How to Identify a Nightmare (and What to Do About It)
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You are outside on a clear evening. As you gaze out across the dewy grass, you notice dozens of snakes in the distance, a massive tangle of pythons inexplicably colored neon pink, orange, and green. Just as you spot these gargantuan reptiles, they turn in unison so that every single one of them is looking right at you. They open their mouths, displaying their fangs. And then the pythons writhe in your direction, moving at rapid speed.
Why are you the target? Because you are in a nightmare. Your own nightmare. And you are in the part of the dream right before you wake up in a puddle of your own sweat.
What Is a Nightmare?
Most people have nightmares at some point in their lives, although the frequency and intensity vary by person. Nightmares primarily occur during rapid eye movement (REM) sleep and, therefore, are more likely to occur during the second half of the night, when REM is typically more prevalent. Nightmares are psychologically defined by several main features:
Nightmares have inherently upsetting content. Themes of nightmares often include attempts to avoid death, injury, or violent aggression. Like that neon python dream, they are also commonly bizarre and can involve a sense of helplessness.
Nightmares cause you to wake up from your sleep. If you finish a bad dream and never wake up, it is not technically a nightmare. Because they lead to awakenings, frequent nightmares can be a major impediment to getting long stretches of restorative sleep.
Nightmares bring up intense distress, which can take the form of fear, horror, terror, or other negative emotions. Sometimes, people who wake up from a nightmare are afraid of going back to sleep in case they have another unsettling dream. This can increase physiological arousal in bed and, over time, cause or exacerbate insomnia.
Nightmares can be remembered after waking. If you wake up in distress but cannot remember what happened, your dream is not considered a nightmare by the psychological definition. Nightmares can be recounted in depth by the dreamer afterward—including all the scary, painful details.
Having the occasional nightmare is a normal human experience and does not necessarily mean that you have a psychological disorder. Approximately 3 to 7 percent of people experience frequent nightmares, which can contribute to poor sleep, pervasive negative emotions, and general impaired functioning. Sometimes, nightmares pull from aspects of a past traumatic memory. Having trauma-related nightmares is one of 20 potential symptoms of posttraumatic stress disorder (PTSD), and approximately two-thirds of people with PTSD experience nightmares related to their trauma. However, not all nightmares are related to traumatic memories, and nightmares are underassessed and undertreated in healthcare settings.
A diagnosis of nightmare disorder can be made for people who repeatedly experience nightmares that cause high distress or impede daily functioning. Nightmare disorder can range from mild (less than one nightmare on average per week) to severe (nightmares occurring every night). Although it can be diagnosed on its own, nightmare disorder is often comorbid with mood, anxiety, and psychotic disorders. Nightmare disorder and insomnia disorder can be mutually aggravating: People with insomnia tend to have more negative dream content, and those with nightmare disorder tend to develop dread related to falling asleep.
Can I Stop Having Nightmares?
The good news is that research suggests it is possible to reduce the frequency and intensity of nightmares. Effectively treating nightmares can also improve sleep quality and even reduce symptoms of PTSD, depression, anxiety, and paranoia. Here are some options for improving your dream content, reducing nightmares, and getting better sleep:
Rewrite the ending to the nightmare. As odd as it might sound, the most effective way to stop having repeated nightmares involves making up a new ending to one of your dreams. Image reversal therapy (IRT) is a brief psychotherapy in which patients are led through a process of writing a new, different ending to a nightmare. Patients are encouraged to include as much detail as possible. The new ending can even be bizarre or comical, but usually involves a sense of agency from the dreamer (for example, you might spray those aggressive neon pythons with a firehose and watch them shrink down to earthworms). The patient then rehearses this new, made-up ending in their imagination each night before going to bed—much as an athlete might imagine things going well before a competition. This mental technique creates an “off-road” for the mind to go while dreaming when it starts to head toward a nightmare. IRT has been shown by meta-analyses to be effective for treating trauma-related nightmares and is recommended by the American Academy of Sleep Medicine (AASM) as the first-line treatment for both nightmare disorder and PTSD-related nightmares.
Improve sleep behaviors.Changing unhelpful sleep habits, which is taught through cognitive behavioral therapy for insomnia (CBT-I), can be helpful for reducing nightmares. In addition, cognitive behavioral therapy for nightmares (CBT-N) is an effective nightmare treatment that incorporates both IRT and elements of CBT-I, such as stimulus control and sleep efficiency training.
Seek treatment for co-occurring psychological disorders. IRT or CBT-N should typically be the first treatment to consider when nightmares are the primary area of concern. However, if you have any other mental health diagnoses, treating those conditions may also help minimize nightmares. In particular, an evidence-based trauma treatment (such as cognitive processing therapy, prolonged exposure, or eye movement desensitization and reprocessing) may be helpful for individuals with PTSD to decrease the sense of threat from their surroundings.
Consult a physician about medication options. IRT (which is also included in CBT-N) is the only treatment recommended by the AASM for nightmare disorder or PTSD-related nightmares. It is a psychological treatment that does not require medications. However, AASM does note in their position paper on treatment of nightmare disorder that certain medications, such as prazosin, “may be used.” Be sure to talk to your physician before starting any medication for the purpose of alleviating nightmares.
Nightmares can get in the way of good sleep, bring up negative emotions, and cause a nightly sense of dread. If you are experiencing significant daily distress or impairment from nightmares, seek out a physician, psychologist, or licensed mental health professional to find out if IRT, CBT-N, or another evidence-based treatment may be a good fit for you.
Interested in Cognitive Behavioral Therapy for Nightmares with Image Reversal Therapy (CBT-N/IRT)? Read more about the therapy or get in touch.
Note: A version of this post has been previously published on Dr. Hylton Jean’s Psychology Today Blog, Mapping Your Mental Health Journey.
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