Home » Sleep Disorders » Nightmares
October 2020 |  Reviewed by:  Reeba Mathew, MD and Anne M. Morse, DO

What are nightmares?

Nightmares that occur frequently and keep you from getting restful sleep are considered a sleep disorder. Nightmare disorder is a parasomnia, a category of sleep disorders that involves unwanted events or experiences that occur while you are falling asleep or waking up or in your sleep.

If you have nightmare disorder, you may fear going to sleep or worry that each night you will have another nightmare. You may also feel anxious and scared when you wake up from a nightmare and be unable to go back to sleep. Sleep loss can cause you to have even more intense nightmares. As a result, you may experience daytime sleepiness.

Nightmares are usually coherent visual dreams that seem real and get more disturbing as they unfold and cause you to wake up. These most often happen towards the end of your sleep period. These dreams most often involve imminent physical danger. Nightmares may also focus on other distressing themes and provoke negative emotions such as:

  • Anxiety
  • Fear
  • Terror
  • Anger
  • Rage
  • Embarrassment
  • Disgust
  • Other negative feelings

In most instances after you wake up, you will be able to clearly remember the details of your nightmare. A disturbing dream that does not wake you up is not considered a nightmare. Instead, it is simply a bad dream. It is possible to have more than one nightmare, often with similar themes, during a night of sleep.

Nightmares tend to happen during REM sleep, the last stage in the sleep cycle. About 20% to 25% of your total sleep time is in REM sleep. The REM stage gets longer during each sleep cycle and your final period in REM may last up to an hour. As a result of this, nightmares are most likely to occur in the final third of the night. Nightmares that arise from trauma, such as in people with posttraumatic stress disorder (PTSD), may also occur in earlier sleep stages.

What are risk factors for nightmares?

Nightmares can happen to anyone, and in most cases the reasons why the nightmares occur are unclear. Stress, anxiety, an irregular sleep routine or being overtired can increase your risk for nightmares.

Some medications, such as antidepressants and medications for hypertension or Parkinson’s disease, may increase the frequency of nightmares. Nightmares that cause sleep problems may also be associated with factors such as:

  • Another sleep disorder
  • A medical condition
  • Medication use
  • A mental health disorder such as depression, anxiety or PTSD
  • Substance abuse

Having the same nightmare repeatedly over time can also be common after severe stress or a traumatic event. These nightmares are often a way of “reliving” the traumatic event.

How prevalent are nightmares?

Nightmares can happen to anyone, but nightmare disorder is relatively rare. The key difference in nightmare disorder is the inability to get sufficient sleep because of disturbing dreams. An estimated 2% to 8% of people have nightmares that cause sleep problems.

Children

Nightmares are especially typical in children aged 3-6 years. Up to 50% of young children have severe nightmares that cause them to wake up their parents. Nightmares in children tend to peak by ten years of age. After that time, nightmares usually decrease. Some children continue to have nightmares as teens and adults. This may be a lifelong problem for these individuals.

Adults

An estimated 50% to 85% of adults report having the occasional nightmare. Nightmares tend to become less frequent and intense as you age. Women tend to report nightmares more often than men but are also more open to discussing their dreams and nightmares.

What are parasomnias similar to nightmares?

Other sleep disorders also classified as parasomnias are sometimes mistaken for nightmares.

Night terrors

These episodes cause you to wake up disoriented from slow-wave sleep or deep sleep in intense fear with your heart racing. Night terrors may cause you to scream, kick, thrash or bolt out of bed. It’s usually difficult to remember what happened, though you may be able to recall brief segments of a terrifying dream. Night terrors tend to occur in the first third of the night.

REM sleep behavior disorder

A potentially dangerous sleep disorder that causes you to act out vivid dreams as you sleep. The dreams are usually filled with action and may even be violent. Because these actions may result in injury to yourself or your partner, REM sleep behavior disorder is considered a dangerous condition that requires medical attention. This disorder is most common in middle-aged men.

How to diagnose nightmares?

Self test

If you think you may have nightmare disorder, ask yourself the following questions:

  • Do you often wake up from sleep due to a disturbing dream?
  • Do these dreams evoke emotions of fear, anger, sadness or disgust?
  • Are you alert and able to think clearly as soon as you wake up?
  • Are you able to clearly recall details of these dreams?
  • Do these dreams often occur during the late portion of your sleep period, such as in the early morning part of your sleep?
  • Do you have difficulty falling back asleep after these dreams?

If you answered yes to these questions, you should talk to your doctor or see a sleep doctor. A sleep doctor is trained to accurately diagnose nightmare disorder and rule out any possible underlying causes or complications.

Diagnosis

The doctor will need to know when you first started having nightmares, how often they occur and the content of the nightmares. Your complete medical history, as well as any past or present drug and medication use, will help the doctor make a diagnosis. Tell the doctor if you have ever had any other sleep disorder, or if any of your family members have sleep problems.

You may be required to keep a sleep diary for two weeks. The sleep diary will help the doctor look at your sleep patterns. This data will give the doctor clues about what is causing your problem and how to correct it.

In most cases, you will not need any tests for nightmares. If your sleep is severely disturbed, or if the doctor suspects there are underlying problems, you may need to have a sleep study.

How to treat nightmares?

In most cases, treatment for nightmares is not necessary. For patients who have nightmare disorder and experience severe sleep disturbances and daytime sleepiness, treatment by a behavioral sleep medicine specialist is recommended.

Types of therapy

Counseling – A therapist can help you address some of the underlying causes of your nightmares. This will require processing your thoughts and feelings. More intensive counseling may be needed if the nightmares are caused by a traumatic event.

Imagery Rehearsal Therapy – This approach helps you reimagine your nightmares with different less frightening outcomes with the goal being to “reprogram” your nightmares to be less disturbing if they recur.

Systematic desensitization – This approach involves gradual exposure to the disturbing or frightening dream content to lessen your emotional response. Systematic desensitization is most useful when recurrent nightmares appear after severe trauma.

Stress management – Managing stress in your life can help you manage your nightmares. This may include relaxation training so that you are able to reduce the anxiety or tension that keeps you from falling asleep and so you can go back to sleep after a nightmare.

Tips for parents

Most children have nightmares. These tips may help if your child has problems with nightmares:

  • Let your child sleep with a special blanket or stuffed animal for security.
  • Plug in a dim nightlight so your child’s bedroom feels safe.
  • Respond quickly to comfort your child when he or she wakes up from a nightmare.
  • Discuss nightmares openly with your child during the day.
  • Assure your child that it is normal for children and even adults to have nightmares.
  • Talk to your child’s pediatrician if recurring nightmares greatly disturb your child.