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Nightmares arise out of REM sleep and are reported by the patient as structured, often stereotyped dreams that are very distressing. Usually the patient wakes up fully and remembers the dream. Psychological methods of treatment may be appropriate, e.g. a program of rehearsing the dream, inventing different endings. In a small number of cases where adverse events such as angina have been provoked by recurrent nightmares it may be appropriate to consider drug treatment with an antidepressant with a marked suppressing effect on REM sleep, such as the MAOI, phenelzine. Night mares of a particularly distressing kind are a feature of post-traumatic stress disorder. Case reports indicate benefit from various pharmacological agents but no particular drug emerges as superior. Many prefer to use a 5HT-blocker such as trazodone or nefazodone.

Night terrors and sleep-walking arise from slow wave sleep and they are often coexistent. There is usually a history dating from childhood and often a family history. Exacerbations commonly coincide with periods of stress and alcohol will increase their likelihood. In a night terror patients usually sit or jump up from deep sleep (mostly early in the night) with a loud cry, look terrified and move violently, sometimes injuring themselves or others. They appear asleep and uncommunicative, often returning to sleep without being aware of the event. These terrors are thought to be a welling-up of anxiety from deep centres in the brain which is normally inhibited by cortical mechanisms. They can occur in up to 30% of normal children but become troublesome and often dangerous in adults. They can be successfully treated with the benzodiazepine, clonazepam or the SSRI, paroxetine.

Nocturnal panic attacks may be distinguished from night terrors by the fact that the patient will wake fully before panic symptoms have reached a peak and is fully aware.

REM behaviour disorder, first described by in 1988, consists of lack of paralysis during REM sleep which results in acting out of dreams, often vigorously with injury to self or others. It can occur acutely as a result of drug or alcohol withdrawal but its chronic manifestation can be idiopathic or associated with neurological disorder (about 50% of each). It is much commoner among older patients. Successful treatment has been described with clonazepam or clonidine which decrease REM sleep without increasing awakenings.

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