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Revised imagery protocol may help some vets.

CHICAGO -- Imagery rehearsal for posttraumatic nightmares was not notably effective in a randomized controlled trial in Vietnam veterans, but after tweaking the protocol, it proved more successful in a pilot study in Operation Iraqi Freedom veterans.

"We believe very firmly that imagery rehearsal can be efficacious in treating posttraumatic nightmares for some veterans, even though the data from this study do not support its use as a standalone group treatment in Vietnam veterans with severe chronic PTSD," Joan Cook, Ph.D., of the department of psychiatry at Yale University in New Haven, Conn., said at the annual meeting of the International Society for Traumatic Stress Studies.

In imagery rehearsal, patients are asked to identify a repetitive nightmare related to a traumatic event, and to create an alternative ending or to insert reminders into the dream that prompt different ways of viewing it.

For example, the bright lights of an explosion are transformed into a star-filled sky; weapons become harmless water pistols or paint-ball guns; or a tunnel filled with rats and snakes becomes a tunnel in Central Park that empties out into a beautiful landscape with children playing.

The patients mentally rehearse the revised dream script and practice progressive muscle relaxation.

Dr. Cook reported on 124 Vietnam War veterans who were randomized to six weekly 1.5-hour group sessions of imagery rehearsal or sleep and nightmare management.

All of the patients also received psychoeducation about PTSD and nightmares, as well as relaxation training.

The study included veterans with co-morbid anxiety and depressive disorders who had been on a stable psychotropic medication regimen for a minimum of 3 months, but it excluded those with schizophrenia, bipolar disorder, and active substance abuse.

The imagery rehearsal and sleep/ nightmare management groups were similar in age (60 and 59 years, respectively) and in mean Combat Exposure Scale scores (26.4 and 27.2).

At 6 months post treatment, there were no significant differences between the imagery rehearsal and the sleep/ nightmare management groups in the number of nightmares a week (4.0 and 3.9, respectively), mean Pittsburgh Sleep Quality Index scores (11.94 and 12.08), mean Clinician-Administered PTSD Scale scores (81.3 and. 79.5), or mean Beck Depression Inventory scores (26.9 and. 23.5), Dr. Cook reported.

However, clinicians who were blinded to treatment assignment observed a significant change in nightmare intensity that favored the imagery rehearsal group.

Nevertheless, the clinicians found that significantly more veterans in the imagery rehearsal group dropped out of the study, compared with those who had been placed in the sleep/nightmare management group.

"You may think that imagery rehearsal is not effective, but that's not true," said Dr. Cook.

"It may be that patients did not receive enough treatment, or that male Vietnam veterans who use [Veterans Affairs] services have significant psychiatric comorbidities that make it difficult for them to focus on just their nightmares."

These patients also have deep-rooted sleep habits that need to be addressed, and they expressed difficulty in sharing details in a group setting, particularly if they had perpetrated violence, she added.

These lessons were taken into account in a pilot study of 11 veterans of Operation Iraqi Freedom (OIF) who underwent seven to eight individual rather than group imagery rehearsal treatment sessions and also received cognitive-behavioral therapy (CBT) for insomnia. Seven of the patients completed treatment.

Assessment at 1 month post treatment indicated improvement in both nightmare frequency and global sleep quality, with a small decrease in overall PTSD symptomatology, Gerlinde Harb, Ph.D., reported at the same meeting, which was cosponsored by Boston University.

Sleep onset latency decreased from 28 minutes to 18 minutes, and total sleep time improved by about 37 minutes.

In terms of response, the seven patients who completed the treatment fell into two distinct groups, said Dr. Harb of the Philadelphia VA Medical Center. The three nonresponders tended to have more frequent nightmares, compared with the responders, and two of them were perpetrators of violence.

One had a target dream focused on guilt, one had suffered traumatic brain injury, and one had significant regular alcohol use.

Of the four patients who dropped out, two were also perpetrators of violence.

Dr. Harb acknowledged that the number of patients was very small, but he said that the combination of imagery rehearsal and CBT for insomnia seems to be "feasible and promising" for OIF returnees.

"We hope that addressing nightmares early on, not 40 years later, will halt that spiral," she said.

Enrollment began recently for a new randomized controlled trial in 160 OIF and Operation Enduring Freedom veterans from the war in Afghanistan who had sleep disturbance and deployment-related nightmares.

The trial will compare six sessions of imagery rehearsal in addition to cognitive behavioral therapy for insomnia versus CBT for insomnia alone.

The study, to be conducted at the Philadelphia VA Medical Center and VA Connecticut Healthcare System, will also investigate salivary alpha-amylase as a possible biomarker of the PTSD-related sleep disturbance, and whether neurocognitive impairment is a moderator of treatment response, Dr. Harb said.

The investigators reported no conflicts of interest.
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Author:Wendling, Patrice
Publication:Clinical Psychiatry News
Date:Apr 1, 2009
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