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

Abstract

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.

Keywords

PTSD related nightmares - nightmares - imagery rehearsal therapy - narrative therapy - PTSD in veterans

Publication History

Received: 31 July 2022

Accepted: 14 February 2023

Article published online:
22 November 2023

• References

• 1 Neylan TC, Marmar CR, Metzler TJ. et al. Sleep disturbances in the Vietnam generation: findings from a nationally representative sample of male Vietnam veterans. Am J Psychiatry 1998; 155 (07) 929-933
• 2 Leskin GA, Woodward SH, Young HE, Sheikh JI. Effects of comorbid diagnoses on sleep disturbance in PTSD. J Psychiatr Res 2002; 36 (06) 449-452
• 3 Bishay N. Therapeutic manipulation of nightmares and the management of neuroses. Br J Psychiatry 1985; 147: 67-70
• 4 Morgenthaler TI, Auerbach S, Casey KR. et al. Position Paper for the Treatment of Nightmare Disorder in Adults: An American Academy of Sleep Medicine Position Paper. J Clin Sleep Med 2018; 14 (06) 1041-1055
• 5 Gieselmann A, Ait Aoudia M, Carr M. et al. Aetiology and treatment of nightmare disorder: State of the art and future perspectives. J Sleep Res 2019; 28 (04) e12820
• 6 Nappi CM, Drummond SP, Thorp SR, McQuaid JR. Effectiveness of imagery rehearsal therapy for the treatment of combat-related nightmares in veterans. Behav Ther 2010; 41 (02) 237-244
• 7 Krakow B, Zadra A. Clinical management of chronic nightmares: imagery rehearsal therapy. Behav Sleep Med 2006; 4 (01) 45-70
• 8 Margolies SO, Rybarczyk B, Vrana SR, Leszczyszyn DJ, Lynch J. Efficacy of a cognitive-behavioral treatment for insomnia and nightmares in Afghanistan and Iraq veterans with PTSD. J Clin Psychol 2013; 69 (10) 1026-1042
• 9 Germain A, Nielsen T. Impact of imagery rehearsal treatment on distressing dreams, psychological distress, and sleep parameters in nightmare patients. Behav Sleep Med 2003; 1 (03) 140-154
• 10 Krakow B, Hollifield M, Johnston L. et al. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial. JAMA 2001; 286 (05) 537-545
• 11 Aurora RN, Zak RS, Auerbach SH. et al; Standards of Practice Committee, American Academy of Sleep Medicine. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med 2010; 6 (04) 389-401
• 12 Cook JM, Harb GC, Gehrman PR. et al. Imagery rehearsal for posttraumatic nightmares: a randomized controlled trial. J Trauma Stress 2010; 23 (05) 553-563
• 13 Davis JL, Wright DC. Randomized clinical trial for treatment of chronic nightmares in trauma-exposed adults. J Trauma Stress 2007; 20 (02) 123-133
• 14 White M, Epston D. Narrative Means to Therapeutic Ends. New York, NY:: Norton; 1990
• 15 Morgan A. What is Narrative Therapy? An Easy-to-Read Introduction. Adelaide, South Australia: Dulwich Centre Publications;; 2000
• 16 Erbes CR, Stillman JR, Wieling E, Bera W, Leskela J. A pilot examination of the use of narrative therapy with individuals diagnosed with PTSD. J Trauma Stress 2014; 27 (06) 730-733
• 17 Stillman JR. Narrative Therapy Trauma Manual: A Principle-Based Approach. Minneapolis, MN:: Caspersen, LLC;; 2010
• 18 Wagner AM, Chiros CE, Erbes CR. Single-Session Treatment of Nightmares Using Imagery Rehearsal Plus Narrative Therapy. Poster presentation at the 116th Annual Convention for American Psychological Association, Boston, MA. 2008
• 19 Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther 1996; 34 (08) 669-673
• 20 Schnurr PP, Chard KM, Ruzek JI. et al. Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans: A Randomized Clinical Trial. JAMA Netw Open 2022; 5 (01) e2136921
• 21 Foa EB, Huppert JD, Cahill SP. Emotional Processing Theory: An Update.. In: Rothbaum BO. ed. Pathological anxiety: Emotional processing in etiology and treatment. : The Guilford Press; 2006: 3-24
• 22 Rousseau A, Belleville G. The mechanisms of action underlying the efficacy of psychological nightmare treatments: A systematic review and thematic analysis of discussed hypotheses. Sleep Med Rev 2018; 39: 122-133
• 23 Pearlin LI, Schooler C. The structure of coping. J Health Soc Behav 1978; 19 (01) 2-21
• 24 Fitzgerald JM, DiGangi JA, Phan KL. Functional Neuroanatomy of Emotion and Its Regulation in PTSD. Harv Rev Psychiatry 2018; 26 (03) 116-128
• 25 Burklund LJ, Creswell JD, Irwin MR, Lieberman MD. The common and distinct neural bases of affect labeling and reappraisal in healthy adults. Front Psychol 2014; 5: 221
• 26 Williams SE, Ford JH, Kensinger EA. The power of negative and positive episodic memories. Cogn Affect Behav Neurosci 2022; 22 (05) 869-903
• 27 Beaudoin MNZJ. Narrative therapy and interpersonal neurobiology: Revisiting classic practices, developing new emphases. J Syst Ther 2011; 30 (01) 1-13
• 28 Zimmerman J. Neuro-narrative therapy: brain science, narrative therapy, poststructuralism, and preferred identities. J Syst Ther 2017; 36 (02) 12-26