An Inner Dream Therapist

August 9, 2012

EEG WomanIn an earlier blog I indicated that dream revision as an antidote for nightmares is an old technique, perhaps even an ancient technique, used to sooth and assist children who awaken with nightmares.

In working with PTSD patients, and in looking at my own recurrent dreams, it has become increasingly apparent to me that dream revision is a natural process which helps us “work” with daytime stresses while we are asleep and unconscious.  Sigmund Freud, the father of psychoanalysis, spoke and wrote about “dream work”.  He viewed dreams as vehicles for fulfilling forbidden wishes, often sexual, in the Victorian era in which he lived.  Freud’s wish-fulfillment concept certainly doesn’t explain posttraumatic nightmares (who would wish for a nightmare?), and his writings have largely ignored this class of dreams.  Nevertheless, his concept of “dream work” may have some validity.

In the absence of PTSD, recurrent dreams tend to change over time, as we adjust to stressful situations.  Certainly this is true of my own dreams, and I see it in the dreams of many of my patients.  My goal in working with patients who suffer from PTSD is to help their natural dream revision mechanism recover from the traumatic experience that put it into overload mode and shut it down.  People with PTSD are like a “broken record” or a scratched (or soiled) DVD that won’t play past a certain point.  Dream therapy is designed to put the record needle back in its proper groove, to repair the scratch (remove the soiled spot) in the DVD, and get the music or video playing again.

Until quite recently, this view of dreaming was considered old fashioned and outmoded by neuroscientists, who viewed dreaming as incidental to sleep, and who viewed dreams as the detritus or garbage left over from the events of the day.  A brain imaging study by Matthew Walker and his colleagues at the University of California, Berkeley, has shown, with normal volunteers as subjects, that rapid eye movement (REM) sleep, when vivid dreaming usually occurs, is accompanied by suppression of activity in the amygdala, the “emotional hub” of the brain.  As a result, emotionally stressful, even potentially traumatizing, experiences are softened after a good night’s sleep.

The goal of dream revision therapy is exactly the same as what Walker and colleagues have reported to occur during restful sleep: softening the stressfulness of dreams.  It is quite possible that Walker and his colleagues in their brain imaging sleep lab setup are watching “dream work” in action.  It would obviously be interesting to know what the subjects in the stress softening sleep studies of Walker and colleagues were dreaming when the stress softening occurred.  However, this would disrupt the experiment, since it would involve extracting the subjects from the brain imaging apparatus and asking them what they were dreaming about.

My colleagues and I conducted awakenings from REM sleep for dream reporting in a study we published some years ago (Dow, Kelsoe, and Gillen, 1996), prior to the availability of brain imaging equipment at our university.  It would be useful if dream content could be read out directly from electronic signals recorded from the brain, without awakening the dreamer, but unfortunately this is not yet possible.

The medication, prazosin, helps block nightmares by reducing adrenalin reactions in the brain during sleep.  Prazosin treatment at bedtime may replicate what happens normally during REM sleep (when norepinephrine levels in the brain decrease dramatically), and what may happen during REM sleep in PTSD sufferers following successful dream revision.

Prazosin is an excellent medication for treating people with posttraumatic nightmares, but it has two important drawbacks.  One, it lowers blood pressure, and cannot be used safely by people whose blood pressure is already low.  Two, it does nothing to fix the underlying PTSD, which returns as soon as the medication is stopped.  The best current treatment for PTSD, in this writer’s opinion, is the use of low dose prazosin (to soften nightmares without totally suppressing them), along with dream revision.  This combination allows posttraumatic nightmares to be eradicated rather than simply suppressed, thus facilitating full recovery from PTSD.