A Systematic Review of Cognitive-Behavioral Treatment for Nightmares: Toward a Well-Established Treatment

Psychosocial treatments for nightmares in adults and children: a systematic review

BACKGROUND

As nightmares may be a risk factor for, or symptom of, multiple psychological disorders, some researchers suggest that nightmares should be screened, diagnosed, and treated. Treatments for nightmares include trauma-focused Cognitive Behavioural Therapy and Image Rehearsal Therapy, and pharmacological interventions such as prazosin and nitrazepam. As recent research has put into question our current understanding of treatment efficacy, there is a need to systematically review findings related to the effectiveness of nightmare treatments to inform best practice. The current review assessed the efficacy of psychosocial treatments of nightmare in all cohorts.

METHODS

A systematic search of four databases for peer reviewed journal articles from 2000 onwards produced 69 (35 RCTs, 34 non-RCTs) eligible articles that underwent narrative synthesis.

RESULTS

The results provide strong evidence for exposure and image rehearsal treatments for the reduction of nightmare frequency, severity, and distress, in civilian, military, idiopathic, and posttraumatic stress disorder (PTSD) cohorts. There is emerging evidence that self-guided and brief treatment modalities offer efficient and effective treatment options. There is an urgent need for clinical trials of treatment effectiveness in children.

CONCLUSIONS

The results suggest that treatments for nightmares are most effective when they facilitate a sense of control or mastery by directly targeting the nightmare content and/or the client's emotional responses to the nightmare content.

TRIAL REGISTRATION

A review protocol was registered with PROSPERO (CRD42020204861).

Sport and mental health performance optimization in an adolescent gymnast: A case evaluation

The Optimum Performance Program in Sports (TOPPS) is a multi-component, sport-specific Family Behavior Therapy that has demonstrated improved sport performance, relationships, and mental health outcomes in adult and adolescent athletes with, and without, diagnosed mental health disorders in clinical trials. The current case trial demonstrates successful implementation of a novel component of TOPPS (i.e., talk aloud optimal sport performance imagery leading to dream mapping) in a biracial Latina and White adolescent gymnast without a mental health diagnosis. The participant demonstrated significant improvements from baseline to both post-treatment and 3-month follow-up in severity of mental health functioning, factors interfering with sports performance, and her relationships with teammates, coaches, and family. Results suggest it may be possible to optimize mental health through sport performance optimization.

Nightmare Rescripting: Using Imagery Techniques to Treat Sleep Disturbances in Post-traumatic Stress Disorder

Besides affecting 8% of the general population, nightmares are one of the most frequent symptoms of traumatized individuals. This can be a significant factor in the treatment of post-traumatic disorders; indeed, several studies demonstrated its strong predictive and prognostic value. Sleep disorders, nightmares in particular, could be very distressing for individuals and need targeted interventions, especially if they are associated with a PTSD diagnosis. To date, the best technique for the treatment of traumatic sleep disturbances seems to be Imagery Rehearsal Therapy (IRT), an empirically supported method. Through a review of the literature on this matter, this article aims to outline the incidence and consequences of nightmares in PTSD, illustrate how IRT could prove useful in their treatment, and investigate its clinical applications.

Non-Constructive Ruminations, Insomnia and Nightmares: Trio of Vulnerabilities to Suicide Risk

OBJECTIVE

Nightmare distress, nightmare frequency and anxiety are related to suicidal risk. Ruminations are a factor maximizing the risk of suicide. Research has identified two types of ruminations: constructive ruminations and non-constructive ruminations. As per our knowledge, no study has verified the links between non-constructive ruminations and sleep disorders and their role in the development of suicidal risk. We aimed to highlight the impact of non-constructive ruminations on nightmares, anxiety and insomnia in the development of suicidal risk.

METHODS

A total of 429 French participants responded to an anonymous online survey using the Qualtrics^® software. To assess variables, we used the Mini Cambridge-Exeter Repetitive Thought Scale, the Suicide Behaviors Questionnaire-Revised, the Nightmare Distress Questionnaire, the Beck Anxiety Inventory, and the Sleep Condition Indicator. Nightmare frequency was assessed by subjective evaluation through a question. We tested the possible effects of confounding variables such as age, gender, marital status and depression (Beck Depression Inventory-II).

RESULTS

Nightmare frequency was found to mediate the link between anxiety and suicidal risk (32.9%). Nightmare distress (37%) and non-constructive thoughts (48%) were also seen to mediate this link. Additionally, we found a moderating effect of insomnia on the link between non-constructive ruminations and suicidal risk (Z = 7.42, p < 0.001).

CONCLUSION

Our results showed that the frequency of nightmares, distress and non-constructive ruminations are closely related to suicidal risk. The interoperability between these elements and insomnia has thus been newly explored. The processes related to nightmares and suicidal risk as well as the underlying cognitive processes between sleep disorders and suicidal risk have been shed light upon.

A clinical approach to nightmares and bad dreams in cognitive–behavioural therapy

Clinicians trained in cognitive–behavioural therapy (CBT) are frequently not trained to work with dreams. Given the high prevalence and impact of nightmares and bad dreams, empowering CBT therapists to effectively work with these sleep phenomena is crucial to improve therapeutic outcomes. This article briefly outlines a cognitive–behavioural model of dreams and reviews some clinical guidelines for directly and indirectly addressing nightmares and bad dreams in CBT practice.

Imagery Rescripting and Imaginal Exposure in Nightmare Disorder Compared to Positive Imagery: A Randomized Controlled Trial

INTRODUCTION

Both imagery rescripting and imaginal exposure have been proven to be effective in the treatment of chronic nightmares when compared to a waitlist condition. Little is known about their comparative efficacy and their efficacy compared to an active control.

OBJECTIVE

The aims of this study were to compare the two treatments to one another and to positive imagery as an active control, and to explore covariates of the treatment effect.

METHODS

In this single-blinded randomized controlled trial, 96 patients with nightmare disorder (idiopathic nightmares) from an outpatient clinic were randomly assigned to a single individual treatment session of rescripting, exposure, or positive imagery and 4 weeks of practice at home. The primary outcome was nightmare distress, and the secondary outcomes were nightmare frequency, nightmare effects, self-efficacy, and general psychopathology.

RESULTS

Nightmare distress was reduced in all groups (imagery rescripting: Cohen's d = -1.04, imaginal exposure: d = -0.68, positive imagery: d = -0.57), as were nightmare frequency, nightmare effects, and psychopathology. Self-efficacy was enhanced. No differential treatment effects were found on any primary or secondary measure. Treatment gains were not associated with demographic or disorder characteristics, baseline values, treatment credibility, or the number of practice sessions.

CONCLUSIONS

Even short nightmare treatments are effective regardless of personal characteristics, and different interventions produce similar results. Future research should aim to clarify the mechanisms of action. Health care should make more use of these powerful and easy-to-administer nightmare treatments.

Insomnia in Patients with Borderline Personality Disorder

OBJECTIVE

Both sleep disorders and BPD are prevalent in the population, and one is often a comorbidity of the other. This narrative review aims to assess contemporary literature and scientific databases to provide the current state of knowledge about sleep disorders in patients with borderline personality disorder (BPD) and clinical suggestions for managing sleep disorders in BPD patients and future research direction.

METHODS

Articles were acquired via PubMed and Web of Science, and papers published between January 1980 and October 2020 were extracted. Authors made a series of literature searches using the keywords: Sleep problems, Insomnia, Nightmares, Obstructive sleep apnea, Borderline personality disorder. The inclusion criteria were: published in peer-reviewed journals; studies in humans; or reviews on the related topic; English language. The exclusion criteria were: abstracts from conferences; commentaries; subjects younger than 18 years. After an inspection of the full texts, 42 papers from 101 were selected. Secondary documents from the reference lists of the primary designated papers were searched, assessed for suitability, and included. In total, 71 papers were included in the review process.

RESULTS

Sleep disturbance is common among patients with BPD. Nevertheless, the number of investigations is limited, and the prevalence differs between 5-45%. Studies assessing objective changes in sleep architecture in BPD show inconsistent results. Some of them identify REM sleep changes and a decrease in slow-wave sleep, while other studies found no objective sleep architecture changes. There is also a higher prevalence of nightmares in patients with BPD. Untreated insomnia can worsen BPD symptoms via interference with emotional regulation. BPD itself seems to influence the subjective quality of sleep significantly. Proper diagnosis and treatment of sleep disorders in patients with BPD could lead to better results in therapy. Psychotherapeutic approaches can improve both sleep disorders and BPD symptoms.

CONCLUSION

Recognising and managing sleep disorders in patients with BPD may help alleviate the disorder's symptoms. Treatment of people with BPD may be more effective if the treatment plan explicitly addresses sleep problems. Further research is needed to reach reliable conclusions.

Fear of sleep and trauma-induced insomnia: A review and conceptual model

Trauma-induced insomnia is a symptom of posttraumatic stress disorder (PTSD), and is reported to be particularly distressing and often persists even after remission of the core symptoms of PTSD. Recently, it has been suggested that fear of sleep plays an important role in the development and maintenance of trauma-induced insomnia. The aim of this review is to propose a conceptual model of fear of sleep as a maintaining factor of trauma-induced insomnia. After a brief overview of the role of sleep in PTSD, the concept of fear of sleep is introduced. Theoretical considerations and empirical findings on the role of fear of sleep for trauma-induced insomnia in the context of PTSD are summarized and integrated. Specifically, links between PTSD symptoms and fear of sleep are presented, as well as possible consequences of fear of sleep leading to trauma-induced insomnia. Finally, we highlight methodological issues, identify areas for future research, and discuss potential clinical implications.

An integrated model of chronic trauma-induced insomnia

Insomnia is the most commonly reported symptom of posttraumatic stress disorder (PTSD), with at least 70% of patients with PTSD reporting disturbed sleep. Although posttraumatic insomnia has traditionally been conceptualized as a consequence of PTSD, it is the most likely symptom to not remit following otherwise successful PTSD treatment. This suggests that the relationship between PTSD and insomnia is more complex, such that they likely share underlying pathological mechanisms and that factors non-specific to PTSD maintain chronic trauma-induced insomnia. Although several theories and hypotheses have been presented to explain the relationship between PTSD and insomnia, neurobiological and psychological models have not been integrated, thereby limiting their comprehensiveness and abilities to inform effective intervention. Further, existing models have not addressed how acute trauma-induced insomnia becomes chronic. The present review examined models of PTSD and insomnia separately, as well as existing theorized mechanisms of their co-morbidity. The distinct characteristics of trauma-induced insomnia were also reviewed and presented to describe the unique clinical presentation of trauma-induced insomnia. Review and integration of the literature were used to propose an integrated model of chronic trauma-induced insomnia informed by a neuropsychobiological framework. Clinical implications and future research directions are presented and discussed.

Mediators of Change in Imagery Rescripting and Imaginal Exposure for Nightmares: Evidence From a Randomized Wait-List Controlled Trial

Imagery rescripting (IR) and imaginal exposure (IE) are two efficacious treatments for nightmare disorder, but their discrete underlying mechanism(s) remain largely unknown. We therefore examined mediators of the treatment effects of IR and IE in a randomized wait-list controlled trial (N = 104). Therapeutic outcomes were assessed at pre- and post-assessment, and mediator assessment took place in between treatment sessions to establish a temporal relationship between mediators and nightmare symptoms (i.e., frequency and distress). In line with the hypothesis, enhanced mastery (or self-efficacy) of the nightmare content mediated the therapeutic efficacy of IR. Furthermore, the treatment effects of IE were mediated by increased tolerability of the negative emotions elicited by nightmares. Even though IR and IE for nightmares seem to produce similar therapeutic effects, the results of this study suggest that IR and IE tap into different underlying processes.

Nightmares and suicide risk in psychiatric patients: The roles of hopelessness and male depressive symptoms

Although nightmares have been shown to increase the risk for suicide, less is known about the mechanisms underlying this relationship. In order to address this gap and guided by the hopelessness theory of suicide risk, we examined hopelessness and male depressive symptoms as risk factors for suicide while considering the frequency of and impairment due to nightmares. Data were collected from 172 psychiatrically hospitalized, adult patients (91 women, 81 men) with an average age of 39.15 (SD = 13.48) years. Patients were administered self-report measures of nightmare frequency/impairment, hopelessness, and male depressive symptoms, as well as undergoing a fully structured diagnostic clinical interview to determine diagnoses and suicide risk. Compared to patients with yearly or no nightmares, those with monthly or weekly nightmares reported nightmares reported higher levels of hopelessness, male depressive symptoms, and suicide risk. Male depressive symptoms significantly mediated the relation between hopelessness and suicide risk in patients who reported monthly to weekly nightmares, but not in those who reported yearly or no nightmares. Moreover, impairment due to nightmares was significantly and positively associated with male depression, but not hopelessness or suicide risk. The results also provide evidence and further understanding about possible mechanisms of emerging suicide.

Efficacy and mechanisms of imagery rescripting and imaginal exposure for nightmares: study protocol for a randomized controlled trial

BACKGROUND

Recurrent nightmares can effectively be treated with cognitive-behavioral techniques such as imagery rehearsal therapy, which involves imagery rescripting (IR) of nightmares, and imaginal exposure (IE) therapy. However, the underlying mechanisms of these treatments remain largely unknown. To investigate this, we identified a number of variables that might mediate the therapeutic effect of rescripting-based and/or exposure-based therapies. Also, to control for the possible confounding influence of (other) treatment components, we designed two stripped-down treatment protocols, which primarily consist of either (1) rescripting of, or (2) exposure to, the nightmare content. In a randomized controlled trial, we aim to investigate the therapeutic efficacy of these stripped-down IR and IE treatments, and explore their working mechanisms.

METHOD

Three weekly sessions of either IR or IE will be compared to a waiting-list control group. Ninety participants suffering from nightmare disorder will be included and randomly allocated to one of the three groups. The primary clinical outcome measures are nightmare frequency and distress caused by nightmares. Secondary clinical outcome measures include sleep complaints, dysfunctional beliefs about nightmares, and posttraumatic stress symptom severity. Outcomes will be assessed weekly from week 1 (pre-assessment) to week 5 (post-assessment). Online follow-up assessments will take place at 3 and 6 months after post-assessment. In order to investigate temporal relationships between mediators and outcome, we will measure the proposed mediators of the treatment effect 1 day after each outcome assessment (but not after the follow-ups). Mediators include nightmare distress and valence, mastery of the nightmare content, predictability, controllability, and tolerability of emotions elicited by nightmares, as well as sleep quality.

DISCUSSION

The proposed trial allows us to investigate the efficacy of IR and IE as intervention techniques for the treatment of nightmares, and to explore mediators of their respective therapeutic effects. The results may advance our understanding of nightmare therapies by identifying possible mechanisms of psychological treatments for chronic nightmares. Moreover, the results of the proposed study might provide useful knowledge about the working mechanism of rescripting-based and exposure-based treatments in general.

TRIAL REGISTRATION

Netherlands Trial Register ( NTR4951 ), registered on 14 December 2014.

Cognitive Behavioral Therapy for Insomnia and Imagery Rehearsal in Combat Veterans with Comorbid Posttraumatic Stress: A Case Series

Disrupted sleep is common among combat veterans and can negatively impact response to mental health treatments. A trial of cognitive behavioral therapy for insomnia (CBT-I) and imagery rehearsal therapy (IRT) for nightmares was conducted with 14 combat veterans diagnosed with insomnia, and who were experiencing posttraumatic stress and/or depression. In the case-series that follows veterans experienced clinically significant changes in sleep, and statistically significant reductions in insomnia, nightmare, depression and posttraumatic stress severity following treatment. Combined CBT-I and IRT is a promising treatment for patients with combat-related trauma and psychiatric morbidity.

Eye Movement Desensitization and Reprocessing Treatment of Nightmares: A Case Report

A single client with depression and chronic nightmares was treated with 4 sessions of eye movement desensitization and reprocessing (EMDR) and showed a decrease in nightmares and improvement in general well-being. The client’s 2 nightmare images were resolved following Luber’s (2010) protocol for nightmare processing. Treatment effects were measured with the Outcome Rating Scale and showed a shift from the clinical range at pretreatment to the nonclinical range at the third session. The ready improvement and gains of this patient have served to highlight various aspects of the EMDR procedures which have worked well for the client, which included targeting the negative cognitions surrounding the theme of helplessness as well as adapting the positive cognition with a collectivistic orientation.

Efficacy of psychological interventions aiming to reduce chronic nightmares: a meta-analysis

This study presents a meta-analysis of the effectiveness of psychological treatments for chronic nightmares using imaginal confrontation with nightmare contents (ICNC) or imagery rescripting and rehearsal (IRR). Pre-post effect sizes (Hedges' g) were calculated for the outcome measures of nightmare frequency, nights per week with nightmares, sleep quality, depression, anxiety, and PTSD severity. Fixed-effects and random-effects models were applied. High effect sizes were found for nightmare frequency (g=1.04), nights per week with nightmares (g=0.99), and PTSD severity (g=0.92). Most of the effect sizes for the secondary outcomes were moderate. One objective was to clarify whether ICNC or IRR is more important for nightmare reduction. The results indicate that a higher duration of time for ICNC is associated with greater improvements: The minutes of applied ICNC moderate the effect sizes for nightmare frequency at follow-up 2 and for nights per week with nightmares at post and follow-up 1. The percentage of applied ICNC moderates the effect sizes for nightmare frequency and nights per week with nightmares at follow-up 1. Thus, dismantling studies are necessary to draw conclusions regarding whether ICNC or IRR is the most effective in the psychological treatment of chronic nightmares.

Randomized controlled trials of psychological and pharmacological treatments for nightmares: a meta-analysis

A meta-analysis of treatments for nightmares is reported. The studies were identified by database searches and by an inspection of relevant reference lists. The inclusion criteria were: nightmares as a target problem, studies published in English, use of a randomized controlled trials and reporting of nightmare-relevant outcomes. A total of 19 studies, published between 1978 and 2012 were identified, which included 1285 participants. Effect sizes were calculated as Cohen's d. A statistically significant improvement for all studies combined (d = 0.47, 95% CI = 0.33-0.60, fixed effects model; d = 0.49, 95% CI = 0.32-0.66, random effects model) and for psychological treatments alone (d = 0.48, 95% CI = 0.36-0.60, random) and for prazosin alone (d = 0.50, 95% CI = 0.03-0.96, random) was found. Individual therapy format yielded a higher effect size than a self-help format (p = 0.03). Minimal interventions (relaxation, recording) yielded lower overall effect size than studies offering more extensive interventions (p = 0.02). It is concluded that there are both psychological and pharmacological interventions which have documented effects for the treatment of nightmares.

Residual sleep disturbances in patients remitted from major depressive disorder: a 4-year naturalistic follow-up study

STUDY OBJECTIVES

To investigate the prevalence and clinical, psychosocial, and functional correlates of residual sleep disturbances in remitted depressed outpatients.

DESIGN

A 4-yr prospective observational study in a cohort of psychiatric outpatients with major depressive disorder was conducted with a standardized diagnostic psychiatric interview and a packet of questionnaires, including a sleep questionnaire, Hospital Anxiety and Depression Scale, NEO personality inventory, and Short Form-12 Health Survey.

SETTINGS

A university-affiliated psychiatric outpatient clinic.

INTERVENTIONS

N/A MEASUREMENTS AND RESULTS: Four hundred twenty-one depressed outpatients were recruited at baseline, and 371 patients (mean age 44.6 ± 10.4 yr, female 81.8%; response rate 88.1%) completed the reassessments, in which 41% were classified as remitted cases. One year prevalence of frequent insomnia at baseline and follow-up in remitted patients was 38.0% and 19.3%, respectively. One year prevalence of frequent nightmares at baseline and follow-up was 24.0% and 9.3%, respectively. Remitted patients with residual insomnia were more likely to be divorced (P < 0.05) and scored higher on the anxiety subscale (P < 0.05). Remitted patients with residual nightmares were younger (P < 0.05) and scored higher on neuroticism (P < 0.05) and anxiety subscales (P < 0.01). Residual insomnia and nightmares were associated with various aspects of impaired quality of life. Residual nightmares was associated with suicidal ideation (odds ratio = 8.40; 95% confidence interval 1.79-39.33).

CONCLUSIONS

Residual sleep disturbances, including insomnia and nightmares, were commonly reported in remitted depressed patients with impaired quality of life and suicidal ideation. A constellation of psychosocial and personality factors, baseline sleep disturbances, and comorbid anxiety symptoms may account for the residual sleep disturbances. Routine assessment and management of sleep symptoms are indicated in the integrated management of depression.

Sleep disturbances and their association with mental health among women exposed to intimate partner violence

BACKGROUND

Intimate partner violence puts the victim at risk for substantial medical and psychiatric morbidity. As with other stress- and trauma-related experiences, intimate partner violence is associated with sleep disturbance, particularly insomnia and nightmares. This association, however, has not been well characterized in terms of general prevalence or its further relationship with depression, suicidality, and posttraumatic stress disorder (PTSD).

METHODS

The present study used validated instruments to characterize insomnia and nightmares among 121 women exposed to intimate partner violence. Participants with and without depression were compared on demographic, abuse, and sleep characteristics as were those with and without suicidality. Logistic regression models were constructed to test sleep variables as independent predictors of depression controlling for demographic factors, abuse severity, and PTSD severity.

RESULTS

Clinically significant insomnia and nightmares were observed in 46% and 32% of participants, respectively. Depressed women had more severe PTSD and were more likely to have insomnia and to have nightmares than nondepressed women. In models controlling for PTSD severity, the presence of insomnia was associated with an approximately eightfold greater risk of being depressed; nightmares were associated with a twofold increase in risk.

CONCLUSIONS

Sleep disturbances were prevalent among women experiencing intimate partner violence, with both insomnia and nightmares predicting the presence of depression even after controlling for PTSD severity. In addition to the need to address common mental health issues such as depression, given that sleep problems are modifiable and potentially less stigmatizing than mental health problems, assessing and addressing insomnia and nightmares in survivors of interpersonal violence warrants strong clinical consideration and further investigation.

Persistence of sleep disturbances following cognitive-behavior therapy for posttraumatic stress disorder

OBJECTIVES

The objectives of the present study were (1) to assess the impact of cognitive-behavior therapy (CBT) for posttraumatic stress disorder (PTSD) on associated sleep disturbances and (2) to explore the correlates of persistent sleep difficulties in terms of anxiety and depression symptoms and perceived health.

METHOD

Fifty-five individuals with PTSD were administered a series of assessments designed to evaluate sleep, PTSD symptoms, symptoms of anxiety and depression, and perceived health before and after individual CBT for PTSD and at 6-month follow-up.

RESULTS

Significant improvements were observed on sleep quality, sleep onset latency, sleep efficiency, and sleep disturbances. These changes were not fully maintained after 6 months, and 70% of people who reported baseline sleep difficulties (Pittsburgh Sleep Quality Index >5) still reported significant problems with sleep after treatment. Persistent sleep difficulties were associated with more severe posttraumatic, anxious, and depressive symptoms as well as poorer health.

CONCLUSION

Although CBT for PTSD had a favorable impact on sleep, the majority of participants suffered from residual sleep difficulties. Individuals with persistent sleep difficulties posttreatment may experience more residual posttraumatic, depression, and anxiety symptoms and poorer mental and physical health than those who do not report sleep problems posttreatment. Further research in this area will allow clinicians to treat sleep problems in these individuals more effectively.

Treating nightmares and insomnia in posttraumatic stress disorder: a review of current evidence

Emerging evidence supports the notion of disrupted sleep as a core component of Posttraumatic Stress Disorder (PTSD). Effective treatments for nighttime PTSD symptoms are critical because sleep disruption may be mechanistically linked to development and maintenance of PTSD and is associated with significant distress, functional impairment, and poor health. This review aimed to describe the state of science with respect to the impact of the latest behavioral and pharmacological interventions on posttraumatic nightmares and insomnia. Published studies that examined evidence for therapeutic effects upon sleep were included. Some behavioral and pharmacological interventions show promise, especially for nightmares, but there is a need for controlled trials that include valid sleep measures and are designed to identify treatment mechanisms. Our ability to treat PTSD-related sleep disturbances may be improved by moving away from considering sleep symptoms in isolation and instead conducting integrative studies that examine sequential or combined behavioral and/or pharmacological treatments targeting both the daytime and nighttime aspects of PTSD. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'.

Treatment options for parasomnias

Parasomnias are undesirable physical or experiential events that occur in and around sleep. Treatments include reassurance in some cases, various forms of cognitive-behavioral therapy (CBT), and pharmacologic agents. Cognitive restructuring, imagery rehearsal, relaxation, hypnosis, desensitization, and anticipatory awakenings are some of the common CBT and nonpharmacologic interventions. Medications that are used belong to a wide variety of pharmacologic classes, such as alpha-blockers (prazosin), tricyclic antidepressants (imipramine and clomipramine), selective serotonin reuptake inhibitors, benzodiazepines (diazepam and clonazepam), anticonvulsants (topiramate and gabapentin), desmopressin acetate, and anticholinergic agents (oxybutynin and tolterodine). Data on efficacy are only available from randomized trials on CBT and prazosin for nightmares and on pharmacologic and alarm therapy for enuresis. No large-scale randomized trials are available to assess the efficacy of the other treatments, and most data come from anecdotal case reports, case series, or small open-label trials.

A combined group treatment for nightmares and insomnia in combat veterans: a pilot study

Insomnia and nightmares are hallmarks of posttraumatic stress disorder (PTSD). Sleep disturbances in PTSD negatively impact clinical course and functioning. In this open clinical trial, the preliminary effects of a combined treatment for insomnia and nightmares in combat veterans with PTSD were assessed. Ten combat veterans participated in a 10-session group treatment combining cognitive-behavioral therapy for insomnia with exposure, rescripting, and relaxation therapy. Participants maintained daily sleep and dream diaries and completed self-report measures of sleep quality and PTSD symptoms pre- and posttreatment. Participants reported improvements in sleep and nightmares following treatment. Future research using controlled designs to evaluate this treatment is warranted.