Posttraumatic nightmares are one of the most frequent symptoms in posttraumatic stress disorder. Prevalence can be up to 96%. These nightmares evoke the experienced traumatic event, causing a negative impact. Besides, they are and independent risk for suicide. There are different pharmacological and non-pharmacological options for PTN, despite is no optimal treatment.

To analyse the different treatment options for PTN.

This was a narrative literature review.

The two main treatments for PTN nowadays are the Imagery Rehearsal Therapy (IRT) and prazosin. IRT is a cognitive-behavioral intervention, that helps the patient to change the content of the nightmare to a “happier ending”. Prazosin is an alpha-adrenergic receptor antagonist that blocks the stress response in the central nervous system receptors. Although it was a promising drug, significant differences compared to placebo have not been found. There is growing data that suggests nabilone, a synthetic cannabinoid, could be helpful in PTN treatment. A clinical trial made in Canada revealed that 72% of patients experienced a complete disappearance or at least an important reduction of PTN.

PTN is a very common and distressing symptom in patients presenting PTSD. Nevertheless, there is no treatment with enough evidence for this pathology. On this account, it is fundamental to do more research in order to find and suitable treatment that can improve the quality of life of these patients.

No significant relationships.

Nightmares are a hallmark symptom of posttraumatic stress disorder (PTSD). This strong association may reflect a shared pathophysiology in the form of altered autonomic activity and increased reactivity. Using an acoustic startle paradigm, we investigated the interrelationships of psychophysiological measures during wakefulness and PTSD diagnosis, posttraumatic nightmares, and nontraumatic nightmares.

A community sample of 122 trauma survivors were presented with a series of brief loud tones, while heart rate (HRR), skin conductance (SCR), and orbicularis oculi electromyogram (EMGR) responses were measured. Prior to the tone presentations, resting heart rate variability (HRV) was assessed. Nightmares were measured using nightmare logs. Three dichotomous groupings of participants were compared: (1) current PTSD diagnosis (n = 59), no PTSD diagnosis (n = 63), (2) those with (n = 26) or without (n = 96) frequent posttraumatic nightmares, and (3) those with (n = 22) or without (n = 100) frequent nontraumatic nightmares.

PTSD diagnosis was associated with posttraumatic but not with nontraumatic nightmares. Both PTSD and posttraumatic nightmares were associated with a larger mean HRR to loud tones, whereas nontraumatic nightmare frequency was associated with a larger SCR. EMGR and resting HRV were not associated with PTSD diagnosis or nightmares.

Our findings suggest a shared pathophysiology between PTSD and posttraumatic nightmares in the form of increased HR reactivity to startling tones, which might reflect reduced parasympathetic tone. This shared pathophysiology could explain why PTSD is more strongly related to posttraumatic than nontraumatic nightmares, which could have important clinical implications.

Prazosin has been an accepted treatment for patients with post-traumatic stress disorder (PTSD) who experience sleep disturbances, including nightmares. Results of a recent large randomized control trial did not find benefit of prazosin vs placebo in improving such outcomes. A meta-analysis that includes this most recent trial was conducted to examine the pooled effect of prazosin vs placebo on sleep disturbances and overall PTSD symptoms in patients with PTSD.

A systematic review of the published literature on trials comparing prazosin vs placebo for improvement of overall PTSD scores, nightmares, and sleep quality was conducted. Hedges’ g standardized mean differences (SMD) between prazosin and placebo were calculated for each outcome across studies.

Six randomized placebo-controlled studies representing 429 patients were included in the analysis, including two studies with a crossover design. Results showed prazosin significantly improved overall PTSD scores (SMD = −0.31; 95% confidence intervals [CI]: −0.62, −0.01), nightmares (SMD = −0.75; 95% CI: −1.24, −0.27), and sleep quality (SMD = −0.57; 95% CI: −1.02, −0.13). In the largest trial, prazosin showed a reduction in clinical outcome measures similar to past studies, but a relatively large placebo effect size, particularly for nightmares, contributed to no treatment differences.

Despite the results of a recent, large randomized study, pooled effect estimates show that prazosin has a statistically significant benefit on PTSD symptoms and sleep disturbances. Limitations that should be considered include heterogeneity of study design and study populations as well as the small number of studies conducted and included in this meta-analysis.

The association of sleep disorders and post-traumatic stress disorder (PTSD) is almost universal. Nightmares are not only one of the most commonly associated but also featured as a diagnostic criterion for PTSD. PTSD-related nightmares are particularly distressing, may impair functioning and increase risk of suicide. No specific pharmacologic agent has been demonstrated to impair dreaming. Inhibition of PTSD-related nightmares with pramipexole has not heretofore been described. Such a case is presented.

Case study - This 60 year-old male with PTSD and trauma-related nightmares upon introduction of pramipexole 0.5mg PO qHS for Restless Leg Syndrome (RLS) had total elimination of dreams, which recurred upon discontinuation of this agent as a result of insomnia and increased anxiety. A lower dose of 0.375mg qHS provided optimal RLS-symptom control and overall improved tolerance despite nightmare recurrence.

Abnormalities on Neurological examination: Recent recall: 2 of 4 objects without improvement with reinforcement. Able to spell the word “world” forwards but not backwards. Abstract thought impaired. Chemosensory testing: Anosmia and normogeusia. Motor: Drift: mild right pronator drift with right cerebellar spooning and right abductor digiti minimi sign. Reflexes: 3+ brachioradialis and biceps bilaterally, absent ankle jerks. Other: CT scan with and without contrast: normal.

Nightmares related to PTSD may occur during Rapid Eye Movement (REM) sleep and non-REM sleep. Underlying sympathetic activation may lead to disruptive motor behavior similar to that seen in REM sleep behavior disorder. The exact mechanism of action by which inhibition of dreams occurred with use of pramipexole is unclear. Such a response is consistent with prior documented evidence of REM sleep suppression with low-dose pramipexole such as it‘s efficacy in reducing the intensity and frequency of nightmares and dream enactment related to REM sleep behavior disorder. Further research on therapeutic interventions that target nightmares directly may be beneficial for the management of patients with PTSD.

The purposes of this study were: (1) to explore cancer patients' complaints of poor sleep, which often involve a combination of somatic symptoms and nightmares; and (2) to understand these sleep disturbances in the light of modern dream theories and intervention modalities.

 The literature search originated with several major articles (Revonsuo, 2000; Krakow & Zadra, 2006; Hobson, 2009) which then opened up the search through their references.  We also used the database PubMed, and employed the following key words:  cancer, nightmares/dreams, sleep disturbances, and dream theory. The literature search covered the interval between 1900 (Freud, 1900) and 2009. Our criteria for selecting studies included the most recent major review articles on the neuroscience of sleep and dreams; articles reviewing sleep disturbances in cancer patients and relevant treatments; and articles reviewing interventions for traumatic dreams.  Approximately 30 articles were deemed worthy of inclusion.

Thirty article/books/chapters met the criteria for relevance related to key theories and clinical interventions related to nightmares and traumatic dreams of cancer patients. Key concepts involve threat simulation theory and imagery rehearsal therapy in regard to theoretical and interventional paradigms significantly generalizable to cancer patients. The dream material included in this article presents patients' attempts to deal with complex threats such as intense dependency/ loss of self-sufficiency, disfigurement, and death. This is especially true with regard to the doctor–patient relationship at all stages of the illness and disease. Imagery rehearsal can facilitate empowerment in light of highly threatening and conflictual cancer-related dreams in which the patient feels helpless and victimized.

This review offers a new lens on current dream theories and understanding of sleep disturbance in cancer patients as well as their familes and medical caregivers. Modern theories lead to opportunities for intervention that can both relieve symptoms and improve communication between medical caregivers and patients and families.