RECENT REPORT BY THE US Committee for Refugees estimates there are 14.9 million refugees and 22 million internally displaced persons in the world. 1 Most have experienced significant trauma, including torture, 2-4 as evidenced by prevalence studies in clinics and nonrepresentative community samples. [5][6][7][8][9][10][11][12] Health problems of refugees have also been documented. Clinical research demonstrates a high prevalence of posttraumatic stress and depression symptoms, 6,10,[13][14][15] and community studies using self-rated scales [2][3][4]8,10,16 and structured diagnostic interviews 9,17-19 have found wide variation in the prevalence of the symptoms of posttraumatic stress (4%-86%) and depression (5%-31%). Refugees experience multiple symptoms, 4,5,[20][21][22][23][24][25][26] perhaps due to the many types of insults experienced, 4,6,20,23,24,27,28 yet the significance of these symptoms is not clear since many are not characteristic of posttraumatic stress disorder (PTSD), depression, or other defined disorders. [29][30][31][32][33][34][35] A few community studies Author Affiliations are listed at the end of this article.

Imagery rehearsal therapy is a brief, well-tolerated treatment that appears to decrease chronic nightmares, improve sleep quality, and decrease PTSD symptom severity.

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Imagery-rehearsal therapy for chronic nightmares was assessed in a randomized, controlled study of sexual assault survivors with posttraumatic stress disorder (PTSD). Nightmares, sleep quality, and PTSD were assessed at baseline for 169 women, who were randomized into two groups: treatment (n = 87) and wait-list control (n = 82). Treatment consisted of two 3-hr sessions and one 1-hr session conducted over 5 weeks. Of 169 participants, 91 women (Treatment, n = 43, Control, n = 48) completed a 3-month follow-up and 78 did not. At follow-up, nightmare frequency and PTSD severity decreased and sleep quality improved in the treatment group with small to minimal changes in the control group. Treatment effects were moderate to high (Cohen's d ranged from 0.57 to 1.26). Notwithstanding the large dropout rate, imagery-rehearsal therapy is an effective treatment for chronic nightmares in sexual assault survivors with PTSD and is associated with improvement in sleep quality and decreases in PTSD severity.

Although insomnia and nightmares were significantly associated with depressive and suicidal symptoms, after controlling for additional variables, such as depression and sex, only nightmares remained associated with suicidality. This association was slightly stronger among women compared with men.

Previous research has demonstrated an association between suicidality and sleep, suggesting that sleep disturbances may exacerbate mood dysregulation in participants suffering from mood disorders. The purpose of this study was to investigate the impact of sleep disturbances and insomnia on depression and suicidality in a nontreatment seeking sample of college students. Results indicated that insomnia and nightmares were significant predictors of symptoms of depression, while only nightmares significantly predicted suicidal ideation. Further analysis indicated that participants with elevated scores on insomnia, nightmares, or both experienced differing levels of depression and suicidal ideation. Future directions and treatment implications are discussed.

This consensus paper provides an overview of the state of the art in research on the aetiology and treatment of nightmare disorder and outlines further perspectives on these issues. It presents a definition of nightmares and nightmare disorder followed by epidemiological findings, and then explains existing models of nightmare aetiology in traumatized and non‐traumatized individuals. Chronic nightmares develop through the interaction of elevated hyperarousal and impaired fear extinction. This interplay is assumed to be facilitated by trait affect distress elicited by traumatic experiences, early childhood adversity and trait susceptibility, as well as by elevated thought suppression and potentially sleep‐disordered breathing. Accordingly, different treatment options for nightmares focus on their meaning, on the chronic repetition of the nightmare or on maladaptive beliefs. Clinically, knowledge of healthcare providers about nightmare disorder and the delivery of evidence‐based interventions in the healthcare system is discussed. Based on these findings, we highlight some future perspectives and potential further developments of nightmare treatments and research into nightmare aetiology.