Reviews of Nightmare Treatment

Roche, L., McLay, L., Sigafoos, J., & Whitcombe-Dobbs, S. (2021)

Sleep disturbances have frequently been associated with trauma and post-traumatic stress disorder (PTSD). Effective treatments for sleep disturbances are therefore likely to be indicated for individuals who have experienced trauma. With the aim of advancing evidence-based practice in this area, this review focuses on studies evaluating behavioral treatments for sleep disturbances among civilians who have experienced trauma. Seventeen studies were identified that met inclusion criteria. Data were extracted from each study on (a) the type of sleep disturbance experienced, (b) assessments used, (c) treatment procedures, (d) outcome measures, and (e) main findings. Research quality was also evaluated. The results of these 17 treatment studies were generally positive, but ratings of the strength of the research varied from strong to weak. Overall, this review finds evidence to support the use of behavioral treatments for sleep disturbances resulting from experiences of trauma. The implications of these findings for clinical practice are discussed.

Roche, L., McLay, L., Sigafoos, J., & Whitcombe-Dobbs, S. (2021). A review of behavioral treatments for sleep disturbances in civilians who have experienced trauma. Behavioral Interventions. https://doi-org.utulsa.idm.oclc.org/10.1002/bin.1853

Yücel, D. E., van Emmerik, A. P., Souama, C., & Lancee, J. (2020)

Pharmacological treatment with prazosin and psychological treatment with imagery rehearsal therapy (IRT) are the two main treatments of posttraumatic nightmares. The American Academy of Sleep Medicine task force recently listed IRT as the recommended treatment for trauma-related nightmares and changed the recommendation of prazosin to ‘may be used’. This new recommendation was based on a single prazosin trial and not on a meta-analytic review of all available trials. The current meta-analysis aims to fill this gap in the literature. Eight studies on IRT and seven studies on prazosin (N = 1.078) were analyzed based on the random effects model. Relative to control groups, prazosin had a moderate to large effect on nightmare frequency (g = 0.61), posttraumatic stress symptoms (g = 0.81), and sleep quality (g = 0.85). IRT showed small to moderate effects on nightmare frequency (g = 0.51), posttraumatic symptoms (g = 0.31), and sleep quality (g = 0.51). No significant differences in effect were observed between prazosin and IRT on any of these outcomes (all p‘s > 0.10). It is concluded that downgrading the recommendation of prazosin may be a premature decision and that the aggregated results in this meta-analysis clearly show efficacy of both treatments.

Yücel, D. E., van Emmerik, A. P., Souama, C., & Lancee, J. (2020). Comparative efficacy of imagery rehearsal therapy and prazosin in the treatment of trauma-related nightmares in adults: A meta-analysis of randomized controlled trials. Sleep Medicine Reviews, 50. https://doi.org/10.1016/j.smrv.2019.101248

Waltman, S. H., Shearer, D., & Moore, B. A. (2018).

Purpose of review: Post-traumatic nightmares (PTN) are a common and enduring problem for individuals with post-traumatic stress disorder (PTSD) and other clinical presentations. PTN cause significant distress, are associated with large costs, and are an independent risk factor for suicide. Pharmacological and non-pharmacological treatment options for PTN exist. A previous review in this journal demonstrated that Prazosin, an alpha blocker, was a preferred pharmacological treatment for PTN and imagery rescripting therapy (IRT) was a preferred non-pharmacological treatment. Since that time, new and important research findings create the need for an updated review. Recent findings: Based on the results of a recent study in the New England Journal of Medicine, Prazosin has been downgraded by both the American Academy of Sleep Medicine (AASM) and the Veterans Health Administration/Department of Defense (VA/DoD) for PTN. In Canada, Nabilone, a synthetic cannabinoid, appears to be promising. Few recent studies have been published on non-pharmacological interventions for PTN; however, recent data is available with regard to using IRT on an inpatient setting, with German combat veterans, and through the use of virtual technology. Recent evidence supports the use of exposure, relaxation, and rescripting therapy (ERRT) with children and individuals with comorbid bipolar disorder and PTN. Prazosin is no longer considered a first-line pharmacological intervention for PTN by AASM and VA/DoD. However, in the absence of a suitable alternative, it will likely remain the preferred option of prescribers. IRT and ERRT remain preferred non-pharmacological treatments of PTN. Combining cognitive behavior therapy for insomnia (CBT-I) with IRT or ERRT may lead to improved outcomes.

Waltman, S. H., Shearer, D., & Moore, B. A. (2018). Management of post-traumatic nightmares: A review of pharmacologic and nonpharmacologic treatments since 2013. Current Psychiatry Reports, 20(12). doi: 10.1007/s11920-018-0971-2

Rousseau, A., & Belleville, G. (2018)

Studies of psychotherapeutic treatments for nightmares have yielded support for their effectiveness. However, no consensus exists to explain how they work. This study combines a systematic review with a qualitative thematic analysis to identify and categorize the existing proposed mechanisms of action (MAs) of nightmare treatments. The systematic review allowed for a great number of scholarly publications on supported psychological treatments for nightmares to be identified. Characteristics of the study and citations regarding potential MAs were extracted using a standardized coding grid. Then, thematic analysis allowed citations to be grouped under six different categories of possible MAs according to their similarities and differences. Results reveal that an increased sense of mastery was the most often cited hypothesis to explain the efficacy of nightmare psychotherapies. Other mechanisms included emotional processing leading to modification of the fear structure, modification of beliefs, restoration of sleep functions, decreased arousal, and prevention of avoidance. An illustration of the different variables involved in the treatment of nightmares is proposed. Different avenues for operationalization of these MAs are put forth to enable future research on nightmare treatments to measure and link them to efficacy measures, and test the implications of the illustration.

Rousseau, A., & Belleville, G. (2018). The mechanisms of action underlying the efficacy of psychological nightmare treatments: A systematic review and thematic analysis of discussed hypotheses. Sleep Medicine Reviews, 39, 122-133. https://doi.org/10.1016/j.smrv.2017.08.004

Brownlow, J. A., Harb, G. C., & Ross, R. J. (2015).

Sleep disturbances are among the most commonly endorsed symptoms of post-traumatic stress disorder (PTSD). Treatment modalities that are effective for the waking symptoms of PTSD may have limited efficacy for post-traumatic sleep problems. The aim of this review is to summarize the evidence for empirically supported and/or utilized psychotherapeutic and pharmacological treatments for post-traumatic nightmares and insomnia. While there are few controlled studies of the applicability of general sleep-focused interventions to the management of the sleep disturbances in PTSD, evidence is growing to support several psychotherapeutic and pharmacological treatments. Future investigations should include trials that combine treatments focused on sleep with treatments effective in managing the waking symptoms of PTSD.

Brownlow, J. A., Harb, G. C., & Ross, R. J. (2015). Treatment of sleep disturbances in post-traumatic stress disorder: A review of the literature. Current Psychiatry Reports,17(41). DOI 10.1007/s11920-015-0587-8

Hansen, K., Höfling, V., Kröner-Borowik, T., Stangier, U. & Steil, R. (2015)

This study presents a meta-analysis of the effectiveness of psychological treatments for chronic nightmares using imaginal confrontation with nightmare contents (ICNC) or imagery rescripting and rehearsal (IRR). Pre–post effect sizes (Hedges’ g) were calculated for the outcome measures of nightmare frequency, nights per week with nightmares, sleep quality, depression, anxiety, and PTSD severity. Fixed-effects and random-effects models were applied. High effect sizes were found for nightmare frequency (g = 1.04), nights per week with nightmares (g = 0.99), and PTSD severity (g = 0.92). Most of the effect sizes for the secondary outcomes were moderate. One objective was to clarify whether ICNC or IRR is more important for nightmare reduction. The results indicate that a higher duration of time for ICNC is associated with greater improvements: The minutes of applied ICNC moderate the effect sizes for nightmare frequency at follow-up 2 and for nights per week with nightmares at post and follow-up 1. The percentage of applied ICNC moderates the effect sizes for nightmare frequency and nights per week with nightmares at follow-up 1. Thus, dismantling studies are necessary to draw conclusions regarding whether ICNC or IRR is the most effective in the psychological treatment of chronic nightmares.

Hansen, K., Höfling, V., Kröner-Borowik, T., Stangier, U. & Steil, R. (2015). Efficacy of psychological interventions aiming to reduce chronic nightmares: A meta-analysis. Clinical Psychology Review, 33(1), 146-155. https://doi.org/10.1016/j.cpr.2012.10.012

Wøien Augedal, A., Schøld Hansen, K., Robstad Kronhaug, C., Harvey, A. G., & Pallesen, S. (2013)

A meta-analysis of treatments for nightmares is reported. The studies were identified by database searches and by an inspection of relevant reference lists. The inclusion criteria were: nightmares as a target problem, studies published in English, use of a randomized controlled trials and reporting of nightmare-relevant outcomes. A total of 19 studies, published between 1978 and 2012 were identified, which included 1285 participants. Effect sizes were calculated as Cohen’s d. A statistically significant improvement for all studies combined (d = 0.47, 95% CI = 0.33–0.60, fixed effects model; d = 0.49, 95% CI = 0.32–0.66, random effects model) and for psychological treatments alone (d = 0.48, 95% CI = 0.36–0.60, random) and for prazosin alone (d = 0.50, 95% CI = 0.03–0.96, random) was found. Individual therapy format yielded a higher effect size than a self-help format (p = 0.03). Minimal interventions (relaxation, recording) yielded lower overall effect size than studies offering more extensive interventions (p = 0.02). It is concluded that there are both psychological and pharmacological interventions which have documented effects for the treatment of nightmares.

Wøien Augedal, A., Schøld Hansen, K., Robstad Kronhaug, C., Harvey, A. G., & Pallesen, S. (2013). Randomized controlled trials of psychological and pharmacological treatments for nightmares: A meta-analysis. Sleep Medicine Reviews, 17(2), 143-152. https://doi.org/10.1016/j.smrv.2012.06.001

Nappi, C.M., Drummond, P.A., & Hall, J.M.H. (2012)

Emerging evidence supports the notion of disrupted sleep as a core component of Posttraumatic Stress Disorder (PTSD). Effective treatments for nighttime PTSD symptoms are critical because sleep disruption may be mechanistically linked to development and maintenance of PTSD and is associated with significant distress, functional impairment, and poor health. This review aimed to describe the state of science with respect to the impact of the latest behavioral and pharmacological interventions on post- traumatic nightmares and insomnia. Published studies that examined evidence for therapeutic effects upon sleep were included. Some behavioral and pharmacological interventions show promise, especially for nightmares, but there is a need for controlled trials that include valid sleep measures and are designed to identify treatment mechanisms. Our ability to treat PTSD-related sleep disturbances may be improved by moving away from considering sleep symptoms in isolation and instead conducting inte- grative studies that examine sequential or combined behavioral and/or pharmacological treatments targeting both the daytime and nighttime aspects of PTSD. This article is part of a Special Issue entitled ‘Post-Traumatic Stress Disorder’.

Nappi, C.M., Drummond, P.A., & Hall, J.M.H. (2012). Treating nightmares and insomnia in posttraumatic stress disorder: A review of current evidence. Neuropharmacology, 62(2), 576-585.

Cranston, C.C., Davis, J.L., Rhudy, J.L., & Favorite, T.K. (2011)

The August 2010 issue of Journal of Clinical Sleep Medicine (Vol. 6, No. 4) included an article suggesting treatment recommendations for adult nightmare disorder. Although we appreciate the work by the authors, we were left with three basic concerns about the methodology utilized and results found. First, works providing evidence for some of the treatments were not reported in the original article. Second, search methodology in the original article was not used consistently at updated time points. Third, the original article only utilized results obtained from PubMed and did not consider other databases. The current study sought to replicate the methodology and compare findings as well as expand by equalizing search methodology across updated time points. The present study expands the original efforts further by conducting article searches again on PsycINFO. Consequent changes to evidence levels and recommendations are discussed.

Cranston, C.C., Davis, J.L., Rhudy, J.L., & Favorite, T.K. (2011). Replication and expansion of ‘Best Practice Guide for the Treatment of Nightmare Disorder in Adults’. Journal of Clinical Sleep Medicine, 7(5), 549-553.

Aurora, R.N., Zak, R.S., Auerbach, S.H., et al. (2010)

Summary of Recommendations: Prazosin is recommended for treatment of Posttraumatic Stress Disorder (PTSD)-associated nightmares. Level A Image Rehearsal Therapy (IRT) is recommended for treatment of nightmare disorder. Level A Systematic Desensitization and Progressive Deep Muscle Relaxation training are suggested for treatment of idiopathic nightmares. Level B Venlafaxine is not suggested for treatment of PTSD-associat- ed nightmares. Level B Clonidine may be considered for treatment of PTSD-associated nightmares. Level C The following medications may be considered for treatment of PTSD-associated nightmares, but the data are low grade and sparse: trazodone, atypical antipsychotic medications, topi- ramate, low dose cortisol, fluvoxamine, triazolam and nitraz- epam, phenelzine, gabapentin, cyproheptadine, and tricyclic antidepressants. Nefazodone is not recommended as first line therapy for nightmare disorder because of the increased risk of hepatotoxicity. Level C The following behavioral therapies may be considered for treatment of PTSD-associated nightmares based on low-grade evidence: Exposure, Relaxation, and Rescripting Therapy (ERRT); Sleep Dynamic Therapy; Hypnosis; Eye-Movement Desensitization and Reprocessing (EMDR); and the Testimony Method. Level C The following behavioral therapies may be considered for treatment of nightmare disorder based on low-grade evidence: Lucid Dreaming Therapy and Self-Exposure Therapy. Level C No recommendation is made regarding clonazepam and indi- vidual psychotherapy because of sparse data.

Aurora, R.N., Zak, R.S., Auerbach, S.H., et al. (2010). Best practice guide for the treatment of nightmare disorder in adults. Journal of Clinincal Sleep Medicine, 6(4), 389-401.

Lancee, J., Spoormaker, V.I., Krakow, B., van den Bout, J. (2008)

The aim of this review is to evaluate the effectiveness of cognitive behavioral therapy (CBT) on nightmare frequency and to determine which kind of CBT is the most effective treatment. A systematic literature search was carried out in PsychInfo and PubMed articles published on or before May 1, 2008. The inclusion criteria were: nightmare treatment study, use of nonpharmacological treatment, not a qualitative case study, randomized-controlled trial (RCT). After selection, 12 peer-reviewed studies about 9 RCTs remained (2 follow-up studies and one displaying preliminary results). Several interventions have been reviewed including, recording one’s nightmares, relaxation, exposure, and techniques of cognitive restructuring. The 12 evaluated articles varied in quality, and none fulfilled CONSORT guidelines. All articles used nightmare frequency as the primary dependent variable, and all found significant in-group differences (pre vs. post) for intervention or placebo (range d = 0.7-2.9). Five studies were able to find a significant group effect for the intervention compared to a waiting list control group. Only one study found significant differences between 2 intervention groups. Nightmare-focused CBT (exposure and imagery rehearsal therapy [IRT]) revealed better treatment outcomes than indirect CBT (relaxation, recording). IRT and exposure showed no meaningful differences, but only one RCT directly compared both techniques. Three different research groups demonstrated the effects of exposure, but only one group showed the effect of IRT. Thus, RCTs that compare IRT with exposure by independent research groups are much needed.

Lancee, J., Spoormaker, V.I., Krakow, B., & van den Bout, J. (2008). A systematic review of cognitive-behavioral treatment for nightmares: Toward a well-established treatment. Journal of Clinical Sleep Medicine, 4(5), 475-480.