Imagery Rescripting and Imaginal Exposure in Nightmare Disorder Compared to Positive Imagery: A Randomized Controlled Trial

Abstract

<b><i>Introduction:</i></b> Both imagery rescripting and imaginal exposure have been proven to be effective in the treatment of chronic nightmares when compared to a waitlist condition. Little is known about their comparative efficacy and their efficacy compared to an active control. <b><i>Objective:</i></b> The aims of this study were to compare the two treatments to one another and to positive imagery as an active control, and to explore covariates of the treatment effect. <b><i>Methods:</i></b> In this single-blinded randomized controlled trial, 96 patients with nightmare disorder (idiopathic nightmares) from an outpatient clinic were randomly assigned to a single individual treatment session of rescripting, exposure, or positive imagery and 4 weeks of practice at home. The primary outcome was nightmare distress, and the secondary outcomes were nightmare frequency, nightmare effects, self-efficacy, and general psychopathology. <b><i>Results:</i></b> Nightmare distress was reduced in all groups (imagery rescripting: Cohen’s <i>d</i> = –1.04, imaginal exposure: <i>d</i> = –0.68, positive imagery: <i>d</i> = –0.57), as were nightmare frequency, nightmare effects, and psychopathology. Self-efficacy was enhanced. No differential treatment effects were found on any primary or secondary measure. Treatment gains were not associated with demographic or disorder characteristics, baseline values, treatment credibility, or the number of practice sessions. <b><i>Conclusions:</i></b> Even short nightmare treatments are effective regardless of personal characteristics, and different interventions produce similar results. Future research should aim to clarify the mechanisms of action. Health care should make more use of these powerful and easy-to-administer nightmare treatments.

Solving the nightmare mystery: The autonomic nervous system as missing link in the aetiology and treatment of nightmares.

“…A recent study found rescripting, exposure and the active control condition (imagining a safe place) all equally effective in a randomized controlled trial of nightmare treatment (Schmid et al, 2021). The researchers compared imagery rescripting (IR) and imaginal exposure (IE) to an active versus waitlist control (positive imagery; PI) with 96 patients with nightmare disorder experiencing idiopathic nightmares.…”

The nightmare severity index (NSI): A short new multidimensional tool for assessing nightmares

“…The emotional impact sub‐score is then closer to the criteria as defined by the DSM‐5 and the ICSD‐3. Additionally, the inclusion of complementary items about the recurrence of nightmares and their content, proves useful in clinical practice, particularly in PTSD and nightmare disorders treatments and while using techniques such as imagery rescripting (IRT), positive imagery, or imaginal exposure (Schmid et al, 2021; Waltman et al, 2018).…”

“…T A B L E 3 Results of the exploratory analysis of items of the NSI questionnaire among the 77 French included patients (Schmid et al, 2021;Waltman et al, 2018).…”

“…Other authors found that nightmare frequency, and not nightmare chronicity or severity/distress, may help to differentiate between single and multiple suicide attempters (Speed et al, 2018). This panel of scales might be also used to assess the effect of treatments for nightmare disorder in the context of a PTSD (Krakow et al, 2000) or without (Schmid et al, 2021). Recent meta‐analyses show that these scales are often used together because of their specific and non‐overlapping nature, except for the DDNSI that evaluates some sub‐dimensions with no differences made between bad dreams and nightmares (Seda et al, 2015; Waltman et al, 2018; Yücel et al, 2020).…”