Nightmare Therapy Update

Chronic nightmares are a distressing condition often taking on a life of its own beyond the original or triggering cause (e.g. traumatic exposure leading to PTSD). Both research and clinical advances now unequivocally demonstrate nightmares are a direct cause of sleep and waking impairment. Evidence continues to mount showing that direct nightmare treatment alleviates not only the bad dreams but also improves distress. In a crucial randomized controlled trial published in JAMA in 2001, we proved that a cognitive-imagery technique known as imagery rehearsal therapy (IRT) decreased both nightmare frequency in sexual assault survivors with PTSD and their posttraumatic stress symptoms (Krakow et al., 2001).

Some have pointed to IRT as a treatment for PTSD; whereas, we think of it as an adjunctive therapy. Nonetheless, in recent training programs conducted for mental health professionals at several U.S. army bases, I learned that some providers start PTSD treatment by focusing on nightmare therapy first and then progress to evidence-based prolonged exposure therapy or cognitive-processing therapy. The anecdotal reports on the integration of this therapeutic model indicate patients were not only increasingly receptive to IRT due to its simplicity, but also success with IRT appeared to enhance receptivity to move forward with more intensive PTSD treatment. The most frequently reported explanation by mental health providers for the utility of this approach was that patients who were sleeping better due to fewer nightmares were more ready, willing and able to enter into PTSD treatment.

Another development with potential implications for the aforementioned sequential pathway is the emergence of an exposure-oriented variant of IRT. The original IRT model we developed in 1988 involved no exposure therapy, and over the course of the 1990s it was clearly organized as a behavioral sleep medicine therapy without the adoption of exposure elements. This sleep model is the most widely researched among practitioners with a bent towards sleep medicine or other sleep focus; whereas, the IRT models with added exposure have arisen from researchers and clinicians with other backgrounds in psychology and in the specific use of exposure treatments for assorted mental health conditions. Of late, two meta-analyses were published demonstrating the two variants (sleep-oriented vs. exposure-oriented) appear roughly the same in efficacy (Casement & Swanson, 2012; Hansen, Hofling, Kroner-Borowik, Stangier, & Steil, 2013).

For those interested in learning the sleep-oriented version of IRT, we offer three main resources available at our website www.nightmaretreatment. com. Our two hour video presentation introduces IRT and earns 2 CEUs. Or, a more in depth program will be found in our Turning Nightmares into Dreams book and audio series, comprised of a 100 page workbook and 4 hours of audio instruction. Last, the book Sound Sleep, Sound Mind provides the framework for our Sleep Dynamic TherapyTM model for treating sleep disorders in mental health patients and within which one section covers imagery use and IRT for nightmares. For more information on exposure-oriented IRT, Dr. Joanne L. Davis has pioneered the variant known as Exposure, Relaxation, and Rescripting Therapy described in her book Treating Post Trauma Nightmares. 

All these approaches remain under-utilized by mental health practitioners in that the most typical treatment a nightmare patient would receive is either psychotherapy or medication directed at the underlying mental health disorder. The lack of dissemination of newer, evidence-based, cognitive-imagery treatments into the mainstream is also a function of the relative paucity of patients who conceive that a nightmare treatment actually exists. In 2006, we looked at this topic at our own sleep center, Maimonides Sleep Arts & Sciences in Albuquerque, NM, where we specialize in the treatment of mental health patients with sleep disorders and where we have a reputation for the treatment of nightmare patients. Notwithstanding, the number of patients unequivocally seeking treatment for nightmare problems is quite low. Of 718 consecutive patients, 26% reported nightmare problems. Of these 186 patients, 117 linked their disturbing dreams to sleep disruption, thus qualifying for the diagnosis of a Nightmare Disorder. Yet, none of these patients had presented to the sleep center with an exclusive complaint of nightmares or for the purpose of seeking treatment for nightmares (Krakow, 2006).

Clinically, in working with nightmare patients for more than 25 years, we are now persuaded this disorder often presents to a sleep center as a Nightmare Triad Syndrome, in which co-occurring insomnia and sleep apnea manifest as well. What is so intriguing about the discovery of this triad is that some studies clearly suggest treatment of sleep apnea with positive airway pressure therapy (PAP) decreases nightmare frequency. In 2000, we published the first case series in a small sample of patients with nightmares and sleep apnea undergoing various forms of treatment, predominantly PAP, and observed a significant association between treatment and improvements in nightmare frequency, posttraumatic stress symptoms, and sleep quality (Krakow et al., 2000). Additional studies were recently published. In 2012, research on 99 nightmare patients demonstrated sizeable nightmare reductions in sleep apnea patients using their PAP devices compared to minimal changes in sleep apnea patients not undergoing treatment. Nightmares disappeared in 91% of the patients who used PAP (50 of 55 patients) compared with only 36% of patients (16 of 45) who refused PAP therapy (p<0.001) (BaHammam, Al-Shimemeri, Salama, & Sharif, 2013). Another study examined changes in nightmare frequency in PTSD patients with sleep apnea. Working with 69 patients, divided into two groups based on either REM-sleep predominant or NREM-sleep predominant sleep apnea, nightmare frequency dropped nearly 50% in both groups and was clearly associated with greater compliance with PAP devices. A 10% improvement in compliance was associated with a mean decrease of 1 nightmare per week (Tamanna, Parker, Lyons, & Ullah, 2014).

It cannot go without saying, however, that PAP therapy is viewed by many patients as a “nightmarish” treatment in and of itself. Thus, for our nightmare patients we have seen much more expedient results when they use advanced PAP therapy devices that deliver dual pressures for inhalation and exhalation and which auto-adjust the airflow settings to suit patient needs second by second. We have described the specific use of these devices in a case series of insomnia patients with sleep apnea (Krakow, Ulibarri, Romero, Thomas, & McIver, 2013). 

In sum, many new therapeutic windows of opportunity are opening up for nightmare patients (and the practitioners who treat them) in addition to the excellent results that may be obtained in treating specific nightmares with the older and established interventions of dream interpretation therapies or related psychotherapies. Still, it remains to be seen how much and how many nightmare patients (and therapists) will avail themselves of either newer or older therapies for this vexing condition once perceived as relatively uncontrollable and untreatable.



BaHammam, A. S., Al-Shimemeri, S. A., Salama, R. I., & Sharif, M. M. (2013). Clinical and polysomnographic characteristics and response to continuous positive airway pressure therapy in obstructive sleep apnea patients with nightmares. Sleep Med., 14, 149-154.

Casement, M. D. & Swanson, L. M. (2012). A meta-analysis of imagery rehearsal for post-trauma nightmares: effects on nightmare frequency, sleep quality, and posttraumatic stress. Clin.Psychol.Rev., 32, 566-574.

Hansen, K., Hofling, V., Kroner-Borowik, T., Stangier, U., & Steil, R. (2013). Efficacy of psychological interventions aiming to reduce chronic nightmares: a meta-analysis. Clin.Psychol. Rev., 33, 146-155.

Krakow, B. (2006). Nightmare complaints in treatment-seeking patients in clinical sleep medicine settings: diagnostic and treatment implications. Sleep, 29, 1313-1319.

Krakow, B., Hollifield, M., Johnston, L., Koss, M., Schrader, R., Warner, T. D. et al. (2001). Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial. JAMA, 286, 537-545.

Krakow, B., Lowry, C., Germain, A., Gaddy, L., Hollifield, M., Koss, M. et al. (2000). A retrospective study on improvements in nightmares and post-traumatic stress disorder following treatment for co-morbid sleep-disordered breathing. J.Psychosom.Res., 49, 291-298.

Krakow, B., Ulibarri, V. A., Romero, E. A., Thomas, R. J., & McIver, N. D. (2013). Adaptive servo-ventilation therapy in a case series of patients with co-morbid insomnia and sleep apnea. Journal of Sleep Disorders: Treatment and Care 2:1. doi:10.4172/2325-9639.1000107

Tamanna, S., Parker, J. D., Lyons, J., & Ullah, M. I. (2014). The effect of continuous positive air pressure (CPAP) on nightmares in patients with posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA). J.Clin.Sleep Med., 10, 631-636.


This piece first appeared in Advances in Cognitive Therapy, a publication of the Academy of Cognitive Therapy ( and International Association for Cognitive Psychotherapy (

Barry Krakow MD


Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.

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