Either idiopathic or trauma-based, nightmares have an adverse effect on sleep continuity and efficiency. However, trauma-based nightmares are more frequent, are more intense, and they can persist throughout the lifespan. As might be expected, patients with PTSD have the highest incidence of trauma-based nightmares. Although nightmares are included in the DSM-5 diagnostic criteria for PTSD, they often persist even after first-line PTSD treatments have been successfully concluded.1
Two evidence-based psychosocial treatments are available for trauma-based nightmares: imagery rehearsal therapy (IRT)2 and exposure, relaxation, and rescripting therapy (ERRT).3 Both modalities utilize a brief, sequential approach that incorporates psychoeducation about trauma nightmares, sleep hygiene, relaxation, visual imagery, and “nightmare rescripting.” Even though IRT and ERRT share these basic aspects, they diverge when it comes to specific methods and their application.
To outline the application of each of these modalities, we provide a case illustration for each method. The cases were chosen based on the similarity of demographics and nightmare presentation in terms of frequency and intensity as well as previous trauma focused treatments.
Imagery rehearsal therapy
IRT is grounded in a “systematic desensitization” approach that creates a hierarchy of nightmares in which the patient moves from a moderately intense nightmare toward more distressing nightmares over the course of treatment. IRT focuses attention on changing the imagery system, which is hypothesized as an entrenched, habitual mental process that is dislodged through practicing alternative “rescripted,” neutral imagery.2,4
Subject information and brief history. Jack is a 66-year-old, married, white, Vietnam War veteran. He retired from an automotive factory job 4 years ago, where he frequently worked overtime or double shifts over the 34 years that he was employed there. He has been married for 35 years and has two adult children and three grandchildren. He describes his family relationships as emotionally distant but supportive.
He and his wife sleep in separate bedrooms because of his protracted nightmares and violent movements during sleep when having a combat-related nightmare. (Rapid eye movement behavior disorder has been ruled out prior to presentation). Jack reports that he has few friends and avoids social activities and public events. He used alcohol for several years to reduce stress and promote sleep. When alcohol abuse threatened his marriage and his job, he stopped drinking and began working overtime as often as he could in an attempt to exhaust himself, so he could sleep. This provided limited results as he got older; he was asked to take early retirement when his company began to lay off workers.
Presenting problems. Jack initially presented at the VA Healthcare System for medical problems related to high blood pressure and diabetes. He also reported that his sleep was poor and that he experienced multiple nightmares about the war every night. Jack was referred to the PTSD clinic for evaluation and treatment. On the Clinician Administered PTSD Scales (CAPS) he had a total score of 106 out of 120, evidencing severe PTSD. He met criteria for all three symptom clusters, ie, re-experiencing, avoidance, hyperarousal.
He reported that he was sleeping 2 to 3 hours each night and that he had vivid, recurrent nightmares each night when he did fall asleep. His nightmares and other PTSD symptoms had noticeably increased since his retirement, and as a consequence he was experiencing feelings of hopelessness and depression. His nightmares typically involve responding to several men screaming for a medic and working frantically to stop bleeding or close wounds only to have the soldier die.
Dr Favorite is Director, University of Michigan Psychological Clinic, Clinical Assistant Professor of Psychiatry, Michigan Medicine, and Clinical Psychologist at the Ann Arbor VA Healthcare System PTSD Clinical Team. Dr Conroy is Clinical Associate Professor of Psychiatry and Clinical Director of the Behavioral Sleep Medicine Program, Michigan Medicine, University of Michigan Hospital, Ann Arbor.
The authors report no conflicts of interest concerning the subject matter of this article.
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