Nightmare Disorder: Symptoms, Causes, and Treatment

Nightmare disorder (ND) is a sleep disorder in which a person consistently experiences ”frightening, vivid or disturbing dreams,” defined as nightmares, that suddenly wakes them.

Most people have a nightmare every once in a while, but when nightmares occur regularly, it may be considered nightmare disorder.

Nightmare disorder is considered a parasomnia, a type of sleep disorder that interferes with a person’s sleep by creating abnormal or undesirable experiences. 

Nightmares only occur during rapid eye movement (REM) sleep, which means they’re more likely to make an appearance after entering into a deeper sleep.

What About Night Terrors?

Night terrors are similar to nightmares but do not happen during REM sleep. Bad dreams are also different from nightmares because they do not cause an individual to wake up in a startled state.

Prevelance of Nightmare Disorder

Nightmares are more common during childhood but also prevalent throughout all ages of life. Almost 20% of children have a nightmare at least one time a week.

Nightmare disorder is prevalent in 2% to 6% of adults. It is more prevalent in women than men, and the highest peak in women is between the ages of 20 and 39. The likelihood of getting nightmares tends to decrease between the ages of 50 and 59. By the age of 60, they are more consistent and there is no longer any gender difference.

A study compared the prevalence of nightmares in older adults and college students. They found nightmares to exist in about 20% of college students and a little over 4% in older adults, presenting a very large difference.

Causes of Nightmare Disorder

The following are possible causes of nightmare disorder or conditions that coexist with nightmare disorder:

• PTSD
• Stress
• Trauma
• Anxiety
• Depression
• Suicidality
• BPD

Comorbidity

The following disorders and conditions tend to coexist with nightmare disorders.

Post-Traumatic Stress Disorder (PTSD)

Post-traumatic stress disorder (PTSD) has been shown to be greatly connected to nightmare disorder. A review of different literature included many research studies that found correlations between nightmares and PTSD.

Researchers also found that those with a history of nightmares reported having greater PTSD symptoms than those without.

Additionally, nightmares related to a traumatic event are associated with more severe PTSD symptoms. PTSD can also predispose an individual to other psychological conditions, like anxiety or depression, and these neurological or mental symptoms can increase the likelihood of having nightmares.

Anxiety, Depression, and Stress

Anxiety and depressive symptoms are associated with the experience of constant nightmares, especially anxiety.

A research study that included children and adolescents students found an association between trauma, PTSD, anxiety, and sleep disturbance.

A different study explored the connection that disturbing dreams had with anxiety and depression in adolescents ages 13 and 16. There was a correlation between SDs with anxiety symptoms and generalized anxiety disorder (GAD) for participants who were 13 years old. Those who were the age of 16, demonstrated a relationship between anxiety disorders, like overly anxious disorder and separation anxiety with SDs.

Research has found that the prevalence of nightmare disorder is high in nurses due to anxiety, depression, and stress.

460 nurses were asked to maintain a 14-day sleep diary, about 44% reported some experiences with nightmares and 7.4% met the criteria for nightmare disorder. Healthcare workers are one group of many that endure a heavy workload causing them a great deal of stress and mental adversities equating to sleep disturbances, such as nightmares.  

Suicidality

Researchers are beginning to believe that “nightmares increase one’s risk of suicidality and suicidal behavior across the lifespan.” In a review of various studies, a link between suicidal ideations and nightmare disorder is blatantly prevalent.

In a study involving women who overcame sexual assault, of those with nightmares 43% reported suicidal ideations.

Another study examined severe suicide attempts that equated to an emergency room visit, which included 165 patients admitted to the hospital. Although insomnia was the greatest sleep complaint, of the 165 participants, two-thirds reported constant nightmares.

Borderline Personality Disorder (BPD)

A study examining the association between borderline personality disorder (BPD) and nightmares, found nightmares, as well as dream anxiety, and negative quality of sleep, to be more prevalent in those with BPD, than in those without.

Of the people diagnosed with BPD, 49% suffered from consistent nightmares, and 95.5% reported some form of sleep disturbance.

Trauma

Both adults and children who have experienced early trauma have a history of altered sleep quality and nightmares. 

77% of individuals who’ve overcome sexual assault reported some form of sleep disturbance, whether it be insomnia, nightmares, or other sleep-related issues that may affect breathing or movement.

Dissociative Disorders

Dissociative disorders, which are mental disorders in which an individual experience disconnects from reality, thoughts, feelings, and identity, is also associated with nightmare disorder. Dissociative disorders may be connected to nightmares due to their comorbidity with PTSD and stress.

A study found that 57% of participants with a dissociative disorder also had nightmare disorder, and those with nightmares presented greater dissociative symptoms.

It was also discovered that undergraduate college students who reported having nightmares had more dissociative-like experiences. 

Impact on Quality of Life

Nightmare disorder has a great impact on sleep quality, mood, and energy levels. Constantly awakening in the middle of the night, especially when not going back to sleep, affects both the quantity and quality of sleep.

Sleep is a very vital aspect of life. It is how one regenerates their body and mind. Poor sleep quality is related to inflammation in the body, fatigue, mental distress, and chronic illnesses. Lack of sleep can cause great consequences to an individual’s quality of life, wellness, and health. 

The panic, anxiety, and depression associated with nightmares are also very impactful on one’s quality of life.

Those who experience PTSD nightmares could have those images resonating with them throughout their day. It is important to seek the appropriate help when nightmares begin to interfere with your quality of life and daily functioning. 

Treatment

Treatment for nightmare disorder could be both pharmacological and/or psychotherapeutic interventions. 

Pharmacological Treatment

After various clinical trials throughout the years examining the effectiveness of different medications on the reduction of nightmares, only prazosin exemplifies the most effective results.

Psychotherapeutic Treatment

Psychotherapeutic interventions consist of methodologies that are most likely conducted during therapy sessions. Some of these techniques would include cognitive-behavioral therapies, like imagery rehearsal therapy (IRT), which involves the client revisiting a specific nightmare, rewriting it to be a more pleasing dream, and imagining experiencing the new dream.  

Exposure, Relaxation, and Rescripting Therapy

Another cognitive-behavioral therapy is exposure, relaxation, and rescripting therapy (ERRT), which “combines IRT with exposure and relaxation therapy.”

There are various other techniques that can be used in therapy, like exposure therapy on its own to lessen fear related to nightmares. Another technique is a therapy treatment that helps increase lucid dreams to help an individual have more control and awareness during their nightmares to be able to alter them. 

Keep in Mind

Nightmares can bring a great deal of disturbance to an individual’s life. If you are experiencing constant nightmares that are impacting your life in some way, consider speaking with a psychiatrist.

Although nightmare disorder can appear alongside the disorders/conditions discussed in this article, that does not mean that you must have one of these in order to have constant nightmares. There could be plenty of other reasons you could be getting nightmares. It also doesn't mean you will get nightmares just because you have any of these conditions.

A nightmare every once in a while is expected, but every day or even every week can become depleting and depressing. If you are getting nightmares this frequently, it may be time to seek professional help so that you can develop a useful treatment method and gain back control of your sleep.