paquet, J., Desautels, A., Zadra, A., Vitaro, F.,…Montplaisir, J. (2015). Childhood sleepwalking and sleep terrors: A longitudinal study of prevalence and familial aggregation. JAMA Pediatrics, 169, 653-658. doi:10.1001/ jamapediatrics.2015.127

Salazar, F., Baird, G., Chandler, S., Tseng, E., O’Sullivan, T., Howlin, P.,…Simonoff, E. (2015). Co-occurring psychiatric disorders in preschool and elementary school-aged chil- dren with autism spectrum disorder. Journal of Autism and Developmental Disorder, 45, 2283- 2294. doi:10.1007/s10803-015-2361-5

Silvestri, R., Gagliano, A., Aricò, I., Calarese, T., Cedro, C., Bruni, O.,…Bramanti, P. (2009). Sleep disorders in children with attention- deficit/hyperactivity disorder (ADHD) re- corded overnight by video-polysomnography. Sleep Medicine, 10, 1132-1138. doi:10.1016/ j.sleep.2009.04.003

Wolke, D., & Lereya, S.T. (2014). Bullying and parasomnias: A longitudinal cohort study. Pediatrics, 134, e1040-e1048. doi:10.1542/ peds.2014-1295

Are you a parent concerned about the frequency and intensity of your child’s bad dreams? Should you be concerned?
Learn more about Nightmare Relief for Everyone designed by nightmare expert Dr. Leslie Ellis, this self-paced user-friendly and accessible online course covers the very latest in science and research about what nightmares are, and what they’re not. Leslie offers some simple steps you can take to get some relief from nightmares and other nocturnal disturbances – both for yourself and for others, including your children.

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Dream Changes During the Pandemic Reflect Massive Collective Trauma

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A multinational study concludes that dreams are a reflection of massive collective trauma, and that dreams and dream recall must be integrated into approaches for improving mental health and health in general.

By Dr. Leslie Ellis

Since the beginning of the COVID-19 pandemic, the world has collectively been dreaming more, and our dreams have reflected the rise in stress levels, fear and uncertainty. A group of 23 researchers from 14 countries teamed up to take an in-depth look at how the pandemic has affected our dream recall and how this impacts health and mental health. They conclude that dreams are “an often-forgotten expression of the existential situation of individuals” and that they need to be integrated into how we understand and support mental health.

A recent multinational study of more than 19,000 adults explored the associations between dream recall frequency and related social, health and mental health factors, comparing data prior to and during the pandemic across four continents and 14 countries. Higher dream recall was linked with nightmares, sleep talking, recurrent disturbing thoughts and PTSD symptoms. As in previous studies, this one showed that women have been affected more than men, but also that those aged 55-64 had lower dream recall than younger people.

While the higher intensity of emotion during the pandemic has generated more dream recall — associated with more PTSD symptoms, problems with sleep maintenance, more nightmares and parasomnias — there is one interesting finding that bears further inquiry. Contrary to earlier studies, in the one, high dream recall was negatively associated with depression and anxiety. This could be because dreaming can help regulate the strong emotions people are experiencing in these turbulent times. However, the authors speculate that it could also be the result of the dream-dampening effect of anti-depressant medication. They said not enough specific data was collected to solve this riddle.

The study’s authors wrote: “The COVID-19 crisis has touched every person in the world in some way, whether it is related to becoming infected, suffering financially, through reduced social contacts, missed opportunities, or an inability to get required supplies and materials. It has become a communal trauma that has a profound impact on people around the world. One of the most difficult aspects of the pandemic is social isolation and confinement. Solitude goes against our inborn social instincts to form and maintain relationships as human beings and live in herd- or swarm-like alignments. Recent research has shown that the pandemic has led to increased anxiety levels, panic attacks, irrational fears, post-traumatic stress, depression, fatigue, reduced sleep quality, and sleep disturbances. Given the effects it has had on our everyday lives, perhaps it is unsurprising that COVID-19 has crept into our dreams.”

Earlier, smaller studies in various parts of the world (China, Italy, USA) have corroborated the findings that our dreams have been more intense and frequent during the pandemic, and that there are differences in how men and women have been dreaming. For example, a US study found that women with higher education were affected more than others, and several Italian studies showed that while all of us have experienced an increase in dream recall, women have been more affected.

“Since the pandemic has reportedly led to worsened mental health and higher levels of depression, anxiety, distress and symptoms of PTSD, heightened dream recall frequency might be an expression of the current mental health status,” according to the study authors. Women may be more affected as they have had to face more of the load – including increased childcare and health care responsibilities and greater job losses.

In their concluding comments, the authors called for more attention to dreams in mental health care and in general. “Dreams and dream activity are an often-forgotten expression of the existential situation of individuals. Based on our results, we assume that disruption in sleep patterns due to changes caused by the pandemic explains the increase in dream recall. Additionally, we propose that the observed increased dream recall frequency in our sample is an expression of the emotional intense and demanding experience of the current situation and could be an indicator that the pandemic is indeed turning into a collective trauma… Therefore, dreams and dream recall deserve more attention as potential support for coping with crisis situations, such as the COVID-19 pandemic and overall in supporting psychological wellbeing. Dreams and dream recall need to be accepted more and integrated into approaches for improving mental health and health in general.”

 

If you are a mental health professional interested in learning more about nightmares, parasomnias, and their treatment, sign up for my short, focused online course. Because I feel this material is important to disseminate, the course is always open, is self-paced, and discounted during the pandemic. Please ask your clients if they have nightmares, and let them know they are treatable.

 

Check out the Short Focused Course on Nightmare Treatment using THIS LINK. 

References

Fränkl E, Scarpelli S, Nadorff MR, Bjorvatn B, Bolstad CJ, Chan NY, Chung F, Dauvilliers Y, Espie CA, Inoue Y, Leger D, Macêdo T, Matsui K, Merikanto I, Morin CM, Mota-Rolim S, Partinen M, Penzel T, Plazzi G, Sieminski M, Wing YK, De Gennaro L, Holzinger B. How our Dreams Changed During the COVID-19 Pandemic: Effects and Correlates of Dream Recall Frequency – a Multinational Study on 19,355 Adults. Nat Sci Sleep. 2021;13:1573-1591
https://doi.org/10.2147/NSS.S324142

Iorio I, Sommantico M, Parrello S. Dreaming in the time of COVID-19: a quali-quantitative Italian study. Dreaming. 2020;30(3):199–215. doi:10.1037/drm0000142

Nielsen T. Infectious dreams. How the COVID-19 pandemic is changing our sleeping lives. Sci Am. 2020;323:31–35.

Pesonen A-K, Lipsanen J, Halonen R, et al. Pandemic dreams: network analysis of dream content during the COVID-19 lockdown. Front Psychol. 2020;11:2569. doi:10.3389/fpsyg.2020.573961

Scarpelli S, Alfonsi V, Mangiaruga A, et al. Pandemic nightmares: effects on dream activity of the COVID-19 lockdown in Italy. J Sleep Res. 2021;e13300. doi:10.1111/jsr.13300

Schredl M, Bulkeley K. Dreaming and the COVID-19 pandemic: a survey in a U.S. sample. Dreaming. 2020;30(3):189–198. doi:10.1037/drm0000146

 

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Sleep quality and PTSD: A bidirectional link

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If you want to effectively treat PTSD, it’s critical to address sleep issues, including nightmares. Currently, there is too little integration of sleep and trauma-focused therapies for the treatment of PTSD according to the authors of a comprehensive review of sleep disorders and PTSD. Weber and Wetter’s (2021) survey of the literature shows that intervening in sleep disturbances also helps daytime PTSD symptoms and may even offer a preventative effect.

 

Sleep problems, a core feature of PTSD, include nightmares, insomnia and nocturnal anxiety. The authors found little evidence for the long-term effectiveness of medication for insomnia and nightmares and called for a more complex and integrated approach to psychological treatment. They stress the importance of addressing sleep issues, noting that sleep problems and PTSD have a bidirectional link. Sleep issues can predispose a person to PTSD and perpetuate it.

 

“Interventions that enable people to sleep better are likely to be of particular therapeutic importance, as they may have immediate remedial effect on PTSD symptoms,” according to the authors. More than 90 percent of those with PTSD also have sleep problems that include post-traumatic nightmares, and difficulty falling and staying asleep. They can also ruminate at night, talk in their sleep, wake up disoriented and suffer from parasomnias.

 

PTSD associated with alterations in the nervous system and sleep architecture

There is much evidence to show that those with PTSD have low parasympathetic tone while awake and resting, and increased sympathetic activation during sleep, especially during REM when most dreaming occurs. It is now considered established that altered heart-rate variability (HRV), a measure often used to assess the state of the nervous system, increases the likelihood of developing PTSD after trauma.

 

The sleep patterns of those with PTSD differs in many measurable ways from normal, healthy sleep, indicating they sleep less deeply, and spend less time in restorative, regulating slow-wave sleep. Sleep spindles, bursts of brain activity that can be seen on EEG readouts during stage 2 non-REM sleep, are associated with memory consolidation and neuroplasticity. These are altered in those with PTSD sufferers. Similar disruptions in sleep spindle patterns were also found recently in those with nightmares associated with early childhood adversity – a finding that suggests trauma nightmares and so-called idiopathic nightmares (of unknown origin) may not be so easily differentiated (Nielsen et al. , 2019). REM sleep patterns are also altered in PTSD in ways that fragment this dream-rich phase of sleep that has been shown to help regulate emotion and attenuate fear and distress.

 

Sleep disturbances are linked to increased suicidality and self-harming behaviours. PTSD is also a risk factor for suicide. Weber and Wetter (2021) note that reciprocal influences of sleep, PTSD and suicide are well documented but not well understood. They do, however, cite a study that suggests “targeted treatment of sleep disorders and nightmares could contrubute to reducing the risk of suicidality in PTSD patients (Bishop et al., 2020).

 

Treatment of PSTD and Sleep Disorder Must Be Integrated

While PTSD treatment helps with insomnia and nightmares, and treatment of sleep problems helps with daytime PTSD symptoms, the two approaches are rarely integrated. The authors note several effective psychotherapeutic approaches to treating nightmares, including IRT, ERRT and EMDR. They also review pharmacological interventions, and the evidence is less favorable. They also studied the impact of sleep inteventions post-trauma as a way to prevent PTSD, and again the evidence was not conclusive.

 

In their conclusions, Webe and Wetter say there is “robust evidence” for psychotherapeutic inteventions and less evidence for medication as a treatment for PTSD. “Integrative concepts and optimized algorithms for sleep and daytime symptoms are needed.” These may also help reduce the risk of suicide, and in future, even prevent the development of PTSD following trauma.

 

References

Bishop T. M., Walsh P. G., Ashrafioun L., Lavigne J.E., Pigeon W. R. (2020). Sleep, suicide behaviors, and the protective role of sleep medicine. Sleep Medicine, 66, 264–70.

Nielsen T., Carr M., Picard-Deland C., Marquis L. P., Saint-Onge K., Blanchette-Carriere C., et al. (2019). Early childhood adversity associations with nightmare severity and sleep spindles. Sleep Medicine, 56, 57–65.

Weber, F. C. & Wetter, T. C. (2021). The many faces of sleep disorders in post-traumatic stress disorder: An update on clinical features and treatment. Neuropsychobiology, published online Seot. 2. DOI: 10.1159/000517329

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Veterans and dreams: Special considerations for treating moral injury and lucid nightmares

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Veterans and dreams: Special considerations for treating moral injury and lucid nightmares

By Dr. Leslie Ellis

Sometimes, traumatic injury is not just an overwhelming event, but one that constitutes a deep moral injury. This kind of trauma, more common among veterans, requires a uniquely sensitive approach. At the most recent conference for the International Association for the Study of Dreams (IASD, June 2021), keynote speaker Eduardo Duran, addressed the complexities of treating the moral injury many veterans suffer – where trauma is not just about what you have witnessed and experienced, but also about things you have done or failed to do in the context of battle, where the usual societal rules do not apply. Taking the life of another or failing to save someone’s life, for example, may lead to devastating moral injury.

 

An indigenous perspective on treating moral injury

Duran brings an indigenous perspective to the question of moral injury, and speaks of the importance of redressing balance. A moral injury refers to an act that weighs heavily on one’s conscience, characterized by profound guilt and shame. In his book, Healing the Soul Wound (2019), Duran writes of the indigenous teachings which say there is an agreement or contract made when one warrior takes the life of another. “Taking anything requires that a balancing act occur in order to harmonize the action. Everything in the universe seeks balance, and actions taken in any situation will either balance themselves unconsciously through the manifestation of symptoms, or will enhance human consciousness if understood from a psycho-spiritual perspective.”

At the IASD conference, Duran spoke of how in some indigenous tribes, taking the life of another indebted the warrior to the deceased soldier’s family for his lifetime. Often those who have taken a life dream of the deceased, both those whose lives they may have directly or indirectly taken, and they also dream of compatriots who lost their lives in battle. These dreams are a constant reminder that keeps their suffering alive, sometimes for decades, unless some kind of healing takes place. There is an understanding that while different rules apply during wartime, there is a need for balance and restitution upon returning to peace, and that these acts of atonement are as important for the agressor as they are for the victims of violence.

Practically speaking, this means that a soldier who has taken a life must make amends in some way to the person or the family and community whose life they have taken. This can be done through offerings, direct service, ceremony, therapy and ultimately, self-forgiveness. Duran said the pull toward suicide in such cases is may also be seen as an attempt to restore balance (a life for a life) but one that merely doubles down on losses. He calls suicide a desire for transformation, an important call, though not one to be taken literally.

In many indigenous traditions, suicide is a spirit that calls for transformation, which can lead to a spiritual rebirth, and a new life. Duran believes Western paradigms misinterpret this as suicidal ideation, as an impulse to take one’s own life in the physical realm. He said it’s crucial to not only treat PTSD symptoms, but also the deep moral injury that can lead to a desire for death. “A larger issue of soul separation is what is calling for a transforming event, such as we encounter in death. Therapeutic ceremony that allows for soul restoration is a must.”

 

Moral injury leads to higher suicide risk

A recent study (Battles et al., 2021) confirmed that suicide risk is higher among those veterans who have suffered a moral injury, which has symptoms in common with PTSD, but also a unique and complex presentation. The researchers found that those with strong guilt and shame, as well as comorbid psychiatric conditions, carried the highest suicide risk. The symptom picture differs from the flashbacks, nightmares and hypervigilance associated with PTSD. Moral injury and the shame associated with it bring depression, anxiety, loss of trust, and social alienation. The researchers concluded that while there is overlap between moral injury and PTSD, there are distinctive differences that need to be considered in treatment and prevention of suicide.

Another recent article addressing the impact of war on veterans found that the way they dream has unique characteristics. Miller, Ross and Harb (2021) studied the dreams of 54 veterans with PTSD and found that more than half of them were experiencing lucid nightmares of the most challenging variety. Participants were aware they were dreaming, but this did not lend them greater control over these distressing dreams. Instead, they reported feeling stuck, anxious and unable to wake themselves up from their distressing dreams.

Normally, lucid dreaming is associated with feelings of greater well-being, autonomy, assertiveness and confidence, but not in these cases. Although lucid dreaming has been studied as a treatment for traumatic nightmares, in these cases, the notion of taking control and achieving mastery over the dream content is not viewed as a promising pathway. The authors suggest that helping veterans who suffer from lucid nightmares to learn to distinguish these dreams from reality might be a useful focus of treatment.

In this and other recent studies, it is apparent that the treatment of veterans suffering from past-traumatic and/or moral injury is a complex business, and one that deserves further attention and study, especially because it may help reduce the high prevalence of suicide in this clinical population. It’s important for clinicians to understand that moral injury, and lucid nightmares are among the complex challenges in working with veterans, but they are treatable. There is hope.

If you are interested in learning more about nightmares and their treatment, sign up for my short, focused online course. Because I feel this material is important to disseminate, the course is always open, is self-paced, and currently discounted during the virus crisis. Please ask your clients if they have nightmares, and let them know they are treatable. Check out our Short Focused Course on Nightmare Treatment using THIS LINK.

 

References

Battles, A. R., Jinkerson, J., Kelley, M. L., & Mason, R. A. (2021). Structural examination of moral injury and PTSD and their associations with suicidal behavior among combat veterans. Journal of Community Engagement and Scholarship, 13(4).

Duran, E. (2019). Healing the soul wound: Trauma-informed counseling for indigenous communities. New York, NY: Teachers College Press, Columbia University.

Miller, K. E., Ross, R. J., & Harb, G. C. (2021). Lucid Dreams in Veterans with Posttraumatic Stress Disorder Include Nightmares. Dreaming, 31(2), 117-127.

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Nightmare-Suicide Link Extends to Adolescents

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Read on to find out how you can help!

If you know or work with a deeply troubled teen, you might consider asking them about their dreams. If they report frequent disturbing dreams or nightmares, they are at a greater risk for suicide. The link between adult suicide and nightmare frequency has been well established, and a new study extends this correlation to young adolescents. The good news is that nightmares are treatable, and some very simple steps can make a meaningful difference.

In a recent study based in Montreal, Canada, Aline Gauchat and colleagues studied both the dreams and suicidal ideation of 170 children when they were 12 and again at age 13. Disturbed dreaming tends to lessen with age and did so in this sample. At the same time, the rate of suicidal ideation increased, and analysis of the data showed that the adolsecents who had suicidal ideation had significantly more disturbing and recurring dreams.

This is another piece of mounting evidence that when working with those with a potential risk of suicide (for example those with depression, borderline personality or a history of complex trauma) you should ask about nightmares as part of the screening process.

 

Why we should ask about nightmares

Dr. Michael Nadorff, who has conducted several studies linking nightmares and suicide, noted with dismay that in the past 50 years, we have not become any better at predicting suicide. Paying attention to dreams, in particular the frequency of disturbing dreams and nightmares, is one way to help determine who is most at risk.

The other important thing to note with respect to the nightmare-suicide link is that effective nightmare treatments are available. In his talk on nightmares at the recent (June, 2021) conference for the International Association for the Study of Dreams, Nadorff noted that of those with dangerously troubling dreams, only one person in ten might report this to a mental health professional. There are a couple of reasons for this: those with frequent nightmares don’t always realize that such dreaming is not typical. And very few people are aware that nightmares can be treated. People also hesitate to talk about their nightmares for fear of being judged for the dark images that haunt their sleep.

However, talking about nightmares, and getting treatment can have positive effects that extend beyond the simple reduction in the frequency and distress caused by disturbing dreams. In general, symptoms of depression and trauma dissipate, and although this has not been specifically studied, it is fair to suggest the risk of suicide drops significantly as well.

Instilling Hope

When asked what he thought made nightmare sufferers more likely to consider taking their own life, Nadorff said he thinks a lack of hope is a major contributing factor. For frequent nightmare sufferers, even sleep is not a refuge from their tortured thoughts. Those contemplating suicide report deep loneliness and a sense that they are a burden to those closest to them. He suggests intensive support for those whose risk of suicude is high, stressing that the periods of high risk are time-limited.

Treating the nightmares of those contemplating suicide is also something Nadorff recommends, though this idea has not taken hold very widely, at least not yet. But Imagery Rehearsal Therapy (IRT), lucid dreaming, and several other nightmare treatment protocols demonstrate that it can be fairly quick and easy to reduce nightmares and their related distress. In my survey of the nightmare literature, I have found that virtually all methods researchers tried seemed to help, and adverse effects seemed absent.

The common denominators in nightmare treatment include instilling hope by teaching those with nightmares that they are treatable and it is entirely possible to change their dream life for the better. The other key elements of treatment are to write, rescript or re-imagine a new ending to their nightmare, ideally one that gives them a sense of mastery over the challenge presented in their dreams. They can, for example, develop a superpower that enables them to escape or overpower their attacker. In my experience, the more richly imagined this new dream ending is, the more power it has to change subsequent dreams. If it sounds too simple, don’t be fooled… it can really be that easy to make a meaningful difference, possibly even save a life.

 

Some further resources:

Help for nightmare sufferers (free PDF) CLICK HERE

A short focused course on nightmare treatment for clinicians CLICK HERE

Are you a parent concerned about the frequency and intensity of your child’s bad dreams? Should you be concerned?
Learn more about Nightmare Relief for Everyone designed by nightmare expert Dr. Leslie Ellis, this self-paced user-friendly and accessible online course covers the very latest in science and research about what nightmares are, and what they’re not. Leslie offers some simple steps you can take to get some relief from nightmares and other nocturnal disturbances – both for yourself and for others, including your children.

 

References

Gauchat, A., Zadra, A., El Hourani, M., Parent, S., Renaud, J., Tremblay, R. E., and Seguin, J. R. (2021). Association Between Recurrent Dreams, Disturbing Dreams, and Suicidal Ideation in Adolescents. Dreaming 31(1), 32-43.

Nadorff, M. (2021). Invited talk for the International Association for the Study of Dreams (IASD) Online Conference, June 13-17, 2021.

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Can Your Apple Watch Stop Your Nightmares?

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For more than 30 years, retired combat Marine veteran Tim Bahr would have his sleep interrupted by a dozen or so nightmares every night. He clearly recalls the morning of August 5, 2017 because that was the first time in decades that he woke up from a full night of sleep and could not recall a single nightmare. Bahr was testing an early version of NightWare and has become a strong advocate for this new nightmare treatment.

Nightware, is a ‘breakthrough’ system that uses an Apple watch and iPhone to help reduce nightmares and their related distress. As you begin to have a nightmare, a gentle vibration from the watch wakes the wearer just enough to change the dream state, allowing the person to sleep on more peacefully. Bahr said the sleep data shows he is still having nightmares but the device ‘breaks’ them before they get to the most intense places, so he is blissfully unaware of them. He also says this does not replace therapy but it does enable him to work through his PTSD with a well-rested body and a clear mind. “I now wake up without that fog.”

Granted FDA approval in November 2020, Nightware is now available on a limited basis by prescription to those who suffer from nightmare disorder or nightmares related to post-traumatic stress disorder (PTSD). This is new order of nightmare treatment was granted ‘breakthrough device’ designation that allowed it to fast-track through the FDA approval process.

Recurrent, realistic nightmares that replicate traumatic events are a cardinal feature of PTSD. They cause considerable distress and impair sleep, and for many, these distressing dreams do not simply go away with time. There have been several effective nightmare treatments developed that involve some variant of nightmare rescripting – in which the dreamer invents and rehearses a new ending to their nightmare. Imagery Rehearsal Therapy (IRT) has the most supportive evidence, and many other, similar psychotherapy-based interventions have been developed over the past 20 years. Medications are often prescribed as well, most often Prasozin, but it was recently downgraded because in a recent study, it did not perform better than placebo. However, NightWare is a new and different kind of treatment that can augment other ways of helping reduce nightmare suffering.

The beauty of Nightware is that this wearable device poses minimal risk and has no side effects. When we have a nightmare, our body reacts as though the terrifying event is really happening – so our heart rate increases, our breath becomes rapid, and we can tend to thrash around a lot more. The Apple watch can detect heart rate and movement. Over the first week or so of wearing the device, the patented Nightware software creates a personalized sleep profile to enable it to detect when a person is likely to be having a nightmare. It will then send a signal to create a gentle vibration in the watch, enough to cause a shift in the dream state, but not enough to wake the wearer up… or if the signal is too strong and does wake the wearer, the watch will adjust the signal and make it softer.

NightWare was tested in 30-day clinical trial with 70 patients who were randomly assigned with the working app, or a placebo app that did not create vibrations. Both groups reported improved sleep quality, but those with the Nightware app reported greater benefit. A larger controlled clinical trial is under way in several Department of Veterans Affairs hospital sites. According to NightWare CEO Grady Hannah, the company was founded specifically to support the physical, mental and emotional health of veterans and active duty service members.

There are some caveats. The FDA suggests that Nightware should be used in conjunction with other treatments and under the supervision of a professional. And it’s not recommended for those who tend to sleepwalk, or become violent or act out their dreams because the device may increase this undesirable activity (called REM Behaviour Disorder). It also recommended only for those 22 years of age or older. Nightware is available by prescription only, and is currently limited to veteran and military individuals. To find out more about it, you can do go the company web site at nightware.com.

 

Dr. Leslie Ellis is an author, researcher and therapist who specializes in PTSD nightmare treatment. If you are interested in learning more about nightmares and their treatment, check out my Short Focused Course on Nightmare Treatment. Or go HERE for a free PDF for clients on ‘What You Can Do About Your Nightmares.’

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New Study Examines Complex Relationship Between Nightmares, Suicide and Depression

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A recent study refutes the research which shows nightmares are indicators of increased risk of suicide. A group of Swedish researchers (Hedström et al., 2020) studied a group of more than 40,000 participants with an average follow-up of 19 years and found the rate of suicide linked to depression was not worsened by nightmares. Their study “revealed no significant effects of nightmares on suicide incidence,” but rather that depression was more prevalent among those who suffer from nightmares.

The conclusion the authors reach regarding the nightmare-suicide link is so at odds with what has been reported in several studies, I asked Dr. Michael Nadorff, an expert in this area, to comment. He wrote:

The study, in my opinion, was clearly underpowered which is why they are saying there was no effect despite nightmares more than doubling suicide risk even after controlling for depression, anxiety, hypnotic use, and a bunch of other factors.  Uncontrolled frequent nightmares put participants at more than five times greater risk.

Despite some methodological flaws, Nadorff and other reviewers noted that this paper offered much that was worthy of note. For example, Hedström and colleagues found that treatment of both depression and nightmares is warranted when these conditions co-occur. The researchers concluded that nightmare treatment “may provide additional therapeutic benefit.”

Other findings of interest related to suicide and depression: women are overrepresented among those who report depressive symptoms, and are more often smokers with lower levels of physical activity, and they suffer more insomnia symptoms. However, in the large sample, it is men who were more likely to commit suicide. Of the 69 suicide deaths reported in the sample over the 19-year follow-up period, 64 percent were men and 36 percent were women. There was a 12-fold increase in suicide risk associated with depression, and the researchers found that the presence of nightmares did not increase that risk.

Still, increasing nightmare frequency predicts greater likelihood of depression: “The odds of depression during follow-up was higher among those who suffered from nightmares than among those who did not.” Therefore, while nightmares do not appear to directly increase suicide risk, the study finds that “nightmares may reflect pre-existing depression.”

The researchers recommend nightmare treatment for several reasons: The distress caused by nightmares, especially when this is severe enough to compromise functioning and well-being, is linked to anxiety and depression. The effectiveness of nightmare treatment has been well documented. So as part of treatment for those with both nightmares and other diagnoses, the direct treatment of nightmares can help reduce some of the distressing symptoms.

Another interesting note is that a recent study shows that the propensity for nightmares may be genetic, but that nightmares in and of themselves do not indicate a predisposition for mental illness. The recent study by Ollila and colleagues (2019) on the genetics of nightmares showed that psychiatric illness predicts nightmares, but that nightmares do not predispose a person to psychiatric problems.

 

Hedström AK, Bellocco R, Hössjer O, Ye W, Lagerros YT, Åkerstedt T. (2020). The relationship between nightmares, depression and suicide, Sleep Medicine: X, https://doi.org/10.1016/ j.sleepx.2020.100016.

Ollila HM, Sinnott-Armstrong N, Kantojärvi K, et al. (2019). Nightmares share strong genetic risk with sleep and psychiatric disorders. BioRxiv 836452; doi:https://doi.org/10.1101/836452.