Med thumb shadowy image

You can be diagnosed with apnea, restless legs, insomnia and exploding head syndrome, but rarely, if ever, will you hear a doctor say, “It appears you suffer from nightmares.”

While they serve a purpose, the horror movies that play out in our heads contribute to stress, sleep deprivation and a host of lingering issues. And so doctors argue that they demand to be recognized as more than a secondary disorder. 

One of these main proponensts is Dr. Barry Krakow, the medical director of both the Maimonides Sleep Arts & Sciences, Ltd. and the Sleep & Human Health Institute in New Mexico. Dr. Krakow has been diagnosing nightmares for 25 years and says they deserve to be recognized as a medical disorder, one that shouldn't take a back seat to the other psychological issues with which they're often associated.

“Most people in the field of mental health think nightmares must be secondary to the primary disorder,” Krakow says. “In other words, for them it’s the nightmares plus the PTSD, the nightmares plus the grief reaction, the nightmares plus anxiety or depression.”

When Dr. Krakow deals with nightmare-sufferers, he speaks to them about their symptoms, determines the severity and comes up with a prescribed treatment in the same manner a doctor would diagnose another illness. This is something he believes most sleep clinics are not equipped to do ("they don't often have psychologists or psychiatrists on staff") and nightmares are so briskly spoken of that patients don't often think to bring them up as a cause for concern or ever learn that there are treatments available. 

“People have all these incredible myths about nightmares,” he says. “Most people know so little about nightmares that it never occurs to them there’s a treatment for them.”

One of the availble treatments Krakow recommends is Imagery Rehearsal Therapy (IRT), a visualization therapy he pioneered that helps patients adjust the content of their nightmares. The three-step process includes writing down the dream, visualizing a more positive outcome of it, and setting aside time every day to think about the new version.  Another treatment is the drug Prazosin. It's a norepinephrine antagonist that reduces overactive neural stress response and is often prescribed to PTSD sufferers. But it's often helpful in lessening the severity of nightmares. However, as with many medications, one side effect is dependency. "One problem is that nightmares often come back when you stop the medication," says Krakow. But, he notes, it's still a viable option for severe cases, an option many don't know about.

Krakow is not alone in his stance. Chad Ruoff, clinicial assistant professor at the Stanford Center for Sleep Sciences and Medicine, supports available treatments and agrees that nightmares deserve to be diagnosed independently, as long as the patient is evaluated by a doctor with a knowledge of bad dreams.

"There is evidence that nightmares place individuals at increased risk for suicide," said Ruoff. "So I do think that nightmares warrant significant attention, or at least more so than what we have been giving them."

And although psychotherapist Jason Durant doesn't use any of the treatment therapies for his patients suffering from nightmares (he works from a psychodynamic perspective), he can see their benefit.

"These treatments, in consultation with a licensed medical professional, are likely to be a fairly robust approach that leads to both symptom reduction and a better understanding of one's inner emotional life and relational patterns, which is the hallmark of the psychodynamic approach," he says.

It's refreshing to know many doctors are for these treatments, and that when your pysche goes bump in the night, there are a number of therapies that bump back. But until our bad dreams are seen as a big picture problem, many needy candidates won't know to seek them out.