F. Imagery Rehearsal Therapy (IRT)

BACKGROUND

Occurrence of nightmare as a problem is frequent; 4 to 8 percent in the general population and 60 percent in PTSD. Evidence shows that nightmares are associated with psychological distress and sleep impairment. A conditioning pattern similar to classic psychophysiological insomnia is produced in the nightmare disturbed loop, along with the negative cognition of “fear of going to sleep.” Studies using brief CBT (desensitization and imagery rehearsal) have demonstrated large reduction in nightmares. Many studies, including Forbes et al. (2001), suggest that PTSD is associated with a propensity toward image, particularly where the posttraumatic symptom picture is characterized by nightmares and flashbacks. IRT incorporates a system to increase the imagery control.

IRT is aimed at changing the content of the patient’s nightmare to promote mastery over the content-threat, thereby altering the meaning, importance, and orientation to the nightmare. The key to successful treatment is the use of imagery. IRT focuses on the following main approaches:

• Deemphasizes exposure by avoiding discussion of trauma or traumatic content of nightmares
• Focuses on habitual components of disturbing dreams and sleeplessness
• Provides no group psychotherapy
• Offers minimal instruction for dealing with unpleasant imagery
• Emphasizes relaxation
• Conveys no specific non-sleep-related instructions for managing posttraumatic stress, anxiety, or depressive symptoms

DISCUSSION

Krakow and colleagues have conducted a number of studies involving IRT and PTSD, to include the following:

Krakow et al., (2001a) studied crime victims with nightmares, insomnia, and PTSD, who averaged thirteen years of chronicity. They demonstrated moderate to large improvement in their symptoms and psychiatric distress after receiving cognitive therapy treatment approaches. The authors found that targeted treatment of sleep problems was associated with improvement in distress.

Over 4 years (1995-1999) 168 women in New Mexico were studied; 95 percent had moderate-to-severe PTSD, 97 percent had experienced rape or other sexual assault, 77 percent reported life-threatening sexual assault, and 58 percent reported repeated exposure to sexual abuse in childhood or adolescence. Participants were randomized to receive treatment (n = 88) or to the wait-list control group (n = 80). Outcome measures included questionnaires that rated sleep quality, frequency of nightmares, and severity of PTSD symptoms at 3- and 6-month follow-up. A total of 114 participants completed follow-up at 3 and/or 6 months. Comparing baseline to follow-up, treatment significantly reduced nights per week with nightmares and number of nightmares per week and improved sleep and PTSD symptoms. Control participants showed small, nonsignificant improvements for the same measures. An intent-to-treat analysis (n = 168) confirmed significant differences between treatment and control groups for nightmares, sleep, and PTSD with moderate effect sizes for treatment and small effect sizes for controls. The authors concluded that IRT is a brief, well-tolerated treatment that appears to decrease chronic nightmares, improve sleep quality, and decrease PTSD symptom severity.

DSM-IV-TR suggests that nightmares occurring with another psychiatric disorder are not a distinctly treatable condition and its remission occurs only through treatment of the primary disorder, such as anxiety disorder, and PTSD.

Krakow et al. (1995) studied 58 chronic nightmare sufferers who were randomly assigned to a treatment group (n = 39) or a wait-list control group (n = 19). Subjects in the treatment group were taught imagery rehearsal. The subjects were assessed pre-treatment and at 3 months follow-up for nightmare frequency, self-rated distress and subjective sleep quality. Compared to the control group, the treatment group showed significant and clinically meaningful decreases in nightmares. Significant improvement in self-rated sleep quality occurred in those treated compared with controls (P = 0.004); and, reduction in nightmares was a significant predictor of improvement in sleep (r = 0.55, P = 0.0001). The authors concluded that, for some chronic sufferers, nightmares may be conceptualized as a primary sleep disorder which can be effectively and inexpensively treated with CBT.

Krakow and colleagues (2001b) studied IRT for the treatment of chronic nightmares in a sample of adolescent girls (treatment group: n = 9; control group: n = 10). These girls had previously suffered a high prevalence of unwanted sexual experiences in childhood and adolescence, and thus many suffered from nightmares, sleep complaints, and posttraumatic stress symptoms. IRT was provided in a 1-day (6-h) workshop. Imagery rehearsal consisted of three steps, all of which are performed in the waking state: (a) select a nightmare, (b) "change the nightmare any way you wish," and (c) rehearse the images of the new version ("new dream") 5 to 20 min each day. The control group participants received no intervention. At baseline, these girls had been suffering from nightmares, on average, for 4.5 years, and they reported experiencing 20 nightmares per month, which occurred at a frequency of at least one bad dream every other night. At 3 months, self-reported, retrospectively assessed nightmare frequency measured in nights per month decreased 57 percent (p =.01, d = 1.4) and measured in nightmares per month decreased 71 percent (p =.01, d = 1.7) in the treatment group, compared with no significant changes in the control group. No significant changes were noted for sleep and PTSD measures in either group. The authors concluded that IRT was an effective treatment option for chronic nightmares in this adjudicated adolescent population.

Forbes et al. (2001) did a follow-up study to asses the efficacy of imagery rehearsal in reducing the frequency and intensity of targeted combat-related nightmares in a group of Vietnam veterans with PTSD. Veterans were specifically instructed to write down their nightmare and subsequently read it aloud to the group. Three treatment groups, comprising 4 veterans in each, completed standardized treatment across 6 sessions. Treatment effects were investigated using nightmare diaries and established instruments. The data demonstrate significant reductions in nightmares targeted, and improvements in PTSD and comorbid symptomatology. The authors recommended that, on the basis of the promising preliminary data, a RCT be established to assess imagery ability and attitude toward nightmares.