Nightmare Disorder

What is nightmare disorder?

Nightmare disorder is a pattern of repeated frightening and vivid dreams that cause significant distress or impaired functioning. Nightmare disorder is one type of parasomnias, which are behavioral sleep abnormalities.

Nightmare disorder ranges in severity based on the occurrence of nightmares:

• Mild: Less than one nightmare per week on average.
• Moderate: One or more nightmares per week, but less than nightly.
• Severe: Nightmares every night.

It can also vary in duration:

• Acute nightmare disorder lasts one month or less.
• Subacute nightmare disorder lasts at least one month but less than six months.
• Chronic nightmare disorder lasts for six months or longer.

Nightmares typically occur during the second half of your sleep period during REM (rapid eye movement) sleep. With nightmare disorder, you remember them upon awakening (unlike sleep terrors).

This condition can significantly disrupt your sleep and affect your quality of life. It can also make underlying mental health conditions, such as depression or anxiety, worse.

Who does nightmare disorder affect?

Nightmare disorder can affect anyone, including children and adults.

It’s more likely to affect people who have any of the following conditions:

• REM behavior disorder (RBD).
• Narcolepsy.
• Sleep apnea.
• Periodic limb movement disorder (PLMD).
• Post-traumatic stress disorder (PTSD).
• Generalized anxiety disorder.
• Social anxiety disorder.
• Depression.

Nightmare disorder occurs in people who have social anxiety disorder or generalized anxiety disorder at approximately three times the rate of the general population. It affects 50% to 90% of people with PTSD.

How common is nightmare disorder?

Approximately 2% to 8% of the general U.S. population has nightmare disorder.

What are the symptoms of nightmare disorder?

The main symptom of nightmare disorder is a pattern of nightmares. While it’s common to have nightmares every once in a while, if you have them frequently and they interfere with your daily functioning, you may have nightmare disorder.

Common themes of nightmares include threats to your:

• Survival
• Physical well-being.
• Security.

You may also experience the following physical symptoms when you have a nightmare:

• Sweating.
• Shortness of breath.
• Racing heart.

The main emotion nightmares cause is fear, although you may experience other emotions such as:

• Anger
• Anxiety.
• Embarrassment.
• Disgust.
• Shame.
• Sadness.

These physical symptoms and emotions can occur during the dreaming episode, upon awakening from the nightmare or when later remembering the dream.

Due to nightmare disorder, you may have:

• Mood disturbance, such as anxiety or depression.
• Sleep resistance.
• Fatigue.
• Daytime sleepiness (hypersomnia).
• Difficulty concentrating.
• Behavioral issues.
• Impaired functioning at work or school.
• Impaired social functioning.

Quality sleep is very important to your overall health, so it’s important to talk to your healthcare provider if you think you have nightmare disorder.

What causes nightmare disorder?

Researchers continue to study sleep and its effect on us. While they’ve learned a lot about sleep, dreams and nightmares, there’s still much that’s unknown.

Researchers don’t know what exactly causes nightmares and nightmare disorder, but they have multiple theories.

One theory is that nightmare disorder may be influenced by increased hyperarousal that builds during the day and remains at night. Hyperarousal is a mood-altering symptom in which you’re consistently irritable, angry and paranoid. It’s a well-known symptom of PTSD and insomnia. Hyperarousal may make certain areas of your brain overactive while you sleep, causing nightmares.

Another theory involves a concept called fear extinction. Under regular circumstances, your brain is able to combine fearful memories with new and unrelated contexts to allow for normal sleep and dreams. This is called fear extinction. According to the impaired fear extinction theory, people with nightmare disorder continue to activate fear memories during sleep. The theory states that people who have difficulty regulating their emotions in stressful situations and tend to react negatively to stress are more prone to nightmares.

How is nightmare disorder diagnosed?

There’s no medical test that can diagnose nightmare disorder. Instead, healthcare providers rely on a thorough history of your nightmares and other symptoms to diagnose nightmare disorder. They’ll also ask questions about your medical and mental health history.

Some medications can cause nightmares, so your provider may assess your current medications or order drug tests to see if that could be the cause. Medications and substances that can cause nightmares include:

• Beta-blockers.
• Antidepressants.
• Nicotine (from smoking and tobacco products).

Withdrawal from misuse of substances like alcohol can also cause nightmares.

How do you treat nightmare disorder?

To treat nightmare disorder, your healthcare provider may recommend a combination of therapies, including forms of psychotherapy (talk therapy) and medication.

The main forms of psychotherapy for nightmare disorder are cognitive behavioral therapy (CBT)-based therapies, including:

• Imagery rehearsal therapy (IRT).
• Exposure, relaxation and rescripting therapy (ERRT).

Psychotherapy for nightmare disorder

The American Academy of Sleep Medicine (AASM) recommends imagery rehearsal therapy (IRT) and related treatments like exposure, relaxation and rescripting therapy (ERRT) as the most effective treatment for nightmare disorder in adults.

IRT and ERRT are individualized treatments that involve several components, including:

• Tracking daily sleep/wake patterns with a sleep log.
• Tracking nightmare frequency and severity with a sleep log.
• Learning about the nature of nightmares.
• Practicing skills that target nightmare-related imagery, thoughts and emotions. This leads to a decrease in occurrence and severity of nightmares.

These CBT-based therapies frame nightmares as having served a beneficial purpose to help you emotionally process past events. But over time, these nightmares become disruptive.

These therapies view nightmares as habits or learned behaviors that you can change with practice. A mental health professional, such as a psychologist or therapist, guides you through reimagining your nightmares with different, less frightening or disturbing outcomes.

Homework is an important aspect of treatment, including rehearsing the revised dream daily. The goal is to “reprogram” your nightmares to be less terrifying if and when they occur again.

Medications for nightmare disorder

Your healthcare provider may consider medications if the above-mentioned forms of psychotherapy don’t help.

Medications that can help treat PTSD-associated nightmare disorder include:

• Olanzapine.
• Risperidone.
• Aripiprazole.
• Clonidine.
• Cyproheptadine.
• Fluvoxamine.
• Gabapentin.
• Nabilone.
• Phenelzine.
• Prazosin.
• Topiramate.
• Trazodone.
• Tricyclic antidepressants.

Medications that can help treat nightmare disorder that’s not associated with PTSD include:

• Prazosin.
• Triazolam.

All medications have possible side effects. It’s important to talk to your provider about the pros and cons of certain medications and see them if side effects develop.

What is the prognosis for nightmare disorder?

The prognosis (outlook) for nightmare disorder varies.

For some people, nightmare disorder may resolve on its own. For others, the condition can persist for decades if it’s untreated.

Untreated chronic nightmare disorder increases the risk of attempting and re-attempting suicide.

Because of this and the fact that sleep is vitally important to overall health, it’s important to seek help if you’re having recurrent nightmares.

When should I see my healthcare provider?

If you’re having frequent nightmares and they’re interfering with your quality of life, see a healthcare provider or mental health professional.

If you’ve been diagnosed with nightmare disorder and your current treatment isn’t working, talk to your provider about other options.

Are nightmares a psychiatric illness?

While nightmares are associated with certain mental health conditions, such as PTSD, anxiety and depression, nightmares aren’t considered a psychiatric illness. They’re a type of parasomnias, which are behavioral sleep abnormalities.

Is nightmare disorder PTSD?

Many people who have post-traumatic stress disorder (PTSD) have nightmare disorder. However, you can have nightmare disorder without having PTSD.

A note from Cleveland Clinic

Sleep is an essential part of our lives. It helps our bodies rest, recharge and repair. Nightmare disorder can significantly affect your quality of sleep and your quality of life. The good news is that it’s treatable. Different talk therapies and medications can help. See a healthcare provider if nightmares are interfering with your life.