Sleep

Nightmare

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Nightmare, Frightening Dream

  • Epidemiology
  1. Gender predominance
    1. Children: Equal among girls and boys
    2. Adults: More common in women
  2. Prevalence
    1. Children (ages 3 to 5 years): 10-50%
    2. Children (ages 5 to 12 years): 20-39% within 1 week
    3. College Students: 47% within prior two weeks
    4. Adults in general: 5-8%
  3. Timing
    1. Onset of Nightmares between ages 3 and 6 years old
    2. Peak Incidence between ages 6 and 10 years old
  • Pathophysiology
  1. Most commonly associated with REM Sleep
  • Symptoms
  1. Vivid, terrifying dreams
  2. Occurs late in sleep, during second half of sleep cycle (4 to 6 am)
  3. Sudden awakening from sleep
  4. Detailed recall of bizarre dream
  5. Difficulty returning to sleep after dream
  6. Increasing reluctance to go to sleep
  7. Increased sympathetic drive
    1. Tachycardia
    2. Tachypnea
    3. Diaphoresis
  • Differential Diagnosis
  1. See Medication Causes of Nightmares
  2. Night Terror (Children under age 8 years)
  3. Post-Traumatic Stress Disorder
  4. Depression
  5. Anxiety Disorder with Panic Attacks
  6. Schizophrenia
  7. Chemical Dependency with Drug Withdrawal
    1. Alcohol Abuse with withdrawal
    2. Benzodiazepine Abuse with withdrawal
    3. Barbiturate Abuse with withdrawal
  8. REM Behavior Disorder associated neurologic disorder
    1. Parkinson's Disease
    2. Narcolepsy
    3. Dementia
  • Management
  1. See Post-Traumatic Stress Disorder
  2. See Night Terrors for Management in Children
  3. Offer reassurance
    1. Episodes tend to resolve spontaneously
  4. General measures
    1. Treat as with other parasomnias
    2. See Sleep Walking
    3. Ensure adequate sleep and consistent sleep schedule
    4. Ensure safe home
  5. REM Behavior Disorder
    1. Consider Selective Serotonin Reuptake Inhibitor (SSRI)
    2. Consider Clonazepam 0.5 to 1.0 mg nightly as needed (adults)
  6. Recurrent Nightmares
    1. Cognitive-Behavioral therapy effective in 70% of patients