As I continue to work with patients with insomnia, an area that starts to intrigue me is the management of nightmare disorder. According to the third edition of International Classification of Sleep Disorders (ICSD-3), nightmare disorder is classified as parasomnia usually associated with (rapid eye movement) REM sleep.

Below is a summary of the the latest position paper for the treatment of nightmare disorders in adults as published in Journal of Clinical Sleep Medicine recently.

HOW TO DIAGNOSE NIGHTMARE DISORDER?

The minimal diagnostic criteria proposed by ICSD-3 are as follows:

A. Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve threats to survival, security, or physical integrity.

B. On awakening from the dysphoric dreams, the person rapidly becomes oriented and alert.

C. The dream experience, or the sleep disturbance produced by awakening from it, causes clinically significant distress or impairment in social, occupational, or other important areas of functioning as indicated by the report of at least one of the following:

  1. Mood Disturbance (e.g. persistence of nightmare effect, anxiety, dysphoria).
  2. Sleep resistance (e.g. bedtime anxiety, fear of sleep/ subsequent nightmares).
  3. Cognitive impairments (e.g. intrusive nightmare imagery, impaired concentration, or memory).
  4. Negative impact on caregiver or family functioning (e.g. nighttime disruption).
  5. Behavioural problems (e.g. bedtime avoidance, fear of the dark).
  6. Daytime sleepiness.
  7. Fatigue or low energy.
  8. Impaired occupational or educational function.
  9. Impaired interpersonal/social function.

WHAT ARE THE DIFFERENT TYPES OF NIGHTMARE DISORDER?

As per the Best Practice Guide for the Treatment of Nightmare Disorder in Adults, nightmares may be idiopathic (without clinical signs of psychopathology) or associated with other disorders including PTSD, substance abuse, stress and anxiety and borderline personality as well as other psychiatric illnesses (e.g. schizophrenia-spectrum disorders).

PTSD-associated nightmares are the most common and most studied. In general, the presence of nightmares following a traumatic experience predicts subsequent onset of PTSD. The symptoms associated with PTSD are classifed into three clusters:

  1. intrusive / re-experiencing
  2. avoidant / numbing, and
  3. hyperaoursal.

The PTSD-associated nightmares are considered part of the intrusive / re-experiencing symptom cluster.

HOW DO YOU TREAT NIGHTMARE DISORDER?

Nightmare disorders can be treated with behavioural and psychological options as well as pharmacological treatments.

Among the various behavioural and psychological options, image rehearsal therapy is the most commonly recommended intervention. It is a modified cognitive behavioural therapy technique and involves changing the content of a nightmare by creating a new set of positive images and rehearsing the rewritten dream scenario for 10-20 minutes per day while awake.

I personally find all the recommended interventions interesting. If you are interested to learn more, have a look at the position paper.

As for pharmacological options, prazosin and atypical antipsychotics are the most studied and remain first and second choices for nightmare disorder.

Initially, I wonder why prazosin is first choice for nightmare disorder given it is an alpha adrenergic antagonist. It turns out that it has traditionally been use in nightmare disorder because it reduces CNS sympathetic outflow throughout the brain. This CNS phenomena is believed to be implicated in the pathogenesis of PTSD and is regulated by alpha1 adrenergic receptors. There have been several studies that demonstrate the efficacy of prazoson. However, the most recent publication conducted by Raskind et al. in 2018 did not show a statistically significant difference between prazosin and placebo. It is argued that most patients in this study were taking an antidepressant, which (especially with SSRI) has been speculated to reduce the efficacy of prazosin. So it is thought that further studies may be warranted. Nonetheless, prazosin has the most experience and evidence for use in nightmare disorder. The studied dose of prazosin ranges from 3mg to 15mg/day. It is usually started at 1mg at bedtime and titrated as needed every 7 days up to maximum fo 15mg/day.

Atypical antipsychotics have also been evaluated for PTSD. Specific agents include aripiprazole, olanzapine and risperidone. Olanzapine is a5-HT 2c receptor antagonist. It is thought to increase slow-wave sleep and reduces rapid-eye movements. Risperidone is also an atypical antipsychotic with significant alpha 1 and alpha 2 noradrenergic antagonism. Aripiprazole is a partial agonist of dopaminergic D2 receptors. All of these agents have been studied in PTSD patients with some promising results.

Note that the American Academy of Sleep Medicine (AASM) also recommends the following medications for PTSD-associated nightmares:

  • Atypical antipsychotics (Olanzapine, risperidone, aripiprazole)
  • Clonidine
  • Cyporheptadine
  • Fluvaxamine
  • Gabapentin
  • Nabilone
  • Phenelzine
  • Prazosin
  • Topiramate
  • Trazodone
  • Tricycle antidepressants.

However both clonazepam and venlafaxine are NOT recommended for the treatment of nightmare disorder. This is mainly due to published evidence evaluating these agents has not demonstrated their efficacy when compared to placebo.

Behavioural &
Psychological
Treatment Options
PTSD-associated nightmaresNightmare disorders
Image Rehearsal
Therapy
YesYes
Cognitive
Behavioural
Therapy
YesYes
Cognitive
Behavioural
Therapy for
Insomnia
YesYes
Eye Movement
Desensitization
and Reprocessing
Yes
Exposure,
Relaxation and
Rescripting Therapy
YesYes
HypnosisYes
Lucid Dreaming
Therapy
Yes
Progressive Deep
Muscle Relaxation
Yes
Sleep Dynamic
Therapy
Yes
Self-Exposure
Therapy
Yes
Systematic
Desensitization
Yes
Testimony MethodYes

While I believe there is no medication officially approved to treat PTSD, there are, however, different treatment options for symptoms or clinical manifestation associated with PTSD. Of these, the most common presentation is nightmare disorder.

I wonder whether behavioural or psychological intervention may be more effective (with possibly less side effects) when compared to medications?

What do you think? Did you know there are that many treatment options for nightmare disorder? I would love to hear about your experience.

Thank you for reading again.