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Pharmacological and non-pharmacological treatments for nightmare disorderInternational Review of Psychiatry, April 2014; 26(2): 225–236 Pharmacological and non-pharmacological treatments for nightmare
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.
form of parasomnia (Levin & Nielsen, 2007). Night-mares primarily occur during rapid eye movement Nightmares have long been discussed in the context (REM) sleep, and hence are more common during of mental health (Freud, 1955) and this interest in the second half of the night (American Academy of nightmares has re-emerged in recent years as clini- Sleep Medicine, 2006). The fact that nightmares cally relevant sleep disorders have been identifi ed as For personal use only.
occur in REM sleep differentiates them from night a common risk factor for mental disorders. Further, terrors, a parasomnia that occurs in non-REM sleep research has demonstrated that the relation between nightmares and negative outcomes are often inde- The DSM-5 (APA, 2013) and ICSD-2 diagnostic pendent of co-morbid disorders such as post- criteria for nightmare disorder are similar in many traumatic stress disorder (PTSD), depression, and ways. Both diagnostic systems require nightmares to anxiety (Nadorff et al., 2011, 2013a; Sj ö str ö m et al., be repeated negative dreams that awaken the indi- 2009). Concurrently to these observations, there vidual from the nightmare, making the individual has been a substantial growth in the literature on rapidly alert and aware of his or her surroundings. effective nightmare treatments. The current review The DSM-5 requires that the nightmares not be bet- will provide a brief discussion of nightmare disorder ter explained by substance use or medication, which and the relation between nightmares and psychopa- Int Rev Psychiatry Downloaded from informahealthcare.com by MSU Coll Veterinary Med on 06/04/14 is not required by the ICSD-2. On the other hand, thology before examining the leading pharmacologi- the ICSD-2, but not the DSM-5, requires the indi- cal and therapy-based treatment options for nightmare vidual to have diffi culty falling back asleep, or for the disorder. Lastly, we review some potential areas of nightmare to occur in the latter half of the night. growth for nightmare treatments as well as potential Bad dreams, which are negative dreams that do novel uses for these therapies. 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 Defi nition of nightmares
nightmares are quite similar, as both require the Nightmares, defi ned as vivid, disturbing, or frighten- recall of a negative dream, and both have been shown ing dreams that awaken the individual, are a common to be associated with sleep disruption and adverse 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: email@example.com. (Received 18 October 2013; accepted 26 January 2014) ISSN 0954–0261 print/ISSN 1369–1627 online 2014 Institute of PsychiatryDOI: 10.3109/09540261.2014.888989 226 M. R. Nadorff et al. daytime consequences (Duval et al., 2013; Nadorff Contemporary theorists have put forth ideas about et al., 2014; Zadra & Donderi, 2000) Due to their the aetiology of nightmares, although little evidence similarities, many researchers combine bad dreams supporting the theories exists. Despite this fact, a and nightmares (Levin & Nielsen, 2007). From a review of the current theories is still warranted, espe- treatment perspective, both nightmares and bad cially given that some of the nightmare treatments dreams can be effectively reduced with pharmaco- are based upon these theories. logical and behavioural treatments targeting negative After studying the histories of many nightmare sufferers from the psychoanalytic perspective, Although nightmares are most common in child- Hartmann (2001) concluded that nightmares are hood, they are prevalent across the lifespan (Levin & ‘ thin boundaries ' . Thin boundaries Nielsen, 2007). Research suggests that bad dreams refer to ‘ the lack of separation between areas and are more prevalent than nightmares (Zadra processes in the mind, and also a lack of walls and Donderi, 2000), though research examining the defense ' (Hartmann, 2001). Supporting this the- prevalence of bad dreams throughout the lifespan is ory, Hartmann (1989) found that thin boundaries lacking. It is estimated that 19% of children experi- were positively correlated with remembering ence nightmares at least once per week (Schredl one ' s dreams, which may lead to remembering et al., 2008). Although nightmares are often viewed one ' s nightmares. Similarly, other researchers as a childhood sleep disorder, research suggests that have also found that thin boundaries are associated nightmares may persist into adulthood, and are a with dream recall, more negative and emotionally function of age and sex. Studies examining night- intense dreams, and regarding one's dreams to be mares in adults have found nightmare disorder prev- meaningful (Schredl et al., 1999). alence rates ranging from 2 – 6%. This prevalence Cartwright (2001) articulated a different view of range is highly consistent across cultures, with nightmares, focusing on emotion processing instead similar rates having been found in the USA, Canada, of boundaries. She stated that when a traumatic France, Iceland, Sweden, Belgium, Finland, Austria, event occurs, an individual may be unable to handle Japan, and the Middle East (Levin & Nielsen, 2007). all of the resulting emotions at that time. Therefore, Women report more monthly nightmares than men nightmares may emerge in order to help process the up until age 60, at which point there is no signifi cant emotions caused by the trauma. gender difference. For women, the rate of nightmares Taking a more biological approach, Levin and signifi cantly increases from ages 10 – 19 to ages 20 – Nielsen (2007) published the AMPHAC/AND For personal use only.
39, then steadily decreases to ages 50 – 59, and after neurocognitive model of disturbed dreaming. The age 60 the rate of nightmares stays constant. For model seeks to explain disturbed dreaming at both men, the rate of nightmares increases from ages 10 – physiological and cognitive levels. The model posits 19 to 30 – 39, and then and decreases from 30 – 39 to that the physiological and cognitive levels serve the 50 – 59 (Nielsen et al., 2006). function of fear-memory extinction during normal Very little research has examined the prevalence of dreaming. In this process, components of fearful nightmares among older adults. However, the events are combined in a new way with non-fearful research that has been done suggests that nightmares memories, disarming the memories. However, for may be less common among older adults compared individuals with signifi cant distress (especially those with children and younger adults. In a study compar- who are predisposed to be sensitive to distress), the ing older adults and college students, only 4.3% of fearful memories may not be altered, or may be Int Rev Psychiatry Downloaded from informahealthcare.com by MSU Coll Veterinary Med on 06/04/14 older adults reported having a problem with night- altered in a way even more frightening than the orig- mares, which was signifi cantly less than the 19.5% inal memory, leading to disturbing dreams (Levin & of college students in the study reporting having a Nielsen, 2009). The AMPHAC/AND model is con- nightmare problem (Salvio et al., 1992). sistent with the activation-synthesis hypothesis of dreaming (Hobson & McCarley, 1977), which is one of the most widely-accepted theories of normal Dream and nightmare theories
dreaming. The activation synthesis hypothesis postu- It is often helpful to have a theoretical framework in lates that dreaming is an event that is physiologically order to understand a disorder and its effects. How- shaped by the sections of the brain that are activated ever, nightmares have historically received little during sleep. In an attempt to make sense of the attention from theorists or researchers. Even Freud, activation, the brain synthesizes the impulses into a who did a considerable amount of work on dreams, narrative, which we experience as dreams. rarely discussed nightmares. In his book The Inter- Nightmares have also been viewed through a pretation of Dreams , Freud only mentions nightmares cognitive behavioural lens. The cognitive behavioural twice, and neither time did he provide a theory as to theory of nightmares posits that nightmares cause why individuals have nightmares (Freud, 1955). sleep avoidance behaviours (Krakow et Treatments for nightmare disorder 227 St-Onge et al., 2009). In this theory the nightmare rated their nightmares as being more distressing is considered to be a conditioned stimulus that causes (Germain & Nielsen, 2003b). a conditioned avoidance response. The awakening Nightmares may also infl uence the development of then reinforces the belief that the only way to avoid PTSD following trauma exposure. PTSD symptoms nightmares is to remain awake, which leads to the are more severe among individuals who reported nightmare sufferer developing other behaviours to having nightmares prior to the traumatic event than avoid sleep. Put simply, an individual may wake up among individuals who did not report experiencing and thereby escape from having the nightmare, which nightmares prior to the trauma (Mellman et negatively reinforces the awakenings that are serving 1995). Similarly, Ohayon and Shapiro (2000) and as an avoidance response. However, the avoidance of Bryant and colleagues (2010) found that pre-trauma the nightmare increases sleep fragmentation, making sleep disturbances increased the risk of developing an individual more likely to remember their dreams, PTSD (and other psychiatric disorders), among large perpetuating the nightmare problem. Additionally, it populations. Mellman and colleagues (2001) found is possible that avoiding the nightmare may prevent having nightmares of the trauma shortly after the exposure to the nightmare, potentially explaining event was related to more severe PTSD symptoms why nightmares persist. six weeks later. Similar fi ndings have also been reported by Kobayashi and colleagues (2008). These fi ndings suggest that nightmares and other sleep dis- Negative consequences of nightmare
turbances (e.g. insomnia) may be confer heightened disorder
vulnerability for poor psychiatric outcomes following trauma exposure. Thus, nightmares – or more gener- Although the most well-known co-morbidity is post- ally, sleep disturbances – and PTSD may arise from traumatic stress disorder, nightmares are also common psychophysiological or neural mechanisms related to other psychiatric disorders, such as (Germain et al., 2008; Levin & Nielsen, 2007). insomnia and borderline personality disorder (APA, 2013). Additionally, nightmares may be a precursor to psychopathology (Mellman et al., 1995; Ohayon Anxiety and depression symptoms & Shapiro, 2000; Sj ö str ö m et al., 2009), and have Nightmares have been shown in clinical samples to been shown to independently contribute to poor be related to anxiety and depressive symptoms psychiatric outcomes. As such, nightmares have throughout the lifespan (Levin & Nielsen, 2007; For personal use only.
great clinical relevance for both prevention and Nadorff et al., 2013a, 2014). However, some com- treatment efforts. Further, nightmares can also munity studies have failed to fi nd this result (Lancee affect more than just the nightmare sufferer, it can et al, 2010b; Spoormaker & van den Bout, 2005), also affect the sufferer ' s bed partner. For example, suggesting that the relation may be driven by those there is a relation between relationship satisfaction with clinically signifi cant anxiety. Nielsen and col- and sleep disorders or prolonged sleep disturbances leagues (2000) found that disturbing dreams were (Troxel et al., 2007), suggesting that the presence associated with anxiety among adolescents. Night- of sleep disorders can put signifi cant strain on a 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 Int Rev Psychiatry Downloaded from informahealthcare.com by MSU Coll Veterinary Med on 06/04/14 Post-traumatic stress disorder adults as well. A recent study of older adults present- Nightmares have a strong association with PTSD ing to a family medicine clinic found a very high (Harvey et al., 2003; Kilpatrick et al., 1994; Mellman correlation between nightmares and depressive symp- et al., 1995; Ohayon & Shapiro, 2000; Ross et al., toms (0.70) (Nadorff, 2013a). Additionally, although 1989). The nightmares observed in PTSD (some- the prevalence of nightmares among older adults is times referred to as traumatic nightmares) can be just above 4% (Salvio et al., 1992), older adults with re-enactments of the traumatic event or can be the- clinically signifi cant depressive and anxiety symp- matically or emotionally related to the original toms had nightmare prevalence rates of 11.4% and trauma, and are consistent with the re-experiencing 17.1%, respectively (Mallon et al., 2000). Relatedly, symptom cluster of PTSD (APA, 2013). Nightmares a recent secondary data analysis of a generalized are often chronic symptoms of PTSD: two studies anxiety disorder (GAD) randomized clinical trial examining war veterans found that nightmares found that the presence of a GAD diagnosis was persisted up to 50 years following the traumatic signifi cantly associated with higher levels of bad experience (Guerrero & Crocq, 1994; Kaup et al., dream frequency, with 21.6% of those with a GAD 1994). Compared to individuals with idiopathic diagnosis reporting weekly bad dreams (Nadorff nightmares, those with PTSD-related nightmares 228 M. R. Nadorff et al. Dissociative disorders Nightmares have also been examined in relation to suicide attempts. Sjostrom et al. (2007) studied Dissociative disorders have been linked to acute 165 patients who had been admitted to the hospital stress disorder and PTSD (Agargun et al., 2003b), following a medically serious suicide attempt. which suggests that they may be associated with Although insomnia was the most common sleep nightmares as well. Agarun and colleagues (2003) complaint, two thirds of participants also reported found that 57% of individuals with a dissociative dis- having nightmares. A regression analysis revealed order met criteria for a nightmare disorder. Individ- that nightmares were signifi cantly associated with uals who reported nightmares also had more higher scores of suicidality, defi ned as the risk of dissociative symptoms than did individuals without attempting suicide, after adjusting for the presence nightmares. In a sample of 292 undergraduate stu- of depression, anxiety, substance use, and PTSD dents those who reported having nightmares scored diagnoses. Further, a follow-up study found that signifi cantly higher on the Dissociative Experiences persistent nightmares predicted suicide attempts in Scale than those who did not report having night- the next two years in the same sample after control- mares (Agargun et al., 2003). Similarly, Semiz, et al. ling for the disorders listed above (Sj ö str ö m et al., (2008) found a signifi cant correlation (0.43) between the Dissociative Experiences Scale and nightmare Nightmares are also related to death by suicide. frequency among individuals with borderline person- al. (2001) examined the relation between nightmares and death by suicide in a prospective study conducted in Finland. When Borderline personality disorder compared with individuals without nightmares, those reporting occasional nightmares were at 57% Researchers have also found a link between greater risk of death by suicide. Further, participants nightmares and borderline personality disorder. In reporting frequent nightmares were at 107% greater Hartmann ' s (1981) sample of adults with weekly risk of suicide compared to those without nightmares. nightmares, he found that 24% met DSM-III criteria This study suggests that nightmares are potentially a for borderline personality disorder. Relatedly, Semiz risk factor for suicide. and colleagues (2008) compared a sample of 88 In summary, nightmares are a prevalent condition participants diagnosed with borderline personality that may confer heightened vulnerability to poor disorder with age and sex-matched controls, fi nding psychiatric outcomes that are often co-morbid with For personal use only.
that the patients with borderline personality disorder psychiatric conditions, and can independently exac- reported more nightmares, greater dream anxiety, erbate clinical outcomes in affected individuals. Thus, and more disturbed sleep than the control partici- targeting nightmares with effective treatment may be pants. Further, those with borderline personality an important component of prevention efforts aimed disorder and a nightmare disorder exhibited more at high-risk samples, and of intervention for indi- severe psychopathology than those with borderline viduals with primary or co-morbid nightmares. personality disorder but without nightmare disorder. Nightmares have also been shown to be associated with borderline personality traits. Claridge et (1998) found that nightmare distress correlated Nightmare treatment
strongly (0.42) with the Borderline Personality Scale Given the strong association between nightmare dis- Int Rev Psychiatry Downloaded from informahealthcare.com by MSU Coll Veterinary Med on 06/04/14 in a sample of 60 undergraduate women. order and subsequent psychiatric complications, nightmares are increasingly being recognized as an important target for treatment, and not only as a Suicidality and suicidal behaviour ‘ secondary ' symptom of psychopathology. Thus, the A rapidly growing literature suggests that nightmares remainder of this paper examines the pharmacologi- ' s risk of suicidality and suicidal cal and psychotherapeutic treatments for nightmare behaviour across the lifespan (Nadorff et al., 2013a; disorder and nightmares co-morbid with other con- al., 2013). Krakow and colleagues ditions. Novel uses of nightmare treatments and tar- (2000) were the fi rst to mention this association in gets for future research are also proposed. their study of female sexual assault survivors who took part in a nightmare treatment study, fi nding that Pharmacological treatments 43% of the sample reported suicidal ideation at intake. Cukrowicz and colleagues (2006) built upon Recently there has been an increased focus on phar- this work through fi nding that nightmares were asso- macological treatments for nightmares, including ciated with suicidal ideation independent of insom- several recent reviews of this literature (Augedal et al., 2013; Aurora et al., 2010; Kung et al., 2012). Treatments for nightmare disorder 229 Despite numerous case reports, open-label trials, and well tolerated, with only two participants reporting randomized controlled clinical trials (see Maher side effects, of mild decreases in blood pressure or et al., 2006, for review), only prazosin has consis- dizziness. Further, there was a signifi cantly larger tently shown effi cacy for the treatment of nightmares reduction in nightmares during the prazosin trial and distressed awakenings. Therefore, prazosin (severity score on the nightmare item of the Clinician was the only medication that was recommended or Administered PTSD Scale [CAPS] reduced from suggested in the latest best practice guidelines for 6.9 to 3.6) than was found during the placebo trial treating nightmare disorder (Aurora et (from 7.1 to 6.7 on the nightmare item of the Thus, our review of pharmacological therapies for nightmare disorder primarily focuses on prazosin, Raskind and colleagues (2007) built upon the but other medications that may be worth consider- previous study in a larger parallel group placebo- ation for future research are also mentioned below. 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 Prazosin placebo conditions for a period of 8 weeks. Prazosin Prazosin is a sympatholytic medication that is FDA- over 8 weeks resulted in a large effect size reduction approved to treat high blood pressure, though it is in distressing dreams and signifi cantly outperformed also used off-label to treat PTSD. Prazosin is an ' s d effect size alpha-1 adrenergic receptor antagonist that crosses However, it should be noted that there was no dif- the blood – brain barrier, and as such is thought to ference between the conditions after 4 weeks of treat- reduce noradrenergic tone during sleep (Feldman & ' s d effect size Weidenfeld, 1996; Hilakivi, 1983; Mallick et Dizziness upon standing was reported by 15 partici- 2005; Raskind et al., 2000; Taylor & Raskind, 2002). pants (nine in the prazosin condition, six in the pla- Recent best practice guidelines from the American cebo condition). There were no signifi cant changes Academy of Sleep Medicine give prazosin a level A in blood pressure for participants in the prazosin recommendation, meaning that prazosin is supported condition between baseline and the end of the study. by a great deal of high quality research (American Thompson and colleagues (2008) examined a related Academy of Sleep Medicine, 2001). Similarly, the question: does prazosin reduce non-nightmare dis- Veterans Administration recommends the use of pra- tressed awakenings in veterans with PTSD. Utilizing zosin to improve sleep quality and reduce trauma night- a chart review of 22 veterans, the authors found sig- For personal use only.
mares (US Department of Veterans Affairs, 2010). nifi cant reductions in trauma nightmares on the Five randomized controlled trials examining the CAPS nightmare item (Cohen ' s d effect size ⫽ 0.56, effect of prazosin on trauma-related nightmares that p ⬍ 0.05), sleep diffi culty on the CAPS D-2 item have been conducted to date (see Table 1 and Kung (Cohen ' s d effect size ⬍ 0.01), and non- et al., 2012 for a full review of this literature). nightmare distressed awakenings (Cohen Raskind and colleagues (2003) compared prazosin size ⫽ 1.49, p ⬍ 0.01). ⫽ 9.5 mg) to placebo in 10 Vietnam The literature was expanded to a civilian sample combat veterans with PTSD diagnoses using a in a study by Taylor and colleagues (2008). The study 20-week double-blind crossover design. Prazosin was consisted of 13 civilians with chronic trauma PTSD, Table 1. Main characteristics of prazosin studies. Int Rev Psychiatry Downloaded from informahealthcare.com by MSU Coll Veterinary Med on 06/04/14 Duration of treatment Germain et al., 2012 Raskind et al., 2003 Placebo (10) Crossover design Raskind et al., 2007 Raskind et al., 2013 Thompson et al., 2008 Taylor et al., 2008 Placebo (13) Crossover design 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). 230 M. R. Nadorff et al. frequent nightmares, and disturbed sleep. The study limitations to this literature worth noting. First, most spanned 7 weeks and consisted of 3-week trials of of the RCT studies involve the same research team. both prazosin and placebo with a 1-week washout Thus, the literature could be strengthened through period in between. The order of the trials was ran- replication by other research groups. There is also a domly assigned and both the experimenters and par- lack of studies examining the extent to which pra- ticipants were blind to the condition. Similar to zosin may be effective in treating idiopathic night- previous studies (Raskind et al., 2007), prazosin mares, or nightmares co-morbid with depression or resulted in large effect size reductions on the CAPS suicidality, for instance. Only the study by Germain nightmare item (Cohen ' s d ⫽ 0.96) and also resulted and colleagues (2012) included individuals without in a large effect size reduction on the PTSD dream PTSD, but this study was also limited by the inclu- rating scale (Cohen ' s d ⫽ 1.4). Further, prazosin out- sion of military veterans, the majority of whom met performed placebo on both nightmare measures criteria for PTSD. Thus, further research is needed (p ⫽ 0.04 – 0.006). to determine whether prazosin is indicated for non- Recently, a different research team from the previ- PTSD nightmares, and replications are warranted in ous three studies compared prazosin, a behavioural larger civilian samples. Lastly, nightmares may recur sleep intervention targeting insomnia and night- upon cessation of prazosin, though this was not seen mares, and a placebo (Germain et al., 2012). The in all samples (Germain et al., 2012) and may be due study consisted of 50 military veterans (mean age to differences in chronicity and co-morbidities 40.9) who were randomly assigned to receive pra- between samples. ⫽ 18), BSI (n ⫽ 17), or placebo (n with each intervention having an 8-week duration. Other pharmacological agents This study signifi cantly built upon the literature in several signifi cant ways, (1) it is the fi rst study to Although no other medication has the empirical sup- compare prazosin to a cognitive behavioural therapy, port of prazosin, there are several other medications (2) the study incorporated data from polysomno- that have been examined as potential nightmare graphic studies, and (3) participants with PTSD treatments (e.g. clonidine, trazodone, risperidone; symptoms but not necessarily with full blown PTSD see Maher (2006) for review). Despite the existence were included (58% of the sample met DSM-IV cri- of effective pharmacological treatments, benzodiaz- teria for PTSD). Germain and colleagues (2012) epines are often utilized despite having been shown found that both prazosin (1.0 to 0.3) and the behav- to be ineffective in reducing nightmares (Maher For personal use only.
ioural sleep intervention (0.9 – 0.0) signifi cantly et al., 2006). In a small crossover clinical trial (N ⫽ 6), reduced nightmare frequency greater than placebo clonazepam failed to show signifi cant improvement (0.4 to 0.5) on prospective sleep diary measures of in any sleep symptom, including nightmare frequency nightmare frequency. There were no signifi cant dif- (Cates et al., 2004). Similarly, in another small cross- ferences between the active treatment groups, though over clinical trial (N ⫽ 10), alprazolam failed to affect this may have been due to insuffi cient power to detect nightmares. Thus, the small literature examining the this effect. The authors report that there were no treatment of benzodiazepines in treating nightmares signifi cant changes in blood pressure for the prazosin suggests that they are ineffective. and placebo groups, and that the frequency of side effects did not differ across the groups. Psychotherapeutic interventions
More recently, Raskind and colleagues (2013) Int Rev Psychiatry Downloaded from informahealthcare.com by MSU Coll Veterinary Med on 06/04/14 recently completed a 15-week randomised controlled There have been several psychological interventions trial (RCT) comparing the effects of prazosin to pla- that have been used to treat nightmares (see Table 2, cebo. The study consisted of 67 active duty service and for recent reviews see Augedal et members who met DSM-IV criteria for combat- Hansen et al., 2013). Due to the presence of these related PTSD. Similar to several previous studies, the recent reviews, the focus of this review is on the treat- outcome measure was the nightmare item on the ments most likely to be used in clinical practice. CAPS. The prazosin group had a signifi cantly greater reduction on the nightmare item between baseline Imagery rehearsal therapy and week 15 (6.0 to 2.9) than placebo (6.6 to 5.4) on the CAPS nightmare item. Similar to previous Imagery rehearsal therapy (IRT) is a cognitive behav- studies, prazosin was well tolerated and blood pres- ioural therapy in which the patient rescripts the sure did not differ between baseline and the end of nightmare anyway he or she wants and then practises the study, nor did it differ by treatment group. the new dream using imagery. Since the dream can In summary, the literature to date demonstrates be rescripted in any way, and does not have to con- cacy of prazosin for the treatment of tain material from the disturbing dream, IRT is not PTSD-related nightmares. However, there are a few considered an exposure-based therapy. Rather, IRT Treatments for nightmare disorder 231 Table 2. Psychotherapeutic treatments for nightmares. ⫽ 9) or control (n ⫽ 10) group. After three months, the treatment group reported a 71% decrease in nightmare frequency (d ⫽ 1.7) whereas Imagery rehearsal Cognitive behavioural therapy in there was no change in the control group. However, which the patient rescripts the there was no signifi cant difference between the nightmare any way he or she wants groups in PTSD symptoms (d ⫽ 0.22 for the treat- and then practises the new dream ment group and 0.27 for the control group). using imagery.
Exposure, relaxation, Cognitive behavioural therapy that is Forbes and colleagues (2003) were the fi rst to designed for trauma-related study IRT in a sample of military veterans. Their nightmares that combines imagery sample consisted of 12 Australian Vietnam veterans rehearsal therapy with exposure and who had been treated for PTSD in the past but were relaxation therapy.
still having at least one trauma-related nightmare per Therapy that helps individuals recognize when they are dreaming week. At post-treatment there were signifi cant reduc- and then instructs them in how to tions in nightmare frequency (d ⫽ 0.70), nightmare change their dream while they are intensity (d ⫽ 0.55), depression symptoms (d ⫽ 0.43), and anxiety symptoms (d ⫽ 0.20). All of the signifi - A gradual exposure method where an cant treatment gains were still present at the 1-year individual utilizes relaxation techniques while being exposed to a follow-up, showing that IRT had a lasting impact in hierarchy of fears.
this sample. Nappi and colleagues (2010) extended Involves the individual confronting the work done by Forbes and colleagues (2003) by him- or herself with his or her testing imagery rehearsal therapy in a larger sample nightmare until it is no longer of 58 veterans. At the end of treatment there was a causing the individual signifi cant distress.
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, is based on the concept that nightmares are a learned IRT has also been shown to be effective in different behaviour (Krakow, 2002, p. 18). Therefore, they can types of nightmare sufferers. Three groups of night- be replaced by a less disruptive behaviour, which in mare sufferers – primary nightmare sufferers, night- this case, is a new dream that does not disrupt sleep mare sufferers with major depression, and nightmare or daytime functions. sufferers with PTSD – were compared to a waiting- For personal use only.
One of the fi rst investigations of IRT consisted of list control condition (Th ü nker & Pietrowsky, 2012). 20 individuals who were randomly assigned to treat- IRT led to a decrease in nightmare frequency in all ment or nightmare recording (Neidhardt et three nightmare groups suggesting that IRT can be 1992). Three months after treatment the authors effective for many different types of nightmare suf- found that although nightmare frequency signifi - ferers, though participants with primary nightmares cantly decreased in both groups, there was a signifi - showed the greatest benefi t from IRT. cantly greater reduction in the IRT group compared Polysomnography has been utilized in a couple to the recording group. Further, only the IRT group studies to assess whether IRT leads to changes in had a signifi cant difference in nightmare severity sleep architecture in addition to nightmares. after 30 months (Krakow et al., 1993). Krakow and Germain and Nielsen (2003a) examined the impact colleagues (2000) followed this study up with a large of one session of IRT on nightmare frequency, psy- Int Rev Psychiatry Downloaded from informahealthcare.com by MSU Coll Veterinary Med on 06/04/14 randomized controlled trial in a sample of 169 female chological distress, and sleep quality (measured by survivors of sexual assault with PTSD. This was the polysomnography) in an uncontrolled study. At fi rst study looking at the effect of IRT in a sample follow-up approximately 2 months post-treatment, with sub-threshold and full-blown PTSD. At 3-month participants had signifi cantly fewer nightmares follow-up nightmare frequency and PTSD symp- (d ⫽ 1.06) and signifi cantly fewer anxiety symp- toms were signifi cantly reduced relative to the con- toms (d ⫽ 1.01) than prior to treatment. However, trol group. Krakow and colleagues (2001a) provided reductions in depressive symptoms (d ⫽ 0.79) and later follow-up results from the previous study. The nightmare distress (d ⫽ 0.9) failed to reach signifi - IRT group evidenced improved sleep quality cance. Polysomnography revealed no signifi cant (d ⫽ 0.67), and reduced PTSD symptoms (d ⫽ 1.0) difference in the percentage of sleep that was relative to the control group. REM sleep, REM latency, or REM density post- Krakow and colleagues (2001b) extended the IRT treatment. Building upon this work, Germain and fi ndings by testing the theory in a sample of adoles- colleagues (2012) compared prazosin, a behav- cent girls who had suffered a sexual assault. The ioural sleep intervention consisting of IRT and cog- sample consisted of 19 adolescent girls at a treatment nitive behavioural therapy for insomnia, and facility who were randomly assigned to either the placebo in a sample of 50 veterans. The authors 232 M. R. Nadorff et al. found no signifi cant changes over time for sleep Exposure, relaxation, and rescripting therapy latency, wake after sleep onset, or sleep effi ciency. Exposure, relaxation, and rescripting therapy (ERRT) However, the authors found that the brief sleep is a cognitive behavioural therapy designed for trau- intervention and prazosin both outperformed pla- ma-related nightmares that combines IRT with cebo in global improvements, sleep continuity, and exposure and relaxation therapy. ERRT also contains nightmare frequency. Similar to Germain and col- a model aimed at modifying maladaptive sleep habits leagues, Lancee et al. (2010a) compared IRT to an and educating the patient about trauma. Trauma- active treatment. In their study, IRT was compared related themes are also a focus of ERRT, but are not with an exposure and recording intervention utiliz- a main component of IRT (Davis, 2009). For recent ing a self-help format. Additionally, a waiting-list reviews please see Augedal and colleagues (2013) control was recruited. IRT and exposure were and Hansen and colleagues (2013). found to be equally effective, with both active treat- In a randomized controlled trial of 43 participants ments outperforming a waiting-list control. who had experienced a trauma and nightmares were Although many studies have found positive results, randomly assigned to either EERT or a no-contact there are a few studies in which IRT has either not waiting-list control, EERT signifi cantly outperformed shown an effect, or had a delayed effect. Cook and the control condition in frequency and severity of colleagues (2010) compared IRT to a credible active nightmares and PTSD scores between pre-treatment comparison condition (psycho-education and ele- and 6-month follow-up. In a second randomized ments of cognitive behavioural therapy for insomnia) controlled trial of 47 participants randomized to in 124 male Vietnam war veterans with PTSD. either treatment or waitlist control (Davis et Contrary to the previous literature, the authors found 2011) there were signifi cant improvements in both that IRT did not outperform the comparison group frequency and severity of nightmares and symptoms for nightmare frequency, sleep quality, or PTSD of depression, PTSD, sleep quality, physical health, symptoms. Similarly, Lu and colleagues examined and dissociation at 6-month follow-up. Thus, there IRT in 15 male US veterans with PTSD and night- is a small but growing literature supporting the effi - mares related to traumatic experiences. The authors cacy of EERT in the treatment of trauma-related found that at post-treatment there were no observed nightmares. However, further research is needed to treatment benefi ts. However, treatment gains emerged determine whether EERT provides any clear benefi t at both the 3- and 6-month follow-ups with night- above and beyond the effects of IRT. mare frequency being signifi cantly reduced at both For personal use only.
time points and PTSD symptoms being signifi cantly reduced at 3 months. Lucid dreaming In sum, there is a large body of literature suggest- ing that IRT is effective in treating nightmares. IRT Lucid dreaming helps individuals recognize when has been shown to decrease nightmare frequency they are dreaming and then instructs them in how to (and in some cases, severity) in children, adolescents, change their dream while they are having it. Two adults, and veterans. Further, several studies suggest aspects of lucid dreaming are reality testing and that treating nightmares with IRT may also improve dream signs, which are events that do not occur in sleep quality and reduce symptoms. Recently, real life (The Lucidity Institute, 1993). Once the Casement and Swanson (2012) conducted a meta- individual is able to recognize when they are dream- analysis on IRT ' s effect on PTSD and nightmares, ing, the individual is then taught to change the dream Int Rev Psychiatry Downloaded from informahealthcare.com by MSU Coll Veterinary Med on 06/04/14 fi nding that IRT decreased nightmare frequency and while experiencing it so that the ending is positive. To date, other than case reports, there have only Lastly, since nightmares and insomnia are often been a handful of studies investigating the effi cacy of co-morbid, the question of whether insomnia treat- lucid dreaming therapy on nightmares (Spoormaker ment should be added to nightmare treatment arises. & van den Bout, 2006). In the fi rst study, 23 night- Casement and Swanson (2012) examined whether a mare sufferers were randomly assigned to either a combination of IRT and cognitive behavioural ther- 2-hour individual lucid dreaming treatment session, apy for insomnia was more effective than just IRT a 2-hour group lucid dreaming treatment session, or alone in helping alleviate sleep disturbances. They a waiting-list control group. At post-test (12 weeks found that even combining IRT with insomnia treat- after treatment), participants receiving both the ment was not more effective for treating nightmares individual and group treatment reported signifi cantly than IRT alone, this treatment combination does fewer nightmares when compared to pre-treatment show better results in overall sleep quality improve- baseline. However, there was no signifi cant difference ment. Thus, in cases where both nightmares and between the treatment and control groups, and no insomnia are present, a combined treatment approach signifi cant change in sleep quality or PTSD symptom may be indicated. severity. In the second study, Lancee and colleagues Treatments for nightmare disorder 233 (2010c) compared IRT, IRT and sleep hygiene, IRT the effi cacy of using a self-administered exposure and lucid dreaming, and waiting-list control. Sur- treatment in 107 nightmare sufferers who met prisingly, IRT alone was shown to be more effective DSM-III-R criteria for recurrent nightmares. than the other two treatment conditions, and was the The participants were randomized into either a self- only treatment condition that resulted in a signifi cant exposure, self-relaxation, or waiting-list control improvement in nightmares compared to the control group. Participants in the self-exposure group had a cantly greater reduction in nightmares The lucid dreaming approach differs signifi cantly (d ⫽ 1.18) at one and six months post-treatment from the other nightmare treatments. Instead of when compared with the self-relaxation and waiting- trying to reduce the frequency or severity of night- list groups. Additionally, those who received the self- mares, it attempts to stop nightmares mid-way exposure treatment also experienced a signifi cant through. Thus, it is possible that lucid dreaming may reduction in their depressive symptoms (d be better tolerated than other nightmare treatments. Grandi and colleagues (2006) also investigated the However, more research is needed before lucid effi cacy of a self-exposure treatment for nightmares, dreaming can be considered for treating nightmare fi 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, Systematic desensitization most of the gains were maintained over 4 years. Systematic desensitization is a gradual exposure Although more research is needed, both studies method where an individual utilizes relaxation that examined use of self-administered exposure techniques while being exposed to a hierarchy of found strong positive results. However, both relied fears, and was one of the fi rst nightmare treatments on participants doing a signifi & Lawrence, 1978; Miller homework each day (30 – 60 min), which may affect 1983). Cellucci and Lawrence (1978) recruited 29 compliance and may even be impossible for some undergraduate students who reported having at least nightmare sufferers. two nightmares per week. The participants were ran-domly assigned to either fi ve sessions of systematic Conclusions and future directions
desensitization, placebo (a nightmare discussion group), or continuous tracking of nightmares. The In summary, both prazosin and IRT are empirically For personal use only.
systematic desensitization treatment group had a sig- supported treatments for nightmares. However, addi- nifi cantly greater improvement in nightmare frequency tional research is needed to enhance response and when compared to the placebo. Miller and Dipilato remission rates following treatment completion or (1983) used systematic desensitization to treat 32 discontinuation, and to examine the extent to which self-referred nightmare sufferers, who reported nightmare treatments are effective in treating suffering an average of nine nightmares per month. nightmares that are co-morbid with other forms of Immediately after treatment there were signifi cant psychopathology. decreases in nightmare frequency for both systematic To the best of our knowledge no study has directly desensitization and relaxation training, when com- compared prazosin and IRT, but a recent study by pared to the waiting-list group. After 25 weeks night- Germain and colleagues (2012) that compared pra- mare intensity was found to be signifi cantly reduced zosin to a brief behavioural intervention that included Int Rev Psychiatry Downloaded from informahealthcare.com by MSU Coll Veterinary Med on 06/04/14 in the systematic desensitization group. IRT found no signifi cant differences between the These studies support the use of systematic desen- treatments. Similarly, a recent meta-analysis (Augedal sitization for nightmare treatment. However, more et al., 2013) found no signifi cant difference between research is needed before systematic desensitization IRT and prazosin. This literature suggests that both can be considered empirically supported for treating prazosin and IRT are effective in treating nightmares nightmare disorder. in individuals with PTSD. However, unlike IRT, pra-zosin has not been studied in treating idiopathic night-mares. Thus, randomized controlled trials are Exposure warranted to evaluate the effi cacy of prazosin for idio- In addition to being a component of other nightmare pathic nightmares. Further, and given that psycho- treatments, exposure therapy has also been examined logical nightmare treatments seem to have more on its own as a treatment for nightmare disorder. durable effects than prazosin or other agents that Treating nightmares through exposure involves require long-term use (Augedal et al., 2013), psycho- confronting an individual with his or her nightmare logical treatments may be a better fi rst-line treatment until it is no longer causing the individual signifi cant for nightmares. Fewer side effects have also been distress. Burgess and colleagues (1998) investigated reported in psychotherapeutic trials, although side 234 M. R. Nadorff et al. effects tend to be less closely monitored in these trials. Cartwright , R . (2001) . Crisis Dreaming: Using Your Dreams to Solve Finally, the effi cacy of combined IRT and prazosin Your Problems . Bloomington, IN: IUniverse . M.D. , & Swanson , (2012) . A meta-analysis of remains unknown, but may be especially promising imagery rehearsal for post-trauma nightmares: Effects on night- for reducing chronic, treatment-resistant nightmares. mare frequency, sleep quality, and posttraumatic stress . Clinical There are several promising directions for future Psychology Review , 32 , investigations. First, as discussed previously, there is a need for studies examining whether prazosin is Woolley , T.W . (2004) . Clonazepam for treatment of sleep dis- effective in treating idiopathic nightmares and turbances associated with combat-related posttraumatic stress nightmares co-morbid with other conditions such as disorder . Annals of Pharmacotherapy , 38 , 1395 – 1399 . depression or suicidality. For instance, the treatment Cellucci , A.J. , & Lawrence , P.S . (1978) . The effi cacy of systematic of nightmares in those at elevated suicidal risk or desensitization in reducing nightmares Journal of Behavior with past attempts may improve clinical outcomes Therapy and Experimental Psychiatry , 9 , 109 – 114 . Claridge , G. , Davis , C. , Bellhouse , M. , & Kaptein , S . (1998) . Bor- over time. In a related manner, nightmare treatments derline personality, nightmares, and adverse life events in the combined with other fi rst-line pharmacological or risk for eating disorders . Personality and Individual Differences , psychological treatments of PTSD may facilitate 25 , 339 – 351 . adherence and improve clinical outcomes. rehearsal for posttraumatic nightmares: A randomized control- Declaration of interest: This research study was
led trial . Journal of Traumatic Stress , 23 , 553 – 563 . doi: 10.1002/ supported by the US Department of Defense Con- gressionally Directed Medical Research Program (PR054093 & PT073961; PI: Germain). The views Krakow , B. , & Joiner , T.E. , Jr . (2006) . The impact of insomnia expressed in this article are those of the authors, and and sleep disturbances on depression and suicidality . Dreaming , 16 , 1 – 10 . doi: 10.1037/1053-0718.104.22.168 do not represent the offi cial policy or position of the Treating Post-Trauma Nightmares: A Cognitive US Department of Defense or the US Government. Behavioral Approach . New York, NY: Springer The authors report no confl icts of interest. The Davis , J.L. , Rhudy , J.L. , Pruiksma , K.E. , Byrd , P. , Williams , A.E. , authors alone are responsible for the content and McCabe , K.M. , & Bartley , E.J . (2011) . Physiological predictors writing of the paper. of response to exposure, relaxation, and rescripting therapy for chronic nightmares in a randomized clinical trial Journal of Clinical Sleep Medicine , 7 , 622 – 631 . doi: 10.5664/jcsm.1466 References
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