Deirdre A. Conroy, PhD

Either idiopathic or trauma-based, nightmares have an adverse effect on sleep continuity and efficiency. However, trauma-based nightmares are more frequent, are more intense, and they can persist throughout the lifespan. As might be expected, patients with PTSD have the highest incidence of trauma-based nightmares. Although nightmares are included in the DSM-5 diagnostic criteria for PTSD, they often persist even after first-line PTSD treatments have been successfully concluded.

Two evidence-based psychosocial treatments are available for trauma-based nightmares: imagery rehearsal therapy (IRT)

 and exposure, relaxation, and rescripting therapy (ERRT).

 Both modalities utilize a brief, sequential approach that incorporates psychoeducation about trauma nightmares, sleep hygiene, relaxation, visual imagery, and “nightmare rescripting.” Even though IRT and ERRT share these basic aspects, they diverge when it comes to specific methods and their application.

To outline the application of each of these modalities, we provide a case illustration for each method. The cases were chosen based on the similarity of demographics and nightmare presentation in terms of frequency and intensity as well as previous trauma focused treatments.

IRT is grounded in a “systematic desensitization” approach that creates a hierarchy of nightmares in which the patient moves from a moderately intense nightmare toward more distressing nightmares over the course of treatment. IRT focuses attention on changing the imagery system, which is hypothesized as an entrenched, habitual mental process that is dislodged through practicing alternative “rescripted,” neutral imagery.

 Jack is a 66-year-old, married, white, Vietnam War veteran. He retired from an automotive factory job 4 years ago, where he frequently worked overtime or double shifts over the 34 years that he was employed there. He has been married for 35 years and has two adult children and three grandchildren. He describes his family relationships as emotionally distant but supportive.

He and his wife sleep in separate bedrooms because of his protracted nightmares and violent movements during sleep when having a combat-related nightmare. (Rapid eye movement behavior disorder has been ruled out prior to presentation). Jack reports that he has few friends and avoids social activities and public events. He used alcohol for several years to reduce stress and promote sleep. When alcohol abuse threatened his marriage and his job, he stopped drinking and began working overtime as often as he could in an attempt to exhaust himself, so he could sleep. This provided limited results as he got older; he was asked to take early retirement when his company began to lay off workers.

 Jack initially presented at the VA Healthcare System for medical problems related to high blood pressure and diabetes. He also reported that his sleep was poor and that he experienced multiple nightmares about the war every night. Jack was referred to the PTSD clinic for evaluation and treatment. On the Clinician Administered PTSD Scales (CAPS) he had a total score of 106 out of 120, evidencing severe PTSD. He met criteria for all three symptom clusters, ie, re-experiencing, avoidance, hyperarousal.

He reported that he was sleeping 2 to 3 hours each night and that he had vivid, recurrent nightmares each night when he did fall asleep. His nightmares and other PTSD symptoms had noticeably increased since his retirement, and as a consequence he was experiencing feelings of hopelessness and depression. His nightmares typically involve responding to several men screaming for a medic and working frantically to stop bleeding or close wounds only to have the soldier die.

 Jack was engaged in prolonged exposure therapy to address his PTSD symptoms and he was prescribed citalopram and trazodone to address symptoms of PTSD, depression, and insomnia. He was able to complete 16 sessions of trauma-focused psychotherapy and reported a moderate reduction in PTSD symptoms (CAPS = 84), primarily regarding avoidance behaviors. He adhered to his medication regimen, which afforded 2 to 3 more hours of sleep some nights. However, he continued to report frequent nightmares.

He was referred to a group application of IRT in which 5 Vietnam war combat veterans were seen weekly for a period of 6 weeks to address trauma-related nightmares. He attended each of the group sessions. He was engaged and complied with treatment, and he was provided with a description of his nightmare as a habitual and self-perpetuating pattern of behavior that could be effectively addressed by treatment. IRT was introduced as well as breathing techniques, sleep hygiene principles, and mental imagery exercises.

Jack was asked to complete a list of his nightmares from the most distressing to the least, and from this hierarchy he chose a nightmare that was in the middle range of intensity using a subjective unit of distress (SUD) rating, from 0 to 100. He then wrote out the nightmare in detail and provided a SUD rating upon completion. He was asked to rescript this nightmare with another imaginal dream sequence of his choosing, which he wrote out in detail, and gave a SUD rating. His homework for the week was to rehearse the rescripted dream and practice sleep hygiene principles.

Each week progress was checked by reviewing his sleep diary, which provided data on sleep hygiene (ie, stimulus control, sleep environment), sleep latency, frequency of nighttime awakenings, wake time as well as nightmare frequency and intensity. When SUD for the target nightmare was reduced (SUD = 50/100), a more intense nightmare in the hierarchy was rescripted and practiced.

Exposure, relaxation, and rescripting therapy

ERRT is a cognitive behavioral, exposure-based approach to nightmare reduction, targeting the most intense nightmare as the focus of treatment. Treatment assists the patient identify core themes contained in the nightmare, such as safety, trust, power/control, intimacy, self-esteem. The nightmare content is rescripted in order to modifying the content based on the theme of the nightmare. As it is with IRT, the practice of rescripted nightmare content is followed by relaxation exercises, such as progressive muscle relaxation.

 Charles is a 68-year-old, white, Vietnam war veteran, in his second marriage of 23 years, with an adult daughter from his previous marriage. He has been self-employed as a plumbing subcontractor for several years. He had had a number of skilled labor jobs but decided that he was better off working for himself. Charles has received treatment through the VA Healthcare System ever since his return from Vietnam in 1968 where he was severely wounded when his squad of 19 Marines walked into an ambush and only 6 survived.

 Charles was referred for nightmare treatment by his primary care physician after he completed 12 sessions of cognitive processing therapy for PTSD. He was able to complete first-line group psychotherapy and reported a moderate reduction in his PTSD symptoms, evidenced by a reduction in his CAPS total score of 18 points. However, he continued to struggle with repetitive nightmares of the ambush he had survived in Vietnam. His sleep was interrupted on a nightly basis and when he attempted to return to sleep the nightmare would continue where it left off. He typically experienced 3 to 4 hours of sleep per night and would stay up late to avoid the nightmare. Charles was having difficulty working because of fatigue, he was often irritable, and his family relationships were strained.

 He started in an ERRT group with 4 other combat veterans who were seen weekly for 6 weeks to address trauma related nightmares. Initial sessions provided psychoeducation on trauma-related nightmares, sleep hygiene, and relaxation methods, which were practiced daily before sleep. He was asked to provide a detailed description of the most frequent and most intense nightmare and SUD rating before and after writing the description. He was also asked to identify the predominant theme of the nightmare (ie, safety, trust, power/control, intimacy, self-esteem), for which he identified safety and control as central themes in his nightmare. While maintaining the basic content of the nightmare, Charles worked with the therapist to construct new elements to the nightmare that addressed safety and control. Again, a SUD rating was established for the rescripted dream. These elements were included in a rescripted dream that Charles practiced every night 1 hour prior to a set bedtime, followed by progressive muscle relaxation.

Jack was able to complete the 6 sessions of IRT, and was adherent with between-session practice and rescription assignments. He was unable to reduce his SUD from his target nightmare to move to a higher-level nightmare, which impeded his progress in the therapy. He chose to rescript his nightmare with a mental image of fishing on a lake rather than content that reflected the subject matter of the nightmare, which appeared to reflect his avoidance of traumatic content. He stated that he could not change what happened in Vietnam and he believed he had nightmares “so that those soldiers would not be forgotten.”

He improved his sleep hygiene by reducing caffeine intake at night and establishing a regular bedtime and optimal bedroom environment. His pretreatment and post-treatment scores are seen in 

Jack was referred for depression treatment and medication review as he continued to complain of low mood and insomnia. Jack continued to report frequent nightmares at the end of treatment. He was also referred to the Sleep Medicine Clinic at the VA for a full sleep study to provide a differential diagnosis and medication review.

Exposure, relaxation, and rescripting therapy.

 Charles completed each of the 6 sessions of ERRT and was adherent to the between-session practice. After his initial rescripting of the entire nightmare, he decided that there was one part of the nightmare that was the most difficult, and he focused on this with a more circumscribed theme identification and rescription. He showed improvement on each of the pretreatment measures (

The most significant outcome for Charles was the change in his attitude toward his sleep and dreaming. This was evidenced in his reduce anxiety, agitation, and fear about having a nightmare about the ambush and his increased sense of efficacy when these nightmares occurred. He reported that he was better able to stay asleep longer while dreaming and that he dreamt about smaller portions of the ambush. He also reported that he found he could return to sleep without the dream repeating.

The challenge in applying each of these approaches to nightmare treatment is that the clinician needs to be reasonably knowledgeable about sleep science, sleep disorders, relaxation methods, and trauma treatment. The presence of violent movements during sleep may also reflect other sleep pathology that warrants assessment by a polysomnogram. In such cases, collaboration with sleep disorders specialists may be of benefit. Overall, these nightmare treatments are brief and each session requires sufficient structure and preparation in order to get the maximum therapeutic benefit. This also applies to the between-treatment work as patients are encouraged to contact the therapist during the week if they are having difficulty with practicing the methods.

The IRT method presents particular challenges in that it is more difficulty to address avoidance behaviors, which are a hallmark of PTSD. Patients who utilize avoidance and/or safety behaviors in the rescripting process limit the therapeutic effect of the treatment. Moreover, it is difficult to move up a patient nightmare hierarchy in 6 to 8 sessions.

ERRT adopts an exposure-based approach in identifying the most difficult nightmare first. This may present a challenge for therapists who are less familiar or uncomfortable with this method. Although the ERRT has a more structured protocol, therapists will require a significant degree of abstract thinking and cognitive flexibility assisting patients with rescripting their nightmares. It is important to note that trauma associated sleep disorder is a newly proposed parasomnia that develops after a traumatic experience and presents with nightmares, dream enactment behaviors, and other symptoms such as night sweats or tachycardia.

Dr Favorite is Director, University of Michigan Psychological Clinic, Clinical Assistant Professor of Psychiatry, Michigan Medicine, and Clinical Psychologist at the Ann Arbor VA Healthcare System PTSD Clinical Team. Dr Conroy is Clinical Associate Professor of Psychiatry and Clinical Director of the Behavioral Sleep Medicine Program, Michigan Medicine, University of Michigan Hospital, Ann Arbor.

The authors report no conflicts of interest concerning the subject matter of this article.

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Treating Post-Trauma Nightmares: A Cognitive Behavioral Approach

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 New York: Psychpubs, Springer; 2013:238-243.

Articles

Two evidence-based psychosocial treatments are available for trauma-based nightmares. The authors provide a case illustration for each method.

Psychosocial Treatments for Trauma-Based Nightmares

Delayed sleep wake phase disorder (DSWPD) is a circadian rhythm sleep disorder characterized by a mismatch between a person’s internal biological clock (or circadian rhythm) and societal norms. As a result of attempting to sleep out of sync with the internal biological clock, individuals with DSWPD report a significantly prolonged sleep onset, difficulties waking in the morning, suboptimal sleep duration, and excessive daytime sleepiness. If the preferred schedule is allowed (eg, the individual goes to bed late and sleeps late into the morning), sleep duration and maintenance are normal.

Onset of DSWPD often occurs during adolescence as a result of behavioral and physiological factors. Prevalence estimates of DSWPD in adolescents vary; however, ranges from 3.3% to 16% have been reported.

Presenting symptoms of DSWPD often mimic those of other sleep disorders, including insomnia or hypersomnia. Polysomnography is not indicated unless symptoms of other sleep disorders are present. Suggested strategies for assessment of DSWPD are provided in 

Assessment of sleep patterns including bedtime routines, bedtimes, sleep-onset latency, wake times, and sleep environment are critical to an effective differential diagnosis. Differentiating the features from insomnia entails understanding the adolescent’s schedule during school compared with weekends or holidays. Individuals with DSWPD often report normal sleep-onset latency and sleep duration on weekends, holidays, or school vacations when they are allowed to sleep on their preferred schedule. In contrast, those with insomnia will report lengthy sleep-onset latency regardless of the time they go to bed. In addition, those with insomnia may report difficulties with sleep maintenance-a feature not as characteristic of DSWPD.

Sleep hygiene is also an important area of assessment. Adolescents with DSWPD may develop compensatory behaviors to manage frustrations related to lengthy sleep-onset latency. Such behaviors often function to alleviate frustration at sleep onset (eg, phone use) or compensate for daytime sleepiness (eg, napping). However, restriction of the sleep-inhibiting behaviors as a stand-alone treatment rarely helps decrease sleep-onset latency in DSWPD.

Because assessment and management of circadian rhythm disorders rely on granular information on night-to-night sleep patterns, sleep logs are typically recommended. Differentiating schedules and sleep-onset latency between school days and weekends can provide evidence toward a delayed sleep phase relative to insomnia. The adolescent should be coached on maintaining the sleep logs for approximately 2 weeks, as parents often have limited information on their teen’s sleep patterns.

Actigraphy entails the use of a portable device, worn on the non-dominant wrist over a period of time to track movement. It is commonly used in research and in clinical practice. Actigraphy can be invaluable in both the assessment of DSWPD and the evaluation of intervention. In clinical practice, actigraphy can be difficult to obtain outside of a sleep setting, and interpretation of data requires some expertise. Commercial devices (eg, FitBit) are less reliable than actigraphy and typically should not be used as a substitute.

Management strategies include use of timed sleep schedules, melatonin, bright light therapy, and chronotherapy. There is insufficient evidence to recommend use of hypnotics at sleep onset or use of stimulants to promote wakefulness. This is in contrast to what is customary in many medical practices. A summary of treatment options can be found in 

Comprising 2 phases-the active phase and the maintenance phase-chronotherapy is an intensive intervention that helps reset the internal clock. The active phase involves a sequential delay of bed and wake times by 2 to 3 hours daily until a desired sleep schedule is achieved. After the active phase of treatment, a strict sleep schedule must be maintained making this treatment challenging to implement. From a clinical perspective, the benefits of the intervention include quickly shifting the schedule, which can be critical if the patient is frequently absent or late for school.

Kate, a 14-year-old, presents to the pediatric sleep clinic because of difficulties with sleep onset. At baseline, she describes sleep-onset latency of 3 to 5 hours with a bedtime of 10 pm, with several nocturnal arousals. On school days, because of the bus schedule, she wakes up between 5 and 6 am. She reports significant fatigue, especially during her morning classes.

On weekends, Kate goes to bed at 2 am; consequently, sleep-onset latency is shorter and she is able to sleep until 9 am. She reports increased energy on weekends when she sleeps on her preferred schedule.

Sleep-inhibiting activities at sleep onset include use of her phone and computer in bed. She also spends significant time in bed not sleeping as a means to escape from negative interactions with her parents and because she prefers to do her homework in her room.

During the initial evaluation, there are no concerns related to sleep-disordered breathing, narcolepsy, or parasomnias.

Kate describes her sleep as a mild problem, although she notes it can negatively affect her mood. She states that she is about to enter high school and plans on being heavily involved in athletics and other extracurricular activities. She believes that her sleep problems would limit her ability to engage in such activities.

Kate’s parents described her sleep concerns as within the moderate range. They describe significant difficulties helping her wake up in the morning, which leads to increased tension that persists throughout the day. In addition, her parents express significant frustration with Kate’s afternoon naps-they feel the naps exacerbate her sleep problems.

Given Kate’s decreased sleep-onset latency and improved sleep maintenance when allowed to have her preferred sleep schedule, the initial assessment indicates a need for more information related to DSWPD. It is recommended that Kate maintain sleep logs for 2 weeks.

At the second visit, the sleep logs support a diagnosis of DSWPD. Kate and her parents are provided with information on DSWPD to diffuse the tension surrounding Kate’s sleep patterns. When discussing treatment options, the family expresses a preference not to use melatonin because of frustrations related to past use. In addition, her parents do not think it is feasible for Kate to wake up earlier to use bright light therapy. Given the significant delay in sleep onset as well as the need to quickly adjust her bedtime to help Kate remain in school, chronotherapy is the best option.

The active phase of therapy means that the bedtime/wake time moves “around the clock” for 6 to 8 days. Keeping the sleep time to less than the recommended 9 hours for adolescents is used to increase sleep drive. Chronotherapy begins with a 3 am bedtime on day 1. This time is selected in the hope of decreasing sleep-onset latency. Subsequent days are outlined with the family, and a chronotherapy schedule is provided (

At the conclusion of the active phase, Kate’s progress is reviewed during the third visit. She reports that she is able to be adherent throughout the week and is maintaining a regular bed and wake time, but she continues to be fatigued upon waking. Emphasis is placed on maintaining the same bed and wake times regardless of whether it is a school day or a weekend (maintenance phase). Problem-solving occurs during this visit to account for special activities (eg, prom, sleepovers). The maintenance phase lasts about 2 months. During this time, it is critical to keep to the same bedtimes and wake times to “set” the internal clock. The recommended sleep time for Kate is 10 pm to 5:30 am.

A final visit is scheduled 2 months later to assess the maintenance phase. Kate reports that her weekend activities help her maintain the sleep schedule because they promote early waking. She no longer naps and falls asleep within 30 minutes of bedtime, and she is able to sleep for 7.5 hours a night. Given the maintenance of gains, visits are moved to an as-needed basis.

Kate is a relatively straightforward patient with no comorbid psychiatric or medical diagnoses. Modifications would need to be made in the case of psychiatric diagnoses in which the patient should not be unsupervised for long periods (eg, depression with suicidal ideation, substance abuse). In these situations, we have had parents go through the active phase of chronotherapy with their child to provide monitoring and support. Sleep deprivation can also exacerbate depression, and close monitoring is needed with such patients.

DSWPD is a circadian sleep disorder commonly seen in adolescents. Thorough and careful assessment is critical to differentiating features of DSWPD from other common sleep problems. DSWPD can affect the patient’s mood and result in chronic sleep deprivation. Several options exist to help manage DSWPD-all of which require close follow-up because relapse is common.

Dr. Dore-Stites is Clinical Assistant Professor of Pediatrics and Communicable Diseases, Michigan Medicine, University of Michigan, Ann Arbor, MI; Dr. Conroy is Clinical Associate Professor of Psychiatry and Clinical Director of the Behavioral Sleep Medicine Program, Michigan Medicine, University of Michigan Hospital, Ann Arbor.

 Sivertsen B, Pallesen S, Stormark K, et al. Delayed sleep phase syndrome in adolescents: prevalence and correlates in a large population based study. 

 Saxvig I, Pallesen S, Wilhelmsen-Langeland A, et al. Prevalence and correlates of delayed sleep phase in high school students. 

 Bartlett D, Biggs S, Armstrong S. Circadian rhythm disorders among adolescents: assessment and treatment options. 

 Auger RR, Burgess HJ, Emens JS, et al. Clinical practice guideline for the treatment of intrinsic circadian rhythm sleep-wake disorders: advanced sleep-wake phase disorder (ASWPD), delayed sleep-wake phase disorder (DSWPD), non-24 hour sleep-wake rhythm disorder (N24SWD), and irregular sleep-W. 

Here: suggested strategies for assessment and management of this circadian sleep disorder commonly seen in adolescents.

Author | Deirdre A. Conroy, PhD

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