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Why Nightmares Matter

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Barry Krakow, MD has spent his career studying and treating nightmares. In this interview, he shares how nightmares affect mental health, and how they point to more than just PTSD.

Published On: 8/22/2021

Duration: 16 minutes, 23 seconds

Related Article:Turning Nightmares Into Dreams,” The Carlat Psychiatry Report, August 2021


Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

In this month’s Carlat Report we interviewed Barry Krakow. Dr. Krakow is a sleep specialized who has spent his career studying and treating nightmares. This interview changed my practice in 3 ways.

First, I’m used to thinking of nightmares as a symptom of a disorder, like PTSD, benzo withdrawal, or a side effect to a medication like lamotrigine, an SSRI, an anti-dementia medicine like donepezil and rivastigmine. Beta-blockers and statins can also cause them. And while that’s true, Dr. Krakow taught me that nightmares are also a cause of problems.

If your patient is having nightmares at least once a week, or they are thinking about the nightmares a lot during the day, it’s very likely that those nightmares are affecting their mood and quality of life.

Dr. Krakow: The question then becomes frequency and distress.

So as an example, we’ve looked for these clinical kinds of pearls for decades, and we’ve seen over and over again one or two things that are really, really obvious. If you report that you have a bad dream once a week or more, but even just once a week, the chance that that bad dream, nightmares, disturbing dream is bothering you is extraordinarily high. It means that something happened like that bad dream is causing you to delay your sleep at night. You don’t want to go to sleep, why? – because you want to avoid sleep because you don’t want to have nightmares. Or you didn’t get enough sleep. Or you know the increasing severity is you know that during the daytime that nightmare actually comes back to you – not so much as a daydream, but as an “Oh, yeah I had that really bad dream and now it’s making me feel sick again. I wish I didn’t have that bad dream.”

So people are impaired in this way, and you can actually ask them questions like you know, “Do you think about your nightmare content at all during the day,?” and they go “Yes,” you go this is somebody who’s been bothered by a stimulus that has been occurring at night.

But the one that’s most obvious is the co-occurring insomnia. A person who has nightmares frequently will say, “Oh yeah, my sleep is getting a little bit later” or “I’m having these awakenings” or “I feel crappy in the morning.” Those are the easiest ways to the see the impairment and to know that that person would be interested in getting some kind of intervention.

CHRIS AIKEN: And this is not just about PTSD. Lots of mental illnesses cause nightmares, and while it may be a symptom of the underlying depression, anxiety, or psychosis, treating the nightmare directly can help the psychiatric disorder that underlies it. Since talking with Dr. Krakow, I’ve come to view nightmares much in the way I see lying in bed all day in depression, or avoidance in anxiety. These may be symptoms of the underlying disorder, but they are also areas where simple interventions can turn those disorders around.

Dr. Krakow: The bottom line is what they found is that you treat nightmares, and psychiatric symptoms, mental health symptoms get better. And they are going wait, this is backwards. You’re supposed to treat the symptoms: the depression, the anxiety, the PTSD, and now the nightmares get better right? Well, they showed that it was the reverse.

KELLIE NEWSOME: Dr. Krakow helped develop a behavioral therapy for nightmares called Imagery Rehearsal Therapy, or IRT for short. IRT has been applied to nightmares of all types, but the study that really made a splash was a controlled trial he published in JAMA – not JAMA psych, but the JAMA for general medicine. There he reported that imagery rehearsal therapy reduced nightmares, improved sleep quality, and helped daytime symptoms of PTSD as well in 168 women with PTSD from sexual assault.

Dr. Krakow: And we found that we treated their nightmares – we just treated their nightmares – we didn’t give them psychotherapy. We did give them the imagery rehearsal therapy technique with a fair amount of psychoeducation in the sense that we had to overcome the barrier that these PTSD patients had been told for an average of 10-20 years: ‘Your nightmares are caused by your PTSD. Treat your PTSD and your nightmares will go away.’ So they’ve been on medications. They had psychotherapy. They had tried exposure therapy. They had tried EMDR. They still had nightmares.

So we do IRT with them, but we had to explain this is a different model of care. The nightmares get better; their PTSD gets better, markedly better, and now we are going down this path ever since then. And that study by the way began in 1994 with a grant, but wasn’t published in JAMA until 2001 – how time flies. But from that point forward other researchers, other colleagues, people all over the USA and the world began doing their own variations of IRT or the same one that we do, and they’re all finding the exact same thing. You treat people’s nightmares and people get better.

KELLIE NEWSOME: If you listened carefully, you might have heard something unusual there. Dr. Krakow said “we didn’t give them psychotherapy…. We gave them the imagery rehearsal therapy technique.” Dr. Krakow is not a psychiatrist and was not trained in psychotherapy.

Dr. Krakow: People always think I’m a psychiatrist and a psychologist and all those things. I am a board certified internist in internal medicine, and I’ve been involved in the fields of emergency medicine, addiction medicine, internal medicine, of course, and sleep medicine. I’ve never been in the field of psychiatry but the irony is most of my mentors, starting in 1988, a while back, were psychiatrists and my predominant field since the early 1990s has been to treat mental health patients with sleep disorders. So I’m very comfortable talking to psychologists and psychiatrists, in fact just about anything, because I have either experienced it working with my mentors or my patients. And my reputation is that people who come to see me are 80-90% mental health patients who couldn’t solve their sleep problems for some reason, and so I’m just an expert in that area. And I even wondered about going back and doing a psychiatry fellowship, but that was about 30-some years ago and I decided I didn’t quite need to do that.

CHRIS AIKEN: But then again Sigmund Freud was not a psychiatrist. He was a neurologist. And neither was Paul McHugh, the influential chair of psychiatry at Johns Hopkins. And Bob Post, who helped repurpose anticonvulsants as mood stabilizers, never did a psychiatric residency. Psychiatry is about as broad as it gets – it’s the human condition – and we need other fields to bring fresh ideas.

KELLIE NEWSOME: And on a practical level, one thing you need to know is that in most of the studies on imagery rehearsal therapy the therapy was not done by psychotherapists. It was done by sleep specialists. What that means is that you don’t need to to see patients for an hour a week to do this therapy. It’s easy to adopt it into a brief medication visit, and in our online interview Dr. Krakow tells us how to do that.

CHRIS AIKEN: That’s the second way he changed my practice. Now I ask every patient if they are having nightmares, and if it’s affecting their life more than once a week I’ll ask if they want to learn a technique to reduce them. Imagery rehearsal therapy is a simple, creative, and kind of fun – it helps patients re-engage with their imagination – what Dr. Krakow calls the mind’s eye.

Dr. Krakow: They began using their daytime imagery to solve problems, which is exactly what normal people do whether they realize it or not you know when you misplace your keys you usually find them by thinking in your mind’s eye – okay well where was I? I was in the bathroom and I set them down there when I went to brush my teeth and I forgot them. Many, many people use that mind’s eye. It’s extremely powerful to learn to use that in solving problems. In fact, I’ve had discussions with a few therapists who clearly use it when they are interacting with patients and they get stuck. And when they get stuck one of the first things they’ll do is look to their mind’s eye to see if something comes up that says I’m missing something here; the conversation is feeling like talking heads; it’s not really going well; let me just pause and see if something pops into my brain.

KELLIE NEWSOME: After helping patients turn nightmares into dreams, Dr. Krakow turned his attention to sleep apnea. And that’s the third way this interview changed our practice. Nightmares, it turns out, are a sign of sleep apnea, something that Dr. Krakow learned from his original cohort of PTSD patients.

Dr. Krakow: Did you know that you could treat nightmares in sleep apnea patients with their CPAP machine, and tons of them get better? I mean literally tons of people; you put them on CPAP therapy for their sleep apnea because lots of sleep apnea patients have bad dreams.

Chris Aiken: Doesn’t that make kind of intuitive sense that if you’re choking at night that you’d have a bad dream or am I jumping to conclusions here?

Dr. Krakow: No, no that’s great. I was just telling a friend of mine I had trouble with my CPAP machine just a couple of days ago and I had to go like 4 or 5 hours without my CPAP machine. I had two suffocation nightmares in one night because I didn’t have my CPAP machine. However, lots of sleep apnea patients don’t have suffocation nightmares; they just have other nightmares.

So they can walk in the door and you wouldn’t even think they had sleep apnea. They might be thin like me and you go, “Well, this person doesn’t have sleep apnea,” but they’ve got nightmares.

(20 minutes)

In fact, we’ve learned in that group of sexual assault survivors we treated in the 1990s with the JAMA article, we found later that more than 60% of them snored, and somewhere in the neighborhood of perhaps 70% of them had a sleep breathing disorder. So here we were treating their nightmares with imagery reversal therapy and they were getting marvelous results, so good that their PTSD symptoms were getting better. But later on discovered that they also had sleep apnea and the ones who reported this went forward and actually got treatment for their sleep apnea.

KELLIE NEWSOME: Barry Krakow spent most of his career as the medical director of Maimonides Sleep Arts & Sciences, Ltd, and principal investigator at the Sleep & Human Health Institute. He now practices in Savannah, Georgia where he consults on sleep disorders and provides digital and in-person training in imagery rehearsal therapy – check out for more.

And now for the word of the day… tricyclic

Tricyclic antidepressants are named for their three ring structure – tri-cyclic. They were developed in the early 1950’s around the same time as the MAOIs, and like the MAOIs their discovery was one of serendipity. Scientists were not looking for antidepressants when they stumbled upon them. They were looking for an antipsychotic to match the new wonder drug, chlorpromazine. Imipramine – synthesized in 1951 – seemed like a good candidate, as its sedative, antihistaminergic properties might calm the agitation of schizophrenia. But the drug did nothing for psychotic patients, except flip a few into mania. That was a surprise – how can a sedative cause mania? The chance discovery led Roland Kuhn and others to speculate that it might lift depression, and it held up to that promise in a 1955 clinical trial that lead to its launch in 1958 in Europe and 1959 in the United States, followed two years later by the second tricyclic, amitriptyline. Next week, join us for a tricyclic tutorial on How to Use Nortriptyline. A few weeks ago we featured the tetracyclic – or 4 rings –amitriptyline

You’ll find step by step details on how to integrate imagery rehearsal therapy into a medication visit in the print edition of this interview.


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