**2.5. Case conceptualization**

Adam's sleep and more particularly, his nightmares were a significant impediment to his daily functioning. He recalled at least four nightmares a week and, sometimes, more than one nightmare a night, that woke him up. He described them as repetitive, with the same ending (a sudden fall from the sky), and without being an exact replica of his traumatic event. The nightmares also generated a lot of distress with the consequences of not being able to go back to sleep and trying to avoid them by setting his alarm to wake him before the onset of the nightmare. We, therefore, offered him the opportunity to focus on his nightmares for the initial three sessions and to approach his PTSD symptoms in a second step.

Eric's primary symptoms were PTSD manifestations with occasional nightmares, and were first treated with CBT for PTSD. At the end of this treatment, the intensity of his global PTSD symptoms decreased but Eric still met DSM-IV-TR criteria for PTSD. In general, his symptoms of intrusive recollection decreased but the frequency of his nightmares increased, and they occurred at least three times a week. He described them as repetitive, with the same theme (three people chasing him until he was stuck in a corner), with the setting changing from one nightmare to another. He described them as being very real, to the point that they made him feel very distressed and, as a consequence, woke him up. No sexual content was reported. Regarding his remaining PTSD symptoms, daily avoidance of activities, places and men in general were recorded. He did not report any sleep loss but mentioned severe difficulties concentrating. Therefore, to deal with his nightmares, five IRT sessions were added after 2 weeks of baseline CBT.

To reduce PTSD symptoms, an empirically validated treatment protocol [2] was adapted following expert recommendations [30, 31]. Twelve sessions were added to the original treatment of Foa et al. [2]. The treatment was designed to last 20 sessions and included the following components: psychoeducation on PTSD symptoms and diaphragmatic relaxation learning; 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].

*2.4.4. Ancillary measures*

84 Cognitive Behavioral Therapy and Clinical Applications

*2.4.5. Self-monitoring booklet*

**2.5. Case conceptualization**

2 weeks of baseline CBT.

*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].

Participants were asked to make daily self-observations on a 10-point Likert scale from 0 (*= not at all*) to 10 (*= a lot*) for the following: sleep quality, the presence or absence of nightmares, nightmare frequency, the level of distress related to these nightmares, the global distress they felt the day before, and three questions on PTSD symptoms (one to evaluate intrusive recol-

All questionnaires were administered in French. Initially, Eric did not receive all the questionnaires described above because of his involvement in another study protocol. As a result, Eric

Adam's sleep and more particularly, his nightmares were a significant impediment to his daily functioning. He recalled at least four nightmares a week and, sometimes, more than one nightmare a night, that woke him up. He described them as repetitive, with the same ending (a sudden fall from the sky), and without being an exact replica of his traumatic event. The nightmares also generated a lot of distress with the consequences of not being able to go back to sleep and trying to avoid them by setting his alarm to wake him before the onset of the nightmare. We, therefore, offered him the opportunity to focus on his nightmares for the

Eric's primary symptoms were PTSD manifestations with occasional nightmares, and were first treated with CBT for PTSD. At the end of this treatment, the intensity of his global PTSD symptoms decreased but Eric still met DSM-IV-TR criteria for PTSD. In general, his symptoms of intrusive recollection decreased but the frequency of his nightmares increased, and they occurred at least three times a week. He described them as repetitive, with the same theme (three people chasing him until he was stuck in a corner), with the setting changing from one nightmare to another. He described them as being very real, to the point that they made him feel very distressed and, as a consequence, woke him up. No sexual content was reported. Regarding his remaining PTSD symptoms, daily avoidance of activities, places and men in general were recorded. He did not report any sleep loss but mentioned severe difficulties concentrating. Therefore, to deal with his nightmares, five IRT sessions were added after

To reduce PTSD symptoms, an empirically validated treatment protocol [2] was adapted following expert recommendations [30, 31]. Twelve sessions were added to the original treatment of Foa et al. [2]. The treatment was designed to last 20 sessions and included the following components: psychoeducation on PTSD symptoms and diaphragmatic relaxation learning;

lection symptoms, one for avoidance, and one to identify hyperarousal reactions).

did not receive the BDI, BAI, PCL-S and NDQ during his conventional CBT.

initial three sessions and to approach his PTSD symptoms in a second step.

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

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 week.

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