Dreams and nightmares: Clinical aspects, management, and links to psychiatric disorders

BACKGROUND: Nightmare complaints are common among individuals with psychiatric disorders and are associated with significant emotional distress and functional impairment. Despite their clinical relevance, they remain frequently under-recognized and under-treated in psychiatric settings. OBJECTIVE: To offer a pragmatic, clinician-oriented framework for the evaluation and management of nightmare complaints within psychiatric practice. METHODS: This narrative synthesis draws from epidemiological, clinical, and translational research, with a focus on: (i) the relationship between nightmares and psychiatric disorders; (ii) a structured diagnostic approach tailored to cases involving psychiatric comorbidity; (iii) current treatment strategies, both pharmacological and non-pharmacological, emphasizing approaches adapted to comorbid psychiatric conditions. RESULTS: Nightmares affect an estimated 34-70% of individuals with psychiatric disorders and are linked to more severe psychopathology, including heightened depressive symptoms and suicidal ideation. Notably, nightmares are independently associated with increased suicide risk, regardless of the underlying diagnosis, underscoring the need to include them in suicide risk assessments. A four-step diagnostic care algorithm is proposed: Differentiating Nightmare Disorder from isolated nightmares; Assessing the four core dimensions of the disorder; Considering differential diagnoses; Identifying predisposing, precipitating, comorbid, and perpetuating factors, particularly psychiatric in nature. Effective treatment should address both the nightmare symptoms and any underlying or comorbid psychiatric or medical conditions. In cases where nightmares co-occur with psychiatric disorders, clinicians should first evaluate whether the primary condition is destabilized and optimize its management. Comorbidities that may sustain nightmares must also be identified and treated. Imagery Rehearsal Therapy (IRT) currently stands as the first-line treatment for Nightmare Disorder. However, while initial findings are promising, especially in comorbid contexts, more targeted and personalized therapeutic strategies are needed. Future research should aim to refine interventions based on comorbidity profiles and further delineate idiopathic versus comorbid nightmare disorders. CONCLUSIONS: Nightmares, frequently neglected in psychiatric care, demand systematic assessment and individualized treatment strategies, particularly when occurring alongside psychiatric disorders, to reduce emotional suffering and improve clinical outcomes.