An Expert Consensus Statement for Implementing Cognitive Behavioral Therapy for Nightmares in Adults

Nightmare disorder affects approximately 5% of adults in the general population, with higher rates among trauma-exposed individuals and those with PTSD. Multiple cognitive behavioral interventions for nightmares have demonstrated efficacy, but variability and overlap in treatment protocols, names, and components hinder comparison and training. The American Academy of Sleep Medicine (AASM) 2018 position paper summarized behavioral treatments but did not differentiate components, contributing to confusion. To address this, the authors propose the umbrella term “Cognitive Behavioral Therapy for Nightmares (CBT-N)” for multi-component treatments, analogous to CBT-I. The expert panel’s key question was: Given available evidence and descriptions of treatment components in manuals used in RCTs, what are the recommended components of CBT-N? The goal is to standardize implementation, terminology, and training for adult nightmare treatment.

The paper reviews epidemiology and prior intervention research, noting nightmare prevalence of 30% among trauma-exposed civilians and 30–40% in military personnel, and 50–70% among post-9/11 service members with PTSD. Prior RCTs and meta-analyses (e.g., Casement & Swanson, 2012) included diverse protocols with overlapping components: ERRT, various forms of Imagery Rehearsal Therapy (IRT/IR), Imagery Rescripting Exposure Therapy (IRET), Sleep Intervention for PTSD, Sleep Dynamic Therapy, and others. The AASM (2018) recommended IRT and listed several other behavioral approaches but did not delineate component-level differences. Manuals varied in their use of exposure to original nightmare content, relaxation training, CBT-I elements (stimulus control, sleep hygiene, sleep restriction), and rescripting practices. Evidence generally shows that imagery-based and exposure-based approaches improve nightmares, PTSD symptoms, and insomnia, though head-to-head mechanistic trials often find no significant differences between active treatments, possibly due to limited power.

A multidisciplinary expert panel (behavioral sleep medicine, trauma-related and idiopathic nightmares, insomnia, trauma, dissemination/implementation, and RCT experience) met three times (twice in 2021, once in 2022) to develop consensus recommendations supporting a DoD-funded web-based provider training for CBT-N (W81XWH-21-1-0576). The panel conducted content analysis of representative manuals tested in adult RCTs: Imagery Rehearsal Therapy (Krakow et al.), Imagery Rehearsal + CBT-I (Harb et al.), Exposure, Relaxation, and Rescripting Therapy (ERRT), ERRT-Military (ERRT-M), CBT-I & Nightmares (CBT-I&N), and Sleep Intervention for PTSD (SIP). The team also systematically identified RCTs via PubMed and PsycINFO using combinations of “nightmare treatment,” “nightmare psychotherapy,” and “randomized controlled trial,” applying inclusion criteria: adult samples (≥18), nightmares in inclusion criteria, at least one full-package cognitive behavioral approach, statistically significant nightmare outcomes, and clinical-provider-delivered protocols (excluding self-help). The panel synthesized evidence and clinical experience to define recommended CBT-N components, indications, and implementation guidance, culminating in a consensus manual structure.

Consensus recommendations include: - Session structure: Optimal dose undetermined; session length should fit clinical setting. The consensus manual suggests six 50–60-minute sessions, with guidance for 30- or 90-minute alternatives. - Indication (DARC): Appropriate for individuals with Dreams causing Awakenings, at least partially Remembered, and causing Clinically significant impairment. Nightmares are distinguished from anxiety dreams (no awakenings), night terrors (not remembered), and nocturnal panic attacks (not dream-triggered). - Cultural considerations: Dream meanings vary across cultures; exposure or rescripting may be contraindicated if inconsistent with patient values; consult spiritual/community leaders as appropriate. - Trauma-related vs idiopathic: Use the same procedures for both; consider additional trauma-focused psychoeducation for trauma-exposed patients. - Essential components: Relaxation training and grounding; CBT-I elements focusing on stimulus control and sleep hygiene are recommended given strong theoretical and empirical support and the high co-occurrence of insomnia and nightmares. - Optional components: Sleep efficiency training/sleep restriction may be considered for trained providers when low sleep efficiency and excessive time in bed are present; may be contraindicated if the sleep window is already restricted due to nightmare avoidance. - Exposure to original nightmare content: Consider as an initial course to leverage a potent approach; conduct in-session written detailed exposure (first person, present tense) and reading aloud when appropriate. Exposure is beneficial but not mandatory; minimal exposure may be used for idiopathic nightmares, limited time, or persistent patient refusal. - Target selection: Encourage starting with the most distressing, vivid, frequent, or trauma-related nightmare to maximize benefit, reduce avoidance, and facilitate generalization. - Nightmare rescription: Identify and address themes (safety, trust, power/control, esteem, intimacy). Write a linked, changed dream script in first person, present tense with sensory details and emotions; aim for a dream the patient would prefer to have (not merely a less severe nightmare). Provide opportunities to target additional nightmares. - Imagery rehearsal of rescripted dream: Recommend approximately 10 minutes nightly rehearsal of the rescription, followed by relaxation before bed; practice in-session to troubleshoot barriers; daytime practice encouraged; optimal dose remains an open question. - Comorbid PTSD: Insufficient evidence to dictate sequencing; both PTSD-focused treatments and CBT-N can improve symptoms; shared decision-making is recommended considering pros/cons of treating PTSD or sleep first. Selected prevalence data: General adult nightmare disorder ~5%; trauma-exposed civilians ~30%; active-duty military/National Guard ~30–40%; civilians with PTSD ~57%; Vietnam-era combat veterans with PTSD ~52%; post-9/11 service members with PTSD ~50–70%.

The panel’s consensus addresses the central question of standardizing CBT-N by defining indications, core and optional components, and implementation guidance across settings and populations. Clarifying exposure, rescription, imagery rehearsal, and CBT-I elements reduces confusion stemming from heterogeneous protocols and nomenclature, thereby facilitating training, dissemination, and research comparability. The recommendations aim to improve clinical uptake and patient outcomes while acknowledging patient preferences, cultural contexts, and comorbidities. The consensus manual and web-based training provide practical frameworks for clinicians, likely enhancing access to evidence-informed care and enabling future studies to build on standardized component definitions.

This expert consensus provides a standardized framework for implementing CBT-N in adults, including clear indications (DARC), core components (relaxation, stimulus control, sleep hygiene, exposure, rescription, imagery rehearsal), and optional elements (sleep efficiency training). The guidance supports both idiopathic and trauma-related nightmares, integrates cultural considerations, and offers practical session outlines. By promoting consistency, the manual and training are expected to improve dissemination and advance research. Future directions include optimizing approaches for idiopathic vs trauma-related nightmares, managing comorbid conditions (insomnia, PTSD, sleep apnea), refining training and consultation strategies, adapting CBT-N to diverse settings, elucidating mechanisms, comparing with or combining medications, determining imagery rehearsal dose, guiding target selection among multiple nightmares, and evaluating efficacy across cultures and special populations (e.g., aphantasia).

The review did not include all nightmare treatment protocols (e.g., lucid dreaming, systematic desensitization, self-management). The expert panel was not exhaustive and recommendations may not reflect all expert views. Component necessity has not been tested via dismantling studies, and outcomes of the consensus protocol are not yet known. Research on children and adolescents was not covered; although cognitive behavioral approaches appear promising, more evidence is needed.