Impact of imagery rehearsal treatment on distressing dreams, psychological distress, and sleep parameters in nightmare patients

Short-term stability and night-to-night variability of sleep parameters in nightmares comorbid with chronic insomnia Disorder across multiple nights of polysomnography

STUDY OBJECTIVES

The purpose of this study was to examine the degree of short-term stability of polysomnographic (PSG) measured sleep parameters and the overall differences between individuals with comorbid nightmares and insomnia compared to those with chronic insomnia disorder alone or good sleeping controls across four nights in the sleep lab.

METHODS

A total of 142 good sleeping controls, 126 chronic insomnia alone, and 24 comorbid insomnia/nightmare participants underwent four consecutive nights of 8-hour PSG recordings. Outcomes included sleep continuity, architecture, and REM-related parameters across nights one through four. Intraclass correlation coefficients with mixed-effect variances and repeated-measure analysis of covariance were used, respectively, to determine short-term stability as well as between-participants and time-by-group interaction effects.

RESULTS

Wake after sleep onset and stage 1 showed "poor stability" in the comorbid insomnia/nightmare group compared to "moderate stability" in the good sleeping controls and chronic insomnia alone group. Significant between-group effects (all ps < .05) showed that the comorbid insomnia/nightmare group took longer to fall asleep and had a greater first-night-effect in stage 1 compared to good sleeping controls and chronic insomnia alone group; in addition, the comorbid insomnia/nightmare and insomnia alone groups slept shorter, with fewer awakenings and REM periods, compared to the good sleeping controls.

CONCLUSIONS

Nightmares are associated with abnormal sleep above and beyond REM disruption, as sleep continuity was the primary aspect in which poor stability and group differences emerged. The greater inability to fall asleep and instability of sleep fragmentation in those with comorbid insomnia/nightmares compared to chronic insomnia alone may be attributed to the impact of presleep anticipatory anxiety and nightmare-related distress itself.

CLINICAL TRIAL INFORMATION

The data analyzed in this study does not come from any current or previous clinical trials. Therefore, there is no clinical trial information to report.

When Night Falls Fast: Sleep and Suicidal Behavior Among Adolescents and Young Adults

Sleep disturbances have been linked to suicidal ideation and behaviors in adolescents. Specifically, insomnia and nightmares are associated with current suicide risk and predict future ideation. Associations between hypersomnia, sleep apnea, and suicide remain inconclusive. Potential biological mechanisms underlying these relationships include executive functioning deficits and hyperarousal. Related psychological factors may include thwarted belongingness, perceived burdensomeness, and negative appraisals. Assessing suicide risk in patients with sleep disturbances, and vice versa, is needed. Therapeutic interventions such as cognitive behavior therapy for insomnia and imagery rehearsal treatment, as well as pharmacologic treatments, show promise in treating sleep disorders and suicidal behavior.

A Retrospective Pilot Study of Imagery Rehearsal Therapy Enhanced with Narrative Therapy Principles for the Treatment of Nightmares in US Military Veterans

Introduction  Chronic nightmares are a common and disabling feature of posttraumatic stress disorder (PTSD) for which broadly effective treatments are still lacking. While imagery rehearsal therapy (IRT) demonstrates benefits for patients with idiopathic nightmares and some patients with PTSD-related nightmares, research indicates it may be less beneficial for veterans. Narrative therapy (NT) is a form of psychotherapy which is client-centered and value-focused and has demonstrated benefits for PTSD patients. The application of NT principles to IRT may provide a valuable therapeutic approach for treatment in veterans. Objective  To perform a retrospective chart review of veteran clients participating in a novel, brief intervention developed by the first author consisting of IRT enhanced with NT principles (N-IRT) for the treatment of nightmares. The primary outcomes were nightmare frequency and intensity, and the secondary outcome was the impact of the intervention on nightmare distress and coping, subjective sleep quality, and overall PTSD symptoms. Materials and Methods  We conducted retrospective chart reviews for eight veterans referred to the first author for the treatment of nightmares, who completed N-IRT, including baseline and end-of-treatment measures. The protocol involved a single 60-minute NT-enhanced rescripting session and assigned homework to rehearse the revised dream script, and a follow-up evaluation 4 weeks later. The subjects completed a sleep and nightmare interview developed by the first author and the PTSD Checklist at baseline and after the intervention at the follow-up evaluation. Paired t -tests were conducted to test for pre-to-post differences. Results  In the statistical analysis, we observed a statistically significant and clinically meaningful reduction in the frequency ( p  = 0.04) and intensity of nightmares ( p  = 0.001) from pretreatment to the 1-month follow-up. Measures of nightmare-associated emotional distress, the ability to cope with nightmares, sleep duration and sleep efficiency, as well as overall PTSD symptoms also demonstrated significant improvements. Conclusion  These pilot data provide compelling preliminary evidence that a single-session IRT intervention modified with NT (N-IRT) is effective in reducing nightmare frequency and intensity, reducing nightmare distress, improving the act of coping with nightmares, and improving sleep quality and overall PTSD symptoms in veterans. Further investigation of this method with gold-standard clinical trial designs and larger sample sizes is indicated to confirm effectiveness and to better understand the possible mechanisms of treatment effect.

Psychosocial treatments for nightmares in adults and children: a systematic review

BACKGROUND

As nightmares may be a risk factor for, or symptom of, multiple psychological disorders, some researchers suggest that nightmares should be screened, diagnosed, and treated. Treatments for nightmares include trauma-focused Cognitive Behavioural Therapy and Image Rehearsal Therapy, and pharmacological interventions such as prazosin and nitrazepam. As recent research has put into question our current understanding of treatment efficacy, there is a need to systematically review findings related to the effectiveness of nightmare treatments to inform best practice. The current review assessed the efficacy of psychosocial treatments of nightmare in all cohorts.

METHODS

A systematic search of four databases for peer reviewed journal articles from 2000 onwards produced 69 (35 RCTs, 34 non-RCTs) eligible articles that underwent narrative synthesis.

RESULTS

The results provide strong evidence for exposure and image rehearsal treatments for the reduction of nightmare frequency, severity, and distress, in civilian, military, idiopathic, and posttraumatic stress disorder (PTSD) cohorts. There is emerging evidence that self-guided and brief treatment modalities offer efficient and effective treatment options. There is an urgent need for clinical trials of treatment effectiveness in children.

CONCLUSIONS

The results suggest that treatments for nightmares are most effective when they facilitate a sense of control or mastery by directly targeting the nightmare content and/or the client's emotional responses to the nightmare content.

TRIAL REGISTRATION

A review protocol was registered with PROSPERO (CRD42020204861).

Enhancing imagery rehearsal therapy for nightmares with targeted memory reactivation

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.

The “Dream Changer”: a randomized controlled trial evaluating the efficacy of a parent-based intervention for childhood nightmares

Study Objectives

Recurrent nightmares in childhood may have a range of detrimental effects for both the child and parents. This randomized controlled trial evaluated the efficacy of a novel parent-based intervention for childhood nightmares, using a new device called the “Dream Changer.”

Methods

A total of 56 children aged 3–10 years (M = 7.1 ± 2.1 years; 51.8% boys), and one of their parents were randomized to either the intervention or waitlist control group. The intervention group received a “Dream Changer”—a light-emitting remote-control-like device that the child was encouraged to take to bed and use upon experiencing a nightmare. Parents completed online surveys at baseline, 1-week, and 2-weeks following the intervention. Parents in the intervention group additionally completed a 3-month follow-up survey. Outcome variables included children’s nightmare frequency, sleep-wake patterns, and sleep anxiety, as well as parents’ daytime sleepiness.

Results

Significant group-by-time interaction effects were found for nightmare frequency (p = 0.001) and sleep anxiety (p = 0.006). Parents of children who received the “Dream Changer” reported fewer nightmares (Mdifference = 1.7, p &lt; 0.001, d = 1.06) and decreased anxiety (Mdifference = 0.9, p = 0.001, d =0.41) at post-intervention, whereas such benefits were not found in the waitlist control group. Three-month follow-up assessments demonstrated that gains were maintained over-time. Interaction effects were not significant for children’s sleep metrics or for parents’ daytime sleepiness.

Conclusions

The present study provides preliminary evidence for the efficacy of a brief, highly accessible intervention for reducing children’s nightmares and nighttime anxiety. Future research may wish to test these effects using larger samples and longer follow-up assessments.

Clinical Trial Registration

The trial has been registered at the Australian New Zealand Clinical Trials Registry (https://www.anzctr.org.au/; Identifier:ACTRN12620000633987).

Targeted Memory Reactivation During REM Sleep in Patients With Social Anxiety Disorder

BACKGROUND

Social anxiety disorder (SAD) is characterized by a significant amount of fear when confronted to social situations. Exposure therapy, which is based on fear extinction, does not often lead to full remission. Here, based on evidence showing that rapid eye movement (REM) sleep promotes the consolidation of extinction memory, we used targeted memory reactivation (TMR) during REM sleep to enhance extinction learning in SAD.

METHODS

Forty-eight subjects with SAD were randomly assigned to two groups: control or TMR group. All patients had two successive exposure therapy sessions in a virtual reality (VR) environment, where they were asked to give a public talk in front of a virtual jury. At the end of each session, and only in the TMR group (N = 24), a sound was paired to the positive feedback phase of therapy (i.e., approval of their performance), which represented the memory to be strengthened during REM sleep. All participants slept at home with a wearable headband device which automatically identified sleep stages and administered the sound during REM sleep. Participants' anxiety level was assessed using measures of parasympathetic (root mean square of successive differences between normal heartbeats, RMSSD) and sympathetic (non-specific skin conductance responses, ns-SCRs) activity, and subjective measures (Subjective Units of Distress Scale, SUDS), during the preparation phase of their talks before (T1) and after (T2) one full-night's sleep and after 1 week at home (T3). Participants also filled in a dream diary.

RESULTS

We observed an effect of time on subjective measures of anxiety (SUDS). We did not find any difference in the anxiety levels of the two groups after 1 week of TMR at home. Importantly, the longer the total duration of REM sleep and the more stimulations the TMR group had at home, the less anxious (increased RMSSD) these participants were. Finally, fear in dreams correlated positively with ns-SCRs and SUDS at T3 in the TMR group.

CONCLUSION

TMR during REM sleep did not significantly modulate the beneficial effect of therapy on subjective anxiety. Yet, our results support that REM sleep can contribute to extinction processes and substantiate strong links between emotions in dreams and waking stress levels in these patients.

Conquering nightmares on the phone: one-session counseling using imagery rehearsal therapy

Background

Since people with nightmares rarely seek help, low-threshold interventions and self-help methods are needed. Among different treatment approaches for nightmares, imagery rehearsal therapy (IRT) is the method of choice.

Objective

In the current study, the authors tested whether IRT is also effective when applied in a short version, within the scope of a single session of telephone counseling.

Methods

The nightmare frequency and nightmare distress of 28 participants was investigated before and 8 weeks after one session of telephone counseling. The 30-minute session included information on nightmare etiology as well as a short version of IRT. The session was followed by an 8‑week period of self-practice. Participants were either part of a student group or part of a group of patients from a sleep laboratory. Within-group and between-group differences were assessed. There was no control group.

Results

The intervention significantly reduced nightmare frequency and nightmare distress in the total sample and in both samples individually analyzed. Effect sizes were very high compared to those of waiting-list control groups of similar studies.

Conclusion

We were able to show that a one-session intervention can be enough to achieve significant relief from nightmares. As nightmares are underdiagnosed and undertreated, this approach might help to provide a low-threshold intervention for nightmare sufferers.

Treatment of Sleep Comorbidities in Posttraumatic Stress Disorder

Purpose of the review

Sleep disturbances, insomnia and recurrent nightmares in particular, are among the most frequently endorsed symptoms of posttraumatic stress disorder (PTSD). The present review provides a summary of the prevalence estimates and methodological challenges presented by sleep disturbances in PTSD, highlights the recent evidence for empirically supported psychotherapeutic and pharmacological interventions for comorbid sleep disturbances implicated in PTSD, and provides a summary of recent findings on integrated and sequential treatment approaches to ameliorate comorbid sleep disturbances in PTSD.

Recent Findings

Insomnia, recurrent nightmares, and other sleep disorders are commonly endorsed among individuals with PTSD; however, several methodological challenges contribute to the varying prevalence estimates. Targeted sleep-focused therapeutic interventions can improve sleep symptoms and mitigate daytime PTSD symptoms. Recently, attention has focused on the role of integrated and sequential approaches, suggesting that comprehensively treating sleep disturbances in PTSD is likely to require novel treatment modalities.

Summary

Evidence is growing on the development, course, and treatment of comorbid sleep disturbances in PTSD. Further, interventions targeting sleep disturbances in PTSD show promise in reducing symptoms. However, longitudinal investigations and additional rigorous controlled trials with diverse populations are needed to identify key features associated with treatment response in order to alleviate symptoms.

When Night Falls Fast: Sleep and Suicidal Behavior Among Adolescents and Young Adults

Sleep disturbances have been linked to suicidal ideation and behaviors in adolescents. Specifically, insomnia and nightmares are associated with current suicide risk and predict future ideation. Associations between hypersomnia, sleep apnea, and suicide remain inconclusive. Potential biological mechanisms underlying these relationships include executive functioning deficits and hyperarousal. Related psychological factors may include thwarted belongingness, perceived burdensomeness, and negative appraisals. Assessing suicide risk in patients with sleep disturbances, and vice versa, is needed. Therapeutic interventions such as cognitive behavior therapy for insomnia and imagery rehearsal treatment, as well as pharmacologic treatments, show promise in treating sleep disorders and suicidal behavior.

Illness pathways between eating disorder and post-traumatic stress disorder symptoms: Understanding comorbidity with network analysis

Eating disorders (EDs) and post-traumatic stress disorder (PTSD) are highly comorbid. However, specific mechanisms by which PTSD-ED comorbidity is maintained are unknown. The current study constructed two PTSD-ED comorbidity networks (25 EDs and 17 PTSD symptoms) in two samples: a clinical (N = 158 individuals with an ED diagnosis) and a nonclinical sample (N = 300 college students). Glasso networks were constructed to identify (1) pathways between disorders (bridge symptoms) and (2) core symptoms. Three illness pathways emerged: between binge eating and irritability, between desire for a flat stomach and disturbing dreams, and between concentration problems and weight and shape-related concentration problems. Our findings suggest that pathways between binge eating and irritability, body dissatisfaction and trauma reminders, and concentration difficulties may be the mechanisms by which comorbidity is maintained. Interventions disrupting these pathways and targeting core and bridge symptoms may be more efficient than traditional treatment approaches.

Efficacy of Imagery Rehearsal Therapy and Cognitive Behavioral Therapy in Sexual Assault Victims With Posttraumatic Stress Disorder: A Randomized Controlled Trial

Sleep disturbances are common among sexual assault victims with posttraumatic stress disorder (PTSD), but cognitive behavioral therapy (CBT) for PTSD does not directly address sleep-related symptoms. Trauma-related sleep disturbances are associated with more impairment and contribute to the maintenance of PTSD. In this study, we evaluated the efficacy of a combination of CBT and nightmare therapy (imagery rehearsal therapy; IRT) compared to CBT alone for the treatment of PTSD. We recruited 42 adult victims of sexual assault who were suffering from PTSD and randomly assigned them to either the experimental (IRT + CBT) or control condition (waiting period followed by CBT). After CBT, both groups demonstrated significant decreases in nighttime symptoms (except nightmare frequency) and PTSD symptoms and showed improvements in functional impairment and mental health, ds = 0.13-0.83, ps = .005-.008. Outcomes between the two groups did not differ significantly after CBT; however, we observed medium to medium-large differences between the control group and experimental group in terms of nighttime symptoms, ds = 0.45-0.63. Although results did not clearly establish the superiority of IRT + CBT over CBT alone, they demonstrated that IRT yielded greater improvement in nighttime symptoms than the waiting period, ds = 0.72-1.13, ps = .006-.047 for all interaction effects. Findings suggest that targeting nightmares at the beginning of treatment for PTSD may yield rapid improvement in nighttime symptoms. This strategy could be useful for patients with time or resource constraints or those for whom nightmares are the primary complaint.

Exploring the effects of galantamine paired with meditation and dream reliving on recalled dreams: Toward an integrated protocol for lucid dream induction and nightmare resolution

An experimental home study examined the impact of a pre-sleep protocol for enhancing self-awareness, lucidity, and responsiveness in dreams. It included ingesting the cholinesterase inhibitor galantamine--which is widely reported to increase the frequency of lucid dreaming--prior to engaging in middle-of-the-night meditation and the imaginary reliving of a distressing dream while exercising new responses. Thirty-five participants completed an eight-night study, which included pre- and post-baseline nights and six conditions: waking for 40 min before returning to bed, called Wake-Back-to-Bed (WBTB); Wake-Back-to-Bed plus placebo (WBTB + P); Wake-Back-to-Bed plus galantamine (WBTB + G); meditation and dream reliving (MDR); meditation and dream reliving plus placebo (MDR + P); and meditation and dream reliving plus galantamine (MDR + G). The outcome measures included lucidity, reflectiveness, interactive behavior, role change, constructive action, and fear and threat, as measured by the participants' self-ratings. The results support the use of this protocol in further studies of lucid dream induction and nightmare/trauma resolution.

Position Paper for the Treatment of Nightmare Disorder in Adults: An American Academy of Sleep Medicine Position Paper

INTRODUCTION

Nightmare disorder affects approximately 4% of adults, occurring in isolation or as part of other disorders such as posttraumatic stress disorder (PTSD), and can significantly impair quality of life. This paper provides the American Academy of Sleep Medicine (AASM) position regarding various treatments of nightmare disorder in adults.

METHODS

A literature search was performed based upon the keywords and MeSH terms from the Best Practice Guide for the Treatment of Nightmare Disorder in Adults that was published in 2010 by the AASM. The search used the date range March 2009 to August of 2017, and sought to find available evidence pertaining to the use of behavioral, psychological, and pharmacologic therapies for the treatment of nightmares. A task force developed position statements based on a thorough review of these studies and their clinical expertise. The AASM Board of Directors approved the final position statements.

DETERMINATION OF POSITION

Positions of "recommended" and "not recommended" indicate that a treatment option is determined to be clearly useful or ineffective/harmful for most patients, respectively, based on a qualitative assessment of the available evidence and clinical judgement of the task force. Positions of "may be used" indicate that the evidence or expert consensus is less clear, either in favor or against the use of a treatment option. The interventions listed below are in alphabetical order within the position statements rather than clinical preference: this is not meant to be instructive of the order in which interventions should be used.

POSITION STATEMENTS

The following therapy is recommended for the treatment of PTSD-associated nightmares and nightmare disorder: image rehearsal therapy. The following therapies may be used for the treatment of PTSD-associated nightmares: cognitive behavioral therapy; cognitive behavioral therapy for insomnia; eye movement desensitization and reprocessing; exposure, relaxation, and rescripting therapy; the atypical antipsychotics olanzapine, risperidone and aripiprazole; clonidine; cyproheptadine; fluvoxamine; gabapentin; nabilone; phenelzine; prazosin; topiramate; trazodone; and tricyclic antidepressants. The following therapies may be used for the treatment of nightmare disorder: cognitive behavioral therapy; exposure, relaxation, and rescripting therapy; hypnosis; lucid dreaming therapy; progressive deep muscle relaxation; sleep dynamic therapy; self-exposure therapy; systematic desensitization; testimony method; nitrazepam; prazosin; and triazolam. The following are not recommended for the treatment of nightmare disorder: clonazepam and venlafaxine. The ultimate judgment regarding propriety of any specific care must be made by the clinician, in light of the individual circumstances presented by the patient, accessible treatment options, and resources.

The mechanisms of action underlying the efficacy of psychological nightmare treatments: A systematic review and thematic analysis of discussed hypotheses

Studies of psychotherapeutic treatments for nightmares have yielded support for their effectiveness. However, no consensus exists to explain how they work. This study combines a systematic review with a qualitative thematic analysis to identify and categorize the existing proposed mechanisms of action (MAs) of nightmare treatments. The systematic review allowed for a great number of scholarly publications on supported psychological treatments for nightmares to be identified. Characteristics of the study and citations regarding potential MAs were extracted using a standardized coding grid. Then, thematic analysis allowed citations to be grouped under six different categories of possible MAs according to their similarities and differences. Results reveal that an increased sense of mastery was the most often cited hypothesis to explain the efficacy of nightmare psychotherapies. Other mechanisms included emotional processing leading to modification of the fear structure, modification of beliefs, restoration of sleep functions, decreased arousal, and prevention of avoidance. An illustration of the different variables involved in the treatment of nightmares is proposed. Different avenues for operationalization of these MAs are put forth to enable future research on nightmare treatments to measure and link them to efficacy measures, and test the implications of the illustration.

Sleep and Dreaming in Posttraumatic Stress Disorder

PURPOSE OF REVIEW

Sleep disturbances are core features of posttraumatic stress disorder (PTSD). This review aims to characterize sleep disturbances, summarize the knowledge regarding the relationships between trauma exposure and sleep difficulties, and highlight empirically supported and/or utilized treatments for trauma-related nightmares and insomnia.

RECENT FINDINGS

Trauma-related nightmares and insomnia, and other sleep disorders, are frequently reported among trauma survivors. The roles of fear of sleep, REM density, and decreased parasympathetic activity are beginning to inform the relationship between trauma exposure and sleep difficulties. Additionally, the potential adaptive role of sleep loss immediately following a traumatic experience is being recognized. Interventions targeting these sleep disturbances show promise in reducing symptoms. Research in understanding the role of sleep on the development, course, and treatment of PTSD is expanding. Longitudinal investigations are needed to further elucidate these relationships and identify treatments most effective in ameliorating symptoms.

Pharmacological and non-pharmacological treatments for nightmare disorder

Interest in the treatment of nightmares has greatly increased over the last several years as research has demonstrated the clinical significance of nightmare disorder. This paper provides an overview of nightmare disorder, its clinical relevance, and the leading treatments that are available. In particular, the paper defines nightmare disorder and then summarize the recent literature examining the clinical relevance of nightmare disorder, including its relation to post-traumatic stress disorder and other psychiatric conditions. The relation between nightmares and suicidality is also discussed. Recent findings on the treatment of nightmare with imagery rehearsal therapy and prazosin are then summarized. Lastly, the paper comments on potential future uses of nightmare treatment including using imagery rehearsal therapy or prazosin as a first-line intervention for post-traumatic stress disorder and using these treatments as an adjunctive therapy to reduce suicide risk in those at risk of suicide with nightmares.

Treatment of sleep disturbances in post-traumatic stress disorder

Sleep disturbances are very common in patients suffering from post-traumatic stress disorder (PTSD) and can have various negative sequelae, including worsening of perceived levels of stress, depression, and suicidal ideation. Although PTSD treatment can lead to improved sleep in some patients, there are a number of patients whose sleep disturbances do not remit even after treatment and can persist long after the original trauma. There are various non-pharmacological and pharmacological treatment modalities that have been studied. Non-pharmacological therapies include image rehearsal therapy (IRT), cognitive behavioral therapy for insomnia (CBTI), prolonged exposure (PE), and eye-movement desensitization and reprocessing (EMDR). Pharmacological studies include alpha-1-adrenergic receptor antagonists, alpha-adrenergic agonists, selective serotonin reuptake inhibitors (SSRIs), selective norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs) monoamine oxidase inhibitors (MAOIs), other antidepressants, atypical antipsychotics, benzodiazepines, sedative hypnotics, and antiepileptics. The therapies with the most evidence to support their use are Image Rehearsal Therapy (IRT) and the alpha-1-adrenergic receptor antagonist, prazosin.

Bad dream frequency in older adults with generalized anxiety disorder: prevalence, correlates, and effect of cognitive behavioral treatment for anxiety

This study investigated the relation between generalized anxiety disorder (GAD) and frequency of bad dreams in older adults. A secondary analysis from a randomized clinical trial comparing cognitive behavioral therapy (CBT) for anxiety to enhanced usual care (EUC) assessed bad dream frequency at baseline, post treatment (3 months), and at 6, 9, 12, and 15 months. Of 227 participants (mean age = 67.4), 134 met GAD diagnostic criteria (CBT = 70, EUC = 64), with the remaining 93 serving as a comparison group. Patients with GAD had significantly more bad dreams than those without, and bad dream frequency was significantly associated with depression, anxiety, worry, and poor quality of life. CBT for anxiety significantly reduced bad dream frequency at post treatment and throughout follow up compared to EUC.

Eye Movement Desensitization and Reprocessing Treatment of Nightmares: A Case Report

A single client with depression and chronic nightmares was treated with 4 sessions of eye movement desensitization and reprocessing (EMDR) and showed a decrease in nightmares and improvement in general well-being. The client’s 2 nightmare images were resolved following Luber’s (2010) protocol for nightmare processing. Treatment effects were measured with the Outcome Rating Scale and showed a shift from the clinical range at pretreatment to the nonclinical range at the third session. The ready improvement and gains of this patient have served to highlight various aspects of the EMDR procedures which have worked well for the client, which included targeting the negative cognitions surrounding the theme of helplessness as well as adapting the positive cognition with a collectivistic orientation.

Efficacy of a cognitive-behavioral treatment for insomnia and nightmares in Afghanistan and Iraq veterans with PTSD

OBJECTIVE

Sleep disturbances are a core and salient feature of posttraumatic stress disorder (PTSD). Pilot studies have indicated that combined cognitive-behavioral therapy for insomnia (CBT-I) and imagery rehearsal therapy (IRT) for nightmares improves sleep as well as PTSD symptoms.

METHOD

The present study randomized 40 combat veterans (mean age 37.7 years; 90% male and 60% African American) who served in Afghanistan and/or Iraq (Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]) to 4 sessions of CBT-I with adjunctive IRT or a waitlist control group. Two thirds of participants had nightmares at least once per week and received the optional IRT module.

RESULTS

At posttreatment, veterans who participated in CBT-I/IRT reported improved subjectively and objectively measured sleep, a reduction in PTSD symptom severity and PTSD-related nighttime symptoms, and a reduction in depression and distressed mood compared to the waitlist control group.

CONCLUSION

The findings from this first controlled study with OEF/OIF veterans suggest that CBT-I combined with adjunctive IRT may hold promise for reducing both insomnia and PTSD symptoms. Given the fact that only half of the patients with nightmares fully implemented the brief IRT protocol, future studies should determine if this supplement adds differential efficacy to CBT-I alone.

Sleep disturbances as the hallmark of PTSD: where are we now?

The hypothesis that rapid eye movement (REM) sleep disturbances are the hallmark of posttraumatic stress disorder (PTSD), proposed by Ross and colleagues in 1989, has stimulated a wealth of clinical, preclinical, and animal studies on the role of sleep in the pathophysiology of PTSD. The present review revisits this influential hypothesis in light of clinical and experimental findings that have since accumulated. Polysomnographic studies conducted in adults with PTSD have yielded mixed findings regarding REM sleep disturbances, and they generally suggest modest and nonspecific sleep disruptions. Prospective and treatment studies have provided more robust evidence for the relationship between sleep disturbances and psychiatric outcomes and symptoms. Experimental animal and human studies that have probed the relationship between REM sleep and fear responses, as well as studies focused more broadly on sleep-dependent affective and memory processes, also provide strong support for the hypothesis that sleep plays an important role in PTSD-relevant processes. Overall, the literature suggests that disturbed REM or non-REM sleep can contribute to maladaptive stress and trauma responses and may constitute a modifiable risk factor for poor psychiatric outcomes. Clinicians need to consider that the chronic sleep disruption associated with nightmares may affect the efficacy of first-line PTSD treatments, but targeted sleep treatments may accelerate recovery from PTSD. The field is ripe for prospective and longitudinal studies in high-risk groups to clarify how changes in sleep physiology and neurobiology contribute to increased risk of poor psychiatric outcomes.

Efficacy of psychological interventions aiming to reduce chronic nightmares: a meta-analysis

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.

Chronische Alpträume: Wirksamkeit eines deutschsprachigen Manuals zur angeleiteten Selbsthilfe mit Imagery Rehearsal Therapy

Theoretischer Hintergrund: Chronische Alpträume stellen eine weit verbreitete Schlafstörung dar, welche einen hohen Leidensdruck hervorruft. Als besonders wirksam in der Behandlung gilt die Imagery Rehearsal Therapy (IRT). Selbsthilfeprogramme stellen hierbei eine effektive, ökonomische Behandlungsoption dar. Fragestellung: Die vorliegende Pilotstudie untersucht die Wirksamkeit einer neuen, IRT-basierten, angeleiteten Selbsthilfe. Methode: 10 Patienten mit chronischen Alpträumen wurden im Rahmen von 4 face-to-face-Sitzungen vor Intervention (T1) sowie 4 Wochen (T2) und 3 Monate (T3) danach hinsichtlich Alptraumhäufigkeit sowie verschiedener psychosozialer Parameter untersucht. Ergebnisse: Die Alptraumhäufigkeit reduzierte sich innerhalb von 4 Wochen signifikant (T1-T2; Effektstärke: 1,0). Dieser Effekt blieb über 3 Monate stabil (T1-T3; Effektstärke: 1,26). Zudem reduzierten sich signifikant Depressions-, Angst- und Anspannungsparameter sowie das Stresserleben. Schlussfolgerung: Das deutschsprachige Selbsthilfemanual könnte eine wirksame Behandlungsmöglichkeit zur Reduktion von Alpträumen darstellen.

In the midnight hour: Cancer and nightmares. A review of theories and interventions in psycho-oncology

OBJECTIVES

The purposes of this study were: (1) to explore cancer patients' complaints of poor sleep, which often involve a combination of somatic symptoms and nightmares; and (2) to understand these sleep disturbances in the light of modern dream theories and intervention modalities.

METHOD

The literature search originated with several major articles (Revonsuo, 2000; Krakow & Zadra, 2006; Hobson, 2009) which then opened up the search through their references. We also used the database PubMed, and employed the following key words: cancer, nightmares/dreams, sleep disturbances, and dream theory. The literature search covered the interval between 1900 (Freud, 1900) and 2009. Our criteria for selecting studies included the most recent major review articles on the neuroscience of sleep and dreams; articles reviewing sleep disturbances in cancer patients and relevant treatments; and articles reviewing interventions for traumatic dreams. Approximately 30 articles were deemed worthy of inclusion.

RESULTS

Thirty article/books/chapters met the criteria for relevance related to key theories and clinical interventions related to nightmares and traumatic dreams of cancer patients. Key concepts involve threat simulation theory and imagery rehearsal therapy in regard to theoretical and interventional paradigms significantly generalizable to cancer patients. The dream material included in this article presents patients' attempts to deal with complex threats such as intense dependency/ loss of self-sufficiency, disfigurement, and death. This is especially true with regard to the doctor-patient relationship at all stages of the illness and disease. Imagery rehearsal can facilitate empowerment in light of highly threatening and conflictual cancer-related dreams in which the patient feels helpless and victimized.

SIGNIFICANCE OF RESULTS

This review offers a new lens on current dream theories and understanding of sleep disturbance in cancer patients as well as their familes and medical caregivers. Modern theories lead to opportunities for intervention that can both relieve symptoms and improve communication between medical caregivers and patients and families.

Effectiveness of imagery rehearsal therapy for the treatment of combat-related nightmares in veterans

Imagery Rehearsal Therapy (IRT) has been shown to be efficacious in reducing nightmares, but the treatment has not been well-studied in veterans. The effectiveness of IRT was assessed from a chart review of veterans seeking outpatient treatment for chronic, trauma-related nightmares. Of those offered IRT, veterans who completed a full course of treatment for PTSD in the past year were more likely to initiate treatment. However, completion of IRT was not related to previous treatment, demographic variables, or nightmare severity reported at the first treatment session. Treatment completers reported significant reductions in nightmare frequency and intensity, severity of insomnia, and subjective daytime PTSD symptoms. Insomnia and PTSD symptoms, on average, were below clinical cutoffs following treatment, and 23% of patients showed a complete treatment response (< or =1 nightmare/week). Findings suggest IRT may be an effective short-term treatment for nighttime and daytime PTSD symptoms among veterans who complete a full course of treatment.

Impact of REM sleep on distortions of self-concept, mood and memory in depressed/anxious participants

INTRODUCTION

We tested the hypothesis that REM sleep contributes to core features of cognitive dysfunction of anxious depression including negative self-appraisals, biased memory processing and unpleasant dream content.

METHODS

After a habituation night in a sleep lab, a convenience sample of 35 healthy college students and 20 depressed/anxious students were awakened 10 min into a REM sleep episode and then 10 min into a NREM sleep episode. Awakenings were counterbalanced to control circadian effects. After each awakening participants reported a dream and then completed memory recall, mood and self-appraisal tasks.

RESULTS

Self-appraisals of depressed/anxious participants were significantly less positive and significantly more negative after awakenings from REM sleep vs NREM sleep. Appraisal of the REM sleep dream self was negative for depressed/anxious subjects only. Recall of negative memories was significantly more frequent after REM vs NREM sleep awakenings for both depress/anxious and healthy participants. REM sleep dreams were associated with greater frequencies of negative emotion, greater aggression and victimization rates than dreams in NREM sleep for depressed/anxious participants.

LIMITATIONS

Depressed/anxious participants were classified as such on the basis of mood scales rather than clinical interview. All participants were drawn from a volunteer college student population and thus our results may not be applicable to some elderly clinical populations.

CONCLUSIONS

REM appears to facilitate cognitive distortions of anxious depression.

REM and NREM sleep mentation

We review the literature on the neurobiology of rapid eye movement (REM) and non-rapid eye movement (NREM) sleep states and associated dreams. REM is associated with enhanced activation of limbic and amygdalar networks and decreased activation in dorsal prefrontal regions while stage II NREM is associated with greater cortical activation than REM. Not surprisingly, these disparate brain activation patterns tend to be associated with dramatically different dream phenomenologies and dream content. We present two recent studies which content-analyzed hundreds of dream reports from REM and NREM sleep states. These studies demonstrated that dreamer-initiated aggressive social interactions were more characteristic of REM than NREM, and dreamer-initiated friendliness was more characteristic of NREM than REM reports. Both REM and NREM dreams therefore may function to simulate opposing types of social interactions, with the REM state specializing in simulation of aggressive interactions and the NREM state specializing in simulation of friendly interactions. We close our review with a summary of evidence that dream content variables significantly predict daytime mood and social interactions.

Imagery rehearsal therapy for frequent nightmares in children

This study examined the applicability of imagery rehearsal therapy (IRT) to children with frequent nightmares. Eleven boys and 9 girls aged 9 to 11, with moderate to severe primary nightmares (1 or more per week for 6 months) and without posttraumatic stress disorder, were randomly divided into an imagery rehearsal treatment group (n = 9) or a waiting-list (n = 11) group. ANCOVA with repeated measures revealed that, following a baseline period, IRT reduced the frequency of nightmares (p < .04; eta(2) = 0.22) in the treated group compared to the waiting-list group. This reduction was maintained over a 9-month follow-up. The effects of IRT on post-nightmare state distress could not be assessed due to low nightmare incidences. However, retrospective trait nightmare distress was not significantly reduced. Future research is needed to validate this simple approach for nightmare reduction and to evaluate its potential for the reduction of the associated nightmare distress.

Sleep patterns and psychological distress in women living in an inner city

Psychological distress, including symptoms of anxiety, depression, and psychological trauma, is common in women living in inner cities and can be associated with disturbed sleep. The purposes of the study of 115 women were to examine: (a) objective and subjective sleep patterns; (b) extent of psychological distress; and (c) the relationship between objective and subjective sleep patterns and psychological distress. Wrist actigraphs were worn. High levels of life stress, sleep pattern disturbance, and psychological distress were common. Self-reported sleep patterns, but not objective sleep pattern variables, explained 12.5% to 44% of the variance in psychological distress, suggesting the importance of screening for sleep and psychological distress. These findings suggest that interventions focusing on sleep or psychological distress may reduce symptoms.

Physiological-emotional reactivity to nightmare-related imagery in trauma-exposed persons with chronic nightmares

Script-driven imagery was used to assess nightmare imagery-evoked physiological-emotional reactivity (heart rate, skin conductance, facial electromyogram, subjective ratings) in trauma-exposed persons suffering from chronic nightmares. Goals were to determine the efficacy of nightmare imagery to evoke physiological-emotional reactivity, correlates (mental health, nightmare characteristics) of reactivity, and consequences (sleep and health problems) of reactivity. Nightmare imagery resulted in significant reactivity relative to control imagery. No mental health variable (posttraumatic stress disorder status, depressive symptoms, dissociation) or nightmare characteristic (months experienced, frequency, similarity to trauma) was associated with reactivity level. However, nightmare imagery-evoked autonomic responses were associated with greater sleep disturbance and reported health symptoms, even when nightmare frequency was controlled. These results suggest nightmare-related autonomic reactions may contribute to sleep and health disturbance.

Disturbed sleep in post-traumatic stress disorder: secondary symptom or core feature?

Sleep disturbances are often viewed as a secondary symptom of post-traumatic stress disorder (PTSD), thought to resolve once PTSD has been treated. Specific screening, diagnosis and treatment of sleep disturbances is therefore not commonly conducted in trauma centres. However, recent evidence shows that this view and consequent practices are as much unhelpful as incorrect. Several sleep disorders-nightmares, insomnia, sleep apnoea and periodic limb movements-are highly prevalent in PTSD, and several studies found disturbed sleep to be a risk factor for the subsequent development of PTSD. Moreover, sleep disturbances are a frequent residual complaint after successful PTSD treatment: a finding that applies both to psychological and pharmacological treatment. In contrast, treatment focusing on sleep does alleviate both sleep disturbances and PTSD symptom severity. A growing body of evidence shows that disturbed sleep is more than a secondary symptom of PTSD-it seems to be a core feature. Sleep-focused treatment can be incorporated into any standard PTSD treatment, and PTSD research needs to start including validated sleep measurements in longitudinal epidemiologic and treatment outcome studies. Further clinical and research implications are discussed, and possible mechanisms for the role of disturbed (REM) sleep in PTSD are described.

Randomized clinical trial for treatment of chronic nightmares in trauma-exposed adults

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.

Effects of a brief behavioral treatment for PTSD-related sleep disturbances: A pilot study

OBJECTIVE

Sleep disturbances are a core feature of post-traumatic stress disorder (PTSD), and are often resistant to first-line pharmacological and psychological PTSD interventions. The goal of this pilot study was to explore the effects of a very brief intervention for PTSD-related nightmares and insomnia in victims of violent crimes with PTSD.

METHODS

Seven adult victims of violent crimes with a current diagnosis of PTSD received a single, 90-min intervention session that used cognitive-behavioral techniques aimed at reducing post-traumatic nightmares and insomnia. Sleep diary measures, and measures of sleep quality, PTSD severity, anxiety, and depression were completed at baseline and 6 weeks post-intervention.

RESULTS

Improvements in self-report and sleep diary measures of sleep quality and dream frequency were observed post-intervention. Clinically meaningful reductions in daytime PTSD symptom severity were also observed.

CONCLUSIONS

A very brief behavioral intervention targeting post-traumatic nightmares and insomnia was associated with significant improvements in sleep and daytime PTSD symptom severity. Brief sleep-focused intervention may be helpful adjuncts to first-line PTSD treatments.

Clinical management of chronic nightmares: imagery rehearsal therapy

Problems with nightmares are reported by a sizable proportion of individuals with a history of trauma and by approximately 5% to 8% of the general population. Chronic nightmares may represent a primary sleep disorder rather than a symptom of a psychiatric disorder, and direct targeting of nightmares is a feasible clinical approach to the problem. Of the treatments proposed, imagery rehearsal therapy (IRT) has received the most empirical support. An up-to-date account of this cognitive-imagery approach shows how to treat nightmares during 4 roughly 2-hr sessions. The main points covered in each therapy session and their underlying rationale are presented. Dismantling protocols are suggested to discern active ingredients of IRT and to develop flexible applications based on patients' needs.

Nightmares: from anxiety symptom to sleep disorder

The DSM-IV-TR definition of nightmares-extremely frightening dreams from which the person wakes up directly-is unnecessarily narrow. Other emotions (anger, grief) have also been reported in nightmares, and direct awakening from a bad dream seems to be unrelated to increased distress. In addition, assessment of nightmares is problematic. Polysomnographic recordings have an ameliorating effect on nightmare frequency, retrospective measurements tend to underestimate nightmare frequency, and persons with frequent nightmares may feel reluctant to fill out (daily) prospective measurements. For studying nightmares, it is necessary to distinguish idiopathic nightmares from posttraumatic nightmares, which are part of a posttraumatic stress reaction or disorder that may result from experiencing a traumatic event. Both types of nightmares have been associated with an elevated level of periodic limb movements, although only posttraumatic nightmares seem to be related to more and longer nocturnal awakenings. Nightmares have also been repeatedly associated with the general level of psychopathology, or the so-called personality factor neuroticism. Nightmare distress, the impact on daily functioning caused by nightmares, may function as a mediating variable. Several studies in the last decades have shown that nightmares can be treated with several cognitive-behavioral techniques. The cognitive-restructuring technique imagery rehearsal therapy is the treatment of choice for nightmares, although a randomized controlled trial with an attention control-group has not yet been carried out. Nightmares are more than a symptom of a larger (anxiety) syndrome and need to be viewed from a sleep medicine perspective: nightmares are a highly prevalent and separate sleep disorder that can and should receive specific treatment.

A brief sleep scale for Posttraumatic Stress Disorder: Pittsburgh Sleep Quality Index Addendum for PTSD

Sleep disturbances reflect a core dysfunction underlying Posttraumatic Stress Disorder (PTSD). Specifically, disruptive nocturnal behaviors (DNB) may represent PTSD-specific sleep disturbances. The Pittsburgh Sleep Quality Index Addendum for PTSD (PSQI-A) is self-report instrument designed to assess the frequency of seven DNB. The goal of this study was to examine the psychometric properties of the PSQI-A to characterize DNB in a group of participants with and without PTSD. Results indicate that the PSQI-A has satisfactory internal consistency and good convergent validity with two standard PTSD measures even when excluding their sleep-related items. A global PSQI score of 4 yielded a sensitivity of 94%, a specificity of 82%, and a positive predictive value of 93% for discriminating participants with PTSD from those without PTSD. The PSQI-A is a valid instrument for PTSD applicable to both clinical and research settings.

Clinical correlates of poor sleep quality in posttraumatic stress disorder

Sleep disturbances (SD) are a core clinical feature of PTSD. The goal of the study was to determine the influence of patient-related characteristics, disorder-related characteristics, and psychiatric comorbidity on the severity of SD in PTSD outpatients (n = 367) who were not recruited for a sleep study. Increased severity of SD paralleled increasing overall PTSD severity. The severity of SD did not differ according to gender, age groups, types of trauma, PTSD chronicity, or psychiatric comorbidity. Results suggest that age, gender, and psychiatric comorbidity have minimal impact on sleep quality in this PTSD sample. The inclusion of PTSD patients who were not specifically seeking treatment for SD reinforces the study findings.