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Sleep Disorder: Nightmares

Updated: Feb 25, 2008

Introduction

Background

Sleep disorders occur in 35-45% of children aged 2-18 years. Nightmares are frightening events for a child and may cause the entire family distress; however, they are sporadic in most children. Nightmare disorder is characterized by repeated episodes of a frightening or unpleasant dream that disrupts the child's sleep. The child's reaction often interrupts the parents' sleep. Upon awakening from a nightmare, the child is alert and aware of the present surroundings, but the sleep disturbance causes distress and impairment in everyday functioning.

Nightmares are often confused with the parasomnia known as night terrors, which are episodes of extreme panic and confusion associated with vocalization, movement, and autonomic discharge. Children with night terrors are difficult to arouse and console and do not remember a dream or nightmare.

Pathophysiology

Sleep is divided into 2 distinct states: rapid eye movement (REM) and nonrapid eye movement (non-REM). REM and non-REM sleep alternate in 90- to 100-minute cycles. In older children and adults, 75% of sleep is non-REM sleep, which consists of 4 stages. Most dreaming occurs during REM sleep. REM sleep is characterized by EEG activity similar to a wakeful pattern.

Frequency

United States

Prevalence varies because of different diagnostic criteria and different study populations. Some studies estimate as many as 50% of children aged 3-6 years have nightmares that disturb both their sleep and the parents' sleep.

Race

Nightmares occur in all races and cultures.

Sex

Both sexes are equally affected.

Age

Peak incidence occurs in children aged 3-6 years.^1,2

Clinical

History

Sporadic nightmares are common in children and usually occur in the middle of the night or early morning, when REM sleep is more common.
The dream typically involves some danger or threat to the child.
- The child may dream about physical danger (eg, being chased).
- A nightmare may also involve psychological threat (eg, being teased).
- Nightmares may involve a monster, ghost, fierce animal, or bad individual.
- Loss of control and fear of injury are common themes.
Vocalizations, movement, and autonomic symptoms are minimal.
When awakened, the child becomes oriented, can be calmed, and usually recalls the details of the dream.

Physical

Nightmares are not associated with specific physical findings.
Heart rate and respiratory rate may increase or show increased variability before the child awakens from a nightmare. Mild autonomic arousal, including tachycardia, tachypnea, and sweating, may occur transiently upon awakening.

Causes

Developmental, genetic, psychological, and organic factors can contribute to occurrence.
Approximately 7% of individuals who have frequent nightmares have family history of nightmares.
Nightmares are more common in children with mental retardation, depression, and CNS diseases; an association has also been reported with febrile illnesses.
Medications may induce frightening dreams, either during treatment or following withdrawal. Withdrawal of medications that suppress REM sleep can lead to an REM rebound effect that is accompanied by nightmares.
Daytime emotional conflicts and psychological stress often contaminate sleep and predispose the child to nightmares.
Nightmares may result from a severe traumatic event and may indicate posttraumatic stress disorder.

Differential Diagnoses

Sleep Disorder: Night Terrors

Workup

Imaging Studies

Routine radiographic, ECG, or EEG studies are unnecessary.

Treatment

Medical Care

Reassurance
- Reassurance is the only treatment required for sporadic nightmares. Although all stressors cannot be removed from a child's life, parents can attempt to make bedtime a safe and comfortable time.
- Encourage parents to spend time reading, relaxing, and talking with the child.
- If the child has a recurring nightmare, instructing parents to encourage the child to imagine a good ending may help.

Consultations

Psychological evaluation is indicated for patients whose nightmares occur more than twice a week over a period of several months.

Medication

Medications are neither helpful nor indicated.

Follow-up

Further Inpatient Care

Inpatient care is not indicated.

Patient Education

Reassure parents and patients that, in most cases, nightmares are sporadic. If a child experiences nightmares following a severe traumatic incident, or if nightmares occur more than twice a week over a period of several months, psychiatric intervention can help. Although not all everyday stressors can be removed, parents can strive to make bedtime a safe and comfortable time by spending time reading and relaxing with the child.
For excellent patient education resources, visit eMedicine's Sleep Disorders Center. Also, see eMedicine's patient education articles Disorders That Disrupt Sleep (Parasomnias), Night Terrors, and REM Sleep Behavior Disorder.

Miscellaneous

Medicolegal Pitfalls

Failure to obtain an adequate history may lead to an incorrect diagnosis and unnecessary testing.
Failure to adequately educate the parents concerning the benign nature of the problem and its final outcome may lead to excessive anxiety and a search for an alternative cure.

References

DiMario FJ Jr, Emery ES 3rd. The natural history of night terrors. Clin Pediatr (Phila). Oct 1987;26(10):505-11. [Medline].
Leung AK, Robson WL. Nightmares. J Natl Med Assoc. Mar 1993;85(3):233-5. [Medline].
Dahl RE. The pharmacologic treatment of sleep disorders. Psychiatr Clin North Am. Mar 1992;15(1):161-78. [Medline].
Guilleminault C, Palombini L, Pelayo R, Chervin RD. Sleepwalking and sleep terrors in prepubertal children: what triggers them?. Pediatrics. Jan 2003;111(1):e17-25. [Medline]. [Full Text].
Ipsiroglu OS, Fatemi A, Werner I, Paditz E, Schwarz B. Self-reported organic and nonorganic sleep problems in schoolchildren aged 11 to 15 years in Vienna. J Adolesc Health. Nov 2002;31(5):436-42. [Medline].
Siegel JM. Why we sleep. Sci Am. Nov 2003;289(5):92-7. [Medline].
Wise MS. Parasomnias in children. Pediatr Ann. Jul 1997;26(7):427-33. [Medline].

Keywords

sleep disorder, anxiety dream, terrifying dream, parasomnias, nightmare, night mare, incubus, rapid eye movement, REM, non-REM, nonrapid eye movement, mental retardation, depression, posttraumatic stress disorder

Contributor Information and Disclosures

Author

Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; Medical Director, Paws for Health Pet Visitation Program
Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Medical Editor

Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center
Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

Further Reading