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Imagery Rehearsal Therapy: Principles and Practice
Abstract
A significant proportion of individuals having been exposed to a traumatic event will experience trauma-related nightmares and approximately 5% to 8% of the general population also report problems with nightmares. Chronic nightmares may represent a primary sleep disorder rather than a symptom of a psychiatric disorder, and direct targeting of nightmares is a feasible clinical approach to the problem. Many treatments for nightmares have been proposed, but there is much empirical support for cognitive-behavioral interventions such as imagery rehearsal therapy (IRT). This article details key components of IRT typically covered in 4 successive weekly therapy sessions and their underlying rationale. Particular attention is given to the importance of developing flexible applications based on variations in patients' needs and clinical history.
... If nightmares start to occur regularly and disrupt sleep patterns, individuals might be diagnosed with a nightmare disorder (American Academy of Sleep Medicine, 2014;American Psychiatric Association, 2013). Diagnostic definitions of nightmares are similar in the diagnostic and statistical manual of mental disorders (DSM) and the International Classification of Sleep Disorders (ICD; Krakow & Zadra, 2010). Nightmares are characterized as recurrent awakenings wherein an individual has had "extremely dysphoric" imagery manifesting in their dreamsusually related to "threats to survival, safety or physical integrity" (American Psychiatric Association, 2013, p. 404 On nightmare occurrences, the DSM-5 suggests that, On awakening, nightmares are well remembered and can be described in detail. ...
... As mentioned previously, not all nightmares are connected to the traumatic experiences of individuals Yücel et al., 2020). However, clinical populations of individuals exhibiting symptoms of PTSD are reported to have high prevalence of nightmares, as do individuals exposed to diverse traumatic experiences (American Psychiatric Association, 2013;Krakow & Zadra, 2010). It follows that nightmares are seen to be a hallmark of posttraumatic stress disorder by some (Campbell & Germain, 2016;Ross et al., 1989). ...
... Further, IRT involves only mild exposure to trauma-induced imagery (Schoenfeld et al., 2012) and affords clients the opportunity to create a scenario in which these nightmares have a more positive outcome (Augedal et al., 2013;Aurora et al., 2010;Schoenfeld et al., 2012;Seda et al., 2015). Krakow and Zadra (2010) propose a four-session model for IRT, wherein, ...
Background: Imagery rehearsal therapy (IRT) is a form of cognitive behavioral therapy wherein clients revise, rescript, and rehearse their nightmares to gain mastery over these narratives, feel less distress about these narratives, and reduce their frequency. Individuals who experience posttraumatic stress symptoms (PTSS) as a result of trauma exposure are highly likely to experience nightmares. The current review aims to synthesize the findings of randomized controlled trials (RCTs) examining the effects of IRT on PTSS including but not limited to nightmare frequency, severity, distress, and loss of sleep. Method: For the purposes of this review, we only focused on RCTs that have clearly specified their treatment as IRT. Similar treatments that have different components and different names were not included. We used four databases (Cochrane CENTRAL, EMBASE, PubMed, Web of Science) to find RCTs fitting our population–intervention–comparison–outcome criteria (n = 4). Outcome: IRT was associated with a decline in nightmare distress, frequency, disruptive nighttime behaviors, and PTSS, not consistently across studies. Further attention should be directed to examine IRT, a treatment under the imagery rehearsal treatment umbrella, as a sole treatment.
... La thérapie par répétition d'imagerie mentale (RIM), ou Imagery rehearsal therapy (IRT) en anglais, est le seul traitement faisant l'objet de recommandations de grade A par l'American Association of Sleep Medicine (AASM) et ayant démontré le plus haut niveau d'efficacité dans le traitement des cauchemars liés à un TSPT ainsi que pour les cauchemars idiopathiques [3,4,6,7]. En effet, il a été démontré que la RIM produisait une réduction significative de la détresse éprouvée par le patient suite à ses cauchemars ainsi que de l'intensité de ses symptômes posttraumatiques [8,9]. Il a été démontré que cette réduction de la détresse ainsi que de la fréquence des cauchemars dans la maladie des cauchemars étaient similaires à celles obtenues par d'autres méthodes de traitement des cauchemars comme la thérapie d'exposition ou l'imagerie positive simple (sans réécriture) pour diverses caractéristiques du troubles et diverses populations [10]. ...
... Il ne semble pas à ce jour y avoir de contre-indications à l'orientation vers une thérapie par RIM si le patient souffre de ses cauchemars et souhaite en travailler le scénario [11]. Toutefois, il peut être pertinent d'évaluer la capacité d'imagerie et d'accès à l'imagination du patient avant de l'orienter vers ce traitement afin de décider si un soutien ou entraînement particulier à cette pratique ne serait pas pertinent en amont [9]. ...
... Cette thérapie s'articule autour de : • l'éducation thérapeutique du patient concernant les cauchemars et ses intrications avec le sommeil et les rythmes veille/sommeil (Education thérapeutique sur la physiologie du sommeil, des rythmes veille/sommeil, et des rêves, présentation d'un modèle etiopathogénique expliquant la transition du cauchemar d'un phénomène aigu vers un trouble chronique) ; • la restructuration cognitive à l'aide du concept d'imagerie mentale positive (information des patients que l'imagerie mentale fait partie de l'activité mentale habituelle et constitue souvent la dernière activité mentale consciente avant l'endormissement, introduction de la théorie de la continuité : l'imagerie mentale en journée est probablement liée à l'imagerie mentale pendant le sommeil et inversement, donc plus on s'imagine des scénarios positifs, plus les rêves seront agréables) ; • de la pratique d'imagerie mentale positive en journée, puis de son application dans le traitement des cauchemars, avec la reconstruction d'un scénario de cauchemars en scénario positif [3,9,12]. ...
Résumé
Les cauchemars chroniques ont un impact majeur sur la santé mentale et le risque suicidaire. Ils présentent une prévalence élevée dans les populations psychiatriques, notamment chez les patients souffrants d’un trouble de stress post-traumatique (TSPT) et également chez les patients atteints de troubles de l’humeur (trouble dépressif unipolaire et troubles bipolaire) ou de schizophrénie. La thérapie par répétition d’imagerie mentale (ou RIM) est considérée à ce jour comme le traitement de référence de la maladie des cauchemars. À l’aide d’éducation thérapeutique et de restructuration cognitive, la RIM consiste à retravailler le scénario des cauchemars en journée, en usant d’imagerie mentale, afin de les modifier la nuit. Cette courte revue propose une description de la thérapie par répétition d’imagerie mentale ainsi qu’un résumé des éléments fondamentaux pour sa mise en place pratique, en s’appuyant notamment sur un exemple concret de mise en place d’un groupe thérapeutique pour le traitement des cauchemars par RIM en 4 brèves séances.
... The patient and the provider processed its themes and motifs and the provider praised the patient's courage and commitment to treatment. After sufficiently processing her target nightmare, the provider outlined a worksheet with an overview of IRT treatment, depicted in Table 3. Extensive, adjunctive psychoeducation focused on explaining the treatment's two-component therapeutic processes, (a) its educational/cognitive restructuring component to help the patient consider her nightmare as a learned sleep disorder and (b) an imagery education/training element to teach her about the nature of human imagery, as well as to appreciate the connections between daytime imagery and dreams (Krakow & Zadra, 2010). Other important elements of this largely psychoeducational session focused on clarifying how nightmares promote insomnia and the potential function of nightmares for emotional adaptation to emotionally traumatic events (Krakow & Zadra, 2010;Levin & Nielsen, 2007). ...
... After sufficiently processing her target nightmare, the provider outlined a worksheet with an overview of IRT treatment, depicted in Table 3. Extensive, adjunctive psychoeducation focused on explaining the treatment's two-component therapeutic processes, (a) its educational/cognitive restructuring component to help the patient consider her nightmare as a learned sleep disorder and (b) an imagery education/training element to teach her about the nature of human imagery, as well as to appreciate the connections between daytime imagery and dreams (Krakow & Zadra, 2010). Other important elements of this largely psychoeducational session focused on clarifying how nightmares promote insomnia and the potential function of nightmares for emotional adaptation to emotionally traumatic events (Krakow & Zadra, 2010;Levin & Nielsen, 2007). The patient denied any questions or concerns about the treatment and, in the provider's estimation, appeared ready and motivated to continue with treatment. ...
... The patient elected to rescript her dream to include magical and realistic modifications (Krakow & Zadra, 2010). With her script requiring no changes, the patient proceeded into Steps 6 and 7 of the IRT treatment, rehearsing the new dream (and not the nightmare) at night before practicing relaxation techniques for homework. ...
Imagery rehearsal therapy (IRT) is an evidence-based treatment for nightmare disorder (ND), and numerous studies have demonstrated its efficacy in reducing the frequency and severity of nightmares. ND and REM sleep behavior disorder (RBD) co-occur, yet the impact of successful treatment of nightmares on dream enactment in RBD has not been studied. In this case study, we present the treatment of ND using IRT and its impact on dream enactment in the context of RBD. A total of 5 sessions of IRT over 5 months resulted in a reduction in nightmares and, according to the patient and her husband, a decrease in dream enactment. We hypothesize that reducing the emotional valence of the dream content may make dream enactment less likely. As a result, IRT may provide helpful adjuvant treatment to pharmacological treatment of RBD.
... However, the conservative estimate would be that at least 3% of the elite athletes in Switzerland experience nightmares once per week or more often. As this frequency might mark the presence of a nightmare disorder (Schredl, 2023), it would be very interesting to conduct further studies regarding the question of whether athletes might benefit from nightmare treatment, for example, Imagery Rehearsal Therapy (Krakow & Zadra, 2010). On the other hand, the response rate of 44.28% should have no or only minor effects on the inter-relationships between nightmare frequency and the various predictors as the variance of the scales is not restricted, that is, the whole range, for example, from no nightmares to frequent nightmares is found in the present sample. ...
... This is especially valid as nightmares are often associated with poor sleep quality (Delage et al., 2024) and might be partly responsible for the relative high percentage of athletes with sleep problems (Charest & Grandner, 2022). It would be very interesting to carry out invention studies with athletes suffering from frequent nightmares, for example, using Imagery Rehearsal Therapy (Krakow & Zadra, 2010), as such interventions might even improve their performance. ...
Nightmares, defined as extremely dysphoric dreams, can cause significant distress in everyday life if they occur frequently. Their aetiology is based on a disposition‐stress model. As elite athletes often experience high stress levels, the present study investigated factors that might be associated with nightmare frequency in a large cohort of 2297 Swiss elite athletes (1066 women, 1231 men) with a mean age of 22.05 ± 7.53 years. In total, about 6% of the athletes reported frequent nightmares (once a week or more often). We found that well‐established factors like female gender and general stress levels were related to nightmare frequency. To a smaller extent, the number of training hours, lost training days due to illness, and having early training sessions were also associated with nightmare frequency. Sport discipline was not related to nightmare frequency. An unexpected finding was the association between late alcohol intake 4 hr prior to bedtime and nightmare frequency. Our findings support the idea that stress related to practicing sports might affect nightmare frequency. Future research should study whether inventions designed for athletes suffering from frequent nightmares are beneficial for them and might even improve their athletic performance.
... Moreover, it has been established that individuals who are high in absorption and imaginative involvement are less able to improve in their respective therapies for OCD, depression, and anxiety (e.g., Spitzer et al., 2007). Possibly, imagination-based interventions such as guided imagery or imagery rescripting/rehearsal (Arntz, 2012;Edwards, 2007;Krakow & Zadra, 2010;Smucker, 2005), or similarly, hypnotic memory restructuring (Gravitz, 1994), might prove to benefit them more than a purely verbal cognitive intervention. Indeed, it has been shown that imagery rescripting is useful in OCD, but knowledge is lacking regarding moderating factors that may interfere with, or facilitate, this efficacy (Strachan et al., 2020). ...
... Notably, imagery rescripting itself not only utilizes the client's imaginative abilities, but also empowers clients' sense of agency and control as they create their own novel, positive imagery. Various authors have underscored the importance that the imagery modification be the client's personal (agentive) creation (e.g., Krakow & Zadra, 2010;Smucker, 2005). In conclusion, clinicians should ask patients not only about the thoughts that come to their mind, but also about the images that do so. ...
Some conceptualizations of dreaming have focused on the visual image-to-verbal thought direction of causality, inspired by bottom-up models of perception. However, dreams are more like imagination than perception, with agentic dream thoughts affecting subsequent nonagentic dream images as well. Thus, oneiric experiences are made up of reciprocal, continuous, moment-to-moment influences between the dream and the dreamer: visual images and verbal, abstract, or otherwise imageless thoughts. A dreamlike cognitive dynamic of everchanging image-thought-image meaningful momentary associations coupled with reduced agentic control of images may be present in waking to a greater or lesser extent. Individual differences in fantasy proneness, suggestibility, dissociative absorption, or imagination tendencies may reflect this type of cognitive processing. In other words, for some individuals, non-agentic visual images may be a significant driving force in their spontaneous mental activity. This carries implications for the field of spontaneous thought. Off-task thinking, or
mind-wandering, are labels that may be used to denote internally generated mentation, but more specificity is needed; Considering the tendency for dreamlike associations may represent one important distinction, which may be relevant for understanding psychopathology. Whereas some individuals may find themselves distracted by abstract, semantic, or otherwise image-less associations (e.g., abstract worries or verbal self-derogatory inner speech, as commonly occurs in depression), others may find themselves drawn to intrusive—or alluring—visual images, that interact significantly with their verbal thoughts and associations, and may be experienced with decreased sense of agency. This may occur in obsessive-compulsive disorder, dissociative disorders, or maladaptive daydreaming, suggesting that clinicians need to pay attention to their clients’ spontaneous visual imagery.
... Phelps and colleagues concluded that, although the quality of evidence was weak, CBT-I was a promising intervention, 41 and they endorsed the use of CBT-I in conjunction with other psychotherapies targeting PTSD nightmares, such as imagery rehearsal therapy (IRT), which aims to rescript recurring nightmares to decrease the correlated distress. 42 Te REA provided little discussion of the shortcomings of CBT-I in addressing Veteran needs and recommended a more detailed evaluation of the efectiveness of the intervention and its individual components. ...
... Te fndings of this review support the conclusion of Phelps and colleagues that CBT-I is best supported in conjunction with a PTSD-specifc psychological treatment, 41 such as IRT or prolonged exposure. 42,53 Te inconsistent efectiveness of CBT-I demonstrated in the evidence base reviewed may be the product of a rigid reliance on targeting a psychiatric construct over an empirically supported psychological formulation of insomnia presentations among Veterans. Such oversight questions the appropriateness of clinical recommendations for a treatment that seemingly solves only half the problem. ...
LAY SUMMARY
Cognitive-behavioural therapy for insomnia (CBT-I) continues to be recommended as the first-line treatment for an increasing number of Veterans seeking help for insomnia. Unfortunately, these recommendations are made on the basis of evidence from the general public, who do not experience the same predisposing, activating, and maintaining causes of insomnia as Veterans. This review considers whether CBT-I really addresses the causes of insomnia among Veterans, which can be labelled as functional (e.g., caffeine use) and traumatic (e.g., nightmares). Nine randomized controlled trials of CBT-I delivered to Veterans having trouble falling or staying asleep were reviewed. Evidence was not consistent enough to support the continued recommendation of CBT-I as a first-line treatment for insomnia among Veterans. On a wider level, the authors question whether psychological causes of a mental health problem are always, or should be, fully considered in the process of creating clinical guidelines for treatment.
... The first component in stage 1 is educational and the second component contains imagery in stage 2 and 3 (see figure 2). Traumafocused exposure is sought minimized (Krakow & Zadra, 2010) containing only one element of exposure which is recounting and re-scripting nightmares (Hagenaars & Arntz, 2012). There is a lack of knowledge about the mechanisms of change in IRT (Kunze et al., 2017;Rousseau & Belleville, 2018). ...
... The IRT manual was developed based on the IRT principles outlined by Krakow & Zadra (2010) for groups. The manual was adapted to the needs of the refugee patients to be administered individually during weekly sessions. ...
Psychotherapy for nightmares and sleep disturbances in refugees suffering from post-traumatic stress disorder (PTSD) is an unexamined area. This case study examines efficacy, acceptability, and patient experiences with Imagery Rehearsal Therapy (IRT) in 8 refugees with Middle Eastern background and PTSD-related nightmares. The aims of the study were to examine: A. if changes before and after IRT can be detected on measures of sleep quality, PTSD, level of functioning, and quality of life, B. if IRT is acceptable to refugees with PTSD-related nightmares, and C. patients’ individual and shared experiences through the three stages of IRT including changes in nightmare frequency on a sleep log. Qualitative (open questions) and quantitative methods (sleep-log, structured measures, drop-out, cancellation-, and no-show rates) were applied in order to create a thick description of the patients’ experiences throughout their IRT treatment process. Despite relatively high drop-out, cancellations and no-show rates; findings indicate that IRT is acceptable for the patients included in this study. Furthermore, a reduction in nightmare frequency, improvement in sleep quality and daytime functioning was indicated for most patients. IRT seems to be a good non-trauma-focused alternative to trauma-focused therapy for trauma-affected refugees and might also be used as an add on to standard trauma-focused treatment.
... In particular, we believe that a better understanding of the development of nightmares during pregnancy may help in providing timely and effective interventions when necessary. This would involve the application of various evidence-based treatments for nightmares, such as Imagery Rehearsal Therapy (IRT) 64 Exposure, Relaxation, and Rescripting Therapy (ERRT), 65 and Cognitive Behavioral Therapy for Nightmares (CBT-N). 66 Based on our findings and the several methodological limitations outlined, we believe that further effort should be made in the research on pregnancy to better understand the relationship between dreaming and women's health. ...
Purpose
This study investigated dream characteristics in women during the first trimester of pregnancy compared to a group of non-pregnant women, aiming to identify variables associated with the observed differences.
Participants and Method
A sample of 100 pregnant women in their first trimester was compared to a control group of 100 age-matched non-pregnant women. Participants completed online questionnaires to assess dream activity, sleep quality, depressive symptoms, and sociodemographic variables.
Results
Controlling for socio-demographic variables, statistical comparisons revealed that pregnant women reported fewer nightmares and showed less interest in their dream activity compared to non-pregnant women. Ordinal logistic regression revealed that being in the control group, greater attention to dreams, the presence of depressive symptoms, and a higher frequency of lucid dreaming were significant predictors of more frequent nightmares. Moderation analysis showed no significant interaction between pregnancy status and dream attitude.
Conclusion
Contrary to expectations, first-trimester pregnant women had fewer nightmares than non-pregnant women. However, the results are coherent with the finding that parasomnia-like events decrease during pregnancy. The rapid hormonal changes and specific sleep and emotional features of this stage of gestation may explain the lower presence of nightmares as compared to our control group. Moreover, we confirmed a crucial role of dream attitude in recalling nightmares, suggesting that some stable, trait-like features may contribute to nightmare experiences independently of pregnancy status. Our results also confirmed, according to the Continuity hypothesis, that depressive symptoms are associated with nightmares. Also, the presence of lucid dreaming in association with nightmares may be interpreted as an attempt to cope with unpleasant emotions. Longitudinal studies are needed to examine how dream activity evolves across pregnancy stages.
... Based on this, the therapist selected strategies to work with each patient according to the following components: sleep consolidation (also known as sleep restriction), stimulus control, cognitive restructuring, sleep hygiene, relaxation techniques. For patients with nightmare disorder, the therapist conducted Imagery Rehearsal Therapy (Krakow & Zadra, 2010). ...
In Mexico, pervasive violence, forced disappearances, and homicides have deeply impacted certain groups, particularly journalists, activists, and human rights defenders, who are at high risk of victimization. While these groups receive state support for physical and legal safety, mental health and sleep-focused interventions remain insufficient. Collaborating with a Mexico City-based institution supporting human rights defenders and journalists, we conducted a psychometric assessment of 47 individuals affected by violence. Results showed that 80% exhibited symptoms of post-traumatic stress disorder, 25.5% showed depression, and 57.4% displayed anxiety; 95.7% reported poor sleep quality based on the Pittsburgh Sleep Quality Index. In a second phase, neuropsychological tests and polysomnographic recordings identified cognitive impairments in attention, memory, and decision-making in some participants, along with sleep disorders such as insomnia, primary snoring, obstructive sleep apnea, and bruxism. A third phase introduced Cognitive Behavioral Therapy for insomnia, nightmares, and circadian rhythm issues. Results showed improvements in sleep quality, total sleep time, and a reduction in depression, anxiety, and post-traumatic stress disorder symptoms. This approach suggests that treating sleep issues in high-risk populations can improve mental health.
... Studies suggest that cognitive behavioral therapy for insomnia (CBTi); cognitive behavioral therapy (CBT) for PTSD; and exposure, relaxation, and rescripting therapy (ERRT) for nightmares are effective treatments for insomnia, nightmares, and other trauma symptoms [13][14][15][16][17][18]. CBTi includes stimulus control, sleep hygiene, sleep restriction, cognitive restructuring, and relaxation training [19,20]. Nightmare treatment using ERRT is effective in giving those who experience nightmares a sense of control over the nightmare through writing benign dreams that can be rehearsed verbally or mentally [21]. ...
BACKGROUND
Symptoms of insomnia, nightmares, and trauma are highly prevalent. However, there are significant barriers to accessing evidence-based treatments for these conditions, leading to poor mental health outcomes.
OBJECTIVE
This pilot trial evaluated the feasibility of a 4-week, digital self-paced intervention combining cognitive behavioral therapy for insomnia and exposure, relaxation, and rescripting therapy for nightmares in survivors of wildfires from Australia, Canada, and the United States.
METHODS
Study participants were recruited between May 2023 and December 2023 through social media platforms, workshops, conferences, and radio interviews. Participants had to meet at least one of the following criteria: a score of ≥8 on the Insomnia Severity Index, a score of ≥3 on the Nightmare Disorder Index, or a score of ≥31 on the PTSD Checklist for DSM-5. In total, 30 survivors of wildfires were allocated to either the treatment group (n=16, 53%) or the waitlist control group (n=14, 47%) in a sequential manner. Participants’ ages ranged from 18 to 79 years, with a mean age of 52.50 (SD 16.26) years. The cohort consisted of 63% (19/30) female and 37% (11/30) male participants. Participants also completed self-report secondary outcome measures, including the Generalized Anxiety Disorder–7, the Patient Health Questionnaire–9, and the Pittsburgh Sleep Quality Index, via the HealthZone digital platform. Assessments were conducted at baseline, the posttreatment time point, and the 3-month follow-up, with the waitlist group undergoing an additional assessment at the pretreatment time point, after 4 weeks of waiting and before crossing over to treatment. This study used intention-to-treat analysis as a primary analysis and per-protocol analysis as a secondary analysis.
RESULTS
Mixed-effects linear regression models and difference-in-differences analyses were used to assess the intervention’s effects. The intention-to-treat analysis revealed significant improvements over time (main effect of time), with a 1.64-point reduction ( P =.001) on the Nightmare Disorder Index and 10.64-point reduction ( P =.009) on the PTSD Checklist for DSM-5 at the postintervention time point. No significant changes were observed in insomnia symptoms. On the secondary measures, there was an interaction effect of condition × time, with a 2.22-point reduction ( P <.001) on the Pittsburgh Sleep Quality Index, and a main effect of time, with a 6.48-point reduction ( P <.001) on the Patient Health Questionnaire–9. No changes were detected on the Generalized Anxiety Disorder–7. The per-protocol analysis yielded comparable results for both the primary and secondary measures.
CONCLUSIONS
The findings of this pilot trial demonstrated a reduction in nightmares and trauma symptoms. Future research studies should aim at evaluating the intervention in a more definitive trial with a larger sample size.
CLINICALTRIAL
Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12623000415606; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385054
... The leading TRNs treatments are rescripting-based therapies, such as Imagery Rehearsal Therapy (IRT) and Exposure, Relaxation, and Rescripting Therapy (ERRT). Rescripting therapies focus primarily on behavioral sleep practices (such as sleep hygiene and stimulus control) and nightmare rescription (the process of rewriting a nightmare into a changed version of the dream and then reading/rehearsing this new version throughout the day and prior to falling asleep) [3]. Rescripting-based therapies have produced positive results, with some studies showing significant reductions in nightmare distress and frequency following treatment completion [4]. ...
This preliminary study investigates the potential for a technique that enables purposeful guiding of dream content (Targeted Dream Incubation; TDI) to change the degree to which an individual feels in control of their dreams (Dream Self-Efficacy; DSE). DSE is a subset of a larger concept of self-efficacy relating to one’s belief in their own abilities and competencies. Examining DSE may be quite important, as past research has demonstrated that DSE may be linked to positive treatment outcomes in specific therapies, such as interventions for trauma-related nightmares. Furthermore, prior research has found that decreasing feelings of helplessness related to sleep has been shown to improve insomnia symptoms and daytime fatigue. Thus, our study sought to examine the relationship between TDI and DSE. We enrolled N = 25 participants in a TDI protocol conducted during a predominantly N1 sleep nap, where participants completed surveys before and after a TDI paradigm. Our results revealed that TDI was linked to DSE, with individuals reporting significantly higher levels of DSE after the TDI protocol. These results provide preliminary evidence for a technique (TDI) that could increase DSE with the overall aim of improving the efficacy of specific sleep-related interventions, such as treatments for trauma-related nightmares. Future research should aim to further confirm these results with a control condition and examine the effects of TDI within the context of behavioral sleep interventions.
... Optional module 5 helps participants negotiate sleep in complicated environments (e.g., noise from bed/roommates, traffic noise, streetlight entering the bedroom). Optional module 6 is for participants who experience nightmares [99]. Optional module 7 is for participants who wish to taper from sleep medications [100]. ...
Background
Poor memory for treatment is associated with poorer treatment adherence and poorer patient outcomes. The memory support intervention (MSI) was developed to improve patient memory for treatment with the goal of improving patient outcomes. The aim of this study protocol is to conduct a confirmatory efficacy trial to test whether a new, streamlined, and potent version of the MSI improves outcomes for midlife and older adults. This streamlined MSI is comprised of constructive memory supports that will be applied to a broader range of treatment content. The platform for this study is the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C). We will focus on midlife and older adults who are low income and experiencing mobility impairments.
Methods
Participants (N = 178) will be randomly allocated to TranS-C + MSI or TranS-C alone. Both intervention arms include eight 50-min weekly sessions. Assessments will be conducted at pre-treatment, post-treatment, 6-, and 12-month follow-up (6FU and 12FU). Aim 1 will compare the effects of TranS-C + MSI versus TranS-C alone on sleep and circadian functioning, daytime functioning, well-being, and patient memory. Aim 2 will test whether patient memory for treatment mediates the relationship between treatment condition and patient outcomes. Aim 3 will evaluate if previously reported poor treatment response subgroups will moderate the relationship between treatment condition and (a) patient memory for treatment and (b) treatment outcome. Exploratory analyses will compare treatment condition on (a) patient adherence, patient-rated treatment credibility, and patient utilization of treatment contents, and (b) provider-rated acceptability, appropriateness, and feasibility.
Discussion
This study has the potential to provide evidence for (a) the efficacy of a new simplified version of the MSI for maintaining health, well-being, and functioning, (b) the wider application of the MSI for midlife and older adults and to the treatment of sleep and circadian problems, and (c) the efficacy of the MSI for sub-groups who are likely to benefit from the intervention.
Trial registration
ClinicalTrials.gov NCT05986604. Registered on 2 August 2023.
... For instance, addressing dream affect can offer quicker access to fears and worries compared to traditional therapies like psychoanalysis, enabling prompt identification and intervention for significant disruptive factors (Goelitz, 2001). Some dream techniques, such as lucid dreaming (see, Zink & Pietrowsky, 2015) or imagery rehearsal therapy for nightmares (see, Krakow & Zadra, 2010), empower patients to work on their dreams independently, reinforcing self-efficacy. ...
Sleep disorders are prevalent among patients with cancer and their caregivers as well, affecting their quality of life. But the relationship between sleep quality, dream experiences, and life satisfaction in patients with cancer and their partners is understudied. The present research aimed to quantitatively investigate the dream experiences of oncology patients and explore the interdependence between patients and their partners in terms of dream experiences and life satisfaction. Therefore, a cross‐sectional study was conducted with 101 dyads, completing a questionnaire assessing demographic and illness‐related data, dream experiences, sleep quality, and life satisfaction. Inferential statistical tests and actor–partner interdependence models were used to analyse the data. Both patients with cancer and their partners reported on average a significant decrease in sleep quality since the cancer diagnosis and for both dyad members significant dreaming predictors for life satisfaction were found. Namely, a positive association for dream stability in patients, and a positive association for positive dream affect as well as a negative association for negative dream affect in partners. Regarding the question of interdependence, dream intensity exhibited a significant group‐specific partner effect, but no overall partner effect, leading to inconclusive results that call for more studies in this field. The study suggests that dreaming may affect life satisfaction beyond sleep quality and underscores the significance of acknowledging dream experiences as potential influencers of quality of life in patients with cancer. Additionally, the study stands out for its examination of the role of partners in dyadic dependency, emphasising the importance of understanding their influence on patients’ experiences.
... Some variations are possible in the practice of this therapy, such as the instructions for rewriting the scenario, individual or group practice, or the number of sessions. Table 2 shows the principle and content of the IRT sessions carried out at our ChronoS psychiatric sleep center in Paris, adapted from the method developed by B. Krakow, R. Kellner, D. Pathak, and L. Lambert [57,58]. A sleep and dream diary is useful to keep track of sessions and assess progress. ...
Purpose of Review
Nightmares, vivid and distressing dreams leading to arousal, can significantly impact sleep and daytime functioning. Nightmare disorder can occur with or without psychiatric disorders and with or without a traumatic event. Effective management of nightmares is crucial not only for nightmare disorder but also to prevent the worsening of psychiatric disorders or complications, such as suicide. This review explores the range of available treatments, encompassing both pharmacological and non-pharmacological, for nightmare disorders and trauma-associated nightmares.
Recent Findings
Different interventions have shown their safety and effectiveness in the therapeutic management of nightmares, such as imagery rehearsal therapy; exposure, relaxation, and rescripting therapy; lucid dreaming therapy; desensitization and exposure therapy; self-exposure therapy; and Prazosin.
Summary
Imagery rehearsal therapy (IRT) stands out with robust evidence supporting its effectiveness in nightmare disorder as well as in trauma-associated nightmares and should be considered as a first-line choice for therapeutic management of nightmares. This psychotherapeutic intervention employs cognitive and behavioral techniques and involves practicing mental imagery during daytime to modify the content of nightmares. This review summarizes the core principles of IRT and presents comprehensive guidelines for clinical practice.
... CBT also deals specifically with nightmares, which frequently manifest anxiety, stress or trauma (Vanek et al. 2021). It uses techniques such as imaginal exposure, dream rescripting or relaxation to reduce the frequency and intensity of nightmares and improve sleep quality (Krakow & Zadra 2010). CBT can also help the client use dreams as a source of motivation, inspiration or creativity (Edwards et al. 2013 The results showed that dream CBT was as effective as pharmacotherapy in reducing the frequency and intensity of nightmares and improving sleep quality. ...
Schema therapy is a therapeutic approach to identifying and changing early maladaptive schemas and schema modes that affect the client's emotions and behaviour. Dreamwork is an approach that helps clients explore and transform their schemas and modes in both dream and waking states and find new ways to cope with their problems and needs. Dreamwork involves collaboration between the client and the therapist, who jointly analyze, interpret and modify the dreams according to the goals of schema therapy. However, dreamwork is also limited, and it is not suitable for every client or dream. This article presents practical guidelines and examples for working with dreams in schema therapy. We first introduce the theoretical background of dreamwork in schema therapy. Then we describe the stages and techniques of dreamwork, such as questioning the dream, identifying schemas and modes, imagery rescripting, mode dialogue, and feedback. We also provide several case studies from our practice illustrating how we applied dreamwork with our clients. We summarize dreamwork's main benefits and challenges in schema therapy and suggest future research and development directions.
... Overall, the present study clearly indicates that there is a gap between adolescents suffering from nightmares and the percentage of adolescents treated for their nightmare condition. In the current study, the students received leaflets explaining the basic principles of imagery rehearsal therapy [11] for display when they present their findings to the school audience. The high percentage of adolescents knowing about lucid dream therapy might be due to popular media, e.g., the movie "Inception [7]"; thus, media and social media might be important outlets in order to inform this age group about possible nightmare treatment options. ...
Research indicates that adults suffering from nightmares rarely seek professional help for their condition. However, nothing is known about the help-seeking behavior in adolescents with frequent nightmares. In a sample of 100 adolescents (50 female, 50 male) with a mean age of 15.30 ± 0.80 years, it was found that none of them ever sought professional help for nightmares, even though 21 participants (15 females, 6 males) reported frequent nightmares (once a week or more often) and/or quite or very distressing nightmares. As nightmares are associated with a variety of mental problems in adolescents and can persist into adulthood, it seems very important to find ways to reduce the number of untreated nightmare sufferers in this age group.
... De-reflection forms one of the central tenets of Viktor Frankl's conception of logotherapy (Krakow and Zadra 2010). De-reflection, which is based on self-transcendence, seeks to redirect one's attention from oneself or one's own goals toward others. ...
Objectives:
Pancreatic cancer is a major site of gastrointestinal tumors and remains a leading cause of cancer death in adults in the United States. There is also a strong association between pancreatic cancer and depression. When struggling with cancer, along the different phases of illness, a human being is confronted with manifold issues, which might profoundly interfere with their sense of meaning and purpose.
Methods:
From this standpoint, several different therapeutic techniques have been designed to manage the psychological needs of the patients. Here we provide 2 clinical scenarios, where there was a strong religious correlation to the therapeutic techniques employed with patients suffering from pancreatic cancer.
Results:
The 2 cases described showed some improvement in their overall life view and could recalibrate their expectations based on a strong religious foundation.
Significance of results:
The role of religion and spirituality in health has also received increasing attention in literature. Religion and spirituality can help patients with cancer find meaning in their illness, provide comfort in the face of existential fears, and receive support from a community of like-minded individuals. In effect, they also provide evidence toward the scope of and integrating the domain of spirituality into holistic cancer care.
... Users can be primed on certain stimulus, and can subsequently use this stimulus to alter their dreams, such as video or music. For example, Krakow and Zadra (2010) find that users who visualize a positive end to a nightmare before initiating sleep tends to resolve nightmares during sleep. ...
The advent of personalized reality has arrived. Rapid development in AR/MR/VR enables users to augment or diminish their perception of the physical world. Robust tooling for digital interface modification enables users to change how their software operates. As digital realities become an increasingly-impactful aspect of human lives, we investigate the design of a system that enables users to manipulate the perception of both their physical realities and digital realities. Users can inspect their view history from either reality, and generate interventions that can be interoperably rendered cross-reality in real-time. Personalized interventions can be generated with mask, text, and model hooks. Collaboration between users scales the availability of interventions. We verify our implementation against our design requirements with cognitive walkthroughs, personas, and scalability tests.
... There are a number of treatments available for nightmares, and of these imagery rehearsal therapy (IRT) has amassed the most evidence (for a complete review of psychological nightmare treatments, see Aurora et al., 2010). IRT involves psychoeducation describing nightmares as a sleep disorder, rescripting the nightmare content in any way the dreamer wishes and rehearsing this during waking hours (Krakow & Zadra, 2010). This practice not only reduces nightmare frequency, but also PTSD symptom severity, sleep problems and general mental health complaints (Krakow et al., 2000(Krakow et al., , 2001. ...
Current theories about the aetiology of nightmares and mechanisms of action that account for their successful treatment have not yet taken the polyvagal theory (Porges, 2011) into consideration. While the polyvagal theory’s updated and multifaceted view of the autonomic nervous system’s (ANS) response to threat has begun to transform the field of trauma treatment, most of these ideas have not yet been applied to nightmares and their treatment. This article outlines how the theory may provide a missing link in understanding specific ways that trauma and adversity lead to chronic nightmares, and it offers a way to make sense of the heterogeneity of trauma-related symptoms and concomitant responses to nightmare treatments. A review of the literature demonstrates evidence of links between measures of ANS and physiological responses to nightmares. Content similarities between threat responses described by polyvagal theory and common nightmare themes provides an additional avenue for assessment and intervention. Theories of nightmare aetiology and treatment are evaluated with respect to polyvagal theory, and lastly, a proposed treatment protocol, nightmare relief, offers a polyvagal-informed, process-experiential approach to treating nightmares, with links to clinical examples.
... Studies suggest that treating sleep disturbances in those with PTSD leads to better outcomes in terms of both improved sleep and also reduced trauma symptoms (Colvonen et al., 2018). Some of the sleep-focused psychological treatments include: (1) cognitive behavioural therapy for insomnia (CBT-I) which encompasses sleep restriction, stimulus control, cognitive component, and sleep hygiene (Morin & Espie, 2007); (2) exposure, relaxation, and rescripting therapy for nightmares (ERRT) which consists of psychoeducation about nightmares, sleep hygiene, muscle relaxation, exposure and rescripting of chronic nightmares (Davis & Wright, 2007); (3) imagery rehearsal therapy (IRT) consists of education about sleep, nightmares, homework of personalized pleasant imagery scenes, rescripting of the nightmare, problem solving and relapse prevention (Krakow & Zadra, 2010). ...
... A strong link between dream emotions and daytime stress levels supports the idea that psychotherapeutic approaches aiming at modulating distressful emotions in dreams could also have an impact in daytime depressive and anxiety symptoms. For example, IRT is a cognitive-behavioral technique, where the nightmare sufferer changes the negative story line, toward a more positive ending, and rehearses the rewritten dream scenario during the day, which ultimately helps to reduce nightmares during sleep (106). This technique can be learned in one session (107) and practiced for 5-10 min per day while awake. ...
Background
Social anxiety disorder (SAD) is characterized by a significant amount of fear when confronted to social situations. Exposure therapy, which is based on fear extinction, does not often lead to full remission. Here, based on evidence showing that rapid eye movement (REM) sleep promotes the consolidation of extinction memory, we used targeted memory reactivation (TMR) during REM sleep to enhance extinction learning in SAD.
Methods
Forty-eight subjects with SAD were randomly assigned to two groups: control or TMR group. All patients had two successive exposure therapy sessions in a virtual reality (VR) environment, where they were asked to give a public talk in front of a virtual jury. At the end of each session, and only in the TMR group (N = 24), a sound was paired to the positive feedback phase of therapy (i.e., approval of their performance), which represented the memory to be strengthened during REM sleep. All participants slept at home with a wearable headband device which automatically identified sleep stages and administered the sound during REM sleep. Participants' anxiety level was assessed using measures of parasympathetic (root mean square of successive differences between normal heartbeats, RMSSD) and sympathetic (non-specific skin conductance responses, ns-SCRs) activity, and subjective measures (Subjective Units of Distress Scale, SUDS), during the preparation phase of their talks before (T1) and after (T2) one full-night's sleep and after 1 week at home (T3). Participants also filled in a dream diary.
Results
We observed an effect of time on subjective measures of anxiety (SUDS). We did not find any difference in the anxiety levels of the two groups after 1 week of TMR at home. Importantly, the longer the total duration of REM sleep and the more stimulations the TMR group had at home, the less anxious (increased RMSSD) these participants were. Finally, fear in dreams correlated positively with ns-SCRs and SUDS at T3 in the TMR group.
Conclusion
TMR during REM sleep did not significantly modulate the beneficial effect of therapy on subjective anxiety. Yet, our results support that REM sleep can contribute to extinction processes and substantiate strong links between emotions in dreams and waking stress levels in these patients.
... Behavioral therapies with rescripting elements such as imagery rehearsal therapy (IRT; Krakow & Zadra, 2006) and exposure relaxation and rescripting therapy (ERRT; are commonly used to treat PNMs. Although IRT was developed with idiopathic nightmares as the primary treatment target (Krakow & Zadra, 2010), ERRT was specifically designed for PNMs . In brief, these treatments use rehearsal or imagery exercises, in which individuals choose a nightmare and construct (i.e., rescript) an altered version of the chosen nightmare that is less distressing (Countryman & Leggett, 2018;. ...
Posttrauma nightmares (PNMs) are initiated by trauma exposure, often include content that resembles the triggering trauma, and are considered a hallmark symptom of posttraumatic stress disorder. Although rescripting therapies are a leading treatment option for PNMs, there are mixed results regarding their effectiveness. One variable that may give us more insight into the relationship between PNMs and rescripting therapies is sleep disordered breathing (SDB), especially when considering SDB may impact nightmare content, frequency, sleep staging, and symptom severity. Thus, given that SDB may influence PNMs, the current study investigated the relationship between SDB, nightmare content, the remembrance of nightmares, and the impact of a nightmare rescripting therapy in a trauma-exposed sample. Although there were no significant differences in nightmare frequency or remembrance among individuals with and without SDB at baseline, the non-SDB group (compared to the probable SDB group) was more likely to report nightmares that were similar to the triggering trauma. Following treatment, the group without SDB symptoms had significantly less nightmares, whereas the probable SDB group showed no significant decrease in nightmare frequency. In conclusion, our results demonstrate that PNMs in the presence of SDB symptoms (complex PNMs) may differ in content than PNMs without comorbid SDB symptoms (isolated PNMs) and that SDB symptoms may interfere with the efficacy of rescripting focused therapies. Future research is needed to determine if there is truly a difference between complex PNMs and isolated PNMs and if types of nightmares (complex and isolated) fare better under different treatment options (continuous positive air pressure vs. rescripting focused therapies).
... When interpreted in the light of the FPT, the integrative model proposed by Rousseau and Belleville (2018) suggests that nightmare-related anticipated events (i.e., the anticipation of experiencing nightmares, of being exposed to nightmare-related cues, or of experiencing consequences from nightmares; variable A in Figure 1) can influence dreaming, sometimes resulting in new nightmares (variable G). This vicious circle might contribute to explain how nightmares tend to take on a life of their own (Krakow & Zadra, 2010). ...
This article presents the feeling priming theory (FPT) of dreaming. According to the FPT, dreaming favors the motivation to avoid aversive anticipated events and to approach gratifying anticipated events. It is suggested that one component of anticipated emotions—anticipated feelings—is reproduced in dreams. Upon awakening and during the day, these anticipated feelings would remain activated (primed) in memory. Consequently, anticipated emotions would exert a greater influence on avoidance and approach behaviors, mainly through an increase in the intensity of anticipatory feelings (i.e., feelings of fear or hope/desire). This article comprises five main sections. First, the need for a new theory of the function of dreaming is addressed. Second, key constructs of the theory are described, including the constructs of “emotion” and “feeling.” Third, a brief overview of the theory is presented. Fourth, seven hypotheses that constitute the core of the theory are discussed along with supporting evidence. Fifth, an explanation of nightmares based on the proposed theory is offered. The FPT represents an alternative to theories that attribute an emotion regulation function to dreaming. It offers a new perspective on the relationship between dreaming and waking emotions. In particular, the FPT does not label nightmares as dysfunctional. Instead, nightmares and other dysphoric dreams are hypothesized to result from the same processes as normal dreaming.
... Dement and Wolpert 130 defined the beginning of studies on dream manipulation in 1958. Subsequently, research has been conducted both during presleep 131,132 and sleep. 133,134 More recently, stimuli were presented in different sleep stages 135 and LDs elicited. ...
The mechanisms involved in the origin of dreams remain one of the great unknowns in science. In the 21st century, studies in the field have focused on 3 main topics: functional networks that underlie dreaming, neural correlates of dream contents, and signal propagation. We review neuroscientific studies about dreaming processes, focusing on their cortical correlations. The involvement of frontoparietal regions in the dream-retrieval process allows us to discuss it in light of the Global Workspace theory of consciousness. However, dreaming in distinct sleep stages maintains relevant differences, suggesting that multiple generators are implicated. Then, given the strong influence of light perception on sleep regulation and the mostly visual content of dreams, we investigate the effect of blindness on the organization of dreams. Blind individuals represent a worthwhile population to clarify the role of perceptual systems in dream generation, and to make inferences about their top-down and/or bottom-up origin. Indeed, congenitally blind people maintain the ability to produce visual dreams, suggesting that bottom-up mechanisms could be associated with innate body schemes or multisensory integration processes. Finally, we propose the new dream-engineering technique as a tool to clarify the mechanisms of multisensory integration during sleep and related mental activity, presenting possible implications for rehabilitation in sensory-impaired individuals. The Theory of Proto-consciousness suggests that the interaction of brain states underlying waking and dreaming ensures the optimal functioning of both. Therefore, understanding the origin of dreams and capabilities of our brain during a dreamlike state, we could introduce it as a rehabilitative tool.
Citation:
Vitali H, Campus C, De Giorgis V, Signorini S, Gori M. The vision of dreams: from ontogeny to dream engineering in blindness. J Clin Sleep Med. 2022;18(8):2051-2062.
... Nightmares are a prominent symptom of PTSD and other stress-related disorders (5)(6)(7)(8), and they often seem to resist classic trauma-focused psychotherapeutic interventions. Moreover, even if reduced, they tend to reappear in the follow-up assessments after several months (60,61). Even when PTSD resolves, nightmares can persist (5,46). ...
Besides affecting 8% of the general population, nightmares are one of the most frequent symptoms of traumatized individuals. This can be a significant factor in the treatment of post-traumatic disorders; indeed, several studies demonstrated its strong predictive and prognostic value. Sleep disorders, nightmares in particular, could be very distressing for individuals and need targeted interventions, especially if they are associated with a PTSD diagnosis. To date, the best technique for the treatment of traumatic sleep disturbances seems to be Imagery Rehearsal Therapy (IRT), an empirically supported method. Through a review of the literature on this matter, this article aims to outline the incidence and consequences of nightmares in PTSD, illustrate how IRT could prove useful in their treatment, and investigate its clinical applications.
... Clinicians may see greater symptom reduction by focusing on the symptoms that are central to Black Americans' PTSD presentation, rather than focusing on symptoms like hypervigilance and cued emotional distress, which may be relevant to many Black Americans' experience beyond the context of PTSD (Williams, Malcoun, Sawyer, Davis, Bahojb Nouri, & Bruce, 2014). Results also suggest the potential for the addition of adjunct image-based therapies, including Image Rehearsal Therapy, to target nightmares, as this symptom was among the most highly discriminating at 1.5 to three standard deviations above the mean (Krakow & Zadra, 2010;Ulmer et al., 2011). ...
Black Americans are more likely to be exposed to certain types of traumatic events and experience posttraumatic stress disorder (PTSD) compared to other racial groups. Consequently, sound assessment of PTSD in this underserved and understudied population is necessary to develop and accurately answer research questions about etiology and intervention efficacy. However, the item-level psychometric properties of one of the most commonly used assessment tools, the PTSD Checklist for DSM-5 (PCL-5), has yet to be examined among Black Americans. To address this gap, we used item response theory (IRT) to assess item difficulty and discrimination in a sample of Black American adults (n = 307). We employed a graded response model with all 20 items of the PCL-5 loading on to a latent PTSD factor. At clinically significant levels of PTSD, the most discriminating items were flashbacks, inability to experience positive emotions, and nightmares and the least discriminating items were cued emotional distress, diminished interest, and hypervigilance. These results emphasize the importance of flashbacks, inability to experience positive emotions, and nightmares and deemphasize the importance of hypervigilance and sleep difficulties when assessing for clinically significant symptoms of PTSD in Black Americans. Treatment implications include a nuanced approach towards hypervigilance.
... Prior studies on childhood nightmares and nighttime fears have evaluated interventions, many of which showed promising findings [9,[13][14][15][16][17]. The most established intervention to date is Imagery Rehearsal Therapy (IRT), which aims to modify the avoidant cognitions and behaviors that form due to nightmarerelated worries [18]. During IRT a client recalls their nightmare and rehearses it frequently to change its narrative, and consequently modifies it to yield more positive cognitive and physical symptoms. ...
Study Objectives
Recurrent nightmares in childhood may have a range of detrimental effects for both the child and parents. This randomized controlled trial evaluated the efficacy of a novel parent-based intervention for childhood nightmares, using a new device called the “Dream Changer.”
Methods
A total of 56 children aged 3–10 years (M = 7.1 ± 2.1 years; 51.8% boys), and one of their parents were randomized to either the intervention or waitlist control group. The intervention group received a “Dream Changer”—a light-emitting remote-control-like device that the child was encouraged to take to bed and use upon experiencing a nightmare. Parents completed online surveys at baseline, 1-week, and 2-weeks following the intervention. Parents in the intervention group additionally completed a 3-month follow-up survey. Outcome variables included children’s nightmare frequency, sleep-wake patterns, and sleep anxiety, as well as parents’ daytime sleepiness.
Results
Significant group-by-time interaction effects were found for nightmare frequency (p = 0.001) and sleep anxiety (p = 0.006). Parents of children who received the “Dream Changer” reported fewer nightmares (Mdifference = 1.7, p < 0.001, d = 1.06) and decreased anxiety (Mdifference = 0.9, p = 0.001, d =0.41) at post-intervention, whereas such benefits were not found in the waitlist control group. Three-month follow-up assessments demonstrated that gains were maintained over-time. Interaction effects were not significant for children’s sleep metrics or for parents’ daytime sleepiness.
Conclusions
The present study provides preliminary evidence for the efficacy of a brief, highly accessible intervention for reducing children’s nightmares and nighttime anxiety. Future research may wish to test these effects using larger samples and longer follow-up assessments.
Clinical Trial Registration
The trial has been registered at the Australian New Zealand Clinical Trials Registry (https://www.anzctr.org.au/; Identifier:ACTRN12620000633987).
... In a pilot study of trauma-exposed adolescent girls in residential treatment, those receiving IRT (n ¼ 9) reported substantial decreases in nightmare frequency and subjective distress, yet not overall sleep disturbance, in comparison to control participants (n ¼ 10; Krakow et al., 2001). IRT has not been evaluated in trauma-exposed children but demonstrates effectiveness for nightmares in children that are not trauma-related (Krakow and Zadra, 2010). In summary, extrapolation of findings from adult studies largely guides the application of psychological interventions for TRSD in youth, given that the existing evidence base is critically limited. ...
Sleep disturbances, particularly nightmares and insomnia, are prototypic symptoms of traumatic stress exposure and subsequent posttraumatic stress disorder (PTSD). Currently, most research of trauma-related sleep disturbance (TRSD) focuses on adult populations, while less is known about the nature of sleep disturbance in trauma-exposed youth, despite that many children and adolescents will experience at least one potentially traumatic event before adulthood. This article reviews the existing research of the intersection between sleep and traumatic stress exposure in youth, which provides valuable insight to the developmental course of TRSD and associated functional consequences across the lifespan.
... This form of distress is likely to trigger or maintain anxiety by repeatedly exposing the child to the frightening dream content when awake. In line with this idea, many studies on imagery rehearsal therapy have shown that working on distressing dream content is associated with reduced nightmare frequency and psychiatric distress, including anxiety (Krakow & Zadra, 2010). ...
Repeated nightmares involving separation are a DSM-5 symptom criterion for separation anxiety disorder. However, research on nightmares and separation anxiety in clinical or non-clinical samples is scarce. To verify whether children’s separation anxiety predicted nightmares’ characteristics (frequency, distress and separation-related content), we conducted an online survey among 237 mothers of a 4- to 12-year-old child. Children’s separation anxiety as assessed by a modified version of the Separation Anxiety Symptoms Inventory predicted frequent nightmares and bad dreams, dreaming of the parents’ death (odds ratio [OR] = 2.65 [1.41, 4.98]) or of any separation theme (OR = 5.97 [2.64, 13.50]) during the last year, and dysphoric dream distress. The association between children’s separation anxiety and dysphoric dream distress was mediated by dysphoric dream frequency. Our findings suggest that dysphoric dream distress may be a better marker of separation anxiety compared with frequency. Future studies in clinical samples are needed to determine whether the DSM-5 nightmare symptom criterion should be reviewed to emphasize the occurrence of any type of dysphoric dreams (bad dreams and nightmares), the presence of distress in relation to these dreams, and their specific content.
... Le Tableau 2 présente les grands axes de chaque séances selon la méthode développée par Kellner, Tableau 2 Présentation des grands axes de la thérapie par répétition d'imageries mentales en 4 séances. Neidhardt, Krakow et Hollifield [32,40]. Le Tableau S1 présente de manière plus détaillée chaque séance. ...
Résumé
Le cauchemar, défini comme un rêve extrêmement dysphorique, impliquant généralement des menaces vitales sur la sécurité ou l’intégrité physique, représente un phénomène courant. Survenant majoritairement en stade de sommeil paradoxal, il se différencie notamment d’autres parasomnies par l’accès rapide à un état orienté et alerte après l’éveil. Sa survenue de façon répétée et son retentissement sur la vie du sujet constituent la maladie des cauchemars. Plusieurs traitements sont actuellement utilisés dans la prise en charge de la maladie des cauchemars. Les approches non-pharmacologiques dérivées des thérapies cognitivo-comportementales sont celles qui ont fait la preuve de l’efficacité la plus robuste. La thérapie par répétition d’imagerie mentale (RIM) est le seul traitement faisant actuellement l’objet de recommandations de grade A par les sociétés savantes. La RIM comprend un volet d’éducation thérapeutique et de restructuration cognitive, ainsi qu’un volet centré sur l’imagerie mentale et sa pratique. Appliquée aux cauchemars, l’imagerie mentale consiste à modifier un cauchemar préexistant pour créer le scénario d’un nouveau rêve qui sera répété quotidiennement durant l’éveil. D’autres traitements psychothérapeutiques peuvent être utilisés, notamment les thérapies d’exposition et de désensibilisation, les thérapies centrées sur les rêves lucides, et dans une moindre mesure les thérapies cognitivo-comportementales classiques ou spécifiques de l’insomnie. L’utilisation des traitements pharmacologiques, au premier rang desquels se trouve la prazosine, se limite à certaines indications précises comme les cauchemars liés au trouble de stress post traumatique.
... For example, figurines of evil characters seen in dreams were produced and later ritually burned, buried or thrown into river in order to dissolve them (Butler, 1998: 195-197). Such ancient Mesopotamian dream rituals that aimed at purifying a person from the impact of terrifying visions can be favourably compared to modern Imagery Rehearsal Therapy designed to cure chronic sufferers from frequent nightmares (Krakow / Zadra, 2010). ...
... Interestingly, considering dreams as a marker of psychopathology can help clinicians to evaluate the progress of the patient in the course of their treatment. Moreover, working with nightmares using the Imagery Rehearsal Therapy (Krakow & Zadra, 2010) can be very helpful for these patients in reducing the number and intensity of nightmares and, as a consequence, improve sleep quality and wakinglife well-being. The brief introduction provided in the book clearly shows that learning how to deal with dreams and nightmares properly should be part of psychotherapeutic training, especially in cognitive-behavioral therapy. ...
The book of Josie Malinowksi is a well-written and informative introduction into psychological dream research. After definitions and a brief review of the history of dreaming, the author integrates many of the current theories about dream function, e.g., processing of emotions, Social Simulation theory, or dreaming as playing. In addition, clinical aspects, e.g., dream sharing, are reviewed with the interesting idea that working with dreams in waking might enhance the function of dreams. Phenomena like lucid dreams, precognitive dreaming, posttraumatic dreams, and sleep paralysis which are currently discussed widely are presented in a very concise format, clearly demonstrating the author’s knowledge that she has accumulated over more than 10 years of dream research. Lastly, the author emphasizes that dream researchers – like scientists in general – should also discuss the ethical implications of their findings, e.g., when influencing dream content with application of external stimuli.
This chapter will focus on addressing sleep disturbance within the context of cognitive processing therapy (CPT) for post-traumatic stress disorder (PTSD). Sleep impairments are a hallmark symptom of PTSD and have been shown to be refractory to trauma-focused treatments for PTSD. Although CPT can improve sleep impairment in PTSD clients, studies have consistently indicated while CPT improves sleep disturbance, too often sleep does not return to normal functional levels. As such, researchers have investigated sleep-focused treatments as a potential augmentation to CPT to improve sleep disturbance. This chapter will provide an overview of sleep disturbance within PTSD populations, review the existing evidence base in this area, and discuss relevant clinical approaches and implications to address sleep outcomes in PTSD patients. A detailed case example will illustrate techniques to address this comorbidity using CPT approaches while maintaining fidelity to CPT implementation.
Background
Symptoms of insomnia, nightmares, and trauma are highly prevalent. However, there are significant barriers to accessing evidence-based treatments for these conditions, leading to poor mental health outcomes.
Objective
This pilot trial evaluated the feasibility of a 4-week, digital self-paced intervention combining cognitive behavioral therapy for insomnia and exposure, relaxation, and rescripting therapy for nightmares in survivors of wildfires from Australia, Canada, and the United States.
Methods
Study participants were recruited between May 2023 and December 2023 through social media platforms, workshops, conferences, and radio interviews. Participants had to meet at least one of the following criteria: a score of ≥8 on the Insomnia Severity Index, a score of ≥3 on the Nightmare Disorder Index, or a score of ≥31 on the PTSD Checklist for DSM-5. In total, 30 survivors of wildfires were allocated to either the treatment group (n=16, 53%) or the waitlist control group (n=14, 47%) in a sequential manner. Participants’ ages ranged from 18 to 79 years, with a mean age of 52.50 (SD 16.26) years. The cohort consisted of 63% (19/30) female and 37% (11/30) male participants. Participants also completed self-report secondary outcome measures, including the Generalized Anxiety Disorder–7, the Patient Health Questionnaire–9, and the Pittsburgh Sleep Quality Index, via the HealthZone digital platform. Assessments were conducted at baseline, the posttreatment time point, and the 3-month follow-up, with the waitlist group undergoing an additional assessment at the pretreatment time point, after 4 weeks of waiting and before crossing over to treatment. This study used intention-to-treat analysis as a primary analysis and per-protocol analysis as a secondary analysis.
Results
Mixed-effects linear regression models and difference-in-differences analyses were used to assess the intervention’s effects. The intention-to-treat analysis revealed significant improvements over time (main effect of time), with a 1.64-point reduction (P=.001) on the Nightmare Disorder Index and 10.64-point reduction (P=.009) on the PTSD Checklist for DSM-5 at the postintervention time point. No significant changes were observed in insomnia symptoms. On the secondary measures, there was an interaction effect of condition × time, with a 2.22-point reduction (P<.001) on the Pittsburgh Sleep Quality Index, and a main effect of time, with a 6.48-point reduction (P<.001) on the Patient Health Questionnaire–9. No changes were detected on the Generalized Anxiety Disorder–7. The per-protocol analysis yielded comparable results for both the primary and secondary measures.
Conclusions
The findings of this pilot trial demonstrated a reduction in nightmares and trauma symptoms. Future research studies should aim at evaluating the intervention in a more definitive trial with a larger sample size.
Trial Registration
Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12623000415606; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385054
Current evidence-based therapies considered efficacious for posttraumatic stress disorder (PTSD) include Prolonged Exposure Therapy (PE), Cognitive Processing Therapy (CPT), Eye Movement Desensitization Reprocessing (EMDR), and medication treatments. Hypnosis, one of the first mind-body therapies known to Western medicine, has been used for mind-body problems such as conversion reactions, medication-less anesthesia, and wound healing. Because PTSD is a mind-body problem, hypnosis seems especially suited for its treatment. Hypnosis is a state-based treatment that can move PTSD patients into a state of calm, downregulate their emotional reactivity, and facilitate altering maladaptive beliefs. Combined with cognitive behavioral therapy (CBT) approaches, hypnosis may magnify their effects. In this article, we present hypnotic techniques applicable to PTSD based on the PTSD symptom clusters they treat. We describe the goals, similarities, and differences between hypnosis and mindfulness, Dialectical Behavioral Therapy, and Acceptance and Commitment Therapy. We describe how adding hypnosis to PTSD treatment protocols such as PE and CPT boosts their impact. We encourage the use of hypnotic techniques which can enhance the therapeutic palette of the CBT practitioner treating PTSD.
Objectives:
Research supports cognitive behavioral therapies for nightmares (CBT-N) in adults. However, the nuances of implementation and unstandardized nomenclature for treatment components has created confusion in the field. To provide clarification, an expert consensus panel convened to review treatment manual components and to develop guidelines for the standardized implementation and terminology of CBT-N. The aims of this paper are to report on the expert panel recommendations.
Methods:
A literature review was conducted for nightmare treatment manuals that have been tested in randomized clinical trials with adults. the panel of experts evaluated the content and the main controversies regarding treatment components. The panel then established recommended treatment guidelines based on the literature and clinical experience.
Results:
Recommendations pertain to which patient symptom presentations are appropriate for CBT-N and considerations for implementing treatment components including session length, relaxation training, stimulus control, sleep efficiency training, sleep hygiene, nightmare exposure, nightmare rescripting, and imagery rehearsal of rescripted dreams. The panel evaluated treatment components to inform the development of a consensus CBT-N treatment manual.
Conclusions:
Using a comprehensive treatment manual based on expert recommendations will not only help disseminate nightmare treatment but also advance the field by providing clarity. These recommendations are based on the status of the field and will need to be revised to incorporate developing research evidence in nightmare treatment.
During most dreams, the dreamer does not realize that they are in a dream. In contrast, lucid dreaming allows to become aware of the current state of mind, often accompanied by considerable control over the ongoing dream episode. Lucid dreams can happen spontaneously or be induced through diverse behavioural, cognitive or technological strategies. Such induction techniques have spurred research into the potential therapeutic aspects of lucid dreams. In this review, we gather evidence on the link between lucid dreams and conditions like nightmare disorder, depression, anxiety, psychosis, and dissociative states, and explore the possible neurobiological basis of these associations. Furthermore, we delve into contemplative sleep practices that train lucid states during sleep, such as Dream/Sleep Yoga and Yoga Nidrâ. The potential drawbacks of lucid dreaming interventions are outlined, accompanied by an examination of the impacts of lucid dreams on individuals without clinical conditions. By shedding light on these intricate relationships, the review contributes to a deeper understanding of the therapeutic possibilities and implications of lucid dreaming.
Intimate partner violence against women causes various traumatic injuries, ranging from mental disorders, such as somatic complaints, anxiety and mood disorders, PTSD, to women's deaths. This chapter emphasizes the most common symptoms that are identified in women victims of domestic violence. Such victims are more prone to feeling hurt, fear, helplessness, shame, and self-blame for being abused. In some cases, exposure to intimate-perpetrated violence leads to intrusive and vivid memories of violent events. In addition, they often suffer from somatic symptoms, such as chronic pain, headaches, fibromyalgia, chronic fatigue syndrome, panic disorder accompanied by somatic symptoms, etc. In this chapter, a novel protocol is presented, combining cognitive-behavior therapy and emotion-focused therapy. The treatment is featured to alleviate somatic symptoms and imagery intrusions, enhance emotion regulation, and encourage engaging in healthy and safe relationships.
Imagery rescripting (ImRs) interventions have been found effective in improving sleep outcomes, although research has mostly focused on civilian, rather than military, samples. The aim of this review was to estimate the overall effectiveness of ImRs interventions for military veterans on primary outcomes of nightmare frequency and sleep quality. A systematic search was conducted in CINAHL, MEDLINE, PsycArticles, PsycINFO, Psychology and Behavioural Sciences Collection and the PTSDpubs database and was completed on 1 November 2021. Randomised controlled trials, nonrandomised trials and pre–post studies of ImRs interventions in veterans with sleep disturbances or nightmares were included. The methodological quality of the studies was assessed using the Effective Public Health Practice Project (EPHPP) tool, and meta‐analysis was performed using Stata. Nineteen articles from 15 empirical studies were included in the review, and data from the 15 studies (involving 658 participants) were included in the meta‐analysis. Meta‐analysis findings indicated that ImRs interventions are associated with significant positive changes from pretreatment to posttreatment for nightmare and sleep quality. Significantly greater improvements were found in ImRs interventions compared to control groups for sleep quality (Hedges' g = −0.65, 95% CI [−1.20, −0.10]) but not for nightmare frequency (Hedges' g = −0.10, 95% CI [−0.34, 0.14]). Overall, the meta‐analysis included a relatively small number of studies with poor methodological quality and considerable heterogeneity; therefore, findings should be cautiously interpreted. Further research should focus on veteran participants with larger samples and from a broader range of sources to determine effectiveness more confidently.
The Neuroscience of Sleep and Dreams provides comprehensive coverage of the basic neuroscience of both sleep and dreams for upper-level undergraduate and graduate students. It details new scientific discoveries, places those discoveries within evolutionary context, and links established findings with implications for sleep medicine. This second edition focuses on recent developments in the social nature of sleep and dreams. Coverage includes the neuroscience of all stages of sleep; the lifespan development of these sleep stages; the role of non-REM and REM sleep in health and mental health; comparative sleep; biological rhythms; sleep disorders; sleep memory; dream content; dream phenomenology, and dream functions. Students, scientists, and interested non-specialists will find this book accessible and informative.
Suicide exposure warrants further investigation as a risk factor for suicide among military service members. This study aimed to examine associations among suicide exposure, suicidal ideation (SI), and psychological symptoms in a clinical sample of service members (N = 1,565, 64.4% suicide‐exposed) and identify how one's relationship with the deceased impacts suicidality and psychological health in exposed individuals. A secondary analysis of cross‐sectional survey data was conducted. Generalized linear regression analyses were used to identify associations between suicide exposure and both current SI and psychological symptoms among all participants; the associations between suicide exposure characteristics and psychological symptoms were only examined among exposed individuals. Exposure was not significantly associated with higher SI, β = .007, SE = .16, p = .965, but was associated with PTSD, β = 1.60, SE = 0.49, p = .001; anxiety, β = .68, SE = .31, p = .031; and insomnia symptoms, β = .98, SE = .25, p < .001. Among participants who had been exposed, high/long impact of exposure was positively associated with SI, β = 0.94, SE = .26, p < .001, and psychological symptoms, PTSD: β = 2.32, SE = .77, p = .002; anxiety: β = 1.39, SE = .50, p = .005; insomnia: β = .96, SE = .39, p = .015. Results illustrate the significant issue of suicide exposure within the military and show consideration of suicide exposure as a potential risk factor for adverse psychological outcomes is warranted.
Nightmare disorder (ND) is characterized by dreams with strong negative emotions occurring during rapid eye movement (REM) sleep. ND is mainly treated by imagery rehearsal therapy (IRT), where the patients are asked to change the negative story line of their nightmare to a more positive one. We here used targeted memory reactivation (TMR) during REM sleep to strengthen IRT-related memories and accelerate remission of ND. Thirty-six patients with ND were asked to perform an initial IRT session and, while they generated a positive outcome of their nightmare, half of the patients were exposed to a sound (TMR group), while no such pairing took place for the other half (control group). During the next 2 weeks, all patients performed IRT every evening at home and were exposed to the sound during REM sleep with a wireless headband, which automatically detected sleep stages. The frequency of nightmares per week at 2 weeks was used as the primary outcome measure. We found that the TMR group had less frequent nightmares and more positive dream emotions than the control group after 2 weeks of IRT and a sustained decrease of nightmares after 3 months. By demonstrating the effectiveness of TMR during sleep to potentiate therapy, these results have clinical implications for the management of ND, with relevance to other psychiatric disorders too. Additionally, these findings show that TMR applied during REM sleep can modulate emotions in dreams.
Patients with psychotic disorders show profound disturbances in sleep, including insomnia, nightmares, and unstable sleep/wake rhythms. While emerging research shows that disrupted sleep reduces the quality of life, increases suicide risk, and provokes psychotic symptoms, patients often lack access to evidence-based behavioral sleep medicine treatments. The goal of this chapter is to prepare behavioral sleep medicine clinicians to treat sleep disturbances in individuals with psychotic disorders.
Sleep disturbance is a major public health problem. Highly prevalent, sleep disturbance is bidirectionally associated with psychiatric and physical illness. This article provides an overview of sleep, sleep disturbance, and evidence-based assessment methods. Then, for each of the most common sleep disorders—namely, insomnia, obstructive sleep apnea, restless leg syndrome, and nightmare disorder—the diagnostic criteria, clinical features, prevalence, and evidence-based assessment and treatment methods are reviewed. Finally, future research directions are highlighted, with an emphasis on comorbidity and transdiagnostic approaches to treatment.
The authors examined (a) how traumatic events are associated with children's dream structure and content and (b) which dream characteristics might moderate the negative impact of traumatic events on mental health. Participants were 122 Kurdish children (9-17 years old, M = 13.02, SD = 1.66). Their dreams were collected during 1 week using a semistructured dream diary and scored according to the dream atmosphere, the role of the dreamer, bizarreness, narrative quality, fragmentation and resolution, and content such as themes of death, persecution and rejection, hostility, and anxiety. The results substantiated the hypothesis that children exposed to a high level of traumatic events would report dreams characterized by unpleasant atmosphere, fragmented flow, and low levels of bizarre narrative quality. Pleasant dreams containing complete narratives and happy endings moderated the negative impact of traumatic events on children's mental health. The authors argue that dreaming allows cognitive-emotional processing of traumatic events and may thus enhance child well-being in war conditions. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Dreams following trauma have been suggested to aid emotional adaptation, yet trauma-related nightmares are a diagnostic symptom of Posttraumatic Stress Disorder (PTSD). There is little published data relating dreams to PTSD soon after trauma. We assessed dreams and PTSD in 60 injured patients after life-threatening events and obtained follow-up assessments in 39 of these participants 6 weeks later. Ten of 21 dream reports from morning diaries were rated and described as similar to the recent traumatic event. The participants reporting these distressing “trauma dreams” had more severe concurrent PTSD symptoms than those reporting other categories of dreams and had more severe initial and follow-up PTSD than those without dream recall. These findings along with our preliminary longitudinal observations relating changes in dream patterns to outcome, suggest a relationship of dream characteristics and early adaptive versus maladaptive patterns of processing traumatic memory.
This study investigated the effectiveness of a psychotherapeutic treatment for nightmares that was adapted for 6- to 11-year-old children from imagery rehearsal therapy. Ten child-mother dyads took part in a 3-session, 8-week treatment protocol. Participation in the study (contact with clinician, keeping a prospective dream log) was associated with decreases unpleasant dreams frequency, nightmare distress, and manifest anxiety. Providing educational information about nightmares did contribute to this positive effect. Results also suggest that drawing modified versions of nightmares for 1 month was associated with further reductions in nightmare distress and anxiety, but with no changes in unpleasant dreams frequency. Follow-ups at 3 and 6 months posttreatment suggest that the intervention had maintained effects. (PsycINFO Database Record (c) 2010 APA, all rights reserved).
Twenty subjects with chronic nightmares for 17.2 years mean duration were randomly divided into two groups: Rehearsal and Recording. At inception, subjects in both groups were instructed to write down their nightmares for one month. The Recording group received no other intervention. Rehearsal subjects received a single treatment group session teaching an imagery rehearsal technique to reduce nightmare frequency. At inception and three months follow-up, both groups were compared for nightmare frequency and for self-rated distress with scales (Symptom Checklist and Symptom Questionnaire) measuring anxiety, depression, hostility, somatization and total distress. Nightmare frequency decreased significantly in both groups: Rehearsal group-7.2 per month to 2.0 per month (72% reduction) (p < 0.006); Recording group-9.4 per month to 5.0 per month (47% reduction) (p < 0.02). There were no statistically significant differences in the nightmare frequency reductions between groups. All anxiety, depression, somatization, hostility and total distress scores decreased substantially in the Rehearsal group. Most changes were significant. Changes in the Recording group were inconsistent and not significant. Two brief case histories are presented.
Chronic nightmares occur frequently in patients with posttraumatic stress disorder (PTSD) but are not usually a primary target of treatment.
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.
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.
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.
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.
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 (chi(2)(1) = 12.80; P<.001).
Imagery rehearsal therapy is a brief, well-tolerated treatment that appears to decrease chronic nightmares, improve sleep quality, and decrease PTSD symptom severity.
Exposure therapy is a well-established treatment for PTSD that requires the patient to focus on and describe the details of a traumatic experience. Nightmares that refer to or replicate traumatic experiences are prominent and distressing symptoms of PTSD and appear to exacerbate the disorder. With this apparent paradox in mind, exposure therapy and the literature on sleep and PTSD are reviewed in the context of the relationship between therapeutic exposure and exposure to trauma-related stimuli that occurs in dreams. It is concluded that nightmares that replay the trauma and disrupt sleep do not meet requirements for therapeutic exposure, whereas other dreaming may aid in the recovery from trauma.
Prazosin is a centrally active alpha(1) adrenergic antagonist. The authors' goal was to evaluate prazosin efficacy for nightmares, sleep disturbance, and overall posttraumatic stress disorder (PTSD) in combat veterans.
Ten Vietnam combat veterans with chronic PTSD and severe trauma-related nightmares each received prazosin and placebo in a 20-week double-blind crossover protocol.
Prazosin (mean dose=9.5 mg/day at bedtime, SD=0.5) was superior to placebo for the three primary outcome measures: scores on the 1) recurrent distressing dreams item and the 2) difficulty falling/staying asleep item of the Clinician-Administered PTSD Scale and 3) change in overall PTSD severity and functional status according to the Clinical Global Impression of change. Total score and symptom cluster scores for reexperiencing, avoidance/numbing, and hyperarousal on the Clinician-Administered PTSD Scale also were significantly more improved in the prazosin condition, and prazosin was well tolerated.
These data support the efficacy of prazosin for nightmares, sleep disturbance, and other PTSD symptoms.
Although the benefits of guided imagery are now more widely recognized, the definitions of imagery used by various health science disciplines are inconsistent.
To conduct an analysis of the concept of imagery as understood among the health science professions.
An inductive, descriptive means of inquiry was used to clarify the concept of imagery. Data were analyzed by categories: surrogates, attributes, contextual information (antecedents; consequences), related terms, and references.
The prevailing surrogate term for mental imagery is visualization. Attributes of imagery include psychophysiological, mental, quasi-reality, dynamic, and process. References include therapeutic settings.
This concept analysis has led to the following working definition: "Imagery, a mental function, is a lived experience that is a dynamic, quasi-real, psychophysiological process." The analysis was intended to identify consensus on the concept of imagery within the health professions, and provide a foundation for further research.
We investigated the impact of imagery rehearsal treatment (IRT) on nightmare frequency, psychological distress, and sleep quality using polysomnography (PSG). 12 chronic nightmare patients completed prospective dream logs, measures of psychological distress, and underwent PSG prior to and 8.5 weeks following a single IRT session. Post-treatment, significant reductions were observed in retrospective nightmare frequency (d = 1.06, p = .007), prospective bad dream frequency (d = 0.53, p = .03), and anxiety scores (d = 1.01, p = .004). Minimal sleep alterations were found post-IRT, and varied as a function of nightmare etiology. The results independently replicate the efficacy of IRT for alleviating disturbing dreams and psychological distress. Sleep improvement may occur later in the recovery process.
Problems with nightmares are reported by a sizable proportion of individuals with a history of trauma and by approximately 5% to 8% of the general population. Chronic nightmares may represent a primary sleep disorder rather than a symptom of a psychiatric disorder, and direct targeting of nightmares is a feasible clinical approach to the problem. Of the treatments proposed, imagery rehearsal therapy (IRT) has received the most empirical support. An up-to-date account of this cognitive-imagery approach shows how to treat nightmares during 4 roughly 2-hr sessions. The main points covered in each therapy session and their underlying rationale are presented. Dismantling protocols are suggested to discern active ingredients of IRT and to develop flexible applications based on patients' needs.
Nightmares are common, occurring weekly in 4%–10% of the population, and are associated with female gender, younger age, increased stress, psychopathology, and dispositional traits. Nightmare pathogenesis remains unexplained, as do differences between nontraumatic and posttraumatic nightmares (for those with or without posttraumatic stress disorder) and relations with waking functioning. No models adequately explain nightmares nor have they been reconciled with recent developments in cognitive neuroscience, fear acquisition, and emotional memory. The authors review the recent literature and propose a conceptual framework for understanding a spectrum of dysphoric dreaming. Central to this is the notion that variations in nightmare prevalence, frequency, severity, and psychopathological comorbidity reflect the influence of both affect load, a consequence of daily variations in emotional pressure, and affect distress, a disposition to experience events with distressing, highly reactive emotions. In a cross-state, multilevel model of dream function and nightmare production, the authors integrate findings on emotional memory structures and the brain correlates of emotion.
An eighteen month follow-up of chronic nightmare sufferers treated with imagery rehearsal, a cognitive-behavioral method, demonstrated significant and clinically meaningful decreases in nightmare frequency. Sixty-eight percent of subjects decreased their nightmares below criteria for a “Chronic Nightmare Disorder”. Significant improvement was also noted for sleep quality and daytime anxiety. The findings support the theory that nightmares may be clinically conceptualized as a primary sleep disorder in some chronic sufferers.
Posttraumatic nightmares are a hallmark of PTSD and distinct from general nightmares as they are often repetitive and faithful representations of the traumatic event. This paper presents data from a pilot study that examined the use of Imagery Rehearsal in treating combat-related nightmares of 12 Vietnam veterans with PTSD. Three treatment groups, comprising 4 veterans in each, completed standardised treatment across 6 sessions. Treatment effects were investigated using nightmare diaries and established instruments, including the IES-R, BDI, BAI, and SCL-90-R. The data demonstrate significant reductions in nightmares targeted, and improvements in PTSD and comorbid symptomatology. The paper recommends that, on the basis of the promising preliminary data, a randomised control trial be established to assess imagery ability and attidude toward nightmares.
Imagery rehearsal therapy (IRT) may help reduce residual nightmares and posttraumatic stress disorder (PTSD) symptoms in veterans after trauma-focused PTSD treatment. Fifteen male U.S. veterans with PTSD and trauma-related nightmares, who had not previously completed trauma-focused PTSD treatment, attended 6 IRT group sessions. No benefits were observed immediately posttreatment. At 3- and 6-month follow-up, however, trauma-related nightmare frequency (nights/week) decreased (p < .01). The number of trauma-related nightmares/week (p < .01), number of total nightmares/week (p < .05), and PTSD symptoms (p < .05) also decreased at 3 months. The overall F test for time was significant (p < .05) for nightmare severity and fear of sleep. No effects were found on measures of the impact of nightmares, sleep quality, or depression. Clinical and research implications are discussed.
This study examined the applicability of imagery rehearsal therapy (IRT) to children with frequent nightmares. Eleven boys and 9 girls aged 9 to 11, with moderate to severe primary nightmares (1 or more per week for 6 months) and without posttraumatic stress disorder, were randomly divided into an imagery rehearsal treatment group (n = 9) or a waiting-list (n = 11) group. ANCOVA with repeated measures revealed that, following a baseline period, IRT reduced the frequency of nightmares (p < .04; eta(2) = 0.22) in the treated group compared to the waiting-list group. This reduction was maintained over a 9-month follow-up. The effects of IRT on post-nightmare state distress could not be assessed due to low nightmare incidences. However, retrospective trait nightmare distress was not significantly reduced. Future research is needed to validate this simple approach for nightmare reduction and to evaluate its potential for the reduction of the associated nightmare distress.
A recurrent nightmare of 14 years' duration rapidly disappeared after it was rehearsed repeatedly in treatment. The nightmare was independent of co-existing compulsive rituals ans sexual problems, but was related to co-existing depression.
The purpose of this study was to examine the effects of one session of instructions on the frequency of chronic nightmares and on self-rated distress.
Twenty-eight volunteers with chronic nightmares (mean duration = 19 years) were treated with either one session of desensitization with instructions on how to practice this treatment or with one session of instructions to change the nightmare and how to rehearse the new version. The authors administered four scales of the SCL-90 and the corresponding scales of the Symptom Questionnaire.
At 7-month follow-up of 23 patients, there was a significant reduction in the frequency of nightmares and significant decreases in self-rated depression, anxiety, and hostility. There were no significant differences between the effects of the two types of treatment. In four patients, whose mean duration of nightmares was 23 years, the nightmares ceased.
The results of this preliminary study suggests that the instructions given to the patients reduced the frequency of their chronic nightmares and decreased their self-rated distress.
Seven cases of nightmare were treated by simple rehearsal of the nightmare and/or rehearsal with an altered ending, followed by earlier introduction of the ending. One-year follow-up of five patients showed complete relief from nightmares in the four patients who achieved early introduction of a 'masterful' ending, and marked improvement in the patient who could only imagine a neutral ending. All but one of the patients also presented with neurotic symptoms (anxiety, phobias, depression and compulsion/obsession). These were treated by rational discussion and the formulation of positive 'threat-eliminating' statements to be repeated as homework and in times of stress.
A cross-sectional study was performed to retrospectively assess self-rated sleep complaints in three groups of subjects: controls without nightmares (N = 77), acute nightmares sufferers (< 6 months duration, N = 36), and chronic nightmare sufferers (> 6 months duration, N = 128). Four specific complaints of sleep disturbance were categorically measured to ascertain the presence or absence of the symptom: fear of going to sleep; awakenings from sleep; difficulty returning to sleep; and fitful, restless sleep. Each of the four separate sleep complaints were significantly more common in the acute (p < .0001) and chronic (p < .0001) nightmare groups compared with controls. A summed aggregate score of the four sleep complaints was also higher in both the acute (p < .0001) and chronic groups (p < .0001) compared with controls. Ninety-one percent of all subjects with nightmares reported at least one sleep complaint. Between-group assessments, comparing acute and chronic nightmare sufferers for any of the four variables and the aggregate, demonstrated no statistically significant findings, although a few trends were noted. A dose-response relationship was not observed for nightmare frequency or chronicity for any of the four sleep variables or their aggregate. The relationship between nightmares and disturbed sleep is discussed.
Fifty-eight chronic nightmare sufferers were randomly assigned to two groups: treatment (n = 39) and wait-list control (n = 19). Treated Ss were taught a cognitive-behavioral technique called imagery rehearsal in which they learned in a waking state to change a nightmare and then to visualize the new set of images. Subjects were assessed pre-treatment and 3 months followup for nightmare frequency, self-rated distress and subjective sleep quality. Compared to controls, the treatment group showed significant and clinically meaningful decreases in nightmares. Treated Ss decreased nightmares as measured in nights/week (mean = -2.0, SD = 1.7, P = 0.0001) and actual number of nightmares (mean = -4.2, SD = 4.5, P = 0.0001). 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). These preliminary results lend support to the theory that, for some chronic sufferers, nightmares may be conceptualized as a primary sleep disorder which can be effectively and inexpensively treated with cognitive-behavioral therapy.
Nightmare frequency and self-rated distress were assessed retrospectively in two groups of chronic nightmare sufferers 30 months after treatment. In the initial phase, the image group (N = 9) learned a cognitive-behavioral technique (imagery rehearsal) for the treatment of nightmares. They were taught in one group session to: (1) record a nightmare; (2) change it (usually to something positive); and (3) rehearse the new images daily. The record group (N = 10) recorded nightmares during the first month only and learned imagery rehearsal subsequent to 3-month follow-up measurements. At 3 months and at 30 months, both groups had significantly fewer nightmares, but only the rehearsal group had less total distress. The results support the theory that nightmares are a primary sleep disorder rather than a symptom of an underlying psychiatric problem.
Twenty-three patients who had experienced a major stressful event were given a debriefing session followed by eight weekly sessions of imaginal exposure and in vivo exposure. Patients recounted their traumatic experiences aloud, using the first person and the present tense, and included as much detail as possible. This account was audiotaped and patients were asked to listen to the tape between treatment sessions. There were reductions of 42 percent in the Impact of Events Scale (IES), of 61 percent in the General Health Questionnaire (GHQ), of 38 percent in the Symptom Checklist-90 (SCL-90) questionnaire, and of 35 percent in the Clinician Administered Post-Traumatic Stress scale (CAPS), all of which were statistically significant. The number of patients who satisfied the diagnostic criteria for post-traumatic stress disorder was halved.
Many nightmare sufferers do not consult a health care professional. Though behavior and cognitive therapy can help, they have not been tested as a self-treatment method at home using a manual.
One hundred and seventy adults with primary nightmares were randomised to four weeks' self-exposure or self-relaxation at home using manuals posted to them, or to a waiting-list as a control group for four weeks. Individuals recorded nightmare frequency and intensity in four-week diaries.
At one- and six-month follow-up, the self-rated nightmare frequency fell more significantly in exposure subjects than relaxation or waiting-list subjects. The self-exposure group had the most drop-outs but remained superior in an over-cautious intent-to-treat analysis. The individuals' partners confirmed the superiority of self-exposure to self-relaxation at one- and six-month follow-up.
Recurrent nightmare sufferers improved more with self-exposure manuals than with self-relaxation manuals or by being on a waiting-list. Self-exposure may be needed for longer than four weeks in order to reduce nightmare intensity as well as frequency. Despite a high drop-out rate, some sufferers of other conditions may benefit from self-treatment manuals.
A descriptive, hypothesis-generating study was performed with 156 female sexual-assault survivors who suffered from insomnia, nightmares, and posttraumatic stress disorder (PTSD). They completed 2 self-report sleep questionnaires to assess the potential presence of intrinsic sleep disorders. Seventy-seven percent of the sample (120 of 156) endorsed additional sleep complaints, besides their insomnia symptoms, that indicate the potential presence of sleep-disordered breathing ([SDB] 81 of 156, 52%) and sleep-related movement disorders ([SMD] 94 of 156, 60%). The potential for SDB was strongly correlated with the body mass index (BMI), an increase in arousal symptoms, and greater total PTSD severity. In some sexual-assault survivors, the relationship between sleeplessness and posttraumatic stress may be caused or exacerbated by intrinsic sleep disorders, and not be solely a function of psychophysiological insomnia--the traditional diagnostic term usually offered to explain the sleep problems associated with PTSD. Prevalence studies that use objective diagnostic evaluations such as polysomnography (PSG) are needed to test these hypotheses.
To assess the impact of treatment for co-morbid sleep-disordered breathing (SDB) on patients with nightmares and post-traumatic stress.
Twenty-three chronic nightmare sufferers (15 with post-traumatic stress disorder, PTSD) who also suffered co-morbid SDB (obstructive sleep apnea, OSA, n=16; upper airway resistance syndrome, UARS, n=7) completed a telephone interview, on average, 21 months after having been offered treatment for SDB at a university sleep disorders clinic.
At follow-up, 14 reported maintaining treatment (Treatment Group) and 9 reported discontinuing treatment (No-Treatment Group). More patients in the Treatment Group reported improvement in sleep (93% vs. 33%) and in daytime well being (93% vs. 33%) compared with those in the No-Treatment group. The Treatment Group reported a median improvement in nightmares of 85% compared with a median 10% worsening in the No-Treatment Group. In the PTSD subset (n=15), nine in the Treatment Group reported a median 75% improvement in PTSD symptoms whereas six in the No-Treatment Group reported a median 43% worsening.
In this small sample of patients, treatment of SDB was associated with improvements in nightmares and PTSD. Relationships between nightmares, PTSD and SDB are discussed.
Sleep disturbance in posttraumatic stress disorder is very common. However, no previous posttraumatic stress disorder studies systematically examined sleep breathing disturbances, which might influence nightmares, insomnia, and posttraumatic stress disorder symptoms.
Forty-four consecutive crime victims with nightmares and insomnia underwent standard polysomnography coupled with a nasal pressure transducer to measure airflow limitation diagnostic of obstructive sleep apnea and upper airway resistance syndrome.
Forty of 44 participants tested positive on objective sleep studies based on conservative respiratory disturbance indices of more than 15 events per hour; 22 patients suffered from obstructive sleep apnea and 18 suffered from upper airway resistance syndrome.
In an uncontrolled study, insomnia and sleep-disordered breathing were extremely prevalent in this small and select sample of crime victims. Research is needed to study 1) prevalence of sleep-disordered breathing in other posttraumatic stress disorder populations using appropriate controls and nasal pressure transducers and 2) effects of sleep treatment on posttraumatic stress symptoms in trauma survivors with comorbid obstructive sleep apnea or upper airway resistance syndrome. In the interim, some posttraumatic stress disorder patients may benefit from sleep medicine evaluations.
Sleep quality and posttraumatic stress disorder (PTSD) were examined in 151 sexual assault survivors, 77% of whom had previously reported symptoms of sleep-disordered breathing (SDB) or sleep movement disorders (SMD) or both. Participants completed the Pittsburgh Sleep Quality Index (PSQI) and the Posttraumatic Stress Scale (PSS). High PSQI scores reflected extremely poor sleep quality and correlated with PSS scores. PSQI scores were greater in participants with potential SDB or SMD or both. PSQI or PSS scores coupled with body-mass index and use of antidepressants or anxiolytics predicted potential sleep disorders. The relationship between sleep and posttraumatic stress appears to be more complex than can be explained by the current PTSD paradigm; and, sleep breathing and sleep movement disorders may be associated with this complexity.
Standard psychiatric classification (DSM-IV-TR) traditionally attributes post-traumatic sleep disturbance to a secondary or symptomatic feature of a primary psychiatric disorder. The DSM-IV-TR paradigm, however, has not been validated with objective sleep assessment technology, incorporated nosological constructs from the field of sleep disorders medicine, or adequately addressed the potential for post-traumatic stress disorder (PTSD) sleep problems to manifest as primary, physical disorders, requiring independent medical assessments and therapies. This paradigm may limit understanding of sleep problems in PTSD by promulgating such terms as "insomnia related to another mental disorder," a.k.a. "psychiatric insomnia." Emerging evidence invites a broader comorbidity perspective, based on recent findings that post-traumatic sleep disturbance frequently manifests with the combination of insomnia and a higher-than-expected prevalence of sleep-disordered breathing (SDB). In this model of complex sleep disturbance, the underlying sleep pathophysiology interacts with PTSD and related psychiatric distress; and this relationship appears very important as demonstrated by improvement in insomnia, nightmares, and post-traumatic stress with successful SDB treatment, independent of psychiatric interventions. Continuous positive airway pressure treatment in PTSD patients with SDB reduced electroencephalographic arousals and sleep fragmentation, which are usually attributed to central nervous system or psychophysiological processes. Related findings and clinical experience suggest that other types of chronic insomnia may also be related to SDB. We hypothesize that an arousal-based mechanism, perhaps initiated by post-traumatic stress and/or chronic insomnia, may promote the development of SDB in a trauma survivor and perhaps other patients with chronic insomnia. We discuss potential neurohormonal pathways and neuroanatomatical sites that may be involved in this proposed interaction between insomnia and SDB.
During the pre-sleep period and in the natural home environment patients with insomnia (N=20) and good sleepers (N=20) were asked to record when an image came to mind by pressing a handheld counter. They then provided an oral description of the image and indicated whether the image was 'pleasant', 'unpleasant', or 'neutral' (responses captured via a voice-activated tape recorder). Subjective and objective (actigraphy) estimates of sleep-onset latency (SOL) were recorded. On both the handheld counter and the audiotape recording, participants with insomnia reported fewer images than the good sleepers. The insomnia group had a higher percentage of unpleasant images compared to good sleepers. For the insomnia group, but not the good sleeper group, there was a positive correlation between unpleasant images and subjective SOL. The insomnia group experienced more images regarding 'intimate relationships' and 'sleep' and fewer regarding 'random/non-connected topics' compared to the good sleeper group. The results are discussed with reference to proposals made by Borkovec, Ray and Stöber (Cognitive Ther. Res., 22, (1998) 561) in the context of generalised anxiety disorder (GAD).
Patients with insomnia commonly report that unpleasant intrusive thoughts and images prevent them falling asleep. Previous research has documented the topics people with insomnia think about during the pre-sleep period, but has not yet distinguished between different types of cognitive activity. Given that research relating to the anxiety disorders suggests that different types of cognitive activity, in particular images and verbal worry, are functionally independent, the present study aimed to provide a detailed phenomenological investigation of imagery and verbal thought in insomnia.
A semi-structured interview, designed to assess the content and management of pre-sleep images and verbal thought, was administered to individuals with sleep-onset insomnia (N = 34) and good sleepers (N = 38) immediately following an afternoon nap. During the nap, heart rate and sleep-onset latency were measured objectively.
The insomnia group was more likely than the good sleeper group to report negative images than positive images. The start, direction and stopping of pre-sleep images was rated as less controllable than pre-sleep verbal thoughts.
Participants disengaged more from images compared with verbal thoughts, and the insomnia patients reported feeling less calm and relaxed at the end of the salient verbal thought compared with the good sleepers.
Prazosin, a central nervous system (CNS) active alpha-1 adrenoreceptor antagonist, has reduced nightmares and sleep disturbance in placebo-controlled studies of combat-related posttraumatic stress disorder (PTSD). We evaluated objective sleep parameters and PTSD symptoms in a placebo-controlled prazosin trial for civilian trauma-related PTSD.
Thirteen outpatients with chronic civilian trauma PTSD, frequent nightmares, and sleep disturbance participated in a randomized placebo-controlled crossover trial of prazosin. Sleep parameters were quantified at home with the REMView (Respironics, Pittsburgh, Pennsylvania). The PTSD symptoms were quantified with the Clinician Administered PTSD Scale (CAPS) "recurrent distressing dreams" and "disturbed sleep" items, a non-nightmare distressed awakenings scale, the PTSD Dream Rating Scale (PDRS), the PTSD Checklist-Civilian (PCL-C), and the Clinical Global Impression of Improvement (CGI-I).
Prazosin compared with placebo significantly increased total sleep time by 94 min; increased rapid eye movement (REM) sleep time and mean REM period duration without altering sleep onset latency; significantly reduced trauma-related nightmares, distressed awakenings, and total PCL scores; significantly improved CGI-I scores; and changed PDRS scores toward normal dreaming.
Prazosin reductions of nighttime PTSD symptoms in civilian trauma PTSD are accompanied by increased total sleep time, REM sleep time, and mean REM period duration in the absence of a sedative-like effect on sleep onset latency.
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Conquering bad dreams & nightmares: a guide to understanding, interpretation, and cure
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Krakow B, Neidhardt EJ. Conquering bad dreams &
nightmares: a guide to understanding, interpretation, and cure. New York: Berkley Books; 1992.
Albuquerque: The New Sleepy Times
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Krakow B, Krakow JK. Turning nightmares into dreams.
Albuquerque: The New Sleepy Times; 2002. Available
at: http://www.nightmaretreatment.com. Accessed
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To breathe, perchance to sleep: sleep-disordered breathing and chronic insomnia among trauma survivors
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