Posttraumatic Nightmares Research Articles

Randomized Controlled Trial of Imagery Rehearsal for Posttraumatic Nightmares in Combat Veterans.

To examine the efficacy of imagery rehearsal (IR) combined with cognitive behavioral therapy for insomnia (CBT-I) compared to CBT-I alone for treating recurrent nightmares in military veterans with posttraumatic stress disorder (PTSD). In this randomized controlled study, 108 male and female United States veterans of the Iraq and Afghanistan conflicts with current, severe PTSD and recurrent, deployment-related nightmares were randomized to six sessions of IR + CBT-I (n = 55) or CBT-I (n = 53). Primary outcomes were measured with the Nightmare Frequency Questionnaire (NFQ) and Nightmare Distress Questionnaire (NDQ). Improvement with treatment was significant (29% with reduction in nightmare frequency and 22% with remission). Overall, IR + CBT-I was not superior to CBT-I (NFQ: -0.12; 95% confidence interval = -0.87 to 0.63; likelihood ratio chi square = 4.7(3), P = .2); NDQ: 1.5, 95% confidence interval = -1.4 to 4.4; likelihood ratio chi square = 7.3, P = .06). Combining IR with CBT-I conferred no advantage overall. Further research is essential to examine the possibly greater benefit of adding IR to CBT-I for some subgroups of veterans with PTSD. Registry: ClinicalTrials.gov; Title: Cognitive Behavioral Therapy (CBT) for Nightmares in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans; Identifier: NCT00691626; URL: https://clinicaltrials.gov/ct2/show/NCT00691626.

Psychometric evaluation of the Hamburg Nightmare Questionnaire (HNQ)

ABSTRACT Background: Nightmares are a widespread phenomenon. In comparison to the general population, they occur in mentally ill and especially in traumatized individuals with an increased frequency. Despite the high prevalence, there is no short questionnaire in the German language that is able to characterize nightmares, to differentiate between different nightmare types and to assess their impact on daytime functioning. Objective: The Hamburg Nightmare Questionnaire (HNQ) has been developed as a short self-rating instrument to fill this gap. Method: Psychometric characteristics of the HNQ were evaluated in a sample of 707 German soldiers passing through the standard diagnostics of the Center for Mental Health at the German Armed Forces Hospital Hamburg. Results: The results of this study show satisfactory psychometric characteristics as a sound factorial structure and adequate internal consistency for the HNQ as well as initial indications of the construct validity of its subscales. Conclusions: The HNQ is a reliable and economic tool for the assessment of posttraumatic nightmares in clinical as well as research settings.

The Role of Executive Function in Predicting Children's Outcomes in a Cognitive Behavioral Treatment for Trauma-Related Nightmares and Secondary Sleep Disturbances.

Predictors of children's outcomes in trauma-focused interventions are well documented. However, little is known about the role of higher-order cognitive processes, specifically executive function (EF) abilities, in determining children's responses to treatments specifically for trauma-related sleep disturbances. EF is independently related to PTSD reactions, sleep deficits, and nightmares. Furthermore, well-developed EF can be protective; thus, we sought to examine whether higher EF predicted better treatment outcomes for trauma-related sleep disturbances. Twenty-three children aged 5 to 17 presenting with post-traumatic nightmares (PTNs) participated in a cognitive behavioral therapy to address their trauma-related nightmares (CBT-NC). Pre- and post-treatment data were used in analyses. Findings from discriminant function analyses revealed that EF was not a statistically significant predictor of treatment outcomes across indices of nightmare frequency and distress, sleep quality, and PTSD symptomology. However, effect sizes suggested that EF was a moderate predictor of sleep quality outcomes, which has clinical implications. Treatment duration for sleep problems could be related to EF with briefer interventions being more suitable for children with high EF, whereas children with low EF may benefit from longer treatment protocols.

Posttraumatic Nightmare Content in Children and its Relation to Posttraumatic Psychopathology

In adult populations, the more similar a posttraumatic nightmare is to a precipitating traumatic event, i.e., the replicativeness of the nightmare, the more distress one experiences, and the greater the frequency and severity of posttraumatic stress symptoms. Posttraumatic nightmare content in children and its relation to posttraumatic psychopathology remains unclear. Nightmare content and trauma-related themes within children’s posttraumatic nightmares remains relatively unexplored. Trauma-exposed children (n = 17) aged 5-17 years-old provided a posttraumatic nightmare narrative and answered questions about the replicativeness of their posttraumatic nightmare. Nightmare content and trauma-related themes were coded. Two one-way ANOVAs examined posttraumatic nightmare replicativeness to levels of posttraumatic stress and to nightmare distress. Findings showed that in children, posttraumatic nightmare replicativeness was associated with posttraumatic stress but not nightmare distress. The most common trauma-related themes in posttraumatic nightmares were safety and power/control. Girls’ nightmares more often contained pursuit and perceived threat whereas boys’ nightmares more often involved aggression. Our study is the first to examine trauma-related themes and qualitative aspects of posttraumatic nightmares in children with a variety of traumas. Future studies should examine gender differences and trauma-related themes, as these may have implications for our understanding and treatment of nightmares in children.

Management of Post-Traumatic Nightmares: a Review of Pharmacologic and Nonpharmacologic Treatments Since 2013.

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. 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.

Association of posttraumatic nightmares and psychopathology in a military sample.

Nightmares are among the most frequent and disturbing symptoms of posttraumatic stress disorder (PTSD). However, basic research questions regarding key associations between certain nightmare characteristics, especially replicativeness, and posttraumatic psychopathology need further empirical elaboration. Sixty-two German soldiers (mean age 33.8 years, 17.7% females) admitted to a hospital-based treatment program for veterans completed extensive assessments consisting of clinical interviews and self-rating measures with respect to sociodemographic characteristics and psychopathology as well as dream-related variables. Although nightmare distress, frequency, and replicativeness were all linked to PTSD symptomatology, only the latter proved to be a significant predictor of PTSD diagnosis. Moreover, none of these nightmare characteristics predicted a depression diagnosis. The replicativeness of nightmares appears to be a key variable for understanding the relationship between posttraumatic nightmares and PTSD, whereas nightmare frequency and distress appear to be more aptly defined as generic markers of mental health. (PsycINFO Database Record

An Ambulatory Polysomnography Study of the Post-traumatic Nightmares of Post-traumatic Stress Disorder.

This study used ambulatory polysomnography (PSG) to investigate post-traumatic nightmares of post-traumatic stress disorder (PTSD). The key research question was whether post-traumatic nightmares occur in both rapid eye movement (REM) and non-REM sleep, and if so, whether nightmares in each sleep stage differed in content, phenomenology, and heart rate response. Underlying sleep disorders were investigated in an exploratory way. Thirty-five treatment-seeking veterans, current serving military members, and emergency service personnel undertook full PSG using the Compumedics (Melbourne, Australia) SomtePSG V1 system, during an inpatient psychiatric admission. The PSG recording included an event button to be pressed when a nightmare occurred, allowing us to determine the stage of sleep, changes in heart rate, and associated sleep events. The content and phenomenological features of participants' nightmares were recorded. Of the 35 participants, 29 reported a nightmare during their sleep study, but only 21 pressed the event button and could recall the content of one or more nightmare. This yielded sleep and nightmare data for 24 nightmares. Of the 24, 10 nightmares arose from REM sleep and 14 from non-REM (stages N1 and N2). Seven were accurate trauma replays and 17 were non-replay or a mixture of replay and non-replay. Most nightmares were associated with respiratory or leg movement events and increase in heart rate on awakening. Post-traumatic nightmares of PTSD occur in both REM and non-REM sleep and are commonly associated with other sleep disturbances. These findings have important treatment implications.

Psychotherapeutic approaches for post-traumatic stress disorder nightmares

Post Traumatic Stress Disorder (PTSD) can affect individuals in both their waking and sleeping life and psychotherapists can utilize interventions towards either wakefulness or sleep. This article reviews the history of PTSD, its socio-cultural contexts, as well as incidence and treatment. We then discuss a multilevel cognitive model of PTSD nightmares and research-supported treatments. Such treatments range from waking exposure, pre-sleep rescripting, to lucid dreaming exposure. The authors conclude with a discussion of Time Perspective Therapy.

The Stress Acceleration Hypothesis of Nightmares.

Adverse childhood experiences can deleteriously affect future physical and mental health, increasing risk for many illnesses, including psychiatric problems, sleep disorders, and, according to the present hypothesis, idiopathic nightmares. Much like post-traumatic nightmares, which are triggered by trauma and lead to recurrent emotional dreaming about the trauma, idiopathic nightmares are hypothesized to originate in early adverse experiences that lead in later life to the expression of early memories and emotions in dream content. Accordingly, the objectives of this paper are to (1) review existing literature on sleep, dreaming and nightmares in relation to early adverse experiences, drawing upon both empirical studies of dreaming and nightmares and books and chapters by recognized nightmare experts and (2) propose a new approach to explaining nightmares that is based upon the Stress Acceleration Hypothesis of mental illness. The latter stipulates that susceptibility to mental illness is increased by adversity occurring during a developmentally sensitive window for emotional maturation—the infantile amnesia period—that ends around age 3½. Early adversity accelerates the neural and behavioral maturation of emotional systems governing the expression, learning, and extinction of fear memories and may afford short-term adaptive value. But it also engenders long-term dysfunctional consequences including an increased risk for nightmares. Two mechanisms are proposed: (1) disruption of infantile amnesia allows normally forgotten early childhood memories to influence later emotions, cognitions and behavior, including the common expression of threats in nightmares; (2) alterations of normal emotion regulation processes of both waking and sleep lead to increased fear sensitivity and less effective fear extinction. These changes influence an affect network previously hypothesized to regulate fear extinction during REM sleep, disruption of which leads to nightmares. This network consists of a fear circuit that includes amygdala, hippocampus, and medial prefrontal cortex and whose substantial overlap with the stress acceleration findings allows the latter to be incorporated into a wider, more developmentally coherent framework.

Mechanisms Underlying Footshock and Psychological Stress-Induced Abrupt Awakening From Posttraumatic "Nightmares".

Background:Posttraumatic nightmares are a highly prevalent and distressing symptom of posttraumatic stress disorder (PTSD), but have been the subject of limited phenomenological investigations.Methods:We utilized a communication box to establish PTSD symptoms in rats through exposure to footshock stress (FS) and psychological stress (PS). The immunohistochemical test and high-performance liquid chromatography with electrochemical detection were used to detect the activity and monoamine levels in the rats’ arousal systems.Results:Twenty-one days after traumatic stress, 14.17% of FS and 12.5% of PS rats exhibited startled awakening, and the same rats showed hyperfunction of the locus coeruleus/noradrenergic system and hypofunction of the perifornical nucleus/orexinergic system. Changes in serotonin levels in the dorsal raphe nucleus showed opposite trends in the FS and PS rats that were startled awake. No differences were found in other sleep/arousal systems.Conclusion:These results suggest that different clinically therapeutic strategies should be considered to treat different trauma-induced posttraumatic nightmares.

Different neural circuitry is involved in physiological and psychological stress-induced PTSD-like "nightmares" in rats.

Posttraumatic nightmares are a core component of posttraumatic stress disorder (PTSD) and mechanistically linked to the development and maintenance of this disorder, but little is known about their mechanism. We utilized a communication box to establish an animal model of physiological stress (foot-shock [FS]) and psychological stress (PS) to mimic the direct suffering and witnessing of traumatic events. Twenty-one days after traumatic stress, some of the experimental animals presented startled awakening (i.e., were startled awake by a supposed “nightmare”) with different electroencephalographic spectra features. Our neuroanatomical results showed that the secondary somatosensory cortex and primary auditory cortex may play an important role in remote traumatic memory retrieval in FS “nightmare” (FSN) rats, whereas the temporal association cortex may play an important role in PS “nightmare” (PSN) rats. The FSN and PSN groups possessed common emotion evocation circuits, including activation of the amygdala and inactivation of the infralimbic prefrontal cortex and ventral anterior cingulate cortex. The decreased activity of the granular and dysgranular insular cortex was only observed in PSN rats. The present results imply that different types of stress may cause PTSD-like “nightmares” in rodents and identified the possible neurocircuitry of memory retrieval and emotion evocation.

Treatment of Sleep Disturbances in Post-Traumatic Stress Disorder: A Review of the Literature.

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.

Screen Memories and Screening Functions: Recollection, Personal Histories, and Post-Traumatic Dreams

The earliest psychoanalytic theoretical formulations viewed external, usually sexual, trauma as the basic pathogenic instigator of repression and of formation of obsessions, compulsions, conversions, delusions, and phobias. Recollection with affect of that trauma was presumed to result in cure. Only in 1899 did Freud realize that that memory itself was not bedrock but itself material for further analysis. Clinical examples illustrate the notion of screen memory per se: of idealized personal myth serving to screen out upsetting features of the patient’s history, and, in the analytic understanding of post-traumatic nightmares, the adult trauma represented in the dream serving to screen predisposing childhood trauma. This pivotal turn in 1899, pointing to memory itself as something to be analyzed and abandoning the notion of bedrock memory, points to the necessity of expanding the notion of trauma beyond a single childhood sexual episode or adult trauma to a sustained cumulative trauma with the potential for exerting a continuous impact.

Cognitive−behavioral treatment for posttraumatic nightmares: An investigation of predictors of dropout and outcome.

Cognitive−behavioral treatment for posttraumatic nightmares: An investigation of predictors of dropout and outcome.

A Critical Review of the Evidence Base of Imagery Rehearsal for Posttraumatic Nightmares: Pointing the Way for Future Research

In this article, the authors provide information on key characteristics of imagery rehearsal treatment protocols and examine the quality of reporting of randomized controlled and uncontrolled trials of imagery rehearsal for treating posttraumatic nightmares. Using a reliable and valid scale, two independent psychologists rated 16 trials. Most reports provided insufficient information on a range of variables including the definition of treatment delivery (e.g., therapist supervision, treatment fidelity), description of the participant sample, data analysis (e.g., determination of sample size), and treatment assignment (e.g., randomization procedures). Low methodological quality and poor reporting can lead to inflation of estimates of treatment effects and inadequately substantiated conclusions, such as inflated effect sizes in meta-analytic studies. Numerous imagery rehearsal protocols exist, but in some cases are given different names and tested in pilot studies, slowing progression in the field. Randomized controlled trials of imagery rehearsal with credible comparison conditions, examination of predictors of dropout and outcome, as well as dismantling studies of imagery rehearsal treatment components are needed.

Therapy with dreams and nightmares: theory, research & practice

Introduction and Background to Dreamwork Theories and Models of Dreamwork The Language of Dreams Objective Approaches to Working with Dreams Subjective and Constructivist Approaches to Working with Dreams Working with Nightmares Post-Traumatic Nightmares and Night Terrors Group and Creative Methods in Dreamwork Themes and Issues in Dreamwork

Risperidone for Night Terrors and Sleepwalking in an Adult: A Case Report

Objective: To report the successful treatment of a case of night terrors and sleepwalking in an adult using low-dose risperidone. Case Summary: A 30-year-old female with a history of nightmares as a teen, but with no prior psychiatric history, presented with new-onset night terrors and sleepwalking related to psychosocial stressors. She recalled images of being chased by monsters and of people trying to hurt her. Sleepwalking sometimes involved self-injurious behavior, as she ran through the house screaming. Intake diagnoses included general anxiety disorder (GAD), obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD). She reported compulsive counting since childhood and episodes of compulsive eating. Risperidone 1 mg was started and eventually titrated to 2 mg at night for night terror and sleepwalking suppression. For GAD, OCD, and OCPD, paroxetine 10 mg was started and titrated to 50 mg. Temazepam 30 mg was added to prolong sleep and cyproheptadine 4 mg was prescribed for anorgasmia. Symptoms were well controlled with the medications for about 8 months. The patient chose to stop the paroxetine and temazepam on day 655, but continued to take risperidone 2 mg for approximately 45 days. When she discontinued the risperidone, the night terrors and sleepwalking returned within 3 days. Discussion: Low-dose risperidone has been shown to modulate combat posttraumatic stress disorder nightmares. Its effectiveness for night terrors and sleepwalking has not been reported. In this case, risperidone was the sole medication suppressing night terrors and sleepwalking for a month and a half. As found in previous studies, 2 mg of risperidone seemed to be the optimal dose. Conclusions: Risperidone dosed at 1–2 mg at night may be a pharmacologic alternative for the symptoms of sleep terrors with sleepwalking.

Experimental Exposure Therapy for Posttraumatic Nightmares

Nightmares are one of the most troubling features of posttraumatic stress disorder (PTSD), yet imagery rehearsal training (IRT) is currently the only empirically supported treatment for posttraumatic nightmares. Although IRT is effective, it is unknown whether IRT or the exposure, which is inherent in this procedure, causes the decrease in nightmares. This study will attempt to clarify this issue by using exposure therapy alone to treat a patient with PTSD. The participant is a 39-year-old male who experienced a single traumatic event. Data were collected on his sleep habits, as well as on the frequency and intensity of the nightmares. Results indicate that exposure-based nightmare treatment for PTSD sufferers should be considered in conjunction with standard treatment packages.

Re-emergence of Posttraumatic Stress Disorder Nightmares With Nursing Home Admission: Treatment With Prazosin

Seniors with a history of emotional trauma decades earlier can experience a recurrence of posttraumatic stress disorder symptoms when transitioning to a nursing home. We present the case of an 86-year-old male Holocaust survivor admitted to a nursing home for physical therapy and rehabilitation 6 weeks after the death of his wife; the patient was expressing a persistent death wish. Despite the multiple risk factors for depression, his distress was specifically related to the reemergence of nightly posttraumatic nightmares. Over the course of 1 week of treatment with 1 mg prazosin at bedtime, his nightmares and his death wish completely resolved. He achieved his rehabilitation goals and was discharged to a community setting. This report highlights the importance of considering posttraumatic stress disorder in nursing home residents with a history of emotional trauma, and understanding how to address these symptoms pharmacologically and nonpharmacologically.

Management of Post-Traumatic Nightmares: A Review of Pharmacologic and Nonpharmacologic Treatments Since 2010

Nightmares are a universal and timeless phenomenon. They occur in most healthy adults as well as a significant portion of clinical populations, especially those exposed to trauma. Considerable advances in the pharmacological and psychological treatment of post-traumatic nightmares have occurred over the last decade with continuing advances in psychological interventions over the last few years. Pharmacologically, the medication prazosin is showing robust clinical effects with minimal side effects. Psychologically, imagery rehearsal therapy commands the greater portion of the nightmare literature due to its established efficacy. These issues are reviewed in the following paper along with recommendations for future studies.