When Should You See a Doctor About Nightmares?
Every few months, I have a nightmare that jolts me out of sleep. I’m usually breathing heavily, covered in sweat, and convinced that I really was just racing through a post-apocalyptic landscape, or battling a shark, or trying to scream for help in a burning house. Once my heart has slowed down and I’ve had a glass of water, I’m usually able to fall asleep again.
But what happens when your nightmares are more than just an occasional annoyance and actually interfere with your day-to-day life in some way? Here’s what you need to know about when nightmares are actually a problem—and what you can do about them.
What’s really happening when you have a dream or a nightmare, anyway?
Each night, you cycle through different sleep stages (1, 2, 3, 4, and rapid eye movement [REM]). Some schools of thought combine the third and fourth phases for four stages total, but the point is that you journey through different modes of sleep a few times every night.
REM sleep, which is when most of your dreaming occurs, usually begins for the first time around 90 minutes after you’ve dozed off, according to the National Institute of Neurological Disorders and Stroke (NINDS). During this time, your eyes start to move quickly from side to side, and your breathing, heart rate, and blood pressure increase. Your brain wave activity is most similar to its daytime state during REM sleep than in any other phase. This heightened brain activity contributes to dreaming. As a safety measure so you don’t react to the vision playing out in your head, your body essentially paralyzes your major muscle groups as you dream, the Cleveland Clinic explains.
As you’ve probably experienced, sometimes during a nightmare you’ll scare yourself awake, gasping for breath, heart pounding. That’s because when you encounter something stressful, your body primes you to respond by releasing hormones like norepinephrine. This induces physiological changes like quicker blood flow and faster breathing to help you better escape a threat (even if said threat is something your brain conjures as you sleep).
If you feel like you’re having nightmares often—or if they’re really affecting you—you should see a doctor for help.
Michael Nadorff, Ph.D., an assistant professor of psychology at Mississippi State University who researches sleep disorders, tells SELF that having a nightmare about once a week may be a sign to talk to a doctor about it, but it really depends on the person. “We often think about frequency, but severity is just as important,” he says.
Of course, having a nightmare is unpleasant no matter what. But if bad dreams truly start to bother you, either by interrupting your sleep to the point where you don’t feel rested, or by emotionally disturbing you so much that you continue thinking about them the next day and beyond, you should seek help, Barry Krakow M.D., a sleep specialist and founder of Maimonides International Nightmare Treatment Center, tells SELF. Having frequent nightmares that cause major distress, anxiety around sleeping, fatigue, and problems concentrating during the day can indicate nightmare disorder, which is when your bad dreams are happening often or severely enough to affect your life.
There are various reasons you might experience harrowing nightmares, including some expected culprits like stress and anxiety.
There’s a lot experts still don’t know about why we dream and where the contents of our dreams come from, but there are a few different theories about what causes regular or problematic nightmares.
Dr. Nadorff says that for many people, anxiety and stress play a role. He subscribes to the activation-synthesis hypothesis of dreaming, which is basically the idea that you dream when your brain is encoding the day into your memory. Think of it as your brain replaying moments and downloading them onto your memory’s “hard drive.” This theory holds that, if you’ve experienced anxiety or stress during the day, it can show up in your dreams as your brain reviews the day’s events, Dr. Nadorff explains.
Another cause of repeated nightmares is post-traumatic stress disorder (PTSD), an anxiety disorder that you can develop after witnessing or experiencing trauma. The Cleveland Clinic reports that around 7 to 8 percent of people in the United States will have PTSD at some point in their lives, and common symptoms include flashbacks, intrusive memories of the event, feeling jittery and on-edge, and having nightmares about the trauma.
There are also some fascinating, less obvious theories about where nightmares originate, like that they’re linked with sleep apnea and insomnia.
Dr. Krakow recently published a paper in the International Journal of Adolescent Medicine and Health that explored the potential connection between nightmares, sleep-related breathing problems like sleep apnea, and insomnia. “We named this the nightmare triad syndrome,” he says. The idea is that these three issues are more likely to appear as a cluster than many people realize, he explains.
Experts don’t yet have total clarity on how the three conditions are connected, Dr. Krakow says. One idea is that drops in oxygen caused by sleep apnea—a disorder that stops and restarts your breathing during sleep—may make people feel like they are choking. This can cause a fear response that triggers bad dreams, he explains. “You will often have nightmare patients tell you they are struggling to breathe,” Dr. Krakow says. “What if that’s not actually due to fear [from a nightmare], but because you are actually choking?”
Another notion is that, since sleep apnea can wake you up often during the night (which is a form of insomnia), it can jolt you out of REM sleep abruptly. This could possibly make it more likely you’ll remember what you were just dreaming, including if it was a nightmare.
Finally, nightmares can also be a side effect from a medication.
Certain drugs classes are known to induce nightmares in some people, according to the Mayo Clinic. Take antidepressants, for example. Much like anxiety and stress, depression might influence your dreams, taking them into a more emotionally negative territory. And, depending on the type of drug you choose, it can feel like antidepressants intensify this effect.
A 2013 review of literature in Sleep Medicine Reviews looked at 21 studies and 25 case reports, finding that people taking antidepressants were more likely to remember their dreams. This could be because some antidepressants suppress your REM sleep, making you more likely to wake up (and possibly recall any dreams you do have), although experts don’t know for sure.
Either way, keep in mind that there are many antidepressants out there, and side effects can vary in different people. Talk to your doctor if you’re concerned about how your dreams might change with antidepressant use.
If your nightmares are due to an underlying condition or medication, your doctor will probably start treatment there.
If you’re dealing with anxiety or PTSD, your doctor may recommend psychotherapy like cognitive behavioral therapy (CBT), which helps change negative thought patterns. You could also be a good candidate for antidepressants or anti-anxiety drugs. If stress is your issue, your physician can talk you through some stress management options like meditation or any recommended lifestyle changes. There are lots of options out there for treating all of these conditions, so don’t hesitate to talk to your doctor.
In the event that your nightmares could be linked to sleep apnea and related insomnia, addressing that will likely be your first step. To diagnose sleep apnea, a doctor would speak to you about any symptoms like excessive daytime sleepiness, snoring, waking up choking or gasping, or waking up with a dry mouth or headache, according to the Mayo Clinic. They may have you undergo a sleep study, where you go to sleep in a lab while connected to various machines measuring your brain activity, breathing, and oxygen levels. Treatments for sleep apnea include wearing a positive airway pressure machine while you sleep, wearing a mouthpiece that helps keep your throat open, or in some cases having surgery to remove excess tissue from your airways.
When it comes to medication-induced nightmares, you and your doctor may decide to tweak or switch your prescription—but never make any changes to your medications without a physician’s go-ahead.
There are also potential treatment methods for the nightmares themselves if it seems like you don’t have any major underlying condition that is causing them.
Both Dr. Nadorff and Dr. Krakow practice imagery rehearsal therapy (IRT), which is a cognitive behavioral treatment.
“We have the person take their nightmare, and we restructure it any way they want so it won’t be frightening,” Dr. Nadorff says. “They can change who is in it, or what’s happening, or give themselves superpowers—it’s a dream, after all. Then you practice that dream using visual imagery a couple of times each day.” Dr. Nadorff says that, in his experience, patients often either stop having their old nightmare or start having the new, reimagined dream after one to three sessions of IRT. (Results can vary, of course.) He says that this therapy has the potential to work on both recurring nightmares and on seemingly random ones, because even those will typically have a common thread that you can tackle.
Finally, physicians may prescribe a medication like prazosin to treat nightmares, although its efficacy for this is still up in the air. Prazosin is actually an antihypertensive medication, but some doctors use it off-label for nightmares. In theory, it works by blocking your responsiveness to norepinephrine, that neurotransmitter that apparently plays a role in inducing nightmares.
Bottom line: You should look forward to sleep for its restorative powers, or at the very least, not fear it. If nightmares are messing with your sleep (and life), talk to a doctor.
Getting adequate sleep is incredibly important, and anything that interferes with that process can make you pretty miserable. If you find that you have bad dreams that bother you, chat with your doctor about what’s happening and your options for fixing it. Sleep is best when you wake up in the morning re-energized—not when you pop up in the middle of the night convinced you’re under zombie attack.
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