Nightmares can be described as horrifying dreamlike content, typically occurring during rapid eye movement sleep (REM) sleep. Occasional nightmares occur for all people. When nightmares occur 3 or more nights per week, for at least 3 months, with related sleep loss and impact on functioning, this classifies as a “Nightmare Disorder”. Many patients with nightmare disorder suffer from sleep avoidance (as they fear going to sleep) and prolonged nighttime awakenings (because they fear return to sleep). Often nightmare disorders occur in patients who have experienced trauma and often also have symptoms of Post Traumatic Stress Disorder (PTSD). In such scenarios, we typically recommend that patients start with evaluation and management of PTSD, before focusing on the nightmare disorder. If ongoing nightmares are present even after trauma symptoms are managed, we then often suggest working with a Behavioral Sleep Medicine specialist to try Imagery Rehearsal Therapy. 

###### _DrLullaby can help with behavioral sleep issues. The information provided here is not intended as a diagnosis or medical treatment, but instead meant as a learning opportunity.  Please schedule an appointment with DrLullaby for more help._


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Nightmares

### What is a lucid dream?

People engage in lucid dreaming when they realize that they are dreaming, while still asleep. This is not considered a pathological concept – meaning, it is not a disorder if you are able to lucid dream. Studies show that 26-77% of people have had at least one lucid dream at some point. To consistently learn to engage in lucid dreaming, some people elect to “train themselves” to do so. Many times people elect to train themselves to lucid dream to make their dreams more pleasurable.

I have had patients ask me to teach them to lucid dream and I do not embark on this journey because: 1. While we can’t say for sure, it seems at least possible that lucid dreaming could disturb sleep quality, and 2. Some theories about possibly experiencing confusion between reality and fantasy and violating such natural boundaries.

Lucid dreamers are typically not experiencing a problem or disorder, unless someone chooses lucid dreaming because of nightmares. If someone is having nightmares (i.e., essentially horror movies during dreams), we first find out if there is history of trauma, and if so, first start by referring for management of trauma, or Post-Traumatic Stress Disorder symptoms. If they continue to have nightmares, we then pursue a protocol called “Imagery Rehearsal Therapy” which is evidence-based for reducing nightmare frequency and severity.

Since the pandemic, we are seeing more people complaining about vivid dreams and trouble sleeping. Actually, more than 50% of our population is now struggling with sleep. And this is a time when sleep is more important than ever since sleep supports healthy immune system functioning. This increase in sleep complaints is why we expedited more support (video coaching with PhD’s) in our sleep app, [DrLullaby](www.drlullaby.com), which provides evidence-based sleep lessons and sleep logging to optimize sleep for all age-groups.


#### What is happening in the brain when you lucid dream?
 
Research shows different EEG (brain wave) activity (i.e., different strength of brain wave activity) during REM sleep (the stage of sleep when dreams occur) in those who are lucid dreaming compared to those who are not. A small sample size study showed activation in brain regions responsible for insight and agency (bilateral precuneus, cuneus, parietal lobes, and prefrontal lobes) during lucid dreams. In a study where researchers stimulated the frontal lobe, they found increased self-reflective awareness in dreams. Overall, it sounds like activation of the frontal lobe, and shifting in brain wave activity, is at least relevant in the process of lucid dreaming.
  
  
#### Are lucid dreams triggered by anything? Or could anyone have one at any time?

There are times when people can randomly just become aware that they are dreaming (i.e., lucid dream). Typically though, people make a decision to train themselves to lucid dream. The most common reason we see is people wanting their dreams to be more pleasurable. That said, there is some data to suggest that certain medications can increase lucid dreaming (cholinergic and dopaminergic drugs).
As mentioned above, I have had patients ask me to teach them to lucid dream and I do not embark on this journey because: 1. While we can’t say for sure, it seems at least possible that lucid dreaming could disturb sleep quality, and 2. Some theories about possibly experiencing confusion between reality and fantasy and violating such natural boundaries.
I would argue instead of learning to lucid dream, it is best to focus on getting enough sleep. Using a digital health tool like [DrLullaby](www.drlullaby.com) is a great way to start a journey on learning healthy sleep habits. You don’t need to have a “problem” to benefit from working on getting more sleep. Most Americans are not getting the sleep they need and would benefit from working on healthy sleep habits. Prioritizing enough sleep [DrLullaby](www.drlullaby.com) is a great way to start learning about sleep and improving the quality of life. Rather than focusing on possible mood benefits from changing the tone to the dream, it’s instead better to consider mood benefits of increasing sleep and improving sleep habits. This also does not have the unknown risk of sleep quality disturbance and blurring the reality vs fantasy lines.

###### _DrLullaby can help with behavioral sleep issues. The information provided here is not intended as a diagnosis or medical treatment, but instead meant as a learning opportunity.  Please schedule an appointment with DrLullaby for more help._

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Lucid dreams

Anxious dreams are described as dreams that evoke worry, or stressful dreams. Many times, people mistake anxious dreams for nightmares because they are another form of unsettling dream-like content. Generally, dreams are a reflection of our waking life. Therefore, when life feels more stressful or anxiety-provoking, we will experience our dreams in a similar way. When I see patients reporting anxious dreams or stressful dreams and nightmare disorder is ruled out, I will often encourage such patients to work on daytime anxiety and stress management if their goal is to reduce anxious dreams.


###### _DrLullaby can help with behavioral sleep issues. The information provided here is not intended as a diagnosis or medical treatment, but instead meant as a learning opportunity.  Please schedule an appointment with DrLullaby for more help._

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Anxious dreams

Parasomnias are generally described as behaviors happening during sleep. Typically, parasomnias occur during the deepest stage of sleep, called Slow Wave Sleep (SWS). Any overlearned behavior (e.g., talking, walking, urinating, eating) can occur during sleep. Night terrors and sleepwalking can be quite normal in young children, and most grow out of such occurrences. These events often occur during the first third of the night. Children will typically not recall these events the following day, so it is best not to bring them up as this might cause confusion. Common triggers for increased frequency of such events can be: stress, sleep loss, illness, or underlying sleep disorders. Safety concerns can be noted in some cases (e.g., falling down steps, walking out the front door). In rare circumstances, seizures can be relevant rule-outs. Talk to your doctor if increased frequency or concerns about safety or seizures are noted. 


###### _DrLullaby can help with behavioral sleep issues. The information provided here is not intended as a diagnosis or medical treatment, but instead meant as a learning opportunity.  Please schedule an appointment with DrLullaby for more help._

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Parasomnias

Delayed sleep phase syndrome falls under the umbrella of circadian rhythm disorders. These are disorders where the time of day when one feels sleepy (or alert) is not conducive to school, social activities or work. Trouble with falling asleep (i.e., insomnia) and daytime sleepiness are also prevalent in these groups. Most teengers have a natural tendency to want to go to bed late and sleep in late which is referred to as a delayed sleep phase tendency. If the delay is 2 hours of more outside what is needed to function, this is more of a “disorder”. We often work with patients to gradually advance the bedtime and waketime, avoid “social jetlag” (sleeping in on weekends) and expose to bright light in the morning. Ideally, we would love to see a world where high school start times were later given that teens have this natural tendency!


###### _DrLullaby can help with behavioral sleep issues. The information provided here is not intended as a diagnosis or medical treatment, but instead meant as a learning opportunity.  Please schedule an appointment with DrLullaby for more help._

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Delayed sleep phase

Bedwetting is also called “nocturnal enuresis” and is when urine is expelled during the sleep window. Most children first learn to use the bathroom effectively during the day and staying dry at night comes later. We typically do not diagnose “nocturnal enuresis” before 7 years old unless there is a significant mood reaction or impact on functioning. Many times, our urologist will first rule out any underlying medical symptoms which might contribute to bedwetting when patients present with these symptoms at a sleep clinic. Common triggers for increased frequency of events can include: stress, illness, sleep loss or underlying medically-based sleep disorders. Sleep apnea can be a common comorbid symptom in the space underlying medically-based sleep disorders. If all else is ruled-out, we often work on behavioral strategies including: making sure to urinate before bedtime, minimize full glasses of fluid after dinner, scheduled awakenings (i.e., parent wakes up child 30 minutes prior to common timing of event to use the bathroom) and bell & pad (i.e., bedwettingstore.com). If behavioral strategies are not effective, prescription medications are also sometimes considered for support.


###### _DrLullaby can help with behavioral sleep issues. The information provided here is not intended as a diagnosis or medical treatment, but instead meant as a learning opportunity.  Please schedule an appointment with DrLullaby for more help._

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Bedwetting

Night eating syndrome is diagnosed when patients struggle to fall asleep or return to sleep without eating. This is different than “sleep eating” which is under the “parasomnia” umbrella and means that the patient is asleep while eating. During night eating, patients are awake and making a conscious choice to eat. This can occur in patients who are struggling with difficulty falling asleep or returning to sleep and using food for comfort or support. While many might think of babies first, as an example of this problem (i.e., they are quite dependent on feeds for sleep), in clinic, we also see older kids and adults with this problem as well. Those who do not consume enough daytime calories (e.g., kids with Attention Deficit Hyperactivity Disorder - ADHD on a stimulant with suppressed daytime appetite; or those on a diet), can be at risk for night eating syndrome. Likewise, when night eating is occurring, daytime appetite is not as high, less calories are then consumed and nighttime events are perpetuated. When working with these patients, we often start with recommending three scheduled meals and ensuring adequate daytime caloric intake and then work on the underlying difficulty with falling asleep or returning to sleep using evidence-based behavioral interventions.


###### _DrLullaby can help with behavioral sleep issues. The information provided here is not intended as a diagnosis or medical treatment, but instead meant as a learning opportunity.  Please schedule an appointment with DrLullaby for more help._

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Night eating syndrome

Nighttime fears are when children are experiencing high anxiety and feeling scared at night. They might report “seeing a ghost” or fear of the dark. This is highly common in young children, especially from the ages of 4-7, and quite normal. We typically suggest use of a nightlight, bedtime buddy (e.g., one special stuffed animal that stays with the child during the night) and reassuring statements (e.g., “your parents are watching over the house and keeping you safe”). We typically discourage parents from “checking for monsters”, as this only reinforces the fear and teaches children that “there might be monsters under your bed later, there just weren’t any there when I checked!”. Nighttime fears exceed what is considered normal when they cause significant delay with falling asleep asleep and related sleep loss. At such times, we then work with families to integrate evidence-based behavioral strategies to help with falling asleep and returning to sleep. 


###### _DrLullaby can help with behavioral sleep issues. The information provided here is not intended as a diagnosis or medical treatment, but instead meant as a learning opportunity.  Please schedule an appointment with DrLullaby for more help._

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Nighttime fears

We sleep in stages including: stage 1, the lightest stage of sleep; also referred to as “the sleep transition stage” as it is the stage that bring us from wake to sleep, stage 2, when our brain waves form sleep spindles and k-complexes, stage 3, the deepest stage of sleep comprised of delta waves, and rapid eye movement (REM) when we typically dream. We sleep in cycles which typically progress from stage 1 to stage 2, to stage 3, back to stage 2, and then into REM sleep. Adults take 90-120 minutes to complete a sleep cycle whereas babies take only about 50 minutes to complete a sleep cycle (babies typically do not have the full range of sleep stages described above either). It is important to know that it is normal to wake briefly at the culmination of a sleep cycle. At the very least, the brain waves will shift from a stage of sleep to a stage of alpha (i.e., wake) for 3 seconds (i.e., a cortical arousal) at the end of a sleep cycle. If the bladder is full, this is point where some people get up to use the bathroom. If children are used to parents being involved at bedtime (i.e., for sleep transition), they will then at this point go find their parent as they are not yet independent with sleep transition and they are naturally awake and ready to start their next sleep cycle. For kids who are breaking bedtime rules, they might tantrum at that point. If kids or adults have mind racing or sleep frustration, they might experience those symptoms at this point. The key to remember is that the awakenings are normal, it is the behaviors or experiences after the awakenings that sometimes need intervention. 


###### _DrLullaby can help with behavioral sleep issues. The information provided here is not intended as a diagnosis or medical treatment, but instead meant as a learning opportunity.  Please schedule an appointment with DrLullaby for more help._

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Sleep stages and cycles

For research or diagnosing medically-based sleep disorders, we study sleep using an overnight sleep study, also known as “polysomnography”. During this study, we measure brain waves, breathing patterns and breathing effort, leg movements, as well as heart and oxygen measures. We measure these items and then “score” or analyze the data through an interpretation process involving marking the sleep stages, respiratory events and leg movements. From this data, doctors can tell if there is an underlying medically-based sleep disorder. The common diagnosis screened for with a sleep study is sleep apnea. Loud snoring and excessive daytime sleepiness are the most common signs of sleep apnea. We do not require or use a sleep study for diagnosing insomnia. Insomnia is instead diagnosed through an interview and often having patients fill in sleep logs. 

###### _DrLullaby can help with behavioral sleep issues. The information provided here is not intended as a diagnosis or medical treatment, but instead meant as a learning opportunity.  Please schedule an appointment with DrLullaby for more help._

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How do we study sleep

Melatonin is our sleep hormone which is experienced naturally in the brain as a sleepiness signal. Melatonin is available in “exogenous” form, over-the-counter as a tool for supporting sleep. In clinic, there are two main times when we consider support of Melatonin: 1. Developmental delay, autism, or other medical/neurogenetic diagnoses are co-occurring with insomnia complaints: in such scenarios we still utilize evidence-based behavioral interventions but such patients may see benefit from adjunct Melatonin; 2. Delayed sleep phase: We may use a very low dose of Melatonin to gradually advance the sleep phase (e.g., 0.5mg taken 4 hours before the natural sleep onset time while the waketime is anchored). if there are severe difficulties with falling asleep and returning to sleep, causing severe impact on functioning, sometimes Melatonin is used even for kids without comorbidities. In such circumstances, we still use the evidence-based behavioral strategies and aim to decrease Melatonin once sleep starts to improve. For children who do not have developmental delay or significant comorbid diagnoses, and whose sleep problems are more mild or moderate, we rarely start with encouraging Melatonin. Evidence-based behavioral strategies are the first line treatment recommended to help with falling asleep and returning to sleep. 

For those families that are currently using Melatonin, use of evidence-based behavioral strategies can be a great way to supplement and/or support tapering off when interested. For those families who are not interested in trying Melatonin, use of behavioral strategies are a great alternative.


###### _DrLullaby can help with behavioral sleep issues. The information provided here is not intended as a diagnosis or medical treatment, but instead meant as a learning opportunity.  Please schedule an appointment with DrLullaby for more help._

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Melatonin

There are currently no FDA approved medication for pediatric insomnia. The first-line treatment recommended for pediatric insomnia is evidence-based behavioral strategies. Even for the adult population, where there are FDA approved medications for insomnia, Cognitive Behavioral Treatment for Insomnia is still considered the first line treatment for chronic insomnia. For adults, sleeping pills can be habit forming and have unpleasant side-effects. Often behavioral methods are just as effective (if not more effective) and dependency/side-effects are not an issue. The only issue is that there are not enough board-certified formally trained insomnia specialists to deliver behavioral strategies to those suffering from trouble with falling asleep or returning to sleep. Digital translation of these strategies is one solution for improving access to these first-line strategies.

###### _DrLullaby can help with behavioral sleep issues. The information provided here is not intended as a diagnosis or medical treatment, but instead meant as a learning opportunity.  Please schedule an appointment with DrLullaby for more help._

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