Nightmare Disorder is a diagnosis defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as:
…repeated awakenings with recollection of terrifying dreams, usually involving threats to survival, safety or physical integrity
Although nightmares are common, nightmare disorder is relatively rare. Nightmare disorder is when nightmares happen often, cause distress, disrupt sleep, cause problems with daytime functioning or create fear of going to sleep.
As many as 34% of veterans have PTSD (post-traumatic stress disorder), and according to the US Department of Veterans Affairs, as many as 71%-96% of veterans with PTSD may have nightmares. Nightmares are a hallmark of PTSD in civilians, too. As many as 5% of young adults and 2% of older adults report nightmares on most nights.
In the National Vietnam Veterans Readjustment Study, 52% of combat Veterans with PTSD reported significant nightmares.
Several approaches to treatment have been tried, including sleeping pills, cognitive behavioral therapy (CBT), treating sleep apnea, etc., but evidence for their effectiveness is less than impressive.
In November 2020 the FDA approved marketing of a new device designed to reduce sleep disturbance related to nightmares in certain adults. It is called NightWare, and was approved under the FDA’s Breakthrough Devices Program. It was invented by Tyler Skluzacek to help his father, who had nightmares from PTSD after returning from a deployment to Iraq. The nightmares were so bad he feared going to sleep and tried to self-medicate with vodka and sleeping pills. His life unraveled, his marriage fell apart, and he lost his house, his job, and everything. Tyler’s invention turned his father’s life around and it is now available to the public by prescription.
How does it work?
It uses the Apple Watch heart sensor, accelerometer, and gyroscope data to determine if the patient is having a nightmare. It uses cumulative data to calculate the level of sleep disturbance. It uses artificial intelligence to learn and improve its algorithms. It monitors and analyzes the data in real time to determine if intervention is needed to disrupt a nightmare. If intervention is indicated, it provides vibrotactile stimulation to the patient’s wrist. This interrupts the nightmare without waking the patient. Sleep quality is improved.
Evidence for efficacy
A randomized, controlled double blind clinical trial was published in The Journal of Clinical Sleep Medicine in October, 2022. It studied 72 veterans with trauma-related sleep disorders. Half were treated with the active device and half with a sham device. There were no significant differences between the two groups, but a post hoc analysis that excluded subjects with low frequency usage showed statistically significant improvement in perceived sleep quality in the active group. They called it preliminary evidence that the device could be effective for compliant users.
Testing in civilians is pending.
- The evidence is only preliminary and is not strong.
- The device does not eliminate or cure nightmares.
- It is not intended to be used alone, but only in conjunction with other treatments.
- It is covered by Tricare for active-duty patients but not covered by most insurance or Medicare.
- It requires a prescription.
- It requires an Apple Watch, an iPhone, and special software.
- It may disturb bed partners.
- It is only intended for adults over the age of 22 who have nightmare disorder or nightmares from PTSD.
- It is contraindicated for those who have acted out their nightmares (sleepwalking, violence).
Conclusion: May help those who use it consistently
This device will not cure nightmares, but if it improves sleep quality it may facilitate other treatments. Inadequate sleep has been associated with a wide range of adverse health consequences including cardiovascular events, high blood pressure, depression, glucose intolerance, mood changes, daytime sleepiness, decreased concentration, arrhythmias, and alcohol use. Further studies will be needed to see if any of these can be shown to improve when using NightWare.