Vivid, upsetting nightmares happen sometimes. When they occur regularly and affect your ability to sleep or function, you may have a nightmare disorder. Sleep therapy, medications, and desensitization methods can all help treat this rare sleep condition.

Nightmares represent the most distressing type of dreams. They can be just about anything — real or imaginary — and even when they involve fantastical elements, they often evoke intense emotions like fear, despair, or desperation.

Almost everyone experiences a nightmare at some point in life. In fact, bad dreams may be more common than good dreams.

But when nightmares become prominent in your life and take a toll on your sleep quality or daily function, you may be living with a sleep disorder called nightmare disorder.

Nightmare disorder, also known as dream anxiety disorder, is a type of sleep-wake disorder called parasomnia.

Parasomnias involve patterns of sleep disturbances featuring unusual behaviors, emotions, or perceptions. They affect how well you fall asleep, stay asleep, or wake up from sleep.

It’s estimated that 4% of adults live with nightmare disorder.

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision (DSM-5-TR) differentiates nightmare disorder from typical nightmares based on dream features, frequency, and how they affect your life.

Under the DSM-5-TR, a diagnosis of nightmare disorder can be given when the following criteria are met:

  • Recurrent, extended, and intensely disturbing nightmares typically involve a threat to your survival, security, or physical self. Nightmares tend to occur during the rapid eye movement (REM) stage of sleep and are vividly remembered on waking.
  • After waking from a nightmare, you’re quickly alert and oriented to your surroundings.
  • The sleep disturbances cause clinically significant functional impairment or distress.
  • Nightmares and related symptoms aren’t caused by the use of any substance or medication.
  • Co-occurring mental and physical health conditions can’t wholly account for the nightmare experience.

A healthcare professional will categorize the disorder with a specifier based on the frequency and severity of your symptoms. Specifiers are diagnostic labels that provide insight into your individual experience.

Frequency-related specifiers for nightmare disorder in the DSM-5-TR include:

  • Acute: Nightmares have been occurring for 1 month or less.
  • Subacute: Nightmares have been occurring for more than 1 month but less than 6 months.
  • Persistent: Nightmares have been present for 6 months or longer.

Severity specifiers in the DSM-5-TR include:

  • Mild: Fewer than one nightmare per week on average.
  • Moderate: One or more nightmares per week but fewer than once per night.
  • Severe: Nightmares every night.

For some people, nightmares occur during the first half of the sleep cycle, known as the NREM phase. When this happens, nightmare disorder is given the DSM-5-TR specifier of “during sleep onset.”

Other symptoms

Frequent, distressing nightmares are the primary symptom of nightmare disorder, but other experiences often accompany these dreams. According to the DSM-5-TR, other nightmare-related symptoms include:

  • sweating
  • rapid heart rate
  • rapid breathing
  • sleep paralysis
  • fear of falling back asleep
  • lasting emotional distress during the day

The exact causes of nightmare disorder aren’t fully understood. Experts theorize several factors may be involved, including:

  • Hyperarousal: Elevated levels of stress, tension, and anxiety during the day may contribute to sleep challenges and the intensity of nightmares.
  • Impaired fear extinction: Intense fear that doesn’t naturally resolve with time, such as that from trauma, can keep the brain in an aroused memory state where it recombines fearful experiences into dream scenarios.
  • Trait susceptibility: Certain personality factors, like high novelty-seeking and genetic predispositions, may increase the chance of having persistent nightmares.
  • Maladaptive coping (thought suppression): Internal habits to cope with stress that involve the suppression of negative thoughts and emotions may cause them to manifest in nightmares.
  • Sleep-disordered breathing: Breathing disorders that affect sleep can contribute to psychological distress, triggering nightmares, and may cause less restorative sleep stages where nightmares are more likely to be remembered.

Experts believe these factors come together in a variety of ways to create what’s known as the “cognitive model of recurrent dreams.” Under this theoretical framework, nightmares are a type of learned behavior, where your subconscious reacts negatively to any elements in a dream that resemble an initial stressor.

For example, if you’ve had a traumatic experience involving water, nightmares might be triggered by seemingly distant dream elements like the color blue, liquid containers, words about the weather, and so on.

Nightmare disorder can be successfully managed with medications, behavioral modification, and psychotherapy.

According to a 2018 position statement from the American Academy of Sleep Medicine (AASM), image rehearsal therapy (IRT) is the recommended treatment for nightmare disorder.

IRT is a type of cognitive behavioral therapy (CBT) that involves discussing your nightmares with a mental health professional.

The goal is to reformat the ending of your nightmare into a positive outcome. With the guidance of your therapist, you’ll rehearse positive, alternative dream endings. Within a few weeks of sessions with regular at-home practice, your nightmares can become less distressing.

IRT is just one treatment option available for nightmare disorder. Other techniques suggested by the AASM include:

A sleep doctor may also prescribe anti-anxiety medications such as

  • nitrazepam
  • prazosin
  • triazolam

Treatment for nightmare disorder can vary depending on your experiences and any co-existing conditions. If you also live with post-traumatic stress disorder (PTSD), for example, your management plan may involve additional therapies and medications.

Is nightmare disorder a mental health condition?

Nightmare disorder is a sleep-wake disorder, but it’s also considered a mental health condition because it can cause significant psychological distress and impairment.

How can I stop having nightmares every night?

Speaking with a doctor or a sleep specialist can help you explore management strategies that reduce the frequency and severity of nightmares. These may include image rehearsal therapy, lucid dreaming therapy, and medication.

Can nightmares cause trauma?

Nightmares alone do not typically cause trauma. They can occur after trauma, and some research suggests they may accelerate the progression of PTSD.

Is nightmare disorder the same as night terrors?

No. Nightmare disorder and night terrors are not the same.

Night terrors are brief episodes of intense agitation and fear that occur during NREM sleep. Unlike nightmares in nightmare disorder, night terrors are short in duration and aren’t recallable like dreams.

Nightmare disorder is a type of parasomnia, a sleep-wake disorder featuring unusual behaviors or perceptions that interrupt sleep. Intense, extended, and vivid nightmares that cause major distress or impairment are the hallmark features of this condition.

Although experts aren’t clear on the underlying causes of nightmare disorder, behavioral interventions, psychotherapy, and medications can help you successfully manage symptoms.