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Volume 14 No. 11
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Accepted Papers

Scientific Investigations

Two Independent Predictors of Nightmares in Posttraumatic Stress Disorder

Katherine E. Miller, PhD1,2; Andrea L. Jamison, PhD1; Sasha Gala, JD1; Steven H. Woodward, PhD1
1National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Palo Alto, California; 2Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California

Study Objectives:

Understanding nightmares (NM) and disturbing dreams (DD) in posttraumatic stress disorder (PTSD) has been limited by the unpredictability of these events and their nonappearance in the sleep laboratory. This study used intensive, longitudinal, ambulatory methods to predict morning reports of NM/DD in veterans in whom chronic, severe PTSD was diagnosed.


Participants were 31 male United States military veterans engaged in residential treatment for PTSD and participating in a service animal training intervention. Participants slept on mattress actigraphs and provided reports of momentary mood, as well as morning NM/DD reports, for up to 6 weeks. Mattress actigraphy provided sleep-period heart rate and respiratory sinus arrhythmia (RSA), and an actigraphic estimate of sleep efficiency. On one night, a respiratory event index (REI) was obtained using an ambulatory system.


A total of 468 morning reports were obtained, of which 282 endorsed NM/DD during the prior night, and 186 did not. After accounting for multiple predictors, only elevated REI and lower prior-night sleep RSA predicted morning endorsement of NM/DD. These two predictors did not interact.


Elevated REI and lower sleep period RSA were independently predictive of NM/DD. The former result is consistent with studies showing that sleep-disordered breathing (SDB) is a factor in NM/DD, and that continuous positive airway pressure (CPAP) can reduce these symptoms in patients with comorbid PTSD and SDB. The latter result implicates dysregulated arousal modulation during sleep in trauma-related NM/DD. It is consistent with findings that NM/DD are reported in patients without SDB and can persist in patients with comorbid PTSD and SDB even when CPAP successfully remediates SDB.


Miller KE, Jamison AL, Gala S, Woodward SH. Two independent predictors of nightmares in posttraumatic stress disorder. J Clin Sleep Med. 2018;14(11):1921–1927.

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