Nightmare Disorder

Sleep disorders, or parasomnias, occur in 35–45% of children aged 2–18 years. Common sleep disorders in children include sleepwalking, sleeptalking, night terrors, and nightmares.

Childhood parasomnias are believed to be benign disorders caused by immaturity of neural circuits, and most resolve during adolescence.[4]

Nightmares are defined as “recurrent episodes of awakening from sleep with recall of intensely disturbing dream mentation, usually involving fear or anxiety, but also anger, sadness, disgust, and other dysphoric emotions.”[5]

Nightmare disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) as repeated awakenings with recollection of terrifying dreams, usually involving threats to survival, safety or physical integrity.[1]

Nightmares are frightening events for a child and may be concerning for the family; however, they are transient and developmentally normal for most children.[6]

Upon awakening from a nightmare, the child is alert and able to recall the dream in detail. The child's reaction to the nightmare may interrupt the parents' sleep. In the morning, children often recall the arousal. The sleep disturbance may impair the child’s daily functioning.

Diagnostic criteria (DSM-5-TR)

The specific DSM-5-TR criteria for nightmare disorder are as follows:[1]

• Recurrent episodes of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival or security or physical integrity. The nightmares generally occur in the second half of a major sleep episode.

• On waking from the nightmare, the individual rapidly becomes oriented and alert.

• The episodes cause significant distress or impairment in social, occupational or other areas of functioning.

• The symptoms cannot be explained by the effects of a drug of abuse or medication.

• The nightmares cannot be attributed to another mental disorder (i.e., posttraumatic stress disorder, delirium) or medical condition.

In addition, nightmare disorder is specified by duration: acute (less than 1 month), subacute (1–6 months), persistent (more than 6 months); and by the severity based on frequency: mild (less than one episode a week), moderate (multiple time a week), severe (nightly).

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. REM sleep is characterized by EEG activity similar to a wakeful pattern. In older children and adults, 75% of sleep is non-REM sleep, which consists of 4 stages.

Dreaming and nightmares occur during REM sleep, and they are more frequent in the second half of the night.

Nightmares are often confused with night terrors, which are episodes of extreme panic and confusion associated with vocalization, movement, and autonomic discharge. Night terrors occur during non-REM sleep. Children with night terrors are difficult to arouse and console and do not recall a dream or nightmare.

Frequency

Nightmares are common, with three quarters of children experiencing a nightmare at least once.[7]

Prevalence varies because of different diagnostic criteria and different study populations. Nightmares have been noted to occur in 2–11% of young children “always and often” and in 15–31% “now and then.”[8] Some studies estimate as many as 50% of children aged 3–6 years have nightmares that disturb both their and the parents' sleep.

Approximately one third of adults with recurrent nightmares have onset of symptoms in childhood.

Race

Nightmares occur in all races and cultures, with no reported differences in prevalence.

Sex

Young children exhibit no sex differences in nightmare prevalence.[7] However, in one study of children aged 13–16 years, more girls than boys reported nightmares.[6]

Among adolescents and young adults, women report nightmares more frequently than men.[9]

Age

In one study, nightmares first emerged as a parent-reported sleep problem in children aged 24–36 months, but onset typically occurs between the ages of 3 and 6 years.[10]

Peak incidence occurs in children aged 7–9 years.[11] A decrease in frequency is noted between ages 10 and 12 years.[7]

The prevalence of nightmares and other parasomnias declines in school age and adolescence, presumably due to progressive neurological maturation and reduction in separation anxiety.[12]

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.

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 content of nightmares is age related, with imaginary creatures most common in 7- to 9-year-old children and being kidnapped common in 10- to 12-year-old children.[1] Other common themes are loss of control and fear of injury.

Vocalizations may occur, but movement and autonomic symptoms are minimal.

When awakened, the child becomes oriented, can be calmed, and usually recalls the details of the dream.

Good history taking allows the clinician to rule out other sleep disorders such as night terrors.

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.

Movement is uncommon owing to REM sleep–induced atonia.

Developmental, genetic, psychological, and organic factors can contribute to occurrence. A high prevalence of parasomnias in early childhood has been associated with separation anxiety.[7]

Multiple studies have demonstrated that a child’s general level of anxiety is related to nightmare severity and frequency.[1]

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, including tricyclic antidepressants and selective serotonin reuptake inhibitors, can lead to an REM rebound effect that is accompanied by nightmares.

Nightmares are associated with anxiety disorders, particularly in adolescents.[13]

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.

In a mainly female adult sample from the United Kingdom, nightmare occurence was associated with higher levels of worry, depersonalization, hallucinatory experiences, paranoia, and sleep duration. Nightmare severity was associated with higher levels of worry, depersonalization, hallucinatory experiences, and paranoia.[14]

In a Finnish adult population, depression and insomnia were the strongest risk factors for nightmare frequency.[15]

Nightmares may be more frequent during pregnancy.[16]

Routine radiographic, ECG, or EEG studies are unnecessary.

Polysomnography may be indicated. The hallmark of the various parasomnias is whether they occur during REM sleep, at the sleep-wake transition, or during slow-wave sleep. Polysomnographic studies demonstrate abrupt awakenings from REM sleep, usually during the second half of the night, prior to report of a nightmare.[1]

Reassurance and conservative management is the only treatment required for sporadic nightmares.

Daytime stressors should be identified and resolution attempted. Bedtime should become a safe and comfortable time when parents read to and talk with the child. Parents should monitor media exposure, as this influences dream content.[2] Television viewing should be avoided for about 2 hours prior to bedtime.[3]

The most common strategies reported by children for handling their nightmares include ignoring/distraction, talking to parents, or hugging soft toys.[1]

Several different cognitive-behavioral methods have been reported to be effective in treating nightmares in children.[17]

Hypnosis has been reported to be effective in treating nightmares and other parasomnias in children and adults.[3]

If the nightmare is recurrent, discussing dream content and rescripting may help.

In adults with PTSD-associated nightmares,[18] image rehearsal therapy is recommended. Other treatments that may be considered for PTSD-associated nightmares include cognitive behavioral therapy; eye movement desensitization and reprocessing; exposure, relaxation, and rescripting therapy; the atypical antipsychotics olanzapine, risperidone, and aripiprazole; clonidine; cyproheptadine; fluvoxamine; gabapentin; nabilone; phenelzine; prazosin; topiramate; trazodone; and tricyclic antidepressants.[19, 20]

In adults with nightmare disorder, the following treatments may be considered: cognitive behavioral therapy; exposure, relaxation, and rescripting therapy; hypnosis; lucid dreaming therapy; progressive deep muscle relaxation; sleep dynamic therapy; self-exposure therapy; systematic desensitization; testimony method; nitrazepam; prazosin; and triazolam.[19]

Clonazepam and venlafaxine are not recommended for the treatment of nightmare disorder in adults.[19]

Psychiatric intervention may be warranted for various therapies.

Psychological evaluation is indicated for patients whose nightmares occur more than twice a week over a period of several months or when the nightmares are of great severity.

Medications are neither helpful nor indicated in children.

Medications for adults with PTSD-associated nightmares or with nightmare disorder are discussed in the Treatment section.