What are ERRT (Exposure, Relaxation, and Rescripting Therapy) and Doxepin?

ERRT and Doxepin: Therapeutic Approaches for Nightmare Disorder and Sleep Disturbances

ERRT (Exposure, Relaxation, and Rescripting Therapy) is a specialized 3-week cognitive behavioral therapy for nightmares that combines sleep hygiene education, progressive muscle relaxation, and exposure to trauma with rescripting of nightmares, while doxepin is a tricyclic antidepressant that can be used to treat insomnia and depression.

ERRT (Exposure, Relaxation, and Rescripting Therapy)

Definition and Components

• ERRT is a modification of Imagery Rehearsal Therapy (IRT) specifically designed for treating trauma-related nightmares 1
• The therapy combines three key elements: sleep hygiene education, progressive muscle relaxation, and exposure to trauma with rescripting of nightmares 1

Treatment Protocol

• Typically delivered in weekly 2-hour sessions over 3 consecutive weeks 1
• Treatment involves psychoeducation about trauma and sleep, sleep habit modification, relaxation training, and exposure procedures including writing out and rescripting nightmares 1
• Patients learn to modify the content of their nightmares through cognitive restructuring techniques 1

Efficacy

• Clinical trials have shown statistically significant reduction in nightmare frequency and severity 1
• A randomized controlled trial demonstrated reduction in nightmares per week from baseline (3.19 ± 2.79) to 6-month follow-up (1.36 ± 3.56) 1
• In a case series, 3 out of 4 subjects reported complete elimination of nightmares at 3-month follow-up 1, 2
• ERRT has been shown to improve not only nightmares but also sleep quality, PTSD symptoms, and depression 3, 4

Clinical Considerations

• The American Academy of Sleep Medicine classifies ERRT as a Level C treatment (may be considered) for PTSD-associated nightmares 1
• Dropout rates of approximately 26% have been reported, which is considered within the typical range for trauma-related therapies 1
• Recent research suggests that ERRT may be effective even without the nightmare exposure and rescripting component 5
• ERRT has been adapted for military personnel (ERRT-M) with medium effect-size reductions in nightmares and related symptoms 3

Doxepin

Pharmacology and Mechanism

• Doxepin is a tricyclic antidepressant with strong antihistaminic (H1) properties
• At low doses, it functions primarily as a selective H1 antagonist, which contributes to its sleep-promoting effects

Clinical Uses

• Used for the treatment of depression at higher doses
• Low-dose doxepin (3-6 mg) is FDA-approved for the treatment of insomnia characterized by difficulties with sleep maintenance
• May help reduce nighttime awakenings and improve sleep quality

Efficacy

• Effective for improving sleep maintenance and total sleep time
• May be particularly useful in patients with both depression and sleep disturbances

Side Effects and Considerations

• Common side effects include sedation, dry mouth, constipation, and blurred vision
• At higher doses used for depression, can cause anticholinergic effects, orthostatic hypotension, and cardiac conduction abnormalities
• Lower doses used for insomnia typically have fewer side effects than higher antidepressant doses

Comparing Treatment Approaches

When to Consider ERRT

• First-line non-pharmacological approach for trauma-related nightmares 1
• Particularly effective when nightmares are related to specific traumatic events 1
• May be combined with other cognitive behavioral therapies for insomnia (CBT-I) for enhanced outcomes 4

When to Consider Doxepin

• When insomnia is the primary concern, particularly with sleep maintenance issues
• When comorbid depression is present
• When non-pharmacological approaches have been unsuccessful or are not feasible

Potential for Combined Approach

• Some patients may benefit from both ERRT for nightmare management and doxepin for underlying sleep or mood disturbances
• The combination may address both the psychological aspects of nightmares and the physiological aspects of sleep disturbance

Recent Developments

• Recent studies suggest ERRT is effective in various populations including active duty military personnel 3
• ERRT has been successfully adapted for use with children and individuals with comorbid bipolar disorder 4
• Research continues to evaluate which components of ERRT are most essential for therapeutic benefit 5