Empirical Research

Nightmares are a frequent and distressing complaint of trauma-exposed veterans. However, less is known about the language of these nightmares and how the nightmare narrative changes in rescripting therapy. This study reports on the Linguistic Inquiry and Word Count variables of word count, affective processes, positive and negative emotion words, cognitive processes, and drives in 20 veterans participating in a study examining the efficacy of exposure, relaxation, and rescripting therapy for posttrauma nightmares. It was hypothesized that there would be significant increases in affective processes, positive emotion words, cognitive processes, and drives and significant decreases in negative emotion words and word count from nightmare transcription to rescription. It was further hypothesized that noncombat-related nightmares would demonstrate significantly larger changes in Linguistic Inquiry and Word Count processes than combat-related nightmares. The analysis revealed a significant decrease in word count (p < .001) and a significant increase in positive emotion words (p < .03). Noncombat-related nightmare rescriptions decreased significantly more in word count than combat-related rescriptions. Results from this study suggest that the content of written nightmare narratives can be significantly changed over the course of rescripting therapy. Further research is needed to investigate how these changes may be linked to other clinical outcomes.

Crowley, M. D., Davis, J. L., Miller, K. E., & Balliett, N. (2022). Text analysis of veteran nightmare scripts in a cognitive-behavioral nightmare treatment. Dreaming. https://doi.org/10.1037/drm0000144

While rescription-based therapies are effective treatments for chronic post-trauma nightmares, mechanisms of change have not yet been defined. We examined the relationship between the use of cognitive-related words in nightmare narratives and the post traumatic cognitions inventory (PTCI) in a sample of 25 trauma-exposed individuals undergoing rescription therapy for post-trauma nightmares. In addition to exploring the relationship between different types of cognitive language use and PTCI scores, the relationship between changes in their frequency of use and post-trauma cognitions were also analyzed. We found that cognitive language use as a whole in addition to the subcategories of tentative, discrepancy, and insight words within the nightmare are significantly negatively related to baseline PTCI scores, while analytic language use was positively correlated. However, cognitive language use in the rescription did not relate to PTCI scores post-treatment. Furthermore, changes in the of use cognitive language, between the nightmare and the rescription, are significantly negatively associated with severity of post traumatic cognitions at the post-assessment. These results demonstrate the importance of understanding cognitive language in nightmare imagery as it may relay important information about treatment outcomes.

Meador, C., Paquet, C.B., Cogan, C.M., Davis, J.L. (2022). Implications of cognitive-oriented language within posttrauma nightmare narratives. Applied Cognitive Psychology, 36, 864– 873. https://doi.org/10.1002/acp.3976

Objective: The current study sought to understand how language use in posttrauma nightmare (PTNM) reports may be related to psychological symptoms over the course of treatment. Method: Multiple regression analyses were conducted to examine the relationship between language use in PTNMs and psychological symptoms. Specifically, cognitive processing words (CPW) and emotional tone (ET) measured in PTNMs were analyzed in their relationship to posttraumatic stress disorder (PTSD) and depression symptom severity, as well as nightmare frequency and distress measured at the midtreatment and last treatment sessions. Follow-up hierarchical regressions were used to assess the relationship of language to nightmare severity when controlling for both PTSD and depression severity. The sample consisted of treatment-seeking predominately Caucasian females from the community with a history of criterion A trauma and weekly nightmares. Results: CPW in the nightmare were negatively associated with PTSD and depression symptom severity, as well as nightmare frequency, at the time of the exposure session. Decreased CPW and negative ET within the nightmare remained significantly associated with nightmare frequency at the time of the exposure session, when controlling for PTSD and depression symptom severity. CPW in the rescripted PTNM were negatively associated with PTSD and depression symptom severity at the time of the last treatment session. Conclusions: These results suggest that language use in nightmares may reveal important information about underlying cognitive and emotional processes that may help understand the etiology and maintenance of PTSD symptoms, as well as support PTNMs as co-occurring symptoms requiring targeted treatment, and not merely secondary symptoms of PTSD.

Paquet, C. B., Cogan, C. M., & Davis, J. L. (2022). Implications of language use in post traumatic nightmares on psychological symptoms. Psychological Trauma: Theory, Research, Practice, and Policy, 10.1037/tra0001266. https://doi.org/10.1037/tra0001266

No abstract available.

McDermott, T. J., Lee, J. Y., Paquet, C. P., Huber, F. A., Sitz, A. L., Robertson, K., & Davis, J. L. (2021). Exposure, relaxation, and rescripting therapy could treat residual nightmares following PTSD treatment. Psychiatry Research, 295. https://doi.org/10.1016/j.psychres.2020.113630

Research has shown that posttraumatic stress disorder (PTSD) is a highly prevalent diagnosis for psychiatric patients, yet individualized care and treatment is limited in the inpatient acute care sector. Two case studies are presented which examine the use of Exposure, Relaxation, and Rescripting Therapy (ERRT) for chronic trauma-related nightmares, within a private acute care inpatient psychiatric hospital setting. ERRT is empirically supported with efficacy for veteran and civilian populations, however no research to date has been conducted with psychiatric inpatients. Two participants diagnosed with PTSD, suffering distressing trauma-related nightmares, completed ERRT over three sessions during their psychiatric hospital admission, with the aim of reducing the frequency and severity of nightmares and related psychological symptoms. PTSD, depression, sleep quality and quantity, and nightmare frequency and related distress, were measured pre-treatment, during treatment, and follow-up at one, 3 and 6 months. Only one participant reported ongoing nightmares by the third week of the intervention, with both participants reporting an absence of nightmares at the one and 3-month follow-ups, but mixed results by the 6-month follow-up. One participant also reported a reduction in PTSD symptoms and a mild improvement in depression. The results offer some preliminary support for the provision of ERRT for the treatment of trauma-related nightmares for psychiatric inpatients.

Reiter, H., & Humphreys, L. (2021). Exposure, Relaxation, and Rescripting Therapy for trauma-related nightmares with psychiatric inpatients: A case series. Clinical Case Studies, 20(1), 3–21. https://doi.org/10.1177/1534650120953614

Study objectives: The aim of this study was to obtain preliminary data on the efficacy, credibility, and acceptability of Exposure, relaxation, and rescripting therapy for military service members and veterans (ERRT-M) in active duty military personnel with trauma-related nightmares. Methods: Forty participants were randomized to either 5 sessions of ERRT-M or 5 weeks of minimal contact control (MCC) followed by ERRT-M. Assessments were completed at baseline, posttreatment/postcontrol, and 1-month follow-up. Results: Differences between ERRT-M and control were generally medium in size for nightmare frequency (Cohen d = -0.53), nights with nightmares (d = -0.38), nightmare severity (d = -0.60), fear of sleep (d = -0.44), and symptoms of insomnia (d = -0.52), and depression (d = -0.51). In the 38 participants who received ERRT-M, there were statistically significant, medium-sized decreases in nightmare frequency (d = -0.52), nights with nightmares (d = -0.50), nightmare severity (d = -0.55), fear of sleep (d = -0.48), and symptoms of insomnia (d = -0.59), posttraumatic stress disorder (PTSD) (d = -0.58) and depression (d = -0.59) from baseline to 1-month follow-up. Participants generally endorsed medium to high ratings of treatment credibility and expectancy. The treatment dropout rate (17.5%) was comparable to rates observed for similar treatments in civilians. Conclusions: ERRT-M produced medium effect-size reductions in nightmares and several secondary outcomes including PTSD, depression, and insomnia. Participants considered ERRT-M to be credible. An adequately powered randomized clinical trial is needed to confirm findings and to compare ERRT-M to an active treatment control. Clinical trial registration: Registry: ClinicalTrials.gov; Title: A Pilot Randomized Controlled Trial of Treatment for Trauma-Related Nightmares In Active Duty Military Personnel; Identifier: NCT02506595; URL: https://clinicaltrials.gov/ct2/show/NCT02506595.

Pruiksma, K. E., Taylor, D. J., Mintz. J., et al; on behalf of the STRONG STAR Consortium. A pilot randomized controlled trial of cognitive behavioral treatment for trauma-related nightmares in active duty military personnel. J Clin Sleep Med. 2020;16(1):29–40. https://doi.org/10.5664/jcsm.8116

Objective: This study investigated whether a brief psychotherapy for post-trauma nightmares (exposure, relaxation, and rescripting therapy [ERRT]), reduced suicidal ideation (SI). We hypothesized that: (a) nightmare frequency and severity, post-traumatic stress disorder (PTSD), depression, and sleep quality would be related to SI at pretreatment; (b) SI would decrease from pre- to post-treatment; and (c) the decrease in SI would remain after controlling for change in PTSD and depression.Seventy-five individuals exposed to a traumatic event and who experienced frequent nightmares (minimum one per week) participated in ERRT. Participants were not required to have a psychological diagnosis. Thirty percent endorsed SI at pretreatment.Results: Depression and PTSD were related to SI at pretreatment. SI decreased following treatment; however, the third hypothesis was not supported. Conclusion:Results suggest brief psychotherapy targeting post-trauma nightmares may decrease SI. More research is necessary to determine what factors contribute to decreases in SI.

Cogan, C. M., Lee, J. Y., Cranston, C. C., Pruiksma, K. E., Rhudy, J. L., & Davis, J. L. (2019). The impact of Exposure, Relaxation, and Rescripting Therapy for post-trauma nightmares on suicidal ideation. Journal of Clinical Psychology, 75(12), 2095-2105. https://doi.org/10.1002/jclp.22852

Objective: This report aims to extend previous findings on predictors of treatment dropout and response within nightmare treatment. Method: Factors predicting treatment noninitiation, dropout, and response were examined in 70 trauma-exposed individuals treated in a randomized controlled trial of 2 conditions (exposure [EX] and nonexposure) of a therapy for trauma nightmares. Results: Together, treatment noninitiation and dropout was predicted by younger age for the EX condition only and by fewer nights with nightmares at baseline for both conditions. Treatment noninitiation was predicted by fewer nights with nightmares. Treatment dropout was not predicted by any variables. For the EX condition, more baseline nightmares predicted more posttreatment nightmares, whereas more reported nights with nightmares at baseline predicted fewer nightmares at posttreatment. Baseline sleep quality and total posttraumatic stress disorder (PTSD) severity predicted posttreatment sleep quality and PTSD severity, respectively. In the nonexposure condition, more traumatic events predicted fewer nightmares at posttreatment, whereas more nightmares predicted more nightmares at posttreatment. Baseline daytime sleepiness predicted worse posttreatment sleep quality, and total PTSD symptom severity predicted posttreatment PTSD severity. Conclusions: Baseline symptom severity on constructs targeted in treatment are the best indicators of response. Treatment initiation appears to be more significant than dropout. Identifying reasons for treatment noninitiation is needed to maximize engagement.

Miller, K. E., Micol, R. L., Davis, J. L., Cranston, C. C., & Pruiksma, K. E. (2019). Predictors of treatment non-initiation, dropout, and response for cognitive behavioral therapy for trauma nightmares. Psychological Trauma: Theory, Research, Practice, and Policy, 11, 122-126. https://doi.org/10.1037/tra0000389

Purpose: Trauma exposure is associated with nightmares, insomnia, and increased reports of obstructive sleep apnea (OSA), which may exacerbate trauma symptoms and interfere with treatment outcome. This study explored the impact of suspected OSA on treatment outcomes following Exposure, Relaxation, and Rescripting Therapy (ERRT) for chronic trauma-related nightmares. Methods: Seventy trauma-exposed adults participated in a trial of ERRT. Self-reported OSA was assessed at baseline. Nightmare frequency and severity, sleep quality, insomnia severity, depression and posttraumatic stress symptoms were measured at baseline, and then one-week, three-months, and six-months following the end of treatment. Results: Individuals with suspected OSA reported greater baseline symptom severity across all outcomes, except nightmare frequency, compared to their non-apnea counterparts. All participants reported significant reductions across symptoms following treatment, yet symptom levels in those with suspected OSA remained elevated compared to the non-apnea group. No significant group by time moderation emerged. Conclusions: Trauma-related nightmares and associated symptoms are amenable to treatment, despite suspected OSA. Yet, individuals with OSA may continue to report clinically-significant symptoms, highlighting the potential need for an integrated therapy approach.

Post-traumatic nightmares (PTN) are a common and enduring problem for individuals with post-traumatic stress disorder (PTSD) and other clinical presentations. PTN cause significant distress, are associated with large costs, and are an independent risk factor for suicide. Pharmacological and non-pharmacological treatment options for PTN exist. A previous review in this journal demonstrated that Prazosin, an alpha blocker, was a preferred pharmacological treatment for PTN and imagery rescripting therapy (IRT) was a preferred non-pharmacological treatment. Since that time, new and important research findings create the need for an updated review.

Waltman, S. H., Shearer, D., & Moore, B. A. (2018). Management of post-traumatic nightmares: A review of pharmacologic and nonpharmacologic treatments since 2013. Current psychiatry reports, 14(108). https://doi.org/10.1007/s11920-018-0971-2.

Previous research on an efficacious cognitive-behavioral treatment for posttrauma nightmares and sleep disturbances (exposure, relaxation, and rescripting therapy; ERRT) has not tested the treatment in individuals with bipolar disorder. However, research suggests that individuals diagnosed with bipolar disorder are at increased risk for trauma exposure and development of posttrauma symptoms. The present pilot study sought to examine the acceptability and preliminary efficacy of a modified version of ERRT (ERRT-B) on reducing the frequency and severity of nightmares and improving sleep quality for 7 trauma-exposed individuals diagnosed with bipolar disorder who also reported frequent posttrauma nightmares (experienced on average for 16 years). Participants attended 5 weeks of ERRT-B and completed baseline, posttreatment, and 3-month follow-up assessments to measure changes in nightmare frequency, nightmare severity, and associated symptoms. Large effect sizes were observed for nightmare frequency, nightmare severity, and posttraumatic stress disorder symptoms, with 6 participants reporting zero nightmares at the 3-month follow-up assessment. Improvements in depression, global sleep quality, and insomnia severity were mixed. Results obtained from this study offer preliminary evidence in support of ERRT-B in reducing nightmare frequency and severity, and posttraumatic stress disorder symptoms. These results suggest clinical utility for the treatment of trauma-related nightmares in individuals with bipolar disorder and encourage more research.

Miller, K. E., Davis, J. L., & Rhudy, J. L. (2018). Pilot study: Brief posttrauma nightmare treatment for persons with bipolar disorder. Dreaming, 28(2), 150. https://doi.org/10.1037/drm0000082

Objective: The aim of this study was to conduct a preliminary dismantling study of exposure, relaxation, and rescripting therapy (ERRT) for nightmares. Method: Participants (N = 70) were randomized to 1 of 2 conditions: ERRT with nightmare exposure and rescripting (full protocol; EX) or ERRT without nightmare exposure and rescripting (NEX). Participants completed follow-ups at 1 week, 3 months, and 6 months posttreatment. Results: Both conditions yielded statistically significant improvements with medium to large effect sizes on primary outcomes related to nightmares (i.e., nights with nightmares, nightmares per week, and nightmare severity). Both conditions also yielded statistically significant improvements on secondary outcomes with medium to large effect sizes on fear of sleep, sleep quality, insomnia severity, daytime sleepiness, posttraumatic stress disorder symptom severity, and depression severity. The conditions did not differ at any time point. Conclusions: Findings indicate that ERRT with and without nightmare exposure and rescripting can significantly alleviate nightmares and related distress. The addition of nightmare exposure and rescription did not contribute incrementally to outcomes in this sample. It is possible that the dose of exposure was not sufficient to result in group differences or that the treatment components included in both conditions (i.e., psychoeducation about trauma, nightmares, and sleep; sleep habit modification; and relaxation training) may adequately treat factors that maintain nightmares for some individuals. Theoretical implications of findings are discussed. The reduction of symptoms of other conditions following this brief intervention provides further evidence for the primary role of nightmares and sleep disturbances posttrauma.

Pruiksma, K. E., Cranston, C. C., Rhudy, J. L., Micol, R. L., & Davis, J. L. (2018). Randomized controlled trial to dismantle exposure, relaxation, and rescripting therapy (ERRT) for trauma-related nightmares. Psychological trauma: theory, research, practice, and policy, 10(1), 67. doi:10.1037/tra0000238

Nightmares and sleep disturbances are gaining attention as targets of treatment interventions for trauma-exposed populations. Measures in trials evaluating these interventions tend to utilize proprietary measures of nightmare characteristics, creating a challenge in comparing findings across studies. The Trauma-Related Nightmare Survey (TRNS) is a questionnaire that was initially developed for utilization in efficacy studies of Exposure, Relaxation, and Rescripting Therapy (ERRT). Preliminary examinations of the psychometric properties have demonstrated good test-retest reliability and convergent validity. The present brief report provides an updated examination of these properties and offers the first open publication of the measure for general use. Results support previous findings that the TRNS demonstrates good test-retest reliability (r = .73) and moderate to strong convergent validity (r = .44–.78) with other commonly utilized measures of sleep and mood symptoms.

Cranston, C. C., Miller, K. E., Davis, J. L., & Rhudy, J. L. (2017). Preliminary validation of a brief measure of the frequency and severity of nightmares: The Trauma-Related Nightmare Survey. Journal of Trauma & Dissociation, 18(1), 88-99. https://doi.org/10.1080/15299732.2016.1191578

Trauma exposure has been linked to external locus of control (E-LOC). This feeling of uncontrollability may be maintained after the trauma by recurring posttrauma nightmares. The present study utilized data from a larger trial, with 19 U.S. veterans, examining the efficacy of a modified version of treatment for nightmares, to examine changes in locus of control in relation to improvements in symptomatology following treatment. Following treatment, internal control beliefs about sleep and nightmares significantly increased, while general control beliefs did not change. Preliminary evidence that exposure, relaxation, and rescripting therapy for military personnel (ERRT-M) is associated with increased sense of control over sleep and nightmares was observed.

Miller, K. E., Davis, J. L., & Balliett, N. E. (2014). Taking control: Examining the influence of locus of control on the treatment of nightmares and sleep impairment in veterans. Military Behavioral Health, 2(4), 337-342.

Two case studies are presented to demonstrate that children who experience trauma-related nightmares may benefit from cognitive-behavioral therapy for this sleep problem. The treatment was adapted from the empirically supported adult treatment for chronic trauma-related nightmares: exposure, relaxation, and rescripting therapy (ERRT). Pretreatment and posttreatment nightmare frequency and severity were measured in addition to subjective nightmare-related distress, behavioral problems, sleep quality and quantity, and symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression. Improvement in nightmare and sleep disturbance frequencies were found as well as reductions in parents’ reports of child behavior problems. This study provides preliminary support for the use of ERRT with children.

Fernandez, S., DeMarni Cromer, L., Borntrager, C., Swopes, R., Hanson, R. F., & Davis, J. L. (2013). A case series: cognitive-behavioral treatment (exposure, relaxation, and rescripting therapy) of trauma-related nightmares experienced by children. Clinical Case Studies, 12(1), 39-59. https://doi.org/10.1080/21635781.2014.963763

Evidence supports the use of cognitive behavioral therapies for nightmares in trauma- exposed individuals. This randomized clinical trial replicated a study of Exposure, Relaxation, & Rescripting Therapy (ERRT) and extended prior research by including broad measures of mental health difficulties, self-reported physical health problems, and quality of life. Additionally, physiological correlates of treatment-related change assessed from a script-driven imagery paradigm were assessed. Forty-seven individuals were randomized to treatment or waitlist control. The treatment group demonstrated improvements relative to the control group at the one- week post treatment assessment. At the six month follow-up assessment, significant improvements were found for frequency and severity of nightmares, posttraumatic stress disorder symptoms, depression, sleep quality and quantity, physical health symptoms, anger, dissociation, and tension reduction behaviors. Participants also reported improved quality of life. Treatment- related decreases in heart rate to nightmare imagery was correlated with improvements in sleep quality and quantity; treatment-related decreases in skin conductance to nightmare imagery was correlated with improvements in nightmare severity, posttraumatic stress disorder symptom severity, sleep quality, and fear of sleep; and treatment-related decreases in corrugator activity to nightmare imagery was correlated with improved physical health. Findings provide additional support for the use of ERRT in treating nightmares and related difficulties and improving sleep.

Arch, J. J., Eifert, G. H., Davies, C., Vilardaga, J. C. P., Rose, R. D., & Craske, M. G. (2012). Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders. Journal of consulting and clinical psychology, 80(5), 750. doi: 10.1037/a0028310

Despite growing support for the use of imagery rescripting to treat posttraumatic nightmares (PTNMs), its underlying mechanisms have not been examined. This secondary data analysis piloted the proposal that modification of posttraumatic cognitions is a mechanism of change when using a manualized PTNM imagery rescripting intervention. Significant linear reductions in posttraumatic cognitions were observed from baseline through 6-month follow-up evaluations. Change in total negative cognitions was significantly correlated with change in posttraumatic stress disorder symptoms. Initial amount of change in subscale scores also predicted the amount of distal change observed at the 6-month follow-up. These findings provide preliminary evidence that trauma-related cognitions may improve over time as a result of imagery rescripting.

Long, M. E., Davis, J. L., Springer, J. R., Elhai, J. D., Rhudy, J. L., Teng, E. J., & Frueh, B. C. (2011). The role of cognitions in imagery rescripting for posttraumatic nightmares. Journal of Clinical Psychology, 67(10), 1008-1016. https://doi.org/10.1002/jclp.20804

This study details results of an open trial of a group psychological treatment for Veterans with posttraumatic stress disorder (PTSD) and chronic posttraumatic nightmares called “Imagery Rescripting and Exposure Therapy” (IRET). IRET is a variant of a successful imagery rescripting treatment for civilian trauma-related nightmares that was modified to address the needs of the Veteran population. Thirty-seven male U.S. Veterans with PTSD and nightmares attended 6 multicomponent group sessions. Findings indicated that the intervention significantly reduced frequency of nightmares and PTSD severity, as well as increased hours of sleep. Unlike the few open trials examining treatment of nightmares in Veterans, effect sizes in this study were similar to those that have been found in the civilian randomized controlled trial. These preliminary findings suggest that a nightmares treatment can be adapted to successfully reduce distress associated with combat Veterans’ chronic nightmares. Clinical and research implications are discussed.

Long, M. E., Hammons, M. E., Davis, J. L., Frueh, B. C., Khan, M. M., Elhai, J. D., & Teng, E. J. (2011). Imagery rescripting and exposure group treatment of posttraumatic nightmares in Veterans with PTSD. Journal of Anxiety Disorders, 25(4), 531-535. doi: 10.1016/j.janxdis.2010.12.007

Posttraumatic nightmares (PTNMs) are trauma-related distressing dreams that cause a person to wake up. PTNMs can be a devastating addition to the clinical picture of posttraumatic stress disorder (PTSD), because they can result in increased levels of PTSD symptoms and overall distress and decreased sleep; they are also often resistant to typical PTSD treatments. While specialized treatments have been developed and empirically examined in the civilian population, these treatments have not been thoroughly explored with the Veteran population, despite the fact that 50%-88% of Vietnam Veterans experience chronic PTNMs. This article presents two case reports involving Vietnam Veterans. These reports describe the initial investigation of a variant of a treatment that has been successful in treating chronic PTNMs in the civilian population and has been modified to meet the needs of the Veteran population. Analyses revealed that both Veterans reported moderate reductions in sleep disturbances over the course of treatment, as well as clinically significant reductions in PTSD and depressive symptoms across assessments. These preliminary findings provide encouraging data that warrant further study. Limitations and future research are discussed.

Wanner, J., Long, M. E., & Teng, E. J. (2010). Multi-component treatment for posttraumatic nightmares in Vietnam veterans: two case studies. Journal of Psychiatric Practice®, 16(4), 243-249. doi:10.1097/01.pra.0000386910.31817.b5

Cognitive-behavioral treatments (CBTs) that target nightmares are efficacious for ameliorating self-reported sleep problems and psychological distress. However, it is important to determine whether these treatments influence objective markers of nightmare-related fear, because fear and concomitant physiological responses could promote nightmare chronicity and sleep disturbance. This randomized, controlled study (N=40) assessed physiological (skin conductance, heart rate, facial electromyogram) and subjective (displeasure, fear, anger, sadness, arousal) reactions to personally relevant nightmare imagery intended to evoke nightmare-related fear. Physiological assessments were conducted at pretreatment as well as 1-week, 3-months, and 6-months posttreatment. Results of mixed effects analysis of variance models suggested treatment reduced physiological and subjective reactions to nightmare imagery, gains that were generally maintained at the 6-month follow-up. Potential implications are discussed. ***Selected as one of the best publications in Sleep Medicine for 2011

Rhudy, J. L., Davis, J. L., Williams, A. E., McCabe, K. M., Bartley, E. J., Byrd, P. M., & Pruiksma, K. E. (2010). Cognitive‐behavioral treatment for chronic nightmares in trauma‐exposed persons: assessing physiological reactions to nightmare‐related fear. Journal of Clinical Psychology, 66(4), 365-382. doi: 10.1002/jclp.20656

Insomnia and nightmares are hallmarks of posttraumatic stress disorder (PTSD). Sleep disturbances in PTSD negatively impact clinical course and functioning. In this open clinical trial, the preliminary effects of a combined treatment for insomnia and nightmares in combat veterans with PTSD were assessed. Ten combat veterans participated in a 10-session group treatment combining cognitive-behavioral therapy for insomnia with exposure, rescripting, and relaxation therapy. Participants maintained daily sleep and dream diaries and completed self-report measures of sleep quality and PTSD symptoms pre- and posttreatment. Participants reported improvements in sleep and nightmares following treatment. Future research using controlled designs to evaluate this treatment is warranted.

Swanson, L. M., Favorite, T. K., Horin, E., & Arnedt, J. T. (2009). A combined group treatment for nightmares and insomnia in combat veterans: a pilot study. Journal of Traumatic Stress: Official Publication of The International Society for Traumatic Stress Studies, 22(6), 639-642. doi: 10.1002/jts.20468

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.

Rhudy, J. L., Davis, J. L., Williams, A. E., McCabe, K. M., & Byrd, P. M. (2008). Physiological–emotional reactivity to nightmare-related imagery in trauma-exposed persons with chronic nightmares. Behavioral Sleep Medicine, 6(3), 158-177. doi: 10.1080/15402000802162539.

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.

Davis, J. L., & Wright, D. C. (2007). Randomized clinical trial for treatment of chronic nightmares in trauma‐exposed adults. Journal of Traumatic Stress, 20(2), 123-133. doi: 10.1002/jts.20199.

Trauma victims frequently report sleep disturbances, including nightmares, following traumatic events. Research indicates that nightmares are associated with the level and severity of other indices of distress. The recognition of the prominence of trauma-related nightmares, in prevalence and impact, has in part heightened efforts to develop and assess techniques to alleviate these difficulties. The majority of such previous efforts were predominantly case studies or uncontrolled group studies; however, recently several controlled studies have been conducted. The treatment with the most empirical support is generally called imagery rehearsal therapy (IRT). This treatment commonly involves relaxation procedures, limited exposure to the nightmare content, rewriting the content of the nightmare, and rehearsal of the altered content. This article provides a description of a modified version of IRT that incorporates all these techniques, with an enhanced exposure component and the addition of trauma themes and alteration of sleep habits. Guidelines for application with clients are outlined. A case study and case series were completed on this variant of IRT and a randomized clinical trial is currently underway.

Davis, J. L., & Wright, D. C. (2006). Exposure, relaxation, and rescripting treatment for trauma-related nightmares. Journal of trauma & dissociation, 7(1), 5-18. doi: 10.1300/J229v07n01_02

Experiencing a traumatic event may initiate or exacerbate the occurrence of nightmares. Nightmares may impact sleep quality and quantity, posttraumatic stress symptoms, and depression. Recently, imagery rehearsal has gained attention in the treatment of trauma-related nightmares and is reported to be promising in the reduction of nightmares. On the basis of the vast literature describing the therapeutic benefits of exposure techniques for anxiety-related problems, the treatment was modified to enhance the exposure component. This article presents a case series using this modified version of imagery rehearsal, Exposure, Relaxation, and Rescripting Therapy, with 1 male and 3 female participants. Overall, the participants treated reported a reduction in nightmare frequency and severity; 3 out of 4 participants also reported a reduction in posttraumatic stress and depression symptomatology and an increase in sleep quality and quantity. Clinical implications and future research directions are discussed.

Davis, J. L., & Wright, D. C. (2006). Exposure, relaxation, and rescripting treatment for trauma-related nightmares. Journal of trauma & dissociation, 7(1), 5-18. https://doi.org/10.1300/J229v07n01_02

Nightmares are a common response to a traumatic event and are one symptom of posttraumatic stress disorder. Although several treatments are currently available for the treatment of posttraumatic stress disorder, few studies report the efficacy of such treatments for nightmares. The current case involves the treatment of an adolescent rape victim who was involved in a treatment that targeted posttraumatic stress disorder and panic attacks. Following this treatment, the adolescent continued to report the experience of nightmares several times per week. The adolescent was then treated with a three-session cognitive behavioral treatment package involving relaxation procedures, exposure to the nightmare content, and rescripting the nightmare. At the one-month and three-month follow-up sessions, the patient reported a decrease in the intensity and frequency of nightmares. In this case it appeared necessary to include exposure and to target salient trauma-related themes in the rescripted dream.

Davis, J. L., De Arellano, M., Falsetti, S. A., & Resnick, H. S. (2003). Treatment of nightmares related to post-traumatic stress disorder in an adolescent rape victim. Clinical Case Studies, 2(4), 283-294. https://doi.org/10.1177/1534650103256289