July 18, 2012

Bruce Dow MD headshotThere are three major components of PTSD, according to our current understanding of the syndrome: reexperiencing, avoidance, and increased arousal.  Effective treatment of PTSD needs to deal with all three.  Many people with PTSD adopt avoidance as a strategy to reduce the other two components: reexperiencing and increased arousal.  If you just stay in your room or in a cabin in the woods (for example) you may be able, temporarily, to avoid being exposed to triggers that might cause flashbacks (reexperiencing) or startle reactions (increased arousal).  The problem with avoidance is not only that it can be very confining; avoidance simply doesn’t work.  Eventually, something will come along that manages to act as a trigger, and then one has the full-blown symptom package of PTSD.

Avoidance can even be seen in the dreams of people with PTSD.  My colleagues and I (Dow, Kelsoe, and Gillin, 1996) looked at this by studying three groups of Vietnam veterans in an overnight sleep lab.  One group of veterans had PTSD; another group had depression but no PTSD; a third group of “control subjects” had neither depression nor PTSD.  What we found was that the veterans with PTSD avoided the present in their dreams.  Veterans in the other two groups had many more dreams set in the present.  Veterans with PTSD dreamt about either the past or (occasionally) the future.  This was not because of nightmares in the veterans with PTSD.  Very few nightmares were reported by any veterans in the study, which we had expected, since the protected setting of a sleep lab tends to lead to fewer nightmares than when sleeping at home.

In unpublished data from the same study, the dreams of veterans with PTSD contained fewer “negative” emotions (guilt, disgust, shame) compared with the dreams of veterans in the other two groups.  Not only did the veterans with PTSD avoid the present in their dreams; they also avoided negative emotions.

Avoidance in dreams, even though unconscious, is not a good strategy, since severe nightmares can occur when the avoidance barrier fails, as it inevitably will.  Avoidance keeps PTSD sufferers from seeking treatment until they are in crisis.  Currently available psychotherapy treatments for PTSD all involve exposure to the trauma (to varying degrees), which can be frightening for PTSD sufferers to contemplate.  Dream revision therapy, the method utilized by this writer, minimizes exposure, since dreams are often symbolic or metaphorical, and can address the trauma indirectly.  The other two therapy methods currently in use, prolonged exposure (PE) and EMDR (eye movement desensitization and reprocessing), require some degree of direct exposure to the trauma.

Fortunately, a prescription medication, prazosin, has been shown to block nightmares without any need for exposure at all.  Prazosin does lower blood pressure slightly, and can only be safely used if one has normal or elevated blood pressure.  The dosage range for prazosin in blocking nightgmares is from 1 mg up to about 20 mg, depending on the individual.  Prazosin for nightmares is typically taken at bedtime, and does help maintain sleep.

A problem with medication treatment alone is that nightmares return when treatment is stopped.  An optimal treatment for PTSD nightmares is low dose prazosin combined with dream revision therapy.  This treatment helps break through avoidance in the least stressful way.