Physiological Predictors of Response to Exposure, Relaxation, and Rescripting Therapy for Chronic Nightmares in a Randomized Clinical Trial

Abstract

Study Objectives: Evidence supports the use of cognitive behavioral therapies for nightmares in trauma-exposed individuals. This randomized clinical trial replicated a study of exposure, relaxation, and rescripting therapy (ERRT) and extended prior research by including broad measures of mental health diffi culties, self-reported physical health problems, and quality of life. Additionally, physiological correlates of treatment-related change assessed from a script-driven imagery paradigm were examined. Methods: Forty-seven individuals were randomized to treatment or waitlist control. Results:The treatment group demonstrated improvements relative to the control group at the one-week post-treatment assessment. At the 6-month follow-up assessment, signifi cant 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 were correlated with improvements in sleep quality and quantity; treatment-related decreases in skin conductance to nightmare imagery were 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 were correlated with improved physical health. Conclusions S C I E N T I F I C I N V E S T I G A T I O N SN ightmares following trauma exposure are consistently associated with sleep disturbance, 1 posttraumatic stress disorder (PTSD) severity, 2 physiological arousal with or without PTSD, 3 and functional impairment over and above PTSD. 4,5 Moreover, chronic nightmares (CN) may be a signifi cant maintaining factor of psychological distress, because successful treatment of CN with cognitive behavioral therapy results in the reduction of symptoms of PTSD, depression, and nightmare-related panic. 6-8 Therefore, CN may pose a pernicious health problem independent of other psychopathology. Preliminary evidence suggests that psychological treatments which broadly target PTSD may have limited impact on sleep disturbances, 9-13 and pharmacological treatments appear to have little effect 14 or only a palliative effect 15 for some individuals. Thus, cognitive behavioral approaches specifi cally addressing sleep disturbances are now being evaluated in trauma-exposed samples. The present study is a replication of a randomized controlled trial (RCT) that examined the effi cacy of exposure, relaxation, and rescripting therapy (ERRT) to treat CN in trauma-exposed persons 7 and expands previous work by assessing the infl uence of treatment on facets of health that were not included in the fi rst RCT and examining physiological predictors of treatment response.The fi rst RCT demonstrated that ERRT reduced nightmare frequency and severity, related psychopathology, and improved sleep in trauma-expo...

Cognitive-behavioral therapy for sleep disturbances in treating posttraumatic stress disorder symptoms: A meta-analysis of randomized controlled trials

“…A variety of outcome measures assessing PTSD symptoms in either self-report or clinician-administered formats were employed: PTSD checklist/PTSD checklist -military (PCL/PCL-M) (Germain et al, 2012;Nakamura, Lipschitz, Landward, Kuhn, & West, 2011;Rose, 2013;Talbot et al, 2014;Ulmer, Edinger, & Calhoun, 2011;Ustinov, 2013), PTSD symptom scale/modified PTSD symptom scale (PSS/ MPSS) (Davis & Wright, 2007;Krakow et al, 2000Krakow et al, , 2001aMack, 2013;Margolies, Rybarczyk, Vrana, Leszczyszyn, & Lynch, 2013), trauma symptom inventory (TSI) (Davis et al, 2011), and Clinicianadministered PTSD scale (CAPS) (Davis et al, 2011;Krakow et al, 2000Krakow et al, , 2001aTalbot et al, 2014). Self-report and clinicianadministered measures of MDD symptoms included Beck depression inventory (BDI) (Davis & Wright, 2007;Germain et al, 2012;Talbot et al, 2014;Ustinov, 2013), patient health questionnaire (PHQ) (Mack, 2013;Margolies et al, 2013;Ulmer et al, 2011), center for epidemiological studies -depression (CES-D) (Nakamura et al, 2011), and trauma symptom inventory (TSI) (Davis et al, 2011). Self-report sleep measures included Pittsburgh sleep quality index (PSQI) (Davis & Wright, 2007;Davis et al, 2011;Germain et al, 2012;Krakow et al, 2000Krakow et al, , 2001aMack, 2013;Margolies et al, 2013;Rose, 2013;Talbot et al, 2014;Ulmer et al, 2011), sleep diary …”

“…Self-report and clinicianadministered measures of MDD symptoms included Beck depression inventory (BDI) (Davis & Wright, 2007;Germain et al, 2012;Talbot et al, 2014;Ustinov, 2013), patient health questionnaire (PHQ) (Mack, 2013;Margolies et al, 2013;Ulmer et al, 2011), center for epidemiological studies -depression (CES-D) (Nakamura et al, 2011), and trauma symptom inventory (TSI) (Davis et al, 2011). Self-report sleep measures included Pittsburgh sleep quality index (PSQI) (Davis & Wright, 2007;Davis et al, 2011;Germain et al, 2012;Krakow et al, 2000Krakow et al, , 2001aMack, 2013;Margolies et al, 2013;Rose, 2013;Talbot et al, 2014;Ulmer et al, 2011), sleep diary (Germain et al, 2012;Mack, 2013;Margolies et al, 2013;Talbot et al, 2014;Ulmer et al, 2011;Ustinov, 2013), insomnia severity index (ISI) (Germain et al, 2012;Mack, 2013;Margolies et al, 2013;Talbot et al, 2014;Ulmer et al, 2011;Ustinov, 2013), and medical outcome study-sleep scale (MOS-SS) (Nakamura et al, 2011). One study included objective measures, polysomnography and actigraphy (Talbot et al, 2014).…”

“…Severity of PTSD symptoms were measured by PCL-M in 3 studies (Nakamura et al, 2011;Rose, 2013;Ulmer et al, 2011), by CAPS in 1 study (Davis et al, 2011), and by PSS in 1 study (Krakow et al, 2001a). In Nakamura et al (2011), PCL-M scores with greater than 50 points at pretreatment were extracted and compared with the PCL-M score at posttreatment.…”

Comparative Meta-Analysis of Prazosin and Imagery Rehearsal Therapy for Nightmare Frequency, Sleep Quality, and Posttraumatic Stress

“…Table 1 presents descriptive characteristics for each study included in the meta-analysis, ordered by publication year. Of these, there are 4 pharmacological trials including prazosin, [24][25][26][27] 10 studies including IRT, either alone or combined with another form of psychological intervention, [28][29][30][31][32][33][34][35][36][37] and one study comprising both IRT and prazosin interventions administered to 2 groups randomly assigned to these treatments. 38 All studies were published between 2000 and 2013.…”

“…36 In studies where there was more than one nightmare measure, we selected the number of nights per week with nightmares as the primary nightmare outcome. 30,31,34,37,38 If this information was not available, we then used one of the following: nights with nightmares per month or number of nightmares per week/ month. 25,28,29,32,33,35,36 In 3 studies, 24,26,27 nightmare outcomes were solely assessed with the item on the Clinician-Administered PTSD Scale (CAPS) "Recurrent distressing dreams."…”