Understanding nightmares: their meaning, causes and ways to get rid of them

By Vladimir Marchenko

1. Nightmare Disorder
2. Causes of Nightmares
3. How Do Nightmares Manifest
4. Complications and Diagnostics
5. Treatment and Prevention of Nightmares

For many centuries, humanity has endowed nightmares with a mystical meaning. They were considered harbingers of bad news and events, and were also associated with the intervention of otherworldly forces. How modern science explains nightmares and what recommendations it gives for getting rid of them.

Nightmare Disorder

A nightmare disorder is one of the sleep disturbances in the form of a dream filled with negative content, usually provoking fear, danger, escape or a feeling of anxiety during sleep. Awakening takes place at the climax and then a person cannot fall asleep for a long time, scrolling in his head strange stories or being under a strong impression. Most often, otherworldly entities that appear in dream plots are villains from art and animation cinematics, animals, chases, enclosed spaces, falling or flying in open spaces, etc.

There are two types of disorders. First is the nightmare which comes closer to the morning, in the REM phase of sleep as a form of vivid visual images and the night terror, being the second one and comes in the deep stage of the NREM phase. Both of them more often occur in people with parasomnia, while the horror of the NREM phase is characterized by the absence of distinguishable images and the inevitable feeling of fear or anxiety upon awakening. It starts after 1-4 hours of sleep, and the awakening may come with cries, sudden movements, sweating, sometimes nausea and disorientation. In this article, we will focus mainly on nightmares of the REM phase.

Often nightmares haunt children and gradually disappear when they reach 12-14 years old. Almost everyone of us has experienced nightmares at least at some point of life. Up to 4% of the US adult population still regularly suffers from them. However if they occur no more often than a couple of times a month - there is no need to worry. Also, regular nightmares provoke severe stress, which can be felt during the day too. If talking about cases of excessively strong experiences, it provokes arterial hypertension and after waking up, a person feels a slight intoxication. All of this is very exhausting and affects the performance, mood and quality of life in general.

The most common nightmare scenarios from the Amerisleep poll

Causes of Nightmares

People tried to explain the nature of nightmares from time out of mind. In German mythology, they have blamed elves that came at night, while the American Indians saw tricks of evil spirits in the nightmares. Modern psychiatry identifies several main causes:

• post-traumatic stress disorder (after an accident, participation in hostilities, rape, major surgery, etc.) - up to 80% of all cases;
• experience of traumatic events (death of a loved one, dismissal, etc.);
• unresolved internal conflicts;
• insomnia;
• mental disorders;
• complexes and subconscious fears caused by including watching thrillers and horror films at bedtime.

Physiological causes of nightmares are also distinguished in addition to psychological ones:

• taking medications - some drugs change the biochemical processes in the brain, enhance or inhibit the activity of neurotransmitters, affect blood circulation. This occurs when taking antidepressants, antibiotics, etc .;
• overeating at night - fatty and spicy food with chemical additives makes sleep intermittent with a frightening "background";
• intaking alcohol and other addictive substances - ethyl alcohol shortens the transition time from one phase of sleep to another, while drugs provoke terrible visions;
• hypoglycemia - low level of sugar in blood makes dreams scary;
• chronic diseases; 
• intoxications and an increase in body temperature - in this case, brain activity fluctuates against the background of hyperthermia, and in the phase of REM sleep thermoregulation is disturbed (body temperature rises), which provokes nightmares.

Deirdre Barrett, a psychologist at Harvard University, believes that periodic nightmares are necessary for the survival of the individual, otherwise evolution would have destroyed us long ago. Perhaps it is a mechanism of paying attention to the problems a person needs to solve. Previously, nightmares served to consolidate survival mechanisms, for example, after a fight with a wild beast or a brawl, that is, they performed the function of consolidating negative experience in the framework of evolutionary development. Necessary skills could be trained during sleep also by means of repetition of the fight in the head in order to memorize and improve efficiency in the future.

How Do Nightmares Manifest

Dreams with unpleasant content occur in the second half of the night, closer to the time of awakening. Although sometimes they can popup in a nap stage caused by muscle relaxation (usually a fall or flight scenarios). In all scenarios a person sees everything in the first person and believes in what is happening.

A sense of psychological discomfort is observed from the very beginning of sleep, as if his eerie ending would have been known in advance. As its intensity increases, heart rate also rises. Upon reaching its climax, breathing changes and quick movement of the eyeballs begins. As large muscles are relaxed, stiffness, inability to resist danger can prevail in a dream.

The nightmare ends when the threat reaches its highest point and the person wakes up. A second before the illusionary death, fall, attack or other. Although upon awakening a person immediately realizes that everything wasn’t real, the experience remains for some time.

Complications and Diagnostics

Regular nightmares provoke distress (severe malaise, which depletes the body’s immunity and opens the way for diseases) and causes fear of falling asleep. Some people begin to delay bedtime, which provokes insomnia. Others self-medicate, taking sleeping pills or alcohol, which only worsens the situation.

Awakenings from nightmares aren’t healthy since they occur earlier than the body has time to relax and recover. Thus, a person still cannot fall asleep for some time, which reduces the total time of night rest. This leads to drowsiness, irritability, fatigue, depression, impaired concentration and memory, and strengthens chronic somatic diseases and mental disorders.

The nightmare is diagnosed by a neurologist, psychotherapist or psychiatrist, depending on the severity. First, the specialist gathers information about the patient’s living conditions, sleep hygiene, addictions, existing physiological or mental illnesses, etc (history). Then nightmares themselves are being studied:

• how often a patient wakes up;
• when does this happen;
• can he reproduce the plot of a nightmare;
• how quickly he then falls asleep;
• whether emotional tension persists after waking up;
• whether relatives have sleep problems.

Sometimes the data collection process ends with polysomnography. In this case, you can determine whether nightmares are associated with other sleep disorders.

Treatment and Prevention of Nightmares

Symptomatic and non-systemic nightmares do not need to be treated at all. However, if there is a concern they come relatively regularly and interfere with normal daily life, you need to see a specialist. There are several treatment methods:

1. Cognitive-behavioral therapy. CBT methods specifically designed for treating nightmares include lucid dream therapy, dynamic sleep therapy, "gradual exposure" method, exposure therapy, hypnosis.

2. Psychotherapeutic sessions to relieve stress and anxiety. If these factors are the root cause, the attending physician may suggest ways to relieve stress, counseling and relaxing therapy.

3. Figurative rehearsal therapy. Used to treat people with post-traumatic stress disorder. The main idea is to study the plots of nightmares during the day, create neutral endings, and rehearse dreams. This technique is practiced for 10-20 minutes a day while awake.

4. Exposition. It combines training in sleep hygiene, the gradual relaxation of muscles during falling asleep, and minimizing the effects of nightmares by understanding them.

5. A set of medical measures. May include both therapeutic sleep and pharmacological treatment. Although drugs are rarely prescribed in this case, it’s more likely to treat people with PTSD to treat side effects that cause nightmares.

You can also try changing your lifestyle strategies:

• limit your intake of heavy food and alcohol at bedtime;
• don’t watch too emotional films and shows;
• do not argue with anyone before bedtime and do not accumulate negative emotions;
• provide a berth with comfort, eliminating unnecessary noise and light, add a suitable temperature regime;
• work on strengthening your resistance to stress;
• do yoga and meditation or light physical activity (LPA)
• keep a sleep diary to record its characteristics.

Recently, Position Paper for the Treatment of Nightmare Disorder in Adults: An American Academy of Sleep Medicine Position Paper was published in the United States. It sets out the position of the American Academy of Sleep Medicine on the treatment of nightmares, including some recommended and not recommended medications. However, it is emphasized that many methods, especially pharmacological, are not well understood, therefore non-pharmacological methods should be standardized and their accessibility should be increased. This also includes measures to prevent nightmares, which can be carried out without contraindications and damage to health.

Before going to bed, practice quiet, relaxing activities, such as reading books, picking up puzzles, or relaxing in a warm bath. Before falling asleep, think positively, imagine your favorite places. Practice deep breathing and simple relaxation exercises. There are some handy mobile applications, such as Hypnopedia, which helps you on your way to improve the quality of sleep and life itself. It also has relaxing, natural sounds and their combinations for you to fall asleep gently. During sleep, it “recharges” you with affirmations designed for various situations. The core feature of the algorithm is that it interacts with Apple Watch sensors and reads affirmations during the specific phase of sleep without waking the user. Last but not least, Hypnopedia has a “smart” alarm clock that helps you wake up in the best morning time at a set interval.

The above methods of treatment and prevention, especially psychological and behavioral, give hope to get rid of nightmares associated with PTSD. If you suffer from frequent and disturbing nightmares, be sure to consult doctors. You may need a referral to a sleep clinic and a more serious course of treatment. Remember about the fact that dreams are not real events or precursors — it can be controlled.