How To Deal With PTSD Dreams

PTSD dreams, or nightmares, are commonly experienced in post-traumatic stress disorder (PTSD), a mental health condition that some people develop after experiencing or witnessing an extremely traumatic event. 

These dreams are understandably distressing, but it’s possible to manage them and improve sleep. 

Is there a connection between PTSD and nightmares?

People with PTSD often experience nightmares or anxiety-provoking dreams that replay the traumatizing event or represent major threats and themes associated with it.

The characteristics of these dreams vary based on the trauma experienced. However, they typically create feelings of dysphoria, anxiety, sudden awakening, and an increase in heart rate. 

PTSD dreams most often occur toward the end of the night, but they can happen in all sleep stages. 

PTSD dreams can negatively affect the functioning and health of the patient, sometimes leading to insomnia, daytime dysfunction, and suicidal thoughts. Also, people who have nightmares shortly after a traumatic event are more likely to have more severe PTSD symptoms after six weeks. 

Are nightmares a common symptom of PTSD? 

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), distressing dreams are a key intrusive or re-experiencing symptom of PTSD. 

These nightmares are a common symptom of PTSD, affecting around 80%¹ people with the condition. 

Why does PTSD affect dreams? 

Some experts² believe that PTSD dreams occur when the patient attempts to make sense of their anxiety and guilt from their traumatic experience. PTSD dreams are a way to process trauma without activating defense mechanisms. 

When someone experiences trauma, their stress response is activated. In healthy people, this switches off when the stressor has gone. 

However, the stress response remains chronically activated in people with PTSD. This leads to greater levels of hyperarousal during the day and night, as well as dysfunction and imbalance of brain structures that are important for mood. 

Can nightmares cause trauma? 

Waking up from a nightmare can be scary and distressing. 

However, it’s not known for sure whether nightmares can cause trauma. Some research³ suggests that nightmares may speed up the development of PTSD and strengthen the symptoms associated with trauma. 

For example, study participants who already had nightmares before developing PTSD went on to have more severe symptoms of the disorder.

Are PTSD nightmares the same as flashbacks?

PTSD nightmares and flashbacks are intrusive symptoms of PTSD where a person relives their traumatic experience. Although similar, they have key differences: 

• Flashbacks are dissociative events where the person feels like they’re reliving the trauma in the present moment. These occur during waking hours.

• Nightmares occur when the person is asleep. Unlike flashbacks, the mind knows that a nightmare isn’t real. 

How can PTSD dreams be managed?

It’s possible to manage PTSD dreams. This may involve several approaches, including medications, therapy, and focusing on sleep hygiene. 

Treating the PTSD 

Traditional PTSD treatments could help people deal with PTSD dreams. 

Medications 

Only some of the medications prescribed for PTSD have shown to be beneficial for managing PTSD dreams.

 If someone is experiencing PTSD dreams, they should speak to their doctor to ensure there are no negative impacts from their medications.

Prazosin

Prazosin is the most frequently prescribed medication for PTSD nightmares. It is an alpha-2 adrenergic antagonist that reduces outflow from the sympathetic nervous system (the division of the nervous system that responds to stress). 

One study⁴ on veterans with PTSD found that prazosin was the only medication that led to total nightmare resolution. 

The starting dose should be low, 1mg each night, and can slowly be increased if needed. 

Psychotherapy

Trauma-focused psychotherapy could help prevent or manage PTSD dreams. 

Psychotherapy should be carried out in a safe and controlled environment with a professional. 

The American Academy of Sleep Medicine⁵ recommends cognitive behavior therapy (CBT) and some of its subtypes for treating PTSD nightmares. 

Cognitive behavior therapy

CBT⁶ is a psychotherapeutic approach that focuses on the connections between our thoughts, emotions, and behavior. CBT helps the patient view nightmares as a learned response, which can be modified using cognitive and behavioral techniques. 

A variation, CBT for insomnia, is specifically recommended¹ for treating PTSD dreams. 

Image reversal therapy

Image reversal therapy (IRT)⁷ is a brief, effective, and well-tolerated treatment for PTSD nightmares. It involves recalling the nightmare and writing it down but changing part of the storyline, ending, or theme to make the dream less traumatic and more positive.

The patient then acts out the altered version of the dream, intending to displace the original traumatic PTSD dream when it’s experienced again. 

IRT is carried out during waking hours, for 10–20 minutes each day. 

A study⁷ found that IRT leads to improved sleep quality, a significant alleviation of disturbing dreams, and a 60% reduction in PTSD symptoms. These positive effects were also maintained at three- and six-month follow-ups. 

Exposure, relaxation, and rescripting therapy

Exposure, relaxation, and rescripting therapy are similar to IRT because it educates patients on their trauma and nightmares. 

While being exposed to the memories and content of the dream, the patient develops relaxation strategies, changes the content of the nightmare to make it less traumatic, and learns how to respond using healthy emotions. Key themes of power and control, trust, intimacy, esteem, and safety are considered.  

EERT also helps the patient improve sleep hygiene. 

Other forms of therapy 

Eye movement desensitization and reprocessing

Eye movement desensitization and reprocessing is a neurological-based treatment that is believed to activate mechanisms in the body to help process trauma. 

It involves identifying, discussing, and focusing on a traumatic memory while simultaneously making quick horizontal back-and-forth movements similar to those made in REM sleep. 

Lucid dreaming therapy 

In a lucid dream, the dreamer is aware they’re dreaming and may be able to control what happens, meaning that someone with PTSD may be able to change the course of events in the dream or wake themselves up. This is hopeful, as it may give the person a sense of self-responsibility and self-control and bring reassurance that they’re not in any physical danger. 

Lucid dreaming therapy is a unique form of therapy because it can be performed while the nightmare is occurring rather than afterward. It’s believed that lucid dreaming therapy can reduce how distressing PTSD dreams are and the frequency of experiencing them. 

Lucid dreaming therapy is usually done over six weeks, but there can be benefits after even one session. 

Sleep hygiene 

It’s important to maintain healthy sleep hygiene after experiencing trauma. Most people with PTSD have sleep dysfunction. 

To improve sleep hygiene, the following tips can help:

• Develop a relaxing night routine and try to maintain it after experiencing a traumatic event.

• Keep the room dark, cool, and quiet. If the dark causes anxiety, a nightlight may help.

• Only use the bed for sleep and intimacy, not while watching TV or using devices like a smartphone.

• Turn off electronic devices one hour before going to sleep.

• Avoid large and greasy meals, caffeine, and alcohol before going to bed.

• Sleep in a room that feels safe.

• Take a warm shower and use the toilet before bed. 

The lowdown

PTSD dreams can be distressing and difficult to manage, but with therapy, sleep hygiene, and potentially medication, people learn how to cope with them. Anyone suffering from PTSD dreams, or other symptoms, shouldn’t be afraid to ask for help. PTSD is not something that should be dealt with alone.