**1.3. Emergence of treatments directly targeting nightmares**

New psychological treatments for PTNM are emerging and being tested. Recently, the Standards of Practice Committee (SPC) of the American Academy of Sleep Medicine (AASM) commissioned a task force to assess the literature on the treatment of nightmares disorder. They presented their results in a Best Practiced Guide [15] and listed six specific CBTs for nightmares: imagery rehearsal therapy (IRT), systematic desensitization, lucid dreaming therapy (LDT), exposure, relaxation and rescripting therapy (ERRT), sleep dynamic therapy, and self-exposure therapy. Although each therapy approaches the treatment for nightmares differently, all conceptualize nightmares as a learned response that can be modified by specific cognitive and behavioral strategies.

Eric (Participant 2) was a 54-year-old Caucasian male, divorced, with three children. He lived alone and received welfare. He was born in Italy but his parents immigrated to Canada when he was 3 months old. He experienced a sexual assault in his home, by three men from the family of a woman he was dating, 10 years prior to his initial evaluation. He did not report any other potentially traumatic events. During the treatment, he followed a prescription for

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

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At the time of the first evaluation, Adam met DSM-IV-TR criteria for PTSD following a serious skateboarding accident. Adam reported that in the month prior to the evaluation, he experienced intrusion symptoms (intrusive and distressing memories of the traumatic event, flashbacks, and physiological reactions). He also reported recurrent nightmares (four/five times a week) after which he could not go back to sleep. He described his nightmares as repetitive, with the same ending (a sudden fall from the sky). He reported persistent avoidance of stimuli associated with his traumatic event (e.g., thoughts, conversations, and spending time with the friend who was present for the event), and numbing symptoms (e.g., diminished interest in significant activities; and he did not expect to have a normal lifespan due to his physical problems). He also avoided his nightmares by programming his alarm clock to wake him up before the anticipated time of his nightmares. He presented persistent symptoms of increased arousal, more particularly sleep difficulties, difficulties concentrating (e.g., Adam had to write down the questions asked by the clinician before answering them), and outbursts of anger (e.g., he had cue cards suggested by his psychiatrist to help him man-

Finally, according to the SCID-I, he had comorbid social phobia in the past and was in partial remission for a major depressive disorder (MDD). Due to his profession as a doctor, he reported other potentially traumatic events but did not present any post-traumatic reactions

Eric met the DSM-IV-TR criteria for PTSD following a sexual assault. At the first evaluation, Eric reported that during the last month he experienced intrusion symptoms, such as intrusive and distressing memories of the traumatic event, and flashbacks. He felt an intense distress and physiologic reactivity after exposure to traumatic reminders (e.g., being with several people in the same room; being alone with only men; and being with people wearing the same religious objects as those who assaulted him). He used distractions (e.g., going out for a walk) to avoid thinking about the assault. He avoided going out in the evenings. Since the event, he also avoided romantic relationships with women. He felt a certain detachment from others, and mentioned his "life ended on the date of the assault" and, therefore, did not plan anything for his future. He reported difficulty concentrating and being hypervigilant (e.g., when walking, he would slow down or change direction to avoid having people walk behind him).

Venlafaxine (225 mg a day) and Quetiapine (150 mg a day).

**2.2. Presenting complaints**

*2.2.1. Participant 1: Adam*

age his anger).

in relation to them.

*2.2.2. Participant 2: Eric*

Imagery rehearsal therapy (IRT) is one treatment that has gained important empirical support to treat this problem. Its rationale is to select a repetitive nightmare, to transform and write it into a new positive or neutral dream, and finally to rehearse it in imagination. Thirteen group studies and a few case studies have already shown the efficacy of IRT in decreasing the frequency of PTNM. The change mechanisms of IRT are still understudied, although Germain et al. [16] have proposed that IRT decreases nightmares by increasing the victim's perception of control over them, and various methods of implementation exist.

A few studies reported the use of IRT with patients diagnosed with PTSD [17], but no studies have tried to incorporate this specific treatment for nightmares into a first line, trauma-focused CBT for PTSD [18]. In addition, there are no guidelines to include nightmare treatment in first-line treatment for PTSD, nor in which order treatments should be delivered. Should IRT be administered before the CBT for PTSD (first-step treatment) in order to facilitate sleep restoration and, therefore, accelerate trauma recovery? Or should IRT follow PTSD treatment, as a second-step treatment, in cases where the nightmares persist? It would be interesting to record the difficulties from a theoretical and practical point of view, and to observe which treatment should be prioritized in order to reduce all PTSD symptoms.

The first objective of this chapter is to present the feasibility of combining both CBT for PTSD and IRT for PTNM in the same interventional procedure. The second goal is to explore different sequences of treatment.
