Nightmare Disorder: Symptoms, Causes, & How to Treat It

What Is Nightmare Disorder?

Nightmares disorder is more than a string of bad dreams. While there are similarities, the disorder wakes you up out of a sleep state routinely, leaving you with the lingering fear inspired by the dream. It happens so often that you wake up tired the next morning and cannot get a whole night of sleep without these distressing dreams.

Nightmare disorder is a form of parasomnia, a sleep disorder that involves unwanted behaviors or experiences when you’re falling asleep, sleeping, or rousing from sleep. Nightmares can happen at any time during the sleep cycle. However, they occur most frequently during rapid eye movement (REM) sleep. REM sleep is crucial for memory processing and cognition. When REM sleep is compromised, it can leave you tired and exhausted the next day and more likely to experience further nightmares.¹

According to the DSM-5, nightmare disorder is distinguished based on the nightmares’ frequency and severity. However, the DSM classification does not include the intensity or level of scariness of the dream.

Nightmare disorder frequency may be classified as:

• Acute: Acute nightmare disorder means the duration of nightmares is less than or equal to 1 month.
• Subacute: Subacute nightmare disorder has a duration of nightmares from 1-6 months.
• Persistent: Persistent nightmare disorder requires a duration of nightmares greater than 6 months.

The severity of nightmare disorder may be classified as:

• Mild: In mild nightmare disorder, you experience less than 1 episode per week.
• Moderate: For moderate nightmare disorder, you experience 1-6 episodes per week.
• Severe: If you have severe nightmare disorder, you have episodes every night.¹

Symptoms of Nightmare Disorder

A person suffering from nightmare disorder will experience common symptoms of insomnia, along with general anxiety about sleeping. Insomnia and anxiety can impact a person’s daily life, relationships, commitments, and especially their nighttime routines, as it can perpetuate restlessness and worry around sleep, potentially triggering nocturnal panic attacks.

Common symptoms of a nightmare disorder include:

• Brain fog
• Extreme fatigue
• Difficulty concentrating
• Poor daytime emotional regulation
• Memory lapses²

Causes of Nightmare Disorder

Identifying the cause of nightmares is not a perfect science. However, it’s widely accepted that the events, feelings, and situations we experience during the day can contribute to dreams and nightmares. We also know that dreams can be a catalyst for us to process emotions. Subsequently, it’s believed that nightmares may be a way to process trauma and negative emotions.

Possible causes of nightmare disorder include:

• Stress and Anxiety: The stress in your waking life can seep into your sleep subconsciously or unconsciously, resulting in nightmares. When the stress and ongoing nightmares become consistent, they may become a nightmare disorder.
• Mental Health Conditions: Nightmares are a common symptom of post-traumatic stress disorder (PTSD) as a trauma response. PTSD is one of many mental health conditions linked to nightmares. Other mental health issues that may cause nightmares include depression, anxiety, and bipolar disorder.
• Medical Conditions: Medical conditions such as Parkinson’s disease or sleep apnea can impact sleep due to how those conditions work through the body.
• Medications: Certain medications can be linked to increased frequency of nightmares or can be a side effect.
• Sleep Deprivation: REM rebound, which means a person gets more REM sleep than usual, can be linked to nightmare disorder as many nightmares tend to happen in REM sleep.
• History of Recurring Nightmares: A history of nightmares is also linked to recurring periods of more nightmares during sleep.
• Sleep Disorders: Other sleep disorders are also linked to having a nightmare disorder as they disrupt the typical sleep processes.²

Nightmare Disorder Comorbidities

There are several conditions and disorders that frequently co-occur with nightmare disorders. Some of the most common ones are outlined below. However, it is essential to talk to your medical team about your symptoms to ensure you are getting the proper treatment.

Nightmare disorder commonly occurs comorbidly with:

Post-Traumatic Stress Disorder (PTSD)

There is a high prevalence of nightmare disorder with PTSD. Due to the way PTSD works in people and the way memories are stored, many of those who experience trauma have nightmares and can develop a nightmare disorder or recurring nightmares from the trauma. There are other symptoms of PTSD that can worsen nightmare disorder, such as experiencing flashbacks at near bedtime that increase anxiety at night.

Anxiety Disorders

Having an anxiety disorder is often comorbid with nightmare disorder. Many people experience anxiety dreams. However, when they become recurring, they can develop into a nightmare disorder. Additionally, if there is a lot of worry around sleep and sleep routines as well as daytime stressors, it can impact sleep quality.

Depression

Depression can also be a comorbid issue with a nightmare disorder. Depression can affect sleep quality and quantity, leading to sleep disorders or parasomnia. Depression naps and excessive sleep combined with stress, or feelings of hopelessness can trigger night terrors or other sleep disorders, including parasomnias like nightmare disorder.³

Complications of Living With Nightmare Disorder

Nightmare disorder can lead to a wide range of complications for those with the condition. The body requires adequate sleep to maintain your physical health and extensive research on the impact of sleep on mental health. Consistently lacking high-quality sleep can lead to damage to the brain, heart, and other vital organs needed for the body to function optimally.

Negative impacts of nightmare disorder may include:

• Increased depression
• Increased anxiety
• Chronic illness
• Agitation
• Heart disease
• Memory issues
• Concentration issues
• Poor problem-solving capabilities⁴

Treatment for Nightmare Disorder

Nightmare disorders can be scary, but there are treatment options. Some of the most effective treatments for nightmare disorder start with addressing other mental health issues you may be dealing with in addition to nightmare disorder. Experiencing nightmares 3-4 times a week and being unable to concentrate during the day is a sign that it is time to talk to a professional. Working with a professional can help you make sense of what is happening and the various treatment options you have to live a restful and balanced life.

Therapy

While nightmare disorders should first be addressed by a physician, working with a therapist can allow you to reduce the effects of your nightmares. Searching an online therapist directory is a good way to choose a therapist for your needs. If you cannot find a local therapist who meets your needs, online therapy options allow you to receive help from the comfort of your home.

Together, you and your medical team can devise a plan to improve your sleep and work through any issues causing your nightmare disorder. In addition, therapy offers many other benefits, allowing you to address and manage the symptoms of conditions like depression, anxiety, or PTSD.

Therapy options for nightmare disorder include:

• Cognitive behavioral therapy (CBT): CBT is an excellent therapy option for depression-related nightmares and sleep issues as it helps to reframe thoughts and behaviors.
• Exposure therapy (ERP): Exposure therapy is a form of CBT that helps people reframe their experiences and improves their body’s reaction to distressing memories.
• Hypnosis: In certain cases, it can be helpful to try hypnotherapy as this practice will help you retrace your experiences and help you change your thoughts about your experiences.
• Systematic Desensitization Therapy: Systematic desensitization therapy is a form of exposure therapy that allows people to experience safe exposure over time to their fear and the subject of their recurring nightmares.
• Interpersonal Therapy (IPT): Interpersonal therapy helps those with depression-related nightmares as it helps to work through interpersonal issues in a safe place to improve overall functioning with others.
• Image Rehearsal Therapy: Image rehearsal therapy can be highly effective in treating nightmares, helping individuals reframe their story so that when they wake up after a nightmare, they learn to replace the negative images with positive ones.
• Eye Movement Desensitization and Reprocessing (EMDR) Therapy: EMDR helps process trauma using eye movements. If these nightmares are related to PTSD, it can be effective, as it is with veterans and those with complex trauma.⁵

Medications

There are no medications approved to treat nightmares specifically. However, there are medication options to treat other co-occurring mental health issues. These treatments may reduce recurring nightmares due to an underlying condition, such as PTSD or a sleep disorder, and mitigate the severity of a nightmare disorder. 

PTSD medications are linked to improved sleep quality, and depending on your specific concerns, other medications can also be recommended. You may need to speak with both your therapist/psychiatrist as well as your primary care doctor or other specialist to obtain the appropriate medication. If your local options are limited, online psychiatry options can help you to get the necessary treatment wherever you are.⁵

Can Nightmare Disorder Be Prevented?

Nightmares can’t be prevented. However, it is essential to consider that keeping a low-stress life can improve your chances of avoiding nightmares. There are some home and lifestyle changes worth considering to reduce the frequency of nightmares. Additionally, developing healthy coping mechanisms can lower everyday stress and manage the effects of nightmares.

Here are nine tips for helping to prevent nightmare disorder:

1. Keep a regular sleep schedule: Having a routine at bedtime can give your body a framework.
2. Avoid caffeine and alcohol: Limiting alcohol and caffeine is a great way to help improve sleep quality.
3. Practice relaxation techniques: Trying breathwork or progressive muscle relaxation before bedtime can help you stay grounded in the present and allow you to drift into sleep more easily.
4. Evaluation and treatment of other disorders: Consider evaluation and treatment for medical or mental disorders such as depression, as it can be linked to recurring nightmares.
5. Keep your bedroom comfortable: A cool, quiet bedroom promotes better sleep, so investing in cooling sheets and a blackout curtain can make a big difference in your sleep quality.
6. Reduce screen time before bed: Many screens emit a blue light that disrupts your sleep, so limit screens before bed.
7. Exercise and yoga: Exercise and yoga are great for the body and the mind and help your body sleep.
8. Practice mindfulness: Mindfulness and meditation can help you ground yourself to have an easier time falling asleep and improve your sleep quality.
9. Check medications: Make sure you are logging medication side effects and speaking with your doctor if it is impacting your sleep.

Final Thoughts

What you are dealing with is unique, but you are not alone. A nightmare disorder can be challenging, but there are ways to move forward. Working on home remedies and collaborating with a therapist can be a great way to learn to manage your triggers and symptoms.