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Guideline Summary
Guideline Title
Best practice guide for the treatment of nightmare disorder in adults.
Bibliographic Source(s)
Aurora RN, Zak RS, Auerbach SH, Casey KR, Chowdhuri S, Karippot A, Maganti RK, Ramar K, Kristo DA, Bista SR, Lamm CI, Morgenthaler TI, Standards of Practice Committee, American Academy of Sleep Medicine. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med. 2010 Aug 15;6(4):389-401. [92 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Nightmare disorder in adults

Guideline Category
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Neurology
Psychiatry
Psychology
Sleep Medicine
Intended Users
Physicians
Guideline Objective(s)

To present recommendations on therapy of nightmare disorder

Target Population

Adults with nightmare disorder

Interventions and Practices Considered
  1. Medications
    • Prazosin
    • Clonidine
    • Other medications, including: trazodone, atypical antipsychotic medications, topiramate, low-dose cortisol, fluvoxamine, triazolam, nitrazepam, phenelzine, gabapentin, cyproheptadine, tricyclic antidepressants, clonazepam
  2. Cognitive behavioral therapy
    • Image rehearsal therapy (IRT)
    • Lucid dreaming therapy
    • Exposure, relaxation and rescripting therapy (ERRT)
    • Sleep dynamic therapy
    • Self exposure therapy
    • Systematic desensitization
  3. Progressive deep muscle relaxation training
  4. Hypnosis
  5. Eye movement desensitization and reprocessing (EMDR)
  6. Testimony method
  7. Individual psychotherapy

Note: Nefazodone and venlafaxine are considered, but not recommended.

Major Outcomes Considered
  • Frequency of nightmares
  • Quality of life

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

A search for articles on the medical treatment of nightmare disorder was conducted using the PubMed database, so that clinically relevant articles on the treatment of nightmare disorder could be collected and evaluated. Other databases such as PsychLit and Ovid were not searched, since it was felt that these databases would not include clinically relevant material. The PubMed search was conducted with no start date limit until February 2008, and subsequently updated in March 2009 to include the most current literature. The key words were: [(Nightmares OR nightmare OR nightmare disorder OR nightmare disorders OR recurrent nightmares) AND (treatment OR drug therapy OR therapy)] as well as [Post-traumatic stress disorder AND (nightmare disorder OR recurrent nightmares OR nightmares) AND treatment]. A second search using the keyword combination "anxiety dreams" with no limits was also conducted in February 2010. "Post-traumatic stress disorder," alone, was not a search term. Although the majority of studies of both pharmacologic and nonpharmacologic treatments of posttraumatic stress disorder (PTSD) assess improvement of global manifestations, very few of these studies have isolated nightmares for evaluation of response to intervention and may not have included "nightmares" as a keyword. The evidence basis for this Best Practice Guide includes only those PTSD studies in which improvement in nightmares could be specifically identified as an evaluable outcome measure.

Each search was run separately and findings were merged. When the search was limited to articles published in English and regarding human adults (age 19 years and older), a total of 1428 articles were identified. Abstracts from these articles were reviewed to determine if they met inclusion criteria. The articles had to have a minimum of 3 subjects to be included in the analysis. The articles had to address at least one of the "PICO" questions (acronym standing for Patient, Population or Problem, provided a specific Intervention or exposure, after which a defined Comparison is performed on specified Outcomes) that were decided upon ahead of the review process (see Table 1 in the original guideline document). Articles meeting these criteria in addition to those identified by pearling (i.e., checking the reference sections of search results for articles otherwise missed) provided 57 articles for review and grading.

Number of Source Documents

57 articles

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

American Academy of Sleep Medicine (AASM) Classification of Evidence (Adapted from Oxford Centre for Evidence-based Medicine)

Evidence Levels Study Design
1 High quality randomized clinical trials with narrow confidence intervals
2 Low quality randomized clinical trials or high quality cohort studies
3 Case-control studies
4 Case series or poor case-control studies or poor cohort studies or case reports
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Evidence was graded according to the Oxford Centre for Evidence-based Medicine Levels of Evidence (see, "Rating Scheme for the Strength of the Evidence" field). All evidence grading was performed by independent review of the article by 2 members of the task force. Areas of disagreement were addressed by the task force until resolved.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The Standards of Practice Committee (SPC) of the American Academy of Sleep Medicine (AASM) commissioned among its members 7 individuals to conduct this review and develop best practice principles. Work began in December 2007 to review and grade evidence in the peer-reviewed scientific literature regarding the treatment of nightmare disorder in adults.

Recommendations were formulated based on the strength of clinical data and consensus attained via a modified Research and Development/University of California, Los Angeles (RAND/UCLA) Appropriateness Method. The nomenclature for the recommendations and levels of recommendation are listed in the "Rating Scheme for the Strength of the Recommendations" field. Recommendations were downgraded if there were significant risks involved in the treatment or upgraded if expert consensus determined it was warranted.

Rating Scheme for the Strength of the Recommendations

Levels of Recommendation

Term Level Evidence Levels Explanation
Recommended/Not Recommended A 1 or 2 Assessment supported by a substantial amount of high quality (Level 1 or 2) evidence and/or based on a consensus of clinical judgment
Suggested/Not Suggested B 1 or 2—few studies

3 or 4—many studies and expert consensus
Assessment supported by sparse high grade (Level 1 or 2) data or a substantial amount of low-grade (Level 3 or 4) data and/or clinical consensus by the task force
May Be Considered/Probably Should Not Be Considered C 3 or 4 Assessment supported by low grade data without the volume to recommend more highly and likely subject to revision with further studies
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

This Best Practice Guide with recommendations was reviewed by external content experts in the area of nightmare disorder.

The Board of Directors of the American Academy of Sleep Medicine (AASM) approved the recommendations. They were submitted and accepted for publication in May 2010.

Recommendations

Major Recommendations

The levels of evidence (1-4) and the levels of recommendations (A-C) are defined at the end of the "Major Recommendations" field.

Medication Treatment Options for Nightmare Disorders

  1. Prazosin is recommended for treatment of posttraumatic stress disorder (PTSD)-associated nightmares. (Level A)
  2. Clonidine may be considered for treatment of PTSD-associated nightmares. (Level C)
  3. The following medications may be considered for treatment of PTSD-associated nightmares, but the data are low grade and sparse: trazodone, atypical antipsychotic medications, topiramate, low dose cortisol, fluvoxamine, triazolam and nitrazepam, phenelzine, gabapentin, cyproheptadine, and tricyclic antidepressants. Nefazodone is not recommended as first line therapy for nightmare disorder because of the increased risk of hepatotoxicity. (Level C)
  4. Venlafaxine is not suggested for treatment of PTSD-associated nightmares. (Level B)
  5. No recommendation is made regarding clonazepam because of sparse data.

Non-pharmacological Treatment Options for Nightmare Disorder

  1. Cognitive behavioral therapy (CBT)
    • Image rehearsal therapy (IRT) is recommended for treatment of nightmare disorder. (Level A)
    • Lucid dreaming therapy (LDT) may be considered for treatment for nightmare disorder. (Level C)
    • Exposure, relaxation and rescripting therapy (ERRT) may be considered for treatment of PTSD-associated nightmares. (Level C)
    • Sleep dynamic therapy may be considered for treatment of PTSD-associated nightmares. (Level C)
    • Self-exposure therapy may be considered for treatment of nightmare disorder. (Level C)
    • Systematic desensitization is suggested for treatment of idiopathic nightmares. (Level B)
  2. Progressive deep muscle relaxation training is suggested for treatment of idiopathic nightmares. (Level B)
  3. Hypnosis may be considered for treatment of PTSD-associated nightmares. (Level C)
  4. Eye movement desensitization and reprocessing (EMDR) may be considered for treatment of PTSD-associated nightmares. (Level C)
  5. The testimony method may be considered for treatment of PTSD-associated nightmares. (Level C)
  6. No recommendation is made regarding individual psychotherapy because of sparse data.

Definitions:

Levels of Recommendation

Term Level Evidence Levels Explanation
Recommended/Not Recommended A 1 or 2 Assessment supported by a substantial amount of high quality (Level 1 or 2) evidence and/or based on a consensus of clinical judgment
Suggested/Not Suggested B 1 or 2—few studies

3 or 4—many studies and expert consensus
Assessment supported by sparse high grade (Level 1 or 2) data or a substantial amount of low-grade (Level 3 or 4) data and/or clinical consensus by the task force
May Be Considered/Probably Should Not Be Considered C 3 or 4 Assessment supported by low grade data without the volume to recommend more highly and likely subject to revision with further studies

American Academy of Sleep Medicine (AASM) Classification of Evidence (Adapted from Oxford Centre for Evidence-based Medicine)

Evidence Levels Study Design
1 High quality randomized clinical trials with narrow confidence intervals
2 Low quality randomized clinical trials or high quality cohort studies
3 Case-control studies
4 Case series or poor case-control studies or poor cohort studies or case reports
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate treatment of nightmare disorder in adults to decrease frequency of nightmares and improve quality of life

Potential Harms

Prazosin

The clinician should monitor the patient for orthostatic hypotension.

Clonidine

Clonidine shares the therapeutic rationale as well as the potential for postural hypotension of prazosin but has not been investigated with the same rigor.

Trazodone

In one study, sixty percent (36/60) of those who tolerated trazodone therapy complained of the following side effects (decreasing order of frequency): daytime sedation, dizziness, headache, priapism, and orthostatic hypotension.

Topiramate

In one study, nine patients discontinued treatment due to side effects, which included urticaria, eating cessation, acute narrow-angle glaucoma, severe headaches, overstimulation/panic, emergent suicidal ideation, and memory concerns.

Fluvoxamine

In one study, 12 subjects dropped out of the trial, 9 due to gastrointestinal problems and worsening of sleep, and 3 for physical complaints not related to fluvoxamine.

Triazolam and Nitrazepam

In a study comparing triazolam and nitrazepam side effects were minor and consisted of difficulty concentrating in the morning and morning sedation.

Phenelzine

In one study, reported side effects included dizziness, drowsiness, and malaise.

Gabapentin

Sedation and mild dizziness were the most commonly reported side effects.

Cyproheptadine

Side effects include drowsiness, irritability, hallucinations, nausea, headache, and worsening of nightmares.

Qualifying Statements

Qualifying Statements
  • The Best Practice Guide endorses treatments based on review of the literature and with agreement by a consensus of the task force. These guidelines should not, however, be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding propriety of any specific care must be made by the physician, in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources.
  • Many patients with posttraumatic stress disorder (PTSD) are on multiple psychotropic medications, making the assessment of efficacy of monotherapy of any particular medication difficult.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Aurora RN, Zak RS, Auerbach SH, Casey KR, Chowdhuri S, Karippot A, Maganti RK, Ramar K, Kristo DA, Bista SR, Lamm CI, Morgenthaler TI, Standards of Practice Committee, American Academy of Sleep Medicine. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med. 2010 Aug 15;6(4):389-401. [92 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Aug
Guideline Developer(s)
American Academy of Sleep Medicine - Professional Association
Source(s) of Funding

American Academy of Sleep Medicine

Guideline Committee

Standards of Practice Committee

Composition of Group That Authored the Guideline

Committee Members: R. Nisha Aurora, MD; Rochelle S. Zak, MD; Sanford H. Auerbach, MD; Kenneth R. Casey, MD; Susmita Chowdhuri, MD; Anoop Karippot, MD; Rama K. Maganti, MD; Kannan Ramar, MD; David A. Kristo, MD; Sabin R. Bista, MD; Carin I. Lamm, MD; Timothy I. Morgenthaler, MD

Financial Disclosures/Conflicts of Interest

All members of the American Academy of Sleep Medicine Standards of Practice Committee (AASM SPC) and Board of Directors completed detailed conflict-of-interest statements and were found to have no conflicts of interest with regard to this subject.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the American Academy of Sleep Medicine (AASM) Web site External Web Site Policy.

Print copies: Available from the Standards of Practice Committee, American Academy of Sleep Medicine, 2510 North Frontage Road, Darien, IL 60561. Web site: www.aasmnet.org External Web Site Policy.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on January 11, 2011. The information was verified by the guideline developer on February 7, 2011. This summary was updated by ECRI Institute on April 13, 2011 following the U.S. Food and Drug Administration advisory on Topamax (topiramate). This summary was updated by ECRI Institute on May 20, 2011 following the U.S. Food and Drug Administration advisory on antipsychotic drugs.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the American Academy of Sleep Medicine (AASM) for information regarding reproduction of AASM guidelines.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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