Medically reviewed by
Dacelin St Martin, MD
Triple board-certified in Sleep Medicine,
Internal Medicine, and Pediatrics.
Epidemiology | Causes | Clinical Features | Differential Diagnosis | Diagnosis | Management
Overview
Nightmares can be disturbing and upsetting for those who have experienced them. They can occur occasionally during normal sleep or occur with more intensity and frequency, which may lead to the development of a disorder.
A nightmare disorder can occur individually or as a symptom of another psychological disorder, such as stress that’s strongly associated with the occurrence of nightmares.[1]
This article will highlight the characteristics of pathological nightmares in adults, and review management options.
Epidemiology
It is hard to say precisely how common nightmares are, but there have been a few studies on the topic.
Nightmares are something everyone has experienced, although it can be challenging to obtain accurate statistics because everyone perceives a nightmare differently.
About 85 percent of adults say they have a nightmare at least once a year. More frequent nightmares, those that could show signs of a nightmare disorder, occur in about 2 to 6 percent of adults who say they have a nightmare at least once a week.[2]
Nightmares also seem to be more commonly reported by women, although the gender gap diminishes with age.
Causes
The causes of nightmares can be varied and could be due to normal levels of stress. However, in cases where nightmares are persistent and could be considered pathological, some possible causes include:
1) Trauma
Those who suffer from trauma-related psychiatric disorders report nightmares as a symptom.
Posttraumatic stress disorder (PTSD) is a condition where nightmares involving the experiences of past traumatic events are common.
Nightmares related to PTSD often occur later than the traumatic experience, usually 30 days after the initial event. Nightmares occurring more recently after a traumatic event are common for those who suffer from acute stress disorder (ASD).
In PTSD and ASD, nightmares can lead to insomnia, severe sleep disturbance, and an insufficient amount of quality sleep.[3]
2) Psychiatric Disorders
The frequent occurrence of nightmares with an unknown cause is commonly associated with psychiatric disorders.[4] Disorders that can have nightmare symptoms include:
- Depression
- Anxiety Disorders
- Schizophrenia
- Borderline Personality Disorder
Stress and anxiety associated with psychiatric disorders are the main contributors to nightmare symptoms. The occurrence of nightmares can make obtaining quality sleep difficult and are linked to higher levels of self-harming behaviors.[5]
3) Medication
Nightmares can be common side-effects of some drugs, with beta-blockers accounting for most medication-related nightmare reports. This adverse effect is well known and should be reported when the medication is prescribed.[6]
Other medications that influence neurotransmitters in the brain, such as dopamine agonists and antidepressants, have also commonly been known to increase the rate of nightmares. This neurological effect is possibly due to the impact these drugs have on the sleep cycle structure.
Coincidentally, the withdrawal of medications can also have the effect of increasing nightmare occurrences. This reaction is especially prevalent when withdrawing from antidepressants, barbiturates, benzodiazepines, and alcohol.
Clinical Features
Nightmares can occur as a part of everyday stress; however, the frequency and intensity of the nightmare episodes can determine whether someone suffers from a nightmare disorder. Features of non-pathological nightmares include:
- Dreams occurring in the latter part of sleep
- Distressing and vivid
- Themes of failure, harm, accidents, or conflict
- Sweating, anxiety, and increased heart rate[7]
Alternately, a nightmare disorder may be similar theme-wise and have the same physiological effects as nightmares; however, they differ in the following ways:
- Dreams are extended and extremely distressing
- Distress affects other parts of life, such as work and relationships
- Rapid alertness upon waking
- Increased frequency of nightmares
- Sleep apprehension, such as dreading bedtime and anxiety surrounding sleep
- Flashbacks and cognitive distress throughout the day[7]
Differential Diagnosis
Several other sleep conditions have a common co-occurrence with nightmares. However, they are not considered nightmare disorders. Conditions that can have similar symptoms to nightmare disorders include:
- REM sleep behavior disorder
- Sleep terrors
- Nocturnal panic attack
- Hallucinations upon sleep or waking
Nightmare disorders have diagnostic criteria that make them distinguishable from other disorders. Namely, nightmare disorders occur without movement, during REM sleep, with vivid dream memory, and full alertness upon waking.[7]
Diagnosis
Diagnosing a nightmare disorder requires an evaluation from a physician. Most importantly, a description of the nightmares will be necessary to determine the presence of pathology. Additionally, information regarding sleep quality will be needed, including abnormal behaviors that occur during sleep.
Other information that is important during the assessment is a medical history. Pertinent information includes any medication or substances use, presence of psychiatric disorders, or history of traumatic events. Questionnaires and interviews may be used to determine if a patient has PTSD or other psychiatric disorders.
Management
Treatment is not always necessary for nightmares and nightmare disorders. Occasionally, nightmares will go away with time and without intervention. However, if symptoms persist, there are treatments available.
The treatment of nightmares and nightmare disorders is often an individualized approach. Initial treatment includes treating any possible causative issues. Treatment of underlying psychiatric problems may be enough to control the occurrence of distressing nightmares. Therapy may consist of cognitive-behavioral therapy or medication to control psychiatric symptoms, including nightmares.[8]
More specific treatments for nightmares include the use of specialized psychotherapy approaches. Imagery rehearsal therapy (IRT) is used to treat non-specific and trauma-related nightmare disorders. Therapy includes thinking about the nightmare in detail and working with the therapist to change the narrative, creating a positive version of the nightmare should it reoccur.[9]
Other treatment options include general lifestyle changes to avoid making the occurrence of nightmares more common. Good sleep hygiene is recommended, including a consistent sleep schedule, sleep routine, and a peaceful sleep environment. Additional recommendations include avoiding spicy food, alcohol, caffeine, or exercise close to bedtime.[9]
Conclusion
If you believe you suffer from a nightmare disorder, it is essential to speak with your physician and ask about what treatments may improve your sleep.
References:
- Nielsen, T., &; Levin, R. (2007, August 11). Nightmares: a new neurocognitive model. Sleep medicine reviews. https://pubmed.ncbi.nlm.nih.gov/?term=17498981.
- Nielsen, T., &; Levin, R. (2007, May). Disturbed Dreaming, Posttraumatic Stress Disorder, and https://www.researchgate.net/publication/6360058_Disturbed_Dreaming_Posttraumatic_Stress_Disorder_and_Affect_Distress_A_Review_and_Neurocognitive_Model.
- Koren, D., Fleisher, W., & Neylan, T. C. (2006, April 1). Sleep disturbance as the hallmark of posttraumatic stress disorder. American Journal of Psychiatry. https://ajp.psychiatryonline.org/doi/abs/10.1176/ajp.146.6.697.
- Hublin, C., Koskenvuo, M., Partinen, M., & Kaprio, J. (1990, August 20). Nightmares: familial aggregation and association with psychiatric disorders in a nationwide twin cohort. American journal of medical genetics. https://pubmed.ncbi.nlm.nih.gov/10402498/.
- Sjostrom, N., Waern, M., & Hetta, J. (2007, January 1). Nightmares and Sleep Disturbances in Relation to Suicidality in Suicide Attempters. OUP Academic. https://academic.oup.com/sleep/article/30/1/91/2708184.
- Thompson, D. F., & Pierce, D. R. (1999, January). Drug-Induced Nightmares – Dennis F Thompson, Dana Reid Pierce, 1999. SAGE Journals. https://journals.sagepub.com/doi/10.1345/aph.18150.
- American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, 2014. no abstract available
- Escamilla, M., LaVoy, M., Moore, B. A., & Krakow, B. (2012, August 5). Management of Posttraumatic Nightmares: A Review of Pharmacologic and Nonpharmacologic Treatments Since 2010. Current Psychiatry Reports. https://link.springer.com/article/10.1007%2Fs11920-012-0306-7.
- Ho, F., Chan, C., & Tang, K. (2016, February). Cognitive-behavioral therapy for sleep disturbances in treating posttraumatic stress disorder symptoms: A meta-analysis of randomized controlled trials. Clinical psychology review. https://pubmed.ncbi.nlm.nih.gov/26439674/.
