A combined group treatment for nightmares and insomnia in combat veterans: A pilot study

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DOI: 10.1002/jts.20468 · Source: PubMed
Insomnia and nightmares are hallmarks of posttraumatic stress disorder (PTSD). Sleep disturbances in PTSD negatively impact clinical course and functioning. In this open clinical trial, the preliminary effects of a combined treatment for insomnia and nightmares in combat veterans with PTSD were assessed. Ten combat veterans participated in a 10-session group treatment combining cognitive-behavioral therapy for insomnia with exposure, rescripting, and relaxation therapy. Participants maintained daily sleep and dream diaries and completed self-report measures of sleep quality and PTSD symptoms pre- and posttreatment. Participants reported improvements in sleep and nightmares following treatment. Future research using controlled designs to evaluate this treatment is warranted.


Journal of Traumatic Stress, Vol. 22, No. 6, December 2009, pp. 639–642 (
A Combined Group Treatment for Nightmares and
Insomnia in Combat Veterans: A Pilot Study
Leslie M. Swanson
Department of Psychiatry, University of Michigan, Ann Arbor, MI
Todd K. Favorite
VA Ann Arbor Healthcare System, Ann Arbor, MI
Elizabeth Horin
Edward Hines, Jr. VA Hospital, Hines, IL
J. Todd Arnedt
Department of Psychiatry, University of Michigan, Ann Arbor, MI
Insomnia and nightmares are hallmarks of posttraumatic stress disorder (PTSD). Sleep disturbances in PTSD
negatively impact clinical course and functioning. In this open clinical trial, the preliminary effects of a combined
treatment for insomnia and nightmares in combat veterans with PTSD were assessed. Ten combat veterans
participated in a 10-session group treatment combining cognitive–behavioral therapy for insomnia with exposure,
rescripting, and relaxation therapy. Participants maintained daily sleep and dream diaries and completed self-
report measures of sleep quality and PTSD symptoms pre- and posttreatment. Participants reported improvements
in sleep and nightmares following treatment. Future research using controlled designs to evaluate this treatment
is warranted.
Posttraumatic stress disorder (PTSD) is prevalent and debili-
tating among combat veterans (Dohrenwend, 2006; Hoge, 2006).
Disturbed sleep and recurrent nightmares, hallmarks of the dis-
order, are common in veterans (Neylan et al., 1998; Ross, Ball,
Sullivan, & Caroff, 1989). Recurrent nightmares may represent
impairment of the emotional processing or fear extinction func-
tions of dreaming (Nielsen & Levin, 2007; Phelps, Forbes, &
Creamer, 2008). Sleep disturbances in PTSD negatively impact
functioning (Clum, Nishith, & Resick, 2001; Krakow, 2002).
Psychotherapies for sleep disturbances have not been widely
studied in populations with PTSD. The gold standard treatment,
cognitive–behavioral therapy for insomnia (CBT-Insomnia), has
been used to treat insomnia in veterans with medical and psy-
chiatric comorbidities, including PTSD (Edinger et al., 2009;
Perlman, Arnedt, Earnheart, Gorman, & Shirley, 2008). Although
CBT-Insomnia shows promise for improving sleep in veterans with
comorbidities, its impact on nightmares is unclear.
Psychotherapies for nightmares, including imagery rehearsal
therapy (IRT) and exposure, relaxation, and rescripting therapy,
improve nightmares and daytime functioning in civilians with
PTSD (Davis & Wright, 2007; Krakow et al., 2001). However,
Correspondence concerning this article should be addressed to: Leslie M. Swanson, 4250 Plymouth Rd, Ann Arbor, MI 48109. E-mail: LMSwan@med.umich.edu.
2009 International Society for Traumatic Stress Studies. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/jts.20468
a recent meta-analysis of therapies for nightmares suggests most
treatments do not find significant sleep improvements (Lancee,
Spoormaker, Krakow, & van den Bout, 2008). Addition of an
insomnia treatment component to a therapy for nightmares may
provide more complete resolution of all sources of sleep disruption.
Indeed, pilot studies of IRT-based treatments that incorporate ele-
ments of CBT-Insomnia have shown posttreatment improvements
in sleep, dreams, and PTSD symptoms in veteran and civilian sam-
ples (Cook, Harb, Ross, Gamble, & Gehrman, 2008; Germain,
Shear, Hall, & Buysse, 2007). The goal of the present study was to
evaluate the preliminary effects of a 10-session combined insomnia
and nightmare-reduction group t reatment using CBT-Insomnia
and exposure, relaxation, and rescripting therapy in a sample of
combat veterans with chronic PTSD, nightmares, and insomnia.
This study was approved by the Ann Arbor Veterans Affairs (VA)
Institutional Review Board. Participants were combat veterans
640 Swanson et al.
recruited from the Ann Arbor VAs PTSD clinic who met diag-
nostic criteria for PTSD using the Clinician-Administered PTSD
Scale (CAPS; Blake et al., 1995), had Insomnia Severity Index
scores in the clinically significant range (Morin, 1993), and re-
ported recurrent nightmares. Participants using antidepressants or
hypnotics were included provided these medications were kept sta-
ble. Exclusion criteria included current substance/alcohol abuse or
dependence, and unstable physical or psychiatric illness. Comor-
bid diagnoses were established from medical records.
Twenty-three veterans were recruited; five did not meet inclu-
sion criteria and eight declined participation due to scheduling
conflicts and illness. Ten male combat veterans (M age = 59
years, SD = 4) were enrolled in three treatment groups of three
to four participants. Two participants withdrew halfway through
treatment for reasons unrelated to the study.
Nine participants were veterans of the Vietnam War, and
one was a Gulf War veteran. Nine were Caucasian, and one was
African American. Consistent with the veteran population, partici-
pants had heterogeneous medical and psychiatric comorbidities,
including major depressive disorder (4), alcohol dependence in
remission, hypertension (5), coronary artery disease (2), and
diabetes mellitus. Four participants used hypnotic medications
during the study, and 6 participants used antidepressants.
Participants reported chronic, moderately severe insomnia (M
duration = 31 years, SD = 10) and PTSD (M duration = 33
years, SD = 12; M CAPS = 67, SD = 19). Participants were
receiving concurrent treatment as usual through the PTSD clinic
(8 in pharmacotherapy, 6 in psychotherapy).
Participants maintained daily sleep and dream diaries throughout
treatment. Sleep diaries included time in bed, sleep latency, and
time spent awake after sleep onset. Summary measures from sleep
diaries included sleep efficiency (time asleep ÷ (time in bed
100)) and total sleep time. Dream diaries collected information
on nightmare frequency and distress level of the worst nightmare
using a 0–10 Likert-type scale (0 = no distress;10= extreme distress;
range of total weekly scores 0–70). Outcomes from diaries were
calculated using weekly averages for baseline and posttreatment
weeks (except for nightmare frequency, which was calculated as a
weekly total). Other self-reported outcomes, completed at baseline
and posttreatment, included the Insomnia Severity Index (Morin,
1993), Pittsburgh Sleep Quality Index (Buysse, 1989), and Post-
traumatic Diagnostic Scale (Foa, Cashman, Jaycox, & Perry, 1997).
Homework adherence was measured daily by self-report for two
of the groups using a yes/no response format.
Treatment consisted of ten 90-minute group therapy sessions de-
livered by doctoral-level clinical psychologists (LMS, TKF). Ex-
posure, relaxation, and rescripting therapy was modified by au-
dio recording rescripted nightmares and providing a recorded re-
laxation exercise. Core components of CBT-Insomnia, including
sleep restriction, stimulus control, sleep hygiene, cognitive restruc-
turing, and relaxation were presented in the first five sessions to
increase participants self-efficacy in managing a chronic prob-
lem. Sleep schedule adjustments and restructuring of sleep-focused
thoughts continued throughout treatment. Nightmare rescript-
ing began in the sixth session; participants wrote and read aloud
a detailed description of their worst nightmare. Thematic pro-
cessing of nightmare content was facilitated by identifying com-
mon nightmare themes (power, safety, intimacy, trust, self-esteem;
Davis & Wright, 2007). Consistent with the domains of dysfunc-
tion typically observed in veterans with PTSD, these themes are
aligned with other evidence-based treatments (i.e., cognitive pro-
cessing therapy). Participants rewrote the nightmare to address
core themes. Participants were audio recorded while reading the
rescripted nightmare aloud and instructed to listen to their re-
scripted nightmare each night (as many times as they wished)
prior to bedtime while visualizing the nightmare, followed by a re-
laxation exercise. Sessions seven and eight were used for discussion
of changes and trouble-shooting. The final two sessions focused
on relapse prevention.
Data Analysis
To estimate missing data, we compared regression imputation
(Little & Rubin, 2002) and multiple imputation strategies us-
ing AMOS (Arbuckle, 2007), and retained the more conservative
values from regression. AMOS fits regression imputation models
using maximum-likelihood (Schafer & Graham, 2002) and then
uses linear regression to predict missing values (Arbuckle, 2007).
The model included baseline scores for the primary outcome vari-
ables as well as age, PTSD duration, and insomnia duration.
Wilcoxon signed-rank tests evaluated baseline to posttreatment
changes in sleep, daytime functioning, PTSD, and nightmares.
Cohens d effect sizes (Cohen, 1988) for repeated measures were
calculated. Effect sizes of 0.2 were considered small, 0.5 considered
medium, and 0.8 considered large. Adherence to homework was
calculated by dividing the sum of adherent days for the sample by
total number of days homework was assigned for the sample.
Participants reported 86% adherence to relaxation and 74% ad-
herence to dream imagery practice. Wilcoxon signed-rank tests
(Table 1) indicated improvement in insomnia severity and sleep
quality. Post-treatment, 6 participants reported sleep efficiencies
in the subthreshold range (85%), 8 reported Insomnia Severity
Index scores in the subthreshold range (8–14), and 5 reported a
50% or greater reduction in weekly nightmare frequency. On av-
erage, participants experienced a 50% reduction in nightmares per
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Combined Treatment for Nightmares and Insomnia in Veterans 641
Tabl e 1 . Pre- and Posttreatment Scores
Pretreatment Posttreatment
Measure MSDMSDWilcoxon Z Cohens effect size d
Sleep efficiency (%) 68.7 15.6 84.4 15.1 2.67
Sleep onset latency (minutes) 41.7 21.9 22.3 17.0 2.19
Wake after sleep onset (minutes) 75.4 72.3 42.1 47.3 1.78 0.46
Total sleep time (hours) 5.1 2.2 6.3 2.0 2.29
Weekly nightmare frequency 15.4 15.6 7.8 10.8 2.31
Weekly nightmare distress
39.2 15.5 17.9 18.8 2.81
Pittsburgh Sleep Quality Index 15.1 3.5 11.6 4.8 2.44
Insomnia Severity Index 21.4 3.9 12.5 5.2 2.67
Posttraumatic Diagnostic Scale 36.0 10.2 31.7 9.8 1.21 0.42
Range of nightmare distress = 0–70.
p <.05.
Figure 1. Average weekly nightmare frequency and distress by
week, and a 46% reduction in total nightmare distress per week
(see Figure 1).
There were large effect sizes for sleep efficiency, sleep onset la-
tency, the Insomnia Severity Index, and weekly nightmare distress
(Table 1). There were medium effects for weekly nightmare fre-
quency, the Pittsburgh Sleep Quality Index, wake after sleep onset,
total sleep time, and the Posttraumatic Diagnostic Scale.
These preliminary findings suggest that combining CBT-Insomnia
with exposure, relaxation, and rescripting therapy has promise for
improving sleep and nightmares in combat veterans with chronic
PTSD. Retention and adherence rates were reasonable. Major
treatment targets (sleep and nightmares) improved. Average in-
somnia severity was in the subthreshold range following treatment,
which corresponds with improvements in sleep diary measures.
Although the sleep quality measure showed statistically significant
improvement posttreatment, the mean score remained in the clini-
cally significant range. Nightmare distress and frequency decreased
by approximately half. Reductions in PTSD symptoms were non-
significant. Effect sizes for changes in nightmare frequency, sleep
quality, and PSTD symptoms were comparable to those found in
a pilot study of IRT plus elements of CBT-Insomnia with veterans
(Cook et al., 2008).
Of the potential explanations for the small reductions in PTSD
symptoms, the most parsimonious is that the treatment did not di-
rectly impact PTSD symptoms. Other explanations include prob-
lems with our measure of PTSD symptoms (the Posttraumatic
Diagnostic Scale; Foa et al., 1997), which has not been specifi-
cally validated in veterans, and the possibility that new learning,
behavioral change, and symptom improvement may not have an
immediate impact on the long-standing sick-role identification as-
sociated with the chronic clinical profile of our participants. In
support of the latter, although no immediate posttreatment im-
provements were seen in a pilot study of IRT in veterans, significant
changes were observed at 3- and 6-month follow-up (Lu, Wagner,
Van Male, Whitehead, & Boehnlein, 2009).
Sleep quality also remained above the clinically significant cut-
off. There is evidence that individuals with PTSD have high rates of
sleep-disordered breathing, but atypical symptom profiles (Krakow
et al., 2006). Thus, it is plausible that undetected sleep-disordered
breathing partially accounts for why sleep quality remained
Several limitations warrant discussion. The uncontrolled design
precludes the conclusion that the treatment produced the observed
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
642 Swanson et al.
effects. Small sample size and use of self-report data should be
considered when interpreting the results. The absence of follow-
up assessments leaves questions as to the durability of symptom
reduction. Finally, the sample was heterogeneous with respect to
comorbidities, which increases generalizability but may hinder
observation of treatment effects.
In sum, results from this small, uncontrolled pilot study of
a combined group treatment for chronic insomnia and night-
mares in combat veterans w ith PSTD and multiple comor-
bidities are promising and warrant further investigation. Areas
for future research include ways to enhance treatment effects
(e.g., multiple, sequential exposure trials to nightmares), develop-
ment of shorter versions of the treatment, and randomized, con-
trolled comparison to pharmacological and nonpharmacological
Arbuckle, J. L. (2007). Amos (Version 16) [Computer software]. Chicago: SPSS.
Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D.,
Charney, D. S., et al. (1995). The development of a Clinician-Administered
PTSD Scale. Journal of Traumatic Stress, 8, 75–90.
Buysse, D. J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for
psychiatric practice and research. Psychiatry Research, 28, 193–213.
Clum, G. A., Nishith, P., & Resick, P. A. (2001). Trauma-related sleep dis-
turbance and self-reported physical health symptoms i n treatment-seeking
female rape victims. Journal of Nervous and Mental Disease, 189, 618–
Cohen, J. (1988). Statistical power analysis for the behavioral sciences. Hillsdale,
NJ: Erlbaum.
Cook, J., Harb, G., Ross, R., Gamble, G., & Gehrman, P. (2008, November).
Open pilot study of imagery rehearsal with OIF returnees and design of bi-
site RCT in OEF/OIF veterans. Paper presented at the annual meeting of the
International Society for Traumatic Stress Studies, Chicago, IL.
Davis, J. L., & Wright, D. C. (2007). Randomized clinical trial for treatment of
chronic nightmares in trauma-exposed adults. Journal of Traumatic Stress, 20,
Dohrenwend, B. P. (2006). The psychological risks of Vietnam for U.S. veterans:
A revisit with new data and methods. Science, 313, 979–982.
Edinger, J.D., Olsen, M. K., Stechuchak, K. M., Means, M. K., Lineberger,
M. D., Kirbuy, A., et al. (2009). Cognitive behavioral therapy for pa-
tients with primary insomnia or insomnia associated predominantly with
mixed psychiatric disorders: A randomized clinical trial. Sleep, 32, 499–
Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. (1997). The validation of a self-
report measure of posttraumatic stress disorder: The Posttraumatic Diagnostic
Scale. Psychological Assessment, 9, 445–451.
Germain, A., Shear, K. M., Hall, M., & Buysse, D. J. (2007). Effects of a brief
behavioral treatment for PTSD-related sleep disturbances: A pilot study. Be-
haviour Research and Therapy, 45, 627–632.
Hoge, C. W. (2006). Mental health problems, use of mental health services, and
attrition from military service after returning from deployment to Iraq or
Afghanistan. Journal of the American Medical Association, 295, 1023–1032.
Krakow, B. (2002). Nightmare frequency in sexual assault survivors with PTSD.
Journal of Anxiety Disorders, 16, 175–190.
Krakow, B., Hollifield, M., Johnston, L., Koss, M., Schrader, R., Warner, T. D.,
et al. (2001). Imagery rehearsal therapy for chronic nightmares in sexual assault
survivors with posttraumatic stress disorder: A randomized controlled trial.
Journal of the American Medical Association, 286, 537–545.
Krakow, B., Melendrez, D., Warner, T. D., Clark, J. O., Sisley, B. N., Dorin, R.,
et al. (2006). Signs and symptoms of sleep-disordered breathing in trauma
survivors: A matched comparison with classic sleep apnea patients. Journal of
Nervous and Mental Disease, 194, 433–439.
Lancee, J., Spoormarker, V. I., Krakow, B., & van den Bout, J. (2008). A sys-
tematic review of cognitive-behavioral treatment for nightmares: Toward a
well-established treatment. Journal of Clinical Sleep Medicine, 4, 475–480.
Little, R. J., & Rubin, D. B. (2002). Statistical analysis with missing data (2nd
ed.). New York: Wiley.
Lu, M., Wagner, A., Van Male, L., Whitehead, A., & Boehnlein, J. (2009). Imagery
rehearsal therapy for posttraumatic nightmares in U.S. veterans. Journal of
Traumatic Stress, 22, 236–239.
Morin, C. M. (1993). Insomnia: Psychological assessment and management. New
York: Guilford Press.
Neylan, T. C., Marmar, C. L., Metzler, T. J., Weiss, D. S., Zatzick, D. F.,
Delucchi, K. L., et al. (1998). Sleep disturbances in the Vietnam generation:
Findings from a nationally representative sample of male Vietnam veterans.
American Journal of Psychiatry, 155, 929–933.
Nielsen, T., & Levin. R. (2007). Nightmares: A new neurocognitive model. Sleep
Medicine Reviews, 11, 295–310.
Perlman, L. M. Arnedt, J. T., Earnheart, K. L., Gorman, A. A., & Shirley, K.
G. (2008). Group cognitive-behavioral therapy for insomnia in a VA mental
health clinic. Cognitive and Behavioral Practice, 15, 426–434.
Phelps, A. J., Forbes, D., & Creamer, M. (2008). Understanding posttraumatic
nightmares: A empirical and conceptual review. Clinical Psychology Review,
28, 338–355.
Ross, R. J., Ball, W. A., Sullivan, K. A., & Caroff, S. N. (1989). Sleep disturbance as
the hallmark of posttraumatic stress disorder. American Journal of Psychiatry,
146, 697–707.
Schafer, J. L., & Graham, J. W. (2002). Missing data: Our view of state of the art.
Psychological Methods, 7, 147–177.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
    • "This suggests that sleep intervention in isolation is not likely to be an effective treatment for PTSD with comorbid depression, but may serve as an important adjunct to evidence-based PTSD and MDD psychotherapies as has been suggested by one case study [17]. Despite recommendations for such adjunctive or combined approaches14151617, and further, despite their potential to alter mechanistic pathways of mental and physical morbidity , integrated approaches have not been tested. Our study combines Cognitive Behavioral Therapy for Insomnia (CBTi) with Cognitive Processing Therapy (CPT). "
    [Show abstract] [Hide abstract] ABSTRACT: Sleep disturbance is a common feature of posttraumatic stress disorder (PTSD), but is not a focus of standard PTSD treatments. Psychological trauma exposure is associated with considerable physical and mental health morbidity, possibly due to the alterations in neuroendocrine function and inflammation observed in trauma exposed individuals. Although PTSD treatments are efficacious, they are associated with high drop-out rates in clinical trials and clinical practice. Finally, individuals with PTSD stemming from exposure to interpersonal violence represent an especially under-treated population with significant sleep disturbance. Community-based participatory research was utilized to design and prepare a clinical trial that randomizes recent survivors of interpersonal violence who have PTSD, depression, and insomnia to receive either: (1) Cognitive Behavioral Therapy for Insomnia (CBTi) followed by Cognitive Processing Therapy (CPT) for trauma, or (2) attention control followed by CPT. Outcome measures include subjective and objective measures of sleep, clinician-administered PTSD and depression scales, inflammatory cytokines, and salivary cortisol. Assessments are conducted at baseline, following the sleep or control intervention, and again following CPT. The design allows for: (1) the first test of a sleep intervention in this population; (2) the comparison of sequenced CBTi and CPT to attention control followed by CPT, and (3) assessing the roles of neuroendocrine function, inflammatory processes, and objective sleep markers in mediating treatment outcomes. The study's overarching hypothesis is that treating insomnia will produce reduction in insomnia, PTSD, and depression severity, allowing patients to more fully engage in, and derive optimal benefits from, cognitive processing therapy.
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    • "However , as noted by Swanson and colleagues, it may require additional time for Veterans to achieve positive results for daytime distress. Because research finds that treating PTSD may not alleviate sleep problems and nightmares (e.g., Zayfert & DeViva, 2004) and treating sleep and nightmares may not alleviate PTSD symptoms in Veterans (e.g., Swanson et al., 2009), future research should investigate the integration of these two approaches. Utilizing both approaches may be needed to better target mechanisms that may underlie both PTSD and sleep and nightmare problems, such as emotion regulation. "
    [Show abstract] [Hide abstract] ABSTRACT: Nightmares and sleep disturbances are common complaints among military Veterans (Plumb & Zelman, 2009) and may be difficult to eradicate (Forbes, Phelps, & McHugh, 2001). A treatment protocol (Exposure, Relaxation, and Rescription Therapy [ERRT]) targeting nightmares and sleep disturbances, which has been used effectively in civilian populations, was adapted for the military (ERRT-M). A pilot study evaluated the efficacy of ERRT-M in improving sleep quality and quantity and reducing nightmares, symptoms of posttraumatic stress disorder, and depression in a trauma-exposed, Veteran sample (N = 19). At 1 week after treatment, analyses revealed improvements in nightmare frequency and severity, depression, sleep quality, and insomnia severity. Treatment gains were maintained at a 2-month follow-up. Fifty percent of the sample was considered treatment responders (i.e., no nightmares in the previous week). Results of this pilot study suggest that directly targeting sleep and nightmares is successful in alleviating sleep disturbances and related psychopathology in some Veterans. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
    Full-text · Article · May 2015
    • "This is perhaps unsurprising given the lack of emphasis on sleep with empirically supported treatments for PTSD [65] . CBT-I for PTSD has been shown to be an effective treatment for managing sleep difficulties including insom- nia [69]. One study compared CBT-I combined with imagery rehearsal therapy (a treatment that focuses on cognitive restructuring of nightmares combined with psychoeducation related to nightmares) to treatment as usual in a sample of veterans with PTSD [70@BULLET]. "
    [Show abstract] [Hide abstract] ABSTRACT: Insomnia is a major public health concern, and is highly comorbid with a broad range of psychiatric disorders. Although insomnia has historically been considered a symptom of other disorders, this perspective has shifted. Epidemiological and experimental studies suggest that insomnia is related to the onset and course of several psychiatric disorders. Furthermore, several randomized controlled trials show that cognitive behavioral therapy for insomnia delivered to individuals who meet diagnostic criteria for insomnia and another psychiatric disorder improves the insomnia as well as the symptoms of the comorbid psychiatric disorder. Taken together, these results encompassing a range of methodologies have provided encouraging evidence and point toward insomnia as a transdiagnostic process in psychiatric disorders.
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