Nightmare disorder
Nightmares, often triggered by stress or trauma, can disrupt daily life. Lifestyle adjustments, such as emotional well-being, avoiding specific substances before bedtime, and maintaining a regular sleep schedule, can alleviate symptoms. Psychotherapy, particularly imagery rehearsal therapy (IRT), is effective for managing recurring nightmares by rewriting and rehearsing them to make them less distressing. When medication is needed, prazosin, an alpha-1 adrenergic receptor antagonist, is a common choice.
2024-01-01 00:01:09 - Editor
Overview of Nightmares
Nightmares are common and can occur throughout life, often caused by stress, negative life events, psychiatric conditions, or medication side effects. Nightmare disorder involves repeated, distressing, and well-remembered dreams that impact social, occupational, or other areas of functioning. These nightmares often involve survival threats and are associated with mood disturbances and cognitive impairments. Polysomnography may be useful for atypical symptoms to rule out other diagnoses. (1, 2, 3)
Management of Nightmares
Initial Evaluation and Lifestyle Modification
An initial sleep evaluation and identifying any predisposing trauma is essential. Lifestyle measures promoting good sleep hygiene can reduce the frequency and severity of nightmares. These include healthy social interaction, emotional stability, avoiding stimulants and electronics before bedtime, regular exercise (not close to bedtime), and maintaining a consistent sleep schedule. (4, 5, 6)
Nightmare-Focused Psychotherapy
Nightmare-focused psychotherapy, particularly imagery rehearsal therapy (IRT), is effective for chronic, persistent nightmares. This involves recalling the nightmare, writing it down, modifying its theme to a more favorable storyline, and rehearsing the modified dream to replace the nightmare content. (7)
Pharmacological Therapy
Prazosin, an alpha-1 adrenergic receptor antagonist, is the preferred first-line medication for nightmares, especially when psychotherapy alone is insufficient. The starting dose is usually 1mg daily. (8)
References
1-American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014.
2-Krakow B, Neidhardt J. Conquering Bad Dreams and Nightmares: A Guide to Understanding, Interpretation, and Cure, Berkley, New York 1992.
3- Zadra A, Donderi DC. Nightmares and bad dreams: their prevalence and relationship to well-being. J Abnorm Psychol 2000;109:273-81.
4-Parasomnias: Clinical Characteristics and Treatment, Kothare SV, Ivanenko A (Eds), Springer-Verlag, New York 2013. p.187.
5- Van Liempt S, Vermetten E, Geuze E, Westenberg H. Pharmacotherapeutic treatment of nightmares and insomnia in posttraumatic stress disorder. Ann NY Acad Sci 2006;1971:502-7.
6- Germain A, Nielsen T. Impact of imagery rehearsal treatment on distressing dreams, psychological distress, and sleep parameters in nightmare patients. Behav Sleep Med 2003;1:140-54.
7-Yücel DE, van Emmerik AAP, Souama C, Lancee J. 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 Med Rev 2020; 50:101248.
8- Peskind ER, Bonner LT, Hoff D, Raskind MA. Prazosin reduces trauma-related nightmares in older men with chronic posttraumatic stress disorder. J Geriatr Psychiatry Neurol 2003;16:165-71.