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What is it?

Nightmare disorder is a parasomnia. A parasomnia involves undesired events that come along with sleep. Nightmares are disturbing, visual dream sequences that occur in your mind and wake you up from your sleep.

Nightmare disorder develops when you have nightmares on a frequent basis. This can cause someone to fear going to sleep. You may worry each night that you will have another nightmare. The nightmares also keep you from sleeping well. They cause you to feel anxious and scared when you wake up. This makes it hard for you to relax and go back to sleep again. This loss of sleep can cause you to have even more intense nightmares. These sleep problems can make you very sleepy during the day.

Nightmares seem very real. They become more disturbing as they unfold. They tend to involve the emotions of anxiety, fear, or terror. Other emotions that nightmares provoke include the following:

• Anger
• Rage
• Embarrassment
• Disgust
• Other negative feelings

The dream content most often involves great danger that comes upon the person dreaming. It may also focus on other distressing themes. You can normally recall very clearly the details of the nightmare when you wake up.

A disturbing dream that does not wake you up is not considered a nightmare. It is simply a “bad” dream. You may have more than one nightmare in a night. The content of these dreams can often have the same theme.

Nightmares tend to occur during rapid-eye-movement (REM) sleep. There are five stages of sleep that make up one sleep cycle. You normally complete four to six sleep cycles in one night. The fifth stage of each cycle is called REM sleep. With normal sleep patterns, people cycle though the five sleep stages about every 90 minutes. REM sleep makes up about 20-25% of your total sleep time.

The first REM period tends to last for only a few minutes. The REM stage gets longer during each sleep cycle. Your last period of REM sleep may last as long as an hour. This means that nightmares are more likely to occur in the last third of the night.

Nightmares that arise due to a trauma can also occur in earlier, non-REM stages of sleep. They may depict some of the events from the trauma. They may even replay the event in the dreamer’s mind.

Nightmare disorder can be confused with sleep terrors or REM sleep behavior disorder (RBD). A person having a sleep terror often screams, kicks, thrashes and even bolts out of bed. He can be very hard to wake up. When he does, he is very confused. He only recalls fragments of a dream. Sleep terrors tend to occur in the first third of the night. RBD involves a person acting out his dream. It can even result in physical injury. It is most common in middle-aged men.

Who gets it?

Nightmares are very common. They can begin at any age. They usually begin before a child reaches six years of age. About 75% of children recall having at least one or a few nightmares during childhood. They occur in equal rates among boys and girls. Estimates are that 10% to 50% of children from three to five years of age have severe nightmares that disturb their parents. Nightmares in children tend to reach a peak by 10 years of age. After that they decrease. Some children may continue to have nightmares as teens and adults. For them it may be a lifelong problem.

About 50% to 85% of adults report having a nightmare at least every now and then. They tend to become less frequent and intense as you age. Teen and adult women report nightmares more often than teen and adult men. Women are also more open to talking about them.

Nightmare disorder is not as common. About 2% to 8% of people have a current problem with nightmares. The use of some medications may be a cause of nightmare disorder. You may be more likely to have nightmare disorder if a relative also has it.

How do I know if I have it?

1. Do you often wake up from sleep due to a disturbing dream?
2. Do these dreams evoke emotions of fear, anger, sadness or disgust?
3. Are you alert and able to think clearly as soon as you are awake?
4. Do you clearly recall details of the dream?
5. Do these dreams often occur during the late portion of your sleep period (near morning)?
6. Do you have trouble going back to sleep after these dreams?

If you answered yes to these questions, then you might have nightmare disorder.

It is also important to know if there is something else that is causing your sleep problems. They may be a result of one of the following:

• Another sleep disorder
• A medical condition
• Medication use
• A mental health disorder
• Substance abuse

Do I need to see a sleep specialist?

You should see a sleep specialist if nightmares cause you great anxiety or often disrupt your sleep. The sleep specialist will help make an accurate diagnosis of your problem. He or she will also rule out possible underlying causes of the problem. Sleep physicians do not typically treat nightmares. Most often they refer you to an experienced counselor or psychologist.

What will the doctor need to know?

The doctor will need to know when the nightmares began. He or she will want to know how often they occur and what they are about. The doctor will need to know your complete medical history. Be sure to inform him or her of any past or present drug and medication use.

Also tell your doctor if you have ever had any other sleep disorder. Find out if you have any family members with sleep problems. It will also be helpful if you fill out a sleep diary for two weeks. The sleep diary will help the doctor see your sleeping patterns. This data gives the doctor clues about what is causing your problem and how to correct it.

Will I need to take any tests?

Tests are not normally needed for someone who suffers from nightmares. Your doctor may have you do an overnight sleep study if your problem is severely disturbing your sleep. This study is called a polysomnogram. It charts your brain waves, heart rate, and breathing as you sleep. It also records how your arms and legs move. This study will help reveal if your nightmares are related to any other type of sleep disorder.

How is it treated?

Nightmare disorder is often treated with counseling or psychotherapy. These methods help resolve conflicts that produce nightmares. A therapist will help you address some of the underlying causes of the nightmares. He or she will also help you process the thoughts and feelings that are involved. Intensive therapy may be needed for a person whose nightmares stem from a traumatic event in his or her life.

Systematic desensitization is another form of treatment. It is used when recurrent nightmares appear after severe trauma. It involves gradual exposure to the dream content.

Hypnosis is also used to address nightmares. But this method has limited scientific evidence.

Managing stress in your life is an important way to help manage nightmares. Relaxation training may also help. It can assist you when the nightmares keep you from being able to go back to sleep. This method helps you reduce the anxiety or tension that keeps you from falling asleep.

Medications are not commonly used for this problem. They may be considered in extreme cases. Some medications may help by reducing the percentage of REM sleep. Others reduce awakenings from dreams.

By Donald R. Townsend, PhD
Updated October 21, 2005

More Information
Dreams and Nightmares

Preventing Parasomnias

Comparing Parasomnias

Comparing Child Parasomnias

Tips for Parents
Most children have a nightmare at least every now and then. Follow these tips to help a child who has nightmares:

• Let your child sleep with a special blanket or stuffed animal for security.
• Use a dim nightlight in your child’s room to help him or her feel safe.
• Respond quickly to comfort your child when he or she wakes up from a nightmare.
• Discuss nightmares openly with your child during the day.
• Assure your child that it is normal for children and even adults to have nightmares.
• Talk to your child’s doctor if recurring nightmares greatly disturb your child.

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