Parasomnia refers to recurrent phenomena occurring during sleep, falling asleep, or waking up.
Nightmare does not have any exact definition, but it is a dream with a strong negative emotional charge: anxiety, fear, or horror. A nightmare is also called a bad dream. Nightmares are accompanied by the activation of sympathetic activity.
As a result, the pupils are dilated, heart rate is fast, blood pressure varies and the person may sweat. Cardiac arrhythmias are possible.
Due to the sympathetic activation, the sleeper usually wakes up in the middle of a nightmare, and therefore the contents of the nightmare can be easily recalled, unlike in sleep terror episodes that are not usually remembered at all. Just before waking up, the sleeper may make a loud cry. After waking up, the person is focused on their surroundings and can remember a distressing nightmare.
Nightmares usually occur during the latter part of the night during REM sleep. Between 2% and 6% of adults see nightmares every week. Nightmares are more common in children: between 37% and 78% of children experience nightmares at least occasionally, and between 1% and 11% often or almost every night.
Nightmares can occur especially after intense emotional reactions. The child may react by seeing the nightmares on traumatic situations in the family, such as quarreling, violence, parental alcoholism, financial difficulties, and chronic illness. Exciting movies, and horror movies in particular, are common causes of nightmares. The death of a relative can cause feelings of guilt and nightmares during sleep.
One can also feel that he is seeing nightmares before something important and stressful happens. In that case, they are actually preparing the brain for an upcoming event.
The occurrence of nightmares in children, as with other parasomnias, may be explained by the development of the brain and emotions. On both sides of the puberty, the child’s imagination is lively, and events in life are easily reflected in dreams. Anxious and exciting events can cause nocturnal nightmares, especially in children. Nightmares are also sometimes very realistic. Usually when people wake up to a nightmare, they realize that it was just a bad dream.
What are dream delusions?
Sometimes a person may think that what happened in their dream has really happened. Less than 5% of healthy people have these types of delusions, which are related to sleep and usually nightmares. In contrast, more than a third of narcolepsy patients have had such dream-related false memories. False memory images can persist for days or even weeks.
For example: This one married woman was deeply distressed by the rape of her husband’s good friend at a Christmas party. She didn’t dare to talk about it to anyone and avoided meeting him. The woman’s anxiety and delusional dream only resolved after several days as she encouraged her mind and talked to the man. It became clear to her that they had never had sex, let alone kissed, each other. It had only been a dream-like delusion.
Why bad dreams are called nightmares?
The name nightmare comes from folklore. Nightmare in English, Nachtmahr in German, Cauchemar in French and Scandinavian equivalent expressions are based on the word mare / mara. Mara or Mare is a male demon of folk tales. This creature is able to get itself into a locked room and sit on top of the sleeper. There it tries to suffocate the sleeper during sleep. This results in fear-filled sleep and awakening. The demon may also ride on the sleeper ‘s chest, causing a chest tightness that causes the sleeper to wake up from his sleep.
Why do people have bad dreams (nightmares)?
Nightmares are often seen in connection with feelings of guilt and distress in life, for example when a loved one dies. Nightmares can remain a recurring and sleep-depriving symptom if the traumatic event that caused them has not been adequately addressed at a conscious level. For example, war veterans may have seen the nightmares of traumatic war experiences for decades. Nightmares can make recovery from a traumatic experience worse and sometimes psychotherapeutic support and possible medication may also be needed.
One institution conducted a nightmare survey in 2012. Nearly 14,000 people were asked about nightmares and other factors related to sleep and nightmares. According to the survey, one third of the population sees nightmares every month, half never and about four percent repeatedly. The association with nightmares was explained by negative self-image associated with depression, insomnia, traumatic experiences, or the use of certain drugs such as beta-blockers and some antidepressants (selective serotonin reuptake inhibitors SSRIs).
The study also found that women saw nightmares more often and that they saw them relatively evenly over different ages. Nightmares seen by men, on the other hand, became more common with age.
Unemployment and dissatisfaction with one’s own life also had an increasing effect on nightmares. As a result, the unemployed and pensioners saw nightmares more often. In addition, nightmares were more common among those with a higher body mass index, lower level of education or lower annual income. If the sleep time at night was less than five hours or more than ten hours, it was also subject to nightmares, according to the survey. Night owls saw more nightmares than early birds. Heavy drinking and smoking also increased the number of nightmares.
Is there a treatment for nightmares?
Frequent nightmares can cause daytime fatigue by breaking the sleep pattern. In the treatment of nightmares, the factors that cause them must be investigated. If traumatic factors are found in a person’s past, conscious handling of them will help.
Nightmares may also be caused by drugs such as beta-blockers or melatonin. Sleep maintenance is important and involves calming yourself down before bed. Avoid watching exciting or violent programs on TV.
Heavy and poorly digested meals late at night can make it difficult to sleep and might also cause nightmares. Drinking lots of alcohol in the evening is a typical cause of nightmares in the small hours.
Nightmares have also been successfully treated with psychotherapy. Nightmares may be reduced by the use of REM sleep suppressants such as serotonin reuptake inhibitors (SSRIs) or other antidepressants. Benzodiazepines also reduce REM sleep, but their use is mainly limited to treating people with severe anxiety.
Usually nightmares don’t need any treatment, and especially children should avoid medication.
What is REM Sleep Behavior Disorder (RBD)?
RBD (REM sleep behavioral disorder) may occur as an independent symptom. Or it may be associated with a neurological disorder such as narcolepsy or Parkinson’s disease.
Long-term follow-up studies have identified RBD as an important risk factor for Parkinson’s disease and other alpha-synuclein diseases. n follow-up studies in Minnesota and Canada, up to 90 percent of RBD patients developed Parkinson’s disease over 15 years of follow-up. In practice, this means that if a person over the age of 50 is suspected of having RBD, it is highly appropriate to investigate whether it is really RBD or some other parasomnia or sleep disorder.
In behavioral REM sleep disorder, the sleeper muscle tension does not disappear during REM sleep, as in a healthy person.
A sleeping person’s muscles work during sleep, and he may function according to the content of his dream. Dreams can be violent in content, and the sleeper may harm himself or others.
Patient’s movement may resemble hitting with a hammer, boxing or drinking. In RBD, a person can laugh, speak clearly, or sing. Epilepsy-related motion, in turn, is stereotyped and does not resemble any clear action.
Behavioral sleep syndrome in association with Parkinson’s disease
A patient suffering from behavioral REM sleep disorder may have decreased sense of smell and may suffer from constipation. The significance of RBD in children and adolescents is not well understood. In older people, RBD predicts the onset of Parkinson’s disease. Long-term follow-up studies have shown that up to 90% of RBD patients develop Parkinson’s disease within 10 to 15 years of onset of RBD. As RBD appears to be an important predictor of Parkinson’s disease, ways to prevent or at least delay the onset of Parkinson’s disease are being explored.
Full night EEG sleep monitoring with video surveillance is required to confirm the diagnosis. Melatonin may be used to treat RBD. REM sleep-relieving medicines may also help. Coffee and dark chocolate also seem to provide some protection against Parkinson’s disease.
The best results for RBD treatment are melatonin intake at about 8pm to 9pm in the evening. Clonazepam, a long-acting benzodiazepine, has also been used for treatment. However, clonazepam does not reduce RBD seizures but only the movements associated with it. As all benzodiazepines have adverse effects, including memory effects, clonazepam should only be used in exceptional cases.
One team investigated the sleep of Parkinson’s patients with RBD as a hypothesis, that an outside observer could determine the relationship between the sleep movement and the content of the sleep. However, such an interpretation was unsuccessful. If the subject reported that his / her sleep was full of activity, the events of the sleep may not have been easily interpreted from the body language of the sleeper during sleep.
Other sleep related disorders
Parasomnias are special disorders during sleep. Typical parasomnias include sleepwalking, sleepwalking, nocturnal horror attacks, and night-time bed wetting. Nowadays snoring is no longer classified as parasomnia as it is a symptom of partially constricted upper respiratory tract. Also, teeth grinding (bruxism) is not currently classified as a parasomnia, but is classified as a sleep disorder.
Most people sometimes talk in their sleep. Between 5% and 7% of adults speak often or always in their dreams. Sleep talk occurs most often during light N2 sleep and is sometimes associated with nightmares. Abundant sleep talking may be a symptom of underlying anxiety. On the other hand loud sleep, singing or yelling at sleep can also be a symptom of behavioral sleep disorder, or RBD
Sleep terror (pavor nocturnus, sleep horror, incubus) is often confused with a nightmare. Horror usually begins one to three hours after falling asleep during deep N3 sleep. Nocturnal sleep horror attacks occur at least sometimes in more than a quarter of young children. Horror attacks in adults are less common, but they may still be more common than epileptic seizures at night.
Nocturnal horror attacks in adults resemble panic attacks. During a nocturnal horror attack, the pulse and breathing speed up and the person sweats. The pupils are enlarged, the eyes are staring, and the person can’t be contacted during the attack. A child or an adult can stand or sit, cry or shout. A child or an adult can stand or sit, cry or scream. Jerking limbs or kicking or swinging movements back and forth are not part of the sleep horror.
Instead, the attack may include sleepwalking: a sleeper may get up from the bed, walk into a corner of the room or a wardrobe and urinate there thinking he is in the restroom. The incident lasts from one minute up to 45 minutes. Calming down won’t help. After awakening, the person is usually confused and disoriented about their environment for a while. Quiet, soothing talk can speed up the end of the incident. In the morning, the person can no longer remember their sleep terror incident.
It is important to distinguish between a nocturnal sleep horror episode and a nocturnal epileptic seizure. Cessation of seizures after initiation of antiepileptic medication does not prove that it is an epileptic seizure, as anti-epileptic drugs also help with sleep horror attacks by reducing the amount of N3 sleep.
Usually children’s sleep horror attacks end spontaneously by puberty and don’t require any treatment. In adults, a small dose of benzodiazepine is sometimes needed. In the long-term, sleep horror attacks in adults may get the best help with psychotherapy, because there may be an old traumatic situation, for example, which interferes with normal sleep and can expose to not only nightmares but also horror attacks.
Sleepwalking, also known as somnambulism
About 15 percent of the children sometimes go sleepwalking in their sleep. The susceptibility to sleepwalking is hereditary, and in most cases, there are other sleepwalkers in the sleepwalker family. Children’s sleepwalking is associated with the development of the brain and sleep-wake rhythm. If a child under school age is gently lifted to their feet about an hour after falling asleep, most of them will start to walk in their sleep. Children’s sleepwalking is unrelated to any psychiatric illness and usually ends by puberty.
Adult sleepwalkers have almost always walked in their sleep as a child. In adults, sleepwalking may reflect underlying psychological problems and old traumas. However, it can also occur in perfectly healthy adults with stress, fatigue and febrile illness.
Sleepwalking, like nocturnal horror attacks, usually begins within one to three hours of falling asleep during a deep N3 sleep. A sleepwalker can walk long distances. A child walking in sleep may urinate unknowingly in a wardrobe or floor and return to their bed. If a person is awakened during sleepwalking, he is confused and disoriented. Seizures should be distinguished from nocturnal epileptic seizures.
A sleepwalker may be injured when walking out the front door. It is therefore necessary to ensure that windows and doors are locked. Alcohol and antipsychotics used in the treatment of psychiatric illnesses may exacerbate sleepwalking. In recent years, there have been several reports of traffic accidents caused by a person driving a vehicle after taking zolpidem as a sleeping pill. The effect of zolpidem is twice as potent in women as in men, and the maximum recommended dose of zolpidem for women is only five milligrams. In adults, drugs that reduce deep sleep may be used to treat frequent sleepwalking. Psychotherapy can also be helpful.
Bedwetting or nocturnal enuresis
Nocturnal enuresis in children is a common cause for seeking medical attention. Between 10 and 20% of five-year-olds have night-time bed wetting. Night time bed wetting is caused by organic ailment in only about one percent of cases. Psychiatric factors are also a minor contributor, and wetting may be due to a deficiency in the bladder regulating system during sleep. However, the possibility of epilepsy should be considered in the differential diagnosis. If something abnormal in the child’s day-to-day activities is observed – distracted, learning disabilities or headaches – child neurology should be consulted. Fluid restriction in the evenings, bladder exercise, and waking the child about 15 minutes before the anticipated nighttime be wetting can help. The bed wetting alarm has also proved to be an effective treatment. Sometimes medication is needed.
Nocturnal epilepsy seizures
Nocturnal epilepsy is relatively common in children. A typical benign nighttime epilepsy in children is called rolandic epilepsy. Nocturnal epilepsy can also be a cause of daytime fatigue and should be considered in the differential diagnosis of hypersomnia.
The most common form of nocturnal epilepsy is nocturnal frontal lobe epilepsy. It is accompanied by repeated jerks or movements of the hands or feet. A person may scream loudly during a scene. A large scale video-EEG sleep- polysomnography may be used as a differential diagnosis. In this case, it is important to simultaneously record breathing movements, airflow, oxygen saturation, cardiac function (ECG), muscle function and eye movements. In epilepsy, the electrical activity of the brain (EEG) can see peaks or eruptions that are not seen in parasomnias. Possible seizures can also be seen in the infrared video.
Nocturnal epileptic seizures usually begin in light N1 sleep or sometimes in N2 sleep, but not in deep N3 sleep, like horror attacks and sleepwalking. If nocturnal epileptic seizure begins in REM sleep, it indicates that it is a local epilepsy. In this case, it is particularly important to determine the location and quality of the epilepsy in the brain. Interpretation of such extensive sleep polysomnography is difficult for clinicians in clinical neurophysiology as it requires expertise not only in epilepsy but also in the interpretation of various stages of sleep and in the interpretation of other sleep events.
As noted above, sleepwalking and nocturnal horror attacks pose a problem for the differential diagnosis of epilepsy. If seizures occur only at night between one and three hours after bedtime, is more likely that the issue is a parasomnia rather than epilepsy. A seizure that occurs early in the morning indicates a possible RBD seizure. High-quality EEG sleep polysomnography and video reveal the diagnosis provided that the subject receives a typical seizure during registration and that the potential discharge focus is achieved by the electrodes used. Daytime sleep EEG registration after a short night’s sleep and being awake (sleep deprivation) is often abnormal in epilepsy patients and is usually normal in non-epileptic patients. On the other hand, it should be noted that parasomnias and epilepsy may co-occur.