CONTENTS
(1) Behavioral treatment for nightmare disorder
(2) Description of imagery rehearsal therapy (IRT)
(3) American Academy of Sleep Medicine - Best practice guide for the treatment of nightmare disorder in adults (2010)
(4) Position Paper for the Treatment of Nightmare Disorder in Adults: An American Academy of Sleep Medicine (2018)
(5) Authoritative online information
(6) Medications associated with nightmares
(7) Resources for professionals
(1) Evidence-based treatments for nightmare disorder
The American Academy of Sleep Medicine has published two guidelines regarding evidence-based treatments for nightmare disorder. In 2010, they published a best practice guideline and in 2018 they published an update in the form of a position paper.
The 2018 position paper gives its strongest recommendation to a behavioral therapy known as Imagery Rehearsal Therapy (IRT) for the treatment of both nightmare disorder PTSD-associated nightmares. The paper states that several other behavioral therapies and medications may be used for the treatment of nightmare disorder and for PTSD-associated nightmares. See references and more detail below.
(2) Description of imagery rehearsal therapy (IRT)
According to Up to Date, "IRT is a specialized... intervention targeting nightmare disorder. It includes CBT techniques of initially recalling the nightmare and negative event, writing it down with details of emotional sensitivity, reading it, and then modifying the theme. The modified story is made more favorable, and the ending of the story line is changed and rewritten. The rewritten dream is then rehearsed so that the modified, more acceptable dream content will replace the nightmare if the dream recurs. This technique aims at rescripting the content and theme of the nightmare to decrease the negative emotion from the dream, rendering it bearable or even favorable to the patient. This technique requires expertise by the therapist and practice by the patient for success. IRT has shown efficacy in patients with both idiopathic nightmare disorder as well as trauma-associated nightmare disorder" (note: An idiopathic disorder is any disorder with an unknown cause or mechanism of apparent spontaneous origin). "In a meta-analysis of 11 randomized trials of IRT alone or combined with other psychological treatments for nightmares in patients with PTSD, IRT showed moderate positive effects on nightmare frequency and sleep quality compared with a control condition."
(3) American Academy of Sleep Medicine. Best practice guide for the treatment of nightmare disorder in adults (2010) [PDF]
Levels of recommendation
Level A: Assessment supported by a substantial amount of high quality evidence and/or based on a consensus of clinical judgment. Recommendation options: Recommended / Not recommended
Level B: Assessment supported by sparse high grade data or a substantial amount of low-grade data and/or clinical consensus by the task force. Recommendation options: Suggested / Not Suggested
Level C: Assessment supported by low grade data without the volume to recommend more highly and likely subject to revision with further studies. Recommendation options: May be considered / Probably should not be considered
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-associated nightmares. Level B
Clonidine may be considered for treatment of PTSD-associated nightmares. Level C
The following medications may be considered for treatment of PTSD-associated nightmares, but the data are low grade and sparse: trazodone, atypical antipsychotic medications, topiramate, low dose cortisol, fluvoxamine, triazolam and nitrazepam, phenelzine, gabapentin, cyproheptadine, and tricyclic antidepressants. Nefazodone is not recommended as first line therapy for nightmare disorder because of the increased risk of hepatotoxicity. Level C
The following behavioral therapies may be considered for treatment of PTSD-associated nightmares based on low-grade evidence: Exposure, Relaxation, and Rescripting Therapy (ERRT); Sleep Dynamic Therapy; Hypnosis; Eye-Movement Desensitization and Reprocessing (EMDR); and the Testimony Method. Level C
The following behavioral therapies may be considered for treatment of nightmare disorder based on low-grade evidence: Lucid Dreaming Therapy and Self-Exposure Therapy. Level C
No recommendation is made regarding clonazepam and individual psychotherapy because of sparse data.
(4) Position Paper for the Treatment of Nightmare Disorder in Adults, by the American Academy of Sleep Medicine (2018)
Reference: Morgenthaler, T. I., Auerbach, S., Casey, K. R., Kristo, D., Maganti, R., Ramar, K., Zak, R., & Kartje, R. (2018). Position Paper for the Treatment of Nightmare Disorder in Adults: An American Academy of Sleep Medicine Position Paper. Journal of clinical sleep medicine: official publication of the American Academy of Sleep Medicine, 14(6), 1041–1055. https://doi.org/10.5664/jcsm.7178
"Position statements: The following therapy is recommended for the treatment of PTSD-associated nightmares and nightmare disorder: image rehearsal therapy. The following therapies may be used for the treatment of PTSD-associated nightmares: cognitive behavioral therapy; cognitive behavioral therapy for insomnia; eye movement desensitization and reprocessing; exposure, relaxation, and rescripting therapy; the atypical antipsychotics olanzapine, risperidone and aripiprazole; clonidine; cyproheptadine; fluvoxamine; gabapentin; nabilone; phenelzine; prazosin; topiramate; trazodone; and tricyclic antidepressants. The following therapies may be used for the treatment of nightmare disorder: cognitive behavioral therapy; exposure, relaxation, and rescripting therapy; hypnosis; lucid dreaming therapy; progressive deep muscle relaxation; sleep dynamic therapy; self-exposure therapy; systematic desensitization; testimony method; nitrazepam; prazosin; and triazolam. The following are not recommended for the treatment of nightmare disorder: clonazepam and venlafaxine. The ultimate judgment regarding propriety of any specific care must be made by the clinician, in light of the individual circumstances presented by the patient, accessible treatment options, and resources."
(5) Authoritative online information
Maimonides International Nightmare Treatment Center (Barry Krakow, MD) [www.nightmaretreatment.com];
Interview with Barry Krakow, MD: https://www.thecarlatreport.com/articles/3507-turning-nightmares-into-dreams
Mayo Clinic - Nightmare disorder
The New Yorker: November 16, 2009 Issue. Nightmare Scenario - Can we learn to rewrite our bad dreams? By Margaret Talbot [link]
New York Times: Following a script to escape a nightmare.
Psychology Tools - Imagery & Imagery Rescripting
WebMD: Nightmares in Adults; Chronic Nightmares
Wikipedia: Nightmare Disorder
(6) Medications associated with nightmares
Acetylcholinesterase inhibitors (e.g., Donepezil, galantamine, rivastigmine. Mechanism: Increase in REM intensity
Antidepressants*: (e.g., Bupropion, MAOIs, mirtazapine, SNRIs, SSRIs, TCAs). Mechanism: Increase in REM intensity with REM delay and cholinergic rebound (which could include: agitation, confusion, psychosis, anxiety, insomnia, hypersalivation, and extrapyramidal manifestations [e.g., muscle spasms and contractions, motor restlessness, parkinsonism characteristic symptoms such as rigidity, slowness of movement, tremor, and irregular, jerky movements]); REM rebound (during withdrawal)
Antihistamines (e.g., Chlorpheniramine): Mechanism: Unclear
Antimicrobials (e.g., Ciprofloxacin, efavirenz, erythromycin, ganciclovir, mefloquine. Mechanism: Unclear; possibly related to cytokine modulation
Atypical antipsychotic medications (e.g., Clozapine, olanzapine, risperidone). Mechanism: Associated with dopamine
Beta blockers (e.g., Labetalol, metoprolol, propranolol). Mechanism: Unclear; may suppress REM
Calcium channel blockers (e.g., Verapamil). Mechanism: Unclear
Dopaminergic drugs (e.g., Amantadine, amphetamine, levodopa, methylphenidate, pramipexole, ropinirole, selegiline. Mechanism: Associated with dopamine
Sedative-hypnotics* (e.g., Alcohol, barbiturates, temazepam, triazolam). Mechanism: REM rebound
Statins (e.g., Atorvastatin. Mechanism: Unclear
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* When administered and during withdrawal.
(7) References
American Academy of Sleep Medicine. Best practice guide for the treatment of nightmare disorder in adults (2010) [PDF] (see pp. 395-397 for non-psychopharmacological treatments) [Aurora RN; Zak RS; Auerbach SH; Casey KR; Chowduri S; Krippot A; Maganti RK; Ramar K; Kristo DA; Bista SR; Lamm CI; Morgenthaler TI. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med 2010;6(4):389-401.]
Common Language for Psychotherapy Procedures - Imagery Rehearsal Therapy Of Nightmares [PDF]
Davis, J. L., & Wright, D. C. (2006). Exposure, relaxation, and rescripting treatment for trauma-related nightmares. Journal of trauma & dissociation, 7(1), 5-18.
Krakow, B., Kellner, R., Pathak, D., & Lambert, L. (1995). Imagery rehearsal treatment for chronic nightmares. Behaviour research and therapy, 33(7), 837-843.
Krakow, B. (2002). Turning Nightmares into Dreams. Maimonides Sleep Arts & Sciences. [Amazon]
Krakow, B., & Zadra, A. (2006). Clinical management of chronic nightmares: imagery rehearsal therapy. Behavioral sleep medicine, 4(1), 45–70. https://doi.org/10.1207/s15402010bsm0401_4
Krakow, B., & Zadra, A. (2010). Imagery rehearsal therapy: principles and practice. Sleep Medicine Clinics, 5(2), 289-298 antoniozadra.com; archive.org
Lancee J; Spoormaker VI; Krakow B; van den Bout J. A systematic review of cognitive-behavioral treatment for nightmares: toward a well-established treatment. J Clin Sleep Med 2008;4(5):475–480.
Long, M. E., Davis, J. L., Springer, J. R., Elhai, J. D., Rhudy, J. L., Teng, E. J., & Frueh, B. C. (2011). The role of cognitions in imagery rescripting for posttraumatic nightmares. Journal of clinical psychology, 67(10), 1008-1016.
Long, M. E., Hammons, M. E., Davis, J. L., Frueh, B. C., Khan, M. M., Elhai, J. D., & Teng, E. J. (2011). Imagery rescripting and exposure group treatment of posttraumatic nightmares in Veterans with PTSD. Journal of anxiety disorders, 25(4), 531-535.
Morgenthaler, T. I., Auerbach, S., Casey, K. R., Kristo, D., Maganti, R., Ramar, K., Zak, R., & Kartje, R. (2018). Position Paper for the Treatment of Nightmare Disorder in Adults: An American Academy of Sleep Medicine Position Paper. Journal of clinical sleep medicine: official publication of the American Academy of Sleep Medicine, 14(6), 1041–1055. https://doi.org/10.5664/jcsm.7178
Schwartz, S., Clerget, A., & Perogamvros, L. (2022). Enhancing imagery rehearsal therapy for nightmares with targeted memory reactivation. Current biology, 32(22), 4808–4816.e4. https://doi.org/10.1016/j.cub.2022.09.032
Swanson, L. M., Favorite, T. K., Horin, E., & Arnedt, J. T. (2009). A combined group treatment for nightmares and insomnia in combat veterans: a pilot study. Journal of traumatic stress, 22(6), 639-642.
Meta-analyses
Casement MD, Swanson LM. A meta-analysis of imagery rehearsal for post-trauma nightmares: effects on nightmare frequency, sleep quality, and posttraumatic stress. Clin Psychol Rev. 2012 Aug; 32(6):566-74.
Seda, G., Sanchez-Ortuno, M. M., Welsh, C. H., Halbower, A. C., & Edinger, J. D. (2015). Comparative meta-analysis of prazosin and imagery rehearsal therapy for nightmare frequency, sleep quality, and posttraumatic stress. Journal of clinical sleep medicine: official publication of the American Academy of Sleep Medicine, 11(1), 11–22. https://doi.org/10.5664/jcsm.4354
Yücel, D. E., van Emmerik, A. 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, 101248. https://doi.org/10.1016/j.smrv.2019.101248
Randomized contolled trials
Cook, J. M., Harb, G. C., Gehrman, P. R., Cary, M. S., Gamble, G. M., Forbes, D., & Ross, R. J. (2010). Imagery rehearsal for posttraumatic nightmares: a randomized controlled trial. Journal of traumatic stress, 23(5), 553–563. https://doi.org/10.1002/jts.20569
Krakow, B. - Nightmare Treatment Pearls and Possibilities [You Tube video]