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.
Telephone-guided imagery rehearsal therapy for nightmares, delivered by postgraduate students, produced large improvements in nightmare frequency, nightmare distress, and insomnia severity compared with a wait-list condition. 70 adults with nightmare disorder were randomized to three treatment sessions over 5 weeks or to a wait list. Effects were sustained at 3- and 6-month follow-up. No significant effects were found on nights with nightmares per week, anxiety, or depression. The treatment effect was mediated by increased mastery at mid-treatment, supporting mastery's mechanistic role in imagery rehearsal therapy. The findings indicate that imagery rehearsal therapy can be effectively delivered in a guided self-help format with minimal therapist training, improving scalability and cost-effectiveness.
Imagery rescripting and imaginal exposure are both effective treatments for nightmare disorder, but they work through different underlying mechanisms. In a randomized wait-list controlled trial with 104 participants, enhanced mastery or self-efficacy regarding nightmare content mediated the therapeutic effects of imagery rescripting. In contrast, increased tolerability of negative emotions elicited by nightmares mediated the effects of imaginal exposure. Although both treatments produce similar therapeutic outcomes, they appear to engage distinct psychological processes.