Nightmares in Adults: Causes and What Helps

Adult nightmares are treatable, and the treatment with the best evidence behind it is not a drug. It is a short psychological technique in which you rewrite the nightmare while you are awake and rehearse the new version, and the American Academy of Sleep Medicine’s position paper on nightmare disorder recommends it. [morgenthaler-2018-aasm-nightmares]

Almost nobody arrives knowing this. Nightmares tend to be treated as weather, something that happens to you and that you wait out, which is why people put up with them for years.

Why adults get nightmares

Nightmares in adults are linked to several distinct things rather than one. Trauma is the most studied of them, and distressing dreams are among the most stubborn symptoms that follow it, but nightmares are not exclusively a trauma symptom and treating them as one is part of why they go unmentioned.

The other common associations are depression, anxiety and insomnia, alcohol, particularly in the days after heavy drinking, and certain medications, including some antidepressants and some blood pressure drugs. Fragmented sleep makes all of it worse for a mechanical reason: most dreaming happens in the later stretches of the night, so a night broken repeatedly is a night spent starting and stopping in exactly the phase where nightmares occur.

They are also more common than their absence from conversation suggests. A study drawing on 69,813 Finnish adults found that 3.5 percent of men and 4.8 percent of women reported frequent nightmares. [sandman-2013-nightmare-prevalence]

When nightmares become a disorder

The threshold is daytime cost, not a count of bad dreams. Nightmare disorder is defined by repeated distressing dreams that you remember on waking and that produce significant distress or impairment, which means the deciding evidence is what the nightmares are doing to your waking life.

The clearest version of that impairment is dread of sleep itself. People start going to bed later, keeping the television on, drinking to get under, or waking at a fixed hour and refusing to go back down. That behaviour is where the real damage accumulates, because it converts a nightmare problem into a sleep-deprivation problem on top of it.

Frequency alone is a poor guide. One recurring nightmare a fortnight that has made somebody frightened of their own bedroom is a bigger clinical problem than four unpleasant dreams a week that are forgotten by breakfast.

Imagery rehearsal therapy: rewriting the dream

Imagery rehearsal therapy is a short treatment in which you deliberately change a nightmare while awake and practise the new version until it is familiar. It is usually delivered in a handful of sessions, it involves no exposure to the original nightmare at night, and the daily practice takes minutes rather than hours.

The procedure is unglamorous. You write out a recurring nightmare in detail, then change it however you like, most commonly by giving it a different ending, though any change counts and people often alter something early instead. You then rehearse the rewritten dream in your imagination for a short period each day, in the same way you would rehearse a speech.

What you do not do is try to steer the dream while it is happening. That is a different practice, and our guide to lucid dreaming covers it. Imagery rehearsal works entirely in waking hours, which is one of the reasons it is straightforward to teach.

What the evidence actually shows

The trial evidence is strong for something this simple. A randomised controlled trial published in JAMA in 2001, in 168 women with chronic nightmares and post-traumatic stress disorder, found large reductions in the number of nights per week with nightmares and in the number of nightmares per week, along with improved sleep and reduced post-traumatic stress symptoms, while the control group showed only small changes. [krakow-2001-irt]

It is not a single-study finding. A meta-analysis of thirteen clinical trials of imagery rehearsal for post-trauma nightmares reported large effects on nightmare frequency, sleep quality and post-traumatic stress from baseline to post-treatment, sustained through six to twelve month follow-up. The same analysis found that combining imagery rehearsal with cognitive behavioural therapy for insomnia improved sleep quality more than imagery rehearsal alone. [casement-2012-irt-meta]

Two limits are worth stating plainly. Much of this evidence comes from people whose nightmares follow trauma, so it is better established there than for nightmares with no identifiable cause. And a reduction is not an ending: trials report large decreases in frequency rather than the disappearance of every bad dream.

The small slice is the one clinical attention goes to, and it is still several people in every hundred. That is the point worth taking from the figure: frequent nightmares are a minority experience and not an unusual one.

No screener on this site measures nightmares. The insomnia screener listed on that hub uses a validated instrument for insomnia, so it is worth taking only if your larger problem is sleep that will not come or will not hold, and a score on it says nothing about nightmares either way.

What medication does and does not offer

Medication has a smaller role here than most people expect. Several drugs are used for nightmares, particularly where post-traumatic stress disorder is involved, but the position paper on nightmare disorder in adults treats most of them as options that may be used rather than as recommended treatments, while recommending imagery rehearsal therapy. [morgenthaler-2018-aasm-nightmares]

There is a second, more immediately useful medication question, which runs in the other direction. Some drugs prescribed for other conditions increase vivid dreaming, including certain antidepressants and some drugs used for blood pressure. If your nightmares began within weeks of a new prescription or a dose change, that timing is worth raising with the prescriber. Never stop a prescribed medication on your own to test the theory.

Alcohol deserves its own mention because it is so often the accidental treatment. It shortens the time to fall asleep and then disrupts the second half of the night, which is the half where dreaming concentrates, so using it to avoid nightmares reliably produces more of them.

What to do tonight

Start with the two things that need no appointment: a fixed wake time and less alcohol in the evening. Nightmares cluster in the later hours of sleep, so anything that fragments the back half of the night gives them more opportunity.

Then write the nightmare down in the morning rather than trying to hold it in memory, and write a changed version beside it. Doing this on your own is a reasonable first step, and it is the same operation the formal treatment uses, though without a clinician to work out which nightmare to start with when there are several.

Keep the bedroom for sleeping and get up if you have been lying awake more than about twenty minutes, which is standard advice from our overview of sleep and mental health. Our guide to relaxation techniques for sleep covers what to do with the wakeful stretch afterwards, which for people with nightmares is often the hardest part of the night.

When to seek help

Speak to a doctor if nightmares are happening most weeks and you have started avoiding or delaying sleep because of them. That combination is what turns a nightmare problem into a sleep-deprivation problem, and it is the version that reliably damages the daytime.

Ask about imagery rehearsal therapy by name. It is short, it has the strongest evidence of the available treatments, and it is frequently not offered unless the patient raises nightmares specifically, because nightmares tend to be recorded as a symptom of something else rather than as the thing to treat.

Mention any recent medication changes at the same appointment, and be straightforward about alcohol, since both are common contributors and both are simple to address once they are on the table.

Go urgently if you have thoughts of harming yourself. Contact your local emergency services or a crisis helpline.

How MyFreud can help

The information that makes this appointment productive is a record of what your nights are actually doing, and it is close to impossible to reconstruct after the fact. MyFreud gives you daily mood tracking that shows the pattern over time, so the link between a bad week and a bad run of nights is visible rather than remembered.

The guided reflections are also a reasonable place to do the writing half of the work. Getting the nightmare out of your head and onto a page in the morning is the step the formal treatment starts with, and it is easier to keep up when there is somewhere to put it.

Download MyFreud and start today: App Store or Google Play.