Understanding and Addressing Chronic Nightmares: Causes and Remedies  

Nightmares are a universal experience, often leaving us feeling unsettled and anxious upon waking. While occasional nightmares are a common part of life, for some individuals, they occur with troubling frequency, leading to significant distress and impacting overall well-being. Chronic nightmares can be more than just bad dreams; they are often a symptom of deeper psychological issues. Understanding why some people experience chronic nightmares and how to manage them is crucial for improving mental health and quality of life. It's important to note that these are just possible psychological causes; for a glimpse into the neuroscience, please read the linked blog post on the neurobiology of chronic nightmares.

Why Do Some People Have Chronic Nightmares?

Nightmares are not just random, frightening images conjured by the subconscious. They often serve as a window into our psychological and emotional states. Several factors can contribute to the prevalence of chronic nightmares, including psychological conditions, emotional distress, sleep disturbances, and even certain medications.

1. Psychological Conditions: One of the most significant predictors of chronic nightmares is the presence of psychological disorders, particularly Post-Traumatic Stress Disorder (PTSD). Research has shown that up to 90% of individuals with PTSD report experiencing frequent nightmares, which are often linked to heightened distress and severity of PTSD symptoms (Meador et al., 2022; Hasler & Germain, 2009). This is particularly true for children diagnosed with PTSD, where studies indicate that nearly all children with full or subsyndromal PTSD experience frequent nightmares (Wittmann et al., 2010). These nightmares are not just scary dreams; they are manifestations of the trauma that the individual has experienced, making them a key marker of underlying psychological distress (Cromer et al., 2022).
2. Emotional Distress: Emotional factors, such as anxiety and depression, are closely linked to the occurrence of nightmares. Children with chronic nightmares have been found to exhibit more psychopathological symptoms, including emotional and conduct problems, compared to their peers who do not experience nightmares (Schredl et al., 2009). In adults, the presence of frequent nightmares significantly increases the likelihood of psychiatric illnesses, with some studies indicating a five-fold increase in such conditions among those who experience regular nightmares (Gill et al., 2023). The relationship between anxiety and nightmares is particularly pronounced in children, where anxiety issues are often considered a contributing factor to the occurrence of these distressing dreams (Mindell & Barrett, 2002).
3. Sleep Disturbances: Sleep quality plays a critical role in the frequency and intensity of nightmares. Poor sleep quality has been consistently associated with an increased likelihood of nightmares (Simor et al., 2012). The architecture of sleep, particularly the REM phase—where most nightmares occur—can be disrupted by various factors, including stress and anxiety (Levin & Nielsen, 2007). External stressors, such as those experienced during the COVID-19 pandemic, have further highlighted the impact of situational stress on sleep disturbances and the subsequent increase in nightmares (Kennedy et al., 2021).
4. Medications: Certain medications can also contribute to the occurrence of nightmares. For example, montelukast, a drug commonly used for asthma, has been reported to cause nightmares in both children and adults (Haarman et al., 2017; Cereza et al., 2012). This underscores the importance of considering pharmacological factors when addressing chronic nightmares, as these can sometimes be an overlooked cause.

How Can You Remedy Chronic Nightmares?

While chronic nightmares can be distressing, there are several evidence-based therapeutic approaches that can help alleviate their frequency and intensity. These treatments range from psychological therapies to pharmacological interventions, and lifestyle modifications, each tailored to address the root causes of the nightmares.

1. Imagery Rehearsal Therapy (IRT): One of the most effective treatments for chronic nightmares, particularly those associated with trauma, is Imagery Rehearsal Therapy (IRT). IRT is a cognitive-behavioral intervention that involves the patient rewriting the narrative of their nightmares while awake. This process helps alter the emotional response associated with the dream, reducing its distressing impact. Research has shown that IRT can significantly reduce the frequency and intensity of nightmares, especially in individuals with PTSD (Harb et al., 2019; Berlin et al., 2010; Casement & Swanson, 2012). Moreover, a meta-analysis highlighted that IRT not only decreases nightmare frequency but also improves overall sleep quality and reduces PTSD symptoms (Casement & Swanson, 2012). The robustness of IRT has been demonstrated even during stressful periods, such as the COVID-19 pandemic, making it a reliable treatment option (Sierro et al., 2020).
2. Exposure, Relaxation, and Rescripting Therapy (ERRT): Another effective method for treating chronic nightmares is Exposure, Relaxation, and Rescripting Therapy (ERRT). This therapy combines elements of exposure therapy with relaxation techniques and narrative rescripting, making it a comprehensive approach to addressing the underlying fears associated with nightmares (Cromer et al., 2022; Reiter & Humphreys, 2020). ERRT has been shown to alleviate nightmare distress and improve sleep quality in various populations, including veterans and psychiatric inpatients (Reiter & Humphreys, 2020). By integrating relaxation techniques, ERRT helps mitigate the physiological arousal that can exacerbate nightmares, thereby promoting a calmer sleep environment (Davis et al., 2011).
3. Pharmacological Interventions: For individuals with PTSD, pharmacological interventions can be a useful adjunct to therapy. Prazosin, an adrenergic antagonist, has been found to reduce the frequency of nightmares and improve sleep quality in PTSD patients (Gehrman & Harb, 2010; Harb et al., 2013). However, it's important to note that pharmacotherapy is often most effective when combined with psychotherapy, as this dual approach addresses both the physiological and psychological aspects of nightmares (Pruiksma et al., 2016; Harb et al., 2013).
4. Cognitive-Behavioral Therapy (CBT) Techniques: CBT techniques, including systematic desensitization and lucid dreaming therapy, have also been explored as potential remedies for chronic nightmares. These methods aim to modify the cognitive patterns and beliefs surrounding nightmares, which can contribute to their persistence (Holzinger et al., 2020; Gieselmann et al., 2019). Lucid dreaming therapy, in particular, empowers individuals to recognize when they are dreaming and take control of the narrative, potentially transforming distressing dreams into more positive experiences (Holzinger et al., 2020).
5. Sleep Hygiene and Lifestyle Modifications: Improving sleep hygiene is a fundamental aspect of managing chronic nightmares. Poor sleep quality, irregular sleep patterns, and sleep disorders such as sleep apnea can exacerbate nightmare frequency (Yu & Thompson, 2016; Stefani & Högl, 2021). Implementing good sleep practices—such as maintaining a consistent sleep schedule, creating a restful sleep environment, and avoiding stimulants before bedtime—can significantly improve sleep quality and reduce nightmares (Stefani & Högl, 2021). Additionally, managing stress through relaxation techniques, such as meditation or deep breathing exercises, can help reduce the occurrence of nightmares.

Conclusion

Chronic nightmares are a complex phenomenon with multiple contributing factors, including psychological disorders, emotional distress, sleep disturbances, and medications. Understanding these underlying causes is crucial for developing effective treatments. Fortunately, several therapeutic approaches, including Imagery Rehearsal Therapy, Exposure, Relaxation, and Rescripting Therapy, pharmacological interventions, and cognitive-behavioral techniques, have been shown to be effective in reducing the frequency and intensity of nightmares. Additionally, improving sleep hygiene and managing lifestyle factors can further help in alleviating chronic nightmares.

By addressing the root causes and utilizing evidence-based treatments, individuals suffering from chronic nightmares can significantly improve their quality of life, leading to better mental health and well-being. If you or someone you know struggles with chronic nightmares, consider exploring these treatment options with a healthcare provider to find the most suitable approach for your needs.

References:

Berlin, K., Means, M., & Edinger, J. (2010). Nightmare reduction in a vietnam veteran using imagery rehearsal therapy. Journal of Clinical Sleep Medicine, 06(05), 487-488. https://doi.org/10.5664/jcsm.27940

Casement, M. and Swanson, L. (2012). A meta-analysis of imagery rehearsal for post-trauma nightmares: effects on nightmare frequency, sleep quality, and posttraumatic stress. Clinical Psychology Review, 32(6), 566-574. https://doi.org/10.1016/j.cpr.2012.06.002

Cereza, G., Doladé, N., & Laporte, J. (2012). Nightmares induced by montelukast in children and adults: table 1–. European Respiratory Journal, 40(6), 1574-1575. https://doi.org/10.1183/09031936.00092812

Cromer, L., Pangelinan, B., & Buck, T. (2022). Case study of cognitive behavioral therapy for nightmares in children with and without trauma history. Clinical Case Studies, 21(5), 377-395. https://doi.org/10.1177/15346501221081122

Cromer, L., Stimson, J., Rischard, M., & Buck, T. (2022). Nightmare prevalence in an outpatient pediatric psychiatry population: a brief report.. Dreaming, 32(4), 353-355. https://doi.org/10.1037/drm0000225

Davis, J., Rhudy, J., Pruiksma, K., Byrd, P., Williams, A., McCabe, K., … & Bartley, E. (2011). Physiological predictors of response to exposure, relaxation, and rescripting therapy for chronic nightmares in a randomized clinical trial. Journal of Clinical Sleep Medicine, 07(06), 622-631. https://doi.org/10.5664/jcsm.1466

Gehrman, P. and Harb, G. (2010). Treatment of nightmares in the context of posttraumatic stress disorder. Journal of Clinical Psychology, 66(11), 1185-1194. https://doi.org/10.1002/jclp.20730

Gieselmann, A., Aoudia, M., Carr, M., Germain, A., Gorzka, R., Holzinger, B., … & Pietrowsky, R. (2019). Aetiology and treatment of nightmare disorder: state of the art and future perspectives. Journal of Sleep Research, 28(4). https://doi.org/10.1111/jsr.12820

Gill, P., Fraser, E., Tran, T., Collier, G., Jago, A., Losinno, J., … & Ganci, M. (2023). Psychosocial treatments for nightmares in adults and children: a systematic review. BMC Psychiatry, 23(1). https://doi.org/10.1186/s12888-023-04703-1

Haarman, M., Hunsel, F., & Vries, T. (2017). Adverse drug reactions of montelukast in children and adults. Pharmacology Research & Perspectives, 5(5). https://doi.org/10.1002/prp2.341

Harb, G., Cook, J., Phelps, A., Gehrman, P., Forbes, D., Localio, R., … & Ross, R. (2019). Randomized controlled trial of imagery rehearsal for posttraumatic nightmares in combat veterans. Journal of Clinical Sleep Medicine, 15(05), 757-767. https://doi.org/10.5664/jcsm.7770

Harb, G., Phelps, A., Forbes, D., Ross, R., Gehrman, P., & Cook, J. (2013). A critical review of the evidence base of imagery rehearsal for posttraumatic nightmares: pointing the way for future research. Journal of Traumatic Stress, 26(5), 570-579. https://doi.org/10.1002/jts.21854

Hasler, B. and Germain, A. (2009). Correlates and treatments of nightmares in adults. Sleep Medicine Clinics, 4(4), 507-517. https://doi.org/10.1016/j.jsmc.2009.07.012

Holzinger, B., Saletu, B., & Klösch, G. (2020). Cognitions in sleep: lucid dreaming as an intervention for nightmares in patients with posttraumatic stress disorder. Frontiers in Psychology, 11. https://doi.org/10.3389/fpsyg.2020.01826

Kennedy, K., Seixas, A., Jean-Louis, G., Killgore, W., Wills, C., & Grandner, M. (2021). 211 pandemic-related sleep changes associated with covid-related general, financial, food, housing, family and relationship stress. Sleep, 44(Supplement_2), A85-A85. https://doi.org/10.1093/sleep/zsab072.210

Levin, R. and Nielsen, T. (2007). Disturbed dreaming, posttraumatic stress disorder, and affect distress: a review and neurocognitive model.. Psychological Bulletin, 133(3), 482-528. https://doi.org/10.1037/0033-2909.133.3.482

Meador, C., Paquet, C., Cogan, C., & Davis, J. (2022). Implications of cognitive‐oriented language within posttrauma nightmare narratives. Applied Cognitive Psychology, 36(4), 864-873. https://doi.org/10.1002/acp.3976

Mindell, J. and Barrett, K. (2002). Nightmares and anxiety in elementary‐aged children: is there a relationship?. Child Care Health and Development, 28(4), 317-322. https://doi.org/10.1046/j.1365-2214.2002.00274.x

Pruiksma, K., Taylor, D., Wachen, J., Mintz, J., Young‐McCaughan, S., Peterson, A., … & Resick, P. (2016). Residual sleep disturbances following ptsd treatment in active duty military personnel.. Psychological Trauma Theory Research Practice and Policy, 8(6), 697-701. https://doi.org/10.1037/tra0000150

Reiter, H. and Humphreys, L. (2020). Exposure, relaxation, and rescripting therapy for trauma-related nightmares with psychiatric inpatients: a case series. Clinical Case Studies, 20(1), 3-21. https://doi.org/10.1177/1534650120953614

Schredl, M., Fricke-Oerkermann, L., Mitschke, A., Wiater, A., & Lehmkuhl, G. (2009). Longitudinal study of nightmares in children: stability and effect of emotional symptoms. Child Psychiatry & Human Development, 40(3), 439-449. https://doi.org/10.1007/s10578-009-0136-y

Sierro, C., Leslie, W., & Putois, B. (2020). Long-term effects of treatment for chronic nightmares: is imagery rehearsal therapy robust in the covid-19 pandemic?. Journal of Clinical Sleep Medicine, 16(11), 1993-1993. https://doi.org/10.5664/jcsm.8742

Simor, P., Horváth, K., Gombos, F., Takács, K., & Bódizs, R. (2012). Disturbed dreaming and sleep quality: altered sleep architecture in subjects with frequent nightmares. European Archives of Psychiatry and Clinical Neuroscience, 262(8), 687-696. https://doi.org/10.1007/s00406-012-0318-7

Stefani, A. and Högl, B. (2021). Nightmare disorder and isolated sleep paralysis. Neurotherapeutics, 18(1), 100-106. https://doi.org/10.1007/s13311-020-00966-8

Wittmann, L., Zehnder, D., Schredl, M., Jenni, O., & Landolt, M. (2010). Posttraumatic nightmares and psychopathology in children after road traffic accidents. Journal of Traumatic Stress, 23(2), 232-239. https://doi.org/10.1002/jts.20514

Yu, C. and Thompson, N. (2016). Sleep problems and the phenomenological factors of dreaming. Sleep and Hypnosis, 8-18. https://doi.org/10.5350/sleep.hypn.2016.180103