Month: January 2025

Tackle the most intense, vivid and distressing nightmare first. Pick up helpful themes in the dreams. Pay attention to sleep hygiene and learn to relax before falling asleep. Consider cultural beliefs. And treat both trauma-related nightmares and those with no known origin the same way. These are a few of the main recommendations from an expert panel on cognitive behavioral nightmare treatment, paving the way for clarity in a field historically mired by complexity and confusion.

We know that nightmare treatment works well in most cases, and that cognitive-behavioral therapy (CBT) approaches have been well supported by empirical research. Despite this, there have been many sources of confusion about how to apply these treatments. To name two: clinical trials have yielded mixed results, and treatment components used in these studies were not consistent, but rather varied and nuanced.

To help resolve the confusion, a group of nightmare treatment experts met three times in 2021 and 2022 with the goal of reaching a consensus on protocols for CBT applied to nightmares (CBT-N) for adults. The project was funded by the US Department of Defense, and the result is a paper (Pruiksma et al. 2025) and a free online training for mental health professionals: CBTNightmares.org

The panel included experts in sleep medicine, nightmare treatment and nightmare research. The group reviewed existing literature and also drew on their collective expertise to create a standardized CBT-based treatment protocol and training. Although there are limitations to this new version of CBT-N, it is a starting place with clearly-defined terms and common ground upon which to stand going forward.

CBT-N includes many elements of the mostly deeply-researched protocol for nightmare treatment, Imagery Rehearsal Therapy (IRT). Exposure, Relaxation, and Rescription Therapy (ERRT) also features prominently, in particular with respect to exposure to the nightmare material and relaxation training. Because nightmare disorder is also implicated in sleep disturbances, sleep hygiene (CBT for insomnia or CBT-I) also forms part of the treatment.

Highlights of the New CBT-N Protocol

Trauma vs idiopathic nightmares.
Nightmares are defined as distressing, well-remembered dreams that cause awakening and clinically significant impairment. Research has clearly delineated a difference between nightmares related to trauma, and idiopathic nightmares with no clear origin. However, clinicians can treat both of these types of nightmares with the same techniques. One caveat: with trauma-related nightmares that closely replicate the trauma to which they refer, it is important to clarify that you are treating the nightmare and not the trauma itself – and to highlight any differences, however small, between the dream and the actual event.

Consider cultural beliefs
Not everyone who suffers from nightmares will be an appropriate candidate for CBT-N. There are many and diverse beliefs and practices around dreams that must be considered. When in doubt, therapists might want to consult with spiritual or community leaders to ensure they are offering treatment consistent with the patient’s beliefs and values.

Relaxation training and sleep efficiency
Relaxation training is now considered an essential component of both insomnia and nightmare treatment because of the link established between parasympathetic activity and disturbed dreaming. The panel recommends relaxation training early in the treatment process, and daily practice for patients. Sleep hygiene is also considered an important aspect of treatment because insomnia and nightmares are inherently linked. Helpful sleep habits include consistent bedtime, a wind-down period before bed, and no screen time or stimulating substances before turning in for the night.

Exposure to the nightmare: “Leverage the strongest approach”
One clear and potentially controversial recommendation from the panel is that the target nightmare to work with first should be the most frequent, vivid and distressing one. In CBT-N, exposure takes the form of writing the nightmare down in first-person, present-tense and to include as much detail and sensory information as possible, including thoughts and feelings that arise. Grammar, wording and legibility are not important, but maximum exposure to the nightmare content is encouraged – unless the patient declines or has limited time for treatment.

One of the reasons for choosing the most intense nightmares is that helpful treatment effects appear to generalize from these powerful dreams to less intense ones – but not the other way around. In addition, nightmare treatment is typically short-term (6 one-hour sessions are recommended), and then patients are able to complete the steps on their own. Therefore, the experts reasoned, it’s best to work with the worst dreams while there is in-person support. In addition, the practice helps patients build tolerance for difficult emotion, giving the dreamer a greater sense of mastery over their nightmare material. If patients are unclear about which dream to choose, the more recent and clearly-recalled is suggested.

The rescripting process: Pick up helpful themes
It has been established that a sense of mastery and control over nightmares helps reduce the distress they cause. Therapists are encouraged to help the dreamer identify supportive themes in their dreams, such as trust, safety, power and control, self esteem and connection and use these themes in their new version of the nightmare. They are asked to write the rescripted version in first person, present tense, and include detail, emotion and thoughts that arise. They are specifically asked to provide a link between the new version and the nightmare. Before going to sleep, and after relaxation practice, they are asked to review the rescription for ten minutes each night (and also during the day if they wish).

Future directions and some caveats

With a clear protocol and defined steps and terms, there can now be more standardization in nightmare treatment and research. One area that was flagged for further clarification is how best to approach the treatment of comorbid nightmares and PTSD. There are arguments for treating the nightmares first and vice versa, and for now, cases should be considered on an individualized basis. More research is also needed into nuances of treatment, such as dosage, and how to combine treatment elements with medication and with other helpful approaches (such as lucid dreaming and other methods not based on CBT). There is also the question of how to treat those with cultural beliefs that clash with CBT-N, as well as those with the inability to visualize (aphantasia).

Although a consensus has been reached among CBT experts about how best to treat nightmares given what we now know, there is still a lack of clarity about which specific elements of the treatment are essential; more dismantling studies that test discrete elements could help. CBT-N begins with education about sleep hygiene and, if applicable, psychoeducation about trauma, followed the core elements of exposure and rescripting – both done by writing the dream or new dream ending in as much detail as possible.

Authors of CBT-N suggest that users of this protocol to be experienced in delivering CBT, and not all therapists follow this orientation, nor do all patients respond well to it. About one-third of patients are not helped by CBT-N, so there is a need for other approaches. Therapists can adapt key treatment elements to other methods (as I have done with embodied experiential dreamwork practices for treating nightmares). The authors note that the recommendations “are not intended to signal that other treatment approaches are not useful or viable” but rather, are offering clarity and consistency by combining the most effective CBT-based methods into one standard protocol.

Clearly, there are many outstanding questions in the complex field of nightmare treatment. However, this consensus statement and free training are huge steps forward, addressing two of the main issues: confusion and compexity around treatment protocols, and lack of available training.

Pruiksma, K. E., Miller, K. E., Davis, J. L., Gehrman, P., Harb, G., Ross, R. J., … & Peterson, A. L. (2025). An Expert Consensus Statement for Implementing Cognitive Behavioral Therapy for Nightmares in Adults. Behavioral Sleep Medicine, 1-19. https://doi.org/10.1080/15402002.2024.2437634

A veteran who dreams about being back in the thick of an intense battle, or a car accident victim who repeatedly wakes up from a nightmare just before what feels like a potentially fatal impact… dreams that create vivid and direct experience of someone’s most traumatic memories are clinical red flags. A new study offers even more support for us to take such dreams seriously.

We already know that nightmares about traumatic events are in a category of their own: they are linked to both PTSD and higher suicide risk. In a recent study (Richards et al. 2025) which examines how nightmares relate to mental health outcomes, one factor emerged as particularly significant: the replicative quality of trauma nightmares. Those who work with trauma should make a habit of asking how closely nightmare content matches the actual traumatic event, and pay particular attention to dreams that feel like an exact replay of terrifying memories.

The notion that replicative dreams indicate unprocessed trauma is not new – dream researchers have already noted that when dreams move along the continuum from real-life replay to more dreamlike and unrealistic, this is an indication of trauma recovery. This latest study strongly supports what we already know and also tests a new data collection method for researchers.

The Study

A research team at UCSF and the San Francisco VA Medical Center studied 103 trauma-exposed adults who experienced at least one nightmare per week. Using a custom designed mobile app, participants logged their nightmare experiences over three weeks, rating various characteristics including how closely their dreams replicated their actual trauma experiences. The results revealed compelling patterns that could help clinicians better assess and respond to nightmare-related distress.

While several nightmare characteristics were associated with negative outcomes, the replicative nature of trauma nightmares stood out as uniquely predictive of suicidal ideation, even when controlling for depression. This suggests that when patients report dreams that closely mirror their traumatic experiences, clinicians should be particularly alert to potential suicide risk.

What makes this finding significant for clinical practice?

Not all trauma nightmares are created equal. In Richards’ study, the characteristics of participant nightmares varied considerably. Some were only loosely connected to trauma through emotional resonance, while others replayed traumatic events in vivid detail. This variation proved meaningful – the more closely a nightmare replicated the actual trauma, the stronger its association with negative outcomes.

The researchers found that different nightmare characteristics predicted different clinical concerns. For instance, nightmare duration and post-dream arousal (difficulty returning to sleep) were strongly linked to next-day mood disturbance. However, replicative quality emerged as the strongest predictor of both PTSD symptom severity and suicidal ideation. Every instance of reported active suicidal ideation came from participants with PTSD.

This pattern makes intuitive sense when we consider the nature of trauma processing. Dreams that exactly replay traumatic events may represent a failure of the natural dream process to integrate and metabolize traumatic memories. Instead of the typical dream-like transformation of daily experiences, the contents of replicative nightmares remain raw and unprocessed. Rather than being incorporated into the associative web of normal memory, these unmetabolized events have an always-current quality that can create a sense of despair in those who experience them.

For clinicians, these findings point to the importance of carefully assessing nightmare content, not just frequency or intensity. When working with trauma survivors who experience nightmares, consider asking:

– How similar are the nightmares to the actual traumatic event(s)?

– Do they replay the trauma exactly, or are elements changed/symbolic?

– Has the content of trauma nightmares evolved over time?

We May Need to Broaden Our Clinical Definition of Nightmares

The study revealed that only about 17-18% of reported distressing dreams met the full diagnostic criteria for nightmares as defined in DSM-5 (awakening with full alertness and detailed recall). This suggests we may need to broaden our clinical attention beyond classical nightmares to include other forms of trauma-related disturbing dreams. In my practice, I treat client dreams as nightmares if they experience them as such, and I do not insist on the awakening criteria.

Why might highly replicative nightmares be especially concerning? One theory is that they represent a particularly devastating form of re-traumatization. Unlike daytime intrusive memories, which patients can often manage with learned coping strategies, nightmares strike when we are least able to employ conscious coping methods. The exact replay of trauma during sleep may intensify feelings of helplessness and hopelessness.

Mobile App Simplifies Data Collection

The study’s findings also highlight the promise of mobile technology in nightmare assessment. The app-based sleep diary yielded rich data about nightmare characteristics with high temporal precision. This suggests that similar tools could help clinicians track nightmare patterns and evolution during treatment.

For clinicians working with trauma survivors, this research underscores the importance of detailed nightmare assessment as part of routine care. Beyond simply asking about nightmare frequency or distress, exploring the replicative quality of nightmares may provide crucial clinical insights and help guide treatment planning and risk assessment. When it comes to trauma nightmares, content matters and dreams that closely mirror traumatic experiences need to be treated.

Richards, A., Santistevan, A., Kovnick, M., Orlova, P., Yack, L., Berg, E., Pracar, S., Metzler, T., Neylan, T., & Woodward, S. (2025). Distressing Dreams in Trauma Survivors: Using a sleep diary mobile app to reveal distressing dream characteristics and their relationship to symptoms and suicidal ideation in trauma-exposed adults. Sleep Advances. Advance online publication. https://doi.org/10.1093/sleepadvances/zpae099