Abstract
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 witnessing his father holding a shotgun to his mothers head when he was 3 years old, finding a dead baby in a bathtub 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 disturbed 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 prescribed 200 mg quetiapine nocte and 100 mg fluvoxamine 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 experience 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 published 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 awakening, 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 improvement, 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.