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Pharmacological and non-pharmacological treatments for nightmare disorder

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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.
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Correspondence: Michael Nadorff, Department of Psychology, Mississippi State University, P.O. Box 6161, Mississippi State, MS 39762, USA. Tel: (662)
325-1222. Fax (662) 325-7212. E-mail: mnadorff@psychology.msstate.edu.
(Rece ived 18 Octo ber 2013; acc epted 26 Ja nuary 2 014)
Pharmacological and non-pharmacological treatments for nightmare
disorder
MICHAEL R. NADORFF
1,2 , KAREN K. LAMBDIN
1 & ANNE GERMAIN
3
1 Department of Psychology, Mississippi State University, Starkville, Mississippi,
2 Menninger Department of Psychiatry,
Baylor College of Medicine, Houston, Texas, and
3 Department of Psychiatry, University of Pittsburgh, Pittsburgh,
Pennsylvania, USA
Abstract
Interest in the treatment of nightmares has greatly increased over the last several years as research has demonstrated
the clinical signifi cance 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 defi nes 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 fi ndings
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 fi rst-
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.
Introduction
Nightmares have long been discussed in the context
of mental health (Freud, 1955) and this interest in
nightmares has re-emerged in recent years as clini-
cally relevant sleep disorders have been identifi ed as
a common risk factor for mental disorders. Further,
research has demonstrated that the relation between
nightmares and negative outcomes are often inde-
pendent of co-morbid disorders such as post-
traumatic stress disorder (PTSD), depression, and
anxiety (Nadorff et al., 2011, 2013a; Sj ö str ö m et al.,
2009). Concurrently to these observations, there
has been a substantial growth in the literature on
effective nightmare treatments. The current review
will provide a brief discussion of nightmare disorder
and the relation between nightmares and psychopa-
thology before examining the leading pharmacologi-
cal and therapy-based treatment options for nightmare
disorder. Lastly, we review some potential areas of
growth for nightmare treatments as well as potential
novel uses for these therapies.
Defi nition of nightmares
Nightmares, defi ned as vivid, disturbing, or frighten-
ing dreams that awaken the individual, are a common
form of parasomnia (Levin & Nielsen, 2007). Night-
mares primarily occur during rapid eye movement
(REM) sleep, and hence are more common during
the second half of the night (American Academy of
Sleep Medicine, 2006). The fact that nightmares
occur in REM sleep differentiates them from night
terrors, a parasomnia that occurs in non-REM sleep
(APA, 2013).
The DSM-5 (APA, 2013) and ICSD-2 diagnostic
criteria for nightmare disorder are similar in many
ways. Both diagnostic systems require nightmares to
be repeated negative dreams that awaken the indi-
vidual from the nightmare, making the individual
rapidly alert and aware of his or her surroundings.
The DSM-5 requires that the nightmares not be bet-
ter explained by substance use or medication, which
is not required by the ICSD-2. On the other hand,
the ICSD-2, but not the DSM-5, requires the indi-
vidual to have diffi culty falling back asleep, or for the
nightmare to occur in the latter half of the night.
Bad dreams, which are negative dreams that do
not lead to a startled awakening, are usually excluded
from the defi nition of nightmares due to their lack
of a startled awakening. However, bad dreams and
nightmares are quite similar, as both require the
recall of a negative dream, and both have been shown
to be associated with sleep disruption and adverse
International Review of Psychiatry, April 2014; 26(2): 225–236
ISSN 0 954– 0261 print/ ISSN 1369–1627 onl ine © 2014 Inst itute of P sychi atry
DOI : 10. 3109 / 095 40 261.2 014.888 989
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226 M. R. Nadorff et al.
daytime consequences (Duval et al., 2013; Nadorff
et al., 2014; Zadra & Donderi, 2000) Due to their
similarities, many researchers combine bad dreams
and nightmares (Levin & Nielsen, 2007). From a
treatment perspective, both nightmares and bad
dreams can be effectively reduced with pharmaco-
logical and behavioural treatments targeting negative
dream content.
Although nightmares are most common in child-
hood, they are prevalent across the lifespan (Levin &
Nielsen, 2007). Research suggests that bad dreams
are more prevalent than nightmares (Zadra &
Donderi, 2000), though research examining the
prevalence of bad dreams throughout the lifespan is
lacking. It is estimated that 19% of children experi-
ence nightmares at least once per week (Schredl
et al., 2008). Although nightmares are often viewed
as a childhood sleep disorder, research suggests that
nightmares may persist into adulthood, and are a
function of age and sex. Studies examining night-
mares in adults have found nightmare disorder prev-
alence rates ranging from 2 6%. This prevalence
range is highly consistent across cultures, with
similar rates having been found in the USA, Canada,
France, Iceland, Sweden, Belgium, Finland, Austria,
Japan, and the Middle East (Levin & Nielsen, 2007).
Women report more monthly nightmares than men
up until age 60, at which point there is no signifi cant
gender difference. For women, the rate of nightmares
signifi cantly increases from ages 10 19 to ages 20
39, then steadily decreases to ages 50 59, and after
age 60 the rate of nightmares stays constant. For
men, the rate of nightmares increases from ages 10
19 to 30 39, and then and decreases from 30 39 to
50 59 (Nielsen et al., 2006).
Very little research has examined the prevalence of
nightmares among older adults. However, the
research that has been done suggests that nightmares
may be less common among older adults compared
with children and younger adults. In a study compar-
ing older adults and college students, only 4.3% of
older adults reported having a problem with night-
mares, which was signifi cantly less than the 19.5%
of college students in the study reporting having a
nightmare problem (Salvio et al., 1992).
Dream and nightmare theories
It is often helpful to have a theoretical framework in
order to understand a disorder and its effects. How-
ever, nightmares have historically received little
attention from theorists or researchers. Even Freud,
who did a considerable amount of work on dreams,
rarely discussed nightmares. In his book The Inter-
pretation of Dreams , Freud only mentions nightmares
twice, and neither time did he provide a theory as to
why individuals have nightmares (Freud, 1955).
Contemporary theorists have put forth ideas about
the aetiology of nightmares, although little evidence
supporting the theories exists. Despite this fact, a
review of the current theories is still warranted, espe-
cially given that some of the nightmare treatments
are based upon these theories.
After studying the histories of many nightmare
sufferers from the psychoanalytic perspective,
Hartmann (2001) concluded that nightmares are
caused by thin boundaries . Thin boundaries
refer to the lack of separation between areas and
processes in the mind, and also a lack of walls and
defense (Hartmann, 2001). Supporting this the-
ory, Hartmann (1989) found that thin boundaries
were positively correlated with remembering
one s dreams, which may lead to remembering
one s nightmares. Similarly, other researchers
have also found that thin boundaries are associated
with dream recall, more negative and emotionally
intense dreams, and regarding one’s dreams to be
meaningful (Schredl et al., 1999).
Cartwright (2001) articulated a different view of
nightmares, focusing on emotion processing instead
of boundaries. She stated that when a traumatic
event occurs, an individual may be unable to handle
all of the resulting emotions at that time. Therefore,
nightmares may emerge in order to help process the
emotions caused by the trauma.
Taking a more biological approach, Levin and
Nielsen (2007) published the AMPHAC/AND
neurocognitive model of disturbed dreaming. The
model seeks to explain disturbed dreaming at both
physiological and cognitive levels. The model posits
that the physiological and cognitive levels serve the
function of fear-memory extinction during normal
dreaming. In this process, components of fearful
events are combined in a new way with non-fearful
memories, disarming the memories. However, for
individuals with signifi cant distress (especially those
who are predisposed to be sensitive to distress), the
fearful memories may not be altered, or may be
altered in a way even more frightening than the orig-
inal memory, leading to disturbing dreams (Levin &
Nielsen, 2009). The AMPHAC/AND model is con-
sistent with the activation-synthesis hypothesis of
dreaming (Hobson & McCarley, 1977), which is one
of the most widely-accepted theories of normal
dreaming. The activation synthesis hypothesis postu-
lates that dreaming is an event that is physiologically
shaped by the sections of the brain that are activated
during sleep. In an attempt to make sense of the
activation, the brain synthesizes the impulses into a
narrative, which we experience as dreams.
Nightmares have also been viewed through a
cognitive behavioural lens. The cognitive behavioural
theory of nightmares posits that nightmares cause
sleep avoidance behaviours (Krakow et al., 2001a;
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Treatments for nightmare disorder 227
St-Onge et al., 2009). In this theory the nightmare
is considered to be a conditioned stimulus that causes
a conditioned avoidance response. The awakening
then reinforces the belief that the only way to avoid
nightmares is to remain awake, which leads to the
nightmare sufferer developing other behaviours to
avoid sleep. Put simply, an individual may wake up
and thereby escape from having the nightmare, which
negatively reinforces the awakenings that are serving
as an avoidance response. However, the avoidance of
the nightmare increases sleep fragmentation, making
an individual more likely to remember their dreams,
perpetuating the nightmare problem. Additionally, it
is possible that avoiding the nightmare may prevent
exposure to the nightmare, potentially explaining
why nightmares persist.
Negative consequences of nightmare
disorder
Although the most well-known co-morbidity is post-
traumatic stress disorder, nightmares are also
related to other psychiatric disorders, such as
insomnia and borderline personality disorder (APA,
2013). Additionally, nightmares may be a precursor
to psychopathology (Mellman et al., 1995; Ohayon
& Shapiro, 2000; Sj ö str ö m et al., 2009), and have
been shown to independently contribute to poor
psychiatric outcomes. As such, nightmares have
great clinical relevance for both prevention and
treatment efforts. Further, nightmares can also
affect more than just the nightmare sufferer, it can
also affect the sufferer s bed partner. For example,
there is a relation between relationship satisfaction
and sleep disorders or prolonged sleep disturbances
(Troxel et al., 2007), suggesting that the presence
of sleep disorders can put signifi cant strain on a
relationship.
Post-traumatic stress disorder
Nightmares have a strong association with PTSD
(Harvey et al., 2003; Kilpatrick et al., 1994; Mellman
et al., 1995; Ohayon & Shapiro, 2000; Ross et al.,
1989). The nightmares observed in PTSD (some-
times referred to as traumatic nightmares) can be
re-enactments of the traumatic event or can be the-
matically or emotionally related to the original
trauma, and are consistent with the re-experiencing
symptom cluster of PTSD (APA, 2013). Nightmares
are often chronic symptoms of PTSD: two studies
examining war veterans found that nightmares
persisted up to 50 years following the traumatic
experience (Guerrero & Crocq, 1994; Kaup et al.,
1994). Compared to individuals with idiopathic
nightmares, those with PTSD-related nightmares
rated their nightmares as being more distressing
(Germain & Nielsen, 2003b).
Nightmares may also infl uence the development of
PTSD following trauma exposure. PTSD symptoms
are more severe among individuals who reported
having nightmares prior to the traumatic event than
among individuals who did not report experiencing
nightmares prior to the trauma (Mellman et al.,
1995). Similarly, Ohayon and Shapiro (2000) and
Bryant and colleagues (2010) found that pre-trauma
sleep disturbances increased the risk of developing
PTSD (and other psychiatric disorders), among large
populations. Mellman and colleagues (2001) found
having nightmares of the trauma shortly after the
event was related to more severe PTSD symptoms
six weeks later. Similar fi ndings have also been
reported by Kobayashi and colleagues (2008). These
ndings suggest that nightmares and other sleep dis-
turbances (e.g. insomnia) may be confer heightened
vulnerability for poor psychiatric outcomes following
trauma exposure. Thus, nightmares or more gener-
ally, sleep disturbances and PTSD may arise from
common psychophysiological or neural mechanisms
(Germain et al., 2008; Levin & Nielsen, 2007).
Anxiety and depression symptoms
Nightmares have been shown in clinical samples to
be related to anxiety and depressive symptoms
throughout the lifespan (Levin & Nielsen, 2007;
Nadorff et al., 2013a, 2014). However, some com-
munity studies have failed to fi nd this result (Lancee
et al, 2010b; Spoormaker
& van den Bout, 2005),
suggesting that the relation may be driven by those
with clinically signifi cant anxiety. Nielsen and col-
leagues (2000) found that disturbing dreams were
associated with anxiety among adolescents. Night-
mares have also been found to correlate strongly with
symptoms of anxiety (0.41) and symptoms of depres-
sion (0.37) in a college student sample (Nadorff
et al., 2013b) These relations hold true among older
adults as well. A recent study of older adults present-
ing to a family medicine clinic found a very high
correlation between nightmares and depressive symp-
toms (0.70) (Nadorff, 2013a). Additionally, although
the prevalence of nightmares among older adults is
just above 4% (Salvio et al., 1992), older adults with
clinically signifi cant depressive and anxiety symp-
toms had nightmare prevalence rates of 11.4% and
17.1%, respectively (Mallon et al., 2000). Relatedly,
a recent secondary data analysis of a generalized
anxiety disorder (GAD) randomized clinical trial
found that the presence of a GAD diagnosis was
signifi cantly associated with higher levels of bad
dream frequency, with 21.6% of those with a GAD
diagnosis reporting weekly bad dreams (Nadorff
et al., 2014).
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228 M. R. Nadorff et al.
Dissociative disorders
Dissociative disorders have been linked to acute
stress disorder and PTSD (Agargun et al., 2003b),
which suggests that they may be associated with
nightmares as well. Agarun and colleagues (2003)
found that 57% of individuals with a dissociative dis-
order met criteria for a nightmare disorder. Individ-
uals who reported nightmares also had more
dissociative symptoms than did individuals without
nightmares. In a sample of 292 undergraduate stu-
dents those who reported having nightmares scored
signifi cantly higher on the Dissociative Experiences
Scale than those who did not report having night-
mares (Agargun et al., 2003). Similarly, Semiz, et al.
(2008) found a signifi cant correlation (0.43) between
the Dissociative Experiences Scale and nightmare
frequency among individuals with borderline person-
ality disorder.
Borderline personality disorder
Researchers have also found a link between
nightmares and borderline personality disorder. In
Hartmann s (1981) sample of adults with weekly
nightmares, he found that 24% met DSM-III criteria
for borderline personality disorder. Relatedly, Semiz
and colleagues (2008) compared a sample of 88
participants diagnosed with borderline personality
disorder with age and sex-matched controls, fi nding
that the patients with borderline personality disorder
reported more nightmares, greater dream anxiety,
and more disturbed sleep than the control partici-
pants. Further, those with borderline personality
disorder and a nightmare disorder exhibited more
severe psychopathology than those with borderline
personality disorder but without nightmare disorder.
Nightmares have also been shown to be associated
with borderline personality traits. Claridge et al.
(1998) found that nightmare distress correlated
strongly (0.42) with the Borderline Personality Scale
in a sample of 60 undergraduate women.
Suicidality and suicidal behaviour
A rapidly growing literature suggests that nightmares
increase one s risk of suicidality and suicidal
behaviour across the lifespan (Nadorff et al., 2013a;
Singareddy et al., 2013). Krakow and colleagues
(2000) were the fi rst to mention this association in
their study of female sexual assault survivors who
took part in a nightmare treatment study, fi nding that
43% of the sample reported suicidal ideation at
intake. Cukrowicz and colleagues (2006) built upon
this work through fi nding that nightmares were asso-
ciated with suicidal ideation independent of insom-
nia symptoms.
Nightmares have also been examined in relation
to suicide attempts. Sjostrom et al. (2007) studied
165 patients who had been admitted to the hospital
following a medically serious suicide attempt.
Although insomnia was the most common sleep
complaint, two thirds of participants also reported
having nightmares. A regression analysis revealed
that nightmares were signifi cantly associated with
higher scores of suicidality, defi ned as the risk of
attempting suicide, after adjusting for the presence
of depression, anxiety, substance use, and PTSD
diagnoses. Further, a follow-up study found that
persistent nightmares predicted suicide attempts in
the next two years in the same sample after control-
ling for the disorders listed above (Sj ö str ö m et al.,
2009).
Nightmares are also related to death by suicide.
Tanskanen et al. (2001) examined the relation
between nightmares and death by suicide in a
prospective study conducted in Finland. When
compared with individuals without nightmares,
those reporting occasional nightmares were at 57%
greater risk of death by suicide. Further, participants
reporting frequent nightmares were at 107% greater
risk of suicide compared to those without nightmares.
This study suggests that nightmares are potentially a
risk factor for suicide.
In summary, nightmares are a prevalent condition
that may confer heightened vulnerability to poor
psychiatric outcomes that are often co-morbid with
psychiatric conditions, and can independently exac-
erbate clinical outcomes in affected individuals. Thus,
targeting nightmares with effective treatment may be
an important component of prevention efforts aimed
at high-risk samples, and of intervention for indi-
viduals with primary or co-morbid nightmares.
Nightmare treatment
Given the strong association between nightmare dis-
order and subsequent psychiatric complications,
nightmares are increasingly being recognized as an
important target for treatment, and not only as a
secondary symptom of psychopathology. Thus, the
remainder of this paper examines the pharmacologi-
cal and psychotherapeutic treatments for nightmare
disorder and nightmares co-morbid with other con-
ditions. Novel uses of nightmare treatments and tar-
gets for future research are also proposed.
Pharmacological treatments
Recently there has been an increased focus on phar-
macological treatments for nightmares, including
several recent reviews of this literature (Augedal
et al., 2013; Aurora et
al., 2010; Kung et al., 2012).
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Treatments for nightmare disorder 229
Despite numerous case reports, open-label trials, and
randomized controlled clinical trials (see Maher
et al., 2006, for review), only prazosin has consis-
tently shown effi cacy for the treatment of nightmares
and distressed awakenings. Therefore, prazosin
was the only medication that was recommended or
suggested in the latest best practice guidelines for
treating nightmare disorder (Aurora et al., 2010).
Thus, our review of pharmacological therapies for
nightmare disorder primarily focuses on prazosin,
but other medications that may be worth consider-
ation for future research are also mentioned below.
Prazosin
Prazosin is a sympatholytic medication that is FDA-
approved to treat high blood pressure, though it is
also used off-label to treat PTSD. Prazosin is an
alpha-1 adrenergic receptor antagonist that crosses
the blood brain barrier, and as such is thought to
reduce noradrenergic tone during sleep (Feldman &
Weidenfeld, 1996; Hilakivi, 1983; Mallick et al.,
2005; Raskind et al., 2000; Taylor & Raskind, 2002).
Recent best practice guidelines from the American
Academy of Sleep Medicine give prazosin a level A
recommendation, meaning that prazosin is supported
by a great deal of high quality research (American
Academy of Sleep Medicine, 2001). Similarly, the
Veterans Administration recommends the use of pra-
zosin to improve sleep quality and reduce trauma night-
mares (US Department of Veterans Affairs, 2010).
Five randomized controlled trials examining the
effect of prazosin on trauma-related nightmares that
have been conducted to date (see Table 1 and Kung
et al., 2012 for a full review of this literature).
Raskind and colleagues (2003) compared prazosin
(mean dose 9.5 mg) to placebo in 10 Vietnam
combat veterans with PTSD diagnoses using a
20-week double-blind crossover design. Prazosin was
well tolerated, with only two participants reporting
side effects, of mild decreases in blood pressure or
dizziness. Further, there was a signifi cantly larger
reduction in nightmares during the prazosin trial
(severity score on the nightmare item of the Clinician
Administered PTSD Scale [CAPS] reduced from
6.9 to 3.6) than was found during the placebo trial
(from 7.1 to 6.7 on the nightmare item of the
CAPS).
Raskind and colleagues (2007) built upon the
previous study in a larger parallel group placebo-
controlled study of prazosin. In this study, 40 veter-
ans with chronic PTSD and trauma nightmares were
randomized either to prazosin (13.3 3 mg/day) or
placebo conditions for a period of 8 weeks. Prazosin
over 8 weeks resulted in a large effect size reduction
in distressing dreams and signifi cantly outperformed
placebo (Cohen s d effect size 1.68, p 0.02).
However, it should be noted that there was no dif-
ference between the conditions after 4 weeks of treat-
ment (Cohen s d effect size 1.61, p 0.09).
Dizziness upon standing was reported by 15 partici-
pants (nine in the prazosin condition, six in the pla-
cebo condition). There were no signifi cant changes
in blood pressure for participants in the prazosin
condition between baseline and the end of the study.
Thompson and colleagues (2008) examined a related
question: does prazosin reduce non-nightmare dis-
tressed awakenings in veterans with PTSD. Utilizing
a chart review of 22 veterans, the authors found sig-
nifi cant reductions in trauma nightmares on the
CAPS nightmare item (Cohen s d effect size 0.56,
p 0.05), sleep diffi culty on the CAPS D-2 item
(Cohen s d effect size
1.80, p 0.01), and non-
nightmare distressed awakenings (Cohen s d effect
size 1.49, p 0.01).
The literature was expanded to a civilian sample
in a study by Taylor and colleagues (2008). The study
consisted of 13 civilians with chronic trauma PTSD,
Table 1. Main characteristics of prazosin studies.
Study Comparison (n) Dose/ session Outcome measures Duration of treatment Military status
Germain et al., 2012 Prazosin (18)
BSI (17)
Placebo (15)
8.9 mg
8 45 min
10.4 mg
S-REP: NN 8 weeks Veterans
Raskind et al., 2003 Prasozin (10)
Placebo (10)
Crossover design
9.5 mg CAPS: IN 20 weeks Vietnam veteran
Raskind et al., 2007 Prasozin (14)
Placebo (15)
13.0 mg CAPS: IN
NFQ: NN
8 weeks Veterans
Raskind et al., 2013 Prasozin (32)
Placebo (35)
15.6 mg 7.0 mg
18.8 mg 10.0 mg
CAPS: IN 15 weeks Active duty
Thompson et al., 2008 Prazosin (22) 9.6 mg 6.0 mg CAPS: IN 3.4 (1.8) Veterans
Taylor et al., 2008 Prasozin (13)
Placebo (13)
Crossover design
3.1 mg CAPS: IN 7 weeks Civilians
S-REP, self-report; NN, number of nightmares; IN, intensity; NFQ, nightmare frequency questionnaire; CAPS, clinical administered PTSD
scale. Portions of this table are adapted from the table found in Augedal et al. (2013, p. 145).
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230 M. R. Nadorff et al.
frequent nightmares, and disturbed sleep. The study
spanned 7 weeks and consisted of 3-week trials of
both prazosin and placebo with a 1-week washout
period in between. The order of the trials was ran-
domly assigned and both the experimenters and par-
ticipants were blind to the condition. Similar to
previous studies (Raskind et al., 2007), prazosin
resulted in large effect size reductions on the CAPS
nightmare item (Cohen s d 0.96) and also resulted
in a large effect size reduction on the PTSD dream
rating scale (Cohen s d 1.4). Further, prazosin out-
performed placebo on both nightmare measures
(p 0.04 0.006).
Recently, a different research team from the previ-
ous three studies compared prazosin, a behavioural
sleep intervention targeting insomnia and night-
mares, and a placebo (Germain et al., 2012). The
study consisted of 50 military veterans (mean age
40.9) who were randomly assigned to receive pra-
zosin (n 18), BSI (n 17), or placebo (n 15),
with each intervention having an 8-week duration.
This study signifi cantly built upon the literature in
several signifi cant ways, (1) it is the fi rst study to
compare prazosin to a cognitive behavioural therapy,
(2) the study incorporated data from polysomno-
graphic studies, and (3) participants with PTSD
symptoms but not necessarily with full blown PTSD
were included (58% of the sample met DSM-IV cri-
teria for PTSD). Germain and colleagues (2012)
found that both prazosin (1.0 to 0.3) and the behav-
ioural sleep intervention (0.9 0.0) signifi cantly
reduced nightmare frequency greater than placebo
(0.4 to 0.5) on prospective sleep diary measures of
nightmare frequency. There were no signifi cant dif-
ferences between the active treatment groups, though
this may have been due to insuffi cient power to detect
this effect. The authors report that there were no
signifi cant changes in blood pressure for the prazosin
and placebo groups, and that the frequency of side
effects did not differ across the groups.
More recently, Raskind and colleagues (2013)
recently completed a 15-week randomised controlled
trial (RCT) comparing the effects of prazosin to pla-
cebo. The study consisted of 67 active duty service
members who met DSM-IV criteria for combat-
related PTSD. Similar to several previous studies, the
outcome measure was the nightmare item on the
CAPS. The prazosin group had a signifi cantly greater
reduction on the nightmare item between baseline
and week 15 (6.0 to 2.9) than placebo (6.6 to 5.4)
on the CAPS nightmare item. Similar to previous
studies, prazosin was well tolerated and blood pres-
sure did not differ between baseline and the end of
the study, nor did it differ by treatment group.
In summary, the literature to date demonstrates
the effi cacy of prazosin for the treatment of
PTSD-related nightmares. However, there are a few
limitations to this literature worth noting. First, most
of the RCT studies involve the same research team.
Thus, the literature could be strengthened through
replication by other research groups. There is also a
lack of studies examining the extent to which pra-
zosin may be effective in treating idiopathic night-
mares, or nightmares co-morbid with depression or
suicidality, for instance. Only the study by Germain
and colleagues (2012) included individuals without
PTSD, but this study was also limited by the inclu-
sion of military veterans, the majority of whom met
criteria for PTSD. Thus, further research is needed
to determine whether prazosin is indicated for non-
PTSD nightmares, and replications are warranted in
larger civilian samples. Lastly, nightmares may recur
upon cessation of prazosin, though this was not seen
in all samples (Germain et al., 2012) and may be due
to differences in chronicity and co-morbidities
between samples.
Other pharmacological agents
Although no other medication has the empirical sup-
port of prazosin, there are several other medications
that have been examined as potential nightmare
treatments (e.g. clonidine, trazodone, risperidone;
see Maher (2006) for review). Despite the existence
of effective pharmacological treatments, benzodiaz-
epines are often utilized despite having been shown
to be ineffective in reducing nightmares (Maher
et al., 2006). In a small crossover clinical trial (N 6),
clonazepam failed to show signifi cant improvement
in any sleep symptom, including nightmare frequency
(Cates et al., 2004). Similarly, in another small cross-
over clinical trial (N 10), alprazolam failed to affect
nightmares. Thus, the small literature examining the
treatment of benzodiazepines in treating nightmares
suggests that they are ineffective.
Psychotherapeutic interventions
There have been several psychological interventions
that have been used to treat nightmares (see Table 2,
and for recent reviews see Augedal et al., 2013;
Hansen et al., 2013). Due to the presence of these
recent reviews, the focus of this review is on the treat-
ments most likely to be used in clinical practice.
Imagery rehearsal therapy
Imagery rehearsal therapy (IRT) is a cognitive behav-
ioural therapy in which the patient rescripts the
nightmare anyway he or she wants and then practises
the new dream using imagery. Since the dream can
be rescripted in any way, and does not have to con-
tain material from the disturbing dream, IRT is not
considered an exposure-based therapy. Rather, IRT
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Treatments for nightmare disorder 231
is based on the concept that nightmares are a learned
behaviour (Krakow, 2002, p. 18). Therefore, they can
be replaced by a less disruptive behaviour, which in
this case, is a new dream that does not disrupt sleep
or daytime functions.
One of the fi rst investigations of IRT consisted of
20 individuals who were randomly assigned to treat-
ment or nightmare recording (Neidhardt et al.,
1992). Three months after treatment the authors
found that although nightmare frequency signifi -
cantly decreased in both groups, there was a signifi -
cantly greater reduction in the IRT group compared
to the recording group. Further, only the IRT group
had a signifi cant difference in nightmare severity
after 30 months (Krakow et al., 1993). Krakow and
colleagues (2000) followed this study up with a large
randomized controlled trial in a sample of 169 female
survivors of sexual assault with PTSD. This was the
rst study looking at the effect of IRT in a sample
with sub-threshold and full-blown PTSD. At 3-month
follow-up nightmare frequency and PTSD symp-
toms were signifi cantly reduced relative to the con-
trol group. Krakow and colleagues (2001a) provided
later follow-up results from the previous study. The
IRT group evidenced improved sleep quality
(d 0.67), and reduced PTSD symptoms (d 1.0)
relative to the control group.
Krakow and colleagues (2001b) extended the IRT
ndings by testing the theory in a sample of adoles-
cent girls who had suffered a sexual assault. The
sample consisted of 19 adolescent girls at a treatment
facility who were randomly assigned to either the
treatment (n 9) or control (n 10) group. After
three months, the treatment group reported a 71%
decrease in nightmare frequency (d 1.7) whereas
there was no change in the control group. However,
there was no signifi cant difference between the
groups in PTSD symptoms (d 0.22 for the treat-
ment group and 0.27 for the control group).
Forbes and colleagues (2003) were the fi rst to
study IRT in a sample of military veterans. Their
sample consisted of 12 Australian Vietnam veterans
who had been treated for PTSD in the past but were
still having at least one trauma-related nightmare per
week. At post-treatment there were signifi cant reduc-
tions in nightmare frequency (d 0.70), nightmare
intensity (d 0.55), depression symptoms (d 0.43),
and anxiety symptoms (d 0.20). All of the signifi -
cant treatment gains were still present at the 1-year
follow-up, showing that IRT had a lasting impact in
this sample. Nappi and colleagues (2010) extended
the work done by Forbes and colleagues (2003) by
testing imagery rehearsal therapy in a larger sample
of 58 veterans. At the end of treatment there was a
signifi cant decrease in nightmare frequency (d 0.45),
nightmare severity (d 0.81), insomnia symptoms
(d
0.72), and PTSD symptoms (d 1.03). Lastly,
IRT has also been shown to be effective in different
types of nightmare sufferers. Three groups of night-
mare sufferers primary nightmare sufferers, night-
mare sufferers with major depression, and nightmare
sufferers with PTSD were compared to a waiting-
list control condition (Th ü nker & Pietrowsky, 2012).
IRT led to a decrease in nightmare frequency in all
three nightmare groups suggesting that IRT can be
effective for many different types of nightmare suf-
ferers, though participants with primary nightmares
showed the greatest benefi t from IRT.
Polysomnography has been utilized in a couple
studies to assess whether IRT leads to changes in
sleep architecture in addition to nightmares.
Germain and Nielsen (2003a) examined the impact
of one session of IRT on nightmare frequency, psy-
chological distress, and sleep quality (measured by
polysomnography) in an uncontrolled study. At
follow-up approximately 2 months post-treatment,
participants had signifi cantly fewer nightmares
(d 1.06) and signifi cantly fewer anxiety symp-
toms (d 1.01) than prior to treatment. However,
reductions in depressive symptoms (d 0.79) and
nightmare distress (d 0.9) failed to reach signifi -
cance. Polysomnography revealed no signifi cant
difference in the percentage of sleep that was
REM sleep, REM latency, or REM density post-
treatment. Building upon this work, Germain and
colleagues (2012) compared prazosin, a behav-
ioural sleep intervention consisting of IRT and cog-
nitive behavioural therapy for insomnia, and
placebo in a sample of 50 veterans. The authors
Table 2. Psychotherapeutic treatments for nightmares.
Intervention Explanation
Imagery rehearsal
therapy
Cognitive behavioural therapy in
which the patient rescripts the
nightmare any way he or she wants
and then practises the new dream
using imagery.
Exposure, relaxation,
and rescripting
therapy
Cognitive behavioural therapy that is
designed for trauma-related
nightmares that combines imagery
rehearsal therapy with exposure and
relaxation therapy.
Lucid dreaming Therapy that helps individuals
recognize when they are dreaming
and then instructs them in how to
change their dream while they are
having it.
Systematic
desensitization
A gradual exposure method where an
individual utilizes relaxation
techniques while being exposed to a
hierarchy of fears.
Exposure Involves the individual confronting
him- or herself with his or her
nightmare until it is no longer
causing the individual signifi cant
distress.
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232 M. R. Nadorff et al.
found no signifi cant changes over time for sleep
latency, wake after sleep onset, or sleep effi ciency.
However, the authors found that the brief sleep
intervention and prazosin both outperformed pla-
cebo in global improvements, sleep continuity, and
nightmare frequency. Similar to Germain and col-
leagues, Lancee et al. (2010a) compared IRT to an
active treatment. In their study, IRT was compared
with an exposure and recording intervention utiliz-
ing a self-help format. Additionally, a waiting-list
control was recruited. IRT and exposure were
found to be equally effective, with both active treat-
ments outperforming a waiting-list control.
Although many studies have found positive results,
there are a few studies in which IRT has either not
shown an effect, or had a delayed effect. Cook and
colleagues (2010) compared IRT to a credible active
comparison condition (psycho-education and ele-
ments of cognitive behavioural therapy for insomnia)
in 124 male Vietnam war veterans with PTSD.
Contrary to the previous literature, the authors found
that IRT did not outperform the comparison group
for nightmare frequency, sleep quality, or PTSD
symptoms. Similarly, Lu and colleagues examined
IRT in 15 male US veterans with PTSD and night-
mares related to traumatic experiences. The authors
found that at post-treatment there were no observed
treatment benefi ts. However, treatment gains emerged
at both the 3- and 6-month follow-ups with night-
mare frequency being signifi cantly reduced at both
time points and PTSD symptoms being signifi cantly
reduced at 3 months.
In sum, there is a large body of literature suggest-
ing that IRT is effective in treating nightmares. IRT
has been shown to decrease nightmare frequency
(and in some cases, severity) in children, adolescents,
adults, and veterans. Further, several studies suggest
that treating nightmares with IRT may also improve
sleep quality and reduce symptoms. Recently,
Casement and Swanson (2012) conducted a meta-
analysis on IRT s effect on PTSD and nightmares,
nding that IRT decreased nightmare frequency and
PTSD symptoms.
Lastly, since nightmares and insomnia are often
co-morbid, the question of whether insomnia treat-
ment should be added to nightmare treatment arises.
Casement and Swanson (2012) examined whether a
combination of IRT and cognitive behavioural ther-
apy for insomnia was more effective than just IRT
alone in helping alleviate sleep disturbances. They
found that even combining IRT with insomnia treat-
ment was not more effective for treating nightmares
than IRT alone, this treatment combination does
show better results in overall sleep quality improve-
ment. Thus, in cases where both nightmares and
insomnia are present, a combined treatment approach
may be indicated.
Exposure, relaxation, and rescripting therapy
Exposure, relaxation, and rescripting therapy (ERRT)
is a cognitive behavioural therapy designed for trau-
ma-related nightmares that combines IRT with
exposure and relaxation therapy. ERRT also contains
a model aimed at modifying maladaptive sleep habits
and educating the patient about trauma. Trauma-
related themes are also a focus of ERRT, but are not
a main component of IRT (Davis, 2009). For recent
reviews please see Augedal and colleagues (2013)
and Hansen and colleagues (2013).
In a randomized controlled trial of 43 participants
who had experienced a trauma and nightmares were
randomly assigned to either EERT or a no-contact
waiting-list control, EERT signifi cantly outperformed
the control condition in frequency and severity of
nightmares and PTSD scores between pre-treatment
and 6-month follow-up. In a second randomized
controlled trial of 47 participants randomized to
either treatment or waitlist control (Davis et al.,
2011) there were signifi cant improvements in both
frequency and severity of nightmares and symptoms
of depression, PTSD, sleep quality, physical health,
and dissociation at 6-month follow-up. Thus, there
is a small but growing literature supporting the effi -
cacy of EERT in the treatment of trauma-related
nightmares. However, further research is needed to
determine whether EERT provides any clear benefi t
above and beyond the effects of IRT.
Lucid dreaming
Lucid dreaming helps individuals recognize when
they are dreaming and then instructs them in how to
change their dream while they are having it. Two
aspects of lucid dreaming are reality testing and
dream signs, which are events that do not occur in
real life (The Lucidity Institute, 1993). Once the
individual is able to recognize when they are dream-
ing, the individual is then taught to change the dream
while experiencing it so that the ending is positive.
To date, other than case reports, there have only
been a handful of studies investigating the effi cacy of
lucid dreaming therapy on nightmares (Spoormaker
& van den Bout, 2006). In the fi rst study, 23 night-
mare sufferers were randomly assigned to either a
2-hour individual lucid dreaming treatment session,
a 2-hour group lucid dreaming treatment session, or
a waiting-list control group. At post-test (12 weeks
after treatment), participants receiving both the
individual and group treatment reported signifi cantly
fewer nightmares when compared to pre-treatment
baseline. However, there was no signifi cant difference
between the treatment and control groups, and no
signifi cant change in sleep quality or PTSD symptom
severity. In the second study, Lancee and colleagues
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Treatments for nightmare disorder 233
(2010c) compared IRT, IRT and sleep hygiene, IRT
and lucid dreaming, and waiting-list control. Sur-
prisingly, IRT alone was shown to be more effective
than the other two treatment conditions, and was the
only treatment condition that resulted in a signifi cant
improvement in nightmares compared to the control
group.
The lucid dreaming approach differs signifi cantly
from the other nightmare treatments. Instead of
trying to reduce the frequency or severity of night-
mares, it attempts to stop nightmares mid-way
through. Thus, it is possible that lucid dreaming may
be better tolerated than other nightmare treatments.
However, more research is needed before lucid
dreaming can be considered for treating nightmare
disorder.
Systematic desensitization
Systematic desensitization is a gradual exposure
method where an individual utilizes relaxation
techniques while being exposed to a hierarchy of
fears, and was one of the fi rst nightmare treatments
(Cellucci & Lawrence, 1978; Miller & DiPilato,
1983). Cellucci and Lawrence (1978) recruited 29
undergraduate students who reported having at least
two nightmares per week. The participants were ran-
domly assigned to either fi ve sessions of systematic
desensitization, placebo (a nightmare discussion
group), or continuous tracking of nightmares. The
systematic desensitization treatment group had a sig-
nifi cantly greater improvement in nightmare frequency
when compared to the placebo. Miller and Dipilato
(1983) used systematic desensitization to treat 32
self-referred nightmare sufferers, who reported
suffering an average of nine nightmares per month.
Immediately after treatment there were signifi cant
decreases in nightmare frequency for both systematic
desensitization and relaxation training, when com-
pared to the waiting-list group. After 25 weeks night-
mare intensity was found to be signifi cantly reduced
in the systematic desensitization group.
These studies support the use of systematic desen-
sitization for nightmare treatment. However, more
research is needed before systematic desensitization
can be considered empirically supported for treating
nightmare disorder.
Exposure
In addition to being a component of other nightmare
treatments, exposure therapy has also been examined
on its own as a treatment for nightmare disorder.
Treating nightmares through exposure involves
confronting an individual with his or her nightmare
until it is no longer causing the individual signifi cant
distress. Burgess and colleagues (1998) investigated
the effi cacy of using a self-administered exposure
treatment in 107 nightmare sufferers who met
DSM-III-R criteria for recurrent nightmares.
The participants were randomized into either a self-
exposure, self-relaxation, or waiting-list control
group. Participants in the self-exposure group had a
signifi cantly greater reduction in nightmares
(d 1.18) at one and six months post-treatment
when compared with the self-relaxation and waiting-
list groups. Additionally, those who received the self-
exposure treatment also experienced a signifi cant
reduction in their depressive symptoms (d 0.76).
Grandi and colleagues (2006) also investigated the
effi cacy of a self-exposure treatment for nightmares,
nding that the exposure treatment signifi cantly
reduced not only nightmare frequency and intensity,
but also symptoms of anxiety, depression, and sleep-
lessness at the post-treatment follow-up. Remarkably,
most of the gains were maintained over 4 years.
Although more research is needed, both studies
that examined use of self-administered exposure
found strong positive results. However, both relied
on participants doing a signifi cant amount of
homework each day (30 60 min), which may affect
compliance and may even be impossible for some
nightmare sufferers.
Conclusions and future directions
In summary, both prazosin and IRT are empirically
supported treatments for nightmares. However, addi-
tional research is needed to enhance response and
remission rates following treatment completion or
discontinuation, and to examine the extent to which
nightmare treatments are effective in treating
nightmares that are co-morbid with other forms of
psychopathology.
To the best of our knowledge no study has directly
compared prazosin and IRT, but a recent study by
Germain and colleagues (2012) that compared pra-
zosin to a brief behavioural intervention that included
IRT found no signifi cant differences between the
treatments. Similarly, a recent meta-analysis (Augedal
et al., 2013) found no signifi cant difference between
IRT and prazosin. This literature suggests that both
prazosin and IRT are effective in treating nightmares
in individuals with PTSD. However, unlike IRT, pra-
zosin has not been studied in treating idiopathic night-
mares. Thus, randomized controlled trials are
warranted to evaluate the effi cacy of prazosin for idio-
pathic nightmares. Further, and given that psycho-
logical nightmare treatments seem to have more
durable effects than prazosin or other agents that
require long-term use (Augedal et al., 2013), psycho-
logical treatments may be a better fi rst-line treatment
for nightmares. Fewer side effects have also been
reported in psychotherapeutic trials, although side
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234 M. R. Nadorff et al.
effects tend to be less closely monitored in these trials.
Finally, the effi cacy of combined IRT and prazosin
remains unknown, but may be especially promising
for reducing chronic, treatment-resistant nightmares.
There are several promising directions for future
investigations. First, as discussed previously, there is
a need for studies examining whether prazosin is
effective in treating idiopathic nightmares and
nightmares co-morbid with other conditions such as
depression or suicidality. For instance, the treatment
of nightmares in those at elevated suicidal risk or
with past attempts may improve clinical outcomes
over time. In a related manner, nightmare treatments
combined with other fi rst-line pharmacological or
psychological treatments of PTSD may facilitate
adherence and improve clinical outcomes.
Declaration of interest: This research study was
supported by the US Department of Defense Con-
gressionally Directed Medical Research Program
(PR054093 & PT073961; PI: Germain). The views
expressed in this article are those of the authors, and
do not represent the offi cial policy or position of the
US Department of Defense or the US Government.
The authors report no confl icts of interest. The
authors alone are responsible for the content and
writing of the paper.
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... 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). ...
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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.
... 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]. ...
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... 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. ...
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... 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]. ...
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... 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. ...
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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). ...
Article
Full-text available
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.
Chapter
“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.
Chapter
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.
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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.
Article
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.
Article
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.
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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.
Article
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.
Article
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.
Article
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.