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http ://d x.d oi. o rg /1 0.1 037/d rm 0000227 The Proportional Experience of Dream Types in Relation to Posttraumatic Stress Disorder and Insomnia Among Survivors of Intimate Partner Violence Alwin E. Wagener Department of Psychology and Counseling, Fairleigh Dickinson University Survivors of intimate partner violence (IPV) commonly suffer from posttrau- matic stress disorder (PTSD), insomnia, and nightmares. Past studies demonstrate a link between replicative (i.e., replay the trauma) and recurrent (i.e., repeating) night- mares and PTSD and insomnia. However, there is a lack of research on the variety of dreams and nightmares experienced in relation to PTSD and insomnia. This study explored 5 types of dreams and nightmares among 499 IPV survivors recruited through social media to complete an online cross-sectional survey. The dream types were selected based on theories of dreaming, suggesting it exists on a continuum of both repetition and emotion (i.e., dream or nightmare) and that more severe PTSD and insomnia symptomology should be linked to repetitive nightmares. Dream types were transformed for each participant into ratios that showed the proportion of each type of dreaming in relation to all the dreaming reported by the participant over the past 3 days. Then, multiple regressions were used to examine whether those dream types were predictive of PTSD, insomnia, and PTSD symptom criteria. The results showed that only replicative nightmares and novel (i.e., new) dreams were predictive.

Additionally, it was discovered that across PTSD and insomnia symptom severities, novel dreams remained relatively constant in number, whereas other types of dream- ing, particularly nightmares, increased in frequency.

Keywords:intimate partner violence, dreams, nightmares, PTSD, insomnia Survivors of intimate partner violence (IPV) often experience nightmares along with other symptoms of posttraumatic stress disorder (PTSD) (Nathanson et al., 2012;Phelps et al., 2008). There is a growing understanding of the relationship between nightmares and PTSD in dream literature (Campbell & Germain, 2016; Lemyre et al., 2019). However, research on nightmares among trauma survivors Alwin E. Wagener https://orcid.org/0000-0002-9804-7274 This study was supported by a Grant from International Association for the Study of Dreams and Dream Science Foundation.

Correspondence concerning this article should be addressed to Alwin E. Wagener, Department of Psychology and Counseling, Fairleigh Dickinson University, 285 Madison Avenue, Madison, NJ 07940, United States. Email:[email protected] 1 Dreaming ©2022 American Psychological Association ISSN: 1053-0797https://doi.org/10.1037/drm0000227 This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. tends to differentiate types of nightmares without examining co-occurring nonnight- mare dreaming (de Dassel et al., 2018;Lemyre et al., 2019). For the above reasons, along with insight from research suggesting that dreaming experiences may exist on a continuum related to the emotion and repetition of dream types (Levin & Nielsen, 2007), theories suggesting dreaming may be part of an internal psychological healing process (Hartmann, 2011;Levin & Nielsen, 2007), and research indicating insomnia may be a co-occurring disorder linked to both PTSD and nightmares (Nappi et al., 2012;Pigeon et al., 2013), the present study investigated the relationship of PTSD and insomnia to a variety of types of dreaming, both nightmares and nonnightmare dreams, among IPV survivors to better understand relationships between partici- pants’oneiric experiences and symptoms.

Intimate Partner Violence and Nightmares IPV is a traumatic experience with many serious adverse consequences includ- ing death, injury,financial hardships, mental illness, and social isolation (Coker et al., 2002;Lutwak, 2018;Spencer et al., 2019;Vos et al., 2006). One of the frequent mental illnesses related to experiencing IPV is PTSD (Golding, 1999;Nathanson et al., 2012;Spencer et al., 2019). A study byNathanson et al. (2012)using a diagnos- tic assessment interview found that 57.4% of a community sample of 101 IPV survi- vors had PTSD. Thisfinding is generally consistent with a prior meta-analysis by Golding (1999)showing PTSD rates among IPV survivors ranging from 31% to 84% depending on the IPV populations and assessment approach, though Nathan- son’sfinding has the benefit of being based on a diagnostic interview as opposed to self-assessments used by most of the studies in the meta-analysis.

A common experience as part of PTSD is nightmares, often with elements of the traumatic experience being replayed within those nightmares (Phelps et al., 2008;Rasmussen, 2007). The frequency of these nightmares, which studies indicate may be present for 30% to 50% of IPV survivors (Pigeon et al., 2011;Rasmussen, 2007), and the reported negative impact of nightmares (Pigeon et al., 2011;Rasmus- sen, 2007), have been documented in studies but without the context of the entirety of oneiric experiences. Specifically, the occurrence of nonnightmare dreaming and the way dreams and nightmares may co-occur among those suffering from PTSD is not understood.

Insomnia is another serious and negative symptom experienced by IPV survi- vors that is both a symptom of PTSD and an independent diagnosis (El-Solh et al., 2018;Nappi et al., 2012;Pigeon et al., 2011). There is support for insomnia some- times having an independent clinical course from PTSD, such that successfully addressing other symptoms of PTSD does not resolve the insomnia (Nappi et al., 2012;Pigeon et al., 2011,2013), though for some individuals, treating PTSD broadly will also resolve insomnia (Pigeon et al., 2011). Among IPV survivors, insomnia is frequently described and identified as a symptom and disorder that impairs both functioning and recovery from the trauma (Pigeon et al., 2011). There is research linking nightmares to insomnia (Habukawa et al., 2007;Woodward et al., 2000), but, as with PTSD, the overall dreaming experience for those suffering from insomnia is not well understood.

2WAGENER This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. In addition to the links between PTSD and insomnia, nightmares also have a relationship to both PTSD and insomnia that defies a simple description of night- mares as a symptom (Phelps et al., 2008;Pigeon et al., 2011,2013). Just as with insomnia, for some individuals, many of the other symptoms of PTSD may be resolved while nightmares persist (Phelps et al., 2008;Pigeon et al., 2011). There is also some support for nightmares prompting individuals to fear sleeping resulting in insomnia, whereas for others, nightmares may occur without insomnia (Phelps et al., 2008;Pigeon et al., 2011). Overall, research broadly shows a complicated rela- tionship between nightmares, insomnia, and PTSD, but little research exists showing how differing types of dreams and nightmares, particularly dreams, are related to insomnia and PTSD.

Dream Emotion and Repetition in Relation to PTSD and Insomnia Links between PTSD severity and nightmares that replicate (i.e., replay) trauma or recur (i.e., happen more than once without replaying trauma) are com- mon and well accounted for in research (de Dassel et al., 2018;Hartmann, 2011; Mellman et al., 2001). However, there is limited research differentiating nightmares based on whether they generate novel (i.e., new) content in relation to PTSD (Hart- mann, 2011;Nielsen & Levin, 2007). This distinction is highlighted as important by several recent theorists who propose that novel nightmares are part of a psychologi- cal recovery process, whereas recurring and replicative nightmares may indicate an impairment in recovery (Hartmann, 2011;Levin & Nielsen, 2007). These theories point to two areas of focus, namely, the emotion (i.e., nightmare or dream) and rep- etition of dreaming (i.e., replicative of a trauma experience, recurring, or novel), for understanding the role of nightmares and dreams in trauma recovery.

Nielsen and Levin’s (2007)neurocognitive model of disturbed dreaming (NMDD) describes the occurrence of a fear extinction process in nightmares, whereasHartmann’s (2011)contemporary theory of dreaming (CTD) proposes that nightmares allow trauma-related emotions to be connected to other experiences, imagined and from memory, thereby lessening the intensity and disruptive quality of those emotions. These conceptualizations of nightmares suggest that replicative and recurring nightmares may be an impairment of the psychological healing pro- cess and that dreams (not nightmares) indicate there is a lower level of affective dis- tress. Both of these theories are based on observations of trauma recovery and understandings of neurological processes in dreaming. However, there is little em- pirical evidence of a healing process linked to nightmares or of whether nonnight- mare dreaming coexists with nightmares among individuals with PTSD.

There have been some recent attempts to understand the relationship between types of nightmares and PTSD and insomnia symptoms (Davis et al., 2007;de Das- sel et al., 2018;Wagener, 2019). Across the studies, several trends are observed con- sistent with theories positing a continuum of nightmare experiences in relation to PTSD (Hartmann, 2011;Levin & Nielsen, 2007). Thefirst is that replicative dreams are most strongly linked to PTSD. The second is that recurrent dreams are also linked to PTSD just not as strongly, and the third is that nightmares with new con- tent are correlated to PTSD but not as strongly as the replicative and recurrent nightmares (Davis et al., 2007;de Dassel et al., 2018;Wagener, 2019). Though PROPORTION OF DREAM TYPES TO PTSD AND INSOMNIA 3 This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. studies suggest possible relationships between dream and nightmare types to PTSD and insomnia (Davis et al., 2007;Wagener, 2019), they notably do not explore whether nonnightmare dreaming occurs simultaneously with nightmares or varies in frequency with PTSD and insomnia as would be predicted by CTD and NMDD.

This information would be valuable for researchers evaluating CTD and NMDD and for clinicians wanting to better understand how the oneiric experiences of patients may relate to PTSD and insomnia symptoms. Toward that end, a research study examining the relationship of PTSD symptoms and insomnia to the frequency of novel dreams, repeating dreams, novel nightmares, recurrent nightmares, and replicative nightmares was conducted to determine whether the previously observed trends remain and discover the relationship of repeating dreams and novel dreams to PTSD and insomnia.

To generate a more detailed understanding of dream types to PTSD symptoms, the frequencies of dream types were also examined in relationship to PTSD symp- tom criteria (i.e., criteria B [reexperiencing], C [avoidance], D [negative cognitions and mood], and E [arousal]) (American Psychiatric Association, 2013). Because there is little specific research on those relationships, the hypotheses regarding those relationships were made tentatively, largely based on the NMDD typology of dreaming showing dream types in relation to affect distress and awakening (Levin & Nielsen, 2007, p. 486). Predictions for two types of dreaming, novel nightmares and recurrent dreams, were influenced by both NMDD and previous theorizing (Domhoff, 2000) that recurrent dreams and nightmares occur because what is caus- ing them is not being addressed. The lack of repetition in novel nightmares was therefore hypothesized to be unrelated to avoidance, whereas the repetition of dreams was hypothesized to be correlated with avoidance. Also, it is important to note that though novel nightmares are linked to trauma recovery by CTD and NMDD, they are also associated with trauma and indicate a reaction to trauma.

Based on that, they are hypothesized to be positively correlated with PTSD and insomnia, though with less strength than replicative and recurrent nightmares.

To better understand the relationship between types of dreaming experiences and PTSD and insomnia, ratios for dream experiences were created. The choice to use ratios instead of reported numbers of dream experiences is due to individual variations in the ability to remember dreams. Numerous studies demonstrate that individuals can learn to remember their dreams, and that as they practice, the num- ber of dreams they remember increases (Aspy et al., 2015;Beaulieu-Prévost & Zadra, 2005). This information indicates that by assessing and comparing the raw number of reported dreams, the memory and focus on remembering dreams is actually one aspect of what is being measured. By generating ratios of dream types for individual participants, it becomes possible to compare dream types more easily between individuals. These ratios were generated with the view that allfive types of dreaming are part of an overall oneiric experience, so each type of dreaming experi- ence was compared with the total reported number of dream experiences.

Method This study used an IRB-approved, online, cross-sectional, survey design using Qualtrics, a survey design and distribution program. In Qualtrics, an online survey 4WAGENER This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. security setting was used preventing multiple entries from the same Internet proto- col (IP) address. Participants were recruited through social media using a $25 dollar gift certificate drawing as an incentive. In the announcement, participants were informed that by completing the survey, they would be entered into a drawing for 20 gift certificates. Initially, the study announcement was sent to online Facebook groups focused on supporting survivors of IPV. This approach generated few responses. To increase recruitment, Facebook advertisements were purchased using funds from an IASD and Dream Science Foundation research grant. The use of advertisements on Facebook to recruit participants is a relatively new approach that demonstrates promise for reaching marginalized populations, increasing the num- ber of participants compared with traditional recruitment, and possibly generating better data than traditional approaches (Harris et al., 2015;Jones et al., 2017;Khatri et al., 2015;Thornton et al., 2016). The advertisements displayed the recruitment announcement that included a link for the online survey and were sent to Facebook members in the United States over 21 years of age who had expressed interest in groups related to IPV, including spousal abuse and domestic violence groups.

This approach generated a large number of survey responses. Facebook pro- vided data on the advertisement that showed 1,893 individuals saw the invitation to the study, 1,179 individuals opened the survey, and 668 individuals met the require- ments for participation and agreed to participate (56.7% of those who opened the survey). Of those, 499 (74.7% of those who agreed to participate) completed the survey to the extent that their responses were used in analyses with 458 (68.6% of those who agreed to participate) fully completing it.

Participant Demographics The average age of participants was 38.73 years (SD= 12.12). In terms of race/eth- nicity, 415 (83.2%) reported they were White, 10 (2%) African American, 16 (3.2%) Hispanic, four (.8%) Asian, seven (1.4%) Native American, one (.2%) Pacific Islander, two (.4%) declined to say, with the remaining 44 (8.8%) participants reporting a combi- nation of race/ethnicities. The gender of participants was predominantly female (N= 470, 94.2%), though also included seven (1.4%) males, four (.8%) trans males, one (.2%) trans female, 14 (2.8%) gender-nonconforming/gender-queer participants, and two(.4%)whoreported“other.” Participants reported a variety of abuse experiences. The categories of abuse were physical, emotional, verbal, and sexual. Only 26 (5.2%) participants reported only a single form of those four types of abuse. Among participants, 356 (71.3%) reported physical abuse, 488 (97.8%) reported emotional abuse, 446 (89.4%) reported verbal abuse, and 263 (52.7%) reported sexual abuse. The types of abuse are consistent with those that lead to PTSD among IPV survivors. TheDSM–5 requires“exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways,”and those ways are direct experience, wit- nessing, learning that it happened to a close friend or family member, or through prolonged exposure to details of traumatic events (American Psychiatric Associa- tion, 2013). The nature of this study makes it impossible to assess whether partici- pants met this criterion, though even participants endorsing just emotional or verbal abuse mayfit the criteria based on having felt threatened with death, physical PROPORTION OF DREAM TYPES TO PTSD AND INSOMNIA 5 This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. violence, or sexual violence or through perceiving others such as their children as being threatened.

Participants’abuse ended an average of 5.80 (SD= 7.16) years prior to complet- ing the survey. The abusive relationships had lasted an average of 7.40 (SD= 7.12) years before ending, with 74.1% of participants reporting they had been out of any abusive relationship for more than a year. Among participants, 62.7% reported more than just one abusive relationship in their lifetime with those reporting more than one relationship having an average of 2.13 (SD= 1.32) abusive relationships prior to the last one experienced. At the time they completed the survey, only 143 participants reported currently dating or being in a committed relationship, down from 480 who reported having been in a committed abusive relationship. Additional demographic information can be seen inTable 1. Taken together, the participants in this study suffered a variety of abuses from their intimate partner with whom they had been together for many years and from whom they have been apart for many years.

Instruments Demographics The demographics instrument in this study included general demographics such as age, ethnicity, and gender along with more detailed information related their Table 1 Participant Demographics Demographic characteristicsn% Sexual orientation Heterosexual 375 75.3 Homosexual 13 2.6 Bisexual 88 17.7 Other 22 4.4 Total 498 100 Relationship status Married 194 38.9 Committed relationship Cohabitating 192 38.5 Living separately 75 15 Dating 14 2.8 Civil union 5 1 Total 480 96.2 Education level Some high school completed 13 2.6 High school diplomas or GEDs 155 31.1 Associates degree 103 20.7 Bachelor’s degree 117 23.5 Graduate or professional degree 60 12 Other 50 10 Total 498 99.9 Household income Under $30,000 296 59.3 $30,000–$59,000 147 29.5 $60,000–$100,000 47 9.4 Over $100,000 9 1.8 Total 499 100 Note. GED = general equivalency diploma. 6WAGENER This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. experiences of IPV such as the types of abuse they experienced. The format and con- tent was adapted from previous studies of IPV survivors (Flasch et al., 2017;Murray et al., 2015;Wagener, 2019) and was used to contextualize the results of the study.

Posttraumatic Stress Disorder Checklist for DSM–5 The Posttraumatic Stress Disorder Checklist forDSM–5(PCL-5) was used to assess PTSD symptoms among participants. The PCL-5 uses 20,five-point Likert questions to assess for PTSD symptoms experienced over the last month. It is a self- report assessment aligned with theDiagnostic and Statistical Manual of Mental Dis- orders(DSM–5) symptom criteria (U.S. Department of Veterans Affairs, 2014; Weathers et al., 2013). The PCL-5 has strong psychometrics, with a recent study showing a Cronbach’s alpha of .96 and test–retest reliability of .84 over a period ranging from 22 to 48 days (Bovin et al., 2016). Additionally, it has been found to have strong construct validity. The PCL-5 has a cutpoint of 31–33 (Bovin et al., 2016;Weathers et al., 2013). In the present study, the Cronbach’s alpha was found to be .912, which is in line with previous studies. To eliminate autocorrelations, the PCL-5 question asking about“repeated, disturbing dreams of the stressful experi- ence”was not used in the primary statistical analyses.

Pittsburgh Sleep Quality Index The Pittsburgh Sleep Quality Index (PSQI) is an instrument used to assess sleep quality and quantity using a 19 item self-assessed questionnaire with open and multiple-choice questions. It uses a scoring system producing results of 1–21, with 5 being a cut-score above which is indicative of impaired sleep quality (Backhaus et al., 2002;Carpenter & Andrykowski, 1998). Studies have shown a Cronbach’s alpha of .80–.85 and test–retest reliability of .86 (45.6618 days) to .90 (2-day inter- val) along with good construct validity (Backhaus et al., 2002;Carpenter & Andry- kowski, 1998). The Cronbach’s alpha for the current study in lower than those found in the studies ofBackhaus et al. (2002)andCarpenter and Andrykowski (1998)but still acceptable at .725 (461). Before using the PSQI in the primary statis- tical analyses, the question in it asking if sleep difficulties are related to“bad dreams”was removed to eliminate autocorrelation.

Types of Dreams and Nightmares Survey The Types of Dreams and Nightmares Survey contains six questions and is adapted from a previous instrument (seeWagener, 2019) that was reviewed by four mental health counseling experts with experience and knowledge related to IPV, dreams, and nightmares. The adaptations were designed tofit the broader explora- tion of dream and nightmare types but retained language from the previous instru- ment where possible. The survey defines thefive types of dreams and nightmares assessed in the survey and asks participants to select the number of each type of dream or nightmare experienced over the last three days.

Asking about the types of dreams experienced over the past three days was a modification done to enable participants to better recall and differentiate between the types of dreams and nightmares they experienced. The short time-period was prompted by observing that studies using a week-long time span generated fewer dream reports than studies in sleep labs recording dreams upon awakening (Krakow et al., 2002;Schredl & Olbrich, 2019;Van Schagen et al., 2016). Three days was a compromise between the two approaches. It was hoped that it was enough time to PROPORTION OF DREAM TYPES TO PTSD AND INSOMNIA 7 This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. gather an adequate number of responses, while not being so long as to make it diffi- cult for participants to recall and identify the type of dreams experienced.

Thefive dream types used in the study were generated based on CTD and NMDD and for the ability to differentiate them in a survey design. A typology for dreaming is found inLevin and Nielsen (2007, p. 486), which was helpful for developing the categories, but the different dream types were weighed against likely participants’ abilities to name and properly categorize their dream types. The currentDSM–5defini- tion of nightmares along with the popular definition of nightmares does not use being awakened by the nightmare as definitional criteria (American Psychiatric Association, 2013;Collins English Dictionary, n.d.), so that differentiation between bad dreams (also called disturbed dreaming) and nightmares was not used. Instead, based on repe- tition of content being linked to greater severity according to CTD and NMDD, bad dreams and nightmares were combined and a differentiation between novel and recur- rent nightmares was used (Hartmann, 2011;Levin & Nielsen, 2007).

Each type of dream and nightmare was named and defined in the survey. An example of how replicative nightmares were presented in the survey was with the description,“Nightmares That Replay Frightening or Disturbing Waking Life Experiences.”Novel nightmares were presented as,“New Nightmares- Nightmares that Do not Repeat and Do Not Replay Abuse you have experienced.”The choices provided for participants to report how many of each type of dream they experi- enced in the past three days were“not at all,”“once,”“twice,”“three times,”“four times,”“five times,”“six times,”or“more than six times.”For those who answered more than six times, they were directed tofill in the specific number of that type of dream or nightmare they experienced over the past three days. The number of dreams for each type of dream or nightmare was then used in the study.

Data Analyses All data were analyzed using the Statistical Package for the Social Sciences (SPSS). There were six dependent variables, PTSD, PTSD symptom criteria B, C, D, and E, and insomnia, used in the analyses andfive independent variables, the ra- tio score for each dream type. Stepwise multivariate regression analyses were used to determine which of the independent variables significantly predicted each of the dependent variables. Becausefive predictor variables were used in the multiple regressions, a Bonferroni correction was applied, and thepvalue was changed from .05 to .001 for all the analyses. Based on the primary analyses, post hoc multiple regression analyses of the raw frequencies of thefive types of dreams in relation to PTSD and insomnia were run after 14 outliers had been removed using a Mahalano- bis Distance Test (Tabachnick & Fidell, 2013). Finally, a multiple regression analysis was used to understand the relationship between the total number of reported dreams and nightmares and PTSD and insomnia in response to a post hoc question.

Results Preliminary Analyses Initial analyses of the study variables showed most of the participant popula- tion had symptoms consistent with PTSD (M= 46.88,SD= 14.49). The cutoff score 8WAGENER This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. can be interpreted as being between 31 and 33, so using the conservative, higher cut- off score of 33, 82% of participants had symptoms consistent with a diagnosis of PTSD. There were even more participants with symptoms consistent with insomnia.

The cutoff score for the PSQI is 5, above which participants have symptoms consist- ent with insomnia. The mean PSQI score in this study was 13.05 (SD= 3.72), and 98.1% of participants scored above the cutoff. The psychometrics for the variables are inTable 2.

In an analysis of dream and nightmare types, most participants reported having each of the dream and nightmare types within the past three days. It is also notewor- thy that of the 499 participants reporting the types of dreaming they experienced, 178 (35.7%) reported no replicative nightmares, 156 (31.3%) no recurrent night- mares, 134 (26.9%) no novel nightmares, 239 (47.9%) no repeating dreams, and 176 (35.3%) no new dreams. Out of 499 participants, the average number of total night- mares and dreams reported by participants was 6.28 (SD= 4.04, Skew = .11, Kurto- sis = .19), meaning that participants reported an average of two dreams per night.

This frequency of dreams and nightmares is surprising and higher than shown in other studies of trauma survivors, with studies of sexual assault survivors reporting between 5.21 and 6.54 nightmares/week (Krakow et al., 2000,2002) and a recent study of participants with diverse mental disorders recording 4.84 (SD= 3.16) night- mares per week (Van Schagen et al., 2016). It is important to note those studies looked at nightmares and did not include dreams. However, when looking at only nightmares in the current study the mean nightmares per three days was 3.97 (SD= 2.96) which translates to 9.26 per week. A difference between this study and many others is that participants were asked about specific dream and nightmare types experienced within the past three days. Requesting for recall within three days instead of a more typical week time-period may, as was intended in the study design, aid memory of oneiric experiences, and prompting recall of specific dreams and nightmares may also aid recall, though that is speculative. Another possibility is that the high level of insomnia among the participants leads to an experience more akin to sleep studies that ask participants to recall dreams after awakening them from REM sleep. In those studies, dream recall rates are higher. A recent study by Schredl and Olbrich (2019)found a mean of 3.67 (SD= 1.76) dreams being remem- bered among 24 participants with insomnia and restless legs syndrome diagnoses Table 2 Variable Psychometrics VariablesNM5% Trimmed meanSDRange Skew Kurt PTSD 499 46.88 47.14 14.49 6–80 0.21 0.47 PSQI 455 13.09 13.16 3.71 2–21 0.25 0.47 Replicative nightmares 495 1.44 1.20 2.17 0–31 6.61 75.75 Recurrent nightmares 495 1.41 1.26 1.50 0–11 1.56 3.83 Novel nightmares 495 1.50 1.34 1.50 0–8 1.38 1.89 Repeating dreams 495 1.14 0.95 1.57 0–12 2.01 6.08 Novel dreams 495 1.43 1.26 1.69 0–18 2.68 18.04 Criterion B 499 11.58 11.62 4.48 0–20 0.14 0.65 Criterion C 499 5.35 5.46 2.06 0–8 0.58 0.37 Criterion D 499 16.54 16.64 6.13 0–28 0.24 0.70 Criterion E 499 13.42 13.47 4.78 1–24 0.15 0.46 Note. PSQI = Pittsburgh Sleep Quality Index; PTSD = posttraumatic stress disorder.

PROPORTION OF DREAM TYPES TO PTSD AND INSOMNIA 9 This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. during a two night period, translating to 12.85 per week. This is an area where future research may be helpful in better understanding dream recall among this popula- tion. Overall, the demographic information indicates that participants in this study were suffering from high levels of PTSD symptoms and insomnia and experiencing frequent nightmares and dreams.

Dream Types in Relation to PTSD and Insomnia SeeTable 3for statistical data from the regressions showing which dream types predict PTSD and insomnia andTable 4for statistical data from regressions show- ing which dream types predict each of the PTSD symptom criteria. Based on these analyses, most hypotheses were not supported. The only dream types to significantly predict PTSD, PTSD symptom criteria, and insomnia were novel nightmares and replicative nightmares.

Post Hoc Analyses Most studies examining dreams use the reported number of dreams, the raw frequencies. To make thefindings in this study more relatable to previous studies, the analyses were run again with raw frequency scores as seen inTable 5. Only two variables were significant in relation to PTSD and insomnia, replicative and recur- rent nightmares. The disappearance of novel dreams from the raw score analyses prompted curiosity as to why novel dreams only appear as significant when put into context with other dream types using the ratio score. To better understand why that difference exists, scatterplot graphs were examined (seeFigure 1). Those graphs demonstrated that the frequency of novel dreams is relatively consistent across PTSD and insomnia scores even as the ratio of novel dreams noticeably decreased as PTSD and insomnia scores increase.

Based onfinding both a lack of change in number of novel dreams and a change in the proportion of novel dreams to all dreams and nightmares in relation to PTSD and insomnia, it seems clear that the number of total dreams and nightmares must increase with PTSD and insomnia severity. To confirm that, multiple regression Table 3 Stepwise Regressions Results Between Dream-Type Ratio Scores and PTSD and Insomnia Variable B 95% CI for BSEBbR 2 DR 2 PTSD (N= 490) Model 1 Constant 41.629 [39.983, 43.275] 0.838 Replicative nightmares 17.267 [11.432, 23.103] 2.970 0.255** 0.065** 0.063** Model 2 Constant 44.297 [41.987, 46.607] 1.176 Replicative nightmares 13.691 [7.509, 19.874] 3.147 0.202** 0.084* 0.08* Novel dreams 9.153 [ 14.765, 3.542] 2.856 0.149* Insomnia (N= 447) Model 1 Constant 13.713 [13.252, 14.174] 0.234 Novel dreams 4.223 [ 5.706, 2.740] 0.755 0.256** 0.066** 0.064** Note. CI = confidence interval; PTSD = posttraumatic stress disorder.

*p= .001. **p,.001. 10WAGENER This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. analyses were conducted. The regressions showed total dreams and nightmares had a significant, positive relationship with both PTSD (R 2= .12,b= .35,F(1, 478) = 66.12,p,.001, 95% CI [.82, 1.34]) and insomnia (R2= .04,b= .21,F(1, 436) = 19.136,p,.001, 95% CI [.09, .25]), consistent with the graphs.

Discussion Understanding the results of this study are aided by recognizing the dream types used in the main analyses are proportions of total dreaming. With that in mind, the results indicate that as the proportion of novel dreams decreases, replaced by the other forms of dreaming, there is a significant and moderate increase in insomnia symptoms and the PTSD criterion E, symptoms of alterations in arousal Table 4 Stepwise Regressions Results Between Dream-Type Ratio Scores and PTSD Symptom Criteria Variable B 95% CI for BSEBbR 2 DR 2 Criterion B with nightmare question removed Model 1 Constant 8.669 [8.240, 9.097] 0.218 Replicative nightmares 5.294 [3.776, 6.813] 0.773 0.296* 0.088* 0.086* Criterion C Model 1 Constant 5.670 [5.420, 5.920] 0.127 Novel dreams 1.492 [ 2.296, 0.688] 0.409 0.163* 0.026* 0.024* Criterion D Model 1 Constant 15.453 [14.712, 16.195] 0.378 Replicative nightmares 5.534 [2.904, 8.163] 1.338 0.184* 0.034* 0.032* Criterion E Model 1 Constant 14.370 [13.794, 14.947] 0.293 Novel Dreams 4.432 [ 6.287, 2.578] 0.944 0.208* 0.043* 0.041* Note. N= 490. CI = confidence interval; PTSD = posttraumatic stress disorder.

*p,.001. Table 5 Stepwise Regressions Results Between Raw Frequency of Dream-Types and PTSD and Insomnia Variable B 95% CI for BSEBbR 2 DR 2 PTSD (N= 481) Model 1 Constant 40.401 [38.823, 41.980] 0.803 Replicative nightmares 3.597 [2.758, 4.435] 0.427 0.360* 0.129* 0.128* Model 2 Constant 38.370 [36.653, 40.087] 0.874 Replicative nightmares 2.706 [1.823, 3.589] 0.449 0.271* 0.176* 0.173* Recurrent nightmares 2.380 [1.483, 3.276] 0.456 0.234* Insomnia (N= 438) Model 1 Constant 11.849 [11.394, 12.303] 0.231 Replicative nightmares 0.747 [0.505, 0.989] 0.123 0.279* 0.078* 0.076* Note. CI = confidence interval; PTSD = posttraumatic stress disorder.

*p,.001. PROPORTION OF DREAM TYPES TO PTSD AND INSOMNIA 11 This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. and reactivity, and a weak but significant increase in PTSD symptoms and PTSD cri- terion C, symptoms of avoidance. Thefinding that a decreasing proportion of novel dreams was the best predictor for insomnia and those two PTSD criteria is surpris- ing and suggests that it may be the appearance of the range of nightmares and not a specific kind that best relates to insomnia and the PTSD linked symptoms of avoid- ance, arousal, and reactivity.

Replicative nightmares are the other type of dreaming ratio found to be signifi- cant in the study. As the proportion of replicative nightmares increases, PTSD and the PTSD symptom criterion B, intrusion symptoms, significantly and moderately increase, whereas criterion D, symptoms of negative alterations in cognitions or mood, significantly and weakly increases. These relationships are in line with expectations but weaker than would be expected. It is also surprising that the pro- portion of recurrent nightmares demonstrates no significant relationship and is not Figure 1 Scatterplot of Raw Frequencies of Novel Dreams to PTSD and Insomnia Note. PTSD = posttraumatic stress disorder. 12WAGENER This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. included in any of the models. That the two ends of the spectrum of dreaming, novel dreams and replicative nightmares, are the two types that proportionally are most significantly related to PTSD and insomnia generallyfits with current understand- ings (Lemyre et al., 2019;Levin & Nielsen, 2007).

In the regressions, the variance of scores is not well explained by the predictor variables. In the context of the study, there are several reasons that may account for this. A likely reason is that in this cross-sectional study, participants were asked about dreaming over the past three nights. In a population in which both dreams and nightmares are occurring frequently, which this study demonstrates is happen- ing, it may be that the variety of dream experiences is difficult to capture in a short period of assessment, particularly coupled with the challenges that may occur in remembering them over the past three days. However, additional research is needed to make sense of thisfinding.

The post hoc analyses provided slightly different results than the main predic- tions and were in line with past studies showing replicative and recurrent nightmares significantly, positively predictive of PTSD and replicative nightmares significantly, positively predictive of insomnia (Davis et al., 2007;de Dassel et al., 2018;Wagener, 2019). Thefindings from this study reinforce the existingfindings supporting rela- tionships between those variables, but this study also demonstrates there is another way to look at reports of dream frequencies. Particularly for evaluating theories of dreaming, it may be more important to understand how different dreaming types relate to the overall dreaming frequency.

There are a few importantfindings from this study. One of the most interesting is how frequently types of nightmares and dreams co-occur. There are suggestions from literature that this sometimes happens (Rasmussen, 2007;Wagener, 2019), but tofind the majority of participants having elevated levels of PTSD and insomnia symptoms along with frequent co-occurring dreams and nightmares within a three- day time period is a novelfinding. It is also unexpected tofind that not only do novel dreams co-occur but remain relatively consistent in frequency. Thesefindings indi- cate an inner landscape that is more complex than is generally captured by research- ers looking at nightmares in relation to trauma. Furthermore, it challenges CTD and NMDD regarding how trauma affects dreaming. With NMDD, it prompts the question, if affect load and distress lead to the inability to generate novel dreaming, as proposed, how can novel dreams be co-occurring, at least within a three-day pe- riod, with replicative nightmares (Levin & Nielsen, 2007). With CTD, it challenges the conceptualization of a gradual transformation from replicative, to recurrent, to novel nightmares, and back to novel dreaming that CTD proposes occurs in reaction to trauma and as part of a healing process from trauma (Hartmann, 2011). With both CTD and NMDD, the general trends proposed by those theories are consistent with thefindings in this study, but the co-occurrences of dream types are not. It may be that the trends described in CTD and NMDD are what generally occurs after trauma, but in a population such as the one in this study, in which most participants are suffering from chronic, high levels of PTSD and insomnia, there is a different manifestation of dreaming. Regardless, the consistency of novel dreams for those experiencing trauma is a newfinding, so it needs to be reproduced in additional studies, but if it holds, it creates new questions related to the formation and function of dreams and nightmares.

PROPORTION OF DREAM TYPES TO PTSD AND INSOMNIA 13 This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Clinical Implications There are clinical implications from this study, though the context of this study, which looked at survivors of IPV, the majority of whom had symptoms of PTSD and insomnia consistent with clinical significance, must be recognized. For counselors and psychotherapists, a primary implication is that the presence of replicative and recurrent nightmares should prompt an exploration of trauma history and PTSD and insomnia symptoms. Replicative nightmares in particular are strongly corre- lated with higher PTSD and insomnia scores. This is not a new implication as similar guidance stems from a variety of other studies (Davis et al., 2007;de Dassel et al., 2018;Pillar et al., 2000).

A relatedfinding for clinical work is that if clients report experiencing novel dreams, it does not mean that replicative and recurrent nightmares are not co- occurring, as this study showed the consistent occurrence of novel dreams even with elevated PTSD levels and co-occurring replicative and recurrent nightmares.

This is a new recommendation based on this study. It is not known if mental health professionals make assumptions about psychological health based on a report of a novel dream, but if any clinicians do make such assumptions, which seems reason- able based on the strong associations between nightmares and problematic mental health (Lancee & Schrijnemaekers, 2013;Lemyre et al., 2019;Levin & Nielsen, 2007;Swart et al., 2013) and the lack of studies suggesting that novel dreams and nightmares co-occur, this study indicates that the presence of dreams may not be a reliable indicator that nightmares are not present.

Future Directions Future research should look to confirm thefindings of this study, as it both used a new proportional approach to understanding dream experience and found novel dreams remaining relatively consistent in frequency even as more nightmares appeared for those with higher PTSD and insomnia scores. Future longitudinal stud- ies would allow for a better evaluation of the relationship of novel dreams to total dreaming. It would be informative to observe the proportions of dream types over time, as those observations might better explain the variance in scores observed in the study and allow for better evaluation of trends in dreaming related to PTSD and insomnia recovery. The latter information would be beneficial for evaluating CTD and NMDD.

One additional area of focus for future research is better differentiating and assessing dream types. The differentiation based on emotion is currently dichoto- mous (i.e., dreams or nightmares), which does not adequately account for the range of emotional experiences in dreaming making it difficult to assess a continuum of emotion as proposed in CTD and NMDD (Hartmann, 2011;Levin & Nielsen, 2007). Repetition suffers from a similar simplification that does not match the real- ities of dreaming. The categories of replicative, repeating, and novel, are useful, but afiner gradation, just as with emotion would be beneficial and allow for a better evaluation of whether it too is part of a continuum as suggested by CTD and NMDD (Hartmann, 2011;Levin & Nielsen, 2007).

14WAGENER This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Limitations There are a few limitations to this study. It is a cross-sectional study, so it is impossible to know how the relationships change over time based on this study, and the results may not fully capture the range of dream types experienced by partici- pants. The online recruitment approach using a monetary inducement could have led to inaccurate responses, though the length of the survey, knowledge that the inducements were limited and would be provided at the end of the study by a draw- ing, and the ability of Qualtrics to prevent the same IP address from doing the sur- vey more than once likely reduced fraudulent survey completion. The sole use of online recruitment is another potential limitation, though the ubiquity of smart phones and other technology makes this limitation far less significant than in the past, as recent surveys suggest that even among the poor and elderly, a large propor- tion of the population has access to both the technology and the Internet and regu- larly use both (Perrin & Atske, 2021). There are additional limitations related to studying dreams. Dreams involve remembered experiences that may vary from the reality of what was experienced, so whether what was recorded actually reflects what was experienced is uncertain. The dream frequency assessment questions were generated for this study by the study author. The study author took a direct approach, asking for specific types of dreams and nightmares, but because it is a novel assessment, there is the potential for structural issues or wording to affect the generated responses. Finally, it must be acknowledged that there are cultural limita- tions to the study. The results were found among a largely white and female partici- pant population actively using social media in the United States. Therefore, the results may not be generalizable to other populations and locations.

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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.