ARTICLE IN PRESS
    1    Imagery Rehearsal
    2
    3    Therapy: Principles
    4
    5    andPractice
    6
   ½Q2                       a,                         b
   ½Q3 Barry Krakow, MD *, Antonio Zadra, PhD
   ½Q4 KEYWORDS
    7      Dreaming  Dream frequency  Dream content
    8      Nightmares  Trauma  Posttraumatic dreams                                                                      49
    9
   10                                                                                                                       50
   11                                                                                                                       51
   12                                                                                                                       52
   13    Manyclinicians in sleep medicine, psychiatry, and     frequency, including maintenance of changes at               53
                                                                              PROOF
         psychology remain unaware of the suffering and        long-term follow-up.6–9 IRT effectively relieves
   14                                                                                                                       54
   15    distress caused by chronic nightmares. This lack      idiopathic, recurrent, and PTSD-related forms of             55
         of awareness extends to the therapeutic tools that    nightmares.6,8,10,11 In these same studies, a rela-          56
   16    effectively reduce or eliminate the problem. Many     tively consistent pattern emerged of decreased
   17                                                                                                                       57
   18    nonpharmacologic      techniques     have    been     psychiatric distress including anxiety, depression,          58
   19    proposed to treat posttraumatic stress disorder       or PTSD symptoms, following successful night-                59
   20    (PTSD)–related or idiopathic nightmares, including    mare treatment. Of the several hundred partici-              60
   21    hypnosis, lucid dreaming, eye movement desensi-       pants and patients, with and without PTSD,                   61
   22    tization and reprocessing, desensitization, and       treated in research protocols with IRT, approxi-             62
   23    imagery rehearsal therapy (IRT). However, only        mately    70% reported clinically      meaningful            63
   24    desensitization and IRT have been the objects of      improvements in nightmare frequency. However,                64
   25    controlled studies, and IRT has received the most     anecdotal observations among those individuals               65
   26    empiricalsupport.Thisarticlehighlightskeyprinci-      who reported regular use of the technique for 2              66
   27    ples behind this technique and the practice           to 4 weeks indicate that significant clinical change         67
   28    methodsusedtoapplyitbypresentinganabridged            occurred in greater than 90% of patients.                    68
                                                  1                                                     12–17
   29    and updated version of an earlier work. Further          Variations exist in the application of IRT and            69
   30    resources are also available to readers interested    IRT has also been adapted for use in children                70
                                                        2,3                              18,19
   31    in additional material on the clinical use of IRT.    suffering from nighttimes.      The distinguishing           71
   32    ForthosepatientsinwhomIRTmaybeimpractical             features between these variations generally revolve          72
   33    or counterproductive, pharmacotherapy (eg, pra-       around the degree of exposure used during treat-             73
   34    zosin, a central a-1 adrenoreceptor blocker) may      ment sessions and/or the specific application of             74
   35    be a useful alternative therapeutic option for        the technique during the sessions. This article              75
         PTSD-related nightmares.4,5 Readers interested        focusesonIRTasdevelopedbyKellner,Neidhardt,                  76
   36    in pharmacologic approaches to nightmare treat-       Krakow, and Hollifield at the University of New
   37                                                                                                                       77
   38    ment and the issue of drug-induced nightmares         MexicoSchoolofMedicine(1988–1999)andatthe                    78
   39    are referred to the article by Pagel in this issue.   Sleep&HumanHealthInstitute(2000topresent).                   79
   40                                                                                                                       80
   41    CONTROLLED TREATMENT STUDIES                          THERAPEUTIC COMPONENTS OF IRT
                                   UNCORRECTED
   42    In the last 20 years, IRT has been tested repeat-     Current Practice
   43    edly in various samples and has shown efficacy        IRT can be conceptualized as a 2-component
   44    in reducing nightmare distress and nightmare          therapeutic process, each of which targets
   45
   46     a Maimonides Sleep Arts & Sciences, Ltd., Maimonides International Nightmare Treatment, Sleep & Human
          Health Institute, 6739 Academy NE, Suite 380, Albuquerque, NM 87109, USA
          b                                   ´          ´
            Department of Psychology, Universite de Montreal, C.P. 6128, succ. Centre-ville, Montreal, Quebec, Canada,
   ½Q5   H3C 3J7
   47     * Corresponding author.
   48     E-mail address: bkrakow@sleeptreatment.com (B. Krakow).                                                         theclinics.com
          Sleep Med Clin - (2010) -–-
          doi:10.1016/j.jsmc.2010.01.004                                                                                  sleep.
          1556-407X/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.
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                                                  ARTICLE IN PRESS
     2             Krakow&Zadra
   81         adistinctyetoverlappingprobleminthenightmare              Box 1                                                 138
   82         sufferer. The first component is an educational/          Overview of the main components in each               139
   83         cognitive   restructuring  element,    focused on                                                               140
                                                                        of the 4 IRTsessions                               ½Q8
   84         helping the nightmare sufferer to consider their                                                                141
   85         disturbing dreams as a learned sleep disorder,            Session 1                                             142
   86         similar  to   psychophysiologic     insomnia.   The        Reiterating that the group will not discuss         143
   87         second component is an imagery education/                   past traumatic events or traumatic content          144
   88         training element, which teaches patients who                of nightmares                                       145
   89         have nightmares about the nature of human                  Addressing treatment credibility                    146
   90         imagery and how to implement a specific set of             Hownightmares can lead to insomnia                  147
   91         imagery steps to decrease nightmares. IRT can              Hownightmarespassfromanacutephaseto                 148
   92         bedeliveredindividually or in groups, but for either        a chronic disorder                                  149
   93         scenario the same progression of treatment steps           Unsuspectedbenefitsfromhavingnightmares             150
   94         is offered. Follow-up time is always recommended          Session 2                                             151
   95         to reassess the patient.                                   Why nightmares might persist long after             152
   96            Thefirst2sessionsencouragepatientstorecog-               traumatic exposure                                  153
   97         nize the effect of nightmares on their sleep by            What happens to symptoms of low well-               154
   98         showing them how nightmares promote learned                 being when nightmares are treated directly          155
   99         insomnia.Theyareofferedtheviewthatnightmares               Concept of symptom substitution                     156
                                                                                      PROOF
  100         themselves may develop as a learned behavior.              proportion of nightmares caused by trauma           157
  101         Thefinal 2 sessions engage the nightmare sufferer           versus conditioning                                 158
  102         to learn about the human imagery system, to                Principles of general imagery and pleasant          159
  103         monitor how this system operates, to appreciate             imagery                                             160
  104         the connections between daytime imagery and                Overcoming difficulties in the use imagery          161
  105         dreams, and to implement the specific steps of            Session 3                                             162
  106         IRT (ie, selecting a nightmare, changing the night-        Broader discussion of imagery                       163
  107         mare into a new dream, and rehearsing the new              Imagery as a vehicle for change                     164
  108         dream). Aspects of each of these 2 components              Changing one’s nightmare identity                   165
  109         are included in all 4 sessions, but learned sleep         Session 4                                             166
  110         disorders predominates in the first 2 sessions and         IRT for nightmares                                  167
  111         imagery work predominates in the last 2 sessions.          Selecting a nightmare                               168
  112         Anoverview of the main points covered in each of           Changing the nightmare any way you wish             169
  113         these sessions is presented in Box 1.                      Rehearsing the new dream                            170
  114            Throughout the sessions, we never discount or                                                                171
  115         ignore patients’ perspectives on triggering inci-                                                               172
  116         dents perceived as the cause of their nightmares.                                                               173
  117         Thispointisespeciallyrelevantfortraumasurvivors         their  nightmares with insomnia. Third, most            174
  118         with nightmares and for the meanings they asso-         patients resonate with the suffering caused by          175
  119         ciate with their disturbing dreams. Nevertheless,       poor sleep, which validates their negative sleep        176
  120         patients are shown how nightmares can be effec-         experiences and thus their reasons for seeking          177
  121         tively treated without any discussion or emphasis       treatment of these vexing sleep disturbances.           178
  122         onprevioustraumaticeventsornon–sleep-related               The current version of IRT focuses on the            179
  123         PTSD symptoms. IRT is organized to minimize             broader concept of poor sleep quality, including        180
  124         exposuretherapyasaningredientofthetechnique.            a discussion of insomnia. This also sets the stage      181
  125                                                                 for future discussions about sleep-disordered           182
  126         SESSION 1                                               breathing, which the authors have found in a high       183
  127         Something to Sleep On                                   rate of trauma survivors with nightmares and            184
                                                                             21–25
  128                                     UNCORRECTED                                                                         185
                                                                      PTSD.        The basic elements of the discussion
  129         In our largest randomized controlled trial with         revolve around the following points: (1) nightmares     186
  130         PTSDpatients,20weintroducedIRTbydiscussing              fragment sleep; (2) sleep fragmentation causes          187
  131         hownightmarespromoteinsomnia.Thisapproach               poor sleep quality; (3) poor sleep quality is           188
  132         serves 3 purposes. First, it immediately shows the      a psychological and physiologic process; (4)            189
  133         patient that our interests are truly focused on         efforts to improve sleep quality provide maximum        190
  134         sleep-relatedproblemsandnotontrauma,current             relief of sleep problems; and (5) treating night-       191
  135         negative life events, or PTSD. Second, it creates       mares is an important step and sometimes the            192
  136         an insightful ‘‘mini-aha’’ experience because           best first step in treating posttraumatic sleep         193
  137         most trauma survivors do not generally associate        disturbance.                                            194
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½Q1                                                Imagery Rehearsal Therapy: Principles and Practice                 3
  195    Nightmare Help and Harm                              dreamshavepersistedforsolong.Tosimplystate                 252
  196    Nightmares not only cause reexperiencing, but        that nightmares are a learned behavior is an               253
  197    they also initiate a cascading sequence of mental    intriguing and provocative statement that may be           254
  198    and physical hyperarousal symptoms, triggered        met by a full range of emotions and responses.             255
  199    bythethreats within the disturbing dreams. These     This claim must be backed up with sufficient               256
  200    arousal symptoms represent a second symptom          examples to persuade the patient to stay in treat-         257
  201    cluster in PTSD.26 Following arousal, patients       ment. When queried beyond the explanations of              258
  202    usually search for ways of preventing this cycle     uncontrollability or unconscious processes, some           259
  203    from recurring, and quite naturally they seek to     patients suggest that nightmares persist because           260
  204    avoid the trigger. In this specific sleep-related    they are a long-term consequence of trauma (ie,            261
  205    instance, trauma survivors report avoiding sleep     the trauma is still causing nightmares). Others            262
  206    onset at bedtime or re-onset in the middle of the    believe that the persistence of nightmares is              263
  207    night with the hope of preventing more bad           caused by malfunctioning or altered neurotrans-            264
  208    dreams. Although patients may not recognize          mitters or a genetic predisposition. Occasionally,         265
  209    sleep avoidance as a conscious process, most         a patient initiating treatment will raise the possi-       266
  210    nightmare sufferers resonate with the schema         bility that nightmares are a habit or a learned            267
  211    once they hear this sequence, which again coin-      behavior (some even speak the phrase ‘‘broken              268
  212    cides with a third symptom cluster of PTSD           record’’).                                                 269
  213                                                           However,mostpatientsarelockedintotheidea                 270
  214    (avoidance).                                                        PROOF                                       271
           The discussion turns to the transition process     that nightmares persist because trauma or other
  215    through which nightmares move from an acute          PTSDsymptomsstickintheirminds.Thisrelation-                272
  216    phase to a chronic disorder. We use a paradigm,      ship is therefore examined in a few ways in an             273
  217    developed by Michael Hollifield, which helps         attempt to produce cognitive restructuring. First,         274
  218    patients recognize that soon after the trauma,       we discuss how nightmares might ‘‘take on a life           275
  219    they made a natural and smart choice to experi-      of their own.’’ Most patients relate to this idea,         276
  220    ence nightmares. That is, disturbing dreams, by      becausetheyareunsurewhatprovokesadisturb-                  277
  221    many accounts from the empirical and theoretic       ing dream on a specific night-to-night basis. We           278
  222    literature, may serve a function of emotional        ask whether it seems possible that some type of            279
  223    adaptation to emotionally salient or traumatic       psychotherapy could be directly targeted at the            280
  224    events.27–30 Early after the trauma, nightmares      nightmares. Could the disturbing dreams now be             281
  225    might help to relive the experience and remember     functioning in some distinct manner, separate              282
  226    important details that might be meaningful to the    from the PTSD process?                                     283
  227    survivor; the dreams might provide useful infor-       Wethenworkthroughaparadigmbasedonthe                     284
  228    mation for emotional processing, either spontane-    question: ‘‘If  you eliminated your disturbing             285
  229    ously through dreaming, rapid eye movement           dreams without influencing or treating any other           286
  230    sleep, or in collaboration with a therapist; and     aspect of your mental health, what would happen            287
  231    the nightmares might serve a survival function       to these 4 distress symptoms: anxiety, depres-             288
  232    by motivating the individual to alter a behavior     sion, somatization, and hostility?’’ Most patients         289
  233    or some other aspect of their lifestyle to remain    declare these symptoms should get worse,                   290
  234    out of harm’s way. This process leads to the         because nightmares must have been serving                  291
  235    closing question, ‘‘Do these nightmares and dis-     a purpose. The term ‘‘symptom substitution’’ is            292
  236    turbing dreams still provide any benefits, once      used regarding this potential downside of treating         293
  237    they have lasted for so long?’’ We suggest that      nightmares directly.                                       294
  238    individuals reflect on this question for the next      Weorganizethediscussion of this process with             295
  239    week, but most people are quick to respond in        the example of aggressive and violent nightmares           296
  240    the negative. This hopefully provides them with      andaskpatients to suggest the types of emotions            297
  241    a hint at the possibility that nightmares can take   experienced during such dreams. Most suggest               298
  242                              UNCORRECTED                                                                           299
         on a life of their own, which is the major focus     anger and rage, and a few mention fear, guilt,
  243    of the next session.                                 horror, or grief. We focus on anger and rage, and          300
  244                                                         then ask what would happen to these feelings if            301
  245                                                         a person were suddenly to stop having these                302
  246    SESSION 2                                            nightmares. Again, patients usually state that             303
  247    Persistence of Nightmares                            because the anger and rage have not been                   304
  248                                                         released through the nightmare experience, these           305
  249    Patients who have nightmares usually believe bad     emotionsmustgosomewhereelse,whichleadsto                   306
  250    dreams are uncontrollable and from the uncon-        further  problems (eg, symptom substitution).              307
  251    scious mind; yet, most want to know why the          When they are again asked what would happen                308
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     4              Krakow&Zadra
  309          to symptomsofanxiety,depression,somatization,           self-explanatory elements that are discussed             366
  310          and hostility following direct treatment of disturb-    include (1) imagery is a natural part of mental          367
  311          ing dreams, most patients again report that these       activity, which is easily described in behavioral        368
  312          symptoms would either worsen or remain                  terms as 1 component of the mental system of             369
  313          unchanged.                                              thoughts,feelings,andimages;(2)imageryisoften            370
  314                                                                  the last conscious activity just before sleep onset;     371
  315          Learning to Have Nightmares                             (3) ergo, imageryduringthedaymaybeabridgeto              372
  316          This phase marks a critical turning point, because      imagery at night (dreams); (4) imagery is not medi-      373
  317          we briefly but clearly describe the results from        tation but simply a daydream with bit more inten-        374
  318          nightmare treatment research in which anxiety           tion or structure as needed or desired; (5)              375
  319          and other distress symptoms usually decrease            imagery skills can be tested in brief exercises of       376
  320          after nightmares have been treated. Most patients       a few minutes, and most trauma survivors have            377
  321          sit back to regroup, because these results do not       a reasonable ability to conduct such tests in            378
  322          resonate with what they learned or believed about       groups or individually; (6) some trauma survivors        379
  323          nightmares.Althoughmanypatientswillnotfullyor           are surprised at their healthy capacity to image         380
  324          immediatelyprocesstheramificationsofthisinfor-          things; and (7) most PTSD patients, except those         381
  325          mation, most participants become curious and            of extremeseverity, canpracticepleasantimagery           382
  326          excited about this new perspective.                     exercises at home without much difficulty.               383
  327                                                                     Special attention is needed during this part of       384
  328            In the final phase of this discussion, the patient                    PROOF                                    385
               is offered an opportunity to estimate the extent        the session for the minority of patients with clear-
  329          to which disturbing dreams can be attributed to         cut imagery deficiencies. They may report either         386
  330          trauma (0%–100%) or to habit (0%–100%) with             outright difficulty as a black or blank screen, or       387
  331          the sum of the 2 estimates equaling 100%.               unpleasant images that force them to open their          388
  332          Although this exercise can be performed earlier         eyes and terminate the imagery session. All indi-        389
  333          and later in the treatment, it is useful at this point  viduals are provided with behavioral tips on how         390
  334          because the patients have begun to experience           to overcome unpleasant imagery (see list of              391
  335          someflux in their perceptions about why they still      common treatment obstacles in Box 2), but we             392
  336          have nightmares.                                        focus on acknowledging the unpleasant image              393
  337            Many telltale indicators of treatment interest or     and choosing to move on to a new, preferably             394
  338          resistance arise from these estimates. Rarely,          more pleasant or neutral image. This process is          395
  339          a few individuals who believe strongly that the         stated in the context of the thoughts, feelings,         396
  340          nightmares are deeply entrenched in their trauma        imagesparadigm,inwhichthepatientappreciates              397
  341          process    will  deny    any   habit   component.       the natural flux in this system. That is, the mind-      398
  342          Conversely, others who have completed success-          body is continuously        presented    with   new      399
  343          ful psychotherapy for their traumatic exposure or       thoughts, feelings and images, and when we               400
  344          other mental health problems might declare their        become aware of certain ones, we may choose              401
  345          bad dreams must be 100% habit. The former               to let go as we observe new ones emerging.               402
  346          group tends to be reluctant to attempt IRT and             All patients are directed to practice pleasant        403
  347          should probably be discouraged from doing so            imagery every day for a few minutes. The first           404
  348          until some shift in their views occurs in the remain-   step in this exercise is to encourage patients to        405
  349          ing sessions. The latter group is not only ready to     recognizethatimageryisafrequentlyexperienced             406
  350          try IRT but these individuals may report decreases      pathwaythatnormalsleepersoftenreportatsleep              407
  351                                                                  onset.32,33 Conversely, nightmare sufferers may          408
  352          in their nightmares following this session before       want to improve their imagery skills but without         409
  353          havinglearnedthefullIRTtechnique.Mostindivid-           over stimulating themselves for fear of triggering       410
  354          uals lie between these extremes (80–20, 50–50, or       more disturbing images. Although few patients            411
  355          20–80 splits are all common), but what is most          report changes in their nightmares after using           412
               interesting and informative is that nearly all of
  356                                     UNCORRECTED                                                                           413
               themreportsomeshiftintheir perceptions toward           pleasant imagery during the ensuing week, their
  357          habit recognition compared with what they would         prospects remain high for future use of IRT              414
  358          have estimated beforehand.                              because they experienced some perceived bene-            415
  359                                                                  fits from simple imagery exercises.                      416
  360          Imagery Skills                                                                                                   417
  361                                                                  Imagery Practice                                         418
  362          The discussion now focuses on imagery, which is                                                                  419
  363          a well-described behavioral therapy component           To practice pleasant imagery, we use 3 possible          420
  364          in the treatment of many other types of medical         versions of standard instructions based on times         421
  365          and psychological conditions.31 The relevant and        of 1, 5, or 15 minutes and guided or unguided            422
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