nightmares

Last edited 05/2020 and last reviewed 11/2020

Nightmares are bad dreams from which full waking occurs.

Nightmares are more prevalent in childhood

• prevalence of nightmares in children is 20 to 40 percent
• 5 to 30 percent of children report having nightmares “often or always"
• in adults, the prevalence of one or more nightmares per month ranges from 8 to 30 percent
• 2-5 percent of young adults and 1 to 2 percent of older adults report having nightmares “often or always" (1)

They usually occur in the last third of the night.

Nightmares are frightening dreams or disturbing mental experiences that usually awaken the sleeper from REM sleep.

• as they unfold, nightmare dream sequences become increasingly more threatening and disturbing
• dream content most frequently involves imminent danger - common themes are attacks or pursuit
  • fear and/or anxiety are the most frequent emotions associated with nightmares; anger, sadness, and dysphoria are also frequently reported
  • the individual is able to relate dream content as well as associated fear and anxiety upon awakening
  • motor activity (such as sitting up, striking, thrashing, speaking, walking) is usually absent in nightmares (in contrast to REM-sleep behavior disorder)
  • stress and traumatic events may increase the frequency of nightmares
  • various drugs may trigger nightmares:
  • nightmares have been reported to be triggered or worsened by many drug treatments including cholinesterase inhibitors, beta-blockers, SRIs (especially paroxetine) levodopa, alcohol and following withdrawal from drugs for depression (2)
  • most nightmare sufferers are without any psychiatric history
    
    
• in contrast to sleep terrors:
• nightmares are not associated with confusion or disorientation
• sleep terrors may evolve into sleepwalking; nightmares never do

Treatment of nightmares:

• seek expert advice
• includes psychotherapy, minimizing or avoiding stress, and minimizing the use of drugs that may precipitate nightmares
• if an individual has poor sleep hygiene
• priorities are to minimise possible trigger factors such as noise, frightening films, caffeine, alcohol or meals late at night; and to make sure there is a stable and adequate sleep-wake schedule- instituting a regular sleep-wake pattern may reduce the frequency and severity of nightmares
• psychological treatments are effective and these focus on exposure – writing down dreams – or guided imagery, pleasant images, and ‘changing the ‘ending’
• evidence of beneficial effects of the alpha-1 adrenergic blocker prazosin in reducing nightmares related to PTSD in both military and civilian settings and in the paediatric population

Reference:

• Broughton RJ. Behavioral parasomnias. In: Chokroverty S, editor. Sleep Disorders Medicine: Basic Science, Technical Considerations, and Clinical Aspects. Boston, MA: Butterworth-Heinemann; 1999. pp. 635–60
• Wilson S et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update. J Psychopharmacol. 2019 Aug;33(8):923-947
• Zanigi S et al. REM behaviour disorder and neurodegenerative diseases. Sleep Medicine 12 (2011) S54–S58
• Nielsen TA, Zadra A. Dreaming disorders. In: Kryger MH, Roth T, Dement WC, editors. Principles and Practice of Sleep Medicine. Philadelphia, PA: WB Saunders; 2005. pp. 753–72.