As a girl, Michelle Heizelman developed an elaborate ritual to fend off the flesh-eating monsters that haunted her dreams.

Each night, she would carefully arrange her stuffed animals and dolls in a circle around her body, and then curl into a fetal position. “My desperate hope was the monsters in my nightmares would eat the animals first and leave me alone,” Heizelman said.

But the nightmares persisted. Night after night, she imagined monsters crawling under her bed and groping at her limbs. At times, she imagined the walls of her bedroom dripping with blood and the shag of her carpet turning into dozens of outstretched hands. Eventually doctors diagnosed Heizelman with a rare and sometimes debilitating condition known as “nightmare disorder,” defined by frequent, extremely vivid dreams that usually involve threats to one’s survival.

Then came a miracle: On Dec. 28, 2016, Heizelman slept through the night without a single nightmare. It marked the first time in 40 years that she awoke without feeling distressed and fatigued.

“I literally felt reborn,” said Heizelman, now 43, who lives in St. Cloud. “It was like a dark shadow had been lifted from my life.”

Heizelman attributes that breakthrough to a promising new treatment approach at Hennepin County Medical Center. Traditionally, sleep disorders have been diagnosed and treated solely as a mental health condition, based on the predominant view that persistent nightmares and other sleep disorders were signs of trauma or deeper psychiatric problems. As a result, patients were prescribed anti-anxiety or psychotropic medications with such serious side effects that they often prevented a restful night’s sleep.

Instead of focusing on a single cause or antidote, the specialists at HCMC use a wide range of treatment methods that go beyond traditional, one-on-one therapy. Patients such as Heizelman have access to a team of specialists including psychiatrists, a neurologist, a psychologist, a pulmonologist (lung doctor) and nurse practitioners. The team meets regularly to discuss cases and to share the latest research on conditions such as insomnia, sleep apnea and narcolepsy.

The multidisciplinary approach is based on the premise that sleep problems are highly complex and require a sophisticated and, at times, experimental response. It also reflects a growing body of research showing that patients with sleep disorders often have a range of overlapping conditions, known as co-morbidities. For example, up to 30 percent of people who suffer from insomnia also have sleep apnea, a common disorder marked by interrupted breathing; and insomnia, in turn, increases a person’s risk for depression and anxiety, researchers have found.

The HCMC clinic also stands apart in its willingness to treat persistent nightmares as a serious health condition. Although commonly thought of as a childhood disorder, nightmares can persist well into adulthood and are associated with an increased risk of suicide, studies show. Yet nightmare screening and treatment remain rare, even in centers that specialize in sleep disorders. One recent study found that just 38 percent of people with “clinically significant” nightmare symptoms actually reported discussing their nightmares with a medical professional.

“There is a broad swath of the population that says, ‘It’s just a nightmare,’ ” said Dr. Ranji Varghese, a psychiatrist and medical director at HCMC’s sleep disorder center, which handles about 4,500 patient visits a year. “But if left untreated, nightmares can severely impair a person’s ability to function normally.”

Rehearsal therapy

For Heizelman, the journey toward recovery began with an all-night sleep test, known as a polysomnogram, at HCMC’s sleep disorder center in downtown Minneapolis. Technicians attached dozens of tiny electrodes to her scalp and chest to measure her brain and breathing patterns during sleep. When these tests failed to detect any obvious irregularities, doctors shifted to psychotherapy and behavioral-based approaches.

For a while, doctors encouraged Heizelman to try a technique known as imagery rehearsal therapy, in which she would “rescript” her dreams by writing them out on paper but converting the distressing endings to something happier. She filled entire notebooks with rescripted dreams, turning violent car crashes into near misses and transforming demonic monsters into popular cartoon characters from her childhood.

Still the nightmares continued. In one recurring dream, the dismembered bodies of her family would emerge from a crashed plane and chase her through the burning wreckage. The nightly horrors and anxiety-filled awakenings became so unmanageable that Heizelman quit a job she loved as a special education teacher after eight years and began having thoughts of suicide. Heizelman even visited a psychic, who suggested she was channeling images of the “coming end of the world,” she said.

Yet like many others with nightmare disorder, Heizelman was reluctant to discuss her condition, for fear that friends and co-workers would think she was mentally unstable, she said. “Throughout my life, there was that voice that said, ‘There must be something seriously wrong with me to have such gruesome thoughts,’ ” she said. “I was numb all day and I stopped going out at night. It was not a life.”

But specialists at HCMC insisted she had no reason to feel ashamed, and kept suggesting new treatment strategies. Varghese and his team found that Heizelman’s symptoms did not match a single diagnosis, so were willing to suggest a range of approaches, from cognitive behavioral therapy to meditation.

“Hers was the most challenging nightmare disorder I have ever seen,” said Varghese, whose desk at HCMC is piled with academic studies on sleep disorders. “It required a comprehensive, multidisciplinary approach.”

Dreams of picking flowers

Finally, nearly two years after Heizelman walked through HCMC’s front door, her treatment team finally had a breakthrough. Varghese had discovered a study showing that a little-known allergy medication, cyproheptadine, helped people relax and prevented nightmares. He discussed the study with the treatment team and they unanimously recommended she try the drug.

Heizelman was doubtful — she had already tried two dozen medications without success. But she also remembered Varghese’s plea, on her first visit to his office, that she keep trying and experimenting until they found a solution.

“He gave me a real sense that we were in this together, that I had to have faith and stick it through,” she said. “It was the first time that I felt a doctor really believed in me.”

The effect was immediate. On the first night after taking the medication, she had a pleasant dream of walking through a shopping mall without being chased or threatened. The next night, she dreamed of picking flowers.

After a week of uninterrupted sleep, the success began to sink in: Heizelman’s 40-year nightmare had finally come to an end. She could return to work as a schoolteacher without feeling exhausted, take up crocheting again and plan vacations with her husband.

“It’s definitely a new chapter in my life,” she said.