Correspondence
Nightmares in the context of PTSD treated with
psychoeducation regarding lucid dreaming
Greg Been and Vikas Garg, Mirrabook Mental Health
Unit, Shellharbour Hospital Shellharbour, New South
Wales, Australia:
A 39-year-old male presented on 14 December to the
emergency department with a history of five suicide
attempts in the previous week. He had three previous
admissions to psychiatric wards with varying diagnoses
including depression, PTSD and alcohol dependence.
The Christmas period was typically very difficult for
him, as Christmas Eve was the anniversary of the murder
of a former fiancé of his.
His primary reason for drinking approximately 16
standard drinks a day was that he had great difficulty
sleeping without it. In his experience, and during his time
on the ward, benzodiazepines and other hypnotics did not
allow him sufficiently restful sleep. Typically, he would
awaken after 2 hours from a nightmare and find it
extremely difficult to return to sleep. These nightmares
usually revisited one of a number of traumatic incidents
which he had witnessed in his life. These included wit-
nessing his father holding a shotgun to his mothers head
when he was 3 years old, finding a dead baby in a bath-
tub when he worked for the department of housing, being
first on scene at a major car accident where two people
were decapitated, and others. These experiences, which
did not seem factitious, emerged in his dreams and dis-
turbed his sleep. He felt that his inability to sleep as
a result of his nightmares was his primary problem, and
was the underlying cause of his drinking.
He was commenced on an alchohol withdrawal scale
(AWS) which was ceased after 5 days. Additionally, he was
© 2010 The Royal Australian and New Zealand College of Psychiatrists
prescribed 200 mg quetiapine nocte and 100 mg fluvox-
amine mane. Initially he was using considerable amounts
of prn temazepam (20 mg nocte) and chlorpromazine
(300 mg daily).
We decided that a trial of lucid dreaming treatment for
his nightmares might be appropriate. Training in becoming
lucid (realising that one is dreaming while still in the expe-
rience of the dream) allows one to alter the storyline of the
dream and avoid the negative emotions associated with once
again re-experiencing a traumatic event. There is one pub-
lished pilot trial of lucid dreaming treatment [1], in which
it seemed effective, although it was not clear from the study
if lucidity was necessarily the therapeutic factor.
The patient was given a print-out of the Wikipedia entry
on lucid dreaming (en.wikipedia.org/wiki/Lucid_dream).
He was then instructed to write out his dreams on awak-
ening, and to then reimagine them as he tried to fall back
asleep. In his reimagining, he was to alter the events so
that in the dream he realised that he was dreaming and
to then change the dream so that it was not as alarming
and unpleasant. After several days of this, he began to
become aware of the fact that he was dreaming in his
dreams when he had a nightmare, and then changed the
dream so that it was more pleasant. The nightmares did
not bother him as much, his sleep improved, and he was
able to sleep 6 hours without awakening as a result of
nightmares, with no medication. It is not clear to what
degree the psychoeducation contributed to his improve-
ment, but the patient was adamant it was the primary
factor in his improvement. He chose to discharge himself
after an inpatient stay of 16 days.
Reference
1. Spoormaker VI, van den Bout J. Lucid dreaming treatment for
nightmares: a pilot study. Psychother Psychosom 2006; 75:389–394.