Context Chronic nightmares occur frequently in patients with posttraumatic stress
disorder (PTSD) but are not usually a primary target of treatment.
Objective To determine if treating chronic nightmares with imagery rehearsal therapy
(IRT) reduces the frequency of disturbing dreams, improves sleep quality,
and decreases PTSD symptom severity.
Design, Setting, and Participants Randomized controlled trial conducted from 1995 to 1999 among 168 women
in New Mexico; 95% had moderate-to-severe PTSD, 97% had experienced rape or
other sexual assault, 77% reported life-threatening sexual assault, and 58%
reported repeated exposure to sexual abuse in childhood or adolescence.
Intervention Participants were randomized to receive treatment (n = 88) or to the
wait-list control group (n = 80). The treatment group received IRT in 3 sessions;
controls received no additional intervention, but continued any ongoing treatment.
Main Outcome Measures Scores on the Nightmare Frequency Questionnaire (NFQ), Pittsburgh Sleep
Quality Index (PSQI), PTSD Symptom Scale (PSS), and Clinician-Administered
PTSD Scale (CAPS) at 3- and 6-month follow-up.
Results A total of 114 participants completed follow-up at 3 and/or 6 months.
Comparing baseline to follow-up (n = 97-114), treatment significantly reduced
nights per week with nightmares (Cohen d = 1.24; P<.001) and number of nightmares per week (Cohen d = 0.85; P<.001) on the NFQ
and improved sleep (on the PSQI, Cohen d = 0.67; P<.001) and PTSD symptoms (on the PSS, Cohen d = 1.00; P<.001 and on the CAPS, Cohen d = 1.53; P<.001). Control
participants showed small, nonsignificant improvements for the same measures
(mean Cohen d = 0.21). In a 3-point analysis (n =
66-77), improvements occurred in the treatment group at 3-month follow-up
(treatment vs control group, Cohen d = 1.15 vs 0.07
for nights per week with nightmares; 0.95 vs −0.06 for nightmares per
week; 0.77 vs 0.31 on the PSQI, and 1.06 vs 0.31 on the PSS) and were sustained
without further intervention or contact between 3 and 6 months. An intent-to-treat
analysis (n = 168) confirmed significant differences between treatment and
control groups for nightmares, sleep, and PTSD (all P<.02)
with moderate effect sizes for treatment (mean Cohen d
= 0.60) and small effect sizes for controls (mean Cohen d = 0.14). Posttraumatic stress symptoms decreased by at least 1 level
of clinical severity in 65% of the treatment group compared with symptoms
worsening or not changing in 69% of controls (χ21
= 12.80; P<.001).
Conclusions Imagery rehearsal therapy is a brief, well-tolerated
treatment that appears to decrease chronic nightmares, improve sleep
quality, and decrease PTSD symptom severity.
Nielsen and Zadra1 recently estimated
that "4 to 8% of the general population have a ‘current problem' with
nightmares." Frequent nightmares are also reported in depression,2 schizophrenia-spectrum disorders,3
and in posttraumatic stress disorder (PTSD) where a prevalence of 60% has
been documented.4 Paradoxically, The International Classification of Sleep Disorders5
lists a prevalence of "perhaps 1%," whereas the Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(DSM-IV-TR) mentions that at least 3% of young adults report frequent
nightmares, but concludes that "actual prevalence of Nightmare Disorder is
unknown."6 These disparities in prevalence
estimates occur because nightmare epidemiological research usually surveys
disturbing dream frequency without inquiring about comorbid conditions,7-9 whereas the DSM-IV-TR states that nightmares occurring with another psychiatric
disorder precludes a nightmare disorder diagnosis.6
This latter and prevailing view of disturbing dreams holds that nightmares
are secondary to another disorder, such as anxiety or PTSD.5,6,10
While this view has nosological support, it suggests that nightmares are not
a distinctly treatable condition and that remission occurs only through treatment
of the primary disorder. For example, if nightmares were attributed to posttraumatic
stress, it seems logical to focus treatment efforts on PTSD, which ought to
reduce bad dreams, distress, and impairment.11
In contrast, evidence shows that disturbing dreams are associated with
and sleep impairment.15,16 Moderate-to-large
correlations between nightmares and anxiety, depression, and PTSD have been
Nightmares disrupt sleep, producing conditioning patterns similar to classic
psychophysiological insomnia along with a specific complaint of "fear of going
Prospective treatment studies of brief cognitive-behavioral techniques, including
desensitization and imagery rehearsal, which solely targeted disturbing dreams
in nightmare sufferers without comorbid psychiatric disorders, demonstrated
large reductions in nightmares.18-22
In some studies, decreased nightmares were associated with decreased anxiety20,21 and improvements in sleep.22 In a preliminary report on nightmare treatment in
PTSD patients, disturbing dreams and posttraumatic stress severity decreased
and sleep quality improved with imagery rehearsal therapy (IRT).23
Wile24 reported the first case series
in which an imagery technique was used in the treatment of nightmares. Several
reports have appeared since25; most notably,
Marks26 theorized that rehearsal of nightmares
provides therapeutic benefits through "exposure, abreaction, and mastery,"
but Bishay27 suggested that exposure and abreaction
were secondary to mastery because he observed that changing the storyline
of the disturbing dream was more effective for the patient than rehearsal
of the original dream. Early in our work with nightmare sufferers, we observed
that mastery was pivotal in the resolution of chronic nightmares. Kellner
et al28 raised the issue of whether IRT would
be effective in treating severe, chronic nightmares in patients with comorbid
psychiatric disorders, such as PTSD, particularly rape survivors who frequently
suffer severe nightmare disturbances.4,29
We also speculated that sexual assault survivors might be receptive to IRT
because of its focus on dreams and sleep and its de-emphasis on exposure to
past traumatic events.
We therefore conducted a prospective randomized controlled trial of
IRT in a sample predominantly consisting of sexual assault survivors with
PTSD to assess treatment effects of targeted nightmare therapy on nightmares,
sleep, and posttraumatic stress. We hypothesized that sexual assault survivors
treated with IRT would report fewer nightmares, improved sleep quality, and
decreased distress compared with a wait-list control group.
The study was approved by the University of New Mexico Health Sciences
Center institutional review board. Eligible participants were female sexual
assault survivors, 18 years or older, with self-reported nightmares, insomnia,
and posttraumatic stress symptoms coupled with a criterion A trauma link.6 Women with acute intoxication, withdrawal, or psychosis
were excluded. Participants were recruited from media efforts (35% of sample),
mental health therapists and facilities (36%), rape crisis centers (17%),
and other resources (10%) from 1995 to 1999. After being given a complete
description of the study, participants provided oral and written consent.
Personal interviews and psychometric instruments were offered to 203 potential
participants. At intake, 79% of participants were concurrently receiving psychotherapy
(primarily counseling) and/or psychotropic medications (primarily tricyclic
antidepressants or selective serotonin reuptake inhibitors).
Randomization and Blinding Procedures
To mask treatment assignment, patients mailed back a postcard after
intake to complete entry into the protocol. The postcard's time and date were
logged into a computer and entered into a previously generated list of numbers
that randomly assigned participants to treatment and control groups. All numbers
and group assignments were generated at the start of the protocol. Randomization
of 168 women produced 2 groups: treatment (n = 88) and wait-list control (n
= 80) (χ2 = 0.38, P = .54) (Figure 1). Of 35 women who did not participate,
29 did not complete full intake packets and 6 did not return postcards. Due
to the wait-list design, blinding was not possible for delivery of treatment.
To limit external bias, blinding occurred at 3 points of data collection:
(1) at intake, group assignment had not been established; (2) at 3-month follow-up,
questionnaires were completed through the mail; and (3) at 6-month follow-up,
interviewers were unaware of group status.
Primary outcome measures consisted of 5 variables assessed by self-report
with validated, standardized questionnaires completed at intake and follow-ups.
The Nightmare Frequency Questionnaire (NFQ) assesses "nights with nightmares"
per unit of time (eg, per week, per month) and actual "number of nightmares."
Test-retest reliability produced weighted κ of 0.85 to 0.90, and concurrent
validity was established with a mean correlation coefficient of 0.38 (r = 0.28-0.49) with measures of anxiety, depression, and
PTSD.17 The Pittsburgh Sleep Quality Index
(PSQI) assesses sleep quality and disturbances during the past month based
on 7 component scores for sleep quality, latency, duration, efficiency, disturbance,
medication use, and daytime dysfunction that sum to a global score (range,
0-21).30 The Clinician-Administered PTSD Scale
(CAPS) measures frequency and intensity of PTSD-related symptoms for the preceding
month (range, 0-136).31 The PTSD Symptom Scale
(PSS) measures PTSD symptoms according to Diagnostic and
Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria to evaluate the severity of intrusion,
avoidance, and arousal symptoms and sums these scales for total severity in
the preceding 2-week period (range, 0-51).32
Higher scores reflect greater severity on each measure.
Secondary measures included the following: Nightmare Effects Survey
(NES) (impairment associated with nightmares),23
Nightmare Distress Questionnaire (NDQ) (distress associated with nightmares),33 Pittsburgh Sleep Quality Index-Addendum (PSQI-A)
(PTSD-related sleep symptoms),30 Hamilton Anxiety
and Depression scales,34,35 Sheehan
Disability Inventory (SDI) (daily functioning),36
and the SF-36 (physical and mental health functioning).37
Information was also collected on baseline history of past traumatic events
and baseline and follow-up use of antidepressants, anxiolytic/hypnotics, and
concurrent psychotherapy. The NFQ, PSQI, and PSS measures were administered
at 3 points in the study; all other measures were administered at baseline
and 6-month follow-up.
Treatment consisted of 3 sessions (two 3-hour sessions spaced 1 week
apart with a 1-hour follow-up 3 weeks later) using a cognitive-imagery treatment,23 presented in groups (led primarily by B.K. and a
few by L.C. [which were observed and supervised by B.K.]). The treatment protocol
followed a manual and focused on nightmares within the framework of an imagery
and cognitive restructuring paradigm. Treatment assumptions conveyed to the
patients were as follows: (1) nightmares may be caused by uncontrollable and
traumatic events, yet may serve a beneficial purpose immediately following
trauma by providing information and emotional processing; (2) nightmares persisting
for months may no longer serve useful purposes and may be viewed more pragmatically
as a sleep disorder; (3) nightmares may be successfully controlled by targeting
them as habits or learned behaviors; (4) working with waking imagery influences
nightmares because things thought about during the day are related to things
dreamed about at night; (5) nightmares can be changed into positive, new imagery;
and (6) rehearsing new imagery ("new dream") while awake reduces or eliminates
nightmares, without requiring changes on each and every nightmare. Groups
of 4 to 8 women were formed, and treatment was provided on average every month
to every other month based on recruitment.
In the first session of IRT, participants are encouraged to examine
2 contrasting views of nightmares: nightmares as a function only of traumatic
exposure vs nightmares as a function of both trauma and learned behaviors.
Participants are asked to explore the possibility that although nightmares
may be trauma-induced, they may also be habit-sustained. At the end of the
first session, participants practice pleasant imagery exercises, learn cognitive-behavioral
tools for dealing with unpleasant images that might emerge, and are asked
to practice pleasant imagery. At the second session, imagery practice is discussed
and any difficulties addressed. Then, participants learn how to use IRT on
a single, self-selected nightmare. The participant writes down her disturbing
dream, then per a model devised by Neidhardt et al,21
is instructed to "change the nightmare anyway you wish" and to write down
the changed dream. Afterward, each participant uses imagery to rehearse her
own "new dream" scenario for 10 to 15 minutes. Next, she briefly describes
her old nightmare and how she changed it, both in her written attempt and,
if applicable, during the actual rehearsal process. After this initial exercise,
participants are encouraged to not write down the old nightmare or the changed
version but to establish the process mentally. They are instructed to rehearse
a new dream for at least 5 to 20 minutes per day but never to work on more
than 2 distinct "new dreams" during each week. Descriptions of traumatic experiences
and traumatic content of nightmares are discouraged throughout the program
in a carefully designed attempt to minimize direct exposure. To facilitate
this approach, participants are instructed to work first with a nightmare
of lesser intensity and, if possible, one that does not seem like a "replay"
or a "reenactment" of a trauma. In 3 weeks, the group meets for a 1-hour session
to discuss progress, share experiences, and ask questions about nightmares,
sleep, and PTSD and how IRT might be useful for other symptoms in addition
Treatment and control participants were mailed a follow-up packet of
questionnaires at 3 months and invited to a personal interview at 6 months.
Of the 168 randomized participants, 96 completed 3-month follow-ups by mail,
and 99 completed the 6-month follow-ups in person. In total, 114 individuals
completed at least 1 follow-up, and 77 participants completed both follow-ups.
Most noncompleters were lost to follow-up early in the program, usually within
1 month of randomization. However, 12 completed treatment sessions and then
were lost to follow-up (Figure 1).
Contact with control participants was limited to brief telephone calls and
letters to remind them of future appointments. All participants were asked
to complete a 5-item questionnaire about potential suicidality at baseline
and follow-ups. A few patients reported acute distress and were referred for
crisis intervention. All controls continued any treatment they were already
receiving and were offered treatment at no charge on completion of their 6-month
Ethnicity, marital status, income, and education were each condensed
into 2 categories due to sparse cells. Comparison of baseline data on main
outcome measures for nightmares, sleep, and PTSD and demographics for treatment
vs control groups by completers (at end point: completed either 3- or 6-month
follow-up) and noncompleters were analyzed using analysis of variance (ANOVA)
and χ2test. Although patients were individually randomized,
treatment was conducted in small groups, and therefore effects may have correlated
with group membership; thus, grouping effects on treatment for all main outcome
variables were initially analyzed with random effects regression38
using PROC MIXED in SAS.39 Because no grouping
effects approached significance (all P>.90), repeated
measures ANOVA was the primary analytic procedure reported in this study.
Treatment efficacy analyses assessed the following: (1) end point (n = 97-114,
changes from baseline to end point based on last follow-up, 3 or 6 month,
observation carried-forward analysis); (2) 3 points (n = 66-77, changes from
baseline to 3-month to 6-month follow-up); and, (3) intent-to-treat (n = 168,
changes in baseline to last observation, including baseline, carried-forward
analysis, ie, all randomized individuals).
To test whether moderator variables influenced treatment effects, repeated-measures
ANOVAs were conducted on the main outcome variables using each potential moderator
as an additional between-subjects independent variable in a treatment ×
time × moderator design. The moderators tested were antidepressant use,
anxiolytic/hypnotic use, concurrent psychotherapy, number of potentially life-threatening
sexual assaults ("high magnitude"), or repeated exposure to sexual abuse.
Repeated measures ANOVAs were also conducted on secondary measures between
baseline and 6 months. All tests used the .05 level of significance and effect
sizes were reported as Cohen d, the standardized
Demographic and Clinical Characteristics
A total of 168 participants were randomized into control and treatment
groups and were compared based on follow-up status: control completers (n
= 60), treatment completers (n = 54), control noncompleters (n = 20), and
treatment noncompleters (n = 34). There was no significant difference for
lost to follow-up rates between control and treatment noncompleters (Fisher
exact test, P = .07). No significant baseline differences
were found between groups with the exception of age (P
= .01), whereby control noncompleters were younger than treatment completers
(Table 1). No significant baseline
differences among the 4 groups for main outcome variables were found (Table 2). No significant differences between
groups for concurrent psychotherapy and anxiolytic/hypnotic use at baseline
were detected, but control noncompleters' concurrent use of antidepressants
was significantly less than use by other groups at baseline (P = .03) (Table 3). No
significant differences were found for frequency of traumatic exposures documented
at baseline interviews (Table 3).
Eighty-three percent of participants reported clinically meaningful
posttraumatic stress severity on the CAPS (score ≥65),31
and 95% reported moderate or worse posttraumatic stress severity on the PSS
(score ≥11), all of whom met DSM-III-R diagnostic
criteria for PTSD.32 The remaining 5% (n =
8) experienced mild posttraumatic stress. Nightmare chronicity was not significantly
different between the 2 groups (treatment: mean [SD] of 21.8 [15.3] years
vs control: 19.3 [13.7] years). Ninety percent experienced sexual, physical,
or emotional abuse as children, with sexual abuse the most frequently reported.
Fifty-eight percent reported repeated exposure to sexual abuse for an average
period of 8 years, among whom 72% were 10 years old or younger when this abuse
first occurred. Seventy-seven percent reported high-magnitude sexual assaults
during their lifetime, among whom 48% experienced 2 or more such events. Three
participants who were exposed to violent, nonsexual assaults were retained
in the protocol and analysis because their baseline data were similar to the
sexual assault survivors.
Treatment × time interaction effects were found with a substantial
decrease in nightmares, sleep, and PTSD scores at end point for the treatment
group but only small changes, on average, for the control group (Table 4). Treatment group improvements
were large for nights per week (d = 1.24), nightmares
per week (d = 0.85), PSQI (d
= 0.67), PSS (d = 1.00), and CAPS (d = 1.53). For the main outcome measures, mean treatment d = 1.06. By contrast, control participants showed small nonsignificant
changes in nights (d = 0.20) and nightmares (d = −0.12) per week, PSQI (d
= 0.13), and PSS (d = 0.29), but moderate improvement
for CAPS (d = 0.53, P =
.001). Mean control d = 0.21. Both nightmare frequency
and PTSD symptoms showed a consistent pattern of decreasing clinical severity
levels compared with controls (PTSD scores were based on the Foa40
scoring system for the newer Posttraumatic Stress Diagnostic Scale, which
yields the same total range of 0-51 as the PSS) (Table 5).
To assess maintenance of treatment effect over time, main outcome variables
were analyzed for 77 women who completed baseline, 3-month, and 6-month nightmare
follow-ups. Mean differences across 3 points were statistically significant
for nights per week (F2,150 = 22.79, P<.001)
and nightmares per week (F2,150 = 23.31, P<.001).
For the 73 women who completed both PSQI follow-ups (F2,142 = 3.35, P<.04) and the 66 women who completed both PSS follow-ups
(F2,128 = 7.04, P<.001), mean differences
were statistically significant (Figure 2).
These treatment group improvements occurred during the first 3 months (treatment
vs control group d = 1.15 vs 0.07 for nights per
week, 0.95 vs − 0.06 for nightmares per week, 0.77 vs 0.31 for PSQI,
and 1.06 vs 0.31 for PSS) and were sustained from 3 to 6 months (with no patient
contact during this interval).
The conservative intent-to-treat analysis confirmed significant differences
between treatment and control groups on all 5 main outcome measures for nightmares,
sleep, and PTSD (all P≤.02), but effect sizes
were smaller (mean treatment d = 0.60 vs mean control d = 0.14) compared with end-point and 3-point analyses.
Moderator Variable Effects
At follow-up, there were no significant differences for concurrent use
of psychotherapy or use of anxiolytics/hypnotics or antidepressants between
control and treatment completer groups (Table 3). However, to test for moderator effects on treatment, 3-factor
treatment × time × moderator variable end-point analyses were
conducted on each main outcome measure. Notwithstanding low power for these
analyses, no reliable main or interaction effects were found on outcomes (nights
per week, nightmares per week, PSQI, PSS, and CAPS) for concurrent psychotherapy,
antidepressant use, anxiolytic/hypnotic use, or degree of high-magnitude sexual
assaults, or repeated exposure to sexual abuse prior to the study. These moderators
did not reduce the magnitude of the treatment × time effects. Because
age was significantly different at baseline between groups, it was entered
as a covariate into each end-point analysis for the main outcome variables
and was not statistically significant (all P>.40).
Large improvements for NES (F1,110 = 19.85, P<.001, d = 1.07), NDQ (F1,92
= 18.33, P<.001, d =
1.31), and PSQI-A (F1,109 = 23.75, P<.001, d = 1.15) were found for the treatment group, whereas small
effects were found for the control group (NES, d
= 0.14; NDQ, d = 0.27; PSQI-A, d = 0.21). Moderate improvements were found for depression in both
treatment (d = 0.57) and control (d = 0.33) groups without statistical differences. Anxiety symptoms
improved slightly in the treatment group (d = 0.39)
and worsened in the control group (d = −0.16)
(F1,80 = 183.84, P = .04). Moderate improvements
in the treatment group compared with controls were observed on SDI for social
life/leisure activities (F1,93 = 4.15, P
= .04, d = 0.54 vs d = 0.14)
and in interviewer-rated global disability (F1,93 = 6.45, P = .01, d = 0.48 vs d = −0.11). Quality of life (SF-36) showed no significant changes
for either treatment or control groups.
Imagery rehearsal therapy significantly improved disturbing dreams,
sleep quality, and posttraumatic stress symptoms in sexual assault survivors
presenting with nightmares, insomnia, and posttraumatic stress. Therapeutic
effects occurred at 3 months follow-up and were maintained at 6 months in
comparison with a control group, which showed on average small or no improvement
at either follow-up. End-point and 3-point analyses yielded significant results
with large effect sizes, and intent-to-treat analysis showed moderate effect
sizes. Regardless of participants' concurrent use of medication or psychotherapy,
IRT—a dream- and sleep-oriented treatment—substantially improved
not only nightmares and sleep, but also decreased mean PTSD symptom severity
from moderately severe to moderate levels. All symptom subscales for PTSD
intrusion, avoidance, and arousal decreased as well. To our knowledge, this
is the first randomized controlled study demonstrating that improvement in
PTSD symptoms with a nightmare-focused intervention is both substantial and
sustained at 6 months follow-up; these changes in posttraumatic stress were
comparable to a recent PTSD treatment study using sertraline.41
Mechanisms for these treatment effects may be understood through several
perspectives. In a sleep model, nightmares, which may be a natural response
to trauma, nonetheless function like insomnia by triggering difficulties in
falling or staying asleep; nightmare sufferers carry an added burden of "fear
of sleep."16 Thus, nightmares and insomnia
are inextricably linked in many PTSD patients, and successful treatment of
nightmares ought to improve sleep and sleep-related effects on distress. Perhaps
by decreasing bad dreams and improving sleep quality, PTSD patients improve
daytime energy, which facilitates coping with other distress symptoms. In
this model, sleep problems in PTSD are not merely a secondary manifestation.
Instead, sleep functions as a vulnerable psychophysiological system that suffers
primary damage through traumatic exposure. Subsequently, if the sleep system
were repaired through whatever means, it might facilitate, enhance, or maximize
therapeutic outcomes. Further evidence of sleep problems in PTSD is emerging;
high rates of medical sleep disorders, such as sleep-disordered breathing,
have recently been described in PTSD samples,42-45
and treatment of sleep-disordered breathing with continuous positive airway
pressure breathing masks in a small number of PTSD patients has been associated
with decreased nightmares, insomnia, and posttraumatic stress symptoms.46,47
In a cognitive-behavioral model, nightmares are noxious conditioned
stimuli triggering a conditioned response, ie, waking up from the bad dream
to avoid unpleasant emotions. Arousal from the dream reinforces the belief
that the only way to diminish the stimuli is to not sleep. The schema of an
unsafe sleep environment develops and is maintained by the view that nightmares
are a fixed and somehow necessary reminder of traumatic experiences, thus
arousal remains essential to protecting oneself in the bedroom. Imagery rehearsal
therapy is a reciprocal inhibitor to the original nightmare, providing a cognitive
shift that empirically refutes the alleged "purpose" of the nightmare.
In a mastery model—another variation of cognitive-behavioral therapy—IRT
impresses on patients that they can control their nightmares. In fact, many
reported that altering nightmares gave them a sense of control that carried
over to wake time activities. Almost 50% of treatment completers reported
using imagery for other problems beyond nightmares. One participant used IRT
to give herself "more positive images, because [she has] a tendency to think
negatively," and another wrote she gained a "feeling of control over [daytime]
moods" and uses IRT to "correct negative or obsessive thoughts." A mastery
framework is also offered at one point in the first treatment session to help
patients distinguish between "suffering from nightmares" and "being a nightmare
sufferer." This distinction has proven important because most individuals
whom we treated reported the duration of their problem for more than a decade;
unsuccessfully attempted various therapies, at least indirectly, to ameliorate
their bad dreams; and had acquired a belief that nightmares were a fixed,
deeply rooted problem that could not be remedied. In short, a "nightmare sufferer
identity" seems to have developed in these women, such that on entry into
the program, it was almost unimaginable that nightmares could be alleviated
within a few months' time. In our view, the mastery aspects of IRT are at
the heart of the patient's ability to shed the "nightmare sufferer identity"
because, clinically, success appeared to evolve among those who adopted 3
key elements of the protocol: nightmares are not inextricably linked to past
trauma; nightmares can be treated as if they were a learned behavior; and
nightmares can be controlled by working on them while awake. For some patients,
it was the rapid resolution of nightmares that prompted acceptance of these
elements, which further enhanced their mastery of the nightmare disorder.
A recent consensus statement concluded that selective serotonin reuptake
inhibitors and exposure therapy are first-line therapies for PTSD.48 Exposure therapy, however, intimidates some patients.49 Anecdotally, when patients start exposure treatment
with desensitization procedures but do not finish, they may worsen their PTSD
by reinforcing avoidance behavior. Psychotropic medications may also produce
adverse effects in PTSD patients who then discontinue therapy.41
Imagery rehearsal therapy produces imagery adverse effects; 4 patients reported
increased negative imagery and eventually withdrew, and 12 of 66 who completed
treatment did not complete follow-up for unknown reasons. Notwithstanding,
this cognitive-imagery approach deemphasizes exposure and discourages discussion
of trauma-related experiences. Its primary focus is to help people sleep better
by teaching them how to eliminate disturbing dreams. Given the large treatment
outcomes, apparent minimal adverse effects, and brevity, physicians and therapists
might choose IRT as a first-line treatment regimen for PTSD patients who are
distressed by their nightmares. This treatment approach also may be suitable
for PTSD cases that are resistant, refractory, or otherwise averse to exposure
or medication. Posttraumatic stress disorder treatment studies comparing IRT,
exposure therapy, and psychotropic medications are needed to examine differences
between these regimens as well as their potential therapeutic synergy.
Two important limitations in this study were (1) the lack of a placebo
control, which may have led to spuriously high effect sizes due to nonspecific
therapist effects50; and (2) relatively large
dropout rates for 3- and or 6-month follow-ups. Neither of these limiting
aspects of design and follow-up can be overcome, but it can be mentioned that
these noncompletion rates were not dissimilar to other research protocols
for sexual assault survivors,29 as well as
other traumatized populations,41 and the intent-to-treat
analysis confirmed the reliability of the results albeit with moderate rather
than large effect sizes. Last, treatment group noncompleters appeared to have
slightly worse nightmares, sleep disturbance, and PTSD at baseline; therefore,
individuals with worse distress may have greater aversion to this therapy.
Among current health care options, persons with chronic nightmares and
PTSD who are seeking treatment for posttraumatic stress symptoms might be
offered singly or in combination 1 of 3 reasonably effective therapeutic approaches:
(1) abreaction-catharsis through psychodynamic psychotherapy51;
(2) exposure therapy48,49; or
(3) psychotropic medication.41,48,49
In addition, IRT directly targeting disturbing dreams appears to be another
useful therapeutic option for sexual assault survivors with chronic nightmares
Nielsen TA, Zadra A. Dreaming disorders in principles and practices in sleep medicine. In: Kryger MH, Roth T, Dement WC, eds. Principles
and Practices of Sleep Medicine. 3rd ed. Philadelphia, Pa: WB Saunders;
Cartwright R, Young MA, Mercer P, Bears M. Role of REM sleep and dream variables in prediction of remission from
depression. Psychiatry Res.1998;80:249-255.Google Scholar
Kilpatrick DG, Resnick HS, Freedy JR.
et al. Posttraumatic stress disorder field trial: evaluation of the PTSD construct-criteria
A through E. In: Widiger TA, Frances AJ, eds. DSM-IV Sourcebook. Washington, DC: American Psychiatric Press; 1998:803-846.
American Academy of Sleep Medicine. The International Classification of Sleep Disorders. Rochester, Minn: Allen Press Inc; 1997:162-165.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
Klink M, Quan SF. Prevalence of reported sleep disturbances in a general adult population
and their relationship to obstructive airways diseases. Chest.1987;91:540-546.Google Scholar
Bliwise DL. Historical change in the report of daytime fatigue. Sleep.1996;19:462-464.Google Scholar
Bixler EO, Kales A, Soldatos CR, Kales JD, Healey S. Prevalence of sleep disorders in the Los Angeles metropolitan area. Am J Psychiatry.1979;136:1257-1262.Google Scholar
Mack J. Nightmares and Human Conflict. Boston, Mass: Houghton Mifflin; 1974.
Lansky M. Post Traumatic Nightmares: Psychodynamic Explorations. Hillsdale, NJ: The Analytic Press; 1995.
Haynes SN, Mooney DK. Nightmares: etiological, theoretical and behavioral treatment considerations. Psychol Rec.1975;25:225-236.Google Scholar
Berquier A, Ashton R. Characteristics of the frequent nightmare sufferer. J Abnorm Psychol.1992;101:246-250.Google Scholar
Zadra A, Dondri DC. Nightmares and bad dreams: their prevalence and relationship to well-being. J Abnorm Psychol.2000;109:273-281.Google Scholar
Kales A, Soldatos CR, Caldwell AB.
et al. Nightmares: clinical characteristics and personality patterns. Am J Psychiatry.1980;137:1197-1201.Google Scholar
Krakow B, Tandberg D, Scriggins L.
et al. A controlled comparison of self-rated sleep complaints in acute and
chronic nightmares sufferers. J Nerv Ment Dis.1995;183:623-627.Google Scholar
Krakow B, Schrader R, Tandberg D.
et al. Nightmare frequency in sexual assault survivors with PTSD. J Anxiety Disord.In press.Google Scholar
Cellucci AJ, Lawrence PS. The efficacy of systematic desensitization in reducing nightmares. J Behav Ther Exp Psychiatry.1978;9:109-114.Google Scholar
Miller WR, DiPilato M. Treatment of nightmares via relaxation and desensitization: a controlled
evaluation. J Consult Clin Psychol.1983;51:870-877.Google Scholar
Kellner R, Neidhardt EJ, Krakow BJ, Pathak D. Changes in chronic nightmares after one session of desensitization
or rehearsal of instructions. Am J Psychiatry.1992;149:659-663.Google Scholar
Neidhardt EJ, Krakow BJ, Kellner R, Pathak D. The beneficial effects of one treatment session and recording of nightmares
on chronic nightmare sufferers. Sleep.1992;15:470-473.Google Scholar
Krakow BJ, Kellner R, Pathak D, Lambert L. Imagery rehearsal treatment for chronic nightmares. Behav Res Ther.1995;33:837-843.Google Scholar
Krakow BJ, Hollifield M, Schrader R.
et al. A controlled study of imagery rehearsal for chronic nightmares in sexual
assault survivors with PTSD: a preliminary report. J Trauma Stress.2000;13:589-609.Google Scholar
Wile IS. Auto-suggested dream as a factor in therapy. Am J Orthopsychiatry.1934;4:449-463.Google Scholar
Halliday G. Direct psychological therapies for nightmares: a review. Clin Psychol Rev.1987;7:501-523.Google Scholar
Marks I. Rehearsal relief of a nightmare. Br J Psychiatry.1978;133:461-465.Google Scholar
Bishay N. Therapeutic manipulation of nightmares and the management of neuroses. Br J Psychiatry.1985;147:67-70.Google Scholar
Kellner R, Singh G, Irogoyen-Rascon F. Rehearsal in the treatment of recurring nightmares, I: posttraumatic
stress disorders and panic disorder: case histories. Ann Clin Psychiatry.1991;3:67-71.Google Scholar
Rothbaum BO, Foa EB, Riggs DS, Murdock T, Walsh W. A prospective examination of post-traumatic stress disorder in rape
victims. J Trauma Stress.1992;5:455-475.Google Scholar
Buysse D, Reynolds C, Monk T, Berman S, Kupfer D. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric
practice and research. Psychiatry Res.1989;28:193-213.Google Scholar
Blake D, Weathers F, Nagy L.
et al. Clinician-Administered PTSD Scale (CAPS). Boston, Mass: National Center for Posttraumatic Stress Disorder;
Foa E, Riggs D, Dancu C, Rothbaum B. Reliability and validity of a brief instrument for assessing post-traumatic
stress disorder. J Trauma Stress.1993;6:459-473.Google Scholar
Belicki K, Chambers E, Ogilvie R. Sleep quality and nightmares. Sleep Res.1997;26:637.Google Scholar
Hamilton M. Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol.1967;6:278-296.Google Scholar
Hamilton M. Diagnosis and rating of anxiety. Br J Psychiatry.1969;(special publication):76-79.Google Scholar
Sheehan DV. The Anxiety Disease. New York, NY: Scribner; 1983.
Ware JE, Koskinski M, Keller SD. SF 36 Physical and Mental Health Summary Scales:
A User's Manual. Boston, Mass: The Health Institute; 1994.
Hedeker D, Gibbons RD, Flay BR. Random regression models for clustered data: with an example from smoking
prevention research. J Consult Clin Psychol.1994;62:757-765.Google Scholar
SAS Institute Inc. SAS/STAT Software: Changes and Enhancements Through
Release 6.12. Cary, NC: SAS Institute Inc; 1997:571-701.
Foa EB. Posttraumatic Stress Diagnostic Scale Manual. Minneapolis, Minn: National Computer Systems; 1995:46.
Brady K, Pearlstein T, Asnis G.
et al. Efficacy and safety of sertraline treatment of posttraumatic stress
disorder: a randomized control trial. JAMA.2000;283:1837-1844.Google Scholar
Krakow B, Germain A, Tandberg D.
et al. Sleep breathing and sleep movement disorders masquerading as insomnia
in sexual assault survivors with PTSD. Compr Psychiatry.2000;41:49-56.Google Scholar
Krakow B, Artar A, Warner TD.
et al. Sleep disorder, depression, and suicidality in female sexual assault
survivors. Crisis.2000;21:163-170.Google Scholar
Krakow B, Melendrez D, Pedersen B.
et al. Complex insomnia: insomnia and sleep-disordered breathing in a consecutive
series of crime victims with nightmares and PTSD. Biol Psychiatry.2001;49:948-953.Google Scholar
Krakow B, Germain A, Tandberg D.
et al. The relationship of sleep quality and posttraumatic stress to potential
sleep disorders in sexual assault survivors with nightmares, insomnia and
PTSD. J Trauma Stress.In press.Google Scholar
Youakim JM, Doghramji K, Schutte SL. Posttraumatic stress disorder and obstructive sleep apnea syndrome. Psychosomatics.1998;39:168-171.Google Scholar
Krakow BJ, Lowry C, Germain A.
et al. A retrospective study on improvements in nightmares and posttraumatic
stress disorder following treatment for co-morbid sleep-disordered breathing. J Psychosom Res.2000;49:291-298.Google Scholar
Ballenger JC, Davidson JR, Lecrubier Y.
et al. Consensus statement on posttraumatic stress disorder from the International
Consensus on Depression and Anxiety. J Clin Psychiatry.2000;61(suppl 5):60-66.Google Scholar
Foa EB, Keane TM, Friedman MJ. Guidelines for treatment of PTSD. J Trauma Stress.2000;13:539-555.Google Scholar
Krakow B, Hollifield M, Warner TD. Placebo effect in posttraumatic stress disorders. JAMA.2000;284:563-564.Google Scholar
Moscarello R. Posttraumatic stress disorder after sexual assault: its psychodynamics
and treatment. J Am Acad Psychoanal.1991;19:235-253.Google Scholar