Nightmare Disorders: Pharmacotherapy or Psychotherapy as The First Line Treatment?

Nightmares are almost an ubiquitous phenomenon but only nightmare disorders would need to be treated. Nightmare disorders result from a variety of causes including posttraumatic stress disorder (PTSD), psychiatric disorders, substance abuse, or idiosyncrasy. Nightmare disorders can be treated by either pharmacotherapy or psychotherapy. We performed literature search to explore eighteen possible pharmacotherapies and eleven possible psychotherapies for nightmare disorders to identify the best pharmacotherapy and psychotherapy through an evidence based approach. For PTSD-related nightmare disorders, topiramate as the first line and nabilone as the second line pharmacotherapy whereas cognitive behavior therapy, imagery rehearsal therapy (IRT), and exposure, relaxation, and rescripting therapy as the appropriate psychotherapies are recommended. For non-PTSD related nightmare disorders, triazolam or nitrazepam as the first line pharmacotherapy and IRT as the psychotherapy of choice are recommended. We then compared between all pharmacotherapies and psychotherapies to identify the best treatment for nightmare disorders in patients with and without post-traumatic stress disorder. For PTSD related nightmare disorders, pharmacotherapy is prioritized over psychotherapy. For non-PTSD related nightmare disorders, either pharmacotherapy or psychotherapy can be offered as the first line treatment.