How to Stop Nightmares and Night Terrors
This week on the Savvy Psychologist podcast, Dr. Ellen Hendriksen outlines 4 differences between nightmares and night terrors. Plus, tips on how to get rid of each so you can drift back to dreamland.
Who hasn’t woken up tangled in sheets, sweating, terrified from a nightmare?
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Whether you’re late for an exam, naked in public, or being chased by anything from a dinosaur to a scary clown, we’ve all been jolted awake, afraid of the monsters in our heads.
But while nightmares are stressful for the dreamer, night terrors are often more stressful for the observer. We see our partner or child sit bolt upright in bed, scream, and thrash around with a panicked look in his or her wide open eyes. Eventually, they’ll drift back into peaceful sleep.
The kicker? They don’t remember any of it in the morning.
This week, we’ll cover the 4 differences between nightmares and night terrors, and talk about a treatment for each, by request from listener Margaret Flannery from Michigan.
Difference #1: Sleep Stages
First, let’s do a quick primer on sleep stages. In 2007, the American Academy of Sleep Medicine updated the phases of sleep. Since 1968, there had been 4 phases plus REM – the stage where dreaming occurs. But in 2007, phases 3 and 4 were consolidated, leaving us with NREM stage 1, NREM stage 2, NREM stage 3, which is also called slow wave sleep, and REM.
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During REM sleep, the brain is as active as when it is awake, and while the jury is still out on the exact function of REM sleep, we do know it’s when dreams (and those chased-by-a-dinosaur nightmares) take place.
Night terrors, on the other hand, occur during NREM stage 3, or slow wave sleep, which is thought to be important for consolidating memories from the day. During slow wave sleep, the brain rests, as evidenced by less blood flow and a slower metabolic rate within the brain. Also, within each wave, a short period occurs where neurons are silent, giving them a break.
This is why, if you wake someone up from a night terror, they are groggy and befuddled. It takes a few moments to transition out of slow wave sleep, get that blood flowing, and get neurons firing like normal again.
Difference #2: Awakening
Speaking of getting woken up, you’re sure to remember a nightmare that’s jolted you awake. Light sleepers and those suffering from anxiety or depression are also more likely to remember their dreams, as both these disorders increase the likelihood of awakenings – whether micro or extended – in the middle of the night.
However, during a night terror, even though your eyes are wide open, your heart is racing, you may talk or yell, and you’re thrashing around or even running through the house, you’re still technically asleep. In sleep parlance, it’s called a partial awakening, though observers might just call it spooky.
Difference #3: Age and Gender
Nightmares can happen to anyone at any age, though frequency declines from childhood on. Still, about 4% of adults have nightmares at least weekly. Nightmares are more often reported by women, but it’s unclear if women are also more likely to report or not.
For night terrors, the highest frequency is also among kids, affecting up to 6.5% of children. Night terrors may start around age 3 or sometimes earlier, are most common from 5-7, and usually taper off by age 12. Only about 1-2% of the adult population experiences night terrors on a regular basis. In childhood, they’re more frequent in boys, but in adulthood, night terrors affect men and women equally.
Difference #4: Links to Mental Health Challenges
A perpetual question about nightmares is whether they’re a sign of some deeper trouble or if a nightmare can just be a nightmare. Turns out the answer to both parts is “Yes.”
There’s some evidence that nightmares are linked to depression and anxiety in adults, as well as to other sleep disorders such as sleep apnea and Restless Legs Syndrome.
And nightmares are strongly linked to PTSD – in fact, they’re a key symptom of re-experiencing, one of the 3 symptom clusters along with avoidance and hyperarousal. When nightmares are chronic, the individual suffering from PTSD may even avoid sleep, rationalizing “If I don’t sleep, I can’t have a nightmare.”
As a result, many self-medicate by drinking gallons of coffee or loading a schedule so full of work, classes, and other obligations that there’s little chance for sleep. It’s productive, but it makes for a lousy (and drowsy) quality of life.
See also: 5 Signs of PTSD and 7 Myths and One Big Fact About PTSD
But sometimes nightmares aren’t the tip of any iceberg larger than temporary sleep deprivation, transient stress, having watched a scary movie, or an unknown X factor. As frightening as it is, a solitary nightmare is nothing to lose sleep over.
With night terrors, a link to psychopathology depends on age. In kids, night terrors are not linked to mental health disorders and are usually a sign of being overtired or stressed from a big change, like moving or starting a new school. And finally, there’s a heavy genetic component – turns out night terrors run in families.
In adults, night terrors can also be caused by genetics or stress, like divorce or a spouse receiving a life-threatening diagnosis. However, night terrors in adults can also be linked to underlying problems like depression, generalized anxiety disorder (GAD), and PTSD. Notably, heavy drinking can also trigger night terrors.
How to Stop Nightmares
So what to do when nightmares and night terrors go bump in the night?
Let’s start with nightmares. I respectfully disagree with Freudian and Jungian analysts who say nightmares are valuable and can teach you about yourself if you just examine their symbolism. I say they’re scary, and especially if they stem from a trauma, can wreck your nights and, by extension, your days.
Now, big breakthroughs in psychology are rare, but one occurred in 2001 with the publication of a study in the prestigious Journal of the American Medical Association. Dr. Barry Krakow, a sleep medicine physician and founder of a sleep research non-profit hypothesized that while nightmares directly following a trauma may be helpful in processing the event, chronic nightmares are just your brain stuck in a rut.
He developed a therapy called Image Rehearsal Therapy, or IRT. In his study, sexual assault survivors with PTSD deliberately changed the plot and imagery of their nightmares – basically, they got to rewrite the whole script.
Krakow asked participants to write down their disturbing dreams, and then instructed them to “change the nightmare any way you wish.” So for example, an assailant with a knife might become a kitten. Balls of fire might become soap bubbles. Being chased might become a stroll on the beach.
The patients rehearsed the new dream for anywhere from 5-20 minutes a day for 3 weeks while they were awake. What happened? Three months after the start of the study, the number of total nightmares per week, number of nights per week with a nightmare, and overall PTSD symptoms were all significantly reduced, while the participants’ sleep was significantly improved.
A 2009 follow-up by a different group of researchers with a different population – U.S. veterans – achieved the holy grail of data replication. They found IRT worked to reduce the frequency of nightmares, both trauma-related and not, and reduced PTSD symptoms 3 months after the program. It almost seems too easy, but it speaks to the resilience of our brains, even after a major trauma.
How to Stop Night Terrors
As for night terrors, if your child or spouse has a once-in-a-while night terror, you don’t need to intervene other than making sure they don’t accidentally hurt themselves (or you). Don’t try to wake them up – there’s no need. In a few minutes, they’ll settle down on their own.
However, if your child or partner has chronic night terrors (or chronic sleepwalking, a closely related phenomenon), try a treatment known as scheduled awakenings. For a few nights, keep track of approximately how long after they fall asleep the night terror occurs. Thankfully, you probably won’t have to burn the midnight oil, as sleep terrors usually occur in the first half of the night.
Once you can predict roughly when it will happen, aim to briefly wake them about half an hour before the sleep terror – usually anywhere between 1 and 2.5 hours after they fall asleep.
Shake them gently and ask them to wake up until they mumble or open their eyes slightly – no need to turn on the light or blast an air horn. You just need to wake them enough to disrupt the slow wave sleep sleep architecture. In a small 1997 study on chronic sleepwalking (not night terrors, but again, a related phenomenon), parents performed one awakening per night for a month and in each case, completely cured the problem.
One last thing: If your child does experience a night terror, there’s no need to mention it to them the next day. Kids have no memory of the night terror – remember, they’re asleep when it happens – so telling them a dramatic, slightly embarrassing story about themselves that they can’t even remember, much less control, may cause them stress or worry. So refrain from launching into an action-packed description when they show up at breakfast.
For a fascinating long read from The New Yorker on IRT for nightmares, click here.
And, if you can’t get to his clinic in Albuquerque, New Mexico, Dr. Barry Krakow has a self-help manual and CD set of his IRT program available for purchase online. I haven’t personally reviewed it, but if you’re interested, you can check it out here.
References
Silber, M.H., Ancoli-Israel, S., Bonnet, M.H., Chokroverty, S., Grigg-Damberger, M.M., Hirshkowitz, M. et al. (2007). The visual scoring of sleep in adults. Journal of Clinical Sleep Medicine, 3, 121-31.
Frank, N.C., Spirito, A., Stark, L., & Owens-Stively, J. (1997). The use of scheduled awakenings to eliminate childhood sleepwalking. Journal of Pediatric Psychology, 22, 345-353.
Krakow, B., Hollifield, M., Johnston, L., Koss, M., Schrader, R., Warner, T.D., et al. (2001). Image rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial. JAMA, 286, 537-45.
Lu, M., Wagner, A., Van Male, L., Whitehead, A., & Boehnlein, J. (2009). Imagery rehearsal therapy for posttraumatic nightmares in U.S. veterans. Journal of Traumatic Stress, 22, 236-9.
Man having nightmare, nightmare cartoon, child nightmare images courtesy of Shutterstock.
About the Author
Dr. Ellen Hendriksen was the host of the Savvy Psychologist podcast from 2014 to 2019. She is a clinical psychologist at Boston University’s Center for Anxiety and Related Disorders (CARD). She earned her Ph.D. at UCLA and completed her training at Harvard Medical School. Her scientifically-based, zero-judgment approach is regularly featured in Psychology Today, Scientific American, The Huffington Post, and many other media outlets. Her debut book, HOW TO BE YOURSELF: Quiet Your Inner Critic and Rise Above Social Anxiety, was published in March 2018.
