**4.2. Recommendations to clinicians**

at home as a way to compensate for a lack of social network. It was agreed that he would not use marijuana before or after exposition exercises. At the end of the treatment, the clinician

In addition, during the first 3 weeks of IRT, Eric showed difficulties in managing his anxiety because of a colonoscopy he needed, which reminded him of some aspects of the traumatic event. This situation led him to report more nightmares the week before the intervention (after session 1 of the IRT), and more flashbacks after his colonoscopy (before session 3 of the IRT).

Adam was assessed at 3 and 6 months post-treatment. At the first follow-up (3 months), on the CAPS, he reported a decrease in his PTSD symptoms (from 89.00 to 80.00), more particularly for the avoidance and numbing symptoms. On the PSQI, his overall sleep remained unchanged, while the score on the PSQI-A increased from 10 to 12. However, he mentioned he was less apprehensive to go to sleep and he continued to apply IRT, which helped him to calm down. One first explanation is the PSQI is a subjective self-report measure of sleep over the previous month. Also, the use of one single score for the PSQI could have limited the

At 6 months follow-up, on the CAPS, we noticed his PTSD symptoms slightly increased (from 80 to 87) to return to the level of the pre-treatment assessment, more particularly for the avoidance and numbing symptoms. He reported having one or two dreams a week but now he could go back to sleep quite easily after them. He also observed it was difficult to separate his nightmares from his pain. On the PSQI and the PSQI-A, the total scores respectively increased from 15 to 17 and to 12 to 16. During the interview he expressed several stressful factors in his life that could have maintained or contributed to the increase in PTSD symptoms and decline in his sleep quantity and quality. These included a dependency to prescribed drugs, family

At 4 months follow-up, Eric's PTSD symptoms had increased slightly (from 60 to 67), except for the intrusive recollection symptoms, which dropped from 12 to 7. He was no longer experiencing nightmares. Avoidance and PTSD symptoms that are common to depression were the most significant symptoms. He still met the diagnostic criteria for PTSD and MDD, and still experienced marijuana dependence. It was not possible to evaluate the other variables as

The present study was exploratory and reported the possibility of combining CBT for PTSD with a specific treatment for nightmares (IRT) for adults diagnosed with PTSD. Observations from both participants demonstrated interesting results with: a) a decreasing trend in the level

observed that Eric had reduced his consumption.

90 Cognitive Behavioral Therapy and Clinical Applications

interpretation of any improvement in different sleep facets [37].

**3.5. Follow-up**

problems and pain.

**4. Discussion**

he did not send us back the questionnaires.

**4.1. Treatment implications of the cases**

Both participants experienced a slight decrease in their sleep difficulties and in the intensity of their PTSD symptoms, as well a decrease in the level of distress from the nightmares (slight for Adam, more pronounced for Eric). In addition, Eric demonstrated a decrease in the frequency of his nightmares, which was contrary to Adam's experience. From the findings of this study, we noted that a specific treatment for nightmares, more particularly IRT, combined with CBT for PTSD is possible, and could also be a way of improving a CBT for PTSD.

From the case study of Adam, having only three IRT sessions at the beginning of treatment seemed too short for him, and more IRT sessions could have been beneficial. Also, sleep hygiene was briefly approached and could have been emphasized more. As mentioned and tested in a recent case study [38], CBT for insomnia (CBT-I) is a safe and effective treatment in patients with comorbid insomnia and PTSD. In the case of Adam, who set his alarm to avoid his nightmares, it would have been interesting to concentrate on a more extended treatment of his sleep disturbances by combining CBT-I and IRT.

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In addition, it is interesting to note that Adam's nightmare distress decreased while his nightmare frequency remained the same. This result underlines those of previous studies mentioning that nightmare frequency was not related to the level of distress [42]. As a consequence, nightmare frequency and nightmare distress concepts should be clearly differentiated and clearly explained to clients. For example, the clinician should specify that the client's nightmares may persist at the end of the treatment, but the nightmares will not be as distressing as before. Future studies should continue to monitor both measures in order to better understand the IRT impact.

Both participants expressed difficulties in understanding the rationale of IRT. This nightmare treatment is easy to implement but its rationale and therapeutic components may be an obstacle to delivery by the psychologist and its understanding by the participant. The CBT rationale for PTSD is that nightmares are a reliving of the traumatic event, and gradual exposure to the memory or the stimuli related to the traumatic event should gradually reduce these intrusions by habituation and reducing avoidance. Therefore, when introducing the IRT rationale and by changing the scenario of the nightmare, it may look like avoiding nightmares rather than confronting them. This emphasizes the importance of reinforcing the idea of not avoiding but taking control of the nightmares by changing something that is not real. This also underlines the importance of changing nightmares that do not replicate the traumatic event as we do not attempt to change the story of something that actually happened.

Finally, as the results of a recent study suggested [41], the degree of distress related to the nightmare content was positively linked to the degree of similarity between the nightmare and the trauma. In the current study, we indicated that the selected nightmares were not a replica of the event. It is, therefore, important to keep specifying this nightmare inclusion criterion for future studies to guarantee exactly what they are evaluating. It would also help to understand what the therapeutic component is for IRT (e.g., exposition, mastering, etc.). Otherwise, in the case of different nightmare content, other specific nightmare treatments could be considered, such as ERRT, LDT, sleep dynamic therapy, or self-exposure therapy. It could even be interesting to explore which treatment is more appropriate according to, for example, the degree of avoidance by the victim, the category of his or her traumatic event, and the content of the nightmares.
