Episode 27: What Really Causes Nightmares, and Can You Stop Them?

Show notes:

We’re here to answer every question you’ve ever had about nightmares. What do we know about them? What distinguishes them from a sleep terror? What are some of the known causes of nightmares in adults — from late-night eating to certain medications to psychological triggers, like anxiety and depression? What have been some of the wildest case studies and what can listeners do if they persist?

Episode-related links:

Nightmares: Symptoms, Causes, and Treatment
30 Causes of Dreams and Nightmares (According to World Mythology)
Why Do We Have Nightmares?

Transcript:

Dr. Shelby Harris: We’re recording this episode right before Halloween. Boo! A time for costumes, candy, scary stories, and sometimes nightmares. And while many might love the occasional fright, there are others who really seriously struggle with disturbing dreams. It can impact your mood, your health, and make bedtime something you actually dread. If you feel this way, this episode’s for you. 

This week, I have no guest. What? Instead, I’ll be sharing strategies and experiences from my own training and practice, helping people deal with their nightmares. So let’s start with a question I get asked very often. What is a nightmare? 

What a nightmare really is, is it’s some sort of dream that can be scary, upsetting. The term we use in sleep medicine and psychology is called dysphoric. So it has to be upsetting to your mood somehow. Just upsetting. That’s the key. It doesn’t have to be like that I’m getting chased by a murderer in the dark kind of scary. 

That’s what a lot of people think nightmares are, is like a traumatic event being replayed, which can happen, don’t get me wrong, but it’s just. Some sort of a dream that’s scary to you. 

People kind of hear this in media, and they don’t always talk about the different nuances of what nightmares are, and they don’t report it to their doctor because they don’t think what they’re having are nightmares. Typically, the definition is that you have to wake up from it or have some sort of recollection of a piece or the entire dream. So, a lot of times when people are having nightmares, they know that they’re having a nightmare or they’re having some sort of disturbing or upsetting dream to them because you’re waking up and you’re feeling upset from it. But like I said, upset is the key, dysphoric is really important, doesn’t have to be totally fear based.

And when we talk about nightmares, you know, some people will have them once in a while. Some people will have them nightly. It really can vary. Having the occasional nightmare is not necessarily problematic. It’s how much weight you put on it, how scared you are by it. Even if you’re only having them once every few weeks, but you are truly upset by it, that it is disrupting your ability to go back to sleep and you start fearing going to bed, fearing sleep. 

There’s actually a scale that we use called the fear of sleep scale, because a lot of patients with nightmares, especially ones who have chronic nightmares multiple times a week, they really, really start fearing sleep. But if you notice, even if you’re having a nightmare once in a while and it’s bothering you and you’re starting to get scared about going to sleep because you don’t know if you’re going to have another nightmare, I got your back. I got some suggestions coming up. 

So very common causes for nightmares are stress and scary content, right? I don’t remember what year Thriller came out, but I will never forget when I was a kid, sorry mom, I’m throwing you under the bus here, that my mom, and my babysitter who lived across the street, they were like watching the thriller video with Michael Jackson when it premiered. I will never forget this.

And I kind of was peeking around the wall and saw a good deal of it and wow, that freaked me out. And I remember having nightmares for a number of nights after then because it was bedtime, and I was watching the thriller video, which now I think if my kids watched it now would be like laughing at it because the special effects are so early 80s, but whoa, it really did a number on me.

I can’t even watch the beginning of Law and Order, even though I know that usually there’s like someone who dies at the beginning. I still can’t even do that. I can’t handle scary content at all, or even just frightening or any sort of Law and Order sort of stuff. So I know I need to stay away from that. There are other people who love the like Shocktober stuff at night. Fine. You got to figure out what works for you. 

Definitely at times of stress. Stress can be a big one. So a lot of people will have the kind of nightmares that I know if I’m stressed, I always end up back in high school and I end up being in a calculus class. It’s the calculus teacher I actually had in high school. But I hadn’t gone for the entire school year. And I showed up for the final exam. And I had no idea what was on the test or anything. So that’s my like recurrent nightmare when I am stressed. I know that that’s usually a sign that I am stressed.

And then the final thing that we do see is PTSD, post traumatic stress disorder. So recurrent nightmares, often it’s the same nightmare or of a flavor of the same nightmare over and over again. Really it’s that re experiencing. And people with PTSD often, having that nightmare, usually it’s a recurring nightmare of the trauma that they had or witnessed. It’s a real thing that needs to get addressed a lot of the time. 

And when it comes to PTSD, if someone is having nightmares as well. The big misnomer in psychiatry is let’s treat the underlying primary issue, and I’m using quotations for a reason, because the idea is that if we help their PTSD with medication or let’s say any sort of prolonged exposure or any sort of like a CBT kind of treatment for PTSD, the idea is that if you treat that, then okay, their nightmares will just get better as their PTSD gets better, or the same thing for anxiety, depression, those sorts of things.

But what we actually see in the research, and I cannot tell you how often I see it in my practice when I have a patient with PTSD or depression who’s having nightmares, the reality is you have to treat the nightmares because when you get someone sleeping a little bit better, guess what? You get better outcomes with their psychiatric treatment overall. Don’t just wait for the other things to get better. Really try to work on the nightmares as best as you can. 

So things that I initially will think about, what’s your sleep schedule look like? A lot of times people will have either disturbing dreams, vivid dreams, they’ll just feel like their sleep’s not that restorative. If they haven’t been keeping any sort of a routine sleep wake schedule. 

So, sleep hygiene actually is something that can help some people when they have nightmares. Making sure, A, you’re getting enough sleep because if you have nights where you actually are sleep deprived and then you try to sleep more, guess what, that can lead to a nightmare on that rebound night because your brain is going into what we call REM rebound.

So your brain is craving REM sleep, which is when we tend to have the most dreams. You can have nightmares in any stage, but we tend to have a lot of them in that REM sleep. So that’s one thing to think about is consistency of your sleep wake timing and getting enough sleep routinely. Then there’s other things that are very common that can cause nightmares for some people.

This could be things like alcohol use. Alcohol can create nightmares for some people for sure. certain substances you might be using. So it could be smoking, nicotine. I mean, it really varies, but alcohol is definitely the biggest one that I see causing nightmares for people. 

Other thing that we don’t always think about is sleep apnea. So if you are someone who is snoring, having pauses in your breathing at night, You might feel like your sleep is non restorative. Nightmares actually can be pretty common in some people with sleep apnea because you’re having essentially very fragmented sleep. So people will report having nightmares during times of apnea and then when people start treating their apnea they might have a heightened amount of vivid dreams or nightmares at the beginning but that usually, just so you know, usually tends to peter off after a few days. So stick with it. It’s just your brain’s way of kind of getting more REM sleep, doing what it needs to do before it starts to even out. 

Another thing that we think about, so we have the sleep wake timing, sleep hygiene stuff, other sleep disorders like sleep apnea can lead to nightmares. We also see nightmares sometimes in patients with narcolepsy. So in narcolepsy, vivid dreaming is very common. We call it intrusion of REM sleep. They might have episodes of hallucinations around sleep, more dreaming during nap times. Those are all actual REM episodes. So your brain is going into REM sleep at times when you are awake or about to fall asleep. So we see there’s a lot more REM in patients with narcolepsy. There’s a lot of vivid dreaming. Sometimes patients will have more nightmares. And I know that there’s people doing research in this area of nightmare and narcolepsy specifically right now, which is wonderful. 

Another thing that we think about that’s very common that can cause nightmares are certain medications. Over the counter medications, the biggest, biggest culprit that I see day in and day out in my practice is melatonin. The thing that people tout as being the cure all for sleep problems. It’s great for certain things, but not everything. And believe it or not, if someone comes to me with insomnia and they are taking melatonin and they’re like oh yeah I have nightmares too which is impacting my sleep, I say stop the melatonin. Just stop it. Because melatonin can lead to more nightmares and believe it or not many people, when they stop the melatonin, they don’t have vivid dreaming or nightmares anymore. So that’s one that doesn’t get spoken about as much but it is a really common issue. And then there are other medications that can cause more nightmares.

So antidepressants can definitely cause nightmares in some people. Certain blood pressure medications and even certain drugs for like Parkinson’s can cause nightmares in some people. So you really want to just keep an eye on that. Look at the side effects, talk with your doctor about the risks and benefits because I don’t want you just stopping your medications.

Melatonin is one though, most people are taking such a low dose that you can just stop that, always talk to your doctor. But melatonin, if you’re having nightmares, you probably just don’t need to be taking it. But the other things definitely have that risk and benefit discussion with your doctor. 

So we’re talking about working on nightmares, right? So what does that mean? What are the different treatment options that we have for nightmares? The reality is, even though most people think that there’s nothing you can do outside of sleep medicine, we actually do have some solid treatment options. 

So the first one that is near and dear to my heart, because this is what I do day in day out, is called Imagery Rehearsal Therapy, or IRT. And what IRT is, it’s essentially changing the dream or the narrative of the nightmare that you’re having, so you’re re scripting it. And it’s something that many of us did as kids, naturally, but as we become adults we think this is the dumbest thing ever and we never think to do it. 

What it is, if you think about nightmares at night, or dreams even, It’s really, it’s imagery that’s happening in your brain at night, so it’s imagery, right? And it’s similar to brain pathways. It’s similar to what your brain pathways are using for daytime imagery, for daytime visualization. So like closing your eyes and picturing your favorite food or yourself on a beach. That kind of visualization is using the same parts of the brain as dreams and nightmares at night.

So what we’re trying to do is give you some control through imagery to change the narrative of the nightmare. Because the one thing that I hear from patients all the time who have nightmares is they say, every night feels like a broken record. And that’s so true. Especially for people who have recurrent nightmares, a similar nightmare, night in and night out essentially.

So what this does is it gives them a feeling of control over that broken record. Because really what happens is when your brain initially has some sort of event that starts a nightmare, it’s almost like you’re waking up from it. So your brain’s not able to make that file of what happens if, you know, this, this event happens, how do I deal with it?

It’s not making that file because you wake up. So what your brain’s trying to do every night is, oh, here we go again. Even if it’s a different kind of flavor of a nightmare, here we go again. Here we go again. Because it’s trying to make the file to file it away. So it’s really an idea of breaking that learned habit that your brain just keeps going in that manner, essentially every single night.

So what do we do? You take the narrative of whatever that nightmare is. Now, if you’re someone who has many different nightmares over the course of weeks, months, years, you’ve just had them for your whole life, whatever it might be. You pick one that you’ve had more recently that was lower on the like, kind of really scary level.

So you want to think about it as a ladder. This is what we do in CBT all the time. When we think about exposure therapy, all these things, we start with things that are less fear inducing for us. So start with something lower. And then what you will do is you take that dream, or that nightmare, and you change it any way you want.

So a piece of it, the whole thing, so it’s not scary to you anymore. And then you practice it, visualizing it in your brain during the day or evening. That’s the key. You’re literally doing it during the day. It’s not a nighttime like lucid dreaming kind of thing. You’re doing this during the day. And you practice that new narrative and you practice seeing it in your head, your mind’s eye, you paint a picture of it, that storyline so it is so vivid that you can see the narrative of the story happening with the changes in it. You could change a tiny piece, the whole thing, it does not matter. You could change it again the next day if you didn’t like the one you had first. 

Here’s two examples I’m going to give you. So the first example is an adult patient that I had many, many years ago. And she was someone who just had frequent nightmares, but they weren’t always the same in quality. So they were always a little different, no trauma, nothing like that. So she wasn’t having any recurrent nightmares of re experiencing anything. But I said to her, I said, we’re going to do IRT. And I gave her the instructions. And the nightmare she chose was one that she’d had over the past week. And it was where she was swimming off the coast of Florida.

And while she was swimming off the coast of Florida, she all of a sudden got surrounded by sharks. And the sharks started to really, like, swim around her, and she started to drown. And then she woke up right as she was drowning. Scary. Understandable. So I said to her, okay, let’s change that nightmare any way you wish, so it’s not scary anymore.

The real instructions, change it any way you wish. And then people say, what do you mean? How is that? I don’t know what you mean. I’ll say, Just take it so it’s not scary anymore. It does not have to be a positive ending. It can be neutral too. It doesn’t have to be anything exciting, but you just change either a tiny bit or you want to change the whole thing and make yourself ski in the Alps, whatever. I don’t care. Do whatever you want. 

So the change that she made was a simple little one. She changed the sharks to dolphins. That’s it. So now she was swimming with dolphins. And then she was a little like cheeky with it and she put bow ties, red bow ties on all the dolphins. And so she was swimming with the dolphins and then so she saw herself going out swimming, like she pictured, she told me all the details. She’s off the coast of Florida swimming, dolphins come around with the bow ties, and then at the end she gets on one of their backs and then swims off. So I had her picture that every day in her brain for about five minutes, and she did it twice a day. There’s no actual real standardization with it, unfortunately, yet. And then she did it every day. And then after about five nights, I had her choose another nightmare to change. And then we did that for five days. Even if you’re having 10 different nightmares in the week, you still only pick one to work on every five days. 

Now, the one other example I’m going to give you is of a child. He was I’m trying to remember. He was probably like eight at the time. Saw him many years ago when I was at Montefiore Medical Center in the sleep lab there. He had just had a sleep study because he was falling asleep in school so often that they actually thought that he had narcolepsy. And it turns out he didn’t have narcolepsy, on the study, but they found out that he was having nightmares. So they sent him to me. And he had a nightmare that was similar in quality every single night. But the person changed. So he was always running through an alley or it was a family member, a dark alley. And there was someone who was running, and this is kind of one of the more like scary ones, like that’s stereotypical, like I said at the beginning, like someone was running after, I think it was a gun or a knife running after him. He was very fearful of sleep because of that. Understandably. 

I have kids draw out the changed dream on a piece of paper because kids are very visual and they love to draw. A lot of them. So I said to him, how would you change that nightmare any way you wish?

And what he did, it was so much easier for him to do. It was amazing to see. He said, I’m changing the location. So he made it so he was in, as he said, Hershey land, which I loved. And he was surrounded by Hershey bunnies. And what he did was he kept the scary figure in the changed dream. So the person was chasing and it was him that he was picturing.

And then what happened was he turned around, in his changed dream, turned around to look at the person chasing him and he turned to chocolate and then all the bunnies and the patient went over and just ate him. Only a kid really would come up with something like that. It’s one of my favorite examples.

So I had him draw out that narrative on a piece of paper. So for him every night he would practice that, but I had him drawing it. And adults like I said could draw too, but with kids it works really well. And then after five nights he changed a little bit more if he wanted to, but he always had similar dreams. So I just had him keep doing it. And guess what? After about three weeks, his nightmare frequency reduced significantly and the same for that adult patient as well. 

So if you notice the theme here, we’re not actually analyzing the nightmares. Right? I’m not sitting here going into what does that mean about you? What do you think these things mean? That’s a whole other type of treatment that they do in more psychoanalytic therapy. But in sleep medicine, we don’t do that. There’s really good data showing that IRT works for many people, whether they’re recurrent nightmares or not. So, IRT, in my opinion, is the way to go if you’re someone who’s having nightmares. And I’ve had a lot of patients come to me who said that they would try to analyze them and it just wasn’t working for them. IRT is a really solid option. 

And something else to think about is medication. So, certain medications might cause nightmares. One big medication that we have is something called Prazizin, which was actually an antihypertensive used for ages. It’s an old school medication. And they found that when people were taking it, some people reported less or fewer nightmares. So that’s another treatment option. It’s not a standard of care. I mean, it is kind of a standard of care, but it doesn’t tend to work long term for a lot of people. Sometimes it does, but not all the time. So we really do try to combine it with IRT, making sure you’re getting enough sleep, limiting alcohol, like that sort of stuff as well. Prazizin is definitely an option for many people. 

And then finally, if you haven’t already done it, I want you to really think about just making sure that your sleep environment is good, right?

So good sleep environment, dark, quiet, cool, comfortable. Like I said, the consistent sleep schedule, you want to avoid the stimulants if possible, like caffeine, screen time, you know, what are you watching on your phone? I mean, this is October. So are you, are you into Shocktober? Are you? So think about those things. Exercise. Avoiding large meals. 

Oh, one other thing. Some people will report that spicy foods can cause nightmares for them, too. So just keep that in mind, that is definitely a trigger for some people and then relaxing a bit before bed to kind of help wind your brain down and only really keeping the bed for sleep and sex only. That’s really the key there. 

So listeners, since we always end with something to sleep on, I’d love to leave you with one last thought to help anyone looking to change their sleep health, especially if you’re having trouble with nightmares. So like I said, if you’re having nightmares, they’re bothering you, they’re getting in the way of you being able to sleep.

Don’t just accept that it’s because you’re stressed, or because of other things going on in your life, or that, you know, it’s normal to have nightmares. If they’re really starting to impact your ability to get good quality sleep routinely, talk with your doctor. And if your doctor says, eh, there’s nothing you can do about it, go to a sleep specialist who actually does treat nightmares.

Don’t take this as normal for an answer. If you’ve tried the basic sleep hygiene stuff, getting enough sleep, if you’ve been doing that for about two weeks, and nothing is improving, then talk with your doctor for sure.

Thanks for listening to Sleep Talking with Dr. Shelby, a Sleepopolis original podcast. Remember, if you’re tired of hitting snooze, hit subscribe or follow right now on YouTube, Apple Podcasts, Spotify, or wherever you’re listening. And for even more sleep tips, visit sleepopolis.com and my Instagram page, @sleepdocshelby.

Today’s episode was produced by Ready Freddie Media. Our Senior Director of Content is Alanna Nuñez. Our head of content is Molly Stout and I’m Dr. Shelby Harris. Until next time, sleep well.