Nightmares and PTSD

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, a rape survivor might experience disturbing dreams about the rape itself or some aspect of the experience that was particularly frightening.

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.


How are nightmares related to PTSD?

A person 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.

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.


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.