To the Editor: Imagery rehearsal therapy is an efficacious treatment for chronic nightmares. In one controlled study using this therapy, chronic posttraumatic stress symptoms decreased as well (1). However, imagery rehearsal therapy has not been tested on acute nightmares or acute posttraumatic stress symptoms. The following case series describes the use of imagery rehearsal therapy with U.S. Army combat soldiers deployed to Iraq. Only soldiers with a primary complaint of acute nightmares received treatment.
Eleven soldiers with a primary complaint of acute nightmares received imagery rehearsal therapy, and each had experienced a traumatic event within 30 days prior to presentation. Each soldier reported the development of nightmares and related sleep complaints subsequent to the event. Imagery rehearsal therapy treatment was provided in four weekly one hour sessions by Dr. Moore, who learned the technique while in Iraq through a comprehensive user’s manual (2) and supplemental coaching by e-mail exchange with Dr. Krakow. As part of clinical care, the number of nightmares (3), posttraumatic stress symptom severity (4), and insomnia severity (5) were assessed at intake, posttreatment, and 1-month follow-up.
Repeated-measures analysis of variance tested each variable across three time points; Hedge’s g effect sizes (for small cohorts) were calculated for changes between intake and 1-month follow-up. Each outcome showed steady reductions from the three time points (Figure 1). The mean number of nightmares decreased 44% at the 1-month follow-up compared with the mean at intake (F=8.026, df=2, 9, p=0.01, Hedge’s g=1.04), and 7 out of 11 soldiers reported marked relief, with an average decrease of 61% in nightmare counts. The mean posttraumatic stress symptom scores decreased 41% at the 1-month follow-up compared with the mean at intake (F=5.999, df=2, 9, p=0.02, Hedge’s g=1.37), and these same seven soldiers reported marked improvements with an average decrease of 58% in symptoms. Insomnia showed a 34% decrease in severity (F=3.946, df=2, 9, p=0.06, Hedge’s g=1.23), with the same seven soldiers reporting the largest improvements. Among the four soldiers who completed the treatment but did not experience fewer nightmares, one showed a slight increase in nightmares, and three reported no changes. Two soldiers showed slight worsening in posttraumatic stress symptoms, and two showed slight improvement.
In this case series, imagery rehearsal therapy was associated with large clinical improvements in acute nightmares, posttraumatic stress symptoms, and insomnia severity. All soldiers with clear-cut decreases in nightmares (N=7 [64%]) reported improvements in posttraumatic stress and insomnia. However, these data from an uncontrolled design and small cohort must be interpreted cautiously because nightmares, insomnia, and other posttraumatic symptoms are known to dissipate spontaneously in a large proportion of trauma survivors in the early aftermath of traumatic exposure. Definitive assessment of imagery rehearsal therapy efficacy in the treatment of acute nightmares demands a randomized controlled study, and future studies in the operational environment offer a unique setting for research investigation.
1.Krakow B, Hollifield M, Johnston L, Koss M, Schrader R, Warner TD, Tandberg D, Lauriello J, McBride L, Cutchen L, Cheng D, Emmons S, Germain A, Melendrez D, Sandoval D, Prince H: Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial. JAMA 2001; 286:537–545
2.Krakow B, Krakow J: Turning Nightmares Into Dreams. Albuquerque, NM, The New Sleepy Times, 2002
3.Krakow B, Zadra A: Clinical management of chronic nightmares: imagery rehearsal therapy. Behav Sleep Med 2006; 4:45–70
4.Foa EB: Posttraumatic Stress Diagnostic Scale. Lawrence, Kan, National Computer Systems, 1995
5.Morin CM, Colecchi C, Stone J, Sood R, Brink D: Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA 1999; 281:991–999
Outcome Using Imagery Rehearsal Therapy
Dr. Krakow reports the following for-profit interests: www.nightmaretreatment.com, www.sleeptreatment.com, Insomnia Cures
, Turning Nightmares into Dreams, and
Maimonides Sleep Arts & Sciences, Ltd. Dr. Moore reports no competing interests.
The views of these authors are their own and do not purport to reflect the position of the Army Medical Department, Department of the Army, or the Department of Defense.