Imagery rehearsal treatment of chronic nightmares in PTSD: a controlled study

Imagery rehearsal treatment of chronic nightmares in PTSD: a controlled study

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KRAKOW B, TANDBERG D, CUTCHEN L, MCBRIDE L, HOLLIFIELD M, LAURIELLO J, SCHRADER R, YAU CL, CHENG DT.

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Sleep Research 1997; 26: 245. UNM Sleep Research, University of New Mexico School of Medicine

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Abstract:

Introduction: Nightmares are a frequently observed symptom in post-traumatic stress disorder (PTSD) and, in many cases of PTSD disturbing dreams represent the major intrusive element. Yet, direct treatment of nightmares in PTSD has gone largely unexplored. Our previous controlled studies on the treatment of chronic nightmares in patients without PTSD have shown that simple cognitive behavioral methods, such as imagery rehearsal and desensitization, can markedly reduce or eliminate nightmares. The additional findings that nightmare reduction consistently leads to improved sleep and decreases in daytime distress suggests the possibility that nightmares, for some patients, represent an independent sleep disorder that may function through a process of "learned behaviors" similar to that seen in psychophysiological insomnia. Accordingly, we have been curious to evaluate the use of imagery rehearsal in the treatment of chronic nightmares in a PTSD population. Preliminary uncontrolled results have been encouraging. Now we present the first controlled evaluation with a three month follow-up.

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Methods: The study was approved by the Human Research and Review Committee. Participants with a trauma history of sexual assault were recruited from Albuquerque, NM and surrounding areas. Participants are randomized into early and late treatment groups (wait-list controls) with baseline evaluation and follow-up at three and six months. Waitlist controls receive treatment six months after intake. Baseline and follow-up interviews focus on three core areas: nightmares, sleep disturbances and PTSD, using three retrospective instruments: Nightmare Frequency Questionnaire (NFQ), Pittsburgh Sleep Quality Index (PSQI) and the PTSD Symptom Scale (PSS).Treatment consists of two three-hour group sessions, the first focusing on the relationship between nightmares and psychophysiological insomnia. In the second session, participants learn imagery rehearsal, a three-step process of Selecting a nightmare, Changing the nightmare and Rehearsing the "new dream" (new images of the changed version). The technique is practiced daily in the waking state. Baseline and three month follow-up data were analyzed for experimental and control groups using paired (within-subjects) and two-sample (between-subjects), or nonparametric tests.

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The findings indicate a pronounced treatment effect. Nightmare frequency (as measured in two ways) was reduced 58% for nights/month and 69% for nightmares/month in the treatment group with no change in the controls. PSQI total scores (a measure of global sleep quality) showed significant decreases in both controls and treated subjects with no differences between groups. We speculate that this improvement occurred because sleep logs were used by both groups for a two week period after baseline intake interviews. PTSD scores decreased significantly only in the treated group (for which it is noted that the sample size is smaller). Anecdotally, many of the women in this study have expressed the view that the use of the imagery rehearsal treatment on nightmares has precipitated dramatic improvements in sleep quality and PTSD symptoms PTSD along with the marked reduction in disturbing dreams.

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Conclusion: These preliminary results support the use of a brief imagery rehearsal technique in the direct treatment of chronic nightmares in female sexual assault survivors with PTSD.

Supported from a grant by NIMH, RO1-MH532391 Ross et al, American Journal of Psychiatry 146(6): 697-707, 19892 Krakow et al, Behaviour, Research and Therapy 33(7): 837-843, 1995

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