Nightmare Disorder

What Is Nightmare Disorder?

People with nightmare disorder have recurring nightmares that disrupt sleep, impair daytime functioning, and cause ongoing distress. Nightmare disorder is one of many parasomnias, which are unpleasant experiences that occur when a person is sleeping, falling asleep, or waking. 

While having nightmares is the defining characteristic of nightmare disorder, not everyone who has nightmares has nightmare disorder. Nightmare disorder is also distinct from night terrors, despite their similar names. 

Nightmares

Nightmares are frightening or disturbing dreams that cause the dreamer to awaken. After having nightmares, most people recall them in detail. This is because they typically happen during the rapid eye movement (REM) stage of sleep, during which brain activity resembles wakefulness. 

Nightmares are often triggered by stress, a difficult life event, or trauma. Having nightmares may be a way for the brain to process anxiety and fear. Some common themes of nightmares include confrontations, chases, near-death experiences, and failure.

Given their alarming themes, nightmares can activate the nervous system’s fight-or-flight response. As a result, people may wake up from nightmares with a racing heart, feelings of panic, or sweat-soaked clothing.

Night Terrors

Unlike people with nightmares, sleepers with night terrors behave as if they are in distress, by screaming, thrashing, and even sleepwalking. While night terrors can affect adults, they are most common in children Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source ages 3 to 7. 

Night terrors occur during the sleep phase that precedes REM, known as deep sleep or slow wave sleep. While sleep terrors can resolve in minutes, some may last more than half an hour. People going through these episodes are often difficult to wake. When they do wake up, they generally have no memory Trusted Source Merck Manual First published in 1899 as a small reference book for physicians and pharmacists, the Manual grew in size and scope to become one of the most widely used comprehensive medical resources for professionals and consumers. View Source of the night terror.

Nightmare Disorder

Nightmare disorder causes frequent, extended nightmares that commonly depict serious threats to the dreamer’s life, safety, and well-being. People with nightmare disorder usually have these episodes hours after falling asleep, and they wake from them feeling alert and deeply distressed. Typically, they can vividly recall the content of the nightmare.

The severity of this disorder can vary significantly. For people with mild cases, more than a week may pass between episodes. In severe cases, episodes happen nightly. Because nightmare disorder compromises sleep and creates stress, it tends to negatively affect other aspects of a person’s life, such as their ability to work.

Between 2% and 5% of adults Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source in the U.S. experience nightmare disorder. Unfortunately, nightmare disorder is underreported Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source and therefore undertreated. Many people do not tell their health care providers about their disruptive, frequent nightmares, and many do not know that recurring nightmares can be managed with treatment.

Risk Factors for Nightmare Disorder

According to researchers, a number of circumstances may generate nightmares or increase their frequency, putting a person at greater risk of developing nightmare disorder.

• Stress: Elevated levels of stress may cause a person to have nightmares. In some cases, a single stressful event might initiate recurring nightmares that feature distressing emotions associated with the event.
• Medications: Many medications produce nightmares as a side effect. Some blood pressure medications known as beta blockers can generate nightmares, as can certain medications for infections, depression, Parkinson’s disease, and restless legs syndrome.
• Alcohol and recreational drugs: Drinking too much alcohol or using certain recreational drugs can trigger nightmares.
• Withdrawal from substances: Nightmares can also result from ending the use of substances, including alcohol, recreational drugs, and certain prescription medications. Many medications suppress REM sleep, and when they are discontinued, the resulting rebound in REM sleep produces nightmares.

Additionally, while nightmare disorder can appear on its own, it often emerges in conjunction with other conditions and disorders Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source .

• Posttraumatic stress disorder (PTSD): More than 70% of people with PTSD experience recurring trauma-related nightmares Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source . In people with PTSD, nightmares may not be isolated to REM sleep but can also intrude while an individual is falling asleep.
• Mental health conditions: Frequent nightmares have been linked to several mental health disorders, including depression, anxiety, schizophrenia, and borderline personality disorder. Depression, in particular, can cause changes in the sleep cycle that increase the likelihood of nightmares.
• Other sleep disorders: Nightmare disorder can occur in tandem with other sleep disorders, including insomnia, sleep apnea, and narcolepsy.

Effects of Nightmare Disorder

Nightmare disorder can affect a person’s life in many ways, both during the day and at night. The more nightmares a person has, the more susceptible they are to the physical, psychological, and social effects Trusted Source UpToDate More than 2 million healthcare providers around the world choose UpToDate to help make appropriate care decisions and drive better health outcomes. UpToDate delivers evidence-based clinical decision support that is clear, actionable, and rich with real-world insights. View Source of nightmare disorder.

Nighttime Effects

The regular, extended nightmares resulting from nightmare disorder can have several unwelcome nighttime effects.

• Fear of falling asleep: People who dread having nightmares may develop somniphobia, the fear of falling asleep. This anxiety may cause some to delay bedtime or attempt to sleep with the lights on, behaviors that can further compromise sleep.
• Compromised sleep quantity and quality: Because nightmares cause a person to wake in a state of high alert, they decrease the amount of sleep that person is able to get. Often, people find it difficult to fall back asleep Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source after a nightmare. When they do, their sleep can be restless and less restorative.
• Disruptions for partners and caregivers: People who wake up after having a nightmare may interrupt the sleep of their partners or caregivers. This can particularly affect the caregivers of children, who often require reassurance following a nightmare.
• Insomnia: Recurring nightmares may lead to insomnia, a sleep disorder characterized by difficulty falling and staying asleep.

Daytime Effects

The sleep disturbances and distress caused by nightmare disorder can create a number of problems during the day.

• Persistent negative emotions: Having recurring nightmares can leave people in a state of distress. In some cases, the emotions that manifest during a nightmare remain long after it has passed.
• Sleepiness: The delayed bedtimes, nighttime awakenings, and poor quality sleep associated with nightmare disorder can all contribute to daytime sleepiness and fatigue.
• Cognitive issues and impaired functioning: Following nightmares, people may have difficulty concentrating or remembering, which may affect their ability to function at home, work, or school.

Diagnosing Nightmare Disorder

A primary care physician or a sleep specialist can provide an initial diagnosis of nightmare disorder. They may ask questions about the frequency, duration, timing, and content of the nightmares, as well as how they affect the person’s sleep and life. A doctor may also gather information using a five-question diagnostic test called the nightmare disorder index. 

A diagnosis of nightmare disorder may be given if a person meets these criteria Trusted Source UpToDate More than 2 million healthcare providers around the world choose UpToDate to help make appropriate care decisions and drive better health outcomes. UpToDate delivers evidence-based clinical decision support that is clear, actionable, and rich with real-world insights. View Source :

• Recurring instances of disturbing and well-remembered nightmares in which the dreamer’s physical safety, security, or survival is at risk
• Alertness and orientation upon waking from nightmares
• Enduring feelings of distress or a compromised ability to function at home, school, work, or in one’s social life

In some situations, doctors may not diagnose nightmare disorder if they determine that a person’s nightmares are symptoms of another physical or mental health condition.

Nightmare Disorder Treatment

For some people, nightmare disorder resolves on its own over time. But for others, clinical interventions or lifestyle changes may be necessary to alleviate or eliminate recurring nightmares.

Psychotherapy

Nightmare disorder frequently occurs alongside mental health conditions like anxiety, depression, and PTSD. Treating these conditions may help to reduce the severity and frequency of nightmares and improve overall well-being. Additionally, several therapeutic approaches may be successful in directly treating nightmare disorder.

• Cognitive behavioral therapy (CBT): A common treatment for nightmare disorder, CBT can help a person understand how their thoughts and emotions might influence their nightmares, as well as how certain behaviors might contribute to or alleviate nightmares and poor sleep.
• Imagery rehearsal therapy (IRT): A variant of CBT, imagery rehearsal therapy involves creating a new script Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source for the recurring nightmare that changes the sequence of events or the storyline into a more pleasant narrative. 
• Hypnotherapy: To treat recurring nightmares, a therapist may ask a person under a highly relaxed state of hypnosis to imagine an ideal night of sleep Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source and also offer words of encouragement, letting them know they are safe and no longer need nightmares.
• Desensitization: Desensitization helps people unlearn responses to a particular situation or stimulus. In children with nightmares, therapists may encourage desensitization by having a child write about or illustrate their nightmares. 

Other possible psychotherapy treatments for nightmare disorder include sleep dynamic therapy, lucid dreaming therapy, muscle relaxation techniques, and exposure, relaxation, and rescripting therapy. Assessment by a psychiatrist or licensed mental health professional can help determine which therapeutic options may be most beneficial for a person with nightmare disorder.

Medications

Some medications, alone or in conjunction with behavioral therapy, show promise in treating nightmare disorder, although research on this topic is limited. It is best to discuss these options with a medical provider.

Wearable Technology

Preliminary evidence indicates that a smartwatch program called NightWare might improve sleep for people with PTSD-related nightmares. Authorized by the U.S. Food and Drug Administration in 2020, this product responds to physiological changes that take place during a nightmare and delivers vibrations intended to take the wearer out of REM sleep without waking them. 

While early data is promising, more research is needed to validate the efficacy of this application as a treatment for nightmare disorder.

Sleep Hygiene

Some lifestyle changes that support better sleep and reduce stress may help with nightmare disorder. People with nightmare disorder may benefit from adopting practices known to promote healthy sleep, collectively called sleep hygiene. These include:

• Going to bed and waking up at the same time every day
• Establishing a bedtime routine that includes relaxing activities, such as a warm bath, gentle stretching, or listening to soothing music
• Creating a quiet and comfortable sleep environment
• Getting regular exercise earlier in the day
• Avoiding large or heavy meals before bedtime
• Avoiding screen time for at least an hour before going to bed 
• Limiting or eliminating caffeine intake, alcohol consumption, and smoking in the hours before bedtime

When to Talk to Your Doctor

If you experience nightmares at least once a week, or if frequent nightmares affect your sleep, mood, or ability to function, consider speaking with a medical or mental health professional. If you suspect that recurring nightmares are caused by a new medication or could be the result of recreational drug use, make sure to mention these concerns to your provider.

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