Nightmares in African Americans

African Americans in the United States appear to experience significant sleep health problems relative to other ethnic minority groups and non-Hispanic whites. Differences in sleep between African Americans and other ethnic minorities as well as non-Hispanic whites in the United States have been documented in numerous studies and several meta-analyses of these studies (see reviews in Durrence and Lichstein, 2006; Ruiter et al., 2010; 2011; Lichstein et al 2004). African American individuals tend to report poorer sleep continuity and quality, excessively short duration, and greater risk of sleep apnea. These sleep problems persist even after controlling for several relevant confounders such as socioeconomic status, occupational factors, neighborhood context, and health comorbidities.

Despite these dozens of studies of sleep disparities among African Americans, there has to my knowledge, never been a study of Nightmare Disorder or recurrent nightmares/disturbed dreaming among this group. I suspect that Nightmare Disorder/disturbed dreaming is prevalent among African Americans and is in fact an underdiagnosed sleep problem. I am not sure why nightmares are not studied among African Americans. It is easy enough to ask patients in a clinic or respondents in epidemiologic surveys whether or not they have experienced nightmares that disturb daytime functioning. Yet that simple question has not been posed consistently.

I assume that, as in other populations, Nightmare Disorder significantly contributes to the other chronic sleep problems documented among African Americans (such as poor sleep quality, short sleep duration and sleep avoidance/insomnia). The lack of attention given to nightmares/disturbed dreaming is particularly unfortunate given that many African Americans very likely carry major risk factors for Nightmare Disorder and recurrent disturbed dreaming: the elevated rates of poverty and systematic racism many are exposed to on an almost daily basis.

The risk factors for Nightmare Disorder include higher rates of PTSD (posttraumatic stress disorder), high childhood adversity, significant history of physical trauma, existence of chronic emotional stressors and anxiety, and chronic sleep dysfunction (such as sleep apnea). In addition, recurrent disturbed dreaming/nightmares significantly increases risk for insomnia (sleep avoidance), poor sleep quality (nonrestorative sleep), and other neuropsychiatric problems, such as suicidal ideation and psychosis.

In short, Nightmare Disorder is very likely a significant sleep problem among African Americans, and yet it is not investigated. The underinvestigation of nightmares is all the more tragic given that there are effective treatments for recurrent and disabling nightmares. There are effective and inexpensive pharmacologic and cognitive behavioral therapies for Nightmare Disorder. It may be that recurrent nightmares are driving some of the other chronic sleep problems among African Americans. For example, people with recurrent nightmares tend to avoid sleep as they do not want to undergo the terrifying experience yet again. These individuals end up chronically sleep deprived. Instead of being diagnosed with nightmare disorder, however, they are diagnosed with insomnia and therefore given the wrong treatments. The available treatments for nightmare disorders could conceivably end this tragic cycle for these individuals.