Nightmare disorder is part of a cluster of diagnoses called the sleep-wake disorders. Sleep-wake disorders are a group of psychiatric conditions that include:
These disorders are broadly characterized by disruptions in sleep and wakefulness. Individuals with insomnia disorder have frequent difficulty falling asleep or staying asleep. Individuals with hypersomnolence disorder feel excessively sleepy during the day, despite obtaining what for most people would be a full night of sleep. Individuals with parasomnias such as non-rapid eye movement sleep arousal disorder and nightmare disorder experience unusual behaviors while sleeping, such as sleep walking, or vivid and disturbing dreams or night terrors.
Some sleep-wake disorders, including insomnia disorder and hypersomnolence disorder, are associated with disturbances in the amount of time the individual spends asleep (too much or too little) or the times at which the individual sleeps (often outside of the desired sleeping window). Other disorders, such as the parasomnias, are not associated with disturbances in the quantity or timing of sleep per se, but are instead associated with behavioral disturbances during sleep or frequent highly distressing dreams.
Nightmare disorder is a psychiatric disorder that increases in prevalence throughout childhood and adolescence (up to 7% of children meet criteria for the disorder) and then decreases in prevalence in adulthood. Nightmare disorder is characterized by repeated nightmares, which are extremely distressing, vivid, and well-remembered dreams.
These dreams usually occur in the second half of the major sleep episode and often include themes of threats to survival, security, or physical integrity. The individual becomes oriented and alert fairly quickly after waking from the dreams.
Occasional nightmares are fairly common in children. Therefore, nightmare disorder is diagnosed only when the nightmares occur repeatedly and cause clinically significant distress or impairment.
Nightmare disorder is more likely to cause severe distress than clinically significant impairment. Nevertheless, impairment can occur if the nightmares lead to sleep avoidance or impaired concentration or efficiency during the day.
Nightmares are often comorbid with other psychiatric disorders, including post-traumatic stress disorder, insomnia disorder, psychosis, mood disorders, anxiety disorders, and grief. For this reason, nightmare disorder should be diagnosed only when the nightmares are sufficiently severe to warrant independent clinical attention. Additionally, nightmare disorder should not be diagnosed in addition to PTSD unless the nightmares are temporally unrelated to PTSD (i.e., precede the onset of PTSD or persist after the remission of PTSD).
Little is known about the neurobiology of nightmare disorder. However, some studies have linked nightmares to various neurotransmitter systems, in particular norepinephrine, serotonin, and dopamine, and to activity in affective neural networks, including the amygdala, hippocampus, medial prefrontal cortex, and anterior cingulate cortex. It is not clear if different types of nightmares (e.g., those associated with nightmare disorder versus substance use or withdrawal) share a common underlying pathophysiology. Individuals with nightmare disorder are more likely to endorse a history of adverse events, which may contribute to the incidence of nightmares.
Published guidelines for the treatment of nightmares and other pediatric sleep disorders are available from the Agency for Healthcare Research and Quality.
Little clinical research has investigated the treatment of nightmare disorder in children and adolescents. Nevertheless, clinical guidelines suggest that the following strategies may be helpful:
Additionally, there are case reports of successful use of prazosin, an alpha-one blocker, to treat nightmares in adolescents. However, controlled trials supporting the use of this and other medications in younger patients are lacking.
Little clinical research has investigated the treatment of nightmare disorder in children and adolescents. Nevertheless, clinical guidelines suggest that the following strategies may be helpful:
Additionally, there are case reports of successful use of prazosin, an alpha-one blocker, to treat nightmares in adolescents. However, controlled trials supporting the use of this and other medications in younger patients are lacking.