**6. Conclusion**

Imagery rehearsal (IR) [136–138] is a form of CBT that targets recurrent nightmares. There is evidence that it promotes increased mastery of nightmare content and experience [139]. IR protocols share the following basic steps: choosing a repetitive nightmare, rescripting it during waking, and imaginally rehearsing the new dream script at bedtime. Two recent meta-analyses of predominantly uncontrolled trials of IR reported large effect sizes for nightmare frequency and sleep quality as well as overall PTSD symptomatology [137, 140]. However, a RCT in Vietnam War veterans with chronic, severe PTSD suggested that IR may hold no advantage over a comparison treatment with elements of CBT-I [141]. In a meta-analysis of studies of CBT-I combined with IR, a large gain in sleep quality was reported, but there was no significant improvement in PTSD severity and the nightmare dis-

28 A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice

The selective serotonin reuptake inhibitors (SSRIs) have the strongest evidence base among pharmacotherapies for PTSD [142, 143]. The use of selective norepinephrine-serotonin reuptake inhibitors (SNRIs), in particular venlafaxine, is also supported by clinical guidelines [142]. However, there is little evidence that insomnia and recurrent nightmares in PTSD

The tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) have not been studied in large RCTs in PTSD [144]. There is only weak support for the usefulness of these classes of psychotropic medication in controlling recurrent nightmares [145]. Considering the prominent REMS suppressant effect of the MAOIs and the evidence that most nightmares emerge from REMS, a methodical investigation of the MAOIs is warranted

The atypical antipsychotic drugs have been minimally studied as a treatment for PTSD. One small placebo-controlled trial of adjunctive olanzapine for combat-related PTSD non-responsive to an SSRI found a greater improvement in sleep, as measured by the Pittsburgh Sleep Quality Index [146]. However, a larger study in veterans showed no significant effect of adjunctive risperidone [147]. There have been no completed RCTs of other medications in this

Little is known about the treatment of insomnia in PTSD with benzodiazepines, commonly used to treat other forms of insomnia [148]. Clonazepam, the mainstay of pharmacological treatment for REMS behavior disorder, could have a role in managing excessive movement during sleep in PTSD, a topic for future research. One RCT of the non-benzodiazepine receptor agonist eszopiclone reported greater improvements in PTSD symptoms including sleep

As noted above, there is strong support for the alpha-1 adrenocepter antagonist prazosin as a treatment for the nightmare disturbance in PTSD. Four placebo-controlled trials of prazosin, two in veterans, one in active-duty US service members, and one in civilians, support its efficacy [12, 150–152]. Prazosin must be administered continuously to avoid the recurrence of

turbance [140].

[145].

class.

disturbance [149].

**5.2. Pharmacotherapies**

respond to either the SSRIs or the SNRIs.

Disturbances of sleep and arousal are significant symptoms of PTSD. Sleep disturbances have also been implicated in the development of PTSD, although, at this time, there is no clear consensus on the role these disturbances may play. As a diagnosis of PTSD may not be determined for several months, there are little data concerning sleep architecture immediately following the precipitating trauma. Thus, the potential role that stress-induced alterations in sleep may play in the development of PTSD is poorly understood and the research questions that could provide answers are inadequately articulated. Problems arise in part because work in animal models, to date, has primarily been descriptive and hypotheses have been based on the effects on sleep arising from experimental stressors that produce diverse effects on subsequent sleep, and can be impacted by a variety of stressor parameters as well as differences in subject vulnerability and resilience. This has led to difficulties in developing hypotheses regarding the potential role of specific sleep states in mediating the outcomes of stress. Thus, improved models of PTSD and improved understanding of the role sleep plays in mediating stress-related psychopathology will be critical for developing more effective treatments for PTSD and sleep symptomatology.
