Persistent Nightmares are Treatable with Therapy and Medications

Many of us have had one. You know—the kind of bad dream that startles you awake, heart pounding and in a sweat. Fortunately, they’re isolated incidents, but for some, they’re persistent, a condition known as nightmare disorder, and one that interferes with sleep and daily routines.

“A nightmare is a dream that is disturbing or distressing, one that wakes you wake up and that you remember throughout the day,” says Dr. Allison Wilkerson, a licensed clinical psychologist in MUSC Health’s Department of Psychiatry and Behavioral Sciences. “Some common examples of nightmares are your teeth falling out or that you’ve shown up for a final exam without ever attending class.”
Nightmares and dreams typically happen in the second half of the night during the REM sleep cycle, a period of light sleep and rapid eye movement, and can occur at any age.

“Nightmares can be trauma-related, in which someone re-lives a traumatic incident or something that reminds them of the traumatic incident, and they can be associated with post-traumatic stress disorder,” Dr. Wilkerson says. Military personnel and people who have co-morbidities such as anxiety, insomnia, neuroticism, or depression are more prone to nightmares. “Someone who is constantly worried about what’s going to happen next can be prone to nightmares. Even those who appear to be calm and totally in control of their lives can have nightmare disorder because they’re accustomed to suppressing their emotions when they feel the most vulnerable,” she says.

Often, nightmares are related to periods of major stress and resolve on their own as stress level goes down, but when they become frequent, disrupt sleep, and can’t be shaken off during the day, that’s when evidence-based intervention is recommended.

Nightmare disorder can be treated with cognitive and behavioral therapy and with medications.

“Image rehearsal therapy (IRT) involves writing down the nightmare and then rewriting a positive ending that makes you feel better and rehearsing it several times a day,” Dr. Wilkerson says. “It can be silly, happy, or anything that makes you feel better. The new ending doesn’t have to be done all at once; you can change something one day at a time. Eventually, your brain will respond.” It also provides education about sleep, best sleep practices, and teaching relaxation strategies.

Exposure relaxation and rescripting therapy (ERRT) is a cognitive behavioral therapy similar to IRT. The major difference is a focus on exposure to the negative or fear-inducing aspects of the nightmare, with the goal of talking and thinking about those things to decrease the chance that they’ll cause anxiety and fear in the future.

“Both treatments usually last about 3 to 6 weeks, with sessions of 1 to 2 hours, and are effective in treating military veterans with PTSD,” she says.

Prazosin, a drug used to lower blood pressure, may also be prescribed for short-term use.

“The encouraging news is that treatments are available for nightmare disorder,” Dr. Wilkerson says. “Something can be done, and you don’t have to suffer through it.”

Learn more about the services at the MUSC Institute of Psychiatry.

Tips For Healthy Sleep

Few things are more blissful than a good night’s sleep. And few things are more miserable than a night of no or too little sleep.

“Unfortunately, people’s sleep has really suffered during the pandemic, and we’ve seen a big shift in sleeping patterns,” says Dr. Wilkerson. “Not everyone requires the same amount of sleep to feel alert and function well throughout the day. Some people require 10 hours to feel re-energized, and others can get by with much less.”

Older people tend to go to bed earlier, rise earlier and sleep fewer hours. Whether you zip out of bed after 6 hours of shuteye or sleep peacefully past sunrise, Dr. Wilkerson has the following tips for protecting your sleep window.

• Use your bedroom for sleep only. Even if you live in a tiny space, avoid watching TV or reading on your bed.
• Keep room temperature low: “Cooler is definitely better,” she says. “The optimal room temperature is mid- to low 60s. Lower temperatures help nudge our circadian rhythm that it is time to sleep, and there is growing evidence that cooling down the brain’s frontal lobe can calm us down and help us sleep.”
• Don’t bring your devices to bed; keep them in another space or another room.
• Establish a bedtime routine, including a regular bedtime, and stick to it.