Nightmare Disorder DSM-5 307.47 (F51.5)

Nightmare Disorder DSM-5 307.47 (F51.5)

Nightmare disorder

Nightmare disorder - also known as dream anxiety disorder - is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) diagnosis assigned to individuals who experience frequent severe nightmares. Nightmare disorder falls under the parasomnia category of sleep disorders, characterized by abnormal events or experiences that occur when an individual is falling asleep, asleep or waking up.

Introduction

From time to time, everyone experiences nightmares, which are unpleasant dreams that result in an intense emotional reaction and often wake the sleeper. Individuals suffering from nightmare disorder experience a higher frequency of nightmares, which may occur as the individual is falling asleep, during periods of sleeping, between sleep stages or when waking up. Typical emotional reactions include fear, distress, anxiety and panic.

Between 80 and 90 per cent of the population is believed to experience nightmares at some point in their lives, with around five per cent of people suffering from nightmares as a chronic condition1. Nightmares differ from bad dreams in that they cause the individual to wake immediately - usually when the feeling of terror reaches a climax.

Nightmare disorder can have several causes or no identifiable cause, and can affect the sufferer’s life in various ways, such as by disrupting sleep and causing sleep deprivation through a fear of falling asleep, as well as causing or exacerbating other psychological or medical conditions1.

Symptoms

Symptoms of nightmare disorder include the following:

  • Frequent, intensely disturbing dreams that wake the sleeper
  • Subsequent dysphoric emotions such as anger or sadness, as well as fear
  • Waking with clear, unconfused recall of the dream
  • Difficulty falling asleep again following the episode
  • Occurrence of nightmares in the latter half of the sleep cycle

Diagnosis criteria for nightmare disorder

There is no specific test for diagnosing nightmare disorder, so physicians may rely on a variety of diagnostic techniques, such as the patient’s medical history, knowledge of past or present use of drugs or medication, presence of any other sleep disorders and questions about whether family members also suffer or have suffered from sleep problems.

Patients may also be required to keep a sleep diary for around two weeks, which will help the physician keep track of the individual’s sleeping patterns and note any contributing factors or underlying causes of the disorder.

This may be followed up by an in-lab sleep study, during which the patient spends the night in a dedicated sleep center, hospital or other agreed location, and is monitored by medical machinery (typically EEG, EOG, ECG, EMG), which measures airflow, bodily movements, heart activity and more.

The patient may also be referred to a psychotherapist for analysis and exploration of any factors or events that may be causing the nightmare disorder2.

Causes of nightmare disorder

There is no single cause of nightmare disorder; instead, there are various underlying or contributing factors, which may include:

Medication and drugs

A number of drugs and medicines are associated with causing nightmares, especially those that affect the central nervous system’s neurotransmitter levels like narcotics, barbiturates and antidepressants. Medications like selective serotonin reuptake inhibitors, beta blockers, selegiline and flutamide, and drugs like ketamine, are all associated with nightmares. Withdrawal from some drugs like alcohol, barbituates and benzodiazepines may also result in nightmares3.

Stress and anxiety

Stress and anxiety can make sleeping difficult, as the mind may turn over concerns even during the night, disrupting normal sleeping patterns. Dreaming is how the brain organizes information, so stressful episodes may, in turn, cause nightmares in which the sufferer relives unpleasant experiences in their sleep.

Trauma

Similarly, trauma can be a contributing factor to the development of nightmare disorder. The loss of a loved one, witnessing an intensely frightening event or suffering physical trauma can all be factors contributing to the onset of nightmare disorder. In particular, dream anxiety disorder is associated with post-traumatic stress disorder (PTSD) - studies have shown that around 80 per cent of PTSD sufferers experience frequent nightmares4.

Mental health disorders

It is not known whether certain mental health conditions can cause nightmare disorder - rather, a number of such conditions, including borderline personality disorder, depression and schizophrenia spectrum disorders, are associated with nightmare disorder.

Personality types

Suggestions have been put forward that personality type may contribute to the development of nightmare disorder in some individuals. People with creative personalities - described in psychological terms as having ‘thin boundaries’ - are thought to be more susceptible to nightmares because of their heightened artistic abilities, sensitivity and related vulnerability5.

Other triggers may include a predisposition to nightmare disorder as an inherited condition - although this has not been proven, and factors like consuming food during nocturnal hours, which may interrupt sleep with digestion-related processes or cause symptoms that wake the sleeper, like gastroesophageal reflux6.

Differential diagnosis

Nightmare disorder shares symptoms with a variety of other conditions, including:

Night terrors - an individual suffering from night terrors may experience nightmares but these usually occur earlier in the night than with nightmare disorder, which manifests during REM sleep. The sufferer cannot usually recall much of the nightmare7.

PTSD - nightmares are characteristic of PTSD, however, these unpleasant dreams usually involve the sufferer reliving trauma and will usually be accompanied by other symptoms like anxiety and difficulty sleeping.

Underlying medical conditions - nightmares may affect individuals suffering from underlying medical disorders, especially those of the brain, like mental impairment or delirium8, as well as seizures9 and depressive illnesses10.

Medication - certain medications and drugs may induce nightmares. Withdrawal from some medications may also result in intensely unpleasant dreams.

Living with nightmare disorder

Nightmare disorder affects children, women and men and is different from regular nightmares in that the dreams usually wake the individual and can be well recalled. While nightmares are very common, nightmare disorder is significantly rarer.

The condition may interfere with everyday life in a number of ways, such as by causing a fear of sleeping and subsequent sleep deprivation, which affects concentration and mood, in turn having the potential to negatively affect occupational capabilities and relationships.

Nightmare disorder may be a lifelong condition but it can be managed, often with therapy and/or medication.

Treatment

Nightmare disorder can be treated in a number of ways, usually with therapy, medication or a combination of both.

Commonly, prazosin is prescribed to treat nightmare disorder but the following medications may also be considered, especially in cases of PTSD-related nightmare disorder11:

  • Trazodone
  • Atypical antipsychotic medications
  • Topiramate
  • Low dose cortisol
  • Fluvoxamine
  • Triazolam and nitrazepam
  • Phenelzine
  • Gabapentin
  • Cyproheptadine
  • Tricyclic antidepressants

Therapies may be advised, either with medication or in isolation. These include:

Cognitive behavioral therapy (CBT)

The most common type of non-medicinal treatment for nightmare disorder is CBT, which encompasses a variety of psychotherapeutic and behavioral techniques. Some of the methods used to treat nightmare disorder include:

Image rehearsal therapy - which requires the patient to recall and write down their nightmare, change the theme or other elements to make the dream more positive, and then rehearse the scenario to influence subsequent dreams.

Self-exposure therapy - requires the patient to expose themselves to situations that provoke their anxiety, starting with the least provocative scenario until their fear decreases and then move up the list.

Lucid dreaming therapy - the patient restructures their nightmare and alters the story line during sleep by realizing that they are dreaming, or becoming ‘lucid’ during the nightmare.

In addition to CBT, other methods of treatment may be utilized, such as hypnosis or the progressive deep muscle relaxation technique, in which the sufferer clenches and relieves every muscle in turn to improve relaxation and release tension.

With treatment, nightmare disorder can be managed to significantly reduce instances of unpleasant dreams and improve the patient’s quality of life.


Dr. Kevin Fleming obtained his PhD from Notre Dame and is the Founder of Grey Matters International (www.greymattersintl.com) a neuroscience-based behavior change consulting firm.

References

1American Sleep Association Nightmares (2007) Referenced at: https://www.sleepassociation.org/patients-general-public/nightmares/

2American Academy of Sleep Medicine Nightmares - Self-Test & Diagnosis (2016) Referenced at: http://www.sleepeducation.org/sleep-disorders-by-category/parasomnias/nightmares/self-test-diagnosis

3Pagel, JF (2000) Nightmares and disorders of dreaming Am Fam Physician Apr 1;61(7):2037-42, 2044 Referenced at: http://www.aafp.org/afp/2000/0401/p2037.html#afp20000401p2037-t1

4Harvard Medical School (2016) Nightmares and the Brain Referenced at: http://neuro.hms.harvard.edu/harvard-mahoney-neuroscience-institute/brain-newsletter/and-brain-series/nightmares-and-brain

5 Hartmann, E; Rosen, R; Rand, W (1998) Personality and Dreaming: Boundary Structure and Dream Content Dreaming 8: 31. doi:10.1023/B:DREM.0000005913.21794.1f. Referenced at https://en.wikipedia.org/wiki/Boundaries_of_the_mind#cite_note-Hartmann1-1

6 Karmos (2012) Do people really get nightmares from eating late? Referenced at: http://www.health.harvard.edu/staying-healthy/do-people-really-get-nightmares-from-eating-late

7Hasler B, Germain A Correlates and Treatments of Nightmares in Adults (2009) Sleep Med Clin. Dec;4(4):507-517 Referenced at: http://patient.info/doctor/nightmare-disorder

8Eiser, A (2007) Dream disorders and treatment Curr Treat Options Neurol Sep;9(5):317-24 Referenced at: http://patient.info/doctor/nightmare-disorder

9 Silvestri R, Bromfield E; Recurrent nightmares and disorders of arousal in temporal lobe epilepsy Brain Res Bull. 2004 Jun 30;63(5):369-76 Referenced at: http://patient.info/doctor/nightmare-disorder

10Nakajima S, Inoue Y, Sasai T, et al (2014) Impact of frequency of nightmares comorbid with insomnia on depression in Japanese rural community residents: a cross-sectional study Sleep Med. 2014 Mar;15(3):371-4. doi: 10.1016/j.sleep.2013.11.785. Epub 2014 Jan 31. Referenced at: http://patient.info/doctor/nightmare-disorder

11 Standards of Practice Committee Best Practice Guide for the Treatment of Nightmare Disorder in Adults (2010) Journal of Clinical Sleep Medicine, Vol.6, No. 4 Referenced at: http://www.aasmnet.org/resources/bestpracticeguides/nightmaredisorder.pdf

 


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