Nightmares and Nightmare Disorder: Diagnosis & Treatment
Lilian White, MD
September 22, 2026
Nightmares are vivid, often terrifying, well-remembered dreams that wake the dreamer from sleep. Dreams or nightmares may occur during any stage of sleep but are most common during the rapid eye movement (REM) stage of sleep. Nearly 50% of adults have experienced a nightmare in the last 2 weeks, and an estimated 25% to 35% of children have experienced nightmares within the past month. Nightmare frequency peaks around ages 10 to 14 years and decreases slightly with age. Nightmare disorder affects 4% of adults, 3% to 6% of children, and tends to occur more in women.
Nightmares may occur as part of another disorder (eg, post-traumatic stress disorder [PTSD], obstructive sleep apnea, narcolepsy) or may be idiopathic. Over 70% of patients diagnosed with PTSD experience nightmares. Enacted nightmares may be an isolated rapid eye movement (REM) sleep behavior disorder, or they can be associated with other conditions, such as Parkinson disease. Genetics appear to play a significant role in the occurrence of nightmares, with those experiencing more frequent nightmares in childhood tending to have more persistent nightmares into adulthood compared to those with less frequent nightmares in childhood.
Nightmares are distinguished from night terrors by several components. Nightmares tend to occur during REM sleep later in the sleep cycle with vivid dreams and complete awakening, whereas night terrors tend to occur during non-REM sleep earlier in the night with no or very fragmentary dream recall, confusion, and frequent morning amnesia regarding the night terror.
Medications impact dreams as well. Beta blockers, dopaminergic drugs, montelukast, selective serotonin reuptake inhibitors, medications that inhibit serotonin/norepinephrine reuptake (eg, mirtazapine), cholinesterase inhibitors, non-benzodiazepine receptor agonists (eg, zolpidem) may induce nightmares. Alpha blockers may reduce nightmares.
Nightmare disorder is a clinical diagnosis with criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders and may be diagnosed when nightmares cause significant subjective distress or impairment in social or occupational functioning. The Nightmare Disorder Index may be used as a screening tool. Nightmares that occur as part of PTSD often involve re-experiencing the initial trauma or elements of it. Polysomnography is not necessary to diagnose nightmare disorder but is recommended when considering other REM sleep behavior disorders.
Treatment of nightmare disorder is primarily behavioral. Image rehearsal therapy is recommended for the treatment of nightmare disorder in adults according to a position paper by the American Academy of Sleep Medicine. Image rehearsal therapy involves reimaging a nightmare into a more positive scene and envisioning the scene for 10 to 20 minutes per day. It has been shown to be effective in patients with nightmare disorder and in those with nightmares as part of PTSD, as well as in children.
Other treatment options include lucid dreaming therapy, cognitive behavioral therapy, progressive deep muscle relaxation, self-exposure therapy, and hypnosis. Medication treatment options include prazosin and nitrazepam, among others. Clonazepam and venlafaxine are not recommended for treatment of nightmare disorders due to lack of effectiveness.