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There’s More to Nightmares Than Meets the Eye

There’s More to Nightmares Than Meets the Eye

  • Parasomnias are undesirable physical, experiential, or behavioral phenomena that occur exclusively during sleep onset, during sleep, or during arousals from sleep. In DSM-5, the parasomnias are non–rapid eye movement (NREM) sleep arousal disorders (sleepwalking, sleep terror types), nightmare disorder (formerly known as dream anxiety disorder), and rapid eye movement (REM) sleep behavior disorder (RBD). Interested readers may refer to Parasomnias: What Psychiatrists Need to Know, on which this slideshow is based. ©MarcosMesaSamWordley/Shutterstock

    View the slideshow in PDF format.

  • 1. NREM sleep arousal disorders. Although not specified in DSM-5, the simplest of the disorders of arousal is confusional, hence disordered, arousal, which is partial awakening with periods of apparent confusion and inappropriate or absent responsiveness to others while in bed. There is typically amnesia for the event and minimal or no recall of dream mentation. This can evolve into spells including intense autonomic activation with vocalization, tachycardia, tachypnea, mydriasis, diaphoresis, and sleep terrors or sleepwalking. ©Ollyy/Shutterstock

  • 2. Substance-/medication-induced sleep disorder. Parasomnias resembling disorders of arousal can be related to the use of many psychotropic drugs, in particular sedative-hypnotics. Sleepwalking and other amnestic complex sleep-related behaviors have been reported among psychiatric patients taking benzodiazepines. Behaviors can be prolonged and include amnestic nocturnal eating, sexual activity, and even sleep driving. ©RinSeiko/Shutterstock

  • 3. Nightmare disorder. Formerly termed “dream anxiety attacks,” nightmare disorder is now recognized as an REM sleep phenomenon, distinct from NREM sleep terrors. As defined in DSM-5, this includes repetitive, extended, extremely dysphoric, and well-recalled dreams that involve threats to survival, security, or physical integrity; episodes usually occur during the second half of the sleep period. Typically, the individual becomes rapidly alert and oriented. Emotional manifestations of fear, anger, and sadness may predominate. ©LukiyanovaNataliaFrenta/Shutterstock

  • 4. REM sleep behavior disorder. RBD patients—most frequently older men with who experience a prolonged, chronic course—typically dream of themselves as defenders, rarely as aggressors. Violent dream enactment can result in injury to the patient and/or bed partner whose presence is often incorporated into the dream content. RBD spells are likely to occur during the latter part of the night, when REM sleep tends to be more prolonged and intense. For about 25% of patients, there is a prodromal period with increased action-packed dream content along with vocalization and limb jerking that can progress over several years. As RBD becomes established, there is a tendency for abrupt, often violent movement concordant with recalled dream content. ©Makieni/Shutterstock

  • 5. Recurrent isolated sleep paralysis. Sleep paralysis is essentially the atonia of REM sleep that has become dissociated and occurs at times other than the typical periods of REM sleep during the night. It can either intrude at sleep onset or persist into awakening at sleep offset, and it is often experienced as discomforting or frightening. It is classically found in association with narcolepsy, but not exclusively. ©IrynaGyrych/Shutterstock

  • 6. Sleep-related events not specified in DSM-5. Clinical features of nocturnal spells can resemble panic disorder, but diagnostic caution must be emphasized. Other disorders that can masquerade as nocturnal panic, such as sleepwalking/sleep terrors, RBD, seizures, gastroesophageal reflux, obstructive sleep apnea, bruxism, nocturnal asthma, and nocturnal cardiac arrhythmias. Sleep disturbances have figured prominently in descriptions of dissociative identity disorder, dissociative amnesia, PTSD, and other disorders. ©Namning/Shutterstock

  • 7. Other rare but relevant disorders with sleep-related manifestations. Sleep-related epilepsy should be considered for any sleep-related behavior that is recurrent, inappropriate and, most importantly, stereotyped. Exploding head syndrome is a sudden sensation of a loud noise or a violent, though painless “explosion” in the head occurring as the affected person is falling asleep or waking during the night. It is a rare, benign but frightening event during the transition between wake and sleep. Sleep-related hallucinations can be related to narcolepsy, ß-adrenergic receptor blocking medications, dementia with Lewy bodies, visual loss (Charles Bonnet hallucinations), and other brain pathology (peduncular hallucinosis). ©Namning/Shutterstock

View the slideshow in PDF format.

Editor's Note: This article was originally published on March 3, 2017 and has since been updated.


I have had two first trimester pregnant patients in the last week with what sound like parasomnias. The first presented with recurrent nightmares which began at around 4 wks gestation, wake her from sleep and prevent her from falling back asleep. Daytime naps are not affected; she reports no meds other than prenatal vitamins and denies the use of drugs, alcohol, nicotine or caffeine. The second woman presented to the ER at 6 wks complaining of severe pains in her upper body when waking from sleep, causing her to thrash and scream, and only relieved by pouring hot water over herself and liberal use of marijuana. These states take several hours to pass and have destroyed her rest, as she is now terrified to fall asleep. The symptoms are less vivid after daytime naps. Neither woman admits to a history of mental illness, seizure disorder, trauma or prior sleep problems. Pregnancy can lend itself to sleep disorders and may increase the amount of time spent in REM sleep; the increased amount of B vitamins may also play a role. I am open to any and all suggestions for both etiology and treatment, as prazosin is not well studied in early pregnancy.

Anne @

Exploding head syndrome appears to occur in about 25 percent of students who experience sleep paralysis. In Galway we have consistently found approximately 30 percent of students report experiencing SP. So in effect the rarity of Exploding head syndrome may be an artefact of not having looked for it.

Jonathan @

Very interesting - anyone have any insights to using prazosin successfully for nightmares? My experience is that in reality the benefit is pretty limited.

Any recommendations for treating parasomnias?

Barbara @

I've had a good number of patients report improvement with low dose prazosin, less frequent, less intense nightmares, sometimes remission. I reserve trial for sleepers with frequency, physiological activation and distress. Adverse reactions in clinic: Unusual report of worsening of nightmares. Sometimes orthostatic hypotension. I hypothesize prazosin interferes with the escalating physiologic activation in sleep. Teaching includes take immediately before going to bed with bp parameters. Teaching about orhostatic hypotension, risk for falls with injury or death, practice of progressive rising if getting up at night is necessary. .I am wary of using prazosin for nightmares generally. Parasomnias are fascinating. One area of practice that remains mostly in the dark.

Richard Anthony Peckham PMHNP-BC

Richard Anthony @

I have had very similar experience as described by John Anthony, and agree with all the teaching points.

Doreen @

Correction, response reference was to Richard Anthony, not John.

Doreen @

There's a lot of anecdotal material on the www about the vivid dream side effects for metropolol, a common high blood pressure med - and I could add my own experience with this. Vivid only begins to describe the experience! A study, small numbers, here:

Eur J Clin Pharmacol. 1985;28 Suppl:69-72.
CNS-related side-effects with metoprolol and atenolol.
Cove-Smith JR, Kirk CA.
Vivid and bizarre dreams, hallucinations, sleep disturbance and psychosis have all been described following treatment with beta-blockers. It has been suggested that these central nervous system (CNS) side-effects are related to the degree of lipophilicity of the beta-blocker. A randomized double-blind crossover study was performed to compare the incidence of CNS side-effects with atenolol and metoprolol in hypertensive patients who had reported CNS side-effects with lipophilic beta-blockers. Eleven women and six men completed the study, in which a 30-item psychiatric questionnaire was used to detect changes in psychological status and possible CNS side-effects. Discontinuation of the original lipophilic beta-blocker produced a significant improvement in quality of sleep, dreams, concentration, memory, energy, and anxiety. No significant CNS side-effects were reported with atenolol, but introduction of metoprolol caused a significant increase in the incidence of sleep disturbance (p less than 0.01) and restless nights (p less than 0.05), as well as failure to achieve satisfactory sexual intercourse (p less than 0.05). When compared with atenolol, metoprolol was associated with a significantly higher incidence of restless disturbed nights (p less than 0.05). Blood pressure control was identical for both beta-blockers. This study appears to confirm the association between CNS-related side-effects and the lipophilicity of beta-blockers.

Alex @

Great information !!!

Kathie @

Interesting topic Want to know more.....

Susan @

My impression is that older sleep episodes that unconscious. We need careful studies on and off
antipsychotics to demonstrate which sleep disorders respond and which don't.
We may well be undertreating serious psychotic symptoms during sleep.

Augustus F. Kinzel, M.D.

Augustus @

GUS I know you from somewhere, but I cant recall where Tufts Med in the 60"s Boston City Hospital USNAVY VN WAR General Patch troop ship??? ken zack harvard '60 tufts med 64 krzack@comcast.net

Kenneth @

An interesting thought about psychosis. This writer once had recurring nightmares. I was a lost soul occupying the attic of an isolated country mansion, a beautiful ruin slowly, dangerously falling down around me. I can see the elegant deteriorating grounds now as I write this. My own ghost haunting the place my weird unsuccessful solitary life in the gloom. I would be surprised to have the dream again and recognize the place. As unbelievably I was making repairs like This Old House. Dreams may serve a purpose. The problem was that my life was the nightmare. I'm feeling much better now if anyone should ask.

Richard Anthony Peckham PMHNP-BC

Richard Anthony @

So how do you treat these?

Anne @

Any research being done on sleep talking (somniloquy)?

Jack @

I had a patient who reported having a seizure while sleeping in several occasions, I send him to an Sleep Lab, to rule out Sleep Apnea, that was confirmed; seizures disappeared with CPAP, to return one night when he had the device disconnected.
The low Oxygen saturation because of Sleep Apnea could trigger a group of neurons to fire and generate the shakes

Jose @

Interesting. Thank you.

veronica @

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