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Pharmacological and non-pharmacological treatments for nightmare disorder
Abstract
Interest in the treatment of nightmares has greatly increased over the last several years as research has demonstrated the clinical significance of nightmare disorder. This paper provides an overview of nightmare disorder, its clinical relevance, and the leading treatments that are available. In particular, the paper defines nightmare disorder and then summarize the recent literature examining the clinical relevance of nightmare disorder, including its relation to post-traumatic stress disorder and other psychiatric conditions. The relation between nightmares and suicidality is also discussed. Recent findings on the treatment of nightmare with imagery rehearsal therapy and prazosin are then summarized. Lastly, the paper comments on potential future uses of nightmare treatment including using imagery rehearsal therapy or prazosin as a first-line intervention for post-traumatic stress disorder and using these treatments as an adjunctive therapy to reduce suicide risk in those at risk of suicide with nightmares.
... Frequent childhood nightmares double the odds of youth suicidal ideation and quadruple the odds of a youth suicide attempt (Liu, 2004). However, if detected, nightmares are treatable with cognitive behavioral (Kearns et al., 2020) or pharmacological (Nadorff et al., 2014) interventions. Currently, rates of nightmares and nightmare disorder in outpatient pediatric psychiatry populations are unknown. ...
... Although EMR data showed that few children with chronic nightmares were identified by clinicians, if given the opportunity for treatment, many families were interested in this option. Even in the absence of meeting nightmare disorder criteria, nightmares are treatable, and when the nightmares are treated, the risk of suicidality and psychiatric problems can be reduced (Kearns et al., 2020;Nadorff et al., 2014). Although it is a clinical decision as to whether comorbid nightmares call for treatment, the correlation of nightmares with trauma and physical health (Rhudy et al., 2008), the predictive value of nightmares for suicidality, and the treatability of nightmares through behavioral and pharmacological means suggest that a brief screener could improve patient care. ...
... Although it is a clinical decision as to whether comorbid nightmares call for treatment, the correlation of nightmares with trauma and physical health (Rhudy et al., 2008), the predictive value of nightmares for suicidality, and the treatability of nightmares through behavioral and pharmacological means suggest that a brief screener could improve patient care. We join with researchers of adult populations in calling for routine screening of nightmares (Nadorff et al., 2014;Nadorff et al., 2015). ...
Treatable pernicious nightmares are underreported in clinical and community samples and are often unrecognized by health-care providers. Frequent childhood nightmares double the odds of youth suicidal ideation and quadruple the odds of a youth suicide attempt. However, if detected, nightmares are treatable with cognitive behavioral or pharmacological interventions. Currently, rates of nightmares and nightmare disorder in outpatient pediatric psychiatry populations are unknown. We report findings of nightmare screening conducted at an outpatient pediatric psychiatry facility. A total of 806 children were seen at the clinic over the period of the study; 782 parents of patients aged 3 to 17 received paper-and-pencil screeners. Of those, 678 (86.7%) completed the screeners, and 276 (40.7%) were positive for nightmares, with most children remembering their nightmares. A total of 89 (32.2%) “always” remembered their nightmares, and 165 (59.8%) “sometimes” remembered the nightmares. In addition, 155 (56.2%) had nightmares the week prior, and of those, 59 (38.1%) “always” remembered the nightmares and 82 (52.9%) “sometimes” remembered. Aggregated electronic medical record data found that of the 806 patients seen during the study period, 12 (0.01%) had been diagnosed with nightmare disorder, 129 (16%) had been diagnosed with posttraumatic stress disorder, and 24 (0.03%) had acute stress disorder. Although electronic medical record data showed that few children with chronic nightmares were identified by clinicians, many families were interested in treatment. We join with researchers of adult populations in calling for routine screening of nightmares.
... IRT describes a behavioral technique wherein the patient rescripts their nightmare however they wish and then rehearses the new script 10-20 min a day while awake (Aurora et al., 2010;Ellis et al., 2019;Gieselmann et al., 2019). IRT inhibits the nightmare by replacing it with a new, nonthreatening dream and reduces the need to escape (Gieselmann et al., 2019;Nadorff et al., 2014). ...
... RBD is classified as repeated vocalization and/or complex motor movements during the REM stage of sleep (American Psychiatric Association, 2013). Although often comorbid with ND, frontline treatment for RBD typically involves combined environmental modifications (e.g., placing barriers on the side of the bed and removing dangerous objects, such as weapons, from the sleep environment) and pharmacotherapy (clonazepam; Howell & Schenck, 2015;Jung & St Louis, 2016) versus behavioral treatments such as IRT for ND (Aurora et al., 2010;Gieselmann et al., 2019;Nadorff et al., 2014). RBD and ND share various comorbidities, including neurodegenerative disorders (Howell & Schenck, 2015), other sleep disorders (Aurora et al., 2010), medication use (Aurora et al., 2010;Nadorff et al., 2014;Neikrug & Ancoli-Israel, 2010;Wolkove et al., 2007), psychiatric conditions (Aurora et al., 2010;Gieselmann et al., 2019;Nadorff et al., 2014), and older age (Neikrug & Ancoli-Israel, 2010;Wolkove et al., 2007). ...
... Although often comorbid with ND, frontline treatment for RBD typically involves combined environmental modifications (e.g., placing barriers on the side of the bed and removing dangerous objects, such as weapons, from the sleep environment) and pharmacotherapy (clonazepam; Howell & Schenck, 2015;Jung & St Louis, 2016) versus behavioral treatments such as IRT for ND (Aurora et al., 2010;Gieselmann et al., 2019;Nadorff et al., 2014). RBD and ND share various comorbidities, including neurodegenerative disorders (Howell & Schenck, 2015), other sleep disorders (Aurora et al., 2010), medication use (Aurora et al., 2010;Nadorff et al., 2014;Neikrug & Ancoli-Israel, 2010;Wolkove et al., 2007), psychiatric conditions (Aurora et al., 2010;Gieselmann et al., 2019;Nadorff et al., 2014), and older age (Neikrug & Ancoli-Israel, 2010;Wolkove et al., 2007). ...
Imagery rehearsal therapy (IRT) is an evidence-based treatment for nightmare disorder (ND), and numerous studies have demonstrated its efficacy in reducing the frequency and severity of nightmares. ND and REM sleep behavior disorder (RBD) co-occur, yet the impact of successful treatment of nightmares on dream enactment in RBD has not been studied. In this case study, we present the treatment of ND using IRT and its impact on dream enactment in the context of RBD. A total of 5 sessions of IRT over 5 months resulted in a reduction in nightmares and, according to the patient and her husband, a decrease in dream enactment. We hypothesize that reducing the emotional valence of the dream content may make dream enactment less likely. As a result, IRT may provide helpful adjuvant treatment to pharmacological treatment of RBD.
... Frequent childhood nightmares double the odds of youth suicidal ideation and quadruple the odds of a youth suicide attempt (Liu, 2004). However, if detected, nightmares are treatable with cognitive behavioral (Kearns et al., 2020) or pharmacological (Nadorff et al., 2014) interventions. Currently, rates of nightmares and nightmare disorder in outpatient pediatric psychiatry populations are unknown. ...
... Although EMR data showed that few children with chronic nightmares were identified by clinicians, if given the opportunity for treatment, many families were interested in this option. Even in the absence of meeting nightmare disorder criteria, nightmares are treatable, and when the nightmares are treated, the risk of suicidality and psychiatric problems can be reduced (Kearns et al., 2020;Nadorff et al., 2014). Although it is a clinical decision as to whether comorbid nightmares call for treatment, the correlation of nightmares with trauma and physical health (Rhudy et al., 2008), the predictive value of nightmares for suicidality, and the treatability of nightmares through behavioral and pharmacological means suggest that a brief screener could improve patient care. ...
... Although it is a clinical decision as to whether comorbid nightmares call for treatment, the correlation of nightmares with trauma and physical health (Rhudy et al., 2008), the predictive value of nightmares for suicidality, and the treatability of nightmares through behavioral and pharmacological means suggest that a brief screener could improve patient care. We join with researchers of adult populations in calling for routine screening of nightmares (Nadorff et al., 2014;Nadorff et al., 2015). ...
Poster to be presented at the American Psychological Association Annual Convention, Washington,DC.
... Significant correlations have been reported between lucid dreaming frequency and nightmare frequency, such that the more individuals engaged in lucid dreaming training, the less nightmares they experienced (Erlacher et al., 2008). Further, it has been suggested that the lucid dreaming approach differs significantly from other nightmare treatments; instead of trying to reduce the frequency or severity of nightmares, it attempts to stop nightmares midway through (Nadorff et al., 2014). Thus, it is possible that lucid dreaming may be better tolerated than other nightmare treatments. ...
... PTSD symptoms were included as a potential covariate considering comorbidity of PTSD, nightmares, and sleep problems (Nadorff et al., 2014) and were measured using the PTSD Checklist-5 (PCL-5; Price et al., 2016). This was an eight-item scale that measures symptom severity for those at risk for PTSD. ...
Nightmares can yield deleterious effects on sleep quality; therefore, it is important to identify modifiable predictors of nightmare distress in order to promote better sleep outcomes. Lucid dreaming and trait mindfulness are both associated with decreased nightmares and may indirectly improve sleep quality; furthermore, these factors may have synergistic effects. To test this, a moderated mediation model was examined. Contrary to our hypothesis, results showed that lucid dreaming was associated with greater nightmare distress, which predicted worse sleep quality, but this effect was moderated by total mindfulness and the subfacet of acting with awareness. For individuals with low and average mindfulness, lucid dreaming increased nightmare distress, yielding a negative indirect effect on sleep quality. These effects were not seen for individuals with high mindfulness; rather, a trend emerged in which lucid dreaming for individuals high in mindfulness may improve sleep quality via lowered nightmare distress. Findings can inform nonmedical approaches to reducing nightmare distress and suggest that abilities in lucid dreaming may only yield benefits on reducing nightmares and corresponding sleep quality among individuals who also possess high mindfulness skills, particularly acting with awareness and nonjudgemental mindfulness.
... In this context, practitioners frequently consider nightmares and disturbing dreams as secondary symptoms, with no predicting or therapeutic relevance. However, even if most of the studies assessing nightmares and suicide are cohorts or case series, and that controlled studies are needed to clarify the role of nightmares on suicidal behavior, the present review suggests that patients should be systematically screened for recurrent or frequent nightmares, as they are both very frequent and seem to be associated with a higher risk of suicide [15,34,44,45,54]. ...
... No studies have reported relationships between nightmare distress and depressive symptoms in patients with MDD, nor the relationship between nightmare distress and suicidality in patients with MDD or psychotic disorders. In the general population, nightmares have been associated with hallucinatory experiences [55] and with psychotic-like experiences [46][47][48][49][50][51][52][53][54][55][56]. ...
Chronic nightmares are very common in psychiatric disorders, affecting up to 70% of patients with personality or post-traumatic stress disorders. In other psychiatric disorders, the relationships with nightmares are poorly known. This review aimed to clarify the relationship between nightmares and both mood and psychotic disorders. We performed a systematic literature search using the PubMed, Cochrane Library and PsycINFO databases until December 2019, to identify studies of patients suffering from either a mood disorder or a psychotic disorder associated with nightmares. From the 1145 articles screened, 24 were retained, including 9 studies with patients with mood disorders, 11 studies with patients with psychotic disorders and 4 studies with either psychotic or mood disorders. Nightmares were more frequent in individuals with mood or psychotic disorders than in healthy controls (more than two-fold). Patients with frequent nightmares had higher suicidality scores and had more frequently a history of suicide attempt. The distress associated with nightmares, rather than the frequency of nightmares, was associated with the severity of the psychiatric disorder. Further studies assessing whether nightmare treatment not only improves patient–sleep perception but also improves underlying psychiatric diseases are needed. In conclusion, nightmares are overrepresented in mood and psychotic disorders, with the frequency associated with suicidal behaviors and the distress associated with the psychiatric disorder severity. These findings emphasize major clinical and therapeutic implications.
... With regard to a stepped-care approach and given that IRT interventions can be delivered quickly and easily, future studies should establish the potential benefit of providing a brief course of IRT in combination with, or possibly prior to, trauma-focused psychotherapy (Nadorff et al., 2014). By improving sleep quality, PTSD patients may also benefit from improved memory encoding and memory consolidation (Diekelmann, Wilhelm, & Born, 2009;Walker & Stickgold, 2006), as suggested by findings that sleep reshapes brain processes involved in learning and memory (Walker & Stickgold, 2006). ...
... https://tango.uthscsa.edu/ssads/507, University of Texas; Nadorff et al., 2014). ...
This consensus paper provides an overview of the state of the art in research on the aetiology and treatment of nightmare disorder and outlines further perspectives on these issues. It presents a definition of nightmares and nightmare disorder followed by epidemiological findings, and then explains existing models of nightmare aetiology in traumatized and non‐traumatized individuals. Chronic nightmares develop through the interaction of elevated hyperarousal and impaired fear extinction. This interplay is assumed to be facilitated by trait affect distress elicited by traumatic experiences, early childhood adversity and trait susceptibility, as well as by elevated thought suppression and potentially sleep‐disordered breathing. Accordingly, different treatment options for nightmares focus on their meaning, on the chronic repetition of the nightmare or on maladaptive beliefs. Clinically, knowledge of healthcare providers about nightmare disorder and the delivery of evidence‐based interventions in the healthcare system is discussed. Based on these findings, we highlight some future perspectives and potential further developments of nightmare treatments and research into nightmare aetiology.
... Normalizing sleep problems as adaptive and expected responses to stressful deployment experiences can be validating and a non-stigmatizing intervention in and of itself. Nonpharmacologic behavioral treatments have the best evidence for their use and are becoming the preferred treatment for insomnia (Peterson et al., 2008) and nightmares (Nadorff, Lambdin, & Germain, 2014). Empirically supported, cognitive behavioral therapy for insomnia (CBT-I) has become the first-line treatment for primary insomnia (Talbot et al., 2014). ...
... The client engages in imaginal rehearsal of the new dream in session. IRT does not include imagining the old nightmare; this would involve exposure therapy (Nadorff et al., 2014). For homework, the client rehearses the new set of images from the altered nightmare for several minutes each day (Krakow, Kellner, Pathak, & Lambert, 1995) using imaginal rehearsal. ...
Sleep disturbances are prevalent among veterans. In particular, insomnia and nightmares are common complaints for this population. Cognitive Behavior Therapy for Insomnia (CBT-I) and Imagery Rehearsal Therapy (IRT) are established treatments for insomnia and nightmares respectively. This paper reviews recent literature on insomnia and nightmares in military personnel. The treatment of insomnia with CBT-I and nightmares with IRT are discussed. Finally, the integration of CBT-I and IRT for sleep disturbances in Veterans with PTSD is presented
... There are several non-pharmacologic options for treatment PTSD-associated nightmare disorder, including image rehearsal therapy (IRT); exposure, relaxation, and re-scripting therapy (ERRT); lucid dreaming therapy; systematic desensitization and exposure therapy [36,54,58,62]. IRT and ERRT have been studied extensively and are well-established, but data supporting the use of the other aforementioned therapies are limited [62][63][64]. ...
... There are several non-pharmacologic options for treatment PTSD-associated nightmare disorder, including image rehearsal therapy (IRT); exposure, relaxation, and re-scripting therapy (ERRT); lucid dreaming therapy; systematic desensitization and exposure therapy [36,54,58,62]. IRT and ERRT have been studied extensively and are well-established, but data supporting the use of the other aforementioned therapies are limited [62][63][64]. Cognitive behavioral therapy for insomnia has been shown to improve sleep in patients with PTSDassociated nightmare disorder, but effects on nightmare frequency and severity have been variable [65][66][67]. ...
Purpose of Review
This paper describes a newly proposed sleep disorder, trauma-associated sleep disorder (TSD). Whether or not this represents a truly unique condition is controversial. In this paper, we describe the overlapping features and differences between TSD, post-traumatic stress disorder (PTSD), and rapid eye movement (REM) sleep behavior disorder (RBD).
Recent Findings
While REM sleep without atonia (RWA) and dream enactment are part of the diagnostic criteria for both RBD and TSD, only TSD features nightmares that occur both in non-REM and REM. A key difference between TSD and PTSD is the presence of symptoms during wakefulness in the latter, though the relationship between the two disorders is, as of yet, unclear. It is unknown whether or not a relationship exists between TSD and neurodegeneration; thus, this needs to be explored further.
Summary
Additional research, such as application of TSD diagnostic criteria to more diverse population, would help to determine whether or not TSD is a distinct clinical entity, its relationships to PTSD, as well as the association of this condition with the development of neurodegeneration.
... Further, nightmares seem to function as well-remembered and themed dreams that occur almost exclusively in REM sleep (which is more prevalent during the latter half of the sleep period). During a nightmare an individual is often startled awake, becoming highly alert and quickly oriented to their surroundings [6]. Both bad dreams and night terrors are parasomnias, however, bad dreams do not cause startled awakening, and night terrors are a non-REM sleep disturbance. ...
... Prazosin is a drug used for high blood pressure and anxiety, but has also shown to significantly improve nightmares. However, research suggests that the nightmares commonly return when prazosin is discontinued [6]. Additionally, further research is needed investigating the implications for longterm use and duration of improvement has yet to be examined [36 ]. ...
The suicide rate in the United States has climbed each year for more than a decade, highlighting the need for greater understanding of, and prevention strategies for suicidal behavior. Nightmares have been shown to be associated with suicidal behavior independent of several psychiatric risk factors for suicide, such as symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD). The specific role of nightmares in contributing to suicide remains unclear due to the difficulty in delineating causal factors. However, the reporting, screening and treatment of nightmares continues to remain rare making progress difficult. Research is beginning to make some progress in uncovering the mechanisms by which nightmares increase suicide risk providing opportunities for intervention and prediction of suicidal behaviors.
... However, lucidity is difficult to achieve, and to date, there is not one method that can reliably induce lucid dreaming (Stumbrys et al., 2012;Tan & Fan, 2022). Other promising treatments for nightmares disorder (for a review see Gieselmann et al., 2019;Spangler & Sim, 2023) include pharmacological therapy (Nadorff et al., 2014), Imagery Rehearsal Therapy (Neidhardt et al., 1992), exposure, relaxation, and rescripting therapy (Davis, 2009), and nightmare deconstruction and processing (Spangler & West, 2018). ...
It is widely known that dreams can be strongly affected by traumatic events, but there may be other ways in which dreams relate to trauma. In this paper, we argue that different types of dreams could both contribute to trauma and alleviate it according to the prediction errors that occur either in dreams or in response to them after waking. A prediction error occurs when an experience contradicts one’s expectation and it is often accompanied by surprise. Prediction errors are involved in memory updating processes that can be long-lasting. Not only nightmares but also unpleasant, and surprisingly, even neutral and pleasant dreams have the potential to contribute to trauma, affecting our waking lives in a similar way to waking traumatic experiences. We postulate that certain dreams can also be beneficial for trauma alleviation. Further, clinical evidence suggests that working with prediction errors that occurred in dreams and during our response to dreams after waking can assist in alleviating the negative effects of trauma.
... However, lucidity is difficult to achieve, and to date, there is not one method that can reliably induce lucid dreaming (Stumbrys et al., 2012;Tan & Fan, 2022). Other promising treatments for nightmares disorder (for a review see Gieselmann et al., 2019;Spangler & Sim, 2023) include pharmacological therapy (Nadorff et al., 2014), Imagery Rehearsal Therapy (Neidhardt et al., 1992), exposure, relaxation, and rescripting therapy (Davis, 2009), and nightmare deconstruction and processing (Spangler & West, 2018). ...
Michelle Maiese: Trauma, dissociation, and relational authenticity
Caroline Christoff: Performative trauma narratives: Imperfect memories and epistemic harms
Aisha Qadoos: Ambiguous loss: A loved one's trauma
Alberto Guerrero Velazquez: El trauma está en la respuesta. Hacia una visión post-causal en la definición de trauma psicológico
Clarita Bonamino, Sophie Boudrias, and Melanie Rosen: Dreams, trauma, and prediction errors
Gabriel Corda: Memoria episódica y trastorno de estrés postraumático en animales no humanos: una propuesta metodológica
María López Ríos, Christopher Jude McCarroll, and Paloma Muñoz Gómez: Memory, mourning, and the Chilean constitution
Sergio Daniel Rojas-Sierra, and Tito Hernando Pérez Pérez: Subjetividades rememorantes, marcas narrativas y trauma cultural en la construcción de memoria de desmovilizados de las FARC-EP en el AETCR Pondores
Germán Bonanni: Y después de la guerra... ¿Qué?
... Second, the potential therapeutic effect of DD treatment on the frequency and intensity of suicidal ideation in at risk populations has yet to be explored. This is all the more important, as there exist effective, short-term cognitive-behavioral treatments (e.g., imagery rehearsal therapy) for idiopathic, chronic, and trauma-related nightmares with wellestablished success rates in adults (Augedal et al., 2013;Krakow & Zadra, 2006;Morgenthaler et al., 2018;Nadorff, Anestis et al., 2014) and which have also been shown to be effective in young children and adolescents (Nadorff, Lambdin et al., 2014;Simard & Nielsen, 2009;St-Onge et al., 2009). ...
Disturbing dreams and recurrent dreams have both been linked to a wide range of psychological difficulties in children. There is growing evidence that the experience of frequent disturbing dreams is associated with suicidal ideation in adults, but studies in young adolescents have been limited and the results inconsistent. In addition, the possible relationship between suicidal ideation and recurrent dreams has yet to be studied. We thus investigated the relation between disturbing dreams, recurrent dreams, and suicidal ideation in a sample of young adolescents. Self-report measures of disturbing dream frequency, recurrent dream frequency, and suicidal ideation were collected at the age of 12 years and again at the age of 13 years from 170 children from a prospective population-based birth cohort. Although the rate of disturbing dreams and recurrent dreams dropped between ages of 12 and 13, the rate of self-reported suicidal ideation increased between the ages of 12 and 13 years. Analyses taking sex and age into account revealed that young adolescents who reported having had suicidal thoughts over the past year had significantly greater frequencies of disturbing dreams and of recurrent dreams than adolescents who had not thought about suicide. These findings highlight the potential clinical value of assessing disturbing and recurrent dreams as part of the screening process for suicidal ideation in young adolescents.
... Frequent nightmares have pathological significance; a meta-analysis showed that both psychological and pharmacological interventions were effective in treating nightmares, where the former seemed to be more durable [30]. Moreover, cognitive behavioral therapy and prazosin are regarded as the main forms of nonpharmacological and pharmacological treatments, respectively [31], but whether they are effective for nightmares with unknown pathological causes remains to be seen. Therefore, we believe that finding economical and effective measures to prevent nightmares has value for athletes, coaches, and sport psychologists. ...
Objective:
Frequent nightmare behavior or deep nightmare experiences may harm the physical and mental health and performance of athletes. This study explores the nightmare experiences of athletes, and includes non-athletes with similar experiences for comparison.
Methods:
The Nightmare Experience Questionnaire (NEQ); Zuckerman-Kuhlman-Aluja Personality Questionnaire, Shortened Form (ZKA-PQ/SF); and Self-Rating Anxiety Scale (SAS) were used. The subjects were 187 athletes (mean age = 20.44 years, SD = 0.85; 91 females, 96 males) and 90 non-athletes (mean age = 20.34 years, SD = 1.65; 52 females, 38 males) who reported having nightmares.
Results:
A total of 87 athletes (46.5%) reported having nightmare experiences. The athlete nightmare group scored significantly higher in neuroticism than the non-nightmare group, and their anxiety scores were significantly higher than those of non-athletes, who scored higher in aggressiveness, neuroticism, and sensation seeking. Moreover, anxiety, neuroticism, and sensation seeking positively predicted athletes' nightmare experiences.
Conclusions:
Personality traits and anxiety levels can be effectively applied to predict athletes' nightmare experiences.
... Insomnia and nightmares are a frequent complaint among trauma-exposed veterans (Gellis et al., 2010) and are associated with poor mental and physical health outcomes, including posttraumatic stress disorder (PTSD; Leskin et al., 2002;Nadorff et al., 2014). Fortunately, there is some evidence to suggest that cognitivebehavioral therapies for nightmares that include a rescription component can reduce nightmare frequency and related distress (Balliett et al., 2015;Harb et al., 2019;Miller et al., 2014). ...
Nightmares are a frequent and distressing complaint of trauma-exposed veterans. However, less is known about the language of these nightmares and how the nightmare narrative changes in rescripting therapy. This study reports on the Linguistic Inquiry and Word Count variables of word count, affective processes, positive and negative emotion words, cognitive processes, and drives in 20 veterans participating in a study examining the efficacy of exposure, relaxation, and rescripting therapy for posttrauma nightmares. It was hypothesized that there would be significant increases in affective processes, positive emotion words, cognitive processes, and drives and significant decreases in negative emotion words and word count from nightmare transcription to rescription. It was further hypothesized that noncombat-related nightmares would demonstrate significantly larger changes in Linguistic Inquiry and Word Count processes than combat-related nightmares. The analysis revealed a significant decrease in word count (p < .001) and a significant increase in positive emotion words (p < .03). Noncombat-related nightmare rescriptions decreased significantly more in word count than combat-related rescriptions. Results from this study suggest that the content of written nightmare narratives can be significantly changed over the course of rescripting therapy. Further research is needed to investigate how these changes may be linked to other clinical outcomes.
... For example, if an emotional reaction can be modulated or can act as a predictive value, it might have an implication for therapeutic intervention. Both pharmacotherapy and behavioral treatment of nightmares seem to help individuals [17,95]. ...
Nightmares usually occur during the sleep phase of rapid eye movement (REM) and are associated with some physical symptoms, including sweating, shortness of breath, and lower limb movements. Emotions of fear, anger, shame, and sadness may also accompany nightmares. These symptoms can occur during dreaming, upon awakening, or later when the dream experience is recollected. Nightmares may sporadically occur for everyone, but nightmare disorders are associated with features of impaired mental and physical health and require professional medical treatment. The occurrence of nightmares with several disorders has been reported in the literature, but in migraines it has only been investigated in a small number of studies. Considering the existing relationship between sleep disorders and migraine, the occurrence of nightmares in migraine can negatively affect this association and elevate the risk of depression and anxiety. This, in turn, further reduces the quality of life of affected individuals. Hence, expanding the knowledge on the link between nightmares and migraine, promoting an acceptable quantity and quality of sleep through pharmacological and nonpharmacological interventions in the management of nightmares in migraine, and further scientific investigation of the biopsychosocial mechanisms underlying the link, will be highly valuable for optimal care. This focused review, therefore, gives a brief overview of the current understanding of nightmares in migraine to highlight the open questions and value of further research. The ultimate goal is to contribute to timely recognition and sufficient action to offer beneficial outcomes for affected patients.
... The disorder is defined by a tendency to avoid people, places, memories, and other stimuli related to the traumatic event, as well as recurrent distressing memories of the event and alterations in mood and hyperarousal (American Psychiatric Association, 2013). Additionally, about 80% of PTSD patients suffer from nightmares which are often emotionally related to the original trauma (Nadorff et al., 2014). Nightmares related to PTSD are equally likely to arise during N1/N2 and REM sleep (Phelps et al., 2018). ...
... As a modifiable risk factor, sleep disturbance should be given more attention by school counselors and the teachers engaging in psychological services, because students may be more willing to seek support and help for sleep-related problems rather than for suicidal behaviors. Further, previous intervention studies have also shown that psychotherapy and drug rehabilitation therapy for nightmares can not only improve sleep functioning, but also reduce suicidal ideation (Nadorff et al., 2014). In addition, further studies are needed to explore and confirm the potential mechanisms underlying these findings. ...
Background
: Sleep disturbance can be an important predictor associated with suicide behaviors. However, to date, few studies have examined the prospective relationships between different types of sleep disturbance and suicidal behaviors. The current study examined which sleep disturbance types were independent risk factors for subsequent suicidal behaviors in a large sample of Chinese college students.
Methods
: Data came from a large-scale health-related cohort study in Guangdong, China. Participants were 11740 college students initially assessed in March and April in 2019 and reassessed six month later. Self-administered structured questionnaires were used to assess suicidal behaviors, insomnia, nightmares, sleep disordered breathing (SDB) symptoms, restless legs syndrome (RLS) symptoms, depression, substance abuse and demographic characteristics. A series of logistic regression analyses were conducted to examine the associations between different types of sleep disturbance and suicidal behaviors.
Results
: Overall, 12.2% and 1.2% of college students reported suicidal ideation and attempts at baseline, and 8.6% and 2.4% reported similar behavior at follow-up. After adjustment for key covariates and prior suicidal behaviors, frequent nightmares (AORs = 1.35-1.69) and RLS symptoms (AOR = 1.37) at baseline predicted subsequent suicidal ideation, and only frequent nightmares (AOR = 2.40) at baseline predicted subsequent suicidal attempts.
Limitations
: All measures were based on self-report instead of objective assessments or clinical diagnostic evaluations.
Conclusions
: Frequent nightmares and RLS symptoms were independently associated subsequent suicidal ideation or attempts. Screening and managing sleep disturbance may be helpful for reducing the risk of suicidal behaviors among college students.
... The disorder is defined by a tendency to avoid people, places, memories, and other stimuli related to the traumatic event, as well as recurrent distressing memories of the event and alterations in mood and hyperarousal (American Psychiatric Association, 2013). Additionally, about 80% of PTSD patients suffer from nightmares (Morgenthaler et al., 2018) which are often emotionally related to the original trauma (Nadorff et al., 2014). Nightmares related to PTSD are equally likely to arise during N1/N2 and REM sleep (Phelps et al., 2018). ...
About 80% of posttraumatic stress disorder (PTSD) patients suffer from nightmares or dysphoric dreams that cause major distress and impact nighttime or daytime functioning. Lucid dreaming (LD) is a learnable and effective strategy to cope with nightmares and has positive effects on other sleep variables. In LDs, the dreamer is aware of the dreaming state and able to control the dream content. The aim of this study is to evaluate the effectiveness of lucid dreaming therapy (LDT) in patients suffering from PTSD. We suggest that learning a technique that enables the affected subjects to regulate the occurrence and content of nightmares autonomously increases the chance of coping with the complex symptoms of PTSD and can reduce suffering. Sleep quality (PSQI, Pittsburgh Sleep Quality Index), daytime sleepiness (ESS, Epworth Sleepiness Scale), quality of life (MQLI, Multicultural Quality of Life Index), psychological distress (SCL-90-R, Symptom Checklist 90-Revised), distress caused by traumatic events (IE-S, Impact of Events Scale), anxiety (SAS, Self-Rating Anxiety Scale), depression (SDS, Self-Rating Depression Scale), and nightmare severity were assessed in a self-rating questionnaire before and after the intervention. LDT had no effect on the investigated sleep variables. No correlation between reduction of nightmare severity and changes in PTSD-profile (IE-S) was found. Nevertheless, levels of anxiety and depression decreased significantly in the course of therapy. LDT could provide an alternate or complementary treatment option for nightmares in PTSD, specifically for symptoms of anxiety and depression.
... depression). These findings may have several important clinical and public health implications because nightmares are more common than usually thought [23], underreported, undetected, and untreated [48] and because nightmares are modifiable by psychological and pharmacological treatments [49][50]. First, the findings underscore the importance of screening adolescents at risk of suicidal behavior by assessing nightmare frequency and associated distress. ...
Study objectives
Nightmares are a significant risk factor of suicidal behavior. This study examined the longitudinal associations of nightmare frequency and distress with suicidal thought (ST), suicide plan (SP), and suicide attempt (SA) and mediating role of depressive symptoms in adolescents.
Methods
6,923 adolescents who participated in the 1-year follow-up of Shandong Adolescent Behavior & Health Cohort were included for the analysis. Participants completed a self-administered questionnaire to assess nightmares, sleep duration, insomnia, depressive symptoms, substance use, prior suicidal behavior, and family demographics in November-December in 2015. One year later, a follow-up survey was conducted to ask participants to report their depressive symptoms and suicidal behaviors.
Results
Of the sample, 26.2% reported having frequent nightmares (at least twice/month) at baseline, and 10.0%, 3.6% and 2.7% reported having ST, SP, and SA over 1-year follow-up. The rates of subsequent ST, SP, and SA all significantly increased with baseline nightmare frequency and distress. Path analyses showed that depressive symptoms had significant mediation effects on the associations of frequent nightmares and elevated nightmare distress with ST, SP, and SA before and after adjusting for adolescent and family covariates and prior suicidal behavior.
Conclusions
Suicidal risk increased with nightmare frequency and distress among adolescents. The association between nightmares and suicidal behavior was at least partially mediated by depressive symptoms. Assessing and intervening nightmares and depressive symptoms associated with nightmares may have important implications for preventing adolescent suicidal behavior.
... 5 Sleep terror presents with sudden waking from sleep, usually during the non-rapid eye movement (NREM) stage, in a terrified state. 6,7 Episodes of sleep terror can occur with poor sleep quality, increased sleep fragmentation, and hyper-arousal. Recurrent sleep terror is often comorbid with psychiatric illnesses such as post-traumatic stress disorder. ...
Background/purpose
Sleep disturbances are associated with chronic tinnitus in humans. However, whether parasomnias are associated with chronic tinnitus is unclear. This study aims to investigate this issue.
Methods
Clinical data for 2907 subjects who had visited the Sleep Center of a community hospital in Taiwan during November 2011 to June 2017 were collected retrospectively. The association of chronic tinnitus with sleep terror, sleep walking, and sleep talking was analyzed using Pearson's Chi-Square test and multivariate logistic regression.
Results
The cohort age ranged from 7 to 91 years old, with a mean age of 49.8 years (standard deviation, 14.3 years). The cohort included 1937 patients without and 970 patients with chronic tinnitus. The percentage of patients who experienced sleep terror was significantly higher among those with tinnitus than those without (p < 0.001). The percentage of patients reporting sleep walking was slightly higher in subjects with tinnitus than in those without, with borderline significance (p = 0.063). The percentage of patients experiencing sleep talking did not differ significantly between the groups. Multivariate logistic regression also showed that sleep terror but not sleep walking was significantly associated with tinnitus after adjusting for age, sex, hearing loss, and insomnia. After adjusting for other factors, subgroup analysis by age showed that sleep terror was significantly positively associated with chronic tinnitus in patients aged 20–44 years but not in those aged 7–19 or >45 years.
Conclusion
Sleep terror is positively associated with chronic tinnitus, especially in young adults.
... For nightmares, psychological treatments are effective and these focus on exposure -writing down dreams -or guided imagery, pleasant images, and 'changing the 'ending' (Burgess et al., 1998;Hansen et al., 2013;Krakow et al., 2001). There is good evidence of beneficial effects of the alpha-1 adrenergic blocker prazosin in reducing nightmares related to PTSD in both military and civilian settings and in the paediatric population (Keeshin et al., 2017;Nadorff et al., 2014). Nightmares have been reported to be triggered or worsened by many drug treatments including cholinesterase inhibitors, beta-blockers, SRIs (especially paroxetine) levodopa, and following withdrawal from drugs for depression. ...
This British Association for Psychopharmacology guideline replaces the original version published in 2010, and contains updated information and recommendations. A consensus meeting was held in London in October 2017 attended by recognised experts and advocates in the field. They were asked to provide a review of the literature and identification of the standard of evidence in their area, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. Each presentation was followed by discussion, aiming to reach consensus where the evidence and/or clinical experience was considered adequate, or otherwise to flag the area as a direction for future research. A draft of the proceedings was circulated to all speakers for comments, which were incorporated into the final statement.
... This finding may be particularly important because nightmares are more common than usually thought, 21 underreported, undetected, and untreated 55 and because nightmares are modifiable by psychological and pharmacologic treatments. 56 Further research needs to examine the mediators and moderators and biological mechanisms of the nightmare-self-harm link and the effects of intervention programs that target coping with distress associated with frequent nightmares in adolescents. ...
Objective:
To determine which sleep variables, including sleep duration, sleep quality, insomnia symptoms, and nightmares, were significantly and independently associated with subsequent adolescent suicidal behavior and non-suicidal self-injury (NSSI).
Methods:
A prospective longitudinal study was conducted in Shandong, China. Participants were 7,072 adolescents initially assessed in November and December in 2015 and reassessed 1 year later in 2016. Self-administered structured questionnaires were used to assess suicidal behavior, NSSI, night sleep duration, insomnia symptoms, sleep quality, nightmares, impulsivity, depression, and family demographics. Logistic regression analyses were performed to examine the associations between sleep variables and suicidal behavior and NSSI.
Results:
At 1-year follow-up, 190 participants (2.7%) attempted suicide and 621 (8.8%) engaged in NSSI. Insomnia symptoms and frequent nightmares (several times a month) at baseline were significantly associated with subsequent suicide attempt and NSSI 1 year later. After adjustment for covariates including adolescent and family demographics, depression, impulsiveness, and prior suicide attempt/NSSI, frequent nightmares in the past year remained significant for suicide attempt (OR = 1.96; 95% CI, 1.15-3.33) and NSSI (OR = 1.52; 95% CI, 1.10-2.08). With further adjustment for insomnia symptoms, sleep quality, and sleep duration, the associations between frequent nightmares and subsequent suicide attempt and NSSI had almost no change. Insomnia, short sleep duration, and poor sleep quality were not independently associated with subsequent suicide attempt and NSSI.
Conclusions:
Frequent nightmares were independently associated with subsequent suicide attempt and NSSI among adolescents. Assessing and intervening for nightmares may have important implications for early identification of adolescents at risk and prevention of adolescent self-harm and suicide.
... In addition to increasing assessment of nightmares, viewing nightmares as a suicide risk factor suggests that providing treatment for nightmares is pertinent. Although both pharmacological and psychological interventions exist for the treatment of nightmares, Imagery Rehearsal Therapy has emerged as a well-established nightmare treatment [35][36][37] (for a review of nightmare treatment, see Nadorff et al. 38 ). ...
Study objectives:
Although nightmares have been associated with suicidal behavior beyond well-known risk factors, the association between nightmares and multiple suicide attempts remains largely unexplored. This study addressed this gap in the literature by examining whether nightmares differentiated between individuals who reported single versus multiple suicide attempts. The individual contributions of nightmare frequency, distress/severity, and chronicity were also investigated to determine which variable contributed the most variance.
Methods:
Participants (n = 225) were recruited as part of a larger data collection through Amazon Mechanical Turk, an online crowdsourcing venue. Participants reported attempting suicide once (n = 107 individuals), multiple times (n = 118), or never (n = 791). Nightmare frequency, distress, and chronicity were assessed with the Disturbing Dreams and Nightmares Severity Index.
Results:
Nightmare frequency differentiated multiple from single suicide attempters, even after controlling for symptoms of depression, posttraumatic stress disorder, insomnia, nightmare severity/distress, nightmare chronicity, and age (P = .019). Comparison participants, those not reporting suicide attempts, reported a significantly lower level of nightmare frequency than those reporting single or multiple suicide attempts.
Conclusions:
Inconsistent with past research, this study showed that nightmare frequency, and not nightmare chronicity or severity/distress, differentiated between single and multiple suicide attempters. This outcome suggests that the number of nightmares experienced may be more pertinent in predicting repeat suicide attempts than their duration or perceived severity. Study limitations include a cross-sectional design, a convenience sampling approach, a lack of control for previous treatment or length of time since last attempt, and a retrospective nightmare measure.
... It had been hoped that insight training that works for nightmares could work in the same way for the insight defect associated with schizophrenia [73], but this has not proven to be effective as of yet [74]. Psychological treatments for nightmares appear to work through the provision of an increased sense of mastery, a reduction of fear, a restoration of sleep, and a dismantling of counterproductive beliefs [75][76][77][78][79][80][81]. In principle, these mechanisms should also be able to exert positive effects on the symptoms of schizophrenia but in a small study by Sheaves, et al. [62] a reduction of nightmare following IRT did not diminish psychotic symptoms although participants did describe a positive change in their emotions. ...
Sleep problems are recognized as widespread in patients with psychosis. Other facts are known as well - that not only can psychiatric illness result in sleep problems, but that these same problems can exacerbate psychopathology and that they constitute risk factors for suicide. Sleep difficulties
are known to respond well to appropriate treatment and yet, with the exception of insomnia, sleep quality is not routinely inquired about during psychiatric assessments. This narrative review focuses on nightmares in the context of schizophrenia and the results suggest that they are both common and distressing. They are also potentially dangerous. The alleviation of nightmares can improve the quality of life for persons suffering from schizophrenia and can lower the risk of suicide
... When treating nightmares, scholars [8] used the imagery rehearsal therapy (IRT) and prazosin, and found that the IRT combined with cognitive-behavioral therapy for insomnia showed more improvement in sleep quality compared to prazosin, or IRT alone. These results also encourage the application of the imagery rehearsal therapy or prazosin as a first-line intervention for post-traumatic stress disorder, or as an adjunctive therapy to reduce suicide risk in patients at risk of suicide with nightmares [9]. It is reasonable that we expect more reliable results using more solid description of nightmare experience in these patients. ...
... Both of these treatments have demonstrated efficacy in treating nightmares. 185 ...
Sleep disturbances are associated with suicide-related thoughts and behaviors, and the incidence of sleep concerns and suicide has increased recently in the US. Most published research exploring the sleep–suicidality relation is focused on select sleep disorders, with few reviews offering a comprehensive overview of the sleep–suicidality literature. This narrative review broadly investigates the growing research literature on sleep disorders and suicidality, noting the prevalence of suicide ideation and nonfatal and fatal suicide attempts, the impact of several sleep disorders on suicide risk, and potential sleep-disorder management strategies for mitigating suicide risk. Aside from insomnia symptoms and nightmares, there exist opportunities to learn more about suicide risk across many sleep conditions, including whether sleep disorders are associated with suicide risk independently of other psychiatric conditions or symptoms. Generally, there is a lack of randomized controlled trials examining the modification of suicide risk via evidence-based sleep interventions for individuals with sleep disorders.
... Cognitive restructuring is thought to occur in two ways: the nightmare itself is conceptualized as an erroneous cognition or it is the erroneous cognitions about nightmares that must be modified. In the first instance, nightmares have been defined as a modifiable habit or a script that can be replaced [12,60]. However, it is difficult to conclude that nightmare scripts are "replaced" as patients often do not dream the new script developed in IRT [72] and as this conception cannot account for the efficacy of exposure treatments. ...
Studies of psychotherapeutic treatments for nightmares have yielded support for their effectiveness. However, no consensus exists to explain how they work. This study combines a systematic review with a qualitative thematic analysis to identify and categorize the existing proposed mechanisms of action (MAs) of nightmare treatments. The systematic review allowed for a great number of scholarly publications on supported psychological treatments for nightmares to be identified. Characteristics of the study and citations regarding potential MAs were extracted using a standardized coding grid. Then, thematic analysis allowed citations to be grouped under six different categories of possible MAs according to their similarities and differences. Results reveal that an increased sense of mastery was the most often cited hypothesis to explain the efficacy of nightmare psychotherapies. Other mechanisms included emotional processing leading to modification of the fear structure, modification of beliefs, restoration of sleep functions, decreased arousal, and prevention of avoidance. An illustration of the different variables involved in the treatment of nightmares is proposed. Different avenues for operationalization of these MAs are put forth to enable future research on nightmare treatments to measure and link them to efficacy measures, and test the implications of the illustration.
... When treating nightmares, scholars [8] used the imagery rehearsal therapy (IRT) and prazosin, and found that the IRT combined with cognitive-behavioral therapy for insomnia showed more improvement in sleep quality compared to prazosin, or IRT alone. These results also encourage the application of the imagery rehearsal therapy or prazosin as a first-line intervention for post-traumatic stress disorder, or as an adjunctive therapy to reduce suicide risk in patients at risk of suicide with nightmares [9]. It is reasonable that we expect more reliable results using more solid description of nightmare experience in these patients. ...
... When nightmares are present, IRT may augment existing pharmacotherapy and psychotherapy for bipolar disorder, including interpersonal and social rhythm therapy (IPSRT), for which psychoeducation about sleep hygiene is a core component (Hlastala et al., 2010). The reader is referred to Nadorff et al. (2014) for a comprehensive review of pharmacological and nonpharmacological treatments for nightmare disorder. Of note, preliminary evidence among the general population suggests that targeting sleep disturbances, such as nightmares, may in turn mitigate suicide risk (Ellis et al., 2017). ...
... A second type of postawakening theory also considers that using dreams in a self-reflection or therapeutic context leads to biologic adaptations, but the mechanisms for such adaptations are not typically specified. One general goal of some such approaches is to alleviate the suffering associated with the nightmares using pharmacologic or behavioral approaches, 127 but another common goal is to use the nightmares as a source for uncovering focal emotional conflicts that can then be addressed therapeutically. In this case, nightmare-focused therapies have been documented for a diversity of emotional conditions, such as bereavement, 128 drug dependencies, 129 and general psychotherapy. ...
Paroxetine is a commonly used drug in psychiatric settings for disorders such as major depressive disorder, obsessive-compulsive disorder, social anxiety disorder, generalized anxiety disorder, panic disorder, premenstrual dysphoric disorder, and posttraumatic stress disorder. However, this drug comes with its own series of adverse effects, including dry mouth, drowsiness, constipation, sexual side effects, etc. In our case study, we wish to highlight a case of depression who developed a rarely documented side effect of serial nightmares after prescribing paroxetine. On cross-tapering it with sertraline, her nightmares gradually resolved with no deterioration of depressive symptoms. By reporting this case, we wish to emphasize on this potential side effects of paroxetine which should be kept in mind while choosing this agent. Such reporting is important as this rare side effect could be confused with other clinical pictures, thereby affecting management. It also helps us enhance our knowledge of how selective serotonin reuptake inhibitors can lead to the development of nightmares.
Nightmares are common among the general population and psychiatric patients and have been associated with signs of nocturnal arousal such as increased heart rate or increased high-frequency electroencephalographic (EEG) activity. However, it is still unclear, whether these characteristics are more of a trait occurring in people with frequent nightmares or rather indicators of the nightmare state. We compared participants with frequent nightmares (NM group; n = 30) and healthy controls (controls; n = 27) who spent 4 nights in the sleep laboratory over the course of 8 weeks. The NM group received six sessions of imagery rehearsal therapy (IRT), the 'gold standard' of cognitive-behavioural therapy for nightmares, between the second and the third night. Sleep architecture and spectral power were compared between groups, and between nights of nightmare occurrence and nights without nightmare occurrence in the NM group. Additionally, changes before and after therapy were recorded. The NM group showed increased beta (16.25-31 Hz) and low gamma (31.25-35 Hz) power during the entire night compared to the controls, but not when comparing nights of nightmare occurrence to those without. Moreover, low gamma activity in rapid eye movement sleep was reduced after therapy in the NM group. Our findings indicate, cortical hyperarousal is more of a trait in people with frequent nightmares within a network of other symptoms, but also malleable by therapy. This is not only a new finding for IRT but could also lead to improved treatment options in the future that directly target high-frequency EEG activity.
Objective:
This article reviews rapid eye movement (REM) sleep behavior disorder (RBD) and other REM sleep parasomnias, particularly recurrent isolated sleep paralysis and nightmare disorder.
Latest developments:
People with RBD have dream enactment behaviors that can be distressing and cause injuries to themselves or a bed partner. Diagnosis of RBD still requires video polysomnography but new evaluative techniques are emerging. Automatic scoring of REM sleep without atonia, the polysomnographic RBD feature, has led to clearer diagnostic cutoff values. Isolated RBD is strongly linked with neurodegenerative disorders, particularly α-synucleinopathies, with a median latency to neurodegenerative disease diagnosis of 8 years. Mounting imaging, electrophysiologic, and pathologic evidence supports neurodegenerative changes in patients with isolated RBD. Safety precautions should be reviewed with patients to reduce the risk of injury. Clonazepam and melatonin are first-line agents for RBD symptoms, and rivastigmine appears to be beneficial for RBD in people with mild cognitive impairment. For nightmare disorder, image rehearsal therapy is effective and can be delivered through online platforms.
Essential points:
While RBD symptoms can often be managed, patients with isolated RBD should be monitored for signs and symptoms of impending neurodegenerative disease. Individuals who wish to know about the associated risk should be counseled accordingly to allow planning and involvement in research if they choose. Exercise may have some neuroprotective effects, although no treatment has been shown to modify the neurodegenerative risk.
Background
As nightmares may be a risk factor for, or symptom of, multiple psychological disorders, some researchers suggest that nightmares should be screened, diagnosed, and treated. Treatments for nightmares include trauma-focused Cognitive Behavioural Therapy and Image Rehearsal Therapy, and pharmacological interventions such as prazosin and nitrazepam. As recent research has put into question our current understanding of treatment efficacy, there is a need to systematically review findings related to the effectiveness of nightmare treatments to inform best practice. The current review assessed the efficacy of psychosocial treatments of nightmare in all cohorts.
Methods
A systematic search of four databases for peer reviewed journal articles from 2000 onwards produced 69 (35 RCTs, 34 non-RCTs) eligible articles that underwent narrative synthesis.
Results
The results provide strong evidence for exposure and image rehearsal treatments for the reduction of nightmare frequency, severity, and distress, in civilian, military, idiopathic, and posttraumatic stress disorder (PTSD) cohorts. There is emerging evidence that self-guided and brief treatment modalities offer efficient and effective treatment options. There is an urgent need for clinical trials of treatment effectiveness in children.
Conclusions
The results suggest that treatments for nightmares are most effective when they facilitate a sense of control or mastery by directly targeting the nightmare content and/or the client’s emotional responses to the nightmare content.
Trial registration
A review protocol was registered with PROSPERO (CRD42020204861).
“Rapid Eye Movement (REM) parasomnias” is a catch-all term referring to all sleep-related conditions thought to occur during REM sleep. The distinction between REM parasomnias and Non-Rapid Eye Movement (NREM) parasomnias may feel arbitrary, but it is clinically useful in that the two categories of disease generally confer different prognoses. Specifically, while NREM parasomnias are generally considered self-limited and relatively common, REM parasomnias are much less common and can have a foreboding association with neurodegenerative disease (Gagnon et al. Lancet Neurol 5:424–32, 2006; Postuma et al. Neurology 72:1296–300, 2009; Boeve Ann N Y Acad Sci 1184:15–54, 2010; Galbiati et al. Sleep Med Rev 43:37–46, 2019; Iranzo et al. Sleep Med Rev 13:385–401, 2009; Iranzo et al. Lancet Neurol 12:443–53, 2013; Heller et al. Sleep Med Rev 34:23–33, 2017). This general rule of thumb has exceptions, as discussed below.
Parasomnias are defined as “undesirable physical events or experiences that occur during entry into sleep, within sleep, or during arousal from sleep.” They occur during the night, without altering the normal structure of sleep, the evolution is usually benign, with spontaneous resolution at puberty. The prevalence is variable depending on the type of parasomnia and the age of occurrence. They are classified as NREM and REM parasomnias and other parasomnias. NREM-related parasomnias are defined as recurrent episodes of incomplete awakening from NREM sleep, characterized by abnormal sleep-related complex movements and behaviors associated with various degrees of autonomic nervous system activation, inappropriate or scarce responsiveness to the external environment that are difficult to differentiate from other episodes occurring during sleep like seizures. REM-related parasomnias are an admixture of the elements of REM sleep together with wakefulness. They comprise REM behavior disorder, nightmare disorders, and sleep paralysis. REM-related parasomnias are more likely to occur later in the night. Other parasomnias include sleep enuresis that is common in childhood and associated with daytime dysfunction and psychological consequences. The management of parasomnias is different for each single disorder, but NREM parasomnias have similar pathophysiology and similar treatment, either pharmacological or non-pharmacological.
Evidence suggests that nightmares increase the risk of suicide and self-harm, independently of insomnia, PTSD, anxiety and depression. A better understanding of this relationship is vital for the development of effective suicide and self-harm interventions. A systematic review of the research investigating the mechanisms underlying the nightmare and suicide/self-harm relationship was therefore conducted. Findings from twelve studies were critically appraised and synthesised under the headings of affect/emotion regulation, cognitive appraisals, psychosocial factors, acquired capability and depression. Despite clear variability in the methodology employed by the studies, the initial evidence suggests cognitive appraisals and affect/emotion regulation play a key role in the nightmare and suicide/self-harm relationship. Consideration is given for the first time to the differences in the mechanisms underlying the relationship between nightmares and suicide. In order to further elucidate and support these findings however, future research utilising longitudinal designs, objective measures of sleep disturbance and investigating the emotional content of nightmares is vital. There is also a call for studies investigating the impact of nightmare interventions on subsequent suicidal thoughts and behaviours, and self-harm. This is especially so given that individuals might find it easier to seek help for nightmares than for suicidality or self-harm.
Abstract: nightmares are scare or disturbing dreams which are associated with negative feelings, such as fear, terror or disgust. These feelings awake a dreamer, who can easily recollect the content of the nightmare. Nightmares with little emotional response are experienced by almost all people once in a while with-out the risk for their health. However, nightmares that occur frequently and prevent the individual from restful sleep might lead to clinically significant impairment in social, occupational and other areas of life. They are considered a sleep disorder (parasomnia) and require a proper treatment. Current review dis-cusses the theoretical models of nightmares, their causes, diagnosis and treatment strategies
Suicide in the United States has reached a 30-year high across all age groups, not only in completed action, but in ideation, according to the National Center for Health Statistics. Suicide is a persistent, yet preventable, cause of death that affects men and women of all races and socioeconomic statuses throughout the lifespan. Researchers have estimated that 9.2% of the US population will have contemplated suicide at least once in their lifetime, and it is estimated that 60% of individuals who have contemplated suicide will follow through within the first year of the onset of ideation. Therefore, identifying and managing patients who are at risk for suicidal behaviors represents an important consideration for all health practitioners who have fragile patients, particularly those with chronic, severe, or intractable pain. Although there are many risk factors for suicide, chronic pain and related factors such as sleep disturbance and depression may strongly contribute to suicidal ideation.
Full article found here: https://www.practicalpainmanagement.com/treatments/interventional/pain-sleep-suicide-core-role-interventional-care
Objective
At-risk high school students, those considered to have a higher probability for academic failure or dropping out, were assessed for various sleep disorders. Effects were compared between students with and without the nightmare triad syndrome (NTS+), the sleep disorders’ cluster of frequent nightmares, insomnia disorder and suspected sleep-disordered breathing (SDB).
Methods
Data were gathered at a charter school for at-risk youth using: computer based surveys, physical airway exams, and mental health interviews by school social worker. Ninety-two students were enrolled, and 70 completed all study components.
Results
Students were teenaged [17.10 (1.50) years], male (52.2%) slightly overweight [BMI 25.50 (6.41)] Hispanics (87.0%); two-thirds (65 of 92) subjectively reported a sleep problem. Frequent nightmares (39.1%), insomnia (ISI ≥ 12, 41.3%), and SDB risk (79.3%) were common. Several presumptive sleep disorders (insomnia, SDB risk, parasomnia, or nightmares) were associated with worse sleep quality and lower quality of life. Nineteen students met criteria for NTS. Compared to NTS−, NTS+ showed significantly lower quality of life (p < 0.003, g = 0.84). Regression analyses revealed higher levels of depression and anxiety symptoms in NTS+ students. NTS was associated with reduced quality of life independent of anxiety symptoms.
Conclusion
Prevalence of presumptive sleep disorders was high with a tendency for clusters of sleep disorders in the same individual. Students with NTS+ showed worse outcomes and reduced quality of life, mediated partially by depression and anxiety. To examine relationships between sleep disorders and mental health in at-risk adolescents, research investigations must include both subjective and objective measurements of sleep.
Trauma-related nightmares distinguish posttraumatic stress disorder from related mood and anxiety disorders and promise a privileged view into its pathophysiology. This promise has been unkept, in part, because nightmares are rarely observed in the sleep laboratory and represent, at best, a free-recall exercise in which the original stimulus is unknown to the experimenter. We discuss below our efforts to learn more about trauma-related nightmares using laboratory and ambulatory polysomnography. These and other results are next integrated into a broader perspective on the possible interaction of sleep and fear systems. Finally, we consider the important findings of Cano, Mochizuki, and Saper and their implications for future work in this area.
PTSD is characterized by the persistence of intense reactions to reminders of a traumatic event, altered mood, a sense of imminent threat, disturbed sleep, and hypervigilance. Cognitive behavioral therapy and anxiolytic or antidepressant agents can ameliorate symptoms.
Objectives: This study sought to assess the utility of Imagery Rehearsal Therapy (IRT) for nightmares in an
inpatient psychiatric setting. Although IRT enjoys a substantial evidence base for efficacy in various
populations, datawith psychiatric inpatients are lacking. Participants: Participantswere 20 adult psychiatric
inpatients (11 male, 9 female; mean age=43.4), in an extended stay psychiatric inpatient facility. All
participants were diagnosed with multiple, treatment resistant, comorbid conditions, including mood
disorders, anxiety disorders, personality disorders, and substance-related disorders. Patients with active
psychosis or significant cognitive impairment were excluded. Methods: This was an open trial utilizing a
case series design. In addition to routine hospital treatment that included psychotherapeutic and pharmacological
interventions, participants received IRTover a span of 3 weeks in 4 small group sessions. Included
were education about sleep and nightmares, instruction in writing new dream narratives and practicing
guided imagery, and support via further consultation and trouble-shooting. Patients were referred by their
psychiatrist or were self-referred, with approval from their treatment teams. Results: Results showed
significant aggregate reductions in nightmare frequency and intensity, as well as improvement in sleep
overall. Patients also improved on a variety of other symptom measures, including suicidal ideation. No
adverse reactions were observed. The present report includes a sampling of individual case vignettes to
illustrate variability in treatment response. Conclusions: This study provides preliminary evidence that IRT
can be used safely and effectively in a hospital environment to benefit patients suffering from serious mental
illnesses, often in the midst of significant life crises. It is not possible in this preliminary study to conclude
that IRT specifically (as opposed to other aspects of hospital treatment) produced these outcomes. Larger,
controlled trials are needed to establish a causal connection between IRT and nightmare reduction.
Background and purpose:
Nightmares associated with posttraumatic stress disorder (PTSD) are a hallmark symptom among U.S. military veterans who have seen combat. Management of combat-related nightmares can be difficult and current pharmacologic options are limited and tend to have adverse side effects. The aim of this review is to explore recent literature regarding the efficacy of prazosin for the treatment of nightmare disorder in the veteran population.
Methods:
Recent literature consisting of three systematic reviews was reviewed, as well as current clinical guidelines published by The Department of Veterans Affairs (VA) and The Department of Defense (DoD) and the American Academy of Sleep Medicine (AASM).
Conclusions:
Prazosin has been shown to be effective in the treatment of PTSD trauma-related nightmares. As a result of its low side effect profile and abilities to improve both sleep and reduce trauma nightmares, prazosin has been recommended as an adjunct therapy.
Implications for practice:
Prazosin should be initiated as an adjunctive treatment to promote sleep in those suffering from PTSD nightmares. It should be initiated at 1 mg and then titrated upward until absence or desired reduction of nightmares is achieved, with a maximum dosage recommendation of 20 mg at bedtime and 5 mg midmorning.
Fifty-one healthy elderly subjects (median age = 65) gave retrospective estimates of nightmare frequency in questionnaires and recorded the occurrence of nightmares in daily logs over a 2-week period. (a) Mean annual nightmare frequency as estimated from logs was only 65% as high among college student controls. (b) Elderly subjects were about 1/5 as likely as college students to report a problem with nightmares. (c) Frequency estimates on the basis of logs were over 10 times higher than retrospective estimates.
Previous research has demonstrated an association between suicidality and sleep, suggesting that sleep disturbances may exacerbate mood dysregulation in participants suffering from mood disorders. The purpose of this study was to investigate the impact of sleep disturbances and insomnia on depression and suicidality in a nontreatment seeking sample of college students. Results indicated that insomnia and nightmares were significant predictors of symptoms of depression, while only nightmares significantly predicted suicidal ideation. Further analysis indicated that participants with elevated scores on insomnia, nightmares, or both experienced differing levels of depression and suicidal ideation. Future directions and treatment implications are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Retrospective estimates of nightmare frequency for a sample of 23,990 respondents to an Internet questionnaire (female: N = 19,367, mean age = 24.9 ± 10.14 years; male: N = 4,623; mean age = 25.5 ± 10.81) were evaluated as a function of age, gender, and pre- versus post-September 11, 2001. Female respondents reported more frequent monthly nightmares (4.44 ± 6.71) than did male respondents (3.39 ± 6.07), and this result was seen for all age strata younger than 60. Also, for female respondents, nightmare frequency increased from ages 10-19 to 20-39 then decreased monotonically to ages 50-59. For male respondents, nightmare frequency was stable from ages 10-19 to 30-39 then decreased to ages 50-59. An increase in nightmare frequency was observed post-September 11 only for male respondents-particularly for 10- to 29-year-olds. This increase was sustained 2 years later. These effects were maintained when dream recall was held constant. Results replicate, in a single sample, previously published gender and age effects and provide new evidence that the nightmares of males may be differentially sensitive to traumatic events for which victims and/or perpetrators are primarily male. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Dreams following trauma have been suggested to aid emotional adaptation, yet trauma-related nightmares are a diagnostic symptom of Posttraumatic Stress Disorder (PTSD). There is little published data relating dreams to PTSD soon after trauma. We assessed dreams and PTSD in 60 injured patients after life-threatening events and obtained follow-up assessments in 39 of these participants 6 weeks later. Ten of 21 dream reports from morning diaries were rated and described as similar to the recent traumatic event. The participants reporting these distressing “trauma dreams” had more severe concurrent PTSD symptoms than those reporting other categories of dreams and had more severe initial and follow-up PTSD than those without dream recall. These findings along with our preliminary longitudinal observations relating changes in dream patterns to outcome, suggest a relationship of dream characteristics and early adaptive versus maladaptive patterns of processing traumatic memory.
Using dream diary procedures and statistically controlling for age and gender, the present study investigated the relationship between Hartmann''s (1991) boundary concept and various aspects of dreaming. Results with a sample of young adults confirmed earlier findings that persons with thin boundaries recall dreams (including nightmares) more often, report dreams that are more negative and emotionally intense, regard their dreams more favorably (i.e., as more meaningful and creative), and dream more frequently of verbal interaction with others.
Evidence supports the use of cognitive behavioral therapies for nightmares in trauma-exposed individuals. This randomized clinical trial replicated a study of exposure, relaxation, and rescripting therapy(ERRT) and extended prior research by including broad measures of mental health difficulties, self-reported physical health problems, and quality of life. Additionally, physiological correlates of treatment-related change assessed from a script-driven imagery paradigm were examined.
Forty-seven individuals were randomized to treatment or waitlist control.
The treatment group demonstrated improvements relative to the control group at the one-week post-treatment assessment. At the 6-month follow-up assessment, significant improvements were found for frequency and severity of nightmares, posttraumatic stress disorder symptoms, depression, sleep quality and quantity, physical health symptoms, anger, dissociation, and tension reduction behaviors. Participants also reported improved quality of life. Treatment-related decreases in heart rate to nightmare imagery were correlated with improvements in sleep quality and quantity; treatment-related decreases in skin conductance to nightmare imagery were correlated with improvements in nightmare severity, posttraumatic stress disorder symptom severity, sleep quality, and fear of sleep; and treatment-related decreases in corrugator activity to nightmare imagery were correlated with improved physical health.
Findings provide additional support for the use of ERRT in treating nightmares and related difficulties and improving sleep.
Abstract This study aimed to evaluate all known and hypothesized predictors for nightmare frequency measures in a population with frequent nightmares. A total of 666 Internet-recruited participants completed questionnaires on nightmares, sleep, and psychopathology, 146 of whom further completed a subsequent 7-day diary. In contrast to previous research, comparison of questionnaire- and diary-measured nightmare frequency revealed a significantly higher log-transformed nightmare frequency on the questionnaire: t(127) = 4.43; P t(127) = 0.61; P= 0.54. Regression analyses showed that subjective sleep quality was the only variable significantly associated with nightmare frequency variables in the whole sample (R2adj between 10.5–11.5%; P Keywords: behavior and cognition; nightmares; parasomnias Document Type: Research Article DOI: http://dx.doi.org/10.1111/j.1479-8425.2010.00447.x Publication date: July 1, 2010 (document).ready(function() { var shortdescription = (".originaldescription").text().replace(/\\&/g, '&').replace(/\\, '<').replace(/\\>/g, '>').replace(/\\t/g, ' ').replace(/\\n/g, ''); if (shortdescription.length > 350){ shortdescription = "" + shortdescription.substring(0,250) + "... more"; } (".shortdescription a").click(function() { (".originaldescription").slideDown(); return false; }); }); Related content In this: publication By this: publisher In this Subject: Anatomy & Physiology By this author: LANCEE, Jaap ; SPOORMAKER, Victor I ; VAN DEN BOUT, Jan GA_googleFillSlot("Horizontal_banner_bottom");
Nightmares are a common disorder with serious consequences. Recently, the cognitive behavioral interventions Imagery Rehearsal Therapy (IRT) and exposure proved effective in a self-help format. The aim of the current study was to compare the following self-help formats to a waiting-list: IRT; IRT with sleep hygiene; and IRT with sleep hygiene and a lucid dreaming section. Two-hundred-seventy-eight participants were included and randomized into a condition. Follow-up measurements were 4, 16, and 42 weeks after baseline. Seventy-three participants filled out all questionnaires and 49 returned the nightmare diaries. Contrary to our expectations, the original IRT was more effective than the two other intervention conditions. Moreover, IRT was the only intervention that convincingly proved itself compared to the waiting-list condition. However, these data should be interpreted with caution due to the low power and high dropout. Yet it seems that in a self-help format, IRT and exposure (which was validated previously) are the treatments of choice for treating nightmares.
One hundred twenty-four male Vietnam War veterans with chronic, severe posttraumatic stress disorder (PTSD) were randomly assigned to imagery rehearsal (n = 61) or a credible active comparison condition (n = 63) for the treatment of combat-related nightmares. There was pre-post change in overall sleep quality and PTSD symptoms for both groups, but not in nightmare frequency. Intent-to-treat analyses showed that veterans who received imagery rehearsal had not improved significantly more than veterans in the comparison condition for the primary outcomes (nightmare frequency and sleep quality), or for a number of secondary outcomes, including PTSD. Six sessions of imagery rehearsal delivered in group format did not produce substantive improvement in Vietnam War veterans with chronic, severe PTSD. Possible explanations for findings are discussed.
Several cognitive-behavioral techniques are effective in reducing nightmare frequency, but the therapeutic factor (e.g. cognitive restructuring, systematic desensitization) remains unclear. The aim of this study was to compare the nightmare treatments imagery rehearsal therapy (IRT), exposure, and recording (keeping a diary)--in a self-help format--with a waiting list.
Participants were recruited through a Dutch nightmare website. After completion of the baseline questionnaires, 399 participants were randomly assigned to a condition, received a 6-week self-help treatment (or were placed on the waiting list), and filled out the post-treatment measurements 11 weeks after baseline.
Compared to the waiting list, IRT and exposure were effective in ameliorating nightmare frequency and distress, subjective sleep quality, anxiety (after imagery rehearsal), and depression (after exposure; Δd = 0.25-0.56). Compared to recording, IRT reduced nightmare frequency while exposure reduced nightmare distress (Δd = 0.20-0.30; p < 0.05). The recording condition was more effective compared to the waiting list in ameliorating nightmare frequency, nightmare distress, and subjective sleep quality (Δd = 0.19-0.28; p < 0.05). IRT had a more rapid reduction on the diary compared to exposure and recording.
IRT and exposure appear equally effective in ameliorating nightmare complaints. Exposure to nightmare imagery may function as the crucial therapeutic factor; however, cognitive restructuring may be a useful addition to increase immediate effects.
Prazosin is recommended for treatment of Posttraumatic Stress Disorder (PTSD)-associated nightmares. Level A. Image Rehearsal Therapy (IRT) is recommended for treatment of nightmare disorder. Level A. Systematic Desensitization and Progressive Deep Muscle Relaxation training are suggested for treatment of idiopathic nightmares. Level B. Venlafaxine is not suggested for treatment of PTSD-associated nightmares. Level B. Clonidine may be considered for treatment of PTSD-associated nightmares. Level C. The following medications may be considered for treatment of PTSD-associated nightmares, but the data are low grade and sparse: trazodone, atypical antipsychotic medications, topiramate, low dose cortisol, fluvoxamine, triazolam and nitrazepam, phenelzine, gabapentin, cyproheptadine, and tricyclic antidepressants. Nefazodone is not recommended as first line therapy for nightmare disorder because of the increased risk of hepatotoxicity. Level C. The following behavioral therapies may be considered for treatment of PTSD-associated nightmares based on low-grade evidence: Exposure, Relaxation, and Rescripting Therapy (ERRT); Sleep Dynamic Therapy; Hypnosis; Eye-Movement Desensitization and Reprocessing (EMDR); and the Testimony Method. Level C. The following behavioral therapies may be considered for treatment of nightmare disorder based on low-grade evidence: Lucid Dreaming Therapy and Self-Exposure Therapy. Level C No recommendation is made regarding clonazepam and individual psychotherapy because of sparse data.
Twenty subjects with chronic nightmares for 17.2 years mean duration were randomly divided into two groups: Rehearsal and Recording. At inception, subjects in both groups were instructed to write down their nightmares for one month. The Recording group received no other intervention. Rehearsal subjects received a single treatment group session teaching an imagery rehearsal technique to reduce nightmare frequency. At inception and three months follow-up, both groups were compared for nightmare frequency and for self-rated distress with scales (Symptom Checklist and Symptom Questionnaire) measuring anxiety, depression, hostility, somatization and total distress. Nightmare frequency decreased significantly in both groups: Rehearsal group-7.2 per month to 2.0 per month (72% reduction) (p < 0.006); Recording group-9.4 per month to 5.0 per month (47% reduction) (p < 0.02). There were no statistically significant differences in the nightmare frequency reductions between groups. All anxiety, depression, somatization, hostility and total distress scores decreased substantially in the Rehearsal group. Most changes were significant. Changes in the Recording group were inconsistent and not significant. Two brief case histories are presented.
The effectiveness of systematic desensitization in ameliorating nightmares was evaluated in a controlled study. Twenty-nine subjects were assigned to either systematic desensitization, a nightmare discussion placebo, or continuous self-recording. The placebo treatment did not differ from desensitization in terms of rated logicalness and potential effectiveness. However, the desensitization group showed a significantly greater reduction in the frequency of nightmares as well as a decrease in rated intensity. Moreover the desensitization subjects also had a significantly greater decrease in reported fear and state anxiety. Related research on nightmares is noted and future research needs are discussed.
Background: Central nervous system (CNS) adrenergic hyperresponsiveness may be involved in the pathophysiology of posttraumatic stress disorder (PTSD). Two Vietnam combat veterans with PTSD prescribed the centrally active alpha(1)-adrenergic antagonist prazosin for symptoms of benign prostatic hypertrophy unexpectedly reported elimination of combat trauma nightmares. This observation prompted an open-label feasibility trial of prazosin for combat trauma nightmares in chronic combat-induced PTSD. Method: Four consecutively identified combat veterans with chronic DSM-IV PTSD and severe intractable combat trauma nightmares participated in an 8-week open trial of escalating-dose prazosin. Nightmare severity response was rated using the nightmare item of the Clinician Administered PTSD Scale and the Clinical Global Impressions-Change scale. Results: The 2 patients who achieved a daily prazosin dose of at lease 5 mg were markedly improved, with complete elimination of trauma nightmares and resumption of normal dreaming. The 2 subjects limited to 2 mg of prazosin to avoid excessive blood pressure reduction were moderately improved with at least 50% reduction in nightmare severity. Conclusion: These clinical observations, together with neurobiological evidence for alpha(1)-adrenergic regulation of CNS neurobiological systems relevant to PTSD, provide rationale for placebo-controlled trials of prazosin for PTSD combat trauma nightmares.
Objective: Whereas the effect of stress on nightmare frequency is well-documented in adults, research on this topic in children is scarce. In addition, these studies are often based on data obtained from the parents which may not be valid with regard to nightmare frequency and subjective stress levels. Method: 95 school children (fifth grade; age range: 9 to 11 years) completed a questionnaire about the occurrence of stressors, their subjective stress level and nightmare frequency. Results: The findings indicate that interindividual differences in nightmare frequency were explained by social stressors like quarreling with a sibling, death of a close person and chronic illness of a close person. Conclusions: The next step will be a longitudinal study measuring the occurrence of stressors as well as personality dimensions and the occurrence of nightmares and their content by applying diaries and self-rated scales together with information obtained from the parents.
This study investigated the relationships between a history of childhood maltreatment, the frequency of disturbing dreams, their associated distress, and the presence of psychopathology in 352 female undergraduate volunteers. Participants completed questionnaires assessing dream recall, bad dream and nightmare frequency, nightmare distress, psychological well-being, and history of childhood trauma. Four groups were investigated based on the type and severity of childhood maltreatments experienced. Women reporting more severe forms of maltreatment reported higher frequencies of disturbing dreams, higher levels of nightmare distress, and greater psychopathology. Results showed that nightmare distress explains frequency of disturbed dreaming beyond the effect of psychopathology and childhood trauma. The results highlight the importance of assessing waking distress associated with disturbing dreams independently from their actual incidence.
Nightmares—vivid, emotionally dysphoric dreams—are quite common and are associated with a broad range of psychiatric conditions. However, the origin of such dreams remains largely unexplained, and there have been no attempts to reconcile repetitive traumatic nightmares with nontraumatic nightmares, dysphoric dreams that do not awaken the dreamer, or with more normative dreams. Based on recent research in cognitive neuroscience, sleep physiology, fear conditioning, and emotional-memory regulation, we propose a multilevel neurocognitive model that unites waking and sleeping as a conceptual framework for understanding a wide spectrum of disturbed dreaming. We propose that normal dreaming serves a fear-extinction function and that nightmares reflect failures in emotion regulation. We further suggest that nightmares occur as a result of two processes that we term affect load—a consequence of daily variations in emotional pressures—and affect distress—a disposition to experience events with high levels of negative emotional reactivity.
Objective:
The authors conducted a 15-week randomized controlled trial of the alpha-1 adrenoreceptor antagonist prazosin for combat trauma nightmares, sleep quality, global function, and overall symptoms in active-duty soldiers with posttraumatic stress disorder (PTSD) returned from combat deployments to Iraq and Afghanistan.
Method:
Sixty-seven soldiers were randomly assigned to treatment with prazosin or placebo for 15 weeks. Drug was titrated based on nightmare response over 6 weeks to a possible maximum dose of 5 mg midmorning and 20 mg at bedtime for men and 2 mg midmorning and 10 mg at bedtime for women. Mean achieved bedtime doses were 15.6 mg of prazosin (SD=6.0) and 18.8 mg of placebo (SD=3.3) for men and 7.0 mg of prazosin (SD=3.5) and 10.0 mg of placebo (SD=0.0) for women. Mean achieved midmorning doses were 4.0 mg of prazosin (SD=1.4) and 4.8 mg of placebo (SD=0.8) for men and 1.7 mg of prazosin (SD=0.5) and 2.0 mg of placebo (SD=0.0) mg for women. Primary outcome measures were the nightmare item of the Clinician-Administered PTSD Scale (CAPS), the Pittsburgh Sleep Quality Index, and the change item of the Clinical Global Impressions Scale anchored to functioning. Secondary outcome measures were the 17-item CAPS, the Hamilton Depression Rating Scale, the Patient Health Questionnaire-9, and the Quality of Life Index. Maintenance psychotropic medications and supportive psychotherapy were held constant.
Results:
Prazosin was effective for trauma nightmares, sleep quality, global function, CAPS score, and the CAPS hyperarousal symptom cluster. Prazosin was well tolerated, and blood pressure changes did not differ between groups.
Conclusions:
Prazosin is effective for combat-related PTSD with trauma nightmares in active-duty soldiers, and benefits are clinically meaningful. Substantial residual symptoms suggest that studies combining prazosin with effective psychotherapies might demonstrate further benefit.
This study examines the prevalence of sleeping difficulties and their relationship to depression and anxiety in 1328 subjects aged 57-79 years by means of a questionnaire. Difficulties initiating sleep (DIS), difficulties maintaining sleep (DMS), early morning awakenings (EMA), and nightmares were assessed with The Uppsala Sleep Inventory (USI) and depression and anxiety with The Hospital Anxiety and Depression Scale (HAD scale). A total of 20.4% reported severe sleeping difficulties (DIS, DMS, or EMA), with a female preponderance. On the basis of the HAD scale we found that 3.4% fulfilled the criteria for 'definite depression' and 10.1% fulfilled the criteria for 'possible depression'. The prevalence of 'definite' and 'possible pure anxiety' (anxiety without depression) was 2.7% and 8.1%, respectively. There was no sex difference in reports of depression, but women more often reported pure anxiety. Altogether, 24.3% of the sample had either depression or anxiety. Nightmares were reported by 2.2% of the sample and associated with both depression and anxiety. We found that 39% of respondents with definite depression and 45.2% with definite pure anxiety reported sleeping difficulties. Depression emerged as the variable most consistently associated with sleeping difficulties when depression, pure anxiety, age, and sex were considered simultaneously. Habitual sleeping pill use was reported by 31.1% of the subjects with definite depression, whereas only 24.4% received antidepressive medication. These findings indicate that sleeping difficulties often are associated with psychiatric symptoms, especially depression.
This study investigated the relation between generalized anxiety disorder (GAD) and frequency of bad dreams in older adults. A secondary analysis from a randomized clinical trial comparing cognitive behavioral therapy (CBT) for anxiety to enhanced usual care (EUC) assessed bad dream frequency at baseline, post treatment (3 months), and at 6, 9, 12, and 15 months. Of 227 participants (mean age = 67.4), 134 met GAD diagnostic criteria (CBT = 70, EUC = 64), with the remaining 93 serving as a comparison group. Patients with GAD had significantly more bad dreams than those without, and bad dream frequency was significantly associated with depression, anxiety, worry, and poor quality of life. CBT for anxiety significantly reduced bad dream frequency at post treatment and throughout follow up compared to EUC.
Duration of insomnia symptoms or nightmares was investigated to see if it was related to suicide risk independent of current insomnia symptoms, nightmares, anxiety symptoms, depressive symptoms, and posttraumatic symptoms. The cross-sectional study involved analyses of survey responses from undergraduate students who endorsed either insomnia symptoms (n = 660) or nightmares (n = 312). Both insomnia symptom and nightmare duration were significantly associated with suicide risk independent of current insomnia symptoms or nightmares, respectively. Relations were also significant after controlling for anxiety symptoms, depressive symptoms, and posttraumatic symptoms. Results suggest that duration of sleep disturbance is relevant when assessing suicide risk.
This study presents a meta-analysis of the effectiveness of psychological treatments for chronic nightmares using imaginal confrontation with nightmare contents (ICNC) or imagery rescripting and rehearsal (IRR). Pre-post effect sizes (Hedges' g) were calculated for the outcome measures of nightmare frequency, nights per week with nightmares, sleep quality, depression, anxiety, and PTSD severity. Fixed-effects and random-effects models were applied. High effect sizes were found for nightmare frequency (g=1.04), nights per week with nightmares (g=0.99), and PTSD severity (g=0.92). Most of the effect sizes for the secondary outcomes were moderate. One objective was to clarify whether ICNC or IRR is more important for nightmare reduction. The results indicate that a higher duration of time for ICNC is associated with greater improvements: The minutes of applied ICNC moderate the effect sizes for nightmare frequency at follow-up 2 and for nights per week with nightmares at post and follow-up 1. The percentage of applied ICNC moderates the effect sizes for nightmare frequency and nights per week with nightmares at follow-up 1. Thus, dismantling studies are necessary to draw conclusions regarding whether ICNC or IRR is the most effective in the psychological treatment of chronic nightmares.
The authors reviewed clinic records of 20 WWII veterans referred for evaluation of posttraumatic stress disorder (PTSD). Twelve patients qualified for a diagnosis of PTSD, and eight reported several symptoms of PTSD. The most frequent symptoms were insomnia (80%), nightmares (75%), and irritability (65%). Fourteen veterans had an exacerbation of symptoms occurring with life stresses, including retirement, deteriorating health, or death of a loved one. The authors conclude that elderly WWII combat veterans should be monitored for changes in PTSD symptoms when significant stressful life events occur.
Copyright (C) 1994 American Association for Geriatric Psychiatry
This study examines the prevalence of sleeping difficulties and their relationship to depression and anxiety in 1328 subjects aged 57?79 years by means of a questionnaire. Difficulties initiating sleep (DIS), difficulties maintaining sleep (DMS), early morning awakenings (EMA), and nightmares were assessed with The Uppsala Sleep Inventory (USI) and depression and anxiety with The Hospital Anxiety and Depression Scale (HAD scale). A total of 20.4% reported severe sleeping difficulties (DIS, DMS, or EMA), with a female preponderance. On the basis of the HAD scale we found that 3.4% fulfilled the criteria for ''definite depression'' and 10.1% fulfilled the criteria for ''possible depression''. The prevalence of ''definite'' and ''possible pure anxiety'' (anxiety without depression) was 2.7% and 8.1%, respectively. There was no sex difference in reports of depression, but women more often reported pure anxiety. Altogether, 24.3% of the sample had either depression or anxiety. Nightmares were reported by 2.2% of the sample and associated with both depression and anxiety. We found that 39% of respondents with definite depression and 45.2% with definite pure anxiety reported sleeping difficulties. Depression emerged as the variable most consistently associated with sleeping difficulties when depression, pure anxiety, age, and sex were considered simultaneously. Habitual sleeping pill use was reported by 31.1% of the subjects with definite depression, whereas only 24.4% received antidepressive medication. These findings indicate that sleeping difficulties often are associated with psychiatric symptoms, especially depression.
Objectives:
Prior research has found that insomnia symptoms and nightmares are associated with suicidal ideation, suicide attempts, and death by suicide. However, to the best of our knowledge, no research has examined the relation between insomnia symptoms, nightmares, and suicidal ideation in older adults. The current project aimed to fill this void by investigating the relation between insomnia symptoms, nightmares, and suicidal ideation in an older adult sample.
Method:
The study utilized a cross-sectional design. The sample consisted of 81 older adult patients (age ≥ 65 years) recruited from a family medicine clinic. The participants were asked to complete surveys about their sleep, symptoms of depression, and suicidal ideation.
Results:
Insomnia symptoms, but not nightmares, were significantly related to suicidal ideation. In addition, insomnia symptoms were related to suicidal ideation independent of nightmares. Furthermore, the relation between insomnia symptoms and suicidal ideation was mediated by depressive symptoms.
Discussion:
These findings have implications for the identification and treatment of suicidal ideation in older adults.
Nightmares, frequently associated with posttraumatic stress disorder and clinically relevant in today's world of violence, are difficult to treat, with few pharmacologic options. We performed a systematic review to evaluate the evidence for the use of prazosin in the treatment of nightmares. A comprehensive search was performed using the databases EMBASE, Ovid MEDLINE, PubMed, Scopus, Web of Science, and Cochrane Database of Systematic Reviews, from their inception to March 9, 2012, using keywords prazosin and nightmares/PTSD or associated terms (see text). Two authors independently reviewed titles and abstracts and selected relevant studies. Descriptive data and outcomes of interest from eligible studies were extracted by 1 author, and checked by 2 others. The risk of bias of randomized controlled trials (RCTs) was assessed independently by 2 reviewers. Articles met criteria for inclusion if prazosin was used to treat nightmares, and outcome measures included nightmares or related symptoms of sleep disorders. Our search yielded 21 studies, consisting of 4 RCTs, 4 open-label studies, 4 retrospective chart reviews, and 9 single case reports. The prazosin dose ranged from 1 to 16 mg/d. Results were mixed for the 4 RCTs: 3 reported significant improvement in the number of nightmares, and 1 found no reduction in the number of nightmares. Reduced nightmare severity with use of prazosin was consistently reported in the open-label trials, retrospective chart reviews, and single case reports.
Nightmares are a common and serious problem in psychotherapeutic practice, although they are seldom considered as independent mental disorders. There are some promising approaches to the treatment of nightmares, notably Imagery Rehearsal Therapy, a cognitive-restructuring treatment. The core of this approach is the modification of the nightmare script and repeated imagination of the new script. However, most evaluation surveys have been conducted only with trauma patients, and thus far there is no standardized manual in the German language. 69 participants were examined using self-rating questionnaires. Participants belonged to three groups: 22 primarily nightmare sufferers, 21 patients with major depression and nightmares, 26 with PTSD and nightmares. 12 of the PTSD patients were randomly assigned to a control condition. Primary outcome measures were nightmare frequency and anxiety during nightmares. Overall, nightmare frequency and the anxiety they caused decreased following the treatment. Nightmare frequency and anxiety during the nightmares were highest in the PTSD group initially. Nightmare frequency decreased in all groups. Anxiety scores decreased least in PTSD patients, in depressive patients and primarily nightmare sufferers anxiety scores decreased during intervention. In primarily nightmare sufferers anxiety remained low up to the catamnesis period as well. Thus, those who suffered primarily from nightmares showed the strongest benefit from the nightmare treatment.
The effects of β-adrenergic drugs alone and in combination with α-adrenergic drugs on the stages of the sleep-waking cycle were studied in adult cats. Polygraphic sleep recordings of 16 h showed that prenalterol (20 and 40 mg/kg i.p.), a β1-adrenoceptor-stimulating drug increased paradoxical sleep (PS) in a dose-related manner during 4–12 h. Salbutamol (40 mg/kg), a β2-adrenoceptor-stimulating drug, decreased PS during the first 4 h. Metoprolol (10 and 50 mg/kg), a relatively selective β1-adrenoceptor blocking drug, increased drowsy waking during the first 4 h. The larger dose also tended to decrease PS. Already at the lower dose metoprolol partially antagonized the PS increase produced by prazosin, an α1-adrenoceptor blocking drug. Propranolol (5 mg/kg), a β1-andβ2-adrenoceptor blocking drug, which alone decreases PS, antagonized the PS increase induced by phentolamine, an α1-andα2-adrenoceptor drug. Atenolol (5 mg/kg), a poorly lipid-soluble β-adrenoceptor blocking drug, failed to counteract phentolamine in increasing PS. Metoprolol (10 and 50 mg/kg) and propranolol (5 mg/kg) clearly potentiated the increase in drowsy waking and decrease in deep slow wave sleep and PS induced by clonidine (0.01 mg/kg), an α2-adrenoceptor-stimulating drug.The results support the involvement of β-adrenoceptors in the regulation of the sleep-waking cycle. A high level of β-adrenergic activity may facilitate the production of PS. A low level of β-adrenergic activity, especially in combination with a high level of α2-adrenergic activity, may facilitate the production of drowsy waking. Central α1-andβ1-adrenoceptors may mediate opposite functions in the regulation of PS.
Several scattered lines of evidence suggest that there is a triad of relationships between early adverse life events, borderline personality structure, and susceptibility to nightmares; and, further, that these associations might throw light on the aetiology of the eating disorders. These possibilities were examined in three studies of non-clinical samples of female subjects who completed scales of borderline personality, trauma, nightmare experience, and, in one study, weight preoccupation. Results showed consistent positive correlations between the personality, life events, and nightmare variables, including, among the latter, measures based on detailed analysis of subjects' reported nightmare content. Also evident in the data were positive associations between weight preoccupation and several of these measures — including sexual and neglectful abuse. However, regression analysis demonstrated that, among the psychological measures, only borderline personality significantly predicted weight preoccupation. Further examination of the nightmare accounts of a small group of seriously abused subjects, who were also extreme on the personality measure, suggested a tentative “discontinuity” hypothesis, proposing that the transition from vulnerability status to eating disordered pathology might require threshold levels to be crossed on several risk variables. Aetiological considerations aside, it was concluded that enquiring into nightmare experience might be a useful adjunct to direct questioning about early trauma in individuals vulnerable to psychological dysfunction, including eating disorders.
Pharmacological and cognitive-behavioral treatments targeting insomnia and nightmares have been shown to be effective in the treatment of military veterans with sleep complaints comorbid with symptoms of stress-related disorders, including Post-Traumatic Stress Disorder (PTSD), but the two approaches have not been directly compared. This randomized controlled trial compared the effects of prazosin vs. a behavioral sleep intervention (BSI), targeting nightmares and insomnia against a placebo pill control condition on sleep and daytime symptoms.
Fifty United States military veterans (mean age 40.9years, SD=13.2years) with chronic sleep disturbances were randomized to prazosin (n=18), BSI (n=17), or placebo (n=15). Each intervention lasted 8weeks. Participants completed self-report measures of insomnia severity, sleep quality, and sleep disturbances. All kept a sleep diary throughout the intervention period. Polysomnographic studies were conducted pre- and post-intervention.
Both active treatment groups showed greater reductions in insomnia severity and daytime PTSD symptom severity. Sleep improvements were found in 61.9% of those who completed the active treatments and 25% of those randomized to placebo.
BSI and prazosin were both associated with significant sleep improvements and reductions in daytime PTSD symptoms in this sample of military veterans. Sleep-focused treatments may enhance the benefits of first-line PTSD treatments.
The purpose of this study was to investigate whether insomnia symptoms and nightmares are related to suicidal ideation independent of one another and independent of the symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD).
The study consisted of questionnaires examining insomnia symptoms and nightmares, and symptoms of depression, anxiety, and PTSD. The questionnaires were administered online.
University.
583 undergraduate students at a large, public university in southeastern United States.
N/A.
Results indicated that both nightmares and insomnia symptoms were related to suicidal ideation, independent of one another. Nightmares, but not insomnia symptoms, were related to suicidal ideation after controlling for the symptoms of anxiety, depression, and PTSD.
Nightmares may be more than a marker of PTSD and hence may be important in the identification of suicidal ideation.
Imagery Rehearsal Therapy (IRT) has been shown to be efficacious in reducing nightmares, but the treatment has not been well-studied in veterans. The effectiveness of IRT was assessed from a chart review of veterans seeking outpatient treatment for chronic, trauma-related nightmares. Of those offered IRT, veterans who completed a full course of treatment for PTSD in the past year were more likely to initiate treatment. However, completion of IRT was not related to previous treatment, demographic variables, or nightmare severity reported at the first treatment session. Treatment completers reported significant reductions in nightmare frequency and intensity, severity of insomnia, and subjective daytime PTSD symptoms. Insomnia and PTSD symptoms, on average, were below clinical cutoffs following treatment, and 23% of patients showed a complete treatment response (< or =1 nightmare/week). Findings suggest IRT may be an effective short-term treatment for nighttime and daytime PTSD symptoms among veterans who complete a full course of treatment.
This study investigated the extent to which sleep disturbance in the period immediately prior to a traumatic event predicted development of subsequent psychiatric disorder.
Prospective design cohort study.
Four major trauma hospitals across Australia.
A total of 1033 traumatically injured patients were initially assessed during hospital admission and followed up at 3 months (898) after injury.
Lifetime psychiatric disorder was assessed in hospital with the Mini-International Neuropsychiatric Interview. Sleep disturbance in the 2 weeks prior to injury was also assessed using the Sleep Impairment Index. The prevalence of psychiatric disorder was assessed 3 months after traumatic injury.
There were 255 (28%) patients with a psychiatric disorder at 3 months. Patients who displayed sleep disturbance prior to the injury were more likely to develop a psychiatric disorder at 3 months (odds ratio: 2.44, 95% CI: 1.62-3.69). In terms of patients who had never experienced a prior disorder (n = 324), 96 patients (30%) had a psychiatric disorder at 3 months, and these patients were more likely to develop disorder if they displayed prior sleep disturbance (odds ratio: 3.16, 95% CI: 1.59-4.75).
These findings provide evidence that sleep disturbance prior to a traumatic event is a risk factor for development of posttraumatic psychiatric disorder.
The aim of this prospective study was to determine if sleep disturbances and nightmares are associated with increased risk of repeat suicide attempt. Patients (n=165) aged 18-68 years who were admitted to medical or psychiatric wards after a suicide attempt completed an initial interview; 98 of these took part in a 2-month follow-up interview. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and two self-report instruments, the Uppsala Sleep Inventory and the Comprehensive Psychopathological Rating Scale (CPRS) Self-Rating Scale for Affective Syndromes, were administered both at baseline and follow-up. Data concerning repeat suicide attempts within 2 years were obtained from hospital records. Analyses were performed using Student's t-test, chi-square test, and logistic regression. In total 42 patients (26%) made at least one repeat suicide attempt within 2 years. While neither difficulties initiating/maintaining sleep nor early morning awakening at baseline predicted repeat attempt, having frequent nightmares did (OR=3.15). The risk was further heightened when nightmares were reported at both baseline and 2-month follow-up (OR=5.20). These associations remained after adjusting for sex, axis-I DSM-IV diagnoses, and self-reported depression and anxiety symptom intensity. Our findings suggest that nightmares might constitute a marker for increased risk of suicidal behavior.