Post: Nightmare Disorder
1- Explain the diagnostic criteria for your assigned sleep/wake disorder. (Nightmare Disorder)
2- Explain the evidence-based psychotherapy and psychopharmacologic treatment for your assigned sleep/wake disorder.
3- Describe at what point you would refer the client to their primary care physician for additional referral to a neurologist, pulmonologist, or physician specializing in sleep disorders and explain why. Nightmare Disorder Essay Paper
4- Support your rationale with references to academic resources.
Discussion Post: Nightmare Disorder
Nightmare disorder is typified by abnormal experiences such as extremely disturbing dreams and the ensuing dysphoric emotions like anger or fear that a person experiences when falling asleep, sleeping, or waking up (van Schagen et al., 2017).
Diagnostic Criteria for Nightmare Disorder
Symptoms of nightmare disorder include repeated incidents of persistent and very dysphoric dreams and after waking from the dream the person becomes alert and oriented very fast. The sleep disturbance leads to significant distress or impairs occupational, social, and normal functioning. To be diagnosed with nightmare disorder, the symptoms of the nightmare disorder should not be caused by the physiological effects of substances or any mental or medical disorder (van Schagen et al., 2017).
Treatment for Nightmare Disorder
The first-line pharmacological treatment for nightmare disorder is prazosin due to its superior long-term efficacy in treating nightmare disorder (Morgenthaler et al., 2018). The psychotherapy choice to treat nightmare disorder is cognitive-behavioral therapy (CBT). During the treatment of nightmare disorder, CBT integrates techniques such as image rehearsal therapy, and self-exposure therapy. In image rehearsal therapy, the patient is advised to remember and write the nightmare and then focus on making the aspects of the dream positive. In self-exposure therapy, the client is advised to expose themselves in scenarios provoking their anxiety until the fear reduces (Morgenthaler et al., 2018). Nightmare Disorder Essay Paper
Referral to the Primary Care Physician
The client should be referred to a physician if the symptoms become chronic and the mental assessment indicates that there is an underlying mental disorder or health condition causing the persistent nightmares. This will facilitate the treatment of the underlying cause of the nightmare disorder (Komada et al, 2016).
Komada Y, Takaesue Y, Matsui K, Masaki N, Nishida S & Inoue Y. (2016). Comparison of clinical features between primary and a drug-induced sleep-related eating disorder. Neuropsychiatr Dis Treat. 1(12), 1275–1280.
Morgenthaler, T. I., Auerbach, S., Casey, K. R., Kristo, D., Maganti, R., Ramar, K., Zak, R., & Kartje, R. (2018). Position Paper for the Treatment of Nightmare Disorder in Adults: An American Academy of Sleep Medicine Position Paper. Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine, 14(6), 1041–1055. https://doi.org/10.5664/jcsm.7178.
van Schagen, A., Lancee, J., Swart, M., Spoormaker, V., & van den Bout, J. (2017). Nightmare disorder, psychopathology levels, and coping in a diverse psychiatric sample. Journal of clinical psychology, 73(1), 65-75.
Patients with nightmare disorder (see Box 36-) should closely adhere to sleep hygiene techniques. Recurrent nightmares in children do not always require active management and may subside with reassurance (Kotagal 2012). In adults, nightmares are usually products of underlying disorders, such as posttraumatic stress disorder or personality disorders, and a thorough evaluation for these disorders should be performed, followed by direct management. Nightmare Disorder Essay Paper
Table 1- lists treatment strategies for nightmare disorder in children and in adults. In adults, the nightmares generally diminish in frequency and intensity with aging, and conservative measures such as sleep hygiene education may suffice (Schenck and Mahowald 2012).
DSM-5 Diagnostic Criteria for Nightmare Disorder
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- Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical integrity and that generally occur during the second half of the major sleep episode.
- On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert.
- The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The nightmare symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
- Coexisting mental and medical disorders do not adequately explain the predominant complaint of dysphoric dreams.
- During sleep onset
- With associated non–sleep disorder, including substance use disorders
- With associated other medical condition
- With associated other sleep disorder
- Coding note: The code 307.47 (F51.5) applies to all three specifiers. Code also the relevant associated mental disorder, medical condition, or other sleep disorder immediately after the code for nightmare disorder in order to indicate the association.
- Acute: Duration of period of nightmares is 1 month or less.
- Subacute: Duration of period of nightmares is greater than 1 month but less than 6 months.
- Persistent: Duration of period of nightmares is 6 months or greater.
Specify current severity:
- Severity can be rated by the frequency with which the nightmares occur:
- Mild: Less than one episode per week on average.
- Moderate: One or more episodes per week but less than nightly.
- Severe: Episodes nightly.
Parasomnias Treatment strategies for nightmare disorder
|Children||Write down or draw pictures of the nightmare content.|
|Rescript; create more pleasant endings to nightmares.|
|Use desensitization techniques.|
|Consider pharmacotherapy, which is rarely required, only in refractory cases.|
|Adults||Treat underlying disorders, such as posttraumatic stress disorder and personality disorders.|
|Identify and consider discontinuing or changing doses of offending agents, such as antidepressants, antihypertensives, dopamine receptor agonists, among others. Avoid acute withdrawal from REM-suppressant agents (resulting in REM-rebound nightmares), such as tricyclic antidepressants, clonidine, stimulants, and others.|
|Use desensitization techniques.|
|Use imagery rehearsal.|
|Use pharmacotherapy in refractory cases: cyproheptadine, prazosin, guanfacine, clonidine.|
|Note. REM = rapid eye movement.|