Fending off the shadows: Using cognitive behavioral therapy to manage nightmares
A new cognitive behavioral therapy-based training is helping providers help patients manage their nightmares
For most, having a nightmare is rare. While frightening when they occur, most people are not debilitated by the experience. But for those who suffer from persistent nightmares, the adverse effects can turn their waking lives into a bad dream.
What is a nightmare?
While there is debate in the field of sleep science on exactly how to define it, a nightmare is typically identified as a dream that causes distress to the point of awakening and is remembered by the dreamer, explained Kristi Pruiksma, PhD, associate professor in the Department of Psychiatry and Behavioral Sciences at The University of Texas Health Science Center at San Antonio. Pruiksma is a clinical psychologist and researcher whose work focuses on supporting the dissemination of evidence-based treatments for sleep disorders and post-traumatic stress disorder.
Likewise, there is no definitive explanation for why we dream. One theory is that when we sleep, the emotion and memory centers of the brain are doing a lot of work and processing. At the same time, the part of the brain that organizes information is partially offline and picks up on this activity.
“So, the frontal lobe is half asleep, but still picking up on all this firing and activity, and it needs to process that and make a story out of it,” Pruiksma said. “But with a nightmare, something gets stuck. The brain is trying to process something it doesn’t understand, but something’s going wrong to the point where it’s causing the awakenings.”
Bad dreams, bad health
Frequent nightmares not only affect sleep, but also impact a wide range of health outcomes. Patients often experience symptoms such as concentration problems, irritability and chronic pain, as well as depression, anxiety and other mental health issues. For those already dealing with daytime symptoms of PTSD, like flashbacks or intrusive memories, lack of sleep from nightmares makes their symptoms even more difficult to manage.
“Individuals who have frequent nightmares, some have them every night, don’t get that chance to escape and rest and restore,” Pruiksma said, noting that insomnia goes hand in hand with nightmares, as many patients report resisting sleep due to fear of having a nightmare.
“Some patients engage in avoidance strategies like trying to stay up as late as possible or drinking a lot of water at night so that they have to wake up to use the bathroom instead of being woken up from a nightmare,” said Pruiksma. “They might also turn to alcohol or other substances, but all of these coping efforts just make sleep problems worse in the long run, which may actually increase the chances of having more nightmares.”
Web-based training for providers
Treatment options for nightmares remain an area in need of more research, but patients are often offered a modified version of insomnia treatment focused on therapy methods rather than medications. In clinical practice, cognitive behavioral therapy for nightmares (CBT-N) has proven to be highly effective. However, access to appropriate CBT-N training for behavioral health providers has been limited — until now.
Pruiksma, along with a team of collaborators, has created a series of free, CBT-N web-based video training modules that can be widely accessed by providers everywhere. (Visit cbtnightmares.org to register for the training modules.)
“Any provider anywhere who has access to the internet can go through these training sessions to learn how to implement this therapy,” Pruiksma said. The modules are self-paced and interactive, with videos demonstrating what a therapy session might look like. The website also provides resources available to download, including manuals and handouts that offer tips for handling a variety of patients and different presentations of symptoms.
Unique military population
The training module project is affiliated with the STRONG STAR Consortium, which is funded by the U.S. Department of Defense to develop interventions for and treatment of combat-related PTSD and related conditions in active-duty military personnel and recently discharged veterans.
STRONG STAR, or the South Texas Research Organizational Network Guiding Studies on Trauma and Resilience, is a national research group led by The University of Texas Health Science Center at San Antonio that brings together the expertise of military, civilian and VA institutions and investigators from across the country.
While Pruiksma’s research has mainly focused on military personnel — a uniquely affected population that experiences higher rates of sleep disorders such as insomnia and nightmares, as well as higher rates of PTSD — the video training is designed to be relevant for a wider audience. It provides recommendations for how to treat people in and out of the military who experience trauma, as well as those with idiopathic nightmares, or nightmares that aren’t related to a stressful event, Pruiksma explained.
“Most people have had some degree of trauma at some point in their lives, but this training is really for anybody who is having nightmares, whether trauma-related or not,” she said.
Flipping the script
Cognitive behavioral therapy (CBT) is a type of psychotherapy that helps patients become aware of and change harmful or unwanted thoughts, emotions and behaviors. Considered the gold standard for several mental health issues including depression, anxiety, insomnia and substance use disorder, CBT has also proven to be a highly effective treatment for nightmares.
“When CBT is used for the treatment of nightmares, therapists are working with patients to examine and change thoughts about sleep and nightmares, unhelpful daytime behaviors and sleep habits,” said Pruiksma.
CBT methods to treat nightmares involve relaxation training for the patient and exposure to their worst nightmares through writing, describing them in detail. Therapists then guide patients to identify and name the important themes within their nightmare and then write a new script for their nightmare based on that theme, giving them a new story with a different ending.
“Patients may have the same nightmare over and over, or nightmares that vary but follow the same theme over and over. It’s like a truck going down a muddy road, and every time it drives on the road, the ruts in it get deeper and deeper,” Pruiksma explained.
“The idea is that we’re starting to create a new path for the mind to drive on. They don’t necessarily go on to dream the new dream, but something happens to the nightmare. The brain doesn’t go down that track anymore, or if it does, it’s not as severe.”
Most patients who undergo this intervention do see changes in their nightmares and their sleep, Pruiksma said. For some of the best-case scenario patients, they stop having nightmares altogether. Others report experiencing fewer nightmares or a greater ability to go back to sleep and have a regular dream. With improvement to the frequency and severity of their nightmares, patients can get better sleep, leading to improvements in how they feel during the day and reducing symptoms of depression and PTSD.
“Through this kind of treatment, patients have more understanding of why they’re having nightmares and feel less alone,” Pruiksma said. “They feel like they have more control over their lives in some way, which is an important outcome — to have the tools that can empower them to take control of their health.”
Leading the way in PTSD and brain injury research
STRONG STAR, or the South Texas Research Organizational Network Guiding Studies on Trauma and Resilience, brings together the expertise of military, civilian and VA institutions and investigators from across the country. In a recent round of grant awards, the U.S. Department of Defense selected the STRONG STAR Consortium for a total of $17 million in funding to launch eight new research projects focused on traumatic brain injury and psychological health. 
“As a group, these new projects will help us better understand and better assess, treat and prevent chronic problems with the two signature wounds of post-9/11 wars — traumatic brain injury and post-traumatic stress disorder — along with a variety of related conditions that stem from them or that contribute to their complexity,” said Alan Peterson, PhD, professor of psychiatry and behavioral sciences at UT Health San Antonio and director of the STRONG STAR Consortium.
“Some of these related conditions are suicide risk, sleep disorders and chronic pain, including post-traumatic headache, or chronic headaches that develop from or worsen following a traumatic brain injury,” said Peterson. The new studies will address these problems through a variety of approaches as part of six randomized clinical trials, one treatment development project and one longitudinal follow-up project with previous research participants.
Long School of Medicine’s class of ‘24 celebrates Match Day
On a cloudy backdrop of an early spring day in San Antonio, fluctuating between comfortably cool and a-bit-too warm — a day of transition — more than 200 senior students from the Joe R. and Teresa Lozano Long School of Medicine announced to their families, fellow students and mentors about the next stage of their career in medicine.
Match Day, held this year on March 15 at the Chicken N Pickle restaurant, is the day medical students learn where they will go for their residency after graduation.
This year’s ceremony, while celebratory, held extra space for reflection and grief after the unexpected passing of UT Health San Antonio president, William Henrich, MD, MACP, who died the day before.
“Dr. Henrich was a leader, a mentor, a friend, an exceptional physician and teacher, and he was really the best of all of us. We know that Dr. Henrich is here today with us in spirit as he was so many times over the years in body and heart,” said Deb Conway, MD, vice dean for undergraduate medical education, before leading a moment of silence.
The future of Texas physicians
The class of 2024 saw a 99% overall match rate to residency programs of their choice. San Antonio will keep 22% of those matched graduates, who matched to local programs, bolstering the health care workforce in Bexar County and the region.
Of the matched students, 60% matched to Texas programs, helping to meet the state’s critical need for quality physicians, and 40% matched to primary care specialties including internal medicine, pediatrics and family medicine. After primary care, other top specialties included psychiatry and anesthesiology.
Words of wisdom
In his remarks to the crowd, Robert Hromas, MD, dean of the Long School of Medicine, urged students to never stop learning.
“This is not the end, but merely the beginning for you. Medical science saves lives, and in the 40 of 50 years of your career, you’re going to see advances that astound you. Never stop learning, because the minute you stop learning, you stop growing.”
He also advised to expect the unexpected and expect disappoint. “You are going to lose patients because that’s the nature of life,” he said. “Celebrate the births, celebrate the victories, make memories, because they help you get through the hard times. Don’t let disappointment stop you.”
To get through the hard times, Hromas emphasized the importance of the support of colleagues and loved ones and working as a team.
“Medicine is football, not golf. You are part of a team,” he said. “And the single most important member on that team is sitting here today with you. It’s your family. You must have your family, they’re the center, they hike the ball. Caring for your family is the same as caring for your patient.”
In his final point of imparted wisdom, Hromas spoke of the importance of mentorship.
“We all stand on the shoulders of someone who taught us. Each of you is here because some faculty said I believe in you. They taught you not only their knowledge, but their values and how they care for patients,” he said. “For me, that mentor was Bill Henrich. He believed I could be a dean when no one else did. I stand on his shoulders, just like all of you stand on someone’s shoulders. Never get so big or so smart or so wealthy that you forget that you are there as a gift from someone else.”
With that, the matching commenced, and the class of 2024 began the next step of their journey in medicine.
The Long School of Medicine congratulates its newly matched senior students!
Growing city, expanded patient care
To meet the needs of San Antonio’s growing population, UT Health San Antonio continues to expand its patient care services. San Antonio is one of the largest and fastest-growing cities in the U.S. and added more than 13,000 residents between 2020 and 2021.
With recent and forthcoming additions to primary care, specialty services, oral health care and cancer therapy, as well as a first-of-its-kind multispecialty and research hospital, patients throughout the community and across the region won’t have to go far to receive the care they need, said UT Health San Antonio President William L. Henrich, MD, MACP.
“The addition of several new programs and clinics being built in strategic locations where the population is rapidly growing will provide a full continuum of services for multiple conditions,” he said. “And our new hospital will further enhance UT Health San Antonio’s ability to build an integrated and comprehensive care model to serve patients more effectively.”
Major growth initiatives:
UT Health Multispecialty and Research Hospital
UT Health San Antonio Multispecialty and Research Hospital
The UT Health San Antonio Multispecialty and Research Hospital broke ground in March 2021 and will provide biomedical research, patient care and medical education to the community. The hospital will focus on prevalent illnesses in the region such as cancer, which is expected to increase in our community.
With plans to open in 2024, the 144-bed, eight-floor hospital will be outfitted with 12 operating rooms, an ICU, pharmacy and imaging center, allowing for treatment of complex conditions in one location.
The new hospital will also connect to UT Health San Antonio’s Mays Cancer Center by a skybridge, uniting inpatient and outpatient care.
With cancer diagnoses being forecast to increase 35% regionally during the next decade, the hospital will feature a strong focus on cancer and will offer early-phase clinical trials and therapies such as immunotherapies, stem cell and bone marrow transplants, and cellular-based therapies.
San Antonio cancer patients who require specialty care and treatment will no longer need to seek care elsewhere, or spend months at a time in temporary quarters, Henrich said.
“We are building this hospital to make it possible for patients in San Antonio, including those with cancer, to stay close to home during their treatment,” he said. “As is true of all our efforts, we continue our commitment to serve the public good through care that puts patients and families first and provides them with the best chances of excellent outcomes.”
Wellness 360
The School of Nursing’s Wellness 360 clinical practice expanded its role in caring for the health of college students around San Antonio by partnering with Alamo Colleges and The University of Texas at San Antonio in 2020 and 2021.
Wellness 360 offers UTSA students and students on the Palo Alto and San Antonio College campuses both virtual and in-person health care services for a variety of medical issues including minor acute care, routine health assessments, nutrition counseling, drug and alcohol abuse prevention and women’s health. The clinic serves students with or without insurance.
“Wellness 360 is a nurse-led practice that takes a holistic approach to the health care needs of our patients,” said Cindy Sickora, DPN, RN, professor and vice chair for practice and engagement in the School of Nursing. “We are proud to partner with Alamo Colleges and UTSA to promote the health of college students in Bexar County.”
UT Health Physicians
UT Health Physicians expanded its patient reach with new primary care and multispecialty locations opening across the city.
With the addition of nearly 90 new physicians in 2021, UT Health Physicians is currently the largest physician group in San Antonio, with 20 locations across the city and 1,500 providers conducting more than 2.5 million patient visits annually.
“The new locations will continue to expand access to our services and extend our care beyond the Medical Center,” said Robert Leverence, MD, FACP, executive director of UT Health Physicians and vice dean for clinical affairs at the Joe R. and Teresa Lozano Long School of Medicine.
In the past year, the practice opened two new locations: UT Health De Zavala, which offers primary care and specialty care such as dermatology, gastroenterology, plastic surgery, sports medicine, imaging and nephrology; and UT Health Gateway, which provides care to children in need of pediatric specialties such as cardiology, gastroenterology, oncology and neurology.
Plans are underway for expansion at UT Health Gateway to increase access and meet the high demand for medical specialties and infusion services. Expected to open in spring 2023, the new location will offer adult speciality services in infectious disease, gastroenterology, nephrology, pulmonology, rheumatology, endocrinology, diabetes and infusion.
A multidisciplinary spine center, slated to open in October 2023 in the Medical Arts and Research Center, will bring together orthopaedic spine, neurosurgery spine and rehabilitative medicine to establish a collaborative approach to spinal care. The center will have the only imaging machine in South Texas able to provide high-quality, low-dose 3D imaging with a full view of the skeletal anatomy.
UT Health Outpatient and Surgery Center at Kyle Seale Parkway is expected to open in winter 2024 on the Park West Campus of The University of Texas at San Antonio. The five-story, 108,000-square-foot community medical facility will provide primary, specialty imaging and surgical care services to the growing area.
UT Dentistry
In January 2022, UT Dentistry launched the initial phase of its first-ever private practice. The General Dentistry Clinic provides dental care to staff, faculty and students of UT Health San Antonio, as well as the surrounding community. Under the private practice model, providers are dedicated dentists rather than teaching faculty.
“An important mission of the UT Health San Antonio School of Dentistry is the provision of clinical care to the community,” said Peter Loomer, BSc, DDS, PhD, MRCD(C), FACD, dean of the School of Dentistry. “With the rapid population growth of San Antonio, I feel the time is right to expand our dental services to meet our increased demand.”
The clinic is expected to grow over the next five years, adding more providers and the possibility of satellite clinics throughout San Antonio.
“Our mission for excellence in our education and training programs will remain a priority,” said Gary Guest, DDS, associate dean for patient care and professor in the School of Dentistry. “And this model allows for dedicated, non-teaching providers to provide high-quality patient care with greater availability and access.”
The School of Dentistry is also expanding its reach to meet the needs of people with cognitive and physical disabilities in a new clinic housed at UT Dentistry’s Center for Oral Health Care and Research on Floyd Curl Drive, designed especially for adults and children with special needs.
The Phil and Karen Hunke Special Care Clinic, named for the San Antonio-area philanthropists who provided seed money for the project, is the first of its kind in an academic environment in South Texas. The practice, expected to open in January 2024, will include seven dental treatment rooms and five IV sedation suites. In addition to providing oral health care to special-needs patients, the practice will offer interdisciplinary educational opportunities for students and residents.
“There are not enough dentists who provide care to those with disabilities,” Loomer said. “Since starting my tenure at the school, it has been my vision and mission to build this clinic to both directly provide care and, equally important, train our students to feel confident in providing care to those with disabilities in their dental practices after they graduate. Everyone deserves access to dental care.”
Center for Brain Health
Plans are underway for the construction of a comprehensive center dedicated to the treatment and research of all types of brain, nerve and neuromuscular disorders.
The Center for Brain Health will integrate research into a patient’s clinical care. Patients will have the opportunity to take part in observational studies as well as clinical trials for new medications and interventions while they receive care.
“The reason we wanted to have the studies in the same building as the clinical care is because we recognize that families of persons with dementia, ALS or other disorders already have a very challenging task looking after their loved ones,” said Sudha Seshadri, MD, founding director of the Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases. “They also often have a strong desire to contribute to finding cures for their loved one and for others. So, we wanted to make it easy for them to volunteer their time to join clinical trials, and one way of doing that is to house both in the same space.”
The center will have 62,250 square feet of program space and state-of-the-art imaging equipment, including a 7-Tesla MRI, which will be the first in San Antonio, and a new PET-CT scan machine. There will also be space for assessing gait, essential for early detection of many neurological diseases, and dedicated space for psychological and genetic counseling, and physical and speech therapy. A mock apartment will be available for occupational therapists to work with patients and families to practice movements such as getting in and out of bed and other day-to-day activities.
The Center for Brain Health will be located next to the Medical Arts and Research Center on Floyd Curl Drive and is expected to open in 2025.