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

Post-traumatic nightmares are a common and distressing problem for people with PTSD and other conditions, linked to high costs and an independent risk of suicide. An updated review finds that Prazosin, previously a preferred pharmacological treatment, has been downgraded by the American Academy of Sleep Medicine and the Veterans Health Administration/Department of Defense following a recent New England Journal of Medicine study. In Canada, Nabilone, a synthetic cannabinoid, appears promising. Non-pharmacological options like imagery rescripting therapy and exposure, relaxation, and rescripting therapy remain preferred, with recent evidence supporting their use in inpatient settings, with German combat veterans, via virtual technology, and with children and individuals with bipolar disorder. Combining cognitive behavior therapy for insomnia with these therapies may improve outcomes.

Study at a glance

Abstract

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.