*2.4.4. Ancillary measures*

*The Beck Depression Inventory* [*BDI*; [28]] measures the presence and severity of depression with 21 items in the last 2 weeks. Finally, *The Beck Anxiety Inventory* [*BAI*] includes 21 self-report items evaluating the anxiety severity. Good psychometric properties were demonstrated [29].

imaginal exposure; in vivo exposure; and relapse prevention (one session). However, the number of sessions was not fixed and we left open the option to add four sessions depending on client needs (e.g., level of avoidance). A treatment manual for the psychologist and a participant manual were available. This treatment was validated in previous studies [32, 33].

Imagery Rehearsal Therapy (IRT) Combined with Cognitive Behavioral Therapy (CBT)

http://dx.doi.org/10.5772/intechopen.70899

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As presented in the introduction of this article, IRT is one of the most promising nightmare treatments [15] and was offered to both participants. IRT sessions were individual meetings of 90 minutes. The course of therapy was derived from strategies outlined in Krakow and Zadra [14], and was initially tested by offering it to another participant in order to adjust it. The content of sessions 1 and 2 were identical for both participants. However, session 1 was split into two sessions for Eric. Also, Eric had two additional sessions in order to give him extra practice. Despite differences in the number of sessions for the two participants, both treatments (IRT and CBT for PTSD) encompassed the same rationale. The sessions were delivered by an experienced psychologist, specialized in CBT and in the treatment of PTSD. She was

Session 1 IRT focus (for Eric, sessions 1 and 2): Psycho-education on sleep related to PTSD, and an introduction on IRT rationale. The functions of nightmares and the beginning of a vicious cycle were introduced to the participant. The psychologist emphasized that nightmares initially present as a PTSD symptom, which, theoretically, help to regulate emotions and the traumatic memory of the event. However, they cause distress because of the different emotions they generate (e.g., anger, guilt, etc.); the nightmares then create sleep difficulties as they awaken the sleeper. At that point, the nightmares prevent the person from functioning well during the day and no longer fulfill their initial function. As the nightmares become a learned habit, it becomes necessary to treat them directly. The psychologist underlined that nightmare was negative imagery, occurring during sleep, and that their content could be modified. She specified that there are currently no scientific reason to believe that they are unconscious psychological conflicts, as many people believe. As a result, the IRT rationale was introduced as a psychological treatment to unlearn this habit by modifying a recurrent nightmare and rehearsing it during the day. During the session, the participant also practiced pleasant imagery to familiarize himself with this technique. At the end of the session, guidelines to select a nightmare for the next session were given. The psychologist explained they should not be a replica of the traumatic event; ideally their content should be repetitive and should generate a medium level of anxiety. At the close of the session, the participant is asked to practice an exercise of pleasant imagery during the

Session 2 IRT focus (for Eric, session 3): IRT practice. This session was devoted to learning how to change the selected nightmare into a positive or neutral dream. Instructions for its modification were introduced. The psychologist helped the participant to identify the "hot spot," that is to say when the nightmare's content caused the most distress for him, and to change the nightmare just before this identified moment. The psychologist encouraged the participant to take control over his nightmares by modifying it in any way he wanted (e.g., changing the setting, adopting super powers, etc.), and to incorporate as many details as possible (e.g., emotions, physical sensations, etc.) in order to facilitate incorporating the new ending into memory. Then,

also trained to deliver IRT. The IRT sessions were conducted as follows:

week.
