If you are a horror-movie buff, you know who Freddy Krueger is—the character from the iconic slasher movie A Nightmare on Elm Street. This murderous villain stalked his victims in their dreams. The movie’s director, Wes Craven, is said to have been inspired, in part, by news reports about a group of Cambodian war refugees who suffered nightmares that were so horrific that many refused to sleep. Some even died—likely as a result of the severe sleep deprivation caused by their nightmares.
Although death is an extreme and exceptional, if unproven reaction to a nightmare, frequent nightmares can be a consequence of serious trauma, depression, anxiety disorder, run-of-the-mill stress and even sleep apnea. About one in 12 people are tormented by frequent nightmares. That’s a lot of anxious, tired people. If you are one of them, don’t think that nothing can be done about the problem. The solution may be much easier—and entertaining—than you think.
Imagery rehearsal therapy (IRT), co-developed more than 25 years ago by Barry Krakow, MD, a sleep disorders expert who founded Maimonides Sleep Arts & Sciences, Ltd., in Albuquerque, New Mexico, has been scientifically proven to reduce nightmares and improve sleep quality—and the proof has been in studies of people with posttraumatic stress disorder (PTSD). In fact, the landmark study of IRT, which involved people with PTSD, showed that just three sessions of IRT spread over four weeks reduced nightmare frequency by more than half. The benefits lasted for six months after treatment ended, with follow-up studies showing that relief can last up to two and a half years.
A recent study of patients with PTSD showed that IRT was just as good as drug therapy with prazosin (Minipress), the main drug that is now used to reduce nightmare frequency in people with PTSD, such as war veterans. But you do not have to be in extreme psychological distress to benefit from IRT, especially given its simplicity. “IRT is actually very simple to do,” said Dr. Krakow. It involves just three steps…
• Choose a recent nightmare. “The most important caveat is to not select a nightmare that feels like a replay of a traumatic event that happened in real life,” Dr. Krakow cautioned. “You can’t change the outcome of something that has really already happened.” (Although there are forms of IRT that neutralize nightmares of real-life traumas, they should be practiced with a therapist, explained Dr. Krakow. Treatment involves exposure therapy whereby the therapist repeatedly guides a patient through recalling the event to change how he or she feels about and remembers it.)
• Replay the selected nightmare in your thoughts, but change the story any way you wish. Dr. Krakow notes that instructions about how to change the story are very open-ended. If, for example, your nightmare involves being chased by a bear, replay it in your daytime recall of it to running after butterflies…or imagine the bear wearing a circus costume and becoming a dancing bear at your command…or imagine that you are watching the dream on a television screen and you can simply change the channel…or imagine any other scene that you wish. “The concept underlying the practice is that what you picture in your mind while awake can influence what you picture in your mind while asleep,” said Dr. Krakow.
• Rehearse your revised dream. You do this by playing it again and again in your mind for five to 20 minutes per day during wake time. After a week, choose a different nightmare to rewrite if another bothersome one exists. Although practice makes perfect, some people practice IRT only a few minutes every other day and still achieve large benefits, perhaps because they begin to feel that they truly can take control of their nightmares, said Dr. Krakow.
In his experience, most people see results within the first two weeks. Nightmares become less frequent, sleep becomes less interrupted and daytime mood is improved. As for whether people begin to actually dream the daytime story used to replace a nightmare, this occurs in less than 10%, said Dr. Krakow.
The largest improvements usually occur between two weeks and two months from the time of starting IRT, he said. Some people practice IRT for up to a year and others need only a few weeks of doing it to resolve their nightmare problem. “We hear about people picking the practice up again if their nightmares return, so IRT becomes a skill that can be applied as needed. Ideally, someone having a nightmare would wake up in the middle of the night, ‘rewrite’ the dream right then and there, and be able to go right back to sleep,” said Dr. Krakow.
With the exception of the curious and tragic case of the Cambodian war refugees, who were clearly suffering from severe PTSD, nightmares themselves aren’t dangerous, but they can leave you agitated and startled. If you have been having nightmares at least once a week, Dr. Krakow suggests that you have a complete medical evaluation, including a sleep study, to find out whether a health issue—namely sleep apnea—is causing the nightmares. If you learn that you do have sleep apnea, treating it will reduce the commonly associated health risks, such as high blood pressure, heart attack and stroke. Recent research is also showing exciting possibilities that treating sleep apnea reduces or perhaps prevents nightmares. Otherwise, Dr. Krakow’s IRT practice tips may be an empowering and creative way to cultivate sweet dreams and get the restful sleep you deserve.
