Need to know
Nightmares are an almost universal experience. They can begin as young as age two and a half, and the majority of adults report having nightmares at least occasionally. While many people have infrequent, one-off nightmares, many others have repeated nightmares with a common theme or focus. As you can see in the following illustrations, there is considerable variety in the content and impact of nightmares; do any of these seem similar to your experiences?
- Work has been very stressful for you, and you have a nightmare in which you accidentally send an important email before you were supposed to. You awaken with a pounding heart, shortness of breath and intense fear. You reassure yourself that the events in the dream aren’t real, but you spend a while thinking about whether you made any recent mistakes that might get you in trouble.
- More than once, you’ve had a nightmare in which your sibling has died in a car accident. In the dream, you receive the call and have to console their partner and children. You feel panic, fear and deep sadness. Upon awakening, you feel upset and afraid, but also relieved that the loved one is alive. While this nightmare hasn’t been too disruptive to your sleep, you wish you never had to experience this grief again, even if its source is imaginal.
- You wake up in a panic after a recurring nightmare that resembles a traumatic experience you’ve had in real life. Right when it’s almost unbearable, you wake up in a sweat, the images sharp in your mind. When it happens, you are upset and awake for more than an hour, sometimes the rest of the night. You dread going back to sleep. You are starting to delay your bedtime and watch TV late at night as a distraction. You’ve noticed yourself feeling fatigued and tense during the day.
Nightmares can be disruptive and draining
A nightmare is an intensely disturbing, well-remembered dream, usually involving fear or anxiety, but potentially also anger, sadness, disgust or other distressing emotions. Nightmares commonly involve threats to security, physical integrity, or survival. Most nightmares occur during rapid eye movement (REM) sleep, which predominates in the latter part of the sleep period. Unlike most dreams, nightmares disrupt the sleeping period, and the dreamer is alert soon after awakening. (Some night-time disturbances, such as sleep terrors, resemble nightmare awakenings but differ in important ways; I’ll discuss these in the Learn More section below.) These night-time disruptions often seep into the day. They can be associated with increases in daytime anxiety and physical complaints, as well as fatigue, sleepiness, mood and attentional problems due to interrupted, unsatisfying sleep.
Nightmares that persist may result in the diagnosis of a sleep disorder. Nightmare disorder, as defined by American Academy of Sleep Medicine, involves repeated occurrences of nightmares that result in ‘clinically significant distress or impairment in social, occupational, or other important areas of functioning’. It is estimated to affect 4 per cent of adults.
In my work as a clinical psychologist specialising in anxiety and sleep problems, I have found that many people who struggle with nightmares lack important information about this common human experience. If you have experienced troubling nightmares yourself – whether they are occasional and relatively moderate in intensity, or more frequent or severe – this Guide will help you get a better grasp on how to cope with them, and how to seek effective help if needed.
Common risk factors for disruptive nightmares
Some people are more likely than others to experience problematic nightmares, including those with anxiety, depression, substance use disorders, and certain other mental health conditions. In some cases, nightmares stem from a traumatic experience, and they may include content and themes from the traumatic event. Nightmares are so common in post-traumatic stress disorder (PTSD) that they are included as part of its diagnostic criteria. Childhood adversity may also predispose a person to nightmares by disrupting the normal development of emotion regulation. People who tend to remember dreams more vividly can be at a higher risk for being nightmare prone. While you may not be able to control these risk factors, knowing you have one or more of them might help you better understand why you’re more likely to experience nightmares, and have greater compassion for yourself.
In the short term, nightmares can be triggered by anxiety and stress. Substance use or withdrawal can precipitate nightmares, and some medications (eg, certain antidepressants, beta blockers, blood pressure medications, and others) can increase their likelihood. Obstructive sleep apnoea, as well as other irregular sleep patterns and insomnia, can increase the risk, too.
Nightmares that persist may need targeted support
In general, the occasional, infrequent nightmare is not a problem. It is also normal and expected for distressing dreams and some disruptive nightmares to provide information and play a role in emotional processing following a significant stressor, trauma or loss. When a source of stress in one’s life has been alleviated or processed, nightmares may diminish. However, if a pattern of nightmares becomes entrenched and persists for months, resolving the underlying emotional or stress-related problem may not cure them; the nightmares may need to be addressed directly. When I worked with patients for the US Department of Veterans Affairs, for example, I saw several veterans with PTSD, some of whom had completed at least one trauma-focused therapy but were still experiencing frequent nightmares.
Sleep scientists have hypothesised mechanisms that may drive nightmares to become persistent and problematic once they have begun. Among these mechanisms, which can be directly addressed, are: attempts to suppress negative thoughts and feelings; going to bed feeling stressed, fearful and tense; worries or frustration about sleep; intense distress upon awakening from a nightmare; habits that interfere with sleep quality more generally (eg, falling asleep with the TV on); and even the brain’s expectation of a particular nightmare ‘script’ upon falling asleep.
There are steps you can take to alleviate nightmares
Fortunately, there are multiple approaches to reducing the impact of nightmares on your sleep and daytime functioning. I’ll briefly describe some of the treatment modalities that help inform the suggestions in this Guide.
In imagery rehearsal therapy (IRT), the first-line treatment for nightmare disorder, people use their imagination to envision a new ending to a problematic nightmare script. For example, if someone has a dream in which a stranger chases them down, then each day they might vividly imagine a new, potentially more positive ending, such as running into the arms of a dear friend. Research and clinical experience indicate that this approach can help many nightmare sufferers. The content of the nightmare itself might change into the rehearsed imagery or to something else completely; frequently, the content stays similar but diminishes in intensity. IRT is a brief treatment, and has been used to treat nightmares in many populations, including for trauma-related nightmares associated with PTSD from combat, sexual assault and childhood sexual abuse.
Cognitive behavioural therapy for insomnia (CBT-I) can be used to treat nightmares as well. CBT-I helps people improve sleep quality such that they may sleep through dreams and not awaken with a nightmare. It also incorporates aspects of relaxation and thinking more helpfully about sleep and dreaming. For individuals with PTSD-related nightmares, an approach called exposure, relaxation and rescripting therapy (ERRT) may be used. It is a modification of IRT that incorporates more written or oral exposure to the nightmare content, identifies common trauma themes in the nightmare content, and has an increased focus on relaxation practices.
In the rest of this Guide, I detail tools from these evidence-based treatments that have been helpful to many of my clients in responding more adaptively to nightmares, building mental and physical relaxation skills, and increasing healthy sleep. If you attempt these approaches and are not seeing much benefit – or you would like more direct support – I recommend that you speak with your doctor about your concerns and/or reach out to a sleep specialist. If your nightmares are severely disrupting your sleep, if you struggle to experience them as dream imagery rather than as a traumatic experience, or if you have experienced self-harm or thoughts of suicide, you will want to do these practices with professional support (see the Links and Books section below for more information on finding treatment providers).
After assessing the current state of your sleep and nightmares, you can try the recommendations stepwise, as any of them might be enough to knock the nightmares off course, or you might benefit from using them all.
What to do
Assess the frequency and intensity of your nightmares
If you don’t know where you’re beginning, you’ll have a hard time gauging your progress. So, before you make any changes to your sleep, jot down the answers to the following questions, and the date on which you answered them. You can continue answering these questions once every week to track your experience as you start making changes:
- How many nightmares, in total, do you recall having over the past week?
- In the past week, how many nights did you have at least one nightmare?
- On a scale from 1-10, where 1 is ‘not distressing’ and 10 is ‘extremely distressing’, how would you rate your nightmares (on average) in the past week? How about the highest level of distress? And the lowest?
- In the past week, how long do you estimate it has taken you to fall back asleep after a nightmare (on average)? Longest time awake? Shortest?
Some additional questions that it might be helpful to answer at the beginning are:
- How long have you been struggling with nightmares? Have they increased or decreased over time? How have they impacted your sleep?
- Have you noticed anything that seems to contribute to an increased frequency of nightmares (eg, medication, stress, arguments, depressed mood, anniversary of a trauma or loss, etc)?
- Is there a repetitive dream involving the same content that you would like to focus on, or perhaps dreams with different content but the same themes?
If you work with a sleep specialist, they will likely have you record a daily sleep diary each morning to get even more specific data about your sleep and nightmares. Typically the sleep diary is kept for about a week before starting any treatment intervention, and continues during the course of treatment. If you are interested in assessing yourself in more detail than the basic weekly questions, you can track your sleep and nightmares using a daily log such as this one.
Create a ‘cope ahead’ plan for when a nightmare wakes you
Just as forming a plan for emergencies can help you act effectively during a crisis, it’s useful to have a plan for when you’re jolted awake by a nightmare.
Below are some foundational elements for a ‘cope ahead’ plan. It is helpful to write a summary version to review each night at bedtime. Ideally keep the summary on a piece of paper (not an electronic device) near your bed so you can review it upon waking up from a nightmare.
- Resist acting on the urge to confirm your safety or to analyse your nightmare. You may wake up from a nightmare with unpleasant sensations like dizziness, sweating, rapid heart rate, or changes in breathing. Your feelings, combined with the disturbing content of your nightmare, might seem in that moment to confirm that you are in danger. You may feel a strong pull to do something to reassure yourself, such as checking on family members (if the nightmare was about a loved one), checking the house (if it was about aggression or danger), trying to stay awake in order to avoid another nightmare, or thinking intently about what the nightmare meant. But these responses confirm to your brain that the nightmare was indeed dangerous and requires your attention and action. Instead, turn to coping thoughts and soothing skills (detailed below).
- Prepare one or more coping thoughts. It is important to remind yourself that nightmares are not dangerous, even if they feel dangerous. Recalling a simple mantra – eg, ‘I was having a nightmare, and nightmares are not dangerous’ – may help lower the distress you feel upon awakening. Some other examples of helpful coping thoughts are ‘I had a bad dream, but nothing bad is happening right now’ or, for those who have had a traumatic experience, ‘I am having a bad dream, but I am not experiencing the trauma again.’
- Ground yourself in the present moment. To further remind yourself that the nightmare content is not real, you can do a ‘5-4-3-2-1 exercise’ to bring yourself into the present moment using your senses. You can identify five things you can see (eg, a lamp next to the bed, a book), four things you can feel (eg, a soft pillow, your shoulder), three things you can hear (eg, a partner’s or a pet’s breathing, the wind outside), two things you can smell (eg, lotion, a pillow) and one thing you can taste (eg, toothpaste, or a general bitter taste).
- Calm your physiology. Any slow, relaxed breathing triggers the brain to let go of anxiety. I personally like soothing rhythm breathing. In this exercise from compassion focused therapy, you breathe with the intention of finding a slow, gentle pace that feels soothing and comforting to you, and with an intention to be kind to yourself. When your mind wanders, gently return to noticing your soothing rhythm. (For an audio instruction in this practice, see the Links and Books section below.) More simply, any breathing that involves exhales that are slower than inhales can de-escalate the stress system; so, you might breathe in for 5 (counting slowly in your mind), pause at the top, and exhale slowly for 7 counts, then repeat. You’ll want to breathe into your belly, so either put your hand on your belly to feel it moving in and out, or you can put a soft item on your belly and watch it rise and fall.
Improve your pre-sleep routine to make awakenings less likely
When sleep is consolidated, meaning relatively uninterrupted and restful sleep, you are less likely to wake up during the REM sleep stage in the latter part of the night when nightmares are more common. The following recommendations for an improved sleep routine will increase the possibility of sleeping through bad dreams.
- Work on your sleep timing. Get into bed when you are sleepy (eg, eyes starting to close, yawning), not before. One of the biggest pitfalls for people with sleep difficulties is going to bed when they think they should sleep versus when their body is ready to sleep. When you are sleepy, your body has been awake long enough that there is sufficient pressure to sleep in your brain. The more pressure, the more likely it is you will fall and stay asleep. Plan to rise at the same time each day – within 15 minutes of waking up – and get some sunlight in your eyes for about 20 minutes to help set your internal clock. If you do have a nightmare and get less sleep on any given night, rise at the usual time the next morning (do not compensate by spending more time in bed), and really build your sleep pressure by staying up until your normal bedtime.
- Adopt a calming bedtime routine. Create a buffer between your day and your sleep. Choose three things that are likely to be relaxing without putting you to sleep, and plan to practise them in the same order each night for a week. Start this routine about 30-60 minutes before bed. Things my clients like to put in their buffer-zone routine include watching a relaxing TV show (though not in the bedroom), a washing/brushing routine, gentle stretching, reading for fun, a mindfulness or relaxation exercise, folding clothes, or laying out their outfits for the next day.
- Turn the lights off when you go to bed. Some people I’ve worked with think that, since they have nightmares when their bedroom is dark, it might help to leave the light or the TV on overnight. However, doing this can actually decrease your sleep quality and increase nightmares. Watching TV or even reading in bed can confuse your brain as to what the bed is for, reducing the association between the bed and sleep, which reduces sleep quality. Light and noise may also lead to disrupted and poorer-quality sleep. As a general rule, use the bed only for sleep and sex. (To help you transition, you may want to start by leaving on just a nightlight, a white noise machine, or an audiobook that automatically turns off after 15 minutes.)
- Do not avoid sleep. With fear and trepidation about their nightmares, some people think: ‘If I’m dreaming too much, I’ll just limit my sleeping time.’ If you’ve seen the horror movie A Nightmare on Elm Street (1984), you might be tempted to follow the advice: ‘Whatever you do, don’t fall asleep.’ Unfortunately, not only can limited sleep impair your functioning during the day, it can bring on an ‘REM rebound’, increasing the likelihood of dreams (including nightmares).
- Reduce or eliminate alcohol use. Some people notice that when they drink alcohol, they feel sleepy, and perhaps think that they will not remember their nightmares. But alcohol can make nightmares more frequent. It increases REM rebound sleep and sleep fragmentation during the second half of the night, when nightmares most frequently occur. You may want to start by reducing your use, and/or moving any use earlier in the day to see if it impacts your sleep and nightmares.
- Write about worries and difficult emotions during the day. If you worry at night or in your bed, set aside time during the day to write about what you’re feeling, reasons why you feel that way, and how you might cope with these worries. By doing some of this thinking during the day, your mind may have less to process at night. Furthermore, if you notice yourself wanting to worry or plan once in bed, you can take a deep breath and remind yourself that you can write about your feelings the next day – so, bedtime is a period when you can allow your body to rest.
Take up a daytime relaxation practice
Since tension and stress in the body may contribute to the persistence of nightmares, it’s advisable to have a regular practice that promotes relaxation. If you already have one that you are comfortable or familiar with, such as a breathing practice, meditation or body scan practice, you can use that.
One technique that has been used in nightmare treatments is progressive muscle relaxation. If you’d like to start this practice, it is important to do so initially when you are feeling calm. Practise daily, during the daytime, for 10-20 minutes in a chair or lying on a yoga mat or blanket. Once you’re comfortable with the practice, it can be used before bed.
In this practice, you purposely tense particular muscles in order to then relax them:
- Start with a specific muscle group, such as the muscles of your shoulders. Take a slow breath, squeeze the muscles (ie, shrugging your shoulders up toward your ears), tight but not so much as to cause a cramp. Notice the tension building in your body for about 5-10 seconds, and pause. Then, stop squeezing and let go of the tension. As you let go, you can say a soothing word if you’d like, such as ‘relax’ or ‘calm’.
- For about 20 seconds, focus on the difference between the state of tension and the more relaxed state you feel after releasing.
- Go through the major muscle groups in this way, including those in your upper and lower arms, abdomen, upper and lower legs, and face (which you can separate into jaw, eyes and forehead).
This relaxation exercise may be challenging at first, and you might feel frustrated or even more anxious initially. It could be difficult to notice the difference between tension and relaxation. Successful practitioners stick with the practice daily for at least a week to two weeks before deciding whether to keep at it (and before trying it when they are feeling tense or anxious). I advise that you keep a record of each practice, including your relaxation level at the start and end of the exercise on a scale from 1-100, to help you notice any improvement. (The Links and Books section below contains some further resources related to progressive muscle relaxation.)
Practise building imagery skills
If you’ve been having repeated nightmares, the use of strong mental imagery can enable you to take some calm control over your nightmare experience – as I’ll discuss in the next and final exercise. Anyone who can imagine a red rubber ball (eg, its size, colour and texture, the smell of rubber, the sound as it bounces) can do imagery exercises.
To strengthen your imagery ability, practise with pleasant, vivid imagery for a couple of weeks. This could coincide with starting to gather baseline information about your sleep and dreaming experiences, discussed in the first step of this What to Do section.
When I introduce someone to guided imagery, I typically lead them through a 10-minute forest or beach scene. This starts with taking a few deep breaths. Then, you notice that you are in a forest (in this example), and begin to imagine the sounds of birds or wind; the feeling of the sun on your face and hands; the firm dirt path underneath your feet; and the smell of flowers, dirt, trees, etc. (For examples of audio-based guided imagery exercises, see the Links and Books section, or search ‘guided imagery’ on YouTube.)
Once you understand the general idea, you are going to create your own pleasant scene that is personal to you. Start with a piece of paper and, at the top, jot down an activity that you enjoy and find soothing (eg, walking on the beach, gardening). Then, close your eyes, or keep a soft gaze ahead of you. Calling the activity to mind, imagine details of the scene such as what you are wearing, what the temperature is like, what you see around you, what you hear, what you smell, whether you are touching anything, and what feelings you have (eg, relaxed, warm, calm). When you open your eyes, write on the same piece of paper a brief description of the sensory details you imagined.
Set aside 2-5 minutes of uninterrupted time each day, for one week, to practise imagery (maybe after or before a relaxation exercise). Block off the time on your calendar. When you’re ready to practise, make yourself comfortable, bring your personal image to mind, and augment it with sensory details, occasionally noticing any pleasant internal body sensations and emotions while doing so. It may not always be easy to concentrate. If you get distracted, including by any negative images that pop up, take a deep breath, exhale and let the distraction go, and then return to the pleasant image.
At the end of the first week of trying imagery, review. Did anything get in the way of completing the practice? Do you need to make any changes so that it is easier for you the second week? After reviewing, schedule and proceed with a second week of daily imagery practice.
Rescript your nightmares
Nightmares are stories with a beginning, middle and end, told with images. Anyone who can engage in pleasant imagery can practise nightmare rescripting, which includes rewriting and then vividly reimagining a new ending to a recurring nightmare. You can change the ending of the nightmare in any way that you wish, although based on my training I’ll offer some ideas for how to generate a helpful new ending. Although it’s uncommon, if you notice any worsening of your sleep or nightmares, you will want to discontinue the practice and reach out for professional help.
If you have only the infrequent nightmare, or if you are still reeling from a recent stressor or loss, this exercise would be premature. This skill is used for entrenched, repetitive nightmares, whether it is the same nightmare each time, or variable content involving similar themes. For milder or infrequent, more acute nightmares, still use the other coping, relaxation and sleep health skills.
To start rescripting practice, begin by identifying your most frequent or most distressing nightmare. If this seems too daunting, you can start with something less intense (eg, a nightmare that does not seem like a replay of a trauma memory) and then move to a more intense nightmare when you feel ready.
- In writing, briefly sketch the sequence of the nightmare and any thematic elements. Note the part of the sequence when the most distressing emotions seem to show up, or where you are the most bothered, as right before this point is when the story is going to take a new turn. If the distressing content is at the very beginning of the nightmare, you will instead want to note something from the nightmare’s content (eg, a sound, a colour, something in the background) that you can use as an anchor to allow your brain to know which dream script is being activated.
- Generate some ideas for how to plan your new ending. In order to do this, first write down the emotions you recall experiencing at the most distressing part of the nightmare. (‘My emotions are… eg, fear, helplessness, guilt, hurt, loss, anger, betrayal, loneliness, horror, etc.)
- Then write down what these emotions seem to tell you about what is important to you. (‘My values are…’) For example, your predominant emotions in the nightmare might be fear and helplessness, due to worrying about someone else’s safety; in that case, you might identify values such as loyalty, compassion, connectedness, protectiveness or caring. Another example would be a dream in which you are chased and feel terror; perhaps you identify valuing things such as survival, security or calm. There are many other potential values that might come to mind, including but not limited to, justice, safety, trust, friendship, worthiness or healthy boundaries.
- In addition to thinking about what you value, you can also write down special interests and hobbies that bring you feelings of pleasure or peace. The new ending will be more effective if it is consistent with your values, and if it includes things that are personally meaningful to you.
- Write out your new dream in the first person, present tense. Start with the beginning of the nightmare, prior to the onset of any distressing content, if possible, or with the ‘anchor’ detail you have identified. Now, having foreknowledge of an impending threat, vividly write a new ending to your dream in which you feel calm, competent and in control – using your values and interests as a guide. Vivid sensory details, humour and creativity are optimal. Feel free to make it fantastical. Avoid any violent content, and limit movement in the new ending to promote calm and relaxed imagery. You will want this new sequence to be long enough that, when you vividly imagine it, it could take approximately 10 minutes.
- You will then engage in daily practice. When you begin, take some slow breaths and allow yourself to relax. This brief relaxation is important to set the tone for the imagery. You may even want to use your regular relaxation practice right before you start. Then, rehearse the new dream in your mind’s eye, seeing it as a movie (not a photograph), using your multisensory imagery skills to master your new ending. The key is consistent practice, so make a commitment to practise this for at least 10-20 minutes every day for a month, before bed or at another time of your choosing. Remind yourself why you are making this commitment. Put it in your calendar, and troubleshoot anything that interferes with your being able to practise so that you can stick with the plan.
As you proceed with your rescripting practice, remember to revisit your baseline assessment questions every week. Are you noticing any reductions in distress? Greater ease in falling back asleep? Fewer nightmares per week? Some treatment providers suggest it can take up to four weeks of daily practice to see clinically significant changes, although most people will notice some change in one to two weeks. Whenever your answers to your assessment questions become satisfactory for you (eg, some people are OK with the occasional nightmare or nightmares that are easier to fall back asleep after), you can stop practising your imagery daily. I would still encourage you, even then, to maintain ongoing healthy sleep and relaxation practices.
If you do not see significant improvement after a few weeks of nightly relaxed practice with your creative new ending, develop a new revised ending and practise that one. Most people benefit from their first revised ending, but some may need a second. If you continue to notice no benefits from this practice, or are struggling to implement it, reach out for professional support.
To end this Guide, I will give an example of how this rescripting can work. I once treated a veteran with military combat trauma who had post-traumatic nightmares. (Details of his story have been changed here to protect his privacy.) In implementing this approach, he realised that the fear and horror he experienced in the nightmare reflected that he valued caring for other people’s safety and wellbeing. This veteran also shared that he loved cooking; it was meaningful to him. In rescripting his dream, he began his revised dream script with a part of the nightmare in which he was driving through streets in Iraq with his unit, to activate the dream script. Then, rather than revisiting the distressing combat content that followed, he imagined feeling calm and in control, with the gift of foreknowledge of a pending threat. From there, he imagined a new, detailed ending that creatively and magically removed him and the other service members from the area, before any combat happened. He transported them all to his favourite lake, where he imagined, with all of his senses, cooking a sensory and savoury meal that they all enjoyed together.
This person used meaning-making, creativity and imagery to disrupt and weaken the stuck nightmare script, reducing the intensity and frequency of his nightmare. As a reminder, a revised script might end up playing out in one’s actual dreams the way it’s been written, but it doesn’t necessarily have to in order to disrupt the nightmare and have a positive impact. My hope is that this approach is as helpful for you as it was for this person – and that you will proceed confidently knowing that there are practices you can use during the day that will benefit your sleep and dreams.
Key points – How to calm your nightmares
- Nightmares can be disruptive and draining. These disturbing, well-remembered dreams interrupt the sleeping period and can be associated with daytime anxiety, fatigue and other problems.
- There are steps you can take to alleviate nightmares. Mental imagery, relaxation and other strategies employed in psychological treatments can reduce nightmares’ negative impact on mental health.
- Assess the frequency and intensity of your nightmares. Keeping a weekly record allows you to notice changes in your experience of nightmares and awakenings as you try new ways of dealing with them.
- Create a ‘cope ahead’ plan for when a nightmare wakes you. Adopt a set of coping thoughts and/or calming exercises to help you manage the distress that immediately follows a nightmare.
- Improve your pre-sleep routine to make awakenings less likely. Prepare yourself for sounder sleep by adopting relaxing rituals before bed, going to bed only when you’re sleepy, and ensuring the lights and TV are off.
- Take up a daytime relaxation practice. An exercise such as progressive muscle relaxation can reduce the physical tension and stress that may contribute to nightmares.
- Build your imagery skills. Create a pleasant, multisensory scene and practise imagining it each day for a couple of weeks to prepare for nightmare rescripting.
- Rescript your nightmares. If you’ve had repetitive nightmares, you can brainstorm a new, positive ending in vivid detail – and then mentally rehearse it each day, using your imagery skills.
Nightmares versus other sleep problems
While nightmares are among the most common sleep disturbances, there are other, somewhat similar ones that can also warrant support-seeking – but which are addressed in different ways.
One way to differentiate between a nightmare and other night-time disturbances is whether the dream content is well remembered upon waking. Sometimes people who wake up with a sudden rush of fear are having a nocturnal panic attack. Waking up with nocturnal panic involves the physiological arousal common in a nightmare, but not the remembering of a corresponding dream. Nocturnal panic attacks are associated primarily with panic disorder, although they can occur with other anxiety disorders or mental health concerns. In this experience, the mind goes to the sorts of thoughts that are typical of panic attacks, such as ‘maybe I’m having a heart attack’, ‘maybe I’m going crazy’, or ‘maybe I’m about to lose control’.
Another point of distinction is whether one is awake and alert during the sleep disturbance. Like nightmares, sleep terrors can have signs such as rapid heart rate, fast breathing and sweating. However, when having these experiences, the sleeper is hard to awaken and, if they do wake up, typically they will be quite confused and difficult to comfort. A person who has had one of these experiences may or may not remember dream content, or even a conversation had during the experience. Sleep terrors typically occur in the first half of the night, when non-REM sleep predominates, and may be more upsetting for a bed partner or parent than the person experiencing them.
Untreated obstructive sleep apnoea, a common sleep-related breathing disorder, is a risk factor for nightmares. Anyone with risk factors for sleep apnoea (eg, loud snoring, feeling sleepy or falling asleep during the day, a witnessed pause in breathing during sleep, larger body size, high blood pressure, age greater than 50) should see a health care provider. They may prescribe a diagnostic test to determine whether treatment for this problem is in order.
If someone is acting out their dreams with complex motor movements, this is not a nightmare disorder. When the body is active during dreaming sleep, it may indicate a disorder of REM sleep called REM sleep behaviour disorder. It can be quite serious and requires diagnosis and monitoring. It is typically uncovered starting when a bed partner notices that the person is moving in their sleep; some people might find themselves out of bed in the morning.
Anyone who thinks they may suffer from one of these sleep problems should ask their doctor if they can be referred to a sleep specialist or specialty sleep clinic. Please see the Links and Books section for websites that have lists of certified providers and centres.
Links & books
The website of the Society of Behavioral Sleep Medicine has an international directory of individual providers who are board-certified in behavioural sleep medicine (you will see ‘DBSM’ after their name).
The website Sleep Education is a resource for people looking to learn more about sleep treatments or to schedule an appointment with a physician who is a sleep specialist in the United States. It includes a searchable list of healthcare centres accredited by the American Academy of Sleep Medicine.
For more information on progressive muscle relaxation, there is a great chapter on ‘Learning to Relax’ in the book Mastery of Your Anxiety and Worry (2nd edition, 2006) by Michelle Craske and David Barlow. The app Insight Timer also offers guidance in progressive muscle relaxation, as well as other mindfulness meditations.
The app CBT-i Coach offers a sleep diary and helpful education about sleep, and it may be of interest when you are adjusting your sleep routine.
The ‘Nightmares and Treatment’ (2023) episode of The Matt Walker Podcast shares further information about IRT, including new adaptations of the treatment approach.
If you are experiencing a mental health crisis or having thoughts of suicide, the following resources offer support:
In Australia, the crisis support service Lifeline is 13 11 14.
Other international helplines can be found at www.befrienders.org