Nightmares in adults: Symptoms, causes, and innovative, science-backed therapies

In a perfect world, sleep offers a respite for body and mind. But for people who experience nightmares, climbing into bed can be like going into battle. Nightmares are most common in childhood, with 25%–30% of children reporting having experienced nightmares in the past month (El Sabbagh, E., et al., Sleep Medicine Reviews, Vol. 71, No. 101834, 2023). For many, those bad dreams continue into adulthood. Occasional nightmares are thought to be common in adults, and in a British study with about 800 participants, about 1 in 20 reported having nightmares every week (Rek, S., et al., Social Psychiatry and Psychiatric Epidemiology, Vol. 52, No. 9, 2017).

For some people, nightmares cause distress that follows them into their waking lives. Nightmare disorder—defined in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition, Text Revision) as repeated dreams that are extremely dysphoric, are well remembered, and cause significant distress or impairment in functioning—affects 2%–5% of adults in the general population. A Dutch study of 962 patients with psychiatric diagnoses including mood, anxiety, and personality disorders suggests that the prevalence of nightmares among this population might rise to nearly 30% (Swart, M. L., et al., Psychotherapy and Psychosomatics, Vol. 82, No. 4, 2013). Meanwhile, a systematic review indicates that frequent nightmares might affect up to 70% of people with posttraumatic stress disorder (PTSD) (Akkaoui, M. A., et al., Journal of Clinical Medicine, Vol. 9, No. 12, 2020).

In people with or without a history of trauma, nightmares can have serious consequences. Disturbing dreams can interfere with healthy sleep, which can lead to downstream problems with emotion regulation and overall mental and physical health. Nightmares can increase anxiety and distress and impair daytime functioning. Research shows they are also associated with an increased risk of suicide.

That link is one important reason that nightmares deserve a fresh look, said Leslie Ellis, PhD, a clinical psychologist in British Columbia who offers courses for clinicians on talking to patients about their dreams and nightmares. Dreams have been of interest to psychologists and psychiatrists since the days of Sigmund Freud and Carl Jung, but that long history can lend “dreamwork” an old-fashioned, unserious air, Ellis said. Yet there is plenty of new research considering nightmares through a more scientific lens. “I think of nightmares as the body’s natural attempt to regulate emotion. And they can indicate that something is serious enough to warrant more attention,” she said.

Despite the significance of nightmares, the public and clinicians alike often fail to recognize the importance of treating them—or even that nightmares can be treated at all. More practitioners would benefit from learning about nightmares and asking patients about them, said William Kelly, PhD, a psychology professor and nightmare researcher at the University of the Incarnate Word in San Antonio, Texas. “Patients don’t always report nightmares if you don’t ask about them, but they could be signaling something important,” he said.

Nightmare types

Nightmares associated with PTSD seem to differ from other nightmares in key ways. Dreams and non-PTSD nightmares occur mostly during rapid eye movement (REM) sleep. PTSD-related nightmares, however, occur across all stages of sleep. They also tend to be more realistic and less fragmented than other dreams. In some cases, nightmares mirror a traumatic event almost exactly, said Deirdre Barrett, PhD, a dream researcher at Harvard University and editor of APA’s journal Dreaming, which published a special section on new research about nightmares in March 2024. Such differences suggest traumatic nightmares may be more akin to flashbacks that occur during sleep, she said. “I think the intrusive memories associated with PTSD are superimposed on every stage of sleep and waking.”

People with frequent non-PTSD nightmares, by contrast, seem less likely to experience the same dream each night, though their nightmares often share similar themes. “Dreams tend to reflect ongoing preoccupations and concerns, sometimes in some bizarre metaphorical ways,” said Antonio Zadra, PhD, a psychology professor at the University of Montreal and a researcher at the Center for Advanced Research in Sleep Medicine. “People might dream of driving off a cliff one night and going down with a sinking ship the next. What’s consistent is a theme of feeling out of control.”

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