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A nightmare is an unpleasant dream that can cause a strong emotional response from the mind, typically fear or horror but also despair, anxiety and great sadness. The dream may contain situations of danger, discomfort, psychological or physical terror. Sufferers often awaken in a state of distress and may be unable to return to sleep for a prolonged period.
Nightmares can have physical causes such as sleeping in an uncomfortable or awkward position, having a fever, or psychological causes such as stress, anxiety, and as a side effect of various drugs. Eating before going to sleep, which triggers an increase in the body's metabolism and brain activity, is a potential stimulus for nightmares. Recurrent nightmares may require medical help, as they can interfere with sleeping patterns and cause insomnia.
"Nightmare" evokes the modern word for a female horse but the terms are wholly unrelated. The word derives from the Old English "Mare", a mythological demon or goblin who torments others with frightening dreams. Subsequently, the prefix "night-" was added to stress the dream-aspect. The word "nightmare" is cognate with the older German term Nachtmahr.
Incidence and Types of Nightmare
Fearfulness in waking life is correlated with the incidence of nightmares. Studies of dreams have estimated that about 75% of the time, the emotions evoked by dreams are negative. However, it is worth noting that people are more likely to remember unpleasant dreams.
One definition of "nightmare" is a dream which causes one to wake up in the middle of the sleep cycle and experience a negative emotion, such as fear. This type of event occurs on average once per month. They are not common in children under five, but they are more common in young children (25% experiencing a nightmare at least once per week), most common in teenagers, and common in adults (dropping in frequency about one third from age 25 to 55).
Theories on the Causes of Nightmares
Scientific research shows that nightmares may have many causes. In a study focusing on children, researchers were able to conclude that nightmares directly correlate with the stress in the children's lives. Children who experienced the death of family or a close friend or know someone with a chronic illness have more frequent nightmares than those who are only faced with stress from school or stress from social aspects of daily life.
Another study researching the causes of nightmares focuses on patients suffering from sleep apnea. The study was conducted to prove whether or not nightmares may be caused by sleep apnea, or not being able to breathe. In the nineteenth century, authors believed that nightmares were caused by not having enough oxygen, therefore it was believed that those with sleep apnea had more frequent nightmares than perfectly normal people. The hypothesis, however, was proven wrong and the results actually showed that healthy people have more nightmares than the sleep apnea patients.
Possible Effects of Nightmares
A study involving a large group of undergraduate students analyzes the effects of nightmares on the quality of sleep. The study showed that the participants experienced abnormal sleep architecture and that the results of having a nightmare during the night were very similar to those of people who suffer from insomnia. This means that, like insomniacs, people who suffer from nightmares do not get as much rest as those who do not suffer from chronic nightmares. Therefore, they experience a lesser quality of sleep than others. This is thought to be from frequent nocturnal awakenings and fear of falling or going back to sleep.
Treatment of Nightmares
Both Sigmund Freud and Carl Jung seemed to have shared a common understanding that people frequently distressed by nightmares could be re-experiencing some stressful event from the past. Both perspectives on dreams suggest that therapy can provide relief from the dilemma of the nightmare experience.
Halliday (1987), grouped treatment techniques into four classes. Direct nightmare interventions that combine compatible techniques from one or more of these classes may enhance overall treatment effectiveness:
- Analytic and cathartic techniques
- Story-line alteration procedures
- Face-and-conquer approaches
- Desensitization and related behavioral techniques.
Recurring post-traumatic stress disorder nightmares in which real traumas are re-experienced respond well to a technique called imagery rehearsal. First described in the 1996 book Trauma and Dreams by Harvard psychologist Deirdre Barrett, this contemporary dream interpretation involves the dreamer coming up with an alternate, mastery outcome to the nightmare, mentally rehearsing that outcome awake, and then reminding themselves at bedtime that they wish this alternate outcome should the nightmare recur. Research has found that this technique not only reduces the occurrence of nightmares and insomnia, but also improves other daytime PTSD symptoms. According to Bret Moore and Barry Kraków, the most common variations of Imagery Rehearsal Therapy (IRT) "relate to the number of sessions, duration of treatment, and the degree to which exposure therapy is included in the protocol". Another kind of treatment not only helping the reduction of nightmares, sleep disturbance, and other PTSD symptoms is prazosin. There have been multiple studies conducted under placebo-controlled conditions. (Am J Psychiatry 2003; 160:371–373)
A comprehensive model has been put forth by Krakow and Zadra (2006) that includes four group treatment sessions, ~2.25 to 2.5 hr in length. The first two sessions focus on how nightmares are closely connected to insomnia and how they become an independent symptom or disorder that warrants individually tailored and targeted intervention. The last two sessions focus on the imagery system and how IRT can reshape and eliminate nightmares through a relatively straightforward process akin to cognitive restructuring via the human imagery system. First, the patient is asked to select a nightmare, but for learning purposes the choice would not typically be one that causes a marked degree of distress. Second, and most commonly, guidance is not provided on how to change the disturbing content of the dream; the specific instruction developed by Joseph Neidhardt is “change the nightmare anyway you wish” (Neidhardt et al., 1992). In turn, this step creates a “new” or “different” dream, which may or may not be free of distressing elements. Our instructions, unequivocally, do not make a suggestion to the patient to make the dream less distressing or more positive or to do anything other than “change the nightmare anyway you wish.” Last, the patient is instructed to rehearse the “new dream” through imagery and to ignore the old nightmare.
A nightmare arises from one's complex that contains residue from some unresolved issue. Some people may experience recurring nightmares due to posttraumatic stress disorder (PTSD), or they may have some other source of anxiety that influences their dreams at night. Whatever the cause, there are treatments available, some of them medical and some psychological. While most treatments are meant for people who have a true disorder, the techniques discussed above will work well for any person dealing with nightmares.
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