Introduction

Sleep is a physiological process where the body and mind go into a rest mode for a brief period. During the rapid eye movement (REM) phase of the sleep cycle, some individuals may encounter distressful and terrifying dreams called nightmares. They are characterised by intense negative emotions such as fear, anxiety, or sadness, which can linger even after the dreamer has woken up. While occasional nightmares are normal, long-standing nightmares that cause major stress or impair daily functioning may indicate nightmare disorder. Statistical data shows that 3% to 7% of the general population experiences nightmares weekly. The treatment options for nightmare disorder involve both medicinal and mindfulness-based therapies, but the latter option of relaxation through a natural way is the key approach for managing nightmares.¹

Understanding Nightmare Disorder

Nightmare disorders are a series of repeated frightening dreams that generally occur once per week, or several times per week in people with psychiatric illness. They are characterised by:

• Well-remembered dreams that awaken the individual, making them fully conscious
• Unpleasant and distressed feelings causing major discomfort or impairment, including a fear of falling asleep 
• No history of substance use or medication effects
• Cannot be explained by other mental or medical conditions

The accumulated sleep deficiency due to nightmare disorders may result in signs of insomnia, fear, anxiety, anger, self-harming behaviour, violence, or even suicide.² Studies have suggested that traumatic events, mental stress in waking hours, or sleep disturbance may contribute to these disorders. Other risk factors include past trauma, high levels of stress, or a hereditary component. Nightmare disorders may occur alone or in combination with comorbid sleep and/or psychological disorders (insomnia, post-traumatic stress disorder, depression, and anxiety). The distress caused by the nightmares further aggravates mental health, creating a loop wherein the psychiatric disorders can lead to severe nightmares more frequently. As age advances, the tendency for these disorders increases in males compared to females.³  

Importance of Non-Pharmacological Interventions

While medicine-based treatment options are available for nightmare disorders, they may only provide symptomatic relief and often accompany certain side effects (memory loss, abnormal thoughts, behavioural changes, and headaches). The drug-based interventions focus only on altering brain chemicals, unlike relaxation methods, which prioritise both the brain and the body. The long-term use of sleeping pills can cause unhealthy dependence, eventually leading to reduced effectiveness over time. As soon as these drugs are discontinued, their benefits are diminished. Studies conducted in the past revealed that the results of medicines are inconsistent. On the other hand, relaxation techniques like meditation and breathing exercises offer a natural and relaxing way to cope with these disorders without any aftermath. These practices also help reduce anxiety and improve the overall sleep quality by promoting a sense of calmness and well-being.⁴

The role of mindfulness in managing nightmares

Inspired by Buddhist traditions, mindfulness refers to the awareness and acceptance of the present moment, thoughts, and feelings without judgement. Practices like meditation and breathing exercises help promote peacefulness and reduce nightmare-associated anxiety. At bedtime, mindfulness is assumed to disrupt negative cyclic thoughts and worry, reduce verbal imposition of excessive rules and regulations, and promote the disconnection necessary to fall asleep. The stages of mindfulness include:⁵

• Self-regulation of attention: focusing on present moment experiences rather than worrying about past nightmares or future sleep
• Orientation to experience: developing an attitude of openness, curiosity, and acceptance toward all experiences, even difficult ones

How often should I practise mindfulness exercises?

A recent meta-analysis showed that practising mindfulness-based exercises for 6 weeks to 2 months can drastically improve sleep quality in people with long-term insomnia or other sleep problems.⁶

Breathing exercises for relaxation

Benefits of deep breathing

Mindful breathing involves focusing one's awareness on the breath, body, and emotions. By being aware of the present moment, your perception of sleep can be changed, thus allowing you to search for solutions with a peaceful mind. Practising slow and deep breathing regularly before bedtime can help:

• Calm the body’s overactive stress response
• Helps you fall asleep faster and deeply with a more stable sleep pattern
• Boosts melatonin production, which helps induce sleep

Studies show that slower breathing (approximately 6 breaths per minute) optimises heart-lung coordination and increases the activity of the parasympathetic nervous system, the part of the body that helps you relax.

Techniques to try

4-7-8 Breathing

Based on the ancient yogic practice called pranayama, the 4-7-8 method helps reduce anxiety and make it easier for you to fall asleep.⁷ In this approach, 

• Lie down flat on your back in a calm and silent room
• Close your eyes gently and stretch out your arms and legs comfortably
• Breathe out completely through your mouth, making a soft "whooshing" sound
• Close your lips and inhale silently through your nose while counting 1 to 4 in your mind
• Hold your breath for a count of 7
• Breathe out again through your mouth with a "whooshing" sound while counting 1 to 8

This technique is particularly effective when practised 30 minutes before bedtime to prepare your brain and body for sleep.

Box breathing

Box breathing, also known as tactical breathing, can be practised by following a simple four-step pattern wherein the duration of inhaling, holding the breath, exhaling, and holding again is all equal. It can be done before, during, and/or after stressful experiences and does not necessarily require a calm environment. Thus, box breathing is helpful when waking from a nightmare, as it can help lower arousal and promote restful sleep. A typical box breathing cycle involves:^8,9

• Inhale for a count of 4 seconds
• Hold your breath for 4 seconds
• Exhale for 4 seconds
• Hold your breath again for 4 seconds

Note: The length of the steps can be adjusted to accommodate the individual (e.g., 2 seconds instead of 4 seconds for each step).

Diaphragmatic (belly) breathing

This slow and deep breathing technique is based on the fact that harmony between mind and body produces a feeling of calmness and relaxation. In this method, the internal organs near the abdomen are massaged, which stimulates the vagus nerve that helps improve sleep and reduce insomnia. Studies have found that diaphragmatic breathing boosts subjective sleep quality and duration by reducing the levels of anxiety, depression, and stress.¹⁰ The steps in diaphragmatic breathing include:

• Beginning (5 minutes): lie down (place one hand on your abdomen and one hand on your upper chest) or sit comfortably (rest your arms on the side), relax your shoulders, and close your eyes. This will boost your focus on the present
• Abdominal breathing (20 minutes): Inhale 8-10 breaths per minute deeply through your nose and exhale via your mouth. While breathing in, contract your diaphragm, relax your abdominal muscles, and let your belly bulge. When breathing out, relax the diaphragm, contract your abdominal muscles, and pull the belly inwards
• Ending (5 minutes): Keep your eyes closed and body relaxed, and focus on the current feelings

Meditation Practices for Better Sleep

Meditation is an ancient mindfulness practice that stems from Eastern ideology, where they believed that "Sukh" or happiness can be achieved by accepting reality (impermanent nature of things) as it is, with a focus on the present. 

Benefits of meditation in nightmare disorders 

In nightmare disorders, meditation induces sleep by helping with several mental and emotional factors. Meditation practices have been shown to reduce overthinking, dilute emotional reactions, and enhance melatonin levels, which makes it easier to fall and stay asleep. Studies reveal that mindfulness may improve sleep via reductions of both primary arousal (mental activity directly related to the inability to sleep) and secondary arousal (thoughts that create a mental bias, where you become overly aware of sleep-related problems, leading to even more difficulty falling asleep). Moreover, it has also been suggested that after only one week of meditation, anxiety and depression scores decrease, and dream imagery changes.¹¹

Types of Meditation

Guided Meditation

Guided meditation involves listening to either a live instructor or an audio recording. These can help you relax by walking you through calming scenarios, such as serene nature scenes or comforting thoughts. You just follow their voice, which takes the pressure off having to “do it right”. A guided meditation is done through these simple steps:

• Find a quiet space and sit or lie down comfortably
• Use a meditation app or online audio/video designed for sleep
• Close your eyes and listen to the voice guiding you
• Let your mind follow the instructions without judgment

This method encourages emotional safety and relaxation, thus reducing the chance of nightmares.

Body Scan Meditation

It is a body-focused meditation method in which you pay attention to how your body feels emotionally and physically and accept it without judgment. This method involves:

• Lying down 
• Directing your awareness slowly from head to toes, covering all areas of your body
• Instead of analysing or judging, simply observe 

The aim is to minimise your physical and mental sensations, which can further reduce anxiety and allow you to relax for sleep. However, if your mind gets distracted, gently bring back the focus to the sensations happening in the moment. Research suggests that body scan meditation mainly improves sleep problems during sleep, like waking up at night or poor sleep quality.^12,13

Loving-Kindness Meditation (LKM)

Where other meditation techniques encourage non-judgemental awareness of experiences, LKM focuses awareness on a mental state of acceptance of self and others, and the intention (motivation) toward wellbeing and happiness of self and all others, with equanimity. This exercise can be practised anytime and in different postures (sitting, lying, or walking). LKM has the potential to reduce depressive symptoms like sadness, lack of pleasure, changes in eating and sleeping, feelings of meaninglessness, and even suicidal intentions.^14,15 

Creating a Nighttime Routine

Studies have concluded that establishing a bedtime routine is associated with improved sleep outcomes.¹⁶ Some routines that can be implemented include:

• Consistent sleep schedule: get up at the same time every day
• Set a bedtime: early enough for you to get at least 7 hours of sleep
• Quiet and relaxing environment:  a cool and comfortable room 
• Bright light: limit exposure before bedtime (evenings)
• Mindfulness and relaxation: exercises like meditation, which enhance melatonin levels to improve sleep quality, and breathing help reduce the frequency of nightmare disorders.
• Electronic devices: turn off at least 30 minutes before going to bed
• Avoid heavy meals: don’t eat a large meal before bedtime, as it may result in heartburn and disrupted sleep
• Avoid stimulants: caffeine (if taken within 6 hours of bedtime) and alcohol (increasing awakenings) can cause sleep disturbances

When to Seek Professional Help

You should consider seeking professional help if you experience any of the following:¹⁷

• Significant distress or impairment: nightmares that are hampering your daily routine (social interactions, work performance, or other important areas of functioning)
• Frequency: persisting for once a week to 6 months or longer
  Associated mental health symptoms: such as distress, anxiety, depression, and even suicidal thoughts or behaviours 
• Daytime disability: tiredness upon waking, daytime sleepiness, lack of energy, irritability, concentration difficulties, or worries about sleep due to nightmares
• Co-occurring psychiatric disorders: such as PTSD and anxiety disorders

Summary

Nightmare disorder can be distressing, but there are natural ways to help your mind and body relax. Mindfulness, meditation, and deep breathing are simple tools anyone can try. With regular practice, these techniques can reduce the frequency and intensity of nightmares, improve sleep, and boost overall mental well-being, without relying on medication. If nightmares continue or interfere with your life, don’t hesitate to seek professional support.