A recent article in the New Yorker caught my attention. "Nightmare Scenario" by Margaret Talbot, discusses the most recent theories on nightmares and how to treat them.Nightmares and their effects on our lives is a subset of sleep hygiene that gets little attention. Nightmares are often thought of as a symptom of a much larger problem or diagnosis, such as anxiety, posttraumatic stress syndromes, insomnia or psychosis. It has not been traditionally thought of as a stand-alone issue until fairly recently. Since it is estimated that up to 30 percent of adults report they have nightmares at least once a month, it is not a small issue. For the sake of this article, I will define nightmares as dreams that impact the sleeper enough to wake them and/or affect their daytime life in a significantly negative way.
At the Maimonides International Nightmare Treatment Center in Albuquerque, the treatment method used for those seeking relief from debilitating nightmares is called imagery-rehearsal therapy. The patient is taught to use visualization during the day to transform the nightmare into a more positive context and have it become a different dream. By training the mind during the day the nightmare becomes less debilitating.
In a 2001 paper by Krakow, et al., 168 women who had been victims of rape and were experiencing repeated nightmares were studied.1 The women were divided equally into a control group and study group. The experimental group was taught to focus on a very relaxing situation they could recall in their minds and to write down their disturbing dream and change it in any way they wished. They were then to spend about 10 minutes a day visualizing this newly configured dream scenario. This process lasted for six months. Those who had done the imagery-rehearsal therapy have fewer nightmares and of less intensity than the control group. Other symptoms, such as insomnia and posttraumatic stress, improved more significantly than the control group.
Since then, other studies were performed with children and war veterans from Iraq and Afghanistan. The returning vets are part of a joint program funded by the Pentagon and administrated by the University of Pittsburgh, led by Anne Germain, a Canadian sleep scientist. All of these studies showed the power of visualization in improving the nightmare scenario.
William Domhoff from UC Santa Cruz is a dream researcher and sleep specialist who is a proponent of imagery-reversal therapy. He believes that the nightmares are manifestation of our deepest concerns. It is not so important that the dreams be analyzed in great detail but rather seen for their overall emotional story. If they are waking the patient up and preventing them from falling asleep again then it is worthwhile focusing on transforming the nightmares into a less destructive force.
An interesting aspect of nightmares is how the greater culture or media influences them. Michael Schredl, a German researcher reviewed studies of nightmares over the last 100 years and found certain trends regarding content. The bogeyman was a prominent theme in nightmare content in the 1920's, which then gave way to ghosts, devils and witches in the 1950's and 1960's. Recently, Freddy Krueger and Voldemort have entered into our collective dreamscape. His study of German children found that there was no appreciable difference between the heavy computer users and TV watchers vs. average TV and computer users regarding frequency of nightmares.2 The content of the nightmares was influenced by media but the frequency was not, so it would seem.
One might ask what the purpose of nightmares might be? Is there an evolutionary reason for having nightmares? Do we need them or are they a type of dysfunction?
One theory is that nightmares evolved as a form of simulation, training for real-life threats that could be worked out or rehearsed in our dream life so that we would be prepared should a real-life scenario present itself. Another theory is that nightmares are a way of desensitizing the sleeper to something frightening by repeated exposure in a less frightening way. Each approximate encounter would act to lessen the reaction in the mind.
Yet another concept is that nightmares, instead of preparation for a possible future encounter, might be a way to resolve a past trauma. Studies have shown that trauma victims have more nightmares, which would indicate some way of working out the disturbing experience in the dream life, or subconscious. The most appealing concept of dreams and nightmares, which makes the most sense to me, is that dream life, like waking life, is purely a reflection of our reactions to our experiences. In waking life, our thoughts and emotions run the spectrum from what we crave and desire to what we resist and fear the most. Why shouldn't our dream life reflect this same spectrum of positive and negative experiences?
Understanding the Dream Life
As physicians, we need to be aware of whether or not the dream life becomes an obstacle to health and well-being, and intervene in a way that is beneficial. David Eisenberg's 1985 book, Encounters With Qi, has a chapter entitled "Freud is not here." He felt that there was a somatization of inner life in modern China, particularly of mental illness. Insomnia was relegated to liver qi stasis, with liver yang rising or heart fire. This is perhaps a vast oversimplification on our part, as Westerners looking into Chinese medicine's treatment of sleep disorders. Or maybe Chinese medicine, as embodied in mainland China in the 1980's, was lacking in a refined approach to treating a disturbing dream life. The West doesn't have much sophistication in this field either until now.
The Tibetans seem to be more attuned to this type of disorder. Dream yoga, as practiced in Tibetan Buddhism, is a way of utilizing the art of lucid dreaming to continue bringing awareness and intention into the dream life. Lucid dreaming can be learned by training the mind to notice dreaming then manipulate the dream while still dreaming.
Tibetan Lamas might argue that there is not much difference on an absolute level between waking and dream experience, both being illusions of reality. What is the difference in experiencing a memory of what happened yesterday at lunch and what happened last night in our dream? Both experiences are conceptual. What the Tibetans and the sleep researchers who are doing imagery-reversal therapy would agree upon is the fundamental understanding that we can alter our experience by using our minds to create new experiences. We can alter our dream life by consciously creating new scenarios, images to focus upon over and over again to condition ourselves to a new outcome. Our mind is our most powerful tool for change.
As an example, basketball players taught to visualize perfect free throws only in their minds outperformed a group who physically practiced shooting free throws. When focusing the mind on a goal, the mental image formed creates a picture that the subconscious can grab. Since the unconscious mind cannot distinguish between real and fake images, it takes all images to be real. The feelings and emotions that result from creating these images have the same effects on the physical body as a real event would have.
The power of visualization as a tool for creating profound change in an individual's life cannot be over emphasized. Whether it is changing the patterns of disturbing dreams or impacting repetitive negative belief systems that underlie bad habits, intentional visualization can create real physiological health.
- Krakow B, Hollifield M, Johnston L, et al. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial. JAMA 2001 Aug 1;286(5):537-45.
- Schredl M, Anders A, Hellriegel S, Rehm A. TV viewing, computer game playing and nightmares in school children. Dreaming Jun 2008;18(2):69-76.
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