Introduction

For diagnosing a nightmare disorder, nightmares must occur so often that they cause clinically significant distress, with nightmares defined as repeated occurrences of extended, extremely dysphoric, and well-remembered dreams [1]. It is estimated that about 2 to 6% of adults experience frequent nightmares (once a week or more often) and, thus, very likely have a nightmare disorder [13]. In patients with mental disorders, the percentage is higher: up to 30% are diagnosed with a nightmare disorder [35]. In children and adolescents, the prevalence rate of frequent nightmares varies von 1 to 11% due to different definitions regarding “frequent” [6]: typically, “frequent” is used for a frequency of nightmares of about once a week or more often, but very often, the participants were not presented with a specific definition of frequency, just the word “frequent.” Again, frequent nightmares are much more common in children with mental disorders [4].

Even though effective and simple treatment strategies for nightmare disorders are available, like imagery rehearsal therapy [16], most individuals with frequent nightmares are not diagnosed and/or treated for their condition [17, 20, 23, 36]. One reason is that health care professionals are not educated in detecting, diagnosing, and treating nightmares [36, 39]. The other reason is that nightmare sufferers themselves rarely seek professional help for their condition: different surveys in adults [17, 25, 28, 29, 36] indicate that only 15 to 30% of persons with frequent nightmares have ever sought professional help. Nightmare sufferers even very rarely consider seeking help for their condition [21]. The same problem, i.e., massively underdiagnosed and therefore undertreated nightmare disorders, was also reported for a pediatric psychiatric sample [4].

Clinical studies [9, 10] indicate that in some adult nightmare sufferers, nightmares started long ago, already in childhood. These clinical observations are in line with the disposition–stress model of nightmare etiology [13], as very creative and sensitive persons are prone to nightmares and these traits are very stable over time [2, 8]. From a clinical point of view, it would be desirable for frequent nightmare sufferers to already seek help in their childhood or adolescence and start their treatment, and, thus, not suffer from nightmares as adults. There is still a lack of research concerning help-seeking behavior in children and/or adolescents with frequent nightmares.

The aim of this study was to investigate whether adolescents seek help for their nightmare condition, provided they suffer from frequent and/or distressing nightmares. Additionally, we wanted to know whether this age group knows anything about possible nightmare treatment strategies.

Methods

Participants

Overall, 100 adolescents (50 female, 50 male) completed the questionnaire. Mean age of the sample was 15.30 ± 0.80 years (range 14 to 17 years).

Research instrument

For assessing nightmare frequency, an eight-point rating scale was used with the question “How often have you experienced nightmares recently (in the past several months)?” and answers 0 = never, 1 = less than once a year, 2 = about once a year, 3 = about two to four times a year, 4 = about once a month, 5 = two to three times a month, 6 = about once a week, 7 = several times a week. The scale included the following definition: “Nightmares are dreams with strong negative emotions that result in awakening from the dream. The dream plot can be recalled very vividly upon awakening.” The retest reliability of this scale is r = 0.765 [22]. Nightmare distress was measured using a five-point scale (0 = not at all distressing, 1 = not that distressing, 2 = somewhat distressing, 3 = quite distressing, and 4 = very distressing). The retest reliability is r = 0.673 [22].

The next two questions were developed for the purpose of this study. The participants were asked whether they had heard about the following nightmare treatment methods (multiple answers were allowed): IRT (imagery rehearsal treatment), EMDR (eye movement desensitization and reprocessing), Gestalt therapy, lucid dreaming therapy, relaxation techniques, medication, and hypnosis. The second question was: “Have you ever considered seeking treatment for your nightmares?” The following response options were provided: “yes,” “no,” “I am already in treatment,” and “I do not have nightmares.”

Procedure

Four students of a German high school (Gymnasium) developed the questionnaire under the supervision of the author. The language of the questionnaire was German. The questionnaire included several topics, including dream recall frequency, different dream topics, and the above-outlined nightmare questions. Overall, N = 120 questionnaires were distributed by these four students within the school; there was no monetary compensation for participation. N = 100 questionnaires were returned and completely filled out. In Germany, a study of this kind does not require ethical approval. The four students entered the data according to a coding system developed by the author. For the analysis performed, the author received an Excel file (Microsoft Corporation, Redmond, USA) with completely anonymized data, i.e., the file did not include codes that would allow linking of the data to a person.

Statistical procedures were carried out with the SAS 9.4 software package for Windows (SAS Institute, Cary, NC), USA). Ordinal regression was used for analyzing the effect of age and gender on nightmare frequency and nightmare distress. All variables were entered simultaneously. Effect sizes were calculated according to J Cohen [3] using the webpage of Lenhard and Lenhard [12].

Results

The nightmare frequency distribution is depicted in Table 1. About a tenth of the participants reported that they had nightmares at least once a week, whereas almost one fifth reported that they experienced nightmares once a year or less often. In Table 2, the distribution of the nightmare distress scale is presented: 12 participants reported that nightmares were quite or very distressing. Overall, 21 participants (15 females, 6 males) reported frequent nightmares (once a week or more often) and/or quite or very distressing nightmares.

Table 1 Nightmare frequency (N = 100)
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Table 2 Nightmare distress (N = 93)
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Nightmare frequency was higher for girls compared to boys (see Table 3). For nightmare distress, the most important factor was nightmare frequency, but gender was also marginally significantly (p-value lower than 0.10, with a small to moderate effect size) associated with nightmare distress—even though the analysis accounted for nightmare frequency.

Table 3 Ordinal regression analyses for nightmare frequency and nightmare distress
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Only 13 participants stated that they do not know any of the nightmare treatment methods presented in the questionnaire. The highest frequencies were found for hypnosis, medication, and relaxation techniques (see Table 4). About one third of the sample stated that they know about lucid dreaming as a treatment option for nightmares. Specific methods like imagery rehearsal therapy (IRT) or eye movement desensitization and reprocessing (EMDR) were less well known. None of the participants stated that they had ever considered seeking help for their nightmares nor were any currently being treated in a nightmare treatment regime; nine participants answered the question about help seeking with “I do not have nightmares.”

Table 4 Knowledge about nightmare treatment methods (N = 100)
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Discussion

Although a sizable percentage of the present sample reported frequent and/or distressing nightmares, none of the adolescents had ever sought professional help for their problem. This value is even lower compared to the findings in adults [17, 25, 28, 36]. Most of the participants knew about a possible treatment strategy (almost 90%), a percentage much higher compared to the two thirds of participants with clinically significant nightmares who believed nightmares cannot be treated [17].

Whereas 15 to 30% of adults with frequent nightmares have sought professional help [17, 25, 28, 29, 36], none of the adolescents had done so. Interestingly, adolescents rarely seek help for mental health problems of any kind—only if the parents actively motivated the adolescent [15, 18]. In case of nightmares, this is a problem, as parents quite often tend to underestimate their children’s nightmare frequency [26], possibly because older children do not tell every nightmare their parents. On the other hand, research in adolescents indicates that nightmares can be associated with depression [37, 38], suicidal thoughts [5], and self-injury [14]. These associations have also been reported for adults [13, 27] and can be a hint toward trauma exposure [33]. Based on this, the question of how diagnosis and treatment of possible nightmare disorders in adolescents could be improved is of utmost importance.

The gender difference regarding nightmare frequency, with females reporting more frequent nightmares compared to males (see regression analyses), is in line with a meta-analysis regarding gender differences in nightmare frequency [31], as especially in adolescents and young adults, the effect sizes were most pronounced. Interestingly, in adults, it was also found that gender contributes to nightmare distress even though nightmare frequency was statistically controlled for [27]. It seems that females are more prone to the negative effects of frequent nightmares than males.

From a methodological viewpoint, it has to be considered that the sample is relatively small and possibly not representative for the German population of adolescents. The school type Gymnasium designates higher education compared to the two other types of high school, i.e., Hauptschule and Realschule. In 2018, about one third of German school attendees completed the highest education (Hochschulreife), whereas about 40% completed the mittlere Reife and about 20% the Hauptschulabschluss [34]. This indicates that the sample is biased towards high education levels. In contrast to studies in adults, especially in students, this sample included an equal number of girls and boys; this is in line with previous dream studies carried out in schools [24, 30] and reflects the gender distribution in schools. The gender distribution in student samples, especially among psychology students, is more shifted toward a higher percentage of females (see, for example, [32]). Similarly, in dream studies carried out online, females outweigh males, as women are more interested in dreams and, therefore, more likely to participate in dream studies (see, for example, [22]). Thus, the balanced ratio of girls and boys in the present sample indicates that selection bias regarding gender was minimal.

However, the nightmare questions were embedded in a more general dream questionnaire; thus, it seems unlikely that the sample was biased in the direction of nightmare sufferers. Nightmare frequency was elicited retrospectively; as research [19] has indicated that prospective measures yielded higher nightmare frequency means compared to retrospective measures, there might be a possible underestimation of nightmare sufferers in the present sample. However, the difference between the two types of nightmare frequency measures is relatively small (effect size d = 0.101) [40]. Thus, a possible underestimation of nightmare sufferers is likely to be small and, if present, would show even more clearly the problem of a respective lack of help seeking in this population.

Overall, the present study clearly indicates that there is a gap between adolescents suffering from nightmares and the percentage of adolescents treated for their nightmare condition. In the current study, the students received leaflets explaining the basic principles of imagery rehearsal therapy [11] for display when they present their findings to the school audience. The high percentage of adolescents knowing about lucid dream therapy might be due to popular media, e.g., the movie “Inception [7]”; thus, media and social media might be important outlets in order to inform this age group about possible nightmare treatment options. In addition, it also seems important to educate parents to ask their children about nightmares and support them in case treatment is needed. If successful, this would reduce the percentage of adult nightmare sufferers considerably.