Nightmare on Main Street, Alabama
Today we welcome a blog post from our friend and colleague, Dr. Courtney Worley. Dr. Worley is a Diplomate in Behavioral Sleep Medicine and Board-Certified Clinical Psychologist. She specializes in Evidence-Based Psychotherapies for PTSD, Insomnia, Nightmare, and Depression as a clinician, trainer, consultant, and researcher. She has provided consultation to clinicians across the United States and internationally. She is the co-author of the forthcoming book The Nightmare and Sleep Disorder Toolkit: A Workbook to Help You Get Some Rest Using Imagery, Rehearsal Therapy and other Evidence-Based Approaches from New Harbinger Press (Fall 2025). Please visit her website here for more information!
Whether you are bedding down in Birmingham, Huntsville, Tuscaloosa, Montgomery, Mobile, or any other town in Alabama, the scenario is the same…you wake up with a racing heart, feeling fearful, and as you look around for whatever was chasing you…you notice you are in your own home, your own room, your own bed. This experience is likely a familiar one. Almost all people dream and have occasional nightmares.
Dreams are a natural part of sleep. They are a product of the visual and emotional parts of our brains actively working to process experiences. They offer a way to work through thoughts and feelings, and they allow us to problem-solve in creative ways as the rules of reality are often suspended. Some of the images we experience can be disturbing, distressing and cause fearful awakenings, leading to the all-too-familiar experience of a nightmare. A nightmare does not always indicate something is wrong, but it can indicate the need to pay more attention to what’s happening. Let’s explore why you might want to pay attention to or seek help with your nightmares.
In this blog, we will discuss the following:
How Common Are Nightmares? Who is at Risk?
Defining “Nightmares”
As noted above, nightmares are upsetting or disturbing dreams that cause awakenings and distress. They most often occur during Rapid Eye Movement (REM) Sleep which is a stage of sleep where emotional processing and memory consolidation occur. REM sleep is also sometimes called paradoxical sleep because it is a light but active stage of sleep. It is easier to wake from this stage of sleep and nightmares cause awakenings and negatively impact sleep quality and quantity. For people who have nightmares frequently, they often notice problems with feeling fatigued, anxious or distressed the next day.
Nightmare disorder is diagnosed using criteria set out by the DSM-5-TR (APA 2023) or the ICSD-3-TR (AASM, 2023). This diagnosis is characterized by disturbing dreams that cause awakenings, have recalled content and impact functioning the next day. Nightmares can occur alone or may co-occur with other sleep disorders or mental health concerns.
How Common Are Nightmares? Who is at Risk?
While everyone may have nightmares from time to time, problematic nightmares—those that cause difficulty with both sleep and next-day functioning—impact roughly 1 in 10 Americans (Worley et al., 2021). They are more common in children, adolescents, and young adults but often persist in middle age. Women and people from historically marginalized groups report higher rates of problematic. However, people from all backgrounds and ages can experience problematic nightmares. Individuals with a history of trauma exposure, both civilians and military Veterans, often experience nightmares related to their trauma. Nightmares are also common in people experiencing depression, anxiety, and other mental health conditions.
The Nightmare Habit
One theory for why nightmares occur is called the Mood Matching Hypothesis. This is the idea that the emotions we are experiencing at bedtime impact the imagery our brain uses for dreams and nightmares. The visual imagery parts of our brains are more active in sleep as compared to the logical thought centers. If we go to bed anxious for example, the brain will match that feeling with anxious imagery. Sometimes this imagery matches real life experiences or imagery we have been exposed to in order to help us process emotions. For trauma survivors, this may mean our brains replay all or part of the trauma experience or bring up imagery that matches the distress and loss of control that was experienced in trauma.
Nightmares can become a habit where our brain replays the same or similar events or themes night after night. This habit develops because nightmares cause distress and sleep disruption, leading to worse daytime functioning and nighttime distress. This becomes a cycle where daytime distress leads to worry or anxiety about having more nightmares. Nighttime distress and worry lead to worsened sleep, more nightmares and the increased probability that one wakes up during REM sleep. These awakenings lead to greater recall of dream content. This in turn leads to more disrupted sleep, poorer daytime functioning, and the cycle continues. In some cases, people attempt to address this nightmare problem using behaviors that may make their sleep or nightmares worse. This includes increased time spent in bed, napping, or using alcohol or other substances to try to fall asleep. People may also try to avoid thinking about nightmares or distressing thoughts and emotions by staying busy or distracted (which is a short-term coping strategy). However, instead of reducing nightmares, avoidance during the day may lead to the brain trying to work out these concerns while they are sleeping through dreams or nightmares. If your dreams or nightmares are consistently causing disruptions in your sleep, distress the next day, and/or you find yourself fearful of sleep or avoiding sleep, you may want to seek help. We will discuss resources below.
Types of Nightmares
When we consider nightmares, especially those related to a traumatic experience, there are usually three types of content: those that are dissimilar, those that are similar, and those that are replicative of real-life events. Dissimilar nightmares do not appear to have any connection to real-life or traumatic events, but have upsetting content nonetheless. Similar dreams may have some of the elements, but then other parts do not match. An example would be a combat veteran replaying a battle, but then family members who were not actually present at the battle showing up on the battlefield in a dream. These can be quite confusing and distressing. Replicative nightmares close a replay of the event with the same sights, sounds, and emotions. Individuals can feel stuck replaying the same distressing event night after night. Tired of dealing with it while they sleep, they may also avoid the content during the day, but this may only make the nightmare more likely to occur.
Are Nightmares Dangerous?
Nightmares are not inherently dangerous, but they can have a negative impact on sleep and a person’s quality of life. Nightmares may also signal that someone is having an increase in other mental health symptoms, which could lead to more severe problems. Recent research has shown that changes in dreams and nightmares may be associated with future suicide risk especially in those with depression (Geoffroy, 2022). So individuals who are experiencing increased distress related to sleep and nightmares or begin to have dreams reflecting suicide should reach out for help. There also appears to be an increased risk of suicide in individuals with trauma-related nightmares. My recent research with US military veterans, and the work of other researchers in this field (Youngren et al., 2024), has identified associations between trauma-related nightmares and multiple health and functional outcomes--even when individuals do not meet criteria for PTSD. The risks associated with trauma-related nightmares and suicide persist even when we account for other causes.
If you or a loved one are having thoughts or suicide or recurrent dreams about suicide, there is help available. Anyone can call “988” to connect directly to the Suicide and Crisis Lifeline. You can also call 911 or go to your nearest emergency room for help.
Assessment and Diagnosis
Many people do not seek help for nightmares because they do not realize it is a treatable condition! And many healthcare providers may not routinely ask about nightmares. Speak up and talk with your healthcare providers about sleep, dreams, and nightmares. A healthcare professional can help with diagnosis. You may consult a psychologist or social worker with specialized training in behavioral sleep medicine for an initial evaluation. Sleep physicians, often trained in pulmonology, can also be an important part of the treatment team. You may be referred to sleep medicine if you are experiencing signs of another sleep disorder like obstructive sleep apnea. Your healthcare provider will likely ask you questions in the appointment as well as asking you to track your experiences using a sleep and nightmare log. Identifying patterns in your sleep and nightmares can be helpful for diagnosis and developing a treatment plan.
Treatment is Available!
There are some very effective treatments for nightmares and for PTSD. We often recommend Cognitive Behavioral Therapy for Nightmares or CBT-N. This behavioral treatment contains skills from evidence-based interventions for nightmares like Imagery Rehearsal Therapy, as well as broader treatments for sleep health. A behavioral sleep medicine clinician, like the ones at Upward Behavioral Health, can often help someone address nightmares in 3-6 sessions of CBT-N. For individuals with co-occurring mental health concerns, it is also important to address symptoms with evidence-based, proven treatments. Trauma survivors can also benefit from pursuing evidence-based psychotherapies for PTSD. The National Center for PTSD has a number of resources to help people learn about and choose treatment that fit their needs.
If you would like to explore how your nightmares might be impacting you, contact Upward Behavioral Health for assessment and treatment. Or, if you prefer more self-help oriented options, I have a book titled The Nightmare and Sleep Disorder Toolkit: A Workbook to Help You Get Some Rest Using Imagery, Rehearsal Therapy and Other Evidence Based Approaches scheduled for publication with New Harbinger Press in Fall 2025. If you are a healthcare provider who is looking to obtain training, I have an upcoming workshop on 10/30/24 detailed below.
Hopefully this blog has helped you with resources to address nightmares and move towards sweeter dreams.
October 30, 2024:
Access Special Halloween Webinar
12:00 - 2:00 pm eastern time
Learning objectives:
* Define Nightmares as distinct from other parasomnias
* Explore Evidence Based Psychotherapies for Nightmares
* Develop skills to deliver behavioral nightmare treatment using case example
Approved for 2 APA CEUs
SBSM Members: attend FREE
Those not members yet: $50
To join or renew click the link
"Mississippi State University is approved by the American Psychological Association to sponsor continuing education for psychologists. Mississippi State University maintains responsibility for this program and its content."
Don’t Ghost Us! Register here: Halloween Webinar (jotform.com)
References
American Psychiatric Association. (2023). Diagnostic and statistical manual of mental disorders (5th edition, Text Revision).
https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787
American Academy of Sleep Medicine (20023). International Classification of Sleep Disorders (3rd ed. Text Revision)
Geoffroy, P., Borand, R., Ambar Akkaoui, M., Yung, S., Atoui, Y., Fontenoy, E., Maruani, J., & Lejoyeux, M. (2022). Bad dreams and nightmares preceding suicidal behaviors. The Journal of Clinical Psychiatry, 84(1), 22m14448.
Worley, C.B., Bolstad, C.J., & Nadorff, M.R. (2021). Epidemiology of disturbing dreams in a diverse US sample, Sleep Medicine, 83, 5-11. https://doi.org/10.1016/j.sleep.2021.04.026
Youngren, W. A., Bishop, T., Carr, M., Mattera, E., & Pigeon, W. (2024). Nightmare types and suicide. Dreaming, 34(1), 1–7. https://doi.org/10.1037/drm0000261