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When You’re Afraid To Sleep: Nightmares and Nightmare Disorders

Nightmares – we all have the occasional bad dream, right?

But what if you experience nightmares so often and so frightening that you avoid going to sleep?

You might have a nightmare disorder.

Listen in as Dr. Blackburn, a behavioral sleep medicine specialist, describes the disorder and what you can do about it.
When You’re Afraid To Sleep: Nightmares and Nightmare Disorders
Featured Speaker:
Richard A. Blackburn, PhD
Dr. Blackburn is a board-certified behavioral sleep medicine specialist, providing safe, effective treatment for insomnia, nightmares and circadian rhythm disorders. He treats insomnia and related sleep disorders using proven, effective behavioral and non-pharmacologic (non-prescription medication) approaches. He helps patients develop tools and skills to get a better night’s sleep.

Learn more about Dr. Blackburn
When You’re Afraid To Sleep: Nightmares and Nightmare Disorders

Melanie Cole (Host):   Most of us experience bad dreams or nightmares at one time or another and then we soon forget about them but for some, frequent or severe nightmares can become a cause for concern. Today my guest is Dr. Richard Blackburn. He’s a board certified behavioral sleep medicine psychologist at the Allina Health Cambridge Clinic. Welcome to the show, Dr. Blackburn. Let’s just start with talking about the difference between a bad dream, a nightmare and something that would qualify as a true nightmare disorder.

Dr. Richard Blackburn (Guest):   Certainly. Thanks for having me, Melanie. A bad dream is just a bad dream that’s unpleasant or undesired but it really differs in intensity from a nightmare. Nightmares are extremely upsetting dreams that usually involve threats of some kind, whether it’s the survival, security or physical safety and they occur in the second half of the night when we spend more time in REM sleep, which is often called “dream sleep.” When people wake up from a nightmare, the person usually will become oriented and alert, but they’ll vividly remember the dream and, usually, the person will experience a length of time when the content can remain upsetting. A nightmare disorder really has to do with how frequently the person has it. The criteria for a nightmare disorder says that that person has to have nightmares at least once per week and for longer than a month. Frequent nightmares can often really cause a lot of distress to the person; it can impair functioning and daily life; it can impact mood, quality of life, work and even social functioning abilities.

Melanie:  And, how do all of these differ from night terrors? My son had one once and it was quite frightening to behold.

Dr. Blackburn:  It is and that’s exactly it. They’re frightening to behold. Sleep terrors or night terrors often occur in young children but they can persist into adulthood. They occur in the same stage of sleep as when a person would sleepwalk which is different from the stage of sleep where nightmares typically occur. During a night terror, the person will often cry out or scream and they’ll appear very frightened, panicky or agitated. They may even be confused, mumble or resist attempts to comfort them. Unlike nightmares, however, night terrors usually aren’t remembered by the person who’s having them and, therefore, they’re not upsetting to the individual but, like you experienced, they can be really upsetting to the person witnessing them. Night terrors don’t occur when the person is dreaming and they tend to occur during the first half of the night when slow wave sleep or deep sleep is predominant. So, a lot of times, night terrors will happen within the first 2 hours of sleep.

Melanie:  What a fascinating topic this is. Are some people just prone to nightmares and are there factors? When our kids are little we say, “You can’t watch a scary movie. You’ll have nightmares.” But, even as adults and in this day and age, it’s easy to have bad dreams and nightmares about things. Are some people just more prone to these?

Dr. Blackburn:  Some people are. You know, nightmares are actually fairly common in adults, in general. About 2-8% of adults will report having problems with nightmares and, depending on which study you look at, 2-6% report having nightmares at least once per week or meeting the criteria for the nightmare disorder. Nightmares occur in rapid eye movement sleep which is the stage of sleep when most dreams occur. This is a stage of sleep that’s preserved. So, if you don’t get enough sleep or you become sleep deprived, we tend to go into REM sleep earlier in the night and we spend more time in REM sleep and, therefore, more time dreaming. So, if the person is prone to nightmares, not getting enough sleep increases the risk of having them. The other thing is, anything that disrupts sleep, like another sleep disorder such as untreated sleep apnea, increases the frequency of remembering dreams or nightmares. So, we typically only remember a dream or a nightmare if we awaken after it. Most people will have 4-5 dreams in a night but they won’t remember them unless they wake up immediately following or during the dream. People who have a lot of stress in their daily lives are also more prone to nightmares. A person under significant stress is more likely to have negative dreams. It’s been suggested but not completely proven that when we dream, we consolidate memories, process events of the day and kind of help regulate the day’s emotions. So, if a person has a lot of negative emotions during the day, that’s likely to be reflected in the content of their dreams at night. There are also certain mental health conditions that tend to increase the risk of having nightmares—things such as depression, PTSD or anxiety disorders can increase the risk of nightmares and, in fact, about 80% of people who have PTSD report PTSD related nightmares. In fact, nightmares are actually part of the diagnostic criteria for nightmares. Also, people who are using certain substances like drugs and alcohol, whether they’re illegal drugs or prescription medication, some of those can also increase the risk of having nightmares. So, there are several antidepressants, barbiturates which aren’t used very much anymore, beta blockers that we use to control blood pressure the neuroleptic medications that are often used to control seizures or psychosis, and even several of the Parkinsonian medications are well-known to increase nightmares. The other thing is that sometimes when we withdraw or we stop taking a medication or a drug, that also increases the risk of having nightmares. So, people who are coming off older antidepressants, alcohol or amphetamines have a greater chance of having nightmares. Then, I just want to say if you think your medications are causing nightmares, it’s really important that you talk to a physician before you stop taking them because just quitting some medications can actually be risky.

Melanie:  Dr. Blackburn, is it true the myth that people say that “bad things can’t really happen in your dreams; in your nightmares”? That they almost happen but then stop before they actually do happen?

Dr. Blackburn:  You mean like the old idea that you can’t die in your dream?

Melanie:  Yes. Exactly.

Dr. Blackburn:  If you die in your dream, you’re actually going to die?  No. That’s not true. Bad things can happen in dreams. A lot of times, at that point, a person becomes so emotionally loaded that they’ll often wake up before the bad thing happens. But, you can experience bad things in dreams and that can be incredibly frightening for people.

Melanie:  Very frightening. Can you change your dreams if you’re somebody who’s subject to some of these nightmares? We’re going to talk a little bit about treatment but can you change what happens during that type of sleep?

Dr. Blackburn:  Yes. So, there’s a skill that’s gotten some research that’s referred to as “lucid dreaming”. Lucid dreaming is where the person is aware that they are dreaming and they can change the content of their dreams. Some people believe that this is a skill that can be taught but research hasn’t really held that out. There’s another treatment that’s referred to as image rehearsal therapy or IRT and image rehearsal therapy actually was something that was really studied by the VA and the Department of Defense to treat PTSD related nightmares. But, in it, one of the things we think nightmares are is that it’s a way of consolidating new learning and things that you think about during the day. So, if you spend a lot of time thinking about the nightmare you had last night, you’re rehearsing it and in that way, it can become a learned behavior and it’s more likely to happen again the next time you sleep. So, image rehearsal therapy is a way of rehearsing the dream but changing it in some way that makes it less scary. So, an example of this is, I had a patient who had a car accident and at night, when she would fall asleep, she would see the headlights coming toward her. When we did image rehearsal therapy, she changed it so she had the Roger Rabbit car where the car could go up and over the headlights.

Melanie:  Wow.

Dr. Blackburn:  And it didn’t actually change that way in her dream but because she changed the dream in a way that was not upsetting, the frequency of the dreams just kind of went away and she just stopped having them.

Melanie:  Wow. That is so fascinating. When should listeners—at what point when they’re having these nightmares—should they seek help?

Dr. Blackburn:  Well, most adults are probably going to have a nightmare. In fact, most people listening to this have probably had one. Like I said, they’re very common. As long as they don’t become habitual, or they don’t influence your ability to function during the day or create a lot of distress or problems with sleep, the person probably doesn’t need any help but if the person has frequent nightmares and these awful dreams carry over and really impact their ability to function the next day or if they disrupt sleep so significantly that they can’t get sufficient sleep or if they become habitual and just really affect the person all the time, there are effective treatments that available and the person doesn’t have to suffer from these.

Melanie:  Dr. Blackburn, in the last minute, what an interesting topic this is. We could talk about it quite a long time. Please give your best advice for the listeners, to those suffering from bad dreams, nightmares or might possibly have nightmare disorder?

Dr. Blackburn:  So, if they’re going to get treatments from them, there’s different types of treatment. There are two that are considered Level A treatments or they’re ones that have been consistently well-supported by research. Those are a medication called Prazosin or Minipress which is a medication which is usually used to control blood pressure but it affects dreams. What they’ve found is, for people who have nightmares that are related to PTSD, Prazosin can be a wonderful medication and help to reduce the frequency and the intensity of nightmares. There’s also some evidence that if you just experience a traumatic event, Prazosin may actually prevent you from developing PTSD. Prazosin, however, doesn’t seem to help with non-PTSD related nightmares or, at least, it tends to be much less effective for those. The image rehearsal therapy that we talked about is also a Level-A treatment and that seems to work both for PTSD related nightmares or nightmares that tend to be somatic. So, the person has a consistent theme every night in their dreams. If they’re just random bad dreams or random nightmares, IRT may not work but it’s something that you can try.

Melanie:  Wow. What great information. Thank you so much. You’re listening to The WELLcast with Allina health. For more information, you can go to That’s This is Melanie Cole. Thanks so much for listening.