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Treatment for Nightmares and Bad Dreams

Most people with nightmares are not aware that there are effective therapies.

Epidemiological studies indicate that 2-6 percent (about 6.4 to 15 million people) of the adult American population experience nightmares at least once a week. Between one half and two-thirds of children experience weekly nightmares.

I receive regular email and telephone requests from people who are desperate to end the frequent nightmares they suffer from. It is difficult for those of us without terrifying dreams to understand the experience. Imagine undergoing a terrifying experience where your heart races, you have difficulty breathing, and you sometimes cannot move—several times a month. Horrifying images from the dream world haunt you during the day and an underlying dread and anxiety take hold. Sometimes the dreams are so bad that you do not want to fall asleep, so you resist the urge to sleep as much as possible, but eventually you succumb and are swallowed into a terrifying alternate reality.

The tragedy is that these people may be suffering for no reason. People often don't tell their doctors about their bad dreams. And even when they do, doctors may not be aware of treatments. But there are effective therapies for nightmares.

The first thing to do is to see a sleep specialist and be studied overnight. There are many different kinds of nightmares. Seizures, trauma, genetics, drugs, and other neurological disorders can cause nightmares. You first want to rule out those causes as they will require special treatments. The vast majority of nightmares have no known causes and these nightmares can be treated effectively.

Imagery rehearsal therapy (IRT) (Krakow et al 2000) is a cognitive behavioral therapy that effectively reduces distress associated with recurrent nightmares. Basically, you take a scary image from one of your nightmares, and then mentally restructure that image so that it is no longer as frightening. You put it into a less scary scenario or story and rehearse that story a few times. There are workbooks that use the principles of IRT that you can do at home, but it's better to do this work with a therapist. You need to work with images that do not distress you, since the goal is to gain mastery over those intrusive images.

Because IRT is effective for treating nightmare distress, components of IRT may potentially be adapted into new delivery formats to increase options for people with recurrent nightmares. My colleagues and I, for example, have been having some success using virtual reality (VR) headsets to deliver a cognitive behavioral therapy that is similar to IRT. We call this ReScript therapy. People work with mildly distressing images in the VR application until they gain mastery and control of these images. They morph the images to be less distressing and rescript the story to be less scary. Unlike IRT, ReScript uses exposure therapy principles as well as cognitive restructuring and memory restructuring principles. However, ReScript is not yet available to patients, because it hasn't undergone double blinded placebo controlled clinical trials. Therefore, this isn't a recommendation but an idea of what's coming down the pike to treat nighmares.

There are also effective drugs that can provide immediate relief from bad dreams. Prazosin is an alpha adrenoceptor blocker that ends bad dreams almost immediately for most people. Like all drugs, it is sometimes associated with significant side effects, especially if taken over time, so consult with your doctor before taking this medication.

To find a sleep expert near you, visit the Psychology Today Therapy Directory.

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Krakow, B., Hollijield, M., Schrader, R., Koss, M., Tandberg, D., Lauriello, J., et al. (2000). Controlled study of imagery rehearsal for chronic nightmares in sexual assault survivors with PTSD: A preliminary report. Journal of Traumatic Stress 13: 589-609.

Krakow, B., Hollifield, M., Schrader, R., Koss, M., Tandberg, D., Lauriello, J., et al. (2000). A controlled study of imagery rehearsal for chronic nightmares in sexual assault survivors with PTSD: A preliminary report. Journal of Traumatic Stress, 13, 589–609.

Krakow, B., Kellner, R., Pathak, D., & Lambert, L. (1995). Imagery rehearsal treatment for chronic nightmares. Behaviour Research and Therapy, 33, 837–843.

Krakow, B., Schrader, R., Tandberg, D., Hollifield, M., Koss, M. P., Yau, C. L., & Cheng, D. T. (2002). Nightmare frequency in sexual assault survivors with PTSD. Anxiety Disorders, 16, 175–190.

Krakow, B., and Zadra, Antonio (2010). Imagery Rehearsal Therapy: Principles and Practice. Sleep Medicine Clinics 4(2): 289-298.

McNamara, P., Holt Moore, K.H. Papelis, Y., Diallo, S., and Wildman, W. (2018), Virtual reality-enabled treatment of nightmares, Dreaming 28, 2 44-58

McNamara, P. (2008). Nightmares: The science and solution of those frightening visions during sleep. Westport, CT: Praeger Perspectives.