Treatments for trauma-related nightmares, side by side

When nightmares replay something that happened to you, it can feel as if sleep itself has stopped being safe. That is a common experience after trauma, and it is treatable. Several approaches have research behind them, and they work in different ways.

This is a calm side-by-side, based mainly on the American Academy of Sleep Medicine’s 2018 position paper,^[1] with notes from the 2023 US Veterans Affairs and Department of Defense guideline on PTSD.^[6] If you are in crisis right now, please skip to help that is available today.

At a glance

In the AASM’s wording, “recommended” means clearly useful for most patients, and “may be used” means the evidence or expert consensus is less clear.^[1]

Imagery rehearsal therapy

Imagery rehearsal asks you to choose a nightmare, change it in any way you like, and rehearse the new version for a few minutes each day. With trauma nightmares, the new version does not have to replay the event; the point is to give the dream somewhere else to go.

Its best-known trial, published in JAMA in 2001, included 168 women in New Mexico, almost all of whom had experienced sexual assault and most of whom had moderate to severe PTSD. Those given three sessions of imagery rehearsal had fewer nightmares, slept better and had fewer PTSD symptoms at three and six months, while the waiting-list group changed little.^[2] The AASM recommends it for both PTSD-associated nightmares and nightmare disorder.^[1]

Guidelines do not all read the evidence the same way. The 2023 VA/DoD guideline found insufficient evidence to recommend for or against imagery rehearsal, or ERRT, specifically for PTSD nightmares.^[6] More detail is in what imagery rehearsal is.

Exposure, relaxation and rescripting therapy

ERRT is a close cousin of imagery rehearsal. The AASM describes it as a three-week course of cognitive behavioural therapy that combines education about sleep habits, progressive muscle relaxation, and exposure to the trauma with rescripting of the nightmare.^[1]

In a 2007 randomised trial in trauma-exposed adults, 27 people completed the treatment. Six months later, 84 per cent of them reported no nightmares in the previous week, and depression, post-traumatic stress, fear of sleep and other sleep problems had also eased.^[3] The trials are small, compared ERRT with a waiting list rather than another treatment, and come mostly from one research group.^[1]

CBT for insomnia

Many people with PTSD sleep badly even on nights without a nightmare: lying awake, waking often, dreading bed. CBT for insomnia works on that directly.

In a 2014 trial at a Veterans Affairs medical centre, 45 adults with PTSD and insomnia were randomly assigned to eight weekly sessions of CBT-I or a waiting list. CBT-I clearly improved sleep, and 41 per cent reached full remission of insomnia, compared with none on the waiting list; gains held at six months. Nightmares improved in both groups, so the effect on nightmares themselves is still uncertain.^[4]

Trauma-focused therapies

Trauma-focused therapies work on the memory itself, rather than on the dream. The VA/DoD guideline strongly recommends cognitive processing therapy (CPT), eye movement desensitisation and reprocessing (EMDR) and prolonged exposure for PTSD, and recommends these individual therapies over medication.^[6] The AASM lists CBT and EMDR among the approaches that may be used for PTSD-associated nightmares.^[1]

Nightmares often ease as PTSD does, though not always. In a study of 108 US soldiers treated in a trial of group therapy for PTSD, 69 per cent reported nightmares before treatment and about half afterwards. Among those who no longer met criteria for PTSD, only 13 per cent still reported nightmares, while insomnia was much more stubborn.^[5] For some people, adding a nightmare-specific or insomnia-specific treatment may make sense.

Medication

Prazosin, an older blood pressure medicine, is the most discussed. Early small trials were positive, but a 2018 trial in 304 veterans found no difference from placebo on nightmares or sleep quality.^[7] The AASM now says it “may be used” while still calling it the first choice when a medicine is used, and the VA/DoD guideline suggests it for PTSD-associated nightmares as a weak recommendation.^{[1, 6]} Several other medicines are listed with weaker evidence. We explain the trials in prazosin and nightmares.

Medicines are a conversation for your doctor. Never start, stop or change a medicine on your own; talk to your doctor or pharmacist.

Why a professional matters here

Several of these treatments involve approaching painful memories on purpose. A trained therapist paces that work, helps when distress rises, and keeps an eye on safety. Rewriting an everyday bad dream on your own is one thing; facing trauma memories alone is another, and is best not attempted without support.

Questions you might bring to a first appointment:

• Is the main goal to treat the nightmares, the PTSD as a whole, or both?
• What training do you have in the approach you are suggesting?
• How will we look after my sleep while we do this work?

If you want to understand why trauma tends to return at night, we wrote about why trauma replays at night.

If things feel like too much

If nightmares come with thoughts of ending your life or harming yourself, you deserve support today. Please call your local emergency number, or reach out to a crisis line. Talking to someone helps, and people do get through this. We also wrote about why nightmares and suicide risk deserve to be taken seriously.

Baku is not a trauma treatment. Its free Nightlight is there for the minutes after you wake, alongside the work you do with a professional.