Staff Perspective: Nightmares and Disturbing Dreams
Today you’re meeting a new patient. They present with a history of combat trauma and report significant sleep disturbances including problems falling asleep because they fear they will have another nightmare.
This may feel familiar to you, and there is a good reason for that. Nightmares are incredibly common after a traumatic event, with some estimates suggesting posttraumatic nightmares occur in 90% of patients with PTSD. They are so common, in fact, that some have proposed posttraumatic nightmares are the hallmark of PTSD. But beyond their high prevalence rate, they also tend to be more stubborn than other symptoms of PTSD –– sleep disturbances and nightmares are among the most commonly unresolved symptoms after treatment, and, in some studies, patients have reported experiencing frequent posttraumatic nightmares more than 45 years after their traumatic event.
Nightmare have a significant impact on a patient’s life and cause substantial distress. They are related to negative affect, negative cognitions while awake, and worse quality of life. We also see negative impacts to patients’ work and social life, energy levels, mood, diet, and their general well-being. In addition to impacting many areas of a patient’s life, nightmares are strongly related to suicidal ideation, with patients who are extremely bothered by posttraumatic nightmares being approximately 10 times more likely to report suicidal ideation than patients without. Despite this, many patients do not report their nightmares to their healthcare providers. There has been speculation about why this may be, with some suggesting that it could be due to stigma or beliefs that nightmares after a traumatic event are expected or normal. However, one of the most important reasons may be that many patients believe nightmares to be untreatable.
Because of patients’ hesitance to report nightmares and their misperceptions about treatment, it increases the importance of including nightmare-related questions as part of a standard intake. However, this can be complicated by the fact that many providers do not have an understanding of nightmares, with a large majority lacking professional experience working with nightmares and/or are unable to define a nightmare. One common misconception is that bad dreams and nightmares are synonymous. Although both are types of disturbing dreams and often are discussed interchangeably, a nightmare differs from a bad dream in that during a nightmare the sleeper is awakened from the disturbing dream. Patients experiencing dreams related to their traumatic experience may have posttraumatic nightmares (frightening dreams related to a traumatic event that awaken the patient), posttraumatic anxiety dreams (frightening dreams related to a traumatic event that do not awaken the patient), or posttraumatic dreams (a dream the patient associates with a traumatic event). These trauma-related dreams may be replicative (essentially replaying the traumatic event) or nonreplicative (has content related to the traumatic event but is not an exact replay). Patients also may have idiopathic disturbing dreams, which are not trauma related and, at this time, have no known cause.
These are the terms that we may use as behavioral health professionals, but these may not be the same terms patients use. One thing that I have found interesting is a patient may deny experiencing bad dreams or nightmares but will use other terms to describe disturbing dreams (e.g., stressful dreams, dreams about the trauma, distressing dreams, waking up from dreams that remind you of the event). This may be due to the stigma surrounding nightmares and mental health, leading a patient to underreport or deny having nightmares. Therefore, it may require repeated query using different terms to accurately assess a patient’s symptoms using terms that they feel comfortable identifying with. There are measures that have been developed for assessing nightmares and disturbing dreams that can be useful as well.
- The Pittsburgh Sleep Quality Index Addendum for PTSD measures disruptive nocturnal behaviors that are common in patients with PTSD and includes four items specific to nightmares.
- The Trauma-Related Nightmare Survey assesses a number of useful aspects of the nightmare experience.
- The Disturbing Dreams and Nightmare Severity Index is a general measure of disturbing dreams and includes both nightmares and bad dreams.
- The Nightmare Disorder Inventory is a screener for nightmare disorder.
- The Fear of Sleep Inventory, though not specific to disturbing dreams, can be a useful accompaniment to your assessment.
The utility of these measures may vary due to the terminology used (e.g., nightmare, bad dream) and your patient’s comfort with endorsing these symptoms. These measures may be most useful when used in conjunction with a thorough patient-centered intake.
If you’re interested in learning about treatments for nightmares, check out these CDP resources:
• CDP Presents: The Wild Wild West of Treatments for Posttraumatic Nightmares: https://deploymentpsych.org/Wild-West-Nightmare-Treatments-Archive
• Options for the treatment of posttraumatic nightmares: https://deploymentpsych.org/blog/staff-perspective-options-treatment-posttraumatic-nightmares
• Treating post-traumatic nightmares: https://deploymentpsych.org/Post-Traumatic-Nightmares • Examining Exposure, Relaxation, and Rescription Therapy (EERT) for Nightmares: https://deploymentpsych.org/blog/staff-perspective-examining-exposure-relaxation-and-rescription-therapy-eert-nightmares
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Maegan Paxton Willing is a Postdoctoral Fellow at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References
Blagrove, M., Farmer, L., & Williams, E. (2004). The relationship of nightmare frequency and nightmare distress to well‐being. Journal of sleep research, 13(2), 129-136. https://doi.org/10.1111/j.1365-2869.2004.00394.x
Cranston, C. C., Miller, K. E., Davis, J. L., & Rhudy, J. L. (2017). Preliminary validation of a brief measure of the frequency and severity of nightmares: The Trauma-Related Nightmare Survey. Journal of trauma & dissociation, 18(1), 88-99. https://doi.org/10.1080/15299732.2016.1191578
Creamer, J. L., Brock, M. S., Matsangas, P., Motamedi, V., & Mysliwiec, V. (2018). Nightmares in United States military personnel with sleep disturbances. Journal of Clinical Sleep Medicine, 14(3), 419-426. https://doi.org/10.5664/jcsm.6990
Cukrowicz, K. C., Otamendi, A., Pinto, J. V., Bernert, R. A., Krakow, B., & Joiner Jr, T. E. (2006). The impact of insomnia and sleep disturbances on depression and suicidality. Dreaming, 16(1), 1. https://doi.org/10.1037/1053-0797.16.1.1
Davis, J. L., Wright, D., & Borntrager, C. (2001). The trauma-related nightmare survey. Tulsa, OK: University of Tulsa.
Dietch, J. R., Taylor, D. J., Pruiksma, K., Wardle-Pinkston, S., Slavish, D. C., Messman, B., Estevez, R., Ruggero, C. J., & Kelly, K. (2020). The Nightmare Disorder Index: Development and initial validation in a sample of nurses. Sleep. https://doi.org/10.1093/sleep/zsaa254
Germain, A., Hall, M., Krakow, B., Shear, M. K., & Buysse, D. J. (2005). A brief sleep scale for posttraumatic stress disorder: Pittsburgh Sleep Quality Index Addendum for PTSD. Journal of anxiety disorders, 19(2), 233-244. https://doi.org/10.1016/j.janxdis.2004.02.001
Guerrero, J., & Crocq, M.-A. (1994). Sleep disorders in the elderly: Depression and post-traumatic stress disorder. Journal of psychosomatic research, 38, 141-150. https://doi.org/10.1016/0022-3999(94)90144-9
Kung, S., Espinel, Z., & Lapid, M. I. (2012). Treatment of nightmares with prazosin: A systematic review. Mayo Clinic proceedings, 87(9), 890-900. https://doi.org/10.1016/j.mayocp.2012.05.015
Lamis, D. A., Innamorati, M., Erbuto, D., Berardelli, I., Montebovi, F., Serafini, G., Amore, M., Krakow, B., Girardi, P., & Pompili, M. (2018). Nightmares and suicide risk in psychiatric patients: The roles of hopelessness and male depressive symptoms. Psychiatry research, 264, 20-25. https://doi.org/10.1016/j.psychres.2018.03.053
Levin, R., & Nielsen, T. A. (2007). Disturbed dreaming, posttraumatic stress disorder, and affect distress: A review and neurocognitive model. Psychological bulletin, 133(3), 482. https://doi.org/10.1037/0033-2909.133.3.482
Miró, E., & Martínez, M. (2005). Affective and personality characteristics in function of nightmare prevalence, nightmare distress, and interference due to nightmares. Dreaming, 15(2), 89. https://doi.org/10.1037/1053-0797.15.2.89
Nadorff, M. R., Nadorff, D. K., & Germain, A. (2015). Nightmares: Under-reported, undetected, and therefore untreated. Journal of Clinical Sleep Medicine, 11(7), 747-750. https://doi.org/10.5664/jcsm.4850
Paxton Willing, M. M., Pickett, T. C., Tate, L. L., Sours Rhodes, C., Riggs, D. S., & DeGraba, T. J. (2021). Understanding the role of sleep on suicidal ideation in active duty service members: Implications for clinical practice. Practice Innovations, 2(2), 67-76. https://doi.org/10.1037/pri0000146
Phelps, A. J., Forbes, D., & Creamer, M. (2008). Understanding posttraumatic nightmares: An empirical and conceptual review. Clinical psychology review, 28(2), 338-355. https://doi.org/10.1016/j.cpr.2007.06.001
Pruiksma, K. E., Taylor, D. J., Ruggero, C., Boals, A., Davis, J. L., Cranston, C., DeViva, J. C., & Zayfert, C. (2014). A psychometric study of the Fear of Sleep Inventory-Short Form (FoSI-SF). Journal of Clinical Sleep Medicine, 10(5), 551-558. https://doi.org/10.5664/jcsm.3710
Robert, G., & Zadra, A. (2008). Measuring nightmare and bad dream frequency: Impact of retrospective and prospective instruments. Journal of sleep research, 17(2), 132-139. https://doi.org/10.1111/j.1365-2869.2008.00649.x
Rosen, C., Adler, E., & Tiet, Q. (2013). Presenting concerns of veterans entering treatment for posttraumatic stress disorder. Journal of Traumatic Stress, 26(5), 640-643. https://doi.org/10.1002/jts.21841
Writer, B. W., Meyer, E. G., & Schillerstrom, J. E. (2014). Prazosin for military combat-related PTSD nightmares: A critical review. The Journal of neuropsychiatry and clinical neurosciences, 26(1), 24-33. https://doi.org/10.1176/appi.neuropsych.13010006
Youngren, W. A., Miller, K. E., & Davis, J. L. (2019). An assessment of medical practitioners’ knowledge of, experience with, and treatment attitudes towards sleep disorders and nightmares. Journal of clinical psychology in medical settings, 26(2), 166-172. https://doi.org/10.1007/s10880-018-9574-7
Today you’re meeting a new patient. They present with a history of combat trauma and report significant sleep disturbances including problems falling asleep because they fear they will have another nightmare.
This may feel familiar to you, and there is a good reason for that. Nightmares are incredibly common after a traumatic event, with some estimates suggesting posttraumatic nightmares occur in 90% of patients with PTSD. They are so common, in fact, that some have proposed posttraumatic nightmares are the hallmark of PTSD. But beyond their high prevalence rate, they also tend to be more stubborn than other symptoms of PTSD –– sleep disturbances and nightmares are among the most commonly unresolved symptoms after treatment, and, in some studies, patients have reported experiencing frequent posttraumatic nightmares more than 45 years after their traumatic event.
Nightmare have a significant impact on a patient’s life and cause substantial distress. They are related to negative affect, negative cognitions while awake, and worse quality of life. We also see negative impacts to patients’ work and social life, energy levels, mood, diet, and their general well-being. In addition to impacting many areas of a patient’s life, nightmares are strongly related to suicidal ideation, with patients who are extremely bothered by posttraumatic nightmares being approximately 10 times more likely to report suicidal ideation than patients without. Despite this, many patients do not report their nightmares to their healthcare providers. There has been speculation about why this may be, with some suggesting that it could be due to stigma or beliefs that nightmares after a traumatic event are expected or normal. However, one of the most important reasons may be that many patients believe nightmares to be untreatable.
Because of patients’ hesitance to report nightmares and their misperceptions about treatment, it increases the importance of including nightmare-related questions as part of a standard intake. However, this can be complicated by the fact that many providers do not have an understanding of nightmares, with a large majority lacking professional experience working with nightmares and/or are unable to define a nightmare. One common misconception is that bad dreams and nightmares are synonymous. Although both are types of disturbing dreams and often are discussed interchangeably, a nightmare differs from a bad dream in that during a nightmare the sleeper is awakened from the disturbing dream. Patients experiencing dreams related to their traumatic experience may have posttraumatic nightmares (frightening dreams related to a traumatic event that awaken the patient), posttraumatic anxiety dreams (frightening dreams related to a traumatic event that do not awaken the patient), or posttraumatic dreams (a dream the patient associates with a traumatic event). These trauma-related dreams may be replicative (essentially replaying the traumatic event) or nonreplicative (has content related to the traumatic event but is not an exact replay). Patients also may have idiopathic disturbing dreams, which are not trauma related and, at this time, have no known cause.
These are the terms that we may use as behavioral health professionals, but these may not be the same terms patients use. One thing that I have found interesting is a patient may deny experiencing bad dreams or nightmares but will use other terms to describe disturbing dreams (e.g., stressful dreams, dreams about the trauma, distressing dreams, waking up from dreams that remind you of the event). This may be due to the stigma surrounding nightmares and mental health, leading a patient to underreport or deny having nightmares. Therefore, it may require repeated query using different terms to accurately assess a patient’s symptoms using terms that they feel comfortable identifying with. There are measures that have been developed for assessing nightmares and disturbing dreams that can be useful as well.
- The Pittsburgh Sleep Quality Index Addendum for PTSD measures disruptive nocturnal behaviors that are common in patients with PTSD and includes four items specific to nightmares.
- The Trauma-Related Nightmare Survey assesses a number of useful aspects of the nightmare experience.
- The Disturbing Dreams and Nightmare Severity Index is a general measure of disturbing dreams and includes both nightmares and bad dreams.
- The Nightmare Disorder Inventory is a screener for nightmare disorder.
- The Fear of Sleep Inventory, though not specific to disturbing dreams, can be a useful accompaniment to your assessment.
The utility of these measures may vary due to the terminology used (e.g., nightmare, bad dream) and your patient’s comfort with endorsing these symptoms. These measures may be most useful when used in conjunction with a thorough patient-centered intake.
If you’re interested in learning about treatments for nightmares, check out these CDP resources:
• CDP Presents: The Wild Wild West of Treatments for Posttraumatic Nightmares: https://deploymentpsych.org/Wild-West-Nightmare-Treatments-Archive
• Options for the treatment of posttraumatic nightmares: https://deploymentpsych.org/blog/staff-perspective-options-treatment-posttraumatic-nightmares
• Treating post-traumatic nightmares: https://deploymentpsych.org/Post-Traumatic-Nightmares • Examining Exposure, Relaxation, and Rescription Therapy (EERT) for Nightmares: https://deploymentpsych.org/blog/staff-perspective-examining-exposure-relaxation-and-rescription-therapy-eert-nightmares
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Maegan Paxton Willing is a Postdoctoral Fellow at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References
Blagrove, M., Farmer, L., & Williams, E. (2004). The relationship of nightmare frequency and nightmare distress to well‐being. Journal of sleep research, 13(2), 129-136. https://doi.org/10.1111/j.1365-2869.2004.00394.x
Cranston, C. C., Miller, K. E., Davis, J. L., & Rhudy, J. L. (2017). Preliminary validation of a brief measure of the frequency and severity of nightmares: The Trauma-Related Nightmare Survey. Journal of trauma & dissociation, 18(1), 88-99. https://doi.org/10.1080/15299732.2016.1191578
Creamer, J. L., Brock, M. S., Matsangas, P., Motamedi, V., & Mysliwiec, V. (2018). Nightmares in United States military personnel with sleep disturbances. Journal of Clinical Sleep Medicine, 14(3), 419-426. https://doi.org/10.5664/jcsm.6990
Cukrowicz, K. C., Otamendi, A., Pinto, J. V., Bernert, R. A., Krakow, B., & Joiner Jr, T. E. (2006). The impact of insomnia and sleep disturbances on depression and suicidality. Dreaming, 16(1), 1. https://doi.org/10.1037/1053-0797.16.1.1
Davis, J. L., Wright, D., & Borntrager, C. (2001). The trauma-related nightmare survey. Tulsa, OK: University of Tulsa.
Dietch, J. R., Taylor, D. J., Pruiksma, K., Wardle-Pinkston, S., Slavish, D. C., Messman, B., Estevez, R., Ruggero, C. J., & Kelly, K. (2020). The Nightmare Disorder Index: Development and initial validation in a sample of nurses. Sleep. https://doi.org/10.1093/sleep/zsaa254
Germain, A., Hall, M., Krakow, B., Shear, M. K., & Buysse, D. J. (2005). A brief sleep scale for posttraumatic stress disorder: Pittsburgh Sleep Quality Index Addendum for PTSD. Journal of anxiety disorders, 19(2), 233-244. https://doi.org/10.1016/j.janxdis.2004.02.001
Guerrero, J., & Crocq, M.-A. (1994). Sleep disorders in the elderly: Depression and post-traumatic stress disorder. Journal of psychosomatic research, 38, 141-150. https://doi.org/10.1016/0022-3999(94)90144-9
Kung, S., Espinel, Z., & Lapid, M. I. (2012). Treatment of nightmares with prazosin: A systematic review. Mayo Clinic proceedings, 87(9), 890-900. https://doi.org/10.1016/j.mayocp.2012.05.015
Lamis, D. A., Innamorati, M., Erbuto, D., Berardelli, I., Montebovi, F., Serafini, G., Amore, M., Krakow, B., Girardi, P., & Pompili, M. (2018). Nightmares and suicide risk in psychiatric patients: The roles of hopelessness and male depressive symptoms. Psychiatry research, 264, 20-25. https://doi.org/10.1016/j.psychres.2018.03.053
Levin, R., & Nielsen, T. A. (2007). Disturbed dreaming, posttraumatic stress disorder, and affect distress: A review and neurocognitive model. Psychological bulletin, 133(3), 482. https://doi.org/10.1037/0033-2909.133.3.482
Miró, E., & Martínez, M. (2005). Affective and personality characteristics in function of nightmare prevalence, nightmare distress, and interference due to nightmares. Dreaming, 15(2), 89. https://doi.org/10.1037/1053-0797.15.2.89
Nadorff, M. R., Nadorff, D. K., & Germain, A. (2015). Nightmares: Under-reported, undetected, and therefore untreated. Journal of Clinical Sleep Medicine, 11(7), 747-750. https://doi.org/10.5664/jcsm.4850
Paxton Willing, M. M., Pickett, T. C., Tate, L. L., Sours Rhodes, C., Riggs, D. S., & DeGraba, T. J. (2021). Understanding the role of sleep on suicidal ideation in active duty service members: Implications for clinical practice. Practice Innovations, 2(2), 67-76. https://doi.org/10.1037/pri0000146
Phelps, A. J., Forbes, D., & Creamer, M. (2008). Understanding posttraumatic nightmares: An empirical and conceptual review. Clinical psychology review, 28(2), 338-355. https://doi.org/10.1016/j.cpr.2007.06.001
Pruiksma, K. E., Taylor, D. J., Ruggero, C., Boals, A., Davis, J. L., Cranston, C., DeViva, J. C., & Zayfert, C. (2014). A psychometric study of the Fear of Sleep Inventory-Short Form (FoSI-SF). Journal of Clinical Sleep Medicine, 10(5), 551-558. https://doi.org/10.5664/jcsm.3710
Robert, G., & Zadra, A. (2008). Measuring nightmare and bad dream frequency: Impact of retrospective and prospective instruments. Journal of sleep research, 17(2), 132-139. https://doi.org/10.1111/j.1365-2869.2008.00649.x
Rosen, C., Adler, E., & Tiet, Q. (2013). Presenting concerns of veterans entering treatment for posttraumatic stress disorder. Journal of Traumatic Stress, 26(5), 640-643. https://doi.org/10.1002/jts.21841
Writer, B. W., Meyer, E. G., & Schillerstrom, J. E. (2014). Prazosin for military combat-related PTSD nightmares: A critical review. The Journal of neuropsychiatry and clinical neurosciences, 26(1), 24-33. https://doi.org/10.1176/appi.neuropsych.13010006
Youngren, W. A., Miller, K. E., & Davis, J. L. (2019). An assessment of medical practitioners’ knowledge of, experience with, and treatment attitudes towards sleep disorders and nightmares. Journal of clinical psychology in medical settings, 26(2), 166-172. https://doi.org/10.1007/s10880-018-9574-7