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If a patient is taking nightmare medication but continues to have dreams that cause awakenings that they can remember and that cause clinically significant distress, then CBT-N is still appropriate. If the patient has the goal of going of nightmare medications, engage in shared decision making around if the patient will start that process with their prescriber before, during, or after CBT-N. 

Yes! As part of this consultation, we are offering the option to achieve provider status in CBT for Nightmares. Provider status requirements include:

1. Complete training

2. Attend and actively participate in a minimum of 10 calls

3. Complete to treatment fidelity a minimum of 3 individual cases, 2 groups, or a combination of both

4. A part of each main component of treatment (e.g., sleep habit review, introducing theories of nightmares, exposure, rescripting, and relaxation training must be demonstrated on a recording in order of the consultant to determine that you have mastered the skill.

Nightmares can be caused by substances and medications. The most commonly reported substance that is associated with nightmares in alcohol but nightmares can also be seen with benzodiazepines, especially when an individual stops using them and they can have a rebound in REM sleep. Some of the most common medications associated with nightmares include antidepressants (e.g., bupropion, selective serotonin reuptake inhibitors (SSRIs), selective norepinephrine reuptake inhibitors and tricyclic antidepressants), anti-hypertensive medications (e.g.,propranolol, metoprolol and verapamil); acetylcholinesterase inhibitors used for treating patients with Alzheimers or dementia (e.g. donepezil and rivastigmine), dopaminergic medications (e.g., levodopa, pramipexole, ropinirole and selegiline which are used in patients with Parkinson’s disease and antimicrobials (e.g., ciprofloxacin, erythromycin, ganciclovir and mefloquine).  

It's always a good idea to encourage our clients to speak with their prescribing provider about their medication concerns as this is outside the scope of practice for the majority of mental health professionals. It may be helpful to ask the client to complete a release of information that will enable collaboration of care.

Physical or ability differences may require adjustments in which an audio recorder is used, the provider or a support person assists in the writing activities.  Use of large print materials or a support person may help with eyesight differences.  Mobility differences may require modifications of stimulus control instructions.

It depends. Shared decision between the clinician and client is key in this situation. Focusing treatment on the client's most pressing concern will likely result in increased client motivation and engagement.

Medications can be helpful for some individuals in reducing the frequency of nightmares or reducing the memory of having nightmares; however, nightmares may return if medications are discontinued. Cognitive behavioral approaches typically result in significant reduction of the frequency and intensity of nightmares for many people.  Improvements in other symptoms [e.g., PTSD, depression, anxiety, sleep quality] are also common following cognitive behavioral approaches.

Individuals with a history of TBI may benefit from increased interaction with the manual [e.g., reading through session materials between sessions] as well as "teach back" techniques in which the provider asks questions throughout the session and the client states the material in their own words.

Shared decision making can be important in this conversation in order to problemsolve while also incorporating the patient's indivudal values and preferences. For example, is it possible for the bed partner to relocate to another room while the patient engages in nightmare treatment? 

Research shows that repeated exposure to the nightmare is not needed in order for individuals to experience a decrease the frequency and intensity of nightmares. 

If the client perpetrated an action in the course of the trauma, no changes are required to the treatment as the focus is on the nightmares, not the trauma.  If the client is a perpetrator in the nightmare, the process of the written exposure and rescription is the same.

Remind the client that nightmare exposure, rescription, even nightmare treatment in general is not trauma treatment. The rescription is to modify the nightmare, not the trauma event. Trauma treatment is available and should be discussed with clients if applicable.

Yes! CBTn is not contraindicated for patients who are at risk for suicide. Of course, suicide risk should be assessed and managed throughout any treatment (e.g., crisis response plan) and individuals at imminent risk for suicide should be linked appropriate levels of care and services. Nightmares are correlated with suicidal ideation and suicide attempts. While CBTn is not a treatment for suicide, addressing the nightmares may help to decrease the patient's distress that could be contributing to suicidal thoughts and behaviors. Of note, suicide specific treatments are available and should be offered to patients as indicated (e.g., BCBT, CBT-SP).

While wearable sleep trackers can provide insight and comfort to many people, the accuracy of the technology is still evolving.  We encourage patients to use the sleep diary and not to rely on the data provided through their wearable tracker. Additionally, if the data from the tracker is causing the patient distress (e.g., hyper focused on sleep times to the point of sleep disruption), we would encourage them to discontinue use while in treatment. 

There is no evidence to suggest that CBT-N would not be helpful or indicated for individuals who are taking medications for nightmares. Of note, if the patient at some point decides to stop taking their prescribed medication, it is not uncommon to experience a rebound effect, where the frequency and/or intensity of the nightmares worsens. Providers should discuss this with their patients and make plans to address the rebound, should it occur.

An overnight sleep study is required for a diagnosis of sleep apnea. This may be conducted in a lab or with a home sleep test. In both types of testing, a patient has their breathing evaluated for air flow, respiratory effort, heart rate and oxygen saturations. For a diagnosis of sleep apnea, a patient must stop breathing > 5 /hour. Most patients who are diagnosed with sleep apnea are prescribed a positive airway pressure machine. When the machine delivers air continuously, it’s known as a CPAP machine, while machine’s that automatically adjust to the patient’s breathing patterns are called APAP machines. For both devices, air pressure is provided to keep the airway open and prevent it from collapsing. Neither CPAP nor APAP actually breath for the patient.  

A common misconception is that sleep apnea only happens to overweight, middle-aged, and older men. While weight and male gender increase the risk for sleep apnea, men, women, and children of all shapes and sizes can have sleep apnea. Women are less likely than men to report classic symptoms of sleep apnea, such as snoring, apneas, or gasping. Instead, they may report nonspecific symptoms like headaches, fatigue, and symptoms of insomnia such as sleep disruption. Untreated sleep apnea is associated with a range of medical and mental health problems including hypertension, heart disease, depression, memory problems, and drowsiness that can increase the risk of car accidents. 

Sleep apnea can be comorbid with insomnia, nightmares, or both, especially in individuals with PTSD. The clinical picture in these patients can be quite complex. Sleep apnea therapies are very effective when used and may even reduce nightmares. However, many patients have difficulties adhering to apnea treatments for a range of reasons, including nightmares. It can be important to encourage the patient to work with their sleep clinic to overcome barriers to sleep apnea treatment adherence. In some cases, treating nightmares and insomnia may help with adherence. While you can move forward with CBT-N, patients should be aware that they may not receive the same benefit when their sleep apnea is inadequately treated.  

CBT-N can easily be implemented via telehealth, keeping in mind a few considerations. First, as with all telehealth, we want to ensure our patients are in a quiet, private space. During the nightmare exposure, we may ask the patient to remain visible so that we can monitor their presentation and engagement. We will also want to make sure the patient has access to the CBTn client workbook, sleep diary, and handouts.

There is limited research examining CBT-N among adolescents and children. However, a treatment manual has been developed and tested. 

Cromer, L., Bell, S. B., Prince, L. E., Hollman, N., El Sabbagh, E., & Buck, T. Efficacy of a telehealth cognitive behavioral therapy for improving sleep and nightmares in children aged 6-17. Frontiers in Sleep, 3, 1401023.

Stay tuned! We plan to add a module on treating nightmares in children and adolescents in 2025!

Some patient populations have difficulty with the instructions of stimulus control that require them to get out of bed when they are not sleepy or asleep during the night. For example, hospitalized inpatients, individuals with Parkinson's’ or other movement disorders, older adults, and individuals with chronic pain may struggle with these instructions or be unable to implement them. In this case, we recommend an alternative approach called “counter control,” which has the same goal and largely achieves the same effects as stimulus control.

In counter control, the patient is instructed to follow the same 15-minute rule of stimulus control. However, instead of getting out of bed after 15 minutes of wakefulness in bed, the patient instead changes the context of their in-bed experience. The goal is to remove sleep effort from the bed—that is, to stop trying to sleep. To achieve this, it is helpful to make some changes to the sleep environment and bed when counter control is being enacted. Depending on the patient’s individual limitations, this could mean switching on a dim light and sitting up against some pillows. Alternatively, a patient could move so that they are laying horizontally on the bed, or put their head at the opposite end than the one they typically use. It may be helpful to encourage the patient to think of two different “modes” that they can be in while in bed – either “sleep mode,” in which they are in their typical sleep position, with lights off, or in “wake mode” in which they change their situations and cues while in bed, and are NOT aiming to fall asleep. Though it may seem counterintuitive given what we prescribe in stimulus control to ask patients to engage in activities other than sleep and sex in the bed, considering the underlying rationale of stimulus control helps to resolve this paradox. We are helping the patient to associate certain cues (“sleep mode”) with sleep, and certain cues (“wake mode”) with wake. Just like in stimulus control, if the patient begins to feel sleepy while in “wake mode,” they should transition back to “sleep mode.” If unable to sleep while in “sleep mode,” they should again follow the 15-minute rule as many times as necessary.

The limited research on counter control suggests it may be equally or somewhat less effective compared to stimulus control. A 1979 study by Zwart and Lisman demonstrated among 47 undergraduates, stimulus control and counter control both experienced improved sleep to a similar extent. A study by Davies and Colleagues (1986) revealed 74% of individuals with sleep maintenance insomnia who were treated with counter control did significantly reduce their wake after sleep onset by an average of 30%. However, the authors note that this magnitude of effect is somewhat attenuated compared to their prior studies of stimulus control.

Ultimately, the choice of whether to use stimulus control or counter control will likely be dictated by the individual patient’s needs. If possible, we recommend starting with stimulus control given the stronger research based. However, if stimulus control is not possible with your patient, then the next best course of action is likely counter control.

Some patient populations have difficulty with the instructions of stimulus control that require them to get out of bed when they are not sleepy or asleep during the night. For example, hospitalized inpatients, individuals with Parkinson's’ or other movement disorders, older adults, and individuals with chronic pain may struggle with these instructions or be unable to implement them. In this case, we recommend an alternative approach called “counter control,” which has the same goal and largely achieves the same effects as stimulus control.

In counter control, the patient is instructed to follow the same 15-minute rule of stimulus control. However, instead of getting out of bed after 15 minutes of wakefulness in bed, the patient instead changes the context of their in-bed experience. The goal is to remove sleep effort from the bed—that is, to stop trying to sleep. To achieve this, it is helpful to make some changes to the sleep environment and bed when counter control is being enacted. Depending on the patient’s individual limitations, this could mean switching on a dim light and sitting up against some pillows. Alternatively, a patient could move so that they are laying horizontally on the bed, or put their head at the opposite end than the one they typically use. It may be helpful to encourage the patient to think of two different “modes” that they can be in while in bed – either “sleep mode,” in which they are in their typical sleep position, with lights off, or in “wake mode” in which they change their situations and cues while in bed, and are NOT aiming to fall asleep. Though it may seem counterintuitive given what we prescribe in stimulus control to ask patients to engage in activities other than sleep and sex in the bed, considering the underlying rationale of stimulus control helps to resolve this paradox. We are helping the patient to associate certain cues (“sleep mode”) with sleep, and certain cues (“wake mode”) with wake. Just like in stimulus control, if the patient begins to feel sleepy while in “wake mode,” they should transition back to “sleep mode.” If unable to sleep while in “sleep mode,” they should again follow the 15-minute rule as many times as necessary.

The limited research on counter control suggests it may be equally or somewhat less effective compared to stimulus control. A 1979 study by Zwart and Lisman demonstrated among 47 undergraduates, stimulus control and counter control both experienced improved sleep to a similar extent. A study by Davies and Colleagues (1986) revealed 74% of individuals with sleep maintenance insomnia who were treated with counter control did significantly reduce their wake after sleep onset by an average of 30%. However, the authors note that this magnitude of effect is somewhat attenuated compared to their prior studies of stimulus control.

Ultimately, the choice of whether to use stimulus control or counter control will likely be dictated by the individual patient’s needs. If possible, we recommend starting with stimulus control given the stronger research based. However, if stimulus control is not possible with your patient, then the next best course of action is likely counter control.

Yes! Use the gear icon on the bottom left of the video to change the speed of the video.

Go to the “Register” page and fill in your information. Once registered, you will be taken to the “Training” page, where you can proceed through the course at your own pace

CBTNightmaresweb and the resulting CE credits offered upon completion of the course are completely free! Simply register to get started!

6.5 Continuing Education (CE) credits for psychologists and some other allied health and mental health professionals for the completion of this training. This program is co-sponsored with The Medical University of South Carolina’s Department of Psychiatry and Behavioral Sciences Office of Continuing Education. The Medical University of South Carolina’s Department of Psychiatry and Behavioral Sciences Office of Continuing Education is approved by the American Psychological Association to sponsor continuing education for psychologists.

The Medical University of South Carolina’s Department of Psychiatry and Behavioral Sciences Office of Continuing Education maintains responsibility for this program and its content. Credit inquiries contact: psych-events@musc.edu or +1(843)792-9113.

If you are unsure if CEs co-sponsored by the American Psychological Association are acceptable for your licensure it is best to inquire with your local board as this can vary by state/territory.

Once the course has been completed and the final post-test has been passed, you will be able to print your personalized CE certificate for your records.

CBTNightmaresweb is designed to take 6.5 hours. However, it is a self-paced training and some find it takes more time and others will take less. Once you have registered, there is a "Modules" page that tells you the amount of "Required" and “Optional” times that each module (lesson) will take.

The videos are not able to be downloaded for copyright purposes, so they must be watched from the website.

If possible, trying on a different browser (e.g., Chrome instead of Safari) and/or device (e.g., laptop instead of tablet) can help resolve some issues that are occasionally experienced. If you are unable to switch or the switch does not remedy the problem please contact us via the Contact Us page or email us at cbtnightmaresweb@musc.edu. If you let us know what browser(s) and device(s) you are using we will be able to troubleshoot further.

This training was created with clinicians in mind, and we want to make sure we make it clear that it is only designed to help clinicians be minimally proficient in CBTN. True expertise requires further consultation and supervision. That being said, we have made the training freely available because we believe everyone can benefit from the concepts taught throughout the training, so please feel free to share with others who you think would find it useful.i

Actively engaging in CBT-N consultation is highly recommended! Currently, we recommend attending weekly consultation for ~ 5 months. The goal is to complete at least two cases in that timeframe. Consultation is conducted via video teleconference in a group format with 4-10 consultees who are learning to implement CBT for nightmares, CBT for insomnia, or both. Contact pruiksma@uthscsa.edu for more information about the next group. More information is also available here: https://lsom.uthscsa.edu/psychiatry/education/pruiksma/