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Fast Fact and Concept #088; Nightmares, 2nd Edition

First Author: Seema Malhotra, MD, Robert Arnold, MD, and Kevin Patterson MD

Background   Good, restful sleep is essential to quality of life – providing renewed energy for the next day. Nightmares are vivid, frightening dreams that typically lead to full awakening with detailed recollection of the dream sequence and content. Following a nightmare, heart rate and blood pressure are elevated, and residual anxiety may interfere with the ability to return to sleep. Nightmares occur almost exclusively during REM (Rapid Eye Movement) sleep.

Causes
• Psychiatric: Anxiety is a common symptom during a life-threatening illness. Specifically, anxieties related to the illness course and prognosis, procedures and treatments, family issues, and death, can be significant. Nightmares may arise as a complication of anxiety or other psychiatric disturbances (such as post-traumatic stress disorder, delirium, mood disorders, schizophrenia, and adjustment disorders).
• Medications/Drugs/Alcohol: Medications causally linked to nightmares include: beta-blockers, sedative/hypnotics, amphetamines and other stimulants, dopamine agonists, and antidepressants. Withdrawal from REM-suppressing drugs, including antidepressants, benzodiazepines, and alcohol, predisposes to the development of nightmares.
• Brain disorders: CNS infections, brain tumors and other structural problems of the brain may lead to nightmares.
• Metabolic: hypoglycemia

Psychotherapeutic Interventions can be particularly helpful for people whose nightmares are related to stress/anxiety or an underlying psychiatric condition.
• Supportive Psychotherapy:  Brief, supportive psychotherapy can address a patient’s anxieties and concerns; the therapist helps the patient with problem solving, seeking information and support, and accepting aspects of their situation which cannot be changed.
• Behavioral techniques:  Relaxation training, desensitization, and dream imagery rehearsal therapy may help reduce nightmares. In imagery rehearsal therapy, the patient writes down the disturbing dream, changes the content, and practices the new, positive scenario mentally during the day; this new imagery during the day reduces nightmares at night.

Pharmacologic Management  The pharmacologic treatment of nightmares has not been studied in controlled clinical trials. Case studies and anecdotal reports suggest the following drugs or drug classes may be effective:
• Atypical Antipsychotics: risperidone (0.5-2mg qhs) and olanzapine (5mg) have both been shown to reduce nightmares in small pilot studies of patients with acute stress and PTSD, including reduction in flashbacks, hyperarousal, and disturbed sleep.
• Alpha-1 Antagonists: prazosin (2-15mg qhs) has been shown to reduce nightmares and other sleep-related symptoms in PTSD patients in multiple small studies and a single randomized controlled trial involving 13 patients.
• Benzodiazepines and Tricyclic Antidepressants may be of benefit in suppressing REM activity. Note: trazadone does not suppress REM activity.
• Other:  Both cyproheptadine and topiramate have been reported to suppress nightmares in small case series.

References
1. Berlant J. Open-Label Topiramate as Primary or Adjunctive Therapy in Chronic Civilian Posttraumatic Stress Disorder: A Preliminary Report. Journal of Clinical Psychiatry. 2002; 63(1): 15-20.
2. Buysse DJ et al, in Treatments of Psychiatric Disorders, 2nd Edition. Gabbard G (Ed), 1995, 2395-2453.
3. Sateia MJ et al, in Oxford Textbook of Palliative Medicine, 2nd Edition. Doyle D (Ed), 1998, 751-767.
4. Krakow B 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.
5. Labbate LA. Olanzapine for Nightmares and Sleep Disturbance in Posttraumatic Stress Disorder [comment]. Canadian Journal of Psychiatry. 2000; 45(7): 667-668.
6. Stanovic JK et al. The Effectiveness of Risperidone on Acute Stress Symptoms in Adult Burn Patients: A Preliminary Retrospective Pilot Study. Journal of Burn Care & Rehabilitation. 2001; 22(3): 210-213.
7. Taylor, FB et al. Prazosin Effects on Objective Sleep Measures and Clinical Symptoms in Civilian Trauma Posttraumatic Stress Disorder: A Placebo-Controlled Study. Biological Psychiatry. 2007; (epub in advance of written publication). PMID: 17868655.
8. Thompson DF et al. Drug-Induced Nightmares. The Annals of Pharmacotherapy. 1999; 33(1): 93-98.

Fast Facts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For comments/questions write to: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu.
Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Malhotra S, Arnold R, Patterson K. Fast Fact and Concept #88. Nightmares. 2nd Edition. October 2007. End-of-Life/Palliative Education Resource Center (www.eperc.mcw.edu).

Disclaimer: Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: October 2007

Format: Self-Study Guide Books

Purpose: Instructional Aid, Self-Study Guide, Teaching

Educational Objective: Fast Fact

ACGME Competencies: Medical Knowledge

Keyword(s): Ethics

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