When Nightmares Disturb More Than Sleep

The Garden of Earthly Delights

Source: Hieronymus Bosch [Public domain]

Several years ago, while visiting Madrid, I had the opportunity to visit the Prado Museum, one of the finest art museums in the world. It was there that I was able to see the original and world famous “Garden of Earthly Delights” by Hieronymus Bosch. While this work is displayed in Spain, Bosch was born and lived in the area of the modern-day Netherlands in the late 1400s and early 1500s. I spent most of the day in the museum, yet only began to take in the vast collection of amazing art. But hours could have been spent pondering this amazing work of art, alone. Generations of art historians and psychologists have tried to understand the bizarre imagery and symbolism contained in it. One might wonder from what source such a vision arose.

I first saw copies of this painting as a child and immediately had the sense that they somehow were the imagery of dreams. And for the right-most panel, nightmares. The right panel has always caught my imagination as a deeply disturbing representation of hell itself, as seen through the lens of a nightmare. It seems to have some deep, almost archetypal quality to it and has inspired other artists to attempt to depict their own versions of a terrifying hellscape — one that would embody the worst nightmare you could imagine. During nightmares, our deepest fears and most repugnant images emerge and can, if only briefly, be remembered upon awakening. Sometimes the memory can linger for years. When awakening from the nightmare, we are in a shaken state that quickly turns to relief as we realize that the imagery was “only a dream.”

Nightmares are experienced as long and unpleasant dreams that cause fear, anxiety, or sadness, although we most often think of them as being anxiety dreams that include intense fear and a sudden awakening. Anyone can have a nightmare at any time, but most often these occur during times of increased stress, insufficient sleep, use of REM-sensitive medications, or as a symptom of PTSD (American Psychiatric Association, 2013). One of the diagnostic criteria for PTSD is, in fact, “recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s)” (American Psychiatric Association, 2013). As I discussed in the past, most nightmares pass quickly and leave the dreamer shaken, but relieved, and sleep usually returns fairly quickly.

But sometimes this doesn’t happen, and nightmares affect more than just one night’s sleep. The negative emotions experienced during the nightmare may persist, even lasting into the daytime. This can leave the person feeling sad, worried, or anxious. The nightmares may occur repeatedly and be very long and be accompanied by extremely negative emotional states that are well-remembered. When these repeated, intensely distressing nightmares affect occupational or social functioning, they become a sleep disorder known as “nightmare disorder” (American Psychiatric Association, 2013). Nightmare disorder is not diagnosed if the nightmares are the result of drug abuse or medications that have been prescribed for other illnesses. Also, for the diagnosis, the impairment of the nightmares cannot be explained by other psychiatric or medical disorders. In the case of co-morbid conditions, the diagnosis is only made if and when the nightmares themselves are so significant that they require treatment independent of the co-morbid condition.

For example, in the case of PTSD, nightmares are frequently present and would be considered a part of the PTSD. It is possible, however, that the nightmares could continue after the PTSD has been successfully treated. If nightmares continue and require treatment, nightmare disorder is diagnosed. Likewise, if the nightmares preceded the onset of PTSD, a separate diagnosis and treatment would be appropriate. Nightmares can be co-morbid with many illnesses, including heart disease, pain, Parkinson’s disease, and cancer. They may also appear during medical treatments, including dialysis, or during withdrawal from drugs that have been abused.

Some nightmare-like experiences that occur at night are distinct from the standard nightmare. For example, dysphoric dreams are common following the loss of a loved one, but usually have a different kind of emotional impact than nightmares. The emotional tone is often one of loss and sadness, not the fear and anxiety that would be experienced with nightmares. REM Sleep Behavior Disorder is a condition in which the person moves and acts out dreams. Patients may call these experiences nightmares and their content may indeed be nightmarish, but they are caused by different brain processes and require different treatment. People with narcolepsy often have nightmares, but their daytime sleepiness and other symptoms are caused by the narcolepsy and are not primarily the effect of the nightmares.

Nightmare disorder usually causes significant daytime emotional distress. This may be the most significant problem for people with the disorder. And when there are frequent disruptions of sleep, the impact can be even greater. This is particularly true for people who develop sleep avoidance due to fear of having nightmares. In my experience, the fear of going to sleep due to the fear of having terrible nightmares is the worst symptom for most patients with this disorder. It is especially problematic, because, as noted above, lack of sufficient sleep is a factor in the occurrence of nightmares. It is easy to see how a vicious cycle of nightmares, sleep avoidance, decreased sleep, increased stress, further nightmares, greater sleep avoidance, and so on can happen. When sleep is affected in this way, other symptoms appear that result in impairment of daytime functioning. These include difficulty attending and concentrating, daytime drowsiness, low mood, irritability, and anxiety. For those afflicted, nightmare disorder can seem like a hellish merry-go-round ride that you just can’t stop.

Fortunately, there is help available. In the next post, I will address some methods that have been successfully used to treat nightmare disorder, including medication and psychotherapeutic interventions.