Nightmares refer to complex dreams that cause high levels of anxiety or terror. 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 as a part of 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 11 th, 2001, might experience frightening dreams about 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 years. 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 nightmare. Estimates suggest that between 6.9% and 8.1%
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. 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. 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. 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 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 see our Where to Get help link on our home page.
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, Prazosin, Nefazodone, Trazodone, and Gabapentin. 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 chronic. 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.
Learn about how traumatic experiences affect people, what
survivors need to know, and the common symptoms of PTSD
References
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Kilpatrick, D.G., Resnick, H.S.,
Freedy, J.R., Pelcovitz, D., Resick, P.A., Roth, S., et al.
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Krakow, B., Schrader, R., Tandberg,
D., Hollifield, M., Koss, M.P., Yau, C.L., et al. (2002).
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