Differential Diagnosis

• Single most likely diagnosis
  • Nightmare disorder: This is the most likely diagnosis because the patient reports having recurrent vivid dreams that cause her significant distress and anxiety upon awakening. The content of the dreams involves themes of assault, which is common in nightmare disorder, and she has no history of actual trauma. The fact that she is afraid to go back to sleep due to fear of the dreams further supports this diagnosis.
• Other Likely diagnoses
  • Anxiety disorder: While not explicitly listed as an option, the patient's anxiety and distress upon awakening from the nightmares could suggest an underlying anxiety disorder. However, without more information on her waking anxiety levels or other symptoms, this remains speculative.
  • Sleep disorder related to substance use (caffeine): The patient's consumption of two to three cups of coffee each morning could potentially contribute to sleep disturbances, including vivid dreams or nightmares, although this is less directly related to the specific symptoms described.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Sleep apnea: Although the patient's symptoms do not directly suggest sleep apnea, and physical examination and laboratory studies show no abnormalities, sleep apnea can sometimes present with non-specific symptoms such as daytime fatigue or sleep disturbances. It's less likely given the information but should be considered due to its potential health implications.
  • Acute stress disorder: This could be considered if the nightmares were triggered by a specific stressful event, but the patient denies any history of assault or recent trauma, making this less likely.
• Rare diagnoses
  • Panic disorder: While panic disorder involves recurrent panic attacks that can be extremely distressing, the patient's symptoms are primarily centered around nightmares rather than panic attacks, making this a less likely diagnosis.
  • Sleep terror disorder: This disorder involves episodes of intense fear, panic, or anxiety during sleep, usually accompanied by screaming or flailing. However, sleep terror disorder typically occurs during non-REM sleep, and the individual often has no recall of the event in the morning, which does not match the patient's symptoms of vivid dream recall and distress upon awakening.