Nightmares and Imagery Rehearsal Therapy


Problems with nightmares are reported by a sizable proportion of individuals with a history of trauma and by approximately 5% to 8% of the general population. Chronic nightmares may represent a primary sleep disorder rather than a symptom of a psychiatric disorder, and direct targeting of nightmares is a feasible clinical approach to the problem. Of the treatments proposed, imagery rehearsal therapy (IRT) has received the most empirical support. An up-to-date account of this cognitive-imagery approach shows how to treat nightmares during 4 roughly 2-hr sessions. The main points covered in each therapy session and their underlying rationale are presented. Dismantling protocols are suggested to discern active ingredients of IRT and to develop flexible applications based on patients’ needs.

Maybe you’ve heard that if you have a recurring nightmare, you should try imagining a new version of the dream and rescripting a more pleasant ending. It’s a simple idea, but one that psychology researchers have elaborated into an entire method of therapy for people with chronic nightmares.

Most people experience nightmares from time to time, but some people – many with PTSD, for example – are plagued by dreams gone awry. For people whose quality of life is being affected by nightmares, one option for treatment is Imagery Rehearsal Therapy, or IRT. Among other things, IRT involves working with a therapist to reimagine recurring nightmares and shape these dreams into something more benign.

Much of the early research into IRT looked at the therapy as a treatment for nightmares in PTSD specifically, since nightmares are often a symptom of the disorder. A 2012 meta-review of thirteen studies came back with some promising results: IRT had a real effect on the frequency of nightmares, the quality of people’s sleep and the severity of PTSD symptoms. Even better, the benefits of therapy were still evident six months and a year later.

Since then, research has started to branch out, looking at whether IRT can be an effective treatment for people with other psychiatric disorders who experience chronic nightmares. A 2015 study, for instance, found that supplementing people’s regular psychiatric treatment with IRT did indeed take a lot of the edge off of those people’s bad dreams.

Most recently, a study done at the Menninger Clinic in Houston tried IRT on 20 inpatients who were being treated for various psychiatric disorders, ranging from anxiety disorders to personality disorders to substance use. By the time the therapy was done, the patients reported experiencing less frequent and less intense nightmares – and better sleep quality.

Sleep disturbances, especially insomnia and nightmares, are common among combat veterans and insomnia is associated with increased risk for medical and psychiatric illness. Nightmares can lead to sleep avoidance, anticipatory anxiety that interferes with sleep initiation, or awakenings that reinforce negative associations with sleep. In addition, sleep disturbances often persist following treatment of posttraumatic stress disorder and mediate the relationship between combat stress and other mental health symptoms. When compounded by stressors faced by returning service members and by the normal travails of aging, insomnia and nightmares are a substantial burden.

This article was written by Neil Petersen for ALLPSYCH.

Dr. Dimitra Takos is a Newport Beach Psychologist specializing in the treatment of adolescents and adults suffering from depression, anxiety, and trauma-and stressor-related disorders.