*3.4.1. Participant 1: Adam*

During the course of treatment, Adam encountered interpersonal problems with his family circle and mentioned their lack of support. He particularly indicated their misunderstanding of his PTSD reactions, reported conflicts with his wife, and expressed his feeling of stigmatization. Social support is reported as being a strong predictor for the development and maintenance of PTSD [34]. Even if Adam demonstrated motivation, these difficulties often had to be addressed during the PTSD treatment, as he felt a lot of anger or isolation when these situations occurred.

It is important to mention that Adam was on sick leave during the treatment and he did not know what to expect regarding the future of his work. A job loss or the threat of losing a job can trigger mixed and confusing feelings, such as anger [35]; on the other hand, a supportive workplace can help in reducing PTSD symptoms by offering, for example, social support. During therapy, Adam began to deal with the possibility of losing his job and this, too, had to be addressed.

A certain cognitive rigidity and significant difficulty concentrating were also observed. To deal with these difficulties, Adam would drink energy drinks before the sessions to be sure to follow everything. Since each session was recorded, Adam sometimes asked to listen to the sessions again, so he could be sure he understood every part of the therapist's intervention. The therapist observed it was difficult for the participant not to be in control of the treatment.

Finally, Adam experienced a lot of pain, more particularly with his back, following the accident, and he received a diagnosis of fibromyalgia during the treatment. Fibromyalgia syndrome is a chronic condition characterized by widespread musculoskeletal pain and multiple tender points on clinical examination. We know from the literature that patients with fibromyalgia are found to be significantly more likely to experience difficulties initiating or maintaining sleep than controls [36]. This variable may have contributed to the quality and quantity of his sleep, as the discomfort awoke him during the night. In addition, it was sometimes difficult for him to report in his self-monitoring booklet if his nightmares were the reason for his waking or if it was because of the pain.

#### *3.4.2. Participant 2: Eric*

Ten years had passed since Eric's traumatic event and it was the first time he had talked to someone about it. This brought a high level of anxiety and complicated imaginal exposure. Even though four additional CBT sessions were offered, it was not possible to complete the imaginal exposure of the whole event. However, by the end of treatment, Eric was able to talk somewhat about the details of his sexual assault.

Also Eric had to deal with his marijuana dependence. During sessions, this aspect was approached as it appeared this behavior was a way to manage his emotions and more particularly his anxiety. Eric was never under the influence of marijuana during sessions but used it at home as a way to compensate for a lack of social network. It was agreed that he would not use marijuana before or after exposition exercises. At the end of the treatment, the clinician observed that Eric had reduced his consumption.

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

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

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

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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 there-

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

Both participants experienced a slight decrease in their sleep difficulties and in the intensity of their PTSD symptoms, as well a decrease in the level of distress from the nightmares (slight for Adam, more pronounced for Eric). In addition, Eric demonstrated a decrease in the frequency of his nightmares, which was contrary to Adam's experience. From the findings of this study, we noted that a specific treatment for nightmares, more particularly IRT, combined

From the case study of Adam, having only three IRT sessions at the beginning of treatment seemed too short for him, and more IRT sessions could have been beneficial. Also, sleep hygiene was briefly approached and could have been emphasized more. As mentioned and tested in a recent case study [38], CBT for insomnia (CBT-I) is a safe and effective treatment in patients with comorbid insomnia and PTSD. In the case of Adam, who set his alarm to avoid

with CBT for PTSD is possible, and could also be a way of improving a CBT for PTSD.

IRT and help clinicians to implement it into their PTSD treatment practice.

affect the results of the combined treatment.

**4.2. Recommendations to clinicians**

fore offers a way to potentially improve CBT for PTSD [39].

In addition, during the first 3 weeks of IRT, Eric showed difficulties in managing his anxiety because of a colonoscopy he needed, which reminded him of some aspects of the traumatic event. This situation led him to report more nightmares the week before the intervention (after session 1 of the IRT), and more flashbacks after his colonoscopy (before session 3 of the IRT).
