It is usual for a person to dream for approximately two hours every night. While experts are not clear about the purpose of dreaming, they theorize that it helps people process experiences and emotions while establishing memories. While dreams are pleasurable most of the time, they can also cause distress, particularly when they involve disturbing or scary scenarios. Such scary dreams are also known as nightmares.
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Experiencing nightmares occasionally is common in both children and adults. Up to 85 percent of adults have at least one such episode yearly. Unfortunately for some, these occurrences may become familiar to the extent that it makes daily functioning harder. When this happens, the scenario points toward a diagnosis of nightmare disorder. Regardless of how severe the condition is, recovery is possible from nightmare disorder but involves appropriate treatment and lifestyle changes.
Overview of Nightmare Disorder
Nightmares describe disturbing or frightening dreams that can cause a dreamer to wake up. Most people can recall the content of a nightmare after experiencing it because these episodes happen during the rapid eye movement or REM stage of sleep. During this stage, the brain activity is similar to the one that occurs when a person is awake, making recollection of a nightmare easier.
In most people, stress is the primary cause of nightmares in addition to other factors like trauma or complex life events. Experts also believe these nightmares are possibly the brain’s way of processing fear and anxiety. Nightmares can include themes such as near-death experiences, failures, chases, and confrontations. Because of their alarming themes, a nightmare can trigger the fight-or-flight response in the nervous system. Consequently, a person may wake up during an ongoing episode with panic, a racing heart, and profuse sweating.
Nightmare disorder is a condition in which a person keeps experiencing nightmares more frequently than usual. The disorder often involves extended, frequent nightmares that include severe threats to a person’s safety, well-being, and life. People suffering from nightmare disorders start experiencing these frightening episodes within hours of falling asleep and wake up distressed and alert. Most of them can vividly recall the theme of their nightmares.
Nightmare disorder can have variable severity. Those with milder forms may have a symptom-free period lasting up to a week between two consecutive nightmares. On the other hand, severe disorders can lead to nightmares every night. Since nightmare disorder can create stress and compromise sleep, it negatively affects various aspects of a person’s personal and professional life.
Up to 5 percent of people in the United States suffer from a nightmare disorder.  However, because the disorder remains highly underreported, not everyone gets treatment for it. Many people avoid telling their healthcare providers about their frequently disruptive nightmares due to a lack of awareness. Hence, without support, the disorder continues to affect their life in the long run.
What Causes Nightmares? Risk Factors for Nightmare Disorder
Researchers believe various circumstances can lead to nightmares or increased frequency, putting an individual at a higher risk of acquiring nightmare disorder. Some of these risk factors include the following:
- Stress: Heightened levels of stress can cause an individual to experience nightmares. However, even a stressful event may sometimes be severe enough to initiate recurring nightmares.
- Medications: Certain medications can also trigger nightmares as a side effect. Beta-blockers are a type of medication with the ability to generate nightmares. Other medicines that may cause nightmares include those used to treat Parkinson’s disease, depression, and infection.
- Withdrawal From Substance: Nightmares may also occur as part of withdrawal due to substance use, such as recreational drugs, alcohol, and certain prescription medicines. Many medicines that suppress REM sleep can cause nightmares when they are stopped.
In some cases, nightmare disorder may happen on its own. However, in such circumstances, the disorder is often in conjunction with other disorders like the following: 
- Posttraumatic Stress Disorder (PTSD): More than 70 percent of individuals with PTSD experience trauma-related recurring nightmares. These nightmares happen during the REM stage of sleep and may also occur as an individual falls asleep.
- Mental Health Disorders: Frequent nightmares may also be linked with other mental health disorders, such as anxiety, depression, borderline personality disorder, and schizophrenia. Depression, in particular, may alter the sleep cycle, increasing the possibility of nightmares.
- Certain Sleep Disorders: Nightmares may also happen with certain sleep disorders, such as sleep apnea, narcolepsy, and insomnia.
How Nightmare Disorder Affects a Person?
Nightmare disorder can affect life in different ways, both during at night and day. The more frequent these nightmares become, the more vulnerable a person is to psychological, physical, and social effects.
Experiencing regular nightmares due to nightmare disorder can lead to the following effects at night:
- Fear of going to sleep: People with nightmare disorder may acquire somniphobia, which makes them fearful of falling asleep. The fear comes from experiencing nightmares that leave them under stress.
- Compromised quality and quantity of sleep: Because nightmares can make a person wake up from sleep feeling high alert, they reduce the amount of sleep a person gets. Moreover, many people find it hard to go back to sleep once they are awake. These frequent awakenings also negatively affect sleep quality, making it less restorative.
- Insomnia: Frequently occurring nightmares can make people suffer from insomnia, a sleep disorder that makes it difficult to fall or stay asleep.
- Collateral effects on partners/caregivers: People who keep waking up due to nightmares may also interrupt the sleep of others sleeping next to them.
The distress and sleep disturbances triggered by nightmare disorder may lead to various problems during the day, such as the following:
- Sleepiness: Nighttime awakenings, delayed bedtime, and poor sleep quality due to nightmare disorder may all lead to fatigue and daytime sleepiness.
- Persistent Negative Emotions: Recurring nightmares can lead to great distress in some people. In some cases, emotions related to nightmares may persist for longer.
- Cognitive Issues & Impairment: Nightmares can cause people to develop problems with concentration and memory, affecting their ability to work at school, work, or home.
How to Diagnose Nightmare Disorder
A sleep specialist or a primary care physician initially diagnoses nightmare disorder. They may ask questions about the timing, duration, content, and frequency of a person’s nightmare while assessing how they affect their life and sleep. Many experts also use the nightmare disorder index test, which involves five questions to collect information and formulate a diagnosis.
A person meeting the following criteria may receive a diagnosis of nightmare disorder:
- Recurring instances of well-remembered, disturbing nightmares that put a dreamer’s security, safety and survival at risk
- Experiencing feelings of distress or noticing a compromised ability to function at work, school, or home
- Orientation and alertness upon waking up due to nightmares
In some cases, doctors may not label a person as a case of nightmare disorder, especially if they believe that their nightmares are due to another physical or mental health issue.
Treating Nightmare Disorder
Nightmare disorder may resolve on its own for many people. However, others may need lifestyle changes or clinical interventions to manage or eradicate the symptoms completely.
Nightmare disorder can commonly occur with other co-existing mental health disorders, such as PTSD, depression, and anxiety. Treating these disorders often causes spontaneous resolution of frequent nightmares. Hence, an expert may include one or more of the following therapeutic approaches as a part of a nightmare disorder treatment plan:
- Cognitive behavioral therapy: Also known as CBT, this therapy is commonly used to manage nightmare disorder. It helps patients understand how their emotions and thoughts influence their nightmares and identify behaviors that may contribute to these experiences.
- Desensitization: This therapy helps people unlearn responses to a specific stimulus or situation. Therapists promote desensitization in children experiencing nightmares by encouraging them to write about their nightmares or illustrate them.
- Hypnotherapy: This therapy includes making a patient enter a state of hypnosis and asking them to imagine an ideal night of sleep while constantly letting them know that they are safe and will not experience any more nightmares. 
- Imagery rehearsal therapy: This therapy is a variant of CBT and involves creating a new script for repeated nightmares that can change the sequence of events and help patients develop a more positive narrative.
Other psychotherapeutic treatments beneficial for nightmare disorder may include the following:
- Muscle relaxation
- Lucid dreaming therapy
- Dynamic therapy
- Rescripting therapy
A professional usually assesses to determine the best modalities to help a patient achieve recovery.
Experts may prescribe medications to treat nightmare disorders, sometimes alone or in conjunction with therapy. However, research supporting this treatment aspect is limited.
Evidence suggests that a program called NightWare can help people sleep despite experiencing nightmares related to PTSD. The U.S. Food and Drug Administration approved the software and is known to respond to physiological changes during a nightmare. After sensing these changes, the software provides vibrations to help people escape REM sleep without waking them.
While the preliminary evidence seems promising, more investigations are inevitable to validate the benefits of this application for treating nightmare disorders.
Specific lifestyle changes that promote sleep while reducing stress can help people with a nightmare disorder. Some of these tips to follow in this aspect include the following:
- Establishing a fixed bedtime routine that includes stress-releasing activities, for example, gentle stretching, a warm bath, or listening to soothing music
- Setting a fixed bedtime and wake-up time and sticking to it
- Getting regular exercise earlier during the day
- Avoiding screens, such as TV or mobile phones, for at least an hour before going to bed
- Creating a quiet and comfortable environment for sleep
- Avoiding heavy meals close to bedtime
- Limiting or completely eliminating caffeine, alcohol, and smoking close to bedtime
Why do I have nightmares every night?
Experts suggest seeking medical advice if you experience nightmares at least once every week or if these episodes are severe enough to negatively affect your mood, sleep, or ability to function. However, experiencing them every night is a warning sign that something is wrong and requires prompt assessment by a professional. While it can be a nightmare disorder, sometimes the underlying cause is another mental or physical issue.
Can medicines cause nightmares?
Certain medications can lead to frequent nightmares in people. These medications include antihypertensive drugs, like beta-blockers, antidepressant medications, anti-parkinsonism drugs like selegiline, and certain sedatives like ketamine.
What is the prognosis for nightmare disorder?
The prognosis for children is excellent as the symptoms of nightmare disorder typically resolve with time. If the symptoms continue even after a child turns six, other factors, such as anxiety disorders, PTSD, or affective distress, should be ruled out. In adults, nightmare disorder may resolve with time but persist for decades if left untreated.
1 Dietch JR, Taylor DJ, Pruiksma K, Wardle-Pinkston S, Slavish DC, Messman B, Estevez R, Ruggero CJ, Kelly K. The Nightmare Disorder Index: development and initial validation in a sample of nurses. Sleep. 2021 May 1;44(5):zsaa254.
2 Morgenthaler TI, Auerbach S, Casey KR, Kristo D, Maganti R, Ramar K, Zak R, Kartje R. Position paper for the treatment of nightmare disorder in adults: an American Academy of Sleep Medicine position paper. Journal of Clinical Sleep Medicine. 2018 Jun 15;14(6):1041-55.
3 Hauri PJ, Silber MH, Boeve BF. The treatment of parasomnias with hypnosis: a 5-year follow-up study. Journal of Clinical Sleep Medicine. 2007 Jun 15;3(4):369-73.