Spontaneous reporting of onset of disturbing dreams and nightmares related to early life traumatic experiences during the COVID-19 pandemic by patients with posttraumatic stress disorder in remission

Citation:

Gupta MA. Spontaneous reporting of onset of disturbing dreams and nightmares related to early life traumatic experiences during the COVID-19 pandemic by patients with posttraumatic stress disorder in remission. J Clin Sleep Med. 2020;16(8):1419–1420.

One month after the December 2019 coronavirus outbreak in Wuhan, China, a study¹ of 285 residents in Wuhan and surrounding cities revealed a 7% prevalence of posttraumatic stress disorder (PTSD) symptoms as measured by the PTSD checklist for the Diagnostic and Statistical Manual of Mental Disorders, 5th edition² (PCL-5); women had more severe symptoms, and patients with better sleep quality (as measured by four items of the Pittsburgh Sleep Quality Index that address symptoms related to insomnia) reported lower posttraumatic stress symptoms.

This report describes the re-emergence of sleep symptoms in association with the coronavirus disease 2019 (COVID-19) pandemic in patients whose PTSD was previously in remission.

On March 17, 2020, to protect the health and safety of the people of Ontario, Canada, the premier of Ontario declared a state of emergency (currently effective until May 12, 2020) for the province. Citizens were advised to stay home and practice social distancing. Other measures included the closure of parks and recreational areas, nonessential workplaces, public places, and bars and restaurants, along with restrictions on social gatherings. During this period, the delivery of essential medical services took precedence over “nonurgent” or routine consultations. Physicians carried out consultations over the phone or by videoconferencing. In my practice, patients were considered “nonurgent” if they had been psychiatrically stable for at least 6 months before March 2020 and were being maintained on a stable treatment regimen (including medications and psychotherapy). Outpatient appointments of nonurgent patients were temporarily cancelled, and patients were given the option to call for a phone consultation.

During the period from March 25 to April 8, 2020, the following were reported during the spontaneous phone calls by the first 20 “nonurgent” patients who had a primary PTSD diagnosis (age range, 25–64 years; all were white; 3 were men, 17 women; 13 of 20 patients were on disability pensions for their PTSD; 4 were police or army veterans; 4 were health care providers working for long-term care facilities; no patients were known to have contracted COVID-19); 11 of 20 (55%) patients reported recent onset of difficulty falling asleep, 14 of 20 (70%) described their sleep as fragmented recently, and they had been waking up two or three times each night, sometimes because of disturbing dreams; 16 of 20 (80%) patients described the onset of disturbing dreams or nightmares, the content of which was not obviously directly related to the COVID-19 pandemic. During the 6 to 12 months before COVID-19, the nonurgent group overall had a PCL-5² score of < 20, which was consistent with PTSD remission. All patients described the COVID-19 experience as stressful but not traumatic.

Patients (9 of 16, 56%) who remembered their dreams described the disturbing dreams as involving trauma that was “deeply buried” and “very upsetting” (eg, involving childhood sexual abuse). On specific questioning, the only common theme that was identified by patients between their past traumas and COVID-19 experience was “a feeling of not being in control.”

Eight of 16 patients reporting disturbing dreams or nightmares had been prescribed prazosin (2–6 mg taken at bedtime) as part of their pre-COVID-19 medical regimen for management of nightmares. Two of these patients, both health care workers, had increased their prazosin dose by 2 mg at bedtime, which decreased the intensity of their nightmares. Both patients noted that if they had not been able to manage their nightmares with prazosin since the state of emergency had been announced, they would have experienced a full relapse of their PTSD.

These findings support the earlier observations of Mellman and Hipolito,³ who reported on the prominence of insomnia and nightmares after trauma, the association of trauma-related dreams in the early aftermath of trauma as a predisposing factor for the subsequent development of PTSD, and the potential role of α-adrenergic receptor–blocking agents in early intervention.³ The dream content of my patients was atypical,³ as it was not directly related to COVID-19. The content of the dreams and nightmares, however, was consistent with the re-emergence of traumatic dreams related to earlier traumas in PTSD patients during times of change and transient stress.⁴ The re-emergence of disturbing dreams and nightmares in patients who did not describe their COVID-19 experience as traumatic may be an early and more subtle sign of sympathetic activation and arousal modulation in PTSD.⁵ These findings in patients whose PTSD was in remission suggest that such disturbing dreams and nightmares may be an early sign of activation of PTSD symptoms and could have important clinical implications for primary or secondary prevention of PTSD (eg, for the COVID-19 workers, who may be at risk for developing PTSD).

DISCLOSURE STATEMENT

All authors have seen and approved the manuscript. The author reports no financial support. Off-label or investigational use includes mention of prazosin for management of nightmares. The author reports no conflict of interest. This article does not report a clinical trial.