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Nightmares can be defined as vivid and terrifying dreams which awaken the dreamer from sleep. Typically, the dreamer wakes from the rapid eye movement (REM) stage of sleep and can remember a detailed, perhaps bizarre dream plot.
Although such dreams are part of normal human experience, for some they can be a recurrent and extremely troubling problem. This is particularly so for young children but they can be disruptive to the whole family. Explanation and reassurance are often helpful particularly for parents who can then in turn be more reassuring to the affected child.
It is important to distinguish nightmare disorder from night terrors (which are episodes of panic and confusion, with difficulty waking or bringing to awareness, and of which the sufferer has no recollection). The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) diagnostic criteria for nightmare disorder are listed below:
DSM-IV criteria for nightmare disorder
- Repeated awakening from sleep or naps with detailed recall of extended and extremely frightening dreams. The nightmare usually involves a significant threat to survival, security or self-esteem.
- Awakening from sleep generally occurs during the second half of the sleep period.
- On awakening, the sufferer is usually rapidly orientated and alert.
- The dream experience, or the sleep disturbance caused by it, leads to clinically significant distress or impairment of social, occupational or other important areas of functioning.
- The nightmares are not exclusively associated with another mental disorder (eg delirium, post-traumatic stress disorder (PTSD)) and are not due to the effects of a substance on the body (eg medication, drugs of abuse, drug or alcohol withdrawal) or a medical condition.
Nightmares are common, particularly in children.
- 10-50% of those aged 3-6 years are estimated to suffer from nightmares that disturb their sleep, or that of their parents.
- This is the normal age for the experience of nightmares to begin.
- The peak incidence of nightmare disorder occurs in this age group. Some studies found that up to 80% of young children experience 'scary dreams'.
- Estimates of adult prevalence of nightmares and troubling dreams are difficult to come by due to variable definitions and recall bias.
- It is thought that the adult incidence of this disorder is low.
- Usually there is no underlying pathology.
- It is thought that recent traumatic events and psychological stress may contribute.
- Many medications are reported to increase nightmares:
Drugs linked to nightmares
- Betablockers (the water-soluble betablockers such as atenolol are less likely to cause nightmares as they are less likely to cross the blood-brain barrier).
- Centrally-acting antihypertensives.
- Antidepressants: selective serotonin reuptake inhibitors (SSRIS), tricyclic antidepressants and monoamine oxidase inhibitors( MAOIs).
- Antiparkinsonian agents: levodopa, selegiline
- Short-acting barbiturates
- Rauwolfia alkaloids
- Medication withdrawal: benzodiazepine or alcohol withdrawal leads to a rebound of REM sleep which may increase nightmares
- Nightmares tend to start in the latter half of the sleep cycle, during REM sleep.
- The nightmare usually involves a threat of danger. This may be a physical threat such as being pursued, or a psychological one such as being teased. Frequent threatening characters for children are monsters, ferocious animals, ghosts. bullies or 'bad' people.
- It is unusual for the person to shout out, move or have autonomic disturbance during the experience, although these things may occur to a minor degree.
- When awoken it is usual for the person to be orientated, alert and responsive and to be receptive to calming by their parents/others. The details of the dream are usually remembered. This contrasts with night terrors where the person may be difficult to rouse and may not recall what has been troubling them.
- There may be a family history of similar problems.
- Take a careful history, preferably also from parents, carers or relatives who have witnessed the event.
- Assess whether mental impairment, mental illness, depression, other central nervous system (CNS) disease or a febrile illness could be contributing.
- Consider medication history and alcohol/benzodiazepine withdrawal.
- Ask if there has been any recent traumatic event or conflict/stress.
See related separate article Night Terrors and Parasomnias.
- Night terrors - the difference from nightmares is that: they tend to occur earlier rather than later during the night; the person may initially be unresponsive or disorientated; unlike nightmares, they usually cannot recall the event; signs of autonomic arousal such as dilated pupils, tachypnoea and tachycardia are more likely.
- Underlying organic brain disorder, eg delirium or mental impairment.
- Post-traumatic stress disorder (PTSD): nightmares are a feature of PTSD. However, in PTSD the dream content often involves reliving the trauma, and there are other symptoms such as poor sleep and daytime anxiety.
- Medication or withdrawal from medication.
- Recurrent febrile illness causing delirium or predisposing to nightmares (this may also cause night terrors).
- Depressive illness with melancholic features may be associated in adults.
- REM sleep behaviour disorder (a problem affecting particularly older adults).
Investigations are not usually necessary if the diagnosis is clear from the history. However, bear in mind that:
- Night terrors (sleep terrors) and sleepwalking (which differ from nightmares, as explained above) have been linked to physical sleep disorders such as obstructive sleep apnoea and other types of sleep disordered breathing. If these problems are suspected, or the diagnosis is unclear, assessment at a sleep clinic may help.
- If there is reason to suspect an underlying cause then EEG, blood tests and CNS imaging may be considered.
- Reassurance of the patient or child and parents is all that is usually required.
- Helpful tips for children:
- It may help to develop a relaxing bedtime routine that does not vary. Attention to causes of stress and upheaval within the home may help reduce the propensity to nightmares.
- Use of night lights and other strategies that may reduce a child's anxiety levels at night can help.
- If the nightmare is recurrent then it may help for the parents to talk through the nightmare and imagine a less scary ending.
- If the problem is occurring, say, on a more than twice-weekly basis persistently, then it may be worth referring for psychological or child-psychiatric input. There is evidence that psychological techniques such as imagery rehearsal treatment may help.
- Drug treatment is not usually helpful and is more likely to cause nightmares. (This contrasts with some other types of sleep disorder, where medication may help.)
The prognosis is very good. The symptoms should resolve as time passes and after reassurance of the child and parents that this is a relatively normal experience for some young children.
Further reading & references
- Pagel JF; Nightmares and disorders of dreaming. Am Fam Physician. 2000 Apr 1;61(7):2037-42, 2044.
- Connelly KP; Sleep disorder: nightmares, eMedicine, Feb 2008
- BehaveNet Clinical Capsule: Nightmare Disorder. Accessed April 2008
- Muris P, Merckelbach H, Gadet B, et al; Fears, worries, and scary dreams in 4- to 12-year-old children: their content, developmental pattern, and origins. J Clin Child Psychol. 2000 Mar;29(1):43-52.
- British National Formulary
- Thiedke CC; Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan 15;63(2):277-84.
- Besiroglu L, Agargun MY, Inci R; Nightmares and terminal insomnia in depressed patients with and without melancholic features. Psychiatry Res. 2005 Feb 28;133(2-3):285-7.
- Trotti LM; REM sleep behaviour disorder in older individuals: epidemiology, pathophysiology Drugs Aging. 2010 Jun 1;27(6):457-70. doi: 10.2165/11536260-000000000-00000.
- Guilleminault C, Palombini L, Pelayo R, et al; Sleepwalking and sleep terrors in prepubertal children: what triggers them? Pediatrics. 2003 Jan;111(1):e17-25.
- Moore M, Allison D, Rosen CL; A review of pediatric nonrespiratory sleep disorders. Chest. 2006 Oct;130(4):1252-62.
- Germain A, Nielsen T; Impact of imagery rehearsal treatment on distressing dreams, psychological distress, and sleep parameters in nightmare patients. Behav Sleep Med. 2003;1(3):140-54.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Sean Kavanagh, Dr Naomi Hartree
Dr Richard Draper