Imagery Rehearsal Therapy for Acute Posttraumatic Nightmares Among Combat Soldiers in Iraq

Eleven soldiers with a primary complaint of acute nightmares received imagery rehearsal therapy, and each had experienced a traumatic event within 30 days prior to presentation. Each soldier reported the development of nightmares and related sleep complaints subsequent to the event. Imagery rehearsal therapy treatment was provided in four weekly one hour sessions by Dr. Moore, who learned the technique while in Iraq through a comprehensive user’s manual (2) and supplemental coaching by e-mail exchange with Dr. Krakow. As part of clinical care, the number of nightmares (3), posttraumatic stress symptom severity (4), and insomnia severity (5) were assessed at intake, posttreatment, and 1-month follow-up.

Repeated-measures analysis of variance tested each variable across three time points; Hedge’s g effect sizes (for small cohorts) were calculated for changes between intake and 1-month follow-up. Each outcome showed steady reductions from the three time points ( Figure 1 ). The mean number of nightmares decreased 44% at the 1-month follow-up compared with the mean at intake (F=8.026, df=2, 9, p=0.01, Hedge’s g=1.04), and 7 out of 11 soldiers reported marked relief, with an average decrease of 61% in nightmare counts. The mean posttraumatic stress symptom scores decreased 41% at the 1-month follow-up compared with the mean at intake (F=5.999, df=2, 9, p=0.02, Hedge’s g=1.37), and these same seven soldiers reported marked improvements with an average decrease of 58% in symptoms. Insomnia showed a 34% decrease in severity (F=3.946, df=2, 9, p=0.06, Hedge’s g=1.23), with the same seven soldiers reporting the largest improvements. Among the four soldiers who completed the treatment but did not experience fewer nightmares, one showed a slight increase in nightmares, and three reported no changes. Two soldiers showed slight worsening in posttraumatic stress symptoms, and two showed slight improvement.