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 nightmares.
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 her.
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 nightmares.
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 torture.
“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 pension.)
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 birds.
“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.”
This article, "Following a Script to Escape a Nightmare," first appeared in The New York Times.