Hostname: page-component-77c89778f8-n9wrp Total loading time: 0 Render date: 2024-07-16T09:33:27.292Z Has data issue: false hasContentIssue false

Autonomic activity, posttraumatic and nontraumatic nightmares, and PTSD after trauma exposure

Published online by Cambridge University Press:  15 June 2021

Thomas Mäder
Department of Psychology, University of Zurich, Zurich, Switzerland Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
Katelyn I. Oliver
Department of Psychiatry, Massachusetts General Hospital, Charlestown, MA, USA Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA, USA
Carolina Daffre
Department of Psychiatry, Massachusetts General Hospital, Charlestown, MA, USA Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA, USA
Sophie Kim
Department of Psychiatry, Massachusetts General Hospital, Charlestown, MA, USA Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA, USA
Scott P. Orr
Department of Psychiatry, Massachusetts General Hospital, Charlestown, MA, USA Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA, USA Department of Psychiatry, Harvard Medical School, Charlestown, MA, USA
Natasha B. Lasko
Department of Psychiatry, Massachusetts General Hospital, Charlestown, MA, USA Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA, USA Department of Psychiatry, Harvard Medical School, Charlestown, MA, USA
Jeehye Seo
Department of Psychiatry, Massachusetts General Hospital, Charlestown, MA, USA Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA, USA Department of Psychiatry, Harvard Medical School, Charlestown, MA, USA Department of Psychological & Brain Sciences, University of Massachusetts, Amherst, MA, USA
Birgit Kleim
Department of Psychology, University of Zurich, Zurich, Switzerland Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland Neuroscience Centre Zurich, University of Zurich, Zurich, Switzerland
Edward Franz Pace-Schott*
Department of Psychiatry, Massachusetts General Hospital, Charlestown, MA, USA Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA, USA Department of Psychiatry, Harvard Medical School, Charlestown, MA, USA
Author for correspondence: Edward Franz Pace-Schott, E-mail:



Nightmares are a hallmark symptom of posttraumatic stress disorder (PTSD). This strong association may reflect a shared pathophysiology in the form of altered autonomic activity and increased reactivity. Using an acoustic startle paradigm, we investigated the interrelationships of psychophysiological measures during wakefulness and PTSD diagnosis, posttraumatic nightmares, and nontraumatic nightmares.


A community sample of 122 trauma survivors were presented with a series of brief loud tones, while heart rate (HRR), skin conductance (SCR), and orbicularis oculi electromyogram (EMGR) responses were measured. Prior to the tone presentations, resting heart rate variability (HRV) was assessed. Nightmares were measured using nightmare logs. Three dichotomous groupings of participants were compared: (1) current PTSD diagnosis (n = 59), no PTSD diagnosis (n = 63), (2) those with (n = 26) or without (n = 96) frequent posttraumatic nightmares, and (3) those with (n = 22) or without (n = 100) frequent nontraumatic nightmares.


PTSD diagnosis was associated with posttraumatic but not with nontraumatic nightmares. Both PTSD and posttraumatic nightmares were associated with a larger mean HRR to loud tones, whereas nontraumatic nightmare frequency was associated with a larger SCR. EMGR and resting HRV were not associated with PTSD diagnosis or nightmares.


Our findings suggest a shared pathophysiology between PTSD and posttraumatic nightmares in the form of increased HR reactivity to startling tones, which might reflect reduced parasympathetic tone. This shared pathophysiology could explain why PTSD is more strongly related to posttraumatic than nontraumatic nightmares, which could have important clinical implications.

Original Article
Copyright © The Author(s), 2021. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders. DSM-5. Arlington, VA: American Psychiatric Publishing. Scholar
Augedal, A. W., Hansen, K. S., Kronhaug, C. R., Harvey, A. G., & Pallesen, S. (2013). Randomized controlled trials of psychological and pharmacological treatments for nightmares: A meta-analysis. Sleep Medicine Reviews, 17(2), 143152. ScholarPubMed
Benjet, C., Bromet, E., Karam, E. G., Kessler, R. C., McLaughlin, K. A., Ruscio, A. M., … Koenen, K. C. (2016). The epidemiology of traumatic event exposure worldwide: Results from the world mental health survey consortium. Psychological Medicine, 46(2), 327343. ScholarPubMed
Blaskovich, B., Reichardt, R., Gombos, F., Spoormaker, V. I., & Simor, P. (2020). Cortical hyperarousal in NREM sleep normalizes from pre- to post- REM periods in individuals with frequent nightmares. Sleep, 43(1), 111. ScholarPubMed
Boscarino, J. A. (2004). Posttraumatic stress disorder and physical illness: Results from clinical and epidemiologic studies. Annals of the New York Academy of Sciences, 1032(1), 141153. ScholarPubMed
Boyraz, G., Granda, R., Baker, C. N., Tidwell, L. L., & Waits, J. B. (2016). Posttraumatic stress, effort regulation, and academic outcomes among college students: A longitudinal study. Journal of Counseling Psychology, 63(4), 475486. ScholarPubMed
Buhlmann, U., Wilhelm, S., Deckersbach, T., Rauch, S. L., Pitman, R. K., & Orr, S. P. (2007). Physiologic responses to loud tones in individuals with obsessive-compulsive disorder. Psychosomatic Medicine, 69(2), 166172. ScholarPubMed
Campbell, A. A., Wisco, B. E., Silvia, P. J., & Gay, N. G. (2019). Resting respiratory sinus arrhythmia and posttraumatic stress disorder: A meta-analysis. Biological Psychology, 144, 125135. ScholarPubMed
Carson, M. A., Metzger, L. J., Lasko, N. B., Paulus, L. A., Morse, A. E., Pitman, R. K., & Orr, S. P. (2007). Physiologic reactivity to startling tones in female Vietnam nurse veterans with PTSD. Journal of Traumatic Stress, 20(5), 657666. ScholarPubMed
Chen, K.-H., Aksan, N., Anderson, S. W., Grafft, A., & Chapleau, M. W. (2014). Habituation of parasympathetic-mediated heart rate responses to recurring acoustic startle. Frontiers in Psychology, 5, 110. ScholarPubMed
Critchley, H., & Nagai, Y. (2013). Electrodermal activity (EDA). In Gellman, M. D.., & Turner, J. R. J. R. (Eds), Encyclopedia of behavioral medicine (pp. 666669). New York, NY: Springer. Scholar
David, D., & Mellman, T. A. (1997). Dreams following hurricane Andrew. Dreaming, 7(3), 209214. Scholar
Davis, J. L., Byrd, P., Rhudy, J. L., & Wright, D. C. (2007). Characteristics of chronic nightmares in a trauma-exposed treatment-seeking sample. Dreaming, 17(4), 187198. Scholar
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), 475481. Scholar
Dückers, M. L. A., Alisic, E., & Brewin, C. R. (2016). A vulnerability paradox in the cross-national prevalence of post-traumatic stress disorder. British Journal of Psychiatry, 209(4), 300305. ScholarPubMed
Galatzer-Levy, I. R., Huang, S. H., & Bonanno, G. A. (2018). Trajectories of resilience and dysfunction following potential trauma: A review and statistical evaluation. Clinical Psychology Review, 63, 4155. ScholarPubMed
Geracioti, T. D., Baker, D. G., Ekhator, N. N., West, S. A., Hill, K. K., Bruce, A. B., … Kasckow, J. W. (2001). CSF Norepinephrine concentrations in posttraumatic stress disorder. American Journal of Psychiatry, 158(8), 12271230. ScholarPubMed
Germain, A., & Nielsen, T. A. (2003). Sleep pathophysiology in posttraumatic stress disorder and idiopathic nightmare sufferers. Biological Psychiatry, 54(10), 10921098. ScholarPubMed
Gieselmann, A., Aoudia, M. A., Carr, M., Germain, A., Gorzka, R., Holzinger, B., … Pietrowsky, R. (2019). Aetiology and treatment of nightmare disorder: State of the art and future perspectives. Journal of Sleep Research, 28(4), e12820. ScholarPubMed
Glover, E. M., Phifer, J. E., Crain, D. F., Norrholm, S. D., Davis, M., Bradley, B., … Jovanovic, T. (2011). Tools for translational neuroscience: PTSD is associated with heightened fear responses using acoustic startle but not skin conductance measures. Depression and Anxiety, 28(12), 10581066. Scholar
Gordan, R., Gwathmey, J. K., & Xie, L.-H. (2015). Autonomic and endocrine control of cardiovascular function. World Journal of Cardiology, 7(4), 204214. ScholarPubMed
Haag, C., Robinaugh, D. J., Ehlers, A., & Kleim, B. (2017). Understanding the emergence of chronic posttraumatic stress disorder through acute stress symptom networks. JAMA Psychiatry, 74(6), 649650. ScholarPubMed
Hawn, S. E., Cusack, S. E., & Amstadter, A. B. (2020). A systematic review of the self-medication hypothesis in the context of posttraumatic stress disorder and comorbid problematic alcohol use. Journal of Traumatic Stress, 33(5), 699708. ScholarPubMed
Kleiger, R. E., Stein, P. K., & Bigger, J. T. (2005). Heart rate variability: Measurement and clinical utility. Annals of Noninvasive Electrocardiology, 10(1), 88101. ScholarPubMed
Kobayashi, I., Sledjeski, E. M., & Delahanty, D. L. (2019). Gender and age interact to predict the development of posttraumatic stress disorder symptoms following a motor vehicle accident. Psychological Trauma: Theory, Research, Practice, and Policy, 11(3), 328336. ScholarPubMed
Koch, M., & Schnitzler, H.-U. (1997). The acoustic startle response in rats – circuits mediating evocation, inhibition and potentiation. Behavioural Brain Research, 89(1–2), 3549. ScholarPubMed
Kwak, S. G., & Kim, J. H. (2017). Central limit theorem: The cornerstone of modern statistics. Korean Journal of Anesthesiology, 70(2), 144156. ScholarPubMed
Laborde, S., Mosley, E., & Thayer, J. F. (2017). Heart rate variability and cardiac vagal tone in psychophysiological research – recommendations for experiment planning, data analysis, and data reporting. Frontiers in Psychology, 8, 118. ScholarPubMed
Lang, P. J., McTeague, L. M., & Bradley, M. M. (2016). RDoC, DSM, and the reflex physiology of fear: A biodimensional analysis of the anxiety disorders spectrum. Psychophysiology, 53(3), 336347. Scholar
Langston, T. J., Davis, J. L., & Swopes, R. M. (2010). Idiopathic and posttrauma nightmares in a clinical sample of children and adolescents: Characteristics and related pathology. Journal of Child & Adolescent Trauma, 3(4), 344356. Scholar
LeBouthillier, D. M., McMillan, K. A., Thibodeau, M. A., & Asmundson, G. J. G. (2015). Types and number of traumas associated with suicidal ideation and suicide attempts in PTSD: Findings from a U.S. Nationally representative sample. Journal of Traumatic Stress, 28(3), 183190. Scholar
Lemyre, A., Bastien, C., & Vallières, A. (2019). Nightmares in mental disorders: A review. Dreaming, 29(2), 144166. Scholar
Levin, R., & Nielsen, T. A. (2007). Disturbed dreaming, posttraumatic stress disorder, and affect distress: A review and neurocognitive model. Psychological Bulletin, 133(3), 482528. ScholarPubMed
Liu, M., Amey, R. C., Magerman, A., Scott, M., & Forbes, C. E. (2020). The role of startle fluctuation and non-response startle reflex in tracking amygdala dynamics [preprint]. bioRxiv. Scholar
Loya, R. M. (2015). Rape as an economic crime: The impact of sexual violence on survivors’ employment and economic well-being. Journal of Interpersonal Violence, 30(16), 27932813. ScholarPubMed
Malik, M. (1996). Heart rate variability: Standards of measurement, physiological interpretation, and clinical use. Circulation, 93(5), 10431065.Google Scholar
Mellman, T. A., Kumar, A., Kulick-Bell, R., Kumar, M., & Nolan, B. (1995). Nocturnal/daytime urine noradrenergic measures and sleep in combat-related PTSD. Biological Psychiatry, 38(3), 174179. ScholarPubMed
Morgenthaler, T. I., Auerbach, S., Casey, K. R., Kristo, D., Maganti, R., Ramar, K., … Kartje, R. (2018). Position paper for the treatment of nightmare disorder in adults: An American academy of sleep medicine position paper. Journal of Clinical Sleep Medicine, 14(06), 10411055. ScholarPubMed
Mueller-Pfeiffer, C., Zeffiro, T., O'Gorman, R., Michels, L., Baumann, P., Wood, N., … Orr, S. P. (2014). Cortical and cerebellar modulation of autonomic responses to loud sounds. Psychophysiology, 51(1), 6069. ScholarPubMed
Mysliwiec, V., Brock, M. S., Creamer, J. L., O'Reilly, B. M., Germain, A., & Roth, B. J. (2018). Trauma associated sleep disorder: A parasomnia induced by trauma. Sleep Medicine Reviews, 37, 94104. ScholarPubMed
Nadorff, M. R., Nadorff, D. K., & Germain, A. (2015). Nightmares: Under-reported, undetected, and therefore untreated. Journal of Clinical Sleep Medicine, 11(07), 747750. ScholarPubMed
Nielsen, T. A. (2017). The stress acceleration hypothesis of nightmares. Frontiers in Neurology, 8, 201. ScholarPubMed
Nielsen, T. A., Carr, M., Picard-Deland, C., Marquis, L.-P., Saint-Onge, K., Blanchette-Carrière, C., & Paquette, T. (2019). Early childhood adversity associations with nightmare severity and sleep spindles. Sleep Medicine, 56, 5765. ScholarPubMed
Nielsen, T. A., Paquette, T., Solomonova, E., Lara-Carrasco, J., Colombo, R., & Lanfranchi, P. (2010). Changes in cardiac variability after REM sleep deprivation in recurrent nightmares. Sleep, 33(1), 113122. ScholarPubMed
Nielsen, T. A., & Zadra, A. (2000). Dreaming disorders. In Kryger, M., Roth, N. & Dement, W. C. (Eds.), Principles and practice of sleep medicine (pp. 753772). Philadelphia, WB: Saunders.Google Scholar
Ohayon, M. M., Carskadon, M. A., Guilleminault, C., & Vitiello, M. V. (2004). Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: Developing normative sleep values across the human lifespan. Sleep, 27(7), 12551273. ScholarPubMed
Orr, S. P., Lasko, N. B., Shalev, A. Y., & Pitman, R. K. (1995). Physiologic responses to loud tones in Vietnam veterans with posttraumatic stress disorder. Journal of Abnormal Psychology, 104(1), 7582. ScholarPubMed
Orr, S. P., Metzger, L. J., Lasko, N. B., Macklin, M. L., Hu, F. B., Shalev, A. Y., & Pitman, R. K. (2003). Physiologic responses to sudden, loud tones in monozygotic twins discordant for combat exposure: Association with posttraumatic stress disorder. Archives of General Psychiatry, 60(3), 283288. ScholarPubMed
Pace-Schott, E. F., Germain, A., & Milad, M. R. (2015). Sleep and REM sleep disturbance in the pathophysiology of PTSD: The role of extinction memory. Biology of Mood & Anxiety Disorders, 5(1), 3. ScholarPubMed
Pace-Schott, E. F., Tracy, L. E., Rubin, Z., Mollica, A. G., Ellenbogen, J. M., Bianchi, M. T., … Orr, S. P. (2014). Interactions of time of day and sleep with between-session habituation and extinction memory in young adult males. Experimental Brain Research, 232(5), 14431458. ScholarPubMed
Phelps, A., Forbes, D., & Creamer, M. (2008). Understanding posttraumatic nightmares: An empirical and conceptual review. Clinical Psychology Review, 28(2), 338355. ScholarPubMed
Phelps, A. J., Forbes, D., Hopwood, M., & Creamer, M. (2011). Trauma-related dreams of Australian veterans with PTSD: Content, affect and phenomenology. Australian & New Zealand Journal of Psychiatry, 45(10), 853860. ScholarPubMed
Pole, N. (2007). The psychophysiology of posttraumatic stress disorder: A meta-analysis. Psychological Bulletin, 133(5), 725746. ScholarPubMed
Raskind, M. A., Peskind, E. R., Chow, B., Harris, C., Davis-Karim, A., Holmes, H. A., … Huang, G. D. (2018). Trial of prazosin for post-traumatic stress disorder in military veterans. New England Journal of Medicine, 378(6), 507517. ScholarPubMed
Reist, C., Streja, E., Tang, C. C., Shapiro, B., Mintz, J., & Hollifield, M. (2020). Prazosin for treatment of post-traumatic stress disorder: A systematic review and meta-analysis. CNS Spectrums, Online ahead of print, May 4, 17. ScholarPubMed
Robert, G., & Zadra, A. (2014). Thematic and content analysis of idiopathic nightmares and bad dreams. Sleep, 37(2), 409417. ScholarPubMed
Robison-Andrew, E. J., Duval, E. R., Nelson, C. B., Echiverri-Cohen, A., Giardino, N., Defever, A., … Rauch, S. A. M. (2014). Changes in trauma-potentiated startle with treatment of posttraumatic stress disorder in combat veterans. Journal of Anxiety Disorders, 28(4), 358362. ScholarPubMed
Schredl, M. (2013). Seeking professional help for nightmares: A representative study. The European Journal of Psychiatry, 27(4), 259264.CrossRefGoogle Scholar
Schreuder, B. J. N., Igreja, V., van Dijk, J., & Kleijn, W. (2001). Intrusive re-experiencing of chronic strife or war. Advances in Psychiatric Treatment, 7(2), 102108. Scholar
Schreuder, B. J. N., Kleijn, W. C., & Rooijmans, H. G. M. (2000). Nocturnal re-experiencing more than forty years after war trauma. Journal of Traumatic Stress, 13(3), 453463. ScholarPubMed
Secrist, M. E., Dalenberg, C. J., & Gevirtz, R. (2019). Contributing factors predicting nightmares in children: Trauma, anxiety, dissociation, and emotion regulation. Psychological Trauma: Theory, Research, Practice, and Policy, 11(1), 114121. ScholarPubMed
Seligowski, A. V., Merker, J. B., Swiercz, A. P., Park, J., Marvar, P. J., Ressler, K. J., & Jovanovic, T. (2020). Examining the cardiovascular response to fear extinction in a trauma-exposed sample. Journal of Psychiatric Research, 124, 8590. Scholar
Shaffer, F., & Ginsberg, J. P. (2017). An overview of heart rate variability metrics and norms. Frontiers in Public Health, 5, 117. ScholarPubMed
Shaffer, F., McCraty, R., & Zerr, C. L. (2014). A healthy heart is not a metronome: An integrative review of the heart's anatomy and heart rate variability. Frontiers in Psychology, 5, 119. Scholar
Simor, P., Horváth, K., Gombos, F., Takács, K. P., & Bódizs, R. (2012). Disturbed dreaming and sleep quality: Altered sleep architecture in subjects with frequent nightmares. European Archives of Psychiatry and Clinical Neuroscience, 262(8), 687696. ScholarPubMed
Simor, P., Körmendi, J., Horváth, K., Gombos, F., Ujma, P. P., & Bódizs, R. (2014). Electroencephalographic and autonomic alterations in subjects with frequent nightmares during pre-and post-REM periods. Brain and Cognition, 91, 6270. ScholarPubMed
Southwick, S. M., Bremner, J. D., Rasmusson, A., Morgan, C. A., Arnsten, A., & Charney, D. S. (1999). Role of norepinephrine in the pathophysiology and treatment of posttraumatic stress disorder. Biological Psychiatry, 46(9), 11921204. ScholarPubMed
Szabadi, E. (2012). Modulation of physiological reflexes by pain: Role of the locus coeruleus. Frontiers in Integrative Neuroscience, 6. ScholarPubMed
Taft, C. T., Watkins, L. E., Stafford, J., Street, A. E., & Monson, C. M. (2011). Posttraumatic stress disorder and intimate relationship problems: A meta-analysis. Journal of Consulting and Clinical Psychology, 79(1), 2233. ScholarPubMed
Tanev, K. S., Orr, S. P., Pace-Schott, E. F., Griffin, M., Pitman, R. K., & Resick, P. A. (2017). Positive association between nightmares and heart rate response to loud tones: Relationship to parasympathetic dysfunction in PTSD nightmares. The Journal of Nervous and Mental Disease, 205(4), 308312. ScholarPubMed
Thünker, J., Norpoth, M., von Aspern, M., Özcan, T., & Pietrowsky, R. (2014). Nightmares: Knowledge and attitudes in health care providers and nightmare sufferers. Journal of Public Health and Epidemiology, 6(7), 223228.Google Scholar
Turpin, G., Schaefer, F., & Boucsein, W. (1999). Effects of stimulus intensity, risetime, and duration on autonomic and behavioral responding: Implications for the differentiation of orienting, startle, and defense responses. Psychophysiology, 36(4), 453463. ScholarPubMed
Ulmer, C. S., Hall, M. H., Dennis, P. A., Beckham, J. C., & Germain, A. (2018). Posttraumatic stress disorder diagnosis is associated with reduced parasympathetic activity during sleep in US veterans and military service members of the Iraq and Afghanistan wars. Sleep, 41(12), 19. ScholarPubMed
Vila, J., Guerra, P., Munoz, M., Vico, C., Viedmadeljesus, M., Delgado, L., … Rodriguez, S. (2007). Cardiac defense: From attention to action. International Journal of Psychophysiology, 66(3), 169182. ScholarPubMed
Vossel, G., & Zimmer, H. (1992). Stimulus rise time, intensity and the elicitation of unconditioned cardiac and electrodermal responses. International Journal of Psychophysiology, 12(1). 4151. ScholarPubMed
Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P., & Keane, T. M. (2013a). The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Retrieved from Scholar
Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013b). The PTSD Checklist for DSM-5 (PCL-5). Retrieved from Scholar
Wittmann, L., Zehnder, D., Schredl, M., Jenni, O. G., & Landolt, M. A. (2010). Posttraumatic nightmares and psychopathology in children after road traffic accidents. Journal of Traumatic Stress, 23(2), 232239. ScholarPubMed
Yücel, D. E., van Emmerik, A. A. P., Souama, C., & Lancee, J. (2020). Comparative efficacy of imagery rehearsal therapy and prazosin in the treatment of trauma-related nightmares in adults: A meta-analysis of randomized controlled trials. Sleep Medicine Reviews, 50, 19. ScholarPubMed
Supplementary material: File

Mäder et al. supplementary material

Mäder et al. supplementary material

Download Mäder et al. supplementary material(File)
File 101.4 KB