Nightmare Scenario

16 minute read
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. Recently, researchers have begun to discover not only that we can learn to have fewer nightmares but also that we can change their content. Because the No. 1 complaint of veterans returning from Afghanistan and Iraq is insomnia–and because so many veterans have nightmares about what they saw in combat–the Department of Defense (DOD) has poured millions of dollars into the study of dreams.

One project, at the University of Pittsburgh School of Medicine, has a $4 million grant to study how veterans can have fewer–or at least less intense–nightmares. Other researchers have received funding from the National Institutes of Health to investigate why an estimated 6 million Americans have such awful nightmares that they have trouble working or sustaining relationships.

In short, we are now studying the science of the dreaming mind in a way unprecedented in psychology. The primitive Freudian theories–that dreams indicate unrequited 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. Or they may result from neurological misfirings that have nothing to do with psychology. 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 change them.

Sleepless Soldiers

It turned out that the first person to help clarify these questions wasn’t a scientist but an Army veteran. Ryan Stocker started having chronic nightmares after he got home from his second deployment. Sleep was so rare in Iraq that when it did come, it was a pleasantly blank interlude. But after Stocker got back to Pennsylvania, 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 in Pennsylvania. He wasn’t sure what he wanted to do–he had thought of 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 Anne Germain, a leading researcher in the study of nightmares and posttraumatic stress disorder (PTSD). Germain is supervising the university’s $4 million Department of Defense and National Institutes of Health grant to study how both active-duty service members and veterans can sleep better. “At the DOD, there used to be a mentality–and I think it’s still there, but it’s shifting–that sleep is a luxury,” she told me. “But compromising sleep actually compromises physical, psychological decisionmaking–how well you can aim at a target.”

The Pentagon became alert to sleep research partly because of studies by a retired Army colonel, Dr. Charles Hoge, a senior scientist with the Walter Reed Army Institute of Research. 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 a Warfighter Sleep Kit, which includes a DVD that begins with a screen reading SLEEP IS ESSENTIAL TO SURVIVAL. The DVD says service members should avoid caffeine, nap only when necessary and–whenever they are safe enough to sleep–wear a camouflage mask and earplugs. The kit includes the mask and plugs.

Germain helped develop the sleep kit. Her research project is now exploring 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, prazosin doesn’t stop all dreams–just the very bad ones. The drug’s usefulness for nightmares suggests that they stem from a brain or circulation disorder.

And yet the other treatment Germain is studying is purely psychological. Coincidentally, in August 2001, the same month that Ryan Stocker went to boot camp, the Journal of the American Medical Association (JAMA) published a seminal paper on a new psychological treatment of nightmares called imagery rehearsal therapy (IRT).

The paper looked at 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 a habit–a behavior not unlike daytime panic attacks, which can seem uncontrollable. But, 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 had thought dreams to be immunable 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 numbness. The patients in a control group who had been waitlisted for IRT–but who 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 research.

I tried IRT for my nightmares and found it useful. But I was skeptical. Various 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, Dr. 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 theory about how best 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, 63, 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 at least 2,000 people with insomnia and bad dreams, Krakow has become convinced that a rather simple physiological problem might 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 went 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 patients who have chronic nightmares have trouble getting oxygen to their brains during sleep. Because they are asleep, their brains cannot indicate to their bodies that the hippocampus is being starved. And so the body has evolved a way for an oxygen-deprived mind to awaken: nightmares. Krakow’s conclusion: 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 begun shifting from the psychological realm toward the pulmonary one.

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 more than $200 million in 2011. In the past few years, sleep doctors have also begun prescribing a drug called armodafinil to be used in concert with CPAPs. Armodafinil, a stimulant-like medication that patients can take in the morning to ensure they don’t nap, can cost $500 per prescription.

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. Earlier this year, the market-research giant IBISWorld estimated that sleep-disorder clinics in the U.S. earn a collective $6 billion in annual revenues–a figure that is growing 13% a year.

The figures are so dazzling that it’s tempting to think physicians and CPAP manufacturers are just cashing in. Surely disordered sleep is not just disordered breathing. And yet even researchers with no profit motive agree that the pulmonary system is key to understanding dreams. “The oxygen story is the biggest story here,” says Dr. 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 deep wheeze. 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. From a fellow nightmare sufferer in New York, I had heard about a way to train yourself to dream lucidly–an approach that combines psychological and physiological techniques to enter bad dreams as they occur and rewrite them. It sounded silly, as if someone were trying to turn the movie Inception into real life. But it was also a really cool idea.

Reformulating Your Dreams

Stephen Laberge often wears a puckish grin, which goes nicely with his white hair that 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, 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 other behavioral experience.

LaBerge is the leading figure behind the idea of lucid dreaming. Clients from around the world seek his help in trying to control their bad dreams. LaBerge and I met at the Newport Beach, Calif., house of one of those clients, Edward Pope, who told me he is an investor in aerospace and other technologies. His opulent home sits behind a gate on a hill overlooking the Pacific.

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 are dreaming. “Dreams and waking experiences are more alike than different,” he wrote in his 2004 book Lucid Dreaming. “Much of what happens during your night life will be little different from what happens during your day life.”

LaBerge’s theories depart radically from the perception of sleep that dominated much of the 20th century. In the early 1950s, scientists identified REM sleep, and eventually many came to believe that dreaming most often occurs during REM. That’s not quite right–dreams during REM aren’t necessarily more frequent than dreams during other sleep states. They are more memorable, though. And yet sleep physicians have assumed that REM is so deep that no conscious thought can penetrate it.

LaBerge and others challenged this idea. Germain at the University of Pittsburgh offered the best explanation of how sleeping life and waking life are more similar than we assume. In 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.”

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 begin to breathe rapidly. LaBerge created a device that sits over 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 wearing 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.

The device is a main physiological part of his training. A psychological part 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, something you ask yourself all the time–and so a question that will begin to occur to you as you fall asleep, and then again in those twilight minutes before you wake up, and eventually during the night, even in the deepest REM sleep.

At least I think that’s the idea. LaBerge has no controlled trials to prove any of this. But his self-actualizing 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 can cause the very thing they’re meant to prevent.

Researchers are forging ahead on both the psychological and physiological problems associated with sleep trouble. But 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 the cure for insomnia is merely a dream.

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