**3. Results**

#### **3.1. Course of treatment and assessment of progress**

The impact of the treatment was measured by daily self-monitoring, clinical evaluations, and questionnaires. Concerning the data collected through self-monitoring, we displayed graphically only the weekly average level of distress related to their nightmares. As we expected the levels to fluctuate according to the number of interventions, we chose to apply a third-order polynomial regression to better fit our data. The results are presented on an individual basis.

#### **3.2. Participant 1: Adam**

It was decided in advance that the psychologist would meet with the participant every 2 weeks, to offer support until stability was reached on the following daily self-monitoring variables: the frequency of the nightmares, the level of distress related to the nightmares, and the level of sleep quality. These measures were considered indicative of the participant's progression during the course of treatment. Therapy did not begin until stability for these three measures was reached.

IRT

Eric

**Figure 1.** Weekly average levels of distress related to nightmares reported by participants from self-monitoring booklet at baseline and during treatment. The horizontal axis indicates session number and vertical axis indicates weekly

average levels of distress related to nightmares over the course of the following week.

Adam

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CBT

Baseline

IRT

Baseline

The weekly average levels of the distress related to his nightmares by week, at baseline, and during the treatment are reported in **Figure 1**. Overall, we can observe some variability in the level of distress throughout treatment; however, the trend suggests a decrease in the level of distress, especially at the end of treatment. Indeed, at baseline, the distress varied from 5.71 to 7.14; after the IRT sessions (session 3), the distress decreased on average to 7.26; after imaginal exposure (session 9), it decreased on average to 6.25. At the end of the treatment, it reached 4.29. Therefore, the combined treatment appeared to have been effective in reducing the distress associated with the traumatic nightmares.

The situation appears to be different for the frequency of the nightmares. At baseline, Adam reported having from 3 to 5 nightmares a week. During IRT sessions, their numbers varied from 4 to 6 nightmares a week; during imaginal exposure, from 4 to 10; and finally, at the end of the whole treatment, he recorded 4 nightmares a week.

For sleep quality as recorded with the daily self-observations, at baseline, Adam's perception of his sleep quality ranged from an average of 0.71 to 1.47. During IRT sessions, the quality did not improve (from 0.43 to 1.71). During imaginal exposure, it improved slightly and varied from 1.14 to 2.14. At completion of the CBT, his sleep quality had reached 2.86.

the participant rehearsed the new dream with the psychologist. Finally, he was encouraged to rehearse the new dream at least twice a day in the time before the next session. Once this strategy was acquired, the participant was directed to continue his practice for the rest of the treatment. For Adam, the whole treatment lasted 20 sessions (three individual IRT sessions at the beginning, and 17 individual CBT sessions for PTSD). For Eric, the whole treatment lasted 29 ses-

The impact of the treatment was measured by daily self-monitoring, clinical evaluations, and questionnaires. Concerning the data collected through self-monitoring, we displayed graphically only the weekly average level of distress related to their nightmares. As we expected the levels to fluctuate according to the number of interventions, we chose to apply a third-order polynomial regression to better fit our data. The results are presented on an individual basis.

It was decided in advance that the psychologist would meet with the participant every 2 weeks, to offer support until stability was reached on the following daily self-monitoring variables: the frequency of the nightmares, the level of distress related to the nightmares, and the level of sleep quality. These measures were considered indicative of the participant's progression during the course of treatment. Therapy did not begin until stability for these three

The weekly average levels of the distress related to his nightmares by week, at baseline, and during the treatment are reported in **Figure 1**. Overall, we can observe some variability in the level of distress throughout treatment; however, the trend suggests a decrease in the level of distress, especially at the end of treatment. Indeed, at baseline, the distress varied from 5.71 to 7.14; after the IRT sessions (session 3), the distress decreased on average to 7.26; after imaginal exposure (session 9), it decreased on average to 6.25. At the end of the treatment, it reached 4.29. Therefore, the combined treatment appeared to have been effective in reducing the dis-

The situation appears to be different for the frequency of the nightmares. At baseline, Adam reported having from 3 to 5 nightmares a week. During IRT sessions, their numbers varied from 4 to 6 nightmares a week; during imaginal exposure, from 4 to 10; and finally, at the end

For sleep quality as recorded with the daily self-observations, at baseline, Adam's perception of his sleep quality ranged from an average of 0.71 to 1.47. During IRT sessions, the quality did not improve (from 0.43 to 1.71). During imaginal exposure, it improved slightly and var-

ied from 1.14 to 2.14. At completion of the CBT, his sleep quality had reached 2.86.

sions (24 individual and CBT sessions, and 5 IRT sessions at the end).

**3.1. Course of treatment and assessment of progress**

86 Cognitive Behavioral Therapy and Clinical Applications

tress associated with the traumatic nightmares.

of the whole treatment, he recorded 4 nightmares a week.

**3. Results**

**3.2. Participant 1: Adam**

measures was reached.

**Figure 1.** Weekly average levels of distress related to nightmares reported by participants from self-monitoring booklet at baseline and during treatment. The horizontal axis indicates session number and vertical axis indicates weekly average levels of distress related to nightmares over the course of the following week.

Total scores for administered questionnaires show a mitigating impact on PTSD symptoms of the combined treatment. From pre- to post-treatment, the overall score of the PCL-S decreased from 81.00 to 70.00. The total scores of CAPS remained unchanged. However, the intrusive recollection symptoms subscale score, including distressing dreams, decreased from baseline to the end of the combined treatment. Also, the hyperarousal symptoms subscale score, which encompassed sleep difficulties, decreased after IRT sessions and remained at the same level through the treatment.

**3.4. Complicating factors**

*3.4.1. Participant 1: Adam*

situations occurred.

to be addressed.

his waking or if it was because of the pain.

somewhat about the details of his sexual assault.

*3.4.2. Participant 2: Eric*

During the course of treatment, Adam encountered interpersonal problems with his family circle and mentioned their lack of support. He particularly indicated their misunderstanding of his PTSD reactions, reported conflicts with his wife, and expressed his feeling of stigmatization. Social support is reported as being a strong predictor for the development and maintenance of PTSD [34]. Even if Adam demonstrated motivation, these difficulties often had to be addressed during the PTSD treatment, as he felt a lot of anger or isolation when these

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It is important to mention that Adam was on sick leave during the treatment and he did not know what to expect regarding the future of his work. A job loss or the threat of losing a job can trigger mixed and confusing feelings, such as anger [35]; on the other hand, a supportive workplace can help in reducing PTSD symptoms by offering, for example, social support. During therapy, Adam began to deal with the possibility of losing his job and this, too, had

A certain cognitive rigidity and significant difficulty concentrating were also observed. To deal with these difficulties, Adam would drink energy drinks before the sessions to be sure to follow everything. Since each session was recorded, Adam sometimes asked to listen to the sessions again, so he could be sure he understood every part of the therapist's intervention. The therapist observed it was difficult for the participant not to be in control of the treatment. Finally, Adam experienced a lot of pain, more particularly with his back, following the accident, and he received a diagnosis of fibromyalgia during the treatment. Fibromyalgia syndrome is a chronic condition characterized by widespread musculoskeletal pain and multiple tender points on clinical examination. We know from the literature that patients with fibromyalgia are found to be significantly more likely to experience difficulties initiating or maintaining sleep than controls [36]. This variable may have contributed to the quality and quantity of his sleep, as the discomfort awoke him during the night. In addition, it was sometimes difficult for him to report in his self-monitoring booklet if his nightmares were the reason for

Ten years had passed since Eric's traumatic event and it was the first time he had talked to someone about it. This brought a high level of anxiety and complicated imaginal exposure. Even though four additional CBT sessions were offered, it was not possible to complete the imaginal exposure of the whole event. However, by the end of treatment, Eric was able to talk

Also Eric had to deal with his marijuana dependence. During sessions, this aspect was approached as it appeared this behavior was a way to manage his emotions and more particularly his anxiety. Eric was never under the influence of marijuana during sessions but used it

Looking at sleep questionnaires, some improvements were noted, although significant residual symptoms persisted at the end of the combined treatment. The NDQ received a score of 45.00 (versus 49.00 at baseline), the PSQI demonstrated a score of 15.00 (18.00 at baseline) and the PSQI-A deceased to 10.00 (with a score of 17.00 at the beginning of the treatment).

From a clinical point of view, Adam showed few improvements on the intensity of his PTSD symptoms and still met criteria for PTSD diagnosis at the end of the combined treatment. However, he reported at the end of the therapy feeling less angry and distressed. He reported having gained control over his nightmares and was less afraid to go to sleep. The clinician noticed that, physically, he seemed more rested and to have more energy.
