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.
This question is of great interest to me, and it reflects a topic I have been addressing frequently for the past two years when travelling to different US bases to train military mental health professionals on our Sleep Dynamic Therapy(TM) model of mind-body sleep medicine.(1) Most military psychologists and other therapists routinely see nightmare patients with co-morbid PTSD in their clinics, and we spend an entire day of the 3-day training program addressing this problem in depth. At the outset, we underscore that nightmares rarely travel alone. Instead, we use the term Nightmare Triad Syndrome to conceptualize the very common finding of co-morbid nightmares, insomnia, and sleep-disordered breathing in patients who report problems with chronic nightmares. I will be delivering a keynote address on this triad concept on June 4 at the International Association for the Study of Dreams in Berkeley, CA.
With this backdrop, I trust you can see there may be many additional areas to explore in your patient, because we already see she suffers co-morbid nightmares and insomnia from your brief description. For now let’s assume the issue of co-morbid obstructive sleep apnea (OSA) or Upper Airway Resistance Syndrome (UARS) is an open question. By the way, we wrote a paper a few years back describing how rarely patients present to a sleep center specifically seeking treatment for chronic nightmares (2), yet within the military mental health clinics it is more common for an individual to present in this manner. Either way, from my clinical experience it still seems likely both types of presentations suffer high rates of the Nightmare Triad Syndrome.
If we target the nightmare problem first, we are strong advocates of Imagery Rehearsal Therapy (IRT), a cognitive-imagery technique that teaches individuals to use their mind’s eye to picture a new waking version of a recent nightmare by changing the bad dream essentially into a new dream by following these simple instructions: “change the dream any way you wish,” which follows the guidelines of Dr Joseph Neidhardt, my mentor and collaborator on our earliest IRT research.(3) For more details on the IRT approach, we sell a workbook and audio series (Turning Nightmares into Dreams) on our website www.nightmaretreatment.com, and we have a 2-hour introductory video available for CEU on the same site.
Because of the remarkable efficacy of IRT, I have had very limited experience in the use of medication for the treatment of nightmares, but there is a great deal of information on the drug Prazosin as an effective agent. The drug is widely used as a first-line therapy among military mental health providers, because it is such an expedient solution. However, one of the reasons the military wanted training in IRT was to provide service members additional non-pharmacologic treatments, and because the cessation of Prazosin often leads to a return of the disturbing dreams. To acquire the best information on the use of Prazosin, follow the scientific papers of Dr Murray Raskind, the pioneer of this pharmacotherapy(4) and also Dr Anne Germain, who has recently published very interesting works comparing and contrasting patients using IRT and/or Prazosin.(5) Unquestionably, Prazosin would be the first choice of medications for your patient unless she suffers from other medical concerns. For example, if the patient experiences low blood pressure, she might be at greater risk for the well-described orthostatic response from Prazosin.
Moving on to the insomnia problem, if the patient is only willing to accept a drug solution, then clearly we must deal with her anxiety about both nightmares and sleep, and she would likely benefit from a specific anxiolytic as a means to reduce her fears at bedtime and perhaps induce some degree of sleepiness. In this instance, I have limited practical experience, because by the time a nightmare patient seeks help at our sleep center, s/he would have already been prescribed and attempted various drugs that obviously failed to work well, at which point the patient is now more interested in a non-pharmacologic therapy.
Accordingly, while CBT-I can be applied to some degree in any insomnia patient with fears about their dreams, two other models may have more appeal to the patient. The most widely used alternative approach applied by certain types of mental health providers would be a dream interpretation technique, whereby exploring the content and emotions within the dream the individual is likely to learn important information about waking conflicts and stressors. Through this model, the patient has potential to witness abatement of the bad dreams if she uncovers valuable lessons by interpreting her dreams. This model is most effectively applied by experienced dream therapists.(6)
Another model would be our development of sleep-related emotion-focused therapy (SR-EFT) as patterned after Dr Leslie Greenberg’s work on standard EFT.(7) In SR-EFT, we examine the specific emotions initially described by the patient (eg, fear of sleep) with a goal of uncovering additional layers of emotion that may also be present. We often see this problem in a patient who fears following through on CBT-I instructions. For example, a patient may fear going to sleep, but may also fear getting up out of bed when not sleeping (stimulus control) or may fear efforts to increase sleep efficiency by restricting time in bed (sleep restriction therapy or as my colleague Dr Bill Moorcroft prefers to call it: “bed restriction therapy,” a term that downplays the appearance of giving up time asleep). In these situations, SR-EFT appreciates that the main issue might actually be fear in general, and therefore, the fear is explored, which in the process often leads to uncovering other layers of emotions, which may hold key insights into how this person may have developed misguided or irrational perspectives about their sleep. Or, in some cases, we learn the patient has other fears in waking life that appear to have been “transferred” into a fear of sleep. Through this exploration of emotion, the individual may become less fearful of the entire nightmaring process and in turn decrease some of her fears about the sleep experience as well.
Last, it is quite remarkable that some research is beginning to show that PAP therapy reduces nightmare frequency.(8) Therefore, it would be critical to discern whether or not your patient suffers from UARS or OSA. We almost invariably test a nightmare patient in the sleep lab unless we sense the lab experience itself would create too much anxiety or fear in the patient and lead to a traumatizing episode. In nearly all nightmare patients tested at our facility, the rate of sleep breathing problems is well over 90%. However, bear in mind that greater than 96% of nightmare patients present with other signs and symptoms of additional sleep disorders that greatly increase suspicions for co-morbid physiological sleep disorders.
Summing up, you can see your patient may have many more therapeutic options to consider besides medications, especially as the Nightmare Triad Syndrome might be in play. In many of our nightmare patients, we have been pleasantly surprised to see preliminary improvements just by focusing on insomnia and sleep breathing problems; whereas those with more severe nightmare problems often benefit by starting sooner on an IRT program as early as feasible. Undoubtedly, using Prazosin to treat a case of acute nightmare-induced fear of sleep could also prove an efficacious option.
1. Krakow B. Sound Sleep, Sound Mind:7 Keys to Sleeping through the Night Hoboken, NJ: John Wiley & Sons, Inc; 2007.
2. Krakow B. Nightmare complaints in treatment-seeking patients in clinical sleep medicine settings: diagnostic and treatment implications. Sleep 2006;29(10):1313-1319.
3. Krakow B, Hollifield M, Johnston L et al. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial. JAMA 2001;286(5):537-545.
4. Raskind MA, Peterson K, Williams T et al. A trial of prazosin for combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and Afghanistan. Am J Psychiatry 2013;170(9):1003-1010.
5. Germain A, Richardson R, Moul DE et al. Placebo-controlled comparison of prazosin and cognitive-behavioral treatments for sleep disturbances in US Military Veterans. J Psychosom Res 2012;72(2):89-96.
6. Barrett D. Trauma and Dreams Harvard University Press; 2001.
7. Greenberg LS. Emotions, the great captains of our lives: their role in the process of change in psychotherapy. Am Psychol 2012;67(8):697-707.
8. BaHammam AS, Al-Shimemeri SA, Salama RI, Sharif MM. Clinical and polysomnographic characteristics and response to continuous positive airway pressure therapy in obstructive sleep apnea patients with nightmares. Sleep Med 2013;14(2):149-154.