Experiencing nightmares? Here’s what you need to know to get quality sleep

A number of studies have in the past revealed the prevalence of sleep disorders among Indians. According to ‘Sleep Disorders Prevalence Studies in Indian Population', a study published in 2019 reveals that these disorders mainly include insomnia, obstructive sleep apnea and sleep deprivation greatly affecting the sleep quality of children and adults alike. Other sleep disorders also include night terrors, nightmares and sleep talking, which are comparatively lesser discussed experiences.

A number of adults experience frequent nightmares or dreams, which can restrict one's sleep or wake them up from sleep at night, breaking their regular sleep patterns. The situation is often aggravated by excessive stress, unhealthy lifestyle and erratic schedule. While experts say it is normal, it is crucial to identify the intensity of these nightmares to understand how serious the problem is. Mid-day Online reached out to Dr Ashutosh Shah, DNB (psychiatry), consultant psychiatrist at Sir H N Reliance Foundation Hospital Mumbai, to understand what causes nightmares and how serious it can get.

What causes nightmares/bad dreams in adults and how does it affect one's sleep quality?

Shah: Nightmares are negative dreams that lead to waking up, whereas bad dreams contain intense negative emotions but do not lead to waking up. Dream is a cognitive functioning of the brain to which we all involuntarily revert to during sleep. Advances in neuroimaging techniques have made it possible to relate dream features to specific patterns of brain activity.

Experiencing nightmares once in a while is physiological i.e. ‘normal' in both children and adults. Frequent nightmares could be due to any of the following: psychiatric disorders like anxiety and depression, PTSD, psychosis; certain medications including withdrawal from some medications, alcohol use or dependence, certain personality factors like neuroticism and genetic predisposition.

Recurrent nightmares could significantly impact an individuals' sleep. Individuals suffering from nightmare disorder are at increased risk of reduction in sleep quantity and quality. Sleep disruptions due to nightmares may wake up an individual in an anxious state, making it hard to relax and get back to sleep. Fear of nightmares may cause sleep avoidance and less time allocated to sleep. In individuals with certain pre-existing disorders (e.g. anxiety, depression, PTSD), nightmares could compound the sleep disturbance and worsen the pre-existing disorder.

Does the condition of nightmares differ in children and adults?

Shah: Up to 50 per cent of children between ages 3-5 years have nightmares. The incidence of nightmares continues to decline as children grow up, and elderly individuals hardly experience nightmares.

The typical contents of nightmares in children and adolescents are the following:

- Being chased (50%)

- Own death or injury (20%)

- Death or injury of others (15%)

- Falling into a bottomless space (10%)

Although detailed studies on the content of nightmares in adults are scarce, the predominating topics encompass falling, being chased, being paralyzed, being late, and the death of close persons.

How does one identify the condition to be serious, which can lead to 'nightmare disorder'?

Shah: Nightmares are experienced from time to time by many people. They do not impair an individual's functioning. Nightmare disorder on the other hand is when an individual gets frequent nightmares which interfere with their mood, sleep and or daytime functioning. Nightmare disorder is a sleep disorder called parasomnia.

To identify if one is potentially having a nightmare disorder, one must monitor the frequency of nightmares by maintaining a sleep diary, observe and chart the change in their mood, sleep and or daytime functioning. Consult a specialist (psychiatrist or sleep medicine expert) if nightmare frequency is more than once a week or if nightmares affect sleep, mood and daytime functioning or if nightmares have started following initiation of a medicine.

Balakrishnan: Nightmares are only considered a disorder if you experience:

a. Frequent occurrences

b. Major distress or impairment during the day, such as anxiety or persistent fear, or bedtime anxiety about having another nightmare

c. Problems with concentration or memory, or you can't stop thinking about images from your dreams

d. Daytime sleepiness, fatigue or low energy

e. Problems functioning at work or school or in social gatherings

f. Behaviour problems related to bedtime or fear of the dark

What does experiencing nightmares say about one's mental health?

Shah: Nightmares by themselves do not indicate any anomaly in brain functioning. Healthy brain functioning is the determinant of good mental health and vice versa.

Very frightening and recurring nightmares (e.g., one or more per week) are not common and may occur in a very small percentage (<1%) of individuals. A nightmare disorder (parasomnia) could indicate underlying brain pathology. A myriad of causes ranging from neurological disorders, psychiatric disorders, obstructive sleep apnea (OSA), certain medications and drugs of abuse can cause the parasomnia.

How can adults tackle this for a good night's sleep?

Shah: Principles of sleep hygiene need to be followed. Main points of sleep hygiene are:

a. Fixed sleep time and wake time, minimum 7-8 hours of night time sleep

b. Eliminate watching all screens (TV, computer, mobile) two hours before intended sleep time

c. Have dinner 2-3 hours before sleep time. Avoid coffee/tea/green tea/red bull/soft drinks after 4 pm

d. Restrict daytime naps to maximum 40 minutes and that too before 2 pm; avoid working in bed

e. Most importantly, do not self-medicate with any sleeping pill (like benzodiazepines) or consume alcohol to fall asleep

If one is experiencing a nightmare (not nightmare disorder), do not avoid going to sleep. Reducing sleep could have a paradoxical effect of worsening the nightmare. This is because nightmares are experienced during a stage of sleep called REM (rapid eye movement) or paradoxical sleep. Reducing or avoiding sleep suppresses REM sleep. There is a rebound REM sleep when the person sleeps in the coming days. During this rebound REM sleep, there is an increase in nightmares.

Nightmares do not need any specific treatment, masterly inactivity suffices. However, for nightmare disorders, best is to consult a psychiatrist or sleep specialist for help.

Balakrishnan: If a mental health condition, such as stress or anxiety, seems to be contributing to the nightmares, your doctor may suggest stress-reduction techniques, counseling or therapy with a mental health professional.

Imagery rehearsal therapy: Often used with people who have nightmares as a result of Post-Traumatic Stress Disorder (PTSD), imagery rehearsal therapy involves changing the ending to your remembered nightmare while awake so that it's no longer threatening. You then rehearse the new ending in your mind. This approach may reduce the frequency of nightmares.

Medication is rarely used to treat nightmares. However, medication may be recommended for severe nightmares associated with PTSD.

Also Read: How parents of children with special needs can deal with bullies

(Disclaimer: This article is not intended as a substitute for professional medical advice, diagnosis or treatment. Mid-day Online does not in any way endorse the accuracy, completeness, efficacy or timeliness of any advice or line of treatment mentioned in this article. Readers must always seek the advice of a certified medical practitioner and/or a mental health professional before deciding on or starting any course of treatment.)