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Efficacy of imagery rescripting and imaginal exposure for nightmares: A randomized wait-list controlled trial
Abstract
Nightmares can be effectively treated with cognitive-behavioral therapies. Though it remains elusive which therapeutic elements are responsible for the beneficial effects on nightmare symptoms, imagery rescripting (IR) and imaginal exposure (IE) are commonly identified as active treatment components of nightmare therapies. With this randomized controlled trial, we compared IR and IE as individual treatments to a wait-list (WL) condition to determine whether these particular therapeutic elements reduced nightmare symptoms. For this purpose, 104 patients with a primary DSM-5 diagnosis of nightmare disorder were randomly assigned to three weekly individual sessions of either IR or IE, or WL. Results showed that compared to WL, both interventions effectively reduced nightmare frequency (ΔdIR-WL = 0.74; ΔdIE-WL = 0.70) and distress (ΔdIR-WL = 0.98; ΔdIE-WL = 1.35) in a sample that predominantly consisted of idiopathic nightmare sufferers. The effects of IR and IE were comparable to those observed for other psychological nightmare treatments. Initial effects at post-treatment were sustained at 3- and 6-month follow-up, indicating that IR and IE both seem to be efficacious treatment components of nightmare therapies. Additional research is needed to directly compare IR and IE among both idiographic and posttraumatic nightmare sufferers with respect to treatment expectancy, acceptability, and effectiveness.
... To sufficiently reactivate the emotions before the intervention, all interventions (ImRs, IE, EMDR) were preceded by a brief imagery exercise (see Kunze et al., 2017). Participants were instructed to close their eyes and imagine the beginning of the scene until they reached the most distressing part of their memory ("hotspot"). ...
... The ImRs protocol was adapted from Arntz and Weertman (1999) (see Kunze et al., 2017). The intervention started with a short explanation of the rationale and the memory reactivation as described above. ...
... Based on Kunze et al. (2017), the IE intervention protocol used in the present study was adapted from Foa and Rothbaum (1998). It began with a brief explanation of the rationale, followed by memory reactivation and imaginal exposure to the autobiographical memory. ...
Clinical theories suggest that trauma-focused interventions reduce intrusive memories while preserving voluntary recall. However, concerns persist that they may inadvertently compromise factual memory content. To test these contrasting predictions, we examined the effects of Eye Movement Desensitization and Reprocessing (EMDR), Imagery Rescripting (ImRs), Imaginal Exposure (IE), on involuntary and voluntary memories of an aversive autobiographical event. Healthy participants (N = 182), recruited between 2021 and 2023, completed a free recall task before receiving either one of the interventions or no intervention (NIC). One week later, the recall task was repeated. Intrusion load and frequency were assessed with an app-diary; psychophysiological responses to intrusions were assessed in a laboratory task. Independent raters evaluated disorganization, coherence, consistency of voluntary memory. All interventions reduced intrusion load, but only ImRs decreased intrusion frequency compared to NIC. Psychophysiological responses to intrusions showed no group differences. IE improved the structural organization of voluntary memory by reducing disorganized thoughts, while EMDR and ImRs enhanced conceptual organization by increasing contextual coherence. None of the interventions impaired memory consistency, with no group differences in contradictions or omissions. These findings suggest that these interventions reduce distressing intrusions without compromising voluntary memory. Further research should replicate these effects in clinical samples.
... To sufficiently reactivate the emotions before the intervention, all interventions (ImRs, IE, EMDR) were preceded by a brief imagery exercise (see Kunze et al., 2017). Participants were instructed to close their eyes and imagine the beginning of the scene until they reached the most distressing part of their memory ("hotspot"). ...
... The ImRs protocol was adapted from Arntz and Weertman (1999) (see Kunze et al., 2017). The intervention started with a short explanation of the rationale and the memory reactivation as described above. ...
... Based on Kunze et al. (2017), the IE intervention protocol used in the present study was adapted from Foa and Rothbaum (1998). It began with a brief explanation of the rationale, followed by memory reactivation and imaginal exposure to the autobiographical memory. ...
Clinical theories suggest that trauma-focused interventions reduce intrusive memories while preserving voluntary recall. However, concerns persist that they may inadvertently compromise factual memory content. To test these contrasting predictions, we examined the effects of Eye Movement Desensitization and Reprocessing (EMDR), Imagery Rescripting (ImRs), Imaginal Exposure (IE), on involuntary and voluntary memories of an aversive autobiographical event. Healthy participants (N = 182), recruited between 2021 and 2023, completed a free recall task before receiving either one of the interventions or no intervention (NIC). One week later, the recall task was repeated. Intrusion load and frequency were assessed with an app-diary; psychophysiological responses to intrusions were assessed in a laboratory task. Independent raters evaluated disorganization, coherence, consistency of voluntary memory. All interventions reduced intrusion load, but only ImRs decreased intrusion frequency compared to NIC. Psychophysiological responses to intrusions showed no group differences. IE improved the structural organization of voluntary memory by reducing disorganized thoughts, while EMDR and ImRs enhanced conceptual organization by increasing contextual coherence. None of the interventions impaired memory consistency, with no group differences in contradictions or omissions. These findings suggest that these interventions reduce distressing intrusions without compromising voluntary memory. Further research should replicate these effects in clinical samples.
... that has been tested for both post-traumatic and idiopathic nightmares (Augedal, Hansen, Kronhaug, Harvey, & Pallesen, 2013;Hansen, Hofling, Kroner-Borowik, Stangier, & Steil, 2013;Yücel et al., 2020). In an earlier study, we demonstrated the efficacy of face-to-face IRT delivered in an isolated single-component treatment format (Kunze, Arntz, Morina, Kindt, & Lancee, 2017). ...
... In order to extend the earlier findings in the current study, we aimed to demonstrate the efficacy of IRT in a telephone-guided self-help format with a protocol similar to the isolated treatment as employed in our earlier study (Kunze et al., 2017). Also, we aimed to replicate the finding that mastery is a mediator of the efficacy of IRT (Kunze et al., 2019). ...
... The power for the current study was based on Kunze et al. (2017), who observed a between-group effect size of d = 0.74. For the current study, we used a more conservative effect size estimate of Cohen's d = 0.60. ...
The currently best‐supported psychological treatment for nightmares is imagery rehearsal therapy. The problem, however, is that not enough trained practitioners are available to offer this treatment. A possible solution is to conduct imagery rehearsal therapy in a guided self‐help format. In the current study, 70 participants with nightmares according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders were randomized to either telephone‐guided imagery rehearsal therapy (n = 36) or a wait‐list condition (n = 34). Participants in the imagery rehearsal therapy condition received three sessions over the course of 5 weeks. Every treatment session was followed by telephone support delivered by postgraduate students. Participants who received imagery rehearsal therapy showed larger improvements on nightmare frequency (d = 1.03; p < .05), nightmare distress (d = 0.75; p < .05) and insomnia severity (d = 1.12; p < .001) compared with the participants in the wait‐list condition. The effects were sustained at 3‐ and 6‐month follow‐up. No significant effects were observed on the number of nights with nightmares per week, anxiety and depression. In line with earlier reports, the treatment effect was mediated by the increase of mastery at mid‐treatment, underlining the mechanistic value of mastery in imagery rehearsal therapy. The present study demonstrates that it is possible to deliver imagery rehearsal therapy in a self‐help format supported by unexperienced therapists and with relatively little time investment. This opens possibilities in terms of cost‐effectiveness, scalability and dissemination of imagery rehearsal therapy in the treatment of nightmares.
... To investigate the efficacy of the isolated treatment components (i.e., IR and IE), we specifically conducted a randomized wait-list (WL) controlled trial (Kunze, Lancee, Morina, Kindt, & Arntz, 2016). Results showed that compared to WL, both IR and IE significantly reduced nightmare frequency (Δd IR-WL = 0.74; Δd IE-WL = 0.70) and distress (Δd IR-WL = 0.98; Δd IE-WL = 1.35) from pre-to post-assessment (for details, see Kunze, Arntz, Morina, Kindt, & Lancee, 2017), indicating that IR and IE are effective treatment elements of nightmare therapies Kunze et al., 2017). ...
... To investigate the efficacy of the isolated treatment components (i.e., IR and IE), we specifically conducted a randomized wait-list (WL) controlled trial (Kunze, Lancee, Morina, Kindt, & Arntz, 2016). Results showed that compared to WL, both IR and IE significantly reduced nightmare frequency (Δd IR-WL = 0.74; Δd IE-WL = 0.70) and distress (Δd IR-WL = 0.98; Δd IE-WL = 1.35) from pre-to post-assessment (for details, see Kunze, Arntz, Morina, Kindt, & Lancee, 2017), indicating that IR and IE are effective treatment elements of nightmare therapies Kunze et al., 2017). ...
... For this purpose, we conducted a randomized wait-list (WL) controlled trial, where we first investigated the efficacy of three weekly IR and IE interventions as stand-alone, stripped-down treatments designed to target nightmares (Kunze et al., 2016). Symptom severity was evaluated at pre-and post-assessment (Kunze et al., 2017), and the proposed mediators of the treatment effect were measured in between the treatment sessions (except for SUD ratings, which were measured during treatment). We hypothesized that (1) reduction in SUD and (2) increased tolerability of emotions elicited by nightmares are important mediators of the treatment effect in IE. ...
Imagery rescripting (IR) and imaginal exposure (IE) are two efficacious treatments for nightmare disorder, but their discrete underlying mechanism(s) remain largely unknown. We therefore examined mediators of the treatment effects of IR and IE in a randomized wait-list controlled trial (N = 104). Therapeutic outcomes were assessed at pre- and post-assessment, and mediator assessment took place in between treatment sessions to establish a temporal relationship between mediators and nightmare symptoms (i.e., frequency and distress). In line with the hypothesis, enhanced mastery (or self-efficacy) of the nightmare content mediated the therapeutic efficacy of IR. Furthermore, the treatment effects of IE were mediated by increased tolerability of the negative emotions elicited by nightmares. Even though IR and IE for nightmares seem to produce similar therapeutic effects, the results of this study suggest that IR and IE tap into different underlying processes.
... Then he/ she is asked to imagine the nightmare, without modifying it, and to relax whenever it causes tension. During exposure therapy, the patient is also asked to imagine the nightmare vividly but without an accompanying relaxation exercise and also without actively changing the story line (Kunze, Arntz, Morina, Kindt, & Lancee, 2017). This method is adapted from traditional techniques for treating PTSD (e.g. ...
... Several trials have demonstrated the effectiveness of desensitization and exposure therapies (Davis & Wright, 2007;Hansen, Höfling, Kröner-Borowik, Stangier, & Steil, 2013). Kunze et al. (2017) showed a pure exposure protocol had similar effect sizes to a pure IRT protocol. ...
... However, one major disadvantage of desensitization and exposure therapies is that the arousal elicited during treatment may cause severe distress in the patient (Arntz, Tiesema, & Kindt, 2007, but see Kunze et al., 2017). ...
This consensus paper provides an overview of the state of the art in research on the aetiology and treatment of nightmare disorder and outlines further perspectives on these issues. It presents a definition of nightmares and nightmare disorder followed by epidemiological findings, and then explains existing models of nightmare aetiology in traumatized and non‐traumatized individuals. Chronic nightmares develop through the interaction of elevated hyperarousal and impaired fear extinction. This interplay is assumed to be facilitated by trait affect distress elicited by traumatic experiences, early childhood adversity and trait susceptibility, as well as by elevated thought suppression and potentially sleep‐disordered breathing. Accordingly, different treatment options for nightmares focus on their meaning, on the chronic repetition of the nightmare or on maladaptive beliefs. Clinically, knowledge of healthcare providers about nightmare disorder and the delivery of evidence‐based interventions in the healthcare system is discussed. Based on these findings, we highlight some future perspectives and potential further developments of nightmare treatments and research into nightmare aetiology.
... Over 20 controlled and uncontrolled trials have now been conducted, from 2001 (Krakow, et al.) to the most recent in 2017 (Kunze, Arntz, Nexhmedin, Kindt, & Lancee, 2017). Four meta-analyses of these trials have also been completed (Augedal, Hansen, Kronhaug, Harvey, & Pallesen, 2013;Casement & Swanson, 2012;Hansen, H€ ofling, Kr€ oner-Borowik, Stangier, & Steil, 2013;Yan-Yee Ho, Chan, & Nga-Sze Tang, 2016). ...
... One issue is that there is no single agreed treatment delivery, and several components are integrated together in different combinations such as: sleep hygiene; relaxation techniques; exposure; imagery rehearsal, and nightmare rescripting. Attempts to isolate which elements have the greatest impact through dismantling studies (Kunze et al., 2017;Pruiksma, Cranston, Rhudy, Micol, & Davis, 2018) have not produced any conclusive results. ...
... This was possibly due to the severe nature of participant symptoms and can be contrasted with more successful trials, where participants were civilians with idiopathic nightmares e.g. (Kunze et al., 2017;Cook et al., 2010) hypothesized that in the same way that psychotherapies for PTSD are less effective for complex and comorbid populations, the same may be true for nightmare treatments. ...
Nightmares are a hallmark symptom of Post-Traumatic Stress Disorder (PTSD), affecting an estimated 90% of trauma-exposed adults. This paper reports on a pragmatic randomized control trial to evaluate the effectiveness of an enhanced treatment approach called Planned Dream Interventions (PDI) compared with a standard sleep hygiene intervention. 92 UK Armed Forces veterans completed self-report measures (sleep quality, nightmares and PTSD) pre- and 1 month post-session. Large between group effect sizes (average d =1.1) were noted across all measures. Overall, findings suggest that PDI is a safe, resource efficient and effective intervention, though further validation is required.
... Over 20 controlled and uncontrolled trials have now been conducted, from 2001 (Krakow, et al.) to the most recent in 2017 (Kunze, Arntz, Nexhmedin, Kindt, & Lancee, 2017). Four meta-analyses of these trials have also been completed (Augedal, Hansen, Kronhaug, Harvey, & Pallesen, 2013;Casement & Swanson, 2012;Hansen, H€ ofling, Kr€ oner-Borowik, Stangier, & Steil, 2013;Yan-Yee Ho, Chan, & Nga-Sze Tang, 2016). ...
... One issue is that there is no single agreed treatment delivery, and several components are integrated together in different combinations such as: sleep hygiene; relaxation techniques; exposure; imagery rehearsal, and nightmare rescripting. Attempts to isolate which elements have the greatest impact through dismantling studies (Kunze et al., 2017;Pruiksma, Cranston, Rhudy, Micol, & Davis, 2018) have not produced any conclusive results. ...
... This was possibly due to the severe nature of participant symptoms and can be contrasted with more successful trials, where participants were civilians with idiopathic nightmares e.g. (Kunze et al., 2017;Cook et al., 2010) hypothesized that in the same way that psychotherapies for PTSD are less effective for complex and comorbid populations, the same may be true for nightmare treatments. ...
Nightmares are a hallmark symptom of Post-Traumatic Stress Disorder (PTSD), affecting an estimated 90% of trauma-exposed adults. This article reports on a pragmatic randomized control trial to evaluate the effectiveness of an enhanced treatment approach called Planned Dream Interventions (PDI) compared with a standard sleep hygiene intervention. Ninety-two U.K. Armed Forces veterans completed self-report measures (sleep quality, nightmares, and PTSD) pre- and 1-month post-session. Large between group effect sizes (average d = 1.1) were noted across all measures. Overall, findings suggest that PDI is a safe, resource efficient and effective intervention, though further validation is required.
... In order to reactivate the emotions sufficiently to address them in treatment, all interventions (ImRs, IE, EMDR) were preceded by a short imagery exercise (see Kunze et al., 2017). Participants were first instructed to close their eyes and to reactivate the beginning of the scene until the worst part of their memory ("hotspot") was reached. ...
... The ImRs protocol was adapted from Arntz and Weertman (1999; see Kunze et al., 2017). The intervention started with a short explanation of the rationale. ...
Eye Movement Desensitization and Reprocessing (EMDR), Imaginal Exposure (IE), and Imagery Rescripting (ImRs) are trauma-focused interventions aimed at reducing trauma-associated psychopathology. Despite their clinical effectiveness, concerns remain about the potential impact of these interventions on the accuracy of memories addressed in treatment. This study therefore examined the effects of EMDR, IE and ImRs on memory accuracy.Two hundred sixty-five healthy participants underwent the Trier Social Stress Test and received one of the three interventions or no intervention (NIC) on the following day. Memory accuracy was assessed one week later using a cued recall task.Contrary to expectations, the interventions showed no differences in their effects on memory accuracy; thus, the three interventions led to neither an improvement nor an impairment in memory compared to NIC. This aligns with recent findings indicating that ImRs and IE do not distort memory. Although there are studies suggesting that EMDR impairs memory accuracy, this could not be confirmed in our study. The findings challenge the notion that trauma-focused psychological treatments such as EMDR, ImRs, and IE cause memory alterations, which is particularly reassuring in legal contexts where accurate memory recall by trauma survivors is crucial. However, further research is needed to ensure that the results generalize to risk constellations and more complex, emotionally charged events in clinical samples.
... Several trials have demonstrated the effectiveness of these therapies [37,39,46]. Notably, Kunze et al. found that a pure exposure protocol produced similar effect sizes to an imagery rescripting protocol at three and six month follow-up [47]. However, a significant drawback of desensitization and exposure therapies is that the arousal induced during treatment can result to severe distress in some patients [47]. ...
... Notably, Kunze et al. found that a pure exposure protocol produced similar effect sizes to an imagery rescripting protocol at three and six month follow-up [47]. However, a significant drawback of desensitization and exposure therapies is that the arousal induced during treatment can result to severe distress in some patients [47]. ...
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.
... indicating high variability in the intervention effects between the included studies. As three studies appeared to be significant outliers (Maloney et al. 2019;Kunze et al. 2017;Sosic-Vasic et al. under review), we conducted an additional analysis with these studies removed (n = 602). Results improved regarding heterogeneity (I 2 = 26.5; ...
... 0.22]) in favor for the imagery rescripting intervention. For both secondary outcome measures (SO1 & SO2) only four studies (Romano et al. 2020;Kunze et al. 2017;Schmid et al. 2021;Ovanessian et al. 2019) reported follow-up assessments comparing the intervention group to the active control group. In both cases, we rated the number of trials as too small to conduct a meta-analysis. ...
There is an unmet need for effective short-term therapeutic techniques to reduce clinical symptoms associated with prospective-, as well as retrospective aversive mental images across mental disorders. We investigated the efficacy of imagery rescripting (IR) as a short-term intervention across clinical disorders, as the literature suggests that this technique could be a promising intervention to reduce psychopathology by altering intrusive mental images. A systematic literature review identified 23 trials including 805 adult patients, out of which 15 trials were designed as randomized controlled trials (RCT) including patients with the following diagnoses: Social anxiety disorder (SAD), Posttraumatic-Stress-Disorder (PTSD), Bulimia Nervosa, Borderline-Personality-Disorder, Obsessive-Compulsive Disorder, nightmare disorder, test anxiety, health anxiety, and Generalized Anxiety Disorder. Most studies (14) comprised of one treatment session. Effect size estimates indicate that IR is highly effective in reducing clinical symptoms associated with mental images from pre-, to post-treatment (g = 1.09, 95% CI = [0.64; 1.53]), as well as from pre-treatment to follow-up (g = 1.90, 95% CI = [1.02; 2.77]). Comparing the IR intervention to a passive control group showed large effect sizes at post-treatment (g =-0.99; 95% CI = [-1.79;-0.20]), however, comparing IR to an active control group resulted in a small effect (g =-0.05; 95% CI = [-0.43; 0.33]). Lastly, large effects of IR were found for the SAD and PTSD subgroups, for comorbid symptoms of depression. In summary, our results indicate that IR is a promising short-term therapeutic technique for clinical symptoms associated with aversive prospective-, and retrospective mental images.
... Plusieurs études ont montré l'efficacité de la thérapie d'exposition comme traitement des cauchemars [49][50][51][52]. Kunze et al. [53] ont montré que la thérapie d'exposition avait une efficacité équivalente à la RIM dans un essai contrôlé randomisé, se poursuivant à 3 et 6 mois de suivi. L'inconvénient de cette technique peut être le risque de réémergence d'une détresse importante lors des séances [53]. ...
... Kunze et al. [53] ont montré que la thérapie d'exposition avait une efficacité équivalente à la RIM dans un essai contrôlé randomisé, se poursuivant à 3 et 6 mois de suivi. L'inconvénient de cette technique peut être le risque de réémergence d'une détresse importante lors des séances [53]. ...
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.
... Imagery Rehearsal Therapy IRT has been tested on different PTSD groups, such as veterans (Moore & Krakow, 2010;Nappi, Drummond, Thorp & Mcquaid, 2010), patients with diverse psychiatric diagnosis (van Schagen, Lancee, de Groot, Spoormaker & van den Bout, 2010) and sexual assault victims (Krakow et al., 2000;Krakow et al., 2001). IRT is the most empirically supported treatment for recurrent nightmares and overall shows promising results (Kunze et al., 2017;Sandahl et al. 2021). ...
... 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). Germain et al. (2004) argue that the exposure element in IRT is not used extensively enough to be the most potent therapeutic method. ...
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.
... Both ImRs interventions were standardized and delivered via audio. The ImRs procedure was adapted from Arntz and Weertman (1999) and consisted of a brief imagery exercise for memory reactivation and a rescripting phase (see Kunze et al., 2017). Participants were first instructed to close their eyes and to reactivate the beginning of the scene as told. ...
Imagery Rescripting (ImRs) has proven effective in reducing involuntary emotional memories. However, it is unclear whether and when it may lead to reduced accuracy of voluntary memory. Although previous analogue studies suggest that ImRs does not pose a general risk regarding memory distortion, it can not be ruled out that ImRs could cause memory impairment under certain risk conditions. In our three-day online trauma film study we investigated in a healthy sample (N = 267) whether specific instructions during ImRs as typically provided in clinical practice (i.e., detailed imagery with a sensory focus) increase the risk of memory distortions. Additionally, we examined whether the completeness of the original memory moderates these instruction effects. Contrary to our expectations, a sensory focus during ImRs was associated with higher memory accuracy in a recognition task, independently of the quality of the original memory. These results extend previous findings by suggesting that ImRs does not even impair memory performance when the quality of the original memory is poor and when the production of sensory-rich images is specifically encouraged. Our results question current practices employed to assess witness statement credibility, which are partly based on concerns that trauma-focused interventions like ImRs undermine memory accuracy.
... Therefore, the patient rewrites the scenario and rehearses it daily in his or her imagination (Aurora et al., 2010;Levrier et al., 2018). IRT not only improves sleep quality, decreases nightmare frequency and distress, it also has a positive effect on PTSD symptoms such as avoidance, intrusion, and hyperarousal (El-Solh, 2018;Kunze et al., 2017). IRT can be considered a stand-alone therapeutic intervention, or it can be received in addition to other therapy. ...
Posttraumatic nightmares (PTN) are a frequent symptom after a traumatic event and often play part in the psychopathology of patients with borderline personality disorder (BPD). Imagery rehearsal therapy (IRT) currently offers the best evidence for an effective treatment to reduce PTNs, although high drop‐out rates are common. Art therapy in IRT may counteract this, by its indirect, nonverbal, and often playful approach that helps to break through avoidance. This case study focusses on the perception of a patient with BPD in an art therapy based IRT treatment for patients with PTNs. It tells the story of Aurelia, a 40‐year‐old woman who, within this treatment, processes traumatic contents of her childhood like physical and sexual violence, but also current interactional problems that manifest themselves in her nightmares. Following the IR‐AT treatment for PTNs Aurelia noticed a reduction in her nightmares, was less afraid of them and felt calmer towards her trauma. She expressed herself in the art medium and by this developed more self‐efficacy. Her process resulted in an integration of the trauma and a perceived decrease in borderline symptoms. Future research can build on this basis to further explore the mechanisms and effects of IR‐AT for PTNs.
... With this growing evidence, the possibilities for its application also broadened. For example, Jung and Steil (2013) showed that ImRs reduced feelings of being contaminated in patients with PTSD due to childhood sexual abuse, and Kunze et al. (2017) showed that ImRs helped in reducing nightmares. A recent study showed that ImRs is as effective as EMDR in reducing PTSD symptoms arising from childhood trauma, with approximately 60 percent of these childhood traumas being sexual abuse (Boterhoven de Haan et al., 2020). ...
This study piloted the efficacy and acceptability of Virtual Reality Imagery Rescripting (VR-ImRs) compared to conventional Imagery Rescripting (ImRs) for PTSD due to childhood sexual abuse (CSA). Eight adult patients with clinician-rated PTSD due to CSA as their primary diagnosis participated, of whom six completed the full treatment. A non-concurrent multiple baseline design with cross-over elements was used, with randomly assigned baseline lengths and treatment conditions. After baseline and a 5-session ‘education and exploration’ phase, six sessions of either ImRs or VR-ImRs were given, followed by another six sessions of the opposite treatment condition and a 5-week follow-up without treatment. The primary outcome was PTSD symptoms (PCL-5), and secondary outcomes were negative and positive emotions (added PCL-5 items), anxiety and depressive symptoms (HADS) and trauma-related cognitions (PTCI). Data were analyzed with mixed regression. Results showed a significant linear reduction of trauma symptoms and negative emotions only during ImRs. No significant treatment effects on positive emotion, anxiety and depressive symptoms were found for both treatment conditions. Both treatment conditions showed significant positive effects on trauma-related cognitions. This study does not support the efficacy of VR-ImRs in reducing PTSD symptoms. Possibly VR-ImRs keeps people from reprocessing their memories, making it less effective.
... Taylor et al., 2020), nightmares (e.g. Kunze et al., 2017), and even metaphorical images generated purely for the purpose of being rescripted : Essentially it can be applied to anything imagebased with a problematic meaning that causes distress or impairment. Imagery rescripting is not generally conceptualized as directly trying to change interpretation biases. ...
In an effort to develop and improve psychological treatments, translational research appears especially promising. In this chapter we present a conceptual framework of translational research, in which we outline different steps in the translational chain from basic research, to experimental psychopathology research, and to clinical trial research. At each step, we summarize which research questions can be answered and which methods are necessary to do so. Based on our conceptual framework, we discuss some challenges of translational research (e.g., replicability and stability of research results) and make recommendations for researchers using this framework.KeywordsTranslational researchBasic researchExperimental psychopathologyClinical trial research
... Despite the effectiveness of cognitive reconstruction in treating nightmares, researches have shown that the symptoms of nightmares remain to a large extent, as in one study, 60% of people in the post-treatment phase still had nightmares. Therefore, a protocol more efficient than imagery and cognitive reconstruction is required (14). The results of a case study on a woman whose nightmares were caused by a road accident showed the treatment of nightmares with interpersonal psychodynamic style reduced the frequency of nightmares to zero (15). ...
Background: Nightmare is a prevalent parasomnia associated with various forms of psychological distress in both clinical and general populations. This study aimed to explain the experiences of a client regarding the effects of nightmares and effectiveness of dream analysis treatment on idiopathic nightmares. Methods: This qualitative study was conducted on a 34-year-old woman who participated in 8 sessions of dream analysis treatment. The client was diagnosed with nightmare disorder based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for nightmare. The hermeneutic method was used to collect and analyze quantitative and qualitative data. This study utilized a simple method for hermeneutic analysis that requires only one person while maintaining research validity. Results: The findings of this study showed the frequency of nightmares decreased during the treatment. The client changed significantly during the treatment, and the dream analysis was responsible for this change. According to Bohart’s grid, there was 72% certainty of change in the client and 87% certainty that improvements were due to therapy. Useful therapeutic factors included analyzing the hidden meaning of nightmares, expressing emotions, self-awareness, and reducing helplessness. Conclusion: The results of the interventions showed that treatment processes made changes in the client that were unexpected and important to her and these changes would not have occurred without the treatment. This method, in addition to exposing the person to the content of the nightmare, leads to the discovery and decoding of the content of the nightmares and understanding of their message to resolve conflicts.
... As nightmares have been under-reported, under-diagnosed, and untreated [18,51], these findings underscore the need to assess and treat frequent nightmares and distress associated with nightmares in routine clinical practice and mental health services for adolescents. Effective nonpharmacological therapies, such as cognitive behavior therapy (CBT) [62], imagery rescripting (IR) and imaginal exposure (IE) [63], should be incorporated into clinical practice for adolescents with frequent nightmares to reduce nightmare frequency and distress. Schoolbased intervention programs targeting nightmare frequency and distress may have important implications for mental health among adolescents at risk. ...
Purpose
Nightmares are common, especially in pediatric populations and psychiatric patients. Nightmares are associated with daytime distress and negative health outcomes. The data on the prevalence and psychopathological profiles of nightmares in Chinese adolescents are limited. This study examined age and gender differences in nightmare frequency and associated psychopathological problems in a large sample of Chinese adolescents.
Methods
A total of 11,831 adolescent students (mean age = 14.9, 12–18 years) participated in the baseline survey of Shandong Adolescent Behavior and Health Cohort. Participants completed a self-administered questionnaire to report their nightmare frequency, trait anger, hopelessness, and multiple domains of behavioral/emotional problems. Univariate and multivariate analyses were performed to examine psychopathological problems in relation to nightmare frequency.
Results
Of the sample, 45.2% reported having nightmares at least once in the past month and 7.9% at least once/week. Girls reported more frequent nightmares than boys. Nightmare frequency significantly declined with age for both boys and girls. Mean scores on trait anger, hopelessness, attention, internalizing problems, and externalizing problems significantly increased with nightmare frequency. Frequent nightmares (at least once/week) were significantly associated with 2–4-fold increased likelihood of behavioral/emotional problems after adjusting for adolescent and family covariates.
Conclusion
Nightmares are prevalent in Chinese adolescents. Frequent nightmares are associated with multiple domains of psychopathological problems. Assessment and intervention of frequent nightmares should be incorporated into routine clinical practice and mental health services in adolescents.
... Due to the current study design enduring effects of imagery could not be investigated. To test this in future studies, short interventions would have to be presented more frequently or the effect would have to be recorded in the short term (e.g., on the next day) (see the studies on imagery rescripting by Kunze et al., 2017;Siegesleitner et al., 2019). A fourth limitation could be that habituation effects could not be tested directly, because a non-imagery condition was not included. ...
Background
Strong feelings of disgust and anxiety are maintaining factors in contamination-related obsessive–compulsive disorder (C-OCD). To this day there are not many studies that investigated strategies for changing pathological disgust. In a previous study, it was shown that imagery rescripting could successfully change disgust. However, whether imagery rescripting or more general imagery processing, helps to reduce pathological disgust, remains unclear. Therefore, the aim of the present study was to investigate how successful imagery rescripting is in comparison to imagery self-compassion and a passive positive imagery condition in reducing disgust.
Methods
For this, the three strategies were compared to each other on 2 days (within-subject) in a laboratory experiment. The study included 24 subjects with diagnosed C-OCD, and 24 matched, healthy controls (between-subject).
Results
The results show that all three strategies changed disgust, they do not differ from each other and that different traits appear to influence the strategies’ success or failure. The theoretically derived underlying mechanisms of the strategies were found in an elaborate content analysis.
Conclusions
The present study provides first indications that imagery in general can help to change pathological disgust experience.
... Actually, in clinical practice, dreams tend to be marginalized, and addressing distress or dysfunction associated with nightmares may well be significant benefits (Leonard and Dawson, 2018). Psychological therapies, such as Cognitive Behavioural Therapy (CBT) (Sheaves et al., 2019), Imagery Rehearsal Therapy (IRT) (van Schagen et al., 2015), Imagery Rescripting (IR) and Imaginal Exposure (IE) (Kunze et al., 2017), have shown significant effectiveness in reducing nightmare frequency and buffering nightmare distress. Interventions for psychopathology, like depressive symptoms, might well benefit from promoting coping strategies aiming to reduce nightmare frequency and nightmare distress. ...
Background
: Frequent nightmares are related to depressive symptoms in adolescents. Little is known about pathways from frequent nightmares to depressive symptoms. This study aimed to examine the mediation effect of nightmare distress in the association between frequent nightmares and depressive symptoms in a large sample of Chinese adolescents.
Methods
: A total of 11831 adolescents who participated in the baseline survey of Shandong Adolescent Behavior and Health Cohort were included in the analysis. A self-administered questionnaire was used to measure nightmare frequency, nightmare distress, depressive symptoms, sleep duration, insomnia, and demographic characteristics. Linear regressions and mediation analyses were performed to examine the associations between frequent nightmares, nightmare distress and depressive symptoms.
Results
: Of 11831 participates, 50.9% were males and the mean age was 14.97. Adolescents with frequent nightmares scored significantly higher on nightmare distress (t=29.87, P<0.001) and depressive symptoms (t=20.05, P<0.001) than those adolescents without frequent nightmares. Frequent nightmares (β=1.04, 95%CI: 0.48-1.60) and nightmare distress (β=0.30, 95%CI: 0.28-0.32) were associated with depressive symptoms. Mediation analyses showed that nightmare distress accounted for 63.76% of the total effects in the entire sample, 51.17% in males and 80.00% in females, respectively.
Limitation
: No causality could be made from the cross-sectional data and possible information bias due to self-report.
Conclusions
: The association between frequent nightmares and depressive symptoms appears to be substantially mediated by nightmare distress. Assessing and intervening distress associated with frequent nightmares may have important clinical implications for reducing the risk of depression in adolescents.
... Imagery rescripting has been studied as an adjunct treatment in many mental disorders (see Morina et al., 2017 for a meta-analysis) such as post-traumatic stress disorder (PTSD; Arntz, Tiesema, & Kindt, 2007;Smucker, Dancu, Foa, & Niederee 1995), social anxiety disorder (Knutsson, Nilsson, Eriksson, & Järild, 2019;Norton & Abbott, 2016;Romano, Moscovitch, Huppert, Reimer, & Moscovitch, 2020;Wild & Clark, 2011) obsessive compulsive disorder (see Strachan, Hyett, & McEvoy, 2020 for a review; Maloney, Koh, Roberts, & Pittenger, 2019), depression (Brewin et al., 2009;Wheatley et al., 2007), personality disorder (Brockman & Calvert, 2017;Schaitz, Kroener, Maier, Connemann, & Sosic-Vasic, 2020), and nightmares (Kunze, Arntz, Morina, Kindt, & Lancee, 2017;Kunze, Lancee, Morina, Kindt & Arntz, 2019). Strachan's recent review (2020) suggested that imagery rescripting is effective in reducing cognitiveaffective, physiological and behavioral symptoms of social anxiety disorders and reductions in OCD symptoms. ...
Imagery rescripting (IR) has been widely used to treat various mental health problems, however, little is known about its usefulness in eating disorders. The primary aim of this pilot study was to evaluate the feasibility of using a face-to-face imagery rescripting as a treatment adjunct among day patients with an eating disorder. Our secondary aim was to investigate within-group effect size changes between groups in order to ensure the suitability of IR in this population. Twelve participants were recruited from the Statewide Eating Disorders Services and were randomly assigned to either treatment as usual (TAU) or treatment as usual plus imagery rescripting (TAU + IR). Participants in the TAU + IR group received a one-hour face-to-face imagery rescripting session with a postgraduate trainee therapist within their first week of treatment. Outcome measures, including psychological distress, eating disorder symptoms, self-compassion and dysfunctional attitudes, were measured at baseline and 4 weeks. Overall, feasibility was promising with all participants completing the protocol and assessment once randomised, but no one completed seven days of home practice. Recruitment was slow with less than 50% agreeing to be randomised. TAU demonstrated a quicker reduction in symptoms than the TAU + IR group. Possible explanations include the timing of the imagery rescripting session was not appropriate for this group of patients, IR has a longer term effect that cannot be observed in merely four weeks, or the current form of imagery rescripting is not appropriate to use with this group of patients. Future research is needed to clarify whether imagery rescripting is indeed appropriate to use for eating disorder patients, and if so, how it can best be delivered (e.g., time point, content, targeted population).
... All intervention sessions were video recorded and an independent graduate student blind to condition rated a randomly selected 10 % of sessions on protocol adherence (see Supplementary Materials for the protocol based on Kunze, Arntz, Morina, Kindt, & Lancee, 2017). Participants also completed the Session Rating Scale (SRS; Duncan et al., 2003), a measure of therapeutic alliance on which they rated the degree to which the session met their needs in terms of four qualities (therapeutic relationship, goals and tasks, therapist approach, and overall fit of the session), yielding a total score on a 0-40 scale, with higher scores indicating stronger ratings of therapeutic alliance (α = .93). ...
Background
Imagery rescripting (IR) is an effective intervention for social anxiety disorder (SAD) that targets autobiographical memories of painful past events. IR is thought to promote needs fulfillment and memory updating by guiding patients to change unhelpful schema through addressing the needs of the younger self within the memory.Methods
Qualitative coding was used to examine the features of clinically relevant strategies enacted during IR to fulfill needs and update memories in 14 individuals with SAD.ResultsParticipants typically enacted multiple strategies to address the needs of the younger self during rescripting, with compassionate and assertive strategies used more frequently than avoidance. Most strategies were practically feasible and enacted by the imagined self rather than imagined others, with the majority of patients achieving a strong degree of needs fulfillment, especially when strategies were consistent with identified needs. Participants’ reflections on how their memories have changed are provided from follow-up data collected 6 months post-intervention. Themes of self-reappraisal, self-compassion, and self-distancing are highlighted as potentially important for facilitating needs fulfilment and memory updating.Conclusions
Findings illuminate the clinical processes through which socially traumatic memories in SAD may be updated in IR by guiding patients to fulfill their needs and promote improved emotional health.
... Furthermore, because perceived daytime stress and depression did not fully mediate the relationship between nightmare distress and positive psychotic experiences, nightmare distress needs to be addressed in interventions separately. Psychological interventions, such as imagery rescripting (IR) and imaginal exposure (IE), have been shown to effectively reduce nightmare frequency and distress [65,66]. Importantly, in recent studies these interventions have also been shown to be efficacious in individuals with persecutory symptoms [28,67]. ...
Background:
There is indication that frequent nightmares are an early indicator of psychotic disorders in adolescents and young adults. Yet which aspects of nightmares are relevant and how they contribute to psychotic experiences has remained unclear.
Methods:
We conducted a cross-sectional online survey in a community sample of young adults between the ages of 18 and 27 (n=486) to identify aspects of nightmares (nightmare frequency (NF), nightmare distress (ND), nightmare contents), that are related to specific psychotic experiences (paranoid thoughts, hallucinations, negative symptoms) after controlling for sleep quality, and examined factors that potentially mediate this relationship (stress, depression).
Results:
Nightmare frequency and -distress were significantly associated with paranoid thoughts, hallucinations and negative symptoms (NF: rs = .293 - .139; ND: rs = .411 - .166). Nightmares significantly added to explaining paranoid thoughts and hallucinations, over and above sleep quality, but not to explaining negative symptoms. The relations between nightmare distress and psychotic experiences were partially mediated by stress (percentage mediated for paranoid thoughts: 38.20%; for hallucinations: 11.77%) and depression (percentage mediated for paranoid thoughts: 56.61%; for hallucinations: 28.02%). The most commonly reported nightmare contents revolved around being chased, falling and losing a close relative and specific contents were significantly related to the frequency of hallucinations (e.g., threatening surroundings, OR = 1.73) or paranoia (e.g., workspace bullying, OR = 2.02).
Conclusions:
Thorough assessments of nightmares and sleep disturbances in young individuals could facilitate early detection of those at risk and help to target preventive treatments. However, longitudinal studies are needed to test for a causal relationship between nightmares and the development of psychotic symptoms.
... All intervention sessions were video recorded and an independent graduate student blind to condition rated a randomly selected 10 % of sessions on protocol adherence (see Supplementary Materials for the protocol based on Kunze, Arntz, Morina, Kindt, & Lancee, 2017). Participants also completed the Session Rating Scale (SRS; Duncan et al., 2003), a measure of therapeutic alliance on which they rated the degree to which the session met their needs in terms of four qualities (therapeutic relationship, goals and tasks, therapist approach, and overall fit of the session), yielding a total score on a 0-40 scale, with higher scores indicating stronger ratings of therapeutic alliance (α = .93). ...
Imagery rescripting (IR) is an effective intervention for social anxiety disorder (SAD) that targets negative autobiographical memories. IR has been theorized to work through various memory mechanisms, including modifying the content of negative memory representations, changing memory appraisals, and improving negative schema or core beliefs about self and others. However, no prior studies have investigated the unique effects of rescripting itself relative to other IR intervention components on these proposed mechanisms. In this preliminary study, 33 individuals with SAD were randomized to receive a single session of IR, imaginal exposure (IE), or supportive counselling (SC). Memory outcomes were assessed at 1- and 2-weeks post-intervention and at 3-months follow-up. Results demonstrated that the content of participants' autobiographical memory representations changed in distinct ways across the three conditions. Whereas IR facilitated increases only in positive/neutral memory details, IE facilitated increases in both positive/neutral and negative memory details and SC facilitated no changes in memory details. Although memory appraisals did not differ across conditions, participants who received IR were more likely to update their negative memory-derived core beliefs. These unique effects of rescripting on memory representations and core beliefs enhance our understanding of the memory-based mechanisms of IR within the context of exposure-based learning for people with SAD.
... It differs with IRT only in the exposure part of therapy [46]. Kunze et al. [49] performed imagery IRT and ERRT in two patients with nightmare disorder and reported positive results (improvement of sleep quality, reduction in the frequency/intensity of nightmares) and this result sustained at 3-and 6-months follow-up as well. Finally, Davis et. ...
Parasomnias are abnormal behaviors that occur during the sleep and can be associated, in particular during adulthood, with impaired sleep quality, daytime dysfunction and occasionally with violent and harmful nocturnal behaviors. In these cases, therapies are often considered. Pharmacological treatments are invasive and often have limited efficacy. Therefore, behavioral approaches remain an important treatment option for several types of parasomnias. However, the evidence-based approaches are limited. In the current review, we highlight results from various non-pharmacological techniques on different types of parasomnias and provide a glimpse into the future of non-pharmacological treatments in this field.
... Enfin, une étude d'utilisation de « self-help treatment » sur six semaines en comparant l'utilisation de l'IRT et de techniques d'exposition auprès de 399 personnes indique que l'IRT réduit la fréquence des cauchemars alors que les expositions réduisent plutôt l'intensité des angoisses [55]. D'une manière générale, l'IRT est plus efficace dans une étude comparée de 268 participants mais le schéma « entraide, IRT, exposition » reste recommandé [56] ; • le traitement par exposition en imagination (IE) et le traitement par re-scénarisation (IRT) semblent avoir la même efficacité sur une étude comparative sur 104 patients, avec un maintien des bénéfices à 3 et 6 mois [57], toutefois Hansen et al. ...
A number of writers from the cognitivist movement have developed tools to tackle the dreams of their clients. As reflections of automatic thoughts or thought patterns, dreams could become tools for change in everyday life. This has yet to be scientifically demonstrated. The therapeutic approach to recurring nightmares, particularly in Post Traumatic Stress Disorders, has led to the development of several care protocols. Among them, Examining Exposure, Relaxation, and Rescription Therapy (ERRT) and Imagery Rehearsal Treatment (IRT) have demonstrated their effectiveness through numerous studies. These treatments are based on the clients’ increased sense and feeling of control. Let us hope that cognitive and behavioral therapies will be able to understand and develop scientifically the utility of dreams on the one hand, and the treatment of nightmares on the other!
... In die Metaanalyse von Augedal et al. [22] sind insgesamt 4 Studien einbezogen worden, die gute Effekte zeigten. Auch eine aktuelle Studie [23] belegt den positiven Effekt von Exposition auf die Albtraumhäufigkeit. Die Aufgabe, die Albträume aufzuschreiben als Gegenmaßnahme zum Vergessenwollen, zeigte zwar einen kleinen Effekt auf die Abnahme der Albtraumhäufigkeit, jedoch war dieser Effekt nicht signifikant [22]. ...
Albträume werden von vielen Menschen zumindest gelegentlich erlebt. Allerdings ist auch die Albtraumstörung, bei der Albträume so häufig auftreten, dass sie das Wachleben klinisch signifikant beeinträchtigen, mit etwa 5 % recht häufig in der Allgemeinbevölkerung. Zur Erklärung der Albträume wird ein Veranlagungs-Stress-Modell herangezogen. Auch das Erleben von Traumata und einige Medikamentengruppen können zu Albträumen führen. Obwohl es wirksame Therapieansätze gibt, ist die Albtraumstörung unterdiagnostiziert (es wird selten explizit danach gefragt) und unterbehandelt. Auch die Betroffenen selbst wenden sich selten an professionelle Helfer. Die am besten evaluierte Behandlungsstrategie ist die Imagery Rehearsal Therapy, die aus 3 Schritten (Konfrontation, Bewältigung, Einüben) besteht. Aufklärungsarbeit ist notwendig, damit die Versorgungssituation für betroffene Personen verbessert werden kann.
... Several hypotheses explaining the effectiveness of nightmare treatments have been put forth, but supporting empirical data are lacking (Nappi et al., 2012). In addition, many IRT variants exist, and few dismantling studies have examined the contributions of various therapeutic components (Kunze et al., 2017;Pruiksma et al., 2016), rendering the choice of which approach to favor unclear (Harb et al., 2013). Thus, a common vision of IRT's mechanisms of action appears necessary to justify new treatment protocols, efficiently orient future research, and help clinicians adapt treatment to their patient's characteristics. ...
Imagery rehearsal therapy (IRT) is an empirically validated therapy targeting recurring nightmares, for which the mechanisms of action remain poorly understood. The objective of this study was to investigate how an exploratory measure of self-efficacy could mediate IRT's effectiveness. Thirty-five victims of sexual assault with recurring nightmares were randomly assigned to either IRT or a control condition. Participants completed questionnaires about self-efficacy and nocturnal symptoms at pre- and posttreatment. Regression analyses showed that IRT predicted greater self-efficacy about dreams (β = .578) and that self-efficacy about dreams predicted improvement in insomnia (β = -.378). IRT also predicted greater self-efficacy about nightmares (β = .366), which in turn predicts sleep quality (β = -.412). However, self-efficacy was not a significant mediator of IRT's effectiveness on insomnia and sleep quality. Although IRT did increase patients' self-efficacy over dreams and nightmares, self-efficacy may not be a primary mechanism of action explaining IRT's effectiveness.
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.
Background
Nightmares may lead to psychotic‐like experiences (PLEs). The present study aimed to examine the potential moderating and mediating effects of mental health literacy (MHL) on the association between nightmare distress (ND) and PLEs among Chinese college students.
Methods
A total of 4000 college students who have had nightmares in the past year were assessed using the Chinese version of the nightmare distress questionnaire (NDQ‐CV), mental health knowledge questionnaire (MHKQ), 15‐item positive subscale of the community assessment of psychic experiences (CAPE‐P15), 2‐item insomnia questionnaire, 2‐item patient health questionnaire (PHQ‐2), and a self‐compiled sample characteristics questionnaire.
Results
Greater ND and lower MHL were associated with an elevated risk of PLEs among college students when adjusting for sample characteristics, insomnia and depressive symptoms. Moderation analysis indicated that MHL buffers the association between ND and PLEs, such that a higher level of MHL attenuates the positive effect of ND on PLEs to a greater extent.
Conclusions
These findings strongly stressed the urgent need for early intervention in college students with ND. Strategies should prioritise treating ND and enhancing MHL, as these may be effective approaches to preventing and reducing PLEs.
BACKGROUND
Most of the recent research on nightmare distress and depressive symptoms has focused on adolescents and students, with less research on the nurse population. Emergency department nurses are at high risk for nightmare distress and depressive symptoms, but no studies have been conducted to explore the relationship between the two; thus, further investigation is needed.
AIM
To understand the relationship between nightmare distress and depressive symptoms among emergency department nurses in China.
METHODS
A convenience sampling method was used to select 280 emergency department nurses from nine provinces, including Jiangxi, Sichuan, Jiangsu, and Shanxi Provinces. The Chinese version of the Nightmare Distress Questionnaire and the Center for Epidemiological Studies Depression Scale (CES-D) were administered.
RESULTS
Emergency department nurses’ nightmare distress scores were positively associated with depressive symptom scores (r = 0.732), depressed affect (r = 0.727), somatic symptoms (r = 0.737), and interpersonal difficulty (r = 0.647). Further multiple linear regression analyses showed that education level, work pressure, self-reported health, and CES-D scores were factors that influenced nightmare distress among Chinese emergency department nurses (P < 0.05).
CONCLUSION
Nightmare distress is closely associated with depressive symptoms in Chinese emergency department nurses, and early intervention is recommended for professionals with this type of sleep disorder to reduce the occurrence of depressive symptoms.
Mental imagery can provide a particularly effective means to affect emotions, cognitions, and behaviour, and has long been used within psychological therapies for this purpose. This chapter explores the relationships between mental imagery and interpretational processing biases, including how mental imagery can be used to change these biases. It starts by considering the broader connections between imagery and interpretation, before addressing techniques commonly used within cognitive behaviour therapy to modify interpretation biases and how imagery can potentially enhance these. It then discusses computerized cognitive training procedures that are designed to target interpretation biases directly, focusing on those in which mental imagery plays a central role. Mental imagery offers many possibilities for changing interpretation biases, and investigating these, and the more fundamental question of the interplay between imagery and interpretation, presents many opportunities for future research to improve treatment outcomes.KeywordsInterpretation biasMental imageryCognitive bias modificationImagery rescriptingCognitive behaviour therapy
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.
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.
Preliminary evidence shows that brief, condensed imaginal exposure only interventions can be effective in the treatment of PTSD, but we need to understand its mechanisms of action. Consistent with extinction learning and retrieval processes, the present study examined whether a pattern of between-session distress reduction observed during standard prolonged exposure (PE) therapy would be observed and predict outcome. Sixty-three patients with PTSD were enrolled in two clinical trials using our treatment protocol consisting of six daily 50-min sessions focusing on imaginal exposure and processing only. Individual patient trajectories of distress reduction were examined over the course of the five imaginal exposure sessions (Sessions 2-6). Overall, significant linear distress reduction was observed for anticipatory (d = 1.18), peak (d = 1.83), and ending imaginal exposure distress (d = 1.21). Consistent with extinction learning, the steeper slope of peak distress (d = 1.03) and end distress (d = 0.68) across imaginal exposure sessions strongly predicted decreases in PTSD symptoms. Distress reduction across sessions was predicted by higher baseline avoidance and hyperarousal but not reexperiencing symptoms. This condensed format of daily 50-min sessions without in vivo exposure may be operating via similar extinction learning processes as longer protocols. Our clinical observations suggest that the brief daily format may offer the advantage of allowing each session to build on the previous one to promote meaningful shifts in the retrieval of the trauma memory. Brief imaginal exposure and processing may be a viable option for PTSD patients in settings where brief interventions are needed. Understanding potential change processes and baseline predictors of change brings us closer toward precision medicine in treating PTSD.
This article in the journal Zeitschrift für Psychodrama und Soziometrie provides an overview of body-oriented and bifocal approaches developed since 1969 for the treatment of post-traumatic stress disorder and other trauma sequelae. Somatic Experiencing (SE), Eye Movement Desensitization and Reprocessing (EMDR), Brainspotting (BSP), Progressive Counting (PC) and Imagery Rescripting (ImRs, IRRT) are briefly introduced. Finally, the advantages and disadvantages of these approaches will be discussed.
Introduction:
Both imagery rescripting and imaginal exposure have been proven to be effective in the treatment of chronic nightmares when compared to a waitlist condition. Little is known about their comparative efficacy and their efficacy compared to an active control.
Objective:
The aims of this study were to compare the two treatments to one another and to positive imagery as an active control, and to explore covariates of the treatment effect.
Methods:
In this single-blinded randomized controlled trial, 96 patients with nightmare disorder (idiopathic nightmares) from an outpatient clinic were randomly assigned to a single individual treatment session of rescripting, exposure, or positive imagery and 4 weeks of practice at home. The primary outcome was nightmare distress, and the secondary outcomes were nightmare frequency, nightmare effects, self-efficacy, and general psychopathology.
Results:
Nightmare distress was reduced in all groups (imagery rescripting: Cohen's d = -1.04, imaginal exposure: d = -0.68, positive imagery: d = -0.57), as were nightmare frequency, nightmare effects, and psychopathology. Self-efficacy was enhanced. No differential treatment effects were found on any primary or secondary measure. Treatment gains were not associated with demographic or disorder characteristics, baseline values, treatment credibility, or the number of practice sessions.
Conclusions:
Even short nightmare treatments are effective regardless of personal characteristics, and different interventions produce similar results. Future research should aim to clarify the mechanisms of action. Health care should make more use of these powerful and easy-to-administer nightmare treatments.
Background
Current research on borderline personality disorder report an association between emotionally dysregulated behaviors and intrusive mental imagery depicting similar scenes. Imagery rescripting techniques have proven effective in reducing intrusive mental imagery in numerous contexts. We developed a two session-short intervention in which intrusive mental images are identified, analyzed, and modified for daily rehearsal at home. This study aimed to reduce the negative emotions and cognitions associated with self-injurious behaviors by replacing unhealthy imagery with more adaptive content.
Methods
Seven females diagnosed with borderline personality disorder who reported intrusive mental imagery of dysregulated behaviors were recruited for participation. Each participant engaged in two individualized treatment sessions and daily homework requiring the rehearsal of modified imagery. Emotion regulation strategies, borderline symptom severity, and depressiveness were assessed before and after treatment.
Results
Acceptance was positive, as no patient dropped out from treatment. Symptom exacerbation was not observed. Borderline symptom reduction was noted and indicia of emotional dysregulation and negative affect declined.
Limitations
The generalizability of results is limited by the small sample size and the absence of a control group. Conclusions: This new two-session short intervention was shown to decrease the emotionally dysregulated behaviors that accompany negative feelings in females with borderline personality disorder.
Introduction: Imagery rescripting is a method to rescript the imagery of fear memory to safety imagery. Although the mechanism of imagery rescripting is not clear, it has been thought to diminish fear memory through reconsolidation. Method: A search of Web of Science and Science Direct was conducted. The search term (“imagery rescripting” and “reconsolidation”) was used. Results: This review revealed that no study has indicated the relation between imagery rescripting and reconsolidation. Conclusions: Further research should (1) compare the late relapse of imagery rescripting and imaginal exposure, (2) compare the brain activities related to imagery rescripting and imaginal exposure, (3) compare the changes of the declarative contents of traumatic memory after imagery rescripting and imaginal exposure, and (4) compare the intervention effects of inserting imagery immediately after retrieval and 10 minutes after retrieval.
Nightmares are defined as very negatively toned dreams and have been experienced by many from time to time. If they occur very often and cause clinically significant distress, a nightmare disorder should be diagnosed. The etiology of nightmares is explained by a disposition-stress model; in addition, traumata and psychoactive drugs might play a role. Interestingly, research has provided evidence that simple cognitive interventions like the imagery rehearsal therapy are very effective for coping with nightmares.
Objective: The aim of this study was to conduct a preliminary dismantling study of exposure, relaxation, and rescripting therapy (ERRT) for nightmares. Method: Participants (N = 70) were randomized to 1 of 2 conditions: ERRT with nightmare exposure and rescripting (full protocol; EX) or ERRT without nightmare exposure and rescripting (NEX). Participants completed follow-ups at 1 week, 3 months, and 6 months posttreatment. Results: Both conditions yielded statistically significant improvements with medium to large effect sizes on primary outcomes related to nightmares (i.e., nights with nightmares, nightmares per week, and nightmare severity). Both conditions also yielded statistically significant improvements on secondary outcomes with medium to large effect sizes on fear of sleep, sleep quality, insomnia severity, daytime sleepiness, posttraumatic stress disorder symptom severity, and depression severity. The conditions did not differ at any time point. Conclusions: Findings indicate that ERRT with and without nightmare exposure and rescripting can significantly alleviate nightmares and related distress. The addition of nightmare exposure and rescription did not contribute incrementally to outcomes in this sample. It is possible that the dose of exposure was not sufficient to result in group differences or that the treatment components included in both conditions (i.e., psychoeducation about trauma, nightmares, and sleep; sleep habit modification; and relaxation training) may adequately treat factors that maintain nightmares for some individuals. Theoretical implications of findings are discussed. The reduction of symptoms of other conditions following this brief intervention provides further evidence for the primary role of nightmares and sleep disturbances posttrauma.
Experimental research on emotional memory reconsolidation interference, or the induction of amnesia for previously established emotional memory, has a long tradition, but the potential of that research for the development of novel interventions to treat psychological disorders has been recognized only recently. Here we provide an overview of basic research and clinical studies on emotional memory reconsolidation interference. We point out specific advantages of interventions based on memory reconsolidation interference over traditional treatment for emotional disorders. We also explain how findings from basic research suggest limitations and challenges to clinical translation that may help to understand why clinical trials have met with mixed success so far and how their success can be increased. In closing, we preview new intervention approaches beyond the induction of amnesia that the phenomenon of memory reconsolidation may afford for alleviating the burden imposed by emotional memories, and we comment on theoretical controversies regarding the nature of memory reconsolidation.
Background
Recurrent nightmares can effectively be treated with cognitive-behavioral techniques such as imagery rehearsal therapy, which involves imagery rescripting (IR) of nightmares, and imaginal exposure (IE) therapy. However, the underlying mechanisms of these treatments remain largely unknown. To investigate this, we identified a number of variables that might mediate the therapeutic effect of rescripting-based and/or exposure-based therapies. Also, to control for the possible confounding influence of (other) treatment components, we designed two stripped-down treatment protocols, which primarily consist of either (1) rescripting of, or (2) exposure to, the nightmare content. In a randomized controlled trial, we aim to investigate the therapeutic efficacy of these stripped-down IR and IE treatments, and explore their working mechanisms.
Method
Three weekly sessions of either IR or IE will be compared to a waiting-list control group. Ninety participants suffering from nightmare disorder will be included and randomly allocated to one of the three groups. The primary clinical outcome measures are nightmare frequency and distress caused by nightmares. Secondary clinical outcome measures include sleep complaints, dysfunctional beliefs about nightmares, and posttraumatic stress symptom severity. Outcomes will be assessed weekly from week 1 (pre-assessment) to week 5 (post-assessment). Online follow-up assessments will take place at 3 and 6 months after post-assessment. In order to investigate temporal relationships between mediators and outcome, we will measure the proposed mediators of the treatment effect 1 day after each outcome assessment (but not after the follow-ups). Mediators include nightmare distress and valence, mastery of the nightmare content, predictability, controllability, and tolerability of emotions elicited by nightmares, as well as sleep quality.
Discussion
The proposed trial allows us to investigate the efficacy of IR and IE as intervention techniques for the treatment of nightmares, and to explore mediators of their respective therapeutic effects. The results may advance our understanding of nightmare therapies by identifying possible mechanisms of psychological treatments for chronic nightmares. Moreover, the results of the proposed study might provide useful knowledge about the working mechanism of rescripting-based and exposure-based treatments in general.
Trial registration
Netherlands Trial Register (NTR4951), registered on 14 December 2014.
Electronic supplementary material
The online version of this article (doi:10.1186/s13063-016-1570-3) contains supplementary material, which is available to authorized users.
Although the relationship between dreaming and psychopathology has been studied quite extensively, research on dreaming in patients with personality disorders has been very scarce. In patients with borderline personality disorder, negatively toned dreams and heightened nightmare frequency have been found—characteristics not determined by co-morbid depression or posttraumatic stress disorder. The review includes suggestions for future studies as the existing results clearly indicate that this line of research is most interesting. Lastly, clinical recommendations especially regarding the treatment of the often found co-morbid nightmare disorder will be given.
Memory of a traumatic event becomes consolidated within hours. Intrusive memories can then flash back repeatedly into the mind's eye and cause distress. We investigated whether reconsolidation-the process during which memories become malleable when recalled-can be blocked using a cognitive task and whether such an approach can reduce these unbidden intrusions. We predicted that reconsolidation of a reactivated visual memory of experimental trauma could be disrupted by engaging in a visuospatial task that would compete for visual working memory resources. We showed that intrusive memories were virtually abolished by playing the computer game Tetris following a memory-reactivation task 24 hr after initial exposure to experimental trauma. Furthermore, both memory reactivation and playing Tetris were required to reduce subsequent intrusions (Experiment 2), consistent with reconsolidation-update mechanisms. A simple, noninvasive cognitive-task procedure administered after emotional memory has already consolidated (i.e., > 24 hours after exposure to experimental trauma) may prevent the recurrence of intrusive memories of those emotional events.
© The Author(s) 2015.
Several trials have demonstrated the efficacy of online cognitive behavioral therapy (CBT) for insomnia. However, few studies have examined putative mechanisms of change based on the cognitive model of insomnia. Identification of modifiable mechanisms by which the treatment works may guide efforts to further improve the efficacy of insomnia treatment. The current study therefore has two aims: (1) to replicate the finding that online CBT is effective for insomnia and (2) to test putative mechanism of change (i.e., safety behaviors and dysfunctional beliefs). Accordingly, we conducted a randomized controlled trial in which individuals with insomnia were randomized to either online CBT for insomnia (n = 36) or a waiting-list control group (n = 27). Baseline and posttest assessments included questionnaires assessing insomnia severity, safety behaviors, dysfunctional beliefs, anxiety and depression, and a sleep diary. Three- and six-month assessments were administered to the CBT group only. Results show moderate to large statistically significant effects of the online treatment compared to the waiting list on insomnia severity, sleep measures, sleep safety behaviors, and dysfunctional beliefs. Furthermore, dysfunctional beliefs and safety behaviors mediated the effects of treatment on insomnia severity and sleep efficiency. Together, these findings corroborate the efficacy of online CBT for insomnia, and suggest that these effects were produced by changing maladaptive beliefs, as well as safety behaviors. Treatment protocols for insomnia may specifically be enhanced by more focused attention on the comprehensive fading of sleep safety behaviors, for instance through behavioral experiments.
Imagery Rescripting (ImRs) is a therapeutic technique addressing specific memories of earlier experiences associated with present problems. By imagining that the course of events is changed in a more desired direction, powerful therapeutic effects have been found. The interest in and applications of ImRs are quickly increasing. This review discusses clinical studies assessing effects of ImRs, as well as possible processes underlying ImRs, and laboratory studies examining these underlying processes. It is concluded that although research into ImRs is still in its infancy, and many studies have their methodological limitations, results are promising. Therefore a research agenda is sketched, suggesting the next steps in both clinical and fundamental research.
To investigate the prevalence of nightmares among the Finnish general adult population during 1972-2007 and the association between nightmare prevalence and symptoms of insomnia, depression, and anxiety in World War II veterans.
Eight independent cross-sectional population surveys of the National FINRISK Study conducted in Finland in 1972, 1977, 1982, 1987, 1992, 1997, 2002, and 2007.
Epidemiologic.
A total of 69,813 people (33,811 men and 36,002 women) age 25-74 years.
N/A.
The investigation of nightmare prevalence and insomnia, depression, and anxiety symptoms was based on questionnaires completed by the participants. Among the whole sample, 3.5% of the men and 4.8% of the women reported frequent nightmares (P < 0.0001 for sex difference), but the prevalence was affected by the age of participants and the year of the survey. Nightmare prevalence increased with age, particularly among the men. The number of people reporting occasional nightmares increased roughly by 20% for both sexes from 1972 to 2007 (P < 0.0001). Participants with war experiences reported more frequent nightmares and symptoms of insomnia, depression, and anxiety than participants without such experiences (P < 0.0001).
Prevalence of nightmares was affected by the sex and age of the participants, and occasional nightmares have become more common in Finland. Exposure to war elevates nightmare prevalence as well as insomnia, depression, and anxiety symptoms even decades after the war; large numbers of war veterans can affect nightmare prevalence on population level.
Sandman N; Valli K; Kronholm E; Ollila HM; Revonsuo A; Laatikainen T; Paunio T. Nightmares: prevalence among the Finnish general adult population and war veterans during 1972-2007. SLEEP 2013;36(7):1041-1050.
Overwriting Human Memory
A consolidated fear memory can enter a transient labile phase upon its reactivation. Pharmacological blockade of the subsequent protein synthesis-dependent restabilization produces a memory deficit. Sevenster et al. (p. 830 ) found that prediction error (a discrepancy between actual and expected events) is a necessary condition for reconsolidation of a fear memory in human subjects. Retrieval cued by a negative prediction error, for example, like a conditioned stimulus presented in the absence of the unconditioned stimulus, resulted in labilization and subsequent reconsolidation was blocked by the drug propranolol. However, if there was no prediction error because the conditioned stimulus and the aversive unconditioned stimulus were presented simultaneously, the memory did not enter a labile state and its reconsolidation could not be blocked.
Four groups of undergraduate students, for a total sample of 540 (358 women, 165 men, 17 undeclared), estimated their nightmare frequency in the prior year and completed a questionnaire assessing the amount of waking distress associated with their nightmares (nightmare distress). This questionnaire included an item on which they indicated their interest in therapy for nightmares. While nightmare frequency was significantly correlated with nightmare distress and interest in therapy, the correlations were sufficiently modest to suggest that these 2 variables should be differentiated both in theoretical/empirical studies of nightmares and in approaches to treatment with nightmares. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Prolonged exposure (PE) is an effective first-line treatment for posttraumatic stress disorder (PTSD), regardless of the type of trauma, for Veterans and military personnel. Extensive research and clinical practice guidelines from various organizations support this conclusion. PE is effective in reducing PTSD symptoms and has also demonstrated efficacy in reducing comorbid issues such as anger, guilt, negative health perceptions, and depression. PE has demonstrated efficacy in diagnostically complex populations and survivors of single- and multiple-incident traumas. The PE protocol includes four main therapeutic components (i.e., psychoeducation, in vivo exposure, imaginal exposure, and emotional processing). In light of PE's efficacy, the Veterans Health Administration designed and supported a PE training program for mental health professionals that has trained over 1,300 providers. Research examining the mechanisms involved in PE and working to improve its acceptability, efficacy, and efficiency is underway with promising results.
In this article we propose mechanisms that govern the processing of emotional information, particularly those involved in fear reduction. Emotions are viewed as represented by information structures in memory, and anxiety is thought to occur when an information structure that serves as program to escape or avoid danger is activated. Emotional processing is defined as the modification of memory structures that underlie emotions. It is argued that some form of exposure to feared situations is common to many psychotherapies for anxiety, and that confrontation with feared objects or situations is an effective treatment. Physiological activation and habituation within and across exposure sessions are cited as indicators of emotional processing, and variables that influence activation and habituation of fear responses are examined. These variables and the indicators are analyzed to yield an account of what information must be integrated for emotional processing of a fear structure. The elements of such a structure are viewed as cognitive representations of the stimulus characteristic of the fear situation, the individual's responses in it, and aspects of its meaning for the individual. Treatment failures are interpreted with respect to the interference of cognitive defenses, autonomic arousal, mood state, and erroneous ideation with reformation of targeted fear structures. Applications of the concepts advanced here to therapeutic practice and to the broader study of psychopathology are discussed.
Beliefs that are negatively biased, inaccurate, and rigid are thought to play a key role in the mood and anxiety disorders. Our goal in this study was to examine whether a change in maladaptive beliefs mediated the outcome of individual cognitive-behavioral therapy (CBT) for social anxiety disorder (SAD). In a sample of 47 individuals with SAD receiving CBT, we measured maladaptive interpersonal beliefs as well as emotional and behavioral components of social anxiety, both at baseline and after treatment completion. We found that (a) maladaptive interpersonal beliefs were associated with social anxiety at baseline and treatment completion; (b) maladaptive interpersonal beliefs were significantly reduced from baseline to treatment completion; and (c) treatment-related reductions in maladaptive interpersonal beliefs fully accounted for reductions in social anxiety after CBT. These results extend the literature by providing support for cognitive models of mental disorders, broadly, and SAD, specifically.
Overwhelming evidence shows the quality of reporting of randomised controlled trials (RCTs) is not optimal. Without transparent reporting, readers cannot judge the reliability and validity of trial findings nor extract information for systematic reviews. Recent methodological analyses indicate that inadequate reporting and design are associated with biased estimates of treatment effects. Such systematic error is seriously damaging to RCTs, which are considered the gold standard for evaluating interventions because of their ability to minimise or avoid bias.
We previously demonstrated that disrupting reconsolidation by pharmacological manipulations "deleted" the emotional expression of a fear memory in humans. If we are to target reconsolidation in patients with anxiety disorders, the disruption of reconsolidation should produce content-limited modifications. At the same time, the fear-erasing effects should not be restricted to the feared cue itself considering that fear generalization is a main characteristic of anxiety disorders. In Experiment I and Experiment I(b), we addressed these issues using a within-subject differential startle fear conditioning paradigm and a test of fear generalization. In Experiment II, we tested whether a behavioral approach targeting the reconsolidation through extinction learning was also effective in weakening the original fear memory. A behavioral procedure is evidently preferred over drug manipulations provided that similar effects can be obtained. Here, the extinction procedure subsequent to retrieval did not "erase" the emotional expression of the fear memory as the retrieval techniques (i.e., reminder shocks and reacquisition) unveiled a return of the startle fear response to the fear-relevant stimuli. In contrast, β-adrenergic receptor blockade during reconsolidation selectively deleted the fear-arousing aspects of the memory (i.e., startle fear response) along with its category-related information. The pharmacological manipulation rendered the core memory trace too weak to observe fear generalization after successful reacquisition. Hence, relearning following the disruption of reconsolidation seems to be qualitatively different from initial learning. Our findings demonstrate that disrupting reconsolidation by pharmacological manipulations, although selective, undermines the generalization of fear, a key feature of anxiety disorders.
Several cognitive-behavioral techniques are effective in reducing nightmare frequency, but the therapeutic factor (e.g. cognitive restructuring, systematic desensitization) remains unclear. The aim of this study was to compare the nightmare treatments imagery rehearsal therapy (IRT), exposure, and recording (keeping a diary)--in a self-help format--with a waiting list.
Participants were recruited through a Dutch nightmare website. After completion of the baseline questionnaires, 399 participants were randomly assigned to a condition, received a 6-week self-help treatment (or were placed on the waiting list), and filled out the post-treatment measurements 11 weeks after baseline.
Compared to the waiting list, IRT and exposure were effective in ameliorating nightmare frequency and distress, subjective sleep quality, anxiety (after imagery rehearsal), and depression (after exposure; Δd = 0.25-0.56). Compared to recording, IRT reduced nightmare frequency while exposure reduced nightmare distress (Δd = 0.20-0.30; p < 0.05). The recording condition was more effective compared to the waiting list in ameliorating nightmare frequency, nightmare distress, and subjective sleep quality (Δd = 0.19-0.28; p < 0.05). IRT had a more rapid reduction on the diary compared to exposure and recording.
IRT and exposure appear equally effective in ameliorating nightmare complaints. Exposure to nightmare imagery may function as the crucial therapeutic factor; however, cognitive restructuring may be a useful addition to increase immediate effects.
Prazosin is recommended for treatment of Posttraumatic Stress Disorder (PTSD)-associated nightmares. Level A. Image Rehearsal Therapy (IRT) is recommended for treatment of nightmare disorder. Level A. Systematic Desensitization and Progressive Deep Muscle Relaxation training are suggested for treatment of idiopathic nightmares. Level B. Venlafaxine is not suggested for treatment of PTSD-associated nightmares. Level B. Clonidine may be considered for treatment of PTSD-associated nightmares. Level C. The following medications may be considered for treatment of PTSD-associated nightmares, but the data are low grade and sparse: trazodone, atypical antipsychotic medications, topiramate, low dose cortisol, fluvoxamine, triazolam and nitrazepam, phenelzine, gabapentin, cyproheptadine, and tricyclic antidepressants. Nefazodone is not recommended as first line therapy for nightmare disorder because of the increased risk of hepatotoxicity. Level C. The following behavioral therapies may be considered for treatment of PTSD-associated nightmares based on low-grade evidence: Exposure, Relaxation, and Rescripting Therapy (ERRT); Sleep Dynamic Therapy; Hypnosis; Eye-Movement Desensitization and Reprocessing (EMDR); and the Testimony Method. Level C. The following behavioral therapies may be considered for treatment of nightmare disorder based on low-grade evidence: Lucid Dreaming Therapy and Self-Exposure Therapy. Level C No recommendation is made regarding clonazepam and individual psychotherapy because of sparse data.
To determine the prevalence of frequent nightmares and their correlates in a large community-based cohort of middle-aged Hong Kong Chinese.
A 2-phase design involving a cross-sectional survey of 8558 subjects (men, 47.6%) with a mean age of 40.9 years (SD 5.5, range 20-78) and subsequently followed by a detailed clinical evaluation of the psychopathology and personality profile of 252 subjects.
Community.
N/A.
The prevalence of frequent nightmares, as defined by at least once per week, was 5.1%. Female sex, low monthly family income, insomnia symptoms, sleep-disordered breathing symptoms, and sleep-related daytime consequences were significantly associated with nightmare frequency. The risk of having a psychiatric disorder was 5.74 times greater for subjects with frequent nightmares (95% confidence interval 2.03-16.26), especially mood disorders (odds ratio = 15.57, 95% confidence interval 3.77-64.37). After exclusion of concomitant psychiatric morbidities, subjects with frequent nightmares still scored significantly higher on neuroticism in the personality scale (p < 0.05).
Frequent nightmares were not uncommon in the general population and were associated with a constellation of factors, including sociodemographic characteristics and comorbid sleep and psychiatric disorders. Moreover, frequent nightmares were independently related to the neuroticism personality trait, irrespective of psychiatric diagnosis. Prospective studies should be conducted to investigate various predisposing, precipitating, and perpetuating factors and the associated repercussions of nightmares.
Overwhelming evidence shows the quality of reporting of randomised controlled trials (RCTs) is not optimal. Without transparent reporting, readers cannot judge the reliability and validity of trial findings nor extract information for systematic reviews. Recent methodological analyses indicate that inadequate reporting and design are associated with biased estimates of treatment effects. Such systematic error is seriously damaging to RCTs, which are considered the gold standard for evaluating interventions because of their ability to minimise or avoid bias.
Recent research on changing fears has examined targeting reconsolidation. During reconsolidation, stored information is rendered labile after being retrieved. Pharmacological manipulations at this stage result in an inability to retrieve the memories at later times, suggesting that they are erased or persistently inhibited. Unfortunately, the use of these pharmacological manipulations in humans can be problematic. Here we introduce a non-invasive technique to target the reconsolidation of fear memories in humans. We provide evidence that old fear memories can be updated with non-fearful information provided during the reconsolidation window. As a consequence, fear responses are no longer expressed, an effect that lasted at least a year and was selective only to reactivated memories without affecting others. These findings demonstrate the adaptive role of reconsolidation as a window of opportunity to rewrite emotional memories, and suggest a non-invasive technique that can be used safely in humans to prevent the return of fear.
Dysregulation of the fear system is at the core of many psychiatric disorders. Much progress has been made in uncovering the
neural basis of fear learning through studies in which associative emotional memories are formed by pairing an initially neutral
stimulus (conditioned stimulus, CS; e.g., a tone) to an unconditioned stimulus (US; e.g., a shock). Despite recent advances,
the question of how to persistently weaken aversive CS-US associations, or dampen traumatic memories in pathological cases,
remains a major dilemma. Two paradigms (blockade of reconsolidation and extinction) have been used in the laboratory to reduce
acquired fear. Unfortunately, their clinical efficacy is limited: Reconsolidation blockade typically requires potentially
toxic drugs, and extinction is not permanent. Here, we describe a behavioral design in which a fear memory in rats is destabilized
and reinterpreted as safe by presenting an isolated retrieval trial before an extinction session. This procedure permanently
attenuates the fear memory without the use of drugs.
The aim of this review is to evaluate the effectiveness of cognitive behavioral therapy (CBT) on nightmare frequency and to determine which kind of CBT is the most effective treatment. A systematic literature search was carried out in PsychInfo and PubMed articles published on or before May 1, 2008. The inclusion criteria were: nightmare treatment study, use of nonpharmacological treatment, not a qualitative case study, randomized-controlled trial (RCT). After selection, 12 peer-reviewed studies about 9 RCTs remained (2 follow-up studies and one displaying preliminary results). Several interventions have been reviewed including, recording one's nightmares, relaxation, exposure, and techniques of cognitive restructuring. The 12 evaluated articles varied in quality, and none fulfilled CONSORT guidelines. All articles used nightmare frequency as the primary dependent variable, and all found significant in-group differences (pre vs. post) for intervention or placebo (range d = 0.7-2.9). Five studies were able to find a significant group effect for the intervention compared to a waiting list control group. Only one study found significant differences between 2 intervention groups. Nightmare-focused CBT (exposure and imagery rehearsal therapy [IRT]) revealed better treatment outcomes than indirect CBT (relaxation, recording). IRT and exposure showed no meaningful differences, but only one RCT directly compared both techniques. Three different research groups demonstrated the effects of exposure, but only one group showed the effect of IRT. Thus, RCTs that compare IRT with exposure by independent research groups are much needed.
In this article we propose mechanisms that govern the processing of emotional information, particularly those involved in fear reduction. Emotions are viewed as represented by information structures in memory, and anxiety is thought to occur when an information structure that serves as program to escape or avoid danger is activated. Emotional processing is defined as the modification of memory structures that underlie emotions. It is argued that some form of exposure to feared situations is common to many psychotherapies for anxiety, and that confrontation with feared objects or situations is an effective treatment. Physiological activation and habituation within and across exposure sessions are cited as indicators of emotional processing, and variables that influence activation and habituation of fear responses are examined. These variables and the indicators are analyzed to yield an account of what information must be integrated for emotional processing of a fear structure. The elements of such a structure are viewed as cognitive representations of the stimulus characteristic of the fear situation, the individual’s responses in it, and aspects of its meaning for the individual. Treatment failures are interpreted with respect to the interference of cognitive defenses, autonomic arousal, mood state, and erroneous ideation with reformation of targeted fear structures. Applications of the concepts advanced here to therapeutic practice and to the broader study of psychopathology are discussed.
Behavioral neuroscience has greatly informed how we understand the formation, persistence, and plasticity of memory. Research has demonstrated that memory reactivation can induce a labile period, during which previously consolidated memories are sensitive to change, and in need of restabilization. This process is known as reconsolidation. Such findings have advanced not only our basic understanding of memory processes, but also hint at the prospect of harnessing these insights for the development of a new generation of treatments for disorders of emotional memory. However, even in simple experimental models, the conditions for inducing memory reconsolidation are complex: memory labilization appears to result from the interplay of learning history, reactivation, and also individual differences, posing difficulties for the translation of basic experimental research into effective clinical interventions. In this paper, we review a selection of influential animal and human research on memory reconsolidation to illustrate key insights these studies afford. We then consider how these findings can inform the development of new treatment approaches, with a particular focus on the transition of memory from reactivation, to reconsolidation, to new memory formation, as well as highlighting possible limitations of experimental models. If the challenges of translational research can be overcome, and if reconsolidation-based procedures become a viable treatment option, then they would be one of the first mental health treatments to be directly derived from basic neuroscience research. This would surely be a triumph for the scientific study of mind and brain.
Background:
Previous studies have suggested that fear memories can be updated when recalled, a process referred to as reconsolidation. Given the beneficial effects of model-based safety learning (i.e. vicarious extinction) in preventing the recovery of short-term fear memory, we examined whether consolidated long-term fear memories could be updated with safety learning accomplished through vicarious extinction learning initiated within the reconsolidation time-window. We assessed this in a final sample of 19 participants that underwent a three-day within-subject fear-conditioning design, using fear-potentiated startle as our primary index of fear learning.
Methods:
On day 1, two fear-relevant stimuli (reinforced CSs) were paired with shock (US) and a third stimulus served as a control (CS). On day 2, one of the two previously reinforced stimuli (the reminded CS) was presented once in order to reactivate the fear memory 10 min before vicarious extinction training was initiated for all CSs. The recovery of the fear memory was tested 24 h later.
Results and conclusion:
Vicarious extinction training conducted within the reconsolidation time window specifically prevented the recovery of the reactivated fear memory (p = 0.03), while leaving fear-potentiated startle responses to the non-reactivated cue intact (p = 0.62). These findings are relevant to both basic and clinical research, suggesting that a safe, non-invasive model-based exposure technique has the potential to enhance the efficiency and durability of anxiolytic therapies.
The effectiveness of systematic desensitization in ameliorating nightmares was evaluated in a controlled study. Twenty-nine subjects were assigned to either systematic desensitization, a nightmare discussion placebo, or continuous self-recording. The placebo treatment did not differ from desensitization in terms of rated logicalness and potential effectiveness. However, the desensitization group showed a significantly greater reduction in the frequency of nightmares as well as a decrease in rated intensity. Moreover the desensitization subjects also had a significantly greater decrease in reported fear and state anxiety. Related research on nightmares is noted and future research needs are discussed.
Objective: Nightmares are associated with psychopathology and daily distress. They are highly prevalent in a psychiatric population (30%). Currently, imagery rehearsal therapy (IRT) is the treatment of choice for nightmares. With IRT, the script of the nightmare is changed into a new dream, which is imagined during the day. However, the effects of IRT in a psychiatric population remain unknown. The aim of this study was to determine the effectiveness of IRT in a heterogeneous psychiatric population.
Method: Between January 2006 and July 2010, 90 patients with psychiatric disorders (DSM-IV-TR) were randomized to IRT or treatment-as-usual conditions. IRT consisted of 6 individual sessions added to the treatment as usual. Nightmare frequency was assessed using daily nightmare logs and the Nightmare Frequency Questionnaire. Nightmare distress was assessed using the Nightmare Distress Questionnaire and the Nightmare Effects Survey. General psychiatric symptoms were assessed using the Symptom Checklist-90 and a PTSD symptom questionnaire. Assessments were administered at the start of the trial, after the IRT and at follow-up 3 months later.
Results: IRT showed a moderate effect (Cohen d = 0.5–0.7, P < .05) on nightmare frequency, nightmare distress, and psychopathology measures compared with treatment as usual. These effects were largely sustained at the 3-month follow-up (Cohen d = 0.4–0.6, P < .10).
Conclusions: IRT is an effective treatment for nightmares among patients with comorbid psychiatric disorders and can be employed in addition to the on-going treatment.
During imagery rescripting (ImRs) an aversive memory is relived and transformed to have a more positive outcome. ImRs is frequently applied in psychological treatment and is known to reduce intrusions and distress of the memory. However, little is known about the necessity to incorporate the central aversive parts of the memory in ImRs. To examine this necessity one hundred participants watched an aversive film and were subsequently randomly assigned to one of four experimental conditions: ImRs including the aversive scenes (Late ImRs), ImRs without the aversive scenes (Early ImRs), imaginal exposure (IE) or a control condition (Cont). Participants in the IE intervention reported the highest distress levels during the intervention; Cont resulted in the lowest levels of self-reported distress. For the intrusion frequency, only the late ImRs resulted in fewer intrusions compared to the Cont condition; Early ImRs produced significantly more intrusions than the Late ImRs or IE condition. Finally, the intrusions of the Late ImRs condition were reported as less vivid compared to the other conditions. To conclude, it seems beneficial including aversive scenes in ImRs after an analogue trauma induction.
Nightmares are a prevalent disorder with negative consequences. This study investigated the association between nightmares and daily distress. Fifty-six participants with frequent nightmares filled out questionnaires and a 10-day diary. The questionnaire concerned: sleep, nightmare distress, depression, neuroticism, posttraumatic stress, and anxiety; the diary: nightmares, sleep, and sleep related distress. Multilevel analyses revealed that nightmare nights, sleep quality, baseline nightmare distress, and depression were significantly associated with daily sleep related distress (P < 0.05). This is the first study that prospectively shows that nightmares are independently associated with daily sleep related distress.
Previous research has recommended several measures of effect size for studies with repeated measurements in both treatment and control groups. Three alternate effect size estimates were compared in terms of bias, precision, and robustness to heterogeneity of variance. The results favored an effect size based on the mean pre-post change in the treatment group minus the mean pre-post change in the control group, divided by the pooled pretest standard deviation.
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.
This study presents a meta-analysis of the effectiveness of psychological treatments for chronic nightmares using imaginal confrontation with nightmare contents (ICNC) or imagery rescripting and rehearsal (IRR). Pre-post effect sizes (Hedges' g) were calculated for the outcome measures of nightmare frequency, nights per week with nightmares, sleep quality, depression, anxiety, and PTSD severity. Fixed-effects and random-effects models were applied. High effect sizes were found for nightmare frequency (g=1.04), nights per week with nightmares (g=0.99), and PTSD severity (g=0.92). Most of the effect sizes for the secondary outcomes were moderate. One objective was to clarify whether ICNC or IRR is more important for nightmare reduction. The results indicate that a higher duration of time for ICNC is associated with greater improvements: The minutes of applied ICNC moderate the effect sizes for nightmare frequency at follow-up 2 and for nights per week with nightmares at post and follow-up 1. The percentage of applied ICNC moderates the effect sizes for nightmare frequency and nights per week with nightmares at follow-up 1. Thus, dismantling studies are necessary to draw conclusions regarding whether ICNC or IRR is the most effective in the psychological treatment of chronic nightmares.
The literature on behavioural treatment for post-traumatic stress disorder (PTSD) is reviewed. Two sets of behavioural procedures have been commonly employed in the treatment of anxiety disorders in general and in the treatment of PTSD specifically: exposure based procedures and anxiety management techniques (AMT). Both sets of procedures appear to be promising in the treatment of PTSD following both combat and rape experiences. © 1989 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted.
Memory allows organisms to predict future events based on prior experiences. This requires encoded information to persist once important predictors are extracted, while also being modifiable in response to changes within the environment. Memory reconsolidation may allow stored information to be modified in response to related experience. However, there are many boundary conditions beyond which reconsolidation may not occur. One interpretation of these findings is that the event triggering memory retrieval must contain new information about a familiar stimulus in order to induce reconsolidation. Presently, the mechanisms that affect the likelihood of reconsolidation occurring under these conditions are not well understood. Here we speculate on a number of systems that may play a role in protecting memory from being destabilized during retrieval. We conclude that few memories may enter a state in which they cannot be modified. Rather, metaplasticity mechanisms may serve to alter the specific reactivation cues necessary to destabilize a memory. This might imply that destabilization mechanisms can differ depending on learning conditions.
A cognitive model of panic is described. Within this model panic attacks are said to result from the catastrophic misinterpretation of certain bodily sensations. The sensations which are misinterpreted are mainly those involved in normal anxiety responses (e.g. palpitations, breathlessness, dizziness etc.) but also include some other sensations. The catastrophic misinterpretation involves perceiving these sensations as much more dangerous than they really are (e.g. perceiving palpitations as evidence of an impending heart attack). A review of the literature indicates that the proposed model is consistent with the major features of panic. In particular, it is consistent with the nature of the cognitive disturbance in panic patients, the perceived sequence of events in an attack, the occurrence of ‘spontaneous’ attacks, the role of hyperventilation in attacks, the effects of sodium lactate and the literature on psychological and pharmacological treatments. Finally, a series of direct tests of the model are proposed.
Disrupting reconsolidation seems to be a promising approach to dampen the expression of fear memory. Recently, we demonstrated that disrupting reconsolidation by a pharmacological manipulation specifically targeted the emotional expression of memory (i.e., startle response). Here we test in a human differential fear-conditioning paradigm with fear-relevant stimuli whether the spacing of a single unreinforced retrieval trial relative to extinction learning allows for "rewriting" the original fear association, thereby preventing the return of fear. In contrast to previous findings reported by Schiller et al. (2010), who used a single-method for indexing fear (skin conductance response) and fear-irrelevant stimuli, we found that extinction learning within the reconsolidation window did not prevent the recovery of fear on multiple indices of conditioned responding (startle response, skin conductance response and US-expectancy). These conflicting results ask for further critical testing given the potential impact on the field of emotional memory and its application to clinical practice.
Nightmares and sleep disturbance are fundamental concerns for victims of trauma. This study examined the efficacy of a manualized cognitive-behavioral treatment (CBT) for chronic nightmares in trauma-exposed individuals via a randomized clinical trial. Participants were randomly assigned to a treatment group or wait-list control group, with 27 participants completing the treatment. At the 6-month follow-up assessment, 84% of treated participants reported an absence of nightmares in the previous week. Significant decreases were also reported in symptoms of depression and posttraumatic stress, fear of sleep, and number of sleep problems, while sleep quality and quantity improved. The present study adds to the growing literature indicating this brief CBT as a first-line treatment for trauma-exposed individuals with chronic nightmares.
This study details results of an open trial of a group psychological treatment for Veterans with posttraumatic stress disorder (PTSD) and chronic posttraumatic nightmares called "Imagery Rescripting and Exposure Therapy" (IRET). IRET is a variant of a successful imagery rescripting treatment for civilian trauma-related nightmares that was modified to address the needs of the Veteran population. Thirty-seven male U.S. Veterans with PTSD and nightmares attended 6 multicomponent group sessions. Findings indicated that the intervention significantly reduced frequency of nightmares and PTSD severity, as well as increased hours of sleep. Unlike the few open trials examining treatment of nightmares in Veterans, effect sizes in this study were similar to those that have been found in the civilian randomized controlled trial. These preliminary findings suggest that a nightmares treatment can be adapted to successfully reduce distress associated with combat Veterans' chronic nightmares. Clinical and research implications are discussed.
Nightmares are defined as disturbing mental experiences that generally occur during REM sleep and often result in awakening. Whereas the number of publications addressing nightmare frequency and psychopathology, nightmare etiology and treatment is increasing rapidly in the last few years, nightmare content has been studied very rarely in a systematic way, especially in adults. The present study investigated nightmare frequency and the frequency of various nightmare topics in a representative German sample. The five most common themes were falling, being chased, paralyzed, being late, and the deaths of close persons. Even though several effects can be explained by the continuity hypothesis of dreaming, further research is needed to investigate the possible metaphoric relationship between nightmare topics like falling or being chased and waking-life stressors.
Nightmares, distressing dreams that primarily arise from REM sleep, are prevalent among the general population and even more so among clinical populations. The frequency of nightmares and related nightmare distress are linked to both sleep disturbance and waking psychopathology. Based on the extant evidence, nightmares appear to be particularly relevant to posttraumatic stress disorder, and may even be implicated in its pathophysiology. Significant advances in treatment have occurred in recent years, with effective pharmacological and psychosocial interventions now available. Despite the progress that has been made, however, more consistent assessment methods and more rigorous study designs are needed to fully understand the causes and consequences of nightmares.
32 self-referred nightmare sufferers (mean age 36 yrs) were randomly assigned to relaxation training, systematic desensitization, or a waiting-list control. Ss on the average had been having 9 nightmares/mo and reported mean problem duration of 12 yrs prior to treatment. After the intervention phase, both treated groups showed significant decreases in nightmare frequency relative to controls. After subsequent treatment, the waiting-list group showed similarly decreased frequency but remained unimproved on nightmare intensity relative to prior treated groups. Hierarchical desensitization did not increase efficacy at 15 wks beyond benefits associated with relaxation alone. At 25 wks, however, desensitized Ss showed significantly greater reduction in nightmare intensity. Overall, at least 80% reduction in nightmares was reported by 20 Ss, of whom 12 reported total elimination of symptoms at 25-wk follow-up. Some Ss experienced fewer but more intense nightmares, others maintained frequency of previously disturbing dreams but were no longer awakened or distressed by them, and 2 reported substantial worsening of symptoms. Unfavorable outcome was associated with personality disorder profiles on the MMPI. Findings are discussed in relation to a conceptualization of nightmares as a symptom of a more generalized arousal disorder. (24 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)