Clinical ReviewNightmares: from anxiety symptom to sleep disorder
Section snippets
Introduction and definition(s)
The Diagnostic and Statistical Manual for Mental Disorders, edition IV-TR,1 defines a nightmare as an ‘extremely frightening dream’ from which a person wakes up directly. After a nightmare orientation is fast and the nightmare leaves a detailed memory ‘usually involving threats to survival, security, or self-esteem’.1
Nightmares are highly visual and have a complicated plot. Nightmares differ from night terrors since the latter phenomenon is not accompanied by visual images, and orientation
Polysomnography
Polysomnographic recordings in the sleep laboratory yield a serious problem: nightmares tend to occur less often in this setting.2 As noted by Woodward et al.,12 several studies have found a low incidence of posttraumatic nightmares in the sleep laboratory—about 1–10% per night.3, 4, 13, 14, 15, 16, 17 The artificial setting of the sleep laboratory may influence the contents of dreams, as two studies found that dreams recalled in the sleep laboratory are less charged with affect than dreams
Genetic factors and persistence
The only published study examining the genetic aspects of nightmares, a nationwide twin-cohort study in Finland, has found a genetic influence on nightmares.30 For childhood nightmares genetic effects accounted for an estimated proportion of 0.45, whereas this proportion was around 0.37 in adult nightmares.
Interestingly, this study also found that about 80–90% of adults who had had nightmares in childhood reported still having nightmares ‘at least sometimes’. Although this finding could have
Pharmacological interventions
The last review on nightmares (1993)75 concluded that cognitive-behavioral treatment is the treatment of choice for nightmares. This conclusion is supported by studies into the pharmacotherapeutic treatment of posttraumatic nightmares, which have shown a poor response to treatment.76
In recent years, however, several studies77, 78, 79, 80 have indicated that Prazosin seems to reduce posttraumatic nightmare frequency. Prazosin, an alpha-1 adrenergic antagonist, has been used for treating
A sleep medicine perspective on nightmares
As Krakow et al. [37] noted, it is still a prevailing view in the (mental) health care that nightmares are secondary to another disorder (e.g. PTSD or another anxiety disorder). In this psychiatric view, nightmares are a symptom of a larger syndrome: a nightly symptom of anxiety. This means that nightmares need not be treated (and diagnosed) specifically. For example, Kaplan and Sadock [99] state in their Synopsis of Psychiatry: ‘No specific treatment is usually required for nightmares.’ In
Conclusion
In summary, many findings on nightmares are preliminary and this developing field of sleep medicine needs to be further investigated. The DSM-IV-TR definition of nightmares needs to be refined since two criteria seem unnecessarily narrow; nightmares are not restricted to fear or anxiety alone and direct awakening is not related to increased waking distress. Bad dreams that do not awaken the person should be included in the definition, preferably with an extra code for the presence of direct
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