Nightmares in PTSD

A common complaint of PTSD patients is the recurrent incidence of terrifying nightmares, occurring throughout the duration of nocturnal sleep. Patients often report dream sequences that seem to repeat themselves and that appear to be related to their traumatic experiences. Frequently, this leads to sleep-related anxiety and reduced sleep quality.

In an attempt to investigate the sleep-related precursors and concomitants of these nightmares, we conducted a pilot study on 6 female PTSD in-patients complaining about nightmares and 6 outpatient controls with undisturbed sleep. Participants were monitored using standard polysomnography during 3 nights. In night 3, they were awakened from REM sleep to collect dream reports. Also, we conducted structured interviews regarding nightmare dream plots, time of onset, and frequency of occurrence. Results suggest an almost total suppression of rapid eye movement (REM) sleep in PTSD patients, accompanied by frequent awakenings throughout the night. Nightmares were not observed during laboratory testing which participants attributed to feeling closely monitored and protected. Dream diaries of non-laboratory nights revealed two types of nightmares: REM-typical highly bizarre dreams which were perceived as uncontrollable and therefore threatening and non-bizarre dreams that were realistic and trauma-related. Based on the finding that REM sleep is sparse in PTSD patients, we consider it likely that many so-called "nightmares" are in reality intrusions or flashbacks that occur during bouts of nocturnal wakefulness. Throughout these episodes of drowsiness, the brain has access to waking memory. However, as frontal lobe functioning is strongly reduced at night, the sleeper is unable to control the emotional impact of these intrusions. One consequence is that patients learn to fear sleep and dreaming. Another is the risk of nocturnal re-traumatization. Treatment options include psychoeducation as well as encouraging REM sleep dreaming through, for example, lucid dreaming and imaging techniques.