What is Nightmare Disorder?
Nightmare disorder is a sleep disorder in which frequent disturbing dreams interfere with a person’s ability to function well during the day or cause emotional distress.
Nightmares typically occur during a phase of sleep called rapid eye movement (REM) sleep. This phase usually occurs relatively late in the sleep period, often in the second half of the night. Some people may experience multiple nightmares during the night.
Nightmares are common in children, but they tend to decrease in frequency as a child gets older. By adolescence, nightmares are usually less frequent, although many adults continue to experience them throughout their lives. Most people have unpleasant dreams from time to time, but the disturbing dreams associated with nightmare disorder are exceptional in their frequency and impact on the dreamer’s emotional state.
Characteristics of Nightmares
Nightmares vary in their content and effects, but they often have common characteristics:
- The dreams are typically vivid and emotionally upsetting.
- They often involve dangerous, life-or-death situations.
- The dream causes the sleeper to wake.
- The dream causes physical effects such as sweating and rapid heartbeat or breathing.
- The person clearly remembers the dream.
- The person feels emotional distress upon waking and may have trouble going back to sleep.
Symptoms of Nightmare Disorder
The symptoms of nightmare disorder go beyond typical, occasional bad dreams and can include:
- Nightmares occur frequently.
- Nightmares cause distress during the day.
- Sleep disruptions cause daytime sleepiness or lack of energy.
- Nightmares result in persistent thoughts of the dreams, mental fogginess, or problems with concentration.
- Nightmares cause fears or behavioral issues associated with sleeping or nighttime.
Difference Between Nightmares and Sleep Terrors
A sleeper’s reaction to nightmares can be similar to another sleep disorder called sleep terrors, but there are key differences:
- Nightmares are conventional dreams that cause fear, while sleep terrors lack the vivid imagery of dreams.
- Nightmares occur during rapid eye movement (REM) sleep. Sleep terrors occur during non-REM sleep, usually earlier in the night.
- People who experience nightmares often remember them in the morning. However, people typically have no memory of a sleep terror episode the following day.
What Causes Nightmare Disorder?
The exact cause of nightmare disorder is unknown, but it is often associated with medical conditions, stress, and other external situations.
Some potential risk factors for nightmare disorder include:
- Lack of adequate sleep
- Bad sleep environment (e.g., an unfamiliar place or one that is too noisy or bright)
- Ongoing emotional stress or anxiety
- Experiencing trauma such as abuse, assault, injury, loss of a loved one, or severe medical illness
- Taking some medications, including some antidepressants
- Having other mental health-related issues
Is Nightmare Disorder Hereditary?
Research suggests a strong genetic component to nightmare disorder and other sleep disorders. Many people who experience nightmare disorder and sleep disorders called parasomnias also have a close family member who has also experienced them.
Scientists have not yet identified a gene or genetic mutation associated with parasomnias. Likely, some people are genetically predisposed to experiencing the disorders, but some external environmental factor usually triggers the symptoms.
How Is Nightmare Disorder Detected?
Nightmares, especially those experienced by children, usually do not require any intervention by a doctor, therapist, or sleep specialist. However, you should seek professional help if the episodes are severe. Warning signs that you should consult a doctor include:
- Nightmares occur frequently and continue for a long time.
- You lose sleep because of nightmares and feel sleepy as a result.
- You’re afraid to go to sleep.
How Is Nightmare Disorder Diagnosed?
Doctors may take several different diagnostic steps when a patient is experiencing sleep terrors.
- Physical exam. A basic physical exam will screen for indications of medical conditions that could be causing the episodes.
- Family medical history. Because parasomnias often run in families, your doctor may ask about your family’s history regarding sleep issues.
- Sleep study. A study of your sleep patterns, which may be conducted at a sleep center, may be recommended if your doctor suspects that a condition such as sleep apnea could be the cause of your nightmares.
To be diagnosed with nightmare disorder, a patient must meet the diagnostic criteria for the disorder outlined in the Diagnostic and Statistical Manual (DSM), used by professionals to identify mental health issues. The criteria for nightmare disorder include:
- Nightmares occur frequently.
- The person is alert and not disoriented after being awakened during a nightmare.
- Nightmares cause significant distress or impairment.
- Nightmares aren’t caused by medication, substance use, a medical condition, or a mental health-related issue.
Nightmare disorder is categorized according to the persistence of the bad dreams:
- In acute nightmare disorder, nightmares have persisted for one month or less.
- In subacute nightmare disorder, nightmares have lasted between one and six months.
- In persistent nightmare disorder, nightmares have persisted for longer than six months.
The disorder is also classified according to severity:
- Mild. Nightmares occur less than once a week on average.
- Moderate. Nightmares occur at least once a week but not nightly.
- Severe. Nightmares occur nightly.
PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.
How Is Nightmare Disorder Treated?
Most of the time, nightmares do not require treatment. In children, episodes usually resolve on their own by adolescence. However, in adults and children with underlying sleep or mental-health disorders, treatment of the underlying condition may help relieve the symptoms of nightmare disorder. Treatment may also be necessary if the episodes are frequent.
Treatments for nightmare disorder may include:
- Psychotherapy such as cognitive-behavioral therapy (CBT) to address sources of anxiety or stress that may be causing nightmares
- Imagery rehearsal therapy (IRT), a form of CBT sometimes used to treat nightmares associated with post-traumatic stress disorder (PTSD). This therapy involves consciously creating a new, less stressful ending for remembered nightmares while you’re awake.
Medications are rarely used to treat nightmare disorder. However, in severe cases that do not respond to other interventions, doctors may recommend medications such as sedatives, antipsychotics, or antidepressants.
How Does Nightmare Disorder Progress?
Nightmares usually do not have long-term complications. However, untreated nightmare disorder and other sleep disturbances can lead to a wide variety of medical problems, quality-of-life complications, and mental health-related issues, including:
- Problems at work or school
- Relationship difficulties
- Accidents caused by fatigue or mental fogginess
- Anxiety or depression
- Substance abuse
- Weight gain
- High blood pressure
- Heart disease
How Is Nightmare Disorder Prevented?
Good sleep habits and a healthy lifestyle can help prevent nightmare disorder and other sleep disorders. Steps you can take to ensure better sleep include:
- Stick to a regular sleep schedule (even on weekends)
- Don’t eat or drink close to bedtime
- Avoid stimulating activities (e.g., watching TV, using electronics) 30 minutes before bedtime
- Use your bedroom only for sleep
- Keep your bedroom dark and cool
- Get plenty of exercise
- Limit consumption of caffeine and alcohol
- Quit smoking
- Don’t take naps
- Try meditation or relaxation techniques
Nightmare Disorder Caregiver Tips
Some people with nightmare disorder also suffer from other brain and mental health-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with nightmare disorder:
Nightmare Disorder Brain Science
Although nightmare disorder causes distress, brain activity during nightmares is part of most people’s typical sleep cycle. Nightmares, like most dreams, occur most often during REM sleep, a phase in which the brain is relatively active. Dreams during REM sleep tend to be vivid and are often bizarre in their content. Non-REM dreams, by contrast, tend to be more coherent.
Nightmares differ from sleep terrors in that a person can typically remember their nightmares, while sleep terrors usually aren’t remembered. The difference probably lies in the varying brain activity in REM sleep and the deeper sleep in which sleep terrors occur.
Sleep terrors usually occur when a person is transitioning to deep sleep. Scientists believe that the episodes result from a mixed state in which part of the brain is asleep, and another part is awake. In the case of night terrors, it’s possible that parts of the brain that control rational thought and memory, such as the neocortex and the hippocampus, are asleep, and the parts responsible for the fear response, including the amygdala and hypothalamus, are awake. These fear-producing areas of the brain activate the sympathetic nervous system, which kicks the body into a “fight-or-flight” state.
The mixed-state theory would help explain why people generally don’t remember their sleep terror episodes. During nightmares, the brain’s higher-level functions are more active, allowing for the creation of vivid dream narratives and memories. However, those parts of the brain are inactive during sleep terrors, resulting in a bout of intense fear that leaves no lasting impression.
Nightmare Disorder Research
Title: Parents Advancing Toddler Health (PATH)
Principal investigator: Amanda R. Tarullo, PhD
Children living in poverty have a high incidence of early-developing sleep and behavior problems, which are often co-morbid. Early sleep and behavior problems are prevalent and persistent risk factors for lifelong poor mental and physical health outcomes and may be key mechanisms underlying early and enduring socioeconomic health disparities. While effective interventions exist, low-income families have low enrollment and retention in these interventions. The stigma of treating behavior problems creates an additional barrier to treatment. This RCT aims to address these barriers to treatment for low-income children with co-morbid sleep and behavior problems. Sleep and behavior problems and family dysfunction transact across time, increasing in severity, while healthy sleep, positive child behaviors, and effective parenting can support each other across development. Thus we posit that intervention in one domain, either sleep or behavior, may improve outcomes both within and across domains.
Although early interventions can improve health equity in young children living in poverty, this promise often is not realized because of barriers to family engagement. The proposed study will target co-morbid behavior and sleep problems in early childhood, comparing child outcomes and family response to sleep and behavior interventions and investigating the novel strategy of letting families select their intervention. Researchers will enroll 500 low-income toddlers with co-morbid sleep and behavior problems, randomized to 4 parent coaching interventions: sleep, behavior, family choice (sleep or behavior), and an active control. At baseline and 1, 5, and 9 months post-intervention, researchers will assess the child’s sleep and behavior and family functioning. They will measure family preference, engagement, and perceived value of each intervention. The goals of the study are: (1) to examine the effects of evidence-based sleep and behavior interventions in young low-income children with co-morbid sleep and behavior problems on child sleep and behavior and family functioning; (2) to determine whether parents prefer, engage with, and value a sleep or behavior intervention more; and (3) to examine if giving families a choice of intervention results in higher engagement, higher perceived value and better family and child outcomes than assignment to intervention. By informing best practices for engaging low-income families to treat co-morbid sleep and behavior problems, results will be critical to reducing health disparities for children living in poverty.
Title: Feasibility Study of Personalized Trials to Improve Sleep Quality
Stage: Not Yet Recruiting
Principal investigator: Karina Davidson, PhD, MASc
New Hyde Park, NY
This pilot study aims to assess the feasibility of using N-of-1 methods in a virtual research study of melatonin intervention for poor sleep quality. Participants (N=60) will be sent a Fitbit device and three smart pill bottles, with one containing 3 mg of melatonin, one containing 0.5 mg of melatonin, and the final bottle containing a placebo pill. The first two weeks will be a baseline period, where no supplement is assigned, but data are collected, including self-report of sleep quality and duration and accelerometer-derived sleep and activity data. After successfully completing the baseline period, participants will be randomized to six 2-week intervention blocks of a 3 mg dose of melatonin, a 0.5 mg dose of melatonin, and a placebo. At the end of the trial, participants will be asked to complete the System Usability Scale, a satisfaction survey (electronic or phone/video call if they are non-responders), and participate in a virtual interview (such as over Microsoft Teams or a phone call) to inform feasibility and acceptability of protocol requirements, study materials, and personalized reports.
Title: Telehealth Delivery of Treatment for Sleep Disturbances in Young Children With Autism Spectrum Disorder
Principal investigator: Cynthia Johnson, PhD
The Cleveland Clinic
Ninety children with Autism Spectrum Disorder (ASD), between the ages of 2 to less than seven years, and their parents will be recruited for this ten-week randomized clinical trial. Participants will be randomized to five individually delivered sessions of Sleep Parent Training (SPT) or five individually delivered sessions of Sleep Parent Education (SPE). Delivery of the programs will be via a telehealth platform that includes parent-child coaching in real-time. In addition to baseline, outcome measures will be collected at week 5 (midpoint of trial) and week 10 (endpoint of trial), as well as follow-up at week 16, to determine the durability of the treatment.
This study will deliver an already initially tested manualized parent training program especially targeting bedtime and sleep disturbances, but delivered via a telehealth platform and enhancing the program using live parent coaching at bedtime. Utilizing REDCap automated survey invitations feature, investigators will provide reminders of the intervention recommendations and data collection requirements. In a randomized clinical trial of 90 children with ASD, ages 2 to less than seven years, a parent training program targeting sleep disturbance (Sleep Parent Training; SPT) will be compared to Sleep Parent Education (SPE). The investigators hypothesize that SPT will be superior in improving child sleep, child daytime functioning as well as parent well-being compared to SPE.