Nightmare Disorder



A nightmare is a nightmare or type of bad dream, typically one that causes distress to the person who experiences it. They usually involve situations of danger and death that somehow represent the dreamer’s inner conflict. Exposure to distressing life events can trigger nightmare episodes; with lingering consequences for mood in adults and terror management issues among children. Rarely, nightmare disorder can manifest as a specific and extremely disturbing recurring nightmare without any apparent cause; such dreams are called “systematized” nightmare disorder. This is an infrequent presentation and is best treated with psychodynamic therapy, which focuses on the meaning of the nightmare.


Nightmares typically occur during the stage of REM sleep or, more rarely, just before waking up. They are a result of “intrusion into REM” and appear to be an evolutionary response to threat (producing adrenaline and noradrenaline), which tends to cause the awakened person to perceive his or her environment as hostile. Nightmares may also occur just after waking up, either with the sensation of falling or with frightening dreams in which one suddenly falls off a cliff, for example. These are known as nightmare disorder (ND) and will be discussed further below.

Causes of nightmare disorder can include:

  • Sleep deprivation
  • Alcohol use/abuse
  • Carbohydrate binging
  • Physical or sexual abuse during childhood or adulthood
  • Noncompliance with psychiatric medications 


A person sitting on the ground

Nightmare disorder is treatable, both on its own and in conjunction with other conditions. An initial nightmare diary for one to two weeks will help the patient determine the frequency of his or her nightmares and their emotional content. If nightmare disorder is associated with another condition, whether it be depression, grief, trauma or another psychiatric illness, the nightmare is considered secondary nightmare disorder and can be treated with therapies appropriate for treating the primary condition. If nightmare disorder exists in isolation, psychotherapy may help determine the underlying cause of the nightmare distress and then develop nightmare management techniques. This may include the use of nightmare imagery rehearsal therapy, nightmare stress reduction therapy, dream theories and reflection upon nightmare content. Nightmare disorder is relatively difficult to treat with medication due to the infrequency of the disorder. When prescribed, nightmare disorder medications are similar to those used for depression treatment with selective serotonin reuptake inhibitors (SSRIs).

A silhouette of a person


The best treatment for nightmare disorder is direct nightmare therapy . This involves discussing the nightmare with the patient and getting him or her to change the dream’s content so that it becomes less frightening. The therapist might have the nightmare sufferer imagine a “safe place” where he or she could go if threatened by an attacker in a nightmare, then encouraging the person to visualize this safe location whenever something threatening occurs in a nightmare. Other techniques include changing certain stimuli within nightmares that are especially scary to ones that are less bothersome, confronting whatever it is within nightmares that produces fear and practicing relaxing strategies such as deep breathing and muscle relaxation to reduce nightmare anxiety.

Nightmares may also be prevented by keeping a nightmare diary in which the nightmare sufferer jots down what he or she remembers of the nightmare when waking up in the middle of the night. Then each morning, before going back to sleep, the person focuses on changing things within nightmares that were particularly disturbing so that they might become less frightening or even turn into pleasant occurrences instead.

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