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.