**3.4. Complicating factors**

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

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

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

Eric reported only occasional nightmares at pre-CBT for PTSD. Since they became present almost every night after the seventh session, and did not disappear post-CBT, we offered Eric five additional IRT sessions. Eric indicated that he was motivated to work on treating his

Regarding the frequency of his nightmares, Eric recorded between five and six nightmares a week during the 2 weeks at baseline post-CBT; during the IRT sessions, their numbers successively decreased to two nightmares a week by the end of his treatment. This decrease is coherent with the level of distress reported for his nightmares. The level of distress he experienced as a result of his nightmares decreased between pre-IRT baseline (3.14 out of 10) and post-IRT sessions (1.29 out of 10) with a peak of 7.07 of 10 after the first session. NDQ score was 28.00 and decreased to 22.00. These results suggest that IRT was an effective treatment for him.

Total scores for administered questionnaires show the efficacy of the combined treatment with a decrease in the CAPS total score from pre-CBT (89.00) to post-CBT (70.00) and post-IRT (60.00), more particularly for the intrusive recollection symptoms and the hyperarousal symptoms. When considering the PSQI (pre-CBT = 10.00; post-CBT = 9.00; post-IRT = 7.00) and the PSQI-A (pre-CBT = 9.00; post-CBT = 11.00; post-IRT = 6.00), sleep improvements were

We observed that the intensity of his PTSD symptoms decreased from 89 to 70 on the CAPS. However, Eric still met the criteria of a clinical PTSD diagnosis. Nonetheless, we observed that, even if he could not complete an imaginal exposure to the whole event, he was able to go into certain details and felt less distressed doing so by the end of the treatment. This step was clinically very important for him, as he had not talked about the event in 10 years.

the PSQI-A deceased to 10.00 (with a score of 17.00 at the beginning of the treatment).

noticed that, physically, he seemed more rested and to have more energy.

through the treatment.

88 Cognitive Behavioral Therapy and Clinical Applications

**3.3. Participant 2: Eric**

observed but sleep difficulties remained.

nightmares.
