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Features of posttraumatic dreams related to PTSD severity




Andrea J Phelps, Senior Clinical Fellow
Mark Creamer1, Professor
Malcolm Hopwood2, Professor
David Forbes1, Professor


1Australian Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Australia
2Albert Road Clinic, Department of Psychiatry, University of Melbourne, Australia



Corresponding Author:	Dr Andrea Phelps
ACPMH, University of Melbourne
Level 3/161 Barry St
Carlton, VIC, 3053
Australia
Ph: 61 3 9035 5599
Email: ajphelps@unimelb.edu.au

Running head: Features of posttraumatic dreams related to PTSD severity



Abstract

Objective: As a first step towards understanding the difference between PTSD dreams (a distressing symptom of psychological disorder) and non-PTSD dreams (possibly serving an adaptive emotional processing function) following trauma, this research investigated which features of PTSD dreams are associated with PTSD severity. 
Method: The sample comprised 40 veterans and 20 civilians with PTSD. Dream phenomenology (structured interview), as well as dream related sleep disturbance and the individual�s response to the dream were assessed.
Results: A series of linear multivariate regression analyses demonstrated that dreams associated with the most severe PTSD were distinguished by the individual�s response to the experience of the dream. 
Conclusions: The individual�s response to their dreams - prior to sleep, on awakening and throughout the day � may serve to maintain posttraumatic dreams in a dysfunctional cycle of fear, arousal and avoidance, and may explain why some posttraumatic dreams persist while others resolve over time. The findings have the potential to enhance the assessment and treatment of this complex condition.  

Key words: dreams, posttraumatic dreams, PTSD, trauma 
Introduction
Posttraumatic dreams are a core symptom of PTSD  ADDIN EN.CITE <EndNote><Cite><Author>APA</Author><Year>1994</Year><RecNum>294</RecNum><DisplayText>[1, 2]</DisplayText><record><rec-number>294</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">294</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>APA </author></authors></contributors><titles><title>Diagnostic and statistical manual of mental disorders </title></titles><edition>4th</edition><dates><year>1994</year></dates><pub-location>Washington D.C.</pub-location><publisher>APA</publisher><urls></urls></record></Cite><Cite><Author>Kilpatrick</Author><Year>1997</Year><RecNum>252</RecNum><record><rec-number>252</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">252</key></foreign-keys><ref-type name="Book Section">5</ref-type><contributors><authors><author>Kilpatrick, D. G.</author><author>Resnick, H.S.</author><author>Freedy, J.R.</author><author>Pelcovitz, D.</author><author>Resick, P.</author><author>Roth, S.</author><author>van der Kolk, B.</author></authors><secondary-authors><author>Widiger, T.A.</author><author>Frances, A.J.</author><author>Pincus, H.A.</author><author>First, M.B.</author><author>Ross, R.</author><author>Davis, W.</author></secondary-authors></contributors><titles><title>The posttraumatic stress disorder field trial: Evaluation of the PTSD construct: Criteria A through E</title><secondary-title>DSM-IV Sourcebook (Volume IV)</secondary-title></titles><dates><year>1997</year></dates><pub-location>Washington DC</pub-location><publisher>American Psychiatric Press</publisher><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_1" \o "APA, 1994 #294" 1,  HYPERLINK \l "_ENREF_2" \o "Kilpatrick, 1997 #252" 2] but are also common in people without PTSD  ADDIN EN.CITE <EndNote><Cite><Author>Lavie</Author><Year>2001</Year><RecNum>117</RecNum><DisplayText>[3]</DisplayText><record><rec-number>117</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">117</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lavie, P.</author></authors></contributors><auth-address>Reprint available from:</auth-address><titles><title>Current concepts: Sleep disturbances in the wake of traumatic events</title><secondary-title>New England Journal of Medicine</secondary-title><alt-title>N. Engl. J. Med</alt-title></titles><pages>1825-1832</pages><volume>345</volume><number>25</number><keywords><keyword>Posttraumatic-stress-disorder</keyword><keyword>Vietnam combat veterans</keyword><keyword>Psychiatric-disorders</keyword><keyword>General-population</keyword><keyword>Hurricane-andrew</keyword><keyword>Accident victims</keyword><keyword>Ptsd inpatients</keyword><keyword>Rem-sleep</keyword><keyword>Survivors</keyword><keyword>Children.</keyword><keyword>General &amp; Internal Medicine in Current Contents(R)/Clinical</keyword><keyword>Medicine. Medical Research, General Topics in Current</keyword><keyword>Contents(R)/Life Sciences.</keyword></keywords><dates><year>2001</year><pub-dates><date>Dec 20</date></pub-dates></dates><accession-num>503JF-0007</accession-num><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_3" \o "Lavie, 2001 #117" 3]. Those that occur as part of PTSD are considered a symptom of pathology - one of the re-experiencing cluster of symptoms.  Conversely, those that occur outside of PTSD are thought to serve an adaptive function in emotional processing of traumatic experience  ADDIN EN.CITE <EndNote><Cite><Author>Newell</Author><Year>2000</Year><RecNum>200</RecNum><DisplayText>[4, 5]</DisplayText><record><rec-number>200</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">200</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Newell, P T</author><author>Cartwright, R D</author></authors></contributors><titles><title>Affect and cognition in dreams: a critique of the cognitive role in adaptive dream functioning and support for associative models.</title><secondary-title>Psychiatry Today</secondary-title></titles><pages>34-44</pages><volume>63</volume><number>1</number><dates><year>2000</year></dates><urls></urls></record></Cite><Cite><Author>Hartmann</Author><Year>1998</Year><RecNum>232</RecNum><record><rec-number>232</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">232</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hartmann, E.</author></authors></contributors><titles><title>Nightmare after trauma as paradigm for all dreams: A new approach to the nature and function of dreaming</title><secondary-title>Psychiatry: Interpersonal and biological processes</secondary-title></titles><pages>223-228</pages><volume>61</volume><number>3</number><dates><year>1998</year></dates><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_4" \o "Newell, 2000 #200" 4,  HYPERLINK \l "_ENREF_5" \o "Hartmann, 1998 #232" 5].  The notion that PTSD and non-PTSD dreams are qualitatively different phenomena has been assumed  ADDIN EN.CITE <EndNote><Cite><Author>Freud</Author><Year>1920</Year><RecNum>248</RecNum><DisplayText>[5, 6]</DisplayText><record><rec-number>248</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">248</key></foreign-keys><ref-type name="Book Section">5</ref-type><contributors><authors><author>Freud, S.</author></authors><secondary-authors><author>J. Strachey</author></secondary-authors></contributors><titles><title>Beyond the pleasure principle.</title><secondary-title>The Standard Edition of the Complete Psychological Works of Sigmund Freud.</secondary-title></titles><pages>pp.3-71</pages><volume>Vol. 18</volume><dates><year>1920</year></dates><pub-location>London</pub-location><publisher>Hogarth Press</publisher><urls></urls></record></Cite><Cite><Author>Hartmann</Author><Year>1998</Year><RecNum>232</RecNum><record><rec-number>232</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">232</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hartmann, E.</author></authors></contributors><titles><title>Nightmare after trauma as paradigm for all dreams: A new approach to the nature and function of dreaming</title><secondary-title>Psychiatry: Interpersonal and biological processes</secondary-title></titles><pages>223-228</pages><volume>61</volume><number>3</number><dates><year>1998</year></dates><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_5" \o "Hartmann, 1998 #232" 5,  HYPERLINK \l "_ENREF_6" \o "Freud, 1920 #248" 6] but not established empirically.   ADDIN EN.CITE <EndNote><Cite AuthorYear="1"><Author>Phelps</Author><Year>2008</Year><RecNum>262</RecNum><DisplayText>Phelps, Forbes [7]</DisplayText><record><rec-number>262</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">262</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Phelps, A.J.</author><author>Forbes, D</author><author>Creamer, M</author></authors></contributors><titles><title>Understanding posttraumatic nightmares: An empirical and conceptual review</title><secondary-title>Clinical Psychology Review</secondary-title></titles><periodical><full-title>Clinical Psychology Review</full-title></periodical><pages>338-355</pages><volume>28</volume><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote> HYPERLINK \l "_ENREF_7" \o "Phelps, 2008 #262" Phelps, Forbes [7] highlight that different methods and foci of investigation into PTSD and non-PTSD dreams following trauma, within the PTSD and dreaming fields respectively, make comparisons between the two on the basis of existing research difficult. 

It may be that posttraumatic nightmares of PTSD are a different phenomenon than other dreams following trauma - better conceptualized as an intrusive symptom rather than a dream - and their course of chronic repetition versus resolution is determined accordingly. On the basis of existing research, it would seem that any categorical distinction is not based on dream content alone. Dreams that replay actual traumatic experiences, while a hallmark of PTSD  ADDIN EN.CITE <EndNote><Cite><Author>Hartmann</Author><Year>1998</Year><RecNum>232</RecNum><DisplayText>[5]</DisplayText><record><rec-number>232</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">232</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hartmann, E.</author></authors></contributors><titles><title>Nightmare after trauma as paradigm for all dreams: A new approach to the nature and function of dreaming</title><secondary-title>Psychiatry: Interpersonal and biological processes</secondary-title></titles><pages>223-228</pages><volume>61</volume><number>3</number><dates><year>1998</year></dates><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_5" \o "Hartmann, 1998 #232" 5], are not exclusive to that condition  ADDIN EN.CITE <EndNote><Cite><Author>Schreuder</Author><Year>2000</Year><RecNum>215</RecNum><DisplayText>[8]</DisplayText><record><rec-number>215</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">215</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schreuder, B.J.N.</author><author>Kleijn, W.C.</author><author>Rooijmans, H.G.M.</author></authors></contributors><titles><title>Nocturnal re-experiencing more than forty years after war trauma.</title><secondary-title>Journal of Traumatic Stress</secondary-title></titles><periodical><full-title>Journal of Traumatic Stress</full-title></periodical><pages>453-463</pages><volume>13</volume><number>3</number><dates><year>2000</year></dates><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_8" \o "Schreuder, 2000 #215" 8].  

An alternate possibility is that all dreams following trauma begin as the same phenomena with their differential course determined by other factors. This would have important implications for early intervention and treatment.

 ADDIN EN.CITE <EndNote><Cite AuthorYear="1"><Author>Phelps</Author><Year>2008</Year><RecNum>262</RecNum><DisplayText>Phelps, Forbes [7]</DisplayText><record><rec-number>262</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">262</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Phelps, A.J.</author><author>Forbes, D</author><author>Creamer, M</author></authors></contributors><titles><title>Understanding posttraumatic nightmares: An empirical and conceptual review</title><secondary-title>Clinical Psychology Review</secondary-title></titles><periodical><full-title>Clinical Psychology Review</full-title></periodical><pages>338-355</pages><volume>28</volume><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote> HYPERLINK \l "_ENREF_7" \o "Phelps, 2008 #262" Phelps, Forbes [7] outlined three potential explanatory models of posttraumatic dreams: 1) that PTSD and non-PTSD dreams are categorically different phenomena from the outset; 2) that they begin as the same phenomenon but sleep disturbance associated with PTSD prevents the normal adaptive function of dreams and leads to their chronic repetition; and 3) that they begin as the same phenomenon but the individual�s response to the experience of posttraumatic dreams determines whether they resolve or persist. Specifically, appraisals that increase a sense of current threat may serve to maintain the posttraumatic dream in a pattern of chronic repetition, a phenomenon reported by  ADDIN EN.CITE <EndNote><Cite AuthorYear="1"><Author>Ehlers</Author><Year>2000</Year><RecNum>230</RecNum><DisplayText>Ehlers and Clark [9]</DisplayText><record><rec-number>230</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">230</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ehlers, A.</author><author>Clark, D. M.</author></authors></contributors><titles><title>A cognitive model of posttraumatic stress disorder</title><secondary-title>Behaviour Research &amp; Therapy</secondary-title></titles><pages>319-45</pages><volume>38</volume><number>4</number><dates><year>2000</year></dates><urls></urls></record></Cite></EndNote> HYPERLINK \l "_ENREF_9" \o "Ehlers, 2000 #230" Ehlers and Clark [9] in reference to PTSD re-experiencing symptoms more generally. 

These models can be tested in a three-stage approach. The first stage is to establish the features of dream phenomenology, sleep, and individual response that are associated with the posttraumatic dreams of PTSD and, in particular, the severity of PTSD. This would establish a point of comparison for the second stage in which these features would be compared with non-PTSD dreams following trauma using the same methodology. Significant differences in phenomenology would support the first hypothesis, that the two are categorically different phenomena, while finding similar phenomenological features but differences in associated sleep or attitudes would support the second or third hypotheses respectively. Such a cross-sectional design, however, would not illuminate whether any differences between PTSD and non-PTSD dreams were a function of PTSD or played a causal role in the development of PTSD. The third stage of model testing would, therefore, require a prospective study that investigated the phenomenological features, and associated sleep and attitudinal variables of dreams in the aftermath of trauma and followed their course over ensuing months and years. 

This paper reports on the first stage of research undertaken to test the alternate models. The study aimed to identify the key features of dream phenomenology, sleep, and attitudes that are associated with PTSD severity. This study builds upon previous research that found no relationship between the severity of PTSD and the extent to which actual traumatic experiences were replayed in dreams  ADDIN EN.CITE <EndNote><Cite><Author>Phelps</Author><Year>2011</Year><RecNum>338</RecNum><DisplayText>[10]</DisplayText><record><rec-number>338</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">338</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Phelps, A.J.</author><author>Forbes, D.</author><author>Hopwood, M.</author><author>Creamer, M.</author></authors></contributors><titles><title>Trauma related dreams of Australian veterans with PTSD: Content, affect and phenomenology</title><secondary-title>Australian and New Zealand Journal of Psychiatry</secondary-title></titles><pages>853-860</pages><volume>45</volume><dates><year>2011</year></dates><urls></urls></record></Cite><Cite><Author>Phelps</Author><Year>2011</Year><RecNum>338</RecNum><record><rec-number>338</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">338</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Phelps, A.J.</author><author>Forbes, D.</author><author>Hopwood, M.</author><author>Creamer, M.</author></authors></contributors><titles><title>Trauma related dreams of Australian veterans with PTSD: Content, affect and phenomenology</title><secondary-title>Australian and New Zealand Journal of Psychiatry</secondary-title></titles><pages>853-860</pages><volume>45</volume><dates><year>2011</year></dates><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_10" \o "Phelps, 2011 #338" 10], a result consistent with Schreuder�s finding noted above, that replay dreams were not exclusive to PTSD. Thus, this research investigated which phenomenological features, apart from content, were related to PTSD severity.
Method
Participants
The study population comprised 60 treatment seeking adults with PTSD. Participants were recruited from a hospital based psychological trauma service, a community based counseling service for veterans, and psychiatrists in private practice over a two-year period. To be included in the study, participants had to have a clinical diagnosis of PTSD (confirmed using a structured diagnostic interview), with endorsement of criterion B2 (posttraumatic dreams). Potential participants were excluded if they had no memory of the event, had sustained a moderate to severe head injury, or were currently suicidal or psychotic. 

Approval for this study was obtained from the Institutional Ethics Committees of the organizations involved. 
Measures
PTSD and Co-morbidities
PTSD was assessed using the Clinician Administered PTSD Scale  ADDIN EN.CITE  ADDIN EN.CITE.DATA [CAPS;  HYPERLINK \l "_ENREF_11" \o "Blake, 1995 #217" 11,  HYPERLINK \l "_ENREF_12" \o "Weathers, 2001 #284" 12]. This is a psychometrically robust instrument, considered the gold standard in PTSD assessment. The CAPS addresses each of the seventeen diagnostic criteria for PTSD in DSM-IV, with each symptom assessed for intensity and frequency and, where possible, behaviourally defined.  The CAPS provides a categorical diagnosis as well as a measure of PTSD severity. In this study it was used to confirm participants� current PTSD status, to confirm a current posttraumatic dream meeting DSM-IV diagnostic criterion, and as a measure of PTSD severity. 
Common co-morbid mental health problems of alcohol misuse, depression and anxiety were assessed to provide a broader symptom profile of the study population . Instruments used were: the Alcohol Use Disorders Identification Test  ADDIN EN.CITE <EndNote><Cite><Author>Babor</Author><Year>1989</Year><RecNum>413</RecNum><Prefix>AUDIT`; </Prefix><DisplayText>[AUDIT; 13]</DisplayText><record><rec-number>413</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">413</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Babor, T.</author><author>de la Fuente, J.</author><author>Saunders, J.</author><author>Grant, M.</author></authors></contributors><titles><title>The alcohol use disorders identification test: Guidelines for use in primary health care</title></titles><dates><year>1989</year></dates><pub-location>Geneva</pub-location><publisher>World Health Organization, Division of Mental Health</publisher><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_13" \o "Babor, 1989 #413" AUDIT; 13]; the Beck Depression Inventory  ADDIN EN.CITE <EndNote><Cite><Author>Beck</Author><Year>1996</Year><RecNum>268</RecNum><Prefix>BDI-II`; </Prefix><DisplayText>[BDI-II; 14]</DisplayText><record><rec-number>268</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">268</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Beck, A. T.</author><author>Steer, R.A.</author><author>Brown, G.K.</author></authors></contributors><titles><title>Beck Depression Inventory-Second Edition</title></titles><dates><year>1996</year></dates><pub-location>San Antonio, TX</pub-location><publisher>The Psychological Corporation</publisher><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_14" \o "Beck, 1996 #268" BDI-II; 14]; and the Beck Anxiety Inventory  ADDIN EN.CITE <EndNote><Cite><Author>Beck</Author><Year>1988</Year><RecNum>269</RecNum><Prefix>BAI`; </Prefix><DisplayText>[BAI; 15]</DisplayText><record><rec-number>269</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">269</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Beck, A. T.</author><author>Epstein, N.</author><author>Brown, G.</author><author>Steer, R.A.</author></authors></contributors><titles><title>An inventory for measuring clinical anxiety: Psychometric properties</title><secondary-title>Journal of Consulting and Clinical Psychology</secondary-title></titles><periodical><full-title>Journal of Consulting and Clinical Psychology</full-title></periodical><pages>893-897</pages><volume>56</volume><dates><year>1988</year></dates><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_15" \o "Beck, 1988 #269" BAI; 15].  Information about medication usage was also collected. 

Dream phenomenology
In the absence of an existing measure, a posttraumatic dream phenomenology structured interview was developed for this research. The interview explored dream content, associated affect and phenomenological features previously reported in posttraumatic dreams  ADDIN EN.CITE <EndNote><Cite><Author>Mellman</Author><Year>2001</Year><RecNum>234</RecNum><DisplayText>[16, 17]</DisplayText><record><rec-number>234</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">234</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mellman, T.A. </author><author>David, D.</author><author>Bustamante, V.</author><author>Torres, J.</author><author>Fins, A.</author></authors></contributors><auth-address>Reprint available from:</auth-address><titles><title>Dreams in the acute aftermath of trauma and their relationship to PTSD</title><secondary-title>Journal of Traumatic Stress</secondary-title><alt-title>J. Trauma Stress</alt-title></titles><periodical><full-title>Journal of Traumatic Stress</full-title></periodical><pages>241-247</pages><volume>14</volume><number>1</number><keywords><keyword>Ptsd</keyword><keyword>Dreams</keyword><keyword>Nightmares.</keyword><keyword>Posttraumatic-stress-disorder</keyword><keyword>Sleep</keyword><keyword>Veterans.</keyword><keyword>Psychology in Current Contents(R)/Social &amp; Behavioral</keyword><keyword>Sciences.</keyword></keywords><dates><year>2001</year><pub-dates><date>Jan</date></pub-dates></dates><accession-num>563XH-0018</accession-num><urls></urls></record></Cite><Cite><Author>Mellman</Author><Year>2004</Year><RecNum>266</RecNum><record><rec-number>266</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">266</key></foreign-keys><ref-type name="Personal Communication">26</ref-type><contributors><authors><author>Mellman, T.A. </author></authors></contributors><titles><title>Personal communication</title></titles><dates><year>2004</year></dates><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_16" \o "Mellman, 2001 #234" 16,  HYPERLINK \l "_ENREF_17" \o "Mellman, 2004 #266" 17] as well as daytime PTSD intrusions  ADDIN EN.CITE  ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_18" \o "Michael, 2005 #216" 18-21]. Participants were asked to rate the following phenomenological features of a selected (most distressing or most typical) posttraumatic dream on a 5 point Likert scale (0=not at all; 1=a little bit; 2=moderately; 3=quite a bit; 4=extremely or exactly): 1) How similar is the content of the dream to waking memory of the traumatic event?; 2) How disturbing is the dream?; 3) How realistic is the dream (events could happen)?;  4) How vivid are the images (sharp, clear, detailed)?; 5) How vivid are other sensory details (e.g. sounds, smells, taste, bodily sensations such as pain)?; 6) Did you �act out� the dream in any way (e.g., kicking, punching, running or screaming)?; 7) Did you have strong physical sensations (e.g., heart rate, sweating, trembling)?; 8) Did you feel like you were reliving the incident, like it was happening again?; and, 9) Did you have an �out of body� experience (e.g., viewing self from above)? 

Sleep
Participants� overall quality of sleep was assessed using the seven component scores of the Pittsburgh Sleep Quality Index  ADDIN EN.CITE <EndNote><Cite><Author>Buysse</Author><Year>1989</Year><RecNum>270</RecNum><Prefix>PSQI`; </Prefix><DisplayText>[PSQI; 22]</DisplayText><record><rec-number>270</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">270</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Buysse, D. J.</author><author>Reynolds, C. F.</author><author>Monk, T. H.</author><author>Berman, S. R.</author><author>Kupfer, D. J.</author></authors></contributors><titles><title>The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research</title><secondary-title>Psychiatry Research</secondary-title><alt-title>Psychiatry Res.</alt-title></titles><periodical><full-title>Psychiatry research</full-title></periodical><pages>193-213</pages><volume>28</volume><dates><year>1989</year></dates><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_22" \o "Buysse, 1989 #270" PSQI; 22].  PTSD-specific sleep disturbances was assessed using the composite score on the Pittsburgh Sleep Quality Index � Addendum for PTSD  ADDIN EN.CITE <EndNote><Cite><Author>Germain</Author><Year>2005</Year><RecNum>182</RecNum><Prefix>PSQI-A`;</Prefix><DisplayText>[PSQI-A;23]</DisplayText><record><rec-number>182</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">182</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Germain, A.</author><author>Hall, M.</author><author>Krakow, B.</author><author>Shear, M. K.</author><author>Buysse, D. J.</author></authors></contributors><titles><title>A brief sleep scale for Posttraumatic Stress Disorder: Pittsburgh Sleep Quality Index Addendum for PTSD</title><secondary-title>Journal of Anxiety Disorders</secondary-title></titles><pages>233-244</pages><volume>19</volume><number>2</number><keywords><keyword>sleep, self-report, Posttraumatic Stress Disorder</keyword><keyword>sexual assault survivors</keyword><keyword>motor-vehicle accidents</keyword><keyword>nightmares</keyword><keyword>disturbance</keyword><keyword>instrument</keyword><keyword>depression</keyword><keyword>symptoms</keyword><keyword>distress</keyword><keyword>insomnia</keyword><keyword>life</keyword></keywords><dates><year>2005</year></dates><accession-num>ISI:000225383200006</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://000225383200006</url></related-urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_23" \o "Germain, 2005 #182" PSQI-A;23]. The PSQI-A is comprised of seven items: hot flashes; general nervousness; memories or nightmares of traumatic experience; severe anxiety or panic not related to traumatic memories; bad dreams not related to traumatic memories; episodes of terror or screaming during sleep without fully awakening; and episodes of �acting out� dreams.

Arousal
PTSD is characterized by ongoing elevated arousal, which may also influence the phenomenology and/or awakening associated with posttraumatic dreams. In addition to its use as a measure of co-morbid anxiety, the Beck Anxiety Inventory  ADDIN EN.CITE <EndNote><Cite><Author>Beck</Author><Year>1988</Year><RecNum>269</RecNum><Prefix>BAI`; </Prefix><DisplayText>[BAI; 15]</DisplayText><record><rec-number>269</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">269</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Beck, A. T.</author><author>Epstein, N.</author><author>Brown, G.</author><author>Steer, R.A.</author></authors></contributors><titles><title>An inventory for measuring clinical anxiety: Psychometric properties</title><secondary-title>Journal of Consulting and Clinical Psychology</secondary-title></titles><periodical><full-title>Journal of Consulting and Clinical Psychology</full-title></periodical><pages>893-897</pages><volume>56</volume><dates><year>1988</year></dates><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_15" \o "Beck, 1988 #269" BAI; 15] was used as a measure of physiological arousal associated with posttraumatic dreams.   Participants were instructed to respond to a second administration of the BAI questions as though they had just woken from a posttraumatic dream. 

Individual�s response to the posttraumatic dream
Participants� cognitive appraisal of their posttraumatic dream and the associated attitudes, beliefs and behaviours, were assessed using the Nightmare Distress Questionnaire  ADDIN EN.CITE <EndNote><Cite ExcludeAuth="1"><Year>1992b</Year><RecNum>395</RecNum><Prefix>NDQ`; Belicki`, </Prefix><DisplayText>[NDQ; Belicki, 24]</DisplayText><record><rec-number>395</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">395</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Belicki, K.</author></authors></contributors><titles><title>The relationship of nightmare frequency to nightmare suffering with implications for treatment and research</title><secondary-title>Dreaming</secondary-title></titles><periodical><full-title>Dreaming</full-title></periodical><pages>143-148</pages><volume>2</volume><number>3</number><dates><year>1992b</year></dates><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_24" \o "Belicki, 1992b #395" NDQ; Belicki, 24]. The NDQ contains 13 items, each rated on a 4 point Likert scale. For the purpose of this research, items were added to assess attitudinal responses that may increase the anxiety associated with nightmares  ADDIN EN.CITE <EndNote><Cite><Author>Halliday</Author><Year>1987</Year><RecNum>291</RecNum><DisplayText>[25]</DisplayText><record><rec-number>291</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">291</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Halliday, G.</author></authors></contributors><titles><title>Direct psychological therapies for nightmares: A review</title><secondary-title>Clinical Psychology Review</secondary-title></titles><periodical><full-title>Clinical Psychology Review</full-title></periodical><pages>501-523</pages><volume>7</volume><number>5</number><dates><year>1987</year></dates><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_25" \o "Halliday, 1987 #291" 25], contribute to a sense of current threat  ADDIN EN.CITE <EndNote><Cite><Author>Ehlers</Author><Year>2000</Year><RecNum>230</RecNum><DisplayText>[9]</DisplayText><record><rec-number>230</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">230</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ehlers, A.</author><author>Clark, D. M.</author></authors></contributors><titles><title>A cognitive model of posttraumatic stress disorder</title><secondary-title>Behaviour Research &amp; Therapy</secondary-title></titles><pages>319-45</pages><volume>38</volume><number>4</number><dates><year>2000</year></dates><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_9" \o "Ehlers, 2000 #230" 9], and contribute to poor sleep in PTSD  ADDIN EN.CITE <EndNote><Cite><Author>DeViva</Author><Year>2004</Year><RecNum>396</RecNum><DisplayText>[26]</DisplayText><record><rec-number>396</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">396</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>DeViva, J.C.</author><author>Zayfert, C.</author><author>Mellman, T.A.</author></authors></contributors><titles><title>Factors associated with insomnia among civilians seeking treatment for PTSD: An exploratory study</title><secondary-title>Behavioral sleep medicine</secondary-title></titles><periodical><full-title>Behavioral sleep medicine</full-title></periodical><pages>162-176</pages><volume>2</volume><number>3</number><dates><year>2004</year></dates><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_26" \o "DeViva, 2004 #396" 26]. These additional items were: 1)  �Are you able to control what happens in your nightmare?�; 2) �When you have a nightmare, does it make you worry that you�re going mad or that bad things will keep happening to you?�; and, 3) �Do you deliberately avoid sleep in order to avoid nightmares?� The additional items were scored on the same Likert scale, with scoring reversed on the question related to ability to control what happens in the nightmare. 
Data analysis
Data analysis proceeded in three stages. In phase 1 correlations between all of the variables of interest and PTSD severity were performed. In light of the large number of comparisons within each set of variables, the significant p value was reduced to .005 according to the principles of Bonferroni correction. In phase 2, a series of linear multivariate regression analyses was undertaken to identify which of the factors within dream phenomenology, sleep, arousal and attitudes/beliefs contributed to the variance in PTSD severity. In phase 3, all of the significant predictors of PTSD severity across these domains were combined into a single forward hierarchical linear multivariate regression analysis to determine the total variance in PTSD severity that could be accounted for.
Results
Participant characteristics
The sample comprised 40 military veterans and 20 survivors of civilian trauma.  Five of the civilians were female; all other participants were male. Participants ranged in age from 28 to 65 (M=52.60; SD = 9.57). Veterans were significantly older than civilians with a mean age of 56.03 (SD=9.02) compared to 45.75 (SD=6.57),  t=4.52, df=58, p<.001. Time since trauma (operationalized as time since deployment for veteran participants) ranged from less than 1 year to 42 years (M= 23.75; SD=16.15). Time since trauma was greater for veterans than it was for civilians with average time since trauma of 31.75 years (SD=12.76) compared to 7.75 years (SD=8.49),  t=7.59, df=58, p<.001).  

Despite these differences in age and time since trauma, there was no difference between veteran and civilian participants on PTSD severity. All participants met diagnostic criteria for PTSD as assessed with the CAPS. Total CAPS score ranged from 30 to 101 with a mean score of 68.95 (SD=17.18) and ANOVA revealed no difference between veteran and civilian participants (F (1,58)=2.64, p=.110). Thus, for subsequent analyses of dream factors related to PTSD severity, veteran and civilian participants were combined.

Consistent with the high level of co-morbidity associated with chronic PTSD (Creamer et al., 2001; Kessler et al., 1995), participants in this sample had problematic alcohol use, (AUDIT M=13.05; SD=11.08) and moderate levels of depression (BDI-II M=29.41; SD= 11.65) and anxiety (BAI M=23.83; SD=11.88). 

Factors related to PTSD severity
In phase 1 of the analysis, the strength and significance of correlations (Pearson�s r) between features of dream phenomenology, sleep disturbance, arousal, and dream related attitudes and beliefs, with PTSD (based on the total CAPS score) were tested. The results are presented in Table 1. 

There were three features of dream phenomenology that were moderately correlated with severity of PTSD, significant at the .005 level. These were:  the intensity of dream disturbance (r=.39, p=.002); the extent to which the dream was behaviorally enacted (r=.38, p=.005); and accompanying strong physical sensations (r=.39, p=.002). Higher ratings on each of these variables were associated with higher CAPS scores. 

Three features of disturbed sleep were correlated with PTSD severity at the .005 significance level: subjective sleep quality (r=.50, p<.001); use of sleep medication (r=.38, p=.003); and PSQI-Addendum for PTSD (r=.37, p=.003). Higher scores on each of these subscales were associated with higher CAPS scores. 

A paired sample t test revealed that BAI scores used as a measure of dream related arousal, were significantly higher than BAI scores as a general measure of anxiety,  [t (58)=- 6.53, p<.001].  Thus, the second administration of the BAI appeared to provide additional information specific to dream arousal. The overall dream related BAI score was moderately correlated with PTSD severity, [r (59) =.37, p=.004]. Correlations between individual items and PTSD severity revealed that a single item, �unable to relax� was correlated at the .005 significance level  (r= .47, p <.001). 

There was a strong correlation between the overall score on NDQ (based on the original 13 items) and PTSD severity (r=.65, p<.001). As shown in Table 1, investigation of individual items revealed a number of dream related attitudes and beliefs to be correlated with PTSD severity at the .005 level of significance. Four of these were of particular interest in capturing beliefs and attitudes about the nightmare experience. These were: difficulty putting nightmare out of mind on waking (r=.53, p<.001); avoiding or disliking someone because they were in the nightmare (r=.37, p=.004); afraid to fall asleep for fear of nightmare (r=.46, p<.001); and nightmares seem real (r=.39, p=.002).  The other five items addressed more general nightmare distress � the impact of nightmares on wellbeing and interest in treatment. These were: difficulty coping with nightmares (r=.37, p=.003); problem with nightmares (r=.43, p=.001); nightmares affect well-being (r=.51, p<.001); considered professional help (r=.40, p=.001); and interest in therapy (r=.46, p<.001). The correlations between each of these variables was high, with the item �do you feel you have a problem with nightmares?� most consistent in the strength of correlation with the others (correlations ranging from r=.54, p=<.001 to r=.70, p<.001).  This item was selected for use in the second phase of the analysis.

In phase 2 of the analysis, variables that correlated with PTSD severity were entered into a series of forward linear multivariate regression analyses as independent variables to determine their contribution to PTSD severity while controlling for other variables. 
Three phenomenology variables were entered into the regression analysis. The regression equation was significant (F (1,49)=8.95, p=.004). Only one variable  �did you act out the dream in any way?�, Fchange (1, 49)=8.95, B= 4.74, SE=1.59, (=0.39, t=2.99, p=.004, significantly contributed, accounting for 15% of the variance  in PTSD severity.

Three sleep variables were entered and again the regression equation was significant (F(2,57)=14.08, p<.001). Two items uniquely contributed to prediction of PTSD severity. These two items, subjective sleep quality, Fchange (1, 58)=19.80,  B=11.07, SE=2.77, (=0.44, t=3.99,  p<.001, and use of medication, Fchange (1, 57)=6.50,  B=3.50, SE=1.37, (=0.28, t=4.45,  p=.014, accounted for 25% and 8% respectively (cumulatively 33%) of the variance in PTSD severity. 

With respect to the attitude/ belief variables,  �do you feel you have a problem with nightmares� was entered into a hierarchical forward linear multivariate regression analysis along with the four previously described items (difficulty putting nightmare out of mind on waking, avoiding or disliking someone because they were in the nightmare, afraid to fall asleep for fear of nightmare and nightmares seem real). The regression equation was significant (F(3,56) = 17.54, p<.001) with three items - difficulty putting nightmares out of mind on waking, Fchange (1, 58) =22.02, B=7.17, SE=1.78, (=0.40, t=4.02, p<.001, afraid to fall asleep for fear of nightmares, Fchange (1, 57) =9.89, B=4.66, SE=1.39, (=3.35, t=3.35, p=.001, and avoiding or disliking someone because they were in your dream Fchange (1, 56) =11.08, B= 3.77, SE=1.13, ( = 0.32, t=3.33, p=.002, accounting for almost 50% of the variance in PTSD severity.  

In summary, the series of regression analyses identified that the following six variables contributed significantly to the variance in PTSD severity:
1) One dream phenomenology item -  �acting out� the dream;
2) Two associated sleep items - subjective sleep quality and use of medication; and,
4) Three associated attitudes and beliefs items - difficulty putting nightmares out of mind on waking, afraid to fall asleep for fear of nightmares and avoiding or disliking someone because they were in your dream.  
Of course, this study design does not allow inferences to be made about the direction of causality in these observed relationships.
In phase 3 of the analysis, these variables were entered into a single forward hierarchical linear multivariate regression analysis, along with the single arousal variable that correlated significantly with PTSD severity, feeling unable to relax on awakening. As shown in Table 2 the regression equation was significant (F (4,46) = 12.07, p<.001), with more than 50% of the variance in PTSD severity accounted for by the following four variables: 1) feeling unable to relax after awakening; 2) difficulty putting nightmare out of mind on awakening; 3) avoiding or disliking someone because they were in your nightmare;  and 4) afraid to fall asleep for fear of having a nightmare.

Discussion
On the basis of the current research, dreams associated with the most severe PTSD are distinguished by the individual�s response to the experience of the dream.  This includes reactions at the time, (feeling unable to relax or put the nightmare out of mind), but also impacts on the individual in anticipation (being afraid to fall asleep), and during their waking hours (avoiding or disliking someone because they were in the dream). These dream features appear to be conceptually related, painting a picture of an individual who awakens from distressing dreams, cannot settle down or put the dream out of their mind, is frightened to go back to sleep in case the dream returns, and even feels and behaves differently during the day towards people who appear in their dream. These reactions could well serve to maintain posttraumatic dreams in a vicious cycle of fear, arousal and avoidance. In contrast, the dreams of individuals who respond in a more adaptive way - for example are readily able to dismiss the dreams from mind on awakening, are not afraid or avoidant of sleep, and do not generalize their emotional reactions to dream images into waking life � may be more likely to resolve over time.  This hypothesis, however, needs to be tested in future research by investigating the attitudes and beliefs associated with non-PTSD posttraumatic dreams that resolve over time.

Nevertheless, the identification of a strong association between the individual�s response to their dream and PTSD severity has value in its own right, with implications for potential targets for intervention.  These potential targets include changing the dream content to render it less distressing, teaching strategies to quickly reduce arousal on awakening from the dream, and changing the individual�s cognitive stance towards the dream to reduce fear and avoidance.  Each of these is elaborated below. 

Changing dream content
Posttraumatic dreams are feared and avoided because of their distressing content. There is emerging evidence for the effectiveness of imagery rehearsal (IR) therapy in the treatment of posttraumatic dreams  ADDIN EN.CITE <EndNote><Cite><Author>Aurora</Author><Year>2010</Year><RecNum>417</RecNum><DisplayText>[27]</DisplayText><record><rec-number>417</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">417</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Aurora, RN</author><author>Zak, RS</author><author>Auerbach, SH  </author></authors></contributors><titles><title>Best practice guide to the treatment of nightmare disorder in adults</title><secondary-title>J. Clin Sleep Medicine</secondary-title></titles><periodical><full-title>J. Clin Sleep Medicine</full-title></periodical><pages>389-401</pages><volume>6</volume><number>4</number><dates><year>2010</year></dates><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_27" \o "Aurora, 2010 #417" 27]. IR essentially involves changing the storyline of the dream in a way that makes it less distressing. This may include, for example, inserting bizarre or distorted elements into the dream or engineering a fantastic end to the dream  ADDIN EN.CITE <EndNote><Cite><Author>Forbes</Author><Year>2001</Year><RecNum>108</RecNum><DisplayText>[28]</DisplayText><record><rec-number>108</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">108</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Forbes, D.</author><author>Phelps, A.</author><author>McHugh, T.</author></authors></contributors><auth-address>Reprint available from:</auth-address><titles><title>Treatment of combat-related nightmares using imagery rehearsal: A pilot study</title><secondary-title>Journal of Traumatic Stress</secondary-title><alt-title>J. Trauma Stress</alt-title></titles><periodical><full-title>Journal of Traumatic Stress</full-title></periodical><pages>433-442</pages><volume>14</volume><number>2</number><keywords><keyword>Imagery rehearsal</keyword><keyword>Nightmares</keyword><keyword>Ptsd</keyword><keyword>Combat veterans.</keyword><keyword>Posttraumatic-stress-disorder</keyword><keyword>Veterans</keyword><keyword>Anxiety</keyword><keyword>Trauma</keyword><keyword>Ptsd.</keyword><keyword>Psychology in Current Contents(R)/Social &amp; Behavioral</keyword><keyword>Sciences.</keyword></keywords><dates><year>2001</year><pub-dates><date>Apr</date></pub-dates></dates><accession-num>451AM-0013</accession-num><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_28" \o "Forbes, 2001 #108" 28]. To the extent that IR reduces distress and hence awakening, it may be instrumental in promoting the resolution of chronic and repetitive posttraumatic dreams.  

Teaching arousal reduction strategies
The elevated physiological arousal associated with PTSD can inhibit sleep onset and may contribute to nightmares and other awakenings during the night. This is compounded by the occurrence of distressing posttraumatic dreams.  As such, strategies to reduce arousal should target both the elevated baseline and triggered escalations of arousal.  Regular rehearsal of progressive muscle relaxation (PMR) prior to sleep is likely to reduce baseline arousal and, to the extent that posttraumatic dreams are triggered by ongoing arousal, may reduce their occurrence. In addition, brief relaxation strategies such as controlled breathing, abbreviated PMR and isometric exercises may be used to reduce arousal after awakening from a posttraumatic dream.

Changing cognitive appraisal
This investigation highlighted four dream related psychological responses that were associated with PTSD severity. The first two features were cognitions on awakening from dreams:  When you awaken from a nightmare, do you find you keep thinking about it and have difficulty putting it out of your mind?; When you have a nightmare, does it ever seem so real that when you awaken you have difficulty convincing yourself it�s �just a dream�?  Both of these items point to the need for strategies to quickly orient the dreamer to the �here and now� after waking from a nightmare and refocus their attention away from the dream.  Effective grounding strategies may include handling a physical object (noticing texture, temperature, weight), describing the immediate environment in detail, naming 5 things the person can see, hear and touch, rehearsing a �safety statement� (e.g. �I�m safe, in my home. Today is ��. �).

The third attitudinal factor was being afraid to fall asleep. An intervention such as imagery rehearsal, that promotes a sense of mastery or control, may help the person to adopt a �face and conquer�  ADDIN EN.CITE <EndNote><Cite Hidden="1"><Author>Marks</Author><Year>1978</Year><RecNum>253</RecNum><record><rec-number>253</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">253</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Marks, I.</author></authors></contributors><titles><title>Rehearsal relief of a nightmare.</title><secondary-title>The British Journal of Psychiatry</secondary-title></titles><pages>461-465</pages><volume>133</volume><dates><year>1978</year></dates><urls></urls></record></Cite><Cite><Author>Marks</Author><Year>1978</Year><RecNum>253</RecNum><record><rec-number>253</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">253</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Marks, I.</author></authors></contributors><titles><title>Rehearsal relief of a nightmare.</title><secondary-title>The British Journal of Psychiatry</secondary-title></titles><pages>461-465</pages><volume>133</volume><dates><year>1978</year></dates><urls></urls></record></Cite></EndNote> approach to the dream.  

The fourth response - fearing, disliking or avoiding someone because they were in the dream - may require a combination of cognitive challenging and graded exposure to break the cycle of fear and avoidance that perpetuates the representation of a person in the dream. 

Limitations
There are a number of limitations of this research that need to be acknowledged.  First, observations of dream phenomenology and associated sleep, arousal and cognitive appraisal were based on a single most distressing or typical dream and may not apply to all B2 criterion dreams. 

Secondly, the study population was characterized by co-morbid depression, anxiety and alcohol use and the majority were taking psychotropic medication.  The potential impact of these factors on nightmares needs to be acknowledged. There is inconsistent evidence for the additive effect of co-morbid conditions on nightmares in people with PTSD  ADDIN EN.CITE <EndNote><Cite><Author>Neylan</Author><Year>1998</Year><RecNum>20</RecNum><DisplayText>[30, 31]</DisplayText><record><rec-number>20</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">20</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Neylan, Thomas C.</author><author>Marmar, Charles R.</author><author>Metzler, Thomas J.</author><author>Weiss, Daniel S.</author><author>Zatzick, Douglas F.</author><author>Delucchi, Kevin L.</author><author>Wu, Roger M.</author><author>Schoenfeld, Frank B.</author></authors></contributors><titles><title>Sleep disturbances in the Vietnam generation: Findings from a nationally representative sample of male Vietnam veterans</title><secondary-title>American Journal of Psychiatry</secondary-title></titles><periodical><full-title>American Journal of Psychiatry</full-title></periodical><pages>929-933</pages><volume>155</volume><number>7</number><dates><year>1998</year></dates><urls></urls></record></Cite><Cite><Author>Gelis</Author><Year>2010</Year><RecNum>410</RecNum><record><rec-number>410</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">410</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gelis, L.A.</author><author>Gehrman, P.R.</author><author>Mavandadi, S.</author><author>Oslin, D.W.</author></authors></contributors><titles><title>Predictors of sleep disturbances in Operation Iraqi Freedom/Operation Enduring Freedom veterans reporting a trauma</title><secondary-title>Military Medicine</secondary-title></titles><periodical><full-title>Military Medicine</full-title></periodical><pages>567-573</pages><volume>175</volume><number>8</number><dates><year>2010</year></dates><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_30" \o "Neylan, 1998 #20" 30,  HYPERLINK \l "_ENREF_31" \o "Gelis, 2010 #410" 31], but the potential for medication effects (vivid nightmares can be induced in some patients by antidepressant and antipsychotic drugs that affect the neurotransmitters serotonin and dopamine) and withdrawal from substances such as alcohol and benzodiazepines that suppress rapid eye movement (REM) sleep are acknowledged  ADDIN EN.CITE <EndNote><Cite><Author>Pagel</Author><Year>2010</Year><RecNum>280</RecNum><DisplayText>[32]</DisplayText><record><rec-number>280</rec-number><foreign-keys><key app="EN" db-id="sesefp59gaezsbew99uvfre02prvffxpwzsz">280</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pagel, J F </author></authors></contributors><titles><title>Drugs, dreams and nightmares</title><secondary-title>Sleep Medicine Clinics</secondary-title></titles><pages>277-287 </pages><volume>5</volume><dates><year>2010</year></dates><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_32" \o "Pagel, 2010 #280" 32]. Thus, the co-morbid mental health problems, alcohol misuse and prescribed medication of the study participants may have contributed to their nightmare experience beyond the impact of their PTSD. Regrettably, accessing a chronic PTSD sample without these complications in order to explore this issue further would be extremely difficult.

Thirdly, study participants had a limited range of trauma experiences. The extent to which these findings can be generalised across a broader PTSD population needs to be established.  

Notwithstanding these limitations, the current study highlights the importance of the individual�s response to the experience of posttraumatic dreams in PTSD, leading to recommendations for intervention and forming the basis for a comparison with non-PTSD dreams following trauma.

Acknowledgement:
The study was undertaken with no financial support. 
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