When Do Nightmares Become A Sleep Disorder?
MAUREEN CAVANAUGH (Host): I'm Maureen Cavanaugh, and you're listening to These Days on KPBS. It's more than likely that some people listening to the show today are tired. There can be lots of reasons for that: too much to do, or maybe you just stayed up too late last night. But some people are tired not because they didn't sleep, but because of what they dreamt about. Bad dreams, complex, terrifying dreams, nightmares, wake you up, leave you feeling shaken and afraid, and ruin a good night's sleep. If they happen often enough, nightmares can develop into a chronic sleep problem. Today we'll be speaking with a doctor who treats people who have chronic nightmares. He’s also author of the books, "Turning Nightmares Into Dreams," and "Sound Sleep, Sound Mind." I’d like to welcome Dr. Barry Krakow. He’s director of the Sleep & Human Health Institute in Albuquerque, New Mexico. Dr. Krakow, welcome to These Days.
DR. BARRY KRAKOW (Director, Maimonides Sleep Arts & Sciences Institute): Welcome. Good morning.
CAVANAUGH: Good morning. Now we invite our listeners to join the conversation. Have you dealt with a recurring bad dream or nightmare? Tell us about it. Or perhaps your child had problems with nightmares. Give us a call with your questions and your comments. And our number is 1-888-895-5727, that’s 1-888-895-KPBS. Dr. Krakow, is there a common kind of nightmare?
DR. KRAKOW: The most common nightmares are ones where someone is chasing you or someone is attacking you. Those are very common. But, really, there are so many different types that people describe.
CAVANAUGH: So what you’ll hear from a lot of people when they come to your office is they have a nightmare that happens regularly where they’re being chased or attacked. How often do you have to have the same nightmare for it to be labeled a recurring nightmare?
DR. KRAKOW: Well, keep in mind that nightmare problems could be the type that you’re referring to where the actual nightmare is repeating but there’s many people that will have different nightmares different nights. And, generally speaking, people with nightmare disorders have the problem once a week or more and, in fact, most people who seek treatment have nightmares around three or four times a week, as much as seven times a week. And, again, some of those dreams might be recurring, like very similar in theme or content, but there’s a whole host of people out there that have nightmares where they’re very different even in the course of just one week.
CAVANAUGH: So is the difference between having nightmares and having a nightmare disorder the number of nightmares you have?
DR. KRAKOW: Not really. It could be for some people but in general it’s more about your response to the action. In other words, I know some artists that have disturbing dreams and nightmares and they use them as inspiration for painting. They don’t want to get rid of their bad dreams.
DR. KRAKOW: On the other hand, there’s many people who really do suffer what we call the nightmare hangover where the bad dreams play out even during the day. They’re exhausted from a bad night of sleep, they have all these symptoms that they don’t always connect to their nightmares, and those people certainly would benefit from treatment.
CAVANAUGH: How common are nightmare disorders? Is this, if you have it, do you know you have it? Or is this perhaps something that some people just think is part of life?
DR. KRAKOW: Well, the second part of that is really interesting because it’s remarkable how many people just take nightmares for granted, they just think you can’t do anything about them, they think it’s part of their personality, they’re too embarrassed to want to do anything about it, so from that point of view there are literally millions of people who have the problem but they would never even think to call it a problem. We actually know data that shows that 4% up to as many as 8% of adults have frequent bad dreams, disturbing dreams and nightmares and yet most of these people would never even bring it to the attention of their doctor as if it were a problem.
CAVANAUGH: That’s interesting. We – I’m speaking with Dr. Barry Krakow. He’s director of the Sleep & Human Health Institute in Albuquerque, New Mexico. He's also the author of the books, "Turning Nightmares Into Dreams," "Sound Sleep, Sound Mind." We’re talking about nightmares, bad dreams, and asking for you to join the conversation about perhaps a nightmare or recurring bad dream that you have or if you know someone who has problems with nightmares, especially a child. 1-888-895-5727 is the number to call. Now, are nightmare disorders more common in women than men?
DR. KRAKOW: They definitely appear to be…
DR. KRAKOW: …but we don’t know if it’s because women are more open about discussing it…
DR. KRAKOW: …whereas men are more embarrassed about talking about it.
CAVANAUGH: And are they also more common in children?
DR. KRAKOW: Well, children have the highest rates of disturbing dreams and nightmares. Usually around the age of five and six is the peak when you’ll see the largest spike in nightmares of any age group. And then through adolescence there are various periods where disturbing dreams and nightmares will crop up but then they start to subside a little bit into adulthood. But in a lot of people who have the nightmares that we see for 30, 50 years, they’ve actually had them since childhood and yet never got rid of them.
CAVANAUGH: We have a caller on the line. We’re taking your calls at 1-888-895-5727. Susan is calling us from Solana Beach, and good morning, Susan. Welcome to These Days.
SUSAN (Caller, Solana Beach): Thank you very much. Good morning. Good morning, Dr. Krakow.
DR. KRAKOW: Good morning.
SUSAN: My question is I guess several parts but since I was a child I always had what they call night terrors. And even when I was an adult, I had nightmares which actually turned into premonition dreams and I guess you could look at them, you know, from a viewpoint of taking the point, you know how they look at dreams in the imagery. But since that particular time of one very large premonition dream where I kept on dreaming about fire all around me and there was actually a fire and part of my house burned and I ran out the house, I rarely dream at all. And I do have trouble sleeping and I know that – I guess this comes from the subconscious or unresolved issues and conflicts including somnambulism or sleepwalking. Do you see a subset of the premonition dreams and nightmares in a certain group of people? I mean, how common is that?
CAVANAUGH: Wow, Susan, there’s a lot of that – a lot of stuff you’re talking about there. Let’s take it step by step, if we can. What about night terrors, where Susan started with this conversation.
DR. KRAKOW: Well, that’s a good place to start because that’s what we call the parasomnias and the parasomnias mean, you know, things that go bump in the night, things that happen at night that either you may be sleeping or you’re awakened from sleep in a way that is very disruptive such as sleep terrors, sleepwalking, nightmares, these are all parasomnia behaviors. Now the one thing that struck me was this recent comment about not dreaming and the possibility of some recent sleepwalking because those are signs of something physiologically wrong with the person’s sleep. I know it’s very interesting to talk about premonition dreams and we do hear about that from our patients from time to time. I don’t at all discount that but I would certainly not consider myself an expert in that area. What I have learned, though, is that there is this cluster of symptoms including such as, you know, the sleep terrors, the nightmares, the sleepwalking, but to say that you don’t dream, that’s a very interesting finding because that usually suggests that something might be physically wrong with your sleep because everybody is supposed to dream and most people actually remember, you know, some degree of their dreams.
CAVANAUGH: That’s interesting. Let’s take another call. We’re taking your calls at 1-888-895-5727. Ellen is calling from La Jolla. Good morning, Ellen, and welcome to These Days.
ELLEN (Caller, La Jolla): Hi. Can you hear me all right?
CAVANAUGH: Yes, I can.
ELLEN: As a child, I had profoundly terrifying dreams. My brother had killed himself in our house and I had a dream about how that had occurred that woke me up throughout my childhood, actually into my adolescence. And it was through another dream that actually showed me the truth of that situation that that healed. And then later I learned the Native American technique. I had another dream of paralysis and then it was a dream where I faced my fear and went on to achieve my dreams, so it was through learning to be active in your dreams that I was able to heal both of those dreams and both of those had profound deleterious affects on my childhood but in my adulthood I learned how to heal this dream. And I just wonder if that’s a technique? And then the other question I have is, as a younger person I had glorious, life-changing, formative dreams—no drugs or anything like that, just a period of time in my life, and I yearn for them. My dreams these days are less colorful, less transformative. My life is good. And I just wonder, oh, you know, and I’ve been checked and I don’t have any sleep disorders, and I just wondered if there’s – if he has any reflections on either of those points.
CAVANAUGH: Thank you so much for the call. And, doctor?
DR. KRAKOW: Well, I think as far as the less colorful, it’s really hard to know about something like that. Again, we always look for physiological dimensions, whether they’re – be obvious or subtle. She mentioned she’s been checked for sleep, I don’t know exactly what that means, but we do know that rapid eye movement sleep is the area of dreaming that we are most aware of. We do dream in all stages of sleep but in rapid eye movement sleep we are more aware of our dreams and so just as a hint, it’s possible that she’s having less rapid eye movement sleep and that’s why her dreams may not be as colorful or as active or as creative in some way. But going back to her first point, absolutely the Native American tradition aligns very much with the modern cognitive behavioral strategies for treating chronic nightmares. We use a technique called imagery rehearsal therapy. There’s other techniques known as lucid dreaming. The IRT method, Imagery Rehearsal Therapy, IRT, is the most studied and the most researched, and it really is all about recognizing that the human mind has a tremendous capacity to picture things. And once you begin to realize how powerful the mind is in doing that then you begin to realize that it would have an influence on your dream content and on controlling your dreams in some fashion.
CAVANAUGH: Before we leave the topic of night terrors, I know that I’ve heard some parents have problems with their children who actually wake up screaming on a, you know, on a recurring basis and I wonder if we know why that is? Is it because of what they see? Is it horror movies? Is it disasters on TV? Is it just a symptom of them going through a certain age period? What would cause that?
DR. KRAKOW: Well, originally the big push on night terrors, that we now call sleep terrors in the field of sleep medicine, was that there’s something about the depth of sleep a person would go into that somehow could trigger it because the person was trying to have an arousal out of deep sleep when they were also already somewhat, I don’t want to say incoherent but just, you know, sleepy.
DR. KRAKOW: They were very sleepy and this connectivity, so to speak, of arousal and yet you’re in a deep sleep may have led to that process. So we do still see that sometimes. However, some of that original data appears to be incomplete because more recent research shows that an enormous number of people, an enormous proportion of people who have these parasomnias, particularly the ones of sleep terror and also of sleepwalking, actually have sleep apnea.
DR. KRAKOW: And nobody realized it for – until more recently that if you do a sleep study on these people, you find they have sleep apnea, you treat the sleep apnea, well then they stop being so disruptive. They stop having the sleep terrors, the sleepwalking and so forth. It’s not true for all patients but it is so common nowadays that we test virtually every patient who has a complaint of a sleep terror, we will test them in the lab to make sure the problem is not sleep apnea.
CAVANAUGH: And remind us again, doctor, what is sleep apnea?
DR. KRAKOW: Sleep apnea or sleep disordered breathing, as we call it, refers to the process where the upper airway, you know, in the human organism is not functioning as it should be during the night. It has a certain level of collapsibility and if it collapses a little too much then air doesn’t get through it the way that it should. The brain then responds and says, well, this isn’t good, I’m not getting enough air.
DR. KRAKOW: So the brain wakes you up and, you know, the remarkable thing about these sleep breathing conditions are you can have these breathing events hundreds of times during the night. It wakes up your brain for 10 or 15 seconds hundreds of times during the night and yet you’re not aware of any of it.
CAVANAUGH: I’m speaking with Dr. Barry Krakow. He’s director of the Sleep & Human Health Institute in Albuquerque. And we’re taking your calls about turning nightmares into dreams, and what kind of bad dreams you’ve been having, 1-888-895-5727. Patrick is calling us from Oceanside. Good morning, Patrick, and welcome to These Days.
PATRICK (Caller, Oceanside): Good morning. Dr. Krakow, just quickly, my wife, she’s a tooth – she’s a teeth grinder when she sleeps. And I’m wondering, is that indicative of her having bad dreams? Are there other things that she can look for? And I’ll take my call off the air. Thanks.
DR. KRAKOW: Well, tooth grinding or bruxism is its own, you know, dental disorder. It’s very common and certainly someone who has it should be, you know, seeking care from a dentist because the grinding can have a great deal of, you know, do a great deal of damage, you know, to your teeth. However, bringing it back again to this physiology of sleep perspective, it’s quite interesting. Some papers have already shown that tooth grinders also have a high incidence of this sleep breathing problem. And what’s really interesting about it is that what one study appeared to suggest is that when you have a sleep breathing event, we know that your brain wakes up for this 10 or 15 seconds—we call that an arousal, you know, an arousal from sleep.
DR. KRAKOW: That appears to be the moment when the tooth grinding might begin. So, once again, we have a situation where you have to ask the question: Could the breathing event be triggering somebody to wake up and then grind their teeth? I don’t think that happens in all patients but it’s an interesting connection between a sleep problem and a dental problem.
CAVANAUGH: Right, and what would be the connection between being awakened all these times with a sleep apnea problem and having nightmares?
DR. KRAKOW: That’s a great question. And that really goes in many different directions. There’s some people who’ve done research showing that the more you wake up from these sleep breathing events, the more you remember your nightmares, and so it’s almost like it’s hand-in-hand. Other people suggest that your sleep is just so fragmented from sleep apnea, as an example, that you can’t even get into REM sleep anymore and so you don’t have any nightmares anymore or whatever you do have is really not that memorable. So the overall problem here, as we like to call it, is the matter of sleep fragmentation.
DR. KRAKOW: And when the sleep is highly fragmented, it can do variable things to different people. Some people have a miserable night of sleep and they’re exhausted and sleepy during the day but other people have this fragmented sleep and they have just raging insomnia where they’re waking up and they’re up for hours on end and they focus on the insomnia at night and not so much being sleepy during the day.
CAVANAUGH: I see. We have so much more to talk about but we have to take a short break and when we return we’ll continue talking about bad dreams, nightmares, and what to do about them, and taking your calls at 1-888-895-5727. You’re listening to These Days on KPBS.
CAVANAUGH: I'm Maureen Cavanaugh. You're listening to These Days on KPBS. We’re talking about bad dreams, nightmares, and what to do about them. My guest is Dr. Barry Krakow. He’s director of the Sleep & Human Health Institute in Albuquerque, New Mexico, also author of the books, "Turning Nightmares Into Dreams," and "Sound Sleep, Sound Mind." We’re taking your calls and comments, 1-888-895-5727. Dr. Krakow, should people worry about the content of their bad dreams?
DR. KRAKOW: Yes and no. It depends. People often get nervous about the content of their disturbing dreams but in terms of two models, the ones that I have both supported in terms of treatment, you know, one is dream interpretation is sometimes very important in therapy, and the other is the technique, you know, we talked about Imagery Rehearsal Therapy. What’s first and most important in managing any disturbing dream is to try to understand the emotions in the dreams. The content can actually be quite misleading sometimes if you’re not paying attention to the strong emotions that are coming forward that may be trying to tell you something, may be trying to give you important information that you can, you know, do, again, with a dream therapist or other therapist or just, you know, you’re your own self-therapy. So I think that’s important. With regards to the second half, in terms of, you know, how we use IRT, we see PTSD patients a great deal of the time because they have the most common, you know, problem with frequent nightmares.
CAVANAUGH: That’s Post Traumatic Stress Disorder.
DR. KRAKOW: Yes, thank you. Post Traumatic Stress Disorder.
DR. KRAKOW: And we know that they are very disturbed by the content and the emotions because there’s specific events that have happened in their life and the question there becomes one of so do you treat the PTSD or do you treat the nightmares or do you treat both? And that’s one of the big, big emerging things in the field of sleep medicine, an area that we’ve worked a great deal in now for almost 20 years where we’ve opened up a PTSD sleep clinic. What we’re actually, you know, seeing is that many people have problems with nightmares, with – I’m sorry, many PTSD patients have problems not just with nightmares but with sleep apnea, with restless legs and leg jerks, all these different sleep disorders these people have and they tend to think, well, it’s just the PTSD. And that’s really not accurate as far as we can tell. So when you ask this question, you know, is the content important, absolutely its content – the content is important from the point of view of somebody who is seeking to deal with that traumatic exposure. But the content may not be as important if you’re also trying to help them learn to sleep better.
CAVANAUGH: Right. Before we get to another phone call—a lot of people want to talk to us—but I want to talk just a little bit more about the Imagery Rehearsal Therapy because basically what you’re trying to teach people to do is kind of rewrite their bad dreams and nightmares.
DR. KRAKOW: Absolutely. In other words, let’s go back to this concept of the human mind and its imagery capacity. Maureen, if I ask you to tell me how to get from the radio station to your favorite restaurant, it’ll take you all of a split second…
DR. KRAKOW: …to picture that in your mind’s eye. And that ability to see that is an awesome, awesome tool, you know, that our creator has, you know, given us and it’s just amazing that the human mind can do this. People often underestimate or just don’t appreciate how powerful human imagery is, that you can actually create a picture in your mind to take a trip so to speak. Well, if it’s that powerful, then certainly you can start to create your own images in your mind of pictures that you would like to see. In fact, we do that all the time. We daydream or we fantasize. Now when someone has the problem of disturbing dreams, what we’ve observed is that many of these people have actually started to block down their imagery capacity because they become afraid of their nightmares and so that’s understandable. However, what we get them to realize is that if they work on their imagery capacity during the day, building it up with pleasant imagery exercises, beginning to realize that they have more control over the images in their mind, that’s one of the first steps we take in helping them take back control of the night.
CAVANAUGH: I’m talking to Dr. Barry Krakow. We’re talking about bad dreams and nightmares, taking your calls at 1-888-895-5727. Or if you’d like, you can go online and post your comment, KPBS.org/thesedays. Let’s hear from Alan in Carlsbad. Good morning, Alan, and welcome to These Days.
ALAN (Caller, Carlsbad): Good morning. Thanks for taking my call. I have severe sleep apnea and I’ve done a couple of surgeries that have been worse, now I’ve been wearing CPAP. I was wondering if at anytime could that be reversed with some therapy or anything or if I have to wear CPAP for the rest of my life?
CAVANAUGH: Okay, Alan in Carlsbad wants to know if his sleep apnea can be reversed or cured, doctor.
DR. KRAKOW: It can be cured every single night when he uses a PAP therapy device. And one of the concerning things he mentioned to me here was that he only is using CPAP. We…
CAVANAUGH: What is that?
DR. KRAKOW: I’m sorry. C…
CAVANAUGH: What is that?
DR. KRAKOW: CPAP is a device. It stands for Continuous Positive Airway Pressure. It’s a device where you put a mask on your face connected to a tube and the tube is connected to a little air compressor box which pushes air into your airway to overcome the collapsibility that we were talking about earlier.
DR. KRAKOW: And when you overcome that collapsibility, then you can get a full, you know, sound sleep through the night. However, in our lab in New Mexico, which, by the way, the name is Maimonides Sleep Arts & Sciences…
DR. KRAKOW: …we don’t prescribe CPAP anymore because we’ve not found it to be as effective as some of these more advanced devices that have come out in the last few years. For example, almost all of our patients are on devices that are called BPAP or bilevel, and these stand for different systems of delivering that air pressure and we’ve found them to be much more effective than CPAP so I would tell the gentleman, if he’s having any trouble with it, perhaps go back to his sleep center and have an evaluation and ask to use a different device beyond CPAP.
CAVANAUGH: I’ve got it. Okay, thank you, Dr. Krakow. Let’s move on to Nora in La Mesa. Good morning, Nora. Welcome to These Days.
NORA (Caller, La Mesa): Hi there. Thanks for taking my call. So it seems…
DR. KRAKOW: Sure thing.
NORA: …that a couple of my what would seem like a nightmare to me, one, getting in a plane crash, and, two, I work at a restaurant and getting, you know, 10 tables at once with no help and people sitting there staring at me, waiting for their food, their drinks. I, almost every night, have those two nightmares. And I’m wondering – You know, and I wake up and I think did that really just happen? A, for me at work, and, B, I’m about to travel, you know, in a couple of days. What can I do, you know, to kind of shake that because it happens almost every night.
CAVANAUGH: Thank you.
DR. KRAKOW: How many years – how many years have you been having this?
NORA: I would say – I would say 10 years.
DR. KRAKOW: Okay, so the interesting question here is, you know, if you’ve had it for 10 years and you’ve traveled on airplanes and nothing happens obviously, you know, that would give you some sense of relief but obviously it’s also, you know, not very satisfying to have to go through that experience each time. So what we’re getting at here is, you know, again, I’m a big fan of dream interpretation methods and if you thought there was something there that you wanted to work on with a therapist or through self-therapy, you know, then go for it. But let’s also – let’s take the context. You’ve had this for 10 years. And this now goes into one of the main points of our treatment model which is that we think bad dreams take on a life of their own over time. That is, they become a habit, they become a learned behavior. It’s possible that’s what’s happened, you know, to this person where the two recurring dreams are just entrenched into her neurocircuitry in a way where whenever stressful things occur these particular dreams always pop up again. The Imagery Rehearsal Therapy technique that we use that is – that we describe in depth in the "Turning Nightmares Into Dreams" book, which, by the way, is an audio and workbook together…
DR. KRAKOW: …they can learn to realize that if these dreams really are a learned behavior, well, then they can unlearn them. And it’s possible to do that with the imagery technique, which is, you know, very exciting.
CAVANAUGH: Let’s take another call. Michelle’s calling from Escondido. Good morning, Michelle. Welcome to These Days.
MICHELLE (Caller, Escondido): Okay, thank you. I suffer from a chronic disease and I have to take a number of medications including muscle relaxants and morphine, and the consequence of taking all of those medications is every night I have very vivid, horrific dreams. And I was wondering if you knew of any way that I could lessen the impact of the medication on my dreams? And I’ll take the answer off the air. Thank you.
CAVANAUGH: Thank you, Michelle.
DR. KRAKOW: It’s a very good question and a somewhat troubling question because it speaks to the issue about, you know, the usage of medication, especially in the field of psychiatry, let’s say with, you know, PTSD. On the specific issue of morphine, we do know that opiates do cause bad dreams and the notion that you’re going to be able to take something to counteract that is probably not likely. If a drug causes that kind of side effect and it’s causing it repeatedly, I’m not aware of a tool that you can use to make that go away other than to find a way to, you know, get off the medication. I would say, though, that if you’re on morphine for a period of time, it’s very important to recognize that if the dose is sizable and you’re using any of it at bedtime, that in itself can depress respiration and can influence someone’s sleep breathing. So it may be something that needs to be investigated there.
CAVANAUGH: Let’s slip in another phone call. Sean is calling us from San Diego. Good morning, Sean, and welcome to These Days.
SEAN (Caller, San Diego): Hi. Thank you. I’m calling because I’m 20 years old and I have a 22-year-old brother, so we’re kind of young. That’s why the situation is a little concern to me. However, we – me and my family believe that my brother has night terrors. He wakes up at night abruptly, screaming and it takes us about 20 seconds to calm him down and bring him back to reality. However, recently we started some drug treatment, you know, we’ve sent him to our doctor. And it’s had some – it’s had significant success, however, it has not completely stopped these night terrors and I’m curious if there’s anything else that you know possibly that we could do?
CAVANAUGH: Thank you.
DR. KRAKOW: Well, there’s a lot that you could do but since I don’t know the full case, I can’t give you, you know, any actual prescriptions. I can tell you that, number one, for somebody who is an adult that’s having a problem with night terrors, sleep terrors, unequivocally you want to be managed by a sleep specialist, board certified in the field of sleep disorders medicine, of which there are many, you know, out in California. So that’s number one. You have to see a sleep specialist because there’s so many possibilities that could be going on including the fact that there’s a variety of medications that people might use for all sorts of good things like depression or PTSD that can actually seem to trigger problems like sleep terrors.
CAVANAUGH: Is it possible, Dr. Krakow, I know that you are an advocate of dream interpretation in some situations but could it be that many of our dreams really aren’t telling us that much?
DR. KRAKOW: Well, that’s a tricky question. I would say that if you had the time to remember a dream every morning and you had the time to spend three or four minutes reflecting on it, I would guarantee you almost 90% of the time you’d find something worthwhile because what would happen is an emotion would be part of that dream and once you reflected on the emotion that was part of that dream, you’d realize that that emotion was important and it was a reflection of something that probably happened the day before or the week before or something that’s ongoing. And that’s why I say that sometimes it’s not always the content of the dream that you have to focus on but just the very fact you have dreams and feelings that come together, you know, we now know that rapid eye movement sleep is – seems to be very, very important in processing human emotions, very important. And so there seems to be this connection between dreams, emotion, and, you know, being able to process the emotion so that the next day you’re in a better mood.
CAVANAUGH: I’m – We’re out of time. But I want to thank you so much for speaking with us.
DR. KRAKOW: You’re welcome. Thank you for having me.
CAVANAUGH: Dr. Barry Krakow is director of the Maimonides Sleep Arts & Sciences Institute in Albuquerque, New Mexico. And he’s also author of the books, an audio book, "Turning Nightmares Into Dreams," and "Sound Sleep, Sound Mind." If we didn’t get a chance to talk about your dream on the air, tell us about it online, KPBS.org/thesedays. You’ve been listening to These Days on KPBS.