Friday, February 3, 2012

A New Home for Nightmare Treatment

by Barry Krakow, MD
A new home for nightmare treatment
Military personnel returning from wars in Afghanistan and Iraq show increasing rates of post-traumatic stress disorder (PTSD) and post-traumatic nightmares. Media coverage of these two vexing mental health conditions is also intensifying and raising public awareness about the need for more effective therapeutic options. With growing attention focused on patients with nightmares, sleep centers have an opportunity to engage these patients. Successfully doing so hinges on applying a standard of care for nightmare assessment and treatment through behavioral sleep medicine specialists.
Traditionally, nightmares reflect emotional turmoil that needs venting through the process of dreaming. This psychological perspective fuels the entrenched and enduring focus on dream interpretation therapy as one of two core treatments for this potent sleep disrupter. The other primary approach known as exposure therapy is gaining ascendency in the mental health community because of the prevailing view that PTSD—the cause of the disturbing dreams—must be treated first. As the theory goes, the nightmares will resolve when their cause is treated. Yet, both these treatment paradigms (dream interpretation and exposure) trigger treatment avoidance among nightmare patients because of their fear of unmasking unpleasant mental health issues. Although this paradox creates an opening for nightmare patients to seek help outside of mental health facilities, it is rare for sleep medicine clinics to encounter patients seeking treatment exclusively for nightmares.
To date, the sleep medicine profession has not applied a standard of care for nightmare assessment and treatment. While recent practice parameters published in the Journal of Clinical Sleep Medicine spell out efficacious treatment strategies for chronic nightmares, no evidence suggests these standards are widely adopted. To make treatment options more readily available, the sleep medicine community, particularly the field of behavioral sleep medicine, must embrace the emerging model of "nightmares as an independent sleep disorder," a paradigm described in the scientific literature for more than 20 years and now inferred by the new practice parameters.

In the practice parameters, imagery rehearsal therapy (IRT) is a Level A treatment and a relatively simple instruction that seems to alter the dreaming cycle by taking advantage of the fact that waking imagery influences sleeping imagery. The technique is no more complicated than asking someone to recall a recent bad dream, change this dream's content into a "new dream" while awake, and then spend a few minutes each day rehearsing the images from the new dream. For nightmare patients without complex comorbidities such as anxiety, depression, or PTSD, one clinic appointment is sufficient to teach IRT. Treatment is more involved among nightmare patients with PTSD who may require as much as 5 to 15 hours of clinical follow-up through individual appointments or group programs, primarily because they need extensive coaching to reach the point of receptivity to, interest in, and comfort with the imagery technique.
In order to more firmly root sleep medicine professionals as leading care providers for this patient population, the next logical step will be facilitating and marketing the role of behavioral sleep medicine specialists as therapists for nightmare patients. The most expedient ways to develop this market include internal development and external outreach. At the most basic level, introducing a few key questions into the sleep center's intake process such as "How often do you suffer from nightmares?" and "Do your nightmares disturb your sleep?" has proven highly reliable in identifying patients likely to be interested in nightmare treatment. Outreach may be straightforward if your sleep center resides in a locale that also houses military installations.
At Maimonides Sleep Arts & Sciences, the single largest source of treatment-seeking nightmare patients is the US Air Force and US Army. The second most useful resource is outpatient mental health clinics or therapists, who routinely see patients with chronic nightmares yet often do not provide effective treatment programs for disturbing dreams. Many of these therapists are frustrated with their inability to resolve the nightmares in their patients, and therefore, they tend to be very receptive to programs such as IRT.
To maximize clinical efforts toward nightmare patients in our PTSD Sleep Clinic, we combine individual patient encounters with a self-help workbook and audio series, Turning Nightmares into Dreams (2002), developed at Maimonides Sleep Arts & Sciences. We believe the workbook not only reinforces treatment efforts, but in the majority of cases it decreases the total number of follow-up appointments.
In clinic, we have also seen that nightmares serve as a marker for much more complex sleep disturbances. Our PTSD Sleep Clinic experience demonstrates that nightmare patients almost always suffer from insomnia and a sizeable proportion (70% or greater) suffer from obstructive sleep apnea (OSA). When testing is conducted for upper airway resistance syndrome, upwards of 90% or more of our nightmare patients suffer diagnosable sleep-disordered breathing. Thus, both cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure therapy (PAP-T) for OSA are important treatments to be considered for nightmare patients seeking help at sleep medical centers.
Other nightmare treatment programs have also been tested, many of which use components of IRT: Burgess, Marks, and Gill (2001) published Self-Help for Nightmares, a manual that uses self-exposure therapy; Davis (2008) recently published Treating Post-Trauma Nightmares, which combines elements of IRT and exposure therapy. In the 1990s, Krakow and Neidhardt published Conquering Bad Dreams & Nightmares (1992), the first book on IRT; Cartwright and Lamberg published Crisis Dreaming (1992), an innovative dream interpretation approach to nightmares; and Lansky published Posttraumatic Nightmares (1995), an authoritative work on the psychodynamic approach.
By embracing and applying a standard of care for nightmare patients, sleep medicine physicians and psychologists are likely to emerge as leading care providers in offering solutions and treatments for afflicted individuals. And as military personnel return from wars in the Middle East and the media expands coverage of related mental health issues, our profession has an opportunity to serve these soldiers and others who need treatment for chronic nightmares.

Barry Krakow, MD, is the author of Sound Sleep, Sound Mind, principal investigator at Sleep & Human Health Institute, and medical director at Maimonides Sleep Arts & Sciences Ltd (, and blogs at He can be reached at
We have seen that nightmares serve as a marker for much more complex sleep disturbances.

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