Quality Sleep in the Face of Anxiety
Chase the Stars (2023), digital art by Stephanie Guillen
A Qualitative Case Study on Cognitive Behavioral Art Therapy and Disturbed Dreaming
Abstract
Disturbed dreams are of growing concern and impact, particularly since the onset of the COVID-19 pandemic. This study examined current literature on disturbed dreaming and art therapy interventions. It found that most existing literature addressed nightmares related to Post-Traumatic Stress Disorder (PTSD) and not anxiety-related bad dreams. Existing literature focused on Image Rehearsal Therapy (IRT) and Cognitive Behavioral Therapy (CBT) for nightmares. Little research was found on treatment for bad dreams with intermittent or little recall. A significant gap in the literature on art therapy interventions for disturbed dreams was discovered. A hypothetical qualitative, intrinsic case study is proposed to help fill the knowledge gap on Cognitive Behavioral Art Therapy (CBAT) 's impacts on anxiety-related bad dreams.
Keywords: Disturbed dreams, anxiety, art therapy, CBT, CBAT.
Introduction
Mental health has come to the forefront of public conversation recently, particularly since the COVID-19 pandemic. Anxiety and disturbed dreaming (bad dreams and nightmares) are of growing concern. This literature review is based on the question, how does cognitive behavioral art therapy intervention affect anxiety-related bad dreams? According to Fernández-de-las-Peñas et al. (2022), anxiety increased to 56.3% among hospitalized individuals with COVID-19 and sleep disorders were often additionally present. This study aims to expand the knowledge base about how art therapy interventions for anxiety can positively impact bad dream frequency or severity and deepen awareness about gaps in the knowledge. That is significant because worry and stress are leading causes of disturbed dreaming, and nightmares are experienced weekly by about one in twenty people within the general population, with a much higher frequency among psychiatric populations (Rek et al., 2017).
Additionally, a growing body of research suggests that "dream content has a bi-directional relationship with psychopathology" (Solomonova et al., 2021, p. 1). Art therapy can serve as a therapeutic method to visually reflect on thoughts and feelings, which may be challenging to put into words. Therefore, art therapy might offer a unique approach to disturbed dreaming, another predominantly visual and felt experience.
Only literature published in the last ten years was reviewed. The primary focus was on peer-reviewed literature; however, some books were included as supplemental resources where peer-reviewed sources were lacking. The literature is grouped into three primary areas of focus:
The leading causes of nightmares and bad dreams are discussed, focusing on anxiety and PTSD.
Common therapeutic interventions are highlighted, with specific attention given to CBT for disturbed dreams.
Art therapy-specific interventions are reviewed, with special consideration given to CBAT for anxiety and how these interventions might affect bad dreams.
Gaps in the literature are discussed. A hypothetical qualitative, intrinsic case study is proposed to fill in some gaps.
Literature Review
Causes of Disturbed Dreaming
Disturbed dreams, including nightmares and bad dreams, can be caused by various afflictions. Nadorff et al. (2014) define nightmares as "vivid, disturbing, or frightening dreams" (p. 29) which jolt the dreamer awake, whereas bad dreams are alarming but do not cause the individual to awaken. Both are forms of parasomnia, and it is yet unclear whether they are two variations of the same phenomena or distinct experiences (Nadorff et al., 2014). Nightmares are frequent occurrences among individuals suffering from traumatic events and PTSD (Rek et al., 2017). In a study conducted by Rek et al. (2017), nightmare causal factors were examined outside of negative affect and PTSD. They found that worry was strongly associated with nightmare severity and frequency. They proposed that "pre-sleep worry" (p. 1130) likely heightens the tendency for nightmares and that nightmares, in turn, may provoke increased worry the following day, feeding and exacerbating a troubling cycle.
Solomonova et al. (2021) examined stress, anxiety, and depression concerning disturbed dreams during the COVID-19 pandemic. They noted that during the pandemic, there was a significant uptick in general levels of stress, anxiety, depression, and nightmare frequency. Additionally, they investigated disturbed dream recall, themes, and the relationship to anxiety, stress, and depression. They concluded that stress and anxiety directly influence bad dream recall and can trigger stress responses. Further, in a study of older populations with Generalized Anxiety Disorder, Nadorff et al. (2014) found a direct link between Generalized Anxiety Disorder and the frequency of bad dreams and a significant association between disturbed dreams and worry, anxiety, and depression. Treating root worry and anxiety as causal factors in disturbed dreaming might be an effective approach for treatment in some populations.
The literature clearly shows worry and anxiety as pivotal causes of disturbed dream phenomena. It is also clear that disturbed dreams increase stress response during dream states and upon waking. Stress, depression, and PTSD are additional causal factors found. However, the scope of this study concentrates on anxiety and worry as causal and cyclical factors of dream disturbances.
Disturbed Dreams Therapy Interventions
CBT is empirically supported and shows promise in treating nightmares. In a study of older adults with Generalized Anxiety Disorder, nightmare prevalence was significantly reduced post-CBT for anxiety and continued throughout follow-up care, suggesting that CBT-based anxiety treatment may be a promising target for individuals suffering from both anxiety and disturbed dreaming (Nadorff et al., 2014). While this sample was based on older populations, the results underscore potential applicability in broader populations and warrant further investigation.
Additionally, Margolies et al. (2013) found that combining CBT for insomnia and IRT for nightmares showed reduced insomnia and severity among combat veterans with PTSD. Belleville et al. (2018) also conducted a study among sexual assault survivors suffering from PTSD and nightmares. They also combined IRT with CBT but compared it against CBT alone. They found that CBT was associated with a significant reduction in nightmare symptoms. However, it was also noted that disturbed dreams frequently returned six months post-treatment (Belleville et al., 2018). For this reason, it makes sense to consider combining CBT and pharmacological solutions for anxiety-related disturbed dreaming.
Nadorff et al. (2014) underscore that "from a treatment perspective, both nightmares and bad dreams can be effectively reduced with pharmacological and behavioral treatments targeting negative dream content" (p.226). They underscore the effectiveness of Prazosin as a pharmacological treatment strategy for disturbed dreams and highlight that both Prazosin and behavioral sleep interventions were found to reduce nightmare frequency. However, due to the durability of psychological treatments over pharmacological ones in the long term, they suggest a psychological approach as a first line of treatment for disturbed dream sufferers (Nadorff et al., 2014). That underscores the need for additional therapeutic intervention options to address upsetting dream experiences.
As previously mentioned, disturbed dreams include both nightmares and bad dreams. Additionally, distressing dreams are not always recalled upon awakening. Sometimes, the residual effect of the dream is present, without lasting memory of the dream itself. Because IRT requires dream recall, CBT can be a promising alternative for bad dreams not regularly recalled or where theme recurrence is lacking. Additionally, while PTSD and anxiety are not the same, they have some similarities. Because research shows positive results regarding CBT treatment for PTSD-related nightmares, it underscores the potential for CBT also to help combat anxiety-related bad dreams, with or without dream recall.
Art Therapy Interventions
Art therapy is a therapeutic intervention that utilizes the creation of visual artwork as a means of nonverbal expression, externalizing experiences, and describing what might be challenging to put into words. Abbing et al. (2019) conducted a randomized controlled trial to investigate the effectiveness of art therapy in reducing anxiety in women. They found a significant reduction in anxiety symptoms after 10-12 art therapy sessions, which persisted through the 3-month follow-up period. Additionally, research shows that art therapy can reduce cortisol levels immediately following the art-making experience and underscores the impact of art on stress response (Kaimal et al., 2016).
As previously noted, CBT shows promise in relieving anxiety, worry, and trauma-related disturbed dreaming. CBAT is an art therapy modality that combines the power of CBT with art therapy exercises. Marcia Rosal (2018) eloquently describes the beauty and effectiveness of art therapy: "When externalized in visual image, once the problem is in visual form, it is easier and safer for the client to explore. The external image of the problem is malleable, can be altered, and can also be a bridge to finding solutions" (p. 8). This notion of malleability and alterability fits right in with CBT's thought-changing foundations.
Wymer et al. (2020) describe expressive art therapy techniques (including art therapy interventions) integrated into trauma-focused cognitive behavioral therapy in a case study with a young girl and highlight a positive outcome in anxiety reduction when the girl "used her thought-stopping song, meditation while coloring her mandala drawings, and deep breathing to calm down" (p.135). They concluded that integrating art with trauma-focused CBT aid in the healing process where words are difficult to find.
One possible way to use CBAT to combat anxiety-related disturbed dreaming is by inviting clients to create an image of a feared thing or situation that causes them anxiety. This exercise is a form of "'imaginal exposure'; exposure to feared stimuli or feared situations" (Hogan, 2015, p. 20). Additionally, clients can be invited to imagine themselves thinking differently about anxiety-provoking stimuli visually through the art-making process (Hogan, 2015). That can both reduce anxiety by offering an alternative reaction to the stimuli and reduce stress response and cortisol levels through the art-making process itself.
Conclusion
In conclusion, CBAT may be helpful for anxiety-related disturbed dreaming and warrants further study. While much of the literature focuses on PTSD induced nightmares, anxiety and worry are also leading causes of disturbed dreams outside of PTSD. CBT also shows promising results in combatting PTSD-related nightmares, and CBAT shows promise in reducing anxiety and worry.
Most of the existing literature and research is on nightmares and PTSD. However, there is less academic study on the relationship between anxiety and disturbed dreaming (with or without recall) of a lesser severity that does not jolt the dreamer awake. Additionally, there is an extensive gap in literature and research on the effect of art therapy on disturbed dreaming, and even more specifically, CBAT. For these reasons, the below hypothetical case study is proposed to further the literature and knowledge on CBAT as a possible treatment for anxiety-related bad dreams.
Methodology and Ethical Considerations
Design
The proposed hypothetical study is a qualitative, intrinsic case study. It asks the question, how does Cognitive Behavioral Art Therapy (CBAT) intervention affect disturbed dreaming? The case study is that of a 14-year-old, white, cisgender, female, currently admitted in a sub-acute residential psychiatric facility for adolescents. She experiences anxiety-related bad dreams with intermittent recall weekly. The patient states a heightened level of anxiety upon waking. The study aims to examine the patient's unique lived experiences as she undergoes CBAT treatment and to expand the knowledge base on how CBAT impacts disturbed dreams and anxiety.
Data Collection
The patient will undergo daily 1-hour CBAT sessions with an art therapist. These sessions will include art-making exercises directly associated with the anxiety-provoking bad dream themes that she remembers, as well as art-making exercises based on waking sources of anxiety, to address anxiety more broadly. She will also be encouraged to keep a dream journal beside her bed. Additionally, the patient will meet weekly with the staff psychiatrist and a CBT counselor.
The data collection will be team-based, using investigator triangulation to form a robust conclusion of patient artwork, journal entries, session notes, observations, and audio-recorded interviews with the patient documenting her experiences. Open coding will be utilized, and findings will be documented in the case record. The team (art therapist, psychiatrist, and counselor) will review the research question and search the case record for patterns and information that contribute to the case as a whole.
Ethical Considerations
First, the proposed study will be sent to the Institutional Review Board (IRB) to ensure risk/reward balance, that voluntary consent needs are met, and that researcher qualifications adhere to expectations. The study will be explained to the patient, and her willingness to participate will be taken into full consideration. Potential risks and hazards of participation will be examined and openly discussed with the patient and her legal guardians. Additionally, the potential impact the study may have on the patient will be explained. Legal guardian and patient consent will be obtained at the start of the study and renegotiated regularly to ensure continued consent. Additionally, at the end of the study, a summary of the results and findings will be shared with the patient to confirm accuracy. With final confirmed consent and any adjustments made to ensure accuracy, the case will be formally written with findings and conclusions.
References
Abbing, A., Baars, E. W., de Sonneville, L., Ponstein, A. S., & Swaab, H. (2019). The effectiveness of art therapy for anxiety in adult women: A randomized controlled trial. Frontiers in. Psychology. 10:1203. http://doi.org/10.3389/fpsyg.2019.01203
Belleville, G., Dubé, F. M., Rousseau, A., & Dubé-Frenette, M. (2018). Efficacy of imagery rehearsal therapy and cognitive behavioral therapy in sexual assault victims with posttraumatic stress disorder: A randomized controlled trial. Journal of Traumatic Stress, 31(4), 591–601. http://doi.org/10.1002/jts.22306
Fernández-de-las-Peñas, C., Martín-Guerrero, J., Cancela-Cilleruelo, I., Moro-López-Menchero, P., Rodríguez-Jiménez, J., & Pellicer-Valero, O. (2022). Trajectory curves of post-covid anxiety/depressive symptoms and sleep quality in previously hospitalized covid-19 survivors: The long-covid-exp-cm multicenter study. Psychological Medicine, 1-2. http://doi.org/10.1017/S003329172200006X
Hogan, S. (2015). Art therapy theories: A critical introduction. Routledge.
Kaimal, G., Ray, K., & Muniz, J. (2016). Reduction of cortisol levels and participants' responses following art making. Art Therapy: Journal of the American Art Therapy Association 33:2, 74-80, http://doi.org/10.1080/07421656.2016.1166832
Margolies, S. O., Rybarczyk, B., Vrana, S. R., Leszczyszyn, D. J., & Lynch, J. (2013). Efficacy of a cognitive-behavioral treatment for insomnia and nightmares in Afghanistan and Iraq veterans with ptsd. Journal of Clinical Psychology, 69(10), 1026–1042. http://doi.org/10.1002/jclp.21970
Nadorff, M. R., Lambdin, K. K., & Germain, A. (2014). Pharmacological and non-pharmacological treatments for nightmare disorder. International Review of Psychiatry, 26(2), 225–236. http://doi.org/10.3109/09540261.2014.888989
Nadorff, M., Porter, B., Rhoades, H., Greisinger, A., Kunik, M., & Stanley, M. (2014). Bad dream frequency in older adults with generalized anxiety disorder: Prevalence, correlates, and effect of cognitive behavioral treatment for anxiety. Behavioral Sleep Medicine, 12(1), 28–40. http://doi.org/10.1080/15402002.2012.755125
Rek, S., Sheaves, B., & Freeman, D. (2017). Nightmares in the general population: Identifying potential causal factors. Social Psychiatry & Psychiatric Epidemiology, 52(9), 1123–1133. http://doi.org/10.1007/s00127-017-1408-7
Rosal, M. (2018). Cognitive-behavioral art therapy. Taylor & Francis.
Solomonova E., Picard-Deland C., Rapoport, I. L., Pennestri, M. H., Saad, M., Kendzerska, T., et al. (2021). Stuck in a lockdown: Dreams, bad dreams, nightmares, and their relationship to stress, depression and anxiety during the covid-19 pandemic. PLoS ONE 16(11): e0259040. http://doi.org/10.1371/journal.pone.0259040
Wymer, B., Ohrt, J. H., Morey, D., & Swisher, S. (2020). Integrating expressive arts techniques into trauma-focused treatment with children. Journal of Mental Health Counseling, 42(2), 124–139. http://doi.org/10.17744/mehc.42.2.03
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