Eur. J. Psychiat. Vol. 27, N.° 4, (259-264)
                2013
                                                                   Keywords: Nightmares; Treatment; Representa-
                                                                   tive sample.
                Seeking professional help for nightmares:
                A representative study
                                                                   Michael Schredl
                                                                   Central Institute of Mental Health, Medical
                                                                   Faculty Mannheim/Heidelberg University
                                                                   GERMANY
                ABSTRACT – Background and Objectives: Nightmares are defined as disturbing mental
                experiences that generally occur during REM sleep and often result in awakening. Even
                though about 5% of the general population suffers from nightmares, little is known about
                seeking professional help in this patient group.
                  Methods: A quota sample of 2019 participants representative for the German popula-
                tion was studied.
                  Results: The findings indicate that every eighth person with frequent nightmares (cut-
                off: every other week or more often) sought at one time of his/her life for professional help
                for coping with nightmares. Socio-demographic variables did not correlate with help-
                seeking behavior.
                  Conclusions: Nightmares are an undertreated condition and future studies should aim
                at a more throughout understanding why nightmare sufferers rarely seek help for their
                condition.
                Received: 15 March 2013
                Revised: 26 August 2013
                Accepted: 29 September 2013
                Introduction                                       tioning7,8, the clinical impression is that most
                                                                   nightmare sufferers do not seek professional
                                                                                          9
                  Nightmares are defined as disturbing men-        help for their problems . Even in sleep clinics,
                tal experiences that generally occur during        nightmares were rarely diagnosed and treated:
                REM sleep and often result in awakening            Krakow10 reported that 16.3% of sleep-dis-
                                  1
                (ICSD-2; AASM) . In representative samples         ordered patients (N = 718) also have a salient
                about 5% of the participants stated that they      nightmare condition that would normally not
                                        2-5
                suffer from nightmares     . Even though fre-      have been diagnosed if he hadn’t specifically
                                                                                                         11
                quent nightmares are associated with poor          asked for it. Similar, Schredl, Binder  found
                sleep quality6 and impaired day-time func-         that 13.4% of patients under going diagnostic
                260 MICHAEL SCHREDL
                procedures in a sleep laboratory (N = 4.001)        asked the following question: “My dreams
                reported nightmares at least once a week; an        have sometimes been so intense that I could
                explicit diagnosis of a nightmare disorder          not stop thinking about them the following
                was given to 1.6% of the sample. These stud-        day” (Yes/No). This could be conceptualized
                ies indicate that nightmares are underdiag-         as an indicator for nightmare severity as more
                                                    12-14
                nosed and very likely undertreated      . How-      intense dreams with negative emotions have
                ever, up to now, there is no systematic             a stronger effect on the subsequent day16.
                research identifying the frequency of night-           To a subsample (persons who reported
                mare sufferers seeking professional help for        nightmares [see above definition] and/or neg-
                their disorder – despite its consequences on        atively-toned dreams at least several times per
                sleep and day-time functioning.                     year) the following two questions were pre-
                   The aim of the present study was to fill this    sented: (1) “I often have worries prior to bed-
                gap and to investigate how often persons with       time due to my frequent nightmares” (Yes/No)
                nightmares in a representative sample seek          and (2) “I have sought professional help for
                professional help for coping with their night-      coping with my nightmares” (Yes/No).
                mares. It was expected that nightmare fre-             The following socio-demographic vari-
                quency and indicators of nightmare severity         ables were included in the study: age, gender,
                would increase the probability of seeking pro-      education (five levels: “primary school” (9
                fessional help. The present data analyses are       years school), “primary school and com-
                an extension of a previous report focusing on       pleted apprenticeship” (9 years school plus
                                                             15
                nightmare frequency and nightmare topics .          apprenticeship), “Realschule” (10 years
                                                                    school), “Abitur” (13 years school). “Abitur
                                                                    with completed studies” (13 years school
                Method                                              plus university degree)), social class (5 levels
                                                                    based on the total income of the household,
                                                                    the educational level, and the profession of
                Measurement instruments                             the head of the household), size of town of
                                                                    residence (10 levels starting from (1) towns
                   For eliciting nightmare frequency, a seven-      with less than 2000 inhabitants to (10) cities
                point frequency scale (coded from 0 = never,        with more than 500,000 inhabitants), and
                1 = very rarely, 2 = several times a year, 3 =      marital status (married/living with partner,
                about once a month, 4 = about once in two           single/living without partner).
                weeks, 5 = about once a week, 6 = several
                times a week) was used in the study. The
                following nightmare definition was given:           Participants and procedure
                strongly negatively-toned dreams with fear or
                panic resulting in immediate awakening.                Overall, a representative sample (that in-
                Within this survey, the frequency of nega-          cluded persons over 14 years of age) of 2019
                tively-toned dreams without specific defini-        persons (1135 women, 884 men) was drawn
                tion was also elicited using a similar scale.       from German households. The study was car-
                This scale was not included in the present          ried out by GfK Marktforschung, Nürnberg,
                analyses but used for selecting the subsample       Germany and was financed by Wort & Bild
                that suffers from bad dreams and/or night-          Verlag, München, Germany. The quota sam-
                mares. In addition, the participants were           ple was representative for the German popu-
                                                                         SEEKING HELP FOR NIGHTMARES 261
                lation. About 500 interviewers in different lo-    the daytime effects of dreams on the “seek-
                cations all over Germany (representative for       ing help for nightmares“ variable (binary), a
                the 16 German states and the variety of town       logistic regression procedure was used.
                sizes) received a list of four to five randomly
                generated combinations of the six stratifica-
                tion criteria: age group (14-19, 20-29, etc.)
                gender, number of persons in the household,        Results
                federal state (of the 16 German federal states),
                town of residence size (less than 5,000, 5,000        Overall, 3.03% of the participants with at
                to 19,999, 20,000 to 99,999, 100,000 or            least some nightmares and/or bad dreams (N
                more), and occupation of the head of the           = 1022) reported that they sought profes-
                household (blue-collar worker, employee,           sional help for coping with their nightmares.
                civil servant, self-employed/freelance, without    Percentages of the “Seeking professional
                occupation like a student, unemployed, and         help” item for each nightmare category are
                retired). The participants were selected by the    depicted in Table 1. Combining the first three
                interviewer with regard to the four or five        categories, 15.19% of the persons with night-
                combinations s/he received. The interviewers       mares about every other week or more often
                were trained by GfK Marktforschung. The            stated that they sought professional help. The
                nightmare questions were part of a multi-          statistical analysis showed that none of the
                topic survey mainly focused on the evaluation      socio-demographic variables affected help-
                of consumer products of different brands.          seeking and only nightmare frequency and
                  The mean age of the sample was 46.4              the self-rated effects of dreams on subse-
                years (SD = 16.9). The subsample reporting         quent waking life were significantly associ-
                nightmares and/or bad dreams at least several      ated with the probability of seeking profes-
                times a year consisted of 1022 persons (623        sional help (see Table 2). Specifically, if the
                women, 399 men) with the mean age of 45.9          person stated that dreams affected their wak-
                ± 17.2 yrs. The range varied from 14 years to      ing life, the more likely the person sought
                92 years. Participants were interviewed face-      help for his or her nightmares.
                to-face at home. After being instructed by the
                interviewer, the section with the nightmare
                questions was filled out on a laptop without       Table 1
                further interaction with the interviewer.          Percentage of persons seeking professional help
                                                                   for nightmares in relation to nightmare frequency
                  Due to problems of the interviewers not          (N = 1022)
                completing their recruiting aim (e.g., due to      Nightmare frequency         N =    Seeking help
                illness since the time interval for collecting     Several times a week         12       25.00%
                the data was only two weeks), the resulting        About once a week            37       10.81%
                data set does not exactly match the represen-
                tativeness of the lists sent to the interviewers.  About every other week       46       17.39%
                For an estimation of this effect, weights were     About once a month           87        4.60%
                computed, 90% were within the range of             Several times a year        217        2.30%
                0.40 to 1.87. Data analyses were carried out
                with the SAS 9.2 software package for Win-         Very rarely                 444        1.35%
                dows. To analyze the effects of socio-demo-        Never                       179        0.56%
                graphic variables, nightmare frequency, and
                262 MICHAEL SCHREDL
                  In the subsample of persons with night-          lowing day. In addition, 4.40% of the sub-
                mares and/or bad dreams (N = 1022) 38.65%          sample (N = 1022) reported worrying about
                of the participants stated that their dreams       nightmares before bedtime. Out of this sub-
                sometimes have been so intense that they           group (N = 45), 35.56% reported that they
                could not stop thinking about them the fol-        have sought professional help.
                Table 2
                Logistic regression of “Seeking professional help” item (N = 1022)
                                                                                            2
                Variable                                    Standardized estimate        Chi            Prob.
                Age                                                -0.0221               0.8          0.8399
                Gender                                             -0.1081               1.0           0.3123
                Social status (married vs. single)                 0.0102                0.0          0.9296
                Education                                          -0.0114               0.0           0.9300
                Socio-economic status                              -0.1471               1.1          0.2852
                Size of town of residence                          0.0163                0.0          0.8798
                Nightmare frequency                                0.4352               27.5         <0.0001
                Effect of dreams on following day                  0.3119                7.1          0.0079
                Discussion                                         any missing combinations by every inter-
                                                                   viewer, the present data set would be repre-
                  This is the first study providing data about     sentative. Due to missing data sets, this aim
                the percentage of persons with nightmares          was not achieved. As most of the weights
                seeking professional help for this disorder.       were within a reasonable range, the data set
                Prior to discussing the finding in detail it is    is still close to being representative (for a
                necessary to take a look on the limitations of     more detailed discussion regarding random
                this study. The item measuring whether the         sampling procedures [problem with avail-
                person sought help for his/her nightmares          ability and rejection] and quota-based sam-
                                                                   ples, see Noelle-Neumann and Petersen17).
                did not include any time frame; this means
                that the person could have sought help re-           Since the study was carried out in Germa -
                cently or ten or twenty years ago but still ha -   ny, the present findings might be limited to
                ve nightmares. One also has to keep in mind        the German health system, implying that pa-
                that nothing was elicited about whether the        tients most often ask the general practitioner
                professional help had any beneficial effect on     for help with this disorder – as for mental dis-
                                                                                   18
                nightmare frequency. It might be speculated        order in general . Whether the patient is re-
                that the effect was minor because current          ferred to a psychotherapist or a psychiatrist
                nightmare frequency correlated with seek-          depends strongly on the knowledge of the
                ing professional help in the past.                 general practitioner about nightmares and
                                                                   their etiology. In the present study, nothing
                  Moreover, if the list given to the inter-        was elicited about other mental disorders that
                viewers would have been completed without          might be associated with the nightmares like