Nightmares
A National Center for PTSD Fact Sheet
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 terror1. 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 3 and 6 years1. From 10% to 50% of children between the ages of 3 and 5 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 nightmare1. Estimates suggest that between 6.9%2 and 8.1%3 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
PTSD4. A recent study of nightmares in female sexual assault survivors found
that a higher frequency of nightmares was related to increased severity of PTSD symptoms5. 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 PTSD6,7. 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 researchers8 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.
Psychologists who use cognitive-behavioral techniques may be familiar with
Imagery Rehearsal Therapy, or may have access to research literature describing
it. If you need help locating a cognitive-behavioral therapist in your area,
try using the clinical referral directory of the Association
for the Advancement of Behavior Therapy.
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 patientís 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 Topiramate9, Prazosin10, Nefazodone11, Trazodone12, and Gabapentin13. 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, consult the fact sheet below.
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 chronic14. If you have been suffering from nightmares for more than 3 months, you are encouraged to contact a mental health professional and discuss with him or her the behavioral treatments described above.
Related Fact Sheets
Discussing Trauma and
PTSD with Your Doctor
A useful checklist to help discuss traumatic
stress symptoms with primary care physicians
Sleep and PTSD
Information about the effects of trauma on sleep patterns
Symptoms of
PTSD
Learn about how traumatic experiences affect people, what survivors need
to know, and the common symptoms of PTSD
References
1. American Psychiatric Association. (1994). Diagnostic
and statistical manual of mental disorders (4th ed.). Washington,
DC: American Psychiatric Association.
2. Bliwise, D.L. (1996). Historical change in the report of daytime fatigue. Sleep, 19, 462ñ464.
3. 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, 540ñ546.
4. 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. 803ñ844) Washington DC: American
Psychiatric Press.
5. 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,
175ñ190.
6. 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, 537ñ545.
7. 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, 2043ñ2047.
8. Forbes, D., Phelps, A., & McHugh, T. (2001). Treatment of combat-related nightmares using imagery rehearsal: A pilot study. Journal
of Traumatic Stress, 14, 433ñ442.
9. 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, 15ñ20.
10. Taylor, F., & Raskind, M.A. (2002). The "1
ñadrenergic antagonist Prazosin improves sleep and nightmares in civilian
trauma posttraumatic stress disorder. Journal
of Clinical Psychopharmacology, 22, 82ñ85.
11. 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, 789ñ796.
12. 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, 128ñ131.
13. 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, 141ñ146.
14. 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, 455ñ475.
