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Shelby Harris, Psy.D., C.BSM is Director of the Behavioral Sleep Medicine Program at the Sleep-Wake Disorders Center at Montefiore Medical Center and Assistant Professor of Neurology as well as Psychiatry[…]

Harris practices Imagery Rehearsal Therapy, which teaches patients to take control of nightmares by rehearsing them during the day and changing them into positive scenarios. 90% of Harris’s patients report this therapy to decrease the frequency of their nightmares.

Question: How are nightmares different than regular dreams? 

Shelby Harris: So nightmares are distinctly different from dreams in the way that people feel them and experience them.  So a lot of people think that a nightmare is something where something is chasing them and you have to wake up screaming.  Yes, that’s one of the more common nightmares that we see is the person chasing someone or they’re being chased.  But really, a nightmare just really has to evoke some sort of, we call it, dysphoric emotion or something uncomfortable.  You could be sad, you could be unhappy; you could be scared, anxious.  But traditionally, the definition is you have to awaken from this nightmare.  So you have it, you awaken from it and you can recall, in detail, what just happened, that’s a nightmare.  So it’s very different from a dream where you generally don’t wake up from it and you don’t have this dysphoric emotion.

There’s some debate as to whether you need to awaken from them because there are some patients who are actually starting to say, “I had these horrible nightmares, but I never woke up from them.”  But they can still recall them when they get up in the morning.  So there’s still some debate in the field.  

When it comes to the reason why we have nightmares, we’re still debating that.  It’s a new area of research, nightmares.  And the way I like to think about it is, our brain – we have stress during the day and our brain needs to learn to process this stress.  So there are people who have repetitive nightmares.  And what happens is their brain is trying to process the stress and help their brain actually deal with what happens if this stress happens again, so their brain’s preparing them to deal with it in case the stress happens again, but it’s so scary that they awaken from it.  So they’re never actually able to finish the file and put it away, it just keep happening because they awaken from it.

Question: How does IRT help one overcome nightmares?

Shelby Harris: So Image Rehearsal Therapy, or IRT, we’ll call it for now, it’s a very, very simple treatment that was developed by Barry Krakow in the late 90’s, early turn of the decade to really help change the imagery that you’re having at night.  So we think of it as imagery during the day, seeing things, picturing things in your head, painting a picture is very similar to imagery at night.  That’s what dreams are, nightmares; imagery in the night.  So what we do is we take these very simple techniques by basically telling someone if they have a nightmare – so take someone who has a recurrent nightmare of being chased by someone.  We’ll have them come in and we’ll say to them, “Okay, not take that nightmare, tell me what it is, but now I don’t want you to think about it anymore.  Just take it almost like it’s on at piece of paper and throw it out.  Change that nightmare anyway you want.  You change a tiny bit of it; you can change the whole thing.  It doesn’t matter.”  And I’m not the one to tell them how to change it.  It’s their dream that they’re making.  “so change it anyway you want to make it – just it could be neutral, it can be positive, whatever.”  So the person chasing them could be a very scary experience.  

What they would do is for example, I had a patient yesterday who changed his nightmare from him being chased to actually having his two younger brothers chasing him around in his old apartment and they were playing.  So just by still having the chasing element, but making it a fun, playful chase with two people he knew, made it a much different dream than the nightmare he was having.  

So then what I had him do was to close his eyes and I had him picture the story of his brothers came in they started chasing him, his mom yelled at them to stop, then they stopped for a minute and then they kept running after each other.  He pictured that whole story in his head into the picture and he could see what everyone was wearing, the smells he could tell, he could see the carpet, every detail.  And once he took himself through that picture for about five minutes, practiced it morning and night, if you keep doing that it actually helps reduced the nightmare frequency because you’re getting control over your nightmare. 

Question: Does the patient then have this new dream while they’re asleep?

Shelby Harris: For some patients, they’ll have that new dream, for others it just reduces the nightmare frequency.  We don’t know why yet.  But it’s such a simple technique because it gives you control over it, over the nightmare that it works – there have been studies that showed for upwards of 90% of patients who actually do this treatment actually report it getting better, the nightmare frequency. 

Question: Are night terrors different from nightmares?

Shelby Harris: Night terrors are very different from nightmares.  A lot of people will think they’re the same, but they’re really not.  Night terrors – you want to look at the time of night when you’re having the problem.  Night Terrors happen in deep sleep.  Nightmares tend to happen in a lighter REM sleep.  So, night terrors are in deep sleep, and they’re more common in kids, as are nightmares, but what happens in a night terror is like a flash – we think a flash of some image or something happens in the brain.  We don’t really quite know what.  And it usually ends up with the child screaming almost like screaming bloody murder.  It’s very scary for the parents or whoever else is around.  But it happens very fast and the child has no recollection of it.  They tend to stare off into space when they’re screaming.  You can’t really engage them at all.  And the child will go right back to sleep afterwards and have no recollection of it in the morning, or very little recollection.  Usually there’s no recollection.  It’s more scary for the parents.  

So in kids, what we think is happening in the brain, the way I like to think about it is, it’s almost like, you’re brain is going through all these stages of sleep and it’s developing in children so fast that it’s almost like you’re shifting gears in a car.  And at some point, you actually stall out a little bit, and that’s kind of what happens during a night terror.  They’re brain is shifting so fast that it stalls out, they have this episode, but then they go back to sleep and everything regulates itself.  

Very common in kids, like I said, it tends to get better as you get older.  Now there’s some night terrors that happen in adults.  And if it starts as an adult and you’ve never had them before, then there might be other things that are happening; it might be anxiety, depression, stress.  And that’s when you might have more of a thorough psychological evaluation.  In kids we don’t generally attribute it to any psychological basis.