Expert Panel Releases Consensus Statement on Implementing CBT for Nightmares

An expert panel released a consensus statement with standardized guidelines for the implementation of cognitive behavioral therapy (CBT) for nightmares. This statement was recently published in Behavioral Sleep Medicine.

Previous research supports CBT as a treatment for nightmares in adults. However, CBT for nightmares has historically lacked standardization in terminology and implementation, leading to confusion and missed training opportunities in the field of nightmare treatment. To provide clarity on the implementation of CBT for nightmares, an expert panel recently released a consensus statement that aims to provide recommendations and guidelines for CBT for nightmares treatment.

The panel consisted of experts in behavioral sleep medicine and covered specialties in idiopathic nightmares, trauma-related nightmares, and insomnia. To decide on which specific CBT treatment components to incorporate into the nightmare treatment guidelines, the expert panel performed a literature review. The panel searched PubMed and PsychINFO databases for randomized control trials (RCTs) that met the following criteria: participants were 18 years of age and older, nightmares were in the inclusion criteria, there was a minimum of 1 CBT approach used as a “full package” — not just for evaluating mechanisms of change, statistically significant findings on the frequency or the severity of nightmares were reported, and a clinical provider performed the treatment protocol.

From this literature review, the expert panel agreed on a definition for nightmares, which is “well-remembered dreams with distressing emotions that cause awakenings.” The experts also decided to encourage flexibility in personalizing the session length to the patient.

Based on available literature, the experts recommended using the same protocols for idiopathic and trauma-related nightmares. However, they provided a caveat to allow clinicians to deliver additional trauma-focused psychoeducation to people who would benefit from understanding the post-traumatic stress response.

Due to a strong theoretical and research foundation, the panel also advises using stimulus control therapy and support in improving sleep hygiene. However, the experts only recommend sleep efficiency training under certain circumstances, such as for individuals with low sleep efficiency.

Given that exposure to the original nightmare content remains a controversial topic of debate, the experts suggest that nightmare exposure may be an initial course of action, but is not a required component. Some people with trauma-related nightmares might find writing down the nightmare to be a powerful and meaningful experience. Other individuals with idiopathic nightmares, for example, may benefit more from rescription.

During the rescription process, the experts recommend helping individuals identify the specific theme in the nightmare. Themes include threats to safety, trust, power or control, esteem, and intimacy. With this theme in mind, clinicians encourage individuals to rescript the dream, which might start out similarly to the nightmare with changes to the most distressing parts.

Afterward, clinicians may proceed to ask individuals to perform an imagery rehearsal. This involves imagining the dream rescription during the day and every night before implementing relaxation exercises.

Research supports relaxation training to decrease tension and stress before bed and during awakenings. Individuals can perform relaxation exercises for at least 10- to 15-min/day. Experts suggest early incorporation of relaxation that include guided imagery with initial training. Guided imagery may help when clinicians ask individuals to imagine rescripted dreams. Experts also support grounding strategies for individuals to immediately use to decrease awakenings after a nightmare event.

Based on the panel’s clinical experience among people with multiple nightmares, the experts suggest to start focusing on the nightmare that is most distressing, well-remembered, or frequent. Additionally, health care providers should help individuals with replicative nightmares separate their anticipatory feelings in the nightmare from the actual events of the trauma.

Among people with frequent nightmares and comorbid post-traumatic stress disorder (PTSD), there is insufficient research to determine the initial course of action in addressing PTSD first or sleep problems first. The experts recommend involving the patient to help with the decision-making process.

“These consensus recommendations by a panel of multidisciplinary experts represent a first step toward greater standardization in nightmare treatment and research,” the paper authors concluded. “Using a comprehensive treatment manual based on expert recommendations will not only help disseminate nightmare treatment but also advance the field by providing clarity.”

Limitations include the lack of a dismantling study and the lack of generalizability to a broad population due to the focus on an adult-only population. Additionally, the included treatment approaches and the panel of experts themselves were not exhaustive, and thus could have affected the scope of the recommendations.

This article originally appeared on Sleep Wake Advisor