Status of Imagery Rehearsal Therapy and Other Interventions for Nightmare Treatment in PTSD.

SummaryThe currently best‐supported psychological treatment for nightmares is imagery rehearsal therapy. The problem, however, is that not enough trained practitioners are available to offer this treatment. A possible solution is to conduct imagery rehearsal therapy in a guided self‐help format. In the current study, 70 participants with nightmares according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders were randomized to either telephone‐guided imagery rehearsal therapy (n = 36) or a wait‐list condition (n = 34). Participants in the imagery rehearsal therapy condition received three sessions over the course of 5 weeks. Every treatment session was followed by telephone support delivered by postgraduate students. Participants who received imagery rehearsal therapy showed larger improvements on nightmare frequency (d = 1.03; p < .05), nightmare distress (d = 0.75; p < .05) and insomnia severity (d = 1.12; p < .001) compared with the participants in the wait‐list condition. The effects were sustained at 3‐ and 6‐month follow‐up. No significant effects were observed on the number of nights with nightmares per week, anxiety and depression. In line with earlier reports, the treatment effect was mediated by the increase of mastery at mid‐treatment, underlining the mechanistic value of mastery in imagery rehearsal therapy. The present study demonstrates that it is possible to deliver imagery rehearsal therapy in a self‐help format supported by unexperienced therapists and with relatively little time investment. This opens possibilities in terms of cost‐effectiveness, scalability and dissemination of imagery rehearsal therapy in the treatment of nightmares.

Citation:Sierro C, Leslie W, Putois B. Long-term effects of treatment for chronic nightmares: is imagery rehearsal therapy robust in the COVID-19 pandemic? J Clin Sleep Med. 2020;16(11):1993.

Comparative meta-analysis of prazosin and imagery rehearsal therapy for nightmares, sleep disturbance and post-traumatic stress

EFFICACY OF A COGNITIVE-BEHAVIORAL TREATMENT FOR INSOMNIA AMONG AFGHANISTAN AND IRAQ (OEF/OIF) VETERANS WITH PTSD By Skye Ochsner Margolies, M.A. A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University. Virginia Commonwealth University, 2011. Major Director: Scott Vrana, Ph.D. Professor Department of Psychology Sleep disturbances are a core and salient feature of PTSD and can maintain or exacerbate associated symptoms. Recent research demonstrates that cognitive-behavioral sleep-focused interventions improve sleep disturbances as well as PTSD symptoms. The present study is a randomized controlled trial comparing Cognitive Behavioral Therapy for Insomnia (CBT-I) to a waitlist control group. Conducted at a Veterans Affairs Medical Center, the study: 1) compared subjective outcome measures of sleep amongst veterans assigned to either a treatment group (CBT-I) or a waitlist control group; (2) examined the influence of the intervention on measures of PTSD, general mood and daytime functioning, comparing veterans in a treatment group to those in a waitlist control group and (3) examined the effect of the CBT-I intervention using objective measures of sleep for veterans included in the treatment arm of the study. Study participants were (n = 40) combat veterans who served in Afghanistan and/or Iraq (OEF/OIF). Participants were randomized to either a CBT-I treatment group or a waitlist control group. Those in the treatment condition participated in four CBT-I sessions over six weeks. CBT-I included sleep restriction, stimulus control, cognitive restructuring, sleep education, sleep hygiene and imagery rehearsal therapy. All participants completed subjective and objective measures at baseline and post-treatment. At six weeks post treatment, veterans who participated in CBT-I reported improved sleep, a reduction in PTSD symptom severity and PTSD-related nightmares, as well as a reduction in depression and distressed mood compared to veterans in the waitlist control group. When controlling for current participation in evidence-based PTSD treatment, veterans in the CBT-I group reported a reduction in PTSD symptom severity while their waitlist counterparts demonstrated an increase in these PTSD symptoms. Veterans in the treatment group also reported improved objectively measured sleep quality between baseline and posttreatment. These data suggest that CBT-I is an effective treatment for insomnia, nightmares and PTSD symptoms in OEF/OIF veterans with combat related PTSD and should be used as an adjunctive therapy to standard PTSD treatment.

Back to table of contents Previous article Next article Letters to the EditorFull AccessImagery Rehearsal Therapy for Acute Posttraumatic Nightmares Among Combat Soldiers in IraqBRET A. MOORE Psy.D.,BARRY KRAKOW M.D.,BRET A. MOORE Psy.D.Search for more papers by this author,BARRY KRAKOW M.D.Search for more papers by this author,Published Online:1 Apr 2007https://doi.org/10.1176/ajp.2007.164.4.683AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Imagery rehearsal therapy is an efficacious treatment for chronic nightmares. In one controlled study using this therapy, chronic posttraumatic stress symptoms decreased as well (1) . However, imagery rehearsal therapy has not been tested on acute nightmares or acute posttraumatic stress symptoms. The following case series describes the use of imagery rehearsal therapy with U.S. Army combat soldiers deployed to Iraq. Only soldiers with a primary complaint of acute nightmares received treatment. Eleven soldiers with a primary complaint of acute nightmares received imagery rehearsal therapy, and each had experienced a traumatic event within 30 days prior to presentation. Each soldier reported the development of nightmares and related sleep complaints subsequent to the event. Imagery rehearsal therapy treatment was provided in four weekly one hour sessions by Dr. Moore, who learned the technique while in Iraq through a comprehensive user’s manual (2) and supplemental coaching by e-mail exchange with Dr. Krakow. As part of clinical care, the number of nightmares (3) , posttraumatic stress symptom severity (4) , and insomnia severity (5) were assessed at intake, posttreatment, and 1-month follow-up. Repeated-measures analysis of variance tested each variable across three time points; Hedge’s g effect sizes (for small cohorts) were calculated for changes between intake and 1-month follow-up. Each outcome showed steady reductions from the three time points ( Figure 1 ). The mean number of nightmares decreased 44% at the 1-month follow-up compared with the mean at intake (F=8.026, df=2, 9, p=0.01, Hedge’s g=1.04), and 7 out of 11 soldiers reported marked relief, with an average decrease of 61% in nightmare counts. The mean posttraumatic stress symptom scores decreased 41% at the 1-month follow-up compared with the mean at intake (F=5.999, df=2, 9, p=0.02, Hedge’s g=1.37), and these same seven soldiers reported marked improvements with an average decrease of 58% in symptoms. Insomnia showed a 34% decrease in severity (F=3.946, df=2, 9, p=0.06, Hedge’s g=1.23), with the same seven soldiers reporting the largest improvements. Among the four soldiers who completed the treatment but did not experience fewer nightmares, one showed a slight increase in nightmares, and three reported no changes. Two soldiers showed slight worsening in posttraumatic stress symptoms, and two showed slight improvement. Figure 1. Outcome Using Imagery Rehearsal TherapyIn this case series, imagery rehearsal therapy was associated with large clinical improvements in acute nightmares, posttraumatic stress symptoms, and insomnia severity. All soldiers with clear-cut decreases in nightmares (N=7 [64%]) reported improvements in posttraumatic stress and insomnia. However, these data from an uncontrolled design and small cohort must be interpreted cautiously because nightmares, insomnia, and other posttraumatic symptoms are known to dissipate spontaneously in a large proportion of trauma survivors in the early aftermath of traumatic exposure. Definitive assessment of imagery rehearsal therapy efficacy in the treatment of acute nightmares demands a randomized controlled study, and future studies in the operational environment offer a unique setting for research investigation.Ft. Hood, Tex.Albuquerque, N.M. Dr. Krakow reports the following for-profit interests: www.nightmaretreatment.com, www.sleeptreatment.com , Insomnia Cures , Turning Nightmares into Dreams, and Maimonides Sleep Arts & Sciences, Ltd. Dr. Moore reports no competing interests. The views of these authors are their own and do not purport to reflect the position of the Army Medical Department, Department of the Army, or the Department of Defense.

Sleep disturbances are a core and salient feature of posttraumatic stress disorder (PTSD). Pilot studies have indicated that combined cognitive-behavioral therapy for insomnia (CBT-I) and imagery rehearsal therapy (IRT) for nightmares improves sleep as well as PTSD symptoms. The present study randomized 40 combat veterans (mean age 37.7 years; 90% male and 60% African American) who served in Afghanistan and/or Iraq (Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]) to 4 sessions of CBT-I with adjunctive IRT or a waitlist control group. Two thirds of participants had nightmares at least once per week and received the optional IRT module. At posttreatment, veterans who participated in CBT-I/IRT reported improved subjectively and objectively measured sleep, a reduction in PTSD symptom severity and PTSD-related nighttime symptoms, and a reduction in depression and distressed mood compared to the waitlist control group. The findings from this first controlled study with OEF/OIF veterans suggest that CBT-I combined with adjunctive IRT may hold promise for reducing both insomnia and PTSD symptoms. Given the fact that only half of the patients with nightmares fully implemented the brief IRT protocol, future studies should determine if this supplement adds differential efficacy to CBT-I alone.

Sleep disturbances following exposure to a traumatic experience are often considered to be secondary to PTSD. However, recent empirical findings suggest a much more complex relationship between posttraumatic nightmares, insomnia symptoms, and PTSD. In fact, sleep difficulties in the aftermath of a trauma predict both the onset and the maintenance of PTSD symptoms. Moreover, sleep difficulties often persist even after an effective psychological treatment for PTSD, suggesting that they are not entirely secondary to PTSD. Effective psychological treatments have been developed to directly address trauma-related sleep difficulties. Imagery rehearsal therapy and cognitive-behavioral therapy for insomnia are currently the psychological treatments of choice to address nightmares and insomnia, respectively. A blend of imagery rehearsal therapy and cognitive-behavioral therapy for insomnia interventions appears to be the best clinical approach. List of Abbreviations CBT Cognitive-behavioral therapy CBT-I Cognitive-behavioral therapy for insomnia DBAS Dysfunctional beliefs and attitudes about sleep scale DSM Diagnostic and statistical manual of mental disorders ERRT Exposure, relaxation, and rescripting therapy IRET Imagery rehearsal and exposure therapy IRT Imagery rehearsal therapy ISI Insomnia severity index NM Nightmare PSQI Pittsburgh sleep quality index PSQI-A Pittsburgh sleep quality index addendum for PTSD PTSD Posttraumatic stress disorder RCT Randomized controlled trial SE Sleep efficiency SOL Sleep onset latency TST Total sleep time WASO Wake after sleep onset

ABSTRACTObjectives: This study sought to assess the utility of Imagery Rehearsal Therapy (IRT) for nightmares in an inpatient psychiatric setting. Although IRT enjoys a substantial evidence base for efficacy in various populations, data with psychiatric inpatients are lacking. Participants: Participants were 20 adult psychiatric inpatients (11 male, 9 female; mean age=43.4), in an extended stay psychiatric inpatient facility. All participants were diagnosed with multiple, treatment resistant, comorbid conditions, including mood disorders, anxiety disorders, personality disorders, and substance-related disorders. Patients with active psychosis or significant cognitive impairment were excluded. Methods: This was an open trial utilizing a case series design. In addition to routine hospital treatment that included psychotherapeutic and pharmacological interventions, participants received IRT over a span of 3 weeks in 4 small group sessions. Included were education about sleep and nightmares, instruction in writing new dream narratives and practicing guided imagery, and support via further consultation and trouble-shooting. Patients were referred by their psychiatrist or were self-referred, with approval from their treatment teams. Results: Results showed significant aggregate reductions in nightmare frequency and intensity, as well as improvement in sleep overall. Patients also improved on a variety of other symptom measures, including suicidal ideation. No adverse reactions were observed. The present report includes a sampling of individual case vignettes to illustrate variability in treatment response. Conclusions: This study provides preliminary evidence that IRT can be used safely and effectively in a hospital environment to benefit patients suffering from serious mental illnesses, often in the midst of significant life crises. It is not possible in this preliminary study to conclude that IRT specifically (as opposed to other aspects of hospital treatment) produced these outcomes. Larger, controlled trials are needed to establish a causal connection between IRT and nightmare reduction.

STEVEN TAYLOR (Ed.) Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-behavioral Perspectives New York: Springer, 2004, 336 pages (ISBN 0-8261-2047-4, US$48.95 Hardcover) To paraphrase Steven Taylor, the editor, in his Preface, this collection of articles on PTSD intends to present reader-practitioners with a stand-alone source of descriptions of the state of the art in PTSD research and treatment. The text was expanded from a issue produced for the Journal of Cognitive Psychotherapy, entitled Current Directions in the Treatment of Posttraumatic Stress Disorder - which might have been a more apt title to retain, as this volume gives a very laudable overview of PTSD treatment from a cognitive-behavioural perspective, but, leaves many unanswered research questions regarding advances in treatment. In this regard, the text could be considered necessary but not sufficient, perhaps reflecting the state of affairs in PTSD research investigations as a whole. The list of noteworthy contributors (33 in total) includes many names well recognized in PTSD circles, with a definite American slant (e.g., the majority of the authors, approximately 82%, are American, along with two Canadians, two Australians and two from the United Kingdom to provide International representation). While this edited volume covers many state of the art CBT approaches in Part I and Part II, ranging from Exposure and EMDR to Cognitive Restructuring and Social Support, its unique and outstanding contribution is in Part III, which is dedicated to Special Populations with PTSD, specifically, Military Populations, those with predominant Anger, Chronic Pain, Dissociation, and Children and Adolescents. This may, in fact, be the first book to single out such special groups and begin to address their particular problems in PTSD treatment. New treatment approaches, such as Imagery Rehearsal Therapy (IRT) for posttraumatic nightmares, and Kubany's Cognitive for Trauma Related Guilt present intriguing possibilities. Again, the research literature is, as yet, limited. Treatment for anger amongst PTSD groups is a complex task, and the contributing authors in this section have rigorously compared Prolonged Exposure, Stress Inoculation Training, and combination interventions to determine the efficacy of CBT in anger reduction. Much of the data (in many of the chapters) are drawn from populations experiencing PTSD as a result of rape, domestic violence, abuse, and motor vehicle accidents. The generalizability of these positive CBT results and treatment applications to other special needs groups, such as survivors of large-scale natural catastrophes, is questionable and requires further investigation, beyond the scope of this volume. The chapter discussing PTSD and dissociation evolves as a theoretical and conceptual review of dissociation, with both encouragement and cautions for the use of Exposure with this particular population. For example, as the effectiveness of exposure therapy is thought to depend on the degree of emotional engagement with the previously avoided traumatic memories, the tendency for the client to dissociate in order to reduce anxiety when exposed to overwhelming stimuli may impede progress. The importance of a thorough clinical assessment of both capacity for dissociation and risk of self-harm prior to beginning exposure treatment is emphasized. Specific strategies are detailed, to help dissociative clients deal with flashbacks (grounding techniques; emphasis on safety and breathing), emotional numbing, and extreme anxiety or panic reactions during exposure treatment vital considerations for the scientist-practitioner. Perhaps the most-detailed treatment protocols are contained in the chapter on Treating PTSD in the Context of Chronic Pain. …

Veterans with combat-related post-traumatic stress disorder (PTSD) experience high rates of chronic nightmares that contribute to emotional distress and sleep disturbance. This chapter presents Imagery Rehearsal Therapy (IRT), which has emerged as the leading non-pharmacologic treatment for nightmares, with a particular focus on its application to combat-related PTSD. The history and growth of IRT over the past 25 years is discussed. Hypothesized mechanisms of IRT are presented as they relate to the assumption that chronic nightmares are a learned behavior symptomatic of a malfunctioning imagery system. Elements of IRT are described, including treatment components (dream rescripting, imagery practice, homework, and self-monitoring), indications/contraindications for treatment, and treatment obstacles (avoidance, adherence, adverse effects). Additionally, treatment modifications consisting of IRT protocol variants, the application of IRT to special populations, and issues related to treatment duration, delivery, and format are discussed. The empirical support for IRT is reviewed, followed by indications for future research. Despite limited research examining the efficacy of IRT in veterans with combat-related PTSD, IRT has demonstrated good success across multiple settings and diverse populations. It is an inexpensive, flexible, short-term intervention that holds promise for ameliorating nightmares and related distress in combat veterans.

Interest in the treatment of nightmares has greatly increased over the last several years as research has demonstrated the clinical significance of nightmare disorder. This paper provides an overview of nightmare disorder, its clinical relevance, and the leading treatments that are available. In particular, the paper defines nightmare disorder and then summarize the recent literature examining the clinical relevance of nightmare disorder, including its relation to post-traumatic stress disorder and other psychiatric conditions. The relation between nightmares and suicidality is also discussed. Recent findings on the treatment of nightmare with imagery rehearsal therapy and prazosin are then summarized. Lastly, the paper comments on potential future uses of nightmare treatment including using imagery rehearsal therapy or prazosin as a first-line intervention for post-traumatic stress disorder and using these treatments as an adjunctive therapy to reduce suicide risk in those at risk of suicide with nightmares.

Effectiveness of Imagery Rehearsal Therapy for the Treatment of Combat-Related Nightmares in Veterans

Comparative efficacy of imagery rehearsal therapy and prazosin in the treatment of trauma-related nightmares in adults: A meta-analysis of randomized controlled trials

Lucid dreams occur when a person becomes aware that he or she is dreaming while still in the dream state. Previous reports on the use of lucid dreaming in the treatment of nightmares do not contain adequate baseline data, follow-up data, or both. A treatment of recurrent nightmares incorporating progressive muscle relaxation, guided imagery, and lucid dream induction is presented for 2 case studies. Three other cases were treated with lucid dream induction alone. The duration of the nightmares ranged from once every few days to once every few months. The procedures were effective in all 5 cases. A 1-year follow-up showed that 4 of the subjects no longer had nightmares and that 1 subject experienced a decrease in the intensity and frequency of her nightmares. The alleviation of recurrent nightmares in these 5 cases parallels the results reported by other authors who have used training in lucid dreaming to treat nightmares. Our results support the idea that treatments based on lucid dream induction can be of therapeutic value. Based on these and other case studies, it remains unclear whether the principal factor responsible for the alleviation of nightmares is lucidity itself, or the ability to alter some aspect of the dream.

Nightmares are associated with psychopathology and daily distress. They are highly prevalent in a psychiatric population (30%). Currently, imagery rehearsal therapy (IRT) is the treatment of choice for nightmares. With IRT, the script of the nightmare is changed into a new dream, which is imagined during the day. However, the effects of IRT in a psychiatric population remain unknown. The aim of this study was to determine the effectiveness of IRT in a heterogeneous psychiatric population. Between January 2006 and July 2010, 90 patients with psychiatric disorders (DSM-IV-TR) were randomized to IRT or treatment-as-usual conditions. IRT consisted of 6 individual sessions added to the treatment as usual. Nightmare frequency was assessed using daily nightmare logs and the Nightmare Frequency Questionnaire. Nightmare distress was assessed using the Nightmare Distress Questionnaire and the Nightmare Effects Survey. General psychiatric symptoms were assessed using the Symptom Checklist-90 and a PTSD symptom questionnaire. Assessments were administered at the start of the trial, after the IRT and at follow-up 3 months later. IRT showed a moderate effect (Cohen d = 0.5-0.7, P < .05) on nightmare frequency, nightmare distress, and psychopathology measures compared with treatment as usual. These effects were largely sustained at the 3-month follow-up (Cohen d = 0.4-0.6, P < .10). IRT is an effective treatment for nightmares among patients with comorbid psychiatric disorders and can be employed in addition to the on-going treatment. ClinicalTrials.gov identifier: NCT00291031.