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Unlocking the Secrets of Nightmares

Don Rosenberg

Unlocking Secrets of Nightmares 
and New Approaches to Calming Dreams©

Don Rosenberg
April, 2025

This is the fifth article in a series on better sleep.  Please check out 10 Solutions for Better Sleep, the Underestimated But Crucial Role of Sleep in Mental Health, and Mindfulness Can Help You Sleep Better, Autogenic Training for Sleep.  A related article that pertains to sleep, but has wider usefulness is our series called Quieting the Anxious Unquiet Mind. 
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A devoted mother, Samantha is worried that her 8-year-old son, Alex, has been waking up  distressed and frightened due to recurring nightmares. Alex said in his dreams he often sees a menacing creature lurking near his bed. Anxious at bedtime, he’s now afraid to go to sleep.

John is a 35-year-old combat veteran who returned home from a war zone with persistent PTSD symptoms. Night after night, he experiences vivid, distressing nightmares in which he relives harrowing combat experiences. These episodes disrupt his sleep, elevate his anxiety, and diminish his overall quality of life.  John’s nightmares typically begin with familiar scenes from his deployment. In these dreams, he often feels unsafe, helpless, and overwhelmed by the chaotic environment of battle. Intense emotions and physical reactions (e.g., rapid heartbeat, sweating) leave him exhausted. Now, he is fearful of falling asleep. The ongoing distress from these dreams contributes to increased daytime anxiety, fatigue, and difficulty concentrating at work. 

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Nightmares have fascinated and troubled humanity for centuries. They are not simply “bad dreams” but complex experiences that can range from fleeting disturbances that may linger in the mind the next day to recurring, terror-filled episodes that disrupt sleep and overall well-being. Recent research expands our understanding of these nocturnal phenomena — revealing distinct types of nightmares, identifying who may be more prone to them, exploring their causes (including their potential link to suicidal ideation), and even pioneering innovative therapies to rewrite these distressing dreams.

So, first, let’s discuss types of nightmares such as bad dreams, nightmares, PTSD-related nightmares, complex nightmares, sleep terrors, and sleep paralysis.  

Second, are some people more prone to nightmares?

Third, what may cause nightmares?

Fourth, therapists have many approaches to helping with nightmares, such as imagery rehearsal therapy and re-scripting therapies.  We’ll review what therapists do with nightmares.

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1. A Spectrum of Nocturnal Disturbances
Not all sleep disturbances are created equal. While the term “bad dream” is often used colloquially, experts distinguish among several forms:

Bad Dreams vs. Nightmares: Whereas nightmares are vivid, emotionally charged, and often result in abrupt arousals from sleep, bad dreams are typically less intense and may not lead to awakening.  Where one is terrifying, the other is merely unpleasant or troubling. 

PTSD-Related Nightmares: These are common among individuals with posttraumatic stress disorder, where traumatic memories intrude during sleep, often with striking realism, vividness, and intense fear (Levin & Nielsen, 2007).

Complex Nightmares: Involving intricate narratives, these dreams may merge everyday stressors with deeper emotional themes (often related to trauma) to create a frightening “story” more like a flashback to an original set of traumata, with high alertness, racing heart rate, and such high distress that it is hard to fall back asleep.  These are associated with a condition known as Complex PTSD that may develop when childhood trauma is prolonged and repeated.

Sleep Terrors and Sleep Paralysis: Sleep terrors are marked by sudden, intense fear during non-rapid eye movement (non-REM) sleep.  These are usually in childhood and the person experiencing a sleep terror is still in REM sleep and is hard to awaken.  If it’s child, keep the child safe and in bed until a sleep terror subsides. The child usually does not remember it the next day. They do outgrow these phenomena. Sleep paralysis involves a temporary inability to move accompanied by vivid dream states like hallucinatory experiences (Spoormaker & Montgomery, 2008).  They occur in REM sleep when our body movement is “turned off” and so there is a sense of inability to physically move to protect one’s self within the dream state.  Although very brief, they can be scary.  

As we can see, traumatic experiences, chronically upsetting life situations, anxiety, and depressed mood can lead to nightmares.  Some psychoactive chemicals, such as marijuana, cocaine, ketamine, LSD, and psylocibin can also trigger them.

2. Who Is Prone to Nightmares?
While anyone can experience nightmares, research has identified certain groups as more vulnerable. Individuals with a history of trauma, heightened anxiety, or chronic stress are at a greater risk (Levin & Nielsen, 2007). Moreover, demographic factors—such as age (childhood and also older adults), gender (more in females), and even genetic predispositions—can influence the frequency and intensity of nightmares. Clinicians have noted that the persistence of nightmares, especially in those with PTSD or depressive disorders, can exacerbate overall mental health challenges.

3. Causes and Consequences
Nightmares can be triggered by a variety of factors:

Stress and Trauma: Acute or chronic stressful events, along with traumatic events, are a well-established contributor to nightmare activity.

Substance Use and Medications: Certain medications and substances can disrupt sleep architecture and precipitate disturbing dreams.

Sleep Disorders: Underlying sleep disorders, including sleep apnea and restless leg syndrome, may also play a role (Spoormaker & Montgomery, 2008).

Suicidal Ideation: Alarmingly, studies have found that the chronic experience of nightmares can be associated with increased suicidal ideation. Although nightmares themselves do not directly cause suicide, their frequent occurrence — especially when paired with mood disorders or PTSD — can contribute to a cascade of mental health challenges that heighten suicide risk (Krakow et al., 2001; Levin & Nielsen, 2007).

4. Rewriting Dreams: New Frontiers in Therapy
A particularly promising area in the treatment of nightmare disorders is the concept of rewriting or re-scripting dreams. This therapeutic approach involves altering the narrative of a recurrent nightmare to reduce its emotional impact:

Image Rehearsal Therapy (IRT):  IRT is a cognitive-behavioral technique where patients learn to visualize a modified, less distressing version of their nightmare during wakefulness. Over time, repeated rehearsal of this new narrative can diminish both the frequency and intensity of the nightmares (Krakow & Zadra, 2006).   

Step 1: Education and Orientation - nightmares are a natural phenomenon, but also a learned pattern for the mind trying to master a painful situation.
Step 2: Keep a detailed diary of nightmares. In time, you will notice patterns, themes, and triggers.
Step 3: Select one that is particularly distressing or frequently recurring.
Step 4: Write out the chosen nightmare in detail, noting emotions, settings, characters, and specific events. Writing it out consciously takes one a step away from being inside it. We call this purposeful dissociation.
Step 5: Rewrite the narrative. The new version often includes a less distressing or empowering ending, transforming negative elements into neutral or positive outcomes.  Rewriting the nightmare helps to break the link between the nightmare’s trigger and the associated fear response.
Step 6: Mental Rehearsal through practicing visualizing the rewritten dream during waking hours, often several times a day.  Repeated rehearsal helps form new associations, gradually reducing the emotional charge of the original nightmare. 
Step 7: Track changes in the frequency and intensity of nightmares.

Here is an example from a firefighter we helped.

Each night, Pierre dreams he’s trapped in a burning building. The smoke chokes him as he searches for his daughter, but he never finds her. Flames block every exit. Just as he reaches a door, the ceiling collapses and he wakes up, heart racing, drenched in sweat.

Steps in Imagery Rehearsal Therapy
1. Psychoeducation
The therapist explains that nightmares, especially in PTSD, often reflect unresolved trauma. IRT helps “rescript” the dream to reduce distress and frequency.

2. Nightmare Selection & Recording
Pierre chooses the recurring fire dream. He writes it down in full detail, focusing on the sensory and emotional experience.

3. Identify the Emotional Themes
Themes include helplessness, fear, guilt (not saving daughter), and entrapment.

4. Create a New Dream Ending
With the therapist, he rewrites the dream:
“I see the flames but find a fire extinguisher. I clears a path and hears his daughter’s voice. I find her safely behind a door. Together, they exit the building into fresh air. She is smiling. I feel relieved.”

5. Rehearsal of New Dream (Imagery Practice)
He rehearses the revised dream daily, eyes closed, vividly imagining the new version for 10–15 minutes.

6. Practice and Monitoring
He repeats the exercise daily for two weeks, recording dream frequency, intensity, and emotional impact.

7. Outcome
Over time, Pierre  notices the nightmare stops occurring. He feels empowered and reports better sleep and reduced anxiety.

Re-scripting Therapies: Similar to IRT, re-scripting therapies empower patients to take control of their dream narratives. By reconstructing the storyline in a safe, conscious environment, individuals may reframe traumatic experiences and reduce the power of recurring nightmares. To explain, assume a nightmare that has some echoes of a real event such as an assault or is an imagined attack.  Usually, we wake up at the point of maximum fear.  What if we were to re-script the dream in various ways, such as, for example, not going into the place where that action takes place, but rather going to some more benign place. Or someone is with us as a companion-protector. Or an older version of ourselves charges into the scene and takes command, preventing harm, and creating safety.

Programming Dreams: An emerging and somewhat experimental concept, programming dreams involves intentionally inducing specific dream content. Early research suggests that this method might one day complement traditional techniques by harnessing the brain’s natural capacity for memory consolidation and emotional processing (Wamsley, 2018). In this method, we write out or plan out the dream we would like to have or the events in the recurrent dream are altered.  We can also implant the idea we are the watcher of the dreamer, being aware that it’s only dreaming (also called Lucid Dreaming).  Write out the dream in exceptional detail and then imagine yourself within the story noting it’s a dream and reprogramming what happens – changing the decision-making and problem-solving, bringing in resources and help.  

Active Imagination: Carl Jung came up with this over 120 years ago.  Sit with the dream image and “dream the dream forward” from that point – while awake and calm.  The dream is composed of unconscious, incomplete experiences.  The conscious mind can now work on completing them. Take notes. As discussed above, this helps with making the less controllable more controllable.  Just let associations emerge without trying to direct them.  Concentrating on parts of the image, note how they transform. 

Hypnotherapy: In a way, the nightmare is a form of hypnotic experience!  In a hypnotic state, we can associate the dream imagery with new outcomes – converting fear to safety or curiosity.  We can also suggest that going to sleep is associated with rest and restoration.

EMDR: In Eye Movement Desensitization and Reprocessing, we bring up the most distressing image in the dream and the associated belief about self – “I am helpless.” “I can’t protect myself.” Then the therapist directs side-to-side eye movements or taps until the image becomes more faint or distant or associations emerge that help us understand how that image connects to some other or deeper experiences. Then we target those. We continue until all the images become non-distressing.  

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Let’s take another look at John’s PTSD-related nightmares. John has some gruesome mental images from combat. He associated them with both great lack of safety, despite coming through unharmed, and with guilt, as if he could have made some kind of decision that would have prevented what happened. Identify the latter as a natural need to make the uncontrollable seem controllable. The responsibility for whatever happened was not his – the proximate cause of violence against a person lies with the violent actor.  (We could reason about deeper causes, but ultimately, the proximate cause is the violent actor’s actions, which could generally have been different.)  In IRT, John changed the cognitive outcome to “I survived, I am safe, my family is the beneficiary of my survival, I can best honor my comrades in others ways” (which he enumerated), and he associated his memory of the event with the relief of being rescued and the ways he could honor those who had been injured.  Over several nights, he reinforced changes in the outcome of the nightmares until he noticed a profound change in what happened and how he felt about it the next day.

Conclusion

From the spectrum of disturbances that range from simple bad dreams to the debilitating impact of PTSD-related nightmares, the science of sleep continues to reveal the profound connections between our nocturnal experiences and our waking lives. As research sheds light on who is most at risk and the myriad factors that contribute to these sleep disturbances, the development of therapies like IRT provide hope.

In a follow-up article, we will talk about helping children manage nightmares. 

References
Krakow, B., Hollifield, M., Johnston, L., et al. (2001). The treatment of nightmares in posttraumatic stress disorder. Journal of Traumatic Stress, 14(3), 511–520.

Krakow, B., & Zadra, A. (2006). Image rehearsal therapy for chronic nightmares: A randomized controlled trial. Sleep, 29(2), 195–201.

Levin, R., & Nielsen, T. A. (2007). Disturbed dreaming, posttraumatic stress disorder, and affect distress: A review and neurocognitive model. Psychological Bulletin, 133(3), 482–528.

Spoormaker, V. I., & Montgomery, P. (2008). Disturbed sleep in posttraumatic stress disorder: Secondary symptom or core feature? Sleep Medicine Reviews, 12(3), 169–184.

Wamsley, E. J. (2018). Targeted dream incubation: Programming dreams for memory consolidation. Neuroscience & Biobehavioral Reviews, 86, 103–112.

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Shorehaven Behavioral Health is a major mental health clinic and training center with therapy offices in Brown Deer, Greenfield, and Mt. Pleasant, and also offering telehealth throughout Wisconsin. We specialize in challenging cases and rapid access to services.  In addition to depression, anxiety, behavioral problems, and most other psychological problems, we work extensively with children & families and with substance use problems. Our DBT program has three groups – for younger adolescents, older adolescents, and adults – and has openings. We also accept referrals for substance abuse care from clinicians who are not comfortable with that population.  Call 414-540-2170.
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