Insomnia and Anxiety (Series in Anxiety and Related Disorders) (37 page)

Given the possibility that nightmares and bad dreams are learned phenomena,

investigators have increasingly turned to the use of cognitive-behavioral interven-

tions that specifically target these phenomena themselves. A few early studies

demonstrated that systematic desensitization, with or without concurrent relaxation

training, is effective for reducing nightmare frequency (Cellucci & Lawrence,

1978; Miller & DiPilato, 1983). However, seemingly the most popular and arguably

promising nightmare therapy has been the treatment known as imagery rehearsal

therapy (IRT). Although, several renditions of IRT have been proposed (Krakow &

Zadra, 2006; Neidhardt, Krakow, Kellner, & Pathak, 1992; Rybarczyk et al., 2005)

all of these include instructions to re-script disturbing dreams/nightmares using

more acceptable storylines and to rehearse the rescripted dreams via imagery

during scheduled daytime rehearsal sessions. The role of nightmare rehearsal has

been touted as the core therapeutic element since it results in exposure, abreaction,

and mastery of disturbing dream content (Marks, 1978). However, it has also been

argued that exposure and abreaction are less important to therapeutic outcome than

is the sense of mastery over the dream process (Bishay, 1985). In either case, IRT

challenges the common view that dreams cannot be controlled/altered and offers

nightmare sufferers the option to influence the dreams they experience.

Since the early 1990s, a number of case reports as well as uncontrolled and

controlled clinical trials that support the efficacy of IRT have been published.

Perhaps, the largest and best controlled study was the randomized clinical trial

by Krakow, Hollifield et al. (2001), in which female sexual assault victims with

nightmares were randomized to IRT or a wait list condition. Results of this trial

showed that those receiving IRT had significantly greater improvements on measures

of nightmare frequency, overall sleep quality, and PTSD symptoms in general.

Other case series and uncontrolled trials have supported the efficacy of this therapy

with such groups as adult crime victims (Krakow, Johnston et al., 2001), combat

veterans (Forbes et al., 2003; Forbes, Phelps et al., 2001), adults with poly-trauma

histories (Rybarczyk et al., 2005), and victims of physical or sexual abuse during

childhood or adolescence (Krakow, Sandoval et al., 2001). In addition, one case

series report suggests that IRT is effective for reducing nightmares and improving

sleep among adults with idiopathic nightmares and no associated trauma histories.

Although the literature would benefit by more randomized controlled trials testing

this therapy, the available data suggest that IRT is a viable therapy that holds much

promise for assisting nightmare sufferers.

Treatment protocol
: To date, most of the information concerning IRT implementa-

tion comes from the work of Krakow and colleagues (Krakow, Hollifield et al., 2001;

Krakow, Kellner, Pathak & Lambert, 1995; Krakow & Zadra, 2006; Neidhardt et al.,

1992). Much of what has been published by this group describes the delivery of IRT

in a group therapy format although Krakow and Zadra (2006) suggest that treatment

delivery via individual therapy format may be similarly effective. Treatment duration

Dream/Nightmare Rescripting

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has varied from abridged one-session formats (Neidhardt et al., 1992) to full day

(i.e. 6 h) workshops (Krakow, Sandoval et al., 2001) and four, 2-hour group therapy

sessions (Krakow & Zadra, 2006). The abridged treatment model includes instruc-

tions to: (1) write out a targeted troublesome nightmare in exacting detail; (2) change

the storyline of the nightmare (usually to include a more positive theme); and (3)

engage in imagery rehearsal of the rescripted nightmare on a daily basis. Specific

rescripting instructions have consisted of changing the nightmare “anyway you

wish” or “change the ending of the nightmare” and both approaches appear to work

equally well (Krakow, Kellner et al., 1995). The unabridged versions of this treat-

ment include rescripting strategies as well as extensive preparatory psychoeducation

concerning the role of nightmares in emotional processing and self protection, the

concept of chronic nightmares as a learned albeit unwanted habits, the role of night-

mares in contributing to insomnia, and the general rationale for treating nightmares

directly (see Krakow and Zadra, 2006 for more details). The more intensive rendi-

tions of Krakow’s treatment approach also typically include guided imagery training

to enhance the imagery skills of those with nightmares. Central to the approach of

Krakow and colleagues is the avoidance of all discussion of past traumatic events or

traumatic content of current nightmares. This approach is taken to enhance the sense

of safety among group participants who may feel too uneasy to discuss such infor-

mation in a group setting. Instead, participants are instructed to engage in all night-

mare rescripting and rehearsal in their homes between sessions so as to minimize

and control exposure to trauma phenomena and enhance mastery and self-control

themes pertinent to the therapy process.

There have been questions about the utility of minimizing the exposure component

of IRT (Rybarczyk et al., 2005) given the documented efficacy of exposure tech-

niques for reducing PTSD symptoms (Connor et al., 2000). Given this obser vation,

the suggestion has been for an altered IRT protocol that combines exposure, relax-

ation, and rescripting strategies to treat nightmares. Accordingly, this so-called

ERRT protocol employs a group therapy format and requires patients to write

out a detailed nightmare description, read it to the group, and engage in-group

discussion about the specific trauma themes the nightmare includes. Like IRT,

ERRT asks people to rescript their nightmares in a favorable manner incorporating

the original trauma themes. However, this rescripting is also completed within the

group and the rewritten nightmares are shared with group members as well.

Homework subsequently includes imagery rehearsal with the rescripted nightmare

followed by completion of a relaxation exercise. Unlike IRT, the ERRT protocol

suggests completion of the imagery rehearsal and subsequent relaxation just prior

to retiring to bed. Although the inclusion of the exposure and relaxation compo-

nents in ERRT seems reasonable, it remains unclear whether people with night-

mares will be as accepting of ERRT as they seemingly have been of the original

IRT approach. Moreover, there have not yet been any direct comparisons of the IRT

and ERRT protocols, so it remains unknown whether the latter approach is any

more effective than the former one.

From the authors’ clinical experience, it does appear useful to provide some

preliminary psychoeducation that reviews that dream content is learned from

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9 Other Issues in Managing the Sleep of Those with Anxiety

daytime experiences, and often disturbing dreams/nightmares reiterate negative or

stressful life events. It is usually useful to ask if they can recall some dreams or

nightmares that include some daytime experiences or concerns they have had.

Usually they can, and reflection on those provides them some evidence that learning

does play a role in the development of bad dreams and nightmares. Given this

realization, people are usually more open to the interpretation that recurrent bad

dreams/nightmares are bad mental habits that need to be altered through specific

targeted treatment efforts on their parts. It is also useful to review and challenge the

belief that dreams are random and uncontrollable by suggesting that the strategies

of IRT are specifically designed to directly influence dream content, and thus pro-

vide eventual mastery over dream experiences. Once open to this idea, the actual

strategy of altering dream content by rewriting and rehearsing a selected disturbing

dream can be introduced. Krakow et al. have suggested starting with a less threaten-

ing nightmare when first employing these strategies. However, in our experience,

some reasonably motivated people seem to be able and eager to begin with a

relatively distressing and persistent nightmare. Hence, the level of motivation and

comfort with addressing the most distressing and persistent nightmares should be

assessed at the start of this therapy so as to better gear the pace of treatment to each

individual.

As noted by Krakow et al., people can be given instructions to “change the dream

anyway you prefer” or “change the ending of the dream.” Whichever of these two

instructional sets is used, the person should be encouraged to practice the rescripted

dream at least one time each day. There are no current data to suggest how long this

practice should last, but we have had success with recommending a minimum of

20 min per day. The rate at which the improvements occur can vary. Some show

fairly rapid improvement, whereas others show more gradual reductions in night-

mare severity and frequency. From clinical observations, we speculate that factors

such as the nature of the bad dream/nightmare, nature of the original causative expe-

riences (e.g., trauma severity), and diligence in adhering to treatment instructions are

among the more important factors in predicting the pace of treatment and eventual

outcome. Those who benefit from treatment usually achieve a subjective endpoint at

which they report a markedly reduced frequency and intensity of the nightmares.

Simply put, they report that they are having the nightmare much less frequently and

that when they do have it, it does not bother them greatly. While it is useful to track

global subjective appraisals through the course of IRT, we also find it useful to pro-

spectively monitor nightmare activity by use of a nightmare log. When circum-

stances permit, it is useful to acquire “baseline” data concerning nightmare frequency

over two to four weeks and then use these data as reference points. Comparison of

these baseline logs with subsequent logs acquired during and after treatment provides

useful information about the degree to which nightmare frequency and intensity

change from treatment.

The following case example demonstrates the application of the core IRT methods

for addressing nightmares in a military veteran.

Mr. C was a 57-year-old self-employed man with a long history of nightmares

and sleep disturbance since his Vietnam War experiences. He reported a recurrent

Is it Time for a Sleep Specialist Consultation?

143

disturbing dream, in which he relieved a traumatic combat related event. The event

in question involved his military unit being subjected to repeated mortar fire while

attempting to unload a supply truck. Mr. C recalls hearing the sound of the mortar

fire and realizing from the sound that their supply truck was about to be hit. He

recalls yelling out in efforts to warn his fellow soldiers, but the warning came too

late for some of his comrades. A mortar shell hit the supply truck and resulted in a

fiery explosion that led to many of his comrades being killed. Although he and

several of his comrades successfully escaped the explosion without injuries, Mr. C

was bothered by intense remorse over his inability to warn everyone in time. Upon

his presentation for treatment, he reported a frequent (weekly) occurrence of a night-

mare that essentially replayed this very frightening and troubling event in his life.

As treatment for his condition, Mr. C agreed to a trial of IRT. He was, thus,

instructed to: (1) write out his nightmare in exacting detail, the next time it occurred;

(2) to rewrite the nightmare with a new and more desirable ending, and (3) to

rehearse the rescripted nightmare via use of visual imagery at least 20 min each day.

He followed these instructions and altered the script of his nightmare to include a new

ending, in which his efforts to warn others were officially recognized and commended

by his commanding officers in a manner that suggested he did everything he was

humanly able to do during the mortar attack to help his comrades. Mr. C practiced

this revise dream at home and was seen for check-in sessions by the therapist every

3–4 weeks over the course of a 3-month period. He eventually reported that his

nightmare frequency and intensity diminished appreciably, and he was satisfied with

his outcome. He subsequently requested and was scheduled for a follow-up visit so

that he could “check in” with the therapist. Mr. C’s follow-up visit unexpectedly

occurred about 1 month after the 9/11/01 terrorist attack on the World Trade Center

and Pentagon. Nonetheless, Mr. C reported no relapse in his symptoms, and he

continued to be satisfied with his status at the time of follow-up.