Too scared to close their eyes: treating PTSD nightmares

Exhaustion tugs at the eyelids and a comfy pillow awaits an eager head, but for people with post-traumatic stress disorder (PTSD), a good night’s sleep is often a dream. Recurring nightmares terrorize at night and prevent productivity during the day. But within five therapy sessions, TU Professor of Psychology Joanne Davis and her clinical trial team can significantly relieve or (in many cases) cure patients with trauma-induced recurring nightmares.

Reliving the trauma

Professor Joanne Davis
Professor Joanne Davis

From veterans to sexual assault survivors, trauma can scar even the subconscious. “Your mind is trying to process some aspect of the trauma that you went through. We get stuck in that process,” Davis explained. “In part, because we are waking up in the middle of this dream sequence, and there is no conclusion or closure to it.”

Since first arriving at TU in 2001, Davis has led randomized clinical trials using a new treatment method she established — exposure relaxation and rescripting therapy. The entire process consists of three components: psychoeducation about sleep and trauma; writing and rescripting the nightmare; and cognitive behavioral therapy targeting insomnia.

Caitlin Paquet
Caitlin Paquet

Recurring nightmares may force patients to relive parts of their trauma or design new scenarios inducing panic and stress similar to the trauma. Serving as the trial coordinator, clinical psychology doctoral student Caitlin Paquet is busy recruiting clients for their studies. Although the trials only require one nightmare a week, “Some people are having nightmares every time they shut their eyes,” Paquet added.

In the community trials, patients have chronic nightmares for an average of 16 to 18 years, but for veterans, it was 40 years. “Nightmares have a huge association with suicidal ideation and behavior, even above and beyond depression,” Davis revealed. “Not only are you not getting sleep, but also you are experiencing these horrific reminders of one of the worst things that ever happened to you.”

Flipping the script

Chelsea Cogan
Chelsea Cogan

In their bad dreams, patients often know their lines and even the staging, but what if they reclaimed their own story? Chelsea Cogan, a clinical psychology doctoral candidate, is a student supervisor for the trial and works with clients to rewrite a different ending for their nightmares. “We rescript based on the five different themes related to trauma: safety, trust, intimacy, powerlessness or control and esteem,” Cogan said.

This does not mean all dreams end with “happily ever after.” Instead of a picture-perfect ending, the patient renegotiates the theme. For example, if a patient feels out of control in their nightmare, they rewrite the story where they control the outcome. “We think that sense of mastery may be a significant component as to why this has been successful,” Davis added.

Sleep tips

Insomnia can cause patients to develop poor sleep habits. Davis and her team teach helpful sleep and relaxation techniques.

  • Stay clear of late-night snacking or relying on alcohol to dull the senses. The result is a restless night with the body trying to metabolize, which promotes nightmares.
  • People with PTSD often tense their body without realizing it. Davis recommends “progressive muscle relaxation, which is tensing and relaxing each of your muscle systems to try and remind your muscles what relaxation feels like.”
  • Sleep restriction sounds counterintuitive, but what it actually means is limiting time in bed for only sleep. Cogan described, “If I’m in bed for 10 hours, but I’m only sleeping for seven of those, I am spending time tossing and turning and getting frustrated. Getting up out of the bed for those three hours can train my mind that when I get in the bed, it is time for sleep.”

International impact

TU students working on the nightmare study for children
TU students working on the nightmare study for children

Exposure relaxation and rescripting therapy is not a panacea, but the results have been overwhelmingly positive. “What we see first is a reduction in the severity of the nightmares. People stop being so disturbed by them,” Davis said. “Some people report that images in the nightmares get fuzzy, and they can’t see as clearly.”

From Australia to U.S. military basecamps, Davis’ nightmare therapy has been extended to veterans, people diagnosed with bipolar disorder and hopefully soon, in another clinical trial, to people who have symptoms of psychosis. TU Associate Professor of Psychology Lisa Cromer even tailored the therapy for children and adolescents.

Recognizing the prevalence of severe nightmares and insomnia in its troops, the U.S. Army Medical Education Department contacted Davis to lead therapy trainings. “One of the questions I ask when I start the training is, ‘Are you already seeing people who have sleep problems and at what percentage of your population?’” Davis said. Almost always, the answer is 75% and above.

“People take for granted the ability to sleep. Society gives us the idea that sleep isn’t a huge priority,” Paquet said. “The sad part is that people with PTSD will spend their whole lives accepting the fact that they don’t sleep well.” Just like a nightmare, Davis and her student-researchers are rewriting that narrative, and the future doesn’t seem as frightening.