From the Guidelines
Nightmares are best treated with a combination of psychological and pharmacological approaches, with imagery rehearsal therapy (IRT) recommended as first-line treatment, as evidenced by the most recent and highest quality study 1.
Evaluation of Nightmare Disorder
To evaluate nightmare disorder, it is essential to assess the frequency and distress caused by nightmares, as well as their impact on daily life and sleep quality. The International Classification of Sleep Disorders (ICSD) provides diagnostic criteria for nightmare disorder, including repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve threats to survival, security, or physical integrity 2.
Treatment Options
IRT involves rewriting and mentally rehearsing altered versions of nightmares during daytime for 10-20 minutes daily. This technique has been shown to be effective in reducing nightmare frequency and distress in both PTSD and non-PTSD populations 1. Prazosin, an alpha-1 adrenergic antagonist, is also recommended as a first-line medication for nightmare disorder, starting at 1mg at bedtime and gradually increasing to 3-15mg as needed 3. Alternative medications include trazodone, clonidine, and low-dose doxepin.
Key Considerations
When treating nightmare disorder, it is crucial to address underlying sleep disorders, such as sleep apnea, and comorbid psychiatric conditions. Improving sleep hygiene and providing education on stress management and relaxation techniques can also be beneficial. The Clinician Administered PTSD Scale (CAPS) is a useful tool for assessing PTSD-associated nightmares and monitoring treatment response 2.
Recommendations
- Imagery rehearsal therapy (IRT) as first-line treatment for nightmare disorder, with patients rewriting and mentally rehearsing altered versions of their nightmares during daytime for 10-20 minutes daily 1.
- Prazosin as first-line medication, starting at 1mg at bedtime and gradually increasing to 3-15mg as needed, with careful monitoring for side effects such as dizziness and orthostatic hypotension 3.
- Address underlying sleep disorders and comorbid psychiatric conditions to ensure comprehensive management of nightmare disorder.
- Improve sleep hygiene and provide education on stress management and relaxation techniques to promote overall sleep quality and well-being.
From the Research
Nightmare Evaluation in PTSD
- Nightmares are a common symptom of post-traumatic stress disorder (PTSD) and can be challenging to treat 4, 5.
- Prazosin, an alpha-1 adrenergic antagonist, has been shown to be effective in reducing nightmares and improving sleep quality in patients with PTSD 4, 5.
- A meta-analysis of six randomized placebo-controlled studies found that prazosin significantly improved overall PTSD scores, nightmares, and sleep quality 4.
- Another systematic review found that prazosin administration resulted in improvement in sleep symptoms, especially nightmares and night waking, in most articles 5.
Treatment Options for PTSD
- Selective serotonin reuptake inhibitors (SSRIs) are the most studied medications for PTSD and are considered first-line treatment 6, 7.
- Sertraline and paroxetine are the only FDA-approved drugs for the treatment of PTSD and have been shown to be effective in reducing symptoms 6, 7, 8.
- Other medications, such as venlafaxine and atypical antipsychotics, may be considered as second-line or adjunctive treatments for PTSD 6, 7.
Predictors of Treatment Response
- Predictors of treatment response to SSRIs in patients with PTSD include gender, childhood sexual trauma, and sexual assault as index trauma 8.
- Latent class analysis identified three classes of treatment response: fast responders, responders with low pretreatment symptom severity, and responders with high pretreatment symptom severity 8.
- Class membership was predicted based on time since index trauma, severity of depression, and severity of anxiety 8.