PSYC 444 Lecture Notes - Lecture 16: Lucid Dream, Nightmare Disorder, Stephen Laberge
14 May 2018
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PSYC 444 – LECTURE 16
FACTORS ASSOCIATED WITH NIGHTMARES
Trauma
• Aggression
• Accidents
• Natural disasters
• Life changes
Psychopathology
• e.g. history of schizophrenia
Personality factors
• e.g. thin boundary: more intense dreams and more frequent nightmares
Medication
• e.g. Professor always has a nightmare after taking flu medication
Nightmares are differentiated by cause
1. Idiopathic: without a known cause
• Accumulation of events
• Does’t eessarily ea that is no cause
2. Traumatic: resulting from a traumatic event
Note that PTSD also happens to civilian populations- outside the war zone
Dysphoric dreaming: when your emotions are negative, your dream content is negative
• Usually results in aversion towards sleep in general
• Association between sleep and traumatic experience can lead to recurrent nightmare disorder
There is not much known about resilience factors against nightmares
NIGHTMARES IN THE CONTEXT OF PTSD
PTSD:
• Exposure to a traumatic event
• Event is persistently re-lived
o Recurrent memories
o Persistent nightmares
o Distress when exposed to stimuli resembling trauma
o Heightened reactivity to the environment
• Persistent avoidance of stimuli associated with trauma
• Autonomic hyperactivity
o Sleep disorders
o Anger and irritability
o Hypervigilance
▪ Constant monitoring of the environment
o Attention difficulties
o Startle response
Normally with nightmares, there is a mixture of past events and imagination. However, nightmares in PTSD patients often involve full recall of events, including the
what, where and when information. The entire temporal sequence is relived.
• Process of memory consolidation gone wrong
• This dysfunction is then manifested into dream content
Nightmares content in PTSD patients is related to the trauma
• Recurrent nightmares are common
• Episodic nightmares: resembling flashbacks
However, not all nightmares are related to the trauma.
NIGHTMARE DISORDER
Nightmare disorder involves a vicious cycle: nightmare distress → sleep disorder
1. Avoid sleep or wake up too early → sleep debt
2. REM sleep debt → rebound → more dreaming
• Recall that there is a lot of dreaming during REM sleep
Sleep and nightmares:
• Fear or anxiety associated with sleep
o Reluctant to go to bed
o Dysphoric emotions
• Non-restorative sleep
o Awakenings; fragmented sleep
• Intrusive imagery at wake
find more resources at oneclass.com
find more resources at oneclass.com
TREATMENT OF NIGHTMARES
Usually CBT
• Imagery rehearsal
o Most common
o One of the best techniques
• Lucid dreams
o One of the best techniques
• Hypnosis
• Pharmacological treatments
o Not recommended because suppressing REM temporarily only causes it to return with vengeance once off medication
• Eye Movement Desensitization and Reprocessing
o Idea is that REM sleep physiological following trauma is not doing its job of decoupling memory and emotion, resulting in repetitive input
• Relaxation techniques
IMAGE REHEARSAL THERAPY
Cognitive behavioral therapy for nightmares: learning to take charge of mental imagery
1. Nightmare report: describe nightmares (causing distress) to a therapist in a safe environment and relaxed state
• Works best with repetitive nightmares (easily recalled)
2. Report while changing some anxiogenic elements
• Change the nightmare as you wish
• Take charge of the narrative and regain agency
• Changed to something not threatening
3. Visualization of the new scenario in a relaxed setting
• Patients almost never dream about the new nightmare but there is a decrease in nightmare frequency
• May be due to deconditioning
• Facing the trauma, opposed to avoiding it, has a huge therapeutic effect alone.
Some argue that image rehearsal therapy only removes symptoms without addressing the core of the nightmare
• Avoiding the anxiogenic core
LUCID DREAMING
Familiarizing yourself with recurrent themes as possible triggers for lucidity. Lucid dreaming works best with a recurrent nightmare: next time I have this nightmare, I
will recognize the unreality and create a virtual reality in my mind
• Either wake up to the nightmare, or
• Taking charge of the scenario and developing agency
Lucid dreaming develops distance between the dreamer and the dream
• Attenuation of emotional response knowing that the dream is not dangerous
• Being aware that you are asleep removes the panic and hyperarousal
Stephen Laberge came up with a list of prescriptions for specific situations (e.g. when something is chasing you, instead of running, turn around and ask whatever is
chasing you why it’s hasig you.
• Sometimes lucid dreams provide explanations and answers
• Why am I having this kind of dream?
Note that people are often reluctant to admit they have PTSD, especially war veterans because they cannot get re-deployed if they have PTSD. Thus, experiments are
reworded: looking for people who have come back from combat and are having sleep difficulties
Lucid dreaming is a non-pharmaceutical treatment that is gaining traction.
• Works well with children
• However, controlling imagery is not an easy task
HYPNOSIS
Hypnosis is efficient, especially if it contains suggestion to change the dream scenario
PHARMACOLOGICAL TREATMENTS
• Diazepam (Valium): anxiolytic
• Antidepressants that act on REM sleep (reduction)
• Prazosin: anxiolytic
Problem: REM rebound and withdrawal effects
• Many also have intense side effects
• Worthwhile as a short-term solution if in intense distress, but not so much long-term.
find more resources at oneclass.com
find more resources at oneclass.com
AASM (2010) Recommendations based on a meta-analysis and level of evidence for different treatments
Level A: based on results of a RCT with a control group, longitudinal studies, or consensus among majority of therapists
• Rare for dream interventions
Level B: some support but no large population RCTs
Level C: treatments that seem to work but require more research evidence
EYE MOVEMENT DESENSITIZATION AND REPROCESSING
1. Recreate REM sleep when wake by moving eyes randomly, like saccadic eye movements during REM sleep
2. Patients are asked to recall traumatic event and bodily phenomenon while relaxed
It is unknown how this technique works but it does show promise (lessens distress and nightmare frequency)
REM SLEEP PARASOMNIAS
Parasomnias: event surrounding sleep; usually the event is undesirable
• Divided into REM associated or non-associated
Example REM parasomnias:
• REM Sleep Behavior Disorder (RBD)
• Sleep paralysis
• Nightmares
• Dream enactments (less known and less studied, but quite prevalent)
• Narcolepsy
Example NREM parasomnias:
• Sleep walking
• Night terrors
REM SLEEP BEHAVIOR DISORDER (RBD)
• Loss of muscle atonia in REM sleep
o Lack of paralysis causes dream enactment
• Range of behaviors (simple to complex)
• Most prevalent cause of consultation: injuries
o Visits to the doctor are often due to hurting their bed partner
o No incorporation of the environment
• Associated with intense and violent dreams
o May be a consultation bias
o Dogma: men over 50 acting out violent dreams
RBD ad its assoiatio ith eurodegeeratie disorders, suh as Parkiso’s, resulted i a ireased focus on this disorder
RBD PREVALENCE
• Prevalence is unclear (maybe around 0.5% of population
o Likely to be under-reported
• Most prevalent in men
o Women usually report less violent expression
• Starts after age 50
RBD DIAGNOSIS
• REM sleep without atonia
• Not due to epilepsy, medication, nor other sleep disorders
• At least one of:
o History of potentially dangerous dream enactments
▪ For self or for others
▪ Injuries
o Documented abnormalities in muscle tonus
▪ As seen in PSG
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
Personality factors e. g. thin boundary: more intense dreams and more frequent nightmares. Medication e. g. professor always has a nightmare after taking flu medication. Note that ptsd also happens to civilian populations- outside the war zone. Dysphoric dreaming: when your emotions are negative, your dream content is negative. Usually results in aversion towards sleep in general. Association between sleep and traumatic experience can lead to recurrent nightmare disorder. There is not much known about resilience factors against nightmares. Normally with nightmares, there is a mixture of past events and imagination. However, nightmares in ptsd patients often involve full recall of events, including the what, where and when information. This dysfunction is then manifested into dream content. Nightmares content in ptsd patients is related to the trauma. However, not all nightmares are related to the trauma. Nightmare disorder involves a vicious cycle: nightmare distress sleep disorder. Avoid sleep or wake up too early sleep debt. Rem sleep debt rebound more dreaming.
