Nightmares in Patients with Narcolepsy

A recent study suggests that nightmares in patients with narcolepsy may be "an under investigated symptom". Do you have any insight to share about why this may be the case? Thanks very much! (Here's the editorial: http://www.ncbi.nlm.nih.gov/pubmed/24958245) 

The link guides us to a commentary, which was written about an original research study on the prevalence of nightmares in narcoleptic patients with or without cataplexy.[1] Two main findings in the study were as follows: “Nightmares were found in one-third of the patients,” and “Polysomnographic correlation of….nightmare groups showed more wakefulness (P<0.05) and higher percentage of NREM1 stage (P<0.05) in narcolepsy patients with cataplexy.”

In the commentary, Dr Schredl points out that this level of prevalence is substantially higher than the general population.[2] He also highlights other research showing how nightmares cause sleep disruption and thus points to how greater “wakefulness” and “percentage of NREM Stage 1” objectively correlates with worse sleep fragmentation in at least some nightmare patients.

The two main unanswered questions from the original article and the commentary are what might be the cause of nightmares in narcolepsy patients and should disturbing dreams be targeted for treatment in these patients. Several theories and speculations are put forward on the cause of nightmares in narcolepsy, yet virtually all these ideas are similar to those espoused by other nightmare researchers regarding the etiology of nightmares in any patient. For the best review on this topic, see review articles by Levin and Nielsen and by Nielsen and Levin.[3;4]

Regarding treatment, the authors highlight the potential value of the imagery rehearsal therapy paradigm for chronic nightmares. However, left unspoken is the increasing variability of therapeutic options for nightmare treatment. As described in previous posts*, evidence continues to mount suggesting surprisingly diverse pathways to treat nightmares, including but not limited to medications (Prazosin), treatment of OSA (PAP therapy), depth psychotherapies (psychodynamic or dream interpretation therapies), as well as the cognitive-imagery techniques that are increasingly recognized as first-line therapy (IRT and its variants).

In sum, nightmares in narcolepsy may prove to be no different than nightmares in any other context, albeit disturbing dreams in narcoleptic patients appear to be more common than in the general population, but arguably less common compared to those who suffer from chronic posttraumatic stress disorder. While research is lacking on the treatment of nightmares in narcolepsy, there is reason to consider all the treatment modalities listed above when considering how to approach this problem.

* See "What is the best class of medication to consider for 34-year-old female who is afraid to sleep because of chronic nightmares? She sleeps 1 to 2 hours in the middle of the night. She has no comorbidities, except mood disorders." "I was reading your article in the Sleep Review on the connection between obstructive sleep apnea (OSA) and PTSD. How does OSA cause PTSD?" and "In your book Sound Sleep, Sound Mind do you address nightmare cures?"

REFERENCES

[1] Pisko J, Pastorek L, Buskova J, Sonka K, Nevsimalova S. Nightmares in narcolepsy: underinvestigated symptom? Sleep Med 2014;15(8):967-972.
[2] Schredl M. Editorial for "Nightmares in narcolepsy--under-investigated symptom?" (SLEEP-D-13-00591) Understanding and treating nightmares in patients with narcolepsy. Sleep Med 2014;15(8):851-852.
[3] Levin R, Nielsen TA. Disturbed dreaming, posttraumatic stress disorder, and affect distress: a review and neurocognitive model. Psychol Bull 2007;133(3):482-528.
[4] Nielsen T, Levin R. Nightmares: a new neurocognitive model. Sleep Med Rev 2007;11(4):295-310.


Barry Krakow MD

Author

Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.



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