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    QUEST - Imagery Rehearsal Therapy

Author:
Wei Jiang, M.D.

IRT FOR CHRONIC NIGHTMARES IN SEXUAL ASSAULT SURVIVORS WITH PTSD

Article: Imagery Rehearsal Therapy (IRT) for Chronic Nightmares in Sexual Assault Survivors with PTSD: A Randomized Controlled Trial JAMA 2001;286:537-45 By B Krakow et al.

Background:

  1. Occurrence of nightmare as a problem is frequent; 4-8% in general population and 60% in PTSD
  2. Evidence shows that nightmare is associated with psychological distress and sleep impairment
  3. A conditioning patter similar to classic psychophysiological insomnia is produced in the nightmare disturbed loop, along with the negative cognition of “fear of going to sleep”
  4. Studies using brief CBT (desensitization and imagery rehearsal) have demonstrate large reduction in nightmares
  5. DSM-IV-TR suggests that nightmares occurring with another psychiatric disorder is not a distinctly treatable condition and its remission occurs only through Tx of the primary disorder, such as anxiety D/O, and PTSD
  6. A preliminary study used IRT targeting solely on nightmares indicated it decreases PTSD severity

Study Design:

  • Randomized, certain level of blinding while data collected (baseline assessment; mailed questionnaire at 3-m F/U; and personal interview at 6-m F/U)
  • female sexual assault survivors >=18yo with self-reported nightmares, insomnia, and SXS of PTSD
  • excluded acute intoxication, withdrawal, and psychosis
  • concomitant intervention: 79% psychotherapy and/or psychotropic meds (mainly TCA and SSRIs)
  • measurements of primary outcome: nightmare frequency questionnaire (NFQ); Pittsburgh sleep quality index (PSQI); clinician-administered PTSD scale (CAPS); and PTSD symptom scale (PSS)
  • intervention: IRT and control; each group of IRT consists 4-8 subjects underwent total of 3 sections with one week apart following a manual focusing on nightmares within the framework of an imagery and cognitive reconstructing paradigm ; 6 assumptions were conveyed to patients during the active interventional phase
  • F/U: questionnaires mailed to subjects at end 3-m; personal interview at end 6-m
  • Data analysis: ANOVA and Chi-square; intention-to-treat done
Validity:
  • Randomized, blinding of group assignment during data collection
  • Aside from the experimental treatment, IRT and control were treated equally
  • Baseline demographics and clinic characteristics were similar between 2 groups except the IRT older (about 5-year older, P=0.01)
  • Intention-to-treat analysis performed
  • Highly applicable to our patients population

Results:

  • (both 3-m and 6-m F/U) Nights with nightmares/week and number of nightmares/week decreased significantly (p=0.001); sleep quality improved (p=0.001); and PSS decreased (p=0.001)
  • intention-to-treat analyses for above parameters showed all p<=0.02 with smaller effect sizes
  • age as well as concomitant treatments as covariate did not change the results

Valuable Features:

  1. prospectively, randomized trial with interviewer blinded from group assignment
  2. large sample
  3. clearly defined targeting behavior with short-term active intervention

Critics:

  1. subjects not blinded, un-avoidable bias
  2. only reported numeric changes of SXS of PTSD; rate of responders/remission could be more helpful
  3. component of PTSD symptomatology not reported, wonder if improvement only attributed by SXS directly related to nightmares

Bottom Line:

  • IRT appears quite effective in modifying nightmares and increase quality of sleeping; IRT appears to be an easily learned technique, requiring short-term intervention (total of 4 hours)
  • Targeting on modify nightmares may improve overall PTSD symptoms

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