A Nightmarish Two Years

By: Dr. Christina Pierpaoli Parker, PhD

COVID-19 has produced unprecedented spikes in psychiatric and sleep symptoms, including those of posttraumatic stress and substance abuse disorders, depression, and insomnia.  2020 onward has felt…nightmarish.

Many reported experiencing bad, unusual dreams at the pandemic’s start—but seemingly unabating psychosocial stressors and collective traumas have transformed these into full-blown nightmares for others. And this makes sense.

Did I just have a nightmare or a bad dream?

Nightmares and bad dreams don’t sleep in the same bed. While they likely evolve from the same essential phenomenon, nightmares and bad dreams differ in their intensity and content. Nightmares typically include:   

·   Extremely dysphoric, disturbing, and well-remembered mental images that usually involve efforts to avoid threats to survival, security, or physical integrity

·   Themes of failure, helplessness, physical aggression, accidents, health-related concerns and death, and interpersonal conflicts

·   Fearful awakenings with psychophysiological symptoms, including tachycardia, sweating, and lingering symptoms of anxiety and panic, as well as

·   Rapid orientation, heightened awareness, and alertness upon awakening

Bad dreams feel less intense and usually don’t include the rude awakenings, physiological symptoms, and vivid memories.  For better or for worse, you’ll usually know if you’ve had a nightmare.

The anatomy of nightmares

Though both dreams and nightmares remain poorly understood, we can conceptualize them as intense mental activity happening mostly during the rapid eye movement (REM) stage of sleep—one of its several stages. During this one, sometimes called paradoxical sleep, the eyes dart back and forth quickly, heart rate and blood pressure rise, and brain activity increases.

Specifically, REM activates the amygdala and hippocampus in the brain: two central fixtures of the human limbic system processing emotion and memory. The limbic system houses meaning-making software that helps us to metabolize our daily experiences.

The ongoing stress of COVID-19 means this software has more emotional demands to triage. The brain prefers order, so its frontal lobes attempt to process and synthesize our emotions—organizing the chaotic REM signals believed to produce dreams into narratives. In other words, nightmares (and weird dreams) may reflect the strong emotions COVID-19 has generated and the output from our meaning-making software.

Dreams can vary in their length, ranging from a couple of minutes to upwards of 30.

Increase of nightmares and weird dreams during COVID-19

But anxiety, stress, and trauma do not entirely explain observed increases in nightmares during the pandemic or generally. Dysregulated sleep schedules, insomnia symptoms, and increased substance use also contribute. Changing sleep schedules

People spend about a quarter of night’s rest in REM, with dream cycles happening about every 90 minutes, getting longer and more intense across the latter half of the evening. 

In this era of working from home, people tend to sleep longer and later. And because REM periods lengthen toward the morning, irregular sleep schedules allow more time for dreaming (and nightmares). To manage this, attempt to anchor your daily wake time, keep it, and only go to bed when you feel sleepy, not tired.  

Coronasomnia

Coronasomnia—difficulties falling, staying asleep, or waking up too early associated with COVID-19— can also reduce total sleep time. Shorter sleep constricts REM, increasing the pressure for REM sleep later, or more REM and quicker upon the next sleep opportunity. During this “REM rebound”, dreams can often feel more vivid, intense, and dysphoric.

Among other things, keeping a regular wake time, using your bed appropriately, getting enough light and movement during the day, and creating a soothing bedtime ritual can facilitate quicker and more consolidated sleep while warding off nightmares and bad dreams.

Don’t drink to that 

Alcohol use has also increased appreciably during COVID-19.

Using alcohol (or withdrawing from it in cases of chronic use) to quiet a racing mind before bed or hasten sleep onset can produce similar and nightmarish rebound effects because alcohol prevents entry into the deepest, most restorative stages of sleep.  It can also cause more intense dreams. 

This cycle gets vicious quickly as nightmares can inspire efforts to avoid sleep or self-medicate with alcohol—behaviors themselves nightmare-producing. 

Other considerations

Nightmares tend to happen more often during stressful periods and appear more common among women. But they can also have associations with medications and psychiatric disorders.

Certain antidepressants affecting neurotransmitters including norepinephrine, serotonin, and dopamine have well-documented links to nightmares. They can also co-occur with psychiatric diagnoses including depression and posttraumatic stress disorder (PTSD). Consult with your doctor to discuss your symptoms and review the timing and type of your medications if you experience nightmares.

Something to sleep on

In some way, though, producing nightmares might seem like a reasonable choice for the brain to make—especially after exposure to intense emotional events, including a prolonged pandemic or a terrorist attack.

After 9/11, for example, one study demonstrated a systematic change in dreams, implicating increased collective trauma.

Thus, nightmares may facilitate adaptation to emotionally salient or traumatic events, helping to relive the experience and remember meaningful details important for avoiding harm and promoting survival. Others have compared this to the process of sorting mail— with the brain throwing out the daily junk and keeping the substantive stuff, like bills and letters—to revisit and process later.  

But what happens when nightmares overstay their welcome, start hogging your side of the bed? Do nightmares still provide any benefits once they have lasted for so long?

Nightmare disorder

The answer? Probably not.

While most adults will have a nightmare about once per year, for about 1-6% of the population, nightmares can start taking on a life of their own, morphing from an acute symptom to a chronic issue called nightmare disorder.

Nightmares recurring with enough frequency and distress to impair nighttime or daytime functioning—including increased suicidal ideation and/or self-injurious behavior—may meet criteria for nightmare disorder.  Those criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) include:

A. Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical integrity and that generally occur during the second half of the major sleep episode.

B. On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert.

C. The sleep disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

D. The nightmare symptoms are not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication)

E. Coexisting mental and medical disorders do not adequately explain the predominant complaint of dysphoric dreams

The DSM-5 also adds modifiers for duration and severity of nightmare disorder – ranging from acute (<1 month) to persistent (>6 months), mild (less than once episode per week on average) to severe (nightly).  As a diagnosis of exclusion, nightmare disorder requires evaluation from a trained doctor – so don’t diagnose yourself.

Medical management

Nightmares may not always require treatment: most people experience a natural resolution of their symptoms over time. But for those requiring it, best practice guidelines for nightmare disorder in adults from the American Academy of Sleep Medicine (AASM) endorse both behavioral and pharmacologic approaches, including prazosin and imagery rehearsal therapy (IRT)—the interventions with the most empirical support.

The decision to use both psychotherapy and medication depends on patient preferences, needs, and access to evidence-based psychotherapy.

Generally, however, most adults struggling with chronic, persistent nightmares have preexisting psychiatric conditions and/or past traumas warranting psychotherapy and adjunctive pharmacotherapy with prazosin—the best studied medication for nightmares. For example, a meta-analysis of seven randomized trials in 528 participants with PTSD found prazosin more effective than placebo at improving nightmares, sleep quality, and illness severity.

Behavioral treatment: Imagery Rehearsal Therapy (IRT)

Imagery Rehearsal Therapy (IRT) ranks as the gold-standard behavioral treatment for nightmare disorder. It describes a technique in which patients learn to rescript their nightmare however they wish and rehearse the new dream for 10 to 20 minutes during wakefulness. IRT aims to change both the content and theme of the nightmare to decrease its negative emotionality and render it bearable—even favorable—to the person experiencing it.

With practice, the new non-threatening dream replaces and inhibits the old nightmare—reducing the need to escape and awaken.

Studies of IRT among patients with idiopathic, recurrent, and PTSD-related nightmares show efficacy in reducing nightmare distress, severity, and frequency at long-term follow up.  For example, in a meta-analysis of 11 randomized trials of IRT alone or combined with other psychological treatments for nightmares in patients with PTSD, IRT showed moderate positive effects on nightmare frequency and sleep quality compared with a control condition.

These same studies also reveal relatively consistent patterns of decreased psychiatric distress following successful nightmare treatment, suggesting IRT’s effects may generalize to anxiety, depression, and PTSD symptoms.

Imagine that: IRT in steps

Broadly, IRT includes 2 core therapeutic components: 1) an educational/cognitive restructuring element to help patients understand nightmare as a learned sleep disorder, and 2) an imagery training element on the nature of human imagery and its connection to dreams.

The treatment has a simple premise: your brain has learned how to have nightmares, so it can unlearn how to have them.  Like muscles, nightmares get stronger the more we have them. IRT aims to decondition nightmares through strengthening new dreams and images. These new muscles—alternative dreams—condition with repeated sets of new story scripts so the old nightmares atrophy.

Other important features of treatment include psychoeducation about how nightmares promote insomnia and the potential function of nightmares for emotional adaptation.

Following extensive psychoeducation, patients learn a set of steps over 4-8 sessions with which to start rescripting their nightmares. Those steps include:   

                Step 1: Selecting a disturbing nightmare—preferably one of lesser emotional intensity to start.

                Step 2: Changing the nightmare.

                Step 3: Rehearsing the new dream (with or without subsequent relaxation), for a few minutes each day.

                Step 4: Rinsing and repeating.

Step 1: Select a nightmare

Start low and slow here. In other words, select a less threatening nightmare to start—one that does not re-enact a trauma— and graduate the intensity of the nightmare as you achieve mastery. Generally, selecting a less intense nightmare facilitates changing it.   

Not every nightmare requires rescripting. IRT may jump start a natural human healing system that previously lay dormant.  Said differently, tackling a subset of nightmares and rescripting those can generalize to more distressing nightmares.

Step 2: Change the nightmare

Change the nightmare in any way that feels right to you, however you wish. It could include unusual or extraordinary properties, such as flying. Write it down.  Changes can take many forms but should: (1) happen before anything traumatic or bad happens (thereby preventing the distressing outcome) and (2) produce a sense of peace upon awakening.

Step 3: Rehearse the new dream

Read what you’ve written. Remind yourself to practice the new dream, not the nightmare. IRT really has no interest in revisiting the trauma or emotionally activating you. Practice the dream you’ve rescripted and attempt to engage your five senses while rehearsing it. What do you see, hear, taste, touch, and smell? Try to practice at least once per day for 10-20 minutes in a way and place that feels comfortable for you.

For some, practicing relaxation after rehearsing the new dream can enhance the rescripting experience.  Many relaxation protocols exist, so consider trying a few before picking one that feels good for you.

My preferred script comes from Lichstein et al. (2001) which includes three components: diaphragmatic breathing, passive muscle relaxation, and autogenic phrases (e.g. “I am at peace…my arms and legs are heavy and warm.”).

For those with insomnia, rehearsing the dream in another room but ending the session with relaxation in bed may enhance sleep quality and duration.   

Step 4: Rinse and repeat

IRT leverages imagery—a naturally occurring process in the human mind—so once the corrupted software that damaged this innate process gets repaired, the original operating system can resume functioning normally.

With consistent practice, many can experience relief within a few weeks—though the length of treatment can vary depending on the severity and complexity of the disorder. Relief can take many forms, including reduced nightmare frequency and severity or complete remission. Most people with nightmares eventually stop having them.

How can I find IRT?

Should your nightmares or general sleep issues cause significant distress and impairment, consult with your healthcare provider or a behavioral sleep medicine doctor– someone specializing in the assessment, diagnosis, and treatment of sleep disorders. You can find a list of some of those specialists, here.

Sweet dreams

Nightmares can interfere with sleep and wakefulness—but rest assured you have more control over them than you think. IRT can alleviate various forms of nightmares and associated distress because it may increase perceived mastery over negative dream elements.  

Sleep better tonight knowing effective, evidence-based treatments exist to get you dreaming safer, sweeter dreams.

Dr. Christina Pierpaoli Parker

Dr. Pierpaoli Parker received a Fulbright-Killam fellowship to the University of Toronto prior to earning her PhD from the University of Alabama and completing her clinical residency at UAB. Her broad research and clinical interests include developing scalable behavioral interventions for preventing and managing comorbid psychiatric and chronic health conditions in primary and specialty care clinics.  She has published research in such peer-reviewed publications as Aging & Health, The Clinical Gerontologist, Journal of Psychotherapy Integration, and International Psychogeriatrics. Dr. Christina Pierpaoli Parker and her work have appeared in The New York Times, CNN, and CNBC.  She writes a blog called Eng(aging) for Psychology Today, which translates clinical science about aging and health into practical takeaways for optimizing physical and psychological health.