Nightmares

A National Center for PTSD Fact Sheet (Veterans Affairs Canada Adaptation)
By Laura E. Gibson, Ph.D., The University of Vermont

What are nightmares?

Nightmares refer to elaborate dreams that cause high levels of anxiety or terror (American Psychiatric Association, 1994). In general, the content of nightmares revolves around imminent harm being caused to the individual (e.g., being chased, threatened, injured, etc.). When nightmares occur in the context of posttraumatic stress disorder (PTSD), they tend to involve the original threatening or horrifying set of circumstances that was involved during the traumatic event. For example, someone who was in the Twin Towers on September 11th, 2001, might experience frightening dreams involving terrorists, airplane crashes, collapsing buildings, fires, people jumping from buildings, etc. A rape survivor might experience disturbing dreams about the rape itself or some aspect of the experience that was particularly frightening (e.g., being held at knifepoint).

Nightmares can occur multiple times in a given night, or one might experience them very rarely. Individuals may experience the same dream repeatedly, or they may experience different dreams with a similar theme. When individuals awaken from nightmares, they can typically remember them in detail. Upon awakening from a nightmare, individuals typically report feelings of alertness, fear, and anxiety. Nightmares occur almost exclusively during rapid eye movement (REM) sleep. Although REM sleep occurs on and off throughout the night, REM sleep periods become longer and dreaming tends to become more intense in the second half of the night. As a result, nightmares are more likely to occur during this time.

How common are nightmares?

The prevalence of nightmares varies by age group and by gender. Nightmares are reportedly first experienced between the ages of three and six years (American Psychiatric Association, 1994). From 10% to 50% of children between the ages of three and five have nightmares that are severe enough to cause their parents concern. This does not mean that children with nightmares necessarily have a psychological disorder. In fact, children who develop nightmares in the absence of traumatic events typically grow out of them as they get older. Approximately 50% of adults report having at least an occasional nightmare (American Psychiatric Association, 1994). Estimates suggest that between 6.9% (Bliwise, 1996) and 8.1% (Klink & Quan, 1987) of the adult population suffer from chronic nightmares.

Women report having nightmares more often than men do. Women report two to four nightmares for every one nightmare reported by men. It is unclear at this point whether men and women actually experience different rates of nightmares, or whether women are simply more likely to report them.

Nightmares and cultural differences

The interpretation of and significance given to nightmares varies tremendously by culture. While some cultures view nightmares as indicators of mental health problems, others view them as related to supernatural or spiritual phenomena. Clinicians should keep this in mind during their assessments of the impact that nightmares have on clients.

How are nightmares related to PTSD?

Nightmares are 1 of 17 possible symptoms of PTSD. One does not have to experience nightmares in order to have PTSD. However, nightmares are one of the most common of the "re-experiencing" symptoms of PTSD, seen in approximately 60% of individuals with PTSD (Kilpatrick et al., 1998). A recent study of nightmares in female sexual assault survivors found that a higher frequency of nightmares was related to increased severity of PTSD symptoms (Krakow et al., 2002). Little is known about the typical frequency or duration of nightmares in individuals with PTSD.

Are there any effective treatments for nightmares?

Yes. There are both psychological treatments (involving changing thoughts and behaviors) and psychopharmacological treatments (involving medicine) that have been found to be effective in reducing nightmares.

Psychological Treatment

In recent years, Barry Krakow and his colleagues at the University of New Mexico have conducted numerous studies regarding a promising psychological treatment for nightmares. This research group found positive results in applying this treatment to individuals suffering from nightmares in the context of PTSD (e.g., Krakow, Hollifield, et al., 2001; Krakow, Johnston, et al., 2001). Krakow and colleagues found that crime victims and sexual assault survivors with PTSD who received this treatment showed fewer nightmares and better sleep quality after three group-treatment sessions. Another group of researchers (Forbes, Phelps, & McHugh, 2001) applied the treatment to Vietnam combat Veterans and found similarly promising results in a small pilot study.

The treatment studied at the University of New Mexico is called "Imagery Rehearsal Therapy" and is classified as a cognitive-behavioral treatment. It does not involve the use of medications. In brief, the treatment involves helping the clients change the endings of their nightmares, while they are awake, so that the ending is no longer upsetting. The client is then instructed to rehearse the new, nonthreatening images associated with the changed dream. Imagery Rehearsal Therapy also typically involves other components designed to help clients with problems associated with nightmares, such as insomnia. For example, clients are taught basic strategies that may help them to improve the quality of their sleep, such as refraining from caffeine during the afternoon, having a consistent evening wind-down ritual, or refraining from watching TV in bed. For more information on improving sleep quality, see the Sleep and PTSD fact sheet.

Psychopharmacological Treatment

Researchers have also conducted studies of medications for the treatment of nightmares. However, it should be noted that the research findings in support of these treatments are more tentative than findings from studies of Imagery Rehearsal Therapy. Part of the reason for this is simply that fewer studies have been conducted with medications at this point in time. Also, the studies that have been conducted with medications have generally been small and have not included a comparison control group (that did not receive medication). This makes it difficult to know for sure whether the medication is responsible for reducing nightmares, or whether the patient's belief or confidence that the medication will work was responsible for the positive changes (a.k.a., a placebo effect).

Some medications that have been studied for treatment of PTSD-related nightmares and may be effective in reducing nightmares include Topiramate (Berlant & van Kammen, 2002), Prazosin (Taylor & Raskind, 2002), Nefazodone (Gillin et al., 2001), Trazodone (Warner, Dorn, & Peabody, 2001), and Gabapentin (Hamner, Brodrick, & Labbate, 2001). Because medications typically have side effects, many patients choose to try a behavioral treatment first. If that does not help improve their symptoms, they may choose to try medication. For suggestions about how to talk to your doctor about your PTSD-related nightmares and the possible use of medications for your symptoms, you may find the fact sheet on Discussing Trauma and PTSD with Your Doctor helpful.

What happens if nightmares are left untreated?

Nightmares can be a chronic mental health problem for some individuals, but it is not yet clear why they plague some people and not others. One thing that is clear is that nightmares are common in the early phases after a traumatic experience. However, research suggests that most people who have PTSD symptoms (including nightmares) just after a trauma will recover without treatment. This typically occurs by about the third month after a trauma. However, if PTSD symptoms (including nightmares) have not decreased substantially by about the third month, these symptoms can become chronic (Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992). If you have been suffering from nightmares for more than three months, you are encouraged to contact a mental health professional and discuss with him or her the behavioral treatments described above.

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.

Berlant, J., & van Kammen, D.P. (2002). Open-label Topiramate as primary or adjunctive therapy in chronic civilian posttraumatic stress disorder: A preliminary report. Journal of Clinical Psychiatry, 63, 15-20.

Bliwise, D.L. (1996). Historical change in the report of daytime fatigue. Sleep, 19, 462-464.

Forbes, D., Phelps, A., & McHugh, T. (2001). Treatment of combat-related nightmares using imagery rehearsal: A pilot study. Journal of Traumatic Stress, 14, 433-442.

Gillin, J.C., Smith-Vaniz, A., Schnierow, B., Rapaport, M.H., Kesloe, J.R., Raimo, E., et al. (2001). An open-label, 12-week clinical and sleep EEG study of Nefazodone in chronic combat-related posttraumatic stress disorder. Journal of Clinical Psychiatry, 62, 789-796.

Hamner, M.B., Brodrick, P.S., & Labbate, L.A. (2001). Gabapentin in PTSD: A retrospective, clinical series of adjunctive therapy. Annals of Clinical Psychiatry, 13, 141-146.

Kilpatrick, D.G., Resnick, H.S., Freedy, J.R., Pelcovitz, D., Resick, P.A., Roth, S., et al. (1998). Posttraumatic stress disorder field trial: Evaluation of the PTSD construct -- criteria A through E. In T.A. Widiger, A.J. Frances, H.A. Pincus, R. Ross, M.B. First, W. Davis, & M. Kline (Eds.), DSM-IV Sourcebook , v. 4. (4th ed., pp. 803-844) Washington DC: American Psychiatric Press.

Klink, M., & Quan, S.F. (1987). Prevalence of reported sleep disturbances in a general adult population and their relationship to obstructive airways diseases. Chest, 91, 540-546.

Krakow, B., Hollifield, M., Johnston, L., Koss, M.P., Schrader, R., Warner, T.D., et al. (2001). Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: A randomized controlled trial. Journal of the American Medical Association, 286, 537-545.

Krakow, B., Johnston, L., Melendrez, D., Hollifield, M., Warner, T.D., Chavez-Kennedy, D., et al. (2001). An open-label trial of evidence-based cognitive behavior therapy for nightmares and insomnia in crime victims with PTSD. American Journal of Psychiatry, 158, 2043-2047.

Krakow, B., Schrader, R., Tandberg, D., Hollifield, M., Koss, M.P., Yau, C.L., et al. (2002). Nightmare frequency in sexual assault survivors with PTSD. Journal of Anxiety Disorders, 16, 175-190.

Rothbaum, B., Foa, E., Riggs, D., Murdock, T., & Walsh, W. (1992). A prospective examination of post-traumatic stress disorder in rape victims. Journal of Traumatic Stress, 5, 455-475.

Taylor, F., & Raskind, M.A. (2002). The "1 -adrenergic antagonist Prazosin improves sleep and nightmares in civilian trauma posttraumatic stress disorder. Journal of Clinical Psychopharmacology, 22, 82-85.

Warner, M.D., Dorn, M.R., & Peabody, C.A. (2001). Survey on the usefulness of Trazodone in patients with PTSD with insomnia or nightmares. Pharmacopsychiatry, 34, 128-131