What are nightmares?
Nightmares are unpleasant dreams which may awaken the sleeper during the night and are usually remembered in the morning. They are most commonly seen in toddlers and generally resolve by school age. Dream sleep (or rapid eye movement (REM) sleep) usually occurs in the second half of the night, towards the early morning. Most children can be reassured that they are in a safe environment with nearby caregivers and will have their nightmares resolve on their own. However, if a child has persistent nightmares which are distressing or disruptive, a daytime stressor should be sought (such as anxiety, depression, or abuse). Adults, however, usually have nightmares associated with either post-traumatic stress disorder (PTSD) or due to medications.
Can medications provoke nightmares?
There are two ways that medications commonly promote nightmares. One is by increasing REM (rapid eye movement) sleep (or dream sleep). The other is by suppressing REM sleep, which then wears off, and REM rebound (or unsuppressed and increased REM sleep) occurs. Medications that increase REM sleep include blood pressure pills (antihypertensives), those that prevent smoking, some anticonvulsants (medications for seizures) and antidepressants (tricyclics and monoamine oxidase inhibitors). Medications which initially suppress REM, then lead to REM rebound include the sedative hypnotics or sleeping pills (barbiturates, benzodiazepines) and alcohol.
What is post-traumatic stress disease (PTSD)?
Post-traumatic stress disease or PTSD refers to a syndrome that results following extreme trauma or stress, such as combat experiences or physical abuse. The nightmares that occur with post-traumatic stress disease usually involve reliving the stressful event repeatedly. This disorder requires professional Psychiatric evaluation and treatment. It sometimes is improved by a medication to block REM sleep known as prazosin.
How are nightmares treated?
In children, nightmares are generally treated with reassurance. The child is shown that the parent or caregiver is readily available and that the bedroom is a safe and secure place. If nightmares persist, then other causes may be sought. These may include violent television shows or video games, bullying at school, and physical abuse. Any child with persistent and recurrent nightmares deserves a thorough evaluation by their Pediatrician or a Sleep Specialist.
In adults, nightmares are frequently treated by stopping the provoking medication or agent, and in children, nightmares may also be a sign of trauma or abuse. Adults may respond to “directed dreaming” or psychotherapy which empowers them to rehearse “happy endings” to better cope with the dreams. Medications which suppress dream sleep (REM) may be necessary in severe cases.
What are sleep terrors (night terrors)?
Night terrors are quite different from nightmares, although they also commonly occur in school-aged children. With night terrors, the child appears to suddenly emerge from a deep and sound sleep with inconsolable screaming and panic. However, after the parent or caregiver rushes into the room and awakens the child, the child denies having any bad dreams and may not be even aware of the episode. It is unclear what causes these episodes, but it is thought to be the disruption of sleep with brief partial awakenings. In general, these disappear in adolescence and are rarely associated with any significant disorders. However, stereotyped episodes, where the same movements and vocalizations occur over and over, may instead be a sign of nocturnal seizures and should be further evaluated. This is usually done with a sleep study (polysomnogram) or electroencephalogram (EEG).
What is dream enacting behavior disorder (REM behavior disorder or RBD)?
REM sleep behavior disorder (RBD) occurs when a person acts out their dreams during sleep. Normally, when one is asleep, you may dream that you are swimming, but your arms and legs do not actually move in the bed while you dream. With RBD, whatever physical activity you dream you do, you actually do. So, a sleeping person with RBD who dreams they are swimming will have their arms and legs rhythmically moving in the bed trying to swim. This can lead to injury to the dreamer or bed partner. For example, a husband may dream that he is fighting off an attacker, and actually be hitting his wife in bed. These dreams are often vivid and remembered by the dreamer. They can be provoked by alcohol, medications (such as antidepressants), and by damage to the brain (tumors, stroke, et cetera).
RBD is also associated with the future development of Parkinson’s and Alzheimer’s dementia. Therefore, patients newly diagnosed with this disorder are often seen by both a Sleep Specialist and a Neurologist. The diagnosis is usually confirmed with the documentation of a loss of expected paralysis during REM sleep, or simply put, moving during dream sleep when you are not supposed to move. Patients may also undergo imaging studies of the brain, such as an MRI (magnetic resonance imaging). Once diagnosed, there are effective medications to suppress the movements and dreams. Most commonly, benzodiazepine medications are used which suppress REM sleep. Steps may also be taken to protect the dreamer and their bed partner, similar to those described in the previous chapter on sleep walking.
What if I wake up dreaming? What are hypnagogic hallucinations?
It is not unusual to occasionally awaken still dreaming, as dream sleep or REM sleep usually occurs in the early morning prior to awakening. However, frequent “daydreams” on early awakening are referred to as hypnagogic hallucinations and may be due to underlying sleep disorders, most commonly, narcolepsy. These dreams usually occur at the cusp of awakening when the sleeper is not fully awake or fully asleep. They can range from visual dreams (colors, shapes, animals, lights) to auditory ones (growling, purring, other sounds). They are brief and are usually easily identified by the sleeper as dream material and fantasy, unlike true hallucinations which seem very real. If frequent and persistent, a thorough evaluation for sleep disorders, especially narcolepsy and severe sleep apnea, should be undertaken.
What if I wake up choking (nocturnal laryngospasm)?
Nighttime choking episodes (or nocturnal laryngospasm) occurs when a sleeper is suddenly awakened with the sensation of throat closing or suffocation. It is usually relieved by sitting up and taking a deep breath or drinking water. The most common causes of this are sleep apnea, gastroesophageal reflux disease or GERD, or nocturnal asthma. It can also rarely be due to epilepsy (or seizures). These patients should all be evaluated by a Sleep Specialist and the choking episodes usually resolve with treatment of the underlying cause. It is possible that asthma or gastroesophageal reflux occur exclusively at night, without episodes in the daytime. For GERD, it can happen exclusively at night because lying on one’s back allows for stomach acid to flow backwards into the throat or esophagus very easily. This is unlikely in the daytime when the upright position and gravity tend to keep acid in the stomach.
Acid reflux may similarly provoke asthma because after a reflux episode, the acid or stomach materials may flow back down the throat and mistakenly enter the lungs instead of returning to the stomach. This will provoke a spastic response of the airways and a sensation of choking or wheezing. Asthma can also be worse during the evening because of the change in the body’s stress hormones (circadian rhythm). Both asthma and GERD are sometimes treated by the addition of medications at three o’clock in the afternoon or bedtime dosing.