Published via DMIHER Datta Meghe Medical

Open Access Review Article College

Understanding and Treating Nightmares: A

Comprehensive Review of Psychosocial Strategies
Received 09/09/2024
for Adults and Children
Review began 09/13/2024
Review ended 09/17/2024 Namita Sahu 1, Pradeep S. Patil 1, Asmita - 1, Imyarila Longkumer 1
Published 09/23/2024

© Copyright 2024 1. Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
Sahu et al. This is an open access article
distributed under the terms of the Creative
Corresponding author: Namita Sahu, namita0694@gmail.com
Commons Attribution License CC-BY 4.0.,
which permits unrestricted use, distribution,
and reproduction in any medium, provided
the original author and source are credited.
Abstract
DOI: 10.7759/cureus.70044
Nightmares are distressing dreams that evoke strong negative emotions, such as fear or anxiety, often
leading to waking from sleep and subsequent sleep disruption. They are prevalent across various age groups,
with significant psychological and physiological health implications. This review explores the nature of
nightmares, distinguishing them from other sleep disturbances like night terrors and sleep paralysis. It
examines the prevalence of nightmares in children and adults, highlighting their impact on mental health
and daily functioning. The review also emphasizes the importance of addressing nightmares through
effective treatment strategies.

While pharmacological options are available, psychosocial interventions offer promising non-
pharmacological solutions. Cognitive behavioral therapy (CBT), imagery rehearsal therapy (IRT), and
mindfulness-based therapies are discussed as key approaches for managing nightmares. These strategies
focus on altering maladaptive thought patterns and emotional responses, reducing nightmares' frequency
and intensity, and improving overall sleep quality. Psychosocial interventions provide a comprehensive
approach to treating nightmares by addressing the underlying cognitive and emotional factors, benefitting
individuals across different age groups. This review aims to highlight the efficacy of these strategies and
their role in enhancing the quality of life for those affected by persistent nightmares.

Categories: Internal Medicine, Medical Education, Medical Simulation

Keywords: mental health, psychosocial interventions, sleep disturbances, imagery rehearsal therapy (irt), cognitive
behavioral therapy (cbt), nightmares

Introduction And Background

Nightmares are distressing dreams that often threaten an individual’s safety, security, or physical integrity,
leading to a sudden awakening [1]. Unlike typical dreams, nightmares are characterized by intense negative
emotions such as fear, anxiety, or sadness, which can linger even after the dreamer has woken up [2]. These
disturbing experiences occur predominantly during the rapid eye movement (REM) stage of sleep, a phase
characterized by vivid dreaming. Upon waking from a nightmare, the person can usually recall the content in
vivid detail, which often contributes to ongoing distress and can disrupt their sleep pattern [3].

It is important to distinguish nightmares from other sleep disturbances, particularly night terrors. While
nightmares occur during REM sleep and involve detailed recollection of the dream upon waking, night
terrors are a type of parasomnia that occurs during non-REM sleep, especially in the deep stages [4].
Individuals experiencing night terrors may scream, thrash, or exhibit signs of panic, but they typically do not
fully awaken or remember the event the following day [1]. Other sleep disturbances, such as sleep paralysis
and REM sleep behavior disorder (RBD), may also be confused with nightmares. Sleep paralysis involves a
sensation of being awake but unable to move, often accompanied by feelings of fear or a perceived threat. In
contrast, RBD involves physically acting out dreams, sometimes violently, though these do not necessarily
involve the emotional terror that characterizes nightmares [1].

Nightmares are a common phenomenon across various age groups, though their prevalence can vary. In
children, nightmares are particularly frequent, with studies suggesting that approximately 10-50%
experience them regularly, especially during the ages of three to six years [5]. As children grow older, the
frequency of nightmares typically decreases. In adults, the prevalence is lower but still significant, with
about 2-8% of the population experiencing frequent nightmares. However, certain populations, such as
those suffering from post-traumatic stress disorder (PTSD) or other anxiety disorders, may experience
nightmares at much higher rates, often with greater severity [6].

The impact of nightmares extends far beyond the discomfort experienced during sleep. Frequent
nightmares can lead to considerable psychological consequences, including heightened levels of anxiety,
depression, and an increased risk of developing other mental health disorders [7]. Physiologically,
nightmares can result in sleep fragmentation, leading to poor sleep quality and chronic sleep deprivation.

How to cite this article

Sahu N, Patil P S, A, et al. (September 23, 2024) Understanding and Treating Nightmares: A Comprehensive Review of Psychosocial Strategies for
Adults and Children. Cureus 16(9): e70044. DOI 10.7759/cureus.70044
 Published via DMIHER Datta Meghe Medical
College

This lack of restful sleep can impair daytime functioning, affecting concentration, memory, and emotional
regulation. The cumulative effect of recurring nightmares can significantly diminish an individual's quality
of life, underlining the importance of addressing and managing these sleep disturbances effectively [8].

Despite their prevalence, nightmares are often overlooked as a serious health concern. However, when
nightmares become frequent or intense, they can cause substantial distress and significantly disrupt daily
life [9]. Persistent nightmares not only exacerbate underlying psychological conditions, such as PTSD, but
can also contribute to the development of new mental health issues. As a result, treating nightmares is
crucial not just for reducing the frequency of these distressing episodes but also for improving the overall
mental and emotional well-being of those affected [9].

While pharmacological treatments are available for nightmares, they often come with side effects and may
not address the underlying causes. Psychosocial strategies, on the other hand, offer non-pharmacological
interventions that can be highly effective in managing nightmares [10]. These strategies include cognitive
behavioral therapy (CBT), imagery rehearsal therapy (IRT), and mindfulness-based therapies. Such
approaches focus on altering the thought patterns and behaviors that contribute to nightmares, helping
individuals regain control over their sleep, and reducing the frequency and intensity of these distressing
events. By addressing both the cognitive and emotional aspects of nightmares, psychosocial interventions
provide a holistic and effective approach to treatment, benefiting individuals across all age groups [10].

Review
Etiology of nightmares
Nightmares are complex phenomena shaped by various psychological, biological, genetic, environmental,
and social factors. Understanding these elements can offer valuable insights into their occurrence and
potential treatment strategies [11]. Psychological factors play a crucial role in the development of
nightmares, with stress, anxiety, and trauma being primary contributors. High levels of stress can lead to
increased arousal during sleep, making individuals more vulnerable to nightmares. Stressful life events, such
as job loss or relationship problems, often trigger intense dreams that mirror these anxieties [12]. Similarly,
anxiety disorders, including generalized anxiety disorder and situational anxiety, frequently manifest in
nightmares. Individuals may dream about their fears or worries, creating a cycle of anxiety and disrupted
sleep. Trauma, especially from events like accidents, violence, or natural disasters, can result in recurrent
nightmares that often replay aspects of the trauma, serving either as a coping mechanism or as a
manifestation of unresolved emotions [13].

Mental health disorders also significantly impact the prevalence of nightmares. PTSD is particularly
associated with vivid, distressing dreams that relive traumatic experiences, leading to significant sleep
disruption. Individuals with PTSD often report recurrent nightmares that are emotionally intense and
disturbing [14]. Additionally, depression is linked to changes in sleep architecture and increased REM sleep,
both of which can contribute to a higher frequency of nightmares. Those suffering from depression may
experience negative dream content that reflects their mood, further complicating their mental health [15].
Biological and genetic factors also play a role in the occurrence of nightmares. Research suggests that there
may be a hereditary component to nightmares. Family studies indicate that individuals with a family history
of nightmares or sleep disorders are more likely to experience them. Genetic predispositions may also
increase susceptibility to anxiety and mood disorders, which are closely associated with nightmares [16].

The role of neurotransmitters and specific brain regions is critical in understanding nightmares. Imbalances
in neurotransmitters such as serotonin and norepinephrine can affect sleep regulation and dream content
[17]. These chemicals are essential for mood regulation and can influence the emotional tone of dreams.
Additionally, the limbic system, particularly the amygdala, plays a key role in processing emotions and is
highly active during REM sleep, potentially contributing to the emotional intensity of nightmares.
Disruptions in the prefrontal cortex, responsible for rational thought and emotional regulation, can lead to
less control over dream content, resulting in more vivid and distressing nightmares [17]. Environmental and
social factors also significantly influence the occurrence of nightmares. Family dynamics can have a
profound impact on both children and adults.

Family stressors, such as conflict or instability, can lead to nightmares as individuals internalize these
issues, which manifest as anxiety in their dreams [18]. Additionally, exposure to violent or distressing media
content can affect dream content, particularly in children, where graphic images or themes can seep into
dreams, resulting in nightmares. Cultural beliefs and practices surrounding dreams can also shape how
individuals interpret and respond to nightmares. In some cultures, nightmares may be viewed as omens or
messages, influencing the psychological response to these experiences [19]. Major life changes or traumatic
events can also trigger nightmares. Significant transitions, such as moving, starting a new job, or
experiencing a loss, often bring about stress and anxiety, which can disrupt sleep patterns and contribute to
the occurrence of nightmares. Traumatic events can leave lasting psychological impacts that manifest in
dreams, leading to recurrent nightmares [20].

Nightmares in children

2024 Sahu et al. Cureus 16(9): e70044. DOI 10.7759/cureus.70044 2 of 10

 Published via DMIHER Datta Meghe Medical
College

Nightmares are a common experience in children, with their prevalence peaking at various developmental
stages. Approximately 50% of children aged 3 to 6 years frequently experience nightmares, while around
20% of children aged 6 to 12 years report the same. Compared to adults, children’s nightmares often involve
more concrete, age-appropriate themes such as monsters, ghosts, or animals. The content of these
nightmares typically reflects the developmental fears and anxieties common at these ages [21]. Frequent
nightmares in children can have significant effects on their emotional well-being, behavior, and academic
performance. Nightmares can lead to increased anxiety, mood disturbances, and difficulties with emotional
regulation. Children who experience frequent nightmares are at higher risk for hyperactivity, attention
problems, and poor academic performance. Recurring nightmares can also contribute to insomnia
symptoms, such as difficulty falling asleep and staying asleep [22].

Several psychosocial interventions have proven effective in managing nightmares in children. CBT for
children (CBT-C) includes techniques such as IRT, where children visualize and rehearse a less frightening
ending to their nightmares during waking hours. This approach can reduce the frequency and intensity of
nightmares. Cognitive restructuring, another CBT technique, helps children reframe their thoughts about
nightmares and develop coping strategies, which can alleviate anxiety and improve sleep quality [23].
Parental guidance and support are crucial in managing nightmares in children. A consistent bedtime routine
can help children feel more secure and reduce sleep-related anxiety. Creating a safe sleep environment by
ensuring the child’s bedroom is comfortable and free from stressors can also help prevent nightmares.

Additionally, parents can offer emotional support by helping children process their bad dreams and
discussing their fears and triggers in a calm, supportive setting [24]. Play therapy and creative expression
techniques, such as art, storytelling, and play, can assist children in expressing and processing their fears
and anxieties in a developmentally appropriate manner. For children experiencing frequent nightmares,
particularly those related to trauma, professional counseling may be necessary. Although medication is
generally not recommended for children, it may be prescribed in certain cases [25].

Nightmares in adults
Nightmares in adults are a significant concern due to their association with various mental health
conditions, their impact on daily functioning, and the availability of psychosocial strategies for treatment.
Understanding these aspects is crucial for effective management and support [26]. Nightmares are
frequently linked to several mental health disorders, particularly PTSD, depression, and anxiety. PTSD is
characterized by recurrent nightmares that often reflect traumatic experiences, exacerbating anxiety and
distress. Individuals with PTSD may find themselves trapped in a cycle where the emotional turmoil from
their nightmares heightens their symptoms, leading to further sleep disturbances. Additionally, adults with
nightmare disorder often have co-occurring conditions such as depression and anxiety [27]. The distress
caused by frequent nightmares can aggravate these mental health issues, creating a feedback loop where the
conditions contribute to increased nightmare frequency and severity. Other psychiatric disorders, including
borderline personality disorder and schizophrenia, have also been linked to nightmares, underscoring the
complex interplay between sleep disturbances and mental health [28].

The impact of nightmares extends beyond mere sleep disruption, affecting various aspects of daily life.
Frequent nightmares can lead to excessive daytime sleepiness, impairing concentration and productivity at
work or school. This diminished focus can result in decreased performance and increased absenteeism,
further compounding stress and anxiety. Moreover, the emotional distress caused by nightmares can strain
personal relationships, leading to irritability or withdrawal and resulting in misunderstandings and conflicts
with family and friends. Over time, the cumulative effects of nightmares can diminish the quality of life,
characterized by increased anxiety, emotional dysregulation, and a general sense of distress. If left
unaddressed, these issues can contribute to further mental health deterioration [9].

Fortunately, several effective psychosocial strategies are available for treating nightmares in adults. CBT for
insomnia (CBT-I) is a structured program that addresses the thoughts and behaviors contributing to
insomnia and nightmares. This therapy helps individuals develop healthier sleep habits and coping
mechanisms, ultimately reducing the frequency and severity of nightmares. Another effective technique is
IRT, where individuals visualize a positive ending to their nightmares while awake. This practice can help
alter the emotional response to the nightmare and reduce its recurrence [29].

In addition to these therapies, mindfulness and relaxation techniques play a vital role in managing
nightmares. Practices such as mindfulness meditation and relaxation exercises help reduce anxiety and
improve overall sleep quality [30]. By promoting a sense of calm, these techniques make it easier for
individuals to cope with the distress associated with nightmares. Furthermore, group therapy or support
groups can provide emotional support and coping strategies. Connecting with others who experience similar
issues fosters a sense of community and shared understanding, which can be beneficial for individuals
dealing with nightmare-related distress [30]. A comparison of nightmares in children and adults, including
prevalence, impact, and treatment approaches, is shown in Table 1.

2024 Sahu et al. Cureus 16(9): e70044. DOI 10.7759/cureus.70044 3 of 10

 Published via DMIHER Datta Meghe Medical
College

Aspect Nightmares in Children Nightmares in Adults

Prevalence Common during early childhood, particularly between ages Less frequent compared to children but can increase in
[31] 3-6. frequency with stress or trauma.

More complex, often involving real-life concerns, stress, or

Content [32] Often related to fears, monsters, or imagined threats.
trauma.

Less frequent, though, may increase during stress or mental

Frequency [33] Higher in children, peaking during early childhood.
health conditions.

It can contribute to mental health conditions such as

Psychological It can affect emotional regulation and cause fear or
anxiety, depression, and post-traumatic stress disorder
Impact [14] reluctance to sleep.
(PTSD).

Associated Often linked with normal developmental stages and Commonly associated with PTSD, anxiety disorders,
Conditions [14] temporary anxieties. depression, or significant life stressors.

Cognitive behavioral therapy for children (CBT-C). Cognitive behavioral therapy for insomnia (CBT-I). Imagery
Treatment
Parental support and guidance. Play therapy and creative rehearsal therapy (IRT). Mindfulness and relaxation
Strategies [34]
expression. techniques.

Impact on
Daily
It can affect mood, behavior, and school performance. Affects productivity, relationships, and quality of life.
Functioning
[35]

Long-term
It mostly resolves with age, though it may persist in cases It can become chronic in adults, particularly in those with
Consequences
of trauma or chronic stress. PTSD or mental health issues.
[27]

TABLE 1: Comparison of nightmares in children and adults: prevalence, impact, and treatment
approaches

Psychosocial treatment modalities

CBT and IRT are two prominent cognitive-behavioral approaches for treating nightmares. CBT focuses on
altering negative thought patterns and behaviors related to nightmares, aiming to help individuals reframe
their perceptions of these distressing dreams [36]. This reframing process can reduce the anxiety and
distress associated with nightmares. IRT, on the other hand, specifically addresses the content of nightmares
by encouraging individuals to visualize a new, positive ending to their distressing dreams while awake. This
mental rehearsal can modify the emotional response to the nightmare, reducing frequency and intensity.
Research has demonstrated that both CBT and IRT are effective in decreasing nightmare frequency and
severity, with IRT showing particularly strong efficacy across various populations, including those with
PTSD. The therapeutic benefits of these approaches often persist over time, indicating lasting
improvements for those affected by nightmares [37].

Mindfulness practices, originating from Buddhist traditions, also play a significant role in reducing
nightmares. Mindfulness involves cultivating present-moment awareness and accepting thoughts and
feelings without judgment. Techniques such as mindfulness-based stress reduction (MBSR) and
mindfulness-based cognitive therapy (MBCT) can be integrated into treatments for nightmares [38]. These
practices promote relaxation and emotional regulation, which can alleviate the anxiety frequently associated
with nightmares. Studies suggest that mindfulness can be an effective self-help intervention, particularly for
individuals who may be hesitant to seek professional assistance. By fostering a non-judgmental awareness of
their experiences, individuals may find it easier to cope with the distress of nightmares, leading to a
reduction in their frequency and intensity [39].

Hypnotherapy is another approach that can be used to address nightmares. This technique involves inducing
a trance-like state to enhance focus and suggestibility, allowing individuals to explore the underlying causes
of their nightmares and reframe their experiences. Although research on the effectiveness of hypnotherapy
for nightmares is still developing, preliminary findings suggest it may help reduce the intensity and
frequency of nightmares by addressing subconscious fears and anxieties [40]. However, more robust
evidence is needed to establish its efficacy compared to other established treatments. The potential of
hypnotherapy lies in its ability to facilitate deep relaxation and promote positive imagery, which can benefit
individuals struggling with recurrent nightmares [40].

2024 Sahu et al. Cureus 16(9): e70044. DOI 10.7759/cureus.70044 4 of 10

 Published via DMIHER Datta Meghe Medical
College

Family therapy and group counseling provide supportive environments for individuals dealing with
nightmares. Involving family members in therapy can help address dynamics that may contribute to
nightmares, particularly in children. Family therapy can improve communication and support, helping
individuals feel more secure and understood [41]. Group interventions allow individuals to share their
experiences and coping strategies, reducing feelings of isolation. These settings foster community and offer
additional emotional support, enhancing treatment outcomes. By encouraging open dialogue and shared
experiences, family and group interventions create a supportive network that promotes healing and
resilience [41].

Innovative approaches are being explored to enhance nightmare treatment. Virtual reality (VR) is one such
method, creating immersive environments for exposure therapy that allow individuals to confront
nightmare themes in a controlled setting. This technology helps desensitize individuals to the fears
associated with their nightmares. Similarly, biofeedback techniques teach individuals to control
physiological responses linked to anxiety and nightmares, promoting relaxation and emotional regulation
[42]. Integrating artificial intelligence (AI) into personalized treatment plans is another exciting
development. AI can tailor interventions based on individual responses and preferences, improving
treatment effectiveness by adapting to the patient's specific needs. These emerging therapies promise to
enhance nightmare management and provide more effective tools for coping with these experiences [42].
The key features and effectiveness of psychosocial treatment modalities for nightmares are summarized in
Table 2.

Treatment
Description Key Features Effectiveness
Modality

Cognitive A structured therapy aimed at

Identifies and challenges distorted Highly effective for reducing nightmare
Behavioral changing negative thought patterns
thoughts. It includes techniques like frequency and intensity in both adults
Therapy and behaviors associated with
IRT. and children.
(CBT) [43] nightmares.

Imagery
A specific type of CBT is where Involves rescripting nightmares with Proven effective, especially for post-
Rehearsal
patients practice changing the endings positive endings. Focuses on traumatic stress disorder (PTSD)-related
Therapy (IRT)
of their nightmares while awake. visualizing alternative outcomes. nightmares in adults.
[37]

Mindfulness-
Focus on relaxation techniques and Techniques include breathing It helps reduce the emotional impact of
Based
increasing present-moment awareness exercises, meditation, and body nightmares and benefits both adults and
Therapies
to reduce nightmare intensity. scanning. children.
[39]

Uses guided relaxation and focused Helps in reducing anxiety associated Effective in decreasing nightmare
Hypnotherapy
attention to alter the subconscious and with nightmares. It can be combined frequency, though research on long-term
[44]
reduce nightmare occurrences. with other therapeutic modalities. effects is still evolving.

Play Therapy Uses play-based activities to help Provides a safe space for children to
Effective for young children, especially
(for Children) children process emotions and reduce express fears. Helps in emotional
when integrated with parental guidance.
[45] the occurrence of nightmares. regulation.

Involves patients sharing experiences Provides peer support and shared Particularly effective for PTSD patients
Group
and coping strategies in a group learning. Commonly used in and those experiencing isolation due to
Therapy [46]
setting to alleviate nightmare distress. combination with other therapies. nightmares.

Engages family members to

Focuses on improving family Effective for children and adults,
Family understand and support the
dynamics and reducing stress triggers especially when nightmares are linked to
Therapy [41] individual’s experience with
at home. family stress or trauma.
nightmares.

Virtual Reality Uses virtual environments to simulate Allows patients to confront fears in a Emerging evidence shows potential in
(Emerging nightmares and practice coping safe, controlled manner. Combines treating nightmare-related PTSD in
Therapy) [42] mechanisms in a controlled setting. with CBT techniques. adults, though research is still limited.

Biofeedback Uses sensors to monitor physiological Monitors heart rate, muscle tension, Shows promise in reducing nightmare-
(Emerging stress responses and helps patients and brain waves. Patients learn to related anxiety; ongoing research is
Therapy) [47] control them. manage stress responses. needed to establish long-term efficacy.

TABLE 2: Psychosocial treatment modalities for nightmares: key features and effectiveness

2024 Sahu et al. Cureus 16(9): e70044. DOI 10.7759/cureus.70044 5 of 10

 Published via DMIHER Datta Meghe Medical
College

Comparative analysis of psychosocial strategies

Research indicates that psychosocial strategies for treating nightmares exhibit varying effectiveness
between adults and children. In adults, CBT, especially IRT, has demonstrated strong efficacy in reducing
nightmare frequency and distress [23]. Systematic reviews have highlighted that exposure-based treatments
significantly decrease nightmare severity and frequency across various adult populations, including those
with PTSD. These therapies often produce rapid results, with many adults experiencing relief within just a
few sessions [23]. Conversely, treatment efficacy in children is less well-documented, with fewer high-
quality studies available. However, parental involvement and psychoeducation are essential, as they help
create supportive environments that can alleviate nightmare-related anxiety [48].

Strategies such as play therapy and family-based interventions may also be beneficial. While some children
respond well to these approaches, more clinical trials specifically targeting pediatric populations are needed
to determine the most effective strategies for this age group [48]. The effectiveness of treatments for
nightmares can differ significantly in terms of short-term and long-term outcomes. Many studies report
immediate reductions in nightmare frequency and distress following interventions like IRT and exposure
therapy [10]. These treatments often yield quick results, particularly in adults, where patients may
experience relief within a few sessions. For example, adults undergoing IRT frequently report a marked
decrease in the intensity and occurrence of their nightmares shortly after beginning therapy [10].

However, longitudinal studies suggest that while short-term improvements are common, the sustainability
of these effects can vary. For adults, continued practice of techniques learned in therapy can help maintain
benefits over time. In children, long-term outcomes are less clear, with some studies indicating that
nightmares may persist or recur if underlying psychological issues are not adequately addressed. Thus,
ongoing support and follow-up may be necessary to ensure lasting improvements in both age groups,
underscoring the importance of a comprehensive approach that includes both immediate intervention and
long-term care [49].

Cultural and socioeconomic factors significantly influence the adaptation and effectiveness of nightmare
therapies. Different cultural backgrounds may shape the perception and interpretation of nightmares. For
instance, in some cultures, nightmares might be viewed as spiritual messages or omens, affecting how
individuals respond to treatment. Therapies may need to be tailored to respect these cultural beliefs while
addressing the psychological aspects of nightmares. Cultural sensitivity can enhance the therapeutic alliance
and improve treatment adherence [50]. Socioeconomic status also impacts access to treatment and the type
of support available. Families with lower socioeconomic status may face additional stressors exacerbating
nightmares in children, such as unstable living conditions or parental mental health issues [51]. Therefore,
interventions must consider these factors, potentially incorporating community resources and support
systems to enhance treatment effectiveness for diverse populations. By addressing cultural and
socioeconomic considerations, therapists can better tailor their approaches to meet individual needs,
ultimately leading to improved outcomes in nightmare treatment [51].

Challenges and future directions

Despite the availability of effective treatments for nightmares, several barriers can impede access to care and
successful management of the condition. One major challenge is the stigma associated with seeking help for
mental health issues. Many individuals may feel embarrassed or ashamed to discuss their nightmares,
fearing judgment or misunderstanding from others. This stigma can prevent them from seeking the support
they need. Additionally, access to care remains a critical issue, particularly in rural or underserved areas
where mental health professionals are scarce [52]. Limited availability of specialists can result in long wait
times or inadequate treatment options for those suffering from persistent nightmares. Furthermore, a lack of
awareness about the treatability of nightmares can lead individuals to believe they must simply endure their
distressing dreams without seeking help. Many may not recognize that persistent nightmares are a
legitimate mental health concern that warrants professional intervention [52].

While significant progress has been made in understanding and treating nightmares, several areas require
further investigation. One such area is the impact of digital media on the prevalence and characteristics of
nightmares. With the increasing use of digital devices and exposure to disturbing content, it is essential to
study how these factors influence the frequency and nature of nightmares in both children and adults.
Additionally, more research is needed to explore cross-cultural differences in the experience and
interpretation of nightmares [19]. Understanding how cultural factors shape the perception of nightmares
can help tailor treatment approaches to meet the needs of diverse populations better. Longitudinal studies
are also necessary to assess nightmare treatments' long-term effectiveness and impact on overall mental
health and well-being. Addressing these research gaps will contribute to a more comprehensive
understanding of nightmares and their treatment [19].

Several promising trends may shape the future of nightmare treatment as research advances. One significant
trend is the integration of technology into therapeutic practices. Innovations such as virtual reality and
mobile applications may enhance the delivery and accessibility of nightmare treatments, particularly for
individuals facing barriers to in-person therapy [53]. These technologies can offer immersive experiences

2024 Sahu et al. Cureus 16(9): e70044. DOI 10.7759/cureus.70044 6 of 10

 Published via DMIHER Datta Meghe Medical
College

that help individuals confront and reprocess their nightmares in a controlled environment. Another trend is
the potential for interdisciplinary approaches, where collaborations between mental health professionals,
sleep specialists, and other healthcare providers lead to more comprehensive and effective treatment
strategies [53].

By combining expertise from various fields, practitioners can develop holistic treatment plans that address
the multifaceted nature of nightmares. Lastly, personalized medicine may become more prevalent as our
understanding of the genetic and biological factors contributing to nightmares improves. Tailoring
treatment approaches to individual needs and characteristics could enhance the effectiveness of
interventions and improve outcomes for those affected by persistent nightmares [53]. Challenges and future
directions in treating nightmares are summarized in Table 3.

Category Challenges Future Directions

Access to Care Limited access to mental health professionals, especially Expand telemedicine and online therapy platforms to reach
[54] in rural or underserved areas. a wider population.

The social stigma surrounding seeking psychological help, Increase awareness and education to reduce stigma and
Stigma [55]
particularly for nightmares, is linked to trauma. normalize mental health care.

Lack of Limited public knowledge of available psychosocial Promote public health campaigns and integrate mental
Awareness [56] treatments for nightmares. health education in schools and communities.

Cultural Cultural differences may impact the acceptance and Adapt treatment modalities to be culturally sensitive and
Barriers [57] effectiveness of certain therapies. inclusive.

Research Gaps Lack of comprehensive, long-term studies on the Conduct more longitudinal studies and randomized
[58] effectiveness of psychosocial interventions. controlled trials to validate and refine treatment strategies.

Treatment Develop personalized treatment plans using artificial

A one-size-fits-all approach may not be effective for
Personalization intelligence (AI) and machine learning for more
diverse populations.
[59] individualized care.

Invest in research and development of innovative

Technological Limited use of emerging technologies such as virtual
technologies like virtual reality and biofeedback for
Integration [60] reality (VR) and biofeedback in mainstream therapy.
nightmares.

Insufficient training for mental health professionals on

Training and Expand professional training programs and resources to
specific therapies like imagery rehearsal therapy (IRT) and
Resources [61] equip practitioners with advanced treatment modalities.
hypnotherapy.

Barriers in Tailor therapies like cognitive behavioral therapy (CBT) and

Pediatric Care Difficulty in applying adult-centric treatments to children. play therapy for younger age groups with age-appropriate
[62] approaches.

Long-Term Uncertainty about the long-term success of some Focus on follow-up studies to assess long-term benefits and
Efficacy [63] psychosocial strategies. side effects of psychosocial treatments.

Interdisciplinary
Lack of collaboration between psychologists, psychiatrists, Promote interdisciplinary approaches combining
Approaches
and sleep specialists. psychological, medical, and technological interventions.
[64]

TABLE 3: Challenges and future directions in the treatment of nightmares

Conclusions
Nightmares are more than just disturbing dreams; they are significant psychological events that can
profoundly impact an individual’s mental and physical well-being. Their prevalence, especially among
vulnerable populations such as children and those with underlying mental health conditions, underscores
the necessity of addressing them with effective treatment strategies. While pharmacological options exist,
psychosocial approaches such as CBT, IRT, and mindfulness-based interventions offer a holistic and often
more sustainable solution. These strategies not only reduce the frequency and intensity of nightmares but
also empower individuals by addressing the underlying cognitive and emotional factors contributing to their
distress. By integrating these non-pharmacological interventions into treatment plans, healthcare providers
can enhance the quality of life for those affected by nightmares, helping them achieve more restful sleep and
better overall mental health.

2024 Sahu et al. Cureus 16(9): e70044. DOI 10.7759/cureus.70044 7 of 10

 Published via DMIHER Datta Meghe Medical
College

Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.

Concept and design: Namita Sahu, Pradeep S. Patil, Asmita -, Imyarila Longkumer

Acquisition, analysis, or interpretation of data: Namita Sahu, Pradeep S. Patil, Asmita -, Imyarila
Longkumer

Drafting of the manuscript: Namita Sahu, Pradeep S. Patil, Asmita -, Imyarila Longkumer

Critical review of the manuscript for important intellectual content: Namita Sahu, Pradeep S. Patil,
Asmita -, Imyarila Longkumer

Supervision: Namita Sahu, Pradeep S. Patil, Asmita -, Imyarila Longkumer

Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.

Acknowledgements
We acknowledge the valuable assistance provided by ChatGPT (OpenAI, San Francisco, CA) in offering
insightful suggestions for ensuring clarity and precision in our writing with Grammarly and Paperpal to
enhance the quality and accuracy of our work.

References
1. Stefani A, Högl B: Nightmare disorder and isolated sleep paralysis. Neurotherapeutics. 2021, 18:100-6.
10.1007/s13311-020-00966-8
2. Nir Y, Tononi G: Dreaming and the brain: from phenomenology to neurophysiology . Trends Cogn Sci. 2010,
14:88-100. 10.1016/j.tics.2009.12.001
3. Paul F, Schredl M, Alpers GW: Nightmares affect the experience of sleep quality but not sleep architecture:
an ambulatory polysomnographic study. Borderline Personal Disord Emot Dysregul. 2015, 2:3.
10.1186/s40479-014-0023-4
4. Van Horn NL, Street M: Night Terrors. StatPearls Publishing, Treasure Island, FL; 2024.
5. Reynolds KC, Alfano CA: Things that go bump in the night: frequency and predictors of nightmares in
anxious and nonanxious children. Behav Sleep Med. 2016, 14:442-56. 10.1080/15402002.2015.1017099
6. Hasler B, Germain A: Correlates and treatments of nightmares in adults . Sleep Med Clin. 2009, 4:507-17.
10.1016/j.jsmc.2009.07.012
7. Sheaves B, Onwumere J, Keen N, Stahl D, Kuipers E: Nightmares in patients with psychosis: the relation
with sleep, psychotic, affective, and cognitive symptoms. Can J Psychiatry. 2015, 60:354-61.
10.1177/070674371506000804
8. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem . Colten HR, Altevogt BM (ed):
National Academies Press, Washington, DC; 2006.
9. Rek S, Sheaves B, Freeman D: Nightmares in the general population: identifying potential causal factors . Soc
Psychiatry Psychiatr Epidemiol. 2017, 52:1123-33. 10.1007/s00127-017-1408-7
10. Gieselmann A, Ait Aoudia M, Carr M, et al.: Aetiology and treatment of nightmare disorder: state of the art
and future perspectives. J Sleep Res. 2019, 28:e12820. 10.1111/jsr.12820
11. Ahn WK, Proctor CC, Flanagan EH: Mental health clinicians’ beliefs about the biological, psychological, and
environmental bases of mental disorders. Cogn Sci. 2009, 33:147-82. 10.1111/j.1551-6709.2009.01008.x
12. Sareen J: Posttraumatic stress disorder in adults: impact, comorbidity, risk factors, and treatment . Can J
Psychiatry. 2014, 59:460-7. 10.1177/070674371405900902
13. Staner L: Sleep and anxiety disorders. Dialogues Clin Neurosci. 2003, 5:249-58.
10.31887/DCNS.2003.5.3/lstaner
14. Center for Substance Abuse Treatment: Trauma-Informed Care in Behavioral Health Services. Substance
Abuse and Mental Health Services Administration, Rockville, MD; 2014.
https://www.ncbi.nlm.nih.gov/books/NBK207201/.
15. Nutt D, Wilson S, Paterson L: Sleep disorders as core symptoms of depression. Dialogues Clin Neurosci.
2008, 10:329-36. 10.31887/DCNS.2008.10.3/dnutt
16. Ollila HM, Sinnott-Armstrong N, Kantojärvi K, et al.: Nightmares share genetic risk factors with sleep and
psychiatric traits. Transl Psychiatry. 2024, 14:123. 10.1038/s41398-023-02637-6
17. Siegel JM: The neurotransmitters of sleep. J Clin Psychiatry. 2004, 65:4-7.
18. Wang C, Shao X, Jia Y, Shen C, Wang W: Nightmare experience and family relationships in healthy

2024 Sahu et al. Cureus 16(9): e70044. DOI 10.7759/cureus.70044 8 of 10

 Published via DMIHER Datta Meghe Medical
College

volunteers and nightmare disorder patients. BMC Psychiatry. 2019, 19:297. 10.1186/s12888-019-2299-9
19. Shabahang R, Kim S, Aruguete MS, et al.: Social media-related nightmare - a potential explanation for poor
sleep quality and low affective well-being in the social media era?. BMC Psychol. 2024, 12:140.
10.1186/s40359-024-01605-z
20. Traumatic events: causes, effects, and management . (2024). Accessed: March 17, 2024:
https://www.healthline.com/health/traumatic-events.
21. Secrist ME, John SG, Harper SL, Conners Edge NA, Sigel BA, Sievers C, Kramer T: Nightmares in treatment-
seeking youth: the role of cumulative trauma exposure. J Child Adolesc Trauma. 2020, 13:249-56.
10.1007/s40653-019-00268-y
22. Gauchat A, Zadra A, El-Hourani M, Parent S, Tremblay RE, Séguin JR: Disturbing dreams and psychosocial
maladjustment in children: a prospective study of the moderating role of early negative emotionality. Front
Neurol. 2020, 11:762. 10.3389/fneur.2020.00762
23. Gill P, Fraser E, Tran TT, De Sena Collier G, Jago A, Losinno J, Ganci M: Psychosocial treatments for
nightmares in adults and children: a systematic review. BMC Psychiatry. 2023, 23:283. 10.1186/s12888-023-
04703-1
24. Mindell JA, Williamson AA: Benefits of a bedtime routine in young children: sleep, development, and
beyond. Sleep Med Rev. 2018, 40:93-108. 10.1016/j.smrv.2017.10.007
25. Bosgraaf L, Spreen M, Pattiselanno K, van Hooren S: Art therapy for psychosocial problems in children and
adolescents: a systematic narrative review on art therapeutic means and forms of expression, therapist
behavior, and supposed mechanisms of change. Front Psychol. 2020, 11:584685. 10.3389/fpsyg.2020.584685
26. Aurora RN, Zak RS, Auerbach SH, et al.: Best practice guide for the treatment of nightmare disorder in
adults. J Clin Sleep Med. 2010, 6:389-401.
27. Mann SK, Marwaha R, Torrico TJ: Posttraumatic Stress Disorder. StatPearls Publishing, Treasure Island, FL;
2024.
28. Sheaves B, Rek S, Freeman D: Nightmares and psychiatric symptoms: a systematic review of longitudinal,
experimental, and clinical trial studies. Clin Psychol Rev. 2023, 100:102241. 10.1016/j.cpr.2022.102241
29. Rossman J: Cognitive-behavioral therapy for insomnia: an effective and underutilized treatment for
insomnia. Am J Lifestyle Med. 2019, 13:544-7. 10.1177/1559827619867677
30. Norelli SK, Long A, Krepps JM: Relaxation Techniques. StatPearls Publishing, Treasure Island, FL; 2024.
31. Anil S, Anand PS: Early childhood caries: prevalence, risk factors, and prevention . Front Pediatr. 2017,
5:157. 10.3389/fped.2017.00157
32. Schneiderman N, Ironson G, Siegel SD: Stress and health: psychological, behavioral, and biological
determinants. Annu Rev Clin Psychol. 2005, 1:607-28. 10.1146/annurev.clinpsy.1.102803.144141
33. von Klitzing K, Döhnert M, Kroll M, Grube M: Mental disorders in early childhood . Dtsch Arztebl Int. 2015,
112:375-86. 10.3238/arztebl.2015.0375
34. Raudenska J, Gumančík J, Raudenský M, et al.: Cognitive-behavioral play therapy and COVID-19 pandemic
trauma in preschool children. Cureus. 2023, 15:e44249. 10.7759/cureus.44249
35. Iliou K, Balaris D, Dokali AM, Fotopoulos V, Kouletsos A, Katsiana A: Exploring the effects of major
depressive disorder on daily occupations and the impact of psychotherapy: a literature review. Cureus. 2024,
16:e55831. 10.7759/cureus.55831
36. Lancee J, Spoormaker VI, Krakow B, van den Bout J: A systematic review of cognitive-behavioral treatment
for nightmares: toward a well-established treatment. J Clin Sleep Med. 2008, 4:475-80.
37. Albanese M, Liotti M, Cornacchia L, Mancini F: Nightmare rescripting: using imagery techniques to treat
sleep disturbances in post-traumatic stress disorder. Front Psychiatry. 2022, 13:866144.
10.3389/fpsyt.2022.866144
38. Hofmann SG, Gómez AF: Mindfulness-based interventions for anxiety and depression . Psychiatr Clin North
Am. 2017, 40:739-49. 10.1016/j.psc.2017.08.008
39. Hofmann SG, Sawyer AT, Witt AA, Oh D: The effect of mindfulness-based therapy on anxiety and
depression: a meta-analytic review. J Consult Clin Psychol. 2010, 78:169-83. 10.1037/a0018555
40. Williamson A: What is hypnosis and how might it work? . Palliat Care. 2019, 12:1178224219826581.
10.1177/1178224219826581
41. Varghese M, Kirpekar V, Loganathan S: Family interventions: basic principles and techniques . Indian J
Psychiatry. 2020, 62:S192-200. 10.4103/psychiatry.IndianJPsychiatry_770_19
42. Maples-Keller JL, Bunnell BE, Kim SJ, Rothbaum BO: The use of virtual reality technology in the treatment
of anxiety and other psychiatric disorders. Harv Rev Psychiatry. 2017, 25:103-13.
10.1097/HRP.0000000000000138
43. Chand SP, Kuckel DP, Huecker MR: Cognitive Behavior Therapy. StatPearls Publishing, Treasure Island, FL;
2024.
44. Vickers A, Zollman C, Payne DK: Hypnosis and relaxation therapies . West J Med. 2001, 175:269-72.
10.1136/ewjm.175.4.269
45. Gupta N, Chaudhary R, Gupta M, Ikehara LH, Zubiar F, Madabushi JS: Play therapy as effective options for
school-age children with emotional and behavioral problems: a case series. Cureus. 2023, 15:e40093.
10.7759/cureus.40093
46. Malhotra A, Baker J: Group Therapy. StatPearls Publishing, Treasure Island, FL; 2024.
47. Frank DL, Khorshid L, Kiffer JF, Moravec CS, McKee MG: Biofeedback in medicine: who, when, why and
how?. Ment Health Fam Med. 2010, 7:85-91.
48. Haine-Schlagel R, Walsh NE: A review of parent participation engagement in child and family mental
health treatment. Clin Child Fam Psychol Rev. 2015, 18:133-50. 10.1007/s10567-015-0182-x
49. Caruana EJ, Roman M, Hernández-Sánchez J, Solli P: Longitudinal studies. J Thorac Dis. 2015, 7:E537-40.
10.3978/j.issn.2072-1439.2015.10.63
50. Kirmayer LJ: Nightmares, neurophenomenology and the cultural logic of trauma . Cult Med Psychiatry. 2009,
33:323-31. 10.1007/s11013-009-9136-4
51. Knifton L, Inglis G: Poverty and mental health: policy, practice and research implications . BJPsych Bull.
2020, 44:193-6. 10.1192/bjb.2020.78

2024 Sahu et al. Cureus 16(9): e70044. DOI 10.7759/cureus.70044 9 of 10

 Published via DMIHER Datta Meghe Medical
College

52. Henderson C, Evans-Lacko S, Thornicroft G: Mental illness stigma, help seeking, and public health
programs. Am J Public Health. 2013, 103:777-80. 10.2105/AJPH.2012.301056
53. Philippe TJ, Sikder N, Jackson A, Koblanski ME, Liow E, Pilarinos A, Vasarhelyi K: Digital health
interventions for delivery of mental health care: systematic and comprehensive meta-review. JMIR Ment
Health. 2022, 9:e35159. 10.2196/35159
54. Nelson D, Inghels M, Kenny A, et al.: Mental health professionals and telehealth in a rural setting: a cross
sectional survey. BMC Health Serv Res. 2023, 23:200. 10.1186/s12913-023-09083-6
55. Ahad AA, Sanchez-Gonzalez M, Junquera P: Understanding and addressing mental health stigma across
cultures for improving psychiatric care: a narrative review. Cureus. 2023, 15:e39549. 10.7759/cureus.39549
56. Siddique MA, Ovi MR, Ahammed T, Chowdhury MA, Uddin MJ: Mental health knowledge and awareness
among university students in Bangladesh. Heliyon. 2022, 8:e11084. 10.1016/j.heliyon.2022.e11084
57. Sue S, Zane N, Nagayama Hall GC, Berger LK: The case for cultural competency in psychotherapeutic
interventions. Annu Rev Psychol. 2009, 60:525-48. 10.1146/annurev.psych.60.110707.163651
58. Smith TB, Workman C, Andrews C, et al.: Effects of psychosocial support interventions on survival in
inpatient and outpatient healthcare settings: a meta-analysis of 106 randomized controlled trials. PLoS Med.
2021, 18:e1003595. 10.1371/journal.pmed.1003595
59. Johnson KB, Wei WQ, Weeraratne D, et al.: Precision medicine, AI, and the future of personalized health
care. Clin Transl Sci. 2021, 14:86-93. 10.1111/cts.12884
60. Lüddecke R, Felnhofer A: Virtual reality biofeedback in health: a scoping review . Appl Psychophysiol
Biofeedback. 2022, 47:1-15. 10.1007/s10484-021-09529-9
61. Frank HE, Becker-Haimes EM, Kendall PC: Therapist training in evidence-based interventions for mental
health: a systematic review of training approaches and outcomes. Clin Psychol (New York). 2020, 27:14-6.
10.1111/cpsp.12330
62. Teleman B, Vinblad E, Svedberg P, Nygren JM, Larsson I: Exploring barriers to participation in pediatric
rehabilitation: voices of children and young people with disabilities, parents, and professionals. Int J
Environ Res Public Health. 2021, 18:4-6. 10.3390/ijerph181910119
63. Duagi D, Carter B, Farrelly M, et al.: Long-term effects of psychosocial interventions for adolescents on
depression and anxiety: a systematic review and meta-analysis. EClinicalMedicine. 2024, 68:102382.
10.1016/j.eclinm.2023.102382
64. Branjerdporn G, Gillespie KM, Dymond A, Reyes NJ, Robertson J, Almeida-Crasto A, Bethi S: Development of
an interprofessional psychosocial interventions framework. Int J Environ Res Public Health. 2023, 20:16-8.
10.3390/ijerph20085495

2024 Sahu et al. Cureus 16(9): e70044. DOI 10.7759/cureus.70044 10 of 10