Section 10: Information that Indicates Nightmare Disorder

DSM-5-TR Code: F51.5

Prevalence = 5.1%

Common Specifiers:

Can this disorder legitimately be diagnosed by a Master’s level clinician?      Yes, with caution. However, a referral to a psychiatrist is generally indicated for persons with this condition and this will serve as an opportunity for confirmation of this diagnosis by another medical provider.

Nightmares are a relatively common phenomenon in most people’s lives. They usually begin occurring between the ages of 2 and 5, when a child’s capacity for imagination is forming and can continue throughout the life cycle, although they diminish with age and are less common in older adults. (Hasler, et al.) Between the ages of 7 and 9, with up to 95% of children reporting nightmares often or sometimes. (Simard et al.)

Nightmare Disorder, however, consists of “repeated occurrences of extended, extremely dysphoric” dream material that causes significant distress or impairment in functioning. Nightmare Disorder of some level has a prevalence rate of about 5%, meaning that about 1 in 20 persons will exhibit this disorder in their lifetime.

Nightmare Disorder is frequently associated with stress, trauma, substance abuse and withdrawal, and other psychiatric symptoms and/or other kinds of sleep disturbance. Clinicians who work with clients suffering from severe Post-Traumatic Stress Disorder are probably the most likely to encounter this disorder in its more serious manifestations, followed closely by clinicians who work in substance abuse facilities where patients undergo detoxification.

Several relatively common medications may also increase the likelihood of this disorder occurring, including beta-blockers, antihypertensives, medications used to treat Parkinson’s Disease, and most antidepressants. When a client expresses concerns about the presence of nightmares, a thorough review of a client’s medication history is indicated. If he/she is taking medications that are known to be associated with an increase in nightmares, the clinician is better positioned to normalize that experience and educate the client about its causes.

Nightmares may also occur as the result of a fever due to a virus or bacterial infection, in which case the nightmares will usually diminish and cease when the fever subsides. Because nightmares may also occur due to a Central Nervous System disease or certain kinds of organic brain injury or insult, the client should be referred for medical evaluation if nightmares persist without a clearly identified etiological cause. 

Because typical nightmares are most likely to occur during a patient’s REM cycle and during the second half of a patient’s major sleep episode, a person who experiences occasional nightmares will usually have them close to the time when they normally wake up in the morning. This creates less disruption to their normal sleep schedule and is less likely to have ongoing ill effects from sleep deprivation.

Persons who experience Nightmare Disorder comorbidly with Post-Traumatic Stress Disorder, Acute Stress Disorder, or other deeply troubling events, are more likely to experience nightmares in ways that interfere with a full night’s sleep, and are therefore more likely to have sleep disruptions that interfere with healthy psychological and physiological functioning. Likewise, patients who experience nightmares in association with alterations to their serotonin or dopamine levels due to the influence of medications or substances may be more likely to experience sleep disruptions due to their nightmares.

Unfortunately, these sleep disruptions may themselves increase the likelihood of further nightmares, establishing a self-reinforcing pattern of sleep disruption – nightmare – sleep disruption, and so forth. Intervention on the part of the mental health clinician will depend upon the causes for the nightmares.

For nightmares associated with stress and trauma, treatment of the underlying causes - utilizing best practices treatment approaches - will generally be the most appropriate course of action.  For nightmares associated with medication and/or medical causative factors, referral to and coordination with other health professionals will be indicated.

Considerations for Differential Diagnosis

It is important to be aware that there are other kinds of sleep problems that might appear very similar to Nightmare Disorder to the uninformed clinician.  Nightmare Disorder is concerned with nightmares that occur in a very specific part of the sleep cycle: during REM sleep. Night Terrors, also known as Pavor Nocturnus, is a separate disorder that occurs in an entirely different part of the sleep cycle and is covered under a separate diagnostic category. This will be the subject of the next section.