Nightmare disorder is frequent, distressing dreams that wake you from REM sleep; sleep terrors are episodes of panic from deep non-REM sleep that are not remembered. Nightmares are treated with imagery rehearsal therapy and, when trauma-related, prazosin; sleep terrors are treated by removing triggers, improving sleep and occasionally medication. Both respond well to treatment.
Sleep terrors are a separate problem that is often confused with nightmares. They arise from deep non-REM sleep in the first third of the night, begin with a scream or a surge of panic, involve a racing heart, sweating and a look of terror, and are not remembered in the morning. They are common in young children and usually outgrown, but they also occur in adults, where they can be dangerous and are frequently driven by sleep deprivation, stress, alcohol or another sleep disorder. At Stedfast Psychiatry we treat both, using therapies and medications with the strongest evidence and addressing the trauma, anxiety or depression underneath.
Symptoms of nightmares
- Repeated dreams involving threats to survival, safety or physical integrity, recalled in detail on waking
- Nightmares that occur mostly in the second half of the night and leave you fully awake and alert
- Difficulty returning to sleep after a nightmare, with lingering fear, anger or sadness
- Dreading bedtime, delaying sleep or using alcohol to suppress dreaming
- Daytime fatigue, irritability, poor concentration and low mood from disrupted sleep
- Sleep terrors: abrupt arousal from deep sleep in the first hours of the night with screaming, sitting up, a racing heart and sweating
- Sleep terrors: confusion, inconsolability and no memory of the event the next morning
- In adults with sleep terrors, getting out of bed or injuring oneself or a bed partner during an episode
Causes and risk factors
Nightmares are generated in REM sleep, and anything that increases REM intensity or fragments it makes them more frequent: sleep deprivation and REM rebound, irregular schedules, fever, and withdrawal from alcohol or REM-suppressing medications. Several drugs provoke nightmares, including beta blockers, some antidepressants (especially when starting or stopping), dopamine agonists, varenicline and donepezil. Trauma is the strongest psychiatric cause. Up to 70 percent of people with PTSD have recurrent nightmares, often replaying the event, and the nightmares in turn maintain the disorder by preventing restorative sleep. Depression, anxiety disorders, borderline personality disorder and grief also raise nightmare frequency, and a tendency to vivid dreaming runs in families.
Sleep terrors come from incomplete arousal out of slow-wave (N3) sleep, the deepest stage. Children have a lot of slow-wave sleep, which is why terrors are common between ages three and seven, and the tendency is strongly genetic. In adults, triggers include sleep deprivation, fever, alcohol, sedative medications, stress, untreated sleep apnea, and anything that forces a sudden arousal from deep sleep, such as noise or a full bladder.
About 2 to 8 percent of adults have nightmares frequent enough to cause clinically significant distress, and an estimated 50 to 70 percent of people with PTSD have recurrent nightmares.
Source: American Academy of Sleep Medicine, Journal of Clinical Sleep Medicine position paper, 2018
Imagery rehearsal therapy is recommended for the treatment of nightmare disorder and PTSD-associated nightmares; prazosin is recommended for PTSD-associated nightmares with lower certainty.
Source: American Academy of Sleep Medicine position paper on the treatment of nightmare disorder in adults, 2018
Sleep terrors affect an estimated 30 to 40 percent of children at some point and about 1 to 2 percent of adults.
Source: American Academy of Sleep Medicine, International Classification of Sleep Disorders, third edition
Nightmares are an independent risk factor for suicidal ideation and attempts, even after accounting for depression and PTSD.
Source: Sjostrom et al., Sleep; and subsequent meta-analyses in Sleep Medicine Reviews
How we diagnose it at Stedfast Psychiatry
Telling nightmares from sleep terrors is the first task, because the treatments differ. We ask about timing (first third versus second half of the night), recall (vivid versus none), the degree of autonomic arousal, and whether you wake fully or remain confused. A bed partner's description is valuable. We use the Disturbing Dream and Nightmare Severity Index to grade frequency and distress and the PCL-5 to screen for PTSD, plus the PHQ-9 and GAD-7. We review all medications and substances with attention to recent starts, stops and dose changes.
We also look for the conditions that mimic or drive these problems: REM sleep behavior disorder (acting out dreams, usually in older adults), nocturnal panic attacks, nocturnal seizures, and obstructive sleep apnea, which can trigger both nightmares and sleep terrors. When adult sleep terrors are frequent, violent or atypical, or when seizures or apnea are possible, we arrange overnight polysomnography. Nightmare disorder itself is diagnosed by history and does not require a sleep study.
Treatment options
Medication management
For trauma-related nightmares, prazosin, an alpha-1 adrenergic blocker, is the most studied medication. It reduces nightmare frequency and intensity in many patients, is started at 1 mg at bedtime and titrated slowly, and its main side effect is dizziness on standing. Evidence is mixed (a large 2018 VA trial was negative while several smaller trials were positive), so we use it as a trial with clear targets rather than a guarantee. When nightmares are part of PTSD or depression, an SSRI such as sertraline or paroxetine treats the underlying condition and often reduces dreaming. We avoid or taper drugs that provoke nightmares and steer away from benzodiazepines and sedative sleep aids except in specific situations. For adult sleep terrors that persist after triggers are removed and sleep is repaired, low-dose clonazepam at bedtime or an SSRI is used off-label, typically for a limited period.
Psychotherapy
Imagery rehearsal therapy (IRT) is the first-line treatment for nightmare disorder, recommended by the American Academy of Sleep Medicine for both idiopathic and PTSD-related nightmares. You write down a recurring nightmare, change it in any way you like so that it is no longer distressing, and rehearse the new version in your imagination for several minutes each day. Over two to four weeks, the rehearsed script begins to replace the nightmare. IRT is brief, has no side effects and works for most people who practice it. Related approaches include exposure, relaxation and rescripting therapy (ERRT) and lucid dreaming training. Cognitive behavioral therapy for insomnia addresses the sleep avoidance that builds up around nightmares, and trauma-focused therapies such as cognitive processing therapy or prolonged exposure treat PTSD at its source. For sleep terrors in children, scheduled awakenings (waking the child briefly 15 to 30 minutes before the usual episode time for a couple of weeks) are effective, along with a consistent schedule and reassurance for parents.
What to expect
Your first visit is a 45 to 60 minute evaluation that maps the episodes, your sleep, trauma history, mood and medications. For nightmares, most patients start imagery rehearsal therapy at the first or second visit and, if trauma-related, begin a prazosin trial alongside it. For sleep terrors, we identify and remove triggers first, address sleep debt and any apnea, and consider medication only if episodes remain frequent or unsafe. Follow-ups at three to six weeks track nightmare frequency with a simple diary. Evaluation, therapy and medication management can all be done through telehealth anywhere in Florida or South Carolina.
When to seek help
Make an appointment if nightmares occur weekly or more, if you are avoiding sleep because of them, if they followed a traumatic event, or if sleep terrors in an adult involve leaving the bed, injury or aggression. Children with sleep terrors usually need no treatment, but see a provider if episodes are nightly, involve injury, continue past puberty, or come with daytime behavioral problems. If nightmares or sleep loss have led to thoughts of suicide or self-harm, call or text 988, the Suicide and Crisis Lifeline, or go to the nearest emergency room.
Idiopathic and trauma-related nightmares
Idiopathic nightmare disorder has no identifiable trigger and often begins in childhood or adolescence in people who are vivid dreamers by nature. It responds well to imagery rehearsal therapy alone. Trauma-related nightmares replay or reshape a traumatic event and are usually part of PTSD or acute stress disorder. They are more frequent, more physiologically intense and more likely to produce sleep avoidance. Treatment combines IRT or a rescripting therapy with medication such as prazosin and, importantly, treatment of the PTSD itself. The distinction matters because trauma-related nightmares rarely resolve fully while the trauma remains unprocessed.
Other non-REM parasomnias
Sleep terrors belong to a family of disorders of arousal from slow-wave sleep that also includes sleepwalking and confusional arousals. They share triggers (sleep deprivation, alcohol, sedatives, fever, apnea), a genetic tendency, and the pattern of partial awakening with no memory. A person may have more than one: a child who has sleep terrors at five may sleepwalk at nine. In adults, these parasomnias occasionally cause injury, driving or other complex behavior while asleep, which makes evaluation and safety planning important. Sleep-related eating disorder, another non-REM parasomnia, is associated with zolpidem and other sedatives.
Differential diagnosis
Several conditions resemble nightmares or sleep terrors. REM sleep behavior disorder involves acting out dreams with punching, kicking or shouting, usually in men over 50, and carries a different significance. Nocturnal panic attacks wake the person with fear but without dream content. Nocturnal frontal lobe seizures can produce screaming and thrashing from sleep but tend to be brief, stereotyped and repeated several times a night. Obstructive sleep apnea produces gasping arousals that patients sometimes experience as dreams of suffocation. PTSD-related nightmares may be confused with flashbacks, which occur while awake. When the history does not clearly fit, a sleep study with video resolves the question.
Safety for adult sleep terrors
Adults with sleep terrors should sleep on the ground floor if possible, lock windows, remove sharp or breakable objects from the bedroom, and consider door alarms if episodes involve leaving the room. Bed partners should avoid restraining the person, which can trigger a defensive reaction, and instead speak calmly and guide them back to bed. These measures are temporary while treatment takes effect.
Lifestyle and sleep hygiene
Both conditions improve with consistent, sufficient sleep. Keep the same bedtime and wake time every day, including weekends, aim for seven to nine hours, and avoid napping late in the day. Avoid alcohol in the evening; it suppresses REM early in the night and causes rebound dreaming and arousals later. Limit caffeine after noon. Keep the bedroom cool and dark. Do not use the hour before bed for distressing content, whether news, work or arguments. If you wake from a nightmare, get up, do something calm for ten minutes and return to bed, rather than lying there replaying it.
Prognosis
Nightmare disorder has one of the best treatment responses in sleep medicine: most patients who practice imagery rehearsal therapy see a large reduction within a month, and gains are maintained at follow-up. Trauma-related nightmares take longer and may need combined therapy and medication, but they, too, improve substantially in most people. Childhood sleep terrors almost always resolve by adolescence. Adult sleep terrors usually stop when triggers are removed and sleep is restored, and medication is rarely needed long term.
Frequently asked questions
What is the difference between a nightmare and a night terror?
Timing, memory and arousal. Nightmares occur in REM sleep, mostly in the second half of the night; you wake up fully, remember the dream clearly and can describe it. Sleep terrors arise from deep non-REM sleep in the first few hours; the person screams or thrashes, looks terrified, is hard to console and does not wake up properly, and in the morning remembers nothing. Nightmares are treated with therapy aimed at the dream content; sleep terrors are treated by removing triggers and protecting deep sleep.
How does imagery rehearsal therapy work?
You choose a recurring nightmare, write it down, and then rewrite it however you want so that it is no longer disturbing: change the ending, the setting, the characters, anything. Then you spend five to twenty minutes a day vividly imagining the new version. Over a few weeks the brain starts producing the rehearsed dream instead of the nightmare, or stops producing it at all. The technique takes a few sessions to learn, has no side effects, and works as well as medication in most studies.
Does prazosin work for nightmares?
For many people, yes, particularly when nightmares are trauma-related. Several trials in veterans and civilians showed meaningful reductions in nightmare frequency and intensity, while a large 2018 Veterans Affairs trial found no benefit over placebo, so the evidence is mixed. In practice, we offer a monitored trial starting at 1 mg at bedtime, increasing every few days as tolerated, and judge results over four to six weeks with a nightmare diary. The main side effect is lightheadedness on standing, so we check blood pressure.
Can antidepressants cause nightmares?
They can, especially when starting, stopping or changing the dose. SSRIs and SNRIs suppress REM sleep, and the rebound when a dose is missed or stopped can produce intense dreaming. Beta blockers, varenicline, dopamine agonists, donepezil and some blood pressure medications also provoke vivid dreams. If nightmares began within weeks of a medication change, that is the first thing we examine. Often a dose timing change or a switch to a different agent resolves them.
Should I wake my child during a night terror?
No. Trying to wake a child in a sleep terror usually prolongs the episode and leaves the child confused and more upset. Stay nearby, keep the child safe from falls or hard objects, speak calmly and let the episode run its course, usually five to fifteen minutes. The child will go back to sleep and will not remember it. Make sure your child gets enough sleep, keep bedtime consistent, and if episodes happen at a predictable time, a brief scheduled awakening fifteen to thirty minutes before can prevent them.
Can nightmares be a sign of something more serious?
Frequent nightmares that begin after a traumatic event are often an early sign of PTSD, and treating them early can prevent the full disorder from taking hold. Nightmares are also associated with depression, anxiety disorders and increased suicide risk, which is why we always screen for mood and safety. In older adults, dream enactment with movements or vocalization may indicate REM sleep behavior disorder, which needs its own evaluation. Nightmares themselves do not mean something is wrong with your mind; they are a treatable sleep symptom.
Is nightmare treatment available by telehealth and covered by insurance?
Yes. Imagery rehearsal therapy, CBT for insomnia, trauma-focused therapy and medication management are all delivered effectively by video, and we see patients anywhere in Florida and South Carolina. Visits are billed as standard psychiatric and psychotherapy services, which most insurance plans and Medicare cover with your usual copay; a self-pay new-patient evaluation is $185. Prazosin and generic antidepressants cost a few dollars a month.
How long does treatment take?
Imagery rehearsal therapy is brief: most people need two to four sessions to learn it and see results within two to four weeks of daily practice. Prazosin, when effective, works within a few weeks of reaching an adequate dose. When nightmares are part of PTSD, treating the full disorder takes longer, typically three to six months of therapy. Sleep terrors in adults often stop within weeks of removing the trigger, whether that is sleep deprivation, alcohol or untreated apnea.
Where to get treatment for nightmare disorder and sleep terrors
Evaluation and treatment for nightmare disorder and sleep terrors is available at every Stedfast Psychiatry office and by video across Florida and South Carolina.
Related conditions
If you are thinking about harming yourself, call or text 988 now, or go to the nearest emergency room. This page is educational and does not replace an evaluation. Clinical content reviewed by Dr. David Husted, board-certified psychiatrist.