PTSD and Nightmares: Why They Happen and What Actually Helps

PTSD nightmares are often vivid replays of previously experienced trauma. Unlike normal nightmares they tend to happen over and over without change, re-traumatizing the dreamer. They are so common in those with PTSD that they are actually a core part of PTSD diagnostic criteria.

Despite this, nightmares are one of the least-treated symptoms of PTSD.

The first thing for you to realize is that you’re not alone if you are dealing with this. Between 80-90% of people with PTSD experience nightmares. (Aurora et al., 2010). These nightmares can also happen up to six nights per week in PTSD, and persist for 40-50 years without treatment. (Levin & Nielsen 2007).

If you’re suffering from PTSD nightmares, don’t lose hope. Treatments such as IRT help stop nightmares and bad dreams even for those with PTSD. Though people with these nightmares can suffer long-term from them, intervention with IRT and other methods has shown to be very effective in reducing the frequency and intensity of nightmares.

Don’t lose hope. You can improve your nightmares.

Jump to: Why Nightmares Repeat · Do PTSD Treatments Help? · What the Research Shows · What is IRT? · How to Do IRT · Medication · Are They Dangerous? · First Steps

Why Do PTSD Nightmares Repeat?

Although we all just wish these nightmares would go away, half of PTSD nightmares are near-exact replays of the traumatic event, with the rest involving mixed or symbolic content (Wittmann et al. 2007). Understandably, this causes great distress for those with PTSD. Repeated nightmares cause stress and anxiety about sleep, which creates a fear that nightly dreaming will continue to contain nightmares.

This creates a vicious cycle: the nightmare disrupts your sleep, which causes poor sleep and increases emotional activation, which leads to worse nightmares.

Can you relate to this at all? Do you dread going to sleep? Does sleep—which should feel restorative and relaxing—seem like a threat?

If so, this is a key area to work on. This is a nightmare loop. Though it seems like it will never end, the important thing is to realize that it can end. Fear feeds this loop. Calm and mastery weaken it.

One study of veterans with PTSD found that typical dreamers have a decrease in noradrenaline while asleep, while PTSD dreamers had an increase in noradrenaline while sleeping (Mellman et al., 1995).

These are hallmarks of PTSD nightmares, and though this may seem scary to read, it also may help you realize that it’s not something wrong with you. These nightmares are neurochemical experiences. We can use specific techniques to help calm your nervous system and reduce this sort of response in your brain and body.

Do PTSD treatments stop nightmares?

Those with PTSD may be asking themselves, “Why am I still having these bad dreams even though I’ve been in therapy and feel better in the daytime?”

One frustrating aspect of PTSD is that even if you’re ‘doing the work’ in therapy you may still be experiencing intense and repetitive nightmares.

One study of combat veterans showed only a 10% reduction in nightmares even after significant improvements in sleep quality, PTSD symptoms, and depression (Margolies et al. 2013). Broad surveys of PTSD studies have shown that nightmares persist after standard PTSD treatments, and predict worse long-term outcomes when left untreated (Albanese et al. 2022).

This may be upsetting to read, but there’s good news. Although standard PTSD treatments don’t seem to help much with PTSD nightmares, IRT has been shown to be extremely effective. In one trial, 79% of participants were already receiving concurrent therapy or medication—yet IRT still produced large additional improvements in nightmares and sleep (Krakow et al. 2001).

There is hope. IRT has been studied very extensively and is very effective.

PTSD Nightmares Treatment: What the Research Shows

IRT is the only AASM Level A recommended behavioral treatment for nightmare disorder—the highest possible evidence rating (Aurora et al. 2010).

It is very effective too.

In a landmark JAMA trial, IRT reduced nights per week with nightmares from 3.88 to 1.33— and PTSD severity dropped from moderate-severe to moderate in 65% of the treatment group (Krakow et al. 2001).

That is a staggering result. Going from roughly four nightmares per week to about one is amazing. The severity of the nightmares dropped as well. Additionally, it’s worth noting that figures from studies like these are aggregates, meaning that some participants had even greater results than others.

As if this wasn’t great enough news, these changes aren’t just powerful, they’re long lasting. Treatment effects from IRT have been maintained up to 30 months in follow-up studies (Germain & Zadra 2009).

This may seem like a lot of data to be absorbing at once, but the science is here for a reason: it’s to help you understand that things can change. Your nightmares don’t have to stick around forever. Just like the participants in these studies, your PTSD nightmares can become less intense and less frequent.

These were well designed studies too. For example, 75% of veterans in one trial achieved normal sleep efficiency after combined sleep and nightmare treatment—compared to 21% of the control group (Margolies et al. 2013).

Though the technique is very powerful, it can be difficult for some people with severe PTSD to fully engage with. It isn’t a cure-all, but so far it has been the most powerfully successful treatment for PTSD nightmares.

What is IRT for PTSD Nightmares?

IRT for PTSD is the practice of re-scripting a nightmare while awake in order to influence the form of the nightmare later while sleeping.

Though it may sound too simple to work, that’s the essence of IRT in summary. Typically the PTSD patient works with a therapist or coach. They’ll write down their nightmare in as much detail as they can imagine. Then, with the support of a professional they will change the nightmare in whatever way they wish.

It is however very important that you feel supported when engaging with this topic. PTSD is a serious condition, and it is often better to have someone navigate you through this process so that you don’t feel alone.

Here are examples of what some patients did:

• • Created alternate endings

• • Inserted positive images

• • Transformed threatening elements

There is no “right way” to modify your nightmare. You can do whatever you want to change it.

Try to include positive sensory elements in your rewritten dream, such as nice smells and sights. Do your best to make the new dream as positive and engaging as possible. Once you’ve changed the story, keep a written copy of it near your bed or some other place that you feel comfortable. Read the story at least once per day and try to engage your senses to make it real.

Even if you can’t access a coach or therapist, there is still hope. One study showed meaningful reductions in nightmare frequency through a six-week self-help course with no therapist contact whatsoever—participants improved significantly more than those on the waiting list control group (Lancee et al. 2010).

How to do IRT for PTSD Nightmares

Here’s a hypothetical example of someone with PTSD working through the IRT process to help with their PTSD Nightmares.

John is a 40 year old combat veteran who suffers from PTSD due to a deployment in his past. Though he’s worked with therapists extensively and has less anxiety and daytime issues, his nightmares are still giving him problems. He’s found a coach that knows the IRT process and they’ve already had a session together where they’ve established a trusting, safe relationship. In the second session they both agree to move forward with the treatment itself.

(Note: if you have PTSD and/or don’t want to read an account of a nightmare, please skip the italicized section below)

John’s nightmare is as follows:

I’m driving down the road in an SUV with some friends while we’re on leave. There’s a rock song on the radio with heavy drums in it. At first I like the song, but then the drums start to sound like gunfire. I look at the car and realize we’re suddenly in a humvee and we’re driving down a road I recognize from my deployment. I smell dust and something burning. I turn around and just as I do, the car is rocked by a huge explosion…

With the support of the professional, John goes on to describe physical details that are an almost exact replay of an incident he experienced while deployed that led to the deaths of some of his fellow service members, as well as an injury to him. He is shaken by the process of recalling the dream, but is able to ride out the experience with breathing techniques and support. Once he’s recalled it he writes the nightmare down so that he has it for the next step of the treatment.

The professional asks, “How would you like to change this dream? You’re the director. You can change the script.”

After careful consideration, John decides to change the music that seems to trigger the dream.

Here’s his new version of the dream:

I’m driving down the road in an SUV with my friends while we’re on leave. A song comes on the radio. We always sang If You Like Piña Coladas together, mostly sarcastically. As the song comes on the radio I feel wind in my hair, and a salty breeze on my face. I look down and see warm white sand on my toes and feel the cold of a Piña Colada in my hand. I bring it up to my lips and take a sip, seeing now that I’m on the beach with my friends looking at a sunset. The drink is sweet and delicious, and we’re all safe and happy. I can’t believe how great the drink tastes and the ocean is so nice to look at.

John notices that he feels physically better after describing the new dream. He’s advised to take the new dream near his bed and read it at least once a day. He’s also encouraged to try and use his imagination to make the new improved dream as real as possible.

That night before bed he holds the paper in front of him and reads it out loud. Then he closes his eyes and tries to imagine it as well as he can. He feels some elevated emotions because he’s nearly thinking about the PTSD dream he usually has, but he feels like he might as well try since he has that same dream most nights anyway.

What’s the harm in trying to change it?

A week later he’s back in session and expressing some frustration with the program. He’s initially upset that though he’s changed the song in his dream, it hasn’t gone away completely. His support professional asks for a full account from John’s dream log, which John provides. After some discussion they both realize that some details—including the song playing in the car, and some of the gruesome images that normally follow it—are different and less intense.

Emboldened by the changes, John re-commits to the treatment and reads the new dream each night with focus, knowing that he can now influence the dream.

Over the course of the next few sessions John reports positive dreams mixed in with his negative ones, and that the original nightmare has changed so much that it doesn’t bother him as much anymore. He knows he has influence over his dreams, and that mastery has improved his sleep immensely. Not only that, but he feels better in the daytime than he has in years.

IRT works, but for those with PTSD it’s also important to understand why treating nightmares goes beyond sleep quality.

What About Medication for PTSD Nightmares?

For some people with PTSD nightmares, medication is part of the picture. Prazosin—a blood pressure medication—was for many years considered the most effective pharmacological treatment for PTSD-related nightmares, and was given the highest recommendation level (Level A) by the American Academy of Sleep Medicine (Aurora et al., 2010).

The evidence behind this was promising: in pre-2018 trials, prazosin meaningfully reduced nightmare severity and improved sleep in PTSD patients.

However, a large 2018 VA randomized controlled trial involving 304 participants found no significant benefit over placebo — a result that complicated the picture considerably (Germain & Zadra, 2009; Hasler & Germain, 2009).

Prazosin works for some people and not others, and nightmares typically return when the medication is discontinued. If you’re considering medication as part of your treatment, this is a conversation to have with a prescribing physician who is familiar with the current evidence—including its contradictions.

Are PTSD Nightmares Dangerous?

Though the nightmare itself can’t hurt you while you are asleep, there is a clear link between PTSD nightmares and suicide. It is critical for those with PTSD to be supported by professionals if this is coming up in their condition.

In one clinical study of PTSD patients, 62% of those who experienced nightmares reported suicidal thoughts, plans, or attempts—compared to 20% of those without nightmares (Littlewood et al. 2016).

At more than three times the rate in that study, suicidality is a serious health risk for those suffering from severe PTSD with nightmares. This association held even after controlling for insomnia and depression—meaning nightmares carry independent suicide risk, not just risk that comes from feeling generally unwell (Littlewood et al. 2016).

Research suggests the pathway runs through feelings of defeat, entrapment, and hopelessness—nightmares can reinforce the sense that there is no escape.

If you are or someone you know are feeling hopeless, thinking about suicide, or in emotional distress, you are not alone. Help is available 24/7:

• • Call or text 988 in the U.S.

• • Use webchat at 988lifeline.org

There is no shame in using these resources, and the world is a better place with you in it. Please use them if you feel the need to.

First Steps for PTSD Nightmares

If you’ve found this information helpful and are looking for more, please check out the structured REST program that incorporates evidence-backed methods for reducing nightmares.

How you respond when you wake from a nightmare matters—responding with fear reinforces the sleep-threat association. Grounding and calming immediately after waking is an evidence-informed first step.

Nightmares are trauma-induced, but habit sustained (Krakow et al. 2001). Though you may have experienced trauma, you can change your habits and break the cycle.

If you’d like structured guidance for building a better nightmare response—including exactly what to do when you wake from a nightmare—I’ve created a printable bedside instruction sheet for exactly that moment.

I’ve also included a five minute audio recording in case you’d rather listen on your phone when you need to.

The goal isn’t just fewer nightmares. It’s knowing exactly what to do when they happen—so they lose their power over your sleep and your days.

If your PTSD is severe or complex, professional support for nightmares specifically—not just general PTSD therapy—is more likely to be effective than ignoring the nightmares or trying to solve them on your own.

You are taking the first step by understanding how and why PTSD nightmares happen and what can help with them. Put the methods you’ve learned in this article into place, and pay close attention to the results.

Even small improvements in nightmare distress—before frequency drops—represent real progress. Research shows distress can fall significantly before the nightmares stop (Swanson et al. 2009).

You can reduce your nightmare frequency and severity, even if your nightmares come from PTSD.

References

Albanese, M., Liotti, M., Cornacchia, L., & Mancini, F. (2022). Nightmare rescripting: Using imagery techniques to treat sleep disturbances in post-traumatic stress disorder. Frontiers in Psychiatry, 13, 866144.

Aurora, R. N., Zak, R. S., Auerbach, S. H., Casey, K. R., Chowdhuri, S., Karippot, A., Maganti, R. K., Ramar, K., Kristo, D. A., Bista, S. R., Lamm, C. I., & Morgenthaler, T. I. (2010). Best practice guide for the treatment of nightmare disorder in adults. Journal of Clinical Sleep Medicine, 6(4), 389–401.

Germain, A., & Zadra, A. (2009). Dreams and nightmares in PTSD. In L. R. Squire (Ed.), Encyclopedia of Neuroscience (Vol. 3, pp. 655–661). Academic Press/Elsevier.

Krakow, B., Hollifield, M., Johnston, L., Koss, M., Schrader, R., Warner, T. D., Tandberg, D., Lauriello, J., McBride, L., Cutchen, L., Cheng, D., Emmons, S., Germain, A., Melendrez, D., Sandoval, D., & Prince, H. (2001). Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: A randomized controlled trial. JAMA, 286(5), 537–545.

Lancee, J., Spoormaker, V. I., & van den Bout, J. (2010). Cognitive-behavioral self-help treatment for nightmares: A randomized controlled trial. Psychotherapy and Psychosomatics, 79(6), 371–377.

Levin, R., & Nielsen, T. A. (2007). Disturbed dreaming, posttraumatic stress disorder, and affect distress: A review and neurocognitive model. Psychological Bulletin, 133(3), 482–528.

Littlewood, D. L., Gooding, P. A., Panagioti, M., & Kyle, S. D. (2016). Nightmares and suicide in posttraumatic stress disorder: The mediating role of defeat, entrapment, and hopelessness. Journal of Clinical Sleep Medicine, 12(3), 393–399.

Margolies, S. O., Rybarczyk, B., Vrana, S. R., Leszczyszyn, D. J., & Lynch, J. (2013). Efficacy of a cognitive-behavioral treatment for insomnia and nightmares in Afghanistan and Iraq veterans with PTSD. Journal of Clinical Psychology, 69(10), 1026–1042.

Mellman, T. A., Kumar, A., Kulick-Bell, R., Kumar, M., & Nolan, B. (1995). Nocturnal/daytime urine noradrenergic measures and sleep in combat-related PTSD. Biological Psychiatry, 38(3), 174–179.

Swanson, L. M., Favorite, T. K., Horin, E., & Arnedt, J. T. (2009). A combined group treatment for nightmares and insomnia in combat veterans: A pilot study. Journal of Traumatic Stress, 22(6), 639–642.

Wittmann, L., Schredl, M., & Kramer, M. (2007). Dreaming in posttraumatic stress disorder: A critical review. Psychotherapy and Psychosomatics, 76(1), 25–39.