Treatment Options for Nightmare Disorder in Adults: A Summary of the AASM Position

Summary: Experts identify several therapeutic approaches and medications that can help manage nightmare disorder in adults.

Overview

The American Academy of Sleep Medicine (AASM) has published a position paper outlining recommended and optional treatments for nightmare disorder in adults. The paper highlights image rehearsal therapy as an evidence-based, recommended approach for nightmares in general and for nightmares associated with post-traumatic stress disorder (PTSD). In addition, the task force presents a range of behavioral, psychological, and pharmacologic options that may be appropriate in specific circumstances, while advising against certain medications.

Image Rehearsal Therapy and Other Behavioral Treatments

Image rehearsal therapy is a behavioral technique in which a person intentionally rewrites the content of a recurring nightmare into a less distressing or more positive scenario, and then practices the revised imagery while awake. The AASM task force found clear evidence supporting this method for both PTSD-related nightmares and idiopathic nightmare disorder, leading to its classification as a recommended treatment.

Beyond image rehearsal therapy, the position paper indicates several behavioral and psychological interventions that may be used depending on clinical judgment and patient needs. These include cognitive behavioral therapy (CBT), cognitive behavioral therapy for insomnia (CBT-I), eye movement desensitization and reprocessing (EMDR), exposure, relaxation, and rescripting therapy (ERRT), hypnosis, lucid dreaming therapy, progressive deep muscle relaxation, sleep dynamic therapy, systematic desensitization, and other exposure-based approaches. Many of these interventions aim to reduce nightmare frequency, lessen distress, and improve overall sleep quality and daytime functioning.

A woman appearing distressed, representing the impact of nightmare disorder — Nightmare disorder involves repeated nightmares that cause significant distress or impairment. It affects roughly 4% of adults, can occur alone or with conditions such as PTSD, and may worsen coexisting mental health problems like depression or anxiety. Image: public domain.

Pharmacologic Options: May Be Used Versus Not Recommended

The task force reviewed pharmacologic options and categorized many as “may be used,” reflecting limited or mixed evidence and the importance of individualized clinical decision-making. Medications listed as potentially useful for PTSD-associated nightmares or nightmare disorder include: atypical antipsychotics (olanzapine, risperidone, aripiprazole), clonidine, cyproheptadine, fluvoxamine, gabapentin, nabilone, phenelzine, prazosin, topiramate, trazodone, tricyclic antidepressants, nitrazepam, and triazolam. The paper emphasizes that recommendations for drug therapy should consider potential benefits, side effects, and interactions, and should be made by clinicians experienced in sleep disorders and psychopharmacology.

By contrast, the AASM position specifically identifies two medications as not recommended for the treatment of nightmare disorder: the benzodiazepine clonazepam and the antidepressant venlafaxine. These agents were judged to be ineffective or potentially harmful for most patients with nightmare disorder based on the available evidence and expert assessment.

Clinical Context and Practical Guidance

Nightmare disorder is defined by repeated nightmares that cause clinically significant distress or impairment. It affects an estimated 4% of adults and can substantially reduce quality of life, contribute to daytime sleepiness, and worsen co-occurring mental health conditions. The AASM emphasizes that the clinician’s judgment is essential: treatment selection should be individualized, taking into account the patient’s clinical history, coexisting conditions (such as PTSD, depression, or anxiety), available resources, and treatment preferences.

For individuals experiencing frequent or distressing nightmares, the AASM recommends beginning the conversation with a primary care provider or sleep specialist. A comprehensive sleep evaluation at an accredited sleep center, performed by a board-certified sleep medicine physician when appropriate, can clarify diagnosis and help guide therapy. Effective treatment of nightmare disorder may lead to improved sleep quality, reduced daytime sleepiness, and better daytime alertness and functioning.

Evidence Review and Research Needs

The AASM task force based its position statements on a systematic review of the literature and expert clinical experience. Searches covered behavioral, psychological, and pharmacologic studies through August 2017 and built on earlier guidance. Positions designated as “recommended,” “may be used,” or “not recommended” reflect qualitative assessment of the available evidence combined with clinical judgment. The task force also highlighted the need for additional high-quality randomized controlled trials and well-designed comparative effectiveness studies to refine guidance and better inform treatment choices.

Position Summary

Recommended for PTSD-associated nightmares and nightmare disorder: image rehearsal therapy.
May be used for PTSD-associated nightmares: cognitive behavioral therapies, EMDR, ERRT, select medications (including some atypical antipsychotics, prazosin, gabapentin, trazodone, and others), and additional psychotherapeutic techniques.
May be used for nightmare disorder: cognitive behavioral therapy, ERRT, hypnosis, lucid dreaming therapy, relaxation methods, and certain medications such as prazosin, nitrazepam, and triazolam (use with caution and clinical oversight).
Not recommended for treatment of nightmare disorder: clonazepam and venlafaxine.
Final treatment decisions should be individualized by clinicians based on each patient’s circumstances and available resources.

Conclusion

The AASM position paper provides clinicians and patients with an updated, evidence-informed overview of available treatments for nightmare disorder in adults. Image rehearsal therapy stands out as a recommended behavioral treatment. A range of other therapies and medications may be appropriate in select cases, but more rigorous research is needed to establish comparative effectiveness and long-term outcomes. Patients suffering from recurrent, distressing nightmares are encouraged to seek medical evaluation to determine the best individualized treatment plan.

Article source and citation information: Position Paper for the Treatment of Nightmare Disorder in Adults: An American Academy of Sleep Medicine Position Paper. Journal of Clinical Sleep Medicine. Published June 2018. Authors include Timothy I. Morgenthaler, MD, and colleagues. This summary is based on the AASM position paper and an accompanying synopsis prepared by NeuroscienceNews.