Management of Nightmare Disorder in Adults

Erin D. Callen, PharmD, BCPS; Tiffany L. Kessler, PharmD, BCPS; Krista G. Brooks, PharmD; Tom W. Davis, MD

US Pharmacist. 2018;43(11):21-26.

Nonpharmacologic Treatment

The only treatment strategy with enough evidence to be recommended in the AASM's position paper is behavioral intervention with imagery-rehearsal therapy (IRT).^[3] IRT is based on the theory that nightmares are a learned behavior and can be replaced by a less disruptive behavior that will not ultimately affect sleep or daytime functioning. Patients are asked to recall the nightmare, write it down, alter its content to a positive outcome, and rehearse the rescripted dream for 10 to 20 minutes each day. Additional treatments that may be used for both PTSD-associated nightmares and nightmare disorder include cognitive behavioral therapy and exposure, relaxation, and rescripting therapies. Other behavioral strategies include hypnosis, lucid-dreaming therapy, eye-movement desensitization and reprocessing, and progressive deep-muscle relaxation techniques.^[3]

1 2 3 4 5 6

Next Section

Table 1. Medications Associated With Nightmares
Drug Class	Medications
Acetylcholinesterase inhibitors	Donepezil, rivastigmine
Antidepressants	Bupropion, MAOIs, SNRIs, SSRIs, TCAs
Antihistamines	Chlorpheniramine
Antimicrobials	Efavirenz, ganciclovir
Atypical antipsychotics	Clozapine, risperidone
Beta-blockers	Atenolol, labetalol, nadolol, propranolol, sotalol
Calcium channel blockers	Verapamil
Dopaminergics	Amantadine, levodopa, ropinirole, selegiline
Sedative/hypnotics	Alcohol, barbiturates, temazepam, triazolam
Statins	Atorvastatin, simvastatin

MAOI: monoamine oxidase inhibitor; SNRI: serotonin-norepinephrine reuptake inhibitor; SSRI: selective serotonin reuptake inhibitor; TCA: tricyclic antidepressant.
Source: Reference 4.

Table 2. AASM-Recommended Medications for Treatment of Nightmare Disorder
Medication	Indication	MOA	Trial and Number of Participants	Trial Dosagea	Common AEs
Prazosin	NDPTSD,^b ND	α₁- adrenergic antagonist	Raskind (2018), RCT; N = 304	14.8 (6.1) mg/day	Dizziness, drowsiness, weakness
			Ahmadpanah (2014), RCT; N = 100	15 mg/day
			Raskind (2013), RCT; N = 67	Men—AM: 4 mg (1.2), PM: 15.6 mg (6)Women—AM: 1.7 mg (0.5), PM: 7 mg (0.5)
			Germain (2012), RCT; N = 50	8.9 mg, range 1–15 mg/day
			Boynton (2009), retrospective chart review; N = 23	2.3 mg/day (1.4)
			Taylor (2008), crossover RCT; N = 13	3.1 mg/day (1.3)
			Raskind (2007), RCT; N = 34	13 mg/day (3)
			Daly (2005), case series; N = 28	1–6 mg/day
			Peskind (2003), open-label case series; N=9	2–4 mg/day
			Raskind (2003), double-blind crossover; N=10	9.5 mg/day (0.5)
Atypical antipsychotic: aripiprazole	PTSD	Serotonin, dopamine, histamine, and α-adrenergic antagonist	Lambert (2006), case series; N = 5	15–30 mg/day	Headache, extrapyramidal reaction, drowsiness
Atypical antipsychotic: olanzapine			Jakovljevic (2003), case series; N = 5	10–20 mg/day
Atypical antipsychotic: risperidone			David (2006), open-label; N = 20	2.3 mg/day (0.6)
Atypical antipsychotic: risperidone			Stanovic (2001), retrospective chart review; N = 10	0.5–2.0 mg/day
Benzodiazepines: ND nitrazepam, triazolam	ND	Enhances effect of neurotransmitter γ-aminobutyric acid (GAB_A) at the GABAA receptor	Ellingsen (1983), crossover RCT; N=40	One dose: 0.5 mg triazolam or 5 mg nitrazepam	Drowsiness, headache, nervousness
Clonidine	PTSD	α₂-adrenergic receptor agonist	Kinzie (1994), 2-wk pilot; N = 4	0.2 mg/day	Rash, Rash, drowsiness
Clonidine	PTSD	α₂-adrenergic receptor agonist	Kinzie (1989), prospective pilot; N = 9	Clonidine 0.2 mg/day + imipramine up to 150 mg/day	Rash, Rash, drowsiness
Cyproheptadine	PTSD	Serotonin antagonist, additional antihistaminicand anticholinergic effects	Clark (1999), case series; N = 16	4–8 mg/day	Drowsiness, incoordination, restlessness
			Gupta (1998), retrospective review; N = 9	4 days, 12 mg/day
			Brophy (1991), case series; N = 4	2–28 mg/day
Gabapentin	PTSD	Unknown, but activity may be due to binding at α₂δ subunit	Hamner (2001), retrospective case series; N=30	1,377 mg/day (701)	Dizziness, drowsiness, ataxia
Nabilone	PTSD	Synthetic CB₁ receptor agonist	Jetly (2015), RCT; N = 10	1.95 mg/day (0.9)	Drowsiness, dizziness, vertigo
Nabilone	PTSD	Synthetic CB₁ receptor agonist	Fraser (2009), open-label; N = 47	0.2–4 mg/day	Drowsiness, dizziness, vertigo
Phenelzine	PTSD	MAO glutamate receptor inhibitor	Lerer (1987), open-label, prospective trial; N = 25	30–90 mg/day	Dizziness, constipation, orthostatic hypotension
Phenelzine	PTSD	MAO glutamate receptor inhibitor	Hogben (1981), case series; N = 5	45–75 mg/day	Dizziness, constipation, orthostatic hypotension
SSRI: fluvoxamine	PTSD	Enhances serotonergic activity	Neylan (2001), open-label; N = 21	50 mg/day, then titrated to 100–250 mg/day	Headache, insomnia, nausea
SSRI: fluvoxamine	PTSD	Enhances serotonergic activity	De Boer (1992), prospective cohort trial; N = 24	Up to 300 mg/day	Headache, insomnia, nausea
Topiramate	PTSD	Unknown, but may be due to blockage of neuronal voltage dependent sodium channels; enhances GABA_A activity, antagonizes glutamatereceptors, andinhibits carbonicanhydrase enzymes	Alderman (2009), open-label pilot study; N = 29	200 mg/day	Paresthesias, decreased serum bicarbonate, upper respiratory tract infection
			Tucker (2007), RCT; N = 40	150 mg/day
			Berlant (2004), case series; N = 33	12.5–25 mg/day, then titrated to clinical response
			Berlant (2002), case series; N = 35	12.5–500 mg/day
Trazodone	PTSD	Serotonin, histamine, and alpha₁- adrenergicantagonist	Warner (2001), retrospective cohortstudy; N = 74	212 mg/day	Drowsiness, hypertension, dizziness
TCAs:amitriptyline, doxepin, imipramine	PTSD	Anticholinergic, antihistamine, inhibits serotonin-norepinephrinereceptors	Boehnlein (1985), case series; N = 10	Imipramine 75–125 mg/day (n = 3); imipramine150 mg/day + phenelzine30 mg bid (n = 1); phenelzine 30 mg bid+ doxepin 50–100 mg/day + amitriptyline100 mg/day (n = 1); amitriptyline 100 mg/day+ doxepin 50–100 mg/day(n = 1); doxepin 50–100mg/day (n = 4)	Anticholinergiceffects, orthostatichypotension, sedation

^a Trial doses are reported as either a mean (standard deviation) or a range.
^b PTSD-associated nightmares.
AASM: American Academy of Sleep Medicine; AE: adverse effect; CB1: cannabinoid type 1; GABA: gamma-aminobutyric acid; GABA_A: gamma-aminobutyric acid type A; MAO: monoamine oxidase; MOA: mechanism of action; ND: nightmare disorder; PTSD: posttraumatic stress disorder; RCT: randomized, controlled trial; SSRI: selective serotonin reuptake inhibitor. Source: References 5–21, 23–40.

Comments

processing....

Management of Nightmare Disorder in Adults

Nonpharmacologic Treatment

Comments

Most Popular Articles

About

Membership

Apps

WebMD Network

Editions

Management of Nightmare Disorder in Adults

Nonpharmacologic Treatment

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

Comments

Most Popular Articles

Email This

Feedback

Find Us On

About

Membership

Apps

WebMD Network

Editions