User:JMilton3/Nightmare disorder

Nightmare disorder is a sleep disorder characterized by repeated intense nightmares that most often center on threats to physical safety and security. The nightmares usually occur during the second half of the night, REM stage of sleep, and the person who experiences the nightmares typically remembers them well upon waking. More specifically, nightmare disorder is a type of parasomnia, a subset of sleep disorders categorized by abnormal movement or behavior or verbal actions during sleep or shortly before or after. Other parasomnias include sleepwalking, sleep terrors, bedwetting, and sleep paralysis.

Nightmare disorders can be confused with sleep terror disorders. The difference is that after a sleep terror episode, the patient wakes up with more dramatic symptoms than with a nightmare disorder, such as screaming and crying. Furthermore, they don't remember the reason of the fear, while a patient with a nightmare disorder remembers every detail of the dream. Finally, the sleep terrors usually occur during NREM Sleep.

Nightmares also have to be distinguished from bad dreams, which are less emotionally intense. Furthermore, nightmares contain more scenes of aggression than bad dreams and more unhappy endings. Finally, people experiencing nightmares feel more fear than with bad dreams.

The treatment depends on whether or not there is a comorbid PTSD diagnosis. About 4% of American adults are affected. Studies examining nightmare disorders have found that the prevalence rates range from 2-6% with the prevalence being similar in the USA, Canada, France, Iceland, Sweden, Belgium, Finland, Austria, Japan, and the Middle East.

Treatment[edit]
There are multiple avenues that can be taken to treat Nightmare Disorder. Some methods require medications and a diagnosis from a psychiatrist or other physician, however, there are other treatments, primarily therapies, that are available which do not require medication approved by a physician. The treatments that do not require medication are as follows: Eye movement Desensitization, Imagery Rehearsal Therapy, Cognitive behavioral therapy for insomnia, Exposure, Relaxation, and Rescripting Therapy, Lucid Dreaming Therapy, and Systematic Desensitization. Therapy usually helps to deal with the frightening themes of the nightmares and alleviate the recurrence of the dreams. The persistent nightmares will usually improve as the patient gets older.

Eye Movement Desensitization and Reprocessing (EMDR) is a specialized intervention in which the focus is to stimulate neural mechanisms to induce disturbing memories and experiences. It has demonstrated a significant nightmares' reduction, especially for the treatment of PTSD. Silver, Brooks and Obenchain have found a decrease of the nightmares with Vietnam War veterans after 90 days of EMDR. Jayatunge has found significant results with people who have survived to a tsunami. Greenwald has successfully used the EMDR with children. There wasn't any negative consequence due to the EMDR sessions.

Imagery rehearsal therapy is a cognitive behavioral therapy where the patient rescripts the nightmare in any way they choose and then practices the new dream they choose to have using imagery. It has been shown as efficient to treat nightmare disorder in PTSD as well as in non PTSD populations. In this treatment, the person has to write a new scenario of the nightmare with positive images that will be rehearsed during 10 to 20 minutes per day, in order to change the negative content of the nightmare. Cognitive behavioral therapy for insomnia (CBT-I) is also efficient to treat nightmares in the PTSD population. This method aims to change sleep habits with a clinician's help and the use of tools such as a sleep diary. Although many studies have been done in which positive results were recorded, there are few studies in which results were inconclusive or had a delayed effect.

Exposure, relaxation and rescripting therapy is used to treat PTSD-related nightmares. This intervention combines Imagery Rehearsal Therapy with exposure and relaxation techniques. It contains a model that focuses on changing poor sleep habits and educating patients about trauma.

Research has been undertaken to investigate if sufferers of nightmares could benefit from the ability to be aware that they are indeed dreaming, a process known as lucid dreaming. The Lucid Dreaming Therapy is a specific method of the Imagery Rehearsal Therapy. The dreamer is conscious during his dream and can modulate it. Consequently, anxiety decreases, controllability increases, expectations change, which will impact the frequency of nightmares. Several studies have shown significant results with the lucid dreaming therapy. Two studies indicate a decrease of the nightmare frequency after only 12 weeks and one study shows, in 80% of the cases, a total disappearance of the nightmares after one year. Although these studies showed the efficacy of this therapy in the reduction of nightmare frequency on patients from the general population, so far evidence for this treatment is still weak.

Systematic Desensitization, using graduated exposure, has been shown to be efficient to treat chronic nightmares. The person has to face the frightening elements of nightmares in a gradually way, from the less to the most stressful. When the person starts to feel unsecure, she has to manage the stress by applying a relaxation technique.

Stress reduction techniques such as yoga, meditation and exercise may help to eliminate stress and create a more peaceful sleeping atmosphere.

Pharmacological treatments
Pharmacological treatments could be also efficient to treat nightmare disorder. Most of the treatments were assessed to patients with PTSD. The most efficient is an alpha-blocker, Prazosin, which reduces tone during sleep by blocking noradrenergic receptors. Prazosin would significantly decrease the number of PTSD related nightmares and would therefore improve sleep quality. However, only few studies considered the effect of Prazosin in idiopathic nightmares. Benzodiazepines are also often used to treat nightmare disorder, despite the lack of efficacy demonstrated in empirical studies. Some patients were also treated with atypical antipsychotic medications. Olanzapine has quickly decreased the nightmares. Two studies have shown the positive effects of Risperidone. Aripiprazole is more tolerated than olanzapine and has demonstrated substantial improvement in the nightmare frequency. Some other drugs as clonidine, cyproheptadine, fluvoxamine, gabapentin, nabilone, phenelzine, topiramate or trazodone have presented an amelioration of the nightmares. But some further researches are needed. Medication has shown efficacy to treat chronic nightmares among a PTSD population but the impact of pharmacological treatments on other populations, such as drug-related nightmares, are unknown. Furthermore, patients usually take more than one medication at a time, whatever the cause related to nightmares, leading to possible interactive effects.

Epidemiology[edit]
About 2-6% of American adults are affected by nightmare disorders. Women seem to be more affected than men, the ratio being 2-4 : 1. This inequality decreases with aging because of a less high prevalence in elderly women. The rate of nightmares increases from ages 10-19 to 20-39, and then decreases during the ages of 50-59. The rates of nightmares for men increases from ages 10-19 to 30-39, and then decreases at the age of 50-59. However, it is still unclear if the difference of prevalence between men and women is real or if it reflects a higher dream recall capacity of women.

According to studies, children at the age of 6–10 years are 41% more likely to experience nightmares and 22% at the age of 11. Children with persistent nightmares range from 10% to 50%. However, only 1% of children meet the criteria of a nightmare disorder. Some factors tend to predict the development of a disorder from the presence of nightmares during childhood, such as a fear of going to sleep or going back to bed after a nightmare, an irregular sleep life and an avoidance of thinking about the nightmare.