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Nightmare Disorder: Symptoms, Causes, Treatments

Written by Andrew

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scary nightmare woods

Most people have woken up from a nightmare in the middle of the night, sweaty, scared and momentarily convinced that the monster under our bed is all too real.

Most people proceed to come to their senses and fall back asleep, knowing their nightmare was a strange apparition that goes away as mysteriously as it comes.

But imagine if it came again. And again. And again.

Enter nightmare disorder—a sleep condition characterized by recurrent, vivid dreams that induce feelings of terror, stress or severe discomfort. This is not your run of the mill dream about being late for class, but something much more serious. Living with nightmare disorder is like being haunted by Freddie Krueger, a looming specter that threatens to make sleep a terrifying experience.

Read on to learn what we know about the symptoms, causes and potential treatments of nightmare disorder.

Symptoms of Nightmare Disorder

It’s probably redundant to acknowledge that nightmares are at the heart of nightmare disorder. Most people are familiar with the characteristics of a nightmare. They are dreams in which we experience extreme fear, stress, terror or any other very unpleasant feeling. Typically we wake from these dreams with a start or recall them with bitterness in the morning. But they are fleeting most of the time.

With nightmare disorder, these unpleasant events happen with alarming frequency. Essentially, nightmares become a disorder when they occur so often that it begins to affect a person’s waking life.

According to the Mayo Clinic, these are the symptoms that set nightmare disorder apart from simply having a nightmare:

  • Frequent occurrences
  • Major distress or impairment during the day, such as anxiety or persistent fear, or bedtime anxiety about having another nightmare
  • Problems with concentration or memory, or you can’t stop thinking about images from your dreams
  • Daytime sleepiness, fatigue or low energy
  • Problems functioning at work or school or in social situations
  • Behavior problems related to bedtime or fear of the dark

While nightmares are common, it is relatively rare that people develop diagnosable nightmare disorder at all. The American Academy of Sleep Medicine (AASM) reports that only 4 percent of all people suffer from nightmares so severe as to be diagnosed with nightmare disorder.

The Causes of Nightmare Disorder are Mixed

Nightmares occur from a complex web of factors. The AASM lists the following conditions as possible triggers or factors that can increase the chance of having regular or intense nightmares:

  • Another sleep disorder
  • A medical condition
  • Medication use (especially antidepressants, medicine for Parkinson’s disease and medicine for hypertension)
  • A mental health disorder such as depression, anxiety, stress or post-traumatic stress disorder
  • Substance abuse
  • Poor sleep hygiene (irregular, poor sleep)
  • High stress levels

Additionally, there is some evidence that adult women experience nightmares more often than men do. However, researchers also note that women tend to be more open and honest when discussing their dreams.

Children are also more prone to nightmares than adults. While it’s rare that children get diagnosed with nightmare disorder, they are much more likely to suffer from severe nightmares that interfere with sleep.

Nightmare Disorder is a form of Parasomnia

Parasomnias are a very specific type of sleep disorder characterized by unconscious, unintentional and otherwise unwanted physical acts that occur when we sleep. They have also been called “partial arousals,” for they put our bodies and minds in the strange area of showing signs of being awake and asleep at the same time.

Other parasomnias include sleepwalking, sleep terrors, REM behavior disorder, sleep paralysis, confusional arousal and more. While each of these is slightly different, they group them based on what part of the sleep cycle they take part in.

Nightmare disorder, along with sleep paralysis and REM sleep behavior disorder, takes place during the rapid eye movement (REM) stage. During this time, vivid dreams are common; as a result, many of the parasomnias occurring during REM sleep are linked to dream-like experiences. Like dreams, but unlike non-rapid eye movement (NREM) parasomnias, REM parasomnia episodes can often be recalled the next morning.

woman lying awake

Diagnosis and treatment options

There is no specific test or metric that a doctor will use to diagnose patients with nightmare disorder. If you feel that nightmares are severely disturbing your sleep, your doctor will likely spend time talking through your symptoms and possibly giving you a physical exam. If they believe the cause of your nightmares may be related to another underlying sleep disorder, it is common to prescribe an overnight sleep study. This will help clinicians offer an accurate diagnosis of your sleep habits and rule out any confounding sleep disturbances.

If you are diagnosed with nightmare disorder, there is treatment available to many patients. Some of the most commonly prescribed treatment options include:

  • Treating underlying medical conditions: Since nightmare disorder is often seen in conjunction with other medical conditions, treating underlying problems can greatly decrease the frequency and intensity of nightmares. Mental health issues like stress, anxiety, depression and especially PTSD are commonly cited as factors. Which leads to the development of nightmare disorder.
  • Changing sleeping habits: Improving sleep hygiene can help reduce the chance that nightmares will occur. Making sure to consider how any recent changes made to diet, lifestyle and schedule will affect sleep is a good first step. Avoid consuming media or any disturbing content close to bedtime, as well as caffeine and alcohol. If you find the themes of your nightmares to be related to any content you are consuming, try avoiding it completely.
  • Therapy: Some therapies have been recommended for the treatment of nightmare disorder. Cognitive-behavioral therapy has proven effective, especially for patients suffering from PTSD. Image rehearsal therapy, in which individuals are coached on how to replace negative images with positive ones in their dreams, also shows promise. Some evidence even suggests hypnosis may improve prognosis.
  • Medication: Certain medications are sometimes prescribed to patients to help alleviate the symptoms of nightmare disorder. Talk to your doctor about what may be right for you and take care to discuss any current medication you already take for other conditions, as these may conflict with new medications or be what’s exacerbating your nightmare disorder in the first place.

 

Sleep Paralysis: Definition, Causes, Treatments

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What Is Sleep Paralysis?

Woman with insomnia can not sleep at nightThroughout the ages, sleep paralysis has been attributed to the likes of demons, aliens and even the devil himself. Before the advent of modern medicine and the creation of research tools that have allowed us a scientific understanding of brain function, it’s not hard to see why this was the case.

Sleep paralysis is one of the most disconcerting, terrifying experiences a sleeper can have. In its strange blend of sleep and wakefulness, people feel powerless and scared, unable to physically control their own bodies. Even with a 21st century understanding of why and how this phenomenon affects certain individuals, sleep paralysis can still feel like the work of a mystical force.

So what is really going on when we wake up unable to move or sense danger? What causes sleep paralysis? Can anything be done to prevent it? Is sleep paralysis a symptom of a more serious underlying condition?

There are two main kinds of sleep paralysis

Sleep paralysis can be broken down into two distinct types: predormital and postdormital. Predormital paralysis occurs a person is falling asleep and slowly relaxes, and postdormital paralysis occurs as one is waking up.

Both forms of the disorder are characterized by the same symptoms. According to the UK’s National Health Services, during an episode of sleep paralysis you may feel:

  • awake but unable to move, speak or open your eyes
  • like someone is in your room
  • like something is pushing you down
  • intense fear

These episodes can last for several minutes. Some studies suggest that this disorder is very rare, with just over 6% of people reporting that they have experienced the phenom in their lifetime. While less than 1% of people reporting having episodes once a week. However, other studies have estimated that up to one-third of adults have experienced sleep paralysis at least once.

Sleep paralysis is a form of parasomnia

woman with sleep paralysis and panic while lying down under the blanket in bedroomLike sleepwalking, night terrors, confusional arousal, hallucinations, and others, sleep paralysis belongs to a broad category of disorders known as parasomnias.

These conditions are characterized by unwanted physical activities and behaviors that occur when our bodies and minds enter an abnormal state somewhere between sleep and wakefulness.

During the course of a normal night in bed, our body cycles through discrete stages, marked by slightly different brain and body functions. This is known as the sleep cycle. Though the term parasomnia summarizes a broad category of different behaviors, all of them take place when people get “caught” in between discrete stages of the cycle and become partially awake.

How it is linked to REM

Without getting too deep into the specifics of the different stages of sleep, there are broadly two categories known as rapid eye movement (REM) and non-rapid eye movement (NREM). Sleep paralysis is a REM type of parasomnia, meaning that it affects individuals as they enter into, or are already in, the REM stage.

During this time, dreams are more common and more vivid. Because of this, the body naturally “paralyzes” its muscles so that sleepers cannot act out their dreams in the middle of the night. This freezing of the muscles is responsible for the immobile sensation associated with paralysis.

Causes of sleep paralysis

While there is no clear cut “cause” of sleep paralysis, sleep researchers have linked this parasomnia with certain triggers and other conditions. Significant factors that can contribute to SP include:

  • Unhealthy or irregular sleep patterns: Not getting enough sleep, or getting it in irregular intervals can lead to SP. Generally speaking, the less routine your nighttime patterns are, the more susceptible to certain disorders you become.
  • Excess stress: High levels of stress can lead to insomnia, which in turn has been linked to episodes of SP.
  • Mental health disorders: Some studies have shown that the prevalence of SP is higher among populations that suffer from mental health disorders.
  • Other sleep disorders: Sleep paralysis has been linked to several other disorders, including narcolepsy, insomnia, and restless legs syndrome (RLS), among others.
  • Certain medications: Some medications might lead to episodes of paralysis, especially those taken for the treatment of ADHD.
  • Substance abuse: Along with many other sleep disorders, there seems to be a link between substance abuse and sleep paralysis, though more research is needed to establish a clear causal link between the two.

This phenomenon can happen to any person regardless of age or gender, though the first experiences with the disorder typically occur during the teenage years.

A young woman doing yoga exercise in morning in a bedroom

 

Treatment Options

Often times, this paralysis occurs so infrequently that it does not require a formal diagnosis and treatment by medical professionals. However, if episodes become frequent, or especially upsetting, there are some treatment options available to combat the episodes.

  • Improve your sleep hygiene: Try to get six-to-eight hours of rest every night. As best you can, try to go to bed and wake at the same time to set a routine your body will naturally adjust to. Avoid alcohol, caffeine, and nicotine in the evenings, as well as electronics with blue light-emitting displays.
  • Treat underlying conditions: The most important thing you can do is seek treatment for any conditions that might underpin sleep paralysis. Talk to your doctor if you suffer from other sleep disorders like insomnia or narcolepsy, or if you suspect you may have untreated mental health disorders like depression or bipolar disorder.
  • Relieve stress before bedtime: Anything you can do that makes the journey into sleepless fraught will improve your chances of healthy uninterrupted rest. Try practicing meditation or yoga in the evening, or wind down with a bath and a good book. Avoid things like social media or checking emails.
  • Talk to your doctor about medication and therapy options: If you take medication for any other condition, speak with your physician about possible side effects that may cause or exacerbate sleep paralysis. They might recommend that you change your prescription. In severe cases, some doctors might recommend cognitive behavioral therapy as treatment.

 

What Are Parasomnias?

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You’ve probably heard of insomnia, and you’re likely familiar with the concept of the paranormal. But what, exactly, is a parasomnia? Some strange combination of the two?

In a sense, yes. The prefix para-, meaning partial, and the suffix -somnia, referring to sleep, combine to accurately describe these odd disorders that manifest in the space between sleep and wakefulness. If you’ve ever had sleep paralysis, sleepwalked or experienced night terrors, you are familiar with the utterly bizarre world of parasomnias. You would probably agree that calling them a form of paranormal insomnia is not entirely wrong!

These conditions are more than a punchline, however. Parasomnia reveals interesting details about the nature of sleep and how our brains function. Moreover, we know that they can be deadly serious if they are not managed properly. Keep reading to learn what we know about this most strange set of sleep afflictions.

Caught in between worlds

In a nutshell, parasomnias refer to the unwanted physical behaviors that occur when we find ourselves in the peculiar position of being both asleep and awake at the same time. As mentioned before, sleepwalking, night terrors and sleep paralysis can all be accurately described as parasomnias; sufferers will enter a parasomniac state in the night, usually return to sleep and often have no memory of it the following morning.

During the course of a normal night, our body cycles through discrete stages, marked by slightly different brain and body functions. This is known as the sleep cycle. Though the term parasomnia encapsulates a broad category of different behaviors, all of them take place when people get “caught” in-between discrete stages of the sleep cycle and become partially awake.

What’s fascinating about parasomnia is that the specific symptoms of each of its forms arise from the unique characteristics of the two states of sleep a person gets caught in between.

NREM sleep parasomnia

Non-rapid eye movement sleep (NREM) occurs at the beginning of the sleep cycle and typically makes up about three-quarters of an adult’s total sleep time. Parasomnias that occur during this period of the cycle usually involve talking and physical movement to some degree and typically occur among younger people, aged 5 to 25. Changes to the external environment like temperature or noises can induce parasomnia during this period, as can internal changes caused by another medical condition.

Some of the most common NREM parasomnias include:

  • Sleepwalking (somnambulism): Affecting between 1 to 4% of the adult population and up to a whopping 15% of children, sleepwalking occurs during the deep sleep stages of NREM (stages III and IV), typically during the earlier part of the evening. Sleepwalkers’ activities range from sitting up in bed, walking around, cooking and even driving. Sleepwalkers will have no memory of any of this activity and can react violently if they are awakened during an episode.
  • Night terrors (sleep terrors): Like sleepwalking, night terrors typically occur during the deep sleep stages of NREM and soon after falling asleep. It is more common in children than in adults, for whom it affects only 1 to 2% of the population. A night terror can induce screaming, flailing, and intense sensations of fear. Sometimes sleepwalking will occur simultaneously. If a sleeper wakes up during this episode, they may become agitated and will certainly be disoriented. They typically have no memory of the episode afterward.
  • Sleep-related eating disorder: This is a direct subcategory of sleepwalking whereby sufferers partially awaken from any stage of the NREM portion of the sleep cycle and subsequently begin eating or drinking in an out-of-control manner. This is most common in individuals who suffer from eating disorders while they are awake, often proving a challenging obstacle to overcome on top of existing damaging habits.
  • Confusional arousal: Confusional arousal affects about 4% of the adult population according to a 2013 literature review. During an episode of confusional arousal, a person might seem to wake up, but be slow or nonsensical in their speech and thought patterns. It takes place during all stages of NREM and can occur at any point throughout the course of a night.

REM sleep parasomnias

Rapid eye movement (REM) sleep is characterized by increased brain activity and the suppression of muscle activity. During this time, vivid dreams are common; as a result, many of the parasomnias occurring during REM are linked to dream-like experiences. Like dreams, but unlike NREM parasomnia, REM episodes can often be recalled the next morning. Some of them include:

  • Sleep paralysis: Sleep paralysis can occur at any time when a person enters the REM portion of the sleep cycle. It is characterized by the awareness of being awake coupled with the inability to engage any muscles in the body. It is one of the more common parasomnias, with an especially high occurrence rate among those under 30 years old. If awakened during this state, sleepers will be lucid and completely remember the episode.
  • Nightmare disorder: This parasomnia involves frequent awakenings as a result of experiencing intense, vivid and unpleasant dreams. The disturbing content of nightmares is what differentiates them from dreams; they are also different from sleep terrors in that the sleeper experiencing a nightmare has the ability to recall the episode and the dream state areas of the brain are activated. Nightmare disorder refers to a clinically diagnosed condition where nightmares occur so frequently as to create a chronic disruption of sleep.
  • REM sleep behavior disorder: REM sleep behavior disorder is a parasomnia whereby sleepers act out their dreams through vocalizations and physical activity. It can occur during any part of the night, but is most frequently experienced in later parts of sleep. REM sleep behavior disorder is found in about 5 to 8% of adults, though it is more common in women. Most of the time this parasomnia is marked by vocalizations alone, though physical activity can sometimes accompany it. Like nightmare disorder or sleep paralysis, sleepers can often recall the dream events they were enacting, though they may be unaware of their actions in the real world.