Management of nightmares in patients with posttraumatic stress disorder: current perspectives

Abstract

Nightmares are considered the hallmark of posttraumatic stress disorder (PTSD). Although the characteristics of these distressing dreams may vary with the type of traumatic event, the pathophysiology exposes central dysfunction of brain structures at the level of the hippocampus, amygdala, and locus coeruleus, modulated by neurochemical imbalance in nor-adrenergic, dopaminergic, and serotonin pathways. Underlying comorbid conditions, including other sleep disorders, may contribute to worsening symptoms. Addressing sleep disruption can alleviate the severity of these nocturnal events and augment the effectiveness of other PTSD treatments. The expansion of behavioral treatment modalities for PTSD-related nightmares has been encouraging, but the core of these interventions is heavily structured around memory manipulation and imagery rescripting. A lack of a standardized delivery and a high dropout rate continue to pose significant challenges in achieving successful outcomes. The efficacy of existing pharmacological studies, such as α-adrenergic blocking agents, antidepressants, and atypical antipsychotics, has been undermined by methodological limitations and absence of large randomized controlled trials. This review is aimed at reviewing the available treatment strategies for alleviating nightmares in subjects with PTSD. Given the intricate relationship between PTSD and nightmares, future clinical trials have to adopt a more pragmatic approach focused not only on efficacy of novel interventions but also on adjunctive iteration of existing therapies tailored to individual socio-cultural background.

Post Traumatic Stress Disorder and Substance Use Disorder as Two Pathologies Affecting Memory Reactivation: Implications for New Therapeutic Approaches

“…These authors are currently investigating this approach in a clinical trial conducted on alcoholic patients. It should be noted that, when given separately, both prazozin and cyproheptadine have been shown to reduce nightmares associated with posttraumatic stress disorder (Gupta et al, 1998; Raskind et al, 2003; El-Solh, 2018). However, it will be of interest to investigate with a preclinical approach the efficacy of their combination.…”

Use of Medicinal Cannabis and Synthetic Cannabinoids in Post-Traumatic Stress Disorder (PTSD): A Systematic Review

“…Given the interactions between cannabinoids and specific neurotransmitters (e.g., GABA, serotonin, glutamate, and dopamine), it has been proposed that cannabis may potentially confer some degree of medical benefit to PTSD. In fact, PTSD subjects may use cannabis and cannabis-related compounds mainly due to their anxiolytic, sedative, hypnotic, dream recall suppressor, and antipsychotic activities [1,14,17,25,28,32,36,37,39]. Interestingly, military veterans are increasingly using cannabinoids for relief of PTSD-induced nightmares [14,28,33,40,42].…”

“…Apart from beneficial effects on anxiety, hyperarousal, and trauma-related symptoms described, synthetic cannabinoids have been reported to induce anxiety in healthy subjects and increase symptom severity in PTSD patients [38,41], effects which have been attributed to a downregulation of the eCB signaling system, resulting in tolerance to the drug’s anti-anxiety effects and, in some cases, an unmasking of pro-anxiety properties [3]. Moreover, some toxic effects, including respiratory depression, hyperthermia, acute cerebral ischemia, and seizures have been related to synthetic cannabinoids [32]. Finally, abrupt discontinuation of daily synthetic cannabinoids use can precipitate withdrawal syndrome three or four days after stoppage characterized by waxing and waning behavioral, mood, and physical symptoms such weakness, sweating, restlessness, dysphoria, sleeping problems, anxiety, craving, and diaphoresis [32].…”

“…Among all, Nabilone appeared to be the most explored synthetic cannabinoid in the treatment of PTSD. It is a synthetic cannabinoid agonist already approved by the Food and Drug Administration (FDA) for the treatment of chemotherapy-induced nausea and vomiting [32], but it has been also shown as promising for the treatment of PTSD-related insomnia and nightmares with increased sleep time and reduction of daytime flashbacks. Interestingly, it has also been proposed for harm reduction in cannabis dependence [28], with little evidence of development of tolerance and abuse recorded [33].…”

Efficacy of yokukansan compared with clonazepam for rapid eye movement sleep behaviour disorder: a preliminary retrospective study

“…23,26 It is well known that post-traumatic stress disorder frequently causes nightmares; its pathophysiology is based on the dysfunction of noradrenaline and dopamine in the hippocampus, amygdala, and locus coeruleus, as well as dysfunction of the serotonin system. 26 Nightmares in patients with post-traumatic stress disorder have often been treated with antidepressants or atypical antipsychotics 27,28 -drugs that have the same action in the serotonergic system as YKS. Hence, the serotonergic action of YKS, which CZP lacks, may explain their differences with regard to improvements in the nature of dreams in patients with RBD.…”