PhD/PsyD Nightmares

[erg923]

I am increasingly seeing people whose primary MH complaint, and many times the only MH symptom, is nightmares. "Nightmares" is used broadly here, because half the time it’s more a label for "vivid dreams about deployment" rather than a recurring reenactment of a specific trauma event.

I have no idea how to treat this when it is pretty much the only residual symptom? I have had little success, anecdotally, with nightmare rescripting. But as I said before, half the time these are just intense dreams that vaguely involve deployment experiences, not necessarily traumas or combat engagement. Should I just have PCC chuck some prazosin at them and have them be on their way? I feel like I am obligated to trying something here?

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[Therapist4Chnge]

General stress management techniques to put them in a decent/better place PRIOR to going to bed? Maybe working on their sleep routine?

Prazosin is definitely the go-to option, pretty robust response (even at low dosing) and a manageable side effect profile. You should also have the PCC look at what kind of seratonin may be kicking around either as a primary or secondary effect of one or more meds, as research has shown that it can lead to an uptick in "vividness" of dreams.

 

[smalltownpsych]

I am increasingly seeing people whose primary MH complaint, and many times the only MH symptom, is nightmares. "Nightmares" is used broadly here, because half the time it’s more a label for "vivid dreams about deployment" rather than a recurring reenactment of a specific trauma event.

I have no idea how to treat this when is pretty much the only residual symptom? I have had little success, anecdotally, with nightmare rescripting. But as I said before, half the time these are just intense dreams that vaguely involve deployments experiences, not necessarily traumas or combat engagement. Should I just have PCC chuck some prazosin at them and have them be on their way? I feel like I am obligated to trying something here?

I was going to say prazosin but you beat me to it. My sexual trauma patients have the same difficulty and I haven't had much success with decreasing frequency or intensity of these. I have done some rescripting, too with minimal success. At times the nightmares reflect some fears or experiences that the patient still needs to verbalize or consciously reprocess. I also normalize the experience for patients and then let them know that they do diminish over time with most patients. This might be more to activate a placebo response but it also serves to alleviate some anxiety about them. I have a patient coming today that likes to blame me for the nightmares because they got worse after we started treatment. You could tell the patient what some insurance companies do, now that you no longer meet full criteria for PTSD after our 12 sessions, you are "cured" and need to stop complaining.

 

[PsyDr]

Screen for medication effects.

Then Image Rehearsal Therapy, or CBT.

 

[erg923]

Screen for medication effects.

Then Image Rehearsal Therapy, or CBT.

I know gabapentin has this SE often, but I am really underinformed about what other medications by be a direct cause for this?

Is what you're talking about different from nightmare rescripting? I really have been dissappointed in the results, or lack thereof, that I have seen using this. Probably 10-20 cases. Compliance is of course an issue too.

 

[473912]

I always thought dreams were just a result of specific life state. Is that not true? Growing up in awkward adolescence from 10-17yo, I had recurring nightmares of dying in a complex factory. For the last 10 years while stuck in a dead-end, unstable job, I would dream/nightmare I'd forget my locker combination in HS and would fail specifically History class... and therefore not graduate. As soon as I graduated UG and I found a positive change in my future, I had a change now I only have a much more positive type of dream.

Would constant nightmares just be a signal to make some significant change? Whether the nightmares change due to improved state or just that the mind is focused on something else... problem solved? Very curious.

 

[irish80122]

I recently wrote a review on nightmare disorder treatments in case it is helpful: http://nadorff.psychology.msstate.edu/Nadorff 2014 Pharmacological and non-pharmacological treatments for nightmare disorder.pdf. I am personally a big fan of IRT. Prazosin is a great option, too, but often I have seen the nightmares return once prazosin is discontinued. Thus, I would lean toward doing IRT first, then prazosin if it is not effective.

Here are the latest guidelines on treating nightmare disorder as well: http://www.aasmnet.org/resources/bestpracticeguides/nightmaredisorder.pdf

 

[PsyDr]

Possible Agents include:

SSRIs/SNRIs- In the SNRI class Ive seen patients usually describe them more as intense dreams that are distressing in their intensity than content.
antimaliarials- There's a lot of funny videos from celebrities talking about this.
HIV medication-
AEDs- I've seen a lot of pts becoming very aggressive and sleep disordered from Keppra.
ACE inhibitors
C+ Channel blockers
Various Pains meds
Statins-
Parkinson's/Restless Leg Syndrome meds
Some antibiotics- mostly the more powerful broad spectrum ones.
Dementia Meds- (a neurologist friend has his pts take aricept in the AM due to this SE)
Chantix-

Then discontinuation syndromes of the above.

I honestly know very little about the implementation of IRT. I mostly study treatment based guidelines and efficacy rates for court stuff.

 

[Existenz]

For some reason, my first thought when reading this thread was about Nightmare on Elm Street

 

[soccercat]

Screen for medication effects.

Then Image Rehearsal Therapy, or CBT.

This and stress management.

My OEF/OIF guys also said they liked meditation tapes as it helped to "start sleep off right". I can't say that it actually helped reduce nightmares, but they at least anecdotally said it was helpful. Plus there is the added benefit of helping with chronic pain management as well.

 

[WisNeuro]

I always thought dreams were just a result of specific life state. Is that not true? Growing up in awkward adolescence from 10-17yo, I had recurring nightmares of dying in a complex factory. For the last 10 years while stuck in a dead-end, unstable job, I would dream/nightmare I'd forget my locker combination in HS and would fail specifically History class... and therefore not graduate. As soon as I graduated UG and I found a positive change in my future, I had a change now I only have a much more positive type of dream.

Would constant nightmares just be a signal to make some significant change? Whether the nightmares change due to improved state or just that the mind is focused on something else... problem solved? Very curious.

I imagine nightmares about awkward adolescence may be different than nightmares about burning bodies and stacking dead bodies. Especially when those things actually happened. I am slightly puzzled by the nightmares being the only residual symptom though. Generally, was symptoms of PTSD improve, so do the nightmares. Anyone have any good lit searches for this effect?

 

[erg923]

I don't think these people probably ever had/met criteria for PTSD. The "nightmares" I am mostly referring to are often intense mix mashed bags of military/deploment themes and content. Consistent theme of being attacked in some form, usually. Many of these people weren't infantry of cav scouts either.

 

[473912]

I imagine nightmares about awkward adolescence may be different than nightmares about burning bodies and stacking dead bodies. Especially when those things actually happened. I am slightly puzzled by the nightmares being the only residual symptom though. Generally, was symptoms of PTSD improve, so do the nightmares. Anyone have any good lit searches for this effect?

My wording wasn't precise. They weren't dreams ABOUT my awkward adolescence... they were dreams DURING adolescence about being smashed, dismembered, disemboweled, burned alive or otherwise killed in a factory. I hadn't lived through any of those things or even seen them. I know it's not the same as people who have lived through similar, but in the absence of meeting PTSD criteria etc., I'm wondering if it's something more... mundane or inexplicable.

 

[smalltownpsych]

I imagine nightmares about awkward adolescence may be different than nightmares about burning bodies and stacking dead bodies. Especially when those things actually happened. I am slightly puzzled by the nightmares being the only residual symptom though. Generally, was symptoms of PTSD improve, so do the nightmares. Anyone have any good lit searches for this effect?

My search of the relevant lit in the past has so far pointed to the nightmares being the more difficult symptom to treat and more persistent. I have seen it play out both ways though. Also, the nightmares seem to increase during treatment. For early childhood sexual trauma the nightmares tend to peak about 3 months into the treatment and then begin to remit at about 6 months or so. I just realized that at about 3 months, they have usually had the last episode of self-harm. Probably a connection.

 

[Therapist4Chnge]

I don't think these people probably ever had/met criteria for PTSD. The "nightmares" I am mostly referring to are often intense mix mashed bags of military/deploment themes and content. Consistent theme of being attacked in some form, usually. Many of these people weren't infantry of cav scouts either.

Sometimes a horse is just a horse…maybe it is unaddressed anxiety that is presenting when they dream? Treat the stress(ors) and maybe pharmacological intervention won't be needed down the road?

 

[Rivi]

All joking aside, this is an interesting thread, as I am not at all familiar with treatments specific to nightmares.

 

[Fan_of_Meehl]

Speaking of horses, I'd also want to rule out some 'zebras' that could be contributing factors like alcohol abuse/withdrawal (which is frequently under-reported) and, since there seem to be tons of cases of sleep apnea showing up at the VA lately, could hypoxic episodes during sleep be contributing? I seem to recall some research on successful CPAP therapy for obstructive sleep apnea sufferers (with comorbid PTSD) being associated with a reduction in nightmare frequency.

 

[smalltownpsych]

Speaking of IRT, which does involve rescripting, one thing to watch for are subtle negative messages still being contained in the conscious script the patient creates. There is a real tendency to blame oneself for trauma as a means of increasing perceived control, but a side effect of guilt and shame. In other words, if I handle it better in the dream, then I am telling myself that if I had done it that way. "See, I should have prevented it. It is all my fault."

 

[erg923]

Speaking of IRT, which does involve rescripting, one thing to watch for are subtle negative messages still being contained in the conscious script the patient creates. There is a real tendency to blame oneself for trauma as a means of increasing perceived control, but a side effect of guilt and shame. In other words, if I handle it better in the dream, then I am telling myself that if I had done it that way. "See, I should have prevented it. It is all my fault."

I have had difficulty in getting people to adhere/follow through with IRT and evern when they have, they have not reported substantial changes. Maybe im not very skilled IRT operator...

 

[smalltownpsych]

I have had difficulty in getting people to adhere/follow through with IRT and evern when they have, they have not reported substantial changes. Maybe im not very skilled IRT operator...

It takes the patients skill more than ours. Sounds like you're describing resistance. What purpose does holding on to the pathology serve for the patient? As I talk about this it helps me see that in some of my own cases this dynamic plays out, too. I also wonder if the setting pulls for expressing emotional distress in terms of nightmares. I usually only hear about frequent nightmares from trauma patients. Not the stressed out going through an extremely difficult situation patients. Those patients might have a nightmare or two during course of treatment, but more than 50% of my patients don't report any during course of treatment.

 

[WisNeuro]

I have had difficulty in getting people to adhere/follow through with IRT and evern when they have, they have not reported substantial changes. Maybe im not very skilled IRT operator...

Setting plays a role, my dropout/nonadherence rates in the VA are higher than any other setting I've worked in.

 

[ela]

I have done IRT at 2 VA's with really good results. We had a three session model, and folks were referred specifically for stand-alone IRT as an adjunct to whatever ongoing (usually) trauma work they were pursuing.

Pretty good interview with Barry Krakow (one of the developers of IRT) over here;
http://shrinkrapradio.com/430-recent-findings-on-the-treatment-of-insomnia-with-barry-krakow-md/

 

[smalltownpsych]

I have done IRT at 2 VA's with really good results. We had a three session model, and folks were referred specifically for stand-alone IRT as an adjunct to whatever ongoing (usually) trauma work they were pursuing.

Pretty good interview with Barry Krakow (one of the developers of IRT) over here;
http://shrinkrapradio.com/430-recent-findings-on-the-treatment-of-insomnia-with-barry-krakow-md/

I like the idea of a stand-alone model. Makes me wonder if at times a specific technique is less effective because of the therapeutic relationship that is already developed or if the placebo. Another example, I understand the dynamics and some of the treatments for chronic pain, but I find it more effective when the education and some of the techniques are delivered by the pain clinic and I focus more on the associated depressed mood and cognitions and interpersonal difficulty. We don't have an IRT specialist I can refer to though.

 

[erg923]

Speaking of horses, I'd also want to rule out some 'zebras' that could be contributing factors like alcohol abuse/withdrawal (which is frequently under-reported) and, since there seem to be tons of cases of sleep apnea showing up at the VA lately, could hypoxic episodes during sleep be contributing? I seem to recall some research on successful CPAP therapy for obstructive sleep apnea sufferers (with comorbid PTSD) being associated with a reduction in nightmare frequency.

The sleep apnea, oh God the sleep apnea...

 

[Fan_of_Meehl]

The sleep apnea, oh God the sleep apnea...

Right. Sleep apnea is one of those compensable conditions that, I think, merits a 50% service connection automatically. I'm still waiting for the study examining the association between compensability of illness/diagnosis and differential rates of symptom presentation in VA vs. non-VA settings.