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Ten sleep specialists assessed widely accepted beliefs and here's what they found.

6 Sleep Myths: Experts Weigh In

Lucid dreams are both voluntary and involuntary events. What this means is that a person is aware that they are dreaming during a lucid dream. It can occur spontaneously, typically during REM 

. People experience lucid dreams only rarely, and they aren't typically distressing.

This type of dream has also been promoted as a means of self-reflection and problem solving. Proponents of the technique suggest that lucid dreams are a type of 

, in which a person could potentially reach another state of awareness to achieve greater insight than during the full waking state. The safety of this technique hasn't been established, however, in terms of psychological well-being or restorative sleep. And the idea of using lucid dreaming as a problem-solving method is not supported by the medical community.

 is Adjunct Professor at John Carroll University, and Instructor, Case Western Reserve University in Cleveland, OH. She is the editor in chief emeritus of 

There is more to dreaming than meets the (shut) eye.

Lucid Dreams: Many Questions Remain

Disordered sleep disturbances associated with alcohol use disorders (AUD) can 

for several years, even when patients experience sustained recovery.

 One naturalistic, longitudinal study found that over 60% of patients with alcohol dependence and insomnia at baseline continue to have insomnia at 6 months, regardless of current alcohol use status (abstinent, moderate, or heavy drinking).

When evaluating treatment options in these patients, there are differential considerations compared with patients with primary insomnia without 

 comorbidity, including reducing risk of alcohol relapse as well as abuse issues with some pharmacologic agents. Indeed, sleep disturbance is associated with alcohol relapse risk after a period of abstinence.

of addiction medicine physicians, only 22% offered pharmacological treatment to more than half of patients with sleep problems in early recovery from AUD.

 reviewed current and potential pharmacologic treatments for patients with insomnia and alcohol use disorders. Study authors searched Medline, EMBASE, and PsycINFO from 1990 through December 2019. They included studies that prospectively evaluated drug effects on insomnia-related sleep parameters in participants with alcohol disorder who were treatment-seeking or abstinent at study entry

The authors also attempted to identify novel molecules in development in the United States that may be useful in the treatment of insomnia. The authors screened 190 abstracts and reviewed 36 full-text articles for eligibility. A total of 18 studies (15 randomized controlled trials [RCTs] and 3 open-label studies) were included, including studies of antidepressants, anticonvulsants, melatonin agonists, and antipsychotics.

Trazodone 50 mg to 200 mg/day was shown to improve sleep in two RCTs, although 1 study showed evidence of an increased risk for alcohol relapse. Overall, trazodone is the most frequently prescribed medication for the treatment of 

One double-blind active comparator trial found evidence for significant improvements in sleep quality in patients with mild-to-moderate alcohol withdrawal for treatment with carbamazepine (versus lorazepam).

Six RCTs have evaluated the efficacy of gabapentin 400 mg to 1800 mg/day. Three of these trials showed significant improvements in sleep parameters, and 4 showed a positive effect on drinking outcomes. The authors noted that gabapentin is non-hepatically metabolized, does not lower seizure threshold, and does not require blood monitoring, although it has been associated with abuse liability and suicidal thoughts and behaviors.

A small, open-label, 4-week study found improvement in sleep parameters with 8 mg ramelteon. Another small, open-label, 6-week study found improvements in subjective sleep quality with agomelatine 25 mg to 50 mg/day. The authors noted that agomelatine has potential hepatoxicity and is not approved by the United States Federal Drug Administration (FDA).

Two placebo-controlled RCTs found that quetiapine at doses up to 400 mg/day significantly improved sleep parameters in patients with AUD.

Two RCTs showed significant improvements with acamprosate in patients with AUD during abstinence.

In a 13-week RCT in veterans with post-traumatic stress disorder and comorbid AUD, prazosin 16 mg/day did not improve sleep parameters or alcohol use compared to placebo.

One placebo-controlled RCT found that the tumor necrosis factor-alpha blocker etanercept at 25 mg significantly reduced the amount and percentage of REM sleep.

The authors identified 8 novel compounds currently being studied in the United States. Three of these agents target the orexin system. Another compound targets gamma-aminobutryic acid receptors. Piromelatine, a melatonin and serotonin agonist is in development for sleep disorders and Alzheimer disease. The atypical antipsychotic lumateperone is also being studied in Phase 2 trials for sleep disorders associated with neuropsychiatric disorders. A nociceptin/orphanin-FQ receptor agonist is also being evaluated in a Phase 2 study in adults with AUD.

The authors note that the prevalence of insomnia in patients with AUD is high, but there is limited data on the persistence of sleep-related disorders for patients with AUD who are in sustained remission. The use of sedative-hypnotic agents (eg, benzodiazepine receptor agonists) are limited due to risk of abuse liability, overdose, and alcohol relapse in this patient population. There is some evidence for other pharmacologic interventions, although these have not been extensively studied and are not approved by the FDA, and several other agents are in development.

There is a need for safe and efficacious treatment options for vulnerable patients with AUD in early and sustained recovery. The following cases serve to illustrate scenarios that could take place in clinical practice. The cases are for illustrative purposes and the identity and details of patients have been changed.

“Mr J” has a longstanding history of schizophrenia and severe AUD, currently with 2 years’ sobriety. His psychosis is currently stable on quetiapine 300 mg nightly, but he reports worsening insomnia over the past 2 months resulting from anxiety associated with the coronavirus pandemic. He has remained abstinent from alcohol but expresses concern about a relapse of drinking. His psychiatrist increased his quetiapine to 400 mg nightly. Over the following month, his insomnia abated, though he noted increased appetite with an associated 3 lb weight gain.

“Ms K” has a 10-year history of moderate AUD and comorbid fibromyalgia. After 3 years of sobriety, she relapsed on alcohol. One month after alcohol detoxification, she noted onset of initial and middle insomnia. Her psychiatrist subsequently initiated treatment with gabapentin 300 mg nightly, and she noted subjective improvements in insomnia and sleep quality, as well as mild improvements in her pain levels.

“Mr M” is a 22-year-old male currently in a long-term residential treatment facility following a first hospitalization for severe AUD. He has been in residential treatment for 2 months. Although he has noted sleep disturbance since he completed alcohol detoxification, he recently reported symptoms of middle and terminal insomnia to his physician. He was prescribed trazodone 50 mg nightly. In the first month of treatment, his insomnia resolved, though he had a slip and consumed 1 alcoholic beverage.

 is professor, Department of Psychiatry and Health Behavior, Augusta University, Augusta, GA. He is the Schizophrenia Section Chief for 

 The author reports that he receives research support from Augusta University, the National Institute of Mental Health, the Brain and Behavior Research Foundation, and the Stanley Medical Research Institute.

1. Chakravorty S, Chaudhary NS, Brower KJ. 

Alcohol dependence and its relationship with insomnia and other sleep disorders

2. Brower KJ, Krentzman A, Robinson EA. Persistent insomnia, abstinence, and moderate drinking in alcohol-dependent individuals. 

3. Arnedt JT, Conroy DA, Brower KJ. Treatment options for sleep disturbances during alcohol recovery. 

4. Friedmann PD, Herman DS, Freedman S, et al. 

Treatment of sleep disturbance in alcohol recovery: a national survey of addiction medicine physicians

5. Roehrs TA, Auciello J, Tseng J, Whiteside G. Pharmacological treatment options for insomnia in patients with alcohol use disorder in recovery. 

6. Schubert JR, Arnedt JT. Management of insomnia in patients with alcohol use disorder. 

Clinical considerations for evaluating treatment options for patients with insomnia and AUD versus patients with primary insomnia without substance use comorbidity.

Understanding Comorbid Insomnia and Alcohol Use

Shift work sleep disorder is characterized by insomnia and excessive sleepiness lasting for at least 3 months in association with fluctuating work schedules. Patients who have this disorder experience an overall decreased amount of sleep. As defined by the 

International Classification of Sleep Disorders

, the condition also known as circadian rhythm sleep-wake disorder, shift work type or circadian rhythm sleep disorder (in DSM-5) is estimated to affect 

Because the inherent circadian rhythm is largely regulated by the 24-hour light/dark cycle, people who work overnight generally feel sleepier at night than during the day, even when they are at work or have slept during the day. Patients who work schedules with some or all shifts during the night when they would otherwise be sleeping may consequently experience disruptions in their circadian rhythm. These disruptions affect one’s ability to get adequate sleep, even when they have enough time to sleep. Most people who have shift work sleep disorder have 

Sleep disruption is also associated with behavioral manifestations of mood changes, such as irritability and social withdrawal. In addition to fatigue as a contributing factor, when mood changes like depression and anxiety are associated with shift work sleep disorder, they are thought to be caused by molecular alterations linked to circadian rhythm disruption. Research 

that the circadian clock is likely to regulate monoaminergic signaling, which mediates changes in dopamine, serotonin, and noradrenaline levels throughout the day.

 A disturbance in the circadian rhythm causes deregulation of these hormones at the level of molecular transcription, and this may result in symptomatic mood alterations.

Many shift workers are unable to adjust their circadian rhythm to their altered sleep wake schedules. This is evidenced by samples of salivary melatonin concentration, which normally 

 The diagnosis of shift work sleep disorder is a clinical diagnosis based on a patient’s medical history. The combination of insomnia, excessive sleepiness during waking hours, lack of sleep, and chronic shift work that is inconsistent with a regular day/night wake/sleep schedule leads to the diagnosis. Research 

that between 10% to 30% of shift workers fit the criteria for shift work sleep disorder, and it unclear why some shift workers are more prone to the condition than others.

Many pharmacological treatment strategies have been used to treat this acquired sleep disorder, including melatonin, zopiclone, lormetazepam, and modafinil. For example, one 

that was fairly representative of the effects of medications on the condition showed that pharmacological therapies increased sleepiness in some patients but did not improve overall sleep for the majority of patients.

 Non-pharmacological interventions include sleep education, use of bright light, napping, and physical exercise. These 

also have not been consistently effective.

A 47-year-old man has trouble falling asleep and reports not getting enough sleep throughout the night. He says he has no energy to do anything other than work and sit around at home.

His wife and daughter have accompanied him to the office visit. They explain that his moodiness has gotten worse over the past year. They say that he is irritable and sometimes seems down and uninterested in talking with them at home.

The patient works rotating shifts in a factory and has had the same job and schedule for about 5 years. He works 10-hour shifts with a schedule that varies weekly. He is scheduled to work from 10 PM to 8 AM on any 4 days of 1 week, followed by a week of working any 4 days from 10 AM to 8 PM. When an extra shift opens up with bonus pay, he takes it. He has often come home and gone back to work within 6 hours for an additional 10-hour shift when he can fit it in, which happens approximately 3 times per month.

The patient often tosses and turns in bed for hours before falling asleep, and sometimes he only gets a few hours of sleep before his next shift. He has not established a consistent sleeping pattern. He and his wife have installed heavy curtains with full window coverage to made sure their bedroom is completely dark during the daytime.

He agrees with his wife and daughter that he is quiet sometimes and irritable at others, but his family says these issues are getting progressively worse and he is very difficult to be around. The patient says he isn’t sad or anxious; instead, he is just tired and “zoned out.”

He gets enough to eat, and his wife is very attentive to planning healthy meals at home and packs healthy meals for him on his works days. He drinks 2 cans of caffeinated cold beverages at the beginning of every shift, and he doesn’t consume caffeine at any other time.

The patient smoked 1 pack of cigarettes per day since his 20s, but he quit about 5 years ago when a friend was diagnosed with lung cancer. He does not have any medical problems, and he isn't stressed at work or home. His physical examination is completely normal.

This patient was preliminarily diagnosed with shift work sleep disorder on his first visit. He and his wife agreed to keep a sleep diary over the course of 1 month. When they returned, they discussed the diary, which showed he had a very inconsistent sleeping schedule. He often came home and went to bed right away after a day or night shift, and sometimes he delayed going to bed for 3 to 7 hours after a day or an evening shift.

While shift work sleep disorder can cause diminished attention and increase the risk of accidents,

 this did not seem to be a problem for him. However, because he did not directly deal with equipment and rarely drove anywhere except work, he had limited opportunities to get into an inattention-induced accident.

The patient said that he did not want to look for a different job, as his pay rate and benefits were the best he had ever had in his life. He was advised to try to regulate his sleep schedule by going to bed at the same time every day during his week of night work and at the same time every day during his week of daytime work. He also wanted to try melatonin.

After several months, he was able to regulate his sleep on the weeks of his daytime shifts, but he still had an inconsistent sleep schedule on his week of nighttime work because he did not want to sleep during the day on his 3 days off. He continued to accept extra shifts whenever possible. He believed the melatonin helped him fall asleep and he felt that he was getting more rest on the days when he took it.

Overall, he did not have more energy, but he tried to be less irritable. His wife and daughter agreed he was more pleasant, yet still not very interactive. The family felt satisfied that learning about the disorder helped all of them cope with its clinical effects. They also all agreed the patient would aim eventually to get a job with a more regular schedule if he could find one without having to take a pay cut.

• Some people are more susceptible to shift work sleep disorder than others, and the reasons for this predisposition are unclear.

• Shift work sleep disorder is extremely difficult to overcome with medication. Because some patients’ symptoms improve with medication, it may be worth trying for those who can’t change their work schedule.

• Alternative therapies have shown limited success in the management of shift work sleep disorder. Nevertheless, sleep education can help patients and families cope and may serve as a motivation to eventually change circumstances when possible.

is Adjunct Professor at John Carroll University, and Instructor, Case Western Reserve University in Cleveland, OH. She is the Editor in Chief Emeritus of 

1. Boivin DB, Boudreau P. Impacts of shift work on sleep and circadian rhythms. 

https://pubmed.ncbi.nlm.nih.gov/25246026/

2. Gumenyuk V, Roth T, Drake CL. Circadian phase, sleepiness, and light exposure assessment in night workers with and without shift work disorder. 

https://pubmed.ncbi.nlm.nih.gov/22823876/

3. Albrecht U. Molecular Mechanisms in Mood Regulation Involving the Circadian Clock. 

https://pubmed.ncbi.nlm.nih.gov/28223962/

4. Liira J, Verbeek JS, Costa G, et al. Pharmacological interventions for sleepiness and sleep disturbances caused by shift work. 

https://pubmed.ncbi.nlm.nih.gov/25113164/

5. Slanger TE, Gross JV, Pinger A, et al. Person-directed, non-pharmacological interventions for sleepiness at work and sleep disturbances caused by shift work. 

https://pubmed.ncbi.nlm.nih.gov/27549931/

A case of a patient with difficult-to-treat insomnia highlights the pervasive daytime effects of this condition.

Insomnia Associated With Shift Work Sleep Disorder

Insomnia is characterized by difficulty falling asleep, trouble staying asleep, and/or early waking. The result is usually inadequate sleep, with daytime effects associated with sleep deprivation. Up to 50% of adults 

they have experienced insomnia at some point in their life.

While not as common as insomnia, anxiety and depression are also fairly prevalent among adults. 

 surveyed a random sample of 3406 participants ranging from aged 18 to 79 years. Of the participants, 13.9% (10.0% men, 17.0% women) reported they had received a diagnosis of anxiety; 6.4% (5.5% of men, 7.1% of women) had received a diagnosis of depression; 28.6% (23.5% of men, 32.7% of women) reported a diagnosis of insomnia; and 14% reported self-perceived stress.

Anxiety and stress are closely linked, and they are among the chief causes of insomnia. The exact prevalence of stress and/or anxiety among persons with insomnia is unknown, but stress and anxiety have an 

 because of a variety of emotional and physical factors.

 As with insomnia due caused by other factors, sleep deprivation due to anxiety-associated insomnia can bring about a variety of distressing symptoms during the day. Fatigue, irritability, anxiety, and depression are common consequences of sleep deprivation of any cause. Health problems like weight gain, hyperglycemia, and elevated lipid levels are associated with chronic sleep deprivation as well.

A 61-year-old man complains of insomnia, with difficulty falling asleep, frequent waking throughout the night, and early morning awakening. He estimates this has been going on for at least 6 months to a year, but he reports it is getting worse. He has been having trouble sleeping every night for the past few months and he naps during the weekend and in the evenings after work. He notes that he feels tired throughout the day and drinks cold caffeinated beverages “all the time,” to stay awake, totaling about 6 standard 8 oz cans per day.

He has gained 35 pounds in the past year. He used to regularly ride his bike for about 20 miles 3 or 4 times per week, but he stopped because of a stressful situation at work that has been distracting him. 

For the past 2 years, he has been embroiled in a lawsuit related to an accidental injury of an employee at his place of business, where he is a manager. The lawsuit is related to what is described as inadequate safety equipment, and he explains that he is part of the group of people who are responsible for implementing safety at his workplace. The patient says the employee’s injury and disability have been upsetting for him. He also says the lawsuit has been stressful. He was disturbed when he heard about the injury, but he was able to manage the stress because he thought the employee would have a quick recovery and the legal proceedings would be resolved within a month or so.

As he began to realize the issue would not be resolved quickly, he became more and more anxious about it. He explains the work environment is anxiety-provoking because there are meetings about the lawsuit approximately once per month, often with just a few hours’ notice. It should be noted that the business and his own salary have not been impacted and he says he is not stressed about the financial implications of the situation.

He lives with his wife and he says he has maintained a calm demeanor at home. He has 2 sons in their late 20s who live on their own and he says there is no strain in his relationships with his family. Over the past years, he has been going to fewer social outings and often leaves gatherings early because he feels bored. He explains his loss of interest in social gatherings began around the same time as the lawsuit.

He reports he has felt anxious and worried for as long as he can remember, but he doesn’t remember ever complaining of insomnia, and he has never felt the need to talk to a doctor about it. The patient mentions he experienced anxiety for a year after his father died because he had to manage his mother’s home and finances when she didn’t know what to do.

Past medical history consists of allergic asthma diagnosed in his 30s for which he takes nasal steroids as needed. He also is sensitive to many foods, which give him a stomach upset and heartburn.

Stress and anxiety are linked with each other. Stress is typically a response to a situation, while anxiety is a lingering feeling of disturbance or unease. Stress can cause anxiety, which is the case in this patient’s situation. The patient’s history strongly suggests a correlation between his difficult experience at work, his anxiety, and his insomnia.

During a clinical workup, it is important to keep in mind that underlying medical issues can contribute to insomnia and anxiety. Thyroid disease and heart disease, in particular, can exacerbate patients’ symptoms. When other causes are not found, it is helpful for patients to understand symptoms such as weight fluctuation, indigestion, stomach upset, sweating, appetite changes, and sexual dysfunction can all be symptoms of anxiety.1 This patient has noted some of these effects.

, especially without a precipitating factor that is out of the ordinary, it is often described as generalized anxiety disorder (GAD).

 The patient suggests he might have GAD, but based on his detailed history, it appear he is not excessively prone to anxiety out of proportion to the circumstances of his life.

The patient described in the vignette also has signs of depression. He has lost interest in socializing and exercise, which he used to enjoy. A depression screening would be beneficial as well. Major depression occurs in almost two thirds of patients with anxiety.

Treatment of comorbid anxiety, depression, and insomnia requires a treatment strategy that is designed to avoid exacerbating any of the 3 issues. Serotonin reuptake inhibitors (SSRIs) are among the 

 Additionally, SSRIs can help reduce symptoms of insomnia for some patients.

This patient started taking paroxetine (Paxil) but became very tired. He was unable to tolerate the fatigue, so the medication was discontinued. He wanted to try another medical treatment, however. He was prescribed amitriptyline (Elavil), a tricyclic antidepressant. He was more satisfied with the treatment and wanted to continue to take it. He also agreed he might benefit from counseling, as he did not see a clear light at the end of the tunnel regarding his situation at work, and he didn’t anticipate an improvement of his symptoms until the issue resolved.

• Anxiety and GAD are not the same conditions, even though people with anxiety may be prone to recurrent episodes.

• Insomnia is caused by and can cause anxiety and depression.

• Treatment of insomnia with anxiety and depression entails a strategy that is mindful of all 3 conditions.

The above case is for illustrative purposes only. Identifying factors have been changed. -Ed

1. Pharmacological Treatment of Mental Disorders in Primary Health Care. In: World Health Organization. 

Pharmacological Treatment of Mental Disorders in Primary Health Care.

https://www.ncbi.nlm.nih.gov/books/NBK143206/

2. Höglund P, Hakelind C, Nordin S. Severity and prevalence of various types of mental ill-health in a general adult population: age and sex differences. 

. 2020;20:209. doi: 10.1186/s12888-020-02557-5 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7212684/

3. Kalmbach DA, Anderson JR, Drake CL. The impact of stress on sleep: Pathogenic sleep reactivity as a vulnerability to insomnia and circadian disorders. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7045300/

4. Munir S, Takov V. Generalized Anxiety Disorder (GAD). 

Treasure Island (FL): StatPearls Publishing; 2020 Jan-. 

https://www.ncbi.nlm.nih.gov/books/NBK441870/

5. Coplan JD, AaronsonCJ, Panthangi V, Kim Y. Treating Comorbid Anxiety and Depression: Psychosocial and Pharmacological Approaches. 

2015;5(4):366-378. doi: 10.5498/wjp.v5.i4.366. 

https://pubmed.ncbi.nlm.nih.gov/26740928/

Anxiety and stress are closely linked, and they are among the chief causes of insomnia. Watch for a variety of emotional and physical factors that may play a role in worsening depression. More in this case report.

Anxiety-Associated Insomnia With a Twist of Depression

There is an unmet need for preventive strategies that delay or forestall the onset of mental illness, particularly in persons at heightened risk. Interestingly, insomnia—a syndrome with chronic sleep onset and/or continuity problems associated with impaired daytime functioning—was a 

 in two meta-analyses with odds ratios (ORs) of 2.3-2.6.

 performed a systematic, quantitative review of longitudinal studies, investigating whether baseline insomnia (including both nighttime and daytime symptoms) is associated with subsequent onset of a mental disorder. Study authors searched for articles in PubMed, Medline, PsycInfo, and PsycArticles, as well as the reference lists of identified studies and recent congress abstracts. 

They included longitudinal studies (with follow-up of at least 12 months) of adults where insomnia was diagnosed based on interview or questionnaire (and covering both nighttime and daytime symptoms); diagnosis of mental disorders were verified by clinical interview or validated self-rating questionnaires; and either subjects with mental disorders other than insomnia at baseline were excluded or the study controlled for baseline psychopathology. Data were analyzed using random effects meta-analysis. Effect sizes (ORs) were calculated for individual mental disorders as well as all mental disorders pooled together. The authors performed assessments of both risk of bias and publication bias.

The authors identified 13 studies, comprising a total sample of 181,798 participants at baseline and 133,967 at the last follow-up. These studies included 10 samples for depression, 6 for anxiety, 2 for alcohol abuse, and 1 for psychotic disorders. The mean duration of study follow-up was 61 months. They found that baseline insomnia was associated with significant increased odds of incident depression (OR=2.8), anxiety (OR=3.2), alcohol abuse (OR=1.4), and psychosis (OR=1.3).

Across all studies pooled together, baseline insomnia was associated with a significant, 2.6-fold increased odds of mental disorder, with evidence of significant between-study heterogeneity. Overall, the risk of bias was rated as moderate for most individual studies. There was no significant evidence of publication bias for either depression or anxiety. There was no evidence that study duration moderated these associations. Furthermore, the pattern of findings did not change in a subgroup analysis of studies of participants without any mental disorders at baseline.

The authors concluded that baseline insomnia is associated with significant increased odds of incident mental disorder. Potential explanations for these associations include brain hyperarousal, neuroplasticity, and emotion regulation. A strength of the meta-analysis is that both nighttime and daytime symptoms of insomnia were required for inclusion, consistent with current diagnostic criteria. The authors note, however, that the observed temporal association does not allow for causal attributions. Nevertheless, findings raise the possibility for treatment of insomnia for the prevention of mental disorders.

Insomnia increases the odds for incident mental disorders.

 is Professor, Department of Psychiatry and Health Behavior, Augusta University, Augusta, GA. He is the Schizophrenia Section Chief for 

1. Baglioni C, Battagliese G, Feige B, et al. 

Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies

Insomnia and the risk of depression: a metaanalysis of prospective cohort studies

Insomnia as a precipitating factor in new onset mental illness: a systematic review of recent findings

4. Hertenstein E, Feige B, Gmeiner T, et al. 

Insomnia as a predictor of mental disorders: a systematic review and meta-analysis

Because insomnia is a syndrome marked by chronic sleep onset and/or continuity problems associated with impaired daytime functioning, it is important that clinicians screen for sleep issues in their patients.

Does Insomnia Predict the Onset of Mental Illness?

Nightmares are among the causes of secondary insomnia. Scary dreams are often associated with sleep disturbances. Waking up from a bad dream interferes with the restorative benefits of sleep. Insomnia, which is different than disturbed sleep, can also occur when bad dreams are recurrent to the point of anticipatory dread.

Dreaming occurs during the rapid eye movement (REM) stage of sleep. Most people remember only a small fraction of their dreams, and many people don’t remember their dreams at all. It is unclear whether people are more inclined to remember bad dreams than dreams with neutral content, but 

 that disturbing dreams are more likely to be recalled, at least in the first few minutes right after waking up from a dream.

Because dream stages (including REM) cycle several times throughout a normal night’s sleep, bad dreams can occur in one of the earlier REM stages of the night. When they cause a person to wake up, these waking episodes can interrupt sleep in the middle of the night and may make it hard to fall back asleep. Abruptly waking up can disrupt some of the restorative effects of a night of sleep.

Insomnia associated with bad dreams is distinct from primary insomnia. Patients may recognize the difference and may seek professional help in pursuit of restful sleep. It isn’t unusual for a patient to request pharmacological therapy to try to fall asleep and sleep through the night-even when insomnia is recognized as secondary to a cause.

The patient described in the vignette below had insight into the source of her insomnia and wanted to get professional help because her resulting sleep deprivation started to affect her overall well-being during the day.

A 28-year-old female seeks medical attention because she has been irritable and having trouble concentrating. Although she has had these symptoms for a year, they are getting worse and starting to interfere with her life. Over the past several months, she has also had intermittent shoulder pain and frequently notices she has dry eyes. She thinks these symptoms are all related to her lack of sleep.

She works full time in a retail store and is enrolled part time in graduate school. Her job is not stressful, and she is doing well in school and getting good grades. She often stays up until about 3 AM to get her assignments done, but she never pulls all-nighters. She has friends and a pleasant social life and gets along with her roommate. She doesn’t smoke and she drinks alcohol every other weekend with friends, typically about one beer or glass of wine.

She says that she doesn’t sleep well in general, even when she has time to sleep. She has been having bad dreams for about a year, and they have become so upsetting that she stays up until she falls asleep from extreme fatigue. The dreams generally involve a vague fear that someone is breaking into her parents’ home or the entrance of the apartment building where she lives, but never entering her childhood bedroom or her apartment unit. During the dreams, she thinks the intruder wanders with bad intentions around her home or in the building, and this presence is frightening to her. She wakes up frequently throughout the night, whether she has had this dream or not. It often takes her some time to get back to sleep, and she doesn’t know how long it takes because she deliberately avoids looking at a clock. She wakes up early in the morning for classes four days a week. She doesn’t like to take naps due to the brightness in her apartment and the sound of her roommate coming in and out throughout the day. She usually sleeps in until about noon on Friday, Saturday, and Sunday and her roommate makes a point of being quiet during these times.

The patient explains that she had a summer job at a local restaurant when she was in college, and the restaurant was robbed while she was working. She says the thieves walked in and pointed a gun at her coworker who was working at the register while customers were present. The coworker handed the thieves a pile of cash, and they left. The patient did not witness the event because she was working in another area of the restaurant. The offenders were caught in what she understands was an uneventful arrest. The patient says she thinks her nightmares could be related to the event, but she doesn’t understand why they just started a year ago and why her sleep wasn’t affected for several years after the robbery.

The only other precipitating factor she can think of is that she and her roommate shared a dog until a year ago when they moved to a building that did not allow pets. Due to the pet restriction, the dog was sent to live with her roommate’s parents. A few months before that, her own childhood dog, who had been with her parents, died. She says she was attached to both dogs and that each one typically slept on a dog bed in her bedroom.

She has no past medical history and her parents and only sibling are healthy. Her physical examination is completely normal. The patient denies symptoms of depression or anxiety, and she has not experienced any delusions or hallucinations. She was administered depression screening, and she did not have any signs of depression.

The patient agreed that her insomnia was likely caused by her reluctance to fall asleep due to her fear of bad dreams. While the patient initially requested medication to help her fall asleep at the urging of her mother, she agreed to first try behavioral therapy and counseling to learn how to reduce both the negativity of her dreams and her apprehension about the dreams.

She and her doctor decided together that she needed to talk through her fears about the robbery and the lack of nighttime comfort she had been getting from her dog. She also felt that she needed some encouragement so she could try to change the course of the fearful feelings during her dreams. She acknowledged that she would also benefit by accepting the fact that she might still occasionally have unpleasant dreams, and that she didn’t want to be so scared of the dreams themselves.

Nightmares that cause sleep disturbances are associated with an 

 This patient does not have signs of mental illness at this point and treating her symptoms could help avert further complications from developing. According to the American Academy of Sleep Medicine, behavioral therapy and pharmacological therapy are both 

 for treating nightmare disorders in adults.

 Physicians are encouraged to decide on the treatment approach based on the individual situation of the patient, and with input from the patient. The statement includes several medication recommendations, including olanzapine and tricyclic antidepressants, and recommends against using certain medications, including clonazepam and venlafaxine.

• Patients do not usually seek help for treatment of insomnia until it begins to affect daytime quality of life.

• Patients who experience insomnia often provide a thorough background regarding the factors that interfere with their sleep. 

• Pharmacological therapy can help improve sleep quality for people who have secondary insomnia, but when there is a clear reason besides primary insomnia, it can be beneficial to address the underlying cause.

The above case is a composite and not meant to identify any one person. -Ed

s Adjunct Professor at John Carroll University, and Instructor, Case Western Reserve University in Cleveland, OH. She is the Editor in Chief Emeritus of 

1. Cipolli C, Ferrara M, De Gennaro L, Plazzi G. 

Beyond the Neuropsychology of Dreaming: Insights Into the Neural Basis of Dreaming With New Techniques of Sleep Recording and Analysis

2. Sheaves B, Porcheret K, Tsanas A, et al. 

Insomnia, Nightmares, and Chronotype as Markers of Risk for Severe Mental Illness: Results from a Student Population

3. Morgenthaler TI, Auerbach S, Casey KR, et al. 

Position Paper for the Treatment of Nightmare Disorder in Adults: An American Academy of Sleep Medicine Position Paper

A patient's sleep deprivation started to affect her overall well-being and compromised her ability to enjoy life.

Insomnia Triggered by Nightmares: Evaluation and Treatment Options

A good night's sleep is foundational to maximal functioning, lowered stress, good reaction time, enhanced cognitive function, and more. For many individuals, when they experience difficulty falling asleep the first inclination is to take some type of medication--a prescription drug for insomnia or an over-the-counter medicine, many types of which are readily available at pharmacies, grocery stores, and convenience stores. Other individuals may turn to cannabis or alcohol. However, all medications or mind-altering agents have adverse effects and risks.

Alternatives exist that can provide lasting benefits to promote predictable, restful sleep through behaviors that enhance the likelihood of falling and staying asleep. Collectively, these behaviors are called "good sleep hygiene." This video will review the many types of behavioral changes that can contribute to falling asleep, staying asleep, and waking up in the morning feeling refreshed.

, Exeter, NH; Consulting Psychiatrist, Exeter Hospital, Exeter, NH; Consulting Psychiatrist, Insight Meditation Society, Barre, MA.

A good night's sleep is foundational to maximal functioning, lowered stress, good reaction time, and enhanced cognitive function. Strategies discussed here.

Elements of Good Sleep Hygiene

Refreshed sleep can be tough even during normal times. With up to 30% of Americans experiencing sleep problems, here are guidelines to a better night’s sleep.

Sleep Hygiene Tips to Prevent Insomnia

Finding and treating the underlying cause of sleep disturbance is critical to effective management. Here are a few medical conditions that may trigger key disrupting symptoms.

Sleep Disorders