When Sleep Doesn’t Feel Safe: Treating Nightmares as Part of Trauma Recovery
People who have experienced trauma, especially those with trauma-related disorders like PTSD, may avoid sleeping or wake themselves frequently at night to avoid re-experiencing persistent nightmares. Night becomes a dreaded time when the nervous system’s fight or flight response stays in overdrive. Without sufficient quality sleep, our bodies become further stressed, worsening this cycle. But there are both medication and non-medication treatments available for nightmare symptoms.
Nightmares are a common phenomenon after experiencing a traumatic event. They can be part of a normal response to trauma in the days and weeks after a traumatic event. Having nightmares doesn’t necessarily mean that someone will develop post-traumatic stress disorder. However, in some patients, these distressing dreams can intensify the emotional impact of trauma, disrupt sleep patterns, and persist long after the initial event. Though there are other causes of nightmares, this article will focus on the causes of nightmares after trauma and discuss strategies to help manage and alleviate their effects.
The Connection Between Nightmares and Trauma
Traumatic experiences can leave a deep emotional imprint on an individual’s psyche. Nightmares may be an attempt by the brain to process and make sense of these distressing events during sleep. The content of nightmares often reflects the themes and emotions associated with trauma. Nightmares can act as a re-living of the traumatic event, causing fear, anxiety, and even physical symptoms on waking.
After experiencing trauma, we store and process memories differently than other experiences. Being able to quickly “turn on” the body’s fight or flight response to similar environmental triggers was an essential asset for the survival of our ancestors. However, sometimes a frightening experience triggers our “fight or flight” system in a way that feels hard to shake. We can develop symptoms that are disruptive to our lives and sense of well-being. Memories may become stuck in a trauma loop, re-emerging in flashbacks and nightmares. Nightmares are a common symptom that impacts the quality of life and occurs in approximately three out of four people with PTSD.
Hypervigilance is the sense of being on edge and needing to be alert and watchful. It can become especially prominent at night when things are quiet, and darkness raises feelings of uncertainty. Feeling on edge can be enough to keep some awake at night. When the body is in this state of increased alertness and ready response to danger, it is not unusual for persistent nightmares related to a traumatic event to occur.
One of the difficult aspects of treating sleep issues in people with nightmares is that most prescription medicines designed to help you fall asleep (“sleep aides” or “sleep medicines”) have the potential to worsen nightmares. These medicines restore deeper sleep, but dreams and nightmares occur in the deeper state of sleep we need to feel restored and refreshed. But there are other options.
Medicines that Can Help Treat Nightmares
The good news is that many patients find relief from medication that helps decrease the baseline “fight or flight” hypervigilance. This can reduce their nightmares, allowing for increased periods of needed rest. Though there are no FDA-approved medications designed for nightmares, there are medications that are useful in treating nightmares in PTSD.
Prazosin is a medication often used in blood pressure treatment. But because it works on the part of the nervous system that is involved in the “fight or flight” response, it has also been studied in the treatment of PTSD. Because it can lower blood pressure, this medication is increased slowly to allow the body time to adjust. Patients are also often cautioned to get out of bed slowly in the morning to avoid falls or fainting if blood pressure does become low, and patients are often instructed to monitor blood pressure at home.
Other medications that may be used to reduce the “fight or flight” response include terazosin, clonidine, guanfacine, and propranolol. These also often affect blood pressure or heart rate, so changes are monitored. Some medications, like propanolol, are not routinely used to help with sleep at night but can benefit certain patients that may already be prescribed it for daytime symptoms. If well tolerated, many of these medications can also be used during the daytime to achieve better symptom control. However, individual response varies greatly, and these medications are not appropriate for all patients.
Decisions on whether these medications would benefit an individual requires many considerations, including the need to ensure an accurate diagnosis of the cause of the nightmares, consideration of any other medical conditions present, baseline vital signs, potential for medication interactions, and special considerations for children, people over 65, and women who are pregnant, pre-conception, or breastfeeding. Some medications also require caution in alcohol use. Talking to a medical professional experienced in using these medications to treat trauma-related disorders can help you decide if these may be helpful in your case.
Image Rehearsal Therapy
Image Rehearsal Therapy (IRT) is a non-medication treatment option that, in some patients, may be as effective as medications for nightmares. It is a brief therapy based on Cognitive Behavioral Therapy principles. The specifics of how IRT is performed will vary somewhat between therapists. But, it usually begins with writing down a recurrent nightmare. The therapist then helps you rewrite the events in a nightmare by imagining a new, non-frightening ending, and this new version of the dream is written down. The IRT approach is based on visualizing and rehearsing this changed version of the dream while awake before going to sleep to change the experience of the nightmares at night. IRT therapy may begin by practicing with a less disturbing nightmare before tackling the most distressing ones.
Additional Ways to Reduce Nightmares
Establish a Safe Sleep Environment: Creating a safe and comfortable sleep environment can significantly reduce the frequency and intensity of nightmares.
Make a calm and relaxing bedroom environment, free from distractions and excessive stimuli.
Practice a consistent bedtime routine to signal to your brain that it’s time to wind down.
Try soothing scents, such as lavender, or calming music to promote relaxation before sleep.
Keep a journal near your bed to write down any vivid dreams or emotions on awakening, allowing for reflection and emotional processing.
Implement Healthy Sleep Habits: Developing good sleep hygiene practices is vital for individuals recovering from trauma. By prioritizing restorative sleep, you can help minimize the occurrence of nightmares and promote overall well-being. Consider the following tips:
Maintain a regular sleep schedule. Aim for a consistent bedtime and wake-up time.
Create a relaxing pre-sleep routine like reading a book or taking a warm bath.
Avoid stimulating activities, caffeine, and electronic devices close to bedtime, as they can disrupt sleep patterns.
Ensure your sleep environment is conducive to quality rest, with comfortable bedding and a cool, dark room.
Engage in Therapy and Supportive Techniques: Seeking professional help is crucial for managing nightmares after trauma. Mental health professionals specializing in trauma therapy can guide individuals through evidence-based techniques to help process the underlying emotional distress. Therapies commonly used as part of trauma recovery and PTSD treatment include Cognitive Processing Therapy (CPT), Trauma-focused Cognitive Behavioral Therapy (TF-CBT), Trauma-focused Acceptance Commitment Therapy (TFACT), Eye Movement Desensitization and Reprocessing (EMDR), and Prolonged Exposure Therapy. Other therapies may also be beneficial. Relaxation techniques such as deep breathing, guided imagry, progressive muscle relaxation, mindfulness, and grounding exercises that help you reconnect with the present can promote relaxation before sleep and reduce anxiety.
Supportive Lifestyle Changes: In addition to therapy, making positive lifestyle changes can significantly impact nightmare frequency. These changes can include:
Engage in regular physical exercise, which can help reduce anxiety and improve sleep quality.
Practice stress-management techniques like mindfulness and yoga to promote relaxation and emotional well-being.
Foster a strong support system by connecting with loved ones or joining support groups.
Conclusion
Nightmares can be a distressing aspect after experiencing trauma. By understanding the connection between trauma and nightmares and implementing the strategies outlined above, individuals can take proactive steps toward healing and recovery. Remember, seeking professional help from qualified mental health practitioners is crucial for personalized guidance and support on this path. With time, patience, and a multifaceted approach, it is possible to transform nightmares into stepping stones on the path to healing and wellness.
References
Paiva HS, Filho IJZ, Cais CFDS. Using Prazosin to Treat Posttraumatic Stress Disorder and Associations: A Systematic Review. Psychiatry Investig. 2021 May;18(5):365-372. doi: 10.30773/pi.2020.0411. Epub 2021 May 14. PMID: 33979949; PMCID: PMC8169333. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8169333/ Accessed 6.16.23
Hudson SM, Whiteside TE, Lorenz RA, Wargo KA. Prazosin for the treatment of nightmares related to posttraumatic stress disorder: a review of the literature. Prim Care Companion CNS Disord. 2012;14(2):PCC.11r01222. doi: 10.4088/PCC.11r01222. Epub 2012 Mar 22. PMID: 22943034; PMCID: PMC3425466. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3425466/ Accessed 6.16.23
Krakow B, Hollifield M, Johnston L, Koss M, Schrader R, Warner TD, Tandberg D, Lauriello J, McBride L, Cutchen L, Cheng D, Emmons S, Germain A, Melendrez D, Sandoval D, Prince H. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial. JAMA. 2001 Aug 1;286(5):537-45. doi: 10.1001/jama.286.5.537. PMID: 11476655. https://pubmed.ncbi.nlm.nih.gov/11476655/ Accessed 6.16.23
Zayfert C, DeViva JC. Residual insomnia following cognitive behavioral therapy for PTSD. J Trauma Stress. 2004 Feb;17(1):69-73. doi: 10.1023/B:JOTS.0000014679.31799.e7. PMID: 15027796. https://pubmed.ncbi.nlm.nih.gov/15027796/ Accessed 6.16.23
Cook JM, Harb GC, Gehrman PR, Cary MS, Gamble GM, Forbes D, Ross RJ. Imagery rehearsal for posttraumatic nightmares: a randomized controlled trial. J Trauma Stress. 2010 Oct;23(5):553-63. doi: 10.1002/jts.20569. PMID: 20839311. https://www.ptsd.va.gov/professional/articles/article-pdf/id84153.pdf Accessed 6.16.23
