Nightmares Disorder — Treatment of Nightmare Disorder
Dreams occur during all stages of sleep. Nightmares are common. They can be associated with poor sleep and diminished daytime performance. Frequent nightmares are not related to underlying psychopathology in most children and in some “creative” adults. However, recurrent nightmares are the most defining symptom of post-traumatic stress disorder and may be associated with other psychiatric illnesses. Night terrors are arousal disorders that occur most often in children and usually occur early in the sleep period. Patients with rapid-eye-movement behavior disorder often present with nocturnal injury resulting from the acting out of dreams. Dream disorders may respond to medication, but behavioral treatment approaches have shown excellent results, particularly in patients with post-traumatic stress disorder and recurrent nightmares.
A dream is the recall of mental activity that has occurred during sleep. Using polysomnography, sleep can be divided into stage 1 (sleep onset), stage 2 (light sleep), and stages 3 and 4 (deep sleep) — the non–rapid-eye-movement (REM) stages. REM sleep occurs cyclically every 90 minutes during the night in association with high brain activity, rapid spontaneous eye movements, and suppressed voluntary motor activity. Dreaming occurs in all stages of sleep. It is reported by 80 percent of persons who are awakened during REM sleep and sleep onset (stages 1 and 2), and 40 percent of persons who are awakened from a deep sleep.
Related: Having Chronic Pain without Opioid May lead to Nightmares
Patient reports about the content of their dreams vary based on the sleep stage from which they are awakened. Patient reports of dreams experienced during REM sleep tend to be bizarre and detailed, with storyline plot associations. In contrast, dreams experienced in deep sleep are more diffuse (e.g., dreams about color or an emotion). The dreams of stages 1 and 2 are simpler, shorter, and have fewer associations than the dreams of REM sleep. The ability to recall dreams may reflect the dream’s accessibility or distance from awake thought; the highest recall seems to occur during sleep stages with electroencephalographic patterns that are most like those in the waking state.
Some researchers believe that dreams have no function. Others think that dreams are the nocturnal continuation of conscious thought processing during the day or a reprogramming of the central nervous system for the next day’s conscious functioning. Evidence suggests that dreaming, like most other physiologic events, is important for learning and memory processing, gives cognitive feedback about a person’s mental functioning and helps a person adapt to emotional and physical stress.
Frightening Dreams: The Nightmare
Nightmares are vivid and terrifying nocturnal episodes in which the dreamer is abruptly awakened from sleep. Typically, the dreamer wakes from REM sleep and is able to describe a detailed, associative, often bizarre dream plot. Usually, the dreamer has difficulty returning to sleep. Nightmares are also common. In a two-week prospective study of college students, 47 percent described having at least one nightmare. Results of a general population study of 1,049 persons with insomnia revealed that 18.3 percent had nightmares. In this study, nightmares were more common in women and were associated with increases in nocturnal awakenings, sleep onset insomnia, and daytime memory impairment, and anxiety following poor nocturnal sleep. Studies of the general population reveal that 5 to 8 percent of the adult population report a current problem with nightmares
Nightmares affect 20 to 39 percent of children between five and 12 years of age. Contrary to popular belief, frequent nightmares in children do not suggest underlying psychopathology. Nightmares are often described by creative persons who demonstrate “thin boundaries” on psychological tests. Persons with thin boundaries are less likely than others to define the world around them in concrete terms. They rarely define issues as being black and white, but instead, see themselves and the world in shades of gray.
Nightmares are also associated with the use of medication, primarily those medications that affect neurotransmitter levels of the central nervous system, such as antidepressants, narcotics, or barbiturates. Intense, frightening dreams may occur during the withdrawal of drugs that cause REM sleep rebounds, such as ethanol, barbiturates, and benzodiazepines
Recommended Medication for Treating Nightmares
Clonazepam (Klonopin), in a dosage of 0.5 to 1.0 mg at bedtime, is generally effective in the treatment of REM behavior disorder. Long-term efficacy and safety have been reported, along with relapse when the medication is discontinued. Response to other medications (primarily antidepressants, e.g Sertraline (Zoloft), Escitalopram(Lexapro)) has been reported with postulated effects secondary to diminished REM sleep. Many parasomnias in adults, including night terrors, respond to this pharmacologic approach.
Some other medications that have been reported as being effective for the treatment of Nightmare Disorder include Benzodiazepines such as Alprazolam (Xanax), Diazepam (Valium), and Ativan (Lorazepam). Though these medications can be very effective for the treatment of Anxiety Attacks, Panic Attacks, and also Nightmare Disorder, patients are advised to consult with their healthcare provider before taking benzodiazepines.
