Trauma-related Nightmares Research Articles

Imagery Rehearsal Based Art Therapy: Treatment of Post-traumatic Nightmares in Art Therapy.

Imagery Rehearsal Therapy (IRT) is effective for trauma-related nightmares and is also a challenge to patients in finding access to their traumatic memories, because these are saved in non-verbal, visual, or audiovisual language. Art therapy (AT) is an experiential treatment that addresses images rather than words. This study investigates the possibility of an IRT-AT combination. Systematic literature review and field research was conducted, and the integration of theoretical and practice-based knowledge resulted in a framework for Imagery Rehearsal-based Art Therapy (IR-AT). The added value of AT in IRT appears to be more readily gaining access to traumatic experiences, living through feelings, and breaking through avoidance. Exposure and re-scripting take place more indirectly, experientially and sometimes in a playlike manner using art assignments and materials. In the artwork, imagination, play and fantasy offer creative space to stop the vicious circle of nightmares by changing theme, story line, ending, or any part of the dream into a more positive and acceptable one. IR-AT emerges as a promising method for treatment, and could be especially useful for patients who benefit least from verbal exposure techniques. This description of IR-AT offers a base for further research.

Nightmare Distress Questionnaire: associated factors.

The diagnosis of a nightmare disorder is based on clinically significant distress caused by the nightmares, eg, sleep or mood disturbances during the day. The question what factors might be associated with nightmare distress in addition to nightmares frequency is not well studied. Overall, 1,474 persons (893 women, 581 men) completed an online survey. Nightmare distress was measured with the Nightmare Distress Questionnaire. The findings indicated that nightmare distress, measured by the Nightmare Distress Questionnaire, correlated with a variety of factors in addition to nightmare frequency: neuroticism, female sex, low education, extraversion, low agreeableness, and sensation seeking. Moreover, the percentage of replicative trauma-related nightmares was also associated with higher nightmare distress. A large variety of factors are associated with nightmare distress, a finding that is of clinical importance. The construct harm avoidance, however, was not helpful in explaining interindividual differences in nightmare distress. Furthermore, the relationship between nightmare distress and other factors, eg, education or agreeableness, is not yet understood.

Exposure, Relaxation, and Rescripting Therapy for Trauma-Related Nightmares With Psychiatric Inpatients: A Case Series

Research has shown that posttraumatic stress disorder (PTSD) is a highly prevalent diagnosis for psychiatric patients, yet individualized care and treatment is limited in the inpatient acute care sector. Two case studies are presented which examine the use of Exposure, Relaxation, and Rescripting Therapy (ERRT) for chronic trauma-related nightmares, within a private acute care inpatient psychiatric hospital setting. ERRT is empirically supported with efficacy for veteran and civilian populations, however no research to date has been conducted with psychiatric inpatients. Two participants diagnosed with PTSD, suffering distressing trauma-related nightmares, completed ERRT over three sessions during their psychiatric hospital admission, with the aim of reducing the frequency and severity of nightmares and related psychological symptoms. PTSD, depression, sleep quality and quantity, and nightmare frequency and related distress, were measured pre-treatment, during treatment, and follow-up at one, 3 and 6 months. Only one participant reported ongoing nightmares by the third week of the intervention, with both participants reporting an absence of nightmares at the one and 3-month follow-ups, but mixed results by the 6-month follow-up. One participant also reported a reduction in PTSD symptoms and a mild improvement in depression. The results offer some preliminary support for the provision of ERRT for the treatment of trauma-related nightmares for psychiatric inpatients.

0803 Clinical and Polysomnographic Features of Trauma Associated Sleep Disorder (TASD)

Abstract Introduction Trauma associated sleep disorder (TASD) is an emerging parasomnia that develops after trauma with clinical features of trauma related nightmares (TRN), disruptive nocturnal behaviors (DNB), and autonomic disturbances. The purpose of this study is to characterize the clinical and polysomnographic (PSG) features of TASD. Methods Clinical history and detailed video-PSG review, to include post-PSG nightmare reports, of a cohort of patients with TASD. Results Patients (n=40, 32 men, 8 women) were active duty service members with a median age of 38.9 yrs (range 24-57 yrs). Dream content typically related to combat (n=37, 92.5%), with 75% (n=30) reporting TRN and 60% (n=24) reporting dream enactment at least weekly. Self-reported DNB included vocalizations, violent limb movements, thrashing, defensive posturing, and jumping from bed. There was a high rate of comorbid insomnia (n=35, 87.5%), PTSD (n=23, 63.9%), anxiety (n=25, 62.5%), depression (n=20, 50%), OSA (n=19, 47.5%), chronic pain (n=12, 30%), and TBI (n=13, 32.5%). Most patients had REM sleep without atonia (RSWA) (n=33, 82.5%), though a minority had purposeful DNB (n=11, 27.5%). Vocalizations were present in seven (17.5%) patients. Patients with PTSD were more likely to have purposeful DNB (n=9, 100%) than those without PTSD (n=13, 50%; p=0.013), whereas patients with purposeful DNB had markedly less N3 sleep (1.0±11.4%) than those without purposeful DNB (13.8±16.2%; p=0.002). There was no significant difference in medications between DNB groups. Conclusion TASD is frequently comorbid with other sleep and behavioral health disorders. Characteristics of TASD are often captured on video-PSG during REM sleep, though DNB may be less pronounced than what patients report in their habitual sleeping environment. Clinical and video-PSG correlations are invaluable in assessing patients with TASD. This study, which is the largest cohort to date, provides a further basis for establishing TASD as a unique REM-related parasomnia. Support N/A

0800 Posttraumatic Stress Disorder and REM Sleep Without Atonia in Veterans

Abstract Introduction In veterans, the prevalence of rapid eye movement (REM) sleep behavior disorder(RBD) is higher than the general population, and there is some evidence that this is related to posttraumatic stress disorder(PTSD). In addition, trauma related nightmares (TRNs) interfere with REM sleep and are often accompanied by motor activity. (rem sleep without atonia; RSWA). The purpose of this study is to determine whether the frequency of dream enactment behavior(DEB) and RSWA is different according to the presence of PTSD or trauma. Methods The patients (n = 2262) who underwent video assisted polysomnography (PSG) and sleep-related questionnaire surveys at Veteran Health Service Medical Center in Republic of Korea were reviewed retrospectively and cross-sectionally. Based on patients diagnosed with PTSD (N = 20; 100% male; 67.9 ± 8.5 years of age), those exposed to trauma but not diagnosed with PTSD (N = 23; 100% male; age 64.0 ± 13.4) and trauma unexposed controls (N = 21; 100% male; age 59.86 ± 10.9) were matched. Results In the PTSD group, patients who reported self-reported DEB tended to be more than the traumatic exposure group and the control group (P = 0.022). In-lab video assisted PSG showed no differences in DEB between the three groups, but RSWA. (p = 0.026) After adjusting for age, hypnotics, apnea hypopnea index (AHI), Beck depression inventory (BDI), and periodic limb movement (PLM) arousal factors, RSWA was significantly higher in the PTSD group than in the traumatic exposure group. (p = 0.006) Conclusion The result that RSWA was significantly higher in the PTSD group than in the traumatic exposure group suggests that there may be an associated pathophysiology between PTSD and RBD. Longitudinal studies are needed to establish the link between RBD with PTSD and neurodegenerative diseases associated with synucleinopathy. Support This study was supported by a VHS Medical Center Research Grant, Republic of Korea. (grant number: VHSMC 19033)

1222 Does Creativity & “Dose” Enhance Outcomes in Imagery Rehearsal Therapy? A Case of Successful IRT

Abstract Introduction Imagery Rehearsal Therapy (IRT) is an efficacious treatment for Nightmare Disorder. In IRT, patients practice pleasant guided imagery techniques, then use these skills to re-script recurring nightmares, which lowers the frequency and intensity of overall nightmare activity. However, the most efficacious methods and dosage of guided imagery and nightmare re-scripting is undetermined. Report of Case The patient was a 70-year-old male with Nightmare Disorder. Patient denied any precipitating event or trauma associated with nightmare onset. He has a longstanding history of depression and OSA (uses CPAP). He was taking Seroquel, which reduced severity of nightmares but not frequency. Trials of other medications for nightmares had failed (including prazosin, Depakote, and trazodone). Patient presented as highly distressed, exhibited distrust towards medical providers, and was skeptical about the effectiveness of IRT. Despite his skepticism, patient self-initiated very detailed and media-enhanced methods for pleasant guided imagery and nightmare re-scripting, including written narratives, voice recordings, and created a movie of his re-scripted nightmare with pictures set to music. He listened to the recordings 2-3x/day. Themes of nightmares included lack of mastery over problems; patient’s re-scripted dreams put him back in control of frightening scenarios. Nightmare logs at baseline showed sleep quality=1.9/5; average=2.0 nightmares/night; average intensity= 6.2/10. At week 15 of treatment, sleep quality=3/5; nightmares/night average=0.25; average intensity=6/10. Sleep disturbance also improved (ISI=18-moderately severe clinical insomnia to 11-subthreshold insomnia); mood was stable (PHQ=5-mild depression). Conclusion Previous studies have suggested that IRT increases patients’ sense of mastery or perceived self-efficacy over nightmares (Rousseau et al., 2018). Additionally, higher verbal memory in persons with trauma-related nightmares has been shown to improve nightmare frequency and severity in IRT (Scott et al., 2017). In this case study, self-efficacy may have been activated by the highly detailed and media-enhanced imagery the patient created. Further empirical research on the mechanisms for enhancing IRT is warranted.

Passive Coping Strategies During Repeated Social Defeat Are Associated With Long-Lasting Changes in Sleep in Rats.

Exposure to severe stress has immediate and prolonged neuropsychiatric consequences and increases the risk of developing Posttraumatic Stress Disorder (PTSD). Importantly, PTSD develops in only a subset of individuals after exposure to a traumatic event, with the understanding of this selective vulnerability being very limited. Individuals who go on to develop PTSD after a traumatic experience typically demonstrate sleep disturbances including persistent insomnia and recurrent trauma-related nightmares. We previously established a repeated social defeat paradigm in which rats segregate into either passively or actively coping subpopulations, and we found that this distinction correlates with measures of vulnerability or resilience to stress. In this study, we examined differences between these two behavioral phenotypes in sleep changes resulting from repeated social defeat stress. Our data indicate that, compared to control and actively coping rats, passively coping rats have less slow-wave sleep (SWS) for at least 2 weeks after the end of a series of exposures to social defeat. Furthermore, resilient rats show less exaggerated motor activation at awakenings from rapid eye movement (REM) sleep and less fragmentation of REM sleep compared to control and passively coping rats. Together, these data associate a passive coping strategy in response to repeated social defeat stress with persisting sleep disturbances. Conversely, an active coping strategy may be associated with resilience to sleep disturbances. These findings may have both prognostic and therapeutic applications to stress-associated neuropsychiatric disorders, including PTSD.

A pilot randomized controlled trial of cognitive behavioral treatment for trauma-related nightmares in active duty military personnel.

The aim of this study was to obtain preliminary data on the efficacy, credibility, and acceptability of Exposure, relaxation, and rescripting therapy for military service members and veterans (ERRT-M) in active duty military personnel with trauma-related nightmares. Forty participants were randomized to either 5 sessions of ERRT-M or 5 weeks of minimal contact control (MCC) followed by ERRT-M. Assessments were completed at baseline, posttreatment/postcontrol, and 1-month follow-up. Differences between ERRT-M and control were generally medium in size for nightmare frequency (Cohen d = -0.53), nights with nightmares (d = -0.38), nightmare severity (d = -0.60), fear of sleep (d = -0.44), and symptoms of insomnia (d = -0.52), and depression (d = -0.51). In the 38 participants who received ERRT-M, there were statistically significant, medium-sized decreases in nightmare frequency (d = -0.52), nights with nightmares (d = -0.50), nightmare severity (d = -0.55), fear of sleep (d = -0.48), and symptoms of insomnia (d = -0.59), posttraumatic stress disorder (PTSD) (d = -0.58) and depression (d = -0.59) from baseline to 1-month follow-up. Participants generally endorsed medium to high ratings of treatment credibility and expectancy. The treatment dropout rate (17.5%) was comparable to rates observed for similar treatments in civilians. ERRT-M produced medium effect-size reductions in nightmares and several secondary outcomes including PTSD, depression, and insomnia. Participants considered ERRT-M to be credible. An adequately powered randomized clinical trial is needed to confirm findings and to compare ERRT-M to an active treatment control. Registry: ClinicalTrials.gov; Title: A Pilot Randomized Controlled Trial of Treatment for Trauma-Related Nightmares In Active Duty Military Personnel; Identifier: NCT02506595; URL: https://clinicaltrials.gov/ct2/show/NCT02506595.

Trauma Associated Sleep Disorder: Clinical Developments 5Years After Discovery.

We review recent and growing evidence that provides support for a novel parasomnia, trauma associated sleep disorder (TASD). Based on these findings, we further develop the clinical and polysomnographic (PSG) characteristics of TASD. We also address factors that precipitate TASD, develop a differential diagnosis, discuss therapy, and propose future directions for research. Nightmares, classically a REM phenomenon, are prevalent and underreported, even in individuals with trauma exposure. When specifically queried, trauma-related nightmares (TRN) are frequently associated with disruptive nocturnal behaviors (DNB), consistent with TASD. Capture of DNB in the lab is rare but ambulatory monitoring reveals dynamic autonomic concomitants associated with disturbed dreaming. TRN may be reported in NREM as well as REM sleep, though associated respiratory events may confound this finding. Further, dream content is more distressing in REM. Therapy for this complex disorder likely requires addressing not only the specific TASD components of TRN and DNB but comorbid sleep disorders. TASD is a unique parasomnia developing after trauma. Trauma-exposed individuals should be specifically asked about their sleep and if they have nightmares with or without DNB. Patients who report TRN warrant in-lab PSG as part of their evaluation.

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.

Traumatic Event Exposure, Posttraumatic Stress Disorder, and Sleep Disturbances in a National Sample of U.S. Adults.

Posttraumatic stress disorder (PTSD) is a highly prevalent, debilitating disorder found to develop after exposure to a potentially traumatic event (PTE). Individuals with PTSD often report sleep disturbances, specifically nightmares and insomnia, which are listed within the criteria for PTSD. This research examined prevalence of insomnia and nightmares within a national sample of 2,647 adults (data weighted by age and sex to correct for differences in sample distribution) who had been exposed to one or more PTEs. Prevalence of self-reported sleep disturbance, sleep disturbances by PTE type, and gender differences were examined. All participants completed a self-administered, structured online interview that assessed exposure to stressful events and PTSD symptoms. Among individuals who met DSM-5 criteria for PTSD, a large majority (more than 92%) reported at least one sleep disturbance. Insomnia was relatively more prevalent than PTE-related nightmares among individuals with PTSD and among all PTE-exposed individuals. A higher number of PTEs experienced significantly increased the likelihood of both trauma-related nightmares and insomnia, McFadden's pseudo R2 = .07, p < .001. Women exposed to PTEs were more likely to endorse experience of insomnia, χ2 (1, N = 2,647) = 99.13, p < .001, φ = .194, and nightmares compared to men, χ2 (1, N = 2,648) = 82.98, p < .001, φ = .177, but this gender difference was not significant among individuals with PTSD, ps = .130 and .050, respectively. Differences in sleep disturbance prevalence by PTE type were also examined. Implications for treatment and intervention and future directions are discussed.

Post-traumatic stress disorder symptom severity, trauma load and sleeping difficulties in trauma-exposed, treatment-seeking adolescents

IntroductionSleep disturbances are associated with various anxiety- and trauma-related disorders, and specifically with post-traumatic stress disorder (PTSD). Two of the core symptoms of PTSD are recurrent distressing dreams about the traumatic event and difficulty in falling or staying asleep (insomnia). Sleep is essential for functioning, with poor sleep compromising cognitive, emotional and behavioural regulations. Sleep is also of particular importance for brain development and information processing in children and adolescents. The aim of this study was to determine if PTSD symptom severity and trauma load is associated with nightmares and insomnia in a sample of trauma-exposed, treatment-seeking adolescents.MethodsA total of 358 South African adolescents, between 12 and 18 years of age, exposed to at least one DSM-5 qualifying traumatic event, were assessed for PTSD-related sleep difficulties using the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS). Childhood exposure to 10 common trauma types was also recorded using the KSADS trauma checklist. PTSD symptom severity was measured using the child PTSD checklist (CPC).ResultsAdolescents reporting current trauma-related nightmares (F[268.2] = 0.68, t = -8.16, p = 0.000) and current insomnia (F[265.2] = 0.16, t = -9.03, p = 0.000) had significantly higher PTSD symptom severity scores compared to those without current nightmares and insomnia. Adolescents with current trauma-related nightmares (F[355.2] = 0.15, t = -3.30, p = 0.001) and insomnia (F[353.2] = 0.15, t = -2.51, p = 0.013) were also exposed to a significantly greater number of different trauma types compared to those without current nightmares and insomnia.ConclusionAssessing and treating sleep difficulties related to PTSD in trauma-exposed adolescents, in an effort to reduce the developmental impact of trauma on the brain and general functioning, should not be overlooked. Longitudinal studies may contribute to a better understanding of the long-term effects of trauma-related insomnia and nightmares on mental and physical health outcomes.

Impact of Traumatic Stress on Sleep and Management Options in Women.

After exposure to traumatic stress, women are at greater risk than men for developing symptoms of some psychiatric disorders, including insomnia and nightmares. Sleep disturbance is one of the most refractory symptoms of posttraumatic stress disorder. Women were included in a few studies that examined efficacy of psychological or pharmacologic interventions for trauma-related sleep disturbances. Studies demonstrated preliminary evidence for efficacy of cognitive behavioral therapy for insomnia, imagery rehearsal therapy, and combinations of these techniques in treating insomnia and nightmares in trauma-exposed women. Prazosin as an adjunct to ongoing treatment is a potentially efficacious strategy for treating trauma-related nightmares in women.

Depression and the relationship between sleep disturbances, nightmares, and suicidal ideation in treatment-seeking Canadian Armed Forces members and veterans

BackgroundResearch on the relationship between insomnia and nightmares, and suicidal ideation (SI) has produced variable findings, especially with regard to military samples. This study investigates whether depression mediated the relationship between: 1) sleep disturbances and SI, and 2) trauma-related nightmares and SI, in a sample of treatment-seeking Canadian Armed Forces (CAF) personnel and veterans (N = 663).MethodRegression analyses were used to investigate associations between sleep disturbances or trauma-related nightmares and SI while controlling for depressive symptom severity, posttraumatic stress disorder (PTSD) symptom severity, anxiety symptom severity, and alcohol use severity. Bootstrapped resampling analyses were used to investigate the mediating effect of depression.ResultsApproximately two-thirds of the sample (68%; N = 400) endorsed sleep disturbances and 88% (N = 516) reported experiencing trauma-related nightmares. Although sleep disturbances and trauma-related nightmares were both significantly associated with SI on their own, these relationships were no longer significant when other psychiatric conditions were included in the models. Instead, depressive symptom severity emerged as the only variable significantly associated with SI in both equations. Bootstrap resampling analyses confirmed a significant mediating role of depression for sleep disturbances.ConclusionsThe findings suggest that sleep disturbances and trauma-related nightmares are associated with SI as a function of depressive symptoms in treatment-seeking CAF personnel and veterans. Treating depression in patients who present with sleep difficulties may subsequently help mitigate suicide risk.

Doomed to Repeat History: The Burden of Trauma-Related Nightmares in Military Personnel.

Doomed to Repeat History: The Burden of Trauma-Related Nightmares in Military Personnel.

Nightmares in United States Military Personnel With Sleep Disturbances

Sleep disturbances are common in United States military personnel. Despite their exposure to combat and trauma, little is known about nightmares in this population. The purpose of this study was to describe the prevalence and associated clinical and polysomnographic characteristics of nightmares in United States military personnel with sleep disturbances. Retrospective review of 500 active duty United States military personnel who underwent a sleep medicine evaluation and polysomnography at our sleep center. The Pittsburgh Sleep Quality Index and the Pittsburgh Sleep Quality Index-Addendum were used to characterize clinically significant nightmares. Subjective and objective sleep attributes were compared between groups. At least weekly nightmares were present in 31.2%; yet, only 3.9% reported nightmares as a reason for evaluation. Trauma-related nightmares occurred in 60% of those patients with nightmares. Patients with nightmares had increased sleep onset latency (SOL) and rapid eye movement (REM) sleep latency (mean SOL/REM sleep latency 16.6/145 minutes, P = .02 and P = .01 respectively) compared to those without (mean SOL/REM sleep latency 12.5/126 minutes). The comorbid disorders of depression (P ≤ .01, relative risk [RR] 3.55 [95% CI, 2.52-4.98]), anxiety (P ≤ .01, RR 2.57 [95% CI, 1.93-3.44]), posttraumatic stress disorder (P ≤ .01, RR 5.11 [95% CI, 3.43-7.62]), and insomnia (P ≤ .01, RR 1.59 [95% CI, 1.42-1.79]) were all associated with nightmares. Clinically significant nightmares are highly prevalent in United States military personnel with sleep disturbances. Nightmares are associated with both subjective and objective sleep disturbances and are frequently comorbid with other sleep and mental health disorders. A commentary on this article appears in this issue on page 303.

Randomized controlled trial to dismantle exposure, relaxation, and rescripting therapy (ERRT) for trauma-related nightmares.

The aim of this study was to conduct a preliminary dismantling study of exposure, relaxation, and rescripting therapy (ERRT) for nightmares. Participants (N = 70) were randomized to 1 of 2 conditions: ERRT with nightmare exposure and rescripting (full protocol; EX) or ERRT without nightmare exposure and rescripting (NEX). Participants completed follow-ups at 1 week, 3 months, and 6 months posttreatment. Both conditions yielded statistically significant improvements with medium to large effect sizes on primary outcomes related to nightmares (i.e., nights with nightmares, nightmares per week, and nightmare severity). Both conditions also yielded statistically significant improvements on secondary outcomes with medium to large effect sizes on fear of sleep, sleep quality, insomnia severity, daytime sleepiness, posttraumatic stress disorder symptom severity, and depression severity. The conditions did not differ at any time point. Findings indicate that ERRT with and without nightmare exposure and rescripting can significantly alleviate nightmares and related distress. The addition of nightmare exposure and rescription did not contribute incrementally to outcomes in this sample. It is possible that the dose of exposure was not sufficient to result in group differences or that the treatment components included in both conditions (i.e., psychoeducation about trauma, nightmares, and sleep; sleep habit modification; and relaxation training) may adequately treat factors that maintain nightmares for some individuals. Theoretical implications of findings are discussed. The reduction of symptoms of other conditions following this brief intervention provides further evidence for the primary role of nightmares and sleep disturbances posttrauma. (PsycINFO Database Record

ПОСТТРАВМАТИЧНИЙ СТРЕСОВИЙ РОЗЛАД: НЕЙРОНАУКОВІ ОСНОВИ ДОКАЗОВОГО ЛІКУВАННЯ

Posttraumatic stress disorder (PTSD) is a relatively common anxiety spectrum syndrome, in which memory of a triggering trauma becomes aberrantly linked to autonomic and emotional arousal. The recurrent, internally generated stress response can produce enduring behavioral and brain changes. Mechanistically, this may involve both dysregulation of the hypothalamo-pituitaryadrenal axis as well as degradation of the capacity of supramodal cortical areas to process and manage trauma-related emotional content. The optimal balance of information processing and hence behavioral reactivity shifts from the refl ective prefrontal cortex in favor of the more emotionally reactive amygdala. Trauma-focused therapies exploit adaptive neuroplasticity to decouple the memory of the trauma from the aberrant emotional and behavioral responses, in effect reconfi guring brain networks. The effect-size of such psychological therapies is generally larger than that for pharmacological treatments which are currently limited to drugs repurposed for PTSD. Nonetheless, in a signifi cant number of patients, some symptoms can be at least partially attenuated by selective serotonin reuptake inhibitors. In addition, the frequency and intensity of trauma-related nightmares can usually be lowered by adrenergic alpha-1 receptor agonists. Even as novel modalities continue to be developed, the judicious implementation of currently available evidence-based treatments for PTSD can target the underlying neurobiology, provide symptomatic relief, and promote psychosocial recovery.

Sleep and Dreaming in Posttraumatic Stress Disorder.

Sleep disturbances are core features of posttraumatic stress disorder (PTSD). This review aims to characterize sleep disturbances, summarize the knowledge regarding the relationships between trauma exposure and sleep difficulties, and highlight empirically supported and/or utilized treatments for trauma-related nightmares and insomnia. Trauma-related nightmares and insomnia, and other sleep disorders, are frequently reported among trauma survivors. The roles of fear of sleep, REM density, and decreased parasympathetic activity are beginning to inform the relationship between trauma exposure and sleep difficulties. Additionally, the potential adaptive role of sleep loss immediately following a traumatic experience is being recognized. Interventions targeting these sleep disturbances show promise in reducing symptoms. Research in understanding the role of sleep on the development, course, and treatment of PTSD is expanding. Longitudinal investigations are needed to further elucidate these relationships and identify treatments most effective in ameliorating symptoms.

The efficacy of prazosin for the treatment of posttraumatic stress disorder nightmares in U.S. military veterans.

Nightmares associated with posttraumatic stress disorder (PTSD) are a hallmark symptom among U.S. military veterans who have seen combat. Management of combat-related nightmares can be difficult and current pharmacologic options are limited and tend to have adverse side effects. The aim of this review is to explore recent literature regarding the efficacy of prazosin for the treatment of nightmare disorder in the veteran population. Recent literature consisting of three systematic reviews was reviewed, as well as current clinical guidelines published by The Department of Veterans Affairs (VA) and The Department of Defense (DoD) and the American Academy of Sleep Medicine (AASM). Prazosin has been shown to be effective in the treatment of PTSD trauma-related nightmares. As a result of its low side effect profile and abilities to improve both sleep and reduce trauma nightmares, prazosin has been recommended as an adjunct therapy. Prazosin should be initiated as an adjunctive treatment to promote sleep in those suffering from PTSD nightmares. It should be initiated at 1 mg and then titrated upward until absence or desired reduction of nightmares is achieved, with a maximum dosage recommendation of 20 mg at bedtime and 5 mg midmorning.