Nightmare Disorder

Nightmare disorder is repeated extended, well remembered dysphoric dreams involving threats to survival or security, with rapid orientation on waking, causing distress or impairment.

• Prevalence 2 to 6% of adults have frequent nightmares; common in children (aged 3 to 6), in PTSD (up to 80%), and in women.
• Arise from REM sleep, usually later in night.
• Triggers: trauma, stress, medications (beta blockers, SSRIs, antiparkinsonian drugs, withdrawal from REM suppressants like alcohol, benzodiazepines), sleep deprivation.
• Comorbid insomnia, depression, anxiety, suicidality.

• Vivid disturbing dreams with full recall, awakening with anxiety, fear of sleep, daytime fatigue.
• Different from sleep terrors (non-REM, no recall, inconsolable) and REM behaviour disorder (acting out dreams).
• Autonomic arousal is mild.

• Clinical history, sleep diary, Nightmare Frequency Questionnaire; drug and substance review.
• Polysomnography only if atypical (violent behaviours, suspected seizures, sleep apnoea).
• Screen for PTSD, depression, anxiety, suicidal thoughts.
• Exclude sleep terrors, REM sleep behaviour disorder, nocturnal seizures, sleep apnoea.

• Imagery rehearsal therapy (rewriting the nightmare and rehearsing the new script daily over 3 to 6 sessions) is first line, with response in 70%.
• CBT for insomnia, sleep hygiene, exposure and relaxation.
• Prazosin 1 mg at night, titrated up to 3 to 15 mg (mixed evidence; monitor orthostatic hypotension), particularly in PTSD.
• Alternatives: clonidine 0.1 to 0.3 mg at night, trazodone 25 to 100 mg, doxazosin 4 to 16 mg.
• Adjust causative medications; treat PTSD.
• Children: reassurance, comforting routine, avoid frightening media.