Randomized Clinical Trial for Treatment of Chronic Nightmares in Trauma-Exposed Adults

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1 Journal of Traumatic Stress, Vol. 20, No. 2, April 2007, pp ( C 2007) Randomized Clinical Trial for Treatment of Chronic Nightmares in Trauma-Exposed Adults Joanne L. Davis and David C. Wright Department of Psychology, University of Tulsa, Tulsa, OK 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 traumaexposed 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 followup 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. Several empirically supported treatments emerged in the past two decades for the amelioration of posttraumatic stress disorder (PTSD) symptoms (e.g., Falsetti, Resnick, & Davis, 2005; Foa et al., 1999; Resick & Schnicke, 1993). Although these treatments report positive results overall, few studies specify the impact of a given treatment on individual symptoms. Among those that do report results at the criterion or symptom-level, a growing body of evidence suggests that chronic nightmares and sleep disturbance may be particularly resistant to treatment efforts aimed at ameliorating PTSD symptoms (Davis, DeArellano, Falsetti, & Resnick, 2003; Forbes, Creamer, & Biddle, 2001; Johnson et al., 1996; Scurfield, Kenderdine, & Pollard, 1990). Sleep disturbance is a primary concern reported by trauma-exposed individuals. A key component of this sleep disturbance is chronic nightmares (Harvey, Jones, & Schmidt, 2003), which are particularly problematic for individuals with PTSD. Currently, estimates of nightmare frequency range from 19% (Ohayon & Shapiro, 2000) to 88% (Forbes et al., 2001) for individuals with PTSD. An increased recognition of the chronic and pervasive nature of nightmares in trauma-exposed individuals drove an interest in developing efficacious pharmacological and psychological treatments specific to these nightmares. Recent pharmacological studies find that several medications (e.g., Prasozin) appear encouraging for the alleviation of nightmares, although they do not appear to have more than a palliative effect. Indeed, Raskind et al. (2003) reported that participants almost always returned to their pretreatment nightmare intensity 1 or 2 days after Prazosin discontinuation (i.e., there was no carryover therapeutic effect) (p. 372; see also Daly, Doyle, Raskind, Raskind, & Daniels, 2005). Most of the first-line PTSD treatments include exposure techniques, but do not generally conduct exposure with nightmare content. Direct therapies for The activities described were supported by an OHRS award for project number HR02-002S, from the Oklahoma Center for the Advancement of Science and Technology, Psi Chi National Honor Society, and by The University of Tulsa s Office of Research and Sponsored Programs internal funding. Portions of this article were presented at the following annual meetings: Association for the Advancement of Behavior Therapy, Oklahoma Psychological Association, and the Disaster Mental Health Institute. We wish to express our appreciation to the members of the Trauma Research: Assessment, Prevention, and Treatment Center for their assistance with this project. Correspondence concerning this article should be addressed to: Joanne L. Davis, 600 South College Avenue, University of Tulsa, Tulsa, OK Joanne-davis@utulsa.edu C 2007 International Society for Traumatic Stress Studies. Published online in Wiley InterScience ( DOI: /jts

2 124 Davis and Wright nightmares in trauma-exposed persons appear to be more successful than pharmacotherapy for nightmares and psychotherapy targeting PTSD symptoms generally (Coalson, 1995; Keane & Kaloupek, 1982). A cognitive behavioral treatment approach for chronic nightmares, imagery rehearsal therapy (IRT), has garnered increased attention over the past decade. Several uncontrolled studies that have targeted individuals with posttraumatic symptoms (e.g., Forbes, Phelps, & McHugh, 2001; Forbes et al., 2003; Germain & Nielsen, 2003; Krakow, Kellner, Pathak, & Lambert, 1996) generally find positive results for nightmare and sleep outcome (see Davis & Wright, 2006 for a discussion of some differences among these variants). To date, one randomized controlled study has examined the efficacy of IRT (Krakow et al., 2001). Krakow and colleagues (2001) examined IRT with 169 adult women with PTSD or PTSD symptoms and a criterion-a event, nightmares at least once per week for longer than 6 months, and insomnia. Participants were randomly assigned to treatment or wait-list control groups. Results indicated that the treatment was effective in reducing the frequency of nightmares per week, nights with nightmares per week, PTSD frequency and severity, and poor sleep quality. Although overall data suggest that IRT results in statistically significant pre- to posttreatment differences, the degree of clinical significance attained is less clear as post-treatment symptom levels in some studies remain in the abnormal range (Krakow et al., 2001). Also, a recent study by Krakow and colleagues (Krakow et al., 2002) examined the efficacy of sleep dynamic therapy, of which IRT is one component, administered in a large group (N = 66) over six sessions. Although the majority of participants reported significant improvement in symptoms, 11 people reported worsening insomnia and 10 people reported worsening PTSD. This was an uncontrolled study, however, so it is unclear if symptom worsening was related to the treatment. The specific procedures utilized under the umbrella of IRT vary across research teams. One area of divergence appears to be in the degree of exposure to the traumatic event(s) and content of the nightmare(s). Based on the substantial body of empirical literature denoting the ample impact of exposure-based techniques on symptoms of anxiety (e.g., Foa et al., 1999), Davis (2003) modified the protocols outlined by Thompson, Hamilton, and West (1995) and Krakow and colleagues (2001) to increase the exposure component of IRT. In addition, similar to some evidence-based PTSD treatments (e.g., Resick & Schnike, 1993), the treatment developed by Davis (2003) includes the identification of trauma-related themes within the nightmare, which generally includes a discussion of the traumatic event as well, and relaxation techniques drawn from cognitive behavioral therapies for anxiety disorders. Behavioral modification of poor sleep habits was also added to maximize the treatment s impact on sleep disturbance. This interdisciplinary approach culminated in exposure, relaxation, and rescripting therapy (ERRT; Davis, 2003). Thus, to date, one research group has utilized a randomized clinical trial design to investigate the efficacy of IRT for chronic nightmares. To augment confidence in the efficacy of this approach, it is important that another research group replicate these findings. The present study sought to examine the efficacy of a manualized exposure-based variant of IRT on the frequency and severity of chronic nightmares, sleep quality and quantity, depression, sleep problems, and posttraumatic stress symptoms and diagnostic criteria in a randomized controlled trial. We hypothesized that treated participants would show improvements in these areas and that they would be significantly different from the wait-list control group at posttreatment. Further, we hypothesized that treatment gains would be maintained across a 6-month follow-up. METHOD Procedure Participants were recruited via flyers, , and radio ads. Potential participants were screened over the phone for inclusion criteria (i.e., experiencing a traumatic event and having nightmares at least one time per week for the previous 3 months) and exclusion criteria (i.e., apparent psychosis or mental retardation, aged less than 18, active suicidality or recent parasuicidal behaviors, or current

3 Treatment of Chronic Nightmares 125 drug/alcohol dependence). There were no restrictions on race or ethnic background. Eligible individuals were invited to participate in the study and, using a random number generator, participants were randomly assigned to either the treatment or wait-list control group. The control group was not contacted during the 3-week period that the treatment group received the intervention, with the exception of a phone call to schedule a time for the reassessment. One week following the completion of the treatment group, both groups were reassessed and the control group was offered the treatment. Individuals who completed treatment were then assessed at 3- and 6-months posttreatment. After receiving training in the assessments used in this study, six upper-level graduate students, blind to the participants allocation, conducted the assessments. At each assessment, participants were provided a $20.00 gift certificate to a local department store to compensate them for their time. Participants The majority of participants were Caucasian, female, and reported at least some college education (see Table 1 for demographic information). Participants reported a mean of 4.6 traumatic events (SD = 2.0, range = 1 9). The most frequent types of trauma reported were car accidents (59.2%), unwanted sexual contact (59.2%), physical assault without a weapon (55.1%), and physical assault with a weapon (53.1%). Although having a PTSD diagnosis was not a requirement of the study, 67.3% (n = 33) of the participants met criteria, including 70.4% (n = 19) of the treatment group and 63.6% (n = 14) of the control group, χ 2 (1, N = 32) =.46, ns. Participants reported a mean of 5.51 (SD = 1.77) hours of sleep per night and approximately one third of the sample reported taking over an hour to get to sleep each night. Regarding the nature of their nightmares, 24% reported that their most recurrent and distressing nightmare was exactly like their trauma, 61% reported it was similar to the trauma, and 15% reported it was unrelated to their trauma. Nightmares were rated an average severity (rated 0 4) of 2.96 (SD = 0.82). Participants initially assigned to either the control or treatment group did not differ significantly on any demo- Table 1. Demographic Information for Study Sample at Intake Demographic n % M SD Gender Women Men Age Household income 25,890 21,203 Highest education level a Less than high school High school graduate Some college College graduate Graduate school Marital status a Divorced Separated Never married Widowed Married Racial and ethnic background a White African American Native American Hispanic Vocational status a Unemployed Employed fulltime Employed part time Disabled (not employed) a Total does not equal 100% due to two participants not reporting marital status or education and three participants not reporting ethnicity and vocational status. graphic variables other than ethnicity, with the treatment group having more participants who classified themselves as Native American (n = 6) compared to the control group (n = 0), χ 2 (1, N = 43) = 5.02, p <.05. Baseline analyses of pretreatment dependent variables yielded no significant differences between the groups. Measures A demographic questionnaire was designed to obtain standard background information about the participants,

4 126 Davis and Wright including age, native language, marital status, educational achievement, ethnicity, vocational status, and household income. The Trauma Assessment for Adults: Self Report Version (TAA; Resnick, Best, Kilpatrick, Freedy, & Falsetti, 1993) assessed for lifetime history of 10 types of traumatic events. Age of first and most recent occurrence is determined for multiple incidents of a given type and follow-up questions are included to assess perceived life threat. Although there are no published psychometric data on the TAA, Saunders and colleagues report that the rates of trauma experiences reported on the TAA are similar to those found with other structured traumatic event assessments (Saunders, Kilpatrick, Resnick, & Tidwell, 1989). The Structured Clinical Interview for DSM-IV: PTSD Module (SCID; Spitzer, Williams, & Gibbon, 1995) is a formulized diagnostic interview developed to assess and closely follow the criteria within the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000). The PTSD module assesses current and lifetime diagnoses of PTSD. Researchers have found the SCID to be a valid and reliable instrument in following diagnostic criteria set forth by the DSM (e.g., Davidson, Smith, & Kudler, 1989). The questions on the SCID were modified at the post and follow-up assessments to account for the timeframe of interest. The Beck Depression Inventory (BDI: Beck, Ward, Medelsohn, Mock, & Erbaugh, 1961) is a 21-item selfreport measure that assesses characteristic attitudes and symptoms of depression (Beck et al., 1961). Psychometric properties of the BDI are good, with internal consistency ranging from.73 to.92 (Beck, Steer, & Garbin, 1988), a split-half reliability coefficient of.93 (Beck et al., 1988). The Pittsburgh Sleep Quality Index (PSQI; Buysse, Reynolds, Monk, Berman, & Kupfer, 1989) is a self-report measure designed to assess certain qualities and problems associated with sleep. Participants rate quality of sleep and degree of sleep difficulties for a set period preceding the assessment. A global sleep quality score is obtained by summing the seven component scores and higher scores reflect poorer sleep quality. The global score may range from The PSQI has good internal homogeneity, test-retest reliability and validity (Buysse et al., 1989). Buysse and colleagues determined a cutoff score of 5 as distinguishing good sleepers from poor sleepers with a diagnostic sensitivity of 89.6% and specificity of 86.5%. The present study examined overall number of sleep problems and the global sleep quality index. The Trauma Related Nightmare Survey (TRNS: Davis, Wright, & Borntrager, 2001) was developed for this study because of a void of measures assessing characteristics of chronic nightmares. Likert-type, categorical, and openended questions assess the frequency, severity, and duration of nightmares, as well as cognitions, emotions, and behaviors related to nightmares. Test-retest analyses revealed adequate reliabilities for past week hours of sleep per night (r =.72), fear of going to sleep (r =.77), depression upon waking (r =.72), feeling rested upon waking (r =.65), frequency of nightmares (r =.64), and severity of nightmares (r =.63). Convergent validity was also found with daily behavioral records of sleep/nightmares: nights with nightmares (r =.82) and number of nightmares (r =.81); and the MPSS nightmare frequency (r =.64) and severity (r =.45). The Modified PTSD Symptom Scale Self Report (MPSS-SR; Resick, Falsetti, Resnick, & Kilpatrick, 1991) is a modification of the PTSD Symptom Scale developed by Foa, Riggs, Dancu, and Rothbaum (1993). Changes were made to assess for both frequency and severity of PTSD symptoms. The scale is composed of 17 items that correspond to PTSD symptom criteria in the DSM-IV- TR (APA, 2000). Frequency of PTSD symptoms are assessed on a 4-point scale (0 = not at all to 3 = 5ormore times per week/very much/almost always). Severity of PTSD is assessed on a 5-point scale (0 = not at all distressing to 4= extremely distressing). The internal consistency of the full-scale MPSS-SR has been reported at levels of.96 and.97, in treatment and community samples, respectively, (Falsetti, Resick, Resnick, & Kilpatrick, 1992, as cited in Falsetti, Resick, Resnick, & Kilpatrick, 1993). The MPSS-SR s psychometric properties are reported as very good, with a positive predictive power of.91, a negative predictive power of 1.0, and overall convergence with

5 Treatment of Chronic Nightmares 127 the SCID-PTSD module of.97 (Wright, Davis, Inness, & Stem, 2003). Exposure, Relaxation, and Rescripting Therapy Exposure, relaxation, and rescripting therapy is conducted for 2 hours once a week for three consecutive weeks and may be used in either an individual or group format. The first session of ERRT consists of psychoeducation about trauma, PTSD, nightmares, and sleep hygiene. Participants are taught progressive muscle relaxation (PMR) in session. Homework following each session includes practicing PMR each evening, choosing one sleep habit to change over the course of the week, and daily monitoring of nightmares, sleep quality and quantity, sleep habit change, and PTSD symptoms. Across the three sessions, the most frequent habits modified included reducing caffeine, liquids, and heavy meals close to bedtime. All participants were also instructed to limit time in bed if they had difficulty sleeping, engage in a relaxing activity until they felt tired, and then return to bed. The second session begins with a review of the homework. The rationale and instructions for exposure are provided and participants are asked to write out their nightmares and read them aloud. They are educated on trauma themes (see McCann, Sakheim, & Abrahamson, 1988; Resick & Schnicke, 1993) including power/control, esteem, trust, intimacy, and safety. Relevant themes are identified within the nightmare. The rationale and instructions are then provided for altering the nightmare. Participants are encouraged to utilize relevant themes in their rescription. For example, if an individual reports feeling very powerless in the nightmare, he or she would be encouraged to increase his or her sense of power in the rescription the exact nature of how this was accomplished was left up to the participants. The participants then write out the rescripted dream and read it aloud. As part of the continued emphasis on relaxation, the second session ends with instruction and practice in diaphragmatic breathing. Additional homework following Session 2 includes rehearsing the rescripted dream imaginally for 15 minutes each evening before going to sleep, followed by PMR, choosing another sleep habit to change, and practicing diaphragmatic breathing twice per day. The third session again begins with a review of the homework. Participants discuss the process of changing their dreams and problem solving occurs for any related difficulties. Slow breathing is taught and practiced in session. Continued practice of skills is emphasized and participants are encouraged to engage in similar rescription procedures with other nightmares if they continue. Data Analyses ANOVA and chi-square tests were used for univariate analyses to assess differences at baseline assessment. ANCOVA analyses were conducted to determine intent to treat and completer differences at the posttreatment assessment, covarying baseline scores. Intent-to-treat analyses were conducted first, with last value carried forward, followed by completer analysis. The treatment and delayed treatment groups were compared to determine whether they could be combined for the follow-up analyses. Generalized linear model repeated measures were utilized to assess pre- to follow-up analyses. Finally, end-state functioning was assessed for the 6-months follow-up assessment. Effect sizes were calculated with Cohen s d using pooled standard deviations. RESULTS Preliminary Analyses Forty-nine participants met the inclusion criteria and were invited to participate in the treatment study. Six individuals refused and did not begin treatment. Forty-three individuals began the study and were randomly assigned to either the treatment condition (n = 21) or the delayed treatment control condition (n = 22). Eleven participants did not complete the Time 2 assessment and these dropouts did not differ across condition, χ 2 (1, N = 43) = 1.30, p = ns. Intent-to-Treat Analyses Comparisons were conducted between those initially assigned to the control group and those who attended at

6 128 Davis and Wright Table 2. Intent to Treat Baseline and Posttreatment Data by Condition Baseline One week posttreatment Treatment Control Treatment Control (n = 21) (n = 22) (n = 21) (n = 22) Variable n % n % n % n % F or χ 2 D or H 2 Nightmares in past week **.17 Positive PTSD diagnosis *.09 M SD M SD M SD M SD Nights with nightmares **.84 Nightmare frequency Nightmare severity *.64 PTSD Symptom total **.53 PTSD Frequency **.67 PTSD Severity **.61 Total sleep problems ***.55 PSQI Global score Average hours of sleep Fearful of sleep Depressed upon waking Restful upon waking ** 1.05 Depression ***.59 Note. Effect sizes calculated for differences at postassessment. PTSD = posttraumatic stress disorder, PSQI = Pittsburgh Sleep Quality Index. p <.05. p <.01. p <.001. least one session of the treatment group (see Table 2. Analyses of immediate posttreatment results revealed significant group differences for nights with nightmares, severity of nightmares, sleep problems, PTSD symptom frequency and severity, feeling rested upon wakening, and depression, all supporting the efficacy of the intervention. Based on the SCID, significantly fewer participants in the treatment sample (33%) met symptom criteria for PTSD at postassessment compared to the control group (64%). Completer Analyses Analyses were conducted between those participants who completed therapy (n = 17) and those participants who completed the second initial evaluation in the control group (n = 15; see Table 3. Analyses revealed significant group differences for having a nightmare in the previous week, frequency and severity of nightmares, PTSD scores, sleep problems, and feeling rested upon wakening, all supporting the efficacy of the intervention. Analysis of the data between the treatment completers in the treatment condition (n = 17) and the waitlist control participants who were offered and completed treatment (n = 10) revealed no differences on any demographic or mental health variables. Thus, these two groups were combined for analyses examining change over time. Only those participants who completed one of the two follow-up analyses (n = 19) were included in the follow-up analyses. Repeated measures analyses were conducted for each dependent variable from pretreatment to 6-month follow-up, with time as the within-subjects factor (see Table 4. Overall, analyses revealed significant differences in frequency and severity of nightmares, PTSD symptoms, sleep quality, number of sleep problems, fear of sleep, depression upon wakening, BDI depression scores, average number of hours slept per night, and feeling rested upon awakening. In terms of PTSD diagnosis, 53% of individuals met criteria at pretreatment and 21% at 6-month follow-up.

7 Treatment of Chronic Nightmares 129 Table 3. Completer Analysis Baseline and Posttreatment Data by Condition Baseline One-week posttreatment Treatment Control Treatment Control (n = 17) (n = 15) (n = 17) (n = 15) Variable n % n % n % n % F or χ 2 D or H 2 Nightmares in past week *.19 PTSDDiagnosis M SD M SD M SD M SD Nights with nightmares **.97 Nightmare frequency Nightmare severity **.88 PTSD Symptom total **.39 PTSD frequency *.30 PTSD severity *.32 Total sleep problems **.89 PSQI Global score Average hours of sleep Fearful of sleep Depressed upon waking Restful upon waking **.86 Depression Note. Effect sizes calculated for differences at postassessment. PTSD = posttraumatic stress disorder, PSQI = Pittsburgh Sleep Quality Index. p <.05. p <.01. p <.001. Table 4. Treatment Completers Through Follow-up Analyses (N = 19) One-week 3-Month 6-Month Pretreatment posttreatment follow-up follow-up Variable n % n % n % n % F D Nightmares in past week PTSD Diagnosis M SD M SD M SD M SD Nights with nightmares *** 0.96 Nightmare frequency ** 0.92 Nightmare severity *** 1.84 PTSD symptom total *** 0.82 PTSD frequency *** 0.83 PTSD severity ** 0.79 Total sleep problems *** 1.44 PSQI Global score *** 1.04 Average hours of sleep * 0.42 Fearful of sleep * 0.53 Depressed upon waking * 0.55 Restful upon waking *** 1.01 Depression *** 0.61 Note. F and d values for pre- to 6-month follow-up analyses. PTSD = posttraumatic stress disorder, PSQI = Pittsburgh Sleep Quality Index. *p <.05. **p <.01. ***p <.001.

8 130 Davis and Wright End-State Functioning For nightmare frequency, we determined that an absence of nightmares in the past week constituted a good response to the treatment. For the SCID, not meeting criteria for PTSD was used as an indication of good end-state functioning. For the Beck Depression Inventory, the generally used cutoff score of 10 was utilized (Kendall, Hollon, Beck, Hammen, & Ingram, 1987), for sleep problems, a cutoff score of 5 on the global sleep index (Buysse et al., 1989), and for the MPSS, treatment sample cutoff scores of 23 for frequency and 47 for severity were used (Falsetti et al., 1993). At the 6-month follow-up, an average of 76% of completers achieved good end-state functioning across measures. Specifically, 84% achieved good end-state functioning for nightmare frequency, 79% for PTSD diagnosis, 79% for PTSD symptom frequency, 90% for PTSD symptom severity, 74% for depression, and 53% for sleep quality. DISCUSSION The present study indicates ERRT as efficacious for the reduction of frequency and severity of chronic nightmares, related psychiatric distress, and improved sleep quality and quantity. Treatment gains were maintained through the 6-month follow-up periods for all variables. Specifically, 84.2% and 78.9% of individuals who completed ERRT and the follow-up evaluations reported an absence of nightmares in the week and month prior to their last follow-up evaluation, respectively. It is important to note that we were inquiring about any nightmares, not only the nightmare targeted in treatment, thus lending further credence to our findings. Effect sizes revealed that the areas of greatest impact appear to be on nightmare severity, sleep problems, sleep quality, and restfulness upon wakening. The large effect for nightmare severity is particularly salient as some research suggests it is nightmare-related distress, as opposed to nightmare frequency, that may influence pathology (Levin & Fireman, 2002). Results of the one-week posttreatment analyses revealed fewer significant findings. This may be due to the small sample size and future studies should include larger samples to help ascertain if these are true insignificant findings or an issue of power. Alternatively, the impact of the treatment might not be fully seen immediately, but may require additional time and practice of techniques to reach maximal impact. The mechanism(s) of change for IRT/ERRT remain to be empirically determined. This uncertainty stems in part from the uncertainty of the nature of chronic nightmares. Nightmares may be conceptualized similar to other reexperiencing symptoms as initially important to process the trauma experience. Chronic nightmares may reflect specific cognitive or emotional aspects of the trauma that remain unresolved (Foa, Rothbaum, & Steketee, 1993; Hartmann, 1998). Thematic exploration of the nightmare may assist individuals in determining those areas that are persistent concerns or stuck points (Resick & Schnicke, 1993, p. 18). The ongoing impact of trauma is also evident in the victims sense that they have little control over much that happens in their lives, whether awake or asleep, which enhances feelings of powerlessness and demoralization. Thus, changing the meaning of the nightmare and achieving mastery via rescription may be a primary impetus to change (see also Krakow et al., 2001). Mastery may also be achieved through the process of exposure to the nightmare. Most participants reported high daytime and nighttime anxiety. Their nightmares often served as triggers for the trauma, which activated the fear network (Foa, Steketee, & Rothbaum, 1989), so that they were unable to gain relief from the memories, but continued to engage in significant avoidance coping by not allowing themselves to think about or visualize the trauma or the nightmare completely, from start to finish. Moreover, waking from the nightmare in a highly aroused state may further sensitize people to the experience of nightmares and the nightmare content (Rothbaum & Mellman, 2001). The exposure component in ERRT may work much as it does in PTSD treatments, in that participants learn to face their fear in a safe environment; this exposure provides a corrective learning experience and may correct problematic aspects of the fear structure (Foa & Kozak, 1986) and reduce anticipatory anxiety. Confronting the nightmare may provide an experience of mastery or confidence that

9 Treatment of Chronic Nightmares 131 may then be directed to other manifestations of distress (Krakow et al., 2001). Krakow argued that chronic nightmares may be initiated by a traumatic event, but eventually the experience of nightmares leads to other sleep-related problems and becomes an entity separate from the trauma response (Krakow et al., 2001). Because of the recurring nightmares and resulting arousal, distress, and apprehension about going to sleep, some people develop sleep hygiene habits that aid in escaping and avoiding the nighttime reminders of the trauma. These behaviors (e.g., drinking alcohol, staying up late, eating late, etc.) may be initially adaptive and helpful, but are rarely so in the long term. Curbing the escape function of these habits through their direct modification may enhance sleep quality directly through the change to positive sleep hygiene and indirectly through the participants learning that they can engage in good sleep behaviors without an exacerbation of their distress. There are a number of other potential maintaining factors of nightmares and future studies should begin to discern those, which may augment our understanding of IRT/ERRT s mechanism(s) of change. Overall, nightmares appear to be a part of a vicious cycle including intrusive experiences, distress, and increased arousal creating more experiences that are intrusive. Nightmares in and of themselves are quite disturbing and disruptive and impact other areas of functioning. It may be that intervening in any one of the above maintaining factors will help to break the cycle and create improvements across the spectrum. Alternately, due to the complexity of the cycle, interventions at several points may be required. Limitations The present study included limitations that must be noted. First, the small sample size limits the generalizability of the results to the broader trauma population. Second, all indications of improvement were assessed via clinical interview or self-report. In future studies it will be important to obtain objective indices of sleep functioning. Third, although the rate of dropout of 26% is within the typical range for trauma-related therapies (e.g., Foa et al., 1999, 2005; Krakow et al., 2001), it is unclear what to attribute this to and future studies should continue to look at ways to increase maintaining participants in clinical research studies. The use of a wait-list control group is common in the early stages of assessing treatment efficacy. Future studies will be enhanced through comparing IRT/ERRT with viable alternatives and placebo conditions. Finally, although we believe the multifaceted nature of this treatment is a strength, it does limit the clear understanding of the findings. Future Directions Based on two randomized clinical trials by two separate research groups, it appears that these variants of cognitive behavioral therapy for chronic nightmares meet the APA s criteria for a probably efficacious treatment and should be considered first-line treatments for trauma-exposed individuals with a primary complaint of chronic nightmares. Future studies need to dismantle the protocols to help determine the specific mechanism(s) of change. Additionally, direct comparisons with other viable treatments would further establish the validity of the treatment. Lastly, given the resistant nature of chronic nightmares, it is important to determine if well-established PTSD treatments might benefit from the addition of IRT/ERRT in ameliorating nightmares and their subsequent distress. REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Beck, A. T., Steer, R. A., & Garbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Archives of General Psychiatry, 4, Beck, A. T., Ward, C. H., Medelsohn, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, Buysse, D., Reynolds, C., Monk, T., Berman, S., & Kupfer, D. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28,

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