Nightmares and Post-Traumatic Stress Disorder (PTSD): A Cognitive Behavioural Therapy Perspective

Leah Fung – EMDR & CBT Therapist, CBT Supervisor in Guildford, London Bridge and Online

Nightmares are more than just disturbing and distressing dreams; they can be a haunting manifestation of underlying psychological distress, particularly for individuals experiencing post-traumatic stress disorder (PTSD).  From a cognitive behavioural therapy (CBT) perspective, understanding and addressing nightmares associated to traumatic experiences is a crucial step towards healing and recovery from PTSD.

The Link Between PTSD and Nightmares

PTSD can develop following exposure to traumatic events such as accidents, natural disasters, or violent assaults. The distinctive symptoms include intrusive memories that are re-lived as though they are happening now, hyper-arousal and avoidance behaviours. Nightmares are common distressing experiences that many individuals with PTSD endure. These nightmares often involve reliving the traumatic event or themes related to this causing significant distress, fear and sleep disruption.

The recurring nature of these nightmares can create a vicious cycle: nightmares lead to poor sleep quality, which in turn exacerbates daytime PTSD symptoms, perpetuating the cycle of distress.

Understanding the Cognitive Behavioural Framework

A CBT approach is underpinned by the interconnection of our thoughts, feelings, and behaviours. This framework helps us understand how traumatic experiences can impact on cognitive (thinking) processes and perpetuate distressing symptoms like nightmares. For instance, a person might develop a belief that the world is entirely unsafe or that they are powerless to prevent bad things from happening, which can manifest in their nightmares.

The Role of Nightmare Rescripting

Nightmare rescripting uses imagery techniques to address nightmares.  It involves rewriting or changing the course of a nightmare in a way that reduces the intensity of fear and distress or instils other feelings that would be preferred in that moment (e.g. sense of feeling protected).

Here is an overview of this technique in therapy:

1. Identify the nightmare: often nightmares are reoccurring or memorable in PTSD as they are related to the traumatic experiences. In therapy, we would identify the nightmare so that it is clear what the nightmare rescripting is targeting. 
   
2. Change the narrative: an alternative course for the nightmare, changes in the imagery or feeling is identified and this is written, drawn out, visualised or audio recorded.
   
3. Rehearse the new narrative: Individuals are encouraged to mentally rehearse the alternative ending/sequence for the dream during the day and again just before going to sleep.  A common query that people have is how they would remember the new narrative during a nightmare.  With rehearsal and practice, this increases the chance of you remembering to use it when the nightmares occur whilst asleep or when you wake up from a nightmare.

For example, if a person’s nightmare involves being chased, they might alter the dream by instilling a sense of safety or outcome of being able to escape with the use of portals that open taking them to a safe place (like those seen in the Marvel films with Dr Strange, or the rabbit hole in Alice in Wonderland, or the doors in Monsters Inc).

How can nightmare rescripting be effective for PTSD when the new narrative didn’t really happen during the traumatic experience and it doesn’t change what actually happened?

This is a common and understandable concern when first encountering the nightmare rescripting technique.  Whilst nightmare rescripting can be a powerful tool, it is part of a broader treatment plan tailored to the individual’s needs. It works in conjunction with other CBT interventions to support overall mental health and well-being.

Let’s break down why this approach can be effective, even though it involves creating a new narrative that differs from the original traumatic experience.

1. Understanding the Purpose of Nightmare Rescripting:
   
   Objective: The primary goal of nightmare rescripting isn’t to change the past but to alter the emotional and psychological impact of the traumatic memory. By changing the storyline of the nightmare, we aim to reduce the distress and fear associated with it.
   
   Mechanism: Nightmares are a manifestation of our brain trying to process traumatic events. By repeatedly experiencing the trauma in our sleep, we reinforce the fear and anxiety linked to the memory. Rescripting the nightmare helps to break this cycle by creating a new, less distressing association.
   
2. Changing Emotional Responses:
   
   Safety and Control: A revised narrative where the individual finds safety or gains control can help foster a sense of empowerment. Over time, this can reduce feelings of helplessness and fear that are often associated with PTSD.
   
   Reduced Fear Response: When the brain rehearses a less frightening version of the nightmare, it can begin to separate the traumatic event from overwhelming fear. This can lead to decreased frequency and intensity of nightmares.
   
3. Reinforcing Positive Coping Mechanisms:
   
   Empowerment: Rescripting allows individuals to take an active role in their healing process. By creatively altering the narrative, they practice cognitive flexibility and resilience, which are essential for coping with PTSD.
   
   Skill Development: The process of rescripting teaches valuable skills such as emotional regulation and cognitive restructuring, which can be applied to other areas of life affected by PTSD.

In summary, while nightmare rescripting does involve creating a narrative that did not occur during the actual traumatic event, its effectiveness lies in changing how the brain processes and responds to the traumatic memory. By reducing the emotional intensity and providing a sense of control, this technique can significantly alleviate the distress caused by PTSD-related nightmares. 

The Journey to Recovery

Overcoming nightmares and PTSD is a journey that requires time, patience, and professional support. CBT provides a robust framework for addressing these challenges by targeting the underlying cognitive and behavioural patterns that perpetuate distress. 

Nightmares are a daunting symptom of PTSD and with the right tools and support, it is possible to break the cycle of fear and distress, paving the way for recovery. 

For more information about PTSD, take a look at my blog on “What is trauma and post traumatic stress disorder?” https://yourtherapywithleah.co.uk/trauma-and-ptsd/

You can book direct into a free 20 minute initial phone or video call with me to discuss therapy for PTSD here https://clientportal.uk.powerdiary.com/clientportal/yourtherapywithleah1