Here’s why and how sleep specialists should screen for nightmare disorder.
By Lisa Spear
Often jostled awake before sunrise, a patient came to the sleep clinic at Walter Reed National Military Medical Center in Maryland to seek relief for insomnia.
But when Brain Robertson, MD, asked her, “Why are you waking up in the middle of the night?” She immediately replied, “Oh, it’s the nightmares.”
The root cause of the patient’s insomnia turned out to be nightmare disorder, characterized by bad dreams that disrupt sleep. Patients with the condition will often experience a racing heart, night sweats, and panic attacks. Despite these symptoms, nightmare disorder is often hidden in plain sight, routinely overlooked, easy to misdiagnose, and under-diagnosed in certain populations.
In one study, only 3.9% of active-duty military personnel reported nightmares as a reason for sleep clinic evaluation, yet weekly nightmares were later found in 31.2%.1 And when nightmare disorder isn’t treated, it can spiral into alcoholism or may drive patients to suicide as they are unaware that there are effective treatment options available. Another recent study, presented at SLEEP 2022, found that nightmares linked to traumatic events in veterans are significantly correlated with suicide reattempts.2
“It is a huge issue,” says Jennifer Creamer, MD, the program director for the Sleep Medicine Fellowship Training Program at Walter Reed National Military Medical Center.
“Patients think that you can’t do anything about it, so why bring it up?” says Robertson, former chief of sleep medicine services at Walter Reed National Military Medical Center and now chief medical officer at NightWare, a digital therapeutic to treat nightmare disorder.
When treating patients at the sleep clinic in Maryland, Robertson found that many people are not forthcoming about bad dreams. Few patients report their nightmares to physicians due to stigma or feelings of embarrassment.
Nightmare disorders can masquerade as other sleep conditions or overlap with them, too. If a patient is afraid of going to sleep, they might push their bedtime further back every night and present with what looks like delayed sleep phase disorder. In some cases, the physical sensations of obstructive sleep apnea could lead to dreams of drowning or seeing a monster sitting on their chest. If the sleep apnea is treated, the bad dreams could fade away.
There are many theories about why people experience nightmares. Bad dreams could be due to a feedback loop that is happening in the brain, says Robertson. For instance, patients with post-traumatic stress disorder (PTSD) have an abundance of the neurotransmitter norepinephrine, which leads to activation of the amygdala. The amygdala drives the sympathetic activation, causing night sweats and changes in heart rate—and might be causing the nightmares, too.
“Perhaps what happens with the nightmares is that you are interpreting and bringing these physical sensations into a dream narrative,” says Robertson. “You should be having those sort of symptoms when you are afraid of something, or in danger, and so your dream narrative becomes one where you are in danger.”
Regardless of the root cause, “it is important to recognize that nightmares are underdiagnosed and patients often won’t present with that as a chief complaint,” says Creamer.
“You have to ask the patients about nightmares because they are not going to volunteer it,” Robertson says.
A study, published in the Journal of Clinical Sleep Medicine, found that in those individuals with clinically significant nightmare symptoms, less than one-third believed that nightmares were treatable.3
Creamer says there are several screening tools available to help clinicians suss out nightmare disorder patients. The option to disclose bad dreams on a written form by checking a box or listing it on a questionnaire can make some patients feel more comfortable. Even just incorporating nightmare questions on a general intake questionnaire could identify cases.
“It can take a while for patients to trust you enough to talk about nightmares because it is a sensitive issue, especially if it is in conjunction with trauma-associated sleep disorder in which they might have disruptive nocturnal behaviors, where they have accidentally injured their bed partner,” says Creamer. “I find that sometimes it takes a couple of visits for them to feel comfortable talking about it.”
In her previous research, Creamer used the Pittsburgh Sleep Quality Index, a self-report questionnaire that assesses sleep quality and asks about bad dreams, but there are many other tools available.
A self-report assessment of nightmare disorder, the Nightmare Disorder Index (NDI), is another questionnaire recommended for screening high-risk populations such as healthcare workers.4 Other tools, such as the Nightmare Distress Questionnaire (NDQ), are designed to measure the severity of the condition. If a patient’s native language is not English, clinicians might be able to find language-specific nightmare surveys for them as well. The Hamburg Nightmare Questionnaire (HNQ), for instance, is for German speakers.
Creamer says it is essential to give patients as many avenues to disclose their nightmares as possible with the goal of making them aware that treatment options are available. A position paper by the American Academy of Sleep Medicine outlines many treatment options for nightmare disorders, including cognitive behavioral therapy, hypnosis, and several prescription medications.5
One of the most effective treatment modalities is image rehearsal therapy, a technique that involves the patient working with a sleep psychologist to rescript the content of a nightmare and rehearse the rewritten dream scenario while awake.
The medication prazosin, sold under the brand name Minipress, is one of the most common drugs used off-label to treat nightmares, but clinicians report mixed results. One randomized controlled trial of prazosin in 67 active-duty soldiers with PTSD who had returned from combat deployments to Iraq and Afghanistan found that prazosin eased the severity of trauma nightmares.6
During the 15-week trial, researchers randomly assigned soldiers to treatment with prazosin or placebo. They titrated the medication based on nightmare response over 6 weeks to a possible maximum dose of 5 mg in the morning and 20 mg at bedtime for men and 2 mg in the morning and 10 mg at bedtime for women.6
“For some of the patients, it works well. It affects the sympathetic activation in the brain that is associated with the nightmares. I had a couple of patients tell me that they still had the nightmares, they just don’t have that physical reaction to the nightmares that they used to have,” says Robertson. “The nightmares are still there, but they are not reacting to them as much, so maybe it is not disturbing their sleep as much.”
But prazosin, which is approved by the US Food and Drug Administration for the treatment of hypertension, might come with challenging side effects. Patients may experience hypotensive symptoms, including dizziness when they stand up. If the dose goes high enough, it could influence athletic performance because cardiac output is decreased, which is an issue in active military populations, according to Robertson.
And not all research shows that prazosin is effective. One of the largest randomized trials of prazosin, which included 304 veterans from 13 medical centers, found that the medication did not alleviate distressing dreams or improve sleep quality.7
For those who want a holistic approach, a prescription-only digital therapeutic called NightWare is cleared by the FDA for the temporary reduction of nightmares in adults 22 years or older who have nightmare disorder or have nightmares from PTSD.
Throughout the night, NightWare sensors work in conjunction with an iPhone and Apple Watch to monitor heart rate and body movement. NightWare then initiates a gentle vibration through the watch when a person enters a nightmare. “It is almost like a distraction—We are distracting the patient from their dream narrative,” says Robertson.
The vibration is just enough to guide the patient out of a bad dream but typically not enough to fully wake them. Patients routinely report that their nightmares go from once or multiple times a week to once a month and continuously decrease, says Grady Hannah, CEO and co-founder of NightWare.
Currently available through TRICARE, the health care program for active-duty military service members, the company plans to release new peer-reviewed research in the months ahead and hopes to expand to treat more patients in the future by working with commercial insurers and Veterans Affairs.
Regardless of the solution that is used, the first step remains to identify those patients who need help the most. “A lot of these patients say they are reliving some of the worst trauma of their lives and that is disturbing their daytime function. Just the insufficient sleep itself is enough to cause dysfunction with emotional regulation during the day, cognition, and memory,” says Robertson.
“I have had patients who just believe that nightmares are just something that goes along with military service, that there is nothing that can be done for it, and it just goes along with the package,” says Creamer.
The first step is just asking the question: “Do you have nightmares?”
Lisa Spear is associate editor of Sleep Review.
1. Creamer JL, Brock MS, Matsangas P, et al. Nightmares in United States military personnel with sleep disturbances. J Clin Sleep Med. 2018 Mar 15;14(3):419-26.
2. Bishop T, Youngren W, Ashrafioun L, et al. 0671 Nightmare type and its association with suicide attempts among veterans. Sleep. 2022 June;45(suppl_1):A294.
3. Nadorff MR, Nadorff DK, Germain A. Nightmares: under-reported, undetected, and therefore untreated. J Clin Sleep Med. 2015 Jul 15;11(7):747-50.
4. Dietch JR, Taylor DJ, Pruiksma K, et al. The nightmare disorder index: development and initial validation in a sample of nurses. Sleep. 2021 May 14;44(5):zsaa254.
5. Morgenthaler TI, Auerbach S, Casey KR, et al. Position paper for the treatment of nightmare disorder in adults: An American Academy of Sleep Medicine position paper. J Clin Sleep Med. 2018 Jun 15;14(6):1041-55.
6. Raskind MA, Peterson K, Williams T, et al. A trial of prazosin for combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and Afghanistan. Am J Psychiatry. 2013 Sep;170(9):1003-10.7. Raskind MA, Peskind ER, Chow B, et al. Trial of prazosin for post-traumatic stress disorder in military veterans. N Engl J Med. 2018 Feb 8;378(6):507-17.