Determining the cause of recurring nightmares

If you are treating an adult patient complaining of reoccurring nightmares, there are several factors you must consider to determine the cause. Nightmares are dreams that are associated with strong emotions such as fear, anxiety and distress. They often involve being chased, being trapped or being faced with a natural disaster, and occur more often in children than adults.

Recently, I consulted with an adult patient who was having nightmares almost daily.  Medical history revealed that she underwent spinal surgery several years ago. Upon awakening from anesthesia, the patient experienced an unexpected outcome — paralysis, which lasted approximately one week.

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During that time, the patient explained that she was afraid she was never going to walk again. Today she is healthy, but continues to have daily nightmares, reliving her paralysis every night when she goes to sleep.

After carefully reviewing her history and ruling out obstructive sleep apnea and medications that might cause nightmares, such as beta-blockers and fluoxetine, I suggested the patient see a psychologist for post-traumatic stress disorder.

I was certain she was not having sleep terrors, as she remembered her dreams. Furthermore sleep terrors typically occur in children, who often report no memory of the event, and generally occur early on in the night. My patient's nightmares were happening in the later part of the night, indicating REM sleep.

It is common for those with post-traumatic stress disorder to have repetitive dreams with a recurring theme. Nightmares can occur in response to traumatic events such as death, divorce or after a motor vehicle accident. They are more common in women than men, and are common among those who have abruptly stopped drinking alcohol or in those who use recreational drugs.

Traditionally, treatment for nightmares associated with post-traumatic stress disorder focuses on conflict resolution. Cognitive behavioral therapy, as well as relaxation and desensitization techniques, may also be helpful. I also suggested that my patient consider writing down her thoughts about the dreams in a journal, as nightmares can be used as a tool for personal introspection.

In my next blog, I will compare home sleep studies and in-lab polysomnograms and explain the role of each.

Sharon M. O'Brien, MPAS, PA-C, works with Presbyterian Sleep Health in Charlotte, N.C. Her main interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.


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