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Utilizing Dream Skills for PTSD Treatment

Nightmares are a common symptom of Post Traumatic Stress Disorder (PTSD), which gives insight into where and how the brain is processing traumatic information. For example, one could easily compare the experience of a flashback to the experience of a nightmare. Studying the physiological mechanisms of dreaming as they relate to the experience of dreaming, may lead to the possibility of mitigating and even eliminating nightmares, flashbacks, and other dissociative symptoms of PTSD.

Dreams and Traumatic Associations

When the brain is asleep, and especially during REM, the neurotransmitters norepinephrine and serotonin stop being released, while the neurotransmitter acetylcholine is released at high amounts concentrated in the hippocampus (Brown, et al., 2013). This shift in nuerochemical modulation makes it more likely that weaker associations are activated (Korteling, et al., 2018) as opposed to strong associations which are usually the most likely to be activated.

In a newly proposed model for understanding dreams, NEXTUP (Network Explorations to Understand Possibilities), Robert Stickgold, PhD suggests that this modulation shift is one of the causes of the commonly described "bizarre" content dreamers experience, and the process of dreaming involves "the discovery and strengthening of previously unexplored weak associations"(Stickgold & Zadra, 2021).

This leads to inquiry about traumatic associations, and why they are so likely to be activated while dreaming, making nightmares one of the most common symptoms of post-traumatic stress. Even where there is minimal to no traumatic stress involved, "stress dreams" are another extremely common type of dream.

One might assume from common sense that traumatic or stress-related associations would likely become strong associations, but perhaps they are in fact weak associations. This could explain why traumatic associations are significantly more difficult to rewire than normal associations, and why, when your dreaming brain is searching for material to incorporate into a dream, it will often go to said "previously unexplored associations" which are likely to be stress or trauma related.

A possible explanation for why traumatic associations could be weak associations comes when observing how we deal internally with reminders of stress and trauma: we avoid them. Consciously, a defining aspect of coping with trauma is the avoidance of reminders that would trigger the fight-or-flight response that occurred while said trauma was happening. This avoidance has been proven to make this fight-or-flight response worse, because it reinforces the idea that you cannot handle the reminder of the trauma, even though the reminder itself is not dangerous. Potentially, your unconscious is also responding to trauma by avoiding it in ways that have not been detected yet. By avoiding these associations, they are not being reinforced enough to create a strong neural association, and are therefore more likely to be activated during REM.

Further questions to be explored: What does this say about flashbacks, which are almost like dreams while awake?

Exposure Therapy and Dreams

One problem with treating PTSD is that a web of traumatic neural associations is almost seamlessly integrated into the brain that link safe and normal stimuli to a real threat or danger. So, a person suffering from PTSD might become afraid of the smell of coconut, for example, because they experienced that olfactory stimulus at the same time as dangerous stimuli.

Prolonged exposure (PE) therapy is used in trauma treatment to create new neural associations over traumatic associations. One main type of exposure used in PE therapy consists of the patient talking through a detailed memory of a traumatic event with a psychologist in a safe environment. After this is done numerous times, the memory, which was once associated with real danger, will now be more strongly associated with the retelling of the memory in a safe place with a person who can help if panic or flashbacks occur. This in turn makes it much less likely for the fight-or-flight response to be activated when presented with trauma associated stimuli.

Dreams could potentially be used as a type of exposure. A 2010 study asked its subjects to memorize the solution to a maze, then take a 90 minute nap, and then try to solve the maze again. Results showed that subjects who remembered dreaming about the maze in some form during this nap were able to solve the maze significantly faster than subjects who did not remember dreaming about the maze. (Wamsley, et al.) This highly suggests that memory consolidation does in fact occur during sleep, and is directly reflected in dream content. By applying dream control techniques to this discovery, a new exposure protocol that occurs mostly within a dream can be developed. An example of this is a patient with PTSD who has traumatic associations linked to brick walls. Brick walls could be incubated as targeted dream content, and when the patient dreams of brick walls, the specific stimuli surrounding brick walls will be consolidated, integrating the associated memory into the mental narrative of the patient. Repeating this protocol multiple times will reinforce these new neural associations, making the traumatic associations less viable.

The importance of a dream-based exposure therapy lies in just how unpleasant the act of an exposure is, thus making it an unpopular method of treatment. Having to relive your trauma is just about the last thing any rational person would seek out, even if it would be helpful in the long run. It would be appealing to those seeking trauma treatment if the exposure is occurring during sleep. There is less room for anticipatory fear, and the patient may not consciously remember the exposure.

The future of this exposure method could include an option in which a patient

Dream-based exposure therapy could lead to a significant increase in the number of people being treated for their trauma. This means a massive increase in the mitigation of the cycles of abuse caused by unresolved trauma which plague societies cross-culturally.

Dreaming Techniques as they relate to PTSD treatments:

*See dream control techniques for a breakdown of the skills mentioned below

Dream incubation

If nightmares are a consistent symptom experienced by a person with PTSD, then it could be beneficial for that individual to practice dream incubation techniques, making it more likely a targeted dream will occur instead of a nightmare.

Dream control

For similar reasons to why dream incubation would be useful for nightmare sufferers, dream control skills could also be used to change a nightmare into a normal dream, or to wake up from a nightmare quickly.

Gaining/maintaining lucidity

Techniques which help maintain lucidity happen to be very similar to techniques proven to be grounding in reality when experiencing dissociation or a high emotional state. Techniques include describing what you see, paced breathing, observing your senses, and observing your body. If control is able to be maintained in dreams, then control will be able to be maintained in waking life, because they are essentially the same thing. Beyond that, the correlation of these techniques and their effects in both lucid dreaming and dissociative states, points to where research should begin when studying more treatments.