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Dreaming After Trauma WAGENER IV, ALWIN E., Ph.D. Dreaming After Trauma: Exploring the Relationship of Replicative and Recurrent Posttraumatic Nightmares to Insomnia, Nightmare Distress, and Posttraumatic Stress Disorder Among Survivors of Intimate Partner Violence. (2015) Directed by Dr. J. Scott Young. 264 pp. Intimate partner violence (IPV) is a widespread problem with significant negative effects. A common result of IPV is the development of posttraumatic stress disorder (PTSD), a disorder that occurs when psychological recovery from a traumatic experience is impaired or arrested. There are a variety of approaches for treating PTSD, but one of the most prevalent symptoms of PTSD, posttraumatic nightmares (PTNMs), frequently does not resolve even when other PTSD symptoms have been significantly reduced or eliminated (Bradley, Greene, & Russ, 2005). In addition, PTNMs of IPV survivors often contain horrific content that is emotionally disturbing (Rasmussen, 2007), and PTNM frequency is linked to increased risk of suicide attempts, with several studies showing this increased risk is independent of depressive symptoms and insomnia (Nadorff et al., 2014; Sjostrom et al., 2007; Tanskanen et al., 2001). Due to the difficulty in resolving PTNMs and their negative effect on IPV survivors, this study sought to increase understanding of the function of PTNMs by examining elements of the Contemporary Theory of Dreaming (CTD) suggesting that nightmares help to integrate the emotion from trauma into the experience of the dreamer. The study also examined Levin and Nielsen's (2009) idea put forth in their (A)mygdala, (M)edial (P)refrontal Cortex, (H)ippocampus, (A)nterior (C)ingulate Cortex/(A)ffective (N)etwork (D)ysfunction (AMPHAC/AND) neurocognitive dreaming model that nightmares allow for fear-memory extinction. Both CTD and the AMPHAC/AND model suggest that when nightmares repeat the dreamer is not formulating new associations, which is an impairment of the normal function of nightmares, namely, to aid trauma recovery. Therefore, this study examined two forms of repeating nightmares that are linked with PTSD and with difficulty recovering from PTSD, and for which there is a dearth of research describing the relationship between these dream types and PTSD. These two types of repeating nightmares are replicative nightmares (nightmares that repeat the trauma exactly) and recurrent nightmares (nightmares that do not repeat the trauma but occur in the same form repeatedly). CTD suggests that insomnia is the likely cause of repeating nightmares, while the AMPHAC/AND model attributes affective distress (as measured through nightmare distress) as the cause. The current study evaluated these competing proposals for the cause of repeating nightmares as well as the relationship between repeating nightmares and PTSD using a cross-sectional correlation design to discover if the reported relationships of repeating nightmares, PTSD, insomnia, and nightmares distress among IPV survivors was consistent with the models (CTD and AMPHAC/AND). Analyses revealed that PTSD and repeating nightmares were strongly correlated among the sample of IPV survivors who participated in the study. In addition, nightmare distress had a strong significant correlation with repeating nightmares and PTSD, while insomnia had a moderate correlation with PTSD and only the replicative type of repeating nightmares. These findings were consistent with the propositions made in the AMPHAC/AND model, however, the CTD proposal that insomnia leads to repeating nightmares was not supported by the findings. There are implications from the research findings. The presence of repeating nightmares in clients should indicate the need for trauma assessment due to the strong relationship between repeating nightmares and PTSD symptom severity. IPV survivors should be assessed for repeating nightmares, and, based on the strong relationship between repeating nightmares, nightmare distress, and PTSD symptom severity, the nightmares of survivors experiencing repeating nightmares should be addressed in counseling to alleviate distress related to the experience of those repeating nightmares. In addition, further research is needed. Longitudinal studies to evaluate whether dreams and nightmares that generate new associations lead to improvements in PTSD symptoms among IPV survivors would provide valuable information towards evaluating the role of dreams and nightmares put forward in the AMPHAC/AND model. Additionally, due to the lack of research on IPV survivors’ dreams and nightmares over time, qualitative research of IPV survivors’ experiences with dreams and nightmares in the maintenance of PTSD and recovery from PTSD is needed. DREAMING AFTER TRAUMA: EXPLORING THE RELATIONSHIP OF REPLICATIVE AND RECURRENT POSTTRAUMATIC NIGHTMARES TO INSOMNIA, NIGHTMARE DISTRESS, AND POSTTRAUMATIC STRESS DISORDER AMONG SURVIVORS OF INTIMATE PARTNER VIOLENCE by Alwin E. Wagener IV A Dissertation Submitted to the Faculty of the Graduate School at The University of North Carolina at Greensboro in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy Greensboro 2015 Approved by ______________________________ Committee Chair APPROVAL PAGE This dissertation written by Alwin E. Wagener IV has been approved by the following committee of the Faculty of The Graduate School at The University of North Carolina at Greensboro. Committee Chair _________________________________ Committee Members ___________________________________ ___________________________________ ___________________________________ ____________________________ Date of Acceptance by Committee _________________________ Date of Final Oral Examination ii TABLE OF CONTENTS Page LIST OF TABLES ............................................................................................................. vi CHAPTER I. INTRODUCTION ................................................................................................. 1 Intimate Partner Violence and Posttraumatic Stress Disorder .................... 1 Posttraumatic Nightmares ........................................................................... 3 Contemporary Theory of Dreaming ............................................................ 5 AMPHAC/AND Neurocognitive Model ..................................................... 7 Sleep and PTSD ........................................................................................... 9 Nightmare Distress .................................................................................... 11 Statement of the Problem .......................................................................... 12 Need for the Study ..................................................................................... 13 Research Questions ................................................................................... 14 Definition of Terms ................................................................................... 15 II. REVIEW OF LITERATURE .............................................................................. 17 Intimate Partner Violence and PTSD ........................................................ 18 Societal costs of PTSD .................................................................. 21 IPV Survivors and PTNMs ........................................................................ 22 Posttraumatic Nightmares ......................................................................... 26 Definition of PTNMs ..................................................................... 26 PTNMs historically and across cultures ........................................ 28 PTNMs and foundational psychological dream theories ............... 34 Contemporary Theory of Dreaming .......................................................... 40 Associative continuum .................................................................. 40 Brain activation from waking to dreaming .................................... 42 Self-healing in dreaming ............................................................... 44 CTD and PTSD .......................................................................................... 49 Replicative and recurrent nightmares ............................................ 50 Insomnia and PTNMs .................................................................... 52 AMPHAC/AND Neurocognitive Model ................................................... 58 Nightmare distress ......................................................................... 62 CTD and the AMPHAC/AND Neurocognitive Model ............................. 64 Current PTNM Treatments ........................................................................ 65 Imagery rehearsal therapy ............................................................. 67 Prazosin ......................................................................................... 70 iii Summary of PTNM treatments ..................................................... 71 Conclusion ................................................................................................. 72 III. METHODOLOGY .............................................................................................. 74 Research Questions and Hypotheses ......................................................... 75 Participants ................................................................................................ 76 Demographics ................................................................................ 78 Instruments ...............................................................................................
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