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Every time, we all tend to experience bad dreams or nightmares. These can be described as negative dreams with some unpleasant feelings (fear or anxiety) attached. Nightmares are very common in children between the ages of 5 and 10. Nightmare disorders, on the other hand, are extremely rare and occur when nightmares are frequent, which causes distress & interruption in the sleep cycle.
What Exactly Nightmare Disorder is?
Individuals suffering from nightmare disorder awaken completely, orient immediately, and remember their dream vividly. A sense of anxiousness also follows. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) outlines the following basic components for diagnosing nightmare disorder.
- Recurrent episodes of extended, extremely dysphoric, and well-remembered dreams usually involve efforts to avoid threats to one's survival or security.
- Excessive daytime fatigue leads to poor functioning at work or in social situations.
- Changes in behavior. And,
- Increased fear/anxious feelings regarding the dark and nighttime.
In terms of frequency, a nightmare disorder can be classified as mild when less than one episode per week on average is reported, a moderate disorder when one or more episodes occur per week but less than nightly, and a severe disorder when there are nightly episodes.
Causes of the Disorder
Nightmares, as discussed above, are vivid dreams which content is associated with some unpleasant feelings. Even though the exact causes of nightmares are not known, research shows they can be triggered by the following- stress, anxiety, trauma, substance misuse, exposure to scary movies/books, etc. Instances such as a big move, death of a loved one, or upcoming examination could be a precursor to increased nightmares. The causes of nightmare disorders are also vague. Instead of a causational relationship, the following psychopathological conditions have been associated with nightmare disorders in a correlational manner. This includes post-traumatic stress disorder (PTSD), Bipolar Personality Disorder (BPD), Major Depressive Disorder (MDD), and substance abuse. Keeping psychiatric populations in focus, studies reported on subsamples such as PTSD at 50–70%, depression at 17.5% & insomnia at 18.3%. These studies suggest a high prevalence of nightmares in a psychiatric population, regardless of the primary diagnosis. However, no study reported prevalence rates of nightmare disorders across all psychiatric disorders. Additionally, a 57% prevalence of nightmare disorder was found among patients with dissociative disorder.
In efforts to quantify and assess the quality of nightmares in a more standardized manner, several assessment tools have been devised. For example, the Nightmare Frequency Questionnaire (NFQ) can assess the frequency of nightmares. More specifically, the Mannheim Dream Questionnaire records the childhood nightmare frequency and the relative number of recurrent nightmares in adults. Other psychometrically constructed instruments, such as the Nightmare Distress Questionnaire (NDQ), assess general concerns about nightmares, including an individual's impact on sleep quality, daytime beliefs & perceptions. Apart from these, some instruments focus on anxiety symptoms, such as the Van Dream Anxiety Scale, or behavioral consequences, such as the Nightmare Behaviour Questionnaire.
Many patients choose to live with their nightmares and associated symptoms, often because they are unaware of any treatment options. Less than one‐third believed their nightmares were treatable, and only 38% reported them to a healthcare provider. Untreated nightmare disorder often persists for decades, and although specific treatment approaches exist, patients are often not treated or are inadequately treated.
The American Academy of Sleep Medicine recommends Image Rehearsal Therapy (IRT) to treat nightmare disorders among psychotherapeutic approaches. This is a cognitive behavioral therapy in which the patient rescripts the nightmare in any way he or she wants and then practices the new dream using imagery. IRT is based on the concept that nightmares are learned behavior that can eventually be replaced with less disruptive behavior. In this case, the less disruptive behavior equates to new imagery of the dream, which does not disrupt sleep or daytime functions. Lucid dreaming is another process that can be undergone by those diagnosed with nightmare disorder. The individual is first taught to recognize when they are dreaming, and the next step is to change the dream while experiencing it so that the ending is positive. Even though only a handful of studies administering lucid dreaming have been conducted, the results are extremely promising. Few psychotherapeutic approaches are beneficial in the case of PTSD-induced nightmare disorders. These include eye movement desensitization and reprocessing (EMDR), hypnosis, etc.
Pharmacological aid for dealing with nightmares is also recommended in this condition. Some medications that show good results with minimal adverse effects are- Prazosin, Nitrazepam & Triazolam. Despite medium to large effect sizes, there is still room for further improvement of treatment outcomes. In particular, the large variance across the different work populations is still poorly understood.
Nightmare disorder, also known as dream anxiety is a subtype of parasomnia. Even though its etiology is unclear, the disorder can be diagnosed based on the frequency of nightmares & the disturbance in daily life functioning, along with high levels of fear and anxiety surrounding sleep. Different available treatment options, as well as their future implications, have been discussed.
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