Nightmares in Children

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Standing outside a house that has seen too many years you wonder how you got here. Soil baked dry by a hundred summer suns tickles over your toes as you look down. No shoes! Why don’t you have any shoes on? The brown dirt crumbles between your toes as you take a single step forward, away from the decaying house.

A noise. The chitter-chatter of a feral Mogwai fed after midnight? It’s a sound you have heard before but cannot quite place. You turn and look behind you. There is nothing. The sound has stopped.

You take another step forward, earth becoming softer, wetter – feet sinking a little. That sound starts up again, except this time it doesn’t appear to be coming from behind you but from the field of never-mowed grass in front. As leaves bend and melt in the wind you can almost imagine them being moved by some small creature, darting away from you, making a path towards…

What the hell is that? The sky, once a dusty half-light is moving. Chunks of sod shifting, swirling, moving as if guided by some unseen agency, rising higher until…

The tentacles of some Elder God reach out towards you from the mess. They undulate unnaturally on a fast moving current of air. As they approach you feel the temperature drop. Hairs start to rise on the back of your neck. You exhale, a smokers exhale of white wisps.

They are getting closer just a few feet a way. If you reach out, you could almost touch them. Or they could touch you…

A fingers breadth now and you are rooted, stuck to the spot, paralysed, waiting for their not so gentle caress…

And – AWAKE.

Most of us have had a nightmare at some time in their lives whether it is about a clown in the drain or a Demogorgon chasing you down a school corridor. As an adult it is pretty easy to rationalise them away but it is not so easy for a child. Nightmares and the fear of nightmares (Kakoneirophobia) can have a real impact on quality of life. I’m going to unpack this in this year’s Halloween themed post.*

So we are all on the same page, a nightmare is dream associated with strong negative emotions that wakes one from sleep and is vividly recalled. It is one of a group of parasomnias, such as night terrors and sleepwalking. They usually occur in the REM stage of sleep and so, more often than not, occur between 4 and 6 am.

Where do nightmare come from?

The prevailing theory is that nightmares are a result of a mish-mash of factors – personality, coupled with anxiety traits and acute stressors.

Take the case of 13 year old Will. He has always had a nervous personality according to his mother Joyce, with his episodes of anxiety increasing in frequency around the time of her divorce from her husband, Lonnie. A recent mystery illness has led to an increase in  intensity of his nightmares.

Given that sleep disturbance of children leads to sleep disturbance of the parents, treating the child often improves the sleep of the parents and thus reduces their anxiety too. This co-dependent relationship also works in reverse. Treating the psychopathology of the parents can reduce nocturnal problems.

Whilst these cognitive-behavioural events are the most common cause of nightmares, potential medical problems such as allergies, reflux, or infantile movement disorders need to be at the back of one’s mind.

 

A variety of models have been used to describe the formation and function of nightmares.

The psychoanalytic model. Why do we dream? Freud didn’t say much about them in his seminal Interpretation of Dreams(1900). His concept that nightmares are the brain transforming these hidden urges of the libido into self-flagellation and anxiety doesn’t fit in with his general dream theory. In this case the dreams do not represent wish-fulfillment. That other great psychoanalyst from history, Jung, argued that nightmares are the leaking out of unresolved psychic stress/conflict.

The evolutionary model. Revonsuo proposed that nightmares are really just a form of virtual reality threat simulation. By actively rehearsing dangerous encounters whilst asleep the dreamer is better at threat-avoidance in the waking world. Children have more nightmares than adults as they are more vulnerable to threats.

Neurobiological models. If dreams are a form of stimulant – with emotional arousal as the end point – there comes a point when, perhaps, after a number of dysphoric dreams, the brain seeks to decouple arousal and response. One neurobiological theory would suggest that nightmares act as a form of decoupling, a circuit breaker if you will.

If you want to delve further into this complex and somewhat baffling topic then read

Nielsen T, Levin R. Nightmares: a new neurocognitive model. Sleep medicine reviews. 2007 Aug 31;11(4):295-310.

 

How common are they?

According to Coolidge et al. as many as 6.4% of children suffer from terrible nightmares at least once a week (7.7% in boys versus 5.1% in girls). This might be an underestimate as researchers often ask the parents (rather than the children themselves) about nightmare symptomatology. And whilst they may seem more common in younger children this may be because they are more likely to tell their parents. Older children are more likely to try and forget about their bad dreams.

 

Can we prevent them?

Whilst it is impossible to wrap children up in cotton wool there are some common sense approaches that may reduce the number of nightmares and their impact. In the main they revolve around good sleep hygiene – avoidance of stimulating games or programmes in the run up to bedtime and having a relaxing routine.

 

What if they happen every night?

The DSM-IV lists Nightmare Disorder as number 307.47 in a longlist of potential psychopathologies. Techniques such as desensitisation, imagery rehearsal, relaxation techniques and eye movement desensitisation.

Desensitisation. Just as the popular press feels we are becoming inured to the violence of everyday life because of the violence we see on screen, desensitisation therapy requires the dreamer to actively recall their bad dreams. The therapist then guides them on a journey of gradual exposure, first to the outer edges of the fear then deeper, to the very heart of it, pausing at each stage of the journey to allow frayed nerves and bounding hearts to settle.

 

Imagery Rehearsal/Rescripting. This psychotherapeutic approach involves a degree of supervised practice as the sufferer reviews a moderately scary nightmare and tries to change it into something more pleasant. This, coupled with daily practice over a 12 week period, has had positive outcomes in the adult population. Investigators have replaced verbal descriptors with drawings as an alternate form of imagery rehearsal therapy and found that though it might decrease frequency it did not decrease the intensity of feeling.

 

 

Eye movement desensitisation. This form of therapy, coined by Shapiro in the late 80’s is based on a curious premise. Shapiro noticed that if she became stressed or anxious her eyes would move more rapidly. She found that by deliberately slowing her eye movements down her stress lessened. Whilst far-fetched there have been a number of case reports of its successful use in sufferers of PTSD as well as victims of recurrent nightmares.

 

*Some people like April Fools themed posts (Damian Roland and Radiopaedia, I’m looking at you). I prefer Halloween.

References

Handler L. The amelioration of nightmares in children. Psychotherapy: Theory, Research & Practice. 1972;9(1):54.

Mindell JA, Barrett KM. Nightmares and anxiety in elementary‐aged children: is there a relationship?. Child: care, health and development. 2002 Jul 1;28(4):317-22.

Pellicer X. Eye movement desensitivation treatment of a child’s nightmares: A case report. Journal of Behavior Therapy and Experimental Psychiatry. 1993 Mar 1;24(1):73-5.

Acierno R, Hersen M, Van Hasselt VB, Tremont G, Meuser KT. Review of the validation and dissemination of eye-movement desensitization and reprocessing: A scientific and ethical dilemma. Clinical Psychology Review. 1994 Jan 1;14(4):287-99.

Schredl M, Fricke-Oerkermann L, Mitschke A, Wiater A, Lehmkuhl G. Longitudinal study of nightmares in children: stability and effect of emotional symptoms. Child psychiatry and human development. 2009 Sep 1;40(3):439-49.

Schredl M, Fricke-Oerkermann L, Mitschke A, Wiater A, Lehmkuhl G. Factors affecting nightmares in children: parents’ vs. children’s ratings. European child & adolescent psychiatry. 2009 Jan 1;18(1):20-5.

Sadeh A. Cognitive–behavioral treatment for childhood sleep disorders. Clinical psychology review. 2005 Jul 31;25(5):612-28.

Coolidge FL, Segal DL, Coolidge CM, Spinath FM, Gottschling J. Do nightmares and generalized anxiety disorder in childhood and adolescence have a common genetic origin?. Behavior genetics. 2010 May 1;40(3):349-56.

Simard V, Nielsen T. Adaptation of imagery rehearsal therapy for nightmares in children: A brief report. Psychotherapy: Theory, Research, Practice, Training. 2009 Dec;46(4):492.

Morgan III CA, Johnson DR. Use of a drawing task in the treatment of nightmares in combat-related post-traumatic stress disorder. Art Therapy. 1995 Oct 1;12(4):244-7.

Nielsen T, Levin R. Nightmares: a new neurocognitive model. Sleep medicine reviews. 2007 Aug 31;11(4):295-310.

Kales A, Soldatos CR, Kales JD. Sleep disorders: insomnia, sleepwalking, night terrors, nightmares, and enuresis. Annals of Internal Medicine. 1987 Apr 1;106(4):582-92.

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About 

An Emergency Physician with a special interest in education and lifelong learning. When not drinking coffee and reading Batman comics he is playing with his children.

@andrewjtagg | + Andrew Tagg | Andrew’s DFTB posts

Author: Andrew Tagg

An Emergency Physician with a special interest in education and lifelong learning. When not drinking coffee and reading Batman comics he is playing with his children.

@andrewjtagg | + Andrew Tagg | Andrew’s DFTB posts