Tuning Out Bad Dreams

Driven by his own sleep problems, TIME writer John Cloud set out in 2012 to find out if science could explain why nightmares occur—and stop them.

BY JOHN CLOUD

ON A GOOD NIGHT, I GET FIVE HOURS. Like 60 million other Americans, I suffer from insomnia.

But I have a peculiar kind of sleeplessness: most nights, it is nightmares that wake me. Some are petrifying—a spectral beast is about to kill me—and some are mere stress dreams: I turn in a story that is just a blank page. For years, I thought nothing could be done about my nightmares. After all, dreams are encased in the unconsciousness of sleep. Right?

Maybe not. Researchers have begun to discover not only that we can learn to have fewer nightmares but also that we can change their content.

In other words, researchers are now studying the science of the dreaming mind in a way unprecedented in psychology. The primitive Freudian theories—that dreams indicate unexplored sexual desires or poor mothering or hidden anxiety—have been discarded as sleep science has advanced.

One new theory is that dreams and nightmares aren’t a secondary symptom of mental illness but rather a primary psychological problem. In other words, dreams themselves may cause mental illness, not the other way around. They may result from neurological misfirings that have nothing to do with psychology but instead have to do with the functions of the brain. Or both theories could be true. Partly driven by my sleeplessness, I set out to find researchers in dream science who could explain why nightmares occur and how, exactly, we can learn to change them.

The first person to help clarify these questions wasn’t a scientist but a Marine veteran. Ryan Stocker started having chronic nightmares after he got home from his second deployment. Sleep was rare in Iraq, but when it did come, it was a pleasantly blank interlude. After Stocker got back to Pennsylvania, however, falling asleep became terrifying.

Some Iraq and Afghanistan veterans I met dreamed of gore and fear: body parts they’d cleaned from roadsides or the terror of climbing into a truck for a mission. For Stocker, the nightmares were mostly about being deployed a third time. In dreams, he would step off a plane and smell the hot, dry air and groan, “Man, I’m back again.” The nightmares got so bad that he and a friend who had served with him slept in their living room on separate couches rather than in their bedrooms. “That felt safer,” he told me.

After Stocker was discharged in September 2008, he finished an undergraduate degree in psychology at Slippery Rock University. He wasn’t sure what he wanted to do—he had thought about firefighting—but when he heard about a University of Pittsburgh study of veterans who had trouble sleeping, he applied for an internship.

It was a fortuitous opportunity. Stocker began working under professor of psychiatry and psychology Anne Germain, a leading researcher in the study of nightmares and post-traumatic stress disorder (PTSD). Germain is supervising the university’s $4 million DOD and National Institutes of Health study on how both current service members and veterans can sleep better.

The Pentagon became alert to sleep research partly because of studies by a retired Army colonel, Charles Hoge, a physician and leading expert on PTSD. In 2007 the American Journal of Psychiatry published an influential paper by Hoge and four colleagues showing that more than 70% of veterans with PTSD symptoms reported trouble sleeping. No other condition—not panic or pain or inability to work—was as common. And because treating people who are constantly tired is often pointless, gaining a better understanding of sleep and dreams became a priority.

The research helped prompt the Pentagon to develop something called a Warfighter Sleep Kit, which includes a DVD that begins with a screen reading, “Sleep is essential to survival.”

Germain helped develop the sleep kit. Her research has explored two approaches to mitigating nightmares. One involves a drug called prazosin. Developed in the 1960s as a hypertension treatment, prazosin didn’t turn out to be especially effective in lowering blood pressure. But for reasons not well understood, those who took it reported that they slept better and had fewer nightmares. Few psychiatrists used prazosin for nightmares until the 2000s, but they made the remarkable discovery that in many patients, it doesn’t stop all dreams, just the very bad ones.

The other treatment Germain has looked at is purely psychological. In August 2001, the Journal of the American Medical Association published a seminal paper on a new psychological treatment for nightmares called imagery rehearsal therapy (IRT). The paper discussed 168 sexual-abuse victims who reported chronic nightmares. The participants were asked to consider the idea that although trauma may induce nightmares, those bad dreams can become habitual—a behavior not unlike daytime panic attacks, which can seem uncontrollable but can be limited through certain kinds of behavioral therapy.

Like daytime panic attacks too, those repetitive dreams turned out to be something like a learned behavior, one that can be unlearned through daytime psychotherapy. Freud and others thought dreams were immune to conscious thought, but the JAMA paper demonstrated that the opposite is true.

Imagery rehearsal therapy is simple: you begin by imagining a dream you would like to have. The dream doesn’t have to be some optimistic reverie about puppies and sunshine. You can imagine any dream you want—boring, anodyne, even gloomy—just not your nightmares. You then write down the new one, and every day, you take a few minutes, preferably with eyes closed, to think about that dream.

The JAMA paper showed remarkable results. Patients who underwent imagery rehearsal therapy dropped from an average of six nightmares per week to just two or three. The IRT patients reported 40% fewer PTSD symptoms, such as shame and emotional numbness. The patients in a control group who had been wait-listed for IRT—but had spoken with a psychologist about their bad dreams—actually showed a small increase in their number of nightmares. The findings held up even after six months, and further studies have replicated the JAMA results.

I tried IRT for my nightmares and found it useful. But I was still skeptical. Studies have shown that prazosin is just as beneficial as IRT in helping people have better dreams, which raises a crucial question: Are dreams psychological, physiological or both? And if we don’t know, how can we understand the sleeping brain?

In our conversations, Germain had repeatedly mentioned one of her mentors, Barry Krakow, the primary author of the JAMA paper. With some diplomatic restraint, she said he had since become “controversial” because although he still uses IRT in his practice, he has developed an unusual new theory about how to treat nightmares.

BREATHING LESSONS

I met Krakow at his New Mexico sleep lab, the Maimonides International Nightmare Treatment Center, which sits incongruously in a dreary Albuquerque office park alongside mortgage firms and title companies.

Krakow started his career as an emergency-room doctor at the University of New Mexico School of Medicine, but in his spare time, he began working with two UNM psychiatrists, Robert Kellner and Joseph Neidhardt, who were developing the idea that dreams could be controlled with daytime therapy. Their idea formed the germ of IRT and eventually led to the JAMA paper.

Since its publication, Krakow has become an acclaimed figure in sleep research, and patients from around the world travel to Albuquerque to see him. But in the past decade, after seeing so many people with insomnia and bad dreams, Krakow has become convinced that a rather simple physiological problem may explain most bad dreams: having trouble breathing.

It’s not just a hunch. When you sleep at Krakow’s lab, a technician attaches 16 sensors to your head, chest and legs. A tube is affixed to your nostrils. For most patients, the ordeal is uncomfortable, but eventually they fall asleep.

Intricate detail emerges from these sleep studies, which show not only how deeply you sleep but also how much you snore, how your body moves during the process and how much you dream—and precisely when your dreams begin and end. Krakow, who reads the results with Talmudic intensity, can tell you exactly when you enter and leave rapid-eye-movement (REM) sleep, the state in which we become more aware of dreams. He can also tell you if you wake from REM sleep because of a leg jerk or a problem breathing, even if you have no memory of waking up at all.

Over the years, Krakow began to notice that at least 90% of patients who came to him with persistent nightmares had either full-blown sleep apnea—a disorder in which your breathing pauses, sometimes for more than a minute, while you sleep—or a milder form of the disorder called upper-airway-resistance syndrome. He showed me several data sets collected after various sleep studies. In every case, the dream state was preceded by or coincided with an episode of disturbed breathing.

“Breathing events can savage REM sleep,” he told me. And when they do so, dreams can burst through the cover of REM sleep to become nightmares that wake us. Krakow isn’t sure why this happens, but one theory is that chronic nightmares result when patients have trouble getting oxygen to their brain during sleep. And so the body has evolved a way for an oxygen-deprived mind to awaken: nightmares. Krakow’s conclusion is that if you treat breathing disorders, you may eliminate nightmares.

Krakow is among a growing number of sleep doctors who believe that many if not most sleep disorders, not just persistent nightmares but also ordinary insomnia, are caused by the brain’s reaction to apneas or other airflow limitations. And so over the past 20 years, the treatment of sleep problems has, among many researchers, begun shifting from the psychological realm toward the pulmonary one.

A growing number of sleep doctors believe that many if not most sleep disorders, including nightmares and insomnia, are caused by sleep apnea.

The change has opened a vast new market in sleep medicine, which has become big business. The most common treatment for serious sleep apnea is the continuous-positive-airway-pressure machine, or CPAP (pronounced “see-pap”), which is sort of like a humidifier that pushes air into your mouth. The best CPAPs cost as much as $5,000. ResMed, the leading CPAP producer, is a publicly traded company that reported net income of almost $350 million in 2014.

Thousands of medical professionals in specialties such as cardiovascular care and ear-nose-throat treatment have begun to include sleep medicine in their practices or have switched exclusively to sleep. In 1996, there were only 337 facilities accredited by the American Academy of Sleep Medicine; today there are more than 2,000. The market-research giant IBISWorld estimated that sleep-disorder clinics in the U.S. earned a combined $6 billion in revenues in 2011—a figure that is growing by double digits every year.

The figures are so dazzling that it’s tempting to think physicians and CPAP manufacturers are just cashing in. Yet even researchers with no profit motive agree that the pulmonary system is key to understanding disordered sleep and the dreams that can come with it.

“The oxygen story is the biggest story here,” says Murali Doraiswamy, head of the division of biological psychiatry at Duke University. “Intuitively, it makes sense. The brain uses a disproportionate amount of oxygen. We think that when the brain is going to sleep, it is shutting down. But oxygen is also going on and off during sleep. That could be a very simple mechanism we’ve overlooked in the search to explain dreams.”

The sleep-apnea explanation is seductive: bad dreams are simply the result of a narrow airway. But the explanation isn’t fulfilling. Surely nightmares, with all their marbled psychological tissue, can’t just be neurological firings after what amounts to a gasp for air. If dreams are random physiological events, why can we control their content with IRT?

There’s also the phenomenon of lucid dreaming—being able to realize you’re dreaming and then control the dream as it occurs. Training yourself to dream lucidly combines psychological and physiological techniques to consciously enter bad dreams as they occur and rewrite them.

REFORMULATING YOUR DREAMS

Stephen LaBerge often wears a puckish grin, which goes nicely with his white hair, which stands on end as though he’s been electrocuted. In 1980 LaBerge earned a Ph.D. in psychophysiology, the study of how the body, brain and mind interact. In the years since, especially when teaching at Stanford University, he has become something of a dream guru. He believes that dreams aren’t walled off from daytime life but are as manageable as any behavioral experience you may have when you’re awake.

At Stanford, LaBerge became convinced that the question of whether dreams are physiological or psychological is not only unanswerable but also irrelevant. He posited that if people practice dream recall—writing in a dream journal morning after morning—they can begin, while asleep, to recognize when they’re dreaming.

LaBerge’s theories depart radically from the perception of sleep that was dominant for much of the 20th century. They also support the idea that sleeping life and waking life are more similar—and integrated—than we assume. As Germain at the University of Pittsburgh notes, in her lectures around the country she is often asked, “Why do you care so much about sleep?” Her response: “Why do you care about wakefulness? Maybe the only point of being awake is to sleep.”

“Maybe the only point of being awake is to sleep.”

—ANNE GERMAIN
University of Pittsburgh School of Medicine

After all, it is during sleep that our immune systems gather strength, and it is during sleep that we consolidate memories. It is both a joke and a fact that most men either fall asleep or want to after sex (although many women do too). Perhaps one biological necessity is linked to the other. Sleep specialists who treat insomniacs routinely recommend that the bed be used not for reading or TV or texting but only for sleep and sex. Germain’s idea suggests that the species has survived not because we hunt, gather, work and socialize but because we spend a third of our lives asleep and then a small but crucial portion having sex.

LaBerge spent part of his early career studying people in high REM-sleep activation—the deepest sleep we experience, which can be dense with dreams. REM sleep has at least two physiological phases: one in which our eyes move left and right and another in which we breathe rapidly. LaBerge created a device that covers your eyes as you sleep and flashes white lights when your eyes begin moving left and right. The idea behind what he calls the DreamLight seems Pavlovian. After you’ve worn it for days or weeks, your brain will begin to recognize when you’re in deep sleep and, therefore, when you’re dreaming. At that point, you can take conscious control. Practice may not make perfect, but with any luck, it will make a significant difference for the sleeper who suffers debilitating nightmares.

The device is an important part of his physiological training. Another involves a sort of extreme form of IRT: you ask yourself five to 10 times a day whether you’re dreaming. The question becomes rote. The idea is that you come to ask it of yourself even while dreaming. At least I think that’s the idea. LaBerge has conducted no controlled trials to prove any of this, but his notion of dream control is at least more appealing than wearing a CPAP mask for the rest of your life. After all, when you wake up with a large tube attached to your face, it’s easy to think you’re having a terrible dream. Which is funny and a bit sad: the best solution we have for nightmares resembles the very thing it’s meant to prevent.

As for myself, the solution was rather boring: many hours of psychotherapy, rigorous exercise and the occasional Ambien. It’s been frustrating, because most sleep doctors aren’t trained in psychology, and most psychologists don’t have the medical training to understand airway problems. And so sleep physicians prescribe biological treatments—Ambien to go to sleep, CPAPs to stay asleep, armodafinil to stay awake—and psychologists prescribe cognitive therapy to resolve the anxiety of going to bed, staying in bed and then facing the day.

More effective sleep treatments will combine both approaches, but right now a total cure for insomnia remains a dream.

THE DREAM DOCTOR Lucid-dreaming expert Stephen LaBerge uses a light-induction mask to train patients to know when they are dreaming.

A Nightmare Quiz

Just how bad are your dreams?

Everyone has nightmares, but bad dreams can indicate—or even cause—psychological problems. Check yes or no for each statement to see what your dreams may mean for your mental health

1. I have disturbing dreams at least once a week.

YES □ NO □

2. I often wake up because of bad dreams.

YES □ NO □

3. As I go to sleep, I feel like I am falling or being paralyzed.

YES □ NO □

4. My nightmares are caused by stress over work or relationships.

YES □ NO □

5. I get anxious before bedtime because I think I might have a nightmare.

YES □ NO □

6. I have the same terrible nightmare repeatedly.

YES □ NO □

7. I remember the fear during bad dreams but not all the details.

YES □ NO □

8. During nightmares, I experience not only anxiety but also anger or shame.

YES □ NO □

9. When I remember a bad dream, I dwell on it the next day.

YES □ NO □

10. My spouse or partner tells me I have night terrors, which I don’t remember.

YES □ NO □

ANSWER KEY

A yes response to statement 1, 2, 5, 6, 7, 8 or 9 could be a sign of nightmare disorder, which the Diagnostic and Statistical Manual of Mental Disorders defines as repeatedly awakening from frightening dreams that begin to affect waking life.

A yes response to 3, 4 or 10 does not indicate a problem with nightmares. Dreams of falling and being paralyzed are so common that they don’t indicate a disorder. Having the same dream every night is also common. And night terrors are more physiological than psychological.

Dreams and Revelations

When scientists examine the workings of religious visions, they see the neurochemistry of dreams

BY EMILY JOSHU

On the night of Sept. 21, 1823, Joseph Smith fell into a slumber that would spark not only a personal awakening but the birth of a religion. An angel named Moroni manifested in his dreams. “After I had retired to my bed for the night … I discovered … a personage appeared at my bedside, standing in the air … He has on a loose robe of most exquisite whiteness … His whole person was glorious beyond description, and his countenance truly like lightning,” Smith recalled. Moroni’s heavenly appearance led Smith to a hill where he uncovered the sacred founding golden pages of the Church of Jesus Christ of Latter-day Saints.

The Mormon prophet was not alone. Saul of Tarsus saw a vision of Jesus, manifested through “a light from heaven,” that led him to become St. Paul and co-found Christianity. In Islam, the Prophet Muhammad was said to have received his first revelation in a series of vivid dreams. Across centuries and religious ideologies, dreams have served as spiritual gateways to ethereal and sometimes haunting revelations. According to research conducted by the Sleep and Dream Database, 51% of American women and 38% of American men have had at least one visitation dream.

The vivid and metaphysical energies surrounding these types of dreams could be tied to stages of consciousness that the body cycles between throughout the night. The majority of memorable and lucid dreams originate in rapid eye movement (REM) sleep. Cycling every 90 minutes, each instance of REM sleep per night lasts about 20 to 25 minutes, and though dreams are no more frequent in this phase, they are more memorable. This stage is also associated with higher levels of dopamine and memory-boosting acetylcholine, along with lower activity in the dorsolateral prefrontal cortex, which controls insight, rationality and judgment. Combined with low levels of serotonin produced during REM sleep, these factors overstimulate the brain’s emotional centers and impede rational centers, which leaves feelings associated with vivid dreams open to wildly dramatic interpretation.

Studies suggest that such revelations could be similar to hallucinations seen in individuals with schizophrenia, which can be similarly difficult to interpret. A 2014 review, for example, found that schizophrenic patients experiencing positive hallucinations had higher levels of religiosity. Researchers also hypothesize that dream cognitions create especially meaningful experiences through mental simulations of alternative realities and other factors that encourage religious significance.

More research is still needed to fully understand the highly personal links between dreams and religious revelations, but in cases like Joseph Smith’s, dreams can spark a movement of lasting spiritual significance.