What are nightmares? What can be done about them?

nightmaresWe have all had nightmares.  Waking from sleep with a distressing feeling, either being aware that we have been dreaming about something that is very unpleasant and that has caused us to wake up, or even being aware that our heart is beating and with such a sense of fear that it is difficult to return to sleep.  Whilst most people experience them occasionally, for some people nightmares occur every night and can induce a fear of even going to bed.

Why do nightmares occur?

We are not entirely sure why nightmares occur but we know some circumstances under which they are likely to occur more often.  When the brain has high levels of ‘fight and flight’ or stress hormones such as adrenaline, noradrenaline, dopamine and serotonin vivid dreams and nightmares are more likely to occur.  These circumstances can occur for people who are on medications. Many of the modern antidepressants which can increase levels of these hormones.  They can also occur when people are more stressed or have higher levels of stress hormones during sleep.  A common condition that is associated with nightmares is post-traumatic stress disorder.  People who have been exposed to previous trauma very commonly have nightmares during sleep.  These can be the same nightmare played repeatedly over and over, if trauma was a particular event, or can be nightmares of varying content.

What’s the difference between nightmares and night terrors?

nightmaresNightmares are when we awaken from a dream and can recall the dream has been unpleasant or distressing.  Night terrors are a form of parasomnia where people wake without that preceding recollection of a dream or visual imagery but wake with a sense of terror with high adrenaline levels.  They can notice their heart is beating very fast and feel like it is difficult to return to sleep.  Night terrors are actually very common in young children of pre-school or early primary school age and less common in adults but can still occur.

How can nightmares be reduced?

Managing nightmares usually starts with using a psychology-based approach.  If the nightmare is of a very similar and predictable theme then a technique called Imagery Rehearsal Therapy has been described which is quite successful.  This involves, whilst awake, rehearsing the dream, progressing to a certain point just before the dream usually becomes distressing and then redirecting the dream to an alternate, less distressing ending.  Research to support this form of treatment showed the number of nights with nightmares per week reduced from an average of 3.8 to 1.3, and the number of nightmares per week reduced from 6.4 to 2.4.

Although at the moment we do not have reliable ways of inducing lucid dreaming there has been some recent research published on techniques that may increase an individual’s ability to lucid dream. If an individual was able to lucid dream, they could then redirect distressing dreams or nightmares when they occurred in a similar way to Imagery Rehearsal Therapy, but would not need to repeatedly rehearse a specific ending and could apply the technique to any nightmares rather than just recurring ones.

If nightmares occur secondary to medications then reducing the dose of medications is often enough to reduce associated nightmares.  Unfortunately, switching from one antidepressant to another often does not fix the problem, as most antidepressants can induce nightmares or vivid dreams.

If nightmares are occurring as part of post-traumatic stress disorder then managing trauma and reducing the effect of stress hormones such adrenaline and dopamine in the brain during sleep can reduce nightmares.  The effect of these hormones can be blocked using medications such as prazosin (alpha-blocker) or propranolol (beta-blocker) which block the effect of adrenaline on the brain.  There is good research for the use of prazosin in nightmares as part of post-traumatic stress disorder in veterans of combat but I will commonly use prazosin in people with nightmares and trauma from other causes.

Although there is not research to support the use of mindfulness for nightmares, it is a technique that I will use. The aim is to use mindfulness to enable disconnecting from the emotion of recurrent nightmares which can be a self-perpetuation cycle. It needs to be done cautiously, as particularly in individuals with post-traumatic stress disorder, periods of quiet meditation can provide ‘space’ for intrusive distressing thoughts or memories. So, I will usually recommended people interested in using mindfulness to help with nightmares work individually with a psychologist with experience in using mindfulness in trauma, rather than as part of a generic group or class.

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