Correlates and Treatments of Nightmares in Adults

Understanding and Treating Nightmares: A Comprehensive Review of Psychosocial Strategies for Adults and Children

Nightmares are distressing dreams that evoke strong negative emotions, such as fear or anxiety, often leading to waking from sleep and subsequent sleep disruption. They are prevalent across various age groups, with significant psychological and physiological health implications. This review explores the nature of nightmares, distinguishing them from other sleep disturbances like night terrors and sleep paralysis. It examines the prevalence of nightmares in children and adults, highlighting their impact on mental health and daily functioning. The review also emphasizes the importance of addressing nightmares through effective treatment strategies. While pharmacological options are available, psychosocial interventions offer promising non-pharmacological solutions. Cognitive behavioral therapy (CBT), imagery rehearsal therapy (IRT), and mindfulness-based therapies are discussed as key approaches for managing nightmares. These strategies focus on altering maladaptive thought patterns and emotional responses, reducing nightmares' frequency and intensity, and improving overall sleep quality. Psychosocial interventions provide a comprehensive approach to treating nightmares by addressing the underlying cognitive and emotional factors, benefitting individuals across different age groups. This review aims to highlight the efficacy of these strategies and their role in enhancing the quality of life for those affected by persistent nightmares.

Trait-based Anxiety Symptoms are Associated with Higher Incidence of Nightmare Frequency in the Wisconsin Sleep Cohort

OBJECTIVES

Nightmares affect up to 12% of the population and are often comorbid with psychiatric disorders like anxiety and depression. Limited research has examined their influence on nightmare frequency. This study investigates the relationship between depression and trait-anxiety symptoms on incident nightmare frequency at follow-up.

METHOD

Cross-sectional and longitudinal analyses were conducted on 758 Wisconsin Sleep Cohort participants. Trait anxiety and depression symptom severity were measured using the State Trait Anxiety Inventory and Zung Depression Scale. Ordinal regression determined nightmare frequency cutoffs based on anxiety and depression severity. Cross-sectional associations were assessed with Spearman and Kruskal-Wallis tests. Longitudinal associations were analyzed using adjusted binomial regression of binary nightmare frequency (low: <4/month, high: >5/month) against clinical cutoffs of trait anxiety and depression.

RESULTS

Adjusted models indicated a small correlation between baseline nightmare frequency and trait anxiety (β = 0.01, p = .010) and depression symptoms (β = 0.01, p = .005). High baseline trait-anxiety symptoms were associated with frequent nightmares at follow-up (OR = 3.75, CI95% [1.306,10.793], p < .014), but depression symptoms were not (OR = 1.35, CI95%[0.399, 4.587], p = .627).

CONCLUSIONS

Our findings suggest that high trait-anxiety symptoms are associated with increased incident nightmare frequency, when adjusted for depression. However, high depression symptoms were not associated with an increase in nightmare frequency when adjusted for trait-anxiety.

Short-term stability and night-to-night variability of sleep parameters in nightmares comorbid with chronic insomnia Disorder across multiple nights of polysomnography

STUDY OBJECTIVES

The purpose of this study was to examine the degree of short-term stability of polysomnographic (PSG) measured sleep parameters and the overall differences between individuals with comorbid nightmares and insomnia compared to those with chronic insomnia disorder alone or good sleeping controls across four nights in the sleep lab.

METHODS

A total of 142 good sleeping controls, 126 chronic insomnia alone, and 24 comorbid insomnia/nightmare participants underwent four consecutive nights of 8-hour PSG recordings. Outcomes included sleep continuity, architecture, and REM-related parameters across nights one through four. Intraclass correlation coefficients with mixed-effect variances and repeated-measure analysis of covariance were used, respectively, to determine short-term stability as well as between-participants and time-by-group interaction effects.

RESULTS

Wake after sleep onset and stage 1 showed "poor stability" in the comorbid insomnia/nightmare group compared to "moderate stability" in the good sleeping controls and chronic insomnia alone group. Significant between-group effects (all ps < .05) showed that the comorbid insomnia/nightmare group took longer to fall asleep and had a greater first-night-effect in stage 1 compared to good sleeping controls and chronic insomnia alone group; in addition, the comorbid insomnia/nightmare and insomnia alone groups slept shorter, with fewer awakenings and REM periods, compared to the good sleeping controls.

CONCLUSIONS

Nightmares are associated with abnormal sleep above and beyond REM disruption, as sleep continuity was the primary aspect in which poor stability and group differences emerged. The greater inability to fall asleep and instability of sleep fragmentation in those with comorbid insomnia/nightmares compared to chronic insomnia alone may be attributed to the impact of presleep anticipatory anxiety and nightmare-related distress itself.

CLINICAL TRIAL INFORMATION

The data analyzed in this study does not come from any current or previous clinical trials. Therefore, there is no clinical trial information to report.

The effectiveness of lucid dreaming therapy in patients with nightmares: A systematic review

OBJECTIVES

Nightmares can be defined as "an unpleasant dream with anxiety and oppression". They represent a symptom possibly leading to serious psychiatric and physical consequences. It occurs to 2% to 8% of the general population. Lucid dreaming therapy (LDT) is an interesting upcoming psychotherapy for the treatment of nightmares. The aim of this study was to evaluate the efficacy of LDT in the treatment of nightmares in adults and children.

METHODS

We performed a systematic review of the literature, based on the Cochrane organisation's methodology. We explored the PubMed, Cochrane library, PsycINFO via Ovid and Embase databases and clinical trial registries (CTR), namely clinicaltrials.gov, EU clinical trials and the WHO clinical trials registry platform.

RESULTS

Four randomized controlled trials (RCT), 2 case series and 5 case reports were included. Most of the included studies found LDT effective in reducing nightmare frequency among adults with chronic and recurring nightmares. We did not identify any reports in children.

CONCLUSIONS

Despite a limited internal validity for the included studies, these first results are encouraging. Nonetheless, larger and more rigorous studies would allow to better assess the utility of LDT for nightmares.

Associations between frequent nightmares, nightmare distress and depressive symptoms in adolescent psychiatric patients

BACKGROUND

Nightmares are common in patients with psychiatric disorders. Patients with psychiatric disorders often experience depressive symptoms. Nightmares have been associated with depressive symptoms among adolescents. Previous studies have explored the mediating role of nightmare distress in the relationship between frequent nightmares and depressive symptoms in the general adolescent population. We aimed to explore the associations between frequent nightmares, nightmare distress, and depressive symptoms in Chinese adolescent patients with psychiatric disorders.

METHODS

A total of 408 adolescents participated in this study. A self-administered questionnaire was used to measure nightmare frequency, nightmare distress, depressive symptoms, and covariates. Linear regressions and mediation analyses were performed to examine the associations between nightmare frequency, nightmare distress, and depressive symptoms.

RESULTS

The mean age of participants was 15.31 ± 1.88 years, and 152 (37.3%) were boys. The prevalence of frequent nightmares in adolescent patients with psychosis was 49.3%. Girls reported more frequent nightmares and had significantly higher scores of depressive symptoms and nightmare distress. Patients with frequent nightmares had higher scores of nightmare distress and depressive symptoms. Frequent nightmares and nightmare distress were significantly associated with depressive symptoms. Nightmare distress had a full mediating effect on the correlation between frequent nightmares and depressive symptoms.

CONCLUSIONS

In Chinese adolescent patients with psychiatric disorders, frequent nightmares and nightmare distress were associated with depressive symptoms, whereas the association between frequent nightmares and depressive symptoms was mediated by nightmare distress. Interventions for nightmare distress may be more useful in reducing depressive symptoms in adolescent patients with psychiatric disorders.

Posttraumatic stress disorder, suicide, and unintended overdose death in later life: A national cohort study of veterans aged 50 and older

BACKGROUND/OBJECTIVES

Although studies have shown posttraumatic stress disorder (PTSD) associated with risk of suicide, the relationship in later life, especially for overdose death, remains unclear. Thus, the aim of the current study was to determine associations between PTSD, suicide, and unintended overdose death in mid- to late-life.

METHODS

A nationwide cohort study integrating Department of Veterans Affairs' (VA) data, Centers for Medicare & Medicaid Services data, and national cause-specific mortality data. Participants were US veterans aged ≥50 years with PTSD diagnoses at baseline (2012-2013) and were propensity-matched 1:1 with patients without PTSD based on sociodemographics, Charlson Comorbidity Index, and neuropsychiatric disorders (N = 951,018). Information on suicide attempts and unintended death by overdose through December 31, 2017 was provided by the VA's National Suicide Prevention Applications Network (non-fatal attempts) and Mortality Data Repository (death).

RESULTS

Veterans with PTSD (N = 475,509) had increased risk of suicide attempt (Hazard Ratio [HR], 1.59; 95% CI, 1.54-1.65; p < 0.001), non-fatal attempt (HR, 1.74; 95% CI, 1.67-1.81; p < 0.001), drug overdose death overall (HR, 1.32; 95% CI, 1.22-1.42; p < 0.001), and suicide overdose death (HR, 1.44; 95% CI, 1.15-1.80; p = 0.002), even after adjusting for sociodemographics, Charlson comorbidity index, and neuropsychiatric disorders. We found increased risk for overdose death by narcotics (HR, 1.30; 95% CI, 1.15-1.46; p < 0.001), antiepileptic/sedative-hypnotics (HR, 1.29; 95% CI, 1.02-1.62; p = 0.032), and for other/unspecified drugs (HR, 1.35; 95% CI, 1.20-1.51; p < 0.001), the last category indicative of polydrug. Results remained robust when examined for unintentional, suicide, and undetermined intent for cause-specific death by other/unspecified drugs.

CONCLUSIONS

PTSD persists throughout mid- to late-life with considerable increased risk for non-fatal suicide attempts and suicide overdose death. These findings suggest the importance of drug-monitoring in preventing late-life suicide.

Improving sleep quality leads to better mental health: A meta-analysis of randomised controlled trials

The extent to which sleep is causally related to mental health is unclear. One way to test the causal link is to evaluate the extent to which interventions that improve sleep quality also improve mental health. We conducted a meta-analysis of randomised controlled trials that reported the effects of an intervention that improved sleep on composite mental health, as well as on seven specific mental health difficulties. 65 trials comprising 72 interventions and N = 8608 participants were included. Improving sleep led to a significant medium-sized effect on composite mental health (g+ = -0.53), depression (g+ = -0.63), anxiety (g+ = -0.51), and rumination (g+ = -0.49), as well as significant small-to-medium sized effects on stress (g+ = -0.42), and finally small significant effects on positive psychosis symptoms (g+ = -0.26). We also found a dose response relationship, in that greater improvements in sleep quality led to greater improvements in mental health. Our findings suggest that sleep is causally related to the experience of mental health difficulties. Future research might consider how interventions that improve sleep could be incorporated into mental health services, as well as the mechanisms of action that explain how sleep exerts an effect on mental health.

Examining the Factor Structure, Reliability, and Validity of the Disturbing Dreams and Nightmare Severity Index (DDNSI) Consequences Sub-component

Background: The Disturbing Dreams and Nightmares Severity Index (DDNSI) is commonly used when assessing the experience of nightmares. It comprises two parts examining i) chronicity and ii) nightmare consequences. The primary aim of the present study was to explore the dimensional structure of the optional and currently unvalidated nightmare consequences component using exploratory factor analysis. Internal reliability and construct validity were also examined. A secondary aim explored the relationships between nightmare chronicity and perceived consequences with measures of anxiety, depression, stress, self-efficacy, and insomnia.Methods: A cross-sectional survey was conducted with complete data from N = 757 students from six UK-based universities. Participants completed the chronicity and consequences components of the DDNSI, alongside the Sleep Condition Indicator, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Perceived Stress Scale, and General Self-Efficacy Scale.Results: Two nightmare consequences factors emerged; 'Sleep-Interference' (four items; α =.848), and 'Psychosocial Well-being' (six items; α =.946). Significantly moderate correlations were observed between the two emerging factors and the nightmare chronicity component, as well as with insomnia, anxiety, depression, perceived stress, and self-efficacy. Perceived 'Sleep-Interference' (β =-.241) was the strongest predictor of insomnia, and 'Psychosocial wellbeing' was the strongest predictor of anxiety (β =.688) depression (β =.804) perceived stress and lower self-efficacy.Conclusions: The perceived nightmare consequences component of the DDSNI is a multidimensional construct comprising two internally consistent and distinct, but related dimensions. The potential importance of distinguishing between types of perceived nightmare consequences and the associations with mental health outcomes in a student population is highlighted.

Nightmares and bad dreams among individuals with musculoskeletal pain: a link to vitamin D and calcium

Nightmares are frightening or disturbing dreams that awaken sleepers while bad dreams are disturbing dreams that do not awaken sleepers. Both types are known to be associated with psychological symptoms including anxiety and depression. Chronic pain is often comorbid with psychological symptoms and vitamin D deficiency increases risk of chronic musculoskeletal pain (MSP), which in turn is associated with increased risk of anxiety and depression. We aimed to investigate associations between types of dreams, psychological symptoms, vitamin D, and calcium intake in individuals with MSP. The study included 191 outpatients with MSP and 191 age/gender matched healthy controls. Psychological symptoms were assessed using Hospital Anxiety and Depression Scale. Serum vitamin D was measured and daily calcium intake was estimated. Participants were asked about types of their dreams (normal, bad, or nightmares) during the past month. Binary logistic regression was used to find predictors of MSP and bad dreams and nightmares. Bad dreams and nightmares, vitamin D deficiency, low calcium intake, anxiety, and depression were more prevalent in cases versus controls (Ps<0.001). Chi-square analyses showed that types of dreams were associated with anxiety, depression, and MSP (Ps<0.001). Participants with normal dreams had higher vitamin D (P<0.01) and calcium intake (P<0.001) and lower anxiety and depression scores (Ps<0.001) compared to participants with bad dreams and nightmares. Anxiety, depression and MSP were predictors for bad dreams and nightmares. Further studies are required to assess if vitamin D supplementation and increasing calcium intake may improve MSP, psychological symptoms and thus prevent nightmares and bad dreams.

Treatment of Sleep Comorbidities in Posttraumatic Stress Disorder

Purpose of the review

Sleep disturbances, insomnia and recurrent nightmares in particular, are among the most frequently endorsed symptoms of posttraumatic stress disorder (PTSD). The present review provides a summary of the prevalence estimates and methodological challenges presented by sleep disturbances in PTSD, highlights the recent evidence for empirically supported psychotherapeutic and pharmacological interventions for comorbid sleep disturbances implicated in PTSD, and provides a summary of recent findings on integrated and sequential treatment approaches to ameliorate comorbid sleep disturbances in PTSD.

Recent Findings

Insomnia, recurrent nightmares, and other sleep disorders are commonly endorsed among individuals with PTSD; however, several methodological challenges contribute to the varying prevalence estimates. Targeted sleep-focused therapeutic interventions can improve sleep symptoms and mitigate daytime PTSD symptoms. Recently, attention has focused on the role of integrated and sequential approaches, suggesting that comprehensively treating sleep disturbances in PTSD is likely to require novel treatment modalities.

Summary

Evidence is growing on the development, course, and treatment of comorbid sleep disturbances in PTSD. Further, interventions targeting sleep disturbances in PTSD show promise in reducing symptoms. However, longitudinal investigations and additional rigorous controlled trials with diverse populations are needed to identify key features associated with treatment response in order to alleviate symptoms.

Frontal Brain Activity and Subjective Arousal During Emotional Picture Viewing in Nightmare Sufferers

Nightmares are intensely negative dreams that awaken the dreamer. Frequent nightmares are thought to reflect an executive deficit in regulating arousal. Within a diathesis-stress framework, this arousal is specific to negative contexts, though a differential susceptibility framework predicts elevated arousal in response to both negative and positive contexts. The current study tested these predictions by assessing subjective arousal and changes in frontal oxyhemoglobin (oxyHB) concentrations during negative and positive picture-viewing in nightmare sufferers (NM) and control subjects (CTL). 27 NM and 27 CTL subjects aged 18–35 rated subjective arousal on a 1–9 scale following sequences of negative, neutral and positive images; changes in oxyHB were measured by Near-Infrared Spectroscopy (NIRS) using a 2 × 4 template on the frontal pole. Participants also completed the Highly Sensitive Person Scale, a trait marker for differential susceptibility; and completed a dream diary reporting negative and positive dream emotionality. The NM group had higher trait sensitivity, yet higher ratings of negative but not positive emotion in diary dreams. NM compared to CTL subjects reported higher subjective arousal in response to picture-viewing regardless of valence. Dysphoric dream distress, measured prospectively, was negatively associated with frontal activation when viewing negative pictures. Results suggest NM sufferers are highly sensitive to images regardless of valence according to subjective measures, and that there is a neural basis to level of trait and prospective nightmare distress. Future longitudinal or intervention studies should further explore positive emotion sensitivity and imagery in NM sufferers.

My Dream, My Rules: Can Lucid Dreaming Treat Nightmares?

Nightmares are defined as repeated occurrences of extremely dysphoric and well-remembered dreams that usually involve subjective threats to survival, security, or physical integrity. Generally, they occur during rapid eye movement sleep (REMS) and lead to awakenings with distress and insufficient overnight sleep. Nightmares may occur spontaneously (idiopathic) or as recurrent nightmares. Recurrent nightmares cause significant distress and impairment in occupational and social functioning, as have been commonly observed in post-traumatic stress disorder, depression and anxiety. By contrast, during lucid dreaming (LD), subjects get insight they are dreaming and may even control the content of their dreams. These features may open a way to help those who suffer from nightmare disorder through re-significations of the dream scene, i.e., knowing that they are dreaming and having control over their dream content. Thus, lucid dreamers might be able to render nightmares normal dreams, thereby assuring a restoring sleep. The aim of the present study is to review the existing literature of the use of LD as an auxiliary tool for treatment of nightmares. We conducted a careful literature search for eligible studies on the use of LD treatment for nightmares. We observed that whereas LD may be a feasible aid in the treatment of patients with nightmares through minimizing their frequency, intensity and psychological distress, the available literature is still scarce and does not provide consistent results. We conclude therefore that more research is clearly warranted for a better estimation of the effective conductance and therapeutic outcome of LD treatment in clinical practice.

Frequent nightmares in Chinese patients undergoing methadone maintenance therapy: prevalence, correlates, and their association with functional impairment

PURPOSE

Nightmares are associated with many negative health outcomes; however, little is known about the characteristics of nightmares in heroin-dependent patients (HDPs). This study examined the prevalence and correlates of frequent nightmares (FNs) and their association with functional impairment in Chinese patients undergoing methadone maintenance therapy (MMT).

PATIENTS AND METHODS

In total, 603 Chinese HDPs from three MMT clinics in Wuhan, China, completed this survey. FNs were defined as reporting nightmares at least once a week. The Sheehan Disability Scale (ShDS) was used to assess the severity of functional impairment of patients. A standardized questionnaire was used to collect data on socio-demographics, drug use characteristics, physical health, mental health, and insomnia.

RESULTS

The prevalence of FNs in Chinese HDPs receiving MMT was 25.9%. Factors significantly associated with nightmares among MMT HDPs included an educational attainment of senior high school and above (OR=2.73, P<0.001), unemployment (OR=3.16, P<0.001), a history of re-education through forced labor (OR=3.14, P<0.001), injecting heroin before MMT (OR=3.62, P=0.002), a high dose of methadone (>70 mg/day) (OR=2.03, P=0.006), use of hypnotics (OR=1.91, P=0.044), the presence of hepatitis B virus core antibody (OR=4.63, P<0.001), pain (OR=3.20, P<0.001), anxiety (OR=2.06, P=0.039), and insomnia (OR=5.75, P<0.001). After controlling for potential confounders, nightmares were still significantly associated with a higher ShDS score (β=2.718, P=0.006).

CONCLUSION

FNs are prevalent among Chinese HDPs receiving MMT and significantly associated with functional impairment. Nightmares are a clinically relevant phenomenon in Chinese MMT clinics, which deserves more clinical and research attention.

Two Independent Predictors of Nightmares in Posttraumatic Stress Disorder

STUDY OBJECTIVES

Understanding nightmares (NM) and disturbing dreams (DD) in posttraumatic stress disorder (PTSD) has been limited by the unpredictability of these events and their nonappearance in the sleep laboratory. This study used intensive, longitudinal, ambulatory methods to predict morning reports of NM/DD in veterans in whom chronic, severe PTSD was diagnosed.

METHODS

Participants were 31 male United States military veterans engaged in residential treatment for PTSD and participating in a service animal training intervention. Participants slept on mattress actigraphs and provided reports of momentary mood, as well as morning NM/DD reports, for up to 6 weeks. Mattress actigraphy provided sleep-period heart rate and respiratory sinus arrhythmia (RSA), and an actigraphic estimate of sleep efficiency. On one night, a respiratory event index (REI) was obtained using an ambulatory system.

RESULTS

A total of 468 morning reports were obtained, of which 282 endorsed NM/DD during the prior night, and 186 did not. After accounting for multiple predictors, only elevated REI and lower prior-night sleep RSA predicted morning endorsement of NM/DD. These two predictors did not interact.

CONCLUSIONS

Elevated REI and lower sleep period RSA were independently predictive of NM/DD. The former result is consistent with studies showing that sleep-disordered breathing (SDB) is a factor in NM/DD, and that continuous positive airway pressure (CPAP) can reduce these symptoms in patients with comorbid PTSD and SDB. The latter result implicates dysregulated arousal modulation during sleep in trauma-related NM/DD. It is consistent with findings that NM/DD are reported in patients without SDB and can persist in patients with comorbid PTSD and SDB even when CPAP successfully remediates SDB.

Self-efficacy as a Mechanism of Action of Imagery Rehearsal Therapy's Effectiveness: An Exploratory Mediation Analysis

Imagery rehearsal therapy (IRT) is an empirically validated therapy targeting recurring nightmares, for which the mechanisms of action remain poorly understood. The objective of this study was to investigate how an exploratory measure of self-efficacy could mediate IRT's effectiveness. Thirty-five victims of sexual assault with recurring nightmares were randomly assigned to either IRT or a control condition. Participants completed questionnaires about self-efficacy and nocturnal symptoms at pre- and posttreatment. Regression analyses showed that IRT predicted greater self-efficacy about dreams (β = .578) and that self-efficacy about dreams predicted improvement in insomnia (β = -.378). IRT also predicted greater self-efficacy about nightmares (β = .366), which in turn predicts sleep quality (β = -.412). However, self-efficacy was not a significant mediator of IRT's effectiveness on insomnia and sleep quality. Although IRT did increase patients' self-efficacy over dreams and nightmares, self-efficacy may not be a primary mechanism of action explaining IRT's effectiveness.

Recent Advancements in Treating Sleep Disorders in Co-Occurring PTSD

PURPOSE OF REVIEW

Comorbidity of posttraumatic stress disorder (PTSD) and insomnia, nightmares, and obstructive sleep apnea (OSA) is high. We review recent research on psychotherapeutic and pharmacological interventions for sleep disorders in PTSD.

RECENT FINDINGS

PTSD treatments decrease PTSD severity and nightmare frequency, but do not resolve OSA or insomnia. Research on whether insomnia hinders PTSD treatment shows mixed results; untreated OSA does interfere with PTSD treatment. Cognitive behavioral therapy for insomnia is the recommended treatment for insomnia; however, optimal ordering with PTSD treatment is unclear. PTSD treatment may be most useful for PTSD-related nightmares. CPAP therapy is recommended for OSA but adherence can be low. Targeted treatment of sleep disorders in the context of PTSD offers a unique and underutilized opportunity to advance clinical care and research. Research is needed to create screening protocols, determine optimal order of treatment, and elucidate mechanisms between sleep and PTSD treatments.

Nightmares in the general population: identifying potential causal factors

BACKGROUND

Nightmares are inherently distressing, prevent restorative sleep, and are associated with a number of psychiatric problems, but have rarely been the subject of empirical study. Negative affect, linked to stressful events, is generally considered the key trigger of nightmares; hence nightmares have most often been considered in the context of post-traumatic stress disorder (PTSD). However, many individuals with heightened negative affect do not have nightmares. The objective of this study was to identify mechanistically plausible factors, beyond negative affect, that may explain why individuals experience nightmares.

METHOD

846 participants from the UK general population completed an online survey about nightmare occurrence and severity (pre-occupation, distress, and impairment), negative affect, worry, depersonalisation, hallucinatory experiences, paranoia, alcohol use, sleep duration, physical activity levels, PTSD symptoms, and stressful life events. Associations of nightmares with the putative predictive factors were tested controlling for levels of negative affect. Analyses were also repeated controlling for levels of PTSD and the recent occurrence of stressful life events.

RESULTS

Nightmare occurrence, adjusting for negative affect, was associated with higher levels of worry, depersonalisation, hallucinatory experiences, paranoia, and sleep duration (odds ratios 1.25-1.45). Nightmare severity, controlling for negative affect, was associated with higher levels of worry, depersonalisation, hallucinatory experiences, and paranoia (R 2s: 0.33-0.39). Alcohol use and physical activity levels were not associated with nightmares.

DISCUSSION

The study identifies a number of potential predictors of the occurrence and severity of nightmares. Causal roles require testing in future longitudinal, experimental, and treatment studies.

Symptom Presentation and Prescription of Sleep Medications for Veterans With Posttraumatic Stress Disorder

This study tested whether sleep medications prescribed to veterans diagnosed with posttraumatic stress disorder (PTSD) are being targeted to patients who report more severe insomnia or nightmares. Secondary analysis of survey and pharmacy data was conducted in samples of veterans from two periods: from 2006 to 2008 and from 2009 to 2013. Logistic regression tested associations between self-reported insomnia and nightmare severity, and being prescribed trazodone, prazosin, zolpidem, and benzodiazepines, controlling for PTSD severity and other covariates. In both samples, insomnia severity independently predicted trazodone receipt, and nightmare severity independently predicted prazosin receipt. In the later study, insomnia severity predicted receipt of zolpidem. Veterans in the later sample were more likely to receive trazodone, prazosin, and non-benzodiazepine hypnotics, and less likely to receive benzodiazepines than those in the earlier sample. Further research is needed to evaluate and optimize pharmacological and psychosocial treatments for sleep problems among veterans with PTSD.

Mechanisms Underlying Footshock and Psychological Stress-Induced Abrupt Awakening From Posttraumatic "Nightmares"

BACKGROUND

Posttraumatic nightmares are a highly prevalent and distressing symptom of posttraumatic stress disorder (PTSD), but have been the subject of limited phenomenological investigations.

METHODS

We utilized a communication box to establish PTSD symptoms in rats through exposure to footshock stress (FS) and psychological stress (PS). The immunohistochemical test and high-performance liquid chromatography with electrochemical detection were used to detect the activity and monoamine levels in the rats' arousal systems.

RESULTS

Twenty-one days after traumatic stress, 14.17% of FS and 12.5% of PS rats exhibited startled awakening, and the same rats showed hyperfunction of the locus coeruleus/noradrenergic system and hypofunction of the perifornical nucleus/orexinergic system. Changes in serotonin levels in the dorsal raphe nucleus showed opposite trends in the FS and PS rats that were startled awake. No differences were found in other sleep/arousal systems.

CONCLUSION

These results suggest that different clinically therapeutic strategies should be considered to treat different trauma-induced posttraumatic nightmares.

Treatment of Sleep Disturbances in Post-Traumatic Stress Disorder: A Review of the Literature

Sleep disturbances are among the most commonly endorsed symptoms of post-traumatic stress disorder (PTSD). Treatment modalities that are effective for the waking symptoms of PTSD may have limited efficacy for post-traumatic sleep problems. The aim of this review is to summarize the evidence for empirically supported and/or utilized psychotherapeutic and pharmacological treatments for post-traumatic nightmares and insomnia. While there are few controlled studies of the applicability of general sleep-focused interventions to the management of the sleep disturbances in PTSD, evidence is growing to support several psychotherapeutic and pharmacological treatments. Future investigations should include trials that combine treatments focused on sleep with treatments effective in managing the waking symptoms of PTSD.

Psychotherapy improved the sleep quality in a patient who was a victim of child sexual abuse: a case report

INTRODUCTION

Victims of child sexual abuse (CSA) often experience symptoms such as recurrent nightmares, which affect their adult life.

AIM

This study aimed to evaluate the effect of psychotherapy on the quality of life and sleep in a female patient with a previous history of CSA.

METHODS

The patient was climacteric (menopausal transition) and treated in an outpatient clinic. She underwent 40 sessions of psychotherapy and was evaluated before and after the sessions using questionnaires and polysomnography (PSG).

MAIN OUTCOME MEASURES

Measurements were taken using the following: Kupperman Index (KI), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Prospective and Retrospective Memory Questionnaire, and PSG. Reports of dream content were also evaluated during the study.

RESULTS

After psychotherapeutic intervention, the frequency of nightmares and their attendant suffering decreased. Additionally, the context of the nightmares changed, and a decrease was noted in the KI, BAI, and BDI parameters. The PSG indicated an increase in rapid eye movement sleep.

CONCLUSION

Psychotherapeutic intervention combined with zolpidem and fluoxetine treatment contributed to a resignification of the dreams of a patient with a history of CSA. The treatment also improved the quality of her dreams and her quality of life.

Sleep medicine pharmacotherapeutics overview: today, tomorrow, and the future (part 2: hypersomnia, parasomnia, and movement disorders)

Over the past 10 years, significant strides have been made in therapeutics for sleep disorders. In this second installment of a two-part review series, we discuss the current evidence surrounding the mechanisms of actions, indications, efficacy, and adverse side effects associated with the current over-the-counter and pharmacotherapeutics for hypersomnia, parasomnias, and movement disorders of sleep.