**2.2. Presenting complaints**

#### *2.2.1. Participant 1: Adam*

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 spe-

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

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

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 differ-

Two participants, Adam and Eric (pseudonyms), were referred for treatment at the Trauma Studies Centre at the Institut Universitaire en Santé Mentale de Montréal, which specializes in the treatment of trauma victims. Evaluations were conducted by doctoral psychology students and therapies were administered by an experienced psychologist. Both participants experienced a traumatic event and met PTSD criteria (i.e., a CAPS global score of 65 or more). They experienced sleep difficulties (i.e., a PSQI global score of 5 or more) and had at least four nightmares per week, which were not an exact replica of the traumatic event at the baseline assessment. They had not received CBT for insomnia, for nightmares, or for their post-trau-

Adam (Participant 1) was a married 45-year-old Caucasian male. He worked as a doctor and had been on sick leave for several months. He experienced a skateboarding accident 2 years prior to the initial evaluation. He was referred by a psychiatrist. Several pharmacological

of control over them, and various methods of implementation exist.

treatment should be prioritized in order to reduce all PTSD symptoms.

cific cognitive and behavioral strategies.

80 Cognitive Behavioral Therapy and Clinical Applications

ent sequences of treatment.

**2.1. Case introduction**

matic symptoms over the course of the past year.

options had been tried in the past but were not effective.

**2. Method**

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 manage his anger).

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 in relation to them.

#### *2.2.2. Participant 2: Eric*

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).

On the SCID-I, he also met criteria for a major depressive disorder (MDD) from the age of 45. He also reported several hospitalizations of 2 or 3 days' duration for suicidal ideation and suicide attempts in the past. Suicidal ideations were always present but he tried to put them aside by taking a walk.

one session of relapse prevention. He was re-evaluated (interviews and questionnaires) after IRT, after imaginal exposure, post-CBT and at three and six months after treatment. Since Eric presented only occasional nightmares at the time of the first evaluation, and since they were not his primary complaints, he was not offered initial nightmare treatment. However, he began reporting recurrent and distressing nightmares at the seventh CBT session. Consequently, 5 IRT sessions were added to the original 20 sessions of CBT for PTSD. Thus, he had 3 weeks of psychoeducation about PTSD symptoms, 6 weeks of imaginal exposure, 14 weeks of exposure in vivo and 5 sessions of IRT. He had evaluations (interviews and questionnaires) as follows: at 3 weeks (after the psychoeducation), at 10 weeks (after imaginal exposure), at the end of his CBT (post-CBT at 23 weeks), at the end of the 5 IRT sessions (post-

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

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

83

The *Structured Clinical Interview for DSM-IV-TR Axis I Disorders* [*SCID-I*; [19]] is a semi-structured interview used to determine if a participant presents a DSM-IV-TR Axis I [20], or major

*The PTSD Checklist – Specific* [*PCL-S*; [22]] is a 17-item self-report measure of the 17 DSM-IV symptoms of PTSD. Participants rate each item from 1 (= *not at all*) to 5 (= *extremely)* to indicate the degree to which they have been bothered by that particular symptom over the past month. It demonstrates good psychometric properties in English [22]. *The Clinician-Administered PTSD Scale* [*CAPS*] is a structured interview to make a categorical PTSD diagnosis. It also provides a measure of PTSD symptoms severity when adding for each item a frequency score from 0 (= *none of the time*) to 4 (*= most or all of the time*), and an intensity score from 0 (*= none*) to

*The Nightmare Distress Questionnaire* [*NDQ*; [24]] is a 13-item self-report questionnaire retrospectively evaluating the waking degree of distress associated with experiencing nightmares. It is a 5-point Likert scale from 0 (= *never*) to 5 (= *always*). It demonstrates good psychometric properties. Since the last two items in the questionnaire evaluate the respondent's interest in following a course of therapy, and participants were already enrolled in therapy, we did not consider these two items in the total score. *The Pittsburg Sleep Quality Index Questionnaire* [*PSQI*; [25]] includes 19 self-rated questions and 5 questions rated by the bed partner or roommate if one is available. The total score varies from 0 to 21. It also demonstrates good psychometric properties in English [26]. *The Pittsburgh Sleep Quality Index Addendum for PTSD* [*IQSP-A*; [27]] is a self-report questionnaire designed to assess the frequency of seven PTSD-specific sleep disturbances during the month preceding completion of the questionnaire. A global score is obtained from the sum of all seven items, and has a range of 0 to 21. It demonstrates good

mental disorders, in research. It presents good psychometric properties [21].

4 (*= extreme*). Psychometric properties are strong [23].

IRT), and 4 months after treatment.

*2.4.1. Diagnostic interview*

*2.4.2. PTSD measures*

*2.4.3. Sleep measures*

psychometric properties [27].

Eric reported being marijuana dependent for 5 years, then stopping use for 1 year, but relapsing 6 months prior to the assessment. At the time of the first evaluation, he was following treatment from an addiction center. He was in complete remission for cocaine abuse after 3 years of use, but admitted that he still smoked marijuana on a daily basis.

#### **2.3. History**

Adam's PTSD symptoms started after a skateboarding accident and subsequent hospitalization 2 years before the first evaluation. He explained that he collided with his friend, with whom he was skateboarding. The collision threw him into the air and he landed on his back. He described feeling at that moment an intense pain; he was breathless; he experienced reactions of dissociation. Someone offered to call Adam an ambulance, but Adam refused. Rather, Adam decided to go back to his hotel by car, which he recalled being a very painful experience. The next morning, Adam did not recall any of the details following the fall. Adam was then hospitalized for 4 days for several fractures, including one in his back. He described his stay as negative, experiencing feelings of helplessness at not being able to move anymore. He expressed that his stay was so difficult that he decided to sign a refusal of treatment. During the pre-treatment evaluation at our center, he reported that his PTSD symptoms had had many consequences for his life: he no longer worked; he experienced marital problems and attended couple's therapy; he had to manage physical problems with his back; and he felt he no longer had any friends, other than those of his wife.

Eric's PTSD symptoms started immediately after his traumatic event. At the time, he had been dating for 1 year a woman of another ethnic origin, whose family disapproved of their relationship. When members of her family asked him to stop seeing her, he refused. A few weeks later, three men attacked him at gunpoint in his apartment and sexually assaulted over several hours. Eric explained that during the event he feared for his life and that of his girlfriend. After the event, he never heard from his girlfriend again. He specified that he had not talked about the event for 10 years.

#### **2.4. Assessment**

Before their pre-treatment evaluations, both participants were asked to be stable on any medications for at least one month. After signing a consent form, participants were assessed with structured clinical interviews (to determine diagnosis at baseline, to check inclusion criteria, and to gather background information). Once selected for the study, participants were given questionnaires and explanations to complete self-monitoring booklets every day.

Adam and Eric followed two different protocols according to their clinical profile. Adam had 3 weeks of IRT, followed by 7 weeks of imaginal exposure, 9 weeks of exposition in vivo and one session of relapse prevention. He was re-evaluated (interviews and questionnaires) after IRT, after imaginal exposure, post-CBT and at three and six months after treatment. Since Eric presented only occasional nightmares at the time of the first evaluation, and since they were not his primary complaints, he was not offered initial nightmare treatment. However, he began reporting recurrent and distressing nightmares at the seventh CBT session. Consequently, 5 IRT sessions were added to the original 20 sessions of CBT for PTSD. Thus, he had 3 weeks of psychoeducation about PTSD symptoms, 6 weeks of imaginal exposure, 14 weeks of exposure in vivo and 5 sessions of IRT. He had evaluations (interviews and questionnaires) as follows: at 3 weeks (after the psychoeducation), at 10 weeks (after imaginal exposure), at the end of his CBT (post-CBT at 23 weeks), at the end of the 5 IRT sessions (post-IRT), and 4 months after treatment.

#### *2.4.1. Diagnostic interview*

On the SCID-I, he also met criteria for a major depressive disorder (MDD) from the age of 45. He also reported several hospitalizations of 2 or 3 days' duration for suicidal ideation and suicide attempts in the past. Suicidal ideations were always present but he tried to put them

Eric reported being marijuana dependent for 5 years, then stopping use for 1 year, but relapsing 6 months prior to the assessment. At the time of the first evaluation, he was following treatment from an addiction center. He was in complete remission for cocaine abuse after 3

Adam's PTSD symptoms started after a skateboarding accident and subsequent hospitalization 2 years before the first evaluation. He explained that he collided with his friend, with whom he was skateboarding. The collision threw him into the air and he landed on his back. He described feeling at that moment an intense pain; he was breathless; he experienced reactions of dissociation. Someone offered to call Adam an ambulance, but Adam refused. Rather, Adam decided to go back to his hotel by car, which he recalled being a very painful experience. The next morning, Adam did not recall any of the details following the fall. Adam was then hospitalized for 4 days for several fractures, including one in his back. He described his stay as negative, experiencing feelings of helplessness at not being able to move anymore. He expressed that his stay was so difficult that he decided to sign a refusal of treatment. During the pre-treatment evaluation at our center, he reported that his PTSD symptoms had had many consequences for his life: he no longer worked; he experienced marital problems and attended couple's therapy; he had to manage physical problems with his back; and he felt he

Eric's PTSD symptoms started immediately after his traumatic event. At the time, he had been dating for 1 year a woman of another ethnic origin, whose family disapproved of their relationship. When members of her family asked him to stop seeing her, he refused. A few weeks later, three men attacked him at gunpoint in his apartment and sexually assaulted over several hours. Eric explained that during the event he feared for his life and that of his girlfriend. After the event, he never heard from his girlfriend again. He specified that he had not

Before their pre-treatment evaluations, both participants were asked to be stable on any medications for at least one month. After signing a consent form, participants were assessed with structured clinical interviews (to determine diagnosis at baseline, to check inclusion criteria, and to gather background information). Once selected for the study, participants were given

Adam and Eric followed two different protocols according to their clinical profile. Adam had 3 weeks of IRT, followed by 7 weeks of imaginal exposure, 9 weeks of exposition in vivo and

questionnaires and explanations to complete self-monitoring booklets every day.

years of use, but admitted that he still smoked marijuana on a daily basis.

no longer had any friends, other than those of his wife.

talked about the event for 10 years.

**2.4. Assessment**

aside by taking a walk.

82 Cognitive Behavioral Therapy and Clinical Applications

**2.3. History**

The *Structured Clinical Interview for DSM-IV-TR Axis I Disorders* [*SCID-I*; [19]] is a semi-structured interview used to determine if a participant presents a DSM-IV-TR Axis I [20], or major mental disorders, in research. It presents good psychometric properties [21].

### *2.4.2. PTSD measures*

*The PTSD Checklist – Specific* [*PCL-S*; [22]] is a 17-item self-report measure of the 17 DSM-IV symptoms of PTSD. Participants rate each item from 1 (= *not at all*) to 5 (= *extremely)* to indicate the degree to which they have been bothered by that particular symptom over the past month. It demonstrates good psychometric properties in English [22]. *The Clinician-Administered PTSD Scale* [*CAPS*] is a structured interview to make a categorical PTSD diagnosis. It also provides a measure of PTSD symptoms severity when adding for each item a frequency score from 0 (= *none of the time*) to 4 (*= most or all of the time*), and an intensity score from 0 (*= none*) to 4 (*= extreme*). Psychometric properties are strong [23].
