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Sometimes a nightmare is just a bad dream—isolated and disagreeable imagery with little emotional response from the dreamer. However, a nightmare can lead to feelings of fear, terror, and anxiety; awakening the individual and causing disturbing emotional response, including insomnia, other difficulties in the sleep cycle, or even daytime distress. Fever, ill health, or poor diet can also bring on nightmares.

Normally, people dream more than two hours a night, and a nightmare usually happens in the later hours of REM sleep, or rapid eye movement sleep. The dreamer often awakens from a nightmare with a good recollection of the imagery and content. Some researchers call negative dreams “threat rehearsals,” where we rehearse the possible threats we encounter in real life; other researchers say that people are working through upsetting events of the day. Most garden variety nightmares are stress related. However, if nightmares become frequent to the point of dysfunction, the individual may be suffering Nightmare Disorder (formerly Dream Anxiety Disorder). Nightmares are more prevalent among girls than boys, with occurrences starting before age 10. Children and adolescents tend to suffer more, with less frequency among adults. About half of the adult population experience nightmares on occasion.

The body cycles through different stages of sleep, from light sleep to the deep sleep of REM. REM sleep happens through signals from the pons, which is located at the base of the brain. This is, in fact, where signals for REM sleep originate and where signals to the spinal cord shut off. This is why the body doesn’t move during deep sleep; but if the pons does not shut down these signals, the individual may act out the dream physically—known as REM sleep behavior disorder. If the individual is running in the nightmare, for example, he may well start running literally.


Signs and symptoms of nightmares, as cataloged by the DSM-5:

  • Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical in­tegrity and that generally occur during the second half of the major sleep episode.

  • On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert.

  • The sleep disturbance causes clinically significant distress or impairment in social, oc­cupational, or other important areas of functioning.

  • The nightmare symptoms are not attributable to the physiological effects of a sub­ stance (e.g., a drug of abuse, a medication).

  • Coexisting mental and medical disorders do not adequately explain the predominant complaint of dysphoric dreams.

Nightmares are more frequent among children and adolescents, with less frequency into adulthood. Half of adults experience nightmares on occasion, and among women more than men. These infrequent bouts do not require treatment. Nightmares may increase with traumatic or adverse events, irregular sleep, sleep deprivation, and jet lag. Some 1 percent of adults who experience frequent nightmares may end up avoiding sleep and should seek help. These individuals may suffer full function at work, school, or home life.

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Cause of nightmares, as cataloged by the DSM-5:

  • Anxiety and stress are major causes of nightmares
  • Trauma or upsetting events such as death of a loved one can bring on nightmares
  • Other causes include a fluctuating sleep schedule, sleep deprivation, jet lag, illness and fever
  • Side effects of a medication or drug
  • Medication or drug withdrawal, such as sleeping pills
  • Alcohol consumption or withdrawal
  • Difficulty breathing during sleep, such as sleep apnea
  • Sleep disorders, such as narcolepsy or sleep terror disorder
  • Eating before bedtime


Treatment of nightmares, as cataloged by the DSM-5:

Support from friends and relatives can help if you are suffering stress. Witnessing or experiencing trauma may affect you in other areas of functioning. Consulting a mental health professional is recommended. Sharing your feelings whether with family, friends, or a therapist may help you better cope with the events that may be disturbing you. In addition, your physical health may need attention, regular exercise and consistent sleep hygiene are helpful. With physical activity, you may fall asleep faster, and enjoy a deeper sleep. Other helpful tips include relaxation therapy to reduce muscle tension and lessen anxiety.

A new medication may also be a culprit. Discussing prescription drugs with you physician or health practitioner may be required. Discontinuing medication and trying alternatives may be needed.

Substances to limit or avoid altogether may include: tranquilizers, alcohol, caffeine, other stimulants, especially at bedtime.

However, substance or alcohol abuse must be addressed. Seeking help through regular therapy or support groups such as Alcoholics Anonymous may help.

If you suffer nightmares more than weekly, contact your physician or health professional. Call your health-care provider if they occur more often than weekly, or if they prevent you from getting a good night's rest and persist for a prolonged period. Your medical history and a physical exam may be needed.

Here are some medical history questions that may be included:

  • Is there a time pattern to the nightmares?
  • Are nightmares recurrent?
  • Do they occur in the first or second half of the night?
  • Are you suddenly fully awake from sleep?
  • Do you feel intense fear and anxiety after the nightmare?
  • Do you remember the imagery, the plot?
  • Have you been recently ill?
  • Did you have a fever?
  • Did you experience a stressful incident?
  • What is, if any, your alcohol intake?
  • Do you take medications?
  • Do you use street drugs? If so, what do you use?
  • Do you take natural supplements or alternative medicine remedies?
  • Do you suffer other symptoms?

The physical exam may include neurological and psychological assessments, blood tests, an EEG, as well as tests for liver and thyroid function.

If all possible above causes are ruled out, assessment by a sleep specialist may be required. The specialist may need to give a polysomnography, a test used to diagnose sleep disorders.

Here are some tips to regain sleep:

  • Adhere to a routine and schedule every night and morning
  • Sleeping at the same time each night can help
  • Avoid sleeping in
  • Limit caffeine and alcohol
  • Do not smoke
  • Relax before bed
  • Exercise daily
  • Wake with the sun
  • Avoid lying in bed while awake
  • Sleep in a cooler temperature

Call your health-care provider if the problem persists. Sleep disorders can be treated with the right help.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
National Institutes of Health, National Library of Medicine
National Institute of Neurological Disorders and Stroke
Last updated: 02/26/2019