Nightmares

• Most people have experienced nightmares, but this phenomenon seems to occur most commonly in children, especially preschoolers between the ages of 3 to 6.
• This may be because this is the age at which normal fears develop and a child's imagination is very active. If nightmares occur repeatedly, the possibility of a nightmare disorder should be considered.
• Nightmares can be distinguished from night terrors as children waking from nightmares are able to recall their dreams vividly both upon awakening and in the morning.
• In contrast, when children experience night terrors, they remain in a deep sleep and do not recall the event. Each of these can be equally upsetting to parents.

A nightmare is a dream turned bad. Most nightmares involve a threat or a dangerous situation that the sleeper feels unable to control during the dream. Through history, nightmares have been attributed to visits from demons to evidence of some type of underlying disturbance. Today, it is recognized that occasional nightmares are a normal event. As stated above, the majority of people have experienced nightmares at some point, although adults seem to have bad dreams less often than children. Nightmares can include monsters or other scary figures or may involve situations such as being chased or other danger.

Nightmares are not the same as night terrors. Children who are experiencing a nightmare do not typically vocalize or thrash about. In contrast, night terrors are associated with crying or screaming and movement where it appears that the child is panic-stricken. Children who experience night terrors remain asleep throughout the event and do not remember that it occurred the next day. Night terrors take place during non-REM sleep and often occur during the first half of the night.

We don't know why nightmares occur. Possible causative factors include normal development, dealing with daytime stresses, or exposure to frightening situations. Febrile illness and various medications may trigger nightmares in some children, as can being overtired or eating too close to bedtime. Additionally, significant life changes (starting class at a new school, parental divorce) may lead to nightmares. Between 5 and 10 percent of children with frequent nightmares have a strong family history of nightmares.

Anxiety disorders, intellectual disability, and depression can also lead to nightmares. Nightmares that follow a particularly traumatic event may be a sign of posttraumatic stress disorder.

Although nightmares are often considered a problem of childhood, adults may experience nightmares as well. Pregnancy can trigger bizarre dreams and nightmares; workers who change shifts routinely may experience shift-work sleep disturbance as well as nightmares. Adults are more likely to be exposed to certain medications that can trigger nightmares either during treatment (such as statins) or as an effect of discontinuing the medication (as with certain antidepressants). Consumption or withdrawal of alcohol or illicit drugs can also lead to nightmares. Paradoxically, medications used to treat insomnia (zolpidem/Ambien® and zalepon/Sonata®) have also been implicated in causing nightmares.

Dreams and nightmares occur during REM (rapid eye movement) sleep. Sleep is categorized into REM and non-REM stages, with most people experiencing four to five sleep cycles each night. Each cycle lasts for 90 to 100 minutes. REM sleep occurs more frequently during the second half of the night. Nightmares occur most commonly at this time.

Research suggests that dreams can be impacted by conscious thought before bed. Remembering fun events or funny stories can sometimes help derail a nightmare before it begins.

• No specific medical treatment is indicated for nightmares.
• If a nightmare occurs, reassurance and comfort are appropriate.
• If nightmares occur frequently, an evaluation of daytime routines is needed. This includes assessing exposure to daytime stressors, television, or video games and bedtime practices.
• Lucid dreaming, or being aware during a dream, can help redirect a nightmare into a pleasant dream.

Nightmare prevention

Practicing good sleep hygiene is important for everyone who has experienced nightmares. This includes:

• establishing a bedtime routine that starts at the same time every evening and
• making bedtime a safe and comfortable time.

For children:

• using a nightlight can decrease fear or anxiety;
• discussing “monsters” -- either under the bed or in the closet -- and showing the child that nothing harmful is present can be reassuring; and
• imagining alternate endings to nightmares can provide a child with a sense of empowerment prior to going to sleep.

For adults, improvement in sleep/wake cycles can be seen with:

• eliminating television or computer exposure an hour or more before bedtime;
• maintaining consistent sleep and wake times;
• eliminating working in bed;
• cutting back on caffeine after 1PM (for those who work daytime hours); and
• practicing lucid dreaming.

If nightmares occur frequently (more than two nights per week over many months), then psychological evaluation is suggested. Different types of psychotherapy, including cognitive-behavioral therapy and hypnosis, can be of benefit in decreasing the frequency of nightmares.

Most people who have experienced a nightmare find that this is an isolated event. The long-term outcome is generally good. If nightmares occur frequently over several months or follow a traumatic event, evaluation by a psychologist or psychotherapist is indicated.

Nightmares are not associated with sleepwalking or other parasomnias (disruptive sleep disorders).