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References

de Dassel, T., Wittmann, L., Protic, S., Höllmer, H., & Gorzka, R. J. (2018). Association of posttraumatic nightmares

and psychopathology in a military sample. Psychological Trauma: Theory, Research, Practice, and Policy,

10(4), 475–481. https://doi-org.library.capella.edu/10.1037/tra0000319

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Association of Posttraumatic Nightmares and Psychopathology in a Military Sample

By: Thérèse de Dassel

The Sunshine Coast University Hospital and International Psychoanalytic University

Lutz Wittmann

International Psychoanalytic University;

Sonja Protic

International Psychoanalytic University and Institute of Criminological and Sociological Research

Helge Höllmer

Hamburg Military Hospital

Robert J. Gorzka

Hamburg Military Hospital

Acknowledgement:

Idiopathic (i.e., nontraumatic) nightmares occur in the general population at a rate of about 5% of

representative samples (Stepansky et al., 1998). Strongly elevated incidences of posttraumatic nightmares

(i.e., nightmares in which content is associated with a traumatic event by the subject) have been found in

representative samples with posttraumatic stress disorder (PTSD) diagnoses, ranging from 39.8% to 71%

(Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Leskin, Woodward, Young, & Sheikh, 2002).

Posttraumatic nightmares have been reliably associated with the PTSD symptom clusters of reexperiencing

(Gerhart, Hall, Russ, Canetti, & Hobfoll, 2014; Schreuder, van Egmond, Kleijn, & Visser, 1998; Schreuder,

Kleijn, & Rooijmans, 2000) and hyperarousal and PTSD severity (Gerhart et al., 2014) as well as a later

diagnosis of PTSD (Holen, 1990). Posttraumatic nightmares have also been associated with a number of non–

trauma-specific mental health outcomes, proving to be a significant predictor of psychiatric symptoms,

psychosomatic reactivity, and time off work in disaster survivors (Holen, 1990). In the following, we will refer to

diagnoses explicitly requiring the occurrence of a traumatic event (e.g., PTSD) as trauma specific, while

labeling diagnoses without such criteria (e.g., depression) as non–trauma specific. This differentiation does not

withstand that traumatic experiences may lead to non–trauma-specific psychopathology.

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The posttraumatic nightmare classification system devised by Schreuder, Igreja, van Dijk, and Kleijn (2001)

designates posttraumatic nightmares as replicative (posttraumatic reenactments), mixed (similar to but not

identical with the traumatic event), or nonreplicative (symbolically related to the trauma). However, because

researchers have used a variety of classifications, summarizing the incidence of different posttraumatic

nightmare types remains challenging. Despite this, empirical findings consistently indicate that substantial

proportions (42–77%) of trauma victims report experiencing replicative posttraumatic nightmares (Harb,

Thompson, Ross, & Cook, 2012; Mellman, David, Bustamante, Torres, & Fins, 2001; Schreuder, Kleijn, &

Rooijmans, 2000; van der Kolk & Fisler, 1995; Wilmer, 2001). Because distinguishing between nonreplicative

posttraumatic nightmares according to Schreuder, Igreja, van Dijk, and Kleijn (2001) and nontraumatic or

idiopathic ones is difficult, we apply the descriptive term nonreplicative nightmare in the following when

referring to our study without judging whether a dream is symbolically related to the trauma. The term

idiopathic nightmares will be used in regard to the literature on nightmares in non–trauma-specific samples.

Evidence is accumulating for a connection between replicative posttraumatic nightmares and the development

of PTSD. Using detailed nightmare interviews with children, Wittmann, Zehnder, Schredl, Jenni, and Landolt

(2010) demonstrated that the occurrence of replicative nightmares early in the posttrauma phase, significantly

predicted PTSD total scores but not depression scores at 2 and 6 months of follow-up. Subjects reporting

mostly replicative nightmares had higher scores on PTSD intrusion symptoms when compared with subjects

whose nightmares were mostly nonreplicative or mostly a mixture of the two (Schreuder, Kleijn, & Rooijmans,

2000). Further investigations demonstrated that PTSD-diagnosed subjects had more replicative nightmares

than other trauma-exposed treatment-seeking subjects (Davis, Byrd, Rhudy, & Wright, 2007). Similarly, Fosse,

Fosse, Hobson, and Stickgold (2003) provided evidence of the almost total absence of repetition of complete

episodic memory traces in dreams (i.e., replicativeness) when subjects have a nontrauma background.

This study retrospectively analyzes clinical nightmare-related data from a military sample. First, we explore the

associations between nightmare characteristics (frequency, distress, and replicativeness) and PTSD symptom

severity and clinical diagnosis. Second, we test the exclusiveness of relationships between nightmare

characteristics and trauma-specific mental health outcomes (PTSD), as compared with non–trauma-specific

psychopathology (depression). We hypothesize that a greater degree of replicativeness would specifically

predict PTSD but not depression.

Method

The study was approved by the Institutional Review Board of the International Psychoanalytic University Berlin

(Germany). The study comprises a retrospective post hoc analysis of data acquired during routine clinical

intake assessments of the Centre for Mental Health (Department VIb), Military Hospital Hamburg (Germany).

Participants

The sample comprised 62 patients (17.7% females, mean age 33.8 years [SD = 10.2; range: 19–62]; see Table

1 for further sociodemographic variables) admitted to a hospital-based inpatient or outpatient treatment

program for veterans with psychological trauma at the Centre for Mental Health (Department VIb), Military

Hospital Hamburg, Germany. This cohort included all patients admitted between February 15 and October 16

in 2012.

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Sociodemographic and Traumatic Event–Related Information

Procedure

The data analyzed for this study represent the standard clinical diagnostic assessment battery of the Military

Hospital Hamburg. Participants completed questionnaires upon admission to the program. Clinical interviews

were then conducted by the treating psychiatric staff. The clinical observations of multidisciplinary teams

including psychiatrists, psychologists, physiotherapists, and occupational therapists, in conjunction with

psychometric results and clinical interviews, contributed to the final International Classification of Diseases,

10th revision, diagnosis (World Health Organization, 2004).

Measures

Demographics and medication

A brief demographic questionnaire was designed as part of the clinical intake, which gathered information

about relationship, education, migration, and medication status.

Nightmares

A six-item posttraumatic nightmare questionnaire, partly drawn from the Nightmare Intervention and Treatment

Evaluation Scale (NITE; Donovan, Padin-Rivera, Chapman, Strauss, & Murray, 2005), was used. Participants

were posed the first question of the NITE, that is, to “think of a nightmare that you keep having that bothers

you very much. This could be the nightmare you would most like to stop having” and were instructed to

respond to subsequent nightmare questions focusing on that chosen target nightmare. They were asked

whether the nightmare content mirrored an actual event they had experienced and, if so, to what extent the

nightmare was the same as the traumatic event (as a percentage, i.e., degree of replicativeness). When

participants’ responses indicated that the nightmare content did not mirror an actual event, but they then gave

a percentage rating of similarity, the percentage rating was treated as missing data. A degree of replicativity of

0–25% was considered as indicating a nonreplicative nightmare, 26–75% indicated a mixed nightmare, and a

degree of replicativity of at least 76% was considered as indicating a replicative one. Nightmare distress was

measured by using a single item from the NITE asking participants to rate the statement, “This nightmare

makes me have bad feelings during the day,” on a 5-point scale with rating points from 1 (strongly disagree) to

5 (strongly agree). Items measuring frequency of occurrence of this target nightmare in the past week and in

the past month were also taken from the NITE.

Trauma exposure

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Trauma exposure was measured using the initial section of the German version of the Posttraumatic

Diagnostic Scale (Foa, 1995; Steil & Ehlers, 2000), which assesses Criterion A from the Diagnostic and

Statistical Manual of Mental Disorders, fourth edition (DSM–IV), PTSD diagnostic criteria. The questionnaire

asks which of a list of 12 potentially traumatizing events the respondent has experienced and includes an

opportunity for participants to add any other traumatic event not listed. The following six items of the

questionnaire assess whether the subjective experience of the identified trauma exposure meets the stressor

criteria A1 and A2 of the DSM–IV PTSD diagnosis. Participants answered yes or no to each item. Amount of

time that has elapsed since the occurrence of the worst traumatic event (henceforth described as time since

trauma) was also derived from the Posttraumatic Diagnostic Scale.

Posttraumatic stress symptom severity

PTSD symptom severity was measured using the German version of the Impact of Event Scale–Revised (IES-

R; Maercker & Schützwohl, 1998; Weiss & Marmar, 1996). The IES-R consists of 22 items assessing the

severity of the three symptom clusters of PTSD corresponding with the DSM–IV PTSD diagnosis: intrusion,

avoidance, and hyperarousal, related to a specific traumatic event. The global IES score was chosen for the

current study as a general marker of self-reported PTSD symptomatology.

Depressive symptoms

Depressive symptoms were measured using the German version of the Centre for Epidemiologic Studies

Depression Scale (CES-D; Hautzinger & Bailer, 1993; Radloff, 1977). The CES-D is a 20-item self-report

questionnaire assessing the severity of depressive symptomatology, weighted by symptom frequency, over the

past week. Items are scored from 0 (rarely/none) to 3 (most of the time), with higher values indicating more

severe symptoms. Psychometric properties of the German-version CES-D have been evaluated with young

adults (Hautzinger, Bailer, Hofmeister, & Keller, 2012), and internal consistency and construct validity were

reported to be high.

Data analysis

Data were analyzed using SPSS for Windows (version 23.0; SPSS Inc., Chicago, IL). Descriptive statistics

illustrate demographic, diagnostic, and nightmare characteristics in the cohort and by gender. For several

variables, the assumption of normality was not met, even after applying a range of transformations, including

log, square-root, and inverse transformations to the scores. Thus, nonparametric analyses, such as Kruskal-

Wallis, Spearman’s rho, and χ tests, were used to examine the relationship between PTSD and nightmare

characteristics as well as to explore gender differences in nightmare characteristics and mental health

outcomes. Two four-step hierarchical logistic regression analyses were performed to test the hypothesis that

nightmare replicativeness, as a categorical variable, is a specific characteristic of PTSD but not depression.

The categorical-variable type of nightmare was entered as an indicator contrast into the logistic regression

analysis. Accordingly, the effect of mixed as well as replicative nightmares was compared with the effect of

nonreplicative ones. When a relationship between nightmares and PTSD symptom severity was tested, the

dream items were removed from the respective symptom score.

Results

Psychopathology

Fifty-six participants (90.3%, two missing values [3.2%]) reported exposure to at least one traumatic event that

met both the DSM–IV A1 and A2 criteria for PTSD, with the remaining four participants (6.5%) meeting either

the A1 or A2 criterion. There was an average rate of exposure to 3.4 lifetime traumatic event types (SD = 1.4;

2

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range: 1–6), and time since occurrence of the worst traumatic event was less than 3 years in 45.2% of

participants (see Table 1 for further data on trauma characteristics in total sample and by gender).

The most frequent types of traumatic events were severe accident, fire or explosion (74.2%; 1.6% of missing

data), war trauma (71%), and violent attack by a stranger (61.3%). The majority of participants with a history of

war trauma (59.2%; 4.5% missing) evaluated this trauma type as the worst traumatic event. Using International

Classification of Diseases, 10th revision, classifications, 45 participants (72.6%) were diagnosed with anxiety

disorders, 28 participants (45.9%) with major depressive disorders, nine participants (14.5%) with adjustment

disorders, and six (9.7%) with substance abuse, and other less common diagnoses were found in less than 5%

of the sample (including somatoform disorders, schizoaffective disorders, gambling, eating disorders, and

personality disorders). There was an average of 1.6 diagnoses (SD = 0.8; range: 0–4) in the sample and 30

participants (48.4%) had more than one diagnosis. Forty-three participants were diagnosed specifically with

PTSD (69.4%). Nineteen participants (30.6%) had comorbid diagnoses of PTSD and major depressive

disorder. Twenty-two participants (35.5%) were taking psychotropic medication for their condition.

Mean posttraumatic stress symptom severity score (IES-R total) was 54.18 (SD = 27.62, range: 1–96), and

mean severity score of depressive symptoms (CES-D total) was 62.76 (SD = 11.49, range: 32–80).

Nightmares

Data on nightmare characteristics in total sample and by gender can be found in Table 2.

Nightmare Characteristics

Forty-one participants (67.2%) reported one or more posttraumatic nightmares in the past week (Median = 1;

range: 0–4 or more), with 50 (83.3%) reporting one or more posttraumatic nightmares in the past month

(Median = 4–6; range: 0–13 or more). Spearman’s correlations of target nightmare frequency with the IES-R

dream frequency item were conducted to determine whether the target nightmare frequency was

representative of general nightmare frequency and found to be .55 (p < .001) with the weekly posttraumatic

nightmare frequency and .66 (p < .001) with the monthly frequency rating. Thus, in the further analyses, we

included only the monthly frequency rating because it has a larger range to avoid redundancy. The nightmare

distress mean score was 2.48 (SD = 1.39). The range of replicativeness reported as a percentage was 0 – 100

(Median = 50). Eight participants (12.9%, all male) were deemed to have missing data, five (8.0%) of which

resulted from participants with contradictory information regarding replicativeness.

Study findings indicate the absence of gender differences in both psychopathology scales (all χ [1] < 1.01, all p

> .317) and nightmare characteristics (for nightmare frequency and distress: all χ [1] < .08, all p > .781; for

2

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nightmare replicativeness: χ [2] = 2.97, p = .226). Therefore, data of male and female participants were pooled

together for the following analyses. Associations of age and nightmare characteristics were tested because of

the large age range. No significant correlations between age and nightmare frequency (ρ = .19, p = .142) or

distress were found (ρ = .08, p = .548) as well as no relationship with replicativeness (χ [2] = 4.13, p = .127). In

addition, we tested a possible association between nightmare characteristics and time since trauma. Results

indicate that neither replicativeness (ρ = −.01, p = .956) nor distress (ρ = .02, p = .846) or nightmare frequency

(ρ = .03, p = .828) was linked to the time since trauma. Finally, the absence of associations between the

number of traumatic event types and nightmare characteristics was shown (nightmare frequency [ρ = −.06, p =

.628]; nightmare distress [ρ = −.15, p = .236]; replicativeness [χ (2) = .45, p = .797]. More specifically,

experience of war trauma was not linked to any of nightmare characteristics (for nightmare frequency and

distress: both χ [1] < 1.07, both p > .300; for replicativeness: χ [2] = 3.89, p = .144). Furthermore, participants

who reported war trauma as the worst traumatic event did not differ in nightmare characteristics from those

who depicted other trauma types (for nightmare frequency and distress: both χ [1] < .701, both p > .400; for

replicativeness: χ [2] = 4.50, p = .105).

Relationship Between Nightmare Characteristics and PTSD

The positive correlations obtained between all three nightmare characteristics and self-reported PTSD

symptom severity are presented in Table 3. Additionally, significant differences between patients with and

without PTSD diagnosis were found. Whereas the majority (>80%) of participants who reported mixed and

replicative nightmares have PTSD, nonreplicate nightmares were more frequent in participants without a

diagnosis of PTSD (see Table 3).

Relationship Between Nightmare Characteristics and PTSD Symptomatology

Further analysis revealed that both nightmare frequency (ρ = .31, p = .015) and distress (ρ = .40, p = .001)

were positively correlated with scores on CES-D, but no such correlation with replicativeness was found (ρ =

−.03, p = .826).

Prediction of Diagnosis

Logistic regression analysis was performed to test whether the nightmare characteristics act as predictors of

PTSD and depression. To control the effect of comorbidity, the total score of depression symptoms was

included in the PTSD prediction model, whereas the IES total score without dream item was included in the

model predicting diagnosis of depression. PTSD model significance and statistics are presented in Table 4.

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Logistic Regression of Depressive Symptoms and Nightmare Characteristics on PTSD Diagnosis

The results showed that neither depression symptoms nor nightmare frequency nor distress scores were

significant predictors of PTSD diagnosis. When nightmare replicativeness was added into the model, however,

it significantly explained 34.9% of the variance and made correct classifications of PTSD in 72.2% of patients.

Furthermore, the data suggest that compared with those with nonreplicative nightmares, participants reporting

partially replicative nightmares are 10.3 times more likely to have PTSD, whereas subjects with replicative

nightmares are 16.8 times more likely to be diagnosed with PTSD. The model’s sensitivity was 79.0%, with a

positive predictive value of 81.6%. Despite good model sensitivity, however, the specificity rate was only

53.0%, with a negative predictive value of 50.0%.

Data for the depression prediction model are shown in Table 5. The findings indicate that none of the models

or factors predicting depression were significant (with specificity of 58.3% and sensitivity of 60.7%) and that the

classification correctness was thus not significantly different from the level of chance (59.6%).

Logistic Regression of PTSD Symptoms and Nightmare Characteristics on Depression Diagnosis

Discussion

This study confirms and extends existing knowledge about posttraumatic nightmares in a military sample. All

three nightmare characteristics (frequency, distress, and replicativeness) were linked to both self-reported

PTSD symptoms and clinical PTSD diagnosis, with distress showing the strongest association with

psychopathology. Nightmare replicativeness was the only characteristic that differentiated participants with and

without PTSD. In addition, after controlling for the influence of diagnostic comorbidity (depression),

replicativeness proved to be the only significant predictor of PTSD with a high level of classification

correctness. The exclusiveness of this connection was supported by the results of a second logistic regression

model predicting depression. After controlling for the influence of PTSD symptomatology, none of the

nightmare characteristics proved to be a significant predictor of depression. These results are in accordance

with those obtained in a study on a sample of children after traffic accidents (Wittmann, Zehnder, Schredl,

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Jenni, & Landolt, 2010).

These findings indicate that in clinical practice, nightmare occurrence and the associated psychological

distress caused can be explained by a range of mental health conditions in traumatized patients, whereas

replicativeness appears to be solely linked to trauma-specific psychopathology. Furthermore, the results that

show a high proportion of PTSD patients that are correctly classified (i.e., good sensitivity and positive

predictive value of the model) and a low proportion of patients without PTSD that are correctly classified (i.e.,

low specificity and negative predictive value of the model) imply two key points, namely that PTSD-diagnosed

patients generally experience replicative nightmares, and furthermore, to understand and identify those non-

PTSD patients who do have replicative nightmares, we should go beyond nightmare characteristics.

Alternatively, the applied threshold for a categorization as replicative nightmare (replicativity of at least 76%)

may have been too low. Futures studies including detailed dream content analysis may help to empirically

define an improved cutoff score.

The increasing evidence that it is specifically the replicative posttraumatic nightmare that is indicative of

trauma-specific psychopathological developments bears diagnostic implications. The latest revision of the

DSM does not appear to have recognized this, in having expanded the dream criteria of its PTSD diagnostic

criteria to “recurrent distressing dreams in which the content and/or affect of the dream are related to the

traumatic event(s).” Considering the available evidence, it is surprising that Bryant, O’Donnell, Creamer,

McFarlane, and Silove (2011) found flashbacks and dissociative amnesia, but not nightmares, to be symptoms

distinguishing PTSD from other diagnoses. One explanation for the differences in findings may be that Bryant

and colleagues did not differentiate replicative from nonreplicative posttraumatic nightmares.

Contrary to robust findings of gender differences in idiopathic nightmare frequency (Schredl & Reinhard, 2011),

the current data indicate no gender difference in posttraumatic nightmare characteristics. Unfortunately,

because of the small number of female participants in our study, we were unable to offer any contribution to

this question based on our data. Given that previous studies in traumatized samples (Babson et al., 2011;

Hinton, Hinton, Pich, Loeum, & Pollack, 2009) also failed to demonstrate the gender differences found in

idiopathic nightmares, further research including more balanced gender distributions is needed.

This study is not without limitations, which need to be considered for any interpretation of the results. We

should emphasize that the cross-sectional nature of the study does not allow causal interpretations of the

results. In addition, all variables excluding diagnoses were assessed with self-report measures, and a rather

large number of tests were performed without correcting for alpha error inflation. Nightmare frequency and

characteristics were assessed retrospectively, which might be avoided by longitudinal studies using dream

diaries. The assessment of nightmares used a partially self-constructed questionnaire based on single items

rather than on validated scales. In addition, focusing the assessment of nightmares on one specific nightmare

rather than on all nightmares experienced may have introduced a bias into participants′ responses. However,

the demonstrated high correlations with IES nightmare items indicate a strong selection bias is not plausible.

Finally, the specific nature of this sample (German military population with a history of trauma in a hospital-

based mental health program) limits the generalizability of our results.

Notwithstanding these limitations, the results offer a meaningful replication and expansion of previous studies

on posttraumatic nightmares. Extending the sentiments of Kramer, Schoen, and Kinney (1984), we conclude

that it is specifically the replicative posttraumatic nightmare “[. . .] [which] may well lie at the heart of PTSD” (p.

93).

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problems/World Health Organization. Geneva, Switzerland: Author.

Submitted: May 29, 2017 Revised: July 25, 2017 Accepted: August 2, 2017

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Source: Psychological Trauma: Theory, Research, Practice, and Policy. Vol. 10. (4), Jul, 2018 pp. 475-481)

Accession Number: 2017-45362-001

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