Nightmares

Nightmares

What is it?

A nightmare is a vivid, disturbing dream that wakes you up, usually in the second half of the night; everyone has them occasionally, often tied to stress, illness, or medication, but nightmare disorder is diagnosed when they recur often enough to cause distress or affect sleep, mood, or daytime functioning.¹

Why could this be a problem?

Frequent nightmares fragment sleep and can create a genuine dread of going to bed, which often develops into insomnia, which comes with its own problems. They can lead to exhaustion, low mood, anxiety, and slowly eat away at your waking hours.

They’re also common after trauma, as part of PTSD, which makes them worth paying attention to rather than dismissing as “just dreams.”

What can be done?

Image Rehearsal Therapy (IRT) is the best-supported psychological treatment: it involves rewriting the ending of a recurring nightmare while awake, then mentally rehearsing the new version.2 This reduces the frequency and intensity of the nightmare over time. Cognitive Behavioural Therapy for Nightmares (CBT-N) more broadly addresses the sleep patterns and anxiety that feed into them. For some people, particularly with trauma-related nightmares, medication can help alongside therapy, coordinated through our Cape Town practice.

Resources

This self-screening tool is intended to help identify patterns worth discussing with a doctor; it is not a diagnosis and does not replace a full medical assessment.

Child curled up asleep, illustrating disrupted sleep patterns

FAQs

Sometimes; but often they’re simply a specific, treatable sleep pattern rather than a symptom of something larger.

Avoidance tends to keep nightmares going. Approaches that engage directly with the content, like image rehearsal, tend to work better.

Many people notice a reduction in frequency within a few weeks of starting a structured programme.

Most people see real improvement; around 60–70% have fewer nightmares, along with knock-on gains in mood and sleep quality. That said, nightmares can return from time to time, particularly during periods of stress; the tools you learn in treatment are there to help you manage a recurrence quickly if it happens.

No. This is focused on the nightmares and reducing their occurrence. We do not provide direct trauma counselling but could refer you if you wanted to find such a provider.

No. The focus is on changing the pattern of nightmares by giving your brain a new path it can go down instead of the nightmares. You will not be psycho-analysed, though the contents of your nightmares can be unpacked if it is related to events you have experienced or fear.

References

  • Gieselmann A, Ait Aoudia M, Carr M, Germain A, Gorzka R, Holzinger B, Kleim B, Krakow B, Kunze AE, Lancee J, Nadorff MR, Nielsen T, Riemann D, Sandahl H, Schlarb AA, Schmid C, Schredl M, Spoormaker VI, Steil R, van Schagen AM, Wittmann L, Zschoche M, Pietrowsky R. Aetiology and treatment of nightmare disorder: State of the art and future perspectives. J Sleep Res. 2019 Aug;28(4):e12820. doi: 10.1111/jsr.12820. Epub 2019 Jan 29. PMID: 30697860; PMCID: PMC6850667.
  • Albanese M, Liotti M, Cornacchia L, Mancini F. Nightmare Rescripting: Using Imagery Techniques to Treat Sleep Disturbances in Post-traumatic Stress Disorder. Front Psychiatry. 2022 Apr 4;13:866144. doi: 10.3389/fpsyt.2022.866144. PMID: 35444578; PMCID: PMC9013762.
  • Marie Pelzer, Lars O.M. Rothkegel, Alessandra Mancini, Natalia Oglanova, Jakob Fink-Lamotte, Efficacy of imagery rescripting in non-fear emotions: A meta-analytic and systematic review, Behaviour Research and Therapy, Volume 193, 2025, 104810, ISSN 0005-7967, https://doi.org/10.1016/j.brat.2025.104810.