Imagery Rehearsal Therapy for Chronic Nightmares in Sexual Assault Survivors With Posttraumatic Stress Disorder A Randomized Controlled Trial
2001
ContextChronic nightmares occur frequently in patients with posttraumatic stress
disorder (PTSD) but are not usually a primary target of treatment.ObjectiveTo determine if treating chronic nightmares with imagery rehearsal therapy
(IRT) reduces the frequency of disturbing dreams, improves sleep quality,
and decreases PTSD symptom severity.Design, Setting, and ParticipantsRandomized controlled trial conducted from 1995 to 1999 among 168 women
in New Mexico; 95% had moderate-to-severe PTSD, 97% had experienced rape or
other sexual assault, 77% reported life-threatening sexual assault, and 58%
reported repeated exposure to sexual abuse in childhood or adolescence.InterventionParticipants were randomized to receive treatment (n = 88) or to the
wait-list control group (n = 80). The treatment group received IRT in 3 sessions;
controls received no additional intervention, but continued any ongoing treatment.Main Outcome MeasuresScores on the Nightmare Frequency Questionnaire (NFQ), Pittsburgh Sleep
Quality Index (PSQI), PTSD Symptom Scale (PSS), and Clinician-Administered
PTSD Scale (CAPS) at 3- and 6-month follow-up.ResultsA total of 114 participants completed follow-up at 3 and/or 6 months.
Comparing baseline to follow-up (n = 97-114), treatment significantly reduced
nights per week with nightmares (Cohen d = 1.24; P<.001) and number of nightmares per week (Cohen d = 0.85; P<.001) on the NFQ
and improved sleep (on the PSQI, Cohen d = 0.67; P<.001) and PTSD symptoms (on the PSS, Cohen d = 1.00; P<.001 and on the CAPS, Cohen d = 1.53; P<.001). Control
participants showed small, nonsignificant improvements for the same measures
(mean Cohen d = 0.21). In a 3-point analysis (n =
66-77), improvements occurred in the treatment group at 3-month follow-up
(treatment vs control group, Cohen d = 1.15 vs 0.07
for nights per week with nightmares; 0.95 vs −0.06 for nightmares per
week; 0.77 vs 0.31 on the PSQI, and 1.06 vs 0.31 on the PSS) and were sustained
without further intervention or contact between 3 and 6 months. An intent-to-treat
analysis (n = 168) confirmed significant differences between treatment and
control groups for nightmares, sleep, and PTSD (all P<.02)
with moderate effect sizes for treatment (mean Cohen d
= 0.60) and small effect sizes for controls (mean Cohen d = 0.14). Posttraumatic stress symptoms decreased by at least 1 level
of clinical severity in 65% of the treatment group compared with symptoms
worsening or not changing in 69% of controls (χ21
= 12.80; P<.001).ConclusionsImagery rehearsal therapy is a brief, well-tolerated
treatment that appears to decrease chronic nightmares, improve sleep
quality, and decrease PTSD symptom severity.
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