What are the risks, benefits, and evidence for using praxis, such as imagery rehearsal therapy (IRT), in the treatment of nightmares in post-traumatic stress disorder (PTSD)?

From the Guidelines

Imagery rehearsal therapy (IRT) is a highly recommended treatment for nightmares in PTSD, with strong evidence supporting its effectiveness in reducing nightmare frequency and intensity, improving sleep quality, and decreasing PTSD symptoms 1.

Benefits of IRT

• Significant reduction in nightmare frequency and intensity
• Improved sleep quality
• Decreased PTSD symptoms
• Effects typically appear within 3-6 weeks of consistent practice
• Can be delivered in individual or group formats, typically over 4-6 sessions
• Can be combined with other PTSD treatments

Risks of IRT

• Temporary distress during initial nightmare recall
• Some patients may experience temporary increases in nightmare frequency or intensity when first confronting their trauma narratives

How IRT Works

• Allows patients to gain control over previously uncontrollable dream content
• Reconsolidates traumatic memories in a less threatening context
• Breaks the conditioned fear response associated with sleep

Recommendations for IRT Practice

• Patients should practice the reimagined dream scenario daily for 10-20 minutes
• Maintain a nightmare diary to track progress
• Continue the practice for at least 4-6 weeks
• IRT is particularly valuable because it directly addresses the nightmare component of PTSD that often persists even after other symptoms improve with standard treatments 1.

Key Considerations

• The ultimate judgment regarding the propriety of any specific treatment must be made by the clinician, considering the individual circumstances presented by the patient, available diagnostic tools, and resources 1.
• IRT is a recommended first-line treatment for nightmares in PTSD, with strong evidence supporting its effectiveness 1.

From the Research

Risks and Benefits of Praxis in Treatment of Nightmares in PTSD

• The use of praxis, such as imagery rehearsal therapy (IRT), in the treatment of nightmares in post-traumatic stress disorder (PTSD) has shown promising results in reducing nightmare frequency and intensity, as well as improving sleep quality and overall PTSD symptoms 2, 3.
• However, the effectiveness of IRT may vary depending on the population being treated, with some studies suggesting that it may be less beneficial for veterans 2.
• The risks associated with praxis in the treatment of nightmares in PTSD are not well-documented, but it is possible that the treatment may trigger or exacerbate symptoms in some individuals.
• The benefits of praxis in the treatment of nightmares in PTSD include:
  • Reduced nightmare frequency and intensity
  • Improved sleep quality
  • Decreased PTSD symptom severity
  • Increased sense of control or mastery over nightmares

Literature Support

• A retrospective pilot study published in 2023 found that a single-session IRT intervention modified with narrative therapy (N-IRT) was effective in reducing nightmare frequency and intensity, as well as improving sleep quality and overall PTSD symptoms in veterans 2.
• A randomized controlled trial published in 2001 found that IRT was effective in reducing chronic nightmares, improving sleep quality, and decreasing PTSD symptom severity in sexual assault survivors with PTSD 4.
• A pilot study published in 2003 found that IRT was effective in reducing posttraumatic nightmares in Australian veterans with chronic combat-related PTSD, with significant improvements maintained at 12-month follow-up 5.
• A systematic review published in 2023 found strong evidence for the effectiveness of exposure and image rehearsal treatments in reducing nightmare frequency, severity, and distress in civilian, military, idiopathic, and PTSD cohorts 3.