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Treatment by systematic desensitization of a recurring nightmare of a real life trauma
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TREATMENT
$1,2.,10/”
BY SYSTEMATIC DESENSITIZATION OF A RECURRING NIGHTMARE OF A REAL LIFE TRAUMA FRED E. SCHINDLER
University of Arizona and Veterans Administration Medical Center, Tucson, Arizona Summary-A modified systematic desensitization procedure was employed in the treatment of a Vietnam war veteran with a recurring nightmare of a gruesome mine explosion. The dream consisted of a vivid recreation of the traumatic events as they actually occurred. After six sessions of desensitization with an additional self-control procedure, the dream ceased to occur and anxiety about sleeping diminished commensurately. Results were maintained at a seven month follow-up. (at least once monthly plus increased frequency before military reserve duty), anxiety about sleeping and dreaming was maintained, and, it occurred every night. Because of the persistence of the dream and the subject’s previous unsuccessful attempts to obtain help which involved the use of imagery, a high expectation for success was included in the description of therapy. A progressive relaxation technique was begun that also included the subject’s selecting and imagining a pleasant scene (The Botanical Gardens in Sydney, Australia) as an aid to induce relaxation. A suitable level of relaxation was rapidly achieved. Since anxiety increased as the dream progressed from beginning to horrible climax, the following seven stage hierarchy was constructed from the chronological progression of events in the dream: (1) A convoy is preparing IO deliver supplies to a neighboring base, sweeping the road for mines in the process. (2) Subject is on the machine gun turret of a truck with three soldiers on foot behind. They are at the end of the convoy. (3) Two Viet Cong flags are encountered ahead, stuck in the ground. The area is methodically checked and no mines are found. (4) Subject asks one of the soldiers on foot if he wants a ride. Reuls is negative because of orders to walk. (5) One-quarter-mile later another Viet Cong flag is found. The aforementioned soldier steps on it, setting-off a mine. The loud explosion shatters the air, triggering an ambush attempt with crossfire from hidden enemy soldiers. (6) Subject tells the truck driver to back up in order to rescue the soldiers on foot. (7) Only two men get on and subsequently a crater is found with the charred remains of the third soldier who had stepped on the mine. The subject reports the gruesome smell of the “burnt meat”. Therapy consisted of traditional desensitization. Selfadministered desensitization at home (Goldfried, 1972) was also encouraged and carried out. Consequently, the last session was spent having the subject practice self-
Case study reports on the application of systematic desensitization to recurring nightmares have appeared on occasion in the literature (Cavior and Deutsch, 1975; Geer and Silverman, 1967; Shorkey and Himle, 1974). With Celluci and Lawrence’s (1978) outcome study demonstrating the efficacy of desensitization in reducing the anxiety associated with nightmares, the extension of desensitization technology to this problem appears to have become established. The present case concerns a 29-yr-old Vietnam veteran whose chief complaint was a chronic recurring nightmare, a vivid reexperiencing of an extremely traumatic war experience. It is unique in that the nightmare was a recreation of a discrete fearful event that actually occurred in the individual’s life. No reports of the behavioral treatment of a nightmare that consisted of a reliving of the aversive event have appeared in the literature. METHOD Therapv consisted of five bi-weekly sessions of approximately thirty minutes’ duration. First a detailed account of the dream was gathered. Questioning revealed that the subject had witnessed the virtual disintegration of a fellow soldier who stepped on a mine. From that moment, nine years previously, the patient reported repeatedly having a fearful dream which consisted of the events leading up to the mine explosion and the subsequent removal of the charred remains. Since the dream occurred relatively unpredictably on some variable interval schedule
Requests for reprints should be addressed to Fred E. Schindler, Department of Psychology, Tucson, AZ 85721. 53
University of Arizona,
FRED E. SCHINDLER
54
administered desensitization of all the scenes in order to learn a means of coping with.future dream anxiety. At a booster session two weeks later, no instances of the dream had occurred and the subject reported recajling other dreams and a vastly improved attitude regarding the feared event and sleeping in general. Follow-up was conducted at three months and seven months bv means of telephone calls to the subject and his wife: they again reported no disturbing recurrence of the dream. A few instances of the dream (or parts of it) did occur before reserve duty but they were essentially anxiety-free episodes.
The conclusions reached by a case study approach must necessarily be limited. However, the accumulating evidence of the successful use of desensitization in the treatment of recurring nightmares points to another use for behavioral techniques, especially in view of the fact that dreams have so long been considered the exclusive domain of more psychodynamically oriented therapists and theoreticians.
DISCUSSION The novel aspects of this report center on the successful use of desensitization in the treatment of an unusual event: recurring nightmare of a real life trauma. However, although the procedure was effective, accounting for the results is a more difficult task. Unlike traditional phobias where the individual avoids the fearful stimuli, the nightmare dreamer repeatedly experiences the feared event, albeit in a different state, with little extinction of fear. Further explication of the theoretical mechanisms operating in desensitization of nightmares is needed.
REFERENCES
Cavior N. and Deutsch A. (1975) Systematic desensitization to reduce dream-induced anxiety, J. Nerv. Menr. Dis. 16L433-435. Celluci A. J. and Lawrence P. S. (1978) The efficacy of systematic desensitization in reducing nightmares, J. Behnv. Ther. & Exp. Psychiat. 9, 109-l 14. Geer J. H. and Silverman I. (1967) Treatment of a recurrent nightmare by behavior modification procedures, J. Abnorm.
Psychol. 72.188-190.
Goldfried M. R. (1972) Systematic desensitization as training in self-control, J. Consult. C/in. Psycho/. 37,228-234.
Shorkey C. and Himle D. P. (1974) Systematic desensitization treatment of a recurring nightmare and related insomnia, J. Behav. Ther. & Exp. Psych&r. 5.97-98.
TREATMENT
$1,2.,10/”
BY SYSTEMATIC DESENSITIZATION OF A RECURRING NIGHTMARE OF A REAL LIFE TRAUMA FRED E. SCHINDLER
University of Arizona and Veterans Administration Medical Center, Tucson, Arizona Summary-A modified systematic desensitization procedure was employed in the treatment of a Vietnam war veteran with a recurring nightmare of a gruesome mine explosion. The dream consisted of a vivid recreation of the traumatic events as they actually occurred. After six sessions of desensitization with an additional self-control procedure, the dream ceased to occur and anxiety about sleeping diminished commensurately. Results were maintained at a seven month follow-up. (at least once monthly plus increased frequency before military reserve duty), anxiety about sleeping and dreaming was maintained, and, it occurred every night. Because of the persistence of the dream and the subject’s previous unsuccessful attempts to obtain help which involved the use of imagery, a high expectation for success was included in the description of therapy. A progressive relaxation technique was begun that also included the subject’s selecting and imagining a pleasant scene (The Botanical Gardens in Sydney, Australia) as an aid to induce relaxation. A suitable level of relaxation was rapidly achieved. Since anxiety increased as the dream progressed from beginning to horrible climax, the following seven stage hierarchy was constructed from the chronological progression of events in the dream: (1) A convoy is preparing IO deliver supplies to a neighboring base, sweeping the road for mines in the process. (2) Subject is on the machine gun turret of a truck with three soldiers on foot behind. They are at the end of the convoy. (3) Two Viet Cong flags are encountered ahead, stuck in the ground. The area is methodically checked and no mines are found. (4) Subject asks one of the soldiers on foot if he wants a ride. Reuls is negative because of orders to walk. (5) One-quarter-mile later another Viet Cong flag is found. The aforementioned soldier steps on it, setting-off a mine. The loud explosion shatters the air, triggering an ambush attempt with crossfire from hidden enemy soldiers. (6) Subject tells the truck driver to back up in order to rescue the soldiers on foot. (7) Only two men get on and subsequently a crater is found with the charred remains of the third soldier who had stepped on the mine. The subject reports the gruesome smell of the “burnt meat”. Therapy consisted of traditional desensitization. Selfadministered desensitization at home (Goldfried, 1972) was also encouraged and carried out. Consequently, the last session was spent having the subject practice self-
Case study reports on the application of systematic desensitization to recurring nightmares have appeared on occasion in the literature (Cavior and Deutsch, 1975; Geer and Silverman, 1967; Shorkey and Himle, 1974). With Celluci and Lawrence’s (1978) outcome study demonstrating the efficacy of desensitization in reducing the anxiety associated with nightmares, the extension of desensitization technology to this problem appears to have become established. The present case concerns a 29-yr-old Vietnam veteran whose chief complaint was a chronic recurring nightmare, a vivid reexperiencing of an extremely traumatic war experience. It is unique in that the nightmare was a recreation of a discrete fearful event that actually occurred in the individual’s life. No reports of the behavioral treatment of a nightmare that consisted of a reliving of the aversive event have appeared in the literature. METHOD Therapv consisted of five bi-weekly sessions of approximately thirty minutes’ duration. First a detailed account of the dream was gathered. Questioning revealed that the subject had witnessed the virtual disintegration of a fellow soldier who stepped on a mine. From that moment, nine years previously, the patient reported repeatedly having a fearful dream which consisted of the events leading up to the mine explosion and the subsequent removal of the charred remains. Since the dream occurred relatively unpredictably on some variable interval schedule
Requests for reprints should be addressed to Fred E. Schindler, Department of Psychology, Tucson, AZ 85721. 53
University of Arizona,
FRED E. SCHINDLER
54
administered desensitization of all the scenes in order to learn a means of coping with.future dream anxiety. At a booster session two weeks later, no instances of the dream had occurred and the subject reported recajling other dreams and a vastly improved attitude regarding the feared event and sleeping in general. Follow-up was conducted at three months and seven months bv means of telephone calls to the subject and his wife: they again reported no disturbing recurrence of the dream. A few instances of the dream (or parts of it) did occur before reserve duty but they were essentially anxiety-free episodes.
The conclusions reached by a case study approach must necessarily be limited. However, the accumulating evidence of the successful use of desensitization in the treatment of recurring nightmares points to another use for behavioral techniques, especially in view of the fact that dreams have so long been considered the exclusive domain of more psychodynamically oriented therapists and theoreticians.
DISCUSSION The novel aspects of this report center on the successful use of desensitization in the treatment of an unusual event: recurring nightmare of a real life trauma. However, although the procedure was effective, accounting for the results is a more difficult task. Unlike traditional phobias where the individual avoids the fearful stimuli, the nightmare dreamer repeatedly experiences the feared event, albeit in a different state, with little extinction of fear. Further explication of the theoretical mechanisms operating in desensitization of nightmares is needed.
REFERENCES
Cavior N. and Deutsch A. (1975) Systematic desensitization to reduce dream-induced anxiety, J. Nerv. Menr. Dis. 16L433-435. Celluci A. J. and Lawrence P. S. (1978) The efficacy of systematic desensitization in reducing nightmares, J. Behnv. Ther. & Exp. Psychiat. 9, 109-l 14. Geer J. H. and Silverman I. (1967) Treatment of a recurrent nightmare by behavior modification procedures, J. Abnorm.
Psychol. 72.188-190.
Goldfried M. R. (1972) Systematic desensitization as training in self-control, J. Consult. C/in. Psycho/. 37,228-234.
Shorkey C. and Himle D. P. (1974) Systematic desensitization treatment of a recurring nightmare and related insomnia, J. Behav. Ther. & Exp. Psych&r. 5.97-98.