Nightmares: From Symptom to System

 

Preface

This book was born from the experience of war in Ukraine. The full-scale invasion that began in February 2022 brought not only catastrophic human loss and destruction, but also a profound wave of psychological suffering rooted in trauma, chronic stress, and a future that refused to come into focus. One motif recurs across clinical reports, research findings, and personal accounts alike: disrupted sleep, repetitive war-related dreams, and sudden awakenings from nightmares that feel impossible to leave behind.

People who have survived shelling, occupation, captivity, forced displacement, or the loss of loved ones describe a strikingly similar experience: at night, it all starts over again. Sleep — which should restore and heal — becomes for many another front. Nightmares of explosions, pursuit, death, guilt, and the unbearable impossibility of saving others appear with painful consistency among Ukrainian soldiers, medical workers, volunteers, and civilians: students, families torn apart, people carrying their homes in a single bag. These are not unusual patients. They are people doing their best to survive, and their nights are making it harder.

We, the authors of this book, work at different points along the intersection of consciousness science, sleep research, and clinical practice. What unites us is not a shared office but a shared question — one that has grown more urgent with each passing year of this war: what is actually happening inside a nightmare, and why do the best available approaches so often fall? We draw on published clinical descriptions, research data, treatment protocols, and contemporary theories of consciousness and functional systems, bringing them into conversation with each other in ways that we hope will feel both intellectually grounded and practically alive.

Modern psychiatry and sleep science already offer a meaningful set of tools for working with nightmares — Imagery Rehearsal Therapy, CBT-N, ERRT, TF-CBT, EMDR, CBT-I, and others. Meta-analyses confirm that these approaches can significantly reduce nightmare frequency and distress. We value them and build on them throughout this book. But the war in Ukraine has also served as a sobering stress test. The sheer scale of trauma, its chronicity, the way combat loss layers onto displacement and grief and social unraveling — all of this has pushed against the limits of treating the nightmare purely as a symptom of something else. Many clinicians working in this context have felt that gap directly.

In this book, we propose a complementary framework: understanding the nightmare as a pathologically stabilized functional system of consciousness — a coherent, self-sustaining organization of experience with its own goal, its own internal model of the world and self, and its own habitual patterns of unfolding and resolution. This is not a rejection of existing diagnoses or protocols. It is an invitation to see them from a wider vantage point, one that may help clinicians understand not just whether an intervention works, but where in the system it works — and why that matters.

The book can be read from several positions. Clinicians will find a different way to think through a case and to combine existing methods with greater intentionality. Researchers in sleep, trauma, and consciousness will find an attempt to bring dispersed findings into a single coherent model, with new hypotheses that lend themselves to empirical investigation. And for those who live with nightmares themselves — or who sit with patients who do — this framework may offer something simpler and perhaps more important: a way to see the nightmare not as chaos, but as a process with its own logic, however painful, and therefore as something that can be understood and changed.

We are candid about the limitations of our approach throughout the book. We do not offer a final theory of nightmares. We do not believe a single model can capture every clinical reality. What we do offer is a language — one that we hope makes it a little easier to think clearly about these experiences, to talk about them with patients, and to keep asking better questions.

It was the war in Ukraine — as painful as it has been, and as generative — that made these questions impossible to set aside. We hope this book will be useful not only where the war continues, but wherever clinicians sit across from someone who wakes each night to the same interior battlefield, and finds themselves wondering: what is this, really — and what can we actually do?

Introduction: Why Another Model of Nightmares?

From Description to Understanding

We already know a great deal about nightmares. Diagnostic criteria are well established, prevalence estimates are reasonably consistent, and the clinical consequences — ranging from insomnia to elevated suicide risk — are documented across a substantial body of literature. Several treatments exist with modest but real effect sizes. On the surface, this would seem sufficient for clinical work.

And yet, looking at the same picture from a different angle, something feels missing. We know what happens — frequency, correlates, treatment outcomes — but we say far less about how a nightmare is organized as a process: what goal this nocturnal configuration serves, what model of the world and self it sustains, and why an episode so reliably ends in a peak-fear awakening even when the person's waking state is gradually improving. The phenomenological language of "what was dreamed" and the symptomatic language of "what it correlates with" are no longer sufficient for these questions.

Three Perspectives That Don't Yet Speak to Each Other

The existing knowledge base can be roughly organized around three perspectives that, at present, operate largely in parallel.

The clinical perspective treats the nightmare as a symptom or a discrete disorder — a parasomnia associated with PTSD, anxiety, depression, insomnia, and somatic illness. At this level, the relevant currency is diagnoses, rating scales, and treatment protocols.

The phenomenological perspective describes dream content and themes, emotional texture, bodily sensations, and the experience of waking. Here it becomes clear that a nightmare is not a random sequence of images, but a recognizable configuration of experience: threat, helplessness, guilt, and an inability to resolve the situation by any means other than sudden awakening.

The neurobiological perspective investigates REM sleep, hyperarousal, the functioning of the amygdala, hippocampus, and medial prefrontal cortex, and the dysregulation of stress-response systems. Chronic nightmares are associated with more fragmented sleep, heightened threat-network activation, and impaired fear extinction.

Each perspective captures something real and important. The problem is that no shared language connects them. Clinical descriptions say little about the internal architecture of the nightmare as a process; phenomenological accounts rarely interface with neurobiological models; data on REM sleep, amygdala reactivity, and hyperarousal tend to remain a separate conversation, difficult to link directly to the question that matters most clinically: what makes a nightmare such a stable and self-sustaining configuration of experience?

The Central Proposal: The Nightmare as a System

This book proceeds from a simple but, we believe, productive proposal: to understand the nightmare as a pathologically stabilized functional system of consciousness.

We suggest describing the nightmare not as an isolated symptom, not as a collection of discrete mechanisms, but as a coherent organization of experience that:

• has its own goal state (reference point) — for example, never be defenseless, always be prepared for the worst, do not allow yourself to forget;
• maintains a specific internal model of the world and self — the world as a space of total, pervasive threat; the self as powerless, guilty, too late, without a voice;
• unfolds through characteristic patterns of action and resolution — threatening scenarios, escalating fear and bodily arousal, awakening at the peak of terror as a stereotyped way of "stopping" the dream, while simultaneously confirming the underlying model (sleeping deeply is dangerous; in sleep I am unprotected).

Within this framework, the nightmare is neither a random malfunction nor mere noise. It is a pathologically stabilized system that reproduces itself night after night, continuously reinforcing its own goal and model. The clinical task shifts accordingly — from reducing nightmare frequency or "dampening symptoms" to something more structural: the reconfiguration of the system itself, at the level of its goals, its internal model, and its characteristic patterns of unfolding and resolution.

One clarification is worth making at the outset. The systems framework proposed in this book is intended to be applicable to nightmares across their full clinical range — regardless of context, diagnosis, or etiology. Whether nightmares arise in the setting of trauma, chronic stress, anxiety, depression, or idiopathic parasomnia, the same organizing logic applies: a goal, a model, a pattern of action, a stereotyped resolution. In this sense, the model is general.

That said, nightmares sometimes occur in the context of an identifiable somatic cause — sleep-disordered breathing, neurological conditions, medication effects, or other medical factors that directly disrupt sleep architecture and lower the threshold for disturbing dream experience. In such cases, as with any clinical approach to nightmares, addressing the underlying somatic condition is the necessary first step. No psychological or systems-level intervention substitutes for treating obstructive sleep apnea, adjusting a medication that triggers REM dysregulation, or managing neurological other somatic disorders that fragments sleep. This priority is not unique to our model; it is a basic principle of sound clinical reasoning. We note it here simply to be clear: the framework that follows is designed to complement good medical care, not to replace it.

Theoretical Foundations

The model proposed here stands at the intersection of several well-developed conceptual traditions that are rarely brought together in the study of nightmares:

• the theory of functional systems (P. K. Anokhin and subsequent developments), which describes activity as organized around the achievement of a result, rather than as a simple response to a stimulus;
• predictive processing frameworks, in which the brain is understood as a system that continuously builds and refines hypotheses about the world, minimizing the discrepancy between what is expected and what is encountered;
• contemporary theories of dreaming, including threat simulation theory, which interprets dreams as threat simulations that under normal conditions support adaptive rehearsal, but in the context of trauma may become fixed in maladaptive modes.

We are not proposing a new grand theory of consciousness. These frameworks are used here as a shared language — one that allows us to describe the nightmare as a system with a goal, an internal model, characteristic actions, and a pattern of resolution, while simultaneously situating it within the concrete neurophysiological architecture of sleep and emotional processing.

How the Book Is Organized

The structure of the book is designed to connect, step by step, the scope of the problem, general knowledge about sleep, clinical observation, and the systems model.

Chapters 1–3 establish how prevalent and clinically significant nightmares are, what we know about sleep and dreaming in general, and how nightmares currently appear in clinical practice — primarily as a symptom embedded in existing diagnostic frameworks and treatment protocols.

Chapters 4–6 develop the systems model: introducing the language of functional systems and predictive processing, describing the nightmare as a pathologically altered functional system of consciousness, and grounding this model in data on REM sleep, emotional networks, and the pathophysiology of chronic nightmares.

Chapters 7–9 turn to clinical practice: showing how existing methods — IRT, CBT-N, ERRT, TF-CBT, EMDR, CBT-I, and others — act on distinct nodes of the system (goal, model, action and resolution patterns), and how this understanding can inform integrative treatment strategies.

Chapters 10–11 address research perspectives and broader implications: which elements of the model already have empirical support, which remain hypothetical, and how the concept of a pathologically stabilized functional system might apply to other chronic conditions — pain, insomnia, and stress-related emotional disorders.

In this sense, the Introduction does not rehearse the motivation of the Preface, nor does it describe clinical presentation in detail. Its purpose is to establish a point of view. From here on, we invite the reader to look at nightmares not merely as symptoms or collections of mechanisms, but as coherent systems — ones that can be described and engaged at multiple levels simultaneously, from lived experience to neurophysiology.

Chapter 1. Nightmares: The Scope of the Problem

Nightmares are not a rare or exotic phenomenon. Even outside the context of war, epidemiological data consistently show that approximately 2–5% of the adult population experience frequent nightmares — occurring at least once a week, recurrent in nature, and meaningfully disrupting quality of life. When occasional or isolated nightmare episodes are included, the proportion rises considerably: up to a quarter to a third of adults report experiencing them at least from time to time. In specific clinical populations — people with psychiatric diagnoses and, most strikingly, those with posttraumatic stress disorder (PTSD) — rates are higher still.

Nightmares rarely exist in isolation. They commonly accompany PTSD, anxiety and depressive disorders, substance use disorders, and chronic insomnia. For a significant number of people, nightmares are the single component most strongly associated with daytime distress, reduced functioning, and elevated suicide risk — independently of how the primary diagnosis is formally classified. They are not merely a symptom among others; for many patients, they are the symptom that shapes the day that follows.

War brought this reality into sharpest focus. It did not create the phenomenon of nightmares, but it functioned as an extreme stress test for the sleep system. The number of people experiencing recurrent, traumatically colored dreams rose sharply — among civilians and combatants alike — as did the number of those seeking help specifically for their nights, even when other symptoms had not yet been recognized as problems. Against this backdrop, the limitations of existing approaches became impossible to overlook: the available interventions work, but often not deeply enough or durably enough for the demands of mass trauma.

This book proceeds from a double observation. Nightmares are clinically significant and widely prevalent in ordinary peacetime life. War has simply made their weight — and the vulnerabilities of our current approaches — impossible to ignore. For this reason, we do not treat nightmares here as a specifically "wartime" problem. They are a general human phenomenon, and any model worth proposing must hold up under both extreme and everyday conditions.

Throughout this book, the term nightmare refers not to any unpleasant dream, but to a clinically meaningful form of the phenomenon: recurrent, emotionally intense dreams marked by vivid fear or other forms of severe distress, frequently involving threats to life or safety, that interrupt sleep and carry daytime consequences — fatigue, anxiety, and avoidance of sleep itself. It is this form of the experience that will remain at the center of our systems model. In what follows, we treat it not merely as an indicator of illness severity, but as a coherent organization of experience — one that requires its own descriptive language and its own strategies for change.

You can learn more by reading our e-book 

Mykola Iabluchanskyi together with Andriy Yabluchanskiy