Bad dreams, bedtime anxiety, and trait anxiety in school-aged children
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Original studies Somnologie https://doi.org/10.1007/s11818-020-00268-3 Received: 12 June 2020 Accepted: 29 August 2020
Michael Schredl
© The Author(s) 2020
Bad dreams, bedtime anxiety, and trait anxiety in school-aged children
Occasional nightmares defined as repeated occurrences of extended, extremely dysphoric, and well-remembered dreams [2] are common in childhood and adolescence [29]. Several researchers [4, 50] differentiated between nightmares as disturbing dreams that awaken the sleeper and bad dreams defined as disturbing dreams that do not awaking the sleeper. Although bad dreams are conceptualized as less distressing than nightmares [13], the overlap between emotional intensity and themes like physical aggression towards the dreamer [21, 51] between these two dream types is considerable. Moreover, it has to be noted that studies eliciting bad dreams and nightmares simultaneously has so far only been carried out in adults, and Simard et al. [46] raised the question whether children can differentiate between distressing dreams that awaken the dreamer and distressing dreams that do not awaken the dreamer. Interestingly, the ICSD-3 (International Classification of Sleep Disorders) focus on the distress part of nightmares and bad dreams (dreams that often result in awakening) as the key criterion of diagnosing a nightmare disorder [2]. Thus, the overview will focus on nightmares, but it should be kept in mind that the broader category of distressing dreams is equally suited but not well studied. The prevalence of frequent nightmares, typically defined as one nightmare or more per week, is estimated to be around 5% in children [1, 14]. Nightmare etiology is best explained by a diatheses-stress model, i.e., genetics, trait factors, as well as state factors con-
Sleep Laboratory, Central Institute of Mental Health, J5, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
tribute to the occurrence of nightmares [8, 13]. Most of the research looking into factors associated with nightmares, however, has focused on young adults [8, 13]. Two studies in children indicate that nightmare frequency is stable over time [35, 46], i.e., showing trait-like characteristics, and a familiar aggregation of nightmares was found by Li et al. [14], supporting the diathesis framework. In addition, trait anxiety and emotional problems [16, 34, 42] and stressors [30, 31] are associated with heightened nightmare frequency in children. So far, the relatively small number of studies on nightmare etiology in children focusing on nightmare is in line with the findings in adults [13, 27]. From a clinical viewpoint, nightmares must cause clinically significant distress, e.g., mood disturbances due to persistence of nightmare affect, bedtime anxiety, intrusive nightmare images during the day, in order for a nightmare disorder to be diagnosed (ICD 10: F51.5; [2]). Therefore, nightmare research should not focus solely on nightmare frequency but also on factors associated with nightmare distress [38, 40]. In adults, nightmare distress i
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