Fast Fact and Concept #88: Nightmares

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Title: Fast Fact and Concept #88: Nightmares

Author(s): Seema Malhotra, MD and Robert Arnold, MD

Good, restful sleep is essential to quality of life, providing renewed energy for the next day. Nightmares are vivid, frightening dreams that typically lead to full awakening with detailed recollection of the dream sequence and content. Following a nightmare, heart rate and blood pressure are elevated, and residual anxiety may interfere with the ability to return to sleep. Nightmares occur almost exclusively during REM (Rapid Eye Movement) sleep.


Psychiatric: Anxiety is a common symptom during a life-threatening illness. Specifically, anxieties related to the illness course and prognosis, procedures and treatments, family issues, and death, can be significant. Nightmares may arise as a complication of anxiety or other psychiatric disturbances [i.e., PTSD (PostTraumatic Stress Disorder), delirium, mood disorders, schizophrenia, and adjustment disorders].

Medications/Drugs/Alcohol: Medications causally linked to nightmares include: beta-blockers, sedative/hypnotics, amphetamines and other stimulants, dopamine agonists, and antidepressants. Withdrawal from REM-suppressing drugs, including antidepressants, benzodiazepines and alcohol, predisposes to the development of nightmares.

Brain disorders: CNS infections, brain tumors and other structural problems of the brain may lead to nightmares.

Metabolic: hypoglycemia

Psychotherapeutic Interventions

Supportive Psychotherapy: Brief, supportive psychotherapy can address a patient?s anxieties and concerns; the therapist helps the patient with problem solving, seeking information and support, and accepting aspects of their situation which cannot be changed.

Behavioral techniques: Relaxation training, desensitization, and dream imagery rehearsal therapy may help reduce nightmares. In imagery rehearsal therapy, the patient writes down the disturbing dream, changes the content, and practices the new, positive scenario mentally during the day; this new imagery during the day reduces nightmares at night.

Pharmacological Management

The pharmacological treatment of nightmares has not been studied in controlled clinical trials. Case studies and anecdotal reports suggest the following drugs or drug classes may be effective:

Atypical Antipsychotics: risperidone (0.5-2mg qhs) and olanzapine (5mg) have both been shown to reduce nightmares in small pilot studies, including reduction in flashbacks, hyperarousal, and disturbed sleep.

Benzodiazepines and Tricyclic Antidepressants may be of benefit in suppressing REM activity. Note: Trazadone does not suppress REM activity.

Other: Both Cyproheptadine and topiramate have been reported to suppress nightmares in small case series.

Also See:
Fast Fact #101: Insomnia: Patient Assessment


Berlant J. Open-Label Topiramate as Primary or Adjunctive Therapy in Chronic Civilian Posttraumatic Stress Disorder: A Preliminary Report. Journal of Clinical Psychiatry. 2002; 63(1): 15-20.

Buysse DJ et al, in Treatments of Psychiatric Disorders, 2nd Edition. Gabbard G (Ed), 1995, 2395-2453.

Sateia MJ et al, in Oxford Textbook of Palliative Medicine, 2nd Edition. Doyle D (Ed), 1998, 751-767.

Krakow B et al. Imagery Rehearsal Therapy for Chronic Nightmares in Sexual Assault Survivors with Posttraumatic Stress Disorder: A Randomized Controlled Trial. JAMA. 2001; 286(5): 537-545.

Labbate LA. Olanzapine for Nightmares and Sleep Disturbance in Posttraumatic Stress Disorder [comment]. Canadian Journal of Psychiatry. 2000; 45(7): 667-668.

Stanovic JK et al. The Effectiveness of Risperidone on Acute Stress Symptoms in Adult Burn Patients: A Preliminary Retrospective Pilot Study. Journal of Burn Care & Rehabilitation. 2001; 22(3): 210-213.

Thompson DF et al. Drug-Induced Nightmares. The Annals of Pharmacotherapy. 1999; 33(1): 93-98.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Malhotra, S and Arnold R. MD Fast Facts and Concepts #88 . Nightmares. April 2003. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

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Creation Date: 4/2003

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