Treating the nightmares associated with PTSD

A standard part of any psychiatric evaluation involves inquiring about a patient’s sleep.  Hidden in the answers that follow the basic question of, “How are you sleeping?” are the clues that are needed to  diagnose what is ailing the patient seeking help from me.

For those with depression, they typically report early morning awakening (i.e. they wake 3-4 hours earlier than needed) and are not able to return to sleep. Those with anxiety disorders often complain of not being able to fall asleep (initial insomnia), they toss and turn for hours, their minds “racing” with anxious thoughts and worries. For those with mania they report that they can’t sleep at all for their energized and overcharged bodies simply have no need for sleep.

My patients with PTSD often report an amalgamation of all of the above in addition to a specific complaint: nightmares.

Nightmares — those threatening or scary dreams that leave you crying out in your sleep, thrashing around in your bed or waking up in a blind panic, soaked in sweat and with your heart pounding in your throat.

Nightmares are very common complaint for those living with PTSD. Some studies reporting up to 80%, of those with PTSD, experience nightmares that have them reliving or re-experiencing the traumatic event for months or years after the actual event took place. 

Nightmares are not only commonly experienced by those living with PTSD but they occur frequently too, sometimes several times a week so their impact on the lives of those living with PTSD can be profound.

The differences in sleep among those with PTSD related nightmares (compared with those who do not have PTSD) are tangible.  They have:

  • increased phasic R (REM) sleep activity
  • decreased total sleep time
  • increased number and duration of nocturnal awakenings
  • decreased slow wave sleep (or deep sleep)
  • increased periodic leg movements during both REM and NREM sleep

In short, their sleep is less efficient and associated with a higher incidence of other sleep related breathing disorders.

Treating nightmares

Clinically, this translates to the sad stories I hear all too often. People turn to alcohol or illicit drugs to “escape” the nightmares or their chronically poor sleep quality leads to other problems such as depression and anxiety. Others start to fear sleep or simply don’t function that well — they lose jobs, are irritable and short tempered with their loved ones, feel tired and lack energy. The nightmares and poor quality sleep chips away at their lives over weeks, months and years.

As a psychiatrist, there is a certain amount of dread associated with learning that your patient is experiencing nightmares for the very simple fact that nightmares related to PTSD can be very hard to treat.

The first approach is to treat the underlying condition: the PTSD.  I offer the patient evidence based psychotherapies and, if necessary, medications that I know work for PTSD and hope that, with time, the frequency and intensity of the nightmares will start to decrease as the underlying PTSD is treated.

But often times, despite PTSD treatment, patients still complain of nightmares. What can I offer them then?

A psychotherapeutic option

Image rehearsal therapy (IRT) is one option:

  • IRT is a modified CBT technique that utilizes recalling the nightmare, writing it down and changing the theme. i.e. change the storyline to a more positive one.
  • The patient rehearses the rewritten dream scenario so that they can displace the unwanted content when the dream recurs (they do this by practicing 10 to 20 minutes per day).
  • In controlled studies, IRT has been shown to inhibit the original nightmare by providing a cognitive shift that refutes the original premise of the nightmare.

Though it is a well tolerated treatment, the issue remains that a patient has to be willing and able to commit to IRT for it to work.

This leaves a need for alternative options for patients who are unable to commit to this type of treatment.

A medication for nightmares

Recently, hope has been offered in new research published about the medication: prazosin

Prazosin is an alpha adrenergic receptor antagonist (traditionally used as an antihypertensive agent). It acts to reduce the level of activating neurochemicals in the brain and, via this action, is thought to damp down neurological pathways which are overstimulated in people with PTSD.

Whilst clinically psychiatrists have been using prazosin for the treatment of PTSD related nightmares for years, the fact remains we still need more evidence, from controlled trials, to support its efficacy.  A small randomized controlled trial of prazosin for sleep and PTSD has, recently, made a much needed contribution to that evidence base.

In a 15 week trial involving 67 active duty soldiers with PTSD, the drug was titrated up based on the participant nightmare response over 6 weeks.  Prazosin was found to be effective in improving trauma related nightmares and sleep quality and, in turn, associated with reduced PTSD symptoms and an improvement in global functioning.

This is encouraging, and increases the enthusiasm with which I will recommend this treatment to my patients with PTSD.

Still, the profound effect nightmares have on the quality of life of those living with PTSD highlights that more needs to be done to expand the array of options available to clinicians, like me, to help these patients.

Shaili Jain is a psychiatrist who blogs at Mind the Brain on PLOS Blogs, where this article originally appeared on November 19, 2013.

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