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Glenn Yank, MD is a Psychiatrist located in Tennessee.


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Question:
I have a question regarding nightmares. For me, when they occur they usually come on hard and last for days and usually the same dream. I’m sure you’re aware of the kind that wake you up screaming dripping with sweat and, well even if I don’t like to admit it, waking up in closets or other places screaming. My question tho isn’t on how to stop them, (unless you have a fix all pill and I WANT IT LOL). It has to do with the fact that I’m not waking up terrified or even sweating, I’m just waking up. I’m not complaining but I am a bit concerned that it may not be due to healing so much as becoming desensitized. Sort of like… people who see violence all the time tend to be able to turn off the emotion to it. My goal is to heal, not to become cold or callous to it, as I don’t see that as healing. My mind tells me healing is when the dreams stop… they’re not stopping they are just (at least this one) not bothering me for lack of a better way to put it. I’m going on over a week of this dream, I go to sleep it’s a given its there waiting. Or maybe its there because I expect it to be, I don’t know. Positive note to it, if you can call it positive, is at least I’m not avoiding sleep. Before you answer that I should talk this over with my shrink, I don’t have one. I have enough on my current plate without adding a shrink and other issues to it. And I use shrink in the most loving of terms. Just looking for your thoughts on this.

Answer:

Thank you for bringing up the issues of nightmares, nocturnal flashbacks (re-experiencing of trauma during the night), and other sleep disorders in people who are trauma survivors. Studies have shown that more than 40% of patients with Post Traumatic Stress Disorder (PTSD) have difficulty falling asleep, and even more have disrupted sleep. Nightmares occur more frequently in PTSD patients than in other populations, and include both the intrusive re-experiencing of traumatic events and other frightening dreams that are not exactly re-experiencing of traumatic events, but may involve themes of death, injury, or capture. Nightmares and sleep disorders are even more likely if the person has a co-morbid panic disorder. Impaired sleep creates additional problems for the person during the daytime, contributing to fatigue, impairing concentration, making it harder to use more adaptive coping skills, and making people more easily frustrated and irritable.

Both psychotherapy and medications have been studied with regard to PTSD nightmares, and there are some useful findings from these studies, even if the studies are relatively small. Imagery Rehearsal is the best studied therapy for nightmares. Imagery rehearsal consists of three steps, all of which are performed in the waking state: (a) select a nightmare, (b) “change the nightmare any way you wish,” and (c) rehearse the images of the new version (“new dream”) 5 to 20 min each day. Modifying and practicing the “new dream” often leads to decrease frequency and emotional intensity of the old nightmare. In addition, cognitive behavior therapy has been shown in a small study to decrease the frequency of nightmares. This includes therapies called exposure therapies, in which the person is taught to relax as they are gradually exposed to stimuli that remind them of their trauma.

Other therapy techniques that can decrease the frequency and intensity of daytime flashbacks may decrease nightmares as well. Although I have seen this in practice, I could not find any literature reviews focusing specifically on decrease in nightmares from these techniques. These techniques include Eye Movement Desensitization and Reprocessing (EMDR) and visual-kinesthetic dissociation (V/KD). There is a good on-line review article about V/KD in the journal Traumatology.

Some of the concepts underlying behavioral exposure treatments and V/KD may have a bearing on your question about whether or not you are becoming desensitized to the traumatic content in your dream. First, I would like to offer a different understanding of what desensitization means. Desensitization merely means that after a certain process occurs, responses to particular stimuli are less intense than they were previously. In other words, the person is less sensitized. It does not imply becoming indifferent, cold, or callous, but it does imply a decrease in the emotional intensity of the responses. People suffering PTSD have become extremely sensitized to memories and reminders of their traumas, and have very intense reactions to these stimuli. In many approaches to the therapy of trauma, treatment seeks to accomplish decreasing the emotional intensity of a person’s response to the memories and reminders of trauma, and thereby to allow more conscious choices about how to respond to these memories and reminders. Such a decrease in the emotional intensity of response would mean that behavioral responses are less automatic and that the person has more ability to stop and think how they want to respond to a memory, a person, or an event. Accompanying this change will also be (hopefully) fewer spontaneous intrusions of traumatic memories into waking consciousness or into dreams. Therefore, I would argue that if your dreams are bothering you less, that is an important milestone on the way to healing.

Memories tend to have less emotional power when viewed as an outside observer (looking at yourself in the situation, which is called second person or second position) compared to looking at them through your own eyes (called first position or first person). V/KD and other techniques that have people imagine watching their traumatic memories on a screen are seeking to change these memories from first person to second person, and thus decrease the emotional intensity of the person’s response to the memories.

In addition to these psychotherapeutic approaches, there is some evidence that certain medications can decrease the intensity and frequency of trauma related nightmares and nocturnal flashbacks. I would offer, on a cautionary note, several disclaimers about the studies on effects of drugs on trauma related nightmares and flashbacks. Much of the literature on this topic is based on open studies, which are not controlled and in which the investigator knows which drugs the patients are taking, which allows for the introduction of bias. Other studies are based on retrospective review of charts, which also is not a good standard of proof of efficacy. Still other studies are very small, so that their conclusions may not hold up in larger samples. Also, much of the literature is based on studies of military veterans with combat-related PTSD, and may not apply to abuse survivors or other civilian trauma situations. Nevertheless, I offer this information because the sleep problems of trauma survivors are very severe, and most medications for insomnia don’t stop the nightmares and flashbacks.

There are small, open and retrospective studies in the literature, dating back over a decade, showing possible effectiveness for Periactin (cyproheptadine), an older antihistamine that also has effects of serotonin receptors. I have used this in my practice and it has helped more than half of the patients to whom I have given it, by reducing the frequency and intensity of their nighttime flashbacks and nightmares of reliving trauma. I mention this medication first, because the side effect profile is relatively mild, and similar to Benadryl. Side effects are sedation, a little bit of dry mouth, and feeling hungry in the morning.

There has been recent interest in using prazosin (a medicine for hypertension) for a number of symptoms of PTSD, including sleep disturbances, and early studies, including open studies and one small controlled study, appear promising. Prazosin works on the autonomic nervous system (by blocking a receptor for norepinephrine, the neurotransmitter involved in arousal, as well as blood pressure control) to decrease PTSD symptoms of hyper- arousal. However, as a medicine intended to treated elevated blood pressure, prazosin can lower blood pressure and cause dizziness or fainting as side effects. I have no personal experience with using this drug for PTSD.

Topamax is an anticonvulsant that has been studied recently in one small retrospective study (35 people) and shown to be possibly effective for PTSD symptoms. Topamax is a powerful anticonvulsant affecting several neurotransmitters that is being studied as a potential mood stabilizer, but has not been proven to work in that capacity. Many people are hopeful it will prove useful because one of its side effects is to suppress appetite and increase appetite, thus promoting weight loss. However, it also has negative effects on memory, including immediate recall and verbal memory. I have used it with a few patients with mood disorders (when drugs with proven efficacy have failed) and in a few with serious weight problems. Because side effects can be a problem, I prefer using drugs with more proven effectiveness (for mood disorders) or less severe side effects – most of my patients cannot afford any impairment in their cognitive functions!

The best studied group of medications for the entire syndrome of PTSD are the Selective Serotonin Reuptake Inhibitor (SSRI) group of antidepressants, which includes Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Celexa (citalopram), Lexapro(escitalopram), and Luvox (fluvoxamine). Although these drugs are well studied and proven to helpful with most PTSD symptoms, including numbing, hyperarousal, anger, emotional upset at reminders, anhedonia, detachment, avoidance of activities, and the feeling of a foreshortened future, the studies show that they may not be as useful for nightmares and nighttime flashbacks. Although I use these medications frequently in patients with PTSD, my experience bears this out.

There are other medications that may be helpful for individuals with PTSD nightmares, and prescribing always has to be individualized. Remeron is a powerful antidepressant that promotes sleep and does not have the sexual side effects of SSRI drugs, but has only been tested in PTSD in open studies so far. It also can increase appetite and weight. Nefazodone, Trazodone, and the sedating atypical antipsychotic drugs Olanzapine and Seroquel are also used for insomnia in PTSD, as well as in other conditions. I have not commented on medications for insomnia in general, such as Ambien, Restoril, chloral hydrate, and benzodiazepines (Klonopin, Xanax, Ativan, Valium, etc.) because they have no specificity for nightmares or flashbacks or other PTSD symptoms, although they are often used for insomnia and can certainly help people get to sleep faster and have less sleep interruptions, although they do not decrease nightmares or flashbacks, as a rule.

As always, comments that I make about therapies and medications are for informational purposes and need to be discussed by you, the reader, with your therapist and/or physician to determine whether they may be of benefit to you. It has been my hope to use this letter to review current information on how people may obtain some relief from the terrible nightmares and other sleep disturbances that can occur after trauma.

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© Copyright 2003-2005. All rights reserved. Contact: ShrinkTime Last edited: 06/21/03.