When Nightmares Won't Go Away

Nightmare therapy may put chronic nightmares to rest.

Medically Reviewed by Marina Katz, MD on September 05, 2011
Written by David Freeman
5 min read

Yael Levy recalls having chronic nightmares as far back as elementary school, when she was living in Israel. The grandchild of Holocaust survivors, she says her dreams were filled with images of suffering and death.

In one recurrent nightmare, Levy was trapped in a concentration camp, facing death. In another, she was drowning in deep water. At their worst, the nightmares occurred on an almost weekly basis, leaving her jittery and desperately fatigued.

"I would wake up so terrified that I was afraid to go back to sleep," Levy says. "And the bad feelings were hard to shake. I would continue to feel frightened throughout the next day."

There's nothing unusual about having an occasional nightmare (which sleep experts define simply as a bad dream that causes the sleeper to wake up). But up to 8% of the adult population suffers from chronic nightmares, waking in terror at least once a week.

Sometimes the nightmares are so frequent and so upsetting that they make sound sleep all but impossible, setting the stage for fatigue and emotional problems like anxiety and depression.

Nightmares vary widely in their themes and specific content -- experts say they can be "about" anything -- but all cause fear, sadness, anger, shame, or another negative emotion. They occur during REM sleep, typically in the latter part of the night. Though more common in children and adolescents, they also strike in adulthood.

In many cases, chronic nightmares are triggered by psychological stress -- such as that stemming from posttraumatic stress disorder, a severe anxiety disorder that strikes people who have been exposed to or witnessed combat, violent assaults, accidents, natural disasters, and other terrifying ordeals.

Other causes of chronic nightmares include alcohol abuse, the use of certain medications, and sleep disorders, including the disordered breathing condition known as sleep apnea.

Now 29 years old and living in New York City with her husband and 4-month-old son, Levy says she endured years of fractured sleep and persistent anxiety because of chronic nightmares. It never occurred to her that help was available.

"People have nightmares," Levy says. "I had mine, and that was that. I didn't think it was the sort of problem that could be treated."

It's a common misconception.

"Lots of people think that nightmares can't be treated," says Shelby Harris, PsyD, director of the behavioral sleep medicine program at Montefiore Medical Center's Sleep-Wake Disorders Center in New York City. "But there are effective treatments."

One treatment option is psychodynamic psychotherapy, in which patients meet regularly with a therapist to discuss their nightmares and consider any emotional problems that might be causing them.

Another option is taking prazosin, a medication usually prescribed for high blood pressure; studies have shown that nightly doses of the drug are effective against chronic nightmares in people with posttraumatic stress disorder.

But Levy found relief not in pills or psychotherapy but from a simple behavioral technique she learned from Harris after seeking treatment not for nightmares but for insomnia.

The technique that Levy used, known as imagery rehearsal therapy (IRT), grew out of research conducted in the 1990s. It's been steadily gaining favor as a treatment for chronic nightmares since 2001 when a landmark study published in the Journal of the American Medical Association found that it not only curbed nightmares among victims of sexual assault but also reduced PTSD symptoms.

"Studies show that 70% to 80% of people who try IRT get significant relief," says Barry Krakow, MD, director of the Maimonides International Nightmare Treatment Center in Albuquerque, N.M. He's one of the researchers who worked on the JAMA study and the author of four books on sleep medicine, including Sound Sleep, Sound Mind.

IRT is surprisingly easy to learn and to use. The basic technique can often be mastered in a few hours; once learned, it's used for only a few minutes a day for a matter of days or weeks.

Krakow says it's possible to try IRT on your own, but he warns that people who suffer from PTSD or another psychological condition should attempt the technique only with the help of a doctor or therapist.

Working with a professional also makes sense for people who have trouble visualizing dream images while awake. "Some people have difficulty painting a picture in the mind's eye," Harris says. "But with help, they get good at priming the pump for imagery."

As described by Krakow and Harris, IRT is a three-step process:

  1. Jot down a brief description of a recent nightmare. If your most recent nightmare is too upsetting to think about, pick another.
  2. Think of a way to change the nightmare. Krakow declines to tell his patients what sort of change to make, encouraging them to rely on their intuition to make an appropriate change.
  3. Set aside a few minutes each day to imagine this altered version of the nightmare. Simply paint a mental picture of the altered version.

Some people with chronic nightmares, especially those who have suffered for years, find it hard to believe that a simple, essentially do-it-yourself technique could be effective.

Krakow says that when he explains IRT to his patients, "it's almost like they think the process is disrespecting them. They say, 'What do you mean I just write down a nightmare and change it and picture it in my mind? That's crazy.' It's almost like they think I'm saying, 'Change two dreams and call me in the morning.'"

Levy can't recall exactly what she thought when Harris told her about IRT. But she tried it and found that it worked. Her nightmare about the concentration camp? She re-imagined herself in a summer camp where she could walk about freely. And the bad dream about drowning? The deep water that threatened to swallow her up became shallow enough to stand up in.

Levy still has nightmares, but they occur much less frequently -- about once every six weeks or so. When they do occur, they are less upsetting.

"Just learning that there was something I could do about my nightmares really helped a lot," Levy says. "Getting help changed things for me significantly. I'm more rested and happier, and I'm able to be more active during the day."