Free AccessLetters to the EditorLong-term effects of treatment for chronic nightmares: is imagery rehearsal therapy robust in the COVID-19 pandemic? Caroline Sierro, MSc, Wendy Leslie, MSc, MBA, Benjamin Putois, PhD Caroline Sierro, MSc Swiss Distance Learning University, Brig, Switzerland Search for more papers by this author , Wendy Leslie, MSc, MBA Clinical Health Psychology, University of Ulster, Ulster, United Kingdom Search for more papers by this author , Benjamin Putois, PhD Swiss Distance Learning University, Brig, Switzerland Lyon Neuroscience Research Center, CNRS UMR 5292, INSERM U1028, Lyon 1 University, France Search for more papers by this author Published Online:November 15, 2020https://doi.org/10.5664/jcsm.8742Cited by:2SectionsAbstractPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutABSTRACTCitation: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.INTRODUCTIONNightmare frequency increases with exposure to stress. In her May 2020 article, “Spontaneous reporting of onset of disturbing dreams and nightmares related to early life traumatic experiences during the COVID-19 pandemic by patients with posttraumatic stress disorder in remission,” Gupta1 found that 80% of patients reported nightmares linked to traumatic memories and not coronavirus disease 2019 (COVID-19) during spontaneous phone calls. Using standardized assessments to rule out bias, we investigated whether COVID-19 increased the prevalence of bad dreams in patients with chronic nightmares in remission.In January–February 2020, we assessed the long-term effects of Imagery Rehearsal Therapy (IRT).2 Just before the French lockdown (17th March), 29 of 48 patients completed 4-year follow-up questionnaires. To measure the effect of lockdown on nightmares and estimate IRT robustness, 23 of these patients completed these questionnaires2 again at the end of lockdown (May). According to dream methodology recommendations,3 2 patients were excluded having changed their antidepressant dosages and 1 because a traumatic event unrelated to COVID-19 occurred during lockdown. Our observations of 20 patients (3 men; average age, 39.5 years) with chronic nightmares 4 years post-IRT, with Wilcoxon matched-pairs tests, were presented thereafter.Before IRT, the mean nightmare frequency per month was 28.8 (SD = 20). After IRT, it remained stable: 8.9 (SD = 8.9) post-IRT, 6.25 (SD = 10.6) at the 4-year follow-up. We confirm Gupta’s results1 that the lockdown period increased nightmare frequency: 19.35 (SD = 32) (Nightmare Frequency Questionnaire: t = 22.0, P = .003); 13/20 (65%) reported increased nightmare frequency and 7/20 (35%) reported no lockdown effect. Only two reported more nightmares during lockdown than pre-IRT (without these two non-responders, nightmare frequency during lockdown was 9.5, SD = 10). The lockdown also deteriorated sleep (Pittsburgh Sleep Quality Index: t = 2.46, P < .05). A significant reduction in PTSD symptoms during IRT continued over 4 years (Posttraumatic Stress Disorder Checklist Scale, t = 20.5, P = .008). No lockdown effect was observed for other traumatic symptoms, generalized self-efficacy, or depression/anxiety.During lockdown, nightmare content was variable: 85% featured worries, 75% conflict, 60% helplessness, 40% assault or failure, 20% illness, 10% lockdown, and 5% COVID-19. This result confirms that nightmares are not “exact replay” dreams representing actual events. Only 30% dreamed about their original trauma. During such crises, increased nightmare frequency could be interpreted not only as reactivation of traumatic memories but also as an increased need for emotional regulation.4For treatment responders (n = 18), 4 years after IRT, nightmare frequency was 9 times lower than pretreatment, and the COVID-19 pandemic tripled this frequency, which nevertheless remained 3 times lower than pre-IRT. IRT therefore seems robust to the effects of stress (no renewal effect) and time (no spontaneous recovery).5DISCLOSURE STATEMENTAll authors have seen and approved the manuscript. The authors report no conflicts of interestREFERENCES1. Gupta MA. Spontaneous reporting of onset of disturbing dreams and nightmares related to early life traumatic experiences during the COVID-19 pandemic by patients with posttraumatic stress disorder in remission. J Clin Sleep Med. 2020;16(8):1419–1420. https://doi.org/10.5664/jcsm.8562 LinkGoogle Scholar2. Putois B, Peter-Derex L, Leslie W, Braboszcz C, El-Hage W, Bastuji H. Internet-based intervention for posttraumatic stress disorder: using remote imagery rehearsal therapy to treat nightmares. Psychother Psychosom. 2019;88(5):315–316. https://doi.org/10.1159/000501105 CrossrefGoogle Scholar3. Putois B, Leslie W, Asfeld C, Sierro C, Higgins S, Ruby P. Methodological recommendations to control for factors influencing dream and nightmare recall in clinical and experimental studies of dreaming. Front Neurol. 2020;11:724. CrossrefGoogle Scholar4. Nielsen T, Levin R. Nightmares: a new neurocognitive model. Sleep Med Rev. 2007;11(4):295–310. https://doi.org/10.1016/j.smrv.2007.03.004 CrossrefGoogle Scholar5. Monfils M-H, Cowansage KK, Klann E, LeDoux JE. Extinction-reconsolidation boundaries: key to persistent attenuation of fear memories. Science. 2009;324(5929):951–955. https://doi.org/10.1126/science.1167975 CrossrefGoogle Scholar Previous article Next article FiguresReferencesRelatedDetailsCited by Dreaming in Adolescents During the COVID-19 Health Crisis: Survey Among a Sample of European School StudentsGuerrero-Gomez A, Nöthen-Garunja I, Schredl M, Homberg A, Vulcan M, Brusić A, Bonizzi C and Iannaco C Frontiers in Psychology, 10.3389/fpsyg.2021.652627, Vol. 12, Nightmare recurrence in patients with post-traumatic stress disorder is likely a primary feature of central sympathetic nervous activationGupta M Journal of Clinical Sleep Medicine, Vol. 16, No. 11, (1995-1995), Online publication date: 15-Nov-2020. Volume 16 • Issue 11 • November 15, 2020ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationJuly 20, 2020Submitted in final revised formAugust 3, 2020Accepted for publicationAugust 3, 2020Published onlineNovember 15, 2020 Information© 2020 American Academy of Sleep MedicinePDF download