Nature and Science of Sleep (Nov 2018)
Management of nightmares in patients with posttraumatic stress disorder: current perspectives
Abstract
Ali A El-Solh1–4 1Research Department, VA Western New York Healthcare System, Buffalo, NY, USA; 2Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, NY, USA; 3Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University of Buffalo, Buffalo, NY, USA; 4Department of Community and Health Behavior, School of Public Health and Health Professions, University of Buffalo, Buffalo, NY, USA Abstract: Nightmares are considered the hallmark of posttraumatic stress disorder (PTSD). Although the characteristics of these distressing dreams may vary with the type of traumatic event, the pathophysiology exposes central dysfunction of brain structures at the level of the hippocampus, amygdala, and locus coeruleus, modulated by neurochemical imbalance in noradrenergic, dopaminergic, and serotonin pathways. Underlying comorbid conditions, including other sleep disorders, may contribute to worsening symptoms. Addressing sleep disruption can alleviate the severity of these nocturnal events and augment the effectiveness of other PTSD treatments. The expansion of behavioral treatment modalities for PTSD-related nightmares has been encouraging, but the core of these interventions is heavily structured around memory manipulation and imagery rescripting. A lack of a standardized delivery and a high dropout rate continue to pose significant challenges in achieving successful outcomes. The efficacy of existing pharmacological studies, such as α-adrenergic blocking agents, antidepressants, and atypical antipsychotics, has been undermined by methodological limitations and absence of large randomized controlled trials. This review is aimed at reviewing the available treatment strategies for alleviating nightmares in subjects with PTSD. Given the intricate relationship between PTSD and nightmares, future clinical trials have to adopt a more pragmatic approach focused not only on efficacy of novel interventions but also on adjunctive iteration of existing therapies tailored to individual socio-cultural background. Keywords: nightmares, posttraumatic stress disorder, cognitive-behavioral therapy, pharmacotherapy, image rehearsal therapy, prazosin, cannabis
