Staff Perspective: Options for the Treatment of Posttraumatic Nightmares
Our sleep team frequently gets asked which treatment we recommend for patients suffering with trauma-related nightmares. Our faculty members often struggle to answer this question because several promising treatments exist, but data is inconclusive when it comes to determining which one works better for whom. Furthermore, the treatment procedures have varied across research studies, leading to some overlap between treatment models. Since this is an emerging field, recommendations are best guided by your patient’s specific needs, your clinical judgment, and the availability of treatments. To help you navigate the options, I will summarize the promising treatments that are most commonly available.
Exposure, Relaxation, and Rescripting Therapy (ERRT): The length of ERRT (Davis & Wright, 2007) varies between research studies, but is generally delivered in three-to-five 90-120-minute sessions, either individually or in group format. The full protocol includes psychoeducation about trauma and nightmares, discussion and modification of sleep habits, relaxation training, exposure to the nightmare content, rescripting of the nightmare, and rehearsal of the rescripted dream each night before bed. Exposure is accomplished through the writing of the nightmare and then reading the account aloud. Rescripting in this model focuses on areas of life that are often impacted by trauma: safety, trust, power/control, esteem, and intimacy. There are some overlaps with CBT for Insomnia, as instruction in stimulus control is included. Initially a key theorized mechanism of action was confrontation of the avoided stimulus (nightmare) with the goal of reducing distress and processing trauma-related content. But a recent dismantling study (Pruiksma, et al, 2018) suggests that the exposure component is not integral to the effectiveness of ERRT; participants had similarly good outcomes when exposure and rescripting were removed from the protocol and treatment focused on relaxation strategies, psychoeducation, and improving sleep habits. Therefore, the mechanism of action in ERRT is not fully understood at this time.
Imagery Rehearsal Therapy (IRT): IRT protocols have evolved since the initial format (Krakow & Zadra, 2006) and treatment developers are upfront that the length and duration of IRT may vary based on patient need, and may be delivered individually or in group format. Several IRT protocols used in clinical research studies we delivered in 4 group sessions, each approximately 2 hours in length. The treatment is conceptualized with two overlapping assumptions: nightmares are a learned behavior and nightmares are a symptom of a damaged imagery system. The first half of treatment is focused on orienting the client to treatment (including the role of imagery) and providing psychoeducation regarding the progression of nightmares from an acute to chronic concern and their relationship with insomnia. The second half of treatment teaches clients about imagery rehearsal and instructs them to rewrite their nightmare in any way they wish. The new script is rehearsed daily and especially before bed. It is important to note that exposure to the trauma-related nightmare is not required as part of IRT; the client is never instructed to write or speak the details of their nightmare. The mechanism of action is hypothesized to be activation and correction of the imagery system.
Cognitive Behavioral Therapy for Insomnia (CBTI): CBTI has decades of research supporting its efficacy in the treatment of insomnia and is recommended as a first line treatment in the VA/DoD Clinical Practice Guidelines (DVA/DoD, 2019). While it is important to note that CBTI was not intended to be a standalone treatment for trauma-related nightmares, there is some recent evidence to suggest that CBTI may be as effective in this regard as the nightmare-focused treatments discussed above. In a dismantling study (Harb et al, 2019) that compared imagery rehearsal + components of CBTI (cCBTI) to cCBTI alone, Veterans experienced equal improvement in nightmare frequency and intensity in both conditions. Imagery rehearsal did not add any benefit. The authors conclude that the components of CBTI (psychoeducation, stimulus control, and relaxation training) used in this intervention were effective in reducing nightmare frequency and intensity. An earlier study (Talbot et al., 2014) of CBTI’s effects on trauma-related nightmares, was less conclusive. Still, CBTI can be a useful addition to our menu of treatment options since it is short, generally well-tolerated, and may appeal to individuals who prefer not to work with their nightmares. The hypothesized method of action is that improved sleep architecture has a direct impact on nightmares. Put another way, improved quantity and quality of sleep may make nightmares less disruptive and less likely to be remembered in the morning.
Prazosin: This is the only pharmacological treatment on the list. Prazosin is a noradrenaline alpha-blocker that is FDA-approved to treat high blood pressure, but has been used off-label to treat PTSD-related conditions, including nightmares. Early research suggested that it led to a decrease in the frequency and intensity of trauma-related nightmares. However, later, more methodologically sound research has not replicated that finding (PHCoE, 2018). For that reason, the current VA/DoD Clinical Practice Guidelines for the Management of PTSD and Acute Stress Disorder (DVA/DoD, 2017) have downgraded their rating of prazosin to “no recommendation for or against.” Put another way, the existing research neither supports nor advises against the use of prazosin to treat trauma-related nightmares in servicemembers and Veterans.
As is evident from the descriptions above, treatment for posttraumatic nightmares is an emerging field of study whose results are not clear cut. The non-pharmacological approaches above all have commonalities between them, and yet approach nightmares in different ways. Prazosin, once seen as a highly promising treatment option, is now less supported by research and clinical experience. While it’s unfortunate that we don’t have a one-size-fits all option, it’s not surprising. That type of certainty doesn’t exist in any psychological arena and we are still learning about the mechanisms underlying posttraumatic nightmares. But viewing it from a different perspective, we have several options that may be effective for our clients and flexibility in how we approach treatment. Understanding the rationale and components of each treatment means that we can choose to practice interventions that make clinical sense to us and that complement our conceptualizations of nightmares. Additionally, research continues in this important area and treatments are being fine-tuned as we speak (for example, a combination treatment of CBTI + nightmare processing called CBTI&N is in development through the STRONG STAR Initiative).
If you frequently work with clients recovering from trauma or who report nightmares, I encourage you to pursue additional information and training in at least one of the interventions described above.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Carin Lefkowitz, Psy.D., is a clinical psychologist and Senior Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References
Davis, J.L., & Wright, D. C. (2007). Randomized clinical trial for treatment of chronic nightmares in trauma-exposed adults. Journal of Traumatic Stress, 20(2), 123-133.
Department of Veterans Affairs and Department of Defense. (2017). VA/DoD Clinical Practice Guidelines for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal012418.pdf
Department of Veterans Affairs and Department of Defense. (2019). VA/DoD Clinical Practice Guidelines for the Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea. https://www.healthquality.va.gov/guidelines/CD/insomnia/index.asp
Harb, G., Cook, J., Phelps, A, Gehrman, P., Forbes, D., Localio, R., Harpaz-Rotem, I., Gur, R., & Ross, R. (2019). Randomized controlled trial of imagery rehearsal for posttraumatic nightmares in combat veterans. Journal of Clinical Sleep Medicine, 15(5).
Krakow, B. & Zadra, A. (2006). Clinical Management of chronic Nightmares: Imagery Rehearsal Therapy. Behavioral Sleep Medicine, 4(1), 45-70.
Pruiksma, K., Cranston, C., Rhudy, J., Micol, R., & Davis, J. (2018). Randomized controlled trial to dismantle exposure, relaxation, and rescripting therapy (ERRT) for trauma-related nightmares. Psychological Trauma, 10(1), 67-75.
Psychological Health Center of Excellence (July 2018). Psych Health Evidence Briefs: Prazosin for Posttraumatic Stress Disorder/Trauma-Related Nightmares. https://www.pdhealth.mil/sites/default/files/images/docs/prazosin_for_PTSDtrauma-Related_nightmares_508v2.pdf
Talbot, L., Maguen, S., Metzler, T., Schmitz, M., McCaslin, S., Richards, A., Perlis, M., Posner, D., Weiss, B., Ruoff, L., Varbel, J., & Neylan, T. (2014). Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: A randomized controlled trial. Sleep, 37(2).
Our sleep team frequently gets asked which treatment we recommend for patients suffering with trauma-related nightmares. Our faculty members often struggle to answer this question because several promising treatments exist, but data is inconclusive when it comes to determining which one works better for whom. Furthermore, the treatment procedures have varied across research studies, leading to some overlap between treatment models. Since this is an emerging field, recommendations are best guided by your patient’s specific needs, your clinical judgment, and the availability of treatments. To help you navigate the options, I will summarize the promising treatments that are most commonly available.
Exposure, Relaxation, and Rescripting Therapy (ERRT): The length of ERRT (Davis & Wright, 2007) varies between research studies, but is generally delivered in three-to-five 90-120-minute sessions, either individually or in group format. The full protocol includes psychoeducation about trauma and nightmares, discussion and modification of sleep habits, relaxation training, exposure to the nightmare content, rescripting of the nightmare, and rehearsal of the rescripted dream each night before bed. Exposure is accomplished through the writing of the nightmare and then reading the account aloud. Rescripting in this model focuses on areas of life that are often impacted by trauma: safety, trust, power/control, esteem, and intimacy. There are some overlaps with CBT for Insomnia, as instruction in stimulus control is included. Initially a key theorized mechanism of action was confrontation of the avoided stimulus (nightmare) with the goal of reducing distress and processing trauma-related content. But a recent dismantling study (Pruiksma, et al, 2018) suggests that the exposure component is not integral to the effectiveness of ERRT; participants had similarly good outcomes when exposure and rescripting were removed from the protocol and treatment focused on relaxation strategies, psychoeducation, and improving sleep habits. Therefore, the mechanism of action in ERRT is not fully understood at this time.
Imagery Rehearsal Therapy (IRT): IRT protocols have evolved since the initial format (Krakow & Zadra, 2006) and treatment developers are upfront that the length and duration of IRT may vary based on patient need, and may be delivered individually or in group format. Several IRT protocols used in clinical research studies we delivered in 4 group sessions, each approximately 2 hours in length. The treatment is conceptualized with two overlapping assumptions: nightmares are a learned behavior and nightmares are a symptom of a damaged imagery system. The first half of treatment is focused on orienting the client to treatment (including the role of imagery) and providing psychoeducation regarding the progression of nightmares from an acute to chronic concern and their relationship with insomnia. The second half of treatment teaches clients about imagery rehearsal and instructs them to rewrite their nightmare in any way they wish. The new script is rehearsed daily and especially before bed. It is important to note that exposure to the trauma-related nightmare is not required as part of IRT; the client is never instructed to write or speak the details of their nightmare. The mechanism of action is hypothesized to be activation and correction of the imagery system.
Cognitive Behavioral Therapy for Insomnia (CBTI): CBTI has decades of research supporting its efficacy in the treatment of insomnia and is recommended as a first line treatment in the VA/DoD Clinical Practice Guidelines (DVA/DoD, 2019). While it is important to note that CBTI was not intended to be a standalone treatment for trauma-related nightmares, there is some recent evidence to suggest that CBTI may be as effective in this regard as the nightmare-focused treatments discussed above. In a dismantling study (Harb et al, 2019) that compared imagery rehearsal + components of CBTI (cCBTI) to cCBTI alone, Veterans experienced equal improvement in nightmare frequency and intensity in both conditions. Imagery rehearsal did not add any benefit. The authors conclude that the components of CBTI (psychoeducation, stimulus control, and relaxation training) used in this intervention were effective in reducing nightmare frequency and intensity. An earlier study (Talbot et al., 2014) of CBTI’s effects on trauma-related nightmares, was less conclusive. Still, CBTI can be a useful addition to our menu of treatment options since it is short, generally well-tolerated, and may appeal to individuals who prefer not to work with their nightmares. The hypothesized method of action is that improved sleep architecture has a direct impact on nightmares. Put another way, improved quantity and quality of sleep may make nightmares less disruptive and less likely to be remembered in the morning.
Prazosin: This is the only pharmacological treatment on the list. Prazosin is a noradrenaline alpha-blocker that is FDA-approved to treat high blood pressure, but has been used off-label to treat PTSD-related conditions, including nightmares. Early research suggested that it led to a decrease in the frequency and intensity of trauma-related nightmares. However, later, more methodologically sound research has not replicated that finding (PHCoE, 2018). For that reason, the current VA/DoD Clinical Practice Guidelines for the Management of PTSD and Acute Stress Disorder (DVA/DoD, 2017) have downgraded their rating of prazosin to “no recommendation for or against.” Put another way, the existing research neither supports nor advises against the use of prazosin to treat trauma-related nightmares in servicemembers and Veterans.
As is evident from the descriptions above, treatment for posttraumatic nightmares is an emerging field of study whose results are not clear cut. The non-pharmacological approaches above all have commonalities between them, and yet approach nightmares in different ways. Prazosin, once seen as a highly promising treatment option, is now less supported by research and clinical experience. While it’s unfortunate that we don’t have a one-size-fits all option, it’s not surprising. That type of certainty doesn’t exist in any psychological arena and we are still learning about the mechanisms underlying posttraumatic nightmares. But viewing it from a different perspective, we have several options that may be effective for our clients and flexibility in how we approach treatment. Understanding the rationale and components of each treatment means that we can choose to practice interventions that make clinical sense to us and that complement our conceptualizations of nightmares. Additionally, research continues in this important area and treatments are being fine-tuned as we speak (for example, a combination treatment of CBTI + nightmare processing called CBTI&N is in development through the STRONG STAR Initiative).
If you frequently work with clients recovering from trauma or who report nightmares, I encourage you to pursue additional information and training in at least one of the interventions described above.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Carin Lefkowitz, Psy.D., is a clinical psychologist and Senior Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References
Davis, J.L., & Wright, D. C. (2007). Randomized clinical trial for treatment of chronic nightmares in trauma-exposed adults. Journal of Traumatic Stress, 20(2), 123-133.
Department of Veterans Affairs and Department of Defense. (2017). VA/DoD Clinical Practice Guidelines for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal012418.pdf
Department of Veterans Affairs and Department of Defense. (2019). VA/DoD Clinical Practice Guidelines for the Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea. https://www.healthquality.va.gov/guidelines/CD/insomnia/index.asp
Harb, G., Cook, J., Phelps, A, Gehrman, P., Forbes, D., Localio, R., Harpaz-Rotem, I., Gur, R., & Ross, R. (2019). Randomized controlled trial of imagery rehearsal for posttraumatic nightmares in combat veterans. Journal of Clinical Sleep Medicine, 15(5).
Krakow, B. & Zadra, A. (2006). Clinical Management of chronic Nightmares: Imagery Rehearsal Therapy. Behavioral Sleep Medicine, 4(1), 45-70.
Pruiksma, K., Cranston, C., Rhudy, J., Micol, R., & Davis, J. (2018). Randomized controlled trial to dismantle exposure, relaxation, and rescripting therapy (ERRT) for trauma-related nightmares. Psychological Trauma, 10(1), 67-75.
Psychological Health Center of Excellence (July 2018). Psych Health Evidence Briefs: Prazosin for Posttraumatic Stress Disorder/Trauma-Related Nightmares. https://www.pdhealth.mil/sites/default/files/images/docs/prazosin_for_PTSDtrauma-Related_nightmares_508v2.pdf
Talbot, L., Maguen, S., Metzler, T., Schmitz, M., McCaslin, S., Richards, A., Perlis, M., Posner, D., Weiss, B., Ruoff, L., Varbel, J., & Neylan, T. (2014). Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: A randomized controlled trial. Sleep, 37(2).