**4. Discussion**

#### **4.1. Treatment implications of the cases**

The present study was exploratory and reported the possibility of combining CBT for PTSD with a specific treatment for nightmares (IRT) for adults diagnosed with PTSD. Observations from both participants demonstrated interesting results with: a) a decreasing trend in the level of distress related to nightmares for Adam and a clear decrease for Eric; b) a slight improvement in sleep; and c) a slight reduction in PTSD symptoms on the CAPS, with a greater reduction for Eric compared to Adam. Nonetheless, both participants still met the criteria for PTSD after treatment. Thus, the results were not as positive as expected. This could be explained by the complicating factors previously outlined, such as pain management, personality traits, and alcohol and drug abuse, which are issues often met by clinicians in their office, and that could affect the results of the combined treatment.

The current study confirmed that both sequences for IRT implementation, before and after CBT for PTSD, are possible. As a result, these data show promising results for clinicians to incorporate IRT, either as a first-step or second-step treatment, for patients diagnosed with PTSD, and who are distressed by their nightmares. Adding a specific treatment for nightmares as a first-step treatment also represents an interesting option for clinicians with clients who are reluctant to directly engage in exposure [38] or are refractory to medication. It therefore offers a way to potentially improve CBT for PTSD [39].

This study is consistent with the findings of past studies' of IRT efficacy in decreasing PTNM distress [40, 41]. Several treatments for nightmares exist, but to our knowledge, it is the first time such a treatment was added as an additional treatment strategy to CBT for PTSD.

Nonetheless, the impact of the combined treatment on the PTSD symptoms was not as positive as we expected. The results are generated from two single-case studies and several complicating factors were reported. Therefore, this study needs to be replicated before conclusions can be drawn. Several aspects should be considered in the future, such as: adding IRT sessions; implementing IRT in a group format; testing the combined treatment with different traumatic events; using a larger sample; and testing the combined treatment with women. Studies should also examine the optimal order for integrating IRT into CBT for PTSD. Also, future controlled and randomized studies are necessary to test IRT efficacy by comparing: IRT alone to IRT combined with a CBT for PTSD and IRT alone to CBT for PTSD alone. Finally, it would also be important to study what the therapeutic component is in order to better adapt IRT and help clinicians to implement it into their PTSD treatment practice.
