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Title: Fast Fact and Concept #88; Nightmares
Authors: Seema Malhotra, MD and Robert Arnold, MD
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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 i.e., PTSD (PostTraumatic 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.
Psychotherapeutic Interventions
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.
Pharmacological Management
The pharmacological 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,
including reduction in flashbacks, hyperarousal, and disturbed sleep.
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
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.
Buysse DJ et al, in Treatments of Psychiatric Disorders, 2nd Edition.
Gabbard G (Ed), 1995, 2395-2453.
Sateia MJ et al, in Oxford Textbook of Palliative Medicine, 2nd Edition.
Doyle D (Ed), 1998, 751-767.
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.
Labbate LA. Olanzapine for Nightmares and Sleep Disturbance in
Posttraumatic Stress Disorder comment. Canadian Journal of Psychiatry.
2000; 45(7): 667-668.
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.
Thompson DF et al. Drug-Induced Nightmares. The Annals of Pharmacotherapy.
1999; 33(1): 93-98.Copyright/Referencing
Information: Users are free to download and distribute Fast Facts for
educational purposes only. Citation for referencing. Malhotra, S and
Arnold R. MD Fast Facts and Concepts #88 . Nightmares. April 2003.
End-of-Life Physician 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.
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