Overview

We have all experienced bad nightmares from time to time, but can you imagine having repeated nightmares every week? This is known as nightmare disorder (ND), which is characterised by nightmares that are clearly remembered and result in impacts on mood, sleep and general behaviour. Currently, nightmare disorder affects around 5% of the population, with a high association with psychiatric disorders.¹ 

Nightmares are much more common amongst children than adults, with up to 50% of children experiencing them regularly. The number of nightmares usually decreases with age, with around 2-8% of adults experiencing them regularly.² Additionally, the causes and symptoms vary between children and adults. This article will dive deeper into the differences in nightmare disorder in children and adults, looking at the causes and symptoms. 

What is nightmare disorder (ND)?

ND is characterised by frequent nightmares (at least once per week), which cause sudden awakening, occur and lead to changes in sleep, mood and behaviour.¹ The key difference between ND and general nightmares is the word frequent - when nightmares become a frequent recurrence, this is where they can be diagnosed as a disorder. Nightmares are associated with inducing negative emotions, including fear and anxiety, and these emotions can persist even after waking up.²

When we sleep, we go through two stages: the non-rapid eye movement (NREM) and rapid eye movement (REM) stages. Nightmares usually occur during the REM stage of sleep, the stage of sleep when most dreaming takes place and brain activity is high.² In terms of classification, ND is classified as ‘acute’ if it lasts for one month or less, ‘subacute’ if it lasts between one and six months, and ‘persistent’ if it lasts for six months or more.³

Effects of nightmare disorder

ND can have negative consequences on mental health, including increased risks of anxiety and depression. The negative impact on sleep quality also causes negative effects on daily life, including memory and concentration. There is also a strong link between ND and post-traumatic stress disorder (PTSD), with patients with PTSD often reporting repeated nightmares. Also, it has shown to increase the severity of PTSD symptoms.²

Nightmare disorder in children

Causes 

The causes of ND in children remain unclear. There is evidence of a genetic link, as children with this condition are more likely to have a parent who experiences increased nightmares themselves. However, the environment is also suggested to have an impact, as there have been associations found with lower family income and nightmare frequency.⁴ 

There is also evidence that parental involvement in sleep development can impact whether a child is more at risk of nightmares - this includes parental behaviours which affect the ability of the child to soothe themselves, for example, excessive comforting before bed and being present as the child falls asleep.⁵

Symptoms

Nightmares are much more common in children than adults, with 50% of children between the ages of 3 and 6 frequently experiencing them. In terms of the content of the nightmares, children reportedly experience themes of animals, monsters and ghosts - this is different to adults. It has been found that the themes of nightmares experienced by children are age-appropriate and reflect the common fears experienced at that age. This disorder can impact children’s mood and academic performance as well as their attention span. Children also commonly have trouble falling or staying asleep.²

Nightmare disorder in adults

Causes 

ND is reported more often in women than in men. This difference has helped guide researchers in finding possible contributing factors. For example, women are statistically more likely to experience anxiety and trauma, both of which have been linked to nightmares. There is also evidence that men and women process emotions differently, which may also play a role.⁶ 

There is some evidence from twin studies in children suggesting a possible genetic link, which may increase the risk of developing ND in adulthood. However, the concordance rate between twins was not 100%, indicating that genetics alone does not determine the disorder and that environmental factors also play an important role.⁶  

Another study suggested that the cause of ND in adults is trauma. During REM, reduced activity in the prefrontal cortex may allow repressed emotional experiences to re-emerge, contributing to distressing dream content. In addition, psychotic experiences, such as hallucinations, may influence the distressing content in nightmares, emphasising the association between ND and other psychiatric disorders.⁷

Symptoms

Despite being less common in adults, ND is still a significant concern due to the increased risk of psychiatric disorders, including PTSD, anxiety and depression. This link is suggested to result from the stress following nightmares, which creates a feedback loop whereby the stress from the nightmare worsens existing mental health conditions, which can go on to contribute to the frequency of nightmares.²

ND in middle-aged and older adults has also been associated with an increased risk of developing dementia and Parkinson’s disease, suggesting that nightmares may be a modifiable risk factor for these diseases.⁸ Furthermore, analyses have found that adults who experience frequent nightmares are 5.87 times more likely to develop a mental disorder, reinforcing the link between mental health and ND.⁶ 

As well as having effects on adult mental health, ND can also affect adults' everyday lives. For example, this may involve impaired concentration at work, sleepiness and effects on relationships. If work performance is affected, this can contribute to further stress and anxiety, causing a reduction in an individual’s overall quality of life. In terms of the content experienced in nightmares in adults, it often involves real-life concerns, stress or trauma - this is very different to the content experienced by children.²

Treatment of nightmare disorder 

Children

Cognitive behavioural therapy (CBT) in children has proven to be an effective treatment for ND. CBT involves several techniques, including imagery rehearsal therapy (IRT), in which children rehearse a modified, less distressing ending to their nightmares whilst they are awake, and cognitive restructuring, which helps children develop more adaptive coping strategies in response to their nightmares. These techniques can help reduce anxiety and the frequency of nightmares. Additionally, a regular sleep schedule, as well as keeping the child’s bedroom comfortable and known as a safe space, can help to  reduce anxiety in relation to sleep.²

Parents can play an important role in helping children manage nightmares. By creating a supportive environment, parents can encourage their children to talk about the nightmare, process any fears, and feel emotionally reassured. This approach is often preferred as it empowers families to manage symptoms without relying on medication. In fact, medication is not usually prescribed for ND, meaning psychological support and parental involvement remain central to treatment.²

Adults

In adults, treatment often takes the form of cognitive behavioural therapy for Insomnia (CBT-I), which targets maladaptive thoughts and behaviours that underlie sleep disturbance and nightmares. This approach can help individuals to identify unhelpful beliefs relating to their nightmares and establish healthier sleep routines. Additionally, patients are taught coping mechanisms to improve their quality of sleep and to help reduce anxiety and the frequency of nightmares.²

IRT may also be used in adults, where they actively reimagine recurring nightmares in ways that reduce their emotional intensity. Furthermore, mindfulness and relaxation exercises can be given to help patients reduce their anxiety, allowing patients to relax and feel a sense of calm, which helps them cope with the stress associated with their nightmares.²

Desensitisation may also be used to prevent nightmares from recurring. Desensitisation involves the repeated exposure to feared nightmare content until the patient becomes used to it and their emotional response declines. Densitisation has proven to be very effective in reducing the frequency of nightmares in adults.⁶ 

Summary 

ND is characterised by the frequent occurrence of nightmares, which can lead to lack of sleep, concentration and have negative effects on mental health. It is more common in children than in adults, and they experience different symptoms and causes of the disorder. In children, nightmares are commonly of ghosts and monsters, which can affect their school performance and general behaviour. In adults, nightmares are usually related to real-world situations and are associated with psychiatric disorders.  Both genetics and the environment can influence the development of ND in children and adults, though the environmental influences often differ between the two. Treatment and management include CBT techniques, desensitisation and relaxation exercises.