Nightmares are normal and, in most cases, an occasional occurrence. However, in a minority of people, they represent an everyday problem: according to an article published in 2022 in the journal Current Biology, approximately 4% of the world’s adult population suffers from a nightmare disorder that makes them experience very frequent distressing dreams, to the point that it affects their daily lives. “You are afraid to go to bed, it is very unpleasant, you are anxious all the time,” says Belén Agüí, who has suffered from it for three years.
Very little is known about this disorder, and the incidence figures show a very wide range. A 2019 study published in the Journal of Sleep Research stated that between 16% and 67% of all adult psychiatric patients had this problem. For Ana Fernández, coordinator of the Sleep Study Group of the Spanish Society of Neurology (SEN), studying it is difficult because those who suffer from it tend to normalize it, so it goes underdiagnosed. Something that is clear, however, is that it affects women more than men. “For certain sleep disorders that are not very widespread, it is difficult to really have the most numerical data,” says the neurologist.
Although, according to Fernández, there is no consensus on how many times it has to occur, or how often, in order to diagnose it, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines the frequency of this pathology between once a week and once a day.
Agüí's nightmares started with the Covid-19 pandemic. From March to June 2020 she had them almost every night, but attributed them to the stress and “the emotional turmoil” of the moment, and did not think much of it. Then, that summer, the frequency dropped and the bad dreams became more sporadic, although they continued to appear.
She started to limit the topics she talked about, as well as the movies and series she watched. Eventually, she stopped going to the movies altogether; she knew that anything that might upset her could become a nightmare that would keep her awake a few hours later. “You have to be vigilant all the time. You restrict your life,” she reflects.
She became accustomed to her situation, until last fall, when the frequency of the unpleasant dreams increased. She began to suffer them daily, for no apparent reason, without having seen or talked about anything unsettling. After looking online, she learned that what was happening was not normal. It was then that she decided to go to the Sleep Research Institute (IIS), in Madrid, Spain.
Some consequences of the nightmare disorder are tiredness, fatigue, irritability, low concentration, depressive symptoms and anxiety, all produced by the exhaustion caused by the interruption of sleep, as well as the emotional impact that the dreams can have on the patient, explains Alba García, a general practitioner who specializes in sleep at the IIS.
García and Francisco Segarra, an expert in sleep medicine from the Rest Management Unit of the Olympia center in Madrid, state that the bad dreams can revolve around survival situations in which a person sees their physical integrity, or that of a loved one, endangered, be it with physical assaults, persecutions, a feeling of suffocation or even murder. Agüí's nightmares are usually about the things that happen to her during the day, good or bad, although sometimes they are completely random. “I dreamed that my mother died and I had a fight with my siblings as a result of that,” she says.
This disorder can appear idiopathically (without apparent cause), as a consequence of other pathologies, such as sleep apnea or post-traumatic stress disorder (PTSD) and after consuming certain drugs (such as some antihypertensives and antidepressants) and some types of substances, as well as with their withdrawal. It can also happen due to psychological causes such as stress, depression or anxiety. The latter appears right before the patient goes to bed because they know what to expect, which causes them to fall asleep thinking about nightmares and therefore making them more likely to occur.
Possible courses of action
First, it is necessary to identify the reason; if it is any of the issues mentioned above, solving it will also make the nightmares go away. To find out, a clinical interview is conducted with the patient, asking about their medical history, the medications they take, their sleep habits and the content of their nightmares. Then a sleep study is carried out. “We rule things out until we see if there is an underlying cause or the disorder is idiopathic,” says García. It is also convenient to have a psychiatric evaluation of the patient, adds Fernández.
Aguí started treating her nightmares by taking some drops that are used to help people with anxiety sleep. At first this seemed to work and the dreams began to go away, but it did not work entirely. When the doctor suggested a change of treatment, she decided not to take any more drugs. It was then that she began to take cognitive behavioral therapy, also with a psychologist from the IIS.
They mainly work on reinforcing and personalizing proper sleep habits, as well as on reducing anxiety. Imagination exposure techniques (imagining the content of the nightmares as realistically as possible), combined with relaxation, are also used. This therapy was not chosen specifically because of the nightmares, but because of the insomnia she developed as a result. Still, she claims that the frequency and intensity of her bad dreams have dropped significantly: “Now I have them once or twice a week, and they’re not so horrible anymore.”
When the content of the nightmares is recurring, as occurs in the case of PTSD patients, imagery rehearsal therapy is often used: the patient describes it in as much detail as possible and works with the therapist to rewrite it and give it a new ending, one that is associated with positive emotions.
Some drugs can help, too, including certain antidepressants that reduce the time of REM sleep, which is when most dreams occur; if it is shorter, the nightmares might decrease and stop tormenting the patient, explains Celia García, a neurologist and an expert in sleep medicine at the Integral Center for Sleep and Neurosciences, in Madrid.
However, sleep expert Francisco Segarra points out that the pharmacological route is still in its early days and, although drugs are being tested that can help improve the prognosis, there is simply not enough evidence yet.
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