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Even if you can't always remember your dreams, research suggests we all have them. But sometimes our dreams can turn into nightmares. While most people experience the occasional nightmare, about 4% of US adults suffer from nightmare disorder, research published in the Journal of Clinical Sleep Medicine found. This condition causes frequent bad dreams that wreak havoc on a person's sleep and daily life.
"When you have frequent nightmares, you try to avoid falling asleep, as you don't want to go back down into that rabbit hole," Patrick McNamara, a neuroscientist and neurology professor at Boston University's school of medicine, said. "So you become sleep-deprived, and that sleep deprivation slowly undermines health."
Despite the stress they cause, nightmares are usually underreported, Kristi Pruiksma, a psychiatry and behavioral-sciences professor at the University of Texas Health Science Center at San Antonio, said.
Luckily, help is available: The American Academy of Sleep Medicine recommends a variety of medications and therapies, including unique rescripting therapies, which can help people suffering from nightmare disorder. These include image-rehearsal therapy and exposure, relaxation, and rescripting therapy (ERRT).
Dreams occur during the rapid-eye-movement cycle of sleep, when the brain is focused on processing your intense emotional experiences and storing them away as memories, McNamara said. Some research suggests that nightmares occur because the brain has a more difficult time making sense of stressful memories.
"If the emotional memory is too intense or traumatic, it's more difficult to integrate it so it sits around in working memory causing repeat bad dreams and nightmares and intrudes into daytime consciousness," McNamara said.
Anyone who has experienced trauma, has a personality disorder, or is suffering from a mood disorder such as major depressive disorder is more prone to recurring bizarre, fear-provoking dreams, research published in the National Library of Medicine found. Medications such as antidepressants, sleep disorders, and other issues can also cause nightmares.
The type of nightmare you may experience depends on many factors. For instance, stress and anxiety can spur idiopathic nightmares, which are more imaginative and don't contain elements of trauma. Post-traumatic nightmares contain either replays of a traumatic event or similar scenarios and can be more arousing.
For many people who have experienced trauma, "their nightmares are different every night, but they have a similar theme," Pruiksma said, adding: "There's usually at least some element of the trauma that is in their nightmare, and it might be like a replay or a representation."
Multiple types of therapy can help solve issues with nightmare disorder.
A review of studies conducted from 2000 to 2020 found that image-rehearsal therapy and ERRT, as well as similar methods, were the most effective for both idiopathic and post-traumatic nightmares. Both types of therapy offer education on healthy sleep habits and relaxation techniques.
The central goal for both is rescripting, where patients write down their nightmares and rewrite them in a way that's not as distressing, McNamara said. The patient then reads this new script before sleep.
"You imagine the monster, but this time you look more closely at it and then recognize it's no monster at all chasing you — it's just a friend trying to catch up with you," he said. "If we can defang the imagery and make it less arousing, controlling, and attention-grabbing, then the mind can reassert control so that the individual is no longer at the mercy of the intense emotions fueling the nightmare."
While ERRT and image-rehearsal therapy are very similar, they do diverge: Pruiksma said that in ERRT sessions, instead of just reimagining the original nightmare, the mental-health professional and patient typically look at it and determine a recurring theme. Pruiksma has been helping military veterans cope with post-traumatic nightmares with ERRT for years as part of her work with the Strong Star Consortium, a trauma- and resilience-research group.
The five themes are trust, intimacy, power and control, safety, and esteem. They use the theme they find in a patient's dreams as a guide to write the new dream.
"We found that having this theme to guide people helps them come up with something more meaningful and powerful so they can rescript in so many ways," Pruiksma said. "Some people give themselves superpowers, and so that they have some safety and control. Some people integrate humor."
The number of sessions a patient needs typically depends on how the initial rescripting works out and whether they want to work on more than one dream. Pruiksma said the patients she'd worked with using ERRT usually underwent six 50-minute sessions. This gives time for them to make edits to dream sequences, work on sleep habits, and approach more dreams.
"People often start having normal dreams for the first time in years," she said, or they still have the nightmare, "but it doesn't wake them up."
She added: "There's just something about that process that sets them up for a more peaceful night."
