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Imagery Rehearsal Therapy for Chronic Nightmares in Sexual Assault Survivors With Posttraumatic Stress Disorder
A Randomized Controlled Trial
Barry Krakow, MD;
Michael Hollifield, MD;
Lisa Johnston, MA,MPH;
Mary Koss, PhD;
Ron Schrader, PhD;
Teddy D. Warner, PhD;
Dan Tandberg, MD;
John Lauriello, MD;
Leslie McBride, BA;
Lisa Cutchen, MA;
Diana Cheng, MA;
Shawn Emmons, PhD;
Anne Germain, MPs;
Dominic Melendrez, PSG-T;
Diane Sandoval, BS;
Holly Prince, MA
JAMA. 2001;286:537-545.
Context Chronic nightmares occur frequently in patients with posttraumatic stress disorder (PTSD) but are not usually a primary target of treatment.
Objective To 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 Participants Randomized 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.
Intervention Participants 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 Measures Scores 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.
Results A 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 ( 21 = 12.80; P<.001).
Conclusions Imagery rehearsal therapy is a brief, well-tolerated treatment that appears to decrease chronic nightmares, improve sleep quality, and decrease PTSD symptom severity.
Author Affiliations: Sleep & Human Health Institute, Albuquerque, NM (Dr Krakow, Ms Johnston, and Mr Melendrez); Health Sciences Center (Drs Krakow, Hollifield, Warner, Tandberg, Lauriello, and Emmons and Mss McBride, Cutchen, Cheng, Sandoval, and Prince), Departments of Emergency Medicine (Drs Krakow, Emmons, and Tandberg and Mss Johnston, McBride, Cutchen, Cheng, Sandoval, and Prince), Psychiatry (Drs Krakow, Hollifield, Lauriello, and Warner and Ms Johnston), and Family and Community Medicine (Dr Hollifield), School of Medicine, and Department of Mathematics and Statistics (Dr Schrader), University of New Mexico, Albuquerque; Health Sciences Center, University of Arizona, Tucson (Dr Koss); and Department of Psychology, University of Montreal and Laboratoire des rêves et des cauchemars, Hôpital Sacré-Coeur, Montréal, Québec (Ms Germain).
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