Nightmares in Fibromyalgia
- 1 Definition
- 2 Neural substrate
- 3 Clinical importance
- 4 Aids to recording nightmares
- 5 Historical note mentioning sleep and nightmares in neurasthenia
- 6 Incubus dreams
- 7 A case history of bad pathologic lucid dreams in fibromyalgia
- 8 Use of Imagery Rehearsal Therapy for the Treatment of Nightmares
These are extremely bad dreams. They relate mainly to themes of good and evil and therefore they are classified here as imaginary evaluative phenomena. They generally involve visual images of characters that are depicted as evil who are doing evil things, typically to the dreamer who feel endangered. They are stories created by the mind using imagination and in the case of PTSD nightmares, there is a element of memory of a traumatic “evil” event.
Logically, they must involve evaluative processing in the brain of an imaginary nature.
Information is limited. This may be due to the difficulty in capturing a nightmare on fMRI, Numerous nightmares have been recorded by sleep labs with EEG during polysomnography studies.
For further information on the neural substrate of nightmares see: Dreaming and the brain: from phenomenology to neurophysiology, Yuval Nir1 and Giulio Tononi1,* Trends Cogn Sci. 2010 Feb; 14(2): 88. Published online 2010 Jan 14. doi: 10.1016/j.tics.2009.12.001, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2814941/
[Author’s opinion: They should be considered clinically important if they frequently disturb sleep. An example is when they contribute to sleep deprivation in cases where it takes an extended period of time needed on awaking to gain composure. Nightmares can result in disturbed, even paranoid thought after they are over before the person has regained their composure.
Since PTSD very often involves nightmares and since PTSD is a fibromyalgia co-morbidity, one would expect more of them in this clinical setting.]
In the experience of the author, some patients develop both PTSD and fibromyalgic at the same time right after a car accident. An example is a patient who was traumatized during the accident by seeing the truck approaching in her rear-view mirror. Her nightmares relived the scene.
Aids to recording nightmares
Since they are frequently forgotten very soon after they are over, a special effort may be needed to capture them. The main factor is the willingness and interest to do so.
[Personal experience: I have occasionally had feeling on awakening as if a big eraser was removing my dreams from my memory or a period of a few seconds. My impression was that this dream forgetting was active process and not a passive disappearance. On one occasion, I fought the process by getting up quickly and typing the dream as fast as I could. This resulted in an extremely long document. I found that while I was recalling one detail, it was easier to recall the next and the next.]
A “thought record” is the term for making a recording of one’s thoughts. Thoughts come in a rapid stream and so it is difficult to record them in detail and in the exact order that they occurred. Thought records can be used to capture any of the author groups into the category of “evaluative phenomena of sleep”. (This includes not only nightmares but also, less severe bad dreams and hypnogogic and hypnopompic phenomena, the incubus phenomena, the evil presence, and the hag phenomena which involve evil figures.) For further information see the entry for “Though Record” in Fibrowiki.
Cell phones now come equipped with a “notes” application. As of 2020 it is standard for them to be equipped for printed dictation by pressing on the microphone button. To capture a nightmare in detail one can keep their phone beside and be determined to start dictating as soon as the wake from any nightmare.
Many people neglect to do this when asked to by their doctor. Perhaps they are afraid.
Incidentally, the thought record is an excellent tool to record any mental activity during the night and during sleep, including sleep mentation or unexplained awakenings whereby some patients wake frequently during the night and then ruin their sleep. They may not know why. If they capture their thought record of what, if anything, is occupying their mind just before they woke up, then they might be able to shed light on why they wake tranquilly.
Historical note mentioning sleep and nightmares in neurasthenia
The “father” of neurasthenia was Beard. He wrote: “Improvement in Sleep— As one of the most constant symptoms of neurasthenia is wakefulness, so one of the first signs of improvement— the earliest evidence that the treatment is doing the work designed— is sounder sleep and more of it; there is less of troubled dreaming, of nightmare, of restlessness, of tossing and pitching about, of positive unrest. The patient finds that he can give up his chloral and falls to sleep more readily and spends more hours in unconsciousness than before. This improvement in sleep appears sometimes during the first week of treatment, and even on the very first few nights.” (Practical Treatise on Nervous Exhaustion (Neurasthenia). Beard GM: A New York: William Wood and Co; 1880, available in full online at: https://archive.org/details/apracticaltreat03beargoog.)
Author’s cumulative anecdotal evidence of the incubus phenomenon in fibromyalgia
It is not known if incubus dreams are more common in fibromyalgia but it is known that fibromyalgia patients often had trauma and post-traumatic nightmares.
This is a fascinating phenomenon. It may be quite rare, but it is not easy to say because it is the kind of bizarre occurrence that most people would prefer to forget.
Gleanings from cases histories seen by the author:
The incubus dreams in fibromyalgia may have an associated fear of the dark.
Female patients may suggest they may have been sexually abused by there father, but they may be vague.
The attacker is experienced as an evil presence or a spiritual presence in the bedroom of the dreamer, such as a black figure or a man siting beside their bed.
They may say they were on their back with the sprit straddling their knees or sodomizing them or fondling their breasts.
They may say the experience makes them feel awful or dirty.
When the wake they may conduct protective measures, such staring to sleep with the light on.
They may develop a severe fear of the dark which makes them fear going to sleep and contribute to their insomnia.
They may have scary illusions of sounds such as hearing a ring and no one is there.
There may be a sleep paralysis associated with the incubus phenomenon in which they want to open their eyes but cannot move. This may be related to the heavy demon on top of them that prevents them from moving. The feeling of the heavy spirit on them is by definition a somatosensory evolutive hallucination of pressure.
There may be an associated nocturnal hypervigilance wherein their mind is filled with ideas and feelings of danger and fears of being attacked in her sleep. This could easily induce or exacerbate insomnia.
The Description of the Incubus Phenomena by Ernest Jones
The incubus nightmares were well documented by Dr. Ernest Jones in his famous book called On the Nightmare. (New York: Liverwright, 1931; 2nd ed, 1951available online at: https://archive.org/details/onthenightmare032020mbp and in full text at: https://archive.org/stream/onthenightmare032020mbp/onthenightmare032020mbp_djvu.txt.)
Jones wrote the classic psychoanalytic study of nightmares. He was Freud’s biographer. In it he describes the idea of the incubus. His book was called “On the Nightmare”. He had a chapter called “Incubus and Incubation”. He wrote: “WE have already commented on the interesting circumstance, so significant for our sexual theory of the Nightmare, that the scientific name for this condition in the Middle Ages also denoted a lewd demon who visits women at night, lies heavily on their chest and violates them against their will. These visitors of women were called Incubi (French follets\ Spanish duendes\ Italian folletti] German A Ipen); those of men were called Succubi (French souleves). As it runs in Caxton's Cronycle (Descrypcion of Wales) 1:
That fende that goth a nyght,
Wymmen full of to gyle,
Incubus is named by ryght:
And gyleth men other whyle,
Succubus is that wyght.
(Page 84, On the Nightmare)
It is clear from the description, that the phenomenon is first a foremost about the psychology of good and evil. This is evident in the poem which uses the words “fende” and “gyleth” which one presumes refers to a fiend who beguiles their victims.
Waller’s description of Incubus (1816)
It seems strange, but in 1816, a doctor in the Royal Navy wrote a whole book about the incubus!. He referred to it as a disease. Waller wrote: “This disease, vulgarly called Night-Mare, was observed and described by physicians and other writers at a very early period. It was called by the Greeks, ἐφιάλτης, [Ephialtes which literally means ‘he who jumps upon’] and by the Romans, Incubus, both of which names are expressive of the sensation of weight and oppression felt by the persons labouring under it, and which conveys to them the idea of some living being having taken its position on the breast, inspiring terror, and impeding respiration and all voluntary motion. It is not very surprising that persons labouring under this extraordinary affection, should ascribe it to the agency of some daemon, or evil spirit; and we accordingly find that this idea of its immediate cause has generally prevailed in all ages and countries.” (Treatise on the Incubus or Night-mare, Disturbed Sleep, Terrific Dreams, and Nocturnal Visions. John Waller, Surgeon of the Royal Navy, London, E. Cox and Son, 1816 available online as a facsimile of the oriental at: https://archive.org/stream/atreatiseonincu00wallgoog#page/n10/mode/1up and in full text which is readily searchable at: https://archive.org/stream/atreatiseonincu00wallgoog/atreatiseonincu00wallgoog_djvu.txt)
For the Wikipedia entry on Incubus see: http://en.wikipedia.org/wiki/Incubus.
A case history of bad pathologic lucid dreams in fibromyalgia
Shamiya et al. have noted that there is a normal type of lucid dreaming which are pleasant and the dreamer “is aware they are dreaming” and they are “capable of controlling content.” Pathologic Lucid Dreams in a Patient with Fibromyalgia: A Case Report, Mohamed Shamiya, Kimberly Hardin, Sleep, Volume 41, Issue suppl_1, April 2018, Page A408, https://doi.org/10.1093/sleep/zsy063.1096, https://academic.oup.com/sleep/article/41/suppl_1/A408/4989055.)
According to Shamiya et al. these “are usually initiated from REM sleep, but without loss of atonia.” Shamiya et al. also note that there is another type of lucid dream which is “pathologic” and which is “associated with negative content and can result in sleep disruption with excessive daytime sleepiness or fatigue.” They reported a case of pathologic lucid dreaming in a 58-year old patient with fibromyalgia.
He complained “of sleep fragmentation beginning 15 years earlier since he was diagnosed with fibromyalgia.” Lucid dreaming in his case preceded this and began since young adulthood without negative symptoms. While having these dream during the period of his life in which he did have fibromyalgia he had what the author’s described as purposeful awakenings from them “due to unpleasant content and difficulty controlling them. He now feels as if he is awake throughout the night and has excess daytime sleepiness.”
He was studied with polysomnography which demonstrated “increased REM and absent slow wave sleep without obstructive sleep apnea, REM behavior disorder or abnormal movements, or seizures.”
He was treated with prazosin, which is a drug that has proven benefit in nightmares in PTSD. They also gave him low dose methadone and they stated that this combination “resulted in improvement sleep fragmentation, tolerance to dream content, and frequency of dreams. Additionally, he had improved daytime function, decreased pain and daytime sleepiness.”
A reasonable alternative therapy idea would have been imagery rehearsal therapy which has good evidence for efficacy for nightmares in PTSD.
Use of Imagery Rehearsal Therapy for the Treatment of Nightmares
This technique has gained considerable respect and now has level A evidence and is part of the official treatment guidelines of the AASM. For further information on it see:
Front Psychol. 2020; 11: 1826. Cognitions in Sleep: Lucid Dreaming as an Intervention for Nightmares in Patients With Posttraumatic Stress Disorder, Brigitte Holzinger,1,2,* Bernd Saletu,3 and Gerhard Klösch1,4 This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY).
Best Practice Guide for the Treatment of Nightmare Disorder in Adults Standards of Practice Committee: R. Nisha Aurora, M.D.1 ; Rochelle S. Zak, M.D.2 ; Sanford H. Auerbach, M.D.3 ; Kenneth R. Casey, M.D.4 ; Susmita Chowdhuri, M.D.5 ; Anoop Karippot, M.D.6 ; Rama K. Maganti, M.D.7 ; Kannan Ramar, M.D.8 ; David A. Kristo, M.D.9 ; Sabin R. Bista, M.D.10; Carin I. Lamm, M.D.11; Timothy I. Morgenthaler, M.D.8 Journal of Clinical Sleep Medicine, Vol.6, No. 4, 2010, https://aasm.org/resources/bestpracticeguides/nightmaredisorder.pdf