Nightmares and Bad Dreams
What they contain, who has them, and the treatment that works.
A bad dream disturbs; a nightmare wakes. Robert and Zadra (2014) collected 9,796 dreams from 572 people over several weeks and analysed the 253 nightmares and 431 bad dreams among them: physical aggression was the commonest nightmare theme (49 per cent), then interpersonal conflict (21), failure and helplessness (16), being chased (11), and a sense of evil (11); bad dreams were dominated by conflict. Nightmares were more bizarre and more often ended badly, and the authors read them as the rarer and more severe form of one process. Fear was the commonest emotion but not the only one: a third of nightmares ran on sadness, anger, or disgust.
Most adults have one or more a year; between two and six in a hundred have one a week (Levin and Nielsen, 2007), more among women, the young, and the anxious. In children they peak between five and ten and fall away. They are a core symptom of post-traumatic stress disorder, where they replay or rework the trauma and are the symptom that lasts longest, and they are raised by the drugs that alter REM (beta-blockers, the dopamine agonists, withdrawal from antidepressants and alcohol) and by fever. Levin and Nielsen’s model holds that the dream’s ordinary work of fear extinction, the recombining of memory elements under lowered affect, fails under a high load of distress in a person disposed to it.
They can be treated, and not with drugs. Imagery rehearsal therapy, in which the dreamer writes the nightmare down, changes it in any way they like while awake, and rehearses the new version for a few minutes a day, reduced nightmares and the symptoms of post-traumatic stress in a randomised trial of 168 assault survivors (Krakow et al., 2001), and the American Academy of Sleep Medicine (2018) recommends it first. Prazosin, a blood-pressure drug that blocks noradrenaline, helped in small trials and failed in a large one of 304 veterans (Raskind et al., 2018). Lucid dreaming, in which the dreamer learns to recognise the nightmare and change it from inside, has case series and small trials behind it.
The night terror is a different thing: a scream and a bolt upright from deep sleep in the first hours of the night, with no dream, no memory, and a child who cannot be comforted and does not remember in the morning; it runs in families, peaks in early childhood, and is outgrown. The sleep-paralysis attack, with its weight on the chest and its presence in the room, is a third thing, and has its own reading in the Clinical Readings.
Sources
- Robert, G., and Zadra, A. (2014). “Thematic and content analysis of idiopathic nightmares and bad dreams.” Sleep 37.
- Levin, R., and Nielsen, T. A. (2007). “Disturbed dreaming, posttraumatic stress disorder, and affect distress: a review and neurocognitive model.” Psychological Bulletin 133.
- Krakow, B., et al. (2001). “Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial.” JAMA 286.
- Raskind, M. A., et al. (2018). “Trial of prazosin for post-traumatic stress disorder in military veterans.” New England Journal of Medicine 378.
- Morgenthaler, T. I., et al. (2018). “Position paper for the treatment of nightmare disorder in adults: an American Academy of Sleep Medicine position paper.” Journal of Clinical Sleep Medicine 14.
A review of the literature for readers; not medical advice.