PTSD Nightmares

What are PTSD nightmares?

PTSD nightmares are considered rapid eye movement (REM) parasomnia, an extreme dream sequence that is preceded by an extreme level of harm.^[1] Combat veterans, victims of assault, survivors of disasters, and other trauma survivors can all experience nightmares as a symptom of PTSD.

Nightmares are one of several intrusive symptoms associated with a diagnosis of PTSD according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). As the DSM-5 states, intrusion symptoms might include “recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).”^[2]

While it’s clear there’s a connection between PTSD and nightmares, the reason they often co-occur is not well understood.^[1] Freud, for example, believed that dreams and nightmares were a way for the unconscious to cope with its desires.^[3] More contemporary theories posit that PTSD-related nightmares are a means of trying to cope with the unresolved trauma.

While PTSD nightmares occur in all stages of sleep (stages 1-4 and REM sleep), they are most common when coming out of REM sleep.^[4] REM sleep stages increase in length throughout the night. Typically, nightmares occur in the latter REM stages as they are lengthier.

Regardless of when PTSD-associated nightmares occur, the pathophysiology is the same - the hippocampus, locus coeruleus, and amygdala are all involved. What’s more, nightmares seem to be associated with imbalances of dopamine and serotonin in the brain.^[1]

Why does PTSD cause nightmares?

As noted above, many theories have been presented over the years about why PTSD and nightmares are interlinked. Today, though, many researchers believe that it's part of the memory consolidation process.

Memory consolidation is how our experiences are integrated into long-term memory. Dreams help us achieve this end.

While PTSD nightmares can be extremely intense, the prevailing theory is that they serve as a “safe” way to expose the brain, mind, and body to threats. In this regard, PTSD nightmares might actually be an attempt by the body to cope more effectively with the trauma.^[5]

The difficulty is that PTSD alters the brain’s functioning. Those alterations can negatively impact the ability to consolidate the traumatic experiences during REM sleep.^[6] In other words, physical changes in the brain combined with changes in sleep architecture and memory functions can diminish the ability to consolidate traumatic memories.

Because these traumatic memories aren’t fully consolidated, they might become resistant to extinction.^[6] This could explain why PTSD nightmares are recurrent for long periods - sometimes decades. What’s more, some people might experience a reduction of PTSD symptoms, yet their nightmares continue, often for the rest of their lives.^[1]

As is the case with human behavior, there are likely many reasons why PTSD causes nightmares, from physiology to memory to environmental experiences.

Are PTSD nightmares always about the trauma?

In many cases, PTSD nightmares relate directly to the trauma that caused PTSD in the first place. Moreover, in these instances, the nightmares are carbon copies of the trauma - the actual event is played out repeatedly, perhaps several nights a week, for prolonged periods.^[1]

These nightmares are often associated with long periods of wakefulness due to fear, anxiety, helplessness, and other feelings the nightmares elicit. Even if someone with PTSD nightmares doesn’t experience a replica of the trauma in the nightmare, the likelihood is high that they will experience the associated fear and anxiety from the event.^[7]

Can nightmares cause PTSD?

Nightmares don’t cause PTSD. However, nightmares can exacerbate PTSD symptoms and reduce psychological and physiological functioning.^[1]

The result is a vicious cycle: PTSD develops, and nightmares commence. These nightmares disrupt sleep, cause anxiety and fear, and diminish one’s ability to cope effectively with the trauma. As a result, PTSD symptoms become more severe, including more frequent nightmares. This cycle can also accelerate the development of PTSD after a traumatic event, leading to faster onset of symptoms and more severe symptoms at that.^[1]

Having said that, research indicates that people who had nightmares before experiencing trauma have more severe PTSD symptoms after trauma. Likewise, people who begin experiencing nightmares immediately after a traumatic event are more likely to develop more severe PTSD symptoms down the road.^[1]

Still, nightmares are not the cause of PTSD. Instead, they are a symptom of the mental health condition and a risk factor for developing more severe symptoms after a traumatic episode.

How to manage PTSD nightmares

If you or someone you know suffers from PTSD nightmares, there are some self-help techniques you can use to minimize the likelihood of nightmares occurring.

It should be noted that these techniques aren’t a “how to stop PTSD nightmares” playbook. Unfortunately, these types of nightmares can be highly resistant to treatment and might last many, many years.^[1] Still, experts agree these methods can be beneficial as a treatment for PTSD nightmares.

Create a quality sleep environment

Though nightmares are difficult to control, what you can control is the environment in which you sleep. The more comfortable your sleeping quarters are, the less likely you’ll wake up during the night. The less you wake up, the less you’ll remember about your nightmares.

A quality sleep environment features a variety of characteristics:^[3]

• A comfortable temperature - not too hot or too cold - around 59-70 degrees Fahrenheit.
• Little to no light - light triggers receptors in our eyes to think it’s time to wake up. Avoid having a TV or other electronics in the bedroom, and invest in room-darkening curtains so you can sleep until the sun rises.
• Sleep-inducing scent - some research indicates that pleasant smells like rose and lavender can help induce relaxation and sleep.
• Comfortable bedding - ensure your bed is supportive and that you have pillows that support your neck and head.
• Eliminate noise - sleeping with a white noise machine can help drown out noises in the house and outside, helping you maintain sleep.

Watch your intake of food and drink

Eating or drinking too close to bedtime increases the likelihood of experiencing stomach problems or the urge to use the restroom overnight.^[3] Avoid late-night snacks in favor of eating your evening meal three or four hours before bedtime.

Develop a sleep routine

Going to bed and waking up at the same time each day can help your body calibrate its internal clock. What’s more, avoid frequent napping, especially in the late afternoon and evenings, as this can make sleeping more difficult at night.^[8]

You might incorporate yoga, mindfulness exercises, structured breathing, or progressive muscle relaxation techniques as part of your sleep routine. These can help you calm down, find your center, and relax before bedtime. The more relaxed you are, the more likely you are to fall asleep faster and the more likely you are to stay asleep.^[9]

Avoid drugs and alcohol

Nicotine, caffeine, alcohol, and other drugs can all negatively impact your ability to sleep and the quality of sleep you get. Avoid using these substances in the hours before bed. Cessation of using these substances altogether will be more helpful and aid in reducing other PTSD symptoms as well.^[3]

Actively discuss the content of your nightmares

Addressing the pain, anxiety, and fear you experience during the trauma or a nightmare can be challenging. However, talking about your experience with a mental health professional or even a loved one can help you work through your feelings and reduce the occurrence of nightmares.

Alternatively, some research indicates that keeping a journal and writing about your feelings can help you work through the stress and anxiety associated with PTSD nightmares.^[3]

When to seek professional help

If the above self-help techniques don’t help you manage your PTSD nightmares, it might be time to seek professional help. Though you may prefer to try to work through it on your own, the fatigue, mood changes, and other effects of not sleeping well can cause severe and debilitating disruptions to everyday life.

By seeing a professional, you can get access to treatment for PTSD nightmares, which might include therapy, medication, or both.

PTSD therapy

Cognitive-behavioral therapy (CBT) is a common approach for treating PTSD and its symptoms. CBT is a form of talk therapy that seeks to identify negative patterns of thinking and replace them with positive thinking patterns that reduce the incidence of the undesired behavior.^[10]

People with PTSD often participate in group therapy as well. Whether it's group CBT, a support group, or something in between, the support of others with similar experiences can be highly beneficial in working through your PTSD and your nightmares.^[10]

A treatment specifically for PTSD nightmares is a form of CBT called imagery rehearsal therapy (IRT). In IRT, you’re asked to recall the nightmare and generate a more positive version in writing. By examining this positive version daily, the original nightmare is displaced.^[3]

A version of IRT called exposure, relaxation, and rescripting therapy (ERRT) focuses on education about nightmares, how to relax, rescripting of nightmares, and other critical components that aid in reducing nightmares.

One of the hallmarks of this treatment is to create a written record of the nightmare and repeatedly read the account aloud. Doing so evokes similar physiological and psychological reactions experienced during the nightmare. Repeated exposures enable one to habituate to feelings of fear and anxiety and minimize those feelings when the nightmare recurs.^[1]

Eye movement desensitization and reprocessing (EMDR) is another popular therapeutic treatment for PTSD nightmares. EMDR requires one to recall the nightmare and, while doing so, experience bilateral sensory input (e.g., side-to-side eye movements).

This type of treatment essentially overloads the working memory. As a result, the emotional reactivity to the fear and anxiety of the nightmare is diminished. What’s more, the imagery of the nightmare also becomes less intense.^[1]

PTSD medication

Medication for PTSD nightmares doesn’t currently exist. However, clinical trials have explored a variety of treatments for nightmares. These include sympatholytic medications like Prazosin, Terazosin, and Clonidine. Antipsychotics, like Thioridazine, Olanzapine, and Risperidone, have also been evaluated as potential treatments.

Unfortunately, there is little evidence to provide a definitive recommendation of any of these prescriptive agents as being highly effective in treating nightmares.^[1] However, more common medications for PTSD can be helpful in addressing related symptoms of nightmares, such as anxiety and fear.

For example, antidepressants like selective serotonin reuptake inhibitors (SSRIs) are the most common type of medication for PTSD. Popular forms include Prozac and Zoloft, which elevate serotonin levels in the brain and help minimize PTSD symptoms.

Another antidepressant, serotonin-norepinephrine reuptake inhibitors (SNRIs), boost serotonin and norepinephrine in the brain. Common SNRIs include Effexor, which diminishes overall PTSD symptoms.

Other medication for PTSD nightmares might be prescribed by your medical doctor or mental health provider based on your specific situation. Generally speaking, the most effective treatment of PTSD symptoms is a combination of medication and therapy.^[10]