Nightmares Are Especially Disturbing When You Have a Mental Illness

At the turn of the century, Sigmund Freud published his revolutionary piece The Interpretation of Dreams. In it, he proposed the theory that dreams are an unconscious representation of our fears, anxieties, and desires. Since then, those interested in understanding human behavior have dug deeper into his theory hoping to find a link between the symbolism of dreams and mental health.

For instance, researchers from the Dream & Nightmare Laboratory in Montreal proposed in 2009 that “dreams function to extinguish fear memories and down-regulate negative emotional arousal.” In simpler words, our dreams could be images created to make us feel better. Based on their findings, dreams have a fear-extinction purpose which helps us cope with our daily lives. Nightmares, by contrast, represent a failure to regulate our emotions, making them a dysfunction in the mood-regulatory role of dreams.

A recent study published in the Journal of Comprehensive Psychiatry has taken this theory even further. “The hypothesis of our study was that repeated and intense nightmares were related to emotional dysregulation, which, consequently, were associate with people engaging in non-suicidal self-injury behaviors,” explains Chelsea Ennis, a doctoral candidate in the clinical psychology program at Florida State University, and one of the authors of the study. The findings point to a link between nightmares and NSSI behaviors, which prompted the researchers to explore ways to help people combat the helplessness that bad dreams can provoke.

NSSI disorder, a diagnosis only recently added to the fifth edition of the Statistical and Diagnostic Manual of Mental Health Disorders (DSM-5), refers to the deliberate destruction of body tissue without the intent to die. “These behaviors can include cutting, burning, scratching, or hitting oneself with the objective to regulate highly intense negative emotions,” Ennis says. Her and her team define these as a “maladaptive coping tools.”

People who engage in NSSI have a multiple risk factors associated with them. “They’re usually people who have a history of depression, anxiety, emotional trauma, or an inability to properly regulate emotions,” Ennis says. NSSI is reported to occur in 17.2 percent of adolescents, 13.4 percent of young adults, and 5.5 percent of older adults. These numbers are what prompted Ennis and her team to investigate how it related to sleep disturbances. “In our research, we discovered that insomnia wasn’t significantly related to these behaviors—but nightmares were,” she says. So it stands to reason that people who cope with intense emotions by engaging in NSSI might be even further provoked to do so when they have experience intense emotions from nightmares.

For Genevieve DeRose, 19, from Baltimore, Maryland, it all started when she was a teenager. "I started just by scratching myself when I was just 13. I would dig my nails into my skin and scratch and see if it could leave a mark.” After struggling for six years with depression and social anxiety, she recognizes now how her behaviors were a way to cope with these intense feelings. “I just wanted to feel something, anything. I wanted to hurt," she says. "And because I couldn't figure out how to express any of that emotional hurt, I wanted to hurt physically.”

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“I don’t remember most of my dreams, but I have had several periods of really intense and violent nightmares…I had this nightmare where I got this call that my best friend had gotten in an accident,” DeRose recalls, “It was always her mom or one of her friends calling me to tell me she might not make it. Every time I got there, it was too late.” She's had periods in which her dreams become increasingly terrifying to the point she “was so scared to even go to sleep.” DeRose identifies these periods as those where she resorts to self-harming behaviors the most.

Vali Maduro, a clinical psychologist based in Panama City, Panama, uses mentalization-based treatment (MBT)—which focuses on helping people to compartmentalize and rationalize thoughts and feelings—to understand these behaviors. “When a person can’t regulate their emotions, they need to make them concrete,” Maduro says. “When they resort to self-harm, they’re placing these emotions into their own bodies to develop congruence between what they’re feeling internally and externally.” MBT is just one of the forms of therapy that can help treat people with NSSI. Cognitive behavioral therapy (CBT) and dialectic behavioral therapy (DBT) have also shown to be promising for this diagnosis.

In regards to the treatment of nightmares, Ennis and her team have suggested imagery rehearsal therapy (IRT) in their study. In this type of therapy, patients are asked to re-imagine their nightmares with different, less scary endings. IRT has proven to be a successful short-term treatment for people struggling with PTSD, a condition known for its intense and frightening nightmares, Ennis tells me. “This short-term approach can help with the nightmares, but it’s important to seek out clinical and/or medical assistance to deal with deeper and prolonged anxiety or depression associated to NSSI behaviors,” she adds.

While the nature of the research makes it impossible to say that intense and constant nightmares always lead to NSSI, it has established an important relationship between nightmares and self-harm. And that means more attention and, potentially, more funding. “It’s really important for clinicians to understand that this relationship exists and its findings can help guide professionals in determining whether nightmares may be maintaining or increasing self-injury behaviors,” Ennis says.

As a clinical psychologist who works closely with children, teenagers, and parents, I see this research as an important step to promote preventive mental health. It not only broadens the concept of self-harming behaviors, but sheds light on the fact that dreams aren’t just nonsensical particles of our subconscious, glued together.

“I want [others] to know that the people who suffer from [NSSI] need someone to care enough to be there for them when they’re trying to stop,” says DeRose, who says still struggles with the urges, but has managed to find a healthier way to cope with her emotional difficulties, including talk therapy. “[Those struggling with NSSI] need the encouragement that they don’t need to hurt themselves, but in a non-accusatory and non-reprimanding way.”

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