Cognitive Behavioral Therapy for Nightmares

Why is Nightmare Specific Treatment Needed?

Nightmares affecting nearly one in ten Americans (Worley et al., 2021) and one in three individuals with a psychiatric diagnosis (Rufino et al., 2025), but often remain an overlooked treatment target in evidence-based psychotherapy. Exploring the reasons for a lack of treatment delivery for this transdiagnostic symptom, we find two key factors: 1) Many people do not seek help for nightmares because they do not realize it is a treatable condition (Nadroff et al., 2015), and 2) many healthcare providers may not routinely ask about nightmares or assess for Nightmare Disorder. All this despite effective treatments being available in both therapist-led (Pruiksma et al., 2025) and self-help formats (Worley & Nadroff, 2025) There is a growing awareness within psychology and ABPP specialists of the impact of nightmares, including a more detailed article last year in the APA Monitor. ABPP specialists are uniquely poised to deploy evidence-based interventions for this transdiagnostic symptom that co-occurs in various psychiatric and sleep disorders. This introduction to Cognitive Behavioral Therapy for Nightmares reviews dreams and nightmares, discusses the assessment and diagnosis of nightmare disorder, and highlights the status of evidence-based psychotherapies for nightmares.  We conclude with a brief discussion of Behavioral Sleep Medicine and credentialing.

Dreams: A Natural Component of Sleep

Dreams are an integral aspect of sleep, originating from the visual and emotional processing of our brains. They serve as a means of processing thoughts and emotions, facilitating creative problem-solving as the constraints of reality are often suspended (Schredl, 2010). While some dream images can be disturbing, distressing, and induce fearful awakenings, leading to the experience of nightmares, dreams are generally considered a natural part of the sleep cycle (Purves et al., 2001).

Nightmares: Upsetting or Distressing Dreams

Nightmares are upsetting or disturbing dreams that cause awakenings and distress. They typically occur during Rapid Eye Movement (REM) sleep, a stage of sleep characterized by emotional processing and memory consolidation. REM sleep is also referred to as paradoxical sleep due to its light but active nature. Unlike other sleep stages, REM sleep is easier to awaken from, and nightmares prolong these awakenings, resulting in negative impacts on sleep quality and subsequent day functioning. Nightmares are more common in children, adolescents, and young adults but often persist in middle age. Women and people from historically marginalized groups report higher rates of nightmares (Worley et al., 2021). However, people from all backgrounds and ages can experience problematic nightmares. Individuals with a history of trauma exposure, both civilians and military veterans, often experience nightmares related to their trauma. Nightmares are also common in depression, anxiety, and other mental health conditions (Rufino et al., 2025). For people who have nightmares frequently, they often notice problems with feeling fatigued, anxious, or distressed the next day. When nightmares are frequent and cause distress and impairment, assessment for nightmare disorder should be considered (APA, 2023).

Assessment and Diagnosis of Nightmare Disorder

A comprehensive assessment is key when an individual is reporting sleep disturbances, as there can be diagnostic confusion or comorbidity with a number of sleep and psychiatric conditions (Sheaves et al., 2023). Commonly prescribed medications can also impact REM sleep and nightmares. Cultural variations in nightmares are also a key factor, where an assessment informed by the DSM-5 Cultural Formulation Interview is imperative. A clinical interview reviewing typical sleep patterns is recommended along with evidence-based assessment measures for sleep concerns, nightmares, and commonly occurring comorbid psychiatric conditions. Evaluation of sleep using polysomnography is not recommended for nightmare disorder alone but may be indicated if the individual is demonstrating other sleep disorder concerns such as Obstructive Sleep Apnea.

Nightmare Disorder is diagnosed using criteria set out by the DSM-5-TR (APA, 2023). This diagnosis is characterized by disturbing dreams that cause awakenings, have remembered content, and impact functioning the next day. Nightmare researchers (Pruiksma et al., 2025) have offered up the DARC mnemonic to aid in recall of the diagnostic criteria:

D – Disturbing Dreams

A -Awakenings

R -Remembered Content

C – Clinical Impairment

These key features can help with differential diagnosis as symptoms of nightmare disorder can be similar to other sleep disorders with some key differences. For example, Obstructive Sleep Apnea, a sleep related breathing disorder, can cause awakenings and clinical impairment with sleep disturbances but would not have recalled dream content.  Some individuals experience both and would have some episodes of awakening with recalled dream content and other episodes due to decreased oxygen alone. Recalled dream content is a key factor in nightmares and can vary from individual to individual and with comorbid psychiatric or sleep disorders.

Nightmares are often categorized by their content into three types: those that are idiopathic, intermediate, or trauma-related. Idiopathic nightmares do not appear to have any connection to real-life or traumatic events, but they have upsetting content, nonetheless. Trauma-related or replicative nightmares are a close replay of the event with the same sights, sounds, and emotions. These can occur in trauma-survivors who do or do not meet diagnostic criteria for Posttraumatic Stress Disorder (PTSD). Intermediate, also called symbolic nightmares, may have some of the same images, emotions, or themes as a person’s lived experience. An example would be a combat veteran replaying a battle, but with key details changing (i.e., the battle is occurring in their hometown). Or the content may be symbolically or emotionally linked to a trauma including themes of safety or power. Intermediate nightmares can be quite confusing and distressing for trauma survivors.

Nightmares can also be classified by their association to other sleep and psychiatric disorders. Most clinicians are familiar with nightmares as an intrusion symptom of the aforementioned Posttraumatic Stress Disorder (PTSD), but trauma-related nightmares can also occur in trauma survivors who do not meet PTSD diagnostic criteria. Narcolepsy-related nightmares are an area of growing research in behavioral sleep medicine. Innovative research is exploring if current cognitive behavioral treatments for nightmares can be applied for individuals with narcolepsy-related nightmares (Mundt et al., 2024). Nightmares can also occur within the context of REM Sleep Behavior Disorder (RSBD). This is a sleep disorder occurring during REM sleep that involves motor symptoms and occurs most often in older adults. Epidemiological research is starting to explore the relation between chronic nightmares and neurodegenerative diseases. RSBD often precedes the development of neurodegenerative diseases, and nightmares are emerging as a risk factor (Otuiku, 2022). Due to the impact on sleep and daytime functioning, evidence-based interventions are recommended for nightmares or nightmare disorder that causes distress and/or impairment.  Given all these contexts and comorbidities for nightmares, it is very likely that ABPP Specialists will see individuals within their practice who are at risk for nightmares.  Awareness of evidence-based interventions for nightmares can augment a specialist’s practice or ensure appropriate referrals for evaluation and treatment.

A Brief Primer on Nightmare Theory

Nightmare Disorder is commonly explained by the mood matching hypothesis. This is the idea that difficulty with arousal at bedtime increases the likelihood of distressing nighttime imagery being pulled by the brain to match these emotions. Nightmares cause distress and awakenings that disrupt sleep, leading to next-day impairments and often more nighttime anxiety. This creates a nightmare cycle that is repeated night after night in those with chronic nightmares. For trauma-survivors, the imagery replayed is often similar to or a replication of lived experience. Trauma survivors often use avoidance during the day with intrusion symptoms.  At night, these avoidance strategies are blocked, and the brain pulls in this imagery. However, without the prefrontal cortex to actively work on incorporating new learning, the individuals get stuck with the imagery, repeating in the nightmare cycle. Cognitive Behavioral Therapy interventions improve sleep and decrease nightmare frequency and intensity by disrupting this nightmare cycle.

Cognitive Behavioral Therapy for Nightmares (CBT-N)

Cognitive Behavioral Therapy for Nightmares (CBT-N) is a brief evidence-based psychotherapy approach that offers potential for alleviating suffering associated with nightmares. The active ingredients of this intervention focus on changing hyperarousal and inhibiting fear extinction. CBT-N includes interventions to improve sleep continuity, reduce hyperarousal, and change the nightmare to a new dream.  How can cognitive behavioral therapy address a phenomenon that occurs primarily during sleep? Much like other therapies that address complex problems, it requires practice outside of the therapy room. These skills are practiced during the day and at bedtime to create new dream script options for REM sleep. CBT-N is used to describe a group of therapies with similar elements that intervene in the nightmare cycle (Pruskima et al., 2025).  This brief intervention includes three nightmare-specific treatments:

• Imagery Rehearsal Therapy (IRT),

• Exposure, Relaxation, and Rescription Therapy (ERRT),

•  Lucid Dreaming Therapy

One of the main variations in these interventions is in exposure to nightmare content. In IRT, there is limited exposure to the nightmare over the 1-3 sessions, with much of the work focused on scripting a new, pleasant dream. In ERRT, there is a greater focus on exposure to the nightmare with writing exposure in session. This treatment is still brief, usually lasting 5-6 sessions.  For trauma survivors enrolled in ERRT, they are asked to consider themes of safety, trust, power/control, esteem, and intimacy represented in the nightmare. The rescription of the nightmare into a new dream incorporates positive representations of these themes. For example, if a lack of safety is represented in the nightmare, the new dream script would work to increase elements of safety. This could include creative changes such as adding protective gear, changing the location, or bringing along trusted friends. Lucid Dreaming Therapy teaches the individual to become lucid during their dreams and make changes as the dream is happening. Each of these options includes some work between sessions to make changes in the thoughts and behaviors around sleep. Cognitive Behavioral Therapy for Insomnia (CBT-I) can also be effective in reducing nightmares by improving sleep continuity. It is sometimes included under the heading of CBT-N and will likely be a familiar treatment for most ABPP Specialists.  

 A table adapted from The Nightmare and Sleep Disorder Toolkit (Worley & Nadorff, 2025) is provided to further highlight the similarities and differences in CBT-N interventions.