Wednesday, July 28, 2010


New York Times, July 26, 2010

Following a Script to Escape a Nightmare


ALBUQUERQUE — Her car is racing at a terrifying speed through the
streets of a large city, and something gruesome, something with giant
eyeballs, is chasing her, closing in fast.

It was a dream, of course, and after Emily Gurule, a 50-year-old high
school teacher, related it to Dr. Barry Krakow, he did not ask her to
unpack its symbolism. He simply told her to think of a new one.

"In your mind, with thinking and picturing, take a few minutes, close
your eyes, and I want you to change the dream any way you wish," said
Dr. Krakow, founder of the P.T.S.D. Sleep Clinic at the Maimonides
Sleep Arts and Sciences center here and a leading researcher of

And so the black car became a white Cadillac, traveling at a gentle
speed with nothing chasing it. The eyeballs became bubbles, floating
serenely above the city.

"We call that a new dream," Dr. Krakow told Ms. Gurule. "The bad dream
is over there" — he pointed across the room — "and we're not dealing
with that. We're dealing with the new dream."

The technique, used while patients are awake, is called scripting or
dream mastery and is part of imagery rehearsal therapy, which Dr.
Krakow helped develop. The therapy is being used to treat a growing
number of nightmare sufferers. In recent years, nightmares have
increasingly been viewed as a distinct disorder, and researchers have
produced a growing body of empirical evidence that this kind of
cognitive therapy can help reduce their frequency and intensity, or
even eliminate them.

The treatments are controversial. Some therapists, particularly
Jungian analysts, take issue with changing nightmares' content,
arguing that dreams send crucial messages to the waking mind.

Nightmares are important because they "bring up issues in bold print,"
said Jane White-Lewis, a psychologist in Guilford, Conn., who has
taught about dreams at the Carl Jung Institute in New York.

While Dr. White-Lewis acknowledged that she does not treat patients
suffering from severe trauma, she said that if a nightmare is
eliminated, "you lose an opportunity to really get some meaning out of
it." Changing eyeballs into bubbles, she added, might have robbed Ms.
Gurule of the chance to find out what the eyeballs were trying to tell

Nightmares have fascinated and perplexed people for centuries, their
meaning debated by therapists and analysts of all schools of thought,
their effects so powerful that one terrifying nightmare can affect a
person for a lifetime.

A nightmare is "a disturbing dream experience which rubs, bites and
sickens our soul, and has an undercurrent of horsepower, lewd demons,
aggressive orality and death," Dr. White-Lewis wrote in "In Defense of
Nightmares," her contribution to a 1993 book of essays about dreams.

From 4 to 8 percent of adults report experiencing nightmares, perhaps
as often as once per week or more, according to sleep researchers. But
the rate is as high as 90 percent among groups like combat veterans
and rape victims, Dr. Krakow said. He said treatment for
post-traumatic stress needed to deal much more actively with

He and other clinicians are increasingly using imagery rehearsal
therapy, or I.R.T., to treat veterans and active-duty troops in the
Iraq and Afghanistan wars. Last month, Dr. Krakow conducted a workshop
on imagery rehearsal and other sleep treatments for 65 therapists,
sleep doctors and psychiatrists, including many working with the
military. And the technique has drawn more attention from other
researchers in the last several years. Anne Germain, an associate
professor of psychiatry at the University of Pittsburgh School of
Medicine, is comparing two treatments — behavioral therapy, including
imagery rehearsal, and the blood-pressure drug prazosin, which has
been found to reduce nightmares.

Preliminary results from a study of 50 veterans showed that both
treatments were effective in reducing nightmares and symptoms of
P.T.S.D., she said, though they differed from patient to patient. She
is continuing to study what factors may lead to those differences.

Deirdre Barrett, a psychologist at Harvard Medical School who is an
expert on dream incubation, inducing dreams to resolve conflicts , and
on the connection between trauma and dreams — said she was struck by
the growing interest in nightmares as a result of war trauma and

"Within the community of psychologists who have put an emphasis on
dreams it used to be about interpretation," she said. "And now
therapists are getting the message that you can influence dreams, ask
dreams about particular issues and change nightmares."

And Hollywood has just produced its own spin on the idea of
controlling dreams, with the release earlier this month of "Inception"
a thriller whose plot swirls through the darkest layers of the dream
world. Underlying the story is the concept of lucid dreaming, another
technique used by clinicians to help patients afraid of their dreams
understand that they are dreaming while a dream is in progress. Dr.
Barrett supports the use of Dr. Krakow's technique, although she said
that ideally the nightmare work should be integrated with psychiatry
and behavioral therapies to treat the underlying condition.

Still, Dr. Barrett said, "Barry has made a huge contribution by
getting the numbers, getting the statistics and getting the proof that
it can work."

Dr. Krakow's nightmare therapy typically includes four sessions of
group treatment and between one and ten individual sessions, though
Dr. Krakow said between three and five sessions are usually effective.
(The clinic visits are covered by insurance.)

Patients participate in sleep studies as needed, and do considerable
work on their own, using a manual he published to guide them, "Turning
Nightmares Into Dreams."

At the clinic here, some patients, like Ms. Gurule, come in for severe
snoring and daytime sleepiness and discover they are suffering from
trauma-induced nightmares. Others come with a diagnosis of
post-traumatic stress or simply report recurring nightmares and
discover they also have other sleep disorders.

Dr. Krakow's latest research, which was presented last month at the
annual meeting of the Associated Professional Sleep Societies, found a
striking connection between P.T.S.D. and a variety of sleep disorders.
In an analysis of the sleep studies conducted on more than a thousand
patients with varying degrees of post-traumatic stress, he found that
5 to 10 other sleep problems may be involved. High rates of sleep
apnea, for example, were found even in patients with moderate symptoms
of post-traumatic stress. "In the world of P.T.S.D. and sleep, no one
is making these connections," Dr. Krakow said.

He refers to his small clinic, in an office park here, as a
"bed-and-breakfast without the breakfast." It has four small bedrooms,
with pastel-colored bedspreads and cheerful, serene paintings of fish
and beaches. Before bed, the technicians place sensors on the patients
to track sleep, breathing and movement.

Dr. Krakow, 61, started out as an internist and then practiced
emergency medicine before studying nightmares and possible treatments
with colleagues at the University of New Mexico in the late 1980s.
With financing from the National Institute of Mental Health, he
conducted his first major research between 1995 and 1999, looking at
the effect of imagery rehearsal on 168 sexual assault survivors who
suffered from nightmares.

The results of a randomized controlled trial were published in a 2001
paper in the Journal of the American Medical Association. Of the
subjects, 95 percent had moderate to severe P.T.S.D., 97 percent had
experienced rape or other sexual assault, 77 percent reported
life-threatening sexual assault and 58 percent reported repeated
exposure to sexual abuse in childhood.

The treatment group, 88 women, participated in three sessions of
imagery rehearsal therapy, while the control group, 80 women, was on a
waiting list and continued with whatever treatment they had been
undergoing. Of the 114 that completed follow-up at three or at three
and six months, those in the treatment group had "significantly"
reduced the nights per week with nightmares and the number of
nightmares per week, the paper said. The control group showed small,
"nonsignificant" improvement on the same measures. And symptoms of
post-traumatic stress decreased in 65 percent of the treatment group,
while they either remained unchanged or worsened in the control group,
according to the findings.

Along with other researchers, Dr. Krakow has continued to publish
further studies on imagery rehearsal, finding that of hundreds of
patients treated, about 70 percent have reported significant
improvements in nightmare frequency after regularly using the
treatment for two to four weeks.

Roberta Barker, 55, was one of Dr. Krakow's first patients and a
participant in the research published in JAMA. Ms. Barker says she was
kidnapped in Japan, where she had gone to teach English, and was raped
and tortured for three days before escaping. (She suffered extensive
physical injuries and now survives on a government disability

Her nightmares, replaying the horror over and over, were so
frightening she could barely sleep. Medications did not seem to work.
She was on the verge of suicide.

"I drank enough coffee to float a battleship," she said in a recent
visit to Dr. Krakow's clinic. "A few times a week I was reliving the
entire set of days in one night."

When Dr. Krakow told her that nightmares can be a learned behavior and
that she had the power to stop what had essentially become a habit,
she was highly skeptical.

He explained that she could come up with another dream and practice it
and that it was possible for her to no longer have the nightmares of
the kidnapping and rape.

"No, it's too easy," she recalled telling him. "It can't work."

Some patients work to change the plot of their dreams; a rape victim
who was receiving treatment with Ms. Barker decided to script a dream
about confronting her rapist with a baseball bat. But Ms. Barker said
she felt she had to come up with an entirely new dream. So she chose

"I've always loved birds, wild birds, doves and pigeons and starlings,
mountain blue jays," she said. "I had fed birds, the images were
solid, I could hear them flying and talking. Now, instead of waking up
screaming, I wake up knowing I've dreamed of birds."