Novel therapy for chronic nightmares decreases stress disorder symptoms

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Last Updated: 2001-07-31 16:01:05 EDT (Reuters Health)

By Karla Gale

WESTPORT, CT (Reuters Health) – Imagery rehearsal therapy for chronic nightmares in female sexual assault survivors with post traumatic stress disorder (PTSD) can not only decrease the nightmares, it can improve overall sleep quality and decrease the severity of PTSD symptoms, according to a report in the August 1st issue of The Journal of the American Medical Association.

In a prospective trial, Dr. Barry Krakow, of the University of New Mexico in Albuquerque, and colleagues randomly assigned 88 subjects to imagery rehearsal therapy and 80 to a wait-list control group. Most patients were concurrently receiving psychotherapy or psychotropic medication or both. A total of 114 patients were available for follow-up.

The therapy is based on a framework of an imagery and cognitive restructuring paradigm, according to the researchers' report. Patients are taught pleasant imagery techniques and cognitive-behavioral tools for dealing with unpleasant images that arise. They learn to mentally process nightmares by transforming them to more acceptable imagery. More information about the technique is available at the Web site

"By treating nightmares, what we are really doing is opening a doorway for the person where they are able to re-evaluate the way they deal with the trauma problem, even though they may not talk directly about it," Dr. Krakow told Reuters Health.

After 3 months, scores on the Nightmare Frequency Questionnaire, Pittsburgh Sleep Quality Index, Clinician-Administered PTSD Scale, and PTSD Symptom Scale were all significantly decreased (p < 0.001) among treated subjects compared with control subjects. Symptom subscales for intrusion, avoidance, and arousal related to PTSD decreased as well. Therapeutic effects were maintained at 6 months.

This treatment will not succeed for everyone, Dr. Krakow pointed out. He does not recommend it for patients with schizophrenia or dissociative disorders. "Dropout rates among patients with severe PTSD tend to be high," he added. "When people cannot divorce the nightmares from trauma, those people have much more difficulty with this technique" and require more intensive therapy.

Dr. Krakow noted that the imagery rehearsal therapy has been used effectively in patients with PTSD induced by trauma other than sexual assault. "I've treated nightmares since 1991 in Vietnam veterans, Holocaust survivors, certainly people who have been sexually tortured," he said.

He believes that the technique could also be of use in post-conflict settings and among refugees–populations with PTSD described in the same issue of JAMA.

A high level of chronic baseline psychiatric disorder and disability among Bosnian refugees is reported by Dr. Richard F. Mollica, of the Harvard Program in Refugee Trauma, in Cambridge, Massachusetts, and colleagues.

Dr. Mollica's group interviewed 376 refugees in a Croatian camp in 1996 and again in 1999. At the second interview, 45% of those initially diagnosed with depression, PTSD or both continued to exhibit symptoms. Another 16% of subjects who had been asymptomatic at baseline developed symptoms by 1999.

In a third study, Dr. Ivan H. Komproe, of the Transcultural Psychosocial
Organisation WHO Collaborating Centre in Amsterdam, the Netherlands, and associates measured prevalence rates of PTSD in Algeria, Cambodia, Ethiopia and Gaza.

Between 1997 and 1999, PTSD prevalence rates were 37.4% in Algeria, 28.4% in Cambodia, 15.8% in Ethiopia, and 17.8% in Gaza. The only risk factor present in all four samples was conflict-related trauma after the age of 12 years old.

Commenting on these reports, Dr. Jonathan R. T. Davidson, of Duke University Medical Center in Durham, North Carolina, notes, "It is clear that the importance of PTSD as a worldwide health problem must be recognized and that it is important for clinicians to be alert to the presence and presentation of PTSD in medical and psychiatric settings."

JAMA 2001;286:537-562,584-587.

-Westport Newsroom 203 319 2700

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