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Nightmare disorder is a
sleep disorder A sleep disorder, or somnipathy, is a medical disorder affecting an individual's sleep patterns, sometimes impacting physical, mental, social, and emotional functioning. Polysomnography and actigraphy are tests commonly ordered for diagnosing sle ...
characterized by repeated intense nightmares that most often center on threats to physical safety and security. The nightmares usually occur during the REM stage of sleep, and the person who experiences the nightmares typically remembers them well upon waking. More specifically, nightmare disorder is a type of
parasomnia Parasomnias are a category of sleep disorders that involve abnormal movements, behaviors, emotions, perceptions, and dreams that occur while falling asleep, sleeping, between sleep stages, or during arousal from sleep. Parasomnias are dissocia ...
, a subset of sleep disorders categorized by abnormal movement or behavior or verbal actions during sleep or shortly before or after. Other parasomnias include
sleepwalking Sleepwalking, also known as somnambulism or noctambulism, is a phenomenon of combined sleep and wakefulness. It is classified as a sleep disorder belonging to the parasomnia family. It occurs during the slow wave stage of sleep, in a state of ...
, sleep terrors, bedwetting, and
sleep paralysis Sleep paralysis is a state, during waking up or falling asleep, in which a person is conscious but in a complete state of full-body paralysis. During an episode, the person may hallucinate (hear, feel, or see things that are not there), wh ...
. Nightmare disorders can be confused with sleep terror disorders. The difference is that after a sleep terror episode, the patient wakes up with more dramatic symptoms than with a nightmare disorder, such as screaming and crying. Furthermore, they do not remember the reason of the fear, while a patient with a nightmare disorder remembers every detail of the dream. Finally, the sleep terrors usually occur during NREM Sleep. Nightmares also have to be distinguished from bad dreams, which are less emotionally intense. Furthermore, nightmares contain more scenes of aggression than bad dreams and more bad endings. Finally, people experiencing nightmares feel more fear than with bad dreams. The treatment depends on whether or not there is a comorbid
PTSD Post-traumatic stress disorder (PTSD) is a mental disorder that develops from experiencing a traumatic event, such as sexual assault, domestic violence, child abuse, warfare and its associated traumas, natural disaster, traffic collision, ...
diagnosis. About 4% of American adults are affected. Studies examining nightmare disorders have found that the prevalence rates ranges 2–6% with the prevalence being similar in the US,
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,
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,
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,
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,
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, and the
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.


Signs and symptoms

During the nightmare, the sleeper may scream and yell out things. The nightmare sufferer is often awakened by these threatening, frightening dreams and can often vividly remember their experience. Upon awakening, the sleeper is usually alert and oriented within their surroundings, but may have an increased heart rate and symptoms of anxiety, like sweating. They may have trouble falling back to sleep for fear they will experience another nightmare. A person experiencing nightmare disorder may have trouble going through everyday tasks; anxiety and lack of sleep caused by the fearful dreams may hinder the individual from completing everyday tasks efficiently and correctly. Upon experiencing this, these nightmare sufferers may consult with a psychiatrist. The sleeper may have recurring episodes of awakening while recalling the intensely disturbing dream manifestations which usually result from
fear Fear is an unpleasant emotion that arises in response to perception, perceived dangers or threats. Fear causes physiological and psychological changes. It may produce behavioral reactions such as mounting an aggressive response or fleeing the ...
or
anxiety Anxiety is an emotion characterised by an unpleasant state of inner wikt:turmoil, turmoil and includes feelings of dread over Anticipation, anticipated events. Anxiety is different from fear in that fear is defined as the emotional response ...
, but can also be triggered by
anger Anger, also known as wrath ( ; ) or rage (emotion), rage, is an intense emotional state involving a strong, uncomfortable and non-cooperative response to a perceived provocation, hurt, or threat. A person experiencing anger will often experie ...
,
sadness Sadness is an emotional pain associated with, or characterized by, feelings of disadvantage, loss, despair, grief, helplessness, disappointment and sorrow. An individual experiencing sadness may become quiet or lethargic, and withdraw the ...
,
disgust Disgust (, from Latin , ) is an emotional response of rejection or revulsion to something potentially contagious or something considered offensive, distasteful or unpleasant. In ''The Expression of the Emotions in Man and Animals'', Charles D ...
, and other dysphoric emotions. Additionally, the sleeper may experience at least one of the following two features: delayed return of going back to sleep after episodes, and having episodes in the latter half of the sleep period.


Consequences

Nightmare disorder is common: it affects about 4% of the adult population. Even if children have more nightmares than adults, only 1% of children meet the criteria of the disorder. Nightmare disorder can impair the quality of life for people who are affected by the condition. It can make the patient avoid sleep, which leads to sleep deprivation, which in turn may lead to even more intense nightmares. Some other consequences of the nightmare disorder are fatigue and
insomnia Insomnia, also known as sleeplessness, is a sleep disorder where people have difficulty sleeping. They may have difficulty falling asleep, or staying asleep for as long as desired. Insomnia is typically followed by daytime sleepiness, low ene ...
. Nightmare disorders have negative consequences on several aspects of the patient's life, such as sleep, cognitive and emotional functioning and well-being. Nightmares can also have negative impact on the bed partner's life.


Content of idiopathic nightmares

Physical aggression is the main theme of nightmares. Other fields, such as interpersonal conflict, failure, helplessness, apprehension, being chased, accidents, evil forces, disasters, insects and environmental abnormalities may also feature in nightmares. Fear is the most frequent emotion associated with nightmares, even if other emotions such as sadness, anger, and confusion can also be present.


Criteria

According to the International Classification of Sleep Disorders, the criteria needed to diagnose a nightmare disorder are the following. First, the presence of frequent nightmares that imply danger for the person and impact mood in a negative way is needed. Second, when waking up from nightmares, the person behaves in an alert way. Finally, the disorder has to have a significant impact on the patient's personal, social or professional functioning, in areas like mood, sleep, cognition, behaviour, fatigue, family and occupation.


Causes

Nightmares can be caused by extreme
pressure Pressure (symbol: ''p'' or ''P'') is the force applied perpendicular to the surface of an object per unit area over which that force is distributed. Gauge pressure (also spelled ''gage'' pressure)The preferred spelling varies by country and eve ...
or
irritation Irritation, in biology and physiology, is a state of inflammation or painful reaction to allergy or cell-lining damage. A stimulus or agent which induces the state of irritation is an irritant. Irritants are typically thought of as chemical age ...
if no other
mental disorder A mental disorder, also referred to as a mental illness, a mental health condition, or a psychiatric disability, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. A mental disorder is ...
is discovered. The death of a loved one or a stressful life event can be enough to cause a nightmare, but conditions such as
post-traumatic stress disorder Post-traumatic stress disorder (PTSD) is a mental disorder that develops from experiencing a Psychological trauma, traumatic event, such as sexual assault, domestic violence, child abuse, warfare and its associated traumas, natural disaster ...
and other psychiatric disorders have been known to cause nightmares as well. If the individual is on medication, the nightmares may be attributed to some side effects of the drug.
Amphetamine Amphetamine (contracted from Alpha and beta carbon, alpha-methylphenethylamine, methylphenethylamine) is a central nervous system (CNS) stimulant that is used in the treatment of attention deficit hyperactivity disorder (ADHD), narcolepsy, an ...
s,
antidepressants Antidepressants are a class of medications used to treat major depressive disorder, anxiety disorders, chronic pain, and addiction. Common side effects of antidepressants include dry mouth, weight gain, dizziness, headaches, akathisia, sexu ...
, and
stimulants Stimulants (also known as central nervous system stimulants, or psychostimulants, or colloquially as uppers) are a class of drugs that increase alertness. They are used for various purposes, such as enhancing attention, motivation, cognitio ...
like
cocaine Cocaine is a tropane alkaloid and central nervous system stimulant, derived primarily from the leaves of two South American coca plants, ''Erythroxylum coca'' and ''Erythroxylum novogranatense, E. novogranatense'', which are cultivated a ...
and
caffeine Caffeine is a central nervous system (CNS) stimulant of the methylxanthine chemical classification, class and is the most commonly consumed Psychoactive drug, psychoactive substance globally. It is mainly used for its eugeroic (wakefulness pr ...
can cause nightmares. Blood pressure medication, levodopa and medications for
Parkinson's disease Parkinson's disease (PD), or simply Parkinson's, is a neurodegenerative disease primarily of the central nervous system, affecting both motor system, motor and non-motor systems. Symptoms typically develop gradually and non-motor issues become ...
have also been known to cause nightmares. The nightmares may be idiopathic or could be associated with psychiatric disorders like post-traumatic stress disorder,
schizophrenia Schizophrenia () is a mental disorder characterized variously by hallucinations (typically, Auditory hallucination#Schizophrenia, hearing voices), delusions, thought disorder, disorganized thinking and behavior, and Reduced affect display, f ...
, and
borderline personality disorder Borderline personality disorder (BPD) is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, an acute fear of Abandonment (emotional), abandonment, and intense emotiona ...
. Nightmares can also be triggered by stress and anxiety and substance abuse, such as drugs that affect the neurotransmitters
norepinephrine Norepinephrine (NE), also called noradrenaline (NA) or noradrenalin, is an organic compound, organic chemical in the catecholamine family that functions in the brain and human body, body as a hormone, neurotransmitter and neuromodulator. The ...
and
dopamine Dopamine (DA, a contraction of 3,4-dihydroxyphenethylamine) is a neuromodulatory molecule that plays several important roles in cells. It is an organic chemical of the catecholamine and phenethylamine families. It is an amine synthesized ...
and
serotonin Serotonin (), also known as 5-hydroxytryptamine (5-HT), is a monoamine neurotransmitter with a wide range of functions in both the central nervous system (CNS) and also peripheral tissues. It is involved in mood, cognition, reward, learning, ...
. Nevertheless, causality between drugs such as beta-blockers or alpha-agonists and nightmares is still unclear and further research needs to be done to investigate the biochemical mechanisms of nightmares. Eighty percent of patients who have PTSD report nightmares. Patients with PTSD have symptoms that are classified into three clusters: intrusive/re-experiencing, numbing, and hyperarousal. Nightmares are usually considered to be part of the intrusive/re-experiencing symptom. Some differences exist between idiopathic and PTSD related nightmares. A person with PTSD having nightmares would wake up during the night more frequently and for a longer time than with idiopathic nightmares. Consequently, people with PTSD would have a poorer sleep quality. Furthermore, nightmares related to PTSD would be more stressful than idiopathic ones. However, further studies have to be conducted in this area to obtain more reliable results.


Assessment

Polysomnography records physiological parameters, such as electroencephalography (EEG), electromyography (EMG) and electrooculography (EOG) in a sleep laboratory. However, the frequency of posttraumatic nightmares tends to decrease in an artificial lab setting, which would impact the content of nightmares. Consequently, assessment of nightmare disorders using polysomnography has to last for a longer period, in order to let the patient get used to the artificial environment. Self-report by a questionnaire or by a diary is another way to investigate nightmare disorders. However, these methods are questionable. Indeed, when filling out questionnaires with questions about a long period, people often tend to underestimate the frequency of their nightmares because of forgetting. On the contrary, filling out a diary every day may lead to an overestimation of the numbers of nightmares, because of the focusing on this phenomenon.


Comorbidity

Studies have reported that nightmare disorders were present in 50–70% of the cases for PTSD, in 17.5% for depression, in 18.3% for insomnia, in 16.7% for schizophrenia and in 49% for borderline personality disorder. For all psychiatric disorders taken together, nightmare disorders are present in 29.9% of the cases, a much bigger rate than for the general population, which is 2–5%. Nightmare disorders can also be associated with sleep disorders such as night terrors, chronic insomnia and sleep-disordered breathing. The presence of nightmares before a trauma would influence severity of PTSD symptoms. Furthermore, having nightmares is linked to a significantly higher risk of attempting suicide and of death by suicide.


Treatment

Stress reduction techniques such as yoga, meditation and exercise may help to eliminate stress and create a more peaceful sleeping atmosphere. Diagnosis and medication can only be given to patients that report the recurring nightmares to a psychiatrist or other physician. Medications like
prazosin Prazosin, sold under the brand name Minipress among others, is a medication used to treat high blood pressure, symptoms of an enlarged prostate, and nightmares related to post-traumatic stress disorder (PTSD). It is an α1 blocker. It is a les ...
are sometimes used to treat nightmares in people with PTSD. (Archived page) Therapy usually helps to deal with the frightening themes of the nightmares and alleviate the recurrence of the dreams. The persistent nightmares will usually improve as the patient gets older. Therapy is usually efficient to treat chronic nightmares in PTSD disorder or in other population.
Eye Movement Desensitization and Reprocessing Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy designed to treat post-traumatic stress disorder (PTSD). It was devised by Francine Shapiro in 1987. EMDR involves talking about traumatic memories while engagin ...
(EMDR) is a specialized intervention in which the focus is to stimulate neural mechanisms to induce disturbing memories and experiences. It has demonstrated a significant nightmares' reduction, especially for the treatment of PTSD. Silver, Brooks and Obenchain have found a decrease of the nightmares with Vietnam War veterans after 90 days of EMDR. Jayatunge has found significant results with people who have survived to a tsunami. Greenwald has successfully used the EMDR with children. There wasn't any negative consequence due to the EMDR sessions. Imagery rehearsal therapy is a cognitive behavioral therapy where the patient rescripts the nightmare in any way they choose and then practices the new dream they choose to have using imagery. It has been shown as efficient to treat nightmare disorder in PTSD as well as in non PTSD populations. In this treatment, the person has to write a new scenario of the nightmare with positive images that will be rehearsed during 10 to 20 minutes per day, in order to change the negative content of the nightmare.
Cognitive behavioral therapy for insomnia Cognitive behavioral therapy for insomnia (CBT-I) is a therapy technique for treating insomnia without (or alongside) medications. CBT-I aims to improve sleep habits and behaviors by identifying and changing thoughts and behaviors that prevent a p ...
(CBT-I) is also efficient to treat nightmares in the PTSD population. This method aims to change sleep habits with a clinician's help and the use of tools such as a sleep diary. Although many studies have been done in which positive results were recorded, there are few studies in which results were inconclusive or had a delayed effect. Exposure, relaxation and rescripting therapy is used to treat PTSD-related nightmares. This intervention combines Imagery Rehearsal Therapy with exposure and relaxation techniques. The main objective is to work on changing maladjusted sleep habits and the trauma-related themes of nightmares. Research has been undertaken to investigate if sufferers of nightmares could benefit from the ability to be aware that they are indeed dreaming, a process known as lucid dreaming. The Lucid Dreaming Therapy is a specific method of the Imagery Rehearsal Therapy. The dreamer is conscious during their dream and can modulate it. Consequently, anxiety decreases, controllability increases, expectations change, which will impact the frequency of nightmares. Several studies have shown significant results with the lucid dreaming therapy. Two studies indicate a decrease of the nightmare frequency after only 12 weeks and one study shows, in 80% of the cases, a total disappearance of the nightmares after one year. Although these studies showed the efficacy of this therapy in the reduction of nightmare frequency on patients from the general population, so far evidence for this treatment is still weak. Systematic Desensitization, using graduated exposure, has been shown to be efficient to treat chronic nightmares. The person has to face the frightening elements of nightmares in a gradual way, from least to most stressful. When the person starts to feel unsecure, she has to manage the stress by applying a relaxation technique.


Pharmacological treatments

Pharmacological treatments could be also efficient to treat nightmare disorder. Most of the treatments were assessed to patients with PTSD. The most efficient is an alpha-blocker,
Prazosin Prazosin, sold under the brand name Minipress among others, is a medication used to treat high blood pressure, symptoms of an enlarged prostate, and nightmares related to post-traumatic stress disorder (PTSD). It is an α1 blocker. It is a les ...
, which reduces tone during sleep by blocking noradrenergic receptors. Prazosin would significantly decrease the number of PTSD related nightmares and would therefore improve sleep quality. However, only few studies considered the effect of Prazosin in idiopathic nightmares. Benzodiazepines are also often used to treat nightmare disorder, despite the lack of efficacy demonstrated in empirical studies. Some patients were also treated with atypical antipsychotic medications. Olanzapine has quickly decreased the nightmares. Two studies have shown the positive effects of Risperidone. Aripiprazole is more tolerated than olanzapine and has demonstrated substantial improvement in the nightmare frequency. Some other drugs as
clonidine Clonidine, sold under the brand name Catapres among others, is an α2A-adrenergic receptor agonist medication used to treat high blood pressure, attention deficit hyperactivity disorder (ADHD), drug withdrawal (e.g., alcohol, opioids, or nic ...
,
cyproheptadine Cyproheptadine, sold under the brand name Periactin among others, is a first-generation antihistamine, first-generation antihistamine with additional anticholinergic, antiserotonergic, and local anesthetic properties. It was patented in 1959 a ...
,
fluvoxamine Fluvoxamine, sold under the brand name Luvox among others, is an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class. It is primarily used to treat major depressive disorder and, perhaps more-especially, obsessive–compu ...
,
gabapentin Gabapentin, sold under the brand name Neurontin among others, is an anticonvulsant medication primarily used to treat neuropathic pain and also for partial seizures of epilepsy. It is a commonly used medication for the treatment of neuropath ...
,
nabilone Nabilone, sold under the brand name Cesamet among others, is a synthetic cannabinoid with therapeutic use as an antiemetic and as an adjunct analgesic for neuropathic pain. It mimics tetrahydrocannabinol (THC), the primary psychoactive compound ...
,
phenelzine Phenelzine, sold under the brand name Nardil among others, is a non-selective and irreversible monoamine oxidase inhibitor (MAOI) of the hydrazine family which is primarily used as an antidepressant and anxiolytic to treat depression and a ...
, topiramate or
trazodone Trazodone is an antidepressant medication used to treat major depressive disorder, anxiety disorders, and insomnia. It is a phenylpiperazine compound of the serotonin antagonist and reuptake inhibitor (SARI) class. The medication is taken or ...
have presented an amelioration of the nightmares. But some further researches are needed.Morgenthaler, T. I., Auerbach, S., Casey, K. R., Kristo, D., Maganti, R., Ramar, K., ... & Kartje, R. (2018). Position paper for the treatment of nightmare disorder in adults: an American Academy of Sleep Medicine position paper. ''Journal of Clinical Sleep Medicine'', 14(06), 1041-1055. Medication has shown efficacy to treat chronic nightmares among a PTSD population but the impact of pharmacological treatments on other populations, such as drug-related nightmares, are unknown. Furthermore, patients usually take more than one medication at a time, whatever the cause related to nightmares, leading to possible interactive effects.


Epidemiology

About 2–6% of American adults are affected by nightmare disorders. About 4% of American adults are affected by nightmare disorders. Women seem to be more affected than men, the ratio being 2–4 : 1. This inequality decreases with aging because of a less high prevalence in elderly women. The rate of nightmares increases from ages 10–19 to 20–39, and then decreases during the ages of 50–59. The rates of nightmares for men increases from ages 10–19 to 30–39, and then decreases at the age of 50–59. However, it is still unclear if the difference of prevalence between men and women is real or if it reflects a higher dream recall capacity of women. According to studies, children at the age of 6–10 years are 41% more likely to experience nightmares and 22% at the age of 11. Children with persistent nightmares range from 10% to 50%. However, only 1% of children meet the criteria of a nightmare disorder. Some factors tend to predict the development of a disorder from the presence of nightmares during childhood, such as a fear of going to sleep or going back to bed after a nightmare, an irregular sleep life and an avoidance of thinking about the nightmare.


Research

* Dissociative disorders are usually paired with Nightmare Disorder 57% of the time. Nightmare disorder is believed to be associated with Dissociative Disorders as a defense mechanism that is used to escape from the traumatic event that caused the Dissociative Disorder. People with Dissociative Disorder and Nightmare disorder are more likely to self-mutilate, attempt suicide, and have
Borderline Personality Disorder Borderline personality disorder (BPD) is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, an acute fear of Abandonment (emotional), abandonment, and intense emotiona ...
. *
Borderline personality disorder Borderline personality disorder (BPD) is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, an acute fear of Abandonment (emotional), abandonment, and intense emotiona ...
with Nightmare Disorder is very common, since the stages of sleep vary from that of a normal person (i.e. increased stage one sleep, and less stage four sleep). People with Borderline Personality disorder and Nightmare Disorder are usually the severest of those who have Borderline Personality Disorder; therefore, treating those with Nightmare Disorder may also help some with Borderline Personality Disorder. *
Hypnosis Hypnosis is a human condition involving focused attention (the selective attention/selective inattention hypothesis, SASI), reduced peripheral awareness, and an enhanced capacity to respond to suggestion.In 2015, the American Psychological ...
seems to be a new and effective treatment for those with Nightmare Disorder, since it increases relaxation. * Nightmare disorder is also associated with those who have lower cholesterol. This connection is unclear; however, cholesterol may affect other hormones in the body (such as
serotonin Serotonin (), also known as 5-hydroxytryptamine (5-HT), is a monoamine neurotransmitter with a wide range of functions in both the central nervous system (CNS) and also peripheral tissues. It is involved in mood, cognition, reward, learning, ...
) which may affect one's sleep.


References


External links

{{DEFAULTSORT:Nightmare Disorder Sleep disorders