Abstract
Objective:Nightmares are relatively common in patients experiencing psychosis but rarely assessed or treated. Nightmares may maintain persecutory delusions by portraying fears in sensory-rich detail. We tested the potential benefits of imagery-focused cognitive behavioural therapy (CBT) for nightmares on nightmare severity and persecutory delusions.Method:This assessor-blind parallel-group pilot trial randomized 24 participants with nightmares and persecutory delusions to receive CBT for nightmares delivered over 4 weeks in addition to treatment as usual (TAU) or TAU alone. Assessments were at 0, 4 (end of treatment), and 8 weeks (follow-up). Feasibility outcomes assessed therapy uptake, techniques used, satisfaction, and attrition. The primary efficacy outcome assessed nightmare severity at week 4. Analyses were intention to treat, estimating treatment effect with 95% confidence intervals (CIs).Results:All participants offered CBT completed therapy (mean [SD], 4.8 [0.6] sessions) with high satisfaction, and 20 (83%) participants completed all assessments. Compared with TAU, CBT led to large improvements in nightmares (adjusted mean difference = −7.0; 95% CI, –12.6 to –1.3; d = –1.1) and insomnia (6.3; 95% CI, 2.6 to 10.0; d = 1.4) at week 4. Gains were maintained at follow-up. Suicidal ideation was not exacerbated by CBT but remained stable to follow-up, compared with TAU, which reduced at follow-up (6.8; 95% CI, 0.3 to 3.3; d = 0.7). CBT led to reductions in paranoia (–20.8; 95% CI, –43.2 to 1.7; d = –0.6), although CIs were wide. Three serious adverse events were deemed unrelated to participation (CBT = 2, TAU = 1).Conclusions:CBT for nightmares is feasible and may be efficacious for treating nightmares and comorbid insomnia for patients with persecutory delusions. It shows promise on paranoia but potentially not on suicidal ideation.
Highlights
Compared with treatment as usual (TAU), cognitive behavioural therapy (CBT) led to large improvements in nightmares and insomnia (6.3; 95% confidence intervals (CIs), 2.6 to 10.0; d 1⁄4 1.4) at week 4
Suicidal ideation was not exacerbated by CBT but remained stable to follow-up, compared with TAU, which reduced at follow-up (6.8; 95% CI, 0.3 to 3.3; d 1⁄4 0.7)
CBT led to reductions in paranoia (–20.8; 95% CI, –43.2 to 1.7; d 1⁄4 –0.6), CIs were wide
Summary
Twenty-four participants were recruited from Oxford Health National Health Service (NHS) Foundation Trust (n 1⁄4 22) and Central and North West London NHS Foundation Trust (n 1⁄4 2). All were referred by their secondary mental health care coordinator or psychiatrist. The exclusion criteria were 1) nightmares that were considered a side effect of medication by the treating psychiatrist; 2) currently receiving CBT or due to commence during the trial period; 3) high risk of sleep apnea indicated by a score of !5 on the STOPBANG questionnaire,[24,25] with no history of having a full assessment and/or treatment (if the participant was receiving optimal treatment for apnoea, or further NHS assessment resulted in no diagnosis, he or she was invited to take part); 4) a primary diagnosis of personality disorder, alcohol or substance dependency, organic syndrome, or learning disability; or 5) a command of spoken English inadequate for completing questionnaire measures and CBT
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