In adults, there is an association between sleepwalking and major depressive episodes and obsessive-compulsive disorder. Children or adults with sleep terrors may have elevated scores for depression and anxiety on personality inventories.
Relationship to International Classification of
The International Classification of Sleep Disorders, 2nd Edition, includes ”confusional arousal” as a NREM sleep arousal disorder.
Diagnostic Criteria 307.47 (F51.5)
A. Repeated occurrences of extended, extremely dysphoric, and weII-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical in- tegrity and that generally occur during the second half of the major sleep episode.
B. On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert.
C. The sleep disturbance causes clinically significant distress or impairment in social, oc— cupational, or other important areas of functioning.
D. The nightmare symptoms are not attributable to the physiological effects of a sub- stance (e.g., a drug of abuse, a medication).
E. Coexisting mental and medical disorders do not adequately explain the predominant complaint of dysphoric dreams.
Specify if:
Specify if:
With associated non—sleep disorder, including substance use disorders
Coding note: The code 307.47 (F51.5) applies to all three specifiers. Code also the relevant associated mental disorder, medical condition, or other sleep disorder imme- diately after the code for nightmare disorder in order to indicate the association.
Specify if:
Acute: Duration of period of nightmares is 1 month or less.
Subacute: Duration of period of nightmares is greater than 1 month but less than 6 months.
Persistent: Duration of period of nightmares is 6 months or greater.
Specify current severity:
Severity can be rated by the frequency with which the nightmares occur:
Mild: Less than one episode per week on average.
Moderate: One or more episodes per week but less than nightly.
Severe: Episodes nightly.
N ightmures are typically lengthy, elaborate, storylike sequences of dream imagery that seem real and that incite anxiety, fear, or other dysphoric emotions. Nightmare content typically focuses on attempts to avoid or cope with imminent danger but may involve themes that evoke other negative emotions. Nightmares occurring after traumatic experi- ences may replicate the threatening situation ("replicative nightmares”), but most do not.
On awakening, nightmares are well remembered and can be described in detail. They arise out sleep but are more likely in the second half of the major sleep episode when dreaming is longer and mdre intense. Factors that increase early-night REM intensity, such as sleep fragmentation or deprivation, jet lag, and REM-sensitive medications, might facilitate nightmares earlier in the night, including at sleep onset.
Nightmares usually terminate with awakening and rapid return of full alertness. How- ever, the dysphoric emotions may persist into wakefulness and contribute to difficulty re- turning to sleep and lasting daytime distress. Some nightmares, known as ”bad dreams,” may not induce awakening and are recalled only later. If nightmares occur during sleep- onset REM periods (hypnagogic), the dysphoric emotion is frequently accompanied by a sense of being both awake and unable to move voluntarily (isolated sleep paralysis).
Mild autonomic arousal, including sweating, tachycardia, and tachypnea, may character- ize nightmares. Body movements and vocalizations are not characteristic because of REM sleep—related loss of skeletal muscle tone, but such behaviors may occur under situations of emotional stress or sleep fragmentation and in posttraumatic stress disorder (PTSD).
When talking or emoting occurs, it is typically a brief event terminating the nightmare.
Individuals with frequent nightmares are at substantially greater risk for suicidal ide- ation and suicide attempts, even when gender and mental illness are taken into account.