Comparative Meta-Analysis of Prazosin and Imagery Rehearsal Therapy for Nightmare Frequency, Sleep Quality, and Posttraumatic Stress

Abstract

Study Objective:In this meta-analysis, we compare the shortterm effi cacy of prazosin vs. IRT on nightmares, sleep quality, and posttraumatic stress symptoms (PTSS). Methods: Reference databases were searched for randomized controlled trials using IRT or prazosin for nightmares, sleep disturbance, and/or PTSS. Effect sizes were calculated by subtracting the mean posttest score in the control group from the mean posttest score in the treatment group, and dividing the result by the pooled standard deviation of both groups. Mixed effects models were performed to evaluate effects of treatment characteristics, as well as sample characteristics (veteran vs. civilian) on treatment effi cacy. Results: Four studies used prazosin, 10 used IRT alone or in combination with another psychological treatment, and 1 included a group receiving prazosin and another group receiving IRT. Overall effect sizes of both treatments were of moderate magnitude for nightmare frequency, sleep quality, and PTSS (p < 0.01). Effect size was not signifi cantly different with type of treatment (psychological vs. pharmacological However, when these frightening dreams occur in a recurrent fashion, the nightmare activity may constitute a disorder. In fact, nightmare disorder is listed in both the DSM-5 and in the ICSD-3 as a distinct disorder whose essential features are the presence of repeated negative dreams that lead to awakening, such that the individual becomes fully alert and aware of his or her surroundings. 2,3Nightmares can have an idiopathic origin or may occur after traumatic events. 4 Along with other sleep disturbances (e.g., insomnia and poor sleep quality), 5 nightmares are a typical symptom of posttraumatic stress disorder (PTSD). 6 Indeed, it has been estimated that around 70% of individuals with PTSD report posttraumatic nightmares. 7,8 Nonetheless, nightmares are not exclusive to PTSD, since they are also associated with anxiety and depression, among other mental health comorbidities. BRIEF SUMMARYCurrent Knowledge/Study Rationale: Imagery rehearsal therapy (IRT) and prazosin are both used for treatment of nightmares in posttraumatic stress. The main aim of this study was a comparative meta-analysis of each treatment on nightmare frequency, sleep quality, and posttraumatic stress disorder symptoms. Study Impact: IRT and prazosin had similar effects for nightmare frequency, sleep quality, and posttraumatic stress disorder symptoms; however, adding cognitive-behavior therapy for insomnia to IRT enhanced its effects for improving sleep quality as well as posttraumatic stress disorder symptoms.

Understanding Recent Insights in Sleep and Posttraumatic Stress Disorder from a Research Domain Criteria (RDoC) Framework

“…Findings are mixed about the efficacy of IRT [65,66]. A recent meta-analysis demonstrated that IRT as compared to prazosin, an alpha-aderenergic blocker previously shown to be effective in reducing nightmares [64], produced equivalent reductions in nightmare frequency and associated sleep and trauma symptoms [67]. As such, the American Academy of Sleep Medicine and Veterans Administration/ Department of Defense endorses prazosin for the treatment of PTSD nightmares [64,68] which was further supported by two prazosin meta-analyses published in 2015 [69,70].…”

“…However, veterans who did not experience a clinically significant improvement entered the study with greater insomnia severity [77]. A recent metaanalysis of nightmare treatments showed sleep and trauma symptom improvement was substantially bolstered by combining cognitive behavioral therapy for insomnia (CBT-I) with IRT [67]. Therefore, directly addressing sleep quality and quantity either prior to or in conjunction with nightmare treatment may produce the greatest benefit for trauma-exposed individuals with both insomnia symptoms and nightmares.…”

Cognitive behavioral therapy for insomnia and imagery rehearsal in combat veterans with comorbid posttraumatic stress: A case series

“…Recent meta-analyses have demonstrated that IRT, both combined with CBT-I and as a standalone therapy, is effective in reducing the frequency of nightmares (Augedal, Hansen, Kronhaug, Harvey, & Pallesen, 2013; Seda, Sanchez-Ortuno, Welsh, Halbower, & Edinger, 2015). In addition, the literature has suggested that when combined with CBT-I, IRT may provide additional utility in the reduction of other sleep quality variables as well as posttraumatic stress (Seda et al, 2015).…”

Treating Nightmares—Sleep Medicine and Posttraumatic Stress Disorder

“…The Seda et al paper in this issue, 21 a comparative metaanalysis of medications and behavioral treatments available for treating nightmares, indicates that both of these approaches can be used to produce excellent results in reducing nightmare frequency, insomnia and next day distress. This meta-analysis is an excellent and needed next step for supporting a role for Sleep Medicine based nightmare therapies in the treatment of PTSD.…”