Chronic Nightmares

Recognizing Nightmares as an Independent Sleep Disorder

The overwhelming majority of nightmare patients do not fully accept that their disturbing dreams represent a sleep disorder.  In fact, when we direct one of our sleep patients to start treatment in our Nightmare Clinic, the most common reply we receive goes something like this:  “Oh, well, nightmares, I’ve always had them; I don’t really think there’s anything you can do about them, and I just wanted to get help for my sleep problems.” 

In other words, nightmare patients do not recognize their disturbing dreams as an integral part of their sleep problems.  This view is outdated and most unfortunate, because a lot of scientific evidence clearly shows two things:

  • Nightmares disrupt sleep, cause some degree of sleep fragmentation, and frequently lead to poor sleep habits that eventually turn into chronic insomnia.
  • Nightmares can be independently treated with non-drug, short-term, cognitive-imagery techniques that not only reduce the disturbing dreams but also improve insomnia. 

While these findings are well-described in the sleep research literature, they still have not disseminated into clinical practices, and so most patients with nightmare are not offered this highly pragmatic point of view or the actual imagery-based treatment that would likely benefit them a great deal.

Nightmare Clinics for PTSD Patients

The most frequent emails I receive on the topic of nightmares come from therapists who are working predominantly with PTSD patients (or the patients themselves), and they are noting that nightmares and insomnia are residual symptoms that for whatever reasons have not responded to the PTSD treatments.

We have long advocated that nightmare and insomnia treatments should be integral components of any PTSD clinic, because these sleep symptoms are so pervasive.  Moreover, trauma survivors seem much more interested in pursuing nightmare treatments, because the nightmares so dramamatically interfere with their lives and their sleep, they are motivated to seek help for the problem.  Moreover, to reiterate, it’s clear that nightmares and insomnia tend to be residual symptoms that remain sometimes in the face of marked improvements in other PTSD symptoms following evidence-based treatments.

As an aside, as a sleep specialist I am disappointed how scant attention is paid to the sleep side-effects of the psychotropic medications prescribed for the PTSD patients.  These medications, particularly SSRIs clearly contribute to Restless Legs Syndrome, Periodic Limb Movement Disorder, and Insomnia; and some may worsen Nightmares.  From my vantage, it is maddeningly ironic that sleep symptoms are frequently not addressed in PTSD patients, but these trauma survivors are prescribed medications that may and often in my experience, worsen sleep complaints. 

Nightmare Assessment 

On our sister site,, we have an extensive Nightmare Quiz program that will help you sort out the likelihood of a Nightmare Disorder.  The quiz consists of 12 questions, and once you submit it online, it will automatically reply to your response, providing pertinent clinical insights depending upon whether you checked Yes or No to the Questions.  It’s very informative, requires just a few minutes, and there is no commitment or fees on your part.

Nightmare Treatments

Joseph Neidhardt and I co-authored a nightmare treatment book, Conquering Bad Dreams & Nightmares, in 1992.  It went out of print shortly thereafter, but it’s alive and well on hundreds of internet bookseller sites, often available for less than five bucks. 

In 2002, I published with great assistance from my wife, Jessica, who served as editor and designer of the work.  The audio series consists of 4 hours of instruction on CD, a workbook comprised of 100 pages of charts, diagrams, instructions, and recommendations, and both elements divided into 20 short and fairly digestible lessons. We had always hoped that nightmare patients would purchase it for self-help, but the most frequent buyers are therapists who want to learn IRT.  The book is available through our websites. 

My newest book, Sound Sleep, Sound Mind devotes one of seven parts (3 chapters) to my use of imagery work in the treatment of insomnia, a number of pearls and instructions on the general use of imagery in promoting well-being and strengthening mental health, and a short section on nightmare treatment. 

We also offer personalized clinical services for patients with chronic nightmares, but we find they do best by starting with one of the 3 treatment book options listed above, and then contacting us for follow-up, coaching and other fine-tuning of the process. 

Nightmare Treatment Pearl

I continue to be amazed and perplexed by the large number of nightmare patients who suffer from sleep-disordered breathing (SDB).  Some clearly see their nightmares diminish with positive airway pressure (PAP) therapy while others see no change.  A few actually see nightmares worsen in the early phase of PAP therapy use due to the natural REM rebound that occurs in patients responding well to the breathing mask treatment.

The Pearl I would like to offer is to never underestimate the potential for the presence of an underlying undiagnosed and untreated sleep breathing disorder if you suffer from chronic nightmares.   Aside from the obvious breathing questions, two very reliable queries are whether the person wakes up at night to urinate (nocturia) or awakens at any time from sleep with a dry mouth.

Both these symptoms are very reliable indicators for SDB, although it’s not clear how well this information is disseminated into clinical practices, such as medical or psychological clinics.  Dry mouth occurs for the obvious reason that the obstructed breathing causes the person to open their mouth while sleeping, eventually drying out the mucosa.  Nocturia is much less obvious, but we have a detailed description written out on one of our websites,  The short explanation is that SDB indirectly stimulates the kidneys to make more urine during the night, thus the increased tendency to wake up to urinate.

If you suffer from nightmares as well as snoring, breathing symptoms, dry mouth, and nocturia, there’s a good chance you also suffer from SDB.  So, just because nightmares emerge from obvious psychological origins, don’t dismiss the idea that they might represent a sign of a physical sleep disorder, too.