Why Do We Have Nightmares? with Alaina Tiani, PhD

Podcast Transcript

John Horton:

Hey there, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

Sleeping at night is supposed to be peaceful, a time when you close your eyes and gently drift off into dreamland. But as horror film directors keep reminding us, that nocturnal journey can take a dark turn. One in 20 people experience a nightmare at least once a week, a statistic that is more than a bit scary. So why do bad dreams lurk in our subconscious? I'm going to wander that trail of terror today with psychologist and sleep medicine specialist Alaina Tiani. Dr. Tiani is one of the many experts at Cleveland Clinic who join our weekly podcast to explain how our minds and bodies work. Now, let's enter the world of nightmares and see if there's a safe way out.

Dr. Alaina Tiani:

Sure, thanks so much for having me.

John Horton:

Well, it seems like people have been trying to understand the cause of nightmares throughout time. And there have been some pretty spooky and colorful explanations, too, including that it was caused by demons sitting on our chests.

Dr. Alaina Tiani:

Yeah, that sounds a little bit more like maybe something we call sleep paralysis, which can involve a nightmare, but certainly can have some kind of spooky underlying pieces to it.

John Horton:

Well, everyone wants to think there's something really creepy going on, but we'll kind of get to the bottom of it here because I'm assuming that nightmares are not brought on by demons hanging out in our beds. So let's dig a little deeper into the potential causes, I guess, starting with stress. Can we really drag the problems of the day into our sleep?

Dr. Alaina Tiani:

Absolutely. Stress, anxiety — whether that's due to things you have going on in your life that represent more of a stressor or a challenge, things like a move, a change in a job, or loss of a loved one — things like that. All of these kinds of unresolved problems that we experience during the day can definitely kind of cross over into our nightmare activity, absolutely.

John Horton:

So I mean, that stress itself, can it really just, I mean, cause those real, I mean, just absolutely terrifying nightmares that wake you up in the middle of the night?

Dr. Alaina Tiani:

Yeah, I mean, we don't exactly know as to the complete purpose of our dreams, but we do know that at least some people kind of hypothesize that it's really kind of our brain trying to play out or deal with some of these unresolved things that may cause us stress and anxiety during the daytime. Oftentimes, those things are kind of fodder for our nightmares.

John Horton:

Let me ask you this, too, because this comes up a lot. If you're up at night watching a horror flick, it does seem like you often will get nightmares after that. Is that just kind of like a byproduct of some self-inflicted cinematic stress?

Dr. Alaina Tiani:

It can be. Yeah, you might find yourself kind of walking more carefully through your home at night after watching a scary movie or maybe checking behind doors and really anything that activates the nervous system in that way or is scary can … things like movies, but it could also be things like watching the news, which can be stressful or having maybe difficult or stressful conversations close to bedtime. All of those things can set the stage for maybe more dreams that could be nightmare-related afterward.

John Horton:

So if there's something really intense going on that you either watch or read or see, it sounds like that can trigger those nightmares at night.

Dr. Alaina Tiani:

Yeah, absolutely. And I think it's probably for most people just the case that they may have a random nightmare here or there and may be more susceptible to them after dealing with stress or watching a scary movie, but there's often other causes. So when we think of stress, we can also think of mental health concerns, for example, like post-traumatic stress disorder, which we may discuss. And so that is another major reason why individuals may experience nightmares.

John Horton:

Well, yeah, let's talk about that a little more. I did see where that is a pretty common thing if you have PTSD, that nightmares can come along with that. What's happening there?

Dr. Alaina Tiani:

Yeah, so PTSD is typically diagnosed after somebody has experienced a significant trauma or stressor such that their life or well-being was threatened or they saw someone else's life or well-being being threatened. However, we do kind of distinguish between nightmare disorder and then nightmares due to PTSD. And so nightmares are one of the main symptoms of post-traumatic stress disorder. Oftentimes, individuals will describe having nightmares that are recurrent, frequent, maybe very vivid, disturbing dreams, and usually they are related to the stressful experience that they encountered.

John Horton:

A couple of times in our conversation here, you've kind of made sure to point out the difference between nightmares and nightmare disorder. Can you kind of explain why those are two different things and kind of what sets them apart?

Dr. Alaina Tiani:

Yeah. So nightmares, most people have an occasional nightmare here or there, and it's usually not something to worry about. But nightmare disorder is when those dreams are more consistent and recurrent, very distressing. There's actually criteria … so in the DSM-5, which is what we use to diagnose certain mental health disorders, there's certain criteria to where the dreams must be very dysphoric, very distressing. Upon awakening from the dream, the person typically is very alert or maybe in more of a distressed state. And typically, it has to cause some type of problem during the daytime to where it can impair them in their social functioning, occupational functioning or other areas, or just cause pretty significant distress. And we also roll out if they're being caused maybe by things like medications, substances or other medical or mental health disorders — those are typically the criteria that we look at.

John Horton:

So nightmare disorders are kind of like that next level where it's tied in with something else as opposed to just, I guess, your run-of-the-mill nightmare, which hits all of us every once in a while and it's just our mind, I guess, having a little bit of fun with us at night.

Dr. Alaina Tiani:

Yeah. These are a little bit more frequent than that. There's actually not a frequency criterion that's set for the disorder, but typically, it's suggested that it may be a mild nightmare disorder could be less than one episode a week on average; moderate would be maybe one or more episodes a week; and then severe would be closer to nightly nightmare episodes.

John Horton:

Now, when we talk about just the nightmare that pops up every once in a while, I thought I had read where late-night snacks or even like a cocktail may kind of be fuel for that.

Dr. Alaina Tiani:

There's been some individuals that will say maybe having caffeine or things that are more stimulating at nighttime might be related, perhaps having alcohol. With alcohol and sleep, we do know that alcohol tends to help you to fall asleep because it's a depressant, but it can wreak havoc on your sleep throughout the night by actually causing more disruption and some changes in your sleep architecture. But certainly, any type of medication and various substances can be linked to nightmares.

John Horton:

What about sleep deprivation? I thought I also saw where, if you're not getting enough sleep and you're that overtired, it seems like your mind is a little apt to crank up the nightmares, too.

Dr. Alaina Tiani:

Yeah, we do know that sleep deprivation or other sleep problems, such as having more of an irregular sleep schedule, can be linked with a higher likelihood of having nightmares. Untreated obstructive sleep apnea, which is another common sleep disorder, where you're not essentially getting enough oxygen, there's breathing disturbance at night, is also strongly linked with a prevalence of nightmares.

John Horton:

Well, I guess if you're going to stop breathing, that would be something to set off a nightmare.

Dr. Alaina Tiani:

Sure, sure. Yeah, and it can be that with the repeated arousals that we see from that sleep disorder, that's really what the link is there between the sleep apnea and the nightmare disorder.

John Horton:

Yeah. Now we've covered a lot of ground here. We're talking about nightmares and nightmare disorders. So when you start looking at the connection between these events and mental health conditions, when does it become an issue where you really need to seek out a medical professional and talk to them about it?

Dr. Alaina Tiani:

Yeah, I think I'd probably go back to more of that nightmare disorder criteria. So typically, when you're having them frequently, they're recurrent, and they're causing some type of problem for you, whether that's just a sleep disturbance or whether that's causing problems during the daytime as far as the distress of the nightmare. And certainly, if there's any thought that there may be a diagnosis of PTSD or a significant history of trauma, we do know that, about estimates are between anywhere from 70 to 90% of people with post-traumatic stress disorder will experience frequent and persistent nightmares. And those can remain in the long term, and so that's definitely probably a time to look at the effects the nightmares are having on your quality of life and probably mention them either to your family doctor or a sleep physician.

John Horton:

That is a staggeringly high number, when you talk 70% to 90%. When you are in that spot, is that something, then, where you treat the PTSD and the trauma and get the counseling on that end and it takes care of the nightmare disorder? Or is there something that's specifically done on the sleep side?

Dr. Alaina Tiani:

So it's always recommended, of course, to connect with a mental health provider who can do a good job of helping an individual to process and manage and work through the symptoms of PTSD and the trauma experience. In addition to that, there is a treatment that's offered specifically for nightmares. So it was actually developed at the VA hospitals for veterans who were experiencing PTSD-related nightmares, and that treatment is called Image Rehearsal Therapy, or we call it IRT for short. And so that therapy really involves taking a look at some of the common themes in the nightmares that the person is experiencing, and it actually involves taking almost a narrative of the dream, getting a good sense of the things that the patient is experiencing in the dream as far as sights, sounds, smells, et cetera, writing that out with them, and then working to do something called rescripting the dream narrative.

John Horton:

That's fascinating. So basically, you kind of change that nightmare and, I mean, is it putting a happy ending on it? Is it just changing the whole story around? Or what do you do with that?

Dr. Alaina Tiani:

Yeah, we first like to get patients started practicing something called positive guided imagery, where we actually have them practice imagining pleasant scenes, so maybe imagining the beach and what the sounds of the waves would be like or what the sand feels like on your toes. And then, we would work on that dream narrative that I described, where we write out the dream, not necessarily the most distressing dream, but a dream that has caused some distress. Working through that script and then looking at, is there a place in the dream where we can make a shift? And it can really be as creative as you want it to be, so maybe you're having a dream that you are falling out of an airplane and at the end of the dream, you hit the ground and you wake up. Maybe instead we can rewrite that to say, "Suddenly I recognize that I have on a backpack and the backpack has this large parachute and I pull the cord and I glide down to the ground safely."

And so it changes the dream to where there can be some more autonomy and sort of gives your brain an alternative route for the dream to go.

John Horton:

That is amazing that you can kind of work on that during the day and that it'll just seep into that overnight dreaming that you have.

Dr. Alaina Tiani:

It's really the repetition and I think the rehearsal and review of these dream narratives. So we'll have patients write them out, come up with alternative endings, review them, and even kind of go over them prior to bedtime because we know some of those rewrites, reviewing them before bedtime can be helpful to kind of remind the brain that when I recognize I am in this situation, there is an alternative ending or an alternative option here that could be happy or it could just be less distressing than the original nightmare.

John Horton:

Now, you had mentioned that as something that's done a lot with people dealing with PTSD and some of those trauma situations. If you are just, I guess, a normal, everyday person having some nightmares, you don't want them, unless you're a horror writer, I guess. Do you have any tips that, I guess, we could all kind of use to prevent a bad dream from ruining a good night's sleep?

Dr. Alaina Tiani:

I do think being mindful of maybe some of the media and things that you're taking in during the nighttime and maybe within the last few hours before bedtime. That's true for probably both adults and kiddos, that media exposure, the things that we might read or the videos we might watch — just being mindful of the content because anything stressful or overwhelming could set us up to potentially, they might not cause nightmares, but may heighten the risk that those themes or feelings could be present in our dreams.

I think also, for just the average person to have a good sense of their ability to manage their day-to-day stressors, and if they have stressors that are chronic or unresolved, those types of themes may pop up as distressing nightmares in their dreams, so trying to be mindful of stress management. And making sure to have a good wind-down routine before bedtime that's relaxing, calming, to promote a more pleasant end to the day.

John Horton:

Yeah, we've talked about that on the podcast before, too, the power of meditation before bed or yoga. I take it that would help put your mind in a better spot before you go to sleep.

Dr. Alaina Tiani:

Yeah, we know that bedtime in general is a great time for our minds to start having worrisome thoughts. It's quiet, it's dark. There's not a whole lot of distraction going on. So really, anything that we can give our brain to help it relax and to really be a little more mindful is a positive thing. So things like guided imagery can be really helpful where individuals might listen to an audio recording, where there is a guide walking them through the meditation. A lot of individuals may find that helpful because it's kind of giving their brain a constructive direction to go in.

John Horton:

How important is it to just establishing a solid sleep schedule? I know, so many people … you're all over the place during the day and you don't have that firm bedtime to just kind of guide things. If you can get that set, will that also help get rid of some of these bad dreams?

Dr. Alaina Tiani:

It could help. Again, the irregularity in the sleep schedule may not necessarily be the sole cause of nightmares, but it certainly could play a role. And so anything we could do to support good sleep health does support the reduction of nightmares. But yeah, having a consistent sleep schedule with the most important piece really being having a consistent wake time and ultimately just going to bed when your body feels sleepy.

John Horton:

Are there any different tips you would have for adults versus kids?

Dr. Alaina Tiani:

As far as adults, I think that we probably go through most of the day feeling a little bit maybe stressed, overwhelmed, we have a lot of things to do, and so we kind of run up right until bedtime and then, expect to just kind of hit the pillow and fall right asleep. And that might not be so realistic. So giving yourself time, like I said, with the wind-down routine as a buffer zone between the daytime and nighttime can help to promote more relaxation.

And for kids, I think probably, again, the media exposure component, watching what kinds of shows or games that they're involved with prior to bedtime, but also having open conversations with them about nightmares and kind of explaining to them the nature of nightmares and kind of having an open space to discuss that between the caregiver and the child is important, providing some of that reassurance to them that this was just a dream.

John Horton:

Well, that is some fabulous advice, and it should lead to some hopefully happier dreaming for everyone here tonight, Dr. Tiani. But before we say goodbye, or I guess even goodnight, depending on when you're watching this, do you have anything else to add about nightmares?

Dr. Alaina Tiani:

Yeah. I think, of course, it is common to have nightmares a little more frequently when we're going through a stressful time. Typically, those should resolve once the stressor resolves, but if it's something more persistent or that continues on for a number of weeks or months, that would be a great time to bring it up to one of your providers.

John Horton:

Well, thank you so much for coming in Dr. Tiani and sharing all this information.

Dr. Alaina Tiani:

Thank you so much for having me.

John Horton:

Nightmares are common and just part of being human. A few healthy changes to your sleep routine may help keep them away. But if bad dreams turn every night into a frightful event, talk to your healthcare provider to help find a solution. If you liked what you heard today, please hit the subscribe button, leave a comment to share your thoughts. Until next time, be well.

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