Chronic Nightmares Are a Common Condition Afflicting at Least 4% of the Adult Population

CHRONIC NIGHTMARES ARE A COMMON CONDITION AFFLICTING AT LEAST 4% OF THE ADULT POPULATION AND A HIGHER, ALBEIT UNDETERMINED, PROPORTION of children and adolescents.1 Nightmares cause or exacerbate insomnia2,3 and psychiatric distress,4-6 as well as impair quality of life.7 Several techniques have been fully developed or explored to treat nightmares, including imagery rehearsal therapy,8-14 lucid dreaming techniques,15 other exposure-oriented techniques (often with imagery aspects),16,17 and medications (e.g., prasozin, trazodone).18,19 In randomized controlled studies, nightmare-specific therapies decreased disturbing dreams, sleep complaints, and psychiatric distress.10,12,20 Imagery rehearsal therapy is the most tested of these treatments and has been suggested as first-line or adjunctive therapy;21-23 2 self-help imagery rehearsal therapy programs have been published.11,24 Despite advances in understanding and treating nightmares, few studies have examined their clinical presentations, most prevalence research has involved university or community samples, and no study has assessed sleep-clinic populations.1 The vast majority of individuals with nightmares, who have been studied, had not sought treatment for this vexing condition, which further explains the limited data about clinical presentations and which also suggests some proportion of these patients do not require treatment. An additional area of confusion arising in the research literature is how to label nightmare problems.23,25 While current efforts both in the field of sleep medicine and psychiatry provide precise nosology about nightmare disorder,26,27 researchers have criticized these criteria for being overly restrictive.23,28 For example, do nightmare sufferers need to awaken from their bad dreams to call them nightmares? Are fear or intense anxiety the exclusive emotions required to indicate a nightmare as opposed to a bad dream? These nosologic issues are further confounded by patients’ inconsistent use of terms such as “bad dreams, disturbing dreams, and nightmares” so that the terms become pragmatically interchangeable,25 notwithstanding nosologic validity. Regardless of the manner in which patients with nightmares describe their difficulties with disturbing dreams, recent research indicates that nightmares may be more usefully appreciated as a specific treatable condition.10,21-23 This newer perspective mirrors current changes in the field of sleep medicine that are attempting to replace “insomnia as a symptom” with “insomnia as a disorder.”29 Failing to view nightmares as a comorbid or independent complaint diverts attention from the problem and steers patients away from evidence-based therapies just like insomnia patients Nightmare Complaints in Treatment-Seeking Patients in Clinical Sleep Medicine Settings: Diagnostic and Treatment Implications