Chronic nightmares arise from an interaction between elevated hyperarousal and impaired fear extinction, facilitated by trait affect distress from traumatic experiences, early childhood adversity, trait susceptibility, elevated thought suppression, and potentially sleep-disordered breathing. Treatment options target nightmare meaning, chronic repetition, or maladaptive beliefs. The paper reviews epidemiological findings, aetiology models for traumatized and non-traumatized individuals, and evidence-based interventions, noting gaps in healthcare provider knowledge and delivery. Future perspectives for nightmare treatment and aetiology research are outlined.
Among refugees with post-traumatic stress disorder (PTSD), 71% of 176 participants reported dream enactment behavior (DEB)—acting out dreams during sleep. Those with DEB showed significantly less improvement in sleep quality after PTSD therapy compared to those without DEB, regardless of the specific treatment received. DEB was not linked to differences in overall symptom severity or daily functioning. Additionally, 60% of participants with DEB did not report trauma-related nightmares, suggesting that trauma-associated sleep disorder (TASD) does not capture all cases of DEB in PTSD. The findings indicate that DEB is a common feature of sleep in PTSD that may limit treatment effectiveness for sleep problems.
Among trauma-affected refugees receiving imagery rehearsal therapy (IRT) for nightmares as an add-on to usual treatment, those with more severe symptoms at baseline showed greater improvement in sleep quality, nightmare severity, and PTSD symptoms. High motivation for psychotherapy predicted better sleep quality and PTSD symptom improvement, while lower cognitive functioning was linked to less PTSD symptom improvement, and using an interpreter was associated with less improvement in sleep quality. These findings suggest that low motivation and low cognitive functioning may be modifiable barriers to benefiting from IRT, though the small sample size limits reliability.