Imagery Rehearsal for Nightmares Related to PTSD

man waking up from nightmare in bed
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If you have post-traumatic stress disorder (PTSD), then you know that nightmares can have a tremendous negative impact on your life. In fact, nightmares are considered the most commonly reported symptoms among people with PTSD.

Nightmares can greatly interfere with your amount and quality of sleep and can cause high levels of anxiety. Nightmares are also often unaffected by standard treatments for PTSD. Because of this, specialized treatment for nightmares has been developed. One such treatment is Imagery Rehearsal Therapy (or IRT).

What Is IRT?

IRT is considered a cognitive-behavioral treatment. In a nutshell, IRT uses techniques that help people with PTSD rescript or alter the endings of their nightmares while they are awake. When you come up with an alternative, less distressing outcome, nightmares can become less upsetting and debilitating.

How Does IRT Work?

In IRT, you will be presented with information on sleep, nightmares, and what IRT entails. You will also learn how to monitor your nightmares.

Your therapist will help you come up with detailed, alternative, non-distressing endings for nightmares that you've experienced.

While awake, you can rehearse each nightmare with the altered ending.

IRT is a time-limited therapy, meaning that there is a defined duration of treatment. One reason for this is that IRT is focused specifically on nightmares and sleep difficulties. It doesn't really address other symptoms of PTSD. Therefore, if you are seeking out treatment for a variety of PTSD symptoms, you may want a more comprehensive treatment, such as exposure therapy.

Does IRT Really Work?

Several studies have been completed to examine whether IRT reduces nightmares in PTSD sufferers.

One 2008 study looked at 15 male U.S. veterans with PTSD who were having trauma-induced nightmares. Each had not already completed trauma-focused PTSD treatment but had attended six IRT group sessions. While no benefits were observed right after treatment, at three and six-month follow-up appointments the participants said trauma-related nightmares had become less frequent.

Other studies have generally found that IRT is successful in reducing the frequency and intensity of nightmares, as well as PTSD symptoms. IRT has also been found to reduce insomnia.

A 2020 meta analysis found that pharmacological treatment with prazosin and psychological treatment with IRT may be effective for posttraumatic nightmares.

Where Can I Find Someone Who Offers IRT or Other Therapies?

You can learn more about IRT at the National Center for PTSD, which also provides a resource for finding cognitive behavioral therapists in your area who may offer IRT.

If you have a hard time finding someone familiar with IRT, you can also consider one of these similar types of therapy:

Lucid Dreaming Therapy

A technique that helps dreamers to become aware of their dreams as they are occurring, and make intentional changes during their dreams.

Sleep Dynamic Therapy

according to an article in the Journal of Sleep Medicine, "is an integrated program combining standard clinical sleep medicine instructions including sleep quality and sleep hygiene with psychotherapeutic interventions using principles of CBT like stimulus control, IRT, etc."

Self-Exposure Therapy

A process by which the patient makes a list of his or her most problematic dreams and then thinks through those dreams on a daily basis, starting with the least anxiety-provoking.

1 Source
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  1. Yücel, Dilan E., Arnold A.P. van Emmerik, Camille Souama, and Jaap Lancee. Comparative efficacy of imagery rehearsal therapy and prazosin in the treatment of trauma-related nightmares in adults: a meta-analysis of randomized controlled trialsSleep Medicine Reviews. 2020;50:101248. doi:10.1016/j.smrv.2019.101248

Additional Reading
  • Krakow, B., & Zadra, A. (2006). Clinical management of nightmares: Imagery rehearsal therapy. Behavioral Sleep Medicine, 4, 45-70.
  • Nappi, C.M., Drummond, S.P.A., Thorp, S.R., & McQuaid, J.R. (2010). Effectiveness of imagery rehearsal therapy for the treatment of combat-related nightmares in veterans. Behavior Therapy, 41, 237-244.
  • Nisha, R. A. et al. Best practice guide for the treatment of nightmare disorder in adults. Standards of Practice Committee: Journal of Sleep Medicine. R. Nisha Aurora, M.D.Vol.6, No. 4, 2010.
  • Spoormaker, V.I., & Montgomery, P. (2008). Disturbed sleep in post-traumatic stress disorder: Secondary symptom or core feature? Sleep Medicine Reviews, 12, 169-184.

By Matthew Tull, PhD
Matthew Tull, PhD is a professor of psychology at the University of Toledo, specializing in post-traumatic stress disorder.