Recurring nightmares can often be caused by nightmare disorder. When left untreated, frequent and severe dysphoric dreams can lead to sleep disturbances and affect your mood, behavior and daily functioning. Seeking treatment for nightmares can help cope with negative effects and improve your overall well being.
Understanding Nightmare Disorder
Nightmares can be an unpleasant experience for most of us. Studies 1 show that occasional nightmares are common for most people. But when such nightmares become increasingly frequent and extended, impairing your ability to function in important areas of your life, then it can hint at a bigger problem. Nightmare disorder is a type of parasomnia characterized by repeated nightmares leading to abrupt awakenings from REM sleep. People with this condition may experience terrifying nightmares that are frequent, exceptionally distressing and long in duration. For them, bedtime leads to severe anxiety and sleep can become a highly stressful activity. Sleep deprivation can lead to serious health issues and affect their well being. Thankfully, well-researched treatment for nightmares is available that can help sufferers relieve the symptoms and improve their sleep.
Treatment For Nightmares
As parasomnias can often be experienced by generally healthy people, treatment may not be necessary in most cases. However, a 2009 study 2 reveals that “Nightmares are associated with a range of psychiatric symptoms, full-blown psychiatric disorders such as posttraumatic stress disorder (PTSD), and sleep disturbances.” Hence, seeking treatment can be very important not only to identify any underlying conditions, but also to treat them. Treatment can especially be necessary if the disorder is constantly affecting the sufferer and their family members or if frequent nightmares are leading to potentially dangerous behavior. In fact, studies 3 have found that repeated nightmares can cause serious clinical problems and can “increase the risk of suicide.”
Treatment for nightmares should always be supervised by a doctor or a mental health professional as treatment may involve psychotherapy or medications or both. A doctor can help the patient find the most appropriate treatment plan based on their symptoms, causes of nightmares, comorbid conditions and overall health.
Here are some of the available treatment options for nightmares and nightmare disorder:
Consulting a therapist can enable the sufferer to share their feelings in a safe environment and get the necessary help to cope with the disturbing events associated with the nightmares. Psychotherapy or talk therapy is a form of treatment for nightmares that aims to understand and restructure negative thinking and behavior. Cognitive Behavioral Therapy (CBT) is typically considered to be the most effective therapy technique for nightmare disorder.
Cognitive behavioral therapy can be highly effective in helping the patient develop long-term and effective strategies to cope with their anxiety and fear related to the nightmares. It can also help them better manage their mood and behavior. CBT is based on the idea that our thoughts, emotions and behaviors are all related. Hence, by addressing and overcoming dysfunctional thoughts, emotions & behavior in a structured, goal-oriented manner, the sufferer can overcome difficult emotions and counterproductive actions. Research 4 shows that different variations of cognitive behavioral therapy, such as CBT for insomnia (CBT‐i) or trauma‐focused CBT, designed for trauma survivors and PTSD patients, can be especially effective for treating daytime and nighttime symptoms.
According to a 2016 clinical trial 5, it was observed that “CBT had a positive impact on NM (frequent nightmares) reduction with 77% of participants who did no longer present NM after the treatment.” Another 2008 study 6 found that nightmare-focused CBT has proven to be more effective than indirect CBT such as recording and relaxation. The researchers state “this first systematic review on nightmare treatment was able to demonstrate that nightmare-focused CBT showed superior effects to other forms of nightmare treatment for both nightmare reduction and amelioration of associated sleep and affective complaints.”
CBT can include a combination of psychotherapeutic and behavioral techniques that are customized for specific distortions of thought and behavior patterns in a person. According to a 2010 study 7, the proven variants of CBT, specifically focused on treatment for nightmares, include –
- Image Rehearsal Therapy (IRT)
- Lucid Dreaming Therapy
- Sleep Dynamic Therapy
- Self-Exposure Therapy
- Systematic Desensitization
- Exposure, Relaxation and Rescripting Therapy
Let us take a closer look at the different types of CBT available for nightmare disorder:
A. Image rehearsal therapy (IRT)
IRT is a form of cognitive behavioral therapy that helps to track and identify the images and content associated with disturbing and unpleasant dreams. In this form of therapy, the patients are required to rescript the plot of their nightmares during wakefulness. The patients need to work with a therapist to evaluate and edit the story and content of their nightmares. Then they are required to spend at least 10-20 minutes every day, while awake, pondering about the edited content of their dreams. As they edit and recreate the images of their dreams, especially the endings, the sufferer can gain a sense of control on their nightmares.
According to a 2019 study 8, image rehearsal therapy is one of the most effective treatment options for nightmare disorder. The researchers state “The IRT approach to treating nightmares is underpinned by the best available evidence and therefore recommended as level A treatment for nightmare disorder by the Oxford Centre for Evidence-Based Medicine, as well as by the AASM.” One 2010 study 9 states “Imagery Rehearsal Therapy (IRT) has been shown to be efficacious in reducing nightmares.” Research also reveals that imagery rehearsal therapy can reduce chronic nightmares in people with posttraumatic stress disorder (PTSD) and improve sleep quality.
B. Lucid dreaming therapy (LDT)
Lucid dreaming therapy focuses on helping people with nightmare disorder influence and control their own dreams directly while dreaming. It is also a helpful treatment for nightmares but it takes a different approach from the other proven methods. Lucid dreams involve the person’s awareness of being in the process of dreaming. LDT can also make the person aware that they can take decisions and control or manage the plot or story of the dream or nightmare. They can either consciously choose to alter the dream content or even choose to intentionally wake up from a nightmare. A 2010 study 7 recommends LDT for the treatment for nightmare disorder and explains “A variant of IRT, the cognitive-restructuring technique of LDT allows one to alter the nightmare storyline during the nightmare itself by realizing that one is dreaming or being “lucid” during the nightmare.”
Studies 8 have also found that lucid dreaming therapy can “improve nightmare and sleep‐related symptoms.” However, reaching the lucid dreaming state can be difficult and it requires a lot of patience and practice. Hence, not all patients will be benefited from this treatment approach.
C. Sleep dynamic therapy (SDT)
According to a 2002 study 10, SDT is an integrated sleep treatment program of mainly “evidence-based, nonpharmacologic sleep medicine therapies coupled with standard clinical sleep medicine instructions,” such as IRT, CBT and other psychotherapeutic interventions for improving sleep hygiene and sleep quality. The researchers found that this form of therapy can help with posttraumatic stress symptoms and improve sleep disturbances, like nightmares. In weekly 2-hour sessions, this treatment may include –
- Sleep quality assessment with behavioural deconditioning
- Sleep hygiene
- Stimulus control
- Image Rehearsal Therapy (IRT)
- Education on posttraumatic stress symptoms
- Physiologic assessment
A 2010 study 7 recommends sleep dynamic therapy for PTSD-associated nightmares as reports suggest improvements in nightmares and insomnia after a 12-week period.
D. Self-exposure therapy
This is another form of CBT that is based on the notion of the process of graded exposure. Usually, conducted under the guidance of a therapist, a counselor may instruct a patient to create a list of dreams and events that may induce anxiety in them. The therapist then asks the patient to go through the list at their own pace, beginning with the event or dream that causes the least amount of anxiety and fear, until such difficult emotions are alleviated. The patient is exposed to the list on a regular basis and a journal is maintained.
A 1994 study 11 found that self-exposure therapy can provide lasting relief to chronic nightmares. Another 2006 study 12 showed that “self-exposure therapy reduced the frequency of nightmares,” and the symptoms “remained improved over the 4-year follow-up.”
E. Exposure and systematic desensitization
This form of psychotherapy can also be helpful in the treatment for nightmares. Exposure and Systematic Desensitization encourages the sufferer to face the content of their nightmares, instead of avoiding them. The objective is to gradually expose the patient to the feared stimuli and stressful thoughts so that they can be systematically desensitized to the feared object. However, unlike customarily feared stimuli, like heights or insects and animals, therapists cannot directly expose the patient to a nightmare. Hence, the doctor or therapist may expose the patient to the distressing content of the nightmare via mental imagery. Being exposed to stress in a controlled and safe environment can help the sufferer to slowly familiarize with the stressful thoughts and eventually overcome them.
According to a 2011 study 13, Exposure and Systematic Desensitization can be effective for nightmares and posttraumatic memories. The study found that findings “suggest exposure in the context of SD (systematic desensitization) may reduce nightmares and increase confidence in the management of nightmare-related affective response.”
F. Exposure, relaxation and rescripting therapy
Exposure, Relaxation, and Rescripting Therapy (ERRT) is a variation of IRT and another effective form of psychotherapeutic treatment for nightmares. Unlike Image Rehearsal Therapy, Exposure, Relaxation, and Rescripting Therapy encourage exposure to the disturbing and distressing content of the patient’s nightmares. ERRT involves a combination of education about:
- Trauma & PTSD
- Sleep patterns and behaviour
- Exposure to content & distressing themes in nightmares
- Rescripting of the nightmare scenario
- Daily progressive muscle relaxation
- Diaphragmatic breathing
The therapy process is conducted under the guidance of a trained and licensed therapist along with the other members of the treatment group. A 2009 study 14 explains that Exposure, Relaxation, and Rescripting Therapy is “associated with long-term improvements in nightmare frequency, depression symptom severity, PTSD symptom severity and sleep quality for trauma-related nightmares.” Moreover, a 2019 study 15 discovered that ERRT can also effectively reduce suicidal ideation in patients with nightmare disorder.
G. Eye movement desensitization and reprocessing (EMDR)
EMDR can be an effective and efficacious treatment for nightmares. It is a psychotherapeutic intervention that integrates aspects from cognitive behavioral, body-centered, psychodynamic, experiential and interpersonal therapies. A 2018 study explains “The principle is to induce the processing of disturbing memories and experiences by stimulating neural mechanisms that are similar to those activated during REM sleep.” A 2014 study 16 found that EMDR can be effective in managing PTSD symptoms, such as nightmares and flashbacks, that trigger disturbing memories. Research 7 shows that EMDR can be helpful in reducing nightmare frequency and improving sleep quality.
H. Relaxation skills training
Relaxation skills can be extremely helpful in managing nightmare disorder symptoms. By learning these skills, the patient can learn how to calm their mind and body after an episode and manage the stress and anxiety experienced after a nightmare. Some of the most common and helpful relaxation skills recommended by therapists include:
- Guided imagery
- Deep breathing
- Body awareness
- Progressive muscle relaxation
Although these may feel a bit awkward or uncomfortable initially, with practice and patience, the sufferer will be able to manage their fear and anxiety and be able to function normally in daily life.
Although medication is typically not recommended in the treatment for nightmares and nightmare disorder, it may be prescribed in extreme cases where therapy is not effective. Moreover, medications can also be used to treat intense nightmares related with PTSD. A doctor may prescribe different types of medications that can be taken independently or along with psychotherapy. However, it is crucial that you consult a doctor before taking any medicine to know about any potential side effects.
Usually, medications which affect our nervous system, like anti-anxiety medication, antidepressants, or antipsychotic drugs are prescribed for this condition. Here are some of the most effective medications for treating the symptoms of nightmare disorder:
A recent 2020 study 17 shows that the alpha-blocker “prazosin resulted in a statistically significant improvement in nightmares.” This medicine reduces the communication in the central nervous system during sleep by blocking noradrenergic receptors and enables the patient to longer periods of undisturbed sleep. Research reveals that Prazosin is considered as the drug of choice for both posttraumatic and idiopathic nightmares. However, high-dose prazosin may be required for the treatment of post-traumatic stress disorder nightmares, according to a 2014 study 18. However, it should be noted that most studies for this medicine focuses on PTSD nightmares and there is limited research on it’s effect in idiopathic nightmares.
B. Nitrazepam and triazolam
Research 19 shows that nitrazepam is a safe and effective hypnotic that can be prescribed for nightmare disorder. This Benzodiazepine sedative can help to limit episodes, manage insomnia and short-term anxiety and to improve sleep. A 2010 study 7 shows that Triazolam and Nitrazepam can effectively reduce nightmare frequency and tend to have limited and minor side effects, such as morning sedation or difficulty concentrating in the morning.
C. Trazodone and nefazodone
These are serotonin-potentiating non-SSRI agents that can have moderate to large positive effects on nightmares, according to open-label and controlled trials. One 2003 study 20 found that Nefazodone shows “an improvement in global subjective sleep quality and a reduction in nightmares.” Moreover, it can also improve objective and subjective sleep quality in PTSD patients and increase total sleep time and sleep maintenance. Research reveals that Nefazodone has over 43% response rate at the endpoint and 60% in treatment completers.
Apart from these, a doctor may also prescribe the following medications for the treatment for nightmares:
- Clonidine 7
- Atypical Antipsychotic Medications, like Olanzapine, Risperidone, and Aripiprazole
- Low-Dose Cortisol 21
- Fluvoxamine 22
- Phenelzine 23
- Gabapentin 24
- Cyproheptadine 25
- Tricyclic Antidepressants (TCAs) 26
- Selective serotonin reuptake inhibitor (SSRIs) 27
- Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) 28
Doctors may also prescribe some other medications not listed here to treat nightmare disorder depending on the symptoms, severity and on the individual. However, it should be noted that certain medications can make the symptoms worse and hence should be avoided. According to a 2018 study 29, clonazepam and venlafaxine “are not recommended for the treatment of nightmare disorder.” The researchers add “The ultimate judgment regarding the propriety of any specific care must be made by the clinician, in light of the individual circumstances presented by the patient, accessible treatment options, and resources.”
Lifestyle Changes And Alternative Treatment For Nightmares
Although psychotherapy and medications can help a patient to successfully overcome the symptoms of nightmare disorder, some sufferers may prefer alternative treatments to be better able to cope with the condition. Here are some helpful treatment alternatives for nightmares:
Research 30 shows that “Hypnosis appears to be a treatment of choice for these (repetitive) nightmares, and techniques for hypnotic treatment may be based upon whether the nightmare mirrors an actual experience of the patient.” Hypnosis is considered as one of the most helpful alternative treatments for nightmares, especially for patients who do not usually respond well to medications or psychotherapy. It is a trance-like state of mind that enables the patient to deeply concentrate on certain thoughts, emotions, sensations or memories without distractions. This makes the person more open to positive suggestions that can help them to modify their own thoughts and behaviors. A licensed and professional hypnotherapist can help the sufferer be more open to facing their fears appearing in the nightmares and experience deep relaxation and concentration.
A study on nightmare disorder treatments found that 71% of patients were symptom-free or experienced improvements in symptoms with hypnotherapy at 18 months. Another 2007 study 31 found that “One or 2 sessions of hypnotherapy might be an efficient first-line therapy for patients with certain types of parasomnias.”
Using herbs can be exceptionally helpful in relaxing the mind, reducing anxiety, improving sleep and managing disturbed sleep patterns. The aromatic and sedative herb hops 32 can reduce feelings of stress and restlessness that occur with insomnia. However, it should be avoided in case of depression. The flowering plant valerian is another strong sedative that impacts the central nervous system. It also helps to relax our internal organs and induce sleep. Wild lettuce and passion flowers can also help to relax the mind and body and improve sleep quality.
3. Essential oils
Certain essential oils can help a person to relax and get undisturbed sleep, especially if they are suffering from nightmare disorder. Essential oil of lavender can greatly help in managing anxiety and promote restorative sleep. It can even help with sleep disturbances and insomnia. According to a 2006 study 33, “lavender fragrance had a beneficial effect on insomnia and depression.” Moreover, Roman chamomile and Vetiver can also help a person to relieve stress and calm down.
4. Diet and supplements
Foods like tomatoes, mustard seeds, cherries, chillies, goji berries, sprouted seeds, fenugreek, lupin, rice and corn provide high levels of sleep-inducing melatonin. Adding seeds, nuts, poultry, yoghurt and other sources of tryptophan to your diet can also help with restorative sleep. Moreover, certain supplements, like Omega-3, Magnesium and Vitamin D can also help to reduce insomnia, improve relaxation and help with nightmare disorder.
5. Sleep hygiene
Apart from therapy, medication and alternative treatment for nightmares, certain lifestyle changes can also help someone to overcome nightmare disorder. Sleep hygiene refers to a person’s routines and habits around bedtime that affect the quantity and quality of their sleep. Maintaining proper sleep hygiene can improve sleep quality and make it more restorative. Here are a few tips for good sleep hygiene:
- Going to sleep at the same time every night
- Having a calm and comfortable environment in the bedroom
- Avoiding large meals, alcohol or caffeine before bedtime
- Keeping work away from the bedroom
- Not doing any intense physical activity or exercise a few hours before going to bed
- Avoiding blue light and technology, like smartphones, laptops and TV screen before bedtime
Treatment Can Help
Nightmare disorder, characterized by frequent nightmares, can be disabling and severely affect your mental, emotional and physical health. Seeking professional help and undergoing medical treatment can help you or your loved one to overcome the symptoms and live a healthier, more meaningful life.
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