The Impact of Imagery Rehearsal Therapy on Dream
                    Enactment in a Patient With REM-Sleep Behavior
                    Disorder: A Case Study
                                                    1                           2                  2
                    Christina Pierpaoli-Parker , Courtney J. Bolstad , Erica Szkody ,
                                        3, 4                        2, 5                            4, 6
                    AmyW.Amara ,Michael R. Nadorff                      , and S. Justin Thomas
                    1 DepartmentofPsychology,UniversityofAlabama
                    2 DepartmentofPsychology,MississippiStateUniversity
                    3 DepartmentofNeurology,UniversityofAlabamaatBirmingham
                    4 Sleep/WakeDisordersCenter,UniversityofAlabamaatBirmingham
      .             5 DepartmentofPsychiatryandBehavioralSciences,BaylorCollegeofMedicine
      dly           6 DepartmentofPsychiatry,UniversityofAlabamaatBirmingham
   hers.broa
   publisated
   iedmin
   all
   itsdisse               Imagery rehearsal therapy (IRT) is an evidence-based treatment for nightmare
   of be            disorder (ND), and numerous studies have demonstrated its efficacy in reducing the
      to            frequency and severity of nightmares. ND and REM sleep behavior disorder (RBD)
   one
   or not           co-occur, yet the impact of successful treatment of nightmares on dream enactment in
      is
   on               RBDhasnotbeenstudied. In this case study, we present the treatment of ND using
      and           IRTandits impact on dream enactment in the context of RBD. A total of 5 sessions
   ociatiuser
   Ass              of IRT over 5 months resulted in a reduction in nightmares and, according to the
   icaldual         patient and her husband, a decrease in dream enactment. We hypothesize that reduc-
      ivi           ing the emotional valence of the dream content may make dream enactment less
   logind           likely. As a result, IRT may provide helpful adjuvant treatment to pharmacological
   sychothe         treatment of RBD.
   P  of
   n
   ricause          Keywords: imagery rehearsal therapy, REM-sleep behavior disorder, case study, older
      l             adults, nightmares
      na
   Ame
   theperso
   by the                 Nightmare disorder (ND) is classified in the Diagnostic and Statistical Manual
   ed for
   ghtly            of Mental Disorders, Fifth Edition, as clinically significant distress across multiple
   pyrisole         domainsoffunctioningcausedbyrepeated,well-remembered,disturbing,orterrify-
   o
   c                ing dreams (American Psychiatric Association, 2013; Gieselmann et al., 2019).
   s
   i  nded
   t                Nightmares occur during the REM phase of the sleep cycle and are not better
      inte
   umenis
   docle
      artic               S. Justin Thomas   https://orcid.org/0000-0002-8709-4083
   This                   S. Justin Thomas has funding from the American Heart Association (19CDA34660139). All other
      This          authorshavenoconflictsofinteresttodisclose.
                          Correspondence concerning this article should be addressed to S. Justin Thomas, Department of
                    Psychiatry, University of Alabama at Birmingham, SC1010, 1720 2nd Avenue South, Birmingham, AL
                    35294–0017,UnitedStates.Email:sjthoma@uabmc.edu
                                                                   195
                                                                                                        Dreaming
                    ©2021 American Psychological Association                                      2021, Vol. 31, No. 3, 195–206
                    ISSN: 1053-0797                                                           https://doi.org/10.1037/drm0000174
            196                                  PIERPAOLI-PARKERETAL.
            explained by the use of a substance or medication (American Academy of Sleep
            Medicine [AASM], 2014; Owens & Mohan, 2016). When treating ND, imagery re-
            hearsal therapy (IRT) is the gold standard, evidence-based treatment, as recom-
            mendedbytheOxfordCenterforEvidence-BasedMedicine(Cranstonetal.,2011)
            and the American Academy of Sleep Medicine (Aurora et al., 2010; Morgenthaler
            et al., 2018). IRT describes a behavioral technique wherein the patient rescripts
            their nightmare however they wish and then rehearses the new script 10–20 min a
            daywhileawake(Auroraetal.,2010;Ellisetal.,2019;Gieselmannetal.,2019).IRT
            inhibits the nightmare byreplacingitwithanew,nonthreateningdreamandreduces
            theneedtoescape(Gieselmannetal.,2019;Nadorffetal.,2014).
               REMsleepbehavior disorder (RBD) is often comorbid with ND. RBD is classi-
    .       fiedasrepeatedvocalization and/or complex motor movements during the REM stage
    dly     of sleep (American Psychiatric Association, 2013). Although often comorbid with ND,
  hers.broa frontline treatment for RBD typically involves combined environmental modifications
            (e.g., placing barriers on the side of the bed and removing dangerous objects, such as
  publisatedweapons, from the sleep environment) and pharmacotherapy (clonazepam; Howell &
  iedmin    Schenck, 2015; Jung & St Louis, 2016)versusbehavioraltreatmentssuchasIRTfor
  all       ND(Auroraetal., 2010; Gieselmann et al., 2019; Nadorff et al., 2014). RBD and ND
  itsdisse  share various comorbidities, including neurodegenerative disorders (Howell &
  ofbe
    to      Schenck, 2015), other sleep disorders (Aurora et al., 2010), medication use (Aurora et
  one       al., 2010; Nadorffetal.,2014;Neikrug & Ancoli-Israel, 2010;Wolkoveetal.,2007), psy-
  ornot
    is      chiatric conditions (Aurora et al., 2010; Gieselmann et al., 2019; Nadorffetal.,2014),
  on
    and     andolderage(Neikrug&Ancoli-Israel,2010;Wolkoveetal.,2007).
  ociatiuser   AlthoughresearchonNDandRBDisscarce,existingresearchsuggestsstrong
  Ass       associations between RBD and ND. For example, a recent Romanian study of 43
  icaldual  individuals with early Parkinson’s disease (PD) or parkinsonian syndrome found
    ivi
  logind    that 81.39% of the sample endorsed depressive symptoms, 46.51% reported night-
  sychothe  mares, and 25.58% reported symptoms of RBD (Tohanean et al., 2018). Another
  P of      study of 661 individuals with PD found that 20.9% of the sample endorsed depres-
  n         sive symptoms, 39.0% endorsed RBD, and 86.4% of individuals with both PD and
  ricause
    l       RBDendorsedotherparasomniasincludingnightmares(Ylikoskietal.,2014).
    na
  Ame          Given the similarities between RBD and ND, there is reason to believe that
  theperso  modifying bad dreams and nightmares may help improve RBD symptoms. Indeed,
  bythe     there is a literature demonstrating an association between negative dream intensity
  edfor     and dream enactment behaviors (Baltzan et al., 2020). Fantini et al. (2005) com-
  ghtly     pared the dream and daytime aggressiveness of individuals with and without RBD,
  pyrisole   nding that although there were no differences in daytime aggressiveness, RBD
  o         fi
  c
  s         patients reported a significantly higher percentage of having at least one dream with
  i nded
  t         aggression (66%) than the control group (15%). This difference is also present in
    inte
  umenis    relation to PD, with those with RBD having significantly more negative dreams
  docle     thanthosewithPD.Inaddition,therewasanearlysignificanttrendtowardalsohav-
    artic   ingmoreintenseactionintheirdreamswhencomparedwiththosewithPD(Valliet
  This      al., 2015). This is important as dream content has been shown to be associated with
    This
            motorbehaviorsinRBD(Vallietal.,2012).
               When treating ND, behavioral treatments such as IRT have been shown to suc-
            cessfully reduce nightmare frequency, posttraumatic stress disorder severity, and other
            mental health problems including depressive symptoms, and increase sleep quality
            (Ellis et al., 2019; Gieselmann et al., 2019). Individuals with ND and comorbid RBD
                     IMAGERYREHEARSALTHERAPYANDDREAMENACTMENT                                                         197
                     vocalize orphysically act out their nightmares, but behavioral treatments are often side-
                     lined in favor of pharmacotherapy combined with environmental modifications to pre-
                     vent injury (Howell & Schenck, 2015; Jung & St Louis, 2016). However, it is possible
                     that IRT may help reduce the dream intensity and aggressive content, which has been
                     shown to be associated with REM behavior. Therefore, we hypothesize that IRT may
                     continue inhibiting nightmares, improving quality of sleep and the likelihood of RBD
                     eventsbychangingtheemotionalvalenceofdreamcontent.
                                                            Case Introduction
                          The patient presented as a 77-year-old non-Hispanic White female with a sig-
      .              nificant prior medical history and concomitant polypharmacy (see Table 1). At
      dly            intake, her primary sleep concerns included nightmares with dream enactment and
    hers.broa        attendantinsomnia.PreviouslydocumenteddiagnosesincludedND,RBD,obstruc-
                     tive sleep apnea partially controlled with intermittent continuous positive airway
    publisated       pressure use, restless leg syndrome, and psychophysiological insomnia with comor-
    iedmin           bidmajordepressivedisorder(MDD).
    all                   In addition to nightmares and dream enactment, the patient reported experi-
    itsdisse
    ofbe             encing unusual perceptual experiences and had a psychiatric history positive for
      to             MDD,generalized anxiety disorder, panic disorder, several psychiatric hospitaliza-
    one
    ornot            tions, as well as suicidal ideation. She also reported a history of childhood sexual
      is
    on               trauma and met criteria for clinically significant posttraumatic stress disorder
      and            related to these traumas. At intake, the patient endorsed significant marital distress,
    ociatiuser       moodsymptoms,andpassivesuicidalideation.Reviewofsystemsrevealedasignifi-
    Ass              cant prior medical history positive for polymorbidity in addition to extensive use of
    icaldual
      ivi            medications(seeTable1).
    logind
    sychothe         Table 1
    P of             List of Patient’s Medical Conditions and Medications
    n
    ricause              Medication                               Dosing                             Use/Treatment of
      l
      na
    Ame              Amlodipine                          5 mg daily                              Hypertension
    theperso         Atorvastatin                        80 mg nightly                           Cholesterol
    bythe            Clopidogrel                         75 mg daily                             Cardiovascular disease
                     Ergocalciferol                      50,000 units once weekly                Vitamin D deficiency
    edfor            Glimepiride                         4 mg BIDwithmeals                       Diabetes mellitus type II
    ghtly            Hydrochlorothiazide                 25 mg daily                             Hypertension
    pyrisole         Levothyroxine                       75 mcg                                  Hypothyroidism
    o                Losartan                            100 mg daily                            Hypertension
    c                Memantine                           5 mg BID                                Parkinson’s disease
    s
    i nded
    t                Metroprolol                         50 mg BID                               Bloodpressure
      inte           Pantoprazole                        40 mg nightly                           GERD
    umenis           Potassium chloride                  20 mEqdaily                             Hypokalemia
    docle            Quetiapine                          50 mg BID                               Mood
      artic          Ropinirole                          0.5 mg nightly                          Restless leg syndrome
    This             Sertraline                          100 mg daily                            Mood
      This           Risperidone                         1 mg every 12 hr PRN                    Mood
                     Tramadol                            50 mg BIDPRN                            Chronic pain
                     Clonazepam                          0.5 mg PRN                              Anxiety and RBD
                     Temazepam                           50 mg BIDPRN                            Insomnia
                     Nitroglycerin                       0.4 mg PRN                              Angina
                     Note.  BID=twiceaday;GERD=gastroesophagealrefluxdisease;PRN=asoccasionrequires;RBD=
                     REMsleepbehaviordisorder.
                    198                                                            PIERPAOLI-PARKERETAL.
                          The patient reported first experiencing nightmares with dream enactment
                    approximately20yearspriortopresentingtotheclinic.Whenthepatientpresented
                    to the clinic, she reported experiencing these symptoms approximately 4 to 5 times
                    per week. A collateral interview with the patient’s husband corroborated the
                    patient’s self-report, emphasizing that enactments almost invariably co-occurred
                    with her nightmares. The patient’s dream enactment presented a danger to both
                    herself and her bedpartner, as she flailed her arms, punched, and fell out of bed at
                    times,causingmusculoskeletaltrauma.
                                              Case and Treatment Conceptualization
      .                   Figure 1 outlines our patient’s case conceptualization, including the biopsycho-
      dly           social componentsofherpresentationandtheirfunctionalconnections.
   hers.broa              The patient’s treatment team, comprising a movement disorders neurologist
   publisated       boardcertifiedinsleepmedicine,aclinicalpsychologistboardcertifiedinbehavioral
   iedmin           sleep medicine (BSM), and a clinical psychology doctoral student, conceptualized
   all              her case as one requiring integrated sleep, depression, health management, and
   itsdisse         harm-preventiontreatmentusingageriatricbehavioralmedicineapproach(Ameri-
   of be            can Psychological Association, 2014). Because treatment focused on managing
      to
   one              insomniaandnightmares,interventioninvolvedaneclecticcombinationofIRTand
   or not
      is            cognitive behavioral therapy (CBT) for late-life insomnia, modified slightly to
   on
      and           address the patient’s contributory depressive symptoms. The team coupled features
   ociatiuser       of these evidence-based treatments with ongoing psychoeducation and safety
   Ass
   icaldual         Figure 1
      ivi
   logind           Depicts the Case Conceptualization of the Patient
   sychothe
   P  of
   n
   ricause
      l
      na
   Ame
   theperso
   by the
   ed for
   ghtly
   pyrisole
   o
   c
   s
   i  nded
   t
      inte
   umenis
   docle
      artic
   This
      This          Note.  HTN=hypertension; DM = diabetes mellitus type II; CHF = congestive heart failure; RLS = rest-
                    less leg syndrome; OSA = obstructive sleep apnea. The far left boxes contain the patient’s predisposing fac-
                    tors. The middle left boxes provide a biopsychosocial conceptualization of the patient’ssymptomsinthese
                    domains. These symptoms then are assumed to have a bidirectional relation with the disorders in the mid-
                    dle right boxes. Perpetuating factors are depicted on the far right. The long arrows at the bottom of the fig-
                    ure depict additional factors that cut across multiple steps of the case conceptualization.